Final Exam Flashcards
(242 cards)
1
Q
Continuous IV Infusion
A
Large volume IV infusion given at a set rate over time.
2
Q
Intermittent IV / Piggyback
A
Medication given for a short period at scheduled intervals (e.g., every 8 hours).
3
Q
IV Bolus / IV Push
A
Small amount of medication injected directly into an IV line over a few minutes.
4
Q
Isotonic IV Solutions
A
Same osmolality as body fluids.
Used to treat hypovolemia.
5
Q
Isotonic IV Solutions Example
A
0.9% NaCl (Normal Saline),
Lactated Ringer’s (LR)
6
Q
Hypotonic IV Solutions
A
Osmolality is less than body fluids.
Used to hydrate cells.
7
Q
0.45% NaCl (½ Normal Saline)
A
A hypotonic solution.
Used as a basic maintenance fluid.
8
Q
0.33% NaCl (⅓ Normal Saline)
A
A hypotonic solution.
Used to treat hypernatremia.
9
Q
Hypertonic IV Solutions
A
Pulls fluid out of cells into the bloodstream.
10
Q
Examples of Hypertonic Solutions
A
D5NS: 5% dextrose in 0.9% NaCl
D5LR: 5% dextrose in Lactated Ringer’s solution
11
Q
What are examples of short-term IV access devices?
A
Peripheral IV
Non-Tunneled Central Line
Used until no longer needed, if complications occur, or based on hospital guidelines.
12
Q
How long does a peripheral IV typically remain in place
A
96 hours to 7 days
13
Q
What is the usual duration for a non-tunneled central line?
A
a few days to 2 weeks
14
Q
Which IV access device is used for medium-term therapy, and how long does it last?
A
4 weeks to 1 year
15
Q
What IV devices are used for extended-term therapy, and how long can they last?
A
Mediports and Tunneled Central Catheters – Can last months to years.
16
Q
What happens to the needle size as the gauge number increases?
A
The larger the gauge number, the smaller the needle.
17
Q
What gauge needle is required for blood products and certain tests or surgeries?
A
18 gauge (green)
18
Q
What are the IV catheter color codes for different gauge sizes?
A
24g – Yellow
22g – Blue
20g – Pink
18g – Green
16g – Gray
19
Q
What gauge sizes are commonly used for most adult infusions?
A
18 – 22 gauge
20
Q
What gauge sizes are used for geriatric and neonatal patients?
A
22 – 24 gauge
21
Q
What gauge sizes are used for blood transfusions and procedures?
A
18 – 20 gauge
22
Q
What is IV infiltration?
A
Infiltration occurs when IV fluid leaks into the subcutaneous tissue because the catheter has been displaced from the vein.
23
Q
What are signs and symptoms of infiltration?
A
Pain/Swelling
Cool/cold skin
No blood return
IV flow is slow or stops
Tissue damage (if severe)
24
Q
How can you prevent IV infiltration?
A
Regularly monitor the IV site
Assess the site frequently
Move the patient with care
25
What should you do if infiltration occurs?
Stop the infusion immediately
Change the IV site
Elevate the affected extremity
Apply warm compress (heat)
26
Extravasation – What is it?
Infiltration of a vesicant (tissue-damaging drug) into the subQ tissue.
27
how is extravasation different from infiltration?
Extravasation = infiltration of a vesicant (damaging drug)
⚠️ It can destroy tissue, unlike regular infiltration.
28
What are the signs and symptoms of extravasation?
BENT Skin
Blanchable
Ecchymosis (bruising)
Necrosis (tissue death)
Taut & cold skin
29
What does the skin feel like with extravasation?
Cold to the touch
Tight or stretched (taut)
Swollen (edema)
30
How do you prevent extravasation?
Flush the catheter before giving meds
Verify IV placement before starting the infusion
31
What should you do if extravasation happens?
Stop the infusion right away
Call the provider immediately
32
What is fluid volume overload?
Too much fluid in the circulatory system.
33
What are the signs of fluid volume overload?
Crackles / Dyspnea (trouble breathing)
Edema
JVD (jugular vein distention)
↑ BP / ↑ HR
34
How do you prevent fluid volume overload?
✅Monitor I&Os
✅ Daily weight
✅ Use an IV pump or set volume limits
35
What do you do if fluid volume overload happens?
🚨 Stop the infusion
📞 Notify the provider
⬆️ Elevate the HOB
💊 Give a diuretic (if ordered)
🩺 Monitor vitals
36
What is phlebitis?
Inflammation of the vein caused by:
Trauma from the needle or catheter
Irritating solutions
37
What are signs and symptoms of phlebitis?
Edema
Throbbing, burning, or pain
Warm, red, or hard vein
Slowed IV infusion rate
38
How can phlebitis be prevented?
1️⃣ Hand hygiene / Aseptic technique
2️⃣ Stabilize the IV site
3️⃣ Dilute the medication (if needed)
39
What should you do if phlebitis occurs?
1️⃣ Stop the infusion/ Change the IV site
3️⃣ Apply a warm compress
4️⃣ Elevate the extremity
5️⃣ Consider site/catheter culture if infection is suspected
40
What is an air embolism?
Air enters the vein, which can block blood flow and cause serious complications.
41
What are signs and symptoms of an air embolism?
1️⃣ Dyspnea →Cyanosis
2️⃣ ↓ Heart rate, ↑ Blood pressure
3️⃣ Low or lost consciousness
42
How do you prevent an air embolism?
1️⃣ Remove air from tubing
2️⃣ Secure all IV connections
3️⃣ Don’t let the IV bag run dry
43
What do you do if an air embolism occurs?
1️⃣ Position: Trendelenburg on left side
2️⃣ Give oxygen/ Check vital signs
3️⃣ Notify the provider
44
What causes an IV-related infection?
Contaminated equipment/Not cleaning the ports
Poor hand hygiene
Bad insertion technique
45
What are signs of a localized IV infection?
Redness and pain
Edema
Drainage at the site
46
What are signs of a systemic IV infection?
Fever, chills, malaise, nausea/vomiting
↓ HR, ↑ BP (when septic)
Possible heart attack
47
What do you do if there's an IV infection?
1️⃣ Check vitals
2️⃣ Change the IV site
3️⃣ Notify the provider
4️⃣ May need cultures, antibiotics, fluids
48
What is thrombosis in an IV?
A blood clot in the catheter.
49
What are signs of thrombosis in an IV line?
Resistance when flushing or pushing
Warm, red IV site
50
How can you prevent thrombosis in an IV?
Change the IV bag before it runs dry
Flush the site regularly
51
What do you do if you suspect IV thrombosis?
1️⃣ Stop the infusion
2️⃣ Change the site
3️⃣ Don’t flush if there’s resistance
4️⃣ Don’t massage the site
5️⃣ Apply a warm compress
52
What is a catheter embolus?
When the catheter hub breaks off and enters the vein.
53
What are signs of a catheter embolus?
Pain at the site where the catheter dislodged
Missing catheter tip when removed
54
How do you prevent a catheter embolus?
❌ Don’t reinsert the needle
❌ Don’t apply pressure over the catheter during removal
55
What do you do if a catheter embolus occurs?
1️⃣ Notify the provider
2️⃣ Apply a tourniquet above the site to stop it from traveling
56
Which IV complications need warm compress
Phlebitis
Thrombosis
Infiltration (Some meds need ice)
57
Which IV complications need Cold Compress
Extravasation
58
Name all 8 IV complications
Infiltration
Extravasation
Fluid Volume Overload
Phlebitis
Air Embolism
Infection (Localized & Systemic)
Thrombosis
Catheter Embolus
59
What allergies should you assess for before inserting an IV?
✅ Skin cleaner (like chlorhexidine or alcohol)
✅ Tape or adhesive
✅ Latex (gloves or IV equipment)
60
What are the steps for IV Insertion
Verify the order
Gather the supplies
Identify the patient, Introduce yourself and explain the procedure
Look for allergies and limb restrictions
61
Where should the tourniquet be placed during IV insertion?
4 inches above the insertion site.
62
What type of vein should you select for IV insertion?
A vein that is bouncy and has no pulse.
63
At what angle should you insert the IV catheter?
At a 15-degree angle.
64
How long should the tourniquet be applied during venipuncture?
Less than 1 minute.
65
What do you do with the tourniquet after finding the vein?
Untie the tourniquet before cleansing the site.
66
What should you do after cleansing the IV insertion site?
Allow the site to dry completely before proceeding.
( Don't fan dry)
67
What do you do after the site dries?
Retie the tourniquet and pull the skin taut with your non-dominant hand.
68
Why must blood be drawn in a specific order during venipuncture?
To avoid cross-contamination of additives between tubes.
69
What is the correct order of blood draw during venipuncture?
1.Blood Culture Bottles
2.Light Blue (Citrate)
3.Red (Serum)
4.Gold/SST (Serum Separator Tube)
5.Green (Heparin)
6.Purple (EDTA)
7.Pink (Cross Match)
8.Gray (Fluoride Oxalate)
70
What is the purpose of Blood Culture Bottles in blood draw?
Detect infections in the blood.
71
What tests use the Light Blue (Citrate) tube?
Clotting tests like PT, INR, and D-dimer.
72
What is the Red (Serum) tube used for?
Bacteriology, virology, and toxicology tests.
73
What does the Gold/SST (Serum Separator Tube) test for?
Electrolytes and liver function.
74
What tests use the Green (Heparin) tube?
Ammonia and glycogen tests.
75
What is the Purple (EDTA) tube used for?
Blood counts, platelets, and hemoglobin tests.
76
What is the purpose of the Pink (Cross Match) tube?
Blood typing and transfusions.
77
What tests use the Gray (Fluoride Oxalate) tube?
Glucose and lactate tests.
78
What materials are vials made of?
Plastic or glass.
79
What do vials contain?
Liquid or powder (may require dilution).
80
How many doses can vials hold?
One or multiple doses.
81
How are vials sealed?
With a plastic cap and rubber diaphragm.
82
What are ampules made of and how many doses do they hold?
Made of glass.
Single-dose only
83
What is the purpose of Packed RBCs?
Carry oxygen to tissues.
84
What do Platelets do?
Help with hemostasis after injury or invasive procedures; used for thrombocytopenia.
85
When is Fresh Frozen Plasma (FFP) used?
In emergency situations to replace clotting factors and volume.
86
What is Plasma used for?
Provides clotting factors.
87
What is Cryoprecipitate (CRYO) used for?
To treat bleeding from hemophilia and DIC (disseminated intravascular coagulation).
88
When is Albumin given?
For hypovolemic shock and liver failure.
89
What are Gamma Globulins?
Part of plasma containing antibodies that help boost the immune system.
90
What is it called when a patient donates their own blood in advance?
Autologous (Autotransfusion)
91
What type of blood donation comes from another person (not the patient)?
Allogeneic
92
What is the blood donation called when a friend or relative donates blood specifically for a patient?
Direct donation
93
What blood type is the universal recipient and why?
AB+ — can receive all blood types.
94
Who can AB+ donate to and receive from?
Donate to: AB+ only
Receive from: All blood types
95
Who can AB- receive from and donate to?
Receive from: AB-, A-, B-, O-
Donate to: AB-, AB+
96
Who can A- receive from and donate to?
Receive from: A-, O-
Donate to: A-, A+, AB-, AB+
97
Who can A+ receive from and donate to?
Receive from: A+, A-, O+, O-
Donate to: A+, AB+
98
Who can B+ receive from and donate to?
Receive from: B+, B-, O+, O-
Donate to: B+, AB+
99
Who can B- receive from and donate to?
Receive from: B-, O-
Donate to: B-, B+, AB-, AB+
100
Why is O- the universal donor?
Because it has no A or B antigens and no Rh antigen, so it can donate to all blood types.
101
Who can O- receive from and donate to?
Receive from: O- only
Donate to: All blood types
102
Who can O+ receive from and donate to?
Receive from: O+, O-
Donate to: O+, A+, B+, AB+
103
What does the Rh system depend on?
Presence or absence of Type D antigen on RBCs.
104
What does Rh+ mean?
What does Rh- mean?
Person has the D antigen.
Person does not have the D antigen.
105
Why do Rh-negative women need Rhogam during pregnancy?
To stop their body from attacking the baby’s blood if the baby has Rh-positive blood.
106
What determines blood type?
Blood type is based on antigens on red blood cells and antibodies made by the body against other antigens.
107
What is the first step before starting a blood transfusion?
Verify the order for the transfusion.
108
After verifying the order, what should you check next?
Verify the consent for the transfusion has been signed.
109
Step 3 in blood transfusion procedure?
Make sure the IV is patent.
110
Step 4 in blood transfusion procedure?
Get the blood from the blood bank.
111
Step 5 in blood transfusion procedure?
Verify the blood with a second RN.
112
Step 6 in blood transfusion procedure?
Get patient vitals before starting the transfusion.
113
Step 7 in blood transfusion procedure?
Infuse the blood over 15 minutes while staying with the patient.
114
Step 8 in blood transfusion procedure?
Adjust the infusion rate per hospital policy.
115
Step 9 in blood transfusion procedure?
Document the transfusion.
116
What information do you need to know before starting a blood transfusion?
Vitals and temperature
Transfusion and medical history
Allergies
CBC results
117
What is the first step if a patient has a reaction to a blood transfusion?
Stop the infusion.
118
After stopping the infusion, what should you do with the tubing and blood bag?
Take down the tubing and blood bag.
119
What fluid should you start immediately after stopping a transfusion reaction?
Start 0.9% normal saline (keep an emergency bag ready before transfusion).
120
What assessments should you do after starting saline during a transfusion reaction?
Assess vitals, breath sounds, and airway.
121
Who do you notify after a transfusion reaction?
Notify the provider.
122
What do you do with the blood bag and tubing after a transfusion reaction?
Return them to the lab.
123
What documentation is required after a transfusion reaction?
Document the reaction and all interventions.
124
How many nurses are needed to confirm the blood type and expiration date before transfusion?
Two Nurses
125
How fast should you start the blood transfusion?
No more than 2 mL per minute for the first 15 minutes.
126
How long should you stay with the patient after starting the transfusion?
Stay with the patient for the first 15 minutes.
127
What is the maximum amount of time a unit of blood can hang?
No more than 4 hours.
128
Can blood administration be delegated to assistive personnel (AP)?
No, but AP can monitor the patient’s vitals.
129
How often should vitals be monitored during a blood transfusion?
Every 15 minutes for the first hour, then every 30 minutes.
130
What medications or actions should you anticipate during a severe blood transfusion reaction?
Benadryl, Epinephrine, and possibly a Code Blue, depending on severity.
131
Is inserting or caring for a CVAD considered a sterile procedure?
Yes, it requires sterile technique to prevent infection.
132
What are the four types of Central Venous Access Devices (CVADs)?
Non-Tunneled CVADs
Peripherally Inserted Central Catheters (PICC)
Tunneled CVADs
Implanted Ports
133
Can a patient with an active infection have a CVAD inserted?
No, infection is a contraindication.
134
Can a patient with coagulopathies have a CVAD inserted?
No, coagulopathies are a contraindication.
135
Can a patient with chest or neck tumors have a CVAD inserted?
No, chest or neck tumors are a contraindication.
136
Can someone who is unable to care for the device or is a poor risk for the procedure have a CVAD?
No, they are contraindicated.
137
Percutaneous CVAD insertion method
Inserted straight through the skin into a big central vein, usually the internal jugular or subclavian vein.
138
PICC (Peripherally Inserted Central Catheter) Insertion method
Inserted in a peripheral vein and threaded into central circulation (lowest risk of complications).
139
Tunneled Central Catheters:
inserted into subcutaneous tissue and tunneled through muscle before entering central circulation.
Types: Hickman’s, Broviac, Quinton.
140
What are Subcutaneous (SubQ) Ports and where are they placed?
Surgically implanted under the skin (subQ) of the upper chest. The catheter is inserted into the vena cava.
141
Where is the most common CVAD insertion sites?
Internal Jugular
Subclavian
Femoral
142
Where are the internal jugular and subclavian CVAD insertion sites located?
Inserted into the internal jugular or subclavian veins.
143
Where does the tip of a CVAD inserted in the internal jugular or subclavian vein end?
At the superior vena cava, above the right atrium.
144
Where does the tip of a femoral CVAD end? and where does it sit?
Sit: inferior vena cava
End: In the lower central circulation.
145
What is the duration for Short-Term use of a Peripheral IV?
1 week or less.
146
How long can a Non-tunneled CVAD be used?
1 to 14 days.
147
What duration is considered Intermediate use for CVADs?
More than 4 weeks but less than 1 year.
148
Which CVAD type is commonly used for Intermediate term, home therapy?
PICC line.
149
What duration defines Long-Term CVAD use?
More than 1 year.
150
What types of CVADs are used for Long-Term use?
Tunneled catheters or implanted ports.
151
What are the top 3 complications of a CVAD?
Pneumothorax
Systemic/local infection (CLABSI) — signs include redness, swelling, fever, drainage
Catheter migration
152
What is an open-ended catheter, and what risks does it have?
Needs to be clamped when not in use. Higher risk of air embolism, bleeding (hemorrhage), and blood clots (thrombosis).
153
What is a valved catheter, and how does it differ from an open-ended catheter?
Does not need clamping. Has a lower risk of air embolism, bleeding, and blood clots.
154
Why is hand hygiene especially important when caring for a CVAD?
Because the central line is close to the heart, so infection risk is high.
155
Who is allowed to access a CVAD port?
Only specially trained nurses.
156
What type of needle is used for implanted ports?
A NON-CORING HUBER needle.
157
What must a patient do during CVAD removal, and what should be checked?
The patient needs to bear down (Valsalva maneuver), and the catheter length should be measured to ensure it is completely removed.
158
What should NOT be done on the arm with the CVAD port?
No blood pressure (BP) or peripheral IVs (PIVs).
159
What should be communicated to phlebotomists regarding blood draws for patients with CVADs?
Peripheral blood draws are no longer needed.
160
What should both patient and nurse wear during CVAD procedures?
Mask
161
How is CVAD tip placement confirmed before use?
Chest Xray
162
What is recommended before and after accessing an implanted port?
Apply topical anesthetic cream before access.
Use a heparin flush after each use.
163
What are the main purposes of an NG tube?
Gastric lavage
Decompression of the bowel
Short-term enteral feedings
164
What is a fine/small bore NG tube used for?
Medication administration and feedings.
165
What is a large bore NG tube (12 French or higher) used for?
Gastric lavage
Decompression of the bowel
166
Is NG tube insertion considered a clean or sterile technique?
clean technique.
167
What are the key steps for inserting an NG tube?
Verify order
Gather supplies
Measure from ear to nose to xiphoid process
Have patient swallow while inserting
Secure tube with nasal tape, bridle, or clip
Confirm placement
168
When should NG tube placement be confirmed?
After placement
After feeding
Periodically in between feedings
169
How do you confirm NG tube placement?
Chest x-ray (gold standard)
Test gastric pH (should be less than 5.5)
170
How do you monitor NG tube position during use?
Measure length at the nose and mark it; regularly check the length to ensure tube hasn’t moved.
171
Where can a dislodged NG tube accidentally go?
Lungs
Esophagus
172
What is required before starting enteral feeding?
Patient must have a functioning gut.
173
What are common reasons for enteral feeding?
Pancreatitis / Malnutrition
Facial trauma
Esophageal trauma / Dysphagia
Patient on a ventilator
174
What is bolus feeding?
200-400 ml of feeding
Given over 15-60 minutes
Administered using a syringe
175
What is intermittent enteral feeding?
Feeding given at regular intervals
Usually with a feeding pump
176
What is continuous enteral feeding?
Feeding given over a long period (12, 14, or 24 hours)
Delivered slowly and steadily
177
What should you check for to assess patient tolerance before enteral feeding?
Check if the patient can handle feeding without nausea, vomiting, diarrhea, constipation, abdominal pain, or distention. If any of these occur, hold the feeding.
178
What is Gastric Residual Volume (GRV) and why is it important?
GRV is the amount of fluid in the stomach before or after feeding. If it’s too high, feeding should be held to prevent complications
179
What is the best way to prevent aspiration during enteral feeding?
Elevate the head of the bed 30-45° during feeding and for 1 hour after feeding or medication administration.
180
How often should you flush an NG tube during continuous enteral feeding?
Flush every 4-8 hours with 15 ml sterile water.
181
What are important nursing roles to maintain during enteral feeding?
Prevent aspiration, provide oral care, change tubing/formula regularly, and flush NG tube properly.
182
How should medications be given through an NG tube?
Give meds one at a time
Flush with 15 ml sterile water before and after each med
Flush with 30 ml if meds are crushed
Use liquid meds if available
183
How much sterile water do you flush before and after each medication with an NG tube?
15 ml sterile water before and after each medication.
184
How much sterile water do you flush if the medication is crushed?
30 ml sterile water before and after the crushed medication.
185
How should medications be given through an NG tube?
Give medications one at a time; do not mix them together.
186
When should you flush the NG tube when giving medications?
Flush the tube after each medication
187
What is an ostomy?
A permanent or temporary opening of an organ to the outside of the body.
188
What is a stoma in relation to an ostomy?
The part of the ostomy that is attached to the skin.
189
What are the two main types of ostomies based on the organ?
Ileostomy: In the ileum, produces watery stool.
Colostomy: In the colon, produces more formed stool
190
What should the appearance of a healthy stoma be?
Beefy red or pink color.
191
Where should the stoma be located?
On the abdominal surface, 1 to 3 inches above the skin.
192
What is expected drainage from a new ostomy in the first 24-48 hours?
Minimal to no drainage.
193
Should a pouch be worn on the stoma?
Yes, a pouch should be on the stoma at all times.
194
What condition should the skin around the ostomy be kept in?
Dry and clean; a skin barrier can be used to protect the skin.
195
What are characteristics of a well-cared-for ostomy?
Odorless, insicoupis (no leaking), comfortable, contains fecal content, and protects the skin.
196
When should the ostomy pouch be emptied?
When it is ⅓ full.
197
How often should the ostomy pouch be changed?
Every 3 to 7 days.
198
How large should the wafer opening be compared to the stoma?
No larger than ⅛ of an inch bigger than the stoma.
199
What dietary advice should be given to a patient with a new ostomy?
Eat a low-fiber diet for the first few weeks.
Drink 10-12 glasses of water daily.
Avoid gassy foods.
Chew food completely and slowly.
200
For which type of colostomy is irrigation done?
Distal colostomies (lower part of the colon) because they have more control over bowel movements.
201
What is the purpose of colostomy irrigation?
To stimulate the colon and promote regular evacuation of stool from the distal colon.
202
How does colostomy irrigation benefit patients?
It reduces or eliminates the need to wear a pouch.
203
Who should NOT have colostomy irrigation?
Patients with IBS, Crohn’s disease, or diverticulitis.
Patients with radiation damage or hernia.
Patients with an ileostomy (because stool is watery and uncontrollable).
204
What is the basic procedure of colostomy irrigation?
Water goes into the colostomy.
Water and stool come out the colostomy.
Use an irrigation sleeve to put waste into the toilet
205
How often is colostomy irrigation done?
Every day or every other day.
206
Which artificial airway can nurses insert for unconscious patients only?
Oralpharyngeal airway
207
How do you measure a Oralpharyngeal airway
Measure from corner of mouth to back of jaw
208
Which artificial airway can nurses insert for both conscious and unconscious patients?
Nasopharyngeal airway
209
How do you measure a
Measure from tip of nose to earlobe
210
Front: Who inserts a tracheostomy and where is it placed?
Inserted by provider
Inserted into the trachea
Can be with or without ventilation
211
What is an endotracheal tube and who inserts it?
Inserted by providerInserted
into the trachea through the mouth
Used with ventilation
212
What trach supplies should always be kept at the bedside?
Two extra trach tubes: one same size, one smaller
Obturator for possible reinsertion (recanalization)
213
How often should tracheostomy care be performed?
Every 8 hours
214
What type of suctioning is used with a tracheostomy?
Sterile suctioning,Provide oxygen if needed
215
What should be provided to a patient with a trach for communication?
Notepad
Phone
Any communication device/tool the patient can use
216
What are the steps to clean a trach
1. Change soiled soiled linens
2. Use cotton tipped applicator and facility approved cleaner
3. Clean inner cannula if the cannula is disposable replace it
4. For cannulas that are not disposable change every 6-8 weeks
5.Clean from stoma site outwards
6.Clean trach plate
7. Change the ties only if they are wet or soiled
8.Oral care every 2 hours
9. Sit patient upright and monitor for aspiration
217
When inserting a suction catheter, should you apply suction?
No. Never apply suction when inserting the catheter. Only apply suction while withdrawing it.
218
When is sterile suctioning required?
Endotracheal suctioning
Tracheal suctioning
Nasopharyngeal suctioning
219
When is aseptic (clean) suctioning used?
Oral suctioning (e.g., Yankauer)
220
What is a pneumothorax?
Air in the pleural space.
221
What is a hemothorax
Blood in the pleural space.
222
What is a pleural effusion?
Fluid in the pleural space.
223
Empyema
Pus in the pleural space
224
Where is a chest tube placed to remove air?
Higher part of the lungs
225
Where is a chest tube placed to remove fluid or blood?
Lower part of the lungs.
226
What size is a chest tube typically?
12-20 French.
227
Why is suction used with a chest tube?
Because the pleural space has more negative pressure than the atmosphere—suction helps maintain lung expansion.
228
What is done after chest tube insertion?
Secure with sutures and an occlusive dressing
Confirm placement with chest X-ray
Connect to a closed drainage system
229
What are the three chambers of a chest tube drainage system?
Suction control
Drainage collection
Water seal
230
What is normal to see in the suction section of a chest tube system?
Bubbling
231
What is normal in the water seal chamber?
Mild fluctuation (tidaling) with the patient’s breathing.
232
What does continuous bubbling in the water seal chamber mean?
There is an active air leak.
233
What are key nursing interventions for chest tube management?
Keep tubing looped at patient level
Water seal chamber must be upright and below chest level
Document I&Os of drainage every shift
233
What should you do if there is continuous bubbling in the water seal chamber?
Notify the provider
With order: May apply extra suction to increase negative pressure and help re-expand the lung.
234
What should you do if the chest tube dislodges?
Cover site immediately with occlusive dressing (keep at bedside)
Assess HR, RR, and pulse
Notify the provider
235
What does an Electrocardiogram (ECG) measure?
The electrical activity of the heart at a given moment (usually over 6 seconds).
236
How many electrodes are used during a standard ECG?
10 electrodes.
237
What do ECG electrodes detect?
Voltage changes in the heart’s cells between electrode positions
238
What skin prep should be done before applying Tele electrodes?
Do not shave the patient—instead, clip the hair to prevent skin irritation and improve electrode contact.
239
Why are Vtach, Vfib, 3rd degree block, and asystole considered emergencies?
Because they are not life-sustaining rhythms and require immediate intervention.
240
What are the “BIG UGLY” cardiac rhythms that are NOT life-sustaining?
Ventricular Tachycardia (Vtach)
Ventricular Fibrillation (Vfib)
3rd Degree Heart Block
Asystole
241
What is a Tele-box used for in cardiac monitoring?
It’s a device worn around the neck that receives signals from electrodes placed on the chest to monitor heart rhythms continuously.
