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NUR 366 Psychomotor 2 Exam
Terms in this set (99)
What is the standard size range for an indwelling urinary catheter? What is the standard balloon size?
14-16 French; 10 mL
Unless the pt is using a belly bag with a special valve, the catheter back should always be kept where? When should the bag be emptied, and how often should catheter care be provided?
Below the level of the bladder; when 1/2 full, or every 8 hours; at least every 8 hours
In order to avoid CAUTI, how should samples be obtained?
Use sampling port, clean it, use a sterile syringe
What should be done before transfers or activity in patients with catheters to prevent CAUTIs?
drain all urine from the tubing into the bag and empty the bag
What are the three types of catheters?
Straight (no balloon, single lumen for urine to drain out); indwelling retention (double lumen - one for air to balloon and one for urine); triple-lumen (air, urine, and irrigation solution - a CBI)
What is the key intervention for preventing HAUTIs?
Removing catheters as soon as possible (when no longer needed)
The presence of large proteins in the urine (proteinuria) is a sign of ____.
The size of the catheter is usually printed on the ____.
UTIs are often caused by which bacteria? What are the three most common nursing-related causes of UTIs?
Poor hand hygiene, inadequate peri care, poor insertion technique
If you have to raise the catheter bag above the level of the bladder, what should you do?
Clamp the tubing or empty the contents of the tubing into the drainage bag
When can a urine specimen be obtained from a catheter bag?
When the catheter is first inserted
Which portion of the catheter tubing should be cleaned during catheter care?
1st 4 inches
Patients should void within _____ hours of catheter removal.
Never administer IV medications through tubing that is infusing _____, ______or _____.
blood, blood products, parenteral nutrition solutions
A piggyback is attached _____ the primary IV bag.
What does CATS PRRR stand for?
C=compatibilities, A=allergies, T=tubing correct, S=site checked, P=pump safety checked, R=right rate, R=release clamps, R=return
What is a nurse's responsibility with a nurse-activated piggyback system?
The nurse must remember to break the seal between the vial and the bag so the med will be administered
If you are adding medication to an IV fluid, it should be a _____, and you should _____.
new bag, verify with another nurse
Each intermittent infusion usually contains ____ to ____ mL of fluid.
When a piggybacked IV solution begins to flow, what happens to the solution from the primary line?
It is stopped by a back-valve and restarted with the piggybacked solution is finished
What is a common error that prevents piggybacked IV solutions from infusing properly?
Forgetting to release the roller clamp
Before you administer medication through a saline-locked IV line, what should you do?
Assess IV site for swelling/inflammation; cleanse port w/alcohol; flush w/2-3 mL of normal saline
____ at an IV site can be a sign of infiltration.
What do you do if you have to give an incompatible medication via IV bolus?
Flush, give the medication, then flush again
Intravenous tubing administration sets can remain sterile for ____.
96 hours (4 days)
Gauze dressings over IV sites must be changed every ____ hours.
What are the elements of a complete order for IV therapy?
Elements of a complete order include patient identification, type of solution or medication, volume, rate of infusion, frequency of infusion, route, dosage (medication) and any special considerations.
What two things should you check before administering potassium?
Pt has adequate renal perfusion (output of 30 mL/hr or more) and the potassium is adequately diluted and given slowly
It is recommended by the Infusion Nurses Society (INS) that a single nurse should not make more than ____ attempts at inserting an IV on any one patient.
When should you perform site care on short peripheral IV catheters?
Only if dressing becomes soiled or is no longer intact; every 48 hours for gauze dressings
Continuous IV infusions should be checked every 1-2 hours for what?
Patency and site integrity, correct type/amount of solution has infused (bag level and infusion totals on machine), infusion or drip rate
In the case of phlebitis, the IV site may be _____; in the case of infiltration and/or extravasation, the site may be _____.
What should you do in case pt receiving IV fluids shows signs of fluid volume excess?
Reduce infusion rate and call provider
You should never _____ flush an IV.
If you are unable to flush an IV catheter and no mechanical cause is found, what should you do?
Aspirate for blood return; if none, start a new IV
If infiltration without extravasation occurs, what should you do?
Start a new IV either in a more proximal location on the same limb or on the other arm; wrap the infiltration site in a warm, moist towel for 20 min.
What do you do if phlebitis develops?
Start a new IV on other arm
What do you do if infection develops at IV site?
Stop IV, notify provider, retain IV catheter/tubing for culture
If you let your IV run dry for too long, what can happen?
A clot can occlude the line
What is the minimum rate to KVO?
_____ crackles indicate fluid volume overload.
If an electronic infusion pump is not available, an _____ may be used. They measure fluids based on _____, and the rate should be verified ____.
IV flow control device, gtt/min, every hour
What is the purpose of the drip chamber?
To verify the number of gtt/min on drip tubing
What is the purpose of the roller clamp on drip tubing?
Used to alter or stop the drip rate
Tubing for continuous infusions should be changed every ____ hours, but the tubing for intermittent IVs should be changed every _____ hours.
96 (4 days), 24 hours
What are the two types of short-term CVADSs?
Nontunneled percutaneous (can stay in several weeks), PICC (peripherally-inserted central catheters - can stay in several months)
External Tunneled (Hickman, Broviac, Groshong) CVADs and implanted venous ports are considered _____. How are they implanted?
Gauze dressings that cover a CVAD site must be changed every ____ hours. When else should you change them?
48 , when changing the catheter, when dressing becomes wet, loose, or soiled
You should not _____ or _____ from the arm with a PICC or midline catheter.
take blood pressures, draw blood
What is a midline catheter?
Shorter version of a PICC - tip rests in upper arm
What are the three types of external tunneled CVADs?
Groshong, Hickman, Broviac
A pt with a CVAD is cyanotic and reports dyspnea. What should you suspect?
What is a CLABSI?
Central-line associated bloodstream infection
When administering medications, obtaining a blood sample, or changing a dressing for a CVAD, how should you position the patient?
Supine, with HOB slightly elevated
A transparent dressing on a CVAD should be changed every _____, or when it becomes _____ and _____.
7 days, loosened, moist
The two most common complications of CVADs are _____ and _____.
Under what circumstances can erythroblastosis fetalis (fetal hemolysis) occur?
Rh- mother has been exposed to Rh+ blood (possibly via previous Rh+ pregnancy); she has now developed anti-D (anti-Rh) antibodies; these are transferred to the Rh+ fetus, and a reaction occurs
Blood products must be _____, and each one may be used for up to ____ of blood.
filtered, 4 units
Tubing should be changed between the administration of ______ and _____.
RBCs/whole blood and platlets
When administering a blood product, the filter must be _____; the drip chamber should be _____.
completely covered, half full
If IV fluids or medications are needed during a blood transfusion, what is needed? What is the exception?
a 2nd IV site; normal saline
Obtain _____ before initiating a transfusion. Under what circumstances should you hold the transfusion?
temperature, Fever >100/37.8
_____ must be obtained from the patient before initiating a transfusion. What is the exception to this?
Calcium binds to ______. What does this mean for blood transfusions?
citrate; blood products with citrate-containing anticoagulants should never be administered concurrently with calcium-containing electrolyte solutions (Lactated ringer's)
How long can blood products be used after the bag has been spiked (refrigerated/room temp)
Refrigerated (24 hours @ 1-6 C), room temp (4 hours)
Blood products must be used or _____ within _____.
refrigerated; 30 minutes
You should ask the patient to _____ before initiating a transfusion.
Initial flow of blood during the first 15 minutes should be ___ ml/min or __ gtt/min.
Patient should be monitored for at least _____ after beginning a transfusion. When should vital signs be checked?
15; 5, 15, 30, and 60 min.
You prepare to administer blood, but the pt's temperature is elevated. What should you do? Why?
Return blood to blood bank and notify provider; because you may not be able to administer the blood within 30 minutes
When administering blood, how often should administration sets be changed?
With each unit, or every 4 hours
Sites to avoid for IV insertion
1) Hands on very old or young pts 2) AC or other sites of flexion 3) Areas with infections or lesions 4) Sites with compromised circulation (fistulas, mastectomy, paralysis, blood clots) 5) Sclerosed, hardened, cordlike veins 6) Ventral side of arm (risk of tendon/nerve damage) 7) Valves/bifurcations 8) Sites distal to previous sites
What range of IV gauges are used for standard infusions?
20 (normal intermittent/continuous infusions, adults), 22 (normal intermittent/continuous infusions, elderly + children), 24-26 (very fragile veins)
For IVPB, squeeze the drip chamber until it is ____.
What are the advantages of central lines?
Better way to give large fluid volumes, irritant drugs, rapid dilution of hypertonic medications; less risk of extravasation, can have multiple lumens (less need for venupuncture), can stay in longer
What size IV catheter is usually used for blood products?
Air bubbles, clots or discoloration of blood products indicate ____ or _____, and they should ____.
bacterial contamination, inadequate anticoagulation, not be used
You must begin a blood transfusion within _____ of taking the blood from the blood bank. You must stay with the patient for ______ after the transfusion begins.
30 minutes; 15 minutes
You should always prime the filter on blood tubing with _____ before starting the flow of blood.
You should obtain ____ and ____, and ask about ____ before initiating a blood transfusion.
baseline vitals, written consent, allergies
What should you do in case of signs of a transfusion reaction?
1) Stop transfusion 2) Disconnect IV tubing at hub and cap 3) Run normal saline at KVO rate from new tubing 4) Save blood, tubing, bag, etc. 5) Call provider
In addition to a transfusion reaction, nurses should monitor for _____ when giving blood transfusions.
You should check _____ before administering a tube feeding. What should it be?
gastric residual volume; 250 mL or less;
Don't administer a tube feeding if gastric residual volume is ____.
500 mL or greater
How do you prepare tablet and capsule medications to be administered via feeding tube?
Tablets - crush and dissolve in 30 mL of warm water; capsules - break/dissolve/aspirate contents and dissolve in 30 mL of warm water
Typical meds given via PCA include ____ and ____.
morphine, hydromorphone (Dilaudid)
Pt education about PCA should be done _____. The _____ determines if a pt is a candidate for a PCA.
PCA pump setting should be verified by _____. The nurse should have _____ and _____ available in case of an overdose.
another nurse, oxygen, naloxone
For the first hour on a PCA pump, the pt's vital signs should be assessed _____.
every 15 min.
The Ramsay scale goes from ____ to ____. The higher the number the _____ the level of consciousness.
1, 6; lower
What are the three types of parenteral nutrition?
1) PN (no fat), 2) TPN - 2-in-one (fat and other components given separately) 3) 3-in-one TPN - all components given together
TPN is administered through a _____; it should have its _____.
central line; own port
To avoid hypoglycemia/hyperglycemia, you should not stop TPN _____ or ____ to "catch up" an infusion.
abruptly, increase the rate
Patients on TPN should have blood sugar monitored _____.
TPN tubing should be changed every _____. PN bags should not hang for more than _____ hours, and lipid bags should not hang for more than ____ hours.
24 hours; 24, 12
Parenteral nutrition requires _____.
Epidural medications should be _____. You should never use ____ or _____ around an epidural.
preservative-free; alcohol, bacteriostatic saline
Nurses may not ____ on an epidural or deliver a ____. What can they do?
change the dressing, bolus dose; change the rate
What should you do if an epidural catheter becomes disconnected?
Stop infusion, cover end of catheter w/sterile gauze, call provider
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