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Nursing 400 Final Exam combined study guides 100% Correct!!

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  • Nursing 400

Dysphagia - ANSWER-inability to swallow or difficulty in swallowing 2 key points about Dysphagia - ANSWER-1. 30 mins prior to meal time, the pt needs to be sitting at 90 degree unless its contraindicated 2. Monitor for possibility of aspiration -s/s of aspiration -Coughing -Wheezing -Redn...

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  • August 18, 2024
  • 103
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • Nursing 400
  • Nursing 400
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Nursing 400 Final Exam combined
study guides 100% Correct!!


Dysphagia - ANSWER-inability to swallow or difficulty in swallowing

2 key points about Dysphagia - ANSWER-1. 30 mins prior to meal time, the pt needs to be sitting at
90 degree unless its contraindicated



2. Monitor for possibility of aspiration

-s/s of aspiration

-Coughing

-Wheezing

-Redness of face

-Decrease O2 sat



2 key points about Nasogastric Tube - ANSWER-Used for pt who suffers from dysphagia (difficulty
swallowing)



Residual volume must always be checked q4h d/t risk for aspiration *** if there is a large amount of
residual volume, that means pt is not digesting the food - inform MD**



Nasogastric Tube Supplies - ANSWER-Nasogastric tube



Irrigation tray - 60 ml syringe



A bottle of sterile water



lubricant



NGT insertion - ANSWER-1. Measure the tube from the nose to the back of the ear and down a little
pass the bottom of the xiphoid process

,2. Mark the tube (sharpie)



3. Have the patient swallow while inserting the tube (with or without ice chips)




-Always count (1-2-3) out loud and tell them how to position or move

themselves.

a. If the patient is weaker on one side, have them put their weight on the stronger side before
standing up.



b. Turn your entire body rather than pivoting to avoid hurting your back



-When re positioning the patient, you has always make sure to avoid hurting your wrists



-Make sure the bed is at your hip level.



-If the patient is too heavy, ask for help.



How do we measure syringe gauge sizes? - ANSWER-THE SMALLER THE NUMBER, THE BIGGER THE
DIAMETER (GAUGE) OF NEEDLE



IV site inspection - ANSWER-look atthe IV catheter insertion site for redness, swelling, or bruising.
Redness can indicate irritation, inflammation, infection, or thrombus formation. ... Assess the
condition of the transparent catheter dressing. The dressing should be clean, dry, and adhere
securely to the skin around the IV catheter insertion site



Intravenous sites - ANSWER--Common sites:

Dorsal area of the hands

Forearm



-Antecubital Fossa

Uncommon sites

,Dorsal area of feet (needs an order)

Cephalic (infants)



Intravenous syringe length - ANSWER-Neonate and Infants:

19 mm (<1 inch)



Child and Older Adult:

1 inch



Adults:

1-1 ¼ inches



Intravenous guages - ANSWER-Neonate and Infants:

24-26 G



Child and Older Adults:

22 G



Adults:

18, 20, and 22 G



Intravenous angle - ANSWER-*** Angle depends upon where the IV insertion site is.



(8) Rights of administration - ANSWER-1. Right Patient

2. Right Medication

3. Right Dose

4. Right Route

5. Right Time

6. Right Reason

7. Right Response

8. Right Documentation

, NGT placement - ANSWER-1. Once the NGT is inserted, aspirate 30 mL of air



2. Place the stethoscope over the stomach and listen to the "wooooosh" sound as you inject the air



3. If necessary, get an order for x ray for proper placement.



NGT medication administration - ANSWER-1. Check if pt is on any fluid restrictions



2. Check gastric residual and put it back after.



3. Make sure to kink the tube so that air won't go in the tube (air causes bloating)



4. Crush medication and mix with water until diluted and poured in the syringe. [except enteric
coated or with granules (Protonix)]



5. Flush 5-10 mL in between medications



6. Flush 30 mL after all medication has been administered



NGT removal - ANSWER-1. Needs a doctor's order



2. Flush with 10 mL water/NS or 30-50 mL of air



3. Have pt take a deep breath while removing the tube quickly



7 Rules about Body mechanics - ANSWER--Always bend the knee and have a wide base for support



-Always point your toes to the direction you're going



-When transferring a patient to a chair or wheelchair, have them hold on to your shoulders and have
your dominant foot in between their legs.

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