CLIENT SAFETY, SECURITY & PRIVACY

REQUIREMENTS in MEDICAL-SURGICAL NURSING PRACTICE
Joyce Black, PhD, RN
Editor Medical Surgical Nursing Associate Professor of Nursing University of Nebraska Medical Center Omaha, NE

Test Plan Structure
◦ ◦ ◦ ◦ ◦ ◦ Safe and Effective Environment Health Promotion/ Maintenance Psychological Integrity Physiological Integrity Pharmacological Intervention Reduction of Risk

Items written based on usual activities of nurses one year after graduation

Safe Effective Care Environment
◦ Management of Care 13-19% ◦ Safety and Infection Control 8-14%

  

Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity
◦ Basic Care and Comfort 6-12% ◦ Pharmacological and Parenteral Therapies 13-19%

 

■ Reduction of Risk Potential 13-19% ■ Physiological Adaptation 11-17%


Multiple Choice

Multiple Answer Fill in the Blank Hot Spot
◦ Usually math

◦ Single right answer ◦ More than 1 right answer ◦ The item will indicate that more than one answer is right

 

◦ Location of something on a figure
 Eg, location of apical pulse

Exhibit items

◦ Information contain in documents within the item

Computer adaptive testing
◦ Items chosen for student based on previous response ◦ The test is designed to decide if you pass or fail and will continue to test you until it is certain

 

Items delivered one at a time Test item must be answered or you cannot go to next item

75 items given one at a time
◦ Computer then judges student’s performance ◦ More items given in areas of poor performance

 

265 is most questions that it will offer Time maximum is 5 hours

I am going to present a test item, give you a minute to answer and then discuss the item and content related to it.

A. B. C.

D.

Explain the actual changes that will occur in her body and then have her sign the consent form Delay having the patient sign surgical consent and ask the surgeon to see her again Allow the patient to sign consent for surgery; she understands the surgery correctly Tell the surgical staff to inform the surgeon that the patient may need further information during recovery

 

Total Hysterectomy is removal of the uterus and ovaries. Menstruation will stop and menopause will start suddenly—which it appears that she does not understand The nurse’s role is not to explain the operation, except for minor issues The nurse’s signature indicates that the patient (and not someone else) signed the consent

  

A legal document that provides evidence that the patient has been given the reason for surgery, the other options (other operations, effect of not operating, medications instead of surgery) and complications of surgery This discussion must be done by the surgeon Nurse witnesses the signature Patient must be awake and not medicated If the patient needs an operation for which he did not consent, they have to be awaken for anesthesia and consent to a new procedure
◦ Many consent forms indicate options for different procedures

A.
B. C.

Higher than the IV dose Lower than the IV dose The same as the IV dose

Oral medications have a ―first pass effect‖ through the liver. The liver excretes or binds a large portion of the medication, making less available to the patient. Therefore the dose of oral meds is higher than IV meds.

To achieve the same level of pain control, 10 mg of Morphine IV is equal to:
◦ 30 mg of oral morphine ◦ 1200 mg of oral codeine ◦ 60 mg of oxymorphone

A. B. C. D.

Monitoring hyperalimentation (TPN) infusion Dressing change on a wound the RN saw yesterday Inserting an NG tube and administering tube feeding Teaching a newly diagnosed diabetic about insulin injections

LPN/LVNs cannot:
◦ insert NG tubes, they can monitor tube feeding ◦ monitor IV fluids or meds ◦ Teach complex material


Delegating is assigning a task to another person, while the RN remains accountable LPN/LVN
◦ A 1 year program of study in practical nursing ◦ Very skilled at tasks and procedures ◦ Can learn complex assessments on the job ◦ ◦ ◦ ◦ Insert NG or IVs Administer IV medications Administer blood Develop care plans

LPN/LVN cannot

A. B. C. D.

Stage Stage Stage Stage

I II III IV

Stage I

Stage III

Stage II

Stage IV

Partial thickness ulcers

Full thickness ulcers

Prevention is key
◦ ◦ ◦ ◦ Intervene based on risk areas Use Braden scale to help Keep skin clean and dry Turn patient side to side q 2 hrs
 Often delegated, consider how you will keep track of patient position

Treatment
◦ Nutrition ◦ Wound care ◦ Sleep surface

A. B. C.

D.

E.

Pain level now 12/10; screaming Pain level 6/10 Pain not present now, but going to PT in 1 hour Pain 2/10; keeping patient from sleeping Pain constant at 8/10

1. 2. 3.

4. 5.

6.

Acetaminophen 600 mg po (Tylenol) Morphine 2 mg IV Oxycodone 5 mg with acetaminophen 500 mg po OxyContin 10 mg po Acetaminophen (500 mg) and propoxyphene (50 mg) (Darvocet) Fentanyl 100mg patch

A. B. C.

D.

E.

Pain level now 12/10; screaming = 2 Pain level 6/10 = 3 or 5 Pain not present now, but going to PT in 1 hour = 3 or 5 Pain 2/10; keeping patient from sleeping =1 Pain constant at 8/10 = 2 and then 4 or 6

1. 2. 3.

4. 5.

6.

Acetaminophen 600 mg po (Tylenol) Morphine 2 mg IV Oxycodone 5 mg with acetaminophen 500 mg po OxyContin 10 mg po Acetaminophen (500 mg) and propoxyphene (50 mg) (Darvocet) Fentanyl 100 mg patch


 

Examine degree of pain Examine tolerance of pain Consider effect of last dose of analgesic Consider side effects and adverse effects of drug


 

Ideal for intense pain Best given IV when pain is high
Side effects
◦ Onset is rapid ◦ Constipation ◦ Tolerance

Adverse Effects

◦ Respiratory Depression
 Do not turn off alarms!

 Oxygen saturation monitor used  But measure rate and depth of respirations


 

Slow release oxycodone Ideal for cancer patients in escalating pain High risk of addiction Do Not Crush these pills
◦ Leads to overdose

Do not confuse with Oxytocin

Indicated for moderate
◦ Onset 30-45 minutes

 

Side effects the same Adverse effect
◦ Hepatotoxicity from acetaminophen over 4000mg in 24 hours

 

Propoxyphene is less potent that the morphones Again is combined with acetaminophen Can lead to confusion in the elderly

A. B. C. D. E. F. G.

Elderly age Use of diuretics Use of sedatives Prior fall Weakness Sensory loss Confusion

Multiple options is a common format in the NCLEX and no partial credit is given for correct answers

A.
B. C.

D.

Carefully lift the patient back to bed Ask the patient why he got out of bed Call the physician to examine the patient Leave the patient on the floor and examine him for signs of fracture

Moving the patient could further harm a fractured limb. Once the probably injury is known, he may best be moved onto a cart for xrays Calling the MD will be done, but not first, first collect some data Asking the patient why he got up will provide data to prevent future falls, but does not help this problem


Most common reason is to use the bathroom High risk patients
◦ Elders, frequent voiding (diuretics), confused

A. B. C. D.

Sharp pain in the hip Internal rotation of the leg Shortening of the leg Bleeding from the hip

Fractured bones lead to spasm of the limb
◦ Shortens the limb ◦ Deforms the limb
 External rotation in the leg

◦ Pain in the limb ◦ Loss of function ◦ Loss of motion

Bleeding is due to tissue injury, not fracture per se

This patient appears to have a broken left hip.

A. B.

C.
D.

I I I I

will will will will

use a chair with arms cross my legs gently only lie on my right side avoid climbing stairs

Flexion of the hip, internal rotation and abduction are to be avoiding Therefore:
◦ She cannot cross her legs ◦ She cannot lie on her sides without a pillow to abduct the leg ◦ She must use a chair with arms to avoid hip flexion

Climbing the stairs is OK


 

Flexion and extension Abduction and adduction Internal and external rotation

A. B.

C.
D.

Maintain NPO status Remove all metal objects Obtain a consent for the procedure Clarify allergies to contrast or shell fish

 

Contrast dye, which can contain iodine, is often used to visualize the vessels The patient does not need to be NPO Metal is not a problem with CT, it is a problem with MRI CT is noninvasive; no consent is needed

Magnetic Resonance

◦ provides much greater contrast between soft tissues ◦ Magnetic rays align atoms ◦ Prep
   Sedation prn if claustrophobic No metal due to magnet Ear plugs prn due to noise

Computerized (Axial) Tomography scan. T

◦ series of cross sectional X-rays ◦ computer to put them together to provide an image ◦ Prep
 

Very rapid, so sedation not used Metal OK

CT scanner requires patient be still. Claustrophobia may be a concern with some patients

A. B. C.

D.

An obese middle-aged woman at bedrest after pelvic surgery An elderly man with a fractured arm up twice daily A normal weight middle-aged man who smokes An demented elderly woman with a fractured hip; up to the chair

 

Her risk factors are immobility, pelvic surgery and obesity Moving patients are at less risk Smoking is a risk factor, but needs to be combined with other risk factors Fractured hips and elders are at risk, especially when bedridden

Risk factors

◦ Sluggish blood movement ◦ Increased blood clotting tendency ◦ Injury to vessels in pelvis or legs
 Fractures of the hips, pelvis  Increased platelet count  Swelling in the pelvis, nonmoving legs

Presentation
◦ ◦ ◦ ◦ ◦ Dyspnea Anxiety Tachycardia Tachypnea Decreased O2 sats

Risk Factors

Presentation

A. B. C. D.

It should dissolve it in 4 to 6 hours Because you have taken a lot of vitamin K, it may be a day or two It will not dissolve the clot, it will prevent new ones from forming It will only soften the clot, which makes it easier for your body to break it down

Antithrombotics work in 4-6 hours
◦ Used in some clients after stroke and MI

Vitamin K does not affect Heparin, vitamin K affects warfarin
◦ It reduces the effectiveness of warfarin ◦ Is used to reverse warfarin

It does not soften the clot, but the body does breakdown the clot

Heparin (heparin sodium)
◦ ◦ ◦ ◦

Low molecular weight heparins
Coumadin (warfarin)

Half life 4 hours Reversible with Monitor partial thromboplastin times Given IV or subq

◦ Given once daily, subq ◦ Cannot be monitored by blood studies ◦ Given orally ◦ Monitor INR (therapeutic 2-3) and prothrombin time (PT) ◦ Can be taken for years ◦ Reversed with vitamin K (Aqua-Mephtyon) ◦ Affected by foods with vitamin K
 Animal heart valves, venous disease

A. B. C. D.

PT INR PTT Bleeding Time

  

Heparin is monitored by PTT
PT (prothrombin time)
◦ Usually drawn every 4-8 hours ◦ Used to monitor Coumadin

INR (International Normalized Ratio)
◦ Used to monitor Coumadin ◦ Standardized international measure
 Allows patients to travel

Bleeding time

◦ Used for unusual bleeding diseases

A. B. C. D.

At At At At

12 ml per hour 25 ml per hour 50 ml per hour 250 ml per hour

250 ml/25,000 units = 100 units/1 ml
◦ 250/25000 = 1/100

Therefore 12 ml delivers 1200 units per hour

This is a very common error in medication delivery and will be tested!!

A. B. C. D.

The son cannot speak English well The son’s breath smells of alcohol The son states his mother does not have insurance The son is talking on his cell phone while listening to the discharge plan

The patient may have an occult (not now visible) head injury:
◦ ◦ ◦ ◦ ◦ Decreasing level of consciousness Pain Vomiting Pupillary changes Loss of motion or strength in limbs


 

Being alert is important to recognize these changes The nurse needs to ask him to put the cell phone down and listen Interpreters can be used to provide information Insurance does not change the standard of care

Advocacy for patients is a very important nursing role
 Demented, sedated, children, unconscious

◦ Especially for those patients who cannot advocate for themselves

Advocacy can mean

◦ Asking MDs for information or orders ◦ Clarifying orders and information provided to the patient ◦ Determining the disposition of the patient

 Who will provide care for patient? Are they competent to do so?

1. 2. 3. 4. 5.

Patient who needs insulin prior to eating breakfast, 0600 blood glucose was 122. Patient who is being dismissed to home today and needs discharge medication instruction. Patient who has been receiving first unit of blood since 0400; second unit is needed. Patient who is going to surgery later this morning and needs consent form signed. Patient who had surgery yesterday and took last prn oral pain med at 0500.


 


3, 5, 1, 4, 2,

patient patient patient patient patient

getting blood who may been in pain who needs insulin going to surgery going home

ABCs helpful

  

Treatments with time limits
◦ Except with head injury

◦ Patient with these issues seen first ◦ Patients at risk for these problems seen first ◦ Or patients who might die of the problem if not seen first ◦ Blood cannot infuse over 4 hours

Actual problems over potential problems Teaching considered low priority in most cases

A. B. C. D. E.

F.

Suctioning a tracheostomy Turning a patient side to side Calculating intake and output Administering an oral medication Feeding a patient who has had a new stroke and is at risk of aspiration Collecting vital signs on a stable patient who has had surgery


Suctioning airways requires sterile technique Administering oral medications requires a license Feeding patients at risk of aspiration requires assessment skill


 

Nurses aides with 6 weeks of training Persons with on the job training Assign them tasks based on:

◦ Task is repetitive and requires little supervision ◦ Relatively noninvasive Medically stable; they do not have assessment skills beyond what they have learned on their own

Assign them to patients who are

Give them specific instructions on what to report back to you and when

A. B. C.

D.

Activate the fire alarm by calling the operator Cover the wound and remove the patient from the room Place a pillow or blanket over the TV to put the fire out Leave the leg undressed and remove the patient from the room

A. B.

The patient is the priority, not infection control If the fire was small, in a waste basket for example, it might be able to be contained, but a TV is an electrical

RACE is the most common acronym
◦ ◦ ◦
 

Rescue the patient Activate the Alarms Contain the Fire Extinguish the Fire

Close the doors Close the fire doors

A. B. C. D.

Draw a sample of blood just before the next dose and at the end of the infusion Draw a sample of blood just before the next dose and 1 hour after the infusion in complete Obtain a sample of urine just before the next dose and at the end of the infusion Obtain a sample of urine just before the next dose and 1 hour after the infusion in complete

Peak concentrations of medications occur when the medicine is at its highest level
◦ For IV meds, this is when the medication has completely infuses ◦ For oral medications, it is about 30-45 minutes after ingestion

Trough (low) concentrations occur just before the next dose

Medications that have a toxic effect on the liver, kidneys or ears need to be monitored Patients with liver or kidney disease cannot excrete the meds and become toxic more rapidly
◦ Therefore doses can be reduced or frequency be made longer (eg, every 18 hours, every other day)

A. B. C. D.

I I I I

drink grapefruit juice every morning. eat a lot of spinach and kale. drink milk with every meal. have changed to K Salt.

Spinach and kale contain large amounts of vitamin K. Vitamin K interferes with the effect of warfarin and should not be eaten.

Dark green vegetables contain vitamin K


Foods may alter absorption or bind with the medication Common problems:

◦ Grapefruit juice is metabolized by the same enzyme that metabolizes medications ◦ Tyramine with MAOs for psychiatric disease leads to hypertensive crisis

 Antibiotics, Antihypertensives (calcium channel blockers), Antiarrhythmics, Hormone Replacements, Cholesterol Blockers
 Tyramine found in beer, red wine, cheese, processed meats, fruit, chocolate and nuts  Delay absorption

◦ Milk or food and antibiotics

Potassium salt is substituted for NaCl
◦ Very bitter and Much more salty ◦ Use with caution with kidney failure

A.

B.
C. D.

Hold the drug and notify the pharmacist Substitute a cephalosporin of equal strength Explain that IV allergies do not cross over to oral allergies Ask the patient to describe what happened last time she took Penicillin

 

Some patients will report being ―allergic‖ when they are not. They believe that having an upset stomach is an allergy The pharmacist will not be able to change the order Allergies are not route dependent The nurse cannot independently change the drug from what is ordered

Several types
◦ Mild localized rash ◦ Systemic effects
 Anaphylaxis
 Airway and facial edema

Occur with a second exposure
◦ Immune system is set to trigger a second response

Hives of the face and neck

Skin rash is common

A.

B.
C. D.

The ability of the patient to swallow Previous allergies to this medication or Penicillin What other medications the patient routinely takes The ability of the patient to adhere to the TID drug regimine

Augmentin pills are large and strep throat may prevent swallowing them Augmentin contains Penicillin and a cross over allergy is possible Other medications, such as birth control pills, may interaction Adherence to a TID regimen may be difficult

Warfarin

◦ NSAID ◦ Sulfa ◦ Macrolides

ACE inhibitors

◦ Quinolones ◦ Phenytoin

 ―- mycin‖ antibiotics
 ciprofloxacin, enoxacin, norfloxacin, and ofloxacin

Digoxin

◦ Potassium replacements ◦ Spironolactone ◦ Amiodarone ◦ Verapamil

Phenytoin

◦ Quinolones

Patients can take 20 or more pills in one day

A. B. C. D.

Jaundice Oliguria Candidiasis Gastric Bleeding

Candidiasis (vaginal is very common) occurs when the bacterial flora are altered and Candida grows unchecked
◦ Presentation is vaginal itching and pain, and a white cheese-like drainage

Jaundice, oliguria and gastric bleeding is not due to antibiotic
◦ Buy if present should be reported to the MD

Proliferation (growth) of organisms not killed by the antibiotic
◦ Vaginal - vaginitis ◦ Bowel -- diarrhea ◦ Oral -- thrush

Prevention with probiotics?
◦ Lactobacillus in yogurt can restore balance

A.

B.
C. D.

Avoid alcohol Limit fluids to 1000 ml per day Avoid exposure to the sunlight Limit consumption of milk products

 

All the sulfa drugs can lead to photosensitivity Alcohol is avoided with Flagyl (metronidazole) Milk delays absorption, it does not interfere with this drug actions

A. B. C. D.

An elderly woman who lives in a nursing home A middle aged woman who has just gotten a ―head cold‖ A young nurse with an allergy to eggs An elderly woman who had a reaction to the flu vaccine last year

High risk patients for influenza are:
◦ ◦ ◦ ◦ The elderly The institutionalized Persons with respiratory disease Health care providers

Influenza vaccine is contraindicated in:
◦ Persons with febrile illness ◦ Persons with egg allergy ◦ Persons who have had a prior reaction

Natural = Nonspecific immunity
◦ From intact skin and white blood cells

Acquired Immunity = Antibodies
◦ Active = have the disease ◦ Active = have an immunization ◦ Passive = borrow the antibodies from others or mother

A. B. C.

Yes No I have no idea!

Thrombolytics are used to dissolve the clot
◦ Drug names end in ―ase‖

However they dissolve all clots
◦ Not used with bleeding strokes, other sources of bleeding

Left sided stroke
◦ Right sided weakness ◦ Language, mathematical and analytic processes impaired

Right sided stroke
◦ Left sided weakness ◦ Visual and spatial loss and loss of proprioception
 Awareness of body in space  Neglect of left side of body

A.

B.
C. D.

Daily oral care with flossing will be needed Take the medication each morning with milk The medication should be used until he is seizure free for 1 year Limit alcohol consumption to 2 glasses of wine daily

Phenytoin is not absorbed with milk or tube feeding It needs to be taken for life Alcohol reduces its absorption
◦ Increases risk of seizures

Phenytoin has a narrow therapeutic range

Gingival hyperplasia from poor oral care

   


Digoxin (digitalis) Phenytoin (Dilantin) Warfarin (Coumadin) Gentamicin Phenobarbital Quinine

 

Patients quickly become toxic Blood levels are drawn when doses are changed Nurses need to monitor for signs and symptoms of toxicity

A. B. C. D.

Heart failure Asthma Diabetes Dementia

Propranolol is a nonselective Alpha and Beta blocker, therefore will cause bronchoconstriction It should be used cautiously in diabetics
◦ May mask hypoglycemia

 

It is used for the treatment of heart failure It has no contraindications in dementia

Alpha 1 receptors are in the arterioles
◦ When stimulated lead sympathetic response
 Flight or fight
 Peripheral vasoconstriction to shunt blood  Tachycardia

Beta 1 receptors

When stimulated lead to increased heart rate and increased myocardial contraction

Beta 2 receptors

When stimulated lead to vasodilation, bronchodilation, muscle contraction

A.

B.
C. D.

Potassium 2.3 Potassium 5.5 Sodium 135 Sodium 145

Furosemide is a potassium wasting diuretic
◦ Loop diuretic

Normal values of potassium are 3 or 3.5 to 5 or 5.5 Sodium range is 135-145
◦ If this patient’s sodium is trending higher, MD should be asked, patient may be becoming dehydrated

You must memorize
◦ Sodium - 135-145 ◦ Potassium 3-5.5 ◦ Calcium 7-9

Dehydration can lead to false positives
◦ Values are higher than true numbers

Overhydration can lead to false negatives
◦ Dilutional effects

A. B. C. D.

Calcium 8.5 Chloride 100 Potassium 3.0 Sodium 122

Sodium is the major extracellular ion When patient is dehydrated
◦ Fluid is lost ◦ Sodium is not ◦ The portion of sodium is larger
 More concentrated

A. B. C. D.

Chew on hard candy for dry mouth Take the medication on an empty stomach Increase the amount of calcium taken daily Increase the amount of fluid and fiber taken daily

Calcium channel blockers increase constipation
◦ Smooth muscle in the colon does not work as well

 

They do not need to be taken on an empty stomach They do not lead to dry mouth They do not require that calcium intake be changed


End in the suffix ―pril‖ inhibit depolarizationinduced Ca2+ entry into smooth and cardiac muscle cells in the cardiovascular system
◦ Smooth muscle in arterioles where BP is controlled

A.

B.
C. D.

1 2 3 4

liter per minute liters per minute liters per minute liters per minute

Oxygen therapy is provided in % by face masks
◦ Each 4 percent = I liter by nasal cannula ◦ Room air is 20%, so
    24% 28% 32% 36% = = = = 1 2 3 4 liter liters liters liters

◦ Maximum oxygen by NC is 6 liters
 At this rate, it dries the nasal mucosa and leads to bleeding

Titrated to oxygen saturation in blood
◦ Measured by probe on finger or ear
 Normal % is over 92%  Use lowest level of oxygen to meet O2 needs

Use of oxygen in patients with emphysema
◦ Drive to breath is hypoxia (not hypercapnia)
 So if oxygen given, drive to breathe can be suppressed  Usually given only1-2 liters of oxygen

Venturi masks can deliver oxygen at specific percentage

A. B. C. D.

Less coughing O2 sats > 95% Respiratory rate of 28/bpm Fewer crackles in the chest

The purpose of suctioning is to remove secretions from the tube and upper airways
◦ Suction catheters do not reach alveoli ◦ Lung sounds will not improve until the patient coughs

 

Suctioning will cause reflex coughing Respiratory rate should decrease

A. B. C.

D.

I will stop using the inhaler if I get hand tremors after using it. I should use the inhaler as a rescue drug if my chest feels tight. I should stop using the inhaler when I am taking steroids. I will take this inhaler daily to keep my asthma in control.

Albuterol is an inhaled bronchodilator used for acute care of bronchospasm. It can lead to tachycardia and tremors because it is an alpha 1 agonist. It is often used in combination with steroids for the treatment of acute asthma. It is not a daily drug or a routine drug; inhaled steroids are used for this purpose.

Allergic response
◦ Inflammation ◦ Airway swells and spasms closed ◦ Wheezing ◦ Dyspnea ◦ Decreased peak flow
 Measured by patient

Presentation

Asthma presentation

Peak flow is key to monitoring

A.
B. C. D.

Presence of gag reflex Color and amount of sputum Ability to turn head side to side Chest pain that worsens with inspiration

The airway is numbed for the procedure
◦ Gag reflex is blocked for up to 2 hours ◦ Do not feed the patient until gag reflex returns
 Aspiration could develop

Assessment of sputum is not unique in this case Injury to the neck from hyperextension could occur, but rare Pneumothorax could occur, but rare and not unique to this procedure

Examination of the bronchi with a lighted tube
◦ Remove mucus ◦ Biopsy airway tumors/masses ◦ Remove foreign objects

 

Patient is sedated Airway is numbed

A.

B. C.

Blood in the collection chamber Air bubbling in the air seal Air bubbling in the suction control chamber

A.

A. From the hemothorax
B.

Blood in the collection chamber

A. From the pneumothorax
C.

Air bubbling in the air seal
Air bubbling in the suction control chamber
Suction control

A. From the wall suction
Water seal

Fluid collection

Placed into the pleural space
If system opens
◦ Upper chest to remove air ◦ Lower chest to remove fluid

◦ Air reenters pleural space and lung can collapse

A. B. C. D.

Ondansetron (Zofran) Metoclopramide (Reglan) Prochlorperazine (Compazine) Dimenhydrinate (Dramamine)

Ondansetron (Zofran) works on the vomiting center in the brain Metoclopramide (Reglan) is a GI stimulant and best used for nausea after surgery Prochlorperazine (Compazine) can lead to extrapyramidal effects
◦ Tremor, restlessness, uncontrollable speech

Dimenhydrinate (Dramamine)
◦ Commonly used for motion sickness

Chemoreceptor trigger zone
◦ area of the brain which receives inputs from bloodborn drugs or hormones, and communicates with the nearby vomiting center to initiate vomiting


Treat nausea prior to chemotherapy Treat nausea prior to surgery

A. B. C.

D.

Let the patient take the meds Review the Medication Administration Record and let her take the important ones Do not let her take the medications, report the error and notify the MD Do not let her take the medications and notify the charge nurse

The patient cannot take the meds, too much time has past and the nurse may have the same meds for 0900 The MD may need to change the prescription to replace the missing medications; something that the charge nurse cannot do

Right drug

Right dose

◦ Know how to correctly compute dose ◦ Check your work 3 times

Right time

Right route

◦ Know schedule for QD, BID, TID, Q 6 hrs, before and after meals ◦ Know incompatibilities with IV meds ◦ Know drug-drug, drugfood interactions ◦ Chart only after the med is given

Right patient

◦ Know algebra and how to compute doses based on body weight ◦ Check ID band ◦ Have patient state his/her name

Right documentation

A.

B.
C. D.

Discontinue the IV Change the IV tubing Slow the infusion rate Apply a hot pack to the IV site

The IV has infiltrated and needs to be stopped. The fluid is infusing into the tissues not the vein. IV tubing is changed every 48 to 72 hours routinely Slowing the infusion rate will not stop the infiltration Hot packs can be applied after the IV catheter is out to help with fluid reabsorption

IVs are often started by RNs 3 attempts is the usual maximum number of tries Usually started first in the hand Then future sites are moved proximal in the arm

IV site complications Infiltration – needle has slipped and fluid is going into tissues Extravasation – toxic meds going into tissues

A.
B. C. D.

Dyspnea Polyuria Confusion IV site infiltration

The IV fluid may have been deposited in his lungs when in fluid overload. Polyuria would be great, it would mean that his kidneys are excreting the fluids. Confusion may be a concern, it may indicate he has developed cerebral edema. IV site infiltration would be worrisome, if the fluid is now in his arm, but not the most severe problem.

Sterile fluids infused into the body through a catheter in a vein Used to replace fluids in the vascular space (vessels) Types of fluids
◦ Isotonic – saline, D5W, LR ◦ Hypertonic – combinations of NS and glucose and Lactated Ringers ◦ Hypotonic – less than NS (.2, .45 NS without glucose)

Prescribed at hourly rates
◦ Adult rates range from 75-125 ml/hr

A.

B.
C.

D.

Remove the catheter and attempt to reinsert it into the urethra Leave the catheter in the vagina and attempt to insert a new catheter into the urethra Ask the patient to use the bedpan so that the urethra is open Examine the perineum more closely and attempt to identify the urethra

 

Common problems include improper exposure and poor lightening Do not reuse the same catheter Leaving the old catheter in the vagina is not a bad idea; it provides a marker Using the bedpan will not open the urethra long enough for you to see it

Sterile items only remain sterile if they touch other sterile items A sterile field is not sterile if you turn your back to it Exposure the perineum with your nondominant hand; so that your gloved hand remains sterile

A. B.

C.
D.

I bought a good moisturizer for my feet. I will use a mirror to check my feet every night. I have found a place to buy shoes that have a broad toe space. I will use a hot baths every night to increase blood flow to my feet.

 

Diabetics develop neuropathy and cannot feel pain. Therefore hot water could burn the patient. Keeping the skin moist prevents fissures and cracks Broad toe in a shoe is idea Examining the skin on the feet with a mirror is critical for finding skin problems early

After 10 years of diabetes, especially if poorly controlled blood glucose
◦ Retinopathy ◦ Nephropathy ◦ Neuropathy
     Loss of vision

 Loss of kidney function  May need dialysis
Dense numbness of the legs Easily injured Very slow to heal open wounds May lead to amputation

◦ Autonomic neuropathy

 Slowed digestion  Blood pressure problems (low or high)

A.
B. C.

D.

Consent to be Treated Advance Directives Patient’s Bill of Rights (Patient Partnerships) Consent for Surgery


 

Tumor? Impaction? Hematoma? Abdominal aortic aneurysm?


Cues: pulsatile, sudden onset Likely treatment: either surgery or allow it to rupture without treatment to end her life Surgery
◦ Likelihood of living is low

So, confirming Advanced Directives is very important

Living Will
◦ The patient’s desires for treatments that prolong life
 DNR, tube feeding, intubation, CPR, cardiac meds

Durable Power of Attorney
◦ A person who can make decisions about life, death, treatments on behalf of the patient

A. B. C.

D.

Plan to do CPR if his heart stops Contact the physician now for an updated DNR order Place a note on the chart for the physician to renew the DNR Ask the patient what he wants done if his heart stops today and do what he wants

Patient’s condition is deteriorating and he may die soon No assumptions can be made about preferred DNR status Patient has to be in ―right mind‖ or sane to make this decision
◦ You could ask and give this information to the MD ◦ Morphine clouds judgement

Once CPR starts, even if on a DNR patient by mistake, it must continue

Orders written by MD after discussion with patient or family In some states, a DNR expires after 6 months
◦ Assuming the patient’s condition may have improved

If no DNR is present on the record, all resusitation takes place

A. B. C. D.

Allow him to leave as he intends Validate that he understands the possible consequences of his decision Have him sign a leaving ―against medical advice‖ document before leaving Ask security to detain him until someone can sign consent to be treated for him

Angina can be due to occlusion of the coronary arteries Angina can precede a fatal myocardial infarction The MD has to be notified, but if the patient is left alone he may leave as he intends Security cannot retain him, this could be seen as false imprisonment


All patients have the right to refuse care They must know and be able to comprehend the consequences of this decision
Documentation of the conversations must be very complete Leaving against medical advice (AMA)
◦ Law suits can occur if patient suffers the consequences and it is not clear that he was fully informed ◦ Demented patients cannot refuse care…they cannot understand the consequences

◦ Legal document that ―protects‖ hospital from law suits ◦ If patient is at risk of harm to self or others may need to be commitment to a mental health facility

A. B.

C.
D.

Ambulate upon return from the study Assess puncture site for hematoma Avoid antiplatelet medications Restrict oral and IV fluids

The femoral artery is often the access site and can quickly develop hematoma or bleed The patient will be at bedrest with a pressure device on the groin (sandbag, pressure gauge) Antiplatelet meds (Clopidogrel [Plavix], aspirin, low molecular weight heparin) are given Oral of IV fluids are pushed to remove the contrast and prevent kidney injury

Dye study of the coronary arteries
◦ Invasive – need consent ◦ Dye – check allergies to iodine or shellfish

Indications
◦ Chest pain ◦ Unstable angina with ST segment changes ◦ Confirmation of the extent of heart disease

A. B. C. D. E. F.

The exact location of the pain If the pain radiates and to where What makes the pain better and worse Does taking a deep breath cause pain Vital signs and oxygen saturation Color of the skin, diaphoresis

Angina in men presents as
◦ ◦ ◦ ◦ Substernal chest pressure Radiation to left jaw and left arm Diaphoresis, gray skin color It gets worse with activity and better with rest

Angina in women often presents as
◦ Back pain ◦ Nausea

The more data the nurse can collect the easier it is to diagnose the problem


Angina and MI Pulmonary Embolus
◦ Some pain, more tachycardia, tachypnea, decreased O2 sats, anxiety

Pleurisy
◦ Pain is worse with breathing and sharp

Gastric distress/ulcers
◦ Pain related to diet ◦ Pain better with food

A. B. C.

D.

Medicate him for pain and splint the chest Suction his airway to remove the secretions Increase his FIO2 to reduce his need to cough Increase his fluid intake to thin the secretions

Incisional pain is made worse with coughing, so analgesics will help His oxygen needs to be kept over 93-95% but it is not to reduce the need to cough Suctioning him would be traumatic and would make him violently cough Fluids are often restricted after heart surgery to avoid fluid overload

Priorities of care

◦ Rhythm management

◦ BP management

 Edema and trauma to fibers

◦ Chest care

 Hypotension may cause grafts to collapse  Hypertension may cause bleeding from grafts  Congestion common

◦ Pain management

A.

B.
C. D.

Nothing Administer sublingual nitroglycerin Call a cardiac arrest, and begin CPR Determine if the patient is conscious, if not proceed with CPR

A. B. C.

D.

Nothing, continue to monitor Administer sublingual nitroglycerin Call a cardiac arrest, and begin CPR Determine if the patient is conscious, if not proceed with CPR

A.

B.
C. D.

Nothing Administer sublingual nitroglycerin Call a cardiac arrest, and begin CPR Determine if the patient is conscious, if not proceed with CPR

A.
B. C. D.

Nothing Administer sublingual nitroglycerin Call a cardiac arrest, and begin CPR Determine if the patient is conscious, if not proceed with CPR

V fibrillation

V tachy (cardia)

Asystole

A. B. C.

D.

I will take my water pill (furosemide) at night. I will take my heart rhythm pill (digoxin) when my pulse gets to 60. I will have my blood (warfarin) tested weekly while I take this blood thinner. I only need to take this blood pressure pill (Captopril) weekly.

PT and INR is monitored weekly at first to make dose changes
Furosemide is taken in the AM Digoxin reduces heart rate
◦ Impacted by vitamin K intake

BP meds are taken daily
◦ BP should be monitored

◦ Pulse needs to be taken for a minute ◦ Toxicity includes seeing yellow rings, fatigue, weakness, confusion and anorexia

A. B. C.

D.

Push 40 mEq of KCl into a central line Push 20 mEq of KCl into a peripheral line Infuse diluted KCl at 20 mEq per hour through a peripheral line Infuse diluted KCl at 20 mEq per hour through a central line


Never, never, ever give undiluted potassium It stops the heart and the heart cannot be fixed! Diluted potassium is given
◦ 10 mEq through a peripheral line ◦ 20 mEq through a central line

Peripheral lines are in the arms and hands

Central lines are placed by MDs into subclavian and other large vessels

A. B. C. D.

Credé maneuvers Kegel exercises Increased calcium intake Limit oral intake of fluids


Kegel exercises strengthen the pelvic floor Credé maneuvers is tapping over the bladder
◦ used by spinal cord injured to relax the bladder

  

Calcium has no impact Oral fluids should not be restricted Other suggestions
◦ Limit alcohol and caffeine ◦ Used prescribed hormone therapy

Stress
◦ Occurs with laughing, jumping, coughing ◦ Mainly in women, follow child birth

Urge
◦ Seen with urinary infections

Functional
◦ Cannot reach the toilet in time or cannot remove clothing in time

Total
◦ Unaware of need to void

A. B. C. D.

Furosemide 20 mg IV stat IV NS 1000 ml bolus over 1 hour Irrigate the catheter with 30 ml NS Continue to monitor for another hour

The patient is dehydrated, he needs fluids and quickly to prevent renal failure Furosemide will create urine, but worsen dehydration The catheter does not appear to be plugged
◦ Plugged catheters produce no urine

Monitoring for another hour does not fix the problem

Prerenal renal failure
◦ Lack of blood getting to the kidneys ◦ Seen in hemorrhage, edema (burns), dehydration ◦ Treated with fluids

Intrarenal renal failure
◦ Diseases of the kidney ◦ Seen with nephrotic syndrome, diabetes, infection, meds ◦ Treatment of the disease

Postrenal renal failure
◦ Obstruction to flow past the kidneys ◦ Seen with prostate disease, kinked of plugged catheters ◦ Treatment is remove the obstruction

A. B. C.

D.

Give him 1-2 units of Lispro SQ Notify the dietician to deliver his food tray now Recheck his blood glucose first then give him 15 g of glucose Give him 15 g of glucose and recheck his blood glucose in 15 minutes

 

Normal blood glucose is 70-100 (110) Hypoglycemia is serious and needs immediate treatment Lispro is rapid acting insulin---would make the problem worse There is no point in rechecking the reading; he is lethargic, it is probably right
◦ Little error in treating

Getting his tray of food won’t help; he can’t eat it

Hypoglycemia
◦ ◦ ◦ ◦ Below 70, treat with 15 g of glucose Below 60, start with 15g and recheck glucose Below 50, add a long acting sugar (eg crackers) Below 40, use glucagon…patient usually nonresponsive

Hyperglycemia
◦ Treat with short acting insulin, called sliding scale
 Based on blood glucose reading

◦ Replace fluids lost with diuresis

A.

B.
C. D.

None, this is a normal finding Irrigate the ileostomy Increase the patient’s activity Notify the surgeon of the bowel obstruction

Ileostomy does not have output for about 3 days after surgery. The initial output is mucus Irrigation would be contraindicated
◦ The suture sites are too new ◦ The output is fluid

Activity could be increased for other reasons, but it would not change bowel output There is no obstruction present

Resection of bowel

Residual stoma produces the type of stool based on where it was prior to surgery Stoma should be pink and above the skin level, so that appliance can be attached

A. B. C. D.

Brownies with ice cream Pasta with marinara sauce Strawberries with sugar Poached eggs on toast

High fat foods with stimulate the gall bladder to contract leading to pain All the foods with sugar or starch or protein are fine

Pain from gallbladder disease presents as
◦ Shoulder blade pain after eating fatty diet ◦ Nausea, belching


Cholecystectomy (not colostomy) Done with scope
◦ Laparoscopic cholecystectomy
 Smaller incision  Shorter hospital stay  Pain from air used in case

◦ Diet afterwards can include
 Fats
 Bile is released continuosly

A. B. C. D.

Vomiting and abdominal pain BP 122/83 lying and 92/66 standing Bluish discoloration around the umbilicus Serum amylase 4 times higher than normal


This patient is dehydrated and needs IV fluids Periumbilical blueness (called Cullen’s sign), elevated amylase, pain and vomiting are expected findings

Serum enzymes are elevated whenever cells are destroyed
◦ Amylase and lipase normally in the pancreas are elevated with pancreatitis ◦ Creatinine kinase and troponin elevated with myocardial injury ◦ Creatinine kinase also elevated with muscle injury

Nurses expected to know which lab values are changed in various diseases and notify MDs when abnormal and unexpected findings are present

A. B. C. D.

Long acting insulin is used Blood glucose is checked daily MD orders are needed for TPN daily Clean technique is used when changing TPN tubing or bags

Hyperalimentation is prescribed daily
◦ Bags are hung to last 24 hours ◦ If delivery falls behind or is ahead of schedule, it is not ―made up‖

Blood glucose is checked 4 times a day and treated with sliding scale regular insulin Sterile technique is used with TPN
◦ Given through central lines

Administration of fluids, protein and calories through a vein. Fats are also commonly given in a separate infusion Indications
◦ unable to absorb nutrients through the intestinal tract
 severe vomiting, diarrhea, or intestinal disease

Also called parenteral nutrition, total parenteral nutrition, and TPN.

Content you know now was learned for a specific test
You need to be able to recall information presented randomly
◦ Study information in sets to see relationships ◦ Make yourself recall it randomly ◦ Mix up the material
 E.g., heart disease

◦ Create a study plan for review

 Make cards to test yourself at odd times  Meet with friends to quiz each other on random topics
 Add priority setting to heart disease, add it to OB, etc

Practice taking long exams before taking this one
◦ Use practice exams

Take breaks when needed

Read the entire test item and distractors
◦ It is easy to assume you know what the test question is asking

◦ They do count in your total time


Eliminate obvious wrong answers This exam does not have obvious errors
◦ Answer C is not always right ◦ Longest answer is not always right

 

OK to guess if you have a sense it is right Do not run through the exam at the end and guess on all unanswered items

Sample test
◦ www.4tests.com/exams ◦ www.nclextestnaswers.com

Daily test items online
◦ Google to find sites

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