Skills Final Flashcards
(48 cards)
Your patient with a PICC line has developed noticeable irregular pulse rate. Your initial nursing action will be?
STOP fluid admin in the PICC line
Your patient is using a ventilator. Part of your hourly safety precautions for this patient it?
Confirm vent settings match provider orders
Nurse should check ventilator settings for ____ if high alarm sounds?
Obstruction
Your patient on parenteral nutrition (PN) may develop these symptoms if PN abruptly discontinued?
s/sx of hypoglycemia; hang D10
A patient with L sided mastectomy requires phlebotomy- Use what arm?
the R arm
Limb threatening condition pressure develops inside muscle in response to IM hemorrhage or edema?
compartment syndrome
Nurse instructs patient w crutches to advance both crutches and the affected leg simultaneously?
3 point
Patient scheduled for ORIF of hip fx tomorrow morning - bucks traction. When you assess setup, 4 things should be found in effective traction?
4 P’s (pounds- correct weight, pull- pulley system align with long axis of leg, pulleys- does pulley rope glide smoothly, pressure- straps and connections intact and not too tight or loose) also make sure body is in countertraction
To prevent skin shear and breakdown for patients supine in Buck’s traction?
Tip them off their back for 10-15 minutes using triangle cushion; remove weight, assess skin and neuro status of limb under boot; reapply traction at least every 4-8 hours and do full neurovascular assessment
Performing assessment on immobilized limb?
5 P’s- pulse, pallor, paresthesia, paralysis, pain
Preparing size of crutches for patient. Do this to ensure protection of brachial plexus or radial nerve?
2-3 fingers from top of crutch to prevent crutch palsy while standing or lying supine. Crutch palsy- pressure on nerve causing tingling
Just delivered shock with AED to patient. Appropriate next step?
Continue CPR for 2 minutes
Patient positioned with head lower than feet during Cental Venous Line insertion?
Trendelenburg
K+ level of 6.5. Lab result may result in this on ECG?
Peaked T, wide QRS complex, flat P wave
Expected norm of Ca?
8.6-10.2
Preparing to insert IV in 36 yo male pt. No scheduled for invasive procedure. What size catheter?
20 or 22 gauge- smallest and shortest length to accomplish ordered IV therapy.
Nursing intervention to prevent hematoma formation if on heparin drip when discontinue IV?
Hold pressure for at least 3 minutes or more
Performing venipuncture. Provide counter traction to IV catheter by doing what?
Place non-dominant thumb 1-2” distal to insertion
Max length recommended to leave tourniquet on when initiating IV?
No longer than 1 minute
Allen’s test performed before inserting arterial line to ensure patient has what?
Collateral circulation- ulnar artery is patent. Ulnar perfusion.
CVP reading less than 2 indicates?
Hypovolemia (normal 2-6)
Normal MAP range is?
Greater than 60
Hemodynamics: Pressure measurements in CVP are most accurate at?
Phlebostatic axis (right atrium)
Hemodynamics: Nurse may obtain accurate radial arterial line pressure reading when stopcock on manometer is zeroed and turned?
Off to air, on to the patient
