lab review

  1. 5 goals of bandaging
    • 1. provide immobilization of body part
    • 2. prevent or reduce swelling by allpying pressure
    • 3.
    • hold a dressing in place on a limb
    • 4. secure limb to a slpint
    • 5. retain warmth
  2. bandaging equipment
    • ace bandage
    • clips or tape
  3. what do open wounds req before bandage is applied
    apply dressing (observe for any abrasions)
  4. what size bandage to use for arm
    5 cm (2in)
  5. what size bandage to use for finger
    2.5 cm (1in)
  6. what size bandage to use for leg
    7.5 cm (3-4in)
  7. what to do to bony prominences and skin surfaces
    pad bony prominences and separate skin surfaces that would other wise  touch
  8. how to overlap bandage
    by two thirds the width with each turn
  9. what to check for before bandaging and after applied periodically
    • Circulation
    • Movement
    • Sensation
    • check for pallor or cyanosis
    • check for color BEFORE to establish baseline
  10. how should joints be before applying bandage
    slightly flexed
  11. how should bandage roll be held
  12. how should bandage be applied (directional)
    • distal to proximal
    • medial to lateral
  13. what kind of pressure to apply when bandaging
    even firm pressure
  14. what part of limb should be exposed and why
    distal part to check circulation
  15. what is a circular turn for and how do you do it
    for holding dressing in place. or cover cylindrical part of body. two cicrular turns to anchor, and two circular turns to complete process
  16. what is figure 8 turn for and how to do it
    for elbow, knee, or ankle.  anchor w two circular turns below joint then go above then below in figure 8 and end w 2 circular turns above joint. (over lap by 2/3's)
  17. what is spiral turn for and how to do it
    used for straight arms and legs. bandage ASCENDS distal to proximal in a spiral manner so that each turn overlapsthe proceeding one by 2/3's
  18. what is reccurent turn for and how to do it
    for head, stump or hand.  anchor w 2 circular, around proximal body part then fold bandage back on itself brought centrally over distal end to be covered. and so on
  19. what is Z-track injection for
    for iron IM and heparin sub-Q.  To give solutions that are highly irritating to the skin
  20. 4 Goals for Z-track
    • 1. injetion given w/o complications
    • 2. painless as possible
    • 3. med enters blood stream and is used by tissues
    • 4. minimize damage to sub-q and skin tissues
  21. what kind of asepsis is Z-track injection
  22. what is special about a heparin injection before you give it
    you may need to check it with another nurse
  23. what angle to go in for heparin
    usually 90 depending on pt size
  24. what type of needle is used for Heparin sub-q z-track injection
    TB syringe (3/8-5/8 inch, 25-27 gauge)
  25. what size needle is needed for Z track (iron dextran)
    1 1/2 to 3 inch 19-20 gauge needle
  26. equipment for Z-track (7)
    • chart
    • MAR
    • 1 1/2 to 3 inch 19-20 (iron) gauge needle
    • 3cc syringe w needle
    • vial
    • alcohol pledget
    • 2x2 gauze
    • gloves
  27. what to do with needle after you draw up solution
    change it to prevent irritating substance from getting on skin
  28. what sites are used for z track (which one specifically for iron dextran)
    ventro gluteal and dorso gluteal (dorso gluteal for iron)
  29. what z track site is used for heparin and what kind of injection is heparin
    use abdomen and its sub-q 1-2 inches from umbilicus and above iliac crest
  30. how many inches to pull skin to side for z-track
    1-1 1/2 inches
  31. when do we aspirate for z track (how long)
    never aspirate for heparin, for all else 5-10 seconds
  32. how long to push med and how long to keep needle in skin for z-track...
    10 seconds per ML and leave in skin 10 seconds afterward before withdrawing
  33. what not to do after z track injection
    massage site
  34. will you need an order for Z-track
  35. what should pt avoind after iron dextran injection
    tiht clothes and exercise
  36. needle gauge for heparin z-track
    25-27 gauge 3/8 to 5/8 inch needle
  37. coagulation test for heparin
    PTT (60-70 sec) and APTT (30-40 sec)
  38. antidote for heparin
    protamine sulfate
  39. what should you moniter for w heparin (side effect)
  40. 3 goals for surgical aseptic technique during dressing change
    • wound granulates and healing process occurs
    • wound is free of pathogenic microoragnisms
    • sterility is maintained
  41. Equipment for sterile dressing (7)
    • sterile dressings, ABDs, 4x4's drain sponge
    • tape or montgomery ties
    • clean gloves
    • sterile gloves
    • cleaning solution or normal saline
    • plastic bag
    • chux
  42. what allergy should you check for with abdominal patients if betadine is going to be used
  43. sterile dressing procedure
    • set up sterile field
    • put on disposible (not sterile) gloves
    • remove old dressing (pull tape toward wound while holding down skin) toss in trash, remove dirty gloves
    • (put on sterile gloves)
    • note ACCO of drainage and how many sponges used
    • clean wound if ordered by pouring sterile solution over gauzes
    • clean wound holding gauze by 4 corners cleanist to dirtiest area (inward to out)
    • apply 4x4's
    • apply ABD pad
    • secure with tape or montgomery straps
    • label
  44. how should you label wound dressing
    with initials, date and time
  45. 5 Goals for IV therapy *re: use of use IV therapy* (calculations)
    • to maintain or restore pt's fluid balance (electrolyte and acid base)
    • to admin meds
    • to provide access for meds
    • to maintain nutritional status
    • to admin blood products
  46. equipment for IV therapy (8)
    • sterile iv solution
    • sterile iv tubing
    • iv pole
    • iv label
    • tape
    • antiseptic solution (alcohol or iodine)
    • transparent dressing or 2x2 gauze
    • gloves
  47. how to label IV bag
    • pt name and room #
    • IV solution amount
    • dosage and any additives
    • absorbtion time
    • drip rate
    • time hung
    • container number
    • signiture
  48. how to hang IV
    • hang bag on pole
    • clamp tubing closed
    • spike bag
    • connect tubing to bag
    • fill drip chamber
    • release tubing clamp and let fluid run thru tubing (prime it)
    • check for bubbles (air)
    • attach to saline lock
    • anchor with tape
  49. IV flow rate (infusion rate) mls per hour
    • put amout of solution on top
    • (i.e. 1 liter=1000mls)
    • put time on bottom (i.e. 8 hours)

    • 1000mls 
    •  8hours
    • (125 mls/hour)
  50. calculate gtts per min
    • take volume (how many mls in bag i.e. 1000) and break down into mls/hour
    • (need to know how many hours for infusion to do so, we will assume 8
    • hours) 1000/8 = 125mls/hr
    • so 125mls goes on top and 60 (time in mins) goes on bottom multiply that by gtt factor on top then
    • divide by time on math short cut if applicable

    • infusion rate*gtt factor
    •        time in mins

    • 125mls*15 gtt/ml
    •        60 mins
  51. calculate remaining infusion time
    • put volume in mls (i.e. 1000 mls)
    • over mls per hour (ex 125mls/hr)

    •  1000mls
    • 125mls/hr

    ans (8 hours)
  52. what is the 2 step problem for IV calculations
    when you don't know the mls per hour figure that out first. or to get infusion rate break down the problem to a mls per hour problem. ex 1000mls to go over 8 hours would be 125mls per hour, now you can figure out drops per min cuz 125 mls * gtt/mls over 60 mins
  53. 11 what are complications of IV therapy
    • hematoma
    • infiltration
    • site infection
    • phlebitis
    • clotting
    • circulatory overload
    • air embolism
    • catheter embolism
    • systemic infection
    • speed shock
    • allergic reaction
  54. what is hematoma
    • raised discolored area caused by leakage of blood at venepuncture site
    • tenderness and bruising
    • remove IV apply compress
    • warm soaks
    • document
    • prevent by not advancing needle past point of resistance, choose right sized needle
  55. what is inflitration
    • leakage of iv fluid into tissue
    • S/S blanched skin, swelling, decreased skin temp, slow flow
    • cause, needle dislodged from vein
    • remove IV, warm soaks, elevate extremity restart IV document
    • prevent by checking site frequently
  56. what is phlebitis
    • irritation along vein
    • S/S vein hard and cordlike when palpated
    • sore, red and tender
    • causes
    • hypertonic solutions
    • repeated use of same vein
    • catheter too large
    • clotting at tip of catheter
    • remove IV, warm soaks, notify doctor, restart IV, document
    • prevent by using central line for irritating solution, rotate site per policy, limit movement w stabilization
  57. what is site infections
    • local contamination of insertsion site
    • S/S redness, warmth, tenderness, swelling at site, possible exudates of infectious material
    • causes: failure to maintain aseptic technique during insertion, IV longer then recommended time
    • nursing action: remove IV, warm soak, notify MD, restart IV, document
  58. what is clotting of IV
    • blockage at end of device in pt vein
    • S/S unable to flush, tenderness at site, sluggish flow rate
    • causes: IV too slow, hep lock not heparinized (no flush) IV bag runs dry
    • remove IV, warm compress, document
    • prevent by maintaining constant flow as ordered, use non dominant side, don't use force when flushing IV
  59. what is circulatory overload
    • More fluid than circulatory system can manage
    • S/S Discomfort, neck vein distention, high blood pressure, fluid in lungs, SOB, dyspnea
    • causes: infusion rate too fast, miscalculation, never play catch up, positional IV
    • slow infusion to KVO, elevate HOB, notify MD, administer meds, O2, monitor vital signs, document
    • prevention: know cardiovascular history
    • monitor lung/breath sounds
    • monitor I&O
    • maintain and monitor infusion rate
    • assess frequently
  60. what is air embolism
    • air in circulatory system
    • S/S sudden chest pain, SOB, lightheadedness, decreased BP, weak rapid pulse, anxiety, pleuritic pain, decreased or loss of consciousness, cyanosis
    • causes: loose connections in the IV system, intro of air during catheter placement, air pumped into the circ system via electronic device, IV tubing not purged of air
    • hang new solution at KVO rate, position pt in lateral left trendelenberg (allows air to enter right atrium and be dispersed via pulmonary artery) administer oxygen, vital signs, notify MD, reassurance, documentation
    • prevention: prime tubing, clamp central line catheters before removing caps or change tubing. do not use scissors near IV tubing
  61. What is speed shock
    • a sudden adverse physiologic reaction to IV meds that are administered too quickly. Some signs of speed shock are a flushed face, headache, a tight feeling in the chest, irregular pulse, loss of consciousness, and cardiac arrest.
    • discontinue drug infusion, begin infusion of dextrose 5% in water at KVO rate, notify MD
    • prevent by following manufactures guide lines before giving any meds
  62. what is are details of allergic reaction with IV infusion
    • S/S itching, rash, SOB, generalized body edema, increased blood pressure, decreased pulse and respirations
    • cause: sensitivity
    • change IV to dextrose 5% and slow to KVO, notify MD
    • prevent by asking questions about history and allergies, check chart, wristband, stay for 10-15 mins when infusing a new med for the first time
  63. what is systemic infection, septicemia, bacteremia
    • introduction of microoganisms into the circulatory system
    • S/S rapid _________ elevataion, chills, shaking, nausea, vomiting, malaise
    • causes: contaminated IV device, or solution, failure to maintain asepsis, immunosuppression, device in vein longer than recommended
    • notify MD, ID possible causes, remove IV per policy, culture tip, document
    • prevention: examine fluid and tubing, moniter VS, maintain asepsis, change site and tubing
  64. What is Cathether embolism
    • all or part of IV device shears off into venous system
    • S/S related to specific location of embolism, discomfort, decreased BP, cyanosis, thready pulse, respiratory distress, unconsciousness, possibly no signs at all, chest pain
    • causes: use of scissors near IV, movement on insertion or removal, device not secured effectively
    • apply tourniquet, notify MD, stop IV infusion, restart IV in opposite extremity at KVO rate, document that catheter intact
  65. what are the 3 goals in adding meds to IVs and IVPB
    • maintain sterility
    • maintain patency of site
    • prevent complications of IV therapy such as phlebitis and infiltration
  66. equipment for IV adding meds to IV (5)
    • secondary tubing
    • antiseptic wipes
    • neddles syringe
    • appropriate med/solution
    • gloves
  67. how to label when adding meds to IV solution
    date, drug, dosage, IV solution name
  68. how to hang IVPB through primary tubing
    hang primary solution on secondary hanger lower than secondary solution, hang secondary solution on other side of pole higher than primary solution, spike tubing (and proceed as you would with any IV solution)cleanse upper Y port on primary tubing from primary IV, and insert secondary tubing into primary tubing thru Y port, open secondary tubing flow clamp
  69. back check valve factors
    keeps flow of secondary solution from going into primary bag. located on primary tubing, the secondary solution hangs higher than primary, as piggyback solution empty backcheck valve moves downward which allows primary solution to begin infusing
  70. 5 goals for administering med thru saline port (and flushing)
    • maintain sterility
    • maintain patency of saline port
    • prevent complications
    • safely administer medication
    • understand SASH method
  71. equipment for fulshing or giving med thru saline lock (7)
    • needles injection cap with primed extension tubing and port (hep/saline lock)
    • 2 normal saline needless syringes or one
    • med syringe or IVPB w primed primary tubing
    • antimicrobial swabs
    • clean gloves
    • gauze
    • band aid
  72. do you aspirate when flushing saline lock
  73. what do you do to a saline lock after infusing IVPB med?
    flush again
  74. when giving IVP med while IV infusing and med is not compatible what do you do?
    close slide lock on port on IV, flush using SASH method then reattach
  75. when giving IVP med while IV infusing and med is compatible what do you do?
    clamp port or pinch tubing, attach syringe, inject med intermittently allowing IV solution to flow
  76. 4 goals of urinary catherization
    • relieve discomfort due to bladder distention
    • asses amount of residual urine
    • obtain urine specimine
    • empty bladder completely prior to surgery
  77. injection sites
    • Deltoid (arm)
    • ventragluteal (side of thigh by greater trochanter)
    • dorsal gluteal
    • rectus femoris (top of thigh)
    • vastus lateralis (side of thigh)
  78. order to put on PPE
    • mask
    • goggles
    • gown
    • gloves
  79. order to remove PPE
    • gloves
    • mask
    • gown
    • goggles
  80. how to give an IVPB med while no other IV is infusing
    • Attach 5ml syringe
    • aspirate
    • flush with 3-5 mls of saline
    • attach IVPB med
    • when infusion complete disconnect med
    • flush again slowly with with 3-5mls
    • document
  81. how to give IVP med while IV is infusing
    • make sure med can be given on unit
    • check IV fluid compatibility
    • use port closest to patient
    • close slide lock above port
    • if incompatible
    • Flush
    • attach med syringe to port and inject med
    • flush again
    • then undo slide lock to allow IV to continue infusing
    • if compatible
    • pinch tubing (or use slide lock)
    • clean port
    • no need to flush
    • attach med syringe to port and inject med
    • allow IV fluid to flow intermittently while giving med (med/IV/med/IV) 
    • remove syringe and make sure IV slide lock is open to allow IV fluid to flow
    • Document
  82. equipment for catheterization
    • sterile catheterization kit
    • gloves (sterile)
    • betadine
    • drapes
    • cotton balls
    • forceps
    • water soluble lubricant
    • appropriate size catheter
    • a receptacle for the urine
    • a specimen container
    • a flashlight
    • disposable gloves
  83. where to stand during catheterazation
    on your dominant side
  84. what position to put female in for catheterazation
    • frog position
    • supine with knees flexed and thighs externally rotated (dorsal recumbant)
  85. what is the most urine that you should remove during straight cath and why
    750 mls, don't want to cause hypovolemic shock
  86. how do you pick up sterile catheter kit to move it
    from the inside
  87. which hand do you use to hold penis or spread labia in catheterazation
  88. where can you sit catheter kit during procedure
    between patients thighs
  89. how to prepare cotton balls for catheterazation
    poor antiseptic solution over cotton balls
  90. order of procedure for catheterization
    • drape pt for privacy
    • do perineal care
    • set up sterile field (including gloving)
    • pour antiseptic over cotton balls
    • lube cath tip
    • separate labia or pull back foreskin (if applicable) this becomes "dirty hand"
    • wipe with cotton ball (swipe/drop/new cotton ball/swipe/drop)
    • place drainage end of cath tip in receptacle
    • then with sterile hand pick up cath tip and insert
    • (5cm) 2inches in for adult and 2.5 cm/1inch for child
    • collect urine specimen if req (30 ml)
    • empty bladder up to 750mls
    • remove
    • dry pt remove equip
    • document A.C.C.O
  91. what kind of pressure do you use on penis for male catheterazation and what angle do you hold penis
    firm but steady pressure at 90 degree angle
  92. 4 goals of NG intubation
    • to provide route for
    • lavage (big tube to clean out)
    • gavage (tube feed)
    • decompression (ng suctioning)
  93. equipment for NG intubation (15)
    • appropriate tubing
    • large syringe
    • emesis basin
    • tissue
    • tape
    • towel
    • stethoscope
    • glass of water with straw
    • water soluble lubricant
    • suction equipment
    • hoffman clamp (gum band)
    • nonsterile gloves
    • flashlight
    • tongue blade
    • rubber band and safety pin
  94. what is the position to put patient in for NG tube insertion
    • high fowlers
    • (may be inserted in side lying or supine position)
  95. how to measure NG tube for insertion
    measure from nose to earlobe and from ear to xiphoid process (for child same except go to middle of xiphoid process and umbilicus)
  96. what type of gloving is required for NG tube insertion
    non sterile
  97. how far to lube NG tube before insertion
    4-6 inches
  98. which nostril should you use for NG tube insertion
    Nostril with most airflow (non stuffy side)
  99. which way should you point NG tube as you first insert it
    towards ear on the same side as nostril you are entering and twist 180 degrees as you advance
  100. which part of upper resp tract do you want to go in when advancing NG tube
  101. how to check placement of NG tube
    • place stethoscope over stomach and pust 5-20ml of air and check for "whoosh" sound
    • aspirate gastric content and check PH
    • xray verification
    • (observe for resp distress)
  102. what to document after NG tube insertion
    time, tube type, what procedure was done, how pt tolerated procedure, and position of the tube
  103. how to remove NG tube
    • place pt in high fowlers
    • turn off suction if applicable or stop feeding
    • inject 30cc of air to clear tube of contents
    • clamp tube to prevent aspiration
    • tell pt to take deep breath and exhale slowly as you pull tube out
  104. what to do if bowel sounds absent before tube feeding
    hold feeding and call doctor
  105. what temp do you administer tube feed formula at
    room temp (to prevent cramping or GI upset)
  106. how far above pt should you hang tube feed
    no more than 18inches above pt
  107. what position should pt be in for tube feeding
    high fowlers
  108. what to do if this is not patients first tube feeding
    check for residuals in stomach (by aspirating contents of stomach), if more than 100 (or 50 depending on policy) then hold feeding...always return aspirated residuals
  109. how long should feeding flow
    20-35 mins unless continuous
  110. what to do when pt tube feeding is finished
    flush with water (check order for prescribed flush amt)
  111. what to document after tube feeding
    • amount of residual
    • time of feeding
    • total cc over period
    • name of formula
    • how pt tolerated feeding
    • amount of H20 given
  112. what should ph of stomach be
    0.8-5 (normally 2-3)
  113. what is norm ph of lung
  114. what is norm PH of intestine
  115. water/air flushes for NG tube
    • NG 30-60mls
    • Gtube 30ml (use sterile water if new GT for 2weeks)
    • air auscultate
    • 5-20mls of air
  116. how to give meds via gtube
    • do initial flush of 30ml
    • then give med
    • then 10mls of water between each med
    • then flush with 30mls of water to clear tubing
  117. 4 goals of insulin injections
    • completed without complications
    • painless as possible
    • exact dosage is given allowing it to be absorbed promptly and utilized by the tissues
    • injection sites are rotated to avoid tissue damage
  118. equipment for insulin injection
    • correct vial of insulin based on prescription
    • correct syringe
    • alcohol swabs
  119. what is special about time of insulin injection
    you want to try to give it at the same time each day (usually 15-30 mins before breakfast and evening meal) *remember lispro must be given at the time food arrives and first bite is about to be taken*
  120. what to do with insulin vial before drawing up insulin
    gently roll between fingers
  121. what to do with insulin once you insert needle
    push in amount of air equivalent to amount you are going to withdraw
  122. when mixing insulin which will you draw up first
    first draw up amount of air for cloudy (NPH) then inject it, then draw up amount of air for clear and inject it, then withdraw amount of clear then go back and withdraw amount of order is clear then cloudy
  123. what do you need to do when you draw up insulin
    have another RN check your dose
  124. what area to avoid giving insulin injection
    within one inch of navel or belt line
  125. what is another site that can be used for insulin in hospital besides abdomen
    scapular site (if enough sub-q fat is there)
  126. what angle to go in for insulin injection
    thin person with 1/2 inch needle go in 90 degrees..."fluffy person" 1/2inch needle go in at 45 degrees
  127. do we aspirate with insulin
    yes (smh)
  128. how often can we use same insulin site
    once every two months
  129. how big is an insulin site
    a one inch square
  130. what to document with insulin injection
    what site was used (may use site chart if available)
  131. 4 goals of nasopharyngeal and oropharyngeal suctioning
    • remove secretions that obstruct the airway
    • facilitate ventilation
    • obtain secretions for dx purposes
    • prevent infection that may result from accumulated secretions
  132. equipment needed for suctioning
    • towel
    • wall or portable suctioning unit
    • sterile disposable container for fluids
    • sterile norm saline or water
    • sterile gloves
    • sterile suction cath kit
    • water soluble lube
    • Y-connector
    • trash bag
  133. amount of pressure needed for wall unit suctioning
    • infant 50-95
    • child 95-100
    • adult 100-120
  134. amount of pressure needed for portable unit suctioning
    • infant 2-5
    • child 5-10
    • adult 10-15
  135. what position to put patient in for suctioning
    semi-fowlers with head turned for oral and neck hyperextended for nasal
  136. which hand will remain sterile during nasal suctioning
    dominant hand which will hold suction catheter
  137. how much norm saline should you fill sterile container with for nasal suctioning
  138. what to do right before suctioning pt after donning sterile gloves
    test to see that suction cath is working by testing a small amount of the sterile water
  139. what to do if O2 is indicated during suctioning
    increase O2 to 100% or what ever is ordered by physician
  140. how to measure how deep to go for suctioning
    measure from pt's nose to ear lobe without touching cath to pt
  141. what to remember when inserting suction cath in nasal area
    do not apply suction going in, only coming out and do intermittently as you pull out cath for no longer than 10 seconds
  142. what can happen if you suction for longer than 10 seconds
    can cause cardiopulmonary compromise, from hypoxia or vagal overload
  143. if you need to repeat nasal suctioning, how long do you wait
    1-2 mins to allow oxygenation
  144. what is the order of suctioning
    nasal first (considered sterile) then rinse with sterile water, then oral
  145. how to dispose of suctioning equip
    detach from wall or portable unit, roll catheter in glove and dispose
  146. color of stomach contents
    • gastric = yellow
    • intestinal = yellowish green cuz of bile
  147. what is considered low intermittent suction
  148. which direction should you open items on sterile field
    open items farthest away first to prevent contamination by reaching over items
  149. where can you find out how long IV piggyback med should infuse
    in drug book
  150. where should piggyback hang in proximity to primary IV bag
    piggyback should hang higher than primary IV
  151. how to prime insulin pen for injection
    dial it to 2
  152. how long do you count drips when calculating IV rate
    for one minute or 30 sec times 2
  153. what to remember about surgical dressings
  154. what to remember about lovonox
    anti coagulant that comes in pre-filled syringe, DO NOT EXPEL BUBBLE FROM SYRINGE BEFORE INJECTION AND DO NOT ASPIRATE
  155. what to evaluate for with heparin
  156. what is coagulation test for coumidin
    PTT & INR
  157. signs of possible hemorrhage with heparin therapy
    • bleeding gums
    • epistaxis
    • petechiae
    • ecchymosis
    • severe headache
    • abdominal and or back pain
    • dark red urine and or stools
    • decrease in BP
    • and or decreased hematocrit
Card Set
lab review
lab exam questions