Final Exam

Question 1

Fluid output

Answer 1

2200-2700 mL/day

Question 2

GI feces output

Answer 2

100-200 mL/ day

Question 3

Kidneys Urine output

Answer 3

1500 mL/day

Question 4

Insensible Skin output

Answer 4

300-600 mL/day

Question 5

Fluid distribution

Answer 5

intacellular- inside the cell. 2/3 of body fluids
extracellular- outside the cell. 1/3 of body fluids

interstitial-around the cells
intravascular- in arteries, capillaries, & veins

isotonic- equal balance
hypertonic- cells shrink
hypotonic- cells swell

Question 6

Goals for prevention and controlling of infections

Answer 6

Prevent exposure
Early detection
Eliminate or reduce the infection
Educate in infection prevention and control

Question 7

Primary defense mechanisms

Answer 7

Skin
Respiratory Tract
Eye
Mouth
Gastrointestinal
Genitourinary

Question 8

Medical Asepsis:

Answer 8

Reducing number and preventing transfer of organisms

AKA “Clean technique”
Hand hygiene
Clean environment
Barrier techniques

Question 9

Standard Precautions

Answer 9

Prevent contact with blood, body fluids, secretions, non-intact skin, and mucous membranes with ALL clients.

Question 10

PPE

Answer 10

Gown
Gloves
Mask
Goggles

Question 11

Droplet illnesses

Answer 11

Influenza (flu)
Mumps
Pertussis (whooping cough)

Question 12

Droplet Barrier protection

Answer 12

Private or cohort room
Surgical mask w/in 3 feet
Patient leaves the room only if necessary
Mask on patient when transporting

Question 13

Airborne illnesses

Answer 13

Measles
Chickenpox
Disseminated herpes zoster
Tuberculosis

Question 14

Airborne barrier precautions

Answer 14

Private room
Negative airflow pressure
Door closed except entering and exiting
Ultraviolet irradiation or air filter
Mask (N95)
Patient leaves the room only if necessary
Mask on patient when transporting

Question 15

Contact indications

Answer 15

MDROs- c. diff, MRSA, VCEs

Wound infections

Skin infections

Eye infections

Question 16

Contact barrier precautions

Answer 16

Private room or cohort patient

Gloves and gown

Question 17

Protective indications

Answer 17

Transplant
Chemotherapy
Immunocompromised
Burns

Question 18

Protective enviroment

Answer 18

Private room
Positive airflow
No plants or fresh fruits
Full PPE

Question 19

Surgical Asepsis

Answer 19

Eliminating microorganisms

Sterile technique
Sterile equipment and supplies
Sterile environments

Question 20

Principles of Surgical Asepsis

Answer 20

• A sterile object remains sterile only when touched by another sterile object.
• Only sterile objects may be placed on a sterile field.
• A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated.
• A sterile object or field becomes contaminated by prolonged exposure to air.

Question 21

Factors that increase susceptibility (Risk Factors)

Answer 21

• Break in primary defenses
• Acute illness and chronic disease
• Some medications
• Invasive procedures
• Tobacco use
• Substance abuse
• Multiple sex partners
• Environmental conditions

Question 22

Local infection

Answer 22

Specific to the location
Examples
Wound
Respiratory
Urinary
Gastrointestinal
Eyes/Ear/Throat

Question 23

Systemic Infections

Answer 23

Fever, chills, diaphoresis
Increased HR and RR
Malaise
Anorexia
Enlarged lymph nodes
Organ failure

Question 24

Healthcare Associated Infections (HAIs)

Answer 24

“Infection not present on admission”
Results in increased:
Patient stay
Discomfort
Cost

Question 25

Peripheral placement iV

Answer 25

Short term use | Ease of insertion

Question 26

Central placement IV

Answer 26

``` Purpose Long term use Large amounts Irritating substances Poor peripheral sites ``` ``` Types PICCs Tunneled Nontunneled Implanted ports ```

Question 27

Isotonic Solution

Answer 27

0.9% Sodium Chloride (NS) Lactated Ringer's (LR) Dextrose 5% in Water (D5W) Expands ECV (vascular and interstitial); does not enter cells

Question 28

Hypotonic solution

Answer 28

0. 45 % Sodium Chloride (1/2 NS) 0. 225% Sodium Chloride (1/4 NS) Expands ECV and rehydrates cells

Question 29

Hypertonic Solutions

Answer 29

3% or 5% Sodium Chloride Dextrose 5% in 0.45% NaCl (D5 ½NS) Dextrose 5% in 0.9% NaCl (D5NS) Dextrose 5% in LR (D5LR) Sodium replacement Draws water from cells

Question 30

Isotonic fluid is used for

Answer 30

Hypotension, hypovolemia

Question 31

Hypotonic fluid is used for

Answer 31

Hyperglycemic, conditions (diabetes ketoacidosis)

Question 32

Hypertonic fluid is used for

Answer 32

Stabilize BP, ^ urine output, and reduce edema Usually after loss or blood or plasma such as burns or hemorrhaging pts

Question 33

16g to 18g is used for ?

Answer 33

rapid infusion, thick fluids, surgical or trauma pts

Question 34

20g

Answer 34

adult blood transfusions

Question 35

20g to 22g

Answer 35

adult peripheral transfusion

Question 36

How many times should you attempt to initiate an IV?

Answer 36

No more than two tries, if you miss the first, go above the initial site or opposite extremity

Question 37

Primary and secondary IV administration sets should be changed how often?

Answer 37

No more frequently than 96 hours, at least every 7 days

Question 38

Intermittent administration sets should be changed how often?

Answer 38

Every 24 hours

Question 39

What is the preferred type of dressing for an IV site? AND WHY?

Answer 39

Transparent semipermeable so you can see the site and permits evaporation or moisture and provide a secure anchor

Question 40

How will you select a site for a peripheral IV?

Answer 40

age (adults = veins in hand or arm, child = scalp or foot) - solution type (use large veins for < irritation when using hypertonic, viscous or irritating substances) - infusion speed (the faster = larger vein and Iv cath - duration (change peripheral IV 72-96 hours) - presence of disease or previous surgery (avoid scarring or impaired circulation)

Question 41

Infiltration

Answer 41

inadvertent administration of a nonvesicant (non tissue damaging) solution or medication into

Question 42

Infiltration CMs

Answer 42

swelling, tenderness, pallor, hardness, and coolness at site, and burning sensation. Nursing response: stop infusion Immediately, restart infusion in different vein, elevate affected arm on a pillow to promote absorption of excess fluid.

Question 43

Extravasation

Answer 43

inadvertent infiltration of vesicant solution or medication into surrounding tissue *if these happen don’t pull out catheter, stop infusion first, talk to pharmacist bc there might be an antidote to put through the catheter.

Question 44

Extravasation CMs

Answer 44

pain, burning, swelling, and coolness of surrounding skin, blistering is a late sign. treatment depends on severity, stop infusion immediately, administer an antidote, apply cold compresses, and elevate the extremity.

Question 45

Phlebitis

Answer 45

inflammation of the vein, can result from the chemical part of fluid going into it or mechanical meaning the inside of catheter is damaging the vein.

Question 46

Phlebitis CMs

Answer 46

redness, warmth, tender, may be palpable. Nursing Response: discontinue iv infusion and restart in new location, apply cold compresses, assess for circulatory impairment, consult HCP.

Question 47

Thrombophlebitis

Answer 47

clot forming in addition of the phlebitis that happened. Discontinue infusion and take out catheter, elevate extremity, apply warm compresses 3-4x a day, restart infuse in a different extremity.

Question 48

Thrombophlebitis nursing response

Answer 48

discontinue iv infusion, and restart in opposite extremity apply warm compresses, consult HCP.