NU 311 Clinical Nursing Skills Final Exam Questions And Answers A+ Guaranteed Pass!

NU 311 Clinical Nursing Skills Final Exam Questions And Answers A+ Guaranteed Pass! Infusion Nursing Society (INS) standards for reducing infection related to IV Therapy - ANS-• Assess the VAD catheter-skin junction site and surrounding area for redness, tenderness, swelling, and drainage by visual inspection and palpation through the intact dressing. Assess short-peripheral catheters minimally at least every 4 hours or more if clinically indicated and daily for outpatient or home care patients. CVADs should be assessed at least daily. • Change the dressing immediately to assess, clean, and disinfect the site in the event of drainage, tenderness, other signs of infection or if dressing becomes loose or dislodged. • Perform hand hygiene before placing and providing any VAD-associated interventions. • Perform dressing changes at a frequency based on the type of catheter and dressing. Short-peripheral catheter dressings are changed if the dressing becomes damp, loosened, and/or visibly soiled; if there is blood or drainage under the dressing; and at least every 5-7 days. Change CVAD dressings at least every 5-7 days for TSM dressings and at least every 2 days for gauze dressings that cover a catheter site or are under a TSM. • Use approved antiseptic agents before venipuncture and when performing skin antisepsis. The preferred skin antiseptic is 0.5% chlorhexidine gluconate (CHG) in alcohol solution. Tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may be used if CHG solution is contraindicated. • Allow skin antiseptic to dry fully before dressing placement; alcoholic chlorhexidine solutions, for at least 30 seconds; iodophors, for at least 1.5-2 minutes. • Use catheter stabilization device that allows visual inspection of access site. • Use vigorous mechanical scrubbing methods when disinfecting needleless connectors before each access using 70% isopropyl alcohol, iodophors, or 0.5% chlorhexidine alcoholic solution. Disinfect before each access when multiple accesses are req The Needle Safety and Prevention Act of 2001 - ANS--Mandates that health care agencies use safe needle devices and manufactured needleless systems to reduce needlestick injury. Systems with catheter ports or Y-connector sites are designed to contain a needle housed in a protective covering. Needleless infusion lines allow a direct connection with the IV line via a recessed connection port, a blunt-ended cannula, or shielded-needle device, eliminating the risk for exposure to an IV needle. Recommendations for the Prevention of Needlestick Injuries - ANS-• Avoid using needles when effective needleless systems or sharps with engineered sharps injury protection (SESIP) safety devices are available. • Do not recap any needle after medication administration. • Plan safe handling and disposal of needles before beginning a procedure. • Immediately dispose of needles, needleless systems, and SESIP into puncture-proof and leak-proof sharps disposal containers. • Maintain a sharps injury log that reports the following: type and brand of device involved in the incident; location of the incident (e.g., department or work area); description of the incident; and privacy of the employees who have had sharps injuries. • Attend education offerings on bloodborne pathogens and follow recommendations for infection prevention, including receiving the hepatitis B vaccine. • Participate in the selection and evaluation of SESIP devices with safety features within your agency whenever possible. Isotonic solutions - ANS-•Dextrose 5% in water -Dextrose is quickly metabolized, leaving free water to be distributed evenly in all fluid compartments so it acts like a hypotonic solution •0.9% sodium chloride† (NS) •Lactated Ringer's‡ -Has multiple electrolytes Hypotonic solutions - ANS-•0.45% sodium chloride (half NS) •0.33% sodium chloride (one-third NS) Hypertonic solutions - ANS-•Dextrose 10% in water •Dextrose 50% in water •3%-5% sodium chloride •Dextrose 5% in 0.9% sodium chloride •Dextrose 5% in 0.45% NaCl sodium chloride •Dextrose 5% in Lactated Ringer's Prepare IV tubing and solution for continuous infusion. - ANS-a. Check IV solution using six rights of medication administration and review label for name and concentration of solution, type and concentration of any additives, volume, beyond-use and expiration dates, and sterility state. If using bar code, scan code on patient's wristband and then on IV fluid container. Be sure that prescribed additives such as potassium and vitamins have been added. Check solution for color and clarity. Check bag for leaks. b. Open IV infusion set, maintaining sterility. NOTE: EIDs sometimes have a dedicated administration set; follow manufacturer's instructions. c. Place roller clamp about 2 to 5 cm (1 to 2 inches) below drip chamber and move roller clamp to "off" position. d. Remove protective sheath over IV tubing port on plastic IV solution bag or top of IV solution bottle while maintaining sterility. e. Remove protective cover from IV tubing spike while maintaining sterility of spike. Insert spike into port of IV bag using a twisting motion. If solution container is glass bottle, clean rubber stopper on glass bottled solution with antiseptic swab and insert spike into rubber stopper of IV bottle. Bottles require vented tubing. f. Compress drip chamber and release, allowing it to fill one-third to one-half full g. Prime air out of IV tubing by filling with IV solution: Remove protective cover on end of IV tubing (some tubing can be primed without removing protective cover) and slowly open roller clamp to allow fluid to flow from drip chamber to distal end of IV tubing. If tubing has a Y connector, invert Y connector when fluid reaches it to displace air. Return roller clamp to "off" position after priming tubing (filled with IV fluid). Replace protective cover on distal end of tubing. Label IV tubing with date according to agency policy and procedure. h. Be certain that IV tubing is Starting and IV Implementation - ANS-1. Swabs injection cap and primes saline lock leaving syringe attached. Loosens protector cap (maintain sterility). Removes over needle catheter (ONC) and transparent dressing from wrappers. 2. Applies tourniquet 4 - 6 inches above selected site (check radial pulse) and assesses vein for appropriateness. If need additional prep time may release tourniquet temporarily. 3. Applies clean gloves 4. Moves saline lock nearby, on over-the-bed table, maintaining in sterile package. 5. Cleanses site with Chlorhexidine - using friction horizontal, vertical, and circular. Cleanse for at least 30 seconds and allow site to completely dry. Do not touch site! 6. Performs venipuncture: Anchors vein 1.5-2 inches below insertion site by gently stretching the skin against the direction of insertion site. Be sure not to touch the cleansed site or allow the ONC to touch the anchoring thumb; advises patient to remain still and that there will be a quick stick; inserts ONC with bevel up at 10-30 ° angle in the direction parallel to the vein. 7. Observes for blood return. Lowers needle and advances 1/4 inch. 8. Continues to hold skin and advances catheter all the way to hub without advancing the stylet/needle. Stabilizes catheter with one hand and releases tourniquet with the other hand. (Push and pop) 9. Apply gentle/firm pressure 1 1⁄4 inch above insertion site and removes stylet/needle of ONC. Disposes of stylet in sharps container if close or temporarily places on bedside table away from patient. 10. Removes cap and maintains sterility; quickly connects end of saline lock to catheter. Secures temporarily with tape. 11. Reassesses for blood return with gentle aspiration and flushes the vein with remaining saline, observing site for swelling. Removes flush syringe and places in sharps container. 12. Applies a sterile transparent dressing Continues....