Exam (elaborations)
NUR 282/283 Blackburn #comp 1 #comp 2 #comp 3- Galen College
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NUR 282/283 Blackburn #comp 1 #comp 2 #comp 3- Galen College/NUR 282/283 Blackburn #comp 1 #comp 2 #comp 3- Galen College
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Highlighted orange=was on comp #1Highlighted purple= was on comp #2
Highlighted pink= comp #3
Week 1
PACU post-op bowel resection with a new colostomy for history of Crohn’s
disease:
Entry level nurses should know routine colostomy care/teaching as noted in IGGY book.
The first action required when receiving a patient is confirming patient identification.
Crohn’s Disease (CD) is a chronic inflammatory disease of the small intestine, colon, or
both. Same as Ulcerative Colitis (UC), Crohn’s is a recurrent disease with periods of
remissions and exacerbations.
What are important assessment points for a patient with Crohn’s disease and what
discharge teaching would you provide regarding management of Crohn’s disease?
See page 1146-1149 in IGGY 10
th
edition. Assessment
points include monitoring for
manifestations of peritonitis, small bowel obstruction, and nutritional/fluid imbalances.
These patients are at high risk for malnutrition, dehydration, and hypokalemia. Monitor
output and daily weights as a decrease in either could indicate dehydration, which means
additional fluids are a priority.
Nutritional supplements may be needed in addition to a high-calorie, high-protein,
high-vitamin, low-fiber diet. TPN or TEN may be needed for a patient with Crohn’s while
hospitalized. 3,000 calories per day is indicated. A low-fiber diet is indicated for patients
with Crohn’s as well as other GI diseases such as diverticulitis.
Teaching should include to
avoid GI stimulants such as alcohol and caffeinated beverages.
Vit B12 injections may be
needed. Fistulas are common with exacerbations and teaching for wound care is indicated
if the patient has this complication.
Dr. Blackburn
Post-op abdominal surgery patients often have an NG placed for decompression of the
stomach. This includes post-op colorectal cancer patients, who may also have a colostomy
depending on procedure performed. Entry level nurses should know care of patients with
an NG tube. Try this practice question and provide a rationale for your response:
A nurse is preparing to inject heparin subcutaneously for a client who is postoperative.
Which of the following actions should the nurse take?
1.
Use a 22 gauge needle.
2.
Select a site on the client’s abdomen.
3.
Use the Z-track technique to displace the skin on the injection site.
4.
Observe for bleb formation to confirm proper placement.
Answer: 2
1.
Not correct. For a subcutaneous injection, use a 25 to 27 gauge needle.
2.
CORRECT:
For a subcutaneous injection, select a site
that has an adequate
fat-pad size (abdomen, upper hips, lateral upper arms, thighs). For a
subcutaneous injection, pinch a section of skin or pull the skin taut using the
thumb and index finger. When administering enoxaparin do not expel the air
bubble in the syringe. It’s nitrous oxide and allows the client to receive all the
medication during the injection.
3.
Not correct.
The Z-track technique for IM injections
is used for medications
that are irritating to the tissue, which includes pulling the skin and tissue taut.
Firmly hold in this position while the needle is inserted and the medication is
injected.
Iron dextran is a medication administered
using the Z-track technique.
Some facilities require the Z-track technique for all IM injections. For IM,
solution volume is usually 1 to 3 mL. The ventrogluteal site is preferable for IM
injections and for injecting volumes exceeding 2 mL. If more than 3 mL is
needed for the ordered dose, the medication will need to be given in two
separate injections. The deltoid site has a smaller muscle mass and can only
accommodate up to 1 mL of fluid.
4.
Not correct. Bleb formation confirms injection into the dermis, not into
subcutaneous tissue. Intradermal are used for tuberculin (Mantoux) testing or
checking for medication or allergy sensitivities. Use small amounts of solution
(0.01 to 0.1 mL) in a tuberculin syringe with a fine-gauge needle (26 to 27
gauge) in lightly pigmented, thin-skinned, hairless sites (the inner surface of the
mid-forearm or scapular area of the back) at a 5° to 15° angle. Insert the needle
with the bevel up. A small bleb should appear. Do not massage the site after
injection. A Mantoux (TB) test should be read 2-3 days after administration. A
positive response indicates the client may have been exposed to the TB
bacteria or dormant disease. 10mm or > induration is considered positive for
exposure to or infection with TB. An induration of more than 5 mm is considered positive for individuals with decreased immunity. Less than 5mm
diameter induration is considered negative.
Further teaching: using a 22 g for a tb test
Dr. Blackburn
Thanks for your response.
Crohn’s disease increases
the risk for colon cancer as does IBD
and history of polyps (polyposis).
You previously
learned about risk factors and teaching
for colon cancer.
Topic- angina:
Try this practice question and provide a rationale for your response:
A nurse is teaching a client who has angina pectoris and is learning how to treat acute
anginal attacks. The clients asks, “What is my next step if I take one tablet, wait 5 minutes,
but still have anginal pain?” Which of the following responses should the nurse make?
1.
“Take two more sublingual tablets at the same time.”
2.
“Call the emergency response team.”
3.
“Take a sustained release nitroglycerin capsule.”
4.
“Wait another 5 minutes then take a second sublingual tablet.”
Answer: 2 is correct.
1.
The client should not take two sublingual doses at once.
2.
CORRECT:
The next step is to call 911 and then take
a second sublingual tablet.
If the first tablet does not work, the client might be having a myocardial
infarction. The client can take a third tablet if the second one has not relieved
the pain after waiting an additional 5 minutes.
3.
Taking an oral sustained-release capsule is not indicated to treat an acute
anginal attack.
4.
The client should not wait an additional 5 minutes. The client should call 911
because they might be having a myocardial infarction.
Teaching for angina episodes:
●
Stop activity. Sit or lie down.
●
Immediately put one sublingual tablet under the tongue and let it dissolve. Rest
for 5 min.
●
If pain not relieved by first tablet, call 911, then take a second tablet.
●
After another 5 min, take a third tablet if pain is still not relieved. Do not take
more than three sublingual tablets. ●
If using nitroglycerin translingual spray, one spray substitutes for one sublingual
tablet when treating an anginal attack.
●
Maintain a fresh supply of sublingual nitroglycerin. Store nitroglycerin in a
light-resistant container.
They will maintain potency
up to five months. After
five months the unused tablets should be discarded.
Dr. Blackburn
hyperbilirubinemia and mom tested negative for rubella titer during pregnancy:
Topic-Phototherapy:
Hyperbilirubinemia is an elevation of serum bilirubin levels resulting in jaundice. Jaundice
normally appears on the head (especially the sclera and mucous membranes), and then
progresses down the thorax, abdomen, and extremities. When phototherapy is
implemented the newborn’s bilirubin should start to decrease within 4 to 6 hr after
starting treatment.
You noted a few, what other nursing interventions (best practices) are appropriate when
caring for an infant receiving phototherapy?
Nursing care for the infant receiving phototherapy includes:
●
Keep the newborn undressed. For a male newborn, a surgical mask should be
placed (like a bikini) over the genitalia to prevent possible testicular damage
from heat and light waves. Be sure to remove the metal strip from the mask to
prevent burning.
●
Maintain an eye mask over the newborn’s eyes for protection of corneas and
retinas.
●
Remove the newborn from phototherapy every 4 hr
○
Unmask the newborn’s eyes for feedings, checking for inflammation
or injury.
●
Avoid applying lotions or ointments to the skin because they absorb heat and
can cause burns.
●
Reposition the newborn every 2 hr to expose all of the body surfaces to the
phototherapy lights and prevent pressure sores.
●
Check the lamp energy with a photometer following facility protocol.
●
Turn off the phototherapy lights before drawing blood for testing.
●
Monitor for adverse effects of phototherapy.
○
Dehydration: poor skin turgor, dry mucous membranes, decreased
urinary output
○
Elevated temperature
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