Final NS Random Flashcards
(121 cards)
1
Q
- What are the differences between and nursing and medical assessment?
A
Nursing:how is the person living, coping, and or functioning with this disease or illness.
Medical: for treatment of the disease
2
Q
Described what is assessed during the Physical Survey (General Status).
A
Overall impression of clients general health status; looks at dress, hygiene, build, apparent age, LOC, behaviors, body movement, affect, facial expressions, speech patterns & clarity plus more (Weber Ch. 6)
Vital Signs are also measured (+ Hgt and Wgt)
3
Q
- Describe the assessment procedure for the Temporomandibular joint (TMJ).
A
a. Place 2-3 fingers over front of each ear and palpate as the client opens and closes their mouth.
b. Also, move jaw from side to side, protrude, & retract their jaw.
c. Check for crepitation, decreased ROM, tenderness, & swelling.
4
Q
- Describe the trachea assessment procedure and what the results indicate.
A
a. Palpate the trachea for landmarks (tracheal rings, cricoid, and thyroid cartilage), alignment and position.
· Normally, the trachea is midline at the suprasternal notch.
· An unequal space between the trachea and the sternocleidomastoid muscle on each side is an abnormal finding indicating tracheal displacement.
5
Q
- What does the nurse inspect for during an eye assessment?
A
a. Any external and/or internal eye structure abnormalities in position, alignment, symmetry, color, edema, or pain
• Asymmetry of position and alignment of the eyes may be caused by muscle weakness or a congenital abnormality.
b. Visual acuity
c. Extraocular movements
d. Peripheral vision.
6
Q
- Describe the eye assessment findings for Ptosis
A
- Drooping of the upper lids (ptosis).
* May be attributable to damage to the oculomotor nerve, myasthenia gravis, or a congenital disorder.
7
Q
Describe the eye assessment findings for Entropion I Inward or inverted turning of the lower lid and lashes.
A
• May be abnormal finding or a possible change with aging.
8
Q
Describe the eye assessment findings for Ectroprion
A
- Outward or everted turning of the lower lid and lashes.
* May be abnormal finding or a possible change with aging.
9
Q
Describe the eye assessment findings for Presbyopia
A
- Impaired near vision
* More common in elderly
10
Q
Describe the eye assessment findings for Pinguecula
A
• Yellowish nodules on bulbar conjunctiva (benign finding).
11
Q
Describe the eye assessment findings for Arcus senilis
A
• White ring around the cornea
12
Q
Describe the eye assessment findings for Mydriasis (dilated pupils)
A
• May be caused by injury to the eye, glaucoma, and certain medications
13
Q
- Describe how to assess for accommodation (part of external eye assessment) and what the results indicate.
A
a. Hold the forefinger, a pencil, or other straight object about 10 to 15cm (4” to 6”) from the bridge of the patient’s nose).
b. Ask the patient to first look at the object, then at a distant object, then back to the object being held.
c. The pupils normally constrict when looking at a near object and dilate when looking at a distant object.
d. PERRLA = pupils equal, round, and reactive to light & accommodation.
14
Q
- Describe how to assess for convergence (part of external eye assessment and what the results indicate.
A
a. Hold your finger about 6” to 8” from the bridge of the patient’s nose.
b. Move your finger toward the patient’s nose to assess convergence.
c. The patient’s eyes should normally converge (assume a cross-eyed appearance).
d. Inability of the eyes to accommodate or converge is abnormal.
15
Q
- What are some abnormal internal eye assessment findings?
A
a. Blood vessels size & shape changes
b. Color & surface characteristics changes
16
Q
- Describe how near visual acuity is assessed.
A
a. With a newspaper approximately 14 inches from client’s head.
17
Q
- Describe when and how an Amsler chart is used to assess visual acuity.
A
a. Performed if over 45 years of age or family history of retinal problems such as macular degeneration.
b. Check vision with Amsler chart posted at eye level 12-14 inches away from where client is standing.
c. The client is asked to wear his or her glasses, cover one eye, and look at the center dot.
18
Q
- Describe the purpose of the 6 Cardinal Fields (Positions Test).
A
a. Tests extraocular muscles and cranial nerve (III,IV,andVI) movements by assessing the 6 cardinal fields of vision for eye muscle coordination and eye alignment.
19
Q
How is a 6 Cardinal Fields (Positions Test) done?
A
a. sit or stand about 2 feet away from pt at eye level
c. Ask the patient to hold the head still and follow the movement of your forefinger or a penlight with the eyes.
d. Keeping your finger or light about 1 foot from the patient’s face, move it slowly through the cardinal positions: up and down, left and right, diagonally up and down to the left, diagonally up and down to the right.
20
Q
What are normal results and abnormal results of a 6 Cardinal Fields test?
A
e. Normally both eyes move together, are coordinated, and are parallel without ptosis. If not, tremors or jerkiness can occur with MS, cranial lesions, inner ear problems, or narcotic use.
21
Q
- Describe the purpose for assessing peripheral vision (or visual fields) and what is normal
A
a. Tests for peripheral vision are used to assess retinal function and optic nerve function.
Full peripheral vision is normal.
22
Q
- Describe how to assess a person’s corneal reflex and what the normal assessment finding would be.
A
a. Lightly touch the cornea with cotton to elicit a blink response
23
Q
- Describe how to assess a person’s corneal light reflex and what the results indicate.
A
a. Hold penlight 12” from eye (face) shining toward bridge of nose and note location light is reflected on corneas.
b. The light reflection should be the same spot bilaterally indicating the eyes are in parallel alignment with good eye muscle strength.
c. An abnormal test would indicate eye muscle strength weakness and/or deviation in eye alignment.
24
Q
- List screening tests done to indicate possible hearing loss.
A
a. Whisper test
b. Weber test
c. Rinne test
25
What are the two pathways of hearing? a.
Air conduction (AC)
· Normal pathway of hearing, the most efficient
b. Bone conduction (BC)
· Bones of the skull vibrate and transmit vibrations to the inner ear and acoustic nerve
26
1. Describe Conductive hearing loss. a.
Conductive
· Mechanical dysfunction of the external or middle ear resulting in partial hearing loss.
· If increased amplitude to reach nerve elements in inner ear, person can hear.
· Causes of this type of hearing loss include: impacted cerumen, foreign body (FB), perforated eardrum, pus/blood in the middle ear, and otosclerosis.
27
Describe Sensorineural hearing loss. b.
Sensorineural (perceptive)
· Pathology of the inner ear, acoustic nerve (VIII) or auditory areas of the cerebral cortex.
· Increased amplitude may not help.
· Causes of this type of hearing loss include presbycusis, a nerve degeneration due to aging (50yrs), or ototoxic drugs.
28
Describe what normal results of an internal eye assessment indicate.
Normal findings are a uniform red reflex; a clear, yellow optic nerve disc; a reddish retina; and light-red arteries and dark-red veins, the veins being about 1.5 times as large as the arteries.
29
Describe what abnormal results of an internal eye assessment indicate.
. Abnormal findings include cloudiness of the lens (from cataracts), changes in the size and shape of blood vessels (from hypertension or arteriosclerosis), and changes in color and surface characteristics (from such health problems as diabetes mellitus, hypertension, trauma, inflammation, or a detached retina).
30
1. Describe how to perform the Whisper Test
Whisper Test is used to detect high-tone loss.
b. Place a finger on the tragus of one ear.
c. Place your head 1-2 feet from your client’s other ear, shield your lips to prevent lip reading & whisper a 2 syllable word such as apple.
d. Repeat on the opposite ear using another word such as baseball.
e. Have the client identify the words.
31
Describe what the Whisper Test is used for and what the results indicate. a.
Whisper Test is used to detect high-tone loss.
| f. Normal finding is correct identification of words.
32
1. Describe how to perform the Weber Test and what the results indicate.
b.
To activate the tuning fork, hold it by the stem & strike the tines softly on the back of the hand
c. Place the base of the vibrating tuning fork on forehead or the center of the top of the client’s head.
d. Ask the client where the sound is heard best.
33
Describe what the Weber Test is used for and what the results indicate. a.
Is used to assess for bone conduction of sound.
Normally, heard in both ears equally or is localized at the center of the head.
f. With conductive hearing loss, the sound is heard better in the affected ear.
g. If the sound is heard better in the ear without a problem, it indicates damage to the inner ear or a nerve disorder.
34
1. Describe how to perform the Rinne Test
| c.
Hold base of vibrating tuning fork against the mastoid process & ask the client to tell you when the sound can no longer be heard.
d. Immediately place the still-vibrating tuning fork close to the external ear canal in the air & ask whether can hear the sound.
e. If able to hear the sound, ask the client to tell you when they can no longer hear the sound.
f. Repeat the test with the other ear.
35
What does the Rinne Test look for? a.
Is used to compare bone and air conduction of sound.
b. Does not determine the degree of hearing loss.
g. Normally, air conduction (AC) is two times greater than bone-conducted (BC) sound (documented as AC > BC).
* Determines if hearing loss is conductive or sensory/neuro
36
What do results from a Rinne Test indicate? g.
Normally, air conduction (AC) is two times greater than bone-conducted (BC) sound (documented as AC > BC).
h. If the hearing loss is conductive, sound of bone conduction will be the same or greater than air conduction. Sound is lateralized to the poor ear.
i. If sensory/neuro hearing loss, sound is lateralized to the good ear.
37
1. Describe how to perform the cover-uncover test and what the results indicate.
a.
Ask patient to focus on distant object straight ahead. Then cover one eye and keep the other eye uncovered. The uncovered eye should not move to refocus on the object when the opposite eye is covered. In addition, the covered eye should not move as the cover is taken away. The covered eye should not have strayed and remained fixed.
b. Repeat for other eye.
38
. What does the cover-uncover test check for and what do the results indicate? c.
Checks for deviation in alignment of eyes and eye muscle strength or weakness as well as ocular movement.
d. There should be no movement
39
give the purpose (definition) of Nutritional-Metabolic- in the Weber Functional framework
Nutritional-Metabolic-determine dietary habits and metabolic needs. The condition of the hair, skin, nails, teeth
40
give the purpose (definition) of Elimination-in the Weber Functional framework
Elimination-determine adequacy of function of bowel and bladder, routines, habits. Problems associated with these and devices used.
41
give the purpose (definition) of Activity-Exercise in the Weber Functional framework
Activity-Exercise-determine ADL’s, including exercise, personal hygiene, cooking, cleaning, shopping, eating, maintaining a home and working. Any factors that affect or interfere with these. Significance of these activities.
42
give the purpose (definition) of Sleep-Rest- in the Weber Functional framework
Sleep-Rest-perception of quality of sleep, relaxation, energy levels. Methods used to promote sleep.
43
give the purpose (definition) of Sensory-Perceptual- in the Weber Functional framework
Sensory-Perceptual-functioning of the 5 senses; devices used to assist with these.
44
give the purpose (definition) of Cognitive in the Weber Functional framework
Cognitive-clients ability to understand, communicate, remember and make decisions.
45
give the purpose (definition) of Role-Relationship in the Weber Functional framework
Role-Relationship-perceptions of roles and responsibilities in family, work, social life and level of satisfaction with these.
46
give the purpose (definition) of Self-perception-Self-concept in the Weber Functional framework
Self-perception-Self-concept-clients perception of his or her identity, body image, abilities, self-worth. Behavior, attitude and emotional pattern are also assessed.
47
give the purpose (definition) of Value-Belief- in the Weber Functional framework
Value-Belief-determine life values, goals, philosophical beliefs, religious and spiritual beliefs and how these affect decisions and choices. Any conflicts in this area. Expectations related to health.
48
1. Describe how to assess for pupillary light reflex (part of external eye assessment) and what the results indicate.
a. Ask the patient to look straight ahead.
b. Bring the penlight from the side of the patient’s face and briefly shine the light on the left pupil.
c. Observe the left pupil’s reaction.
d. The left pupil normally rapidly constricts (direct response).
e. The right pupil normally also constricts (indirect or consensual response) when a light is shined into the left pupil.
f. Repeat the procedure for the right eye.
g. Also, assess each pupil’s size in millimeters for symmetry.
h. Decreased or absent pupillary response indicates blindness or serious brain damage.
49
Describe what results from a thyroid gland indicate. f.
Palpate for size, shape, symmetry, tenderness, and presence of any nodules.
g . If palpable, the thyroid gland should feel soft, but elastic.
h. It should be non-tender and have no enlargement, masses, or nodules.
i. These findings could indicate thyroid gland disease, infection, or cancer.
j. If you find an enlarged thyroid, auscultate the thyroid while having the client hold his or her breath to check for a possible bruit indicating hyperthyroidism.
k. Thyroid may be more nodular or irregular with aging.
50
• In what functional category will the cardiac and vascular assessment data be placed
Gordon’s Activity & Exercise Functional Framework Category
51
What are the 6 P’s of limb ischemia (arterial occlusion)?
--Pallor (unusually pale skin color)
--Pain
--Paresthesia (burning, prickling, tingling, numbness, skin crawling, or itching sensation in toes, legs, fingers, or arms)
--Paralysis
--Pulselessness
Poikilothermia (inability to regulate own body temperature)
52
Describe what pitting edema is, how to assess for it, and how to document edema.
•
Pitting edema can be demonstrated by depressing the skin with a finger. If the pressing causes an indentation that persists
• Assess for Edema by pushing against a bony prominence if possible.
• 0 = absent
• 1+ pitting edema = 2mm indentation
• 2+ pitting edema = 4mm indentation
• 3+ pitting edema = 6mm indentation
• 4+ pitting edema = 8mm indentation
53
Describe how to document pulse amplitudes according to your Weber textbook.
* +1 = thready, weak
* +2 = normal
* +3 = increased
* +4 = bounding
54
Describe how to perform the Allen’s test.
* used to detect arterial insufficiency of the hand.
* Ask the patient to rest his or her hand on the examining table with the palm up and to make a fist.
* occlude the radial and ulnar arteries and ask the patient to open his or her hand (the palm will be pale).
* Release your thumb pressure and observe the return of color to the palm (this should normally take 3 to 5 seconds.
55
What are symptoms of arterial insufficiency? --
Decreased or absent pulses
- -Decreased or absent extremity hair growth
- -Skin color pale when elevated or dusky, rubor when dependent
- -Skin cool to cold temperature
- -No edema
- -Shiny skin, nails thick and rigid, ulcers on toes
- -Pain increases with activity, decreases with rest, parathesias
- -(Pale extremity that is cool to touch with minimal to no pulse is a critical sign needing immediate follow up)
56
What are symptoms of venous Insuficiency? o
Pulses present
o Color pink to cyanotic, brown pigments at ankles
o Warm temperature
o Edema present
o Skin discolored, scaly, flaky, ulcers on ankles
o Leg pain with standing or sitting too long, decreases with leg elevation
57
1. List the various regulatory mechanisms that control blood pressure in the body.
Peripheral resistance, compliance (elasticity) of the vessels, neural (ANS), Hormones
(regulate body fluids), Extracellular( or intravascular) fluid volumes.
58
Identify what causes the S1 (lub) sound and what this sound signifies.
Describe where would you expect to hear the sound the loudest.
What position should the patient be in for maximum auscultation?
First sound (S1 or “lub”) correlates with the closing of the mitral and tricuspid valves. Best heard in mitral area (5thICS at left mid-clavicular line) and especially at the apex
(Apical) of the heart. It signifies the onset of ventricular contraction or systole.
sitting or supine with the head of the bed at least at 30 degrees
59
Identify what causes the S2 (dub) sound and what this sound signifies.
Describe where would you expect to hear the sound the loudest.
What position should the patient be in for maximum auscultation?
Second sound (S2 or “dub”) correlates with the closing of the aortic and pulmonic semilunar valves.
Best heard in 2ndintercostal spaces (aortic) at the base of the heart. Termination of ventricular systole and start of ventricular diastole (filling).
sitting or supine with the head of the bed at least at 30 degrees
60
When and how is a S3 sounds heard?
A S3 sound is best heard with bell of stethoscope at the mitral area (apex of the heart), with the patient lying on the left side.
• A S3 sound is accentuated during inspiration.
• A S3 sound is the result of vibrations caused by the blood hitting the ventricular wall during rapid ventricular filling.
61
What is an extra heart sound that sounds like “Tennessee”?
Where would this extra heart sound be best auscultated?
* The sound is a S4 Extra Heart Sound.
* A S4 sound is an atrial gallop.
* A S4 sounds like “dee-lub-dub” or “Tennessee”.
* A S4 sound is best heard in left lateral position while listening at the tricuspid valve.
* A S4 sound is heard at the end of diastole when atria contract just before S1.
* A S4 sound is caused by blood flowing rapidly into ventricles after atrial contractions.
62
List Adventitious breath sounds and what might cause each to occur.
Sibilant
Sibilant: high pitched musical sounds during mostly expiration (can also be on inspiration) caused by constricted passages
*Cause: caused by constricted passages
63
List Adventitious breath sounds and what might cause each to occur.
Strider
Strider: Harsh, honking wheeze with severe Broncho laryngospasm
64
List Adventitious breath sounds and what might cause each to occur.
Sonorous
Sonorous: low pitched snoring or moaning sound primarily on expiration. May clear with coughing; often heard in cases of bronchitis.
Cause: often heard in cases of bronchitis.
65
List Adventitious breath sounds and what might cause each to occur:
Rubs:
Rubs: caused by inflamed pleural surfaces rubbing together
Cause: inflammation or infection
66
What is Hemoptysis?
blood in the sputum
67
What is Active (AROM)?
Active (AROM) - patient m9ves all extremities on own
68
What is Passive-
(PROM)? Passive- (PROM) Care giver must completely move all extremities
69
What is Active assistive (AAROM)?
Active assistive (AAROM) - patient can move joint a small amount but nurse must assist the extremity in moving through full range.
70
Identify pediatric variations of the musculoskeletal system.
Lower extremities – bow legged growth pattern persists and begins to disappear at 18 months; at 2 years a knock-kneed pattern is common persisting until ages 6-10
71
Describe normal or abnormal palpation of integument assessment findings and how to assess for them.
• Brawny edema
* Brawny edema
* No pitting. The tissue palpates as firm or hard. The skin surface is shiny, warm, & moist.
* Brawny edema is due to fluid no longer being able to be displaced secondary to excessive interstitial fluid accumulation.
72
• describe the following primary skin lesions that are a Non-palpable color change:
o Macule
o Macule
| Flat skin lesion that is less than (
73
• describe the following primary skin lesions that are a Non-palpable color change:
o Patch •
o Patch
| Flat skin lesion that is greater than (>) 1 cm
74
• describe the following primary skin lesions that are Palpable, Elevated Solid (without fluid) lesions:
o Papule
o Papule
| < or equal to 0.5 cm and superficial
75
• describe the following primary skin lesions that are Palpable, Elevated Solid (without fluid) lesions:
o Nodule
o Nodule
0.5 cm-2 cm and deeper
Tends to be firmer than a papule
76
o describe the following primary skin lesions that are Palpable lesions with fluid
o Vesicle
o Vesicle
< or equal to 0.5cm
Filled with serous fluid
77
o describe the following primary skin lesions that are Palpable lesions with fluid
o Bulla
o Bulla
| >0.5cm
78
o describe the following primary skin lesions that are Palpable lesions with fluid
o Pustule
o Pustule
| Filled with pus, not serous fluid
79
Describe the lesions listed that are associated with aging.
| • Senile keratosis (i.e. seborrheic keratosis)
* Senile keratosis (i.e. seborrheic keratosis)
* Warty, crusty brown lesion
* Tan to black macular-papular lesions on neck, chest, or back
80
Describe the lesions listed that are associated with aging.
• Senile lentigines (len-tig-ines)
•
Flat, brown macule on hands, arms, neck, or face
| • Also known as liver spots or age spots.
81
Describe the lesions listed that are associated with aging.
Acrochordons • Acrochordons (ak-ro-kor-don)
•
Soft, light-pink to brown skin tags
82
The functional reflex that allows the eyes to focus on near objects is referred to as what?
Accommodation
83
What are soft breezy sounds normally heard over the lung periphery are what?
Vesicular sounds
84
When is hearing S3 normal?
When is it abnormal? •
A S3 sound is normal in children (disappears upon standing or sitting up), people with high CO, and third trimester pregnancy rarely normal over age 40.
• A S3 sound is associated with ventricular dysfunction, decreased ISCD, myocardial contractility myocardial failure, CHF, volume overload from valvular disease.
85
When is the S4 normal?
When is it abnormal? • A S4 sound is normal in trained athletes and some older patients especially after exercise.
•
A S4 sound is associated with CAD, HTN aortic and pulmonic stenosis and acute MI.
• A S4 sound will not be heard in the absence of atrial contraction.
• A S4 sound indicates increased resistance to ventricular filling.
• A S4 sound results from vibrations caused by forceful atrial ejection into enlarge or hypertrophied ventricles that do not move or expand as they should.
86
Techniques of surgical asepsis must be followed strictly for giving injections. Which of the following does not need to remain sterile?
A)the inside of the barrel of the syringe.
b) the needle.
c) the plunger that enters the barrel.
d) the needle hub.
the needle hub.
87
Which of the following needles is the best needle to be used to administer an IM injection?
1 1/2 inch, 22 gauge
88
When giving an IM injection, the needle is inserted into the muscle and the very next step is:
stabilizing the syringe.
89
A patient with a gastric feeding tube is at higher risk for which of the following complications as compared to a patient with an intestinal feeding tube?
aspiration
90
Before administering any fluid, medication, or feeding by the enteral route, it is necessary to check tube placement. Which method is the most accurate in verifying correct tube placement?
measurement of gastric aspirate PH
91
The patient has a NG tube attached to suction. The nurse has just administered Maalox (an antacid) 30mL into the patient's NG tube. The nurse must:
clamp the NG tube for 20-30 minutes then reconnect the tube to suction
92
To prevent damage to the stomach mucosa during suctioning, a Levin tube ( a single-lumen tube) is usually attached to which type of suction?
intermittent
93
Enteral nutrition that is delivered at regular intervals introducing the nutrition gradually over a set period of time is considered :
intermittent
94
How can the Chain of infection Be Broken at the Reservoir
Breaking the Chain Interventions: Hand hygiene, no standing water, cleaning surfaces, cleaning of linens, proper food prep
95
For the purpose of transmission-based precautions (tier 2): what 3 modes of transmission are there?c
contact, airborne, or droplet.
96
Describe the principles or rules Hampers (linen and trash)
All linens are treated as contaminated.
| Must be able to close bags to transport!
97
What is MATC policy on nail care?
clear and not chipped nails.
| Nail length 0.5cm (< ¼ inch) per CDC
98
List the 7 components of a medication order and why these are so important.
Patient, drug, dose, time, route, frequency, date/time of order and signature of physician
99
Discuss the steps involved in a nurse transcribing the medication order from the order sheet onto the MAR.
“Taking off” a Medication Order- Complete, Legible and Accurate orders are transcribed from the actual order sheet to the Patients Medication Administration Record (MAR).
Once transcribed, the MAR is initialed by a nurse so medications can be given.
This can be done in written form or electronically (usually an icon indicates if the order needs to be checked).
100
How does a nurse know if the medications on the MAR have been “checked off” or “taken off” by a nurse?
A nurses initials should be displayed on a paper MAR or flagged with an icon or symbol on the computer, that it has been reviewed by a nurse.
101
When should a nurse question a medication order (not giving it but calling the prescriber)?
Anytime a patient questions an order; “I’ve never taken this before”
Illegible (written poorly)
Patient allergic to med
The drug doesn’t make sense for this patient
Missing any of the 7 components
Nurses have the right to refuse to give, rarely happens, patient safety primary goal of all.
102
Describe proper documentation of a medication administration.
Full signature and title should be either on file or on the MAR; exact time of administration and initials. Do not document until after the patient has taken the meds.; ASAP after taken the medication;
Most facilities using paper MARs do not allow them to go in patient’s rooms. CPOE’s usually go in the room to the bedside.
103
Elixir and syrups compared to suspension
Elixirs & Syrups-no need to shake
Emulsions and Suspensions- must shake for accurate administration
No lipping with liquid meds
Palm the label (cover most important label if labeled all around)
Wipe outside rim of bottle after pouring. (Cap sitting with inside up to maintain sterility of inside of bottle)
104
Lozenge or Troche
Sublingual- under the tongue; very vascular, dissolves quickly Ex: Nitroglycerine, Morphine
Buccal-between cheek and gum, quick systemic effects as it dissolves into the blood stream; local effect (fungal infection in mouth)
Do not chew or swallow.
105
During the 3 Safety checks of the medication what 2 items are being compared?
The MAR and the drug packaging label
106
When are the 5 Rights checked?
3 times when taking from drawer, when comparing right next to the MAR and a third time before opening into the cup
107
In addition to the 5 R’s ad 3 safety checks, a nurse looks for other safety features on the MAR and medication packages prior to administering the medications. List 4 other things nurses are checking for.
Expiration date, 2. Allergies, 3. if the med has been given yet, 4. if the order has been signed off by a nurse ( all 7 components are present)
108
List 4 ways to minimize errors during the medication administration procedure.
Avoid Distraction; Never leave open drugs unattended; The nurse who prepares, gives and documents; Scan the MAR
Allergies
Sign, full name and title (SN)
ALWAYS read MAR’s Top to Bottom and Left to Right
109
How does a nurse know if a medication has been discontinued from the patient’s orders?
(what happens on the MAR) It is usually shaded out or removed from the HER or moved to the bottom of the page , if on a paper MAR, usually yellowed out and discontinued written in space with date.
110
What is the process if a nurse needs to hold a medication? (Consider teaching, documenting and notifying)
Assessment shows (ex. pulse too low, stools loose)
Patient nauseated
Too sedated to take
Condition changed
Needs to be documented in Medication Narrative with assessment data and reason (policies differ)
111
```
Explain why the follow abbreviations were changed and list the new approved abbreviations.
CC’s-
OU-
U –
SQ-
```
CC’s- mistaken for 0’s, mL
OU- mistaken for 0 also given in wrong eye
U –mistaken for 0- units
SQ- mistaken for 50
112
What is the initial first response initiated by the CDC making it healthcare provider’s responsibility when coming into contact with a patient, family member, or visitor coughing, sneezing?
provide tissues or a mask & instruct the person to use them. -No-touch receptacles; Posting signage in different languages at entrances and strategic places for persons with symptoms to cover mouth and noses when sneezing and coughing; Providing resources and instructions for hand hygiene at convenient locations
Providing 3 feet spatial separation in clinic waiting areas
113
How do you perform an Abdominal Assessment?
```
Have pt empty bladder
Knees slightly bent
Instruct to take slow deep breaths
Inform pt at each step of assessment
ORDER- Inspection, Auscultation, Indirect Percussion; Light Palpation; Assess for symmetry during all four steps of assessment
```
114
What should a nurse do if a medication and an enteral feeding are scheduled to be administered during the same time frame If the medication is not compatible with the feeding?
,the feeding would need to be stopped (not given) 1-2 hours prior to the medication administration.
115
What should a nurse do if a medication and an enteral feeding are scheduled to be administered during the same time frame If the medication should be given on an empty stomach,?
you would also not give it in the same time frame. Feedings would not be given for at least 30 minutes prior to administering the medication in this situation.
116
What should a nurse do if a medication and an enteral feeding are scheduled to be administered during the same time frame.
If you need to give the medication with food and the medication is compatible with the formula? being used, you would administer the first flush, the formula, a small flush, the medication and then the final flush in the same time fram
117
Why is The enteral tube flushed before the first medication, between each medication, and after the last medication administered?
to maintain tube patency and decrease drug-to-drug interactions.
118
How much is too much residual for enteral feedings For continuous enteral feedings:?
residual > 10-20% above previous hour or above hourly rate
| In addition, increasing residuals pattern requires further intervention.
119
How much is too much residual for enteral feedings For intermittent enteral feedings:?
residual > 400mL or > 50% of previous feeding in some facilities
In addition, increasing residuals pattern requires further intervention.
120
Describe what should be included in gastrointestinal decompression documentation.
Type and size of tube inserted and pt’s response; Technique to assess placement;Character & amount of drainage; Type of suction and pressure setting; GI assessment findings; Nasal and oral hygiene measures; Pt’s tolerance of decompression
121
What are Cyclic enteral feedings
are administered over a 12-16 hour period each day, usually overnight so it does not interfere with the client’s daily routine.
