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109 Cards in this Set
- Front
- Back
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solution with the same osmotic pressure as blood
used for extracellular replacement expands the body's blood volume without a fluid shift |
isotonic
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What are some examples of isotonic solutions?
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0.9% NS
D5W LR |
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solution with less osmotic pressure than blood
causes cells to expand used in dehydration |
hypotonic
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solution with higher osmotic pressure than blood
causes cell to shrink used in overhydration |
hypertonic
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What are some examples of hypotonic solutions?
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0.45% NS
0.25 NS |
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What are some examples of hypertonic solutions?
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D5NS
D10NS D10W D5 1/2 NS D20W D5LR |
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Why would you use hand veins for an IV?
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short term therapy
ex. medication for surgery/sedation |
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What are the advantages of using hand veins for an IV?
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most distal site
easy to palpate usually no hair |
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What are the disadvantages of using hand veins for an IV?
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they are small
IV is easily dislodged veins tend to roll around |
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Why would you use forearm veins for an IV?
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longer term therapy
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What are the advantages of using forearm veins for an IV?
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they are larger than hand veins
they don't impede ADL's like hand veins do they don't roll around as badly can use dominant or non-dominant arm |
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What are the disadvantages of using forearm veins for an IV?
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they are hard to find/hard to palpate
they are deeper, so it causes more pain any hair on the arm will have to be taped |
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Why would you use antecubital fossa veins for an IV?
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if you need to use a large bore needle
for giving blood for rapid administration of medications during surgery |
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What are the advantages of using antecubital fossa veins for an IV?
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it is a quick stick
can use a large bore IV |
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What are the disadvantages of using antecubital fossa veins for an IV?
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it limits mobility
can't go distal if it infiltrates |
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Veins in the ________ are rarely used for IVs in adults because of the risk of thrombophlebitis.
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lower extremities
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What are the advantages of using lower extremity veins for IVs in children?
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easier to stick
kids don't focus on them as much |
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What are the disadvantages of using lower extremity veins for IVs in children?
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they are small veins
only the very experienced can do this |
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an IV site that is not being used, so it is kept "plugged" with a male adapter
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saline lock/heparin lock
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preoperative donation of a patient's own blood up to 5 weeks in advance of surgery
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autologous transfusion
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What is the max amount of time that a blood transfusion can take?
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4 hours (any longer and the blood is at risk for contamination)
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blood product that replaces red cell mass and plasma volume
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whole blood
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preferred method of replacing RBC mass
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packed cells
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replaces plasma without RBCs or platelets
contains coagulant factors and complement |
fresh frozen plasma
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What are the S/S of circulatory overload (IV complication)?
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headache
flushed skin increased pulse, B/P, respirations cough shortness of breath dyspnea syncope pulmonary edema |
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What can the nurse do to prevent circulatory overload (IV complication)?
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assess client for heart condition
monitor IV flow rate closely monitor elderly and children take accurate I&O's |
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What should the nurse do if a patient has circulatory overload (IV complication)?
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stop the infusion
call MD |
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What are the S/S of thrombophlebitis (IV complication)?
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tender vein
inflammation redness warmth hard cord-like vein swelling *may lead to clot formation |
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How can the nurse prevent thrombophlebitis (IV complication)?
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Change IV site as per hospital protocol
Dilute IV meds accordingly Assess IV site and surrounding areas frequently |
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What should the nurse do if thrombophlebitis (IV complication) occurs?
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D/C IV and restart elsewhere
Use cold compress to decrease inflammation MD may order antithrombolytic agent if client has clot |
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What are the S/S of air embolism (IV complication)?
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decreased BP
tachycardia chest pain loss of consciousness |
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How can the nurse prevent air embolism (IV complication)?
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Replace IV bags before empty
Prime tubing carefully |
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What should the nurse do if a patient develops an air embolism (IV complication)?
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Put patient in Trendelenberg on left side - air will go into right ventricle --> lungs to dissipate
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What are the S/S of equipment failure (IV complication)?
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infiltration
kinked tubing solution not infusing |
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How can the nurse prevent equipment failure (IV complication)?
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Frequently check tubing for kinks.
Avoid IV site at vein junction. Don't flush if not patent. Check for pump functioning. |
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What should the nurse do if she notices equipment failure (IV complication)?
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Increase height of solution.
Change position of arm. D/C IV and restart. |
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What are the S/S of pyrogenic reaction (contaminated IV solution)?
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occurs 30-60 minutes after solution starts
increased temp chills flushing headache N/V decreased BP |
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How can the nurse prevent pyrogenic reaction (contamined IV solution)?
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Assess solution appearance.
Change bag and tubing as per policy (usually every 2-3 days) Change site as per policy (usually every 2-3 days) Use IV only when necessary |
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What should the nurse do for a pyrogenic reaction (contamined IV solution)?
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Stop infusion.
Call MD. Check vital signs. Treat symptoms: Give Tylenol/Benadryl. Possible volume replacement to increase BP. Stay with client Save solution and tubing for lab analysis. |
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What are the S/S of IV infiltration?
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swelling
skin blanching pain decreased flow/flow stops coolness at site |
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How can a nurse prevent IV infiltration?
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secure angiocath
limit arm movement |
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What should a nurse do to treat IV infiltration?
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Stop infusion.
Notify MD D/C IV and start elsewhere Warm compress to increase fluid absorption **Make sure IV med is not necrosis-causing before giving warm compress! |
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What angle do you use to insert an IV?
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very small (less than 30 degrees)
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How often do you check vital signs while doing a blood transfusion?
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every 5 minutes for the first 15 minutes
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Who must check the blood from the blood bank to make sure it is right for the patient?
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2 RNs
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What rate do you begin blood transfusions at?
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2 mL/min
blood set drip rate i 10 gtt/mL |
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What are the first signs of a blood transfusion reaction?
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fever
tachycardia hypotension *later signs: chills back pain headache nausea chest tightness anxiety dyspnea pruritus urticaria |
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blood transfusion reaction that occurs because of ABO or Rh incompatability
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acute hemolytic reaction
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blood transfusion reaction against non-ABO donor antigens
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delayed hemolytic reaction
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blood transfusion reaction that occurs because of sensitivity to donor's leukocytes or platelets
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febrile, non-hemolytic
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blood transfusion reaction that occurs because of an allergy to plasma proteins in the donor's blood
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mild allergic reaction
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blood transfusion reaction that occurs because of an allergy to donor antigens (IgA)
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severe/anaphylactic allergic reaction
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blood transfusion reaction that occur when donor lymphocytes attack recipient RBCs as if they were foreign proteins
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graft vs. host reaction
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blood transfusion reaction that occurs because of excessive volume or excessively rapid rate
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circulatory overload
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blood transfusion reaction that occurs becaue of bacteria contamination of the product
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bacterial sepsis
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What are the 6 rights of medication administration?
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right drug
right dose right patient right route right time right documentation |
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When do you check the medication order?
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1. Before removing from drawer
2. When removing from drawer/container 3. Before giving to patient |
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What is important to remember about drugs that cause GI distress?
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Give before (AC) or after (PC) meals.
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What is important to remember about oral liquids given to effect the oral mucus membranes?
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Do not follow with a "chaser".
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What is important to remember about oral liquids with an unpleasant taste?
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Give cold or at room temp.
Flavoring may be added. |
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What is important to remember about medications that will discolor teeth?
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Give via a straw.
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How should you position your patient when giving an opthalmic medication?
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supine or upright with the neck slightly hyperextended
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Where do you instill opthalmic drops or ointment?
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into the conjunctival sac
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What should a patient do after receiving an otoscopic medication?
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Maintain head-tilt position for 2-3 minutes.
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What should the nurse do for a patient who has just received an otoscopic medication?
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Gently apply pressure to the tragus (area in front of the ear) or put cotton ball in for 15 min.
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What position should the patient be in to receive enteral medications (through NG tube)?
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semi-fowlers
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How can you determine that the NG tube is in the right place before giving medications through it?
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1. Inject 10 mL of air and auscultate over epigastric area.
2. Draw up secretions and make sure pH is around 4. 3. Check with x-ray. |
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What should you do before giving medicine through an NG tube?
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flush with 30 mL of water (unless contraindicated)
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What areas of the syringe and needle are sterile?
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needle
tip of syringe inside of barrel stopper end of plunger |
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What kind of needle do you use to draw up medicines out of an ampule?
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filter needle
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What type of syringe do you use to give an ID medication?
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1 mL Tuberculin
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What length needle do you use to give an ID medication?
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3/8 - 5/8 in.
*usually 1/2 - 5/8 in. |
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What gauge needle do you use to give an ID medication?
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25-27
usually 26-27 |
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What is the max amount of medication you can give ID?
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0.1 mL
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Do you massage or aspirate an ID injection?
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no!
dermis is relatively avascular so there is no need to aspirate. massage may dispere medication into underlying tissues and alter test results. |
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What size syringe do you use for a SQ injection?
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1-3 mL
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What length needle do you use for a SQ injection?
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3/8 - 5/8 in.
usually 1/2 - 5/8 in. |
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What gauge needle do you use for a SQ injection?
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25-27
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What is the max amount of medication you can give SQ?
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1 mL
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Do you aspirate or massage a SQ injection?
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no!
aspiration is not necessary b/c piercing a blood vessel is very rare. massage can damage underlying tissue. |
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When mixing insulins, which do you draw into the syringe first?
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the fastest
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What size syringe do you use for an IM injection?
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1-3 mL
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What length needle do you use for IM injections?
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1 - 1 1/2 in.
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What needle gauge do you use for an IM injection?
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21-25
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What is the max amount of medication that can be given IM?
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3 mL
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What is the max amount of medication that can be given IM in the deltoid?
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1 mL
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What is the max amount of medication that can be given IM to children?
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1 mL
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What position should the patient be in for an IM injection in the deltoid?
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seated
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What position should the patient be in for a vastus lateralis IM injection?
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supine
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What position should the patient be in for a ventrogluteal IM injection?
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lateral or prone
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What position should the patient be in to receive a dorsogluteal IM injection?
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prone or standing bent with feet pointed in
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Do you aspirate or massage an IM injection?
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yes, aspirate
no, massage *apply gentle pressure but do not massage site. massage will damage underlying tissue. |
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What causes a false positive result for occult blood on a stool test?
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ingesting significant amounts of red meat within 3 days of the test
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What are the symptoms of pelvic inflammatory disease?
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sudden fever
suprapubic pain and tenderness acute rigid boardlike lower abdominal musculature PID is usually caused by gonorrhea or chlamydia |
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What is the most common STD in the U.S.?
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chlamydia
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When obtaining an endocervical specimen, a __________ gives a higher yield of endocervical cells at the ___________ ___________.
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cytobrush
squamocolumnar junction |
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What color indicates a positive result for occult blood on a stool test?
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blue
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clusters of small, shallow vesicles with surrounding erythema on genital areas and inner thigh
causes local pain, dysuria, and fever |
Herpes simplex - type 2
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STD that causes painless worty growths that may be single or multiple in a cauliflowerlike patch
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HPV
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Infertility is considered after _____ of engaging in unprotected sex without conceiving.
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1 year
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cessation of menstruation
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menopause
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What is TSE?
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testicular self-examination
T = timing (once a month) S = shower (warm water relaxes scrotal sac) E = examine (check for changes and report any immediately) |
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What should you tell a woman before she comes in for a Pap smear?
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do not douche, have sex, or put anything into the vagina within 24 hrs before collecting the specimen
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Absence of an abdominal reflex could indicate:
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pyramidal tract lesion
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Babinski reflex in someone over age 1 could indicate:
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pyramidal tract lesion
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Loss of balance in the Romberg test indicates:
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cerebellar ataxia or vestibular dysfunction
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When testing the sensory system, loss of sensation could indicate:
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spinal tract, brain stem, or cerebral lesions
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In the position test (moving finger up or down), loss of sensation may indicate:
Symmetrical sensory loss may indicate: |
peripheral neuropathy (diabetes, alcoholism, vitamin B12 deficiency)
polyneuropathy |
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Having tactile agnosia may indicate:
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parietal lobe lesion
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