ATI fundies

The diaphragm of the stethoscope is better for listening for what
High-pitched sounds such as the heart and lungs
The bell of the stethoscope is best for hearing what
Low pitched sounds
When using an otoscope blank millimeters for pediatric exams and blank for adult exams
Two, four
A patient with a BMI of blank or above is considered overweight, one with a BMI of blank or above is considered obese and a patient with a BMI of less than blank is considered underweight
25, 30, 18.5
Pupils should blank with far gaze and blank with near gaze
Dilate, constrict
What is nystagmus
Shakey Eye motion
What is a normal respiration rate in adult
12-20 breaths per minute
What kind of breath sound should you here anteriorly over the trachea and large bronchi
Loud, high-pitched hollow sound called a bronchial breath sounds
Over the mainstem bronchi, which are relatively large diameter airways, you should hear blank sounds called bronchovesicular breath sounds
Medium pitched and quieter sounds
Over most of the lung tissue, you should hear blank called vesicular breath sounds
Soft, fine, breezy low pitched sounds
Low pitched wheezes are sometimes called blank
What is Stridor
A high-pitched sound typically generated when a larger airway is blocked by a foreign body, severe inflammation or a mass
What does a friction rub sound like
Scratching or squeaking sound that persist throughout the respiratory cycle and does not clear with coughing
S1 is the closing of the tricuspid and mitral valve and indicates
The beginning of systole
S2 is the closing of the aortic and pulmonic valves which is heard best at the base of the heart and indicates
The beginning of diastole
What could an S III heart sound indicate
Congestive heart failure
What could an s4 heart sound indicate
Hypertension, coronary artery disease and myocardial infarction
What is your primary goal in performing a comprehensive physical assessment
To develop a plan of care
Over which abdominal quadrant are bowel sounds most active and therefore easiest to auscultate
Right lower quadrant
What is a rebound tenderness
An increase in pain when deep palpation over a tender area is released
What is antipyretic
An agent that reduces fever
What is eupnea
Normal respiration
What is febrile
What are korotkoff sounds
A series of five sounds heard during the Auscultatory determination of blood pressure and produced by sudden distention of the artery because of the proximally placed pneumatic cuff
What is the pulse deficit
Difference between the apical and radial pulse rates
In general in oral body temperature range of blank to blank is acceptable
How many degrees higher is a rectal temperature than an oral temperature
How many degrees lower is an axillary and tympanic temperature then an oral temperature
How do you convert Fahrenheit to Celsius
Subtracting 32 and then dividing by 1.8
How do you convert Celsius to Fahrenheit
C x 1.8 (+ 32)
Where is the apical pulse located
Left side of the sternum to the fifth intercostal space midclavicular line
To calculate the pulse deficit what should you do
Subtract the radial pulse rate from the apical pulse rate
According to ATI the normal respiratory rate for an adult is what
For most adult patients you will document the fifth korotkoff sound as what
Diastolic blood pressure
Normal oxygen saturation for a healthy adult is above what
Appropriate documentation of temperature includes what
Degrees, scale, assessment site
Appropriate documentation of pulse includes
Rate, rhythm, and volume
Appropriate documentation of respiration includes
Rate, rhythm and depth
The appropriate documentation of blood pressure includes
S/d, The limb was performed on, and the position of the patient
When taking blood pressure and unsupported arm can cause what kind of reading
False hi
When taking blood pressure and arm positioned above the heart level can cause what kind of reading
False low
You are assessing a patient’s vital signs. The patient has a temperature of 102. Which of the following do you expect to find
And elevated pulse rate. A fever increases metabolic rate and peripheral vasodilation, resulting in increased pulse rate
The difference between a patient systolic and diastolic blood pressure is called
Pulse pressure
When taking a patient’s blood pressure, why is it important to notice the pressure on the manometer when you hear the fourth korotkoff sound or phase
You might not hear a fifth korotkoff sound
When you are measuring a patient’s temperature Orally where do you place the probe
In the posterior lingual pocket lateral to the midline
How far should you insert the probe into an adult when taking the temperature rectally
1.5 inches
A private room is important component of what kind of precautions
Contact precautions
Blink, are directed at protecting the patient from contact with micro organisms transmitted from staff, other patients or visitors. This form of protection includes the use of personal protective equipment as well as a private room and disposable or patient dedicated equipment
Protective isolation precautions
Standard precautions mandate that you should do what after removing your gloves
Disinfect hands immediately
Contact precautions would be mandated for a hospitalized adult patient diagnosed with what
Infectious diarrhea
You are caring for a patient diagnosed with mycoplasmal pneumonia. Droplet precautions have been instituted so you must do what
Protect your eyes
After completing a procedure that required wearing personal protective equipment consisting of a gown, respirator, face shield and gloves which of the following should the nurse remove first when removing PPE separately
The gloves
You were about to irrigate a patient’s open wound. Besides gloves which other item of PPE must you wear
A face shield
When do you put on a sterile gown when going into a surgical procedure
Immediately after completing a surgical hand scrub and drying your hands and forearms thoroughly with a sterile towel
Why is hot water not recommended for surgical handwashing
Because it has a drying effect that can result in cracking of the skin and it is too uncomfortable to wash for the recommended amount of time
When removing surgical contaminate PPE what order is it
Gloves, gown, mask
The recommended pouring distance for pouring fluid on the edge of the sterile field is how many inches
Prior to entering the surgical scrub area, which of the following PPE items do the team members Don
Protective eyewear, hair cover, mask, shoe covers
A nurse putting on sterile gloves knows that the proper technique for gloving the dominant hand prevents contact between the contaminated hand and the non-contaminated glove because
The inner edge of the cuff will lie against the skin and thus will not be sterile
What is a nociceptor
A peripheral sensory receptor for pain, stimulated by various types of tissue injury
What is somatic pain
Generally well localized pain that results from activation a peripheral pain receptors without injury to the peripheral nerve or CNS, such as musculoskeletal pain
What is the process of nociception pathway
Transduction, transmission, perception and modulation
What is neuropathic pain? And what is it better controlled with
Pain that arises from abnormal or damaged pain nerves. Better controlled with adjuvant medications such as anticonvulsants, antidepressants, and local anesthetics
The benefit of applying cold is that it causes vasoconstriction and reduces swelling. It helps reduce blank pain and blank initially from an injury
Acute, swelling
Heat causes vasodilation, fuss improving circulation and promoting healing. Heat is often used to reduce blank and blank pain
Muscle, joint
Blank, delivers an electric current over a painful region via electrodes applied to the skin. The patient activates the unit when feeling pain. The tingling sensation it creates helps reduce pain perception
What is contralateral stimulation
Involves stimulating the skin in an area opposite of the painful region. Such as the patients left ankle is casted and itchy, scratching the corresponding area on the right ankle can sometimes relieve the unpleasant sensation
What is biofeedback
A process that involves collecting data about the bodies physiological responses of the autonomic nervous system to various thoughts, feelings and other forms of stimuli.
What are two examples of non-opioid medication
Toradol and Celebrex
What are some anticonvulsants that are used for chronic neuropathic pain
Tegretol, klonopin, gabapentin
What are two antidepressants that are used for chronic neuropathic pain
Cymbalta, elavil
What are two corticosteroids that are used for an anti-inflammatory effect
Dexamethasone, prednisone
Prolonged exposure to severe pain can have long-lasting effects on the neurological system. If this process is not controlled what can happen
It can contribute to the development of chronic pain by leaving an imprint on the nerves, which may result in long term nerve damage and chronic neuropathic pain
What happens with global aphasia
Patient is unable to understand speech or express themselves verbally in a meaningful manner
What is talwin
Opioid agonist – antagonist agent that can trigger opioid withdrawal date opioid dependent patient
Many studies have suggested that pain ratings above blank increased stress and reduce immune system function
A nurse is about to use the faces pain scale to assist a patient in assessing his pain level. Which of the following should the nurse know in order to use this pain scale
This scale is useful for adult patients of cognitive impairments
A nurse is caring for two patients of different cultural backgrounds. Both patients returned from the same type of surgery two hours ago. Which of the following should the nurse expect to be the same for both patients
Class of medication used to treat acute postoperative pain
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter blood is spilled on the floor. What solution to the nurse use to clean the spill
A nurse is conducting a breast examination on a patient who has a family history of breast cancer. Which of the following should the nurse report to the provider?
Dimpling of the tissue in the upper outer quadrant
Nursing knowledge is based on which of the following
Nursing research, discipline specific research
A nurse is collecting data on a patient who is diagnosed with schizophrenia and is taking clozapine which of the following findings indicate the patient is experiencing an adverse effect of the medication
White blood cell count lower than normal. Because clozapine blocks h1 histamine receptors
A nurse is caring for a patient was experiencing night sweats and hemoptysis it is expected to have active pulmonary tuberculosis. What test would you use to confirm this diagnosis
Sputum culture for acid-fast bacillus
A client that is competent and has requested a DNR. Which of the following is necessary to legally change the clients code status to DNR
A written prescription from the provider
What is the disease that requires a patient to be placed on droplet precautions
A nurse discovers that a patient who is diagnosed with dementia received the wrong medication. Which of the following should be the nurses first action
Determine the patient’s condition
What is a side effect of the tuberculosis drug ethambutol that we require immediate discontinuation
Ocular toxicity. Examples include changes of color vision and loss of visual acuity
A nurse and a local clinic is caring for a female patient who is 35 years old. What screening should the nurse recommended to the patient
Dermatologist evaluation every three years to detect skin cancer
What age should women began having annual mammograms
A nurse is caring for a patient who had a cerebrovascular accident two days ago. Which of the following is the first sign of increased intracranial pressure
Blank is an indication of pregnancy induced hypertension and should be reported immediately to a provider
Mass casualty event tagging system
What is a class one
Patients that have injury that pose a threat to life but a potential for survival exist with treatment
What is a class 2
Patients have injuries that may be extensive but do not pose a threat to life even with delayed treatment
What is a class III
Non-urgent, patients have injuries that are not extensive and do not pose a threat to life even with delayed treatment
What is a class 4
Patients who’s injuries are extensive and not compatible with life, even with treatment
A blank is expected for 2-3 days following an abdominal aortic aneurysm repair and is indicated by the absence of bowel sounds
Paralytic ileus
What is the earliest manifestation of fat embolism syndrome
A change in level of consciousness’s
What are the components of a medical prescription
Date and time of order, dosage of medication, route of administration, generic name of medication, providers signature
A nurse should never administer medication that she did not
A nurse is preparing to administer a medication subcutaneously. Which size needle should she use
5/8 inch, 25 gauge needle
Typically facility policy permits the nurse to administer medications within blank minutes of schedule time for administration
A nurse is planning atraumatic care for a preschooler who has a prescription for an intramuscular medication. A parent is with the child. Which of the following actions should the nurse include in the plan of care
Provide an explanation of the hospital alarm system, suggest that a parent bring the child’s favorite toy to the hospital, use a doll to demonstrate the procedure
A nurse is preparing to administer potassium chloride 40 mEq to a patient. Available is potassium chloride 20 mEq effervescent tablets. In addition to checking the correct dosage before administration what else should the nurse do
Check the amount of liquid in which to dissolve the tablet, the type of liquid in which to dissolve the tablet, and the acceptable does range of the medication
When a walker is properly fitted the upper bar of the Walker should be blank
Slightly below your waist
Which action is appropriate when transferring the patient to the gurney using a slide board and three team members
Have one person holds the slide board study while the other to pull the patient onto the gurney
A nurse is observing an assistive personnel who is using a mechanical lift with a hammock sling to transfer a patient from the bed to a chair. The nurse should intervene if the AP does what
Leaves the bed in the lowest position throughout the procedure
Crutches should be held on what side when preparing to sit in a chair
The unaffected side
Which body movement should indicate to a nurse that a patient has full range of motion of the shoulder
Flexing the shoulder by raising the arm from a side position to 180° angle
Which action is appropriate for a nurse was witnessed a breach of patients privacy in a primary care providers office
Complete a health information privacy complaint form and submit it to the appropriate agency
Nurses on a clinical unit wish to research the incidence of falls among patients following joint replacement surgery. Which of the following should they do to ensure the study complies with the HIPPA privacy rules
Submit their proposal to the institutional review board for review and describe how they will D identify patients information
Who do you report HIPPA violations do
Office of civil rights (OCR)
Which route of drug administration are there no barriers to absorption
An uncommon, unexpected or individual drug response thought to result from a genetic predisposition is called
Idiosyncratic effect
Which of the following is the highest priority action for ensuring overall safety during medication administration
Identify the patient by two acceptable methods
After checking placement of an NG tube also check gastric residual. Connect the syringe to the end of the tube and gently aspirate some of the content. If the aspirate is more than what has been given enterally in the past two hours what should you do
Returning to the stomach withhold medications and notify the patient’s physician. A large volume of aspirin can indicate delayed gastric emptying, which can cause gastric distention, reflex and vomiting
Medicated eyedrops are distributed more evenly after installation if the patient does what with his eyes
Closes his eyes gently
Which of the following should the nurse assess before administering medications through a nasogastric tube
Amount of residual volume left in stomach
The primary reason insulin is injected via the subcutaneous route is that
Medication absorption is slower from subcutaneous tissue, and important factor in the effectiveness of insulin therapy
To determine the best needle length for a subcutaneous injection, you gently pinch the patient’s skin at the injection site and select a needle that is
One half the length of the skinfold
Since IM injection delivers medication into the muscle, you best determine the appropriate needle length by assessing what
The patient’s muscle mass and weight
What is the angle for an IM injection
The proper needle length when giving an intramuscular injection into the ventrogluteal Area to an average size adult is which of the following
One and a half inches
What is the equation for IV flowrate
Volume/time multiplied by drop factor
What is PICC stand for
Peripheral inserted central catheter
Patients with P ICC lines should not have what done to them
Blood pressure measurements, venipunctures, or injections in the extremity with the PICC
Central venous catheter’s are most often placed in the blank or blank
Internal jugular or subclavian vein
To prevent backflow into an IV line that could cause clotting, you should do what
Maintain pressure on the plunger while withdrawing it from the port, clamp off the tubing before removing the syringe from the port
It is common practice to hang the blank bag higher than the blank bag and mandatory for infusions by gravity
Secondary, primary
A PICC line is a long catheter inserted through the veins of what
Antecubital fossa
The nurse should understand that a disadvantage of parenterally administered medications is that they are
A nurse is assessing a patient receiving IV normal Celine at 125 milliliters/hour which of the following should the nurse recognize as a possible complication related to the intravenous therapy
Patient reports cough and shortness of breath
A patient was admitted to the hospital for same day surgery and has orders for continuous IV therapy. Before performing a venipuncture, the nurse should
Inspect the IV solution for fluid color, clarity, and expiration date
How far above a venipuncture should the tourniquet be placed
4 to 6 inches above
According to recent estimates, which of the following sources of healthcare Waze has had the largest financial impact
Unwarranted use of medical resources or services
With an anaphylactic reaction, blank or blank is more likely than Peripheral edema
Angioedema or facial swelling
What are signs of anaphylactic reaction
Low blood pressure, wheezing, difficulty swallowing
Grapefruit juice can increase the amount of drug available for blank
A healthcare professional is caring for a patient who is about to begin taking Mirapex to treat Parkinson’s disease. The healthcare professional should recognize that which of the following laboratory tests require monitoring
What is the side effect that should be monitored for a patient who is taking Aricept for Alzheimer’s disease
What is an adverse side effects of Dantrium taken for skeletal muscle spasms
What kind of drug is thiopental
Short acting barbiturate
What are side effects of interferon Beta drugs
Fever, chills, headaches and muscle aches
When a patient is beginning an Imitrex therapy to treat migraine headaches which of the following adverse side effects should the patient look out for
Chest pain, Imitrex is not appropriate choice for patients have a history of coronary artery disease
What is a potentially serious side effect of lidocaine
What is baclofen
A centrally acting muscle relaxant that can cause CNS depression
Valproic acid can cause which two side effects
Drowsiness and rash
Amitriptyline is a tricyclic antidepressant and can cause side effects such as
Orthostatic hypotension and anticholinergic effects so the person should increase fiber and fluid intake
What diagnostic test should a healthcare professional recommend periodically for a patient receiving lithium
Thyroid function tests
Lithium toxicity can occur if a patient is also taking this kind of medication
Indications of serotonin syndrome include blank, blank and blank
Agitation, confusion and anxiety
Echothiophate can cause blank
A person who is taking betaxolol eyedrops to treat glaucoma should expect this adverse side effect
A patient taking Nardil should avoid tyramine enriched foods because it increases the risk for what
Hypertensive crisis
Disease modifying antirheumatic drugs are initially given with what when beginning therapy
Glucocorticoids may reduce the absorption of what
What is one rare but serious side effect of alendronate
Alendronate works by
Reducing bone resorption
Methotrexate causes bone marrow suppression and increases the risk for blank
A nurse observes and assistive personnel make a clients bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task
The AP reuses the patients blanket and spread
While performing a complete bed bath for a patient the nurse should do what
Raised the room temperature
Bathing of the patient should be completed from blank to blank and not side to side
Top to bottom
What is a bulla
Large blister, as seen with burns
What is dehiscence
Spontaneous opening of the edges of the surgical wound with partial or total separation of wound layers
What is ecchymosis
Hemorrhagic spot, or bruise, caused by bleeding under the skin and irregularly formed in blue, purple or brown patches
What is exudate
Material such as fluid with a high content of protein and cellular debris that has escaped from blood vessels and has been deposited into issues or on tissue services, usually as a result of inflammation oh
What is eschar
Slough produced by a thermal burn, a corrosive application or gangrene
What is slough
Hard crust or mass of dead tissue
What is granulation
Development of red voice tissue made up of new blood vessels, indicating the progression of wound healing
What is fistula
Any abnormal tubelike passage in the body
What is maceration
Softening or dissolution of tissue after lengthy exposure to fluid
What is petechiae
Minute reddish or purpleish spots containing blood that appear in skin or mucous membranes as a result of localized hemorrhage
What are the phases of wound healing
Inflammatory phase usually last 24 hours, epithelialization, proliferative, remodeling
What is suspected deep tissue injury guidelines
It pertains to tissue with discolored but intact skin caused by damage to underlying tissue
What is a stage one pressure ulcer
Defined as non-blanchable redness caused by pressure or sheer typically over a bony prominence
What is a stage to pressure ulcer or
Involves partial thickness skin loss with a visible ulcer
What is a stage III pressure ulcer
Involves Full thickness tissue loss without exposed muscle or bone
What is a stage for pressure ulcer
Involves a full thickness tissue loss with exposed bone, muscle, the possibility of tunneling and sometimes eschar or slough
What is eschar
Black scab like material
What is slough
Tan, yellow or green scab like material
The final stage of pressure ulcers is the unstageable. Who’s stage cannot be determined because
Eschar or slough obscures the wound
What is debridement
Mechanical cleansing of a pressure ulcer with sterile instruments
What is biologic debridement
Uses larvae or maggots to help remove necrotic tissue
What are Penrose drains
Commonly used as open drainage systems for wound care. Downside is it’s difficulty in assessing the amount of drainage and in controlling the transmission of micro organisms
Closed drainage systems use what and advantage is they reduce the risk of infection and allow more accurate measurement of drainage
Compression and section to remove drainage and collected in a reservoir
What is one example of a closed drainage system
Jackson – Pratt drain
Dry dressings generally work well for wounds with small amounts of exudate. However what is the issue of large amounts
They can stick to the wound bed of heavily exudative wounds or expose the wound to the outside environment
What is the disadvantage of wet to dry dressing
They are nonselective with debridement; therefore, they take healthy as well as necrotic tissue with them
Wet to dry dressing’s are time-consuming to apply and are generally painful to remove. Surrounding wound edges can become macerated because of the moisture contained in the dressing and that can lead to
Enlargement of the wounds diameter. Cross-contamination is also an issue
Foam dressings are absorptive and provide a moist healing environment while protecting wounds that resulted from pressure, friction or shear. These dressings are widely used for
Early-stage pressure ulcers
Alginate dressings are composed of calcium, calcium or sodium salts or seaweed within a gel dressing. Alginates provide a moist environment for healing and good absorption of exudate, establish hemostasis and do not adhere to the wound. They are helpful in treating wounds with large amounts of exudate including
Ulcers, donor sites, tunneling wounds and some bleeding wounds
Do not blink alginates before applying them to a wound. contact with the wound bed should help activate the gel and to protect the wound bed fully apply a secondary dressing
What are Hydro fiber dressings
Similar to alginate dressing’s however they do not affect hemostasis
What are Hydro fiber dressings composed of and what do they do when they come in contact with exudate
Composed of polymer carboxymethylcellulose A substance that can absorb exudate vertically. This sheet material swell on contact with exudate
What are transparent film dressings and what are the benefits of them
They have a thin layer of plastic that covers the wound area. This dressing type provides no absorption but does create a barrier to the environment. They allow some oxygen exchange to reduce anaerobic bacteria growth and a wet environment to promote healing
What are transparent film dressings commonly used for
Dry eschar or for superficial skin tears and not recommended for infected wounds. Removal of transparent dressings can cause damage to underlying skin and the uniform application can cause maceration of wound edges
What are hydrogel dressings and how do they work
They are used for autolytic debridement or promoting the bodies own natural function of removing necrotic tissue. They work by maintaining a moist wound environment.
What are hydrogel dressings used for and what do you not use them on
Used for wounds with necrosis, infection and moderate amounts of exudate and a need for a moist healing environment. Do not use to treat dry gangrene or dry ischemic wounds
Hydrocolloid dressings are used for? And what do they not allow
Autolytic debridement. They do not allow oxygen to into the wound which could lead to anaerobic bacterial growth. They are not recommended for infected wounds but are helpful for wounds that are vulnerable to infection. Do not use these dressings to treat dry gangrene or dry ischemic wounds
Binders are a form of bandaging that provides support to the body area they surround. Assess binders every blank hours and rewrap them every blank hours or sooner if needed
Four, eight
Negative pressure wound therapy systems should be used cautiously in patients who have
Decreased sensation, taking anticoagulants, or have wounds with tracks or tunneling
Anti-septic agents include products such as
Betadine, silver agents and hydrogen peroxide
What are three types of antibiotic ointment
Bacitracin, neomycin and polymyxin B
What are some antifungal agents
Nystatin, ketoconazole, miconazole
What are two common debridement ointments
Panafil, accuzyme
What are common barrier creams
Zinc oxide, vitamin A & D
While assessing a patient’s abdomen, you note that the Jackson – Pratt drains reservoir is expanded and half full of blood. Which is the appropriate action for you to take at this time
Empty the reservoir
To maintain your patient safety and to prevent dislodgment of the drain you secure the Jackson – Pratt drainage system to what
The patients gown
When checking the dressing you note that the Jackson-Pratt drain is intact and draining and that there is also a quarter sized area of fresh Red bloody drainage noticeable on the dressing. The appropriate action for you to take at this time is to
Mark the edges of the area of drainage with tape and document with date and time you marked the dressing in the patient’s record
Using too much force while irrigating a wound can cause
Tissue trauma and lead to further bleeding
What helps maintain an airtight seal for the wound VAC device
Shave the hair along the wound borders, use strips of transparent film to patch any air leaks, avoid wrinkling the transparent film while applying it to the foam, Cut the transparent film to extend 3 to 5 cm beyond the wound borders
In general, keeping some moisture within a wound reduces pain. Blank, dressings work by maintaining a moist wound environment, so they are good choice for helping to reduce the pain associated with dressing changes
A nurse is caring for a patient who was admitted with multiple wounds sustained in a motor vehicle crash. Understanding the patient specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient’s plan of care to prevent a prolongation of this phase
Apply oxygen at 2L/minutes via nasal cannula
Vitamin C aids in tissue building and many metabolic reactions, such as
Wound and fracture healing
What is the normal serum albumin level range
3.4-5.4 G/DL
How do you assess a patient for adequate swallowing
Place fingers on the patients throat at the level of the larynx and ask them to swallow, A nurse should be able to palpate the movement of the pharynx
Blank, is a poor short-term indicator of protein status
What is the general onset, peak and duration of rapid acting insulin’s such as Humalog, NovoLog and Apidra
10-30 minutes, 30 minutes to three hours, 3-5 hours
Regular insulin is short acting and has an onset, peak and duration of what
30-60 minutes, 1-5 hours, up to 10 hours
Intermediate acting insulin’s such as NPH have an onset, Peak, and duration of what
60-1 20 minutes, 6-14 hours, 16-24 hours
Another intermediate acting insulin such as Levemir has an onset, peak, and duration of what
Slow onset, 12-24 hours and duration varies the dosage
Long acting insulin glargine has an onset, peak and duration of what
70 minutes, peakless , 24 hours
Blank, is an incretin mimetic medication available for treating type two diabetes. This medication is prescribed for patients who are already taking metformin, a sulfonylurea, or both and have not achieved adequate blood glucose control
Exenatide is it a jacked up on medication with some risk of hypoglycemia and delayed gastric emptying. Most patients experience some blank with this medication which is an advantage over insulin therapy
Weight loss
What are side effects of exnatide
Hypoglycemia, nausea and pancreatitis
Blank is an amylin mimetic medication used to supplement the effects of insulin in patients who have type one or type two diabetes. It works by
Pramlintide, reduce postprandial glucose by delaying gastric emptying and suppressing glucagon secretion
What are common sulfonylureas
Glyburide, Glipizide, and glimepiride
What are some side effects of sulfonylurea
Weight gain and hypoglycemia
How do sulfonylureas work
By increasing insulin secretion by the beta cells of the pancreas
What are Meglitinides
Work by increasing insulin secretion by the beta cells of the pancreas
Meglitinides Target post Crandall glycemia and you’re less likely to cause blank but nevertheless there is still a risk with this medication
What are two examples of Meglitinides
Repaglinide, and nateglinide
How do thiazolidinediones work
Increase the cellular response to insulin by decreasing insulin resistance
What are some side effects of thiazolidinediones
Weight gain, edema, impaired liver function, elevated lipid levels and reduction in the effectiveness of oral contraceptives
How do alpha glucosidase inhibitors work
By delaying carbohydrate digestion
How did gliptins work
By augmenting naturally occurring incretin hormones, which promote the release of insulin and decrease the secretion of glucagon
Which variables can contribute to hypoglycemia in adolescence who have type one diabetes
Physical activity, diet fluctuations
After confirming hypoglycemia a nurse can give a patient what to raise the blood sugar
4-6 ounces of fruit juice, 8 ounces of skim milk, 1 tablespoon of honey, or 3 to 4 commercially prepared glucose tablets
What are straight catheters
One time use in a removed immediately after insertion and drainage of urine
What are retention catheters
Most commonly used postoperatively because they have multiple lumens to allow for drainage of urine, irrigation of the bladder and installation of medications into the bladder
What are coude catheters
A catheter that has A curved tip to allow for easier installation. Most commonly used for patients with prostatic hyperplasia
What are suprapubic catheter’s
Similar to indwelling catheters except that they are placed surgical opening in the abdomen rather than through the urethra
What a condom catheters
Have a latex or rubber sheets to place over the penis
How often do you need to assess catheters
Minimum of every eight hours
Collection bags from catheters need to be emptied how often
Every six hours
What are the steps for obtaining a urine sample from a closed system catheter
Locate the collection port in the drainage tubing, cleanse the port thoroughly with aseptic solution and use the appropriate syringe/needle to draw urine out of the port
When introducing fluid into the bladder that is significantly below body temperature what can result
Bladder spasms
A nurse is preparing to insert an indwelling urinary catheter in for a female patient. When beginning the insertion procedure The nurse should instruct the patient to do what
Bear down
Why do you ask a female patient to bear down when insertion begins
It relaxes the external sphincter and aids in the insertion procedure
How much of a space should you leave between the penis and a catheter tip when applying a condom catheter
2.5-5 cm should be left between the tip of the penis and the end of the catheter
According to ETI what are acceptable fasting blood glucose ranges
70-105 mg/dL
What is a fecal occult blood testing
Widely used screening tool for Colorectal cancer. Routinely recommended for asymptomatic patients over the age of 50 as a prerequisite to colonoscopy
Patients that need a stool specimen collection should avoid ingesting a blank, blank and blank because they can alter test results
Barium, mineral oil and laxatives
When should you collect sputum samples were they will produce the most accurate results
Most accurate when collected in the morning after sputum has accumulated over night from the deeper areas of the pulmonary system and before the patient has anything to eat or drink
Before collecting a sputum sample in the morning what should the patient do
Clear their nose and throat and rinse the mouth this will help reduce contamination of the specimen
How often is an acid-fast bacilli test performed
It is performed on three serial samples collected in the early morning on three consecutive days
Gastric pH should be more acidic then secretions from other areas of the body which are generally below blank
NG tube placement is initially confirmed by chest x-ray; this is the most reliable method for checking placement. Second only to x-ray is blank
Gastric pH testing
A nurse is collecting a blood specimen for culture from a patient hospitalized for pneumonia prior to doing a venipuncture what should the nurse do
Stroke the arm from distal area to the proximal area below the proposed site to help dilate the vein
Urine culture and sensitivity test require what
A clean catch or Catheterized specimen in a sterile collection cup
What kind of food can cause a false positive fecal occult blood testing result
Red meat, poultry, seafood and some raw vegetables
What you need for a routine urinalysis
A routine urinalysis can be done on a random clean voided specimen collected during normal voiding into a clean urine cup
What is a gastrostomy tube
A hollow cylindrical device inserted through a surgically created opening in the stomach
A nasogastric or nasal intestinal tubes are indicated more for blank therapy meaning less then blank weeks
Short term, four
Anything longer than four weeks would indicate the need for a blank or blank tube
Gastrostomy, jejunostomy
Determine the portion of the tube when inserting a nasogastric tube that needs to be inserted by measuring from
The tip of the patient’s nose to her earlobe to the xiphoid process of her sternum
In addition if needing to do a duodenal or jejunal tube insertion how much should you add to the tube length after measuring from the tip of the patient’s nose to the earlobe to the xiphoid process of the sternum
20 to 30 cm
Gastric fluid from a patient was fasted for at least four hours usually has a pH range of white and the fluid would look like what
One – four, fluid would be grassy green, off-white or tan with the consistency of water
Intestinal pH is usually higher than blank and since it contains file it will appear to look like what
Six, light to golden yellow or brownish green with a syrupy consistency
In contrast respiratory fluid is usually clear with a pH above blank
What are polymeric formulas
Deliver one – two kcal/ML and require that the patient can absorb whole nutrients. They include milk-based blenderized foods and commercially prepared whole nutrient formulas
What are modular formulas
Contain single macronutrients such as proteins, glucose, polymers and lipids. They are not nutritionally complete. They deliver 3.8- 4.0 K CAL/ml and are used to supplement patient’s nutritional needs.
What are elemental formula
They contain predigested nutrients, making it easier for a partially dysfunctional gastrointestinal tract to absorb them. They provide 1-3 kcal/ML
What are specialty formulas
They range from 1-2 kcal/ML and are designed to meet specific nutritional needs related to specific illnesses, such as liver failure, pulmonary disease, diabetes or HIV infection
To regulate the flow of the enteral formula through the NG tube you open the tubing and
Raise the syringe to a height no greater than 18 inches above the patient’s head
A patient with a gastric ileus postoperatively requires nutritional support for approximately two weeks. Which of the following types of feeding tubes is appropriate for this patient
Nasal intestinal tube
A patient who is post operative following a laryngectomy would require what kind of feeding tube
What are side effects of vitamin B 12
Diarrhea and hypokalemia
What are side effects of desmopressin
Fluid retention and hyponatremia
What are side effects of antiplatelet inhibitors such as Plavix and ticlopidine
Gastric upset, abdominal pain, diarrhea, nausea, gastric ulceration and bleeding, thrombotic thrombocytopeniaPurpura
Why would you give thrombolytic drugs
To break down thrombi that have already developed
What is one thrombolytic drug
What is a side effect of Activase
What are side effects of erythropoietic growth factor
Hypertension, cardiovascular and cerebrovascular events, malignancy progression
What is a side effect of the leukopoietic growth factor drug filgrastim
Leukocytosis, bone pain, fever and splenomegaly
What does Nascobal vitamin B 12 preparation treat
Pernicious anemia
What does a reticulocyte count do
Measures the amount of immature RBCs and folic acid that is essential for erythropoiesis
In the early stages of hypoxia the patient is often restless and confused and may report feeling
The patient’s vital signs in relation to hypoxia will be
Elevated, with complaints of dyspnea
In the late stages of hypoxia the patient is likely to develop
Hypotension, bradycardia and and metabolic acidosis, decreased level of consciousness, decreased activity level and cyanosis
Patients with chronic hypoxia will have the symptoms
Clubbing of the fingers and toes, peripheral edema, right-sided HF and and O2 sat below 87%, with the respiratory acidosis
When patients with COPD receive oxygen at two high flow rate, blank, can result indicated by confusion, tremors, convulsions and coma which can ultimately lead to respiratory arrest
Carbon dioxide narcosis
If the flow rate is 4 L/minute or more considered blank to decrease drying of the mucous membranes
How much oxygen does a nasal cannula administer to the patient
Concentrations of 22% to 50% with flow rates from 1 to 6 L/minute
A nasal cannula is usually indicated for what kind of patients
Patients who are noncritical with minor breathing problems and for patients who cannot wear an oxygen mask. Humidification is rarely required
A simple oxygen mask is indicated for what kind of patients
Patients who require a moderate flow rate for a short period of time
A simple mask has the ability to deliver how much oxygen
02 concentrations of 40% to 60% with flow rates from 6 to 10 L/minute
What should you consider doing for patients receiving a simple mask to help keep the patients mucous membranes from becoming dry
A non-rebreather mask, which is a low flow system, can deliver oxygen concentrations of
60% to 95% with flow rates from 10 to 15 L/minute
When using a non-breather mask do not allow the reservoir bag to blank. If it does the patient is likely to breathe in large amounts of exhaled carbon dioxide
A Venturi mask can deliver oxygen concentrations from
24% to 60% with flow rates from 4 to 12 L/minutes
Because a Venturi mask delivers a precise oxygen concentration and carbon dioxide buildup is minimal it is commonly used for patients who have blank. Humidification is usually unnecessary with this device
A face tent is often used as an alternative to an aerosol mask, especially for patients who report feeling claustrophobic with
Aerosol mask
A face tent delivers oxygen concentrations of
28% to 100% with flow rates from 8 to 12 L/minutes
A face tent is convenient for delivering both humidification and oxygen however it is difficult to control that
Concentration of oxygen administered since the actual concentration oxygen depends on the rate and depth of the patients respirations
What is a manual resuscitation bag used for
To provide high concentrations of oxygen to a patient prior to the procedure, such as suctioning or intubating and during respiratory or cardiac arrest
What is the flow rate for a tracheostomy mask sometimes referred to as a tracheostomy collar.
10 L/minute
Patients who have artificial airway’s require continuous blink, since the airway bypasses the normal filtering and blank process of the nose and mouth
Noninvasive ventilation, is used to maintain positive airway pressure and to improve alveolar ventilation without the need for an artificial airway. It is commonly used for patients who have
Congestive heart failure, sleep disorders, pulmonary diseases, reduce and reverse atelectasis, and improve cardiac function
Oxygen tense and hoods are usually used for pediatric patients who have airway inflammation, croup, or other respiratory infections. And oxygen hood delivers oxygen at
28% to 85% O2 concentration
Airway management module
What is an oropharyngeal airway used for
To keep the upper airway patent when it is at risk for becoming obstructed by the tongue or by secretions.
Oropharyngeal airway’s stimulate the gag reflex, it should be used only for patients whose
Level of consciousness is altered
How do you determine the correct size for an oropharyngeal airway Device
Measure the oropharyngeal airway from the corner of the patient’s mouth to the angle of the jaw
When inserting an oral airway, the curved end should initially point upward. Once it reaches the back of the mouth, it is
Rotated 180° so that the curved part of points down and follows the natural curve of the tongue
Nasopharyngeal airway’s, sometimes called nasal trumpet, are also used to keep the upper airway patent. They are inserted through the nares and extend into the oropharynx. Because this type of airway does not stimulate the gag reflex it can be used for
Patients who are alert
How do you determine the appropriate size for a nasopharyngeal airway
The airway is measured from the patient’s nose to the angle of the jaw
What are endotracheal tube used for
Patients undergoing a procedure that requires general anesthesia and/or mechanical ventilation
Endotracheal tubes are inserted either through the nose or the mouth past the epiglottis and vocal cords into the trachea and down to
Where the trachea bifurcates into the bronchi
What is usually the longest ET tubes are left in place
14 days, to decrease risk for infection and airway injury
What are tracheostomy tubes used for
Long term airway support
Most tracheostomy tubes have a blank, that is temporarily removed during tracheostomy care
Inner cannula
Why is it important to hyper oxygenate the patient before suctioning and to assess the patient before, during and after the procedure
Because sectioning can cause complications such as hypoxia, injury to the airway, nosocomial infections, and cardiac dysrhythmias
Any type of tracheal suctioning is considered
What is a yankauer suction catheter
Helps clear secretions from the mouth. Patients require this type of suctioning is for patients who can cough effectively but cannot swallow or expectorate secretions
What does a nasopharyngeal and nasotracheal suctioning do
Helps remove secretions from the lower airway of patients who cannot cough and do not have an artificial airway in place.
How do you insert a nasopharyngeal and nasotracheal suctioning device
Insert a small, sterile, flexible catheter into the nares until the tip reaches the pharynx or the trachea
Critically ill patients who have an endotracheal or tracheostomy tube in place usually require suctioning of secretions via the open or closed method of suctioning. With both of these is important to insert the catheter without
Applying suction, applying suction on insertion could injure the airway. After you insert the catheter apply suction while using a rotating motion to remove it (except with closed)
What is the advantage of using a closed suction system
You do not have to disconnect the patient from the mechanical ventilator
Signs and symptoms of oxygen toxicity result from its effects on the
CNS and pulmonary system
Vibration is used after percussion or alternately with percussion to increase the turbulence of
Exhaled air and loosen secretion
When do you perform vibrations
Only when the patient is exhaling
What is postural drainage
To remove secretions by gravity from different areas of the lungs
Postural drainage is commonly performed 2 to 3 times a day, often before blank and at blank
Meals, bedtime
If a patient is receiving continuous tube feedings, stop the feeding and check gastric residual at least blank minutes before performing postural drainage
Before starting postural drainage and during the procedure, evaluate the patient’s tolerance of the various positions. The patient usually remains in each position for how long
10 to 15 minutes, however this time maybe shorter initially and then gradually increased
What should you do if the tracheostomy tube is migrating outward from the stoma
Attempt to reposition it
What do you do if the tracheostomy tube completely moved out of the stoma
Extend the patient’s neck to allow for ventilation
A nurse is caring for a patient who has a tracheostomy tube in place. During tracheostomy care, which of the following should the nurse place underneath the flanges of the outer cannula
Commercially prepared fenestrated dressing
A nurse is caring for a patient who has a tracheostomy tube with an inner cannula in place. Which of the following supplies should the nurse use to dry the inner cannula of the patients tracheostomy tube after cleaning it
Folded pipe cleaners. They remain intact without leaving any particulate matter the patient could aspirate on
A nurse is preparing to perform endotracheal tube care in plans to use tape to secure the tube. Which of the following is an appropriate preparatory action for this procedure
Have tincture of benzoin ready to apply to the patient’s face
Closed chest drainage module
What is the purpose of a chest tube
To restore a collapsed long or to drain fluid from the pleural cavity
What is a single chamber closed chest drainage system used for
The collection of smaller amounts of drainage while still providing a water seal
For larger amounts or more accurate measurements of chest drainage, use the blank, which allows fluid to flow in the collection chamber as air flows into the waterseal chamber
Two chamber drainage system
When are all three Chambers Essential
When using a controlled suction source to draw air or fluid out of the pleural space
The middle chamber is typically for the what
Waterseal; it allows air to exit the plural space on exhalation and keeps air from entering the plural or mediastinal Space on inspiration
What does continuous bubbling in the waterseal chamber indicate
An air leak
What is the Heimlich valve
A one-way letter valve that allows air to escape and keeps it from reentering the chest cavity.
A nurse is assessing a patient who has a chest tube in place attached to a closed chest water – seal drainage system. When the nurse palpates the area around the chest tube insertion site she is checking for
Subcutaneous emphysema
IV therapy module
What are the most often type of catheter used for initiating IV therapy
Over the needle catheters with built in safety devices
What size catheter gauge is adequate for diffusing fluids and medications for adults
20 to 22 gauge
Which size gauge is most adequate for children, older adults and anyone who has small fragile veins
22-24 gauge
If a patient will receive large quantities of fluids at a rapid rate or blood or blood products, use a larger catheter such as a blank gauge
If you’re patient will not have a continuous infusion, initiate a saline lock also called
Heparin lock
Since fluids do not infuse continuously through a saline lock to maintain patency of the IV line, you must flush the lock usually with normal saline, blank to blank milliliters before and after you administer each medication or at regular intervals
5 to 10 mL
What is the direct method for inserting a peripheral IV catheter
Pierce the skin immediately over the vein and approximately 1/2 inch below the proposed IV site
What is the indirect method of inserting a peripheral IV catheter
Pierce the skin along the side of the vein and then angling the catheter toward the vein
Once you have pierced the skin and thread the catheter a short distance into the vein, pull the needle back so that the tip is not extending past the end of the catheter. Then thread the catheter into the vein until
The hub of the catheter is resting against the skin at the insertion site. Then remove the needle the rest of the way, activate the safety device and dispose of the needle in the sharps container. Then secure the catheter
If a patient is critically ill or requires long term IV therapy, the provider typically considers what kind of catheter
Peripherally inserted central catheter or or PICC
What should you do for older adults that need an IV catheter
When inserting the catheter be sure to pull the skin below the insertion site taut to stabilize the vein. Also if possible use a mesh dressing to stabilize the catheter once inserted
To keep air from entering the tubing and being infused, be sure to keep the drip chamber at least
Half full
When using the piggyback set up, leave both the primary and secondary lines open. To regulate the flow of the secondary infusion what should you do
Open the roller clamp on the secondary tubing completely and use the roller clamp on the primary tubing to adjust the flow rate
When the secondary infusion is complete the primary infusion resumes. If the primary infusion rate differs from that of the secondary infusion, remember to
Adjust the rate as soon as possible after the secondary infusion is complete
To secure an IV site apply a transparent dressing to protect the IV site from contamination while still allowing visibility. Position the dressing over the vein so that it
Extends to the lip of the hub of the catheter. Leave the connection between the catheter hub and the IV tubing uncovered to facilitate changing the tubing
Also do not wrap the tape around the patient’s arm either because
This can impair circulation if the arm swells
To protect the patient’s skin, place a small gods pad under the hub of the IV catheter to elevate it and
Keep it from exerting pressure on the patient’s skin
When you begin your assessment of an IV site start by inspecting for
Redness or swelling
Next palpate the area around the site and along the vein for any
Pain, firmness or swelling, also note temperature
A peripherally inserted venous catheter is usually replace every
72 to 96 hours
What is phlebitis characterized by
Increased temperature, redness along the vein
What is phlebitis treated with
Discontinue the IV line and apply a warm, moist compress over the area
Infiltration results when the IV catheter is dislodged and fluid infuses into the tissue. It is characterized by
Edema, pallor, decreased skin temperature around the site and pain
Extravasation is characterized by
Pain, stinging or burning at the site, swelling and redness
How do you treat extravasations
Discontinue the IV line and apply a cool compress to the area. If the medication has an antidote it should be prescribed in a ministered immediately
A short peripheral catheter is appropriate when IV therapy is planned for up to
seven days
To minimize personal risk of injury while inserting an IV access device into a patient’s hand you stabilize the vein
Below the proposed insertion site
You are most likely to be successful in accessing a superficial vein with an 18 gauge catheter by inserting the catheter at what angle
10 to 30° angle to the skin
A nurse initiating a peripheral IV infusion punctures the skin and selected vein and observes blood return in the flashback chamber of the IV catheter. What action should the nurse perform next
Lower the catheter until it is almost flush with the skin
Nasogastric intubation module
What are Orogastric tubes such as ewald, lavacuator, and eldich
Large bore tubes with wide proximal outlets for removing gastric contents and are primarily used in emergency departments and ICUs
What is the lavacurator tube
Has two lumens, a larger lumen for evacuating gastric contents and a smaller lumen for instilling an irrigant
The most common nasogastric tube is the double lumen gastric sump tube (Salem). This type of tube is useful for irrigating the stomach but is most often used for drawing out fluid and gas from the stomach. In fact, it is the preferred tube for
Gastric decompression
The single lumen (Levin) nasogastric tube is useful for
Decompressing the stomach, withdrawing specimens for diagnostic analysis, washing the stomach free of toxic substances and irrigating the stomach to diagnose and treat upper gastrointestinal bleeding. It can also be used to administer feedings and or medications
There are several brands of dual purpose tubes that can provide gastric section and enteral feeding. these to allow for removal of
Excess feeding formula from the stomach thereby reducing reflux
Some brands such as Moss include a 3rd lumen that inflates a gastric retention balloon. These tubes are used primarily for patients undergoing
A miller Abbet tube is a 3 m double lumen nasointestinal tube. These tubes are used to sample gastrointestinal fluid and to provide decompression for
Small bowel obstruction or ileus
The sengstaken-blakemore tube is used to treat
Upper gastrointestinal bleeding from Esophageal varices
What is gastric Lavage
The irrigation of the stomach
Lavage May also be used as a therapy for blank or blank to help stabilize the body temperature
Hyper or hypotherma
How often do you include intermittent irrigation
Every four hours
How often do you want to assess and document intake and output
Every eight hours
What is imperative for both the patient comfort and to reduce the risk of infection because patients usually become mouth breathers
Frequent oral hygiene, or if allowed they may suck on ice chips or hard candies.
For a patient who is unconscious or does not have a gag reflex the link is strongly recommended, along with an oral airway to keep the patient from biting on the blank
Endotracheal tube
What are the contraindications for gastric lavage in regards to ingestion of poisons
Hydrocarbon with a high aspiration potential, ingestion of a corrosive substance such as a strong acid or alkali
Before beginning gastric lavage explain the procedure to the patient and obtain her verbal agreement to begin the procedure. Then
Test the patients gag reflex
Oro or nasogastric compression is used to
Control bleeding from esophageal or gastric varices
What is the most common electrolyte disturbance associated with nasogastric decompression
A nurse is performing a nasogastric intubation. What with the nurse do immediately after inserting the tube to the predetermined length
Inspect the oropharynx with a penlight and tongue blade
Enemas module
What is the most common reason for administering an enema
To relieve constipation
Before administering an enema position the patient on
The left side in the Sims position with the right knee flexed
A cleansing enema acts by stimulating peristalsis by instilling a solution or irritating the mucosa of the colon. When administering a cleansing enema be cautious about instilling blank. Because it is a hypotonic solution therefore it pulls electrolytes from the body into the fluid and increases the risk of electrolyte imbalance
Tap water
Soapsuds enema is act by stimulating peristalsis through intestinal irritation. As long as blank is used it is considered a safe procedure
Pure Castile soap
Some patients having a procedure or surgery involving the bowel have an order for an enema to be administered until clear. This means
You need to repeat the enema and tell the patient passes fluids that are clear of fecal matter. Do not administer more than three enemas
What are return flow enemas used for usually
In oil retention enema is administered to lubricate the rectum and the colon. The oil is absorbed by the feces making them
Softer and easier to pass
Medicated enemas may be given for the local effect they exert on the rectal mucosa. An example of one containing kayexalate is administered to treat patients who have
Dangerously high serum potassium levels
Hypertonic enema solutions should be held in the bowel for how long
Until the patient feels that urge to defecate which is usually in 2 to 5 minutes
What kind of solution is used to administer enemas until clear
Normal saline
You evaluate that the enemas have had a desired effect when you find a
Large amount of slightly brown solution with no solid fecal matter
How should you prepare a soapsud enema
1 teaspoon of soap in a liter of fluid
When administering enema what should you do if the patient reports cramping
Lower the height of the solution bag to slow The installation rate
A nurse is preparing to administer an oil retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for
At least 30 minutes but preferably as long as they can
Ostomy care module
The opening of an ostomy is call a
A colostomy is created from
The end of the large intestine to divert waste from the digestive system
With a blank the damage section of the bowel is removed and the working end is brought through the abdomen to the skins surface
End colostomy. It will normally be reconnected in about 3 to 6 months
Why would you need an end colostomy
Tumor resection, traumatic injury to the colon or inflammation of the bowel
With a loop colostomy, a loop of the bowel is brought through the abdomen to the skins surface and temporarily supported by a plastic bridge or Rod. It is typically created as an emergency procedure to relieve
An intestinal obstruction or perforation. It can normally be removed within 1 to 2 weeks
A double barrel colostomy is when two separate stomas are created. They may be created because
Of trauma, tumors, or inflammation and it may be temporary or permanent
What part of the colon is used for a temporary ostomy
Transverse colon
What part of the colon is a more common type of colostomy
Descending colon
What part of the colon is the most common location for a permanent colostomy particularly for cancer of the rectum
Sigmoid colon
What is it ileostomy created for
A surgical opening created in the ileum to bypass the entire large intestine
A procedure used to treat calling cancer, total proctocolectomy involves
Surgical removal of the entire colon, rectum and anus with closure of the anus
Where is the stoma created for an ileostomy
Right lower quadrant
An alternative to the standard ileostomy is Kocks continent ileostomy. During the procedure and internal pouch is created from the distal segment of the ilium, which serves as a reservoir for stool. During surgery, a one-way nipple valve is constructed through the stomal opening so that eventually the patient can insert a catheter through the stoma and through the one-way valve to drain the fecal contents of the internal pouch. This type of ostomy he is occasionally created to treat
Ulcerative colitis and may be an option for patients who do not wish to wear an external pouch over the stoma
What is a urostomy
A urinary diversion that allows urine to exit the body after removal of a diseased or damaged section of the urinary tract
What is the most common type of urinary diversion
Ileal conduit
In Indiana continent urinary reserve is formed from the colon and the cecum. This allows the patient to
Self Catheterize to empty the reservoir
A healthy stoma appears
Pink or red and moist and should protrude about three quarters of an inch from the abdominal wall
What should patients use to clean a stoma
Typically a mild, pH balanced soap or no soap at all and just water
How often should patients empty there pouch
it is one 3rd to 1/2 full
What are signs and symptoms of food blockage
Abdominal cramping, nausea, vomiting, high volume odorous effluent, swelling of the stoma and no ileostomy output for at least six hours
What should patients do if they experience symptoms of a food blockage
Place moist towels on the abdomen, drink hot tea, lie down and assume a neat chest position to relieve intra-abdominal pressure and/or massage the abdominal area to promote peristalsis
What are signs and symptoms of dehydration or electrolyte imbalance
Extreme thirst, dry skin and oral mucous membranes, decreased urine output, weakness, fatigue, headache, dizziness, muscle cramps, abdominal cramps, nausea, vomiting, shortness of breath, orthostatic hypotension
What type of ostomy pouching system is best for a new incision
A two-piece pouching system with a cut to fit skin barrier
Stomal stenosis and retraction can develop as a ostomy heals by
Secondary intention
A nurse is replacing the ostomy appliance for a patient who is newly created colostomy is functioning. After removing the pouch which of the following should the nurse do first
Cleanse the stoma and the peristomal skin
Central venous access devices module
Central access devices are inserted into
Large veins in the central circulation, such as the internal or external jugular vein’s or into the lower third of the vena cava that leads to an area just above the right atrium
How long can a central line device remain in place
For more than a year
A fairly common MLC configuration is three ports, commonly labeled as follows
Distal port: the largest lumen; used for central venous pressure or high volume or biscuits fluids, colloids or medications. The medial port: used for parental nutrition, medications. The proximal port: used for blood sampling, medications, blood component administration
The distal port is the largest and has the greatest flow rate which makes it ideal for
Blood sampling
For additional insurance that laboratory results won’t be altered by the solutions infusing through the central access device, turn off the distal infusions and clamp the tubing for blank minutes before obtaining the blood sample
1 to 5 minutes
What are common manifestations of sepsis
Fever, chills, hypotension, tachycardia and and confusion
What is pneumothorax
Air in the pleural space, that is outside the lung
What is hemothorax
Blood in the pleural space
What are symptoms of an air embolism
Dyspnea, chest pain, tachycardia, hypertension, anxiety, nausea, dizziness and confusion
If you suspect in the air embolism what should you do
Clamp the catheter, administer oxygen and place the patient on his left side in Trendelenburg position
Catheter occlusion: If you cannot flush the catheter, check to make sure it is not clamped or kinked sometimes the problem is that the catheter tip rest against the wall of the vein. Try these strategies
Have the patient turn his head and cough. Ask the patient to raise his arms over his head. Place the patient in Trendelenburg position. Have the patient take a deep breath. Have the patient stand up. Have the patient change positions in bed.
Catheter occlusion: it may be that the sutures securing the vascular access device are constructing the catheter. If so, obtain in order to remove the sutures and apply a stabilizing device. If the obstruction is with an implantable port, check to make sure the noncoring needle is correctly placed in the port. If it is not correctly placed remove
The needle and replace it with a correctly positioned needle
Thrombotic occlusion’s are caused by clotting inside the catheter for outside around the catheter tip that blocks the catheters lumen. This can make it impossible to draw blood from the catheter, to flush it or to use it for infusion try
Heparin and other chemicals might clear the blockage; when those measures do not help, the catheter must be replaced
When he central catheter is inserted into the subclavian vein, the clavicle and rib can move together and compress the central line catheter, causing pinch off syndrome. Warning signs include
Difficulty drawing blood samples and resistance to the infusion of IV fluid. Ask the patient to change position of his arm on the catheters side by raising it or by pulling his shoulder backwards
What is a catheter malposition
When a central catheter becomes dislodged as a result of improper technique when removing a dressing, in adequate securing of a catheter and physical activity
What is it advantage of the implanted port
They are cosmetically appealing, low risk of infection, and allow patients to carry-on virtually all activities including swimming
What is a disadvantage of an implanted port
Accessing it can be painful
What do you use to access an implanted port
A non-coring, non-barred needle.
Implanted ports may be open ended or valved. Open ended ports require
Heparin flashing while valved ports do not
Non-tunneled catheter’s are inserted into
That internal jugular or subclavian vein, with the catheter tip resting in the superior vena cava
What is the insertion method for non-tunneled catheter
Percutaneous venipuncture.
How long can a non-tunneled catheter remain in place
Typically 3 to 4 weeks
Having a non-tunneled catheter puts you at a higher risk for what
Infection and pneumothorax
PICC’s are usually intended for patients who require therapy for periods of 1 to 12 weeks but some have been known to remain in place
for years
Most PICs are secured with
Wound closure strips or a securing device
Your assessment includes measuring the patient’s upper arm circumference to establish
Baseline data
Also be sure to measure and document the length of the external portion of the catheter from the
Insertion site to the hub of the access. Later you will compare the length of the external catheter to the previously documented Lane to detect catheter dislodgment from the insertion site
Ongoing care of a PIC includes a dressing change 24 hours post insertion and then
On a weekly basis. Assess the site for redness, drainage, swelling and pain
A typical schedule for flushing a PIC site is every
12 hours we medications or fluids are not being administered
What kind of aseptic technique do you use for changing dressings on catheter sites
The CDC recommends changing addressing when it is damp, Lucinda or soiled. And changing God dressings every blank hours and transparent dressing every blank days or whenever they are no longer intact
48, 3 to 7 days
The preferred dressing is what
Semi permeable membrane dressing. Typically gods dressings are not recommended unless there is drainage from the site
When using alcohol and povidone-iodine, to clean the catheters insertion site what should you do
Move outward and apply for a minimum of 30 seconds and allow to dry completely before applying the povidone-iodine
When using chlorhexidine, use a back and forth motion and cleanse the site for
30 seconds
Central venous catheter’s have a special cap on the end where IV tubing or syringes connect into the line. This Is called the injection or access cap. Typically injection caps are changed every blank hours for continuous infusions and every blank days for intermittent infusions, most likely at the same time as a dressing change
72-96 hours, seven days
Tunneled central venous access devices are designed for
Long term years, months to years
Examples of brand names for tunneled central venous access devices include
Hickman and Broviac
Hickman and Broviac catheters differ in women size. A Hickman catheter has a larger lumen compared with the single lumen Broviac,which is primarily used for
Pediatric patients
A Groshong catheter differs from the Hickman and Broviac catheters because of its valve tip. Valve tip catheters are not heparinized and do not require
What is a Dacron cuff on tunneled catheter’s
It lies within the subcutaneous tunnel, where tissue granulate into the cuff there for defectively anchoring the catheter and acting as a barrier for preventing the spread of organisms along the catheter
What is a really good catheter to deliver parental nutrition
The first sign that DVT is developing is
Edema on the forearm
During a sterile procedure everyone in the room is required to
A facemask
What immediate complications do you monitor a patient for during the insertion of a CVAD
Pneumothorax, dysrhythmia, hematoma
You are aware that the catheter tip position for a properly placed CVAD is in the
Superior vena cava
How often should a patient flush an implanted infusion port
Every 4 to 6 weeks
A nurse is caring for a patient who has a central venous access device in place. Which of the following routine measures should the nurse use specifically to prevent lumen occlusion
Clamping the extension tubing while removing a syringe from the injection cap
When implanted port remains accessed for and infusion, the needle must first be supported and incurred, then
The port and needle are covered with a transparent dressing
Valved tips do not require
Heparinized saline solutions for flush
A patient who sustained trauma from a motor vehicle accident is transported to an emergency department. The provider determines the need for immediate central venous access for fluid and blood replacement and prophylactic antibiotic therapy. The appropriate central venous access device for this patient is
A non-tunneled percutaneous central catheter
When performing postural drainage what should you do
First position the patient, then percuss and vibrate, then remove the secretions either by having the patient cough or by suctioning the patient’s airway
Blood administration module
Because the use of whole blood has a greater effect on fluid volume than any of the components do, it is used only when needed or when individual blood components are not available. What is the timeframe for transfusing whole blood
It must be transfused within 24 hours of collection because coagulation factors deteriorate after that timeframe
Plasma in the blood is responsible for maintaining blood pressure and providing essential proteins, serves as a medium for cellular exchange of vital minerals and electrolytes and for the elimination of
Cellular waste products
Red blood cells are kept refrigerated at specific temperatures and are viable for blank days but maybe frozen for extended storage up to 10 years
What is plasma used for
Treating bleeding and coagulation disorders, replace fluid volume in patients with massive burns and for those with liver failure and to replace platelet aggregating inhibitors in patients who have thrombocytopenic Purpura or hemolytic uremic syndrome
Plasma can be frozen for 1 to 7 years. Once thought it it must be transfused within
24 hours
One fractionated product of plasma is the protein blank, essential for maintaining blood volume and blood pressure
What is immune globulin
A concentrated solution of the anti-body IgG, is prepared from large pools of plasma
What is immunoglobulin used for
To replace inadequate amounts of IgG for patients at risk for recurrent bacterial infections, such as those with chronic leukemia
What is cryoprecipitate anti-hemophilic factor used for
It is transfused to prevent or control bleeding and people who have hemophilia, to correct low fibrinogen levels and to treat von willebrand disease and other clotting disorders
What would a granulocyte infusion be used for
What blood types can receive AB plasma
Rh system: A person who has the D antigen is classified as blank. A person who does not have the D antigen is classified as blank
Rh positive, Rh negative
The basic rules are that the red blood cells transfuse must not have the antigens to which the patient has
Anti-bodies and that the plasma and platelets transfused must not have the antibodies against the patients antigen
What is hemolysis
The premature destruction of red blood cells within or outside of the vasculature
Hemolysis can occur prior to and during blood administration. To prevent hemolysis do not apply more then blank of pressure
300 MM HG
Another way to prevent hemolysis is when you must use a pressure device for rapid infusion, make sure the IV access catheter is a blank gauge or larger to avoid vein damage
When warming blood use a device approved by the FDA. Never use
Microwave or hot water baths
Administer all blood components through a sterile, pyrogen free filter designed to retain clots and aggregates that might otherwise harm the patient. Usually a standard the link micron filter
170-260 µm filter
Although you can administer blood safely through a 22-25 gauge catheter, use a blank gauge catheter. Larger Cathers encourage blood flow and reduce the risk of hemolysis
18 to 20 gauge catheter
With the exception of blank, never add or infuse medications and IV solutions unless they have met two criteria by the FDA
0.9% sodium chloride
Never use blank solutions with blood, because glucose causes red blood cell aggregation
Dextrose containing solutions
Because they are stored at room temperature, blank are the most likely of all blood products to become contaminated with bacteria
From the time the integrity of the bag is broken, make sure the unit is transfused within blank. This is the maximum time a blood unit may infuse at a room temperature
Four hours
Start the infusion within blank minutes of its issue from the blood bank. If the blood is not going to be transfused return it to the blood bank within this time also
If the bag is spiked with an administration set and kept refrigerated between 34° and 43°F, keep in mind that the bag expires in
24 hours
What is autologous transfusion
The process of collecting, storing and reinfusing the patient’s own blood
What is directed donation
Patients select their own donors in an attempt to ensure safety.
What are febrile non-hemolytic transfusion reactions
Accounts for about 90% of all reactions. Most common in patients who are immunosuppressive or pregnant. Symptoms include chills followed by a temperature increase of more than 1.8°F from baseline develop any time from 30 minutes after the transfusion is started to six hours after it is completed. In addition muscle stiffness, headache flushed appearance and nervousness can appear
What is acute intravascular hemolytic reaction
It is an antigen – anti-body immune mediated reaction. Most common causes are errors in blood component labeling or patient identification. A potentially fatal reaction. Initial symptoms are pain at the IV site, elevated heart rate, chills, fever, anxiety, nausea, back pain and difficulty breathing
A reaction that results in symptoms similar to those of an acute intravascular hemolytic reaction is immune mediated hemolysis. What happens during this reaction
Red blood cells become hemolyzed by high temperatures resulting from improper shipping or storage or heating of the blood, it can also result from unapproved pressurized administration devices, The use of small bore needles for administration, adding drugs or concentrated solutions to the blood or using unapproved solutions for Y set priming
An allergic reaction can develop at any time during the transfusion and up to one hour after completion. Most of these reactions are mild and subside with antihistamines. Symptoms include
Hives, itching and Flushing
Transfusion related acute lung injury is the leading cause of transfusion related deaths. The symptoms may develop at any time during the transfusion to within six hours after the transfusion is completed. Symptoms include
Chills and set in respiratory distress, which can lead to respiratory failure, pulmonary edema may also present
A delayed hemolytic reaction can develop 2 to 14 days following transfusion as a result of an antibody response to non-ABO donor antigens that were not detected during crossmatch. Symptoms include
Graft versus host disease develops primarily in immune compromised individuals, when T lymphocytes in the transfused component attack and react against tissue antigens in the recipient. Is a rare but serious complication. Symptoms develop days to weeks following the transfusion and include
Skin rash, fever, jaundice and bone marrow suppression. Irradiating blood components is the only known and approved method of inactivating T lymphocytes
Post transfusion Purpura is a rare complication arising 7 to 10 days after blood transfusion. A dramatic, sudden, but self limiting destruction of native and transfuse platelets results from an immune response to
platelet specific antigens
Circulatory overload results when your patient is unable to tolerate the rate or volume of the blood product being transfused. Mild symptoms are
Difficulty breathing, cough, rapid heart rate, and hypertension.
What should you do to reduce the incidence of circulatory overload
Infuse the blood component at the prescribed rate typically no faster than 2-4 mL/kg/hr.
You just initiated a blood transfusion him. Your highest priority action at this point is to remain with the patient for
15 to 30 minutes
What is a normal human platelet count range
From 150,000 to 450,000 platelets per microliter of blood
One common definition of thrombocytopenia is a platelet count below
50,000 per microliter
What is a classic symptom of a septic reaction from a blood transfusion
Hypotension. Other symptoms include rapid onset of chills, fever
How often can a patient donate blood for an autologous infusion
Every 3 to 4 days
What do you autologous infusions eliminate the risk for
Practice tests modules
What must be done for any patient before pain medication can be administered
Assess for pain which means you must examine the body part of a child first before you can administer medication
A nurse is precepting a newly licensed nurse who is preparing to help a patient perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included
Cotton balls
While measuring a clients vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate
Count the apical pulse rate for one full minute and describe the rhythm in the chart
A simultaneously apical/radial pulse is used to identify a
Deficit between The apical and radial pulse rates. It is not used to assess irregularity in the pulse
What kind of thermometer do you want for patient requiring rectal temperature monitoring
One with a short, blunt insertion end
A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse
Refrigerate the collected specimen
Oxygen toxicity is associated with oxygen concentrations above blank for longer than 24 to 48 hours
A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per an hour
4 to 5
A nurse is teaching a client with the new colostomy about how to irrigate the ostomy The nurse realizes that the client needs further teaching when the client
Positions the irrigating solution bag 30 inches above the stoma
A critical concept related to effect of cardiac chest compressions is to
Push hard and deep on the chest
A nurse has inserted an indwelling urinary catheter for a mail client. Where should the nurse take the catheter to prevent pressure on the clients urethra at the penoscrotal junction
Lower abdomen
Which nursing action prevent injury to a clients eye during the administration of eyedrops
Tilting your head forward helps promote what while eating
What nutrient can depress the respiratory system
What classification is the drug tamoxifen
Anti-estrogenic and anti-neoplastic’s
Gemfibozil is indicated for
What is the medication ergotamine tartrate indicated for
Migraine headaches
What is a really good indicator of renal function
Serum creatinine levels
Metoclopramide is a
Following a cerebrovascular accident, the patient is at high risk for what
Airway obstruction and aspiration due to loss of muscle control
Antihistamines should be used cautiously in patients who have
What is a food that’s contraindicated in people that have gout
Lentil soup
The term co- morbidity refers to medical conditions knowing to
Coexist in a patient
What is something that all patients over 50 should have performed annually
Adequate folic acid intake is associated with a reduced risk for
Heart disease
What are foods that are rich with folic acid
Orange juice, beans, legumes, Green leafy vegetables
A nurses caring for a client who is immobilized knows that, without interventions to prevent constipation and fecal impaction, this client is at risk for
Intestinal obstruction
A patient is prescribed a hypothermia blanket. When caring for the patient the nurse should place
A layer of cloth between the client and the blanket
When giving an enema the solution bag should be placed A maximum of blank feet above the client
A post operative clients knee dressing becomes completely saturated with blood one hour after transferred to the clinical unit. What is an appropriate nursing action
Apply direct pressure to the operative site
A nurse caring for pre-operative client and ministers atropine as prescribed to
Minimize oral and respiratory secretions. Anti-cholinergic medications are given to dry the oral and respiratory mucous membranes
A nurses caring for a patient who has acute renal failure. The nurse knows that on a day to day basis the most accurate measure of the clients fluid status is the
Daily weight
Active range of motion is preformed before passive range of motion to determine limitation of movement. This helps ensure that
No injury will develop during passive range of motion
A hypothermia blanket is used to
Cool a client with a high fever and responsive to antipyretics
Fluorouracil is an anti-neoplastic drug that is also classified as a
Total parenteral nutrition should have a uniform, usually milky white blank and blank
Consistency and appearance
Pepto-Bismol is used in the treatment of peptic ulcer disease because of its
Antimicrobial action
A nurse is preparing to administer IM Iron dextran to a client. What is the appropriate site for administration
The vastus lateralis muscle is a large muscle used when iron dextran is administered
What is cyclosporine used for
Immunosuppressive agent. Patients that receive organ transplants will need to take them for the rest of their lives
Glucocorticoids should not be taken on it empty stomach. In addition some of the side effects of long-term glucocorticoid therapy can be avoided by using
Alternate day therapy
Saw Palmetto is used primarily for symptoms related to
Prostatic conditions such as benign prostatic hypertrophy
A patient taking isoniazid will need frequent monitoring of what
AST as part of liver function tests
What is a sign of digoxin toxicity
Nausea so you should assess the apical pulse if a patient complains of nausea
Patients are instructed to withhold digoxin at the heart rate is below
The onset of action for a regular insulin is blank with a peak of blank
30-60 minutes, 2 to 4 hours
Theophylline is a xanthine derivative bronchodilator. The earliest manifestation of toxicity is
CNS stimulation often seen as tremors. Other symptoms include insomnia, confusion and irritability
What are the stages of grief
Denial, anger, bargaining, depression, acceptance
What are the things that would help a bowel training program
Increase of fiber, increase of fluid to 2500-3000 mL, and an increase in exercise
Where should transdermal medication patches be applied on older adults
Hairless area of the torso
What is Agnosia
The inability to identify familiar objects
Tympanometry measures variations in air pressure in the external ear canal. This test may cause
Transient vertigo, nausea or dizziness
Oxygen can provide comfort and is not considered resuscitative when given by
Nasal cannula for patients that have a no resuscitate order
What is oliguria
Low output of urine
A hydraulic lift device requires how many staff members
Phases of korotkoff sounds
What is phase 1
Sound is sharp thump or tapping that corresponds with The patient’s systolic blood pressure
What is phase 2
The sound is blowing, swishing, or whooshing
What is phase 3
Sound is crisp, steady, intense tapping. This phase approximates the midpoint between the clients systolic and diastolic pressure
What is phase 4
Soft, blowing or muffled sound that fades
A nurses caring for a patient is post operative. Which of the following intervention should the nurse plan to prevent nausea
Provide clear liquids as peristalsis returns
What position should a patient in for an NG tube insertion
An infant should be able to hold their head steady by what age
Six months
For patients with gastrostomy tube how often do their feeding bags need to be replaced
Every 24 hours
The first step in reducing anxiety is to promote
Process of a 24 hour urine collection
The first voiding is discarded and all other subsequent voiding’s are collected
Raltegravir just treat patients with
What are symptoms of a Tylenol overdose
Diaphoresis, nausea and diarrhea
What kind of medication is a macrolide an acceptable alternative to penicillin
A patient who is taking Keflex Long term should be monitored for renal function by which laboratory test
What is suprainfection
Infection caused by antibiotics
Can a nurse caring for a patient with tuberculosis use antimicrobial hand sanitizer
A nurse is caring for a patient receiving IV fluids. During a routine check, the nurse determines that the patient has developed phlebitis and removes the IV catheter. Which action should the nurse take next
A serum albumin level below 3 g/dL indicates
Protein deficiency, putting a patient at risk for pressure ulcer formation and poor wound healing
A nurse is caring for a patient who has an NG tube that is irrigated every eight hours. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance
.9% sodium chloride
Arterial bruits are blowing sounds resulting from
Blood flowing through occluded or narrow arteries
A patient fluid output should approximate the
Daily fluid intake
What is a symptom that should indicate to a nurse the need to section a clients tracheostomy
What are symptoms of decreased oxygen to the tissues A.k.a. hypoxemia
Irritability, hypertension, pallor, tachycardia
Infiltration is indicated by
Cool skin, blanching
A nurse is planning care for a patient who has dysphasia following a stroke. The nurse should initiate a referral for which of the following therapies
Speech therapy
And adolescent who has visible accessory muscle movement while breathing is demonstrating labored breathing. Which is an
Abnormal finding
A nurse is providing discharge teaching for a patient who has a prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the patient and his family
Check the cord routinely for frays or tearing, consider purchasing a generator for back up power, monitor for signs of hypoxia
How far away should oxygen be kept away from a heat source
At least 8 feet
A nurse is caring for a patient who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take
Pour warm water over the clients perineum
What should patients use when they have a tracheostomy and they like to go outdoors
Tracheostomy cover
How long should you fast before asking blood sugar test
8 to 12 hours
A nurse has an order to remove sutures from a patient. After retrieving the suture remover Kit and applying sterile gloves what should the nurse do next
Clean the sutures along the incision site
What kind of data she do document in the medical record
What should the nurse do when providing medication reconciliation for a newly admitted patient
Compare the patient’s home medications with the providers prescriptions while performing medication reconciliation
Avocados are an excellent source of
Acceptable identifiers include
A patients name, assigned identification number, telephone number, birthdate or use a barcode scanner to identify patients
When would you prefer a patient to a laboratory technician
An example would be when a provider needs to see a patient’s complete blood count results immediately
When would you refer a patient to an occupational therapist
When a patient has difficulty using in the eating utensil with her dominant hand following a stroke (usually upper extremities)
When would you refer a patient to a physical therapist
Following hip arthroplasty, a patient requires assistance learning to ambulate and regain strength (usually lower extremities)
When would you refer a patient to a respiratory therapist
And example would be when a patient has a respiratory disease and is short of breath and request a nebulizer treatment
You should never leave dentures on
A meal tray
Airborne precautions need to take place for diseases such as
Measles, Varicella, pulmonary or laryngeal tuberculosis
Droplet precautions need to take place for diseases such as
Streptococcal pharyngitis or pneumonia, influenza type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague
Contact precautions need to be in place for patients that have
Respiratory Syncytial virus, shigella, enteric diseases, wound infections, herpes Symplex, impetigo, scabies and multi-drug-resistant organisms
The Crede’s maneuver helps to manage
Reflex incontinence
What is for Borborygmi
Unexpected loud growling sounds that indicate increased gastrointestinal motility, such as in cases of diarrhea
If gastric residual before and NG tube feeding exceeds 250 mL for each of two consecutive assessments what should you do
Withhold the feeding, notify the provider, maintain semi Fowler’s position and recheck residual in one hour