1
Q
Suctioning an airway:
A
- Client should be pre-oxygenated with 100%O2
- Suction should be applied for no more than 10 seconds
- The nurse must wait 1-2 minutes between passes for the client to ventilate
- The suction catheter should be no more than half the width of the artificial airway and inserted WITHOUT suction
- 100-120mmHg pressure for adults
- 50-75mmHg for children
2
Q
When is it appropriate to use an indwelling catheter?
A
- Clients with urinary obstruction or retention, or a need for strict I/Os in critically ill patients
- Perioperative use
- Prolonged immobilization/when bed rest is essential
- To improve end of life comfort
- To facilitate healing of an open perineal or sacral wound
3
Q
An MRI is contraindicated in clients with:
A
- Aneurysm clips
- Metallic implants: ICDs, pacemakers, electronic devices, hearing aids, shrapnel
4
Q
Donning PPE:
A
- Hand hygiene
- Gown
- Mask or respirator
- Goggles or face shield
- Gloves
5
Q
Droplet precautions:
A
Used to prevent transmission of respiratory infection; this included the use of a mask and a private room
6
Q
Caring for patients with cellulitis:
-Typically caused by bacterial infection (Staph) resulting from insect bite, cut, abrasion, etx.
A
- Apply a warm compress: promotes circulation to the area of infection, alleviates discomfort and helps reduce edema
- Affected extremity is elevated
7
Q
Extravasation:
A
Infiltration of a drug into the tissue surrounding the vein
8
Q
The nurse should implement the following interventions to manage norepinephrine extravasation:
A
- Stop the infusion immediately and disconnect the IV tubing
- Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating
- Elevate the extremity above the heart to reduce edema
- Notify HCP and obtain prescription for antidote phentolamine
* Norepi should be infused through central line when possible
9
Q
Preparing medication from a glass ampule:
A
- Flicker the upper stem of the ampule with a fingernail several times to ensure removal of med
- Using sterile gauze to break the ampule away from the nurse’s body
- Setting the ampule on a flat surface or inverting it to withdraw the medication
- Disposing of the ampule in the sharps container
- DONT INJECT AIR into the vial
- Use a filter needle to get med out of ampule
10
Q
Airborne infections:
A
TB, measles, chickenpox
-Patients with this must wear surgical mask when transporting around the hospital
11
Q
What is the most common complication of central venous access?
A
Catheter occlusion. The nurse should first assess for mechanical, nonthrombotic problems by- repositioning the client, assessing IV tubing for clamps, kinks, and precipitate. The nurse should then attempt to flush the line again
12
Q
Airborne precaution indications:
A
- TB
- Varicella zoster (chickenpox)
- Herpes zoster (shingles)
- Rubeola (measles)
Precautions:
- N95 mask
- negative pressure isolation room
- Only when uncrusted lesions are present; contact precautions are required
- *Only in immunocompromised client; contact precautions are required
13
Q
Abdominal paracentesis patient positioning:
A
Patient should be seated in high-fowlers and should void prior to the procedure
14
Q
In the event of an air embolism, how should the patient be positioned?
A
head of the bed should be lowered (trendelenburg) and the client should be positioned on the left side; causes the air to rise to the right atrium
15
Q
Chest tube placement patient position:
A
Clients arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm.
16
Q
After a liver biopsy, how should the patient be positioned?
A
The client should lie on the right side for a minimum of two hours and then supine for an additional 12-14 hours
17
Q
For a lumbar puncture, how is the client positioned
A
Side-lying with the head, back, and knees flexed.
18
Q
When is a chest tube removed?
A
When drainage is minimal (<200mL/24hr) or absent, an air leak is resolved, and the lung has re-expanded
19
Q
What are the steps for chest tube removal?
A
- Premedicate the client with analgesic 30-60 minutes before the procedure
- Provide the HCP with sterile suture removal equipment
- Instruct the client to breathe in, hold it, and bear down while the tube is being removed to decrease the risk for a pneumo
- Apply a sterile airtight occlusive dressing
- Performa chest x-ray within 2-24 hours
- Client should be placed in semi-fowlers position or on the unaffected side
20
Q
Proper positioning on nasal medication administration:
A
- Assume a high-fowlers position with head slightly tilted forward
- Insert the nasal spray nozzle into an open nostril, occlude the other one
- Point the nasal spray tip toward the side and away from the center of the nose
- Spray the medication into the nose while inhaling deeply
- Remove the nozzle and breathe through the mouth
- You can blot runny nose with tissue but refrain from blowing nose
21
Q
Central line dressing changes:
A
- Use sterile technique; wearing gloves and a mask to prevent contamination
- During injection cap, tubing, and dressing change, client ia instructed to hold the breath to prevent air from entering the line, traveling to the heart and forming an air embolism
- Client is placed in supine position
22
Q
Isotonic IV fluids:
A
Expand only the extracellular fluid and are used as fluid replacement for fluid volume deficit
-Ex: NS, lactated ringers
23
Q
PICC care:
A
- Dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing
- scrub the hub for 10-15 seconds
24
Q
Pertussis:
A
highly contagious disease that requires droplet precautions
-Paroxysms of rapid coughing that lead to vomiting are key features of the infection
25
Common causative factors of falsely low SpO2 include:
- Dark fingernail polish or fake nails
- Hypotension and low cardiac output
- Vasoconstriction
- PAD
26
Muffled heart tones in a client with pericardial effusion can indicate the development of ?
Cardiac tamponade: build-up of fluid in the pericardial sac, which can lead to compression of the heart.
Signs: hypotensions, tachypnea, JVD, narrowed pulse pressure, and the presence of pulsus paradoxus
27
What is pulsus paradoxus?
Exaggerated fall in systemic BO >10mmHg during inspiration
*The nurse should measure the difference between korotkoff sounds auscultated during expiration and throughout the respiratory cycle
28
Preferred IM injection site for a newborn and infants (1-12mo)?
Vastus lateralis muscle
- The needle should be 5/8 inch in length for newborns and 5/8-1 inch for infants.
- A 22-25 gauge needle is appropriate for clients age <12mo
29
Peripheral IV sites should be selected in the hand or forearm to reduce the risk of catheter-related bloodstream infections. T/F
true
30
Preferred site for venipuncture when collecting blood specimens is?
Antecubital fossa's median cubital vein
31
1 tbsp = _____ mL?
15
32
Interventions to prevent abdominal wound dehiscence?
- Administering stool softeners to prevent straining and constipation
- Administering antiemetics as needed for nausea to prevent straining
- Applying an abdominal binder
- Monitor tight glucose control
- Splinting the abdomen by holding a pillow or folded blanket against the wound for support when coughing and moving
33
To determine the most appropriate method to transfer a client safely for the first time the nurse should assess 2 factors:
1. Whether the client can bear weight: neuro deficits, decreased muscle strength, trauma
2. Whether the client is cooperative and able to follow instructions: AMS, decreased cognitive ability
34
The IOM recognizes 4 types of errors:
1. Diagnostic: delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring
2. Treatment: error in performance of procedure, treatment, dose; avoidable delay
3. Preventive: failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment
4. Other: failure of communication, equipment failure, system failure
35
Wound culture procedure:
1. Perform hand hygiene, remove old dressing, and remove and discard gloves.
2. Perform hand hygiene again and apply sterile gloves
3. Assess the wound bed. Cleanse the wound and surrounding skin with normal saline
4. Apply prescribed topical medication (bacitracin) after obtaining cultures.
5. Swab from the wound center toward the outer margin
36
Steps for ETT suctioning:
1. Perform hand hygiene and don clean gloves
2. Suction the oropharynx and perform oral care
3. Ensure that the system is connected to the appropriate wall suction (<120mmHg)
4. Hyperoxygenate the lungs (100%FiO2)
5. Advance the catheter into the trachea until resistance is met. DONT suction while advancing the catheter
6. Gently remove the catheter while suctioning and rotating it. Dont suction for more than 10 seconds
7. Evaluate client tolerance. If secretions remain, suctioning can be repeated 1-2 times
37
Epi injection rules:
- Should always be available for emergency use
- Should be given when the client first notices any anaphylactic symptoms
- The injection should be given in the mid-outer thigh and can be given through clothing
- The client should receive emergency care ASAP
38
Normal platelet count:
150,000-400,000
| -A potential complication of heparin therapy is thrombocytopenia
39
A nurse is caring for a client on life support who has been declared brain death. What intervention is appropriate at this time?
Call the local organ procurement services rep.
| -Cardiac and resp support continue if organ donation is being discussed/performed
40
Immune thrombocytopenia (ITP):
Acquired disorder in which antibodies cause decreased platelet survival and production
- Petechiae, pinpoint lesions on the skin from capillary hemorrhages are a common sign
- Usually resolved quickly without complication
41
Symptoms including fever, sore throat, stridor, drooling, restlessness, and tripod position are evident to what life-threatening emergency:
Acute epiglottitis: Nurse should prepare to assist with an emergent endotracheal intubation
42
Thyrotoxicosis:
Thyroid storm: a complication of hyperthyroidism that occurs when excessive amounts of thyroid hormone are released into the circulation, requires monitoring.
43
Advance care planning documents may include the following:
- A health care proxy: durable power of attorney for health care or medical power of attorney- is a person appointed by the client to make decisions on behalf of the client
- A living will: advanced directive describing the type of life-sustaining treatments that the client wants initiated if unable to make decisions
44
Serum carboxyhemoglobin levels:
Normal = <5%
In smokers = <10%
A client with CO poisoning is the highest priority for treatment and requires immediate O2 administration
45
Superior mesenteric artery SMA syndrome (cast syndrome):
Rare complication of an overly tight cast that involves compression of the duodenum by the SMA. Immobilization of clients in body casts decrease peristalsis and may cause a paralytic ileus.
46
UAPs can perform suctioning. T/F
T R U E
47
Nurse canNOT accept a personal gift over $20. T/F
T R U E
48
Parenteral and oral anticoagulant medications are administered concurrently until the INR reaches a therapeutic range of ?
2-3
49
Itching and nausea are common side effects associated with the administration of opioids. T/F
TRUE
50
Clinical manifestations of SIRS:
fever or hypothermia, tachycardia, leukocytosis or leukopenia, and tachypnea, often associated with a low PaCO2 value.
-Clients who develop SIRS require aggressive fluid resuscitation and antibiotic treatment
51
Tympanostomy tube:
Pressure-equalizing tubes placed in the tympanic membrane to facilitate drainage of middle ear fluid
52
A client with COPD and chronic bronchitis has increased hematocrit >53% and hemoglobin >17 (this is an expected finding). T/F
TRUE
53
Leukocytosis (WBC = >11,000) is expected in a client with C DIFF. T/FQ
TRUE
54
Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning and moving. T/F
TRUE
55
To leave AMA, a client must be legally competent to make the educated decision to stop treatment. What are the disqualifications for legal competency?
Altered consciousness
Mental illness
And being under chemical influence
56
When is the nurse legally required to report to civil authorities?
- Suspected elder abuse- must report signs of abuse regardless of the client's ability or willingness to advocate for themselves
- The nurse should report deaths that need medical examiner reporting guidelines (suspected to be the result of a crime, trauma, or suicide). The medical examiner has the legal authority and obligation to perform an autopsy independent of the family's wishes.
- Report intoxicated co-workers
- HEALTH authorities must be notified of a reportable STD
57
To prevent injury and provide proper support of the affected extremity, the nurse should evaluate the proper fit of the sling by assessing for the following factors:
1. Elbow is flexed at 90 degrees
2. Hand is held slightly above the level of the elbow
3. Bottom of the sling ends in the middle of the palm with the fingers visible.
4. Sling supports wrist joint
58
Steps for trach care:
1. Gather supplies to the bedside, then place the client in semi-fowlers position
2. Don PPE (mask, goggles, and clean gloves) to maintain universal precautions. Auscultate lungs and suction secretions if necessary
3. Remove soiled dressing and also remove clean gloves
4. Done sterile gloves, remove old disposable cannula and replace with a new one
5. Clean around stoma with sterile water or saline, dry and replace sterile gauze pad
59
Removal of PPE equipment:
1. Place the call light within the clients reach
2. Remove the gown and gloves
3. Discard the gown and gloves
4. Exit the negative pressure room and immediately close the door
5. Remove and discard the N95 respirator mask
60
NORMAL PLATELET COUNT =
150,000-400,000
61
Normal hematocrit =
39%-50%
62
What is needed to run while with a PCA pump?
Continuous IV solution is required to keep the vein open and flush the PCA medication through the line so that it reaches the client.
63
A complication on a thoracentesis:
Pneumothorax and bleeding
64
Signs of a pneumothorax
Increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen sats, absent breath sounds
65
Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include:
1. Asses client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements and gas
2. Assess feeding tube placement
3. Keep HOB greater than 30 degrees
4. Keep endotracheal cuff inflated at appropriate pressure (about 25)
5. Suction any secretions
6. Use caution when giving sedatives and frequently monitor for over-sedation
7. Avoid bolus tube feeds
66
What is MOST important for the nurse to do before the client leaves the building AMA?
Remove IV catheter
67
The Venture mask:
A high-flow device that deliver a guaranteed oxygen concentration regardless of the clients RR, depth, or TV.
-In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device
68
Nasal Cannula:
Can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs
69
Non-rebreathing reservoir mask:
Can deliver 60-95% oxygen concentration and is usually used in short-term.
-Often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis
70
An oxymizer:
Nasal reservoir cannula-type device that conserves on oxygen use.
71
Normal albumin level:
3.5-5
72
To perform wound irrigation:
- Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect
- Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to prevent infection
- Fill a 30-60mL sterile irrigation syringe with prescribed solution
- Attach and 18-19 gauge needle
- Use continuous pressure to flush the wound, repeating until drainage is clear
- Dry the surrounding wound area to prevent skin breakdown and irritation
73
WOUNDS SHOULD BE CLEANED FROM THE LEAST TO THE MOST CONTAMINATED AREA TO PREVENT RECONTAMINATION. T/F
TRUE
74
To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions:
1. Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of getting air into the vessels.
2. Instruct the client to bear down or exhale
3. Apply an air-occlusive dressing
4. Pull the line cautiously and never pull if there is resistance
75
Normal WBC count=
4,000-11,000
76
Normal neutrophil count =
2200-7700
77
The following neutropenic precautions include:
- A private room
- Strict hand washing
- Avoiding exposure to people who are sick
- Avoiding all fresh fruits, veggies, and flowers
- Ensuring the all equipment used with the client has been disinfected
78
You should flush CVC with what?
heparin
| Dose = 2-3mL containing 10U/mL-100U/mL
79
TPN should be administered through a CVC?
YES!
- Change the occlusive dressing on a CVC every 7 days
- The distal port of a triple lumen is the largest lumen tube and should be used for CVP
80
What is ventricular bigeminy?
Is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC).
- PVCs in the presence of an MI indicate ventricular irritability and increase the risk for a more serious dysrhythmia.
- Possible causes of it include: electrolyte imbalances and ischemia --> after assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer amiodarone, and notify HCP
81
What is the "First, Second, and Third" priority level framework is used in emergency and non-emergency setting to prioritize client needs from the highest to the lowest level of risk as follows:
1. ABCs plus V-airway, breathing, circulation, and vital signs
2. Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal lab values, and risks
3. Longer-term issues such as health education, rest, and coping
82
The following actions related to ostomy care are generally in the LPN scope of practice:
1. Provide ostomy care and observe for skin breakdowns
2. Perform specific assessments (bowel sounds, stoma color)
3. Monitor drainage characteristics
4. Reinforce education
5. Irrigate an established ostomy
6. Document observations and interventions
83
When to file an incident or occurrence report:
- Assault and injury: Physical, verbal, or sexual assault occurring in a health facility
- Client falls, with or without injury
- Staff and visitor falls, regardless of acceptance or refusal of treatment
- Treatment and intervention: Failure to obtain or intervene upon the results of diagnostic procedures
- Inadequate or delayed diagnosis and monitoring
- Delay, omission, or incorrect performance or administration of prescribed therapies and medications
- Hospital equipment failure
84
Nurses assisting clients to collect sputum culture should instruct the client to:
- Rinse the mouth out with water before collecting
- Avoid touching the inside of the sterile container or lid
- Inhale deeply several times and then cough forcefully
- Sit upright
85
24 hour urine collection:
A 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids)
-Results >80-120 mcg/hr indicates cushings is present
86
Instructions for 24-hour urine collection:
1. Use a dark jug containing special powder (obtained from the lab) to protect the urine from light during collection.
2. Must span over 24 hours: start time must coincide with an empty bladder
3. Keep the urine in a fridge or cooled ice chest with the lid tightly screwed on for preservation.
87
Venipuncture is contraindicated in upper extremities affected by:
- Weakness
- Paralysis
- Infection
- Arteriovenous fistula or graft (used for dialysis)
- Impaired lymphatic drainage (
88
Common droplet precautions:
- Neisseria meningitidis
- Haemophilus influenzae type B
- Diphtheria
- Mumps
- Rubella
- Pertussis
- Group A strep
- Viral influenza
NEED: surgical mask, private room, gloves, gown, goggles/face shield
89
If a client is uncircumcised, should the foreskin be pulled back prior to application of a condom cath?
NO! Could cause paraphimosis --> swelling of the foreskin, and impaired lymph and blood flow
90
Important considerations to remember when initiating IV therapy in older adults:
1. Cardiovascular and renal function changes may put the client at risk for rapid development of hypervolemia
2. Use of an infusion pump is recommended
3. Fragile veins are at an increased risk for infiltration
4. Fragile skin will tear easily
5. Use a 24-26 gauge needle and go in at a 5-15 degree angle on insertion
91
Antiplatelets need to be stopped how many days prior to surgery?
5-7 days
92
Nursing interventions when working the blind:
- Offer the client an elbow for guidance while walking slightly ahead and describing the environment
- Announce room entry and exit
- Describe location of items using clock-face orientation
- Instruct the client to use a cane with the dominant hand
- Orient the client to the room and maintain orientation for safety
93
Enteral nutrition:
Orally or through a feeding tube
94
Negative-pressure wound therapy:
- Administer pain medication 30 minutes before the procedure
- Apply skin barrier cream to intact skin surrounding the wound
- Ensure that the foam dressing shrinks after the device is turned on
- A sterile foam dressing is cut to fit the wound shape and size and is placed in the wound bed
- The foam dressing should compress when the device is turned on, indicating a proper seal and functioning equipment
95
Reconstituting a powdered medication for parenteral administration:
1. Perform hand hygiene and don clean gloves
2. Withdraw an amount of air from the vial equal to the prescribed amount of diluent to create negative pressure that will be equalized when the diluent is injected into the vial
3. Inject the appropriate diluent into the vial. DONT SHAKE
5. Withdraw the medication from the vial into a sterile syringe for administration
6. Label
96
Gentle, continuous bubbling in the suction control chamber of the chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. T/F
TRUE
97
ABGs:
Indicate the acid-base balance in the body and how well oxygen is being carried to the tissues.
-It is common to measure ABGs after ventilator change to assess how well the client has tolerated it
98
What factors can impact the ABG results
- Changes in the clients activity level or oxygen settings
| - Suctioning within 20 minutes prior to blood draw
99
What should be assessed periodically in a client receiving enoxaparin?
- Anticoag that can cause bleeding and thrombocytopenia
| - A CBC (hemoglobin, hematocrit, platelet count) should be assessed.
100
What should be monitored before the administration of digoxin>
Dig tox = >2
| -Potassium levels should also be monitored in clients
101
Clients prescribed prednisone should be observed for what?
Hyperglycemia
102
INR is monitored when clients are receiving what med?
Warfarin
NCLEX REVIEW
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