*REVIEW* FUNDAMENTALS-skills and procedures NCLEX

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where is the best place to inject enoxaparin? (low molecular weight heparin)
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Terms in this set (184)
Enoxaparin is a low-molecular-weight heparin used in the prevention and treatment of DVT. It is administered as a deep subcutaneous injection and is usually given in the abdomen. Clients or family members may be taught how to administer the injections. The injection should be made on the right or left side of the abdomen, at least 2 in from the umbilicus. An inch of skin should be pinched up and the injection made into the fold of skin with the needle inserted at a 90-degree angle.
In the event of a disaster involving the release of hazardous substances (eg, bioterrorism, chemical warfare agents), decontamination is vital to limit injury to the client and prevent exposure to other clients and staff. Disaster triage areas typically include a decontamination area (eg, showering station, cleansing station) that should be used to eliminate any residual hazardous materials and debris from the client.

In addition to bathing the client under copious amounts of running water, the nurse should remove any clothing or personal effects and discard them appropriately to further eliminate sources of hazardous material. After clients are appropriately decontaminated, necessary activities of care (eg, full assessment, diagnosis, intervention/treatment, planning) can be safely performed.
Ibuprofen is a nonsteroidal anti-inflammatory drug used to treat pain and fever in adults and children. Pediatric drug dosages are prescribed based on age and weight (unit per kilogram), either per 24 hours or per dose. A pediatric drug reference should be available, and the nurse must check medication prescriptions for the pediatric client prior to administration.
3-point gait -> 2-point gait -> 4 point gait

the 4-point gait is the most advanced gait. It requires weight bearing on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1 foot; 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left foot, and advance left crutch, then right foot.
1. Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent).
2. Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption.
3. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years. Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years.
4. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption.
5. Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion.
6. If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository.
All clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems.

The client takes gingko biloba to relieve symptoms of intermittent claudication; it was discontinued 2 weeks ago because it can increase the risk for excessive bleeding.

Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery.
When administering subcutaneous anticoagulant injections (eg, heparin, enoxaparin), the nurse must select the appropriate needle length and angle to avoid accidental intramuscular injection, especially in clients with insufficient adipose tissue (eg, cachexia). Intramuscular injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation.

The nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped. Anticoagulants are best absorbed if administered in the abdomen at least 2 in (5 cm) away from the umbilicus.
The priority when administering 2 IV medications concurrently is to determine drug compatibility. Incompatible drugs given through the same IV line will deteriorate or form a precipitate. This change is visualized through either a color change, a clouding of the solution, or the presence of particles. If 2 or more drugs are not compatible, the nurse may consider inserting a second IV or consulting the pharmacist and the health care provider to determine the safest and most beneficial plan for the client.
administration of benzodiazepine for sedationMidazolam (Versed) is a benzodiazepine commonly used to induce conscious sedation in clients undergoing endoscopic procedures. The initial dose is 1 mg and is titrated up slowly (eg, 2 minutes before each 1-mg increment) until speech becomes slurred. Usually no more than 3.5 mg is necessary to induce conscious sedation. It is commonly administered with an opioid analgesic (eg, morphine, Fentanyl) because of their synergistic effects. Side effects can include airway occlusion, apnea, hypotension (especially in the presence of an opioid), and oxygen desaturation with resultant respiratory arrest. Flumazenil (Romazicon) is the antidote drug used to reverse the sedative effects of benzodiazepines.what medication is given for extrapyramidal side effects of antipsychotic medications?Benztropine (Cogentin) is used in the treatment of extrapyramidal side effects associated with antipsychotic medications or metoclopramide.enoxaparin injection and air bubbles in pre-filled syringesLow-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication errorsteps of the z track techniqueThe Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue and is universally recommended for the administration of IM injections. Displacing the skin while injecting the medication, and then releasing the skin back to its normal position after removing the needle creates a zigzag track. The procedure for administering an IM injection using the Z-track technique includes these steps: 1. Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site. 2. Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle - taut skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle. 3. Inject the medication slowly into the muscle while maintaining traction - slow injection promotes comfort and allows time for tissue expansion to facilitate absorption of the medication. 4. Wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin; this allows the medication to diffuse before needle removal and helps to prevent tracking. 5. Release the hold on the skin - this allows the tissue layers to slide back to their original position, sealing off the needle track. 6. Apply gentle pressure at the injection site, but do not massage as this can cause the medication to seep back up to the skin surface and cause local tissue irritationpulse oximeterA pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached to the client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO2).factors that affect pulse O2 monitor readingsNormal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO2 include: 1. Dark fingernail polish or artificial acrylic nails 2. Hypotension and low cardiac output (eg, heart failure) 3. Vasoconstriction (eg, hypothermia, vasopressor medications) 4. Peripheral arterial diseasenorepinephrine and extravasationExtravasation is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established.treating extravasation from norepinephrineThe nurse should implement the following interventions to manage norepinephrine extravasation: 1. Stop the infusion immediately and disconnect the IV tubing 2. Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. 3. Elevate the extremity above the heart to reduce edema 4. Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine)what is the antidote for adrenergic agonists such as norepinephrine and dopaminephentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine)bumetanide (bumex)Bumetanide (Bumex) is prescribed for clients with heart failure to promote diuresis and mobilize excess fluid in the systemic circulation and the lungs, which results in increased cardiac output and improved gas exchange.scopolamine patchScopolamine is an anticholinergic medication used to prevent nausea and vomiting from motion sickness and as an adjunct to anesthesia to control secretions. Transdermal scopolamine is placed on a clean, dry, hairless area behind the ear for proper absorption. Clients should be instructed to: 1. Apply the patch at least 4 hours before starting travel to allow for absorption and medication onset. Patches usually have slower onset but longer duration of action. 2. Replace the patch every 72 hours as prescribed to guarantee ongoing medication absorption. 3. Remove and discard the old patch before placing a new one behind the opposite ear to prevent overdosing. 4. Dispose of the patch out of reach of children and pets to avoid accidental toxicity. 5. Wash hands with soap and water after handling the patch to avoid inadvertent drug absorption and contact with the eyeswhat kind of IV solution should be provided to a patient with anaphylactic shockAnaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients.huff cough for COPDThe low-pressure "huff" cough, which uses a series of mini-coughs, is more effective in mobilizing and expectorating secretions in clients with COPD. When this technique is done correctly, there is less airway collapse, less energy and oxygen consumption, and greater secretion removal. The steps are as follows: 1. Position upright - maximizes lung expansion and gas exchange 2. Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths - deflates excess air from lungs 3. Hold breath for 2-3 seconds following an inhalation, keeping the throat open - opens glottic structures and prevents a high-pressure cough 4. Deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound (huff cough); repeat 2 more times (eg, "ha, ha, ha") - keeps airways open while moving secretions up and out of the lungs. 5. Inhale deeply using abdominal breathing and give one forced huff cough - the last, increased force ("ha") usually results in mucus being expectorated from the larger airways.therapeutic partial thromboplastin time should not exceed what?70 secondswhy a client with asthma exacerbation needing corticosteroids is not a priority over a client with heart failure and shortness of breathEven though this client has asthma exacerbation, steroids (methylprednisolone [Solu-Medrol]) do not show their effect immediately. These drugs control underlying inflammation but take several hours/days to take effect. Bronchodilators such as albuterol or ipratropium work immediately.trazadoneantidepressant and sedative. Priapism is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department.adenosine and administrationAdenosine is the drug of choice to treat SVT and has a 5- to 6-second half-life (the time it takes for the drug to be reduced to half of its original concentration). Placing the IV line as close as possible, not distal, to the heart is essential for the drug to have full effect. Adenosine is given rapidly over 1-2 seconds and then followed by a rapid 20-mL normal saline flush. Transient asystole is common, and clients often experience flushing and dizziness.what is the initial intervention for a client with supra ventricular tachycardiaClients with paroxysmal supraventricular tachycardia (SVT) (regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers. The act of "bearing down" as if having a bowel movement (Valsalva) is an example of these maneuvers and may need to be attempted more than once. Vagal maneuvers work by increasing intra-thoracic pressure and stimulating the vagus nerve, which supplies parasympathetic nerve fibers to the heart, resulting in slowed electrical conduction through the atrioventricular node.tourniquet application and pulsating red bloodA tourniquet is applied 3-5 inches above the desired puncture site for no longer than 1 minute when looking for a vein. If longer time is needed, release the tourniquet for at least 3 minutes before reapplying. Prolonged obstruction of blood flow by the tourniquet can change some test results. The filled tube should be gently inverted 5-10 times to mix anticoagulant solution with the blood. Vigorously shaking the tube can cause hemolysis and false results. Pulsating bright red blood indicates that an artery was accessed. If this happens, the needle should be removed immediately and pressure should be applied for at least 5 minutes, followed by a pressure dressing to prevent a hematoma.application of ophthalmic medicationsIf applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination Wait 5 minutes before instilling a different medication into the same eyethoracentesisThoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier.lumbar puncture positionfetal position, with knees drawn to abdomen and hands clasped around themreasons to change peripherally inserted catheter sites.Peripheral IV (PIV) catheter sites should be changed usually no more frequently than every 72-96 hours unless signs of complications develop. Signs of phlebitis include erythema, edema, warmth, pain, and palpable venous cord. Manifestations of infiltration include edema and coolness to the touch around the insertion site (Option 1). The nurse should also monitor for edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent areas without obvious signs of infiltration at the PIV site, particularly in the elderly. If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change Potassium is a known irritant to veins. Discomfort is not a sign of infiltration, although the site should be regularly monitored for complications. Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location.8 month old infant with vomiting and diarrhea concernsPersistent vomiting and diarrhea in an 8-month-old would warrant concern for dehydration. IV fluid resuscitation may be required. This client, with potential circulatory compromiseinterventions during newborn circumcisionApplication of a blanket restraint or the use of a special board prevents injury during circumcision. Swaddling and the use of non-nutritive sucking are nonpharmacologic approaches to manage pain during circumcision. A loose-fitting diaper is put on the newborn after circumcision to avoid irritation to the penis. Sterile technique is used during the surgical procedure of circumcision. The infant should not be fed during circumcision to prevent the risk of aspiration. A pacifier dipped in a concentrated sucrose solution is offered as a nonpharmacologic pain management technique.paracentesisParacentesis is a procedure that involves removal of excess fluid from the peritoneal cavity (ascites) and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal (>5 L). The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia (eg, orthostatic hypotension, tachycardia, reduced pulse volume, decreased urine output), as decreased circulating volume can lead to hemodynamic instability.abdominal paracentesis positioningAbdominal paracentesis is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder punctureair embolus positioningIn the event of an air embolus, the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the clientchest tube insertion positioningChest tube insertion should be performed with the client's 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 diaphragmpost liver biopsy positioningAfter a liver biopsy, the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk.lumbar puncture positioningDuring a lumbar puncture, the client is positioned side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine or with head of the bed elevated 30 degrees).what side does the nurse stand on during an abdomen assessment?right sidecontraindications to an MRIMagnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium. A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP. Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. Smoking does not affect MRI visualization and is not a contraindication.febrile seizuresThis client likely has febrile seizures. It is important to never leave seizing clients alone as the goal is to prevent them from causing self-injury. The nurse should call out for help if needed. The main objective is to ensure that seizing clients maintain their airway; therefore, it is important to monitor their oxygen saturation levels. If these levels begin to drop or cyanosis occurs, prompt intervention is needed, which may be as simple as a head tilt or jaw thrust. Aspirin should not be used in children to treat fever, except in a setting such as Kawasaki disease; this is because aspirin use is associated with Reye syndrome (swelling of the liver and brain). Fever in children is treated with ibuprofen or acetaminophen. Most clients experiencing a febrile seizure do not require anti-seizure medications to stop convulsions. Once seizing has stopped, the fever needs to be treated. If seizing is continuous, medication administration may be necessary. Many clients experiencing a febrile seizure are able to maintain their own airway with no intervention needed. It would not be necessary to bag mask this client if there are no signs of hypoxia or distress.reasons for suction in endotracheal tubingClients with endotracheal tubes (ETTs) have impaired cough and gag reflexes and require suction to clear retained bronchial secretions and promote ventilatory efficacy. Ventilator circuits for ETTs typically have a reusable in-line endotracheal suction device, which remains sterile, in a flexible plastic sleeve. Oral secretions may pool near the base of the ETT and drip into the trachea; therefore, oropharyngeal suctioning and oral care are performed before ETT suctioning to prevent introduction of oral bacteria into the lungs.steps for suctioning endotracheal tubeThe steps for suctioning an ETT include: 1. Perform hand hygiene and don clean gloves 2. Suction the oropharynx and perform oral care 3. Ensure that the system is connected to appropriate wall suction (<120 mm Hg). 4. Hyperoxygenate the lungs (100% FiO2) 5. Advance the catheter into the trachea just until resistance is met (level of the carina) 6. Do not suction while advancing the catheter. 7. Gently remove the catheter while suctioning and rotating it. Do not suction for more than 10 seconds 8. Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. 9. Document the procedure when complete 10. Resume oxygenation and ventilation settings as prescribed.foreign aspiration of a batteryForeign body aspiration can be life-threatening depending on the object's location, type, and size. Up to 50% of children with foreign body ingestion are asymptomatic at the beginning. Alkaline batteries can be corrosive to the esophageal and intestinal mucosa; if ingested, they must be removed emergently by endoscopy as perforation can occur.what catheter gauge is recommended for blood transfusionAn 18-gauge catheter is typically indicated for infusing blood or large amounts of fluid in adults.when to use large bore IV catheter to give IV fluidsA 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or for hypovolemicadministration of cleansing enemaCleansing enemas (eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon. Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration. Lubricate the enema tubing tip and gently insert 3-4 in (7.6-10 cm) into the rectum. Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation. Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes). Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administrationroutes of parenteral medicationsParenteral medications are administered via injection into body tissues using aseptic technique (eg, intradermal, intramuscular, subcutaneous, IV).intradermal medication administrationAdminister injections at a 5- to 15-degree angle to reduce risk of injection into subcutaneous tissue. Apply firm pressure to the injection site to reduce bleeding. Massaging the site introduces medication into deeper tissues and should be avoidedintramuscular medication administrationAcceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal is preferred as fewer large blood vessels and nerves are present. Position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections. Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfortwithdrawing medication from an ampuleUse a filter needle when withdrawing medication from a glass ampule to prevent aspiration and injection of glass. After the medication is withdrawn, the filter needle can be discarded and an injection needle can be attached (eg, 20-gauge, 1-in [2.5-cm] needle).correct placement of an arm slingTo 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 to support the forearm, prevent swelling, and relieve shoulder pressure 2. Hand is held slightly above the level of the elbow, through adjustment of the neck strap, to prevent venous pooling and edema 3. Bottom of the sling ends in the middle of the palm with the fingers visible, to be able to assess circulation, sensation, and movement 4. sling supports the wrist joint with the thumb facing upward or inward toward the body, to maintain proper alignment 5. Skin irritation, which can occur under the sling and around the neck if the strap is too tightcollecting urine specimen from a child who is not toilet trainedNephrotic syndrome is characterized by massive proteinuria and hypoalbuminemia, which results in severe edema most evident in the abdomen, face, and perineum. Daily dipstick urinalysis determines the presence and pattern of urine protein loss to monitor for exacerbations. To collect a nonsterile urine specimen from a child who is not toilet trained, the nurse can place several cotton balls in a dry diaper and later squeeze urine onto a dipstick. The diaper is checked frequently and the sample collected and tested within 30 minutes of urination for the most accurate result.nephrotic syndrome and immunosuppressionChildren with nephrotic syndrome have a high risk for infection from immunosuppressive effects of corticosteroid therapy. Intermittent or continuous catheterizations are invasive procedures that may cause urinary tract infections. Urine cultures are the only specimen requiring sterile collection techniques (eg, clean catch, catheterization).administering medications in a clients feeding tubeFailure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form as liquid medications are less likely to clog the tube Medications should be crushed, dissolved, and administered separately to prevent interactions (chemical reactions) between medications or interference with absorption A feeding tube should be flushed with sterile water to avoid drug interactions and eliminate contaminants found in tap water. The feeding tube should be flushed before and after each medication is given When using a feeding tube, each medication should be administered individually to prevent interactions between medications. Medications mixed with enteral feedings may form a thick consistency and clog the tube.what is the only IV solution that should be run with blood productsNormal saline (NS) is the only fluid that can be given with a blood transfusion. Dextrose solutions may lyse the red blood cells. All other IV solutions and medications may cause precipitation and are incompatible with blood. Blood transfusions should be infused through a dedicated IV line. If a transfusion must be started in an IV catheter currently in use, the nurse should discontinue the infusion(s) and tubing, and then flush the catheter with NS prior to connecting the blood administration tubing. After transfusion, the catheter should be cleared with NS before any other IV fluids are administered.wound irrigationBefore an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil or dirt greatly increases the risk of infection. To perform wound irrigation: 1. Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect. 2. Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. 3. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. 4. Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. 5. Use continuous pressure to flush the wound, repeating until drainage is clear. 6. Dry the surrounding wound area to prevent skin breakdown and irritation. 7. Immunization history is reviewed to determine tetanus vaccination status. Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound.administration of potassium chlorideTreatment of hypokalemia may require an IV infusion of potassium chloride (KCL). The infusion rate should not exceed 10 mEq/hr (10 mmol/hr). Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. IV KCL should be diluted and never given in a concentrated amount. Furthermore, too rapid infusion can cause cardiac arrest. The charge nurse would need to intervene if the new nurse was attempting to administer IVPB KCL via gravity infusion instead of a pump.gastric pH and NG tube placementGastric pH should be acidic (pH ≤5). A pH ≥6 requires x-ray confirmation of tube placement. In addition, any newly inserted nasogastric tube requires x-ray confirmation of tube location.nursing actions before starting a feedingThe head of the bed should be elevated to a minimum of 30 degrees (semi-Fowler position) during enteral feedings and for 30-60 minutes afterward, thereby decreasing aspiration risk. Many institutions have policies that require the nurse to hold the feeding if the client must be supine (eg, diagnostic tests). Gastric residual volumes are checked every 4 hours with continuous feeding or before each intermittent feeding and medication administration. Continuing feedings despite a large volume residual increases the client's risk for emesis and aspiration. Recent evidence suggests that holding the feeding for a residual volume >100 mL is not necessary, and some institutional policies allow a residual volume of up to >500 mL as long as the client is asymptomatic. Flush the tube before and after bolus feedings to keep the tube patent and avoid contamination of the stagnant feeding solution. Sterile fluid is used to help prevent infection in vulnerable clients. Aspirated residual volume should be returned to the stomach. If acidic gastric juices are repeatedly discarded (2,500 mL secreted daily), there is risk for metabolic alkalosis and hypokalemia.The steps for administering a continuous enteral feeding include: 1. Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) (Option 4) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. 2. Elevate the head of the bed ≥30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration 3. Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation 4. Check gastric residual volume. 5. Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration 6. Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pumpinterventions for a client with air embolismPriority interventions for active or suspected air embolism are as follows: 1. Clamp the catheter to prevent more air from embolizing into the venous circulation. 2. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. 3. Administer oxygen if necessary to relieve dyspnea. 4. Notify the HCP or call an RRT to provide further resuscitation measures. 5. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.glycoprotein IIb/IIIa receptor inhibitors - platelet inhibitorGlycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) are used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention. The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk. Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administeredophthalmic ointment at bedtimeSome clients use the ophthalmic ointment at bedtime and the eye drops during the day due to blurred vision that ointments and gels can cause.sputum collectionSputum collection is prescribed to identify respiratory pathogens (eg, in the setting of bacterial pneumonias or tuberculosis). Collection should be done in the morning, as secretions accumulate overnight. A nebulizer treatment may be prescribed to help mobilize secretions. To collect a sputum specimen, the nurse should instruct the client to: 1. Rinse the mouth with water to reduce specimen contamination by oral flora 2. Sit on the side of the bed, if possible, or in a high or semi-Fowler position to allow maximum lung ventilation and expansion 3. Inhale deeply several times to provide enough air to force secretions from the lower airways to the pharynx 4. Cough deeply to raise enough sputum (4-10 mL), and expectorate into the sterile specimen container The nurse should immediately close and label the specimen container as this will prevent contamination or transmission of microorganisms and assure proper client information. The specimen and requisition are transported to the laboratory per policy; some specimens must be sent immediately, and others may be refrigerated. The nurse should then provide oral care for the client and document pertinent information (eg, sputum characteristics, tolerance of procedure).liver biopsyThe client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy. Blood should be typed and crossmatched in case hemorrhage occurs. After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later. The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. the client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.NG tube insertionDuring NG tube insertion, the tube sometimes slips into the larynx or coils in the throat, which can result in coughing and gagging. The nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths. After the client stops coughing, the nurse can proceed with advancement, asking the client to take small sips of water to facilitate advancement to the stomach. The client should not be asked to swallow during coughing or aspiration may occur. If resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it. If resistance continues, the tube should be withdrawn and inserted into the other naris if possibleTST (Mantoux) testTST (Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: Injection of purified protein derivative solution under the first layer of skin of the forearm Evaluation of the injection site 48-72 hours later The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB.QuantiFERON-TB blood testThe QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB bacteria. Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is more expensive, it requires only a single visit to the health care provider and results are available in 24 hours.Sodium polystyrene sulfonate (Kayexalate)Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia. Potassium is exchanged for sodium in the intestines and excreted in the stool, thereby lowering the serum potassium. In clients without normal bowel function (eg, post surgery, constipation, fecal impaction), there is a risk for intestinal necrosis. During sodium polystyrene sulfonate therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop. Frequent monitoring of electrolyte status is required. Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk of developing volume overload (water follows sodium). The client should be monitored for signs of fluid overload (eg, crackles, jugular venous distension, edema) and have daily weights and intake and output assessment. the most important assessment prior to administration is assessment of the client's abdomen and reviewing the medication record for frequency of stoolspreschooler and medication administrationPediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of controlhow much fluid should you flush into a lumen of a central venous catheterFlushing the lumen of a central venous access device (central venous catheter [CVC]) with normal saline is recommended to assess patency before medication infusion, prevent medication incompatibilities after infusion, and prevent occlusion after blood sampling. A 10-mL syringe is generally preferred for flushing the lumen of a CVC. The smaller the syringe, the greater the amount of pressure per square inch exerted during injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting normal saline into the CVC catheter and stopping for any resistance. Injecting against resistance can damage the CVC, which may result in complications, including embolism and malfunction. The nurse should always consult the specific manufacturer guidelines and facility policy when caring for a CVC.IV insertion for a client with radical mastectomyA modified radical mastectomy includes removal of axillary lymph nodes that are involved in lymphatic drainage of the arm. Any trauma (eg, IV extravasation) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefore, starting an IV line in this arm is contraindicated. The nurse should insert the IV line into the most distal site of the unaffected side (Option 2). For client safety, it is also important to ensure documentation of the mastectomy history, place a restricted extremity armband on the affected arm, and place a sign above the client's bed notifying hospital staff of necessary mastectomy precautions (eg, no blood pressure measurements, venipuncture, or IV lines) In general, venipuncture is contraindicated in upper extremities affected by: Weakness Paralysis Infection Arteriovenous fistula or graft (used for hemodialysis) Impaired lymphatic drainage (prior mastectomy)fentanyl patchFentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one. Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregiversindwelling catheter for a femaleCritical steps to indwelling catheter insertion for the female client include the following: 1. Perform hand hygiene 2. After ensuring privacy, position client in the dorsal recumbent position and drape 3. Open the catheterization kit on a clean bedside table or between client's legs 4. Touching only the outside 1" border, place sterile drape under the client's hips 5. Apply sterile gloves 6. Apply fenestrated drape over perineum 7. Organize remaining items in the kit. Place top tray on a sterile field and ensure the clamp on the catheter is closed. 8. Open antiseptic swabs with stick end up or pour antiseptic solution over cotton balls 9. Squirt lubricant into tray 10. Remove protective sheath from catheter and place the tip in lubricant 11. Using the nondominant hand, spread the labia to expose the urethral meatus 12. Use the antiseptic swab (or cotton ball with forceps) to cleanse the perineum. Wipe in the direction from clitoris to anus. Always use a new swab or cotton ball with each swipe. Cleanse far labial fold, near labial fold and finally the meatus. 13. Using the dominant hand, pick up catheter and insert until urine is visualized (usually about 3"), then advance another 1-2". If obstruction occurs, do not force the catheter. 14. Let go of the labia but hold the catheter securely in place with the nondominant hand. Inflate the balloon according to manufacturer instructions (most manufacturers now warn against testing the balloon prior to insertion) 15. Anchor indwelling catheter and secure drainage bag to the bed framewhat do you do if the client has stopped breathing and is DNR?check the apical pulsedrawing blood for a laboratory testWhen performing phlebotomy, clean the site, "fix" or hold the vein taut, and then insert the needle bevel up at a 15-degree angle (no steeper than 30 degree). Some recommend bevel down for children. This will help prevent going through the vein completely. The Infusion Nurses Society (INS) identifies the standard of care as no more than 2 attempts by any 1 individual. If the nurse is unable to successfully draw blood after 2 attempts, a phlebotomist or a different nurse should be asked to complete the blood draw. The affected side of a client who has had a mastectomy (especially with lymph node removal) should not be used. It places the client at risk for infection and lymphedema. An arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between. The finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges tends to make the blood run down the ridges and will hamper collection. A heel stick collection on an infant should be done on the plantar surface.suctioning an artificial airwayThe process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option 1). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4). In addition, deep rebreathing should be encouraged. The suction catheter should be no more than half the width of the artificial airway and inserted without suction. The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and can cause hypoxia. Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction.what the nurse initially monitors for after thoracentesisThoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain. A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring.24-hour urine collectionA 24-hour urine is collected to evaluate Cushing syndrome (a condition that results from chronic increased corticosteroids). The urine is tested for free cortisol, and results >80-120 mcg/24 hr (220-330 nmol/day) indicate that Cushing syndrome is present. Instructions for collecting a 24-hour urine are as follows: -Use a dark jug containing a special powder (obtained from the lab) to protect the urine from light during collection. The powder helps preserve the urine and adjusts its acidity. -Collection of the 24-hour urine should span over exactly 24 hours. It is important to first record the time and empty the bladder into the toilet so that the start time coincides with an empty bladder. At that exact time the next day, the bladder should be emptied for a final time and collected into the jug. All urine between the start time and end time should be collected into the container. The time for each urination between start and end does not need to be recorded. -Keep the urine in a refrigerator or a cooled ice chest with the lid tightly screwed on for preservationdrawing up regular and NPH insulin1. Clean both vial tops with alcohol swabs 2. Inject air into the NPH insulin vial without touching the needle to the solution 3. Withdraw the needle from the NPH insulin vial and inject air into the regular insulin vial 4. Invert the regular vial and withdraw the regular solution into the syringe 5. Insert the needle into the NPH insulin vial and withdraw the solutionmixing insulinsMixing insulins allows multiple insulin preparations to be delivered in a single subcutaneous injection, thereby sparing the client from multiple injections. Intermediate-acting insulins (eg, NPH) can be mixed with short-acting (eg, regular) or rapid-acting (eg, aspart, lispro) insulins. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and are typically packaged in prefilled syringes. When drawing up multiple insulins, there is a risk for contaminating the shorter-acting vials with the longer-acting insulin, which would slow the action of later doses withdrawn from the shorter-acting insulin vial. Multidose vials of regular insulin that have been contaminated with other insulins are unsafe for IV administration.when do administer IV narcotics to a laboring womanAdministration of IV narcotics (eg, nalbuphine, butorphanol, meperidine) during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth. Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief.hydromorphone administrationHydromorphone IV push, given undiluted or diluted with 5 mL of sterile water or normal saline, should be administered slowly over 2-3 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, nausea, itching).morphine sulfate administrationUndiluted morphine IV push should be administered slowly over 4-5 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, hypotension, flushing).ketorolacKetorolac is a nonsteroidal anti-inflammatory drug (NSAID) analgesic administered (orally, IV, or intramuscularly [IM]) for short-term relief of mild to moderate pain. Usage should not exceed 5 days due to adverse effects (eg, kidney injury, gastrointestinal ulcers, bleeding). Ketorolac IM should be administered into a large muscle using the Z-track method to mitigate burning and discomfort. A 1- to 1½-in (2.5- to 3.8-cm) needle is recommended to inject medication into the proper muscular space in average-weight individuals.cyanocobalaminMaintenance doses of cyanocobalamin for vitamin B12 deficiency are usually administered every 4 weeks.femoral-popliteal bypass surgeryFemoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately.allergic reaction to blood transfusionSigns and symptoms of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion. These include shortness of breath, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension. When a transfusion reaction is suspected, the first step is to stop the infusion. An infusion of normal saline is typically started. It is important that normal saline be administered through a different port of the CVC using new tubing or at the closest access point to the client. Flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction. The HCP must then be notified. Because the client has shortness of breath and chest tightness, an assessment of breath sounds is appropriate. Adventitious sounds could indicate bronchospasm or excess fluid in the lungssumatriptanSumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs, like sumatriptan, work by constricting cranial blood vessels, and clients should be instructed to take a dose at the first sign of a migraine to help prevent and relieve symptoms. Sumatriptan is contraindicated in clients with coronary artery disease and uncontrolled hypertension because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute myocardial infarction. The nurse should question the client about a past medical history of uncontrolled hypertension and report this to the health care providerpurpose of neonatal heel stickThe neonatal heel stick (heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria).performing a neonatal heel stickProper technique is essential for minimizing discomfort and preventing complications and includes: 1. Select a location on the medial or lateral side of the outer aspect of the heel. Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. 2. Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation. 3. Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain. 4. Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis.central venous catheter occlusionCatheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first assess for mechanical, nonthrombotic problems by: 1. Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall 2. Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath.what is pulses paradoxusPulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.how to measure pulses paradoxusThe procedure for measurement of pulsus paradoxus is as follows: 1. Place client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using a manual BP cuff 4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP 5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure 6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure 7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox 8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.what is not a therapeutic nursing intervention to limit risks associated with suctioningInstilling 5-10 mL of sterile normal saline solution (NSS) is thought to help loosen thick secretions and stimulate cough. Although saline lavage is a common practice in some facilities, the installation of NSS into the airway prior to suctioning is not recommended. It can dislodge bacteria, causing increased bacterial colonization, and can stimulate excessive coughing.complications with endoscopic retrograde cholangiopancreatographyEndoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase)abdominal cramps after colonoscopyAbdominal cramps can occur after a colonoscopy due to air inflation during the proceduregreen bile in small bowel obstructionCopious, bile-colored (greenish-brown) drainage is expected in a client with a small bowel obstruction. The nurse should watch for signs and symptoms of electrolyte imbalances (hypokalemia), dehydration, and metabolic alkalosis.When performing tracheostomy care, the nurse follows institution policy and observes principles of infection control and client safety. Sterile technique is used to prevent infection of the lower airway. The steps for performing the procedure for a client with a disposable inner cannula include the following: 1. Gather supplies to the bedside, then place client in semi-Fowler's position, if not contraindicated, to promote lung expansion and oxygenation and prevent aspiration of secretions. 2. Don personal protective equipment (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. Don sterile gloves; remove old disposable cannula and replace with a new one. While stabilizing the back plate with the nondominant hand, unlock (unclip) the old cannula with the dominant hand; remove gently by pulling it out in line with its curvature; pick up the new cannula, touching only the outer locking portion (to prevent contamination and maintain asepsis); insert; and lock (clip) into place. 5. Clean around stoma with sterile water or saline, dry and replace sterile gauze pad to remove dried secretions, and dry around stoma well to limit the growth of microorganisms. Some tracheostomy tubes are sutured in place and do not require a dressing. If secretions are copious, apply a dressing.otic administrationWhen administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal. For an infant, the pinna is pulled downward and straight back The medication dropper should be held near the entrance to the ear canal without touching it. This technique allows the drops to fall against the wall of the canal, reducing discomfort while avoiding contamination of the dropper. After instilling the drops, the child should remain with the affected ear up for several minutes to allow full coverage of the medication. Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage. Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazardsteps for a lumbar punctureA lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when assisting with a lumbar puncture includes the following: 1. Verify informed consent 2. Gather the lumbar puncture tray and needed supplies 3. Explain the procedure to older child and adult 4. Have client empty the bladder 5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) 6. Assist the client in maintaining the proper position (hold the client if necessary) 7. Provide a distraction and reassure the client throughout the procedure 8. Label specimen containers as they are collected 9. Apply a bandage to the insertion site 10. Deliver specimens to the laboratoryintervention for a client receiving a cleansing enema experiencing cramping and painToo rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation.assessment findings that indicate a need for suctioning1. Decreased oxygen saturation 2. Altered mental status (eg, irritability, lethargy) 3. Increased heart rate 4. Increased respiratory rate 5. Increased work of breathing (eg, flared nostrils, use of accessory muscles) 6. Adventitious breath sounds (eg, crackles, wheezes, rhonchi) 7. Pallor, mottled, or cyanotic skin coloringnormal infant respiration and heart rate valueheart rate - (normal infant range: 90-160) respiratory rate - (normal infant range: 30-60)safe blood administrationThe procedure for safe blood administration includes the following: 1. Obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 2 client identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time. 2. Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help. 3. Use a Y tubing, prime with NS, and then clamp the NS side. 4. Spike the blood product, leaving the blood side of the Y tube open while keeping the saline side clamped for infusion. The saline is only used to prime the tubing and flush after the infusion. It does not infuse simultaneously. 5. Set the infusion pump to deliver blood over 2-4 hours as prescribed. Rapid infusion of the blood puts the client at greater risk for transfusion reaction and fluid volume overload. 6. Remain with the client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion immediately if a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions. 7. Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always take a final set of vital signs after the infusion is complete. 8. On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through with NS. 9. Return the blood bag with the attached set-up to the laboratory after completion or dispose of in accordance with hospital policy. Use new IV Y tubing set-up for the second unit of blood.going up and down the stairs using a caneWhen descending stairs, the client should: Lead with the cane Bring the weaker leg down next (in this client, it is the left leg) Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: Step up with the stronger leg first Move the cane next, while bearing weight on the stronger leg Finally, move the weaker leg To remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg.instructions for using a clonidine (antihypertensive) patchInstructions for using the clonidine (transdermal) patch: 1. Apply the patch to a dry hairless area on the upper outer arm or chest once every 7 days. 2. Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars. 3. Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after application. 4. Wash the area with soap and water, then rinse and wipe with a clean, dry tissue. 5. Remove the patch from the package. Do not touch the sticky side. 6. Rotate sites of patch application with each new patch. Remove the old patch only when applying a new one. Do not wear more than 1 patch at a time unless directed by your health care provider (HCP). 7. When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested. 8. Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without discussing this with the HCP as rebound hypertension can occurtimed urine collection testTimed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voidingforeign body aspirationForeign body aspiration is an emergency that requires immediate intervention when witnessed or highly suspected. The primary rescue intervention for adults and children over age 1 is abdominal thrusts, known as the Heimlich maneuver. This maneuver entails applying upward thrusts with a fist to the upper abdomen just beneath the rib cage. The upward action causes the diaphragm to forcefully expel air out of the airway, carrying the foreign body out with it. If the child is conscious and able to cough or make sounds, the nurse should ask the child to forcefully cough before intervening. These signs indicate a partial obstruction still allowing airflow, which may be cleared with strong coughing. However, any signs of respiratory distress (eg, stridor, inability to speak, weak cough, and cyanosis) require immediate intervention.mixing of insulinsIntermediate-acting insulins (NPH) can be safely mixed with short-acting (regular) and rapid-acting (lispro, aspart) insulins in one syringe (Option 4). Six units of regular insulin are needed to address the client's blood glucose reading (220 mg/dL [12.21 mmol/L]) along with the scheduled 20 units of NPH insulin. Most long-acting insulins (eg, glargine, detemir) are not suitable for mixing and typically are packaged in prefilled injection pens. Regular insulin should be drawn first to avoid contaminating the regular insulin vial with NPH insulin (mnemonic - RN: Regular comes before NPH).giving ear drops not at room temperatureWarm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremesiron IVThere is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. This client should be assigned to a more experienced nurse.ultrafiltrationUltrafiltration (removal of excess fluid) is a complex task that requires extra training to perform. It is performed for clients who are not responding to IV diuretics. In addition, clients receiving ultrafiltration are more likely to be hemodynamically unstable due to their advanced heart failure; therefore, it is better for these clients to receive care from an experienced nurse.orthostatic vital signsOrthostatic vital signs help assess the body's ability to compensate hemodynamically during postural changes. Changing position normally triggers vasoconstriction in the extremities to promote venous return. Without this response, hypotension and subsequent hypoperfusion of internal organs and the brain occur. Clients with impaired compensatory mechanisms (eg, hypovolemia, sepsis) may exhibit orthostatic hypotension, in which hypotension and/or neurologic impairment (eg, syncope) occur with position change. This increases the client's risk for falls. Orthostatic vital signs involve measuring the client's blood pressure (BP) and heart rate in the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care providerchest tube drainage systemThe water seal chamber of the chest tube drainage system is filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity. The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling. This movement occurs in section B of the water seal chamber and indicates that the system is functioning properly and maintaining appropriate negative pressure. (Section A) This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. (Section C) The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. (Section D) This is the drainage collection chamber in which fluid from the client's pleural cavity will collect; the nurse will assess the color and amount and record the output. Educational objective: Tidaling is the fluctuation that occurs in the water seal chamber in relation to the client's respiratory movements. The level of sterile water will rise with inspiration and fall with expiration, indicating proper function of the chest tube drainage system.retrieving a wound cultureWound cultures identify microorganisms to aid in prescribing appropriate antibiotics and are obtained as follows: 1. Perform hand hygiene, and apply clean gloves. 2. Remove the old dressing. Remove and discard gloves. 3. Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline (eg, flushing, swabbing with gauze) to remove drainage and debris. Remove and discard gloves. 4. Perform hand hygiene, and apply clean gloves. 5. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin. Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. 6. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container. 7. Apply prescribed topical medication (eg, bacitracin) after obtaining cultures to prevent interference with microorganism identification. 8. Apply new dressing. 9. Remove and discard gloves, and perform hand hygiene. Label the specimen, and document the procedure. CHANGE GLOVES 3 TIMESImmediate postoperative nursing and nauseaImmediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit.tasks that can be delegated to the UAPMeasurement of vital signs Fingerstick blood glucose testing Personal hygiene and skin care Oral care (oropharynx suctioning) Passive or active range-of-motion exercises Measurement of urine outputwhat area should be avoided for IV insertionThe antecubital space should be avoided when possible (except for emergency insertion) as it inhibits mobility and may be positional. Other considerations when selecting IV sites include avoidance of areas that have obstructed blood flow, dialysis sites, areas distal to old puncture sites, bruised areas, painful areas, or areas with skin conditions or signs of infection.medications contraindicated in NG tubesenteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. for medications that are allowed, The nurse should flush the tube with water before and after each drug administration.SIADH and appropriate IV solutionsSyndrome of inappropriate antidiuretic hormone secretion (SIADH) is associated with increased water reabsorption and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional hyponatremia. In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45% NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance. A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia.first protein seen on urine dipstick. reasons for trace protein to be presentThe protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities. Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. Proteinuria is characterized by elevated urine protein and can be an early sign of kidney disease. Occasional loss of up to 150 mg/day of protein in the urine, which may reflect as negative or trace protein on a dipstick, is typically considered normal and usually does not require further evaluation. Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing.normal serum creatinine level0.6-1.3 mg/dLwhat surgeries are contraindicated when platelet count is <50,000Only neurosurgery and ocular surgery require a platelet count >100,000/mm3 (100 x 109/L). Most other surgeries can be performed when the platelet count is >50,000/mm3 (50 x 109/L). Although the platelet count is low (normal 150,000-400,000/mm3 [150-400 x109/L]), it is not the most important finding to report to the HCP.incentive spirometryIncentive spirometry is recommended in postoperative clients to prevent atelectasis associated with incisional pain, especially in upper abdominal incisions (close to the diaphragm). Adequate pain medication should be administered before using the incentive spirometry. Guidelines recommend 5-10 breaths per session every hour while awake. Volume-oriented or flow-oriented sustained maximal inspiration (SMI) devices can be used.client teaching to perform incentive spirometer breathingThe client instructions for using a volume-oriented SMI device include: 1. Assume a sitting or high Fowler position, which optimizes lung expansion, and exhale normally 2. While holding the device at an even level, seal the lips tightly on the mouthpiece to prevent leakage of air around it 3. Inhale deeply through the mouth until the piston is elevated to the predetermined level of tidal volume. The piston is visible on the device and helps provide motivation. 4. Hold the breath for at least 2-3 seconds (up to 6 seconds) as this maintains maximal inhalation 5. Exhale slowly to prevent hyperventilation 6. Breathe normally for several breaths before repeating the process 7. Cough at the end of the session to help with secretion expectorationpertussisParoxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious disease and requires droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation immediately to prevent the spread of disease.when is chickenpox no longer contagiousChickenpox is no longer contagious after the lesions have crusted and dried, but this process can take as long as 3 weeks. This client would not require isolation. (varicella vaccine)when is impetigo no longer contagiousImpetigo is no longer contagious after 24 hours of antibiotics. This client would not require isolation.how to measure for large bore NG tubeTraditional Method: Using the end of the tube that will eventually rest in the stomach, measure from the tip of the nose, extend the tube to the earlobe and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removedPCA pumps and continuous IV solutionPatient-controlled analgesia (PCA) delivers a set amount of IV analgesic each time the client presses the administration button. With many PCA pumps, a continuous IV solution (eg, normal saline) is required to keep the vein open and flush the PCA medication through the line so that the boluses reach the client. Many facilities have a policy regarding IV fluid for use with PCA; however, a prescription may be required. To ensure uninterrupted delivery of this client's PCA, the nurse should contact the health care provider to clarify the prescription to discontinue the normal saline.milliliters in a cup240 ml in a cupperforming NG tube insertion for gastric decompression1. Perform hand hygiene and apply clean gloves (no need for sterile gloves) 2. Place client in high Fowler's position 3. Assess nares and oral cavity and select naris 4. Measure and mark the tube 5. Curve 4-6" tube around index finger and release 6. Lubricate end of tube with water-soluble jelly 7. Instruct client to extend neck back slightly 8. Gently insert tube just past nasopharynx, aiming tip downward 9. Rotate tube slightly if resistance is met, allowing rest periods for client 10. Continue insertion until just above oropharynx 11. Ask client to flex head forward and swallow small sips of water (or dry if NPO) 12. Advance tube to marked point 13. Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below). 14. Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method. 15. Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration.chest tube removalA chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: 1. Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal. place them in semi-fowler's position 2. Provide the health care provider (HCP) with sterile suture removal equipment. 3. Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space 4. Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space 5. Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame.who is the universal blood recipient?AB+ is the "universal recipient" as the lack of antibodies allows any blood type to be transfusedhow long should a blood transfusion run for?Most facilities want the transfusion completed in 2-4 hours. "Old" blood is more likely to break apart and cause hyperkalemia from the intracellular potassium leak. Most policies have the RN checking with another RN or qualified health care professional prior to blood administration. At least 2 identifiers such as name, medical record number, or date of birth can be used. Client identifiers never include a room number.initiating IV therapySteps to promote safety and reduce infection risk when initiating IV therapy include the following: 1. Perform hand hygiene using Centers for Disease Control and Prevention guidelines 2. Prepare equipment: Open IV tray, prime tubing with prescribed IV solution for infusion, set IV pump if indicated, prepare tape, and open the over-the-needle catheter (ONC) with safety device 3. Don clean (non-sterile) gloves 4. Identify a possible venipuncture site 5. Apply a tourniquet, ensuring it is tight enough to impede venous return but not tight enough to occlude the artery 6. Select a venipuncture site after palpating the vein. Ask the client to open and close the hand several times to promote vein distension. The tourniquet may need to be released temporarily to restore blood flow and prevent trauma from extended application. 7. Clean the site with chlorhexidine, alcohol, or povidone iodine. Use friction and clean per facility protocol, either back and forth or in a circular motion from insertion site to outward area (clean to dirty direction). 8. Stretch the skin taut using the nondominant hand to stabilize the vein 9. Insert the IV ONC bevel up at a 10- to 30-degree angle and watch for blood backflow as the catheter enters the vein lumen, advancing ¼ inch into the vein to release the stylet. On visualization of blood return, lower the ONC almost parallel with the skin and thread the plastic cannula completely into the vein to the insertion site. Never reinsert the stylet after it is loosened. Use the push-tab safety device to advance the catheter. 10. Apply firm but gentle pressure about 1¼ inch above the catheter tip, release the tourniquet, and retract the stylet from the ONC 11. On removal, guide the protective guard over the stylet for safety and feel for a click as the device is locked. Never try to recap a stylet. 12. Attach a sterile connection of primed IV tubing to the hub of the catheter and stabilize the catheter with tape and dressing using sterile technique. Dispose of the stylet in the sharps container.why a client voids prior to a blood transfusionThe nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls.fluticasone nasal sprayFluticasone nasal is used to treat nasal symptoms such as congestion, sneezing, and runny nose caused by seasonal or year-round allergiesteaching for self-administration of nasal spray1. Assume a high Fowler's position with head slightly tilted forward 2. Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger 3. Point the nasal spray tip toward the side and away from the center of the nose 4. Spray the medication into the nose while inhaling deeply 5. Remove the nozzle from the nose and breathe through the mouth 6. Repeat the above steps for the other nostril 7. Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillationappropriate needle length and site for children <1 year oldThe needle length and injection site for IM injections are dependent on a client's age and muscle mass. The vastus lateralis muscle in the anterolateral middle portion of the thigh is the preferred IM injection site for newborns (age <1 month) and infants (age 1-12 months). Selection of the most appropriate needle length is an important factor in ensuring immunization success and minimizing local reactions to vaccine components. If the needle is too short, the IM vaccine is injected into subcutaneous fat, resulting in vaccine failure due to poor mobilization of the antigen within adipose tissue. Infants typically require a 1-in (25-mm) needle for IM injectionswhen can you begin using the ventrogluteal muscle for IM injectionsThe ventrogluteal area in an infant does not have enough muscle mass for use and is not recommended until at least age 3.what to do when a nasoenteric tube has been displaced while in the clientA nasoenteric feeding tube is used for administration of continual or intermittent enteral feedings and medications. The tube is marked at the exit site (nare) with indelible ink during the initial placement x-ray. The tube may have moved out of the correct position if its external length changes. If this occurs, the nurse should contact the health care provider (HCP) and request a prescription for a repeat x-ray to determine tube location. Based on the x-ray results, enteral feeding may be resumed or the HCP may prescribe insertion of a new tube according to institution policy Even if bedside methods to determine placement are used (eg, gastric aspirate pH and appearance), advancing the tube to the original marking does not guarantee correct placement; these methods are not accurate indicators. Tube feedings should not be resumed after tube dislodgment without x-ray verification of correct placement.central venous catheter useA central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring. Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port. CVCs may have multiple lumens. These are used to administer incompatible drugs simultaneously, for blood draws, and for hemodynamic monitoring. Enteral nutrition is given only through the GI tract (orally or through a feeding tube). Parenteral nutrition is administered through the IV route via a central vein.peripheral pulse ratings0 Absent 1+ Weak 2+ Normal 3+ Increased, full, boundingremoving a central venous catheterTo 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 air getting into the vessel. 2. Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure. 3. Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line 4. Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vesselPICC line migrationA peripherally inserted central catheter (PICC) is inserted via the basilic or cephalic veins into the superior vena cava. The nurse should measure and document the external length of the PICC during dressing changes. A change in the length of the external portion of the catheter can indicate migration of the tip of the catheter from its original position. The nurse should hold IV fluids and medications, secure the PICC to prevent further movement, and notify the health care provider for x-ray evaluation of catheter tip placement.case manager and social workerThe case manager and social worker on the interdisciplinary team have expertise in discharge planning and health care finance. They can assess the adequacy of the discharge setting and support systems, arrange for resources at home, or discharge to an alternate setting, such as a rehabilitation facility. They can also help advocate for safe, effective discharge planning.when to change IV tubingEvidence-based practice guidelines recommend changing a continuous IV peripheral tubing administration set no earlier than every 72 hours unless it becomes contaminated (institutional policies and procedures vary). Intermittent infusions and hypertonic solutions (eg, total parenteral nutrition, propofol, blood) require more frequent changes (eg, 4-24 hours) due to increased risk for infection.what is the recommended way to clean a client with a MRSA infectionCurrent evidence supports the recommendation for clients with MRSA or other drug-resistant organisms to be bathed with pre-moistened cloths or warm water containing chlorhexidine solution. Bathing clients in this way can significantly reduce MRSA infection.how long can a picc line be used for?Peripherally inserted central catheter (PICC) lines can be left in for weeks or months. The occlusion of one lumen does not necessitate removal of the catheter.what is the most effective way to prevent falls in the home?the one with the greatest impact is the removal of all area rugs and installation of grab bars in the bathroom. Area rugs can still cause falls for the client with a walker, with new glasses, and with someone present. In addition, many falls occur in the bathroom while toileting and bathing, making grab bars highly beneficial.dosing for maintaining potency CVC lumen when not in useMost CVC lumens require anticoagulation in the form of a heparin flush to maintain patency and prevent clotting when not in use. The nurse should check the institution's protocol and the HCP prescription to determine the correct dose. Doses of 2-3 mL containing 10 units/mL-100 units/mL are the standard of care for flushing a CVC. Doses of 1000-10,000 units are given for cases of venous thromboembolism; therefore, this prescription is an error and should be clarified by the nurse. The Centers for Disease Control and Prevention (CDC) recommend that a single-dose vial or prefilled syringe be used to reduce infection risk. Heparin is a high-alert medication (at high risk for causing significant harm to the client if given in error).how often to change dressing of CVC lumen, what is distal port of triple lumen used forAccording to the CDC, an occlusive dressing should be changed every 7 days. The nurse should check the institution's protocol for frequency of dressing changes. The distal port of a triple lumen CVC is the largest lumen (tube) and should be used for CVP (right atrium pressure) monitoring. The distal end of the CVC is in reverse as regards the client; therefore, the distal end is at the tip of the catheter in the superior vena cava vein, closest to the right atrium of the heart.the pneumonic that addresses what the nurse should do in the event of a fireFires can be extremely dangerous in health care facilities, where clients may be incapacitated. Nurses must be aware of the agency's fire safety plan. Most agencies use the mnemonic RACE in their protocols to ensure that all employees perform the priority actions consistently. These actions are: R - Rescue any clients in immediate danger and move them to safety A - Alarm - sound the alarm and activate the agency's fire response C - Confine the fire by closing all doors to all rooms and fire doors to the entrance of the unit E - Extinguish the fire, if possible, with a fire extinguisherwhat food is considered cross-sensitivity to latexBananas, avocados, chestnuts, and kiwifruit have been classified as having high-risk potential for cross-reaction allergy development. Clients should be advised to watch for potential allergic reactions due to a cross-allergen. A classic screening question is whether the lips swell when blowing up balloons (which have latex in them). Another is if your hands itch and/or burn after wearing rubber glovespseudohyperkalemia and avoidance on second lab drawWith the exception of clients in end-stage renal disease, a serum potassium value >6.5 mEq/L (6.5 mmol/L) in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting. A serum potassium level of 7.0 mEq/L (7.0 mmol/L) would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest. An assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the health care provider (HCP). In this case, it is likely that a repeat blood draw would be prescribed. Pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching, and use of a larger gauge needle for the sample.early dislodgment of a peg tubeA PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacementtumor lysis syndromeTumor lysis syndrome occurs due to rapid lysis of cells and the resulting release of intracellular potassium and phosphorus into serum. Phosphorus binds to calcium, leading to hypocalcemia. The breakdown of cellular nucleic acids causes severe hyperuricemia. IV hydration and hypouricemic medications (eg, allopurinol) are prescribed to promote purine excretion and prevent acute kidney injury.dicyclomine (anticholinergic)Dicyclomine (Bentyl) is an anticholinergic/antispasmodic drug prescribed to manage symptoms of intestinal hypermotility in clients with irritable bowel syndrome. Dicyclomine is contraindicated in clients with paralytic ileus as it decreases intestinal motility and would exacerbate the condition (Option 2). The nurse should question this prescription and contact the health care provider.hand hygiene MRSA and VRE vs C. diff and scabiesPerform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies)Middle East Respiratory SyndromeMiddle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the Centers for Disease Control and Prevention recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS.what is the Romberg testThe Romberg test, part of a focused neurologic examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation.isoniazid (INH)Isoniazid (INH) is a first-line antitubercular drug prescribed as monotherapy to treat latent tuberculosis infection. Combined with other drugs, INH is also used for active tuberculosis treatment. Two serious adverse effects of INH use are hepatotoxicity and peripheral neuropathy. A teaching plan for a client prescribed INH includes the following: 1. Avoid intake of alcohol and limit use of other hepatotoxic agents (eg, acetaminophen) to reduce risk of hepatotoxicity 2. Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy 3. Avoid aluminum-containing antacids (eg, aluminum hydroxide (Maalox)) within 1 hour of taking INH 4. Report changes in vision (eg, blurred vision, vision loss) 5. Report signs/symptoms of severe adverse effects such as: Hepatoxicity (eg, scleral and skin jaundice, vomiting, dark urine, fatigue) Peripheral neuropathy (eg, numbness, tingling of extremities)tricyclic antidepressant toxicityAmitriptyline is a tricyclic antidepressant (TCA) that can produce cardiac toxicity and neurological disturbances by altering cholinergic pathways, sodium channels, and calcium channels, causing symptoms such as atrioventricular block, hypotension, cardiac arrest, and seizure. TCAs have a narrow therapeutic index and rapid onset of action, so ingestion of even a small amount may be life-threatening for a toddler. Symptoms of toxicity are usually evident within hours of ingestion, but cardiac failure can develop days after. Neurological and hemodynamic assessments, as well as ECG monitoring in an emergency department setting, are recommended Amitriptyline. Amoxapine. Desipramine (Norpramin) Doxepin. Imipramine (Tofranil) Nortriptyline (Pamelor) Protriptyline (Vivactil) Trimipramine (Surmontil)bed bugsIt is a common misconception that bed bugs are drawn only to dirty environments. They can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding. Although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep. Bed bugs should be exterminated, especially in a home with children. It is important to treat the entire house for bed bugs. Washing a single pillowcase or blanket will not stop the infestation. Bed bugs multiply quickly and can hide in any crevice. Once pest control is complete, the home will need to be monitored for signs of lingering bugs. Bed bug bites can cause a rash that clients, especially children, will be inclined to scratch. Precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections. Once a home is infested, the bugs can travel quickly and occupy spaces and crevices. All household members and pets will be afflicted.c. diff precautionsClostridium difficile requires contact precautions under the guidelines published by the Centers for Disease Control and Prevention. Place the client in single-room isolation (preferred) or cohort with other C difficile-infected clients All surfaces within 3 feet of the bed are considered contaminated Personal protective equipment (gown and gloves) must be discarded before leaving the room Hand hygiene must be performed with soap and water Alcohol-based hand sanitizers do not kill C difficile spores Dedicated medical equipment (stethoscope, blood pressure cuff) should remain in the roomfodaparinuxFondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis.MRSA and VRE precautions (contact)In addition to standard precautions, the client infected with multidrug-resistant organisms (eg, vancomycin-resistant enterococci [VRE] or methicillin-resistant Staphylococcus aureus [MRSA]), Clostridium difficile, and scabies will require contact precautions that include the following: 1. Place client in a private room (preferred) or semi-private room with another client with the same infection 2. Dedicate equipment for client (must be kept in the client's room and disinfected when removed from room) 3. Wear gloves when entering the room Perform excellent hand hygiene before exiting the room (use soap and water or alcohol-based hand rubs for MRSA and VRE, but only soap and water for C difficile and scabies) 4. Wear gown with client contact and remove it before leaving the room Place door notice for visitors Ensure client leaves the room only for essential clinical reasons (ie, tests, procedures) The client with MRSA or VRE is allowed to have visitors. However, these individuals will need instructions from the nursing staff about hand hygiene and the use of gloves and gowns and their disposal prior to leaving the client's room. A sign should be placed on the client's door to inform visitors about these precautions.tuberculosis required PPE at all timesN95 mask and hand washing Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis).St. John's WortSt John's wort is an herbal supplement commonly used to treat depression and anxiety. Some clients with mild or moderate depression claim that its antidepressant effect is comparable to that of prescription medications. The herbal supplement mimics the action of selective serotonin reuptake inhibitors (SSRIs) by increasing available serotonin in the brain. Taken in combination with an SSRI (eg, sertraline, fluoxetine, citalopram, paroxetine), St John's wort may cause an excess of serotonin, resulting in serotonin syndrome, which is characterized by mental status changes, autonomic dysregulation, and neuromuscular hyperactivity.black cohoshBlack cohosh is used by some clients for menopausal hot flashes. The main side effects are thickening of the uterine lining and potential liver toxicity.methylphenidateStimulant medications are commonly used to treat ADHD in children and adults. Methylphenidate (Ritalin) and amphetamines (eg, dextroamphetamine, lisdexamfetamine) are the most commonly used stimulants. The major problems with stimulant medications include: 1. Decreased appetite and weight loss - can lead to growth delays 2. Cardiovascular effects - hypertension and tachycardia (particularly in adults) 3. Appearance of new or exacerbation of vocal/motor tics 4. Excess brain stimulation - restlessness, insomnia 5. Abuse potential - misuse, diversion, addictionMorgan lens for chemical eye burnsA chemical burn to the eye is an emergency. Alkali burns (concrete, drain cleaners containing lye) are particularly concerning as they will denude the protein and continue to penetrate until the substance is completely removed. Copious irrigation with water (at home) or normal saline/lactated Ringer's solution is started immediately. If the client cannot open the eye, another person should help open the eyelid. The irrigation should continue in the ambulance and in the emergency department with a special irrigating device that looks like a large contact lens. The pH of the eye is obtained prior to irrigation and irrigations continue until the eye pH is 7.0-7.5. Irrigation can last up to 60 minutes. Topical anesthetic eye drops may be instilled prior to eye irrigation as eye burns are very painful. Systemic analgesia is not a priority.glyburide and the elderly populationSulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin)required droplet precautions PPEsurgical mask, private room Bacterial meningitis (eg, Neisseria meningitidis) and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet (1.8 meters) away from the client. Droplet precautions for routine care (eg, medication administration) require the use of a surgical mask, as the highest risk of transmission is through inhalation of droplets. Wearing a face shield, gown, and gloves is required if there is a risk of splash or contact with body fluids from procedural client care (eg, suctioning, wound care). Dedicated medical equipment (eg, stethoscope, blood pressure cuff) should remain in the room to limit spread of infection.needle stick injuryfollowing a needlestick injury, the nurse's immediate actions should be to remove their gloves and thoroughly wash the affected area with soap and water. Exposure should be reported to the nurse's supervisor and the facility exposure hotline as soon as possible to facilitate the evaluation process. The nurse should then seek evaluation and treatment from the employee health clinic or emergency department. Blood should be drawn for baseline testing, and postexposure prophylaxis will be given based on the risk of exposure. Postexposure prophylaxis for HIV infection is most effective when given within two hours of an exposure incident.treatment for c. diff (medication)metronidazole (flagyl) or vancomycincare for a client in restraintsWhen caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (eg, every 2 hours): 1. Provide skin care and range-of-motion exercises; ensure basic needs are met (eg, fluids, nutrition, elimination). 2. Assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints, if necessary, to protect skin 3. Determine the need for continued restraint by releasing restraints briefly and assessing the client's reaction; regularly assessing the need for restraints promotes discontinuation as soon as possible 4. Restraint straps should be attached to areas that move with the bed frame (ie, elevates with the frame and head of the bed). Areas that do not move with (eg, base) or move independently of (eg, side rails) the frame should never be used, as injury may occur when they are raised or lowered (eg, pulling, entrapment). 5. Supine positioning increases aspiration risk as the client may be unable to self-reposition if vomiting occurs. Side-lying or semi-Fowler position promotes drainage of emesis or oral secretions. 6. Restraint straps should be tied in a quick-release knot, in case of emergency, and never in a square knot, which is difficult to release quickly.botulismBotulism is caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis. The organism is found in the soil and can grow in any food contaminated with the spores. Manifestations include descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis). The main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw (wild) honey. The immature gut system in these children makes them more susceptible.