Nursing 400 Final Exam combined study guides Questions And Answers
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Course
NURS 400
Institution
NURS 400
Dysphagia - ANS inability to swallow or difficulty in swallowing
2 key points about Dysphagia - ANS 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
-Whe...
Nursing 400 Final Exam combined study
guides Questions And Answers
Dysphagia - ANS inability to swallow or difficulty in swallowing
2 key points about Dysphagia - ANS 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 - ANS 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 - ANS Nasogastric tube
Irrigation tray - 60 ml syringe
A bottle of sterile water
lubricant
NGT insertion - ANS 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)
NGT placement - ANS 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 - ANS 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 - ANS 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 - ANS -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.
-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? - ANS THE SMALLER THE NUMBER, THE
BIGGER THE DIAMETER (GAUGE) OF NEEDLE
IV site inspection - ANS 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 - ANS -Common sites:
Dorsal area of the hands
Forearm
-Antecubital Fossa
Uncommon sites
Dorsal area of feet (needs an order)
Cephalic (infants)
Intravenous syringe length - ANS Neonate and Infants:
19 mm (<1 inch)
Child and Older Adult:
1 inch
Adults:
1-1 ¼ inches
Intravenous guages - ANS Neonate and Infants:
24-26 G
Child and Older Adults:
22 G
Adults:
18, 20, and 22 G
Intravenous angle - ANS *** Angle depends upon where the IV insertion site is.
(8) Rights of administration - ANS 1. Right Patient
2. Right Medication
3. Right Dose
4. Right Route
5. Right Time
6. Right Reason
, 7. Right Response
8. Right Documentation
(Parenteral routes of medication administration)
Intradermal - ANS 1. Medication is injected in the dermis (just below the epidermis)
2. Must form a "wheal"
3. Longest absorption time for parenteral routes
4. Dosage is usually less than 0.5mL
(Parenteral routes of medication administration)
Subcutaneuos - ANS 1. Injected in the adipose tissue
2. Absorption is slow to the capillaries
3. Dosage is usually no more than 1mL
4. Inject slowly so medication can disperse (10 sec/ 1 mL)
(Parenteral routes of medication administration)
Intramuscular - ANS Injected in the muscle
Faster onset than intradermal and subQ
(Parenteral routes of medication administration)
Intravenous - ANS Injected in the vein
Fastest absorption which also means fastest reaction to medication
(Parenteral routes of medication administration) (7)
Transdermal - ANS 1. Applied topically on the skin using a patch that contains medication
2. Remove old patch and wipe of remnants of medication
3. Clean and dry the area
4. Apply patch on different location (sites must be rotated to avoid skin irritation)
5. If the pt is hairy, trim the hair
6. Label the patch with date, time, and you initials
7. Most common patch used: Nitroglycerin - a vasodilator used to prevent angina (chest pain)
for pts with CAD (Coronary Artery Disease)
Urinary catheterization preparation - ANS Doctor's order is needed for all catheterizations
Ask for latex and iodine allergies
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