Final Exam

Question 1

IGEL Insertion

Answer 1

1. Don PPE
2. Pre-oxygenate the patient for 2-3 minutes with a BVM or NRB at 15L/min and 100% oxygen and a NC at 15L/min
3. Choose I-Gel device based on patient’s weight
4. Assess patient for RODS
5. Inspect the I-Gel for malformations or leaks
6. Remove I-Gel from package and cradle. Place small bolus of water soluble lubricant on the middle of the cradle
7. Apply lubricant to the back, sides, and front of the I-Gel, using sterile technique
8. Place the airway support strap behind the occipital area of the head to avoid putting pressure on
   the jugular veins or the carotid arteries
9. Place your patient in the sniffing position and ensure the tragus in-line with the sternal notch
10. Grasp the I-Gel along the bite block and position the device so that the cuff outlet is facing the patient’s chin
11. Insert the soft distal end of the I-Gel into the mouth and glide the device along the hard palate
    downwards with a continuous but gentle push until resistance is felt and horizontal line of the
    integral bite block is at the teeth line.
    Note: Do not apply excessive force on the I-Gel during insertion. If resistance is felt in the posterior pharynx while inserting the I-Gel, apply a jaw thrust and re-introduce the device a second time
12. Attach the tube to the following devices:
     HEPA filter (closest to the patient)
     ETC02 device
     Attach PEEP to BVM using connector and set PEEP to 5cmH20 pressure
13. Auscultate the epigastrium (1st) and apices and bases of bilateral lung fields (2nd) to confirm tube
    placement
14. Monitor ETC02 waveform with each ventilation and maintain a range appropriate to patient
    condition
15. Assist ventilations at a rate of 8-10 breaths/min (1 breath q 6 seconds)
16. Secure the I-Gel with an I-Gel commercial holder or cloth tape.
17. Take the electric suction tubing and using the connector piece, connect it to the French catheter
    suctioning.
     *The key point re: suction is to ensure you have a closed unit at all times.
     Measure the distal end of the French suction from the corner of the mouth to the tragus of the ear and mark that point using a piece of IV tape on the French catheter.
     Insert the distal end of the French catheter into the gastric channel on the I-gel until you reach the tape
18. Turn on suction to 30-80mmHg in an intermittent/as needed fashion.
     Start with low suction and increase as needed to the maximum allowance.
     Only suction 1 time for 5 seconds only every 5 minutes
    Note: Do not turn on suction and leave it running unattended. When the suction is not being used,
    keep the French catheter attached to the electric suction catheter. If needing to detach the patient
    from the electric suction for any reason, ensure you cap off the end of the French suction catheter
    using a syringe cap to close it off. You may also kink the tubing and tape the kink in place if no cap available.
    *Note: pediatric I-gels do not come with a head strap, lubrication, or French catheter. You will
    need to prepare these items separately
19. Document procedure

Question 1

King-LTE Insertion

Answer 1

1. Don PPE
2. Pre-oxygenate the patient for 2-3 minutes with a BVM or NRB at 15L/min and 100% oxygen and a NC at 15L/min *Consider the need for OPA/NPAs and 2-person BVM ventilations during this time
3. Choose King Tube based on patient height
4. Assess patient for RODS:
    Restricted mouth opening (trismus, TMJ pathology, micrognathia, wired jaw)
    Obstruction (at or below the glottis-edema, FB, abscess, trauma, burn)
    Distorted/displaced airway (radiation, trauma, surgery)
    Stiff chest/lungs/neck (severe bronchospasm, flexion neck deformity, stiff lungs)
5. Inspect the King Tube for malformations or leaks around bulbs with inflation via air filled syringe
   with appropriate amount of air based on size of King Tube chosen.
6. Lubricate the distal end of the King Tube with a water soluble lubricant ensuring not to cover the
   air port , using sterile technique
7. Place the head in a neutral position,
8. Open the patient’s mouth with the head tilt chin lift or modified jaw thrust maneuver and insert the
   King airway in either corner of the mouth with the airway facing outwards.
9. Advance the tip behind the base of the tongue while rotating the tube back to midline so that the
   blue orientation line faces the patient’s chin.
10. Advance the tube until the base of the connector is aligned with the teeth or gums.
11. Briefly let the tube go, and inflate the cuff with the recommended amount of air or just to seal the
    device, noting that tube may elevate while settling into place in the airway.
12. Attach the tube to the following devices:
     HEPA filter (closest to the patient)
     ETC02 device
     BVM at 15L/min and 100% oxygen.
     PEEP set at 5cm H20 pressure
13. Auscultate the epigastrium (1st) and apices and bases of bilateral lung fields (2nd) to confirm tube
    placement.
14. Monitor ETC02 waveform with each ventilation and maintain a range appropriate to patient
    condition.
15. Assist ventilations at a rate of 8-10 breaths/min (1 breath q 6 seconds)
16. Secure the King Tube with a Thomas tube holder or cloth tape.
17. Document the procedure.

Question 2

LMA Insertion

Answer 2

1. Don PPE
2. Pre-oxygenate the patient for 2-3 minutes with a BVM or NRB at 15L/min and 100% oxygen and
   a NC at 15L/min.
   *Consider the need for OPA/NPAs and 2-person BVM ventilations during this time
3. Choose LMA device based on patient’s weight.
4. Assess patient for RODS:
    Restricted mouth opening (trismus, TMJ pathology, micrognathia, wired jaw)
    Obstruction (at or below the glottis-edema, FB, abscess, trauma, burn)
    Distorted/displaced airway (radiation, trauma, surgery)
    Stiff chest/lungs/neck (severe bronchospasm, flexion neck deformity, stiff lungs)
5. Inspect the cuff of the LMA by inflating it with 50% more air than is required for that size LMA,
   then deflate the cuff completely. Ensure the cuff is shaped like a “boat” when deflated to assist in
   easy insertion
6. Lubricate the base of the device with a water soluble lubricant ensuring not to cover the air port
   using sterile technique
7. Place the patient’s head in the sniffing position.
8. Open the patient’s mouth with your non-dominant hand using your thumb and index finger.
9. Insert your finger between the cuff and the tube. Place the index finger of your dominant hand in
   the notch between the tube and the cuff.
10. Insert the LMA along the roof of the mouth. Use your finger to push the airway against the hard
    palate until the LMA will not advance any further.
11. Briefly let the tube go, and inflate the cuff with the recommended amount of air or just to seal the
    device, noting that tube may elevate while settling into place in the airway.
12. Attach the tube to the following devices:
     HEPA filter HEPA filter (closest to the patient)
     ETC02 device
     BVM at 15L/min and 100% 02
     PEEP set at 5cm H20 pressure
13. Auscultate the epigastrium (1st) and apices and bases of bilateral lung fields (2nd) to confirm
    tube placement.
14. Monitor ETC02 waveform with each ventilation and maintain a range appropriate to patient
    condition
15. Assist ventilations at a rate of 8-10 breaths/min (1 breath q 6 seconds)
16. Secure the LMA with a Thomas Tube Holder or cloth tape
17. Document the procedure

Question 3

Conduct Peripheral Venipuncture

Answer 3

1. Don PPE
2. Explain the procedure and need for procedure to the patient
    Gain consent (if applicable)
3. Apply tourniquet proximally to insertion site
4. Palpate suitable vein
5. Cleanse site with alcohol/betadine solution in circular motion beginning from inside of circle
   moving in an outward fashion only.
6. Perform venipuncture
    Pull traction distal to site
    Hold needle with thumb, middle, and index fingers
    Insert needle bevel up at a 15-30 degree angle may feel a “pop”
    Note or verbalize flashback
    Flatten needle until flush with skin before advancing catheter
    Advance catheter with index finger while simultaneously pulling needle back until
   catheter hub flush with skin
7. Release tourniquet.
8. Without touching sterile site, place tegaderm dressing over catheter hub
9. Occlude catheter proximal to hub while stabilizing hub of catheter with same hand using middle
   and fourth (ring) finger, leaving thumb and pointer finger to assist with line or lock placement
10. Remove needle and safely dispose needle in appropriate sharps container
11. Attach saline line or lock to catheter and pass fluid through catheter.
     Ensure no proximal bubbling under skin
     Ensure line “flushes” easily without resistance
12. Tape the lock or line in place in appropriate fashion overtop of tegaderm.

Question 4

MAINTAIN PERIPHERAL IV ACCESS DEVICES AND INFUSIONS OF
CRYSTALLOID SOLUTIONS WITHOUT ADDITIVES

Answer 4

1. Don PPE
2. Examine the bag for colour, clarity, concentration, and expiration date.
3. Choose appropriate drip set for the desired flow rate, and attach it to the appropriate fluid.
4. Make sure infusion site is patent.
5. Pull on the rubber pigtail on the end of the IV bag to remove it.
6. Roll the clamp on the IV line up to approx. 1-2” away from the drip chamber and close the roller
   clamp.
7. Remove the protective cover from the piercing spike.
8. Slide the spike into the IV bag until you see fluid enter the drip chamber.
9. Fill the drip chamber by squeezing it or compressing it until it is approx. ½ full.
10. Release the roller clamp.
11. Allow the solution to run freely through the drip chamber and into the tubing to “prime the line”
    and flush the air out of the tubing.
    *Remove all air bubbles by tapping each IV port until bubbles are absent from the line
12. Check infusion site for signs of infection, infiltration, phlebitis, thrombophlebitis
13. Document the procedure.

Question 5

1. Don PPE
2. Identify need for pressure infusion
   *Shock states requiring rapid fluid resuscitation.
3. Assemble equipment
    large bore IV established and patent
    infuser device is clean and calibrated (pressure dial is resting within allowable limits)
4. Wrap pressure infuser snugly around the IV bag
5. Hang pressure infuser on IV pole.
6. Ensure three way stop cock is open to allow infuser to be pressurized with bulb, pump to 150-300
   mmHg, close stop cock to prevent slow leakage of pressure from bulb. Ensure IV roller is wide
   open.
7. Maintain this pressure during procedure by repeating step 6 as needed.
8. Continue to monitor patient vital signs and for signs and symptoms of fluid overload.
9. Be vigilant, watching for depletion of IV fluid quickly, replace as necessary.
10. Document procedure.

Question 6

CONDUCT VENOUS BLOOD DRAW

Answer 6

1. Don PPE
2. Explain the procedure and need for procedure to the patient. Gain consent (if applicable)
3. Apply tourniquet proximally to insertion site
4. Palpate suitable vein
5. Cleanse site with alcohol/betadine solution in circular motion beginning from inside of circle
   moving in an outward fashion only.
6. Perform venipuncture
    Apply gentle traction to the vein distal of insertion site
    Insert needle, bevel up at a shallow angle 10-30 degrees
    Note or verbalizes flashback
    Flatten needle until flush with skin before advancing catheter
    Advance catheter 1-3 mm with index finger while simultaneously pulling needle
   back until catheter hub flush with skin
    Keep needle motionless
    Push vacuum tubes into the tube holder, use care to avoid dislodging needle from
   vein
7. Release tourniquet when blood starts to flow.
8. After removing tube, gently invert the tube 6 to 8 times to mix the contents,
   DO NOT SHAKE the tubes.
9. Fill tubes in proper sequence order
10. In one motion, remove needle then immediately apply pressure to site with gauze and safely
    disposes needle in appropriate sharps container.

Question 7

MEDICATION ADMINISTRATION-SUBCUTANEOUS INJECTION

Answer 7

1. Don PPE
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs.
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. Assemble and check equipment needed:
    Alcohol pads
    Filterline needle
    Choose appropriate syringe for medication amount
    Choose appropriate gauge/length needle for subcutaneous medication administration
7. Ampule: Gently tap/shake excess medication from neck to body of ampule, using gauze pad to
   break ampule AWAY from you
   Vial: Remove sterile cap, do not contaminate by touching the rubber top
8. Draw up the correct dose of medication with filter-line needle (2 mL max)
9. Choose appropriate site-upper arm
10. Cleanse the area for the administration using aseptic technique and allow to dry
11. Switch out filter-line needle for SC needle and dispose in sharps container
12. Remove any excess air from needle/syringe and confirm proper dose remains
13. Pinch the skin surrounding the area, advise the patient of a stick, and insert the needle at a 45-
    degree angle
14. Pull back on the plunger to aspirate for blood.
    *If present procedure should be discontinued and repeated with new equipment/medication. If
    no blood, inject the medication and remove the needle
15. To disperse the medication throughout the tissue, rub the area in a circular motion with gauze
16. If needed, cover injection site with adhesive bandage strip
17. Monitor the patient’s condition and document procedure and reassessment as per industry
    professional standards.

Question 8

MEDICATION ADMINISTRATION – INTRAMUSCULAR (AMPULE)

Answer 8

1. Don PPE (gloves and glasses minimum)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs.
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. Assemble and check equipment needed:
    Alcohol pads
    Filterline needle
    Choose appropriate syringe for medication amount
    Choose appropriate gauge/length needle
7. Gently tap/shake excess medication from neck to body of ampule, using gauze pad to break
   ampule AWAY from you
8. Draw up the correct dose of medication with filter-line needle (5 mL max)
9. Choose appropriate site-vastus lateralis
10. Cleanse the area for the administration using aseptic technique and allow to dry
11. Switch out filter-line needle for IM needle and dispose in sharps container
12. Remove any excess air from needle/syringe and confirm proper dose remains
13. Pull skin taunt, apply Z track to the area, advise the patient of a stick, and insert the needle at a
    90-degree angle
14. Pull back on the plunger to aspirate for blood. If present procedure should be discontinued and
    repeated with new equipment / medication. If no blood, inject the medication and remove the
    needle
15. To disperse the medication throughout the tissue, rub the area in a circular motion with gauze
16. If needed, cover injection site with adhesive bandage strip
17. Monitor the patient’s condition and document procedure and reassessment as per industry
    professional standards.

Question 9

MEDICATION ADMINISTRATION-INTRAMUSCULAR (VIAL)

Answer 9

1. Don PPE (gloves and glasses minimum)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs.
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. Ensure all required equipment is prepared:
    1mL or 3mL syringe
    Alcohol swab
    Blunt fill 18g 1 ½ inch needle with filter
    22-23g 1-1 ½ inch BD safety glide needle (adult)
    25g 1 inch BD safety glide needle (pediatric)
    Naloxone vial
    Adhesive bandage
    4x4 dressing
    Sharps container
7. Clean the rubber stopper with an alcohol swab
8. Attach a blunt fill needle to the 1mL or 3mL syringe
9. Inject into the vial a volume of air equivalent to the solution to be withdrawn
   Ex) inject 2mL of air into the syringe to withdraw 2mL of fluid
10. Holding the vial above the syringe and ensuring the tip of the needle is below the level of the
    fluid, pull on the plunger and withdraw the desired volume
11. Remove the fill needle from the vial and replace with:
     Adult: 22-23g 1-1 ½ inch BD safety glide needle
     Pediatric: 25g 1 inch BD safety glide needle
12. Holding the needle-end upright, flick the sides of the syringe to dislodge any air bubbles clinging
    to the sides
13. Gently depress the plunger to expel any air from the syringe
14. Locate the appropriate injection site
     Lateral aspect of the patient’s thigh midway between the waist and knee, avoiding the
    IT band (1-2 cm anterior)
15. Swab the injection site with an alcohol swab in a circular motion from inside to outside
16. Apply the “Z track” technique
     Pull skin taut and pulls downwards without contaminating the injection site
17. Insert the appropriately sized needle into the patient’s skin at a 90-degree angle
18. Hold the syringe steady with one hand and draw back slightly on the plunger to ensure the
    needle has not punctured a blood vessel.
    If you visualize blood in the syringe, withdraw the needle from the patient and begin steps
    8-14 again with new equipment and medication.
19. After confirming no blood is visible in the syringe, push the plunger and inject the medication
     Withdraw the needle and apply the needle guard
20. Dispose of the needle in a biohazard (sharps) container
21. Cover the injection site with an adhesive bandage
22. Document the procedure and reassessment as per professional standard.

Question 10

MEDICATION ADMINISTRATION – VIA IV

Answer 10

1. Don PPE (gloves and glasses minimum)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs.
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. Assemble and check equipment needed.
    Alcohol swab
    Filterline needle
    Choose appropriate syringe for medication
7. Verify patency of IV line
8. Draw appropriate dose of medication into syringe
9. Detach filterline needle and dispose in sharps container
10. Expel any excess air from syringe
11. Cleanse the injection port with alcohol (allow to dry)
12. Screw the syringe on to the port or insert the needle into the port while holding it carefully
13. If needed, pinch off IV tubing above port
14. Administer medication at appropriate rate. If resistance is felt, or if the patient reports any
    discomfort, discontinue administration immediately.
15. Detach medication syringe/needle (dispose in appropriate container)
16. Flush IV line wide open for 30 seconds
17. Monitor the patient’s condition and document the procedure and reassessment as per
    professional standard

Question 11

MEDICATION ADMINISTRATION – SUBLINGUAL

Answer 11

1. Don PPE (gloves and glasses minimum)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. If medication is in a bottle with a spray pump, prime the line once with the stream pointed away
   and close to the floor
7. Ask the patient to lift their tongue. Place the tablet or spray the dose under the tongue (you may
   also ask the patient to do so)
8. Advise the patient not to talk, chew or swallow
   *This allows the medication to dissolve/absorb properly
9. Monitor the patient’s condition
10. Document the procedure and reassessment as per professional standard

Question 12

MEDICATION ADMINISTRATION – BUCCAL

Answer 12

1. Don PPE (gloves and glasses minimum)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. Draw up appropriate medication dose if not in commercial tubing
7. Place the medication in between the patient’s cheek and gum in a long thin line from back to front
   of mouth not overflowing over teeth
8. Advise the patient not to chew or swallow the medication but to let it absorb/dissolve slowly.
9. Monitor the patient’s condition
10. Document the procedure and reassessment as per professional standard

Question 13

MEDICATION ADMINISTRATION – ORAL

Answer 13

1. Don PPE (gloves and glasses minimum)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. Assemble the medication and instruct patient on any specific instructions before swallowing
   medication if needed (e.g., chew completely)
7. If available and needed, instruct the patient to swallow the medication with water
8. Monitor the patient’s condition
9. Document the procedure and reassessment as per professional standard

Question 14

MEDICATION ADMINISTRATION – MDI USE WITH MANUAL
VENTILATIONS AND/OR ADVANCED AIRWAY

Answer 14

1. Don PPE (gloves, gown, glasses, N95 mask, face shield)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs.
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. Prepare the medication for use
    Shakes the canister for 30-60 seconds to mix the medication with the propellant
7. Assemble the BVM with the following equipment:
    MDI circuit (purple) with medication attached
    HEPA filter
    ETC02 line
    Diverter and PEEP valve set to 10cm H20 pressure
    *all the above is set in the order written starting at the distal end of the advanced airway
   and or BVM
8. Deliver the medications in the following format:
    Respiratory distress: alternating medication delivery every 60 seconds
    Respiratory failure: alternation medication delivery every 30 seconds
   *Provide medications by attaching the medication cannister only to the MDI circuit and
   depress once for medication administration. You must wait a full 30 seconds before
   administration of
    second puff. *this allows the cannister to prime again.
9. Document the procedure and reassessment as per professional standard

Question 15

MEDICATION ADMINISTRATION – NEBULIZER

Answer 15

1. Don PPE (gloves, gown, glasses, N95 mask, face shield)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs.
4. Explain procedure to patient.
5. Use aseptic technique throughout administration
6. If the medication is in a pre-mixed package, add it to the bowl of the nebulizer. If it is not pre-
   mixed, add the medication to the bowl and mix it with the specified amount of normal saline.
7. Connect the T-piece with the mouthpiece to the top of the bowl or the mask to the bowl, and
   connect it to the oxygen tubing
8. Set the flowmeter at 6-8 lpm to produce a steady mist from the mask
9. Instruct the patient on the proper way to breathe. Have the patient breathe as deeply as possible
   and hold their breath for 3-5 seconds before exhaling, telling them not to talk
10. Monitor the patient’s procedure and reassessment as per professional standard
    Note:
    Cardiac monitoring is essential when administering a beta agonist. If cardiac
    dysrhythmias are noted
     Stop the administration of the medication
     Administer high-flow oxygen
     Contact direct medical control

Question 16

MEDICATION ADMINISTRATION – INTRANASAL

Answer 16

1. Don PPE (gloves, gown, glasses, N95 mask, face shield)
2. Follow safe medication principles:
    List indications/contraindications
    List 7 Rights of safe medication administration
    Check colour, clarity, concentration and expiry date
    Perform “3 checks” with a partner
3. Obtain history, assessment, allergies and vital signs.
4. Explain the procedure to patient.
5. Use aseptic technique throughout the administration
6. Pick the appropriate syringe size
7. Draw up the appropriate dose of medication in the syringe.
8. Attach the mucosal atomizer device to the syringe
9. Tilt patient’s head back or lay patient flat
10. Spray half of the medication dose into each nare. (max 1 mL per nare), away from the septum
11. Monitor the patient’s condition
12. Document the procedure and reassessment as per professional standard