Nursing 400 Final Exam combined |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
study guides exam with correct |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answers
Dysphagia - correct answer✔✔inability to swallow or difficulty in swallowing |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2 key points about Dysphagia - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔Nasogastric tube |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Irrigation tray - 60 ml syringe |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,A bottle of sterile water
|||\\\ |||\\\ |||\\\ |||\\\
lubricant
NGT insertion - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔-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? - correct answer✔✔THE SMALLER THE NUMBER,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
THE BIGGER THE DIAMETER (GAUGE) OF NEEDLE
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
IV site inspection - correct answer✔✔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 - correct answer✔✔-Common sites: |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Dorsal area of the hands |||\\\ |||\\\ |||\\\ |||\\\
Forearm
-Antecubital Fossa |||\\\
Uncommon sites |||\\\
Dorsal area of feet (needs an order) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Cephalic (infants) |||\\\
Intravenous syringe length - correct answer✔✔Neonate and Infants: |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
19 mm (<1 inch)|||\\\ |||\\\ |||\\\
Child and Older Adult: |||\\\ |||\\\ |||\\\
1 inch
|||\\\
study guides exam with correct |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
answers
Dysphagia - correct answer✔✔inability to swallow or difficulty in swallowing |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
2 key points about Dysphagia - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔Nasogastric tube |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Irrigation tray - 60 ml syringe |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
,A bottle of sterile water
|||\\\ |||\\\ |||\\\ |||\\\
lubricant
NGT insertion - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔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 - correct answer✔✔-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? - correct answer✔✔THE SMALLER THE NUMBER,
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
THE BIGGER THE DIAMETER (GAUGE) OF NEEDLE
|||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
IV site inspection - correct answer✔✔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 - correct answer✔✔-Common sites: |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Dorsal area of the hands |||\\\ |||\\\ |||\\\ |||\\\
Forearm
-Antecubital Fossa |||\\\
Uncommon sites |||\\\
Dorsal area of feet (needs an order) |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
Cephalic (infants) |||\\\
Intravenous syringe length - correct answer✔✔Neonate and Infants: |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\ |||\\\
19 mm (<1 inch)|||\\\ |||\\\ |||\\\
Child and Older Adult: |||\\\ |||\\\ |||\\\
1 inch
|||\\\
