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Flashcards in Procedure (IV/med surge stuff) Deck (9):
1

The respiratory technician arrives to draw blood for arterial blood gas (ABG) analysis. What should the nurse understand about the procedure?

A: Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn

B: The femoral artery is the preferred sample site

C: The blood sample must be kept at room temperature and delivered to the lab as soon as possible

D: Supplemental oxygen should be turned off 30 minutes prior to collecting the sample

A: Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn

The radial artery is preferred; the second choice is the brachial artery and then the femoral artery. If a client is receiving oxygen, it should not be turned off unless ordered. After drawing the sample, it's very important to press a gauze pad firmly over the puncture site until bleeding stops or at least five minutes. Do not ask the client to hold the pad because if insufficient pressure is used, a large painful hematoma may form. The sample of arterial blood must be kept cold, preferably on ice to minimize chemical reactions in the blood.

2

The nurse is preparing to administer a routine feeding through a gastrostomy tube (G-tube). Before administering the feeding, the nurse should conduct which priority nursing assessment?

A: Verify G-tube patency

B: assess the breath sounds

C: Palpate the abd

D: Check temp

A: Verify G-tube patency

G-tube patency should be checked prior to all feedings. If more than 125 mL of aspirate or residual is obtained, the feeding should be held. The residual should be returned into the stomach. The feeding should not be attempted if the tube is not patent or aspirate cannot be obtained.

3

A group of nurses on a unit are discussing stoma care for clients who have had a stoma made for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown?

A: Sigmoid colostomy

B: Transverse colostomy

C: Ileal conduit

D: Ileostomy

D: Ileostomy

Ileostomy output, which is from the small intestine, is of continuous, liquid nature. This high pH, alkaline output contains gastric and enzymatic agents that when present on skin can denude skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy the output is formed with an intermittent output. An ileal conduit is a urinary diversion with the ureters being brought out to the abdominal wall.

4

The clients listed below are all using patient-controlled analgesic (PCA) pump for pain control. Which of these clients is least appropriate to use a PCA pump?

A: A preschooler w/intermittent episodes of alertness

B: An older adult pt w/numerous arthritic nodules on the hands

C: A teenager who reads at a 4th-grade level

D: A young adult w/a HO Down syndrome

A: A preschooler w/intermittent episodes of alertness

A preschooler is the one client most likely to have difficulty with the use or understanding of a PCA pump. The preschooler also has a decreased level of consciousness and would not be able to fully benefit from the use of a PCA pump. School-age children, ages 6 and up, are better candidates for PCA electronic pumps.

5

The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.)

A: move bed into flat position

B: Pull the client up from the head of the bed

C: Use a friction-reducing device

D: Adjust the height of the bed for caregivers

E. Coordinate lifting the pt by counting to 3

A, C, D, E

The algorithm for safe client handling and repositioning a client from side-to-side or up in bed states: use 2 to 3 caregivers for a client who can partially assist and who weighs less than 200 pounds, use a friction-reducing device, move the bed so that it’s flat and at a comfortable height for the caregivers. The client should not be pulled from the head of the bed. There really is no safe method to manually lift another adult.

6

A nurse is caring for a postoperative client who develops evisceration of the abdominal incision. Which intervention should the nurse implement first to prevent additional complications?

A: Cover the wound w/a sterile saline-soaked dressing

B: Medicate the pt for pain w/a PRN order

C: Call the MD w/in the hour

D: PLace the pt in dorsal recumbent position

A: Cover the wound...

When evisceration occurs, the wound should first be quickly covered by sterile saline soaked dressings. This prevents tissue damage and drying of the area until a surgical repair can be done. The other interventions are also appropriate, though the call to the provider should occur immediately, as this is a medical emergency.

7

Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.)

A: Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device

B: Confirm pressure setting of 45 mm Hg

C: Check for appropriate fit

D: Explain that the health care provider ordered the device and it cannot be removed

E: Inform the client that removing the device will likely result in the formation of deep vein thrombosis

A, B, C

In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35 to 55 mm Hg. Explanations to the clients should support their informed decision-making capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching.

8

A nurse is observing a client during an excretory urogram. Which of these observations indicate there is a complication?

Within two minutes of the dye injection the client states, “I have a feeling of getting warm.”

Within one minute after the dye is injected the client’s entire body turns a bright red color

Five minutes into the procedure the client gags and states, “I am getting sick.”

A client complains of a salty taste in the mouth when the dye is injected

Within one minute after the dye is injected the client’s entire body turns a bright red color

This observation suggests anaphylaxis from the dye injection, which can cause massive vasodilation and shock. Other findings of anaphylaxis are immediate wheezing and/or respiratory arrest. The salty taste in the mouth, the feeling of warmth and the complaint of nausea are expected side effects of the injection of the dye.

9

A respiratory therapist (RT) is collecting an arterial blood gas (ABG) sample. The RT must respond to an emergency and asks the nurse to manage the puncture site. Which actions should be completed? (Select all that apply.)

A: Apply pressure for 5 to 10 minutes
B: Apply snug gauze and secure with tape
C: Thoroughly wash the site with saline, then apply an antibacterial solution
D: Remove dressing in one hour
E: Check for distal capillary refill

A, B, E

Five to 10 minutes of pressure ensures adequate coagulation at the site. Checking capillary refill indicates if there are any changes to blood flow to the hand. The dressing can be removed prior to the next stick or within 24 hours.