Exam 1 RNSG 1216 Questions & Answers Correct 100%

What are the SIX rights of medication administration? - Answer 1.)patient 2,) medication 3.)dose 4.)time 5.)route 6.)Documentation How much volume can the nurse administer in different muscles for IM injections? Deltoid - Answer Deltoid: up to 2 mL with a 1-in to 1-1/2 in pre schoolers get 0.5 to 1 inch Which route of medication has the fastest absorption? - Answer Intravenous How much volume can the nurse administer in Ventrogluteal muscles for IM injections? preferred site for infants - Answer 1.) 3 mL of medication with an 18- to 25-gauge, 1½-inch for oil based or viscous solutions 2.) Use a 22- to 27-gauge, ⅝- to 1-inch needle for aqueous solutions. 3.)infants get 1mL with 1 inch needle 4.) smaller infants get 0.5 mL with 5/8 needle How much volume can the nurse administer in different muscles for IM injections? Vastus Lateralis: - Answer adult 3 mL 18- to 25-gauge, 1½-inch oil & V (adult 22- to 27- gauge AS) infant1 mL with a ½- to 1-inch, 21- to 25-gauge smaller 0.5 mL with a ⅝-inch, 21- to 25-gauge toddler 2 mL with a 1-inch, 21- to 25- 3 and older 2 to 3 mL with a ½- to 1-inch, 21- to 25-gauge What is the max volume to be administered intramuscularly? - Answer Normal adult: 2-5mL Children, older adults, and thin patients: 2mL Small children/older infants: 1mL Smaller infants: 0.5mL What is the proper way to administer an Intramuscular injection? - Answer Palpate bony land marks. Use Z-track Method. Gauge: usually 22-27 Needle Length: 1-1.5 inches Angle: 90 degrees Gauge and Needle Length choice for IM injections must be made based on: - Answer Size of the muscle Thickness of adipose tissue at injection site Volume to be administered Injection Technique Depth below the muscle surface to be injected What are all the muscles that can be used for IM injections? - Answer Deltoid Ventrogluteal Vastus Lateralis What is the proper way to administer a subcutaneous injection? - Answer Pinch injection site as needle is inserted. Rotate sites at least 1 inch away from previous site. Gauge: 31-25 Needle Length: 3/8 to 5/8 inch Angle: 45 or 90 degrees If you can grasp 2 inches of tissue, insert the needle at what angle? - Answer 90 degrees If you can grasp 1 inch of tissue, insert the needle at what angle? - Answer 45 degrees What is the max volume for subcutaneous injections? - Answer adults: 0.5-1.5 mL children: 0.5mL or less Where are the proper locations to give a subcutaneous injection? - Answer Outer posterior aspect of the upper arms Abdomen from below the costal margins to the iliac crests (fastest absorption) Anterior aspects of the thighs Scapular areas of the upper back Upper ventral/dorsal gluteal areas What is the proper way to administer an intradermal injection? - Answer injected into dermis where blood supply is reduced and medication absorption occurs SLOWLY Gauge: 27-25 Needle Length: 1/2 to 5/8 inch Angle: 15 degrees Where are the proper locations to give an intradermal injection? - Answer site needs to be lightly pigmented, free of lesions, and relatively hairless to allow you to easily assess for changes in color and tissue integrity. inner forearm upper back What are the principles and mechanisms of thermoregulation? - Answer regulation of balance between heat lost and heat produced Neural and Vascular Control Heat Production Heat Loss Neural and Vascular Control (mechanism of thermoregulation) - Answer hypothalamus controls heat loss and heat production Anterior hypothalamus controls? - Answer heat loss Posterior hypothalamus controls? - Answer heat production What are nursing measures that promote heat loss? - Answer antibiotics are administered to destroy pyrogenic bacteria 2.)tepid sponge baths bathing with alcohol water solutions, applying ice packs to axillae and groin areas, water cooled blankets What are nursing measures that promote heat conservation? - Answer removing wet clothing replacing with dry clothes wrapping the patient in blankets move them to a warm room. What are physiological changes associated with fever? - Answer When trying to reach a new set point, the patient experiences chills, shivering, and feeling cold. This phase resolves when a new set point (high temp) is achieved. The plateau: chills subside and the person feels warm and dry If new set point is "overshot", set point drops which initiates heat loss responses. Skin becomes warm and flushed (vasodilation) Diaphoresis assists in evaporative heat loss How do you assess body temperature? - Answer taking an oral, rectal, temporal, axillary and tympanic temperature with a thermometer How do you assess pulse? - Answer -Pulse is most easily felt at a pulse point where a major artery lies near the surface and can be pressured gently against a bone or solid organ -If a pulse is present you will need to palpate (feel) the pulse What are some sites that pulse can be taken in the upper extremity? - Answer temporal carotid apical brachial radial ulnar What are some sites that pulse can be taken in the lower extremity? - Answer femoral popliteal posterior tibial dorsalis pedis How do you assess respirations? - Answer after taking your pulse rate begin to count the respirations of the patient for a full minute How do you assess oxygen saturation? - Answer place a pulse oximeter on the patients finger earlobe or bridge of adults nose or the sole of infants foot How do you assess blood pressure? - Answer use a sphygmomanometer and a stethoscope to take the blood pressure use the two step process by finding auscultatory gap then going 30 units of pressure up and taking the blood pressure What is the physiology of normal regulation of blood pressure? - Answer cardiac output peripheral resistance blood volume viscosity elasticity