Review for Funds Final Case Studies

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NS 307: Fundamentals of Nursing: Review for Final Exam, Fall 2017 D. Mager The following case studies with multiple-answer-questions are designed to help you determine which areas you need more preparation with, as you study for the final exam. The case studies are overviews of the content areas. They do not cover every single piece of information that was covered in the course, but are a guide to help you study. Unit: Respiratory Care Your 77 year old is two days post op status/post tracheostomy (he had a tracheostomy done two days ago). He is on continuous oxygen and requires frequent tracheostomy suctioning. Based on what you know about respiratory care of patients with a tracheostomy, please circle all that apply to this case: a. the patient will most likely have humidified oxygen over the trach opening b. many tracheostomy tubes have a permanent outer cannula, and a removable inner cannula that may be reusable or disposable c. the nurse should apply suction as the catheter is inserted into the tracheostomy tube d. suction should not be applied for longer than 20 seconds e. patients are sometimes hyper-oxygenated prior to suctioning f. the nurse should leave the trach oxygen collar on the patient while suctioning g. the yankaur suction device is used to suction a patient with a tracheostomy h. a patient who is being suctioned may have an episode of a lower pulse oximetry reading during the suctioning, for example 95 %. i. if your patient with a tracheostomy also has COPD, you may need to obtain orders to increase his oxygen higher, so that his pulse oximetry reaches normal 95-100 % j. patients with a tracheostomy are unable to cough, so it is important to listen to their lungs before and after suctioning k. atelectasis may occur with any post-operative or immobile patient, therefore it is important to encourage deep breathing, coughing, and moving.

Your patient is a 55 year old female who fell off of a ladder and punctured her lung. As a result, a chest tube was inserted. Based on what you know about chest tubes, please circle all that apply: a. the chest tube is used to promote re-expansion of the lung b. the tube may be used to remove air or fluid from the pleural space c. hemothorax is blood in the pleural space d. pneumothorax is fluid in the pleural space e. the patient will likely need to be on oxygen in high levels; the best choice to deliver oxygen would be a nasal cannula at 12 lpm with humidification f. this patient will most likely require an artificial airway until the chest tube is removed g. when the suction is on, the suction control chamber should NOT be bubbling; bubbling in this chamber means there may be a leak in the system h. the water seal chamber on the chest tube should fluctuate with inspiration and expiration i. drainage in the collection chamber usually starts out somewhat bloody and gets less so after time j. it is normal for the amount of chest tube drainage to increase after the first 24-48 hours of insertion. k. the chest tube container/device must be kept above the level of the heart to avoid reflux/backflow of the contents of the l. for any patient with a chest tube, it is very important to monitor Intake and Output (I and O) each shift

Unit: Urinary Care You are caring for a 72 year old female with urinary retention of unknown origin. Her physician orders a straight catheterization to monitor the issue. Based on what you know about straight versus indwelling catheters, circle all that apply below: a. straight catheters have a single lumen that is divided by a wall so that you can inflate the balloon with sterile water b. straight catheters are designed to leave in until the patient no longer requires a catheter c. the use of straight catheters may be avoided if one has access to a bladder scanner d. straight catheters are occasionally used to monitor the amount of residual urine left in the bladder e. in the hospital, sterile technique is not required when performing straight catheters, but it is required for indwelling catheter insertion f. straight catheters are sometimes used to obtain a sterile urine specimen g. straight catheters are often used to assist patients who are incontinent, and for those who need strict Intake and Output (I and O) measurements h. when using a straight catheter, the bedside drainage bag or leg bag must be kept below the level of the bladder i. straight catheters may be important in avoiding UTIs, as the urine becomes more basic and prone to UTI as it sits in the bladder j. straight catheters may contribute to UTIs, as UTIs are a common nosocomial infection that occur due to poor technique and/or contaminated equipment k. anesthesia sometimes causes difficulty voiding, and may require the person to have a straight catheter until the anesthesia wears off. l. medications, edema, nerve/neurological deficits may all contribute to the need for using a straight catheter m. equipment needed when inserting a straight catheter include sterile gloves, betadine, a straight catheter, a sterile drape, and a basin to catch the urine in

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NS 307: Fundamentals of Nursing: Review for Final Exam, Fall 2017 D. Mager Unit: Intravenous Care The 65 year old patient has a diagnosis of sepsis (systemic infection). She has a primary IV of D51/2 NS running at 125 ml/hr. In addition, she gets 2 antibiotics intravenously every 6 hours: gentamycin and ampicillin. She does not have an IV pump for her fluids, the IV is dripping by gravity only. Considering what you know about IV care, please circle all that apply: a. the D5 1/2NS means it is a 5% dextrose solution, with 0.45% normal saline in it b. the primary IV is the D5 1/2 NS and is probably running with a macro drip tubing c. the IV tubings are each good for 72-96 hrs depending on the institution's policy to change tubing d. it is important to check that the gentamycin and ampicillin are compatible with the D51/2 NS e. each antibiotic is intermittently administered when it is due, by using a secondary tubing for each one, and plugging it in at a high port in the primary line f. when the secondary IVs run, the primary should stop g. it is not necessary to count the small bags of antibiotics in the I and O for this patient, only the primary IV fluid is counted. h. if this patient is deemed to have "no veins" another alternative would be to insert a central line for IV hydration. i. usually the RN on the unit will reconstitute the powdered medications needed to make up the secondary IV bags, in this case, the antibiotics j. all IV fluids and medications need to be labeled. k. IV care includes checking the IV site per protocol, usually this means hourly l. if the IV site is infiltrated, an order must be obtained to get a new site started m. central lines start out either in the periphery or in the jugular veins, and end in a central vein (Vena Cava) near the right atrium of the heart n. it is not necessary to use sterile technique when changing the dressing on a central line, since the skin is not sterile, nor is the IV tubing

Unit: Nasogastric and Bowel Unit You are caring for a patient who had a bowel resection 12 hours ago, due to a blockage in the intestine. At this time he has a colostomy, and an NG tube to low suction. Considering what you know about nasogastric and bowel care, please circle all that apply: a. this patient will mostly likely have a paralytic ileus, and so you will be able to hear soft bowel sounds b. he will likely be on a clear fluid diet as long as he is not having nausea and vomiting c. you will need to measure and document I and O each shift d. it is not unusual to have some bleeding on the stoma of a new colostomy e. to test the stool for occult blood, the provider may order a guaiac test f. guiaic tests are extremely accurate, and therefore, a positive guiaic confirms blood in the stool g. this patient will most likely have a kangaroo pump with “ensure” or another liquid supplement running h. abdominal girths may be ordered for this patient i. it is not possible to experience constipation if a patient has a colostomy j. there is a potential for skin breakdown around the ostomy site k. the NG tube drainage in the suction container will likely be bloody for several days l. when removing the NG tube, it will be important to have the patient sip water m. it would be highly unlikely, and unsafe, to administer an enema in any form, to this patient at this time n. only a fleets enema would be safe to administer to this patient at this time o. black, tarry stool from the ostomy site may indicate a GI bleed and is called melena p. if a culture were needed to test for clostridium difficile, you would use a clean, not a sterile specimen cup because the stool is never sterile q. if testing for O and P, you would refrigerate the specimen immediately after collecting it

Parenterals Unit You are caring for a 38 year old female who is morbidly obese (378 pounds), and requires several different injectable medications every 8 hours. One of the medications needs to be reconstituted from powder to liquid, and then injected intramuscularly. Considering what you know about injectable medications, Please circle all that apply: a. For the IM injection, a 21 gauge 1 inch needle will be used b. when reconstituting the powder, the nurse will need to consider the dose required, how irritating the medication is, and what size muscle the medication will be injected into, in order to decide what strength to reconstitute to c. if reconstituting a medication, any remaining liquid in the vial should have a label that contains the only following additional information: time, date, and initials of who reconstituted it d. when giving an IM injection, use a dart like motion to inject at a 90 degree angle e. evidence based practice suggests that there may not be a need to aspirate for blood once the needle has entered the patient during an IM injection f. air locks are not routinely used with IM injections , but they used to be commonly used with IMs ; there are several newer drugs that are given subcutaneously and the manufacturer recommends using an airlock when administering them. g. heparin is usually injected into the subcutaneous tissue of the abdomen h. insulin is usually injected intramuscularly into the posterior upper arm i. site rotation is as follows: move to a new site each week; within each site, move 1 inch away from the last injection, clockwise. Document where you injected j. if the medication is viscous, then a smaller gauge needle, 27g will work better k. the vastus lateralis site is not acceptable to use for IM injections due to the unknown location of the sciatic nerve l. to landmark for the ventrogluteal site, one hand goes over the trochanter, and the thumb faces the rectum; the index finger points toward the anterior ileac spine, the middle stretches toward the iliac crest and the triangle in the center is where to give the injection. m. the arm should be straight when injecting into the deltoid

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Unit: Oral Medications (PO) You are working in the acute care setting on a pediatric medical/surgical unit during the night shift. It is your role tonight to administer medications to the patients on the unit. Please consider all that you know about medication administration, and circle all that apply below: a. when administering medications it is critical to ensure that the 6 rights are in place: right drug, dose, time, route, patient, and documentation b. when administering a liquid medication to a child, use a syringe to draw up the correct amount c. administer the medication into the side of the cheek, between the gum and cheek, pushing steadily into the mouth (not too fast, not too slow) d. to administer ear drops properly to a small child, pull the auricle up and out to straighten the ear canal e. use the capsule form of a pill whenever possible, for a young child to swallow so that the taste of a liquid medication does not cause them to vomit f. for a child who is vomiting, they will likely order an oral antiemetic in liquid, not pill form g. use of the safe dosing formula is not needed if you are giving a pill, rather than a liquid or an injectable medication to a toddler (Please review safe dosing on ATI) h. 1 lb = 2.2 kg i. gtts means drops j. os (right eye), ou (both eyes), and od (left eye) are not acceptable abbreviations to use anymore, as it is easy to make an error with these abbreviations. k. 1 mg=1000mcg; 1 liter=1000ml; 1 gr= 60 or 65 mg; nitroglycerin is sometimes labeled in gr l. it is acceptable to crush a long acting medication but only if the child cannot swallow the pill; however it is not acceptable to crush sustained release or enteric coated medications ever. m. it is important to check that the baby is the right patient: to do so, you should check the name band, the name tag on the bed, and ask him/her to state his name. n. there are numerous ways to name the same medication, including the brand name, generic name, chemical name, and official name.

Unit: Wound Care You are caring for a 92 year old male who has a stage 3 decubitus ulcer on his sacrum. Considering what you know about decubiti and wounds, please circle all that apply: a. a stage 3 wound is partial thickness, and involves a shallow crater affecting the epidermis and dermis layers b. due to the depth of this wound, sterile technique will most likely be ordered for performing wound care c. if the wound is not healing, and has foul discharge and redness around the edges, most likely a wound culture will not be considering most decubiti are contaminated wounds d. a hydrocolloid dressing, like duoderm may be ordered as an autolytic agent to debride this wound e. if there is no granulation tissue but there is non viable or necrotic tissue in the wound bed, mechanical debridement may be warranted f. wounds heal best when irrigated with normal saline, and we should avoid cytotoxic cleansers like betadine solution g. a nurse does not need orders to dress a wound h. nurses may surgically remove eschar only, with a scalpel, but only if there is a doctor's order i. transparent dressings include opsite and tegaderm, but they are not useful for stage 3 wounds, unless used to "tape" the primary dressing in place j. wound vac may be ordered to help this wound heal, due to the positive pressure it uses to rid the wound of extra fluid, and to promote granulation tissue growth k. it is possible for a decubitus ulcer to have a tunnel l. wound tunnels do not need to be packed or dressed, as they are inside the wound bed, and remain moist and covered by the primary dressing m. if this wound has no bone or muscle showing, and it gets covered over entirely in black eschar, it will be un-stageable.

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