Nursing 400 Final Exam combined study
guides
Dysphagia - ANS-inability to swallow or difficulty in swallowing
2 key points about Dysphagia - ANS-1. 30 mins prior to meal time, the pt needs to be
sitting at 90 degree unless its contraindicated
2. Monitor for possibility of aspiration
-s/s of aspiration
-Coughing
-Wheezing
-Redness of face
-Decrease O2 sat
2 key points about Nasogastric Tube - ANS-Used for pt who suffers from dysphagia
(difficulty swallowing)
Residual volume must always be checked q4h d/t risk for aspiration *** if there is a large
amount of residual volume, that means pt is not digesting the food - inform MD**
Nasogastric Tube Supplies - ANS-Nasogastric tube
Irrigation tray - 60 ml syringe
A bottle of sterile water
lubricant
NGT insertion - ANS-1. Measure the tube from the nose to the back of the ear and
down a little pass the bottom of the xiphoid process
2. Mark the tube (sharpie)
3. Have the patient swallow while inserting the tube (with or without ice chips)
NGT placement - ANS-1. Once the NGT is inserted, aspirate 30 mL of air
,2. Place the stethoscope over the stomach and listen to the "wooooosh" sound as you
inject the air
3. If necessary, get an order for x ray for proper placement.
NGT medication administration - ANS-1. Check if pt is on any fluid restrictions
2. Check gastric residual and put it back after.
3. Make sure to kink the tube so that air won't go in the tube (air causes bloating)
4. Crush medication and mix with water until diluted and poured in the syringe. [except
enteric coated or with granules (Protonix)]
5. Flush 5-10 mL in between medications
6. Flush 30 mL after all medication has been administered
NGT removal - ANS-1. Needs a doctor's order
2. Flush with 10 mL water/NS or 30-50 mL of air
3. Have pt take a deep breath while removing the tube quickly
7 Rules about Body mechanics - ANS--Always bend the knee and have a wide base for
support
-Always point your toes to the direction you're going
-When transferring a patient to a chair or wheelchair, have them hold on to your
shoulders and have your dominant foot in between their legs.
-Always count (1-2-3) out loud and tell them how to position or move
themselves.
a. If the patient is weaker on one side, have them put their weight on the stronger side
before standing up.
b. Turn your entire body rather than pivoting to avoid hurting your back
-When re positioning the patient, you has always make sure to avoid hurting your wrists
,-Make sure the bed is at your hip level.
-If the patient is too heavy, ask for help.
How do we measure syringe gauge sizes? - ANS-THE SMALLER THE NUMBER, THE
BIGGER THE DIAMETER (GAUGE) OF NEEDLE
IV site inspection - ANS-look atthe IV catheter insertion site for redness, swelling, or
bruising. Redness can indicate irritation, inflammation, infection, or thrombus formation.
... Assess the condition of the transparent catheter dressing. The dressing should be
clean, dry, and adhere securely to the skin around the IV catheter insertion site
Intravenous sites - ANS--Common sites:
Dorsal area of the hands
Forearm
-Antecubital Fossa
Uncommon sites
Dorsal area of feet (needs an order)
Cephalic (infants)
Intravenous syringe length - ANS-Neonate and Infants:
19 mm (<1 inch)
Child and Older Adult:
1 inch
Adults:
1-1 ¼ inches
Intravenous guages - ANS-Neonate and Infants:
24-26 G
Child and Older Adults:
22 G
Adults:
18, 20, and 22 G
, Intravenous angle - ANS-*** Angle depends upon where the IV insertion site is.
(8) Rights of administration - ANS-1. Right Patient
2. Right Medication
3. Right Dose
4. Right Route
5. Right Time
6. Right Reason
7. Right Response
8. Right Documentation
(Parenteral routes of medication administration)
Intradermal - ANS-1. Medication is injected in the dermis (just below the epidermis)
2. Must form a "wheal"
3. Longest absorption time for parenteral routes
4. Dosage is usually less than 0.5mL
(Parenteral routes of medication administration)
Subcutaneuos - ANS-1. Injected in the adipose tissue
2. Absorption is slow to the capillaries
3. Dosage is usually no more than 1mL
4. Inject slowly so medication can disperse (10 sec/ 1 mL)
(Parenteral routes of medication administration)
Intramuscular - ANS-Injected in the muscle
Faster onset than intradermal and subQ
(Parenteral routes of medication administration)
Intravenous - ANS-Injected in the vein
Fastest absorption which also means fastest reaction to medication
(Parenteral routes of medication administration) (7)
Transdermal - ANS-1. Applied topically on the skin using a patch that contains
medication
2. Remove old patch and wipe of remnants of medication
3. Clean and dry the area
guides
Dysphagia - ANS-inability to swallow or difficulty in swallowing
2 key points about Dysphagia - ANS-1. 30 mins prior to meal time, the pt needs to be
sitting at 90 degree unless its contraindicated
2. Monitor for possibility of aspiration
-s/s of aspiration
-Coughing
-Wheezing
-Redness of face
-Decrease O2 sat
2 key points about Nasogastric Tube - ANS-Used for pt who suffers from dysphagia
(difficulty swallowing)
Residual volume must always be checked q4h d/t risk for aspiration *** if there is a large
amount of residual volume, that means pt is not digesting the food - inform MD**
Nasogastric Tube Supplies - ANS-Nasogastric tube
Irrigation tray - 60 ml syringe
A bottle of sterile water
lubricant
NGT insertion - ANS-1. Measure the tube from the nose to the back of the ear and
down a little pass the bottom of the xiphoid process
2. Mark the tube (sharpie)
3. Have the patient swallow while inserting the tube (with or without ice chips)
NGT placement - ANS-1. Once the NGT is inserted, aspirate 30 mL of air
,2. Place the stethoscope over the stomach and listen to the "wooooosh" sound as you
inject the air
3. If necessary, get an order for x ray for proper placement.
NGT medication administration - ANS-1. Check if pt is on any fluid restrictions
2. Check gastric residual and put it back after.
3. Make sure to kink the tube so that air won't go in the tube (air causes bloating)
4. Crush medication and mix with water until diluted and poured in the syringe. [except
enteric coated or with granules (Protonix)]
5. Flush 5-10 mL in between medications
6. Flush 30 mL after all medication has been administered
NGT removal - ANS-1. Needs a doctor's order
2. Flush with 10 mL water/NS or 30-50 mL of air
3. Have pt take a deep breath while removing the tube quickly
7 Rules about Body mechanics - ANS--Always bend the knee and have a wide base for
support
-Always point your toes to the direction you're going
-When transferring a patient to a chair or wheelchair, have them hold on to your
shoulders and have your dominant foot in between their legs.
-Always count (1-2-3) out loud and tell them how to position or move
themselves.
a. If the patient is weaker on one side, have them put their weight on the stronger side
before standing up.
b. Turn your entire body rather than pivoting to avoid hurting your back
-When re positioning the patient, you has always make sure to avoid hurting your wrists
,-Make sure the bed is at your hip level.
-If the patient is too heavy, ask for help.
How do we measure syringe gauge sizes? - ANS-THE SMALLER THE NUMBER, THE
BIGGER THE DIAMETER (GAUGE) OF NEEDLE
IV site inspection - ANS-look atthe IV catheter insertion site for redness, swelling, or
bruising. Redness can indicate irritation, inflammation, infection, or thrombus formation.
... Assess the condition of the transparent catheter dressing. The dressing should be
clean, dry, and adhere securely to the skin around the IV catheter insertion site
Intravenous sites - ANS--Common sites:
Dorsal area of the hands
Forearm
-Antecubital Fossa
Uncommon sites
Dorsal area of feet (needs an order)
Cephalic (infants)
Intravenous syringe length - ANS-Neonate and Infants:
19 mm (<1 inch)
Child and Older Adult:
1 inch
Adults:
1-1 ¼ inches
Intravenous guages - ANS-Neonate and Infants:
24-26 G
Child and Older Adults:
22 G
Adults:
18, 20, and 22 G
, Intravenous angle - ANS-*** Angle depends upon where the IV insertion site is.
(8) Rights of administration - ANS-1. Right Patient
2. Right Medication
3. Right Dose
4. Right Route
5. Right Time
6. Right Reason
7. Right Response
8. Right Documentation
(Parenteral routes of medication administration)
Intradermal - ANS-1. Medication is injected in the dermis (just below the epidermis)
2. Must form a "wheal"
3. Longest absorption time for parenteral routes
4. Dosage is usually less than 0.5mL
(Parenteral routes of medication administration)
Subcutaneuos - ANS-1. Injected in the adipose tissue
2. Absorption is slow to the capillaries
3. Dosage is usually no more than 1mL
4. Inject slowly so medication can disperse (10 sec/ 1 mL)
(Parenteral routes of medication administration)
Intramuscular - ANS-Injected in the muscle
Faster onset than intradermal and subQ
(Parenteral routes of medication administration)
Intravenous - ANS-Injected in the vein
Fastest absorption which also means fastest reaction to medication
(Parenteral routes of medication administration) (7)
Transdermal - ANS-1. Applied topically on the skin using a patch that contains
medication
2. Remove old patch and wipe of remnants of medication
3. Clean and dry the area
