Reduction of Risk Potential Flashcards

Question

jackson pratt drainage and ahemovac

Answer 1

attached to a bulb-like (JP) or spring like (hemovac) container that applies suction when it is compressed

Answer 2

placed in the comon bile duct of the gallbladder to allow for the passage of bile

Answer 3

regular assessment/data collection document color, consistency, and odor of the drainage - with changes noted and reported to surgeon monitoring the skin around the drain for damage and signs of infecting

Answer 4

oil retention soapsuds tap water used to administer Kayexalate for treatment of hyperkalmiea

Answer 5

should not administer if client had recent colon or rectal surgery, acute myocardial infarction or appendicitisw should be used with caution for elderly clients because they are more at risk for hyperphosphatemia, perforation and sepsis

Answer 6

also known as moderate or conscious sedation ``` common drugs for procedural sedation: - benzodiazepines (midazolam, diazepam) - fentanyl - propofol these are administered IV push ``` an RN may administer procedural sedation under a physicians supervision

Answer 7

airway management able to see life threatening dysrhythmias ensure emergency resuscitation equipment continuous ECg, capnography and pulse oximetry drug reversal agents -naloxone, fulmazenil

Answer 8

``` advantages: wicks away wound exudate does not interact with wounds comes in mayn sizes and lengths supplied as a roll ``` ``` disadvantages: non adhesive non-occlusive fibers may shed or adhere to the wound absorbs topically applied medications like ointment or cream ```

Answer 9

premedicate the client with ana analgesic before a complex dressing change if a drain is present, carefully remove wound dressing one layer at a time to avoid disloding the drain FIRST post-operative dressing change is usually performed by the surgeon, not the nurse

Answer 10

monitor neuro status elevate affected extremity on several pillows apply ice for 24 hours ``` never relieve itching by inserting something into the cast immediately notify HCP if experiencing: - foul odor - drainage from a cast - changes in integrtiy of the cast ``` reassess for numbness, pain, impaired circulation a cast may smell "sour" but not "foul"

Answer 11

bucks tractions, skeletal traction, cervical skeletal traction like a halo brace - screws are surgically inserted directly into the bone - allows for longer traction time and heavier weights inspect traction equipment at least every 8-12 hours weights should NOT be allowed to rest on the floor implement pressure reduing measures perform pin site care notify HCP if severe pain from muscle spams diligently monitor and treat clients pain

Answer 12

monitor amount and character drainage | monitor signs of hypovolemia and hypovolemic shock

Answer 13

``` monitor signs of: low O2 dyspnea adventitious breath sounds productive cough fever leukocytosis, tachyardia ```

Answer 14

monitor signs of: calf pain swelling suddent onset of shortness of breath as indicative of pulmonary embolism

Answer 15

monitor for bowel sounds, abdominal distention and the passage of flatus or stool

Answer 16

``` CK-MB Troponin C-reactive protein Liquid Profile.Panel BNP ```

Answer 17

detected in the blood within 3-5 hours post MI

Answer 18

elevated 4-8 hours after heart attack used to diagnose a heart attack and to assess the damage to the heart

Answer 19

protein produced by the liver levels rise with inflammaiton throughout the body may help determine the risk of future cardiac events who had a heart attack can get with simple blood draw

Answer 20

should taking nothing but water by mouth 8-12 hours prior to blood draw

Answer 21

helps diagnose and evaluate clients for heart failure use for prognosis and to monitor therapy of clients with HF normal range: <100

Answer 22

use to evaluate specific areas of the arterial system by injecting a dye through a catheter at the femoral or radial artery dye makes coronary arteries visible on fluoroscopy preoperatively: evaluate history of allergy to iodine or radiopague dye - if allergic, then premedicate for antihistamine clients with impared renal functions are at an increased risk for futher renal damaged - will receive large amounts of IV fluids to flush out the contast dye during procedure acetylcysteine may be prescribed as a renal protectant postoperatively: clients who have catheter inserted in their groin will have a compression bandage on the insertion site - must lie flat on their back for several hours post procedure monitor catheter insertion site for bleeding or hematoma developmoent distal pulses and vital signs are monitored for 7 hours: - 4 times in 15 minute intervals - 4 times in 30 minute intervals - 4 times in hourly intervals

Answer 23

can be done at bedisde and performed by technician used to evaluate structural defects and abnormalities of the heart valves, chambers and muscles risk free and does not require specialized intervention before or after procedure may be performed trans-esophgally TEE

Answer 24

maintain NPO status during prescribed hours before TEE monitor return of gag reflex post procedure monitor for resp depression due to procedural sedation offer throat lozenges for residual throat discomfort

Answer 25

clients walk on treadmill or ride stationary bicycle while connected to ECG monitoring will exericse until predetermined heart rate is reached, 20 min have elapsed or if the clients starts to experience chest pain, fatigue, dyspnea, vertigo, or hypotension

Answer 26

ensure that client adhere to pre-procedure diet restrictions: - avoiding caffeine or caffeinated beverages making sure client remains NPO or only eats a light meal wear comfortable clothing and footwear

Answer 27

client eliminates in a 24 hour period collection should be kept on ice during collection

Answer 28

amount of urine produced by the kidney/min normal: 90-120 describes the stages of chronic kidney disease: stage 1: GFR greater than 90 mL/min stage 2: GFR 60- 89 ml/min - mild CKD stage 3: 30-59 ml/min - moderate CKD stage 4: 15 - 29 ml/min - severe CKD stage 5: less than 15 ml/min - end stage kidney disease

Answer 29

endoscopic procedure for direct visualization of the bladder and urethra performed to dilate the urethra, place ureteral stents, resent and enlarged prostate gland pre-procedure: informed consent completel bowel prep to empty the GI tract of any stool ensure that client is NPO for prescribed time frame post-procedure: monitor character and volume of urine check for abdominal distention, urinary frequency urine is typically pink in color after the exam if client expierneces worsening abdominal or pelvin pain post exam - that can indicate urinary tract or bladder perforation

Answer 30

provides x ray of kidneys, ureters and bladder bowel preparation is required night before test, client may be NPO after midnight before procedure: determine iodine sensitivity during injection, it is normal for clients to experience burning in the vein or a salty taste in their mouth x-rays are taken at intervals after dye is injected

Answer 31

should go straight to the lab do not allow specimen to sit at room temperature

Answer 32

needle aspiration of fluid from abdominal cavity used for examination and treatment of ascites can be done at bedisde in semi-fowlers position instruct client to empty bladder BEFORE procedure to decrease the risk of accidnetal puncture post procedure: monitor worsening abdominal pain abdominal rigidity and rebound tenderness - these can be indicative of peritonitis

Answer 33

evaluate size and shape of liver radiopague dye is used during the exam ask about previous allergies and previous iodine sensistivity - must be monitored for anaphylaxis those who are sensitive should use a aqueous of water based dye will administer cleaning enema after the exam to remove barium and prevent impaction x-rays may be repeated after all the barium has left the body

Answer 34

help and diagnose acute chronic pancreatitis client will restrict food for 1-2 hours before the test and avoid opiates for 2 hours before the test normal value: 23-85

Answer 35

used to investigate changes in behavior and latered level of oconsciousness due to severe liver disease use to support reye syndrome refrain from smoking for several days prior to collection of sample

Answer 36

used to determine if abnomral lung cells are present identify cause of pulmonary infection should be encouraged to take fluids the night before the test if possible, collection should take place in morning prior to test, client should rinse their mouth with water - dont brush teeth, eat or use mouthwash before the test

Answer 37

used to dientify causative agent for TB 3 sputum samples are collected early in the morning on 3 different days prior to test: client can rinse their mouth with plain water, NOT mouthwash difference between spit and sputum should be emphasized sputum: mucus that you cough up from deep inside your lungs spit: saliva

Answer 38

readings are taken 48-72 hours after injection -positive result is injection isred and swollen false positive may result if people have receive BCG vaccine

Answer 39

used to investigate source of bleeding in lungs, biopsy, remove secretion and foreign bodies NPO at least 4 hours before the procedure and in most cases client will receive procedural sedation may experience sore throat post test remind client to sit or lie on their side remain NPO until their gag reflex returns

Answer 40

measures the lungs capacity to hold air, move air in and out exchange oxygen and carbon dioxide refrain from smoking for 4 hours prior to test may also be asked to withhold bronchodilator until after test

Answer 41

fluid from pleural space is removed for diagnostic testing will be asked to sit at the side of the bed and lean forward local anestheticis used prior to needle insertion may feel some pain as their lungs fill with air and expand against the chest wall - may need to cough, feel light-headed and or short of breath during or after procedure no more than 1,000mL should be removed at one time monitor breath sound and vitals frequently monitor for leakage of fluid at puncture site - sterile dressing will be applied after the test and a chest X-ray may be ordered

Answer 42

if contrast dye is used with scan, informed consent must be obtained -painless but client ust remain immbolie during exam this can cause anxiety and may be challenging for clients with dementia, delirium, claustrophobia if contrast dye is used - may experience flushed, warm face and/or metallic taste during injection assess for allergic response to dye like rash, itching, angioedema, uritcaria after CT scan, encourage client to intake fluids to pee out the contrast

Answer 43

must remove all metal

Answer 44

provides 2-3D dimensional pictures of the brain used to diagnose stroke, brain tumor, epilepsy, parkinsons and head injuries clients inhales or is injected with radioactive substance and then is scanned must lie still while gamma rays are detecting the body tissues - may experience dizziness and headaches, during and after the test

Answer 45

appearance of CSF is normally colorless, clear and almost entirely free of colles normal pressure: 50-180

Answer 46

informed consent position client on one side in a fetal position with knee close tot heir chest or leaning forward while sitting local anesthetic will be injected - will feel a stinging sensation and pressure as theh spinal needle is inserted instruct clients to lie flat for severl hour afterward drink additional fluids administer analgesics as needed apply sterile dressing to the site perform neuro-sensory assessment every 15-30 min until pt is stable

Answer 47

painless test that measures electricaly activity in the brain can have bright or flashing light or noises usually reclines in a chair or ona bed during the test and may take up to an hour - if taken dring sleep, it can take around 3 hours after test, nurse will remove electrode paste from scalp and hair

Answer 48

involves the use of a radionucleide administered through IV and creates an image radioactive material poses no threat because is readily deteriorates in the body taken to nuclear medicine department 4-6 hours after injection - procedure take around 30-60 in - patient must lie still for accurate test results no special care is required radioisotope is excreted in stool and urine, but no preautions are required in handling the excreta - remin client to increase fluid intake

Answer 49

used to screen and diagnose osetoporosis low dose X-rays are used to examine bone density at lower spine, hip and wrist normal: <1 SD below normal osetopenia: 1.0 - 2.5 SD below normal osteoporosis: >2.5 SD below normal

Answer 50

diagnosis of diabetes mellitus client must fast for 12 hours prior to the test during test, blood samples are drawn at set intervals after client drinks liquid containined concentrated glucose test can take up to 3 hours glucose levels are taken 2 hours after drinking the glucose levels that are greater than 200 means positive

Answer 51

blood draw should be done prior to digital rectal exam or biopsy six weeks after manipulation of the prostate

Answer 52

used to confirm or monitor pregnancy no special preparation is needed negative: <5 positive: >25

Answer 53

recommended that client does not have vaginal intercourse, use tampons or take vaginal medications a day or 2 before the colposcopy can use OTC analgesics prior to and after the procedure

Answer 54

no anesthesia is needed may feel a cramping sensation during or after the test should wait 3 days to have intercourse, douche or go swimming

Answer 55

instruct to use OTC analgesics for post-procedural pain - acetaminophen - ibuprofen

Reduction of Risk Potential Flashcards

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