NUR 172 QUIZ #3 FINAL EXAM
QUESTIONS AND ANSWERS
Fluid Volume Deficit - ANSWER-Cause: Blood Loss, Fluid Loss, burns, NG suction,
third space fluid shifts
S/S: Increased HR, low BP, tenting, low urine output, dry lungs, weight loss, flat
jugular veins
Tx: IV fluid, HOB flat (=increased BP), strict I&O, hourly urine output (greater than 30
hr x 2 hours = ATN), blood products
Dextrose - ANSWER-is glucose
it gives the patient energy
it reduces catabolism of protein
is irritating to the veins
should not be used to administer blood products
is not compatible with all solutions or medication
What is the #1 National Safety Patient Goal - ANSWER-wash your hands
Phlebitis - ANSWER-inflammation of a vein
can lead to a local infection or a BSI
GRADE-
0- None
1- Red
2- +red, sore edema
3- +red streak, palpable cord
4-+pus (purulent drainage)
phlebitis treatment - ANSWER-#1 get IV out
warm compress, elevate the area, give tylenol, determine cause and treat
Start new IV in a different extremity
Mechanical phlebitis - ANSWER-caused by too large of a catheter in a small vein
causing irritation of the vein
chemical phlebitis - ANSWER-occurs when a vein becomes inflamed by irritating or
vesicant solutions or medications
bacterial phlebitis - ANSWER-Poor hand hygiene, lack of aseptic technique, failure
to check equipment, or recognize early signs of phlebitis
Often occurs during insertion
S/S of BSI/Sepsis? - ANSWER-fever
chills
nausea
malaise
hypotension
profuse cold sweat
, tachycardia
evidence of decreased perfusion
change in mental status
hypoxia
elevated lactate levels
diminished urine output
elevated WBC
Preferred antiseptic for IV site? - ANSWER-chlorahexadine
chloraprep
CVC should be changed? - ANSWER-every 7 days or every 48 hours with gauze
Central Line Bundle - ANSWER-Hand hygiene
Sterile barrier
Barrier precautions (wears cap, mask, sterile gloves, gown)
chlorahexadine skin antisepsis
Avoid femoral site
Daily review of line necessity with prompt removal if line is unnecessary
Some NPSG guidelines - ANSWER-Joint commission med safety: 3 med checks 2
pt identifiers
insulin and Heparin check with another nurse
labeling, communication, readback, delegation
Can you give potassium IV push - ANSWER-No
LPN scope of practice? - ANSWER-no pediatric IV, No IV push, No IVPB with
Zantac, only antiinfectives
Airborne precautions - ANSWER-TB, measles, chicken pox
Single pt room, negative pressure room, N95 mask
Droplet precautions - ANSWER-mumps, rubella, influenza, adenovirus, rhinovirus,
pertussis
eye protection, mask, private room, pt wear mask if they leave their room
contact precautions - ANSWER-VRE, Cdiff, norovirus, RSV
gloves, gown
(Don PPE when entering the room and discard before exiting the room)
BUN - ANSWER-10-20
Creatinine - ANSWER-0.6-1.2
Levofloxacin - ANSWER-Levaquin
Increased risk of achilles tendon rupture especially if patient is also taking steroids
increased potassium - ANSWER-hyperkalemia
Tx: Kayexelate
QUESTIONS AND ANSWERS
Fluid Volume Deficit - ANSWER-Cause: Blood Loss, Fluid Loss, burns, NG suction,
third space fluid shifts
S/S: Increased HR, low BP, tenting, low urine output, dry lungs, weight loss, flat
jugular veins
Tx: IV fluid, HOB flat (=increased BP), strict I&O, hourly urine output (greater than 30
hr x 2 hours = ATN), blood products
Dextrose - ANSWER-is glucose
it gives the patient energy
it reduces catabolism of protein
is irritating to the veins
should not be used to administer blood products
is not compatible with all solutions or medication
What is the #1 National Safety Patient Goal - ANSWER-wash your hands
Phlebitis - ANSWER-inflammation of a vein
can lead to a local infection or a BSI
GRADE-
0- None
1- Red
2- +red, sore edema
3- +red streak, palpable cord
4-+pus (purulent drainage)
phlebitis treatment - ANSWER-#1 get IV out
warm compress, elevate the area, give tylenol, determine cause and treat
Start new IV in a different extremity
Mechanical phlebitis - ANSWER-caused by too large of a catheter in a small vein
causing irritation of the vein
chemical phlebitis - ANSWER-occurs when a vein becomes inflamed by irritating or
vesicant solutions or medications
bacterial phlebitis - ANSWER-Poor hand hygiene, lack of aseptic technique, failure
to check equipment, or recognize early signs of phlebitis
Often occurs during insertion
S/S of BSI/Sepsis? - ANSWER-fever
chills
nausea
malaise
hypotension
profuse cold sweat
, tachycardia
evidence of decreased perfusion
change in mental status
hypoxia
elevated lactate levels
diminished urine output
elevated WBC
Preferred antiseptic for IV site? - ANSWER-chlorahexadine
chloraprep
CVC should be changed? - ANSWER-every 7 days or every 48 hours with gauze
Central Line Bundle - ANSWER-Hand hygiene
Sterile barrier
Barrier precautions (wears cap, mask, sterile gloves, gown)
chlorahexadine skin antisepsis
Avoid femoral site
Daily review of line necessity with prompt removal if line is unnecessary
Some NPSG guidelines - ANSWER-Joint commission med safety: 3 med checks 2
pt identifiers
insulin and Heparin check with another nurse
labeling, communication, readback, delegation
Can you give potassium IV push - ANSWER-No
LPN scope of practice? - ANSWER-no pediatric IV, No IV push, No IVPB with
Zantac, only antiinfectives
Airborne precautions - ANSWER-TB, measles, chicken pox
Single pt room, negative pressure room, N95 mask
Droplet precautions - ANSWER-mumps, rubella, influenza, adenovirus, rhinovirus,
pertussis
eye protection, mask, private room, pt wear mask if they leave their room
contact precautions - ANSWER-VRE, Cdiff, norovirus, RSV
gloves, gown
(Don PPE when entering the room and discard before exiting the room)
BUN - ANSWER-10-20
Creatinine - ANSWER-0.6-1.2
Levofloxacin - ANSWER-Levaquin
Increased risk of achilles tendon rupture especially if patient is also taking steroids
increased potassium - ANSWER-hyperkalemia
Tx: Kayexelate
