suctioning procedures, nasotracheal suctioning
When suctioning an adult client, the wall suction should be set at 80 to 120 mm Hg (portable suction is set at 7 to 15 mm Hg). Elevated suction pressure settings can increase the risk of trauma to the mucosa and can induce greater hypoxia. The catheter sh
Oral Suctioning procedure
Wash the hands before performing any procedure
applies a face shield because suctioning may cause splashing of body fluids, and then dons a clean glove.
A clean rather than a sterile glove can be used in this procedure because the oral cavity is not steri
procedure for administering mouth care to the client who is unconscious
The client who is unconscious is at a great risk for aspiration. The client should have the head of the bed elevated because a flat supine position presents the risk of aspiration. The UAP should either place the client in a side-lying position or turn th
procedure for removing a nasogastric tube.
After explaining the procedure to the client, the nurse would assess for the presence of bowel sounds. The tube would not be removed if bowel sounds are absent. The nurse would don clean gloves, place the client in an upright position, and place a towel a
procedure for inserting an indwelling urinary (Foley) catheter.
Before insertion of the catheter, the client should be positioned on the back with the posterior sides of the feet touching one another with the knees bent. This allows for optimal visualization and access to the urethral meatus. Lubricates the catheter b
procedure for pulse oximetry measurement
If the client has peripheral vascular disease, the pulse oximetry probe would be placed on the earlobe or bridge of the nose because peripheral vasoconstriction or inadequate blood flow to the peripheral areas of the body will interfere with the oxygen sa
the procedure for collecting a midstream urine sample.
As part of correct procedure, the client should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample after starting the flow of urine. T
complementary and alternative therapies.
simple relaxation technique, such as muscle relaxation, can help reduce any existing anxiety and promote sleep.
Herbal therapy involves the use of herbs (plant or a plant part). Some herbs have been determined to be safe, but other herbs, even in small am
the methods of transmission of human immunodeficiency virus (HIV).
HIV is transmitted through anal or oral sexual contact with infected semen or vaginal secretions, through contact with infected blood or blood products, by transmission of the virus from mother to fetus during childbirth, through breastfeeding, or from ot
transmission-based precautions.
Droplet, contact, and airborne precautions are more specific types of precautions and are known as transmission-based precautions.
Droplet precautions require the use of a mask and are used when organisms can be spread by respiratory droplets but are unab
informed consent for the treatment of minors.
Parents normally must give informed consent for treatment of a minor. Some exceptions to this include the need for emergency treatment; when the consent of the minor is sufficient, such as for treatment of a sexually transmitted infection; or when a court
stapedectomy
Following stapedectomy, no air travel is allowed for 1 month. The acute onset of vertigo needs to be reported to the health care provider because this could be indicative of a complication. The client is instructed to lie on the nonoperative ear with the
care of a newly created colostomy - irrigation
The irrigation bag should be hung no higher than 12 to 18 inches above the level of the stoma; a clothes hook is too high. Fluid flowing into the intestines can cause distention and discomfort; clamping the tubing is an appropriate intervention. The tip o
discharge instructions for a client who will be receiving total parenteral nutrition (TPN) at home
The less disruptive the procedure, the greater the acceptance by the client. Most often, total parenteral nutrition is set up to run daily during sleeping hours. Depending on the type of circulatory access used, it may not need to be changed for weeks. Th
Which nursing behavior is an intentional tort?
Divulging private information is an invasion of privacy, which is an intentional tort. Miscounting gauze pads during a client's surgery, causing a burn when applying a wet dressing to a client's extremity, and failing to monitor a client's blood pressure
obtaining consent for surgery
Informed consent means the client must comprehend the surgery, the alternatives, and the consequences. Describing the risks involved in the surgery is not within nursing's domain. Although obtaining a signature is routine, explaining that obtaining the si
the primary role of a nurse epidemiologist
The nurse epidemiologist helps to devise an infection control strategy. The role of a primary health care provider is to decide what antibiotics should be prescribed for infections. The role of the laboratory technician or technologist is to work in the l
full-thickness and deep partial-thickness burns
The response that full-thickness burns extend into the subcutaneous tissue and deep partial-thickness burns extend through the epidermis and involve only part of the dermis correctly describes the difference between full-thickness and deep partial-thickne
thermometer with a long slender tip
an oral or axillary thermometer
has a long slender insertion end to provide more surface area contact with the tissues under the tongue or the axilla.
bc the bulb is long and narrow rather than blunt it has a greater chance for injuring the pts rectal tis
witnessing informed consent
the nurse acts as a witness solely to attest that it is the clients signature on the preoperative consent form. it is the responsibility of the surgeon who will preform the procedure to inform the client of the risks and benefits and obtain their consent
tracheostomy care
hydrogen peroxide 1/2 strength is used to clean the inner cannula.
a clean towel useful in protecting the bed linens and the clients gown.
a small brush or pipe cleaners may be used to remove thick or crusty secretions from the inner cannula
surgical scrubbing
must last at least 5 minutes to decontaminate the skin adequately
scrub the hands first then work toward the elbows
hands must be held higher than the elbows so that the dirty areas can drain from the clean area to the dirty areas
scrubbing is preformed w
abdominal assessment
inspection, auscultation, percussion, palpation
irregularity in heart rate
if the pulse rate is noted to be irregular then the nurse should count the apical pulse for 1 full minute and the irregularity should be noted in the clients record
IV site infiltrated signs and symptoms
the infusion slows or stops despite the fact that the tubing is not kinked.
swelling, hardness, or pain around the needle site.
blood fails to return to the tubing when the bottle is lowered
the area around the injection site will feel cooler than the sur
secondary intention wound healing
the wound edges are left open in a wound healing by secondary intention. most wounds left to heal by secondary intention within 5 - 21 days by forming granulation tissue that fills in the wound edges, and then forms a scar.
as they are poorly approximated
primary intention wound healing
sutured wounds with well-approximated wound edges are healed by primary intention
skin grafting wound healing
is required for deeper wounds healing, such as a full-thickness burn and is only rarely required for surgical wounds that do not heal
liquid stool specimen for ova and parasites
must be sent immediately to the lab and examined within 30 minutes to preserve the life of the ova. if it cannot be examined within 30 minutes then some of the specimen should be placed in a preservative, not the refrigerator
100% partial rebreathing mask
delivers concentrations of 60 -90% inspired O2. (Inspired O2 concentrations with O2 flow to the reservoir bag and with hoe much the bag collapses with inspiration.) O2 toxicity is associated with O2 concentrations above 50% for longer than 24-48 hours
21% oxygen
room air. cannot cause O2 toxicity with delivered by mech vent
40% oxygen or less
is considered nontoxic for a short term therapy regardless of the method of delivery is irrelevant
6L/min of oxygen via NC
delivers the equivalent or approx. 30% O2, which is considered nontoxic for short-term therapy, regardless or the method of delivery. (Inspired O2 concentrations vary when a NC is in use bc it is a low-flow system that depends in part on the clients respi
silicone spray
is used over the adhesive to hold the dressing in place. the silicone waterproofs the dressing so that the client can breath, it also isolates the area from contamination. its purpose is not to reduce skin irritation
Montgomery straps
are adhesive strips applied to the skin on either side of the surgical wound. the strips have holes for using gauze to tie the dressing securely. when the dressing is changed, the ties are released, the dressing is replaced, and the ties secured again wit
hypoallergenic tape
is used for clients sensitive to adhesive material but it still has to be removed with each dressing change. this could increase the risk of skin irritation
large absorbent pads
absorb more wound drainage but do not prevent skin irritation around the incisional area
closed suction drainage (hemovac)
is a self suction device that has a drainage catheter connected to a spring-loaded drum, it is not possible to irrigate the tubing.
to ensure proper functioning the device must be collapsed periodically to create enough suction to pull fluid into the coll