REXPN 2
Circulatory overload transfusion reaction - answer when too much volume or rate, can
lead to pulmonary edema, increase risk with those with cardiovascular or kidney
problems
Cough, dyspnea, pulmonary congestion, hypertension, tachycardia, bounding pulse,
distended jugular veisn, restlessness and confusion - answer what are some
manifestations of circulatory overload blood tx reaction
Slow or stop infusion as ordered, elevate clients head, monitor for resp distress, monito
I and o, admin diruetics - answerwhat should you do with circulatory overload blood tx
reaction
Tracheostomy tube - answertube inserted right into trachea via an incision made into
neck
Endotracheal tube, - answertube inserted into trachea via mouth or nose
Relieves obstruction, route for mechanical ventilation, secretion removal and protects
airway from aspiration - answerwhy are there respiratory tubes
Maintain placement, patency, cuffinflation, oxygenation, oral and skin care - answer
Well established - answerwhat kind of trach can RPN deal with
Ascultate for bilateral breath sounds, observe symmetric chest wall movement, chest
tube placement should be verified by x ray immediately after insertion, adnominal
distention should be observed - answerwhat helps maintain tube placement
Tracheal airway suctioning - answerextends to lower airway and is intended to remove
resp secretions and maintain airway, this is sterile
Decreased o2 sat, anxiousness, tachypnea, gurgling, wheezing, pallor, cyanosis,
fatigue decreased oc - answerindications for tracheal suctioning
Conduct assessment, comfirm patient id, explain to client, set suction to 100-120,
hyperoxygenate with 100 oxygen 30-60 secondsp prior, use aspetic technique, apply
goggles mask and sterile gloves, insert into tube until resistance is felt then pull back 1
cm, suction slowly withdrawing and roatete the cath for no more than 10 seconds,
reapply oxygen inbetween and allow rest, rinse catheter and connect with normal saline
if prescribed - answerhow to tracheal suctioning
,Cuff inflation - answerperform hand hygine and apply clean gloves and face shield,
suction secretions, connect syringe to balloon port, place stethescop on sternal notch
on tracheal and listen for air leak on inspiration, if no leak is aculated remoa la air and
reinfflate as prescrived, if no excessive leak is heard ,slowly add air until leak is minimal,
remove equipemtn ad reposition client to promote comfort, how to inflate a cuff for trach
Unlock and remove inner cannula, immerse non disposalve cannulas in sterile solution,
clean inside and out and dry, replace tracheal oxygen mask as need to prevent hypoxia,
se forcepts to remove soiled ressings around tbe, assess and clean the stoma site, use
gauze pad soaked in sterile solution to remove dried secretons, apply new trachesomty
dressing, replace ties, two fingers should be able to fit between the ties - answerhow to
do trachesomty care
Admin suction, remove old tape and device, remove secretions and provide oral and
nasal care, secure endotracheal tube, remove , clean and reinsert oral airway -
answerhow to do endotracheal tube care
Airway obstruction, stoma inection, haemorrhage, tube displacement, decannculation,
aspiration, tube occlusion - answerwhat are some complications of trachesomty
Less than 7 days old contact physican and maintain ventilation using ambu bag, if 7
days old or greater, call for assistance and replace dislodge cannula, remove inner
cannula and insert obturatory, then gently reinsert the tube at 45 degree angle using
lubricant, if cannot be replaced, assess for resp distress and place in semi fowlers
postion - answerhow to help with accidental decanncualtion
Acidental extubation - answerclient is able to talk or yello still, activationing of ventilator
alarms, diminished breath sounds, resp distress, gastric distention, stay with client and
call for help, maintain and support ventilationg use a bag valve mask and oxygen as
required, prepare for reintubation
Aspiration - answersalivation, client positioning, trachesopahgeal fistula, improper cuff
inflation, preventative measures include frequent suctioning, prevent omitting, maintain
head of bed at 30-45 degrees
Ng tube - answerflexible plastic tubei nserte through the nostrils, down the nasopharynx
and into the stomach, this is used to deiver nutrietns or to remove gastric contents
Gastrostomy - answera stoma created from the abdominal wall into the stomach
thourhg which a short feeding tube is surgicall inserted
PEG - answertubes are placed endoscopically
NG tube insertion - answerHCP order is required, assess the condition of nares and oral
cavities, assess the client for adominadistention, pain, explain procedure and verify
,order, perform hand hygiene, position client in high fowlers position, measure and
moniter vital signs,determine length of tube, test tube for patency and cut tape, lubricate
end of tube and apply cean gloves, insert tuve through the nostril with curved point
poiting down, have the client swallow, assess correct placement of NG, may be gastric
contents esting or x ray
Total enteral nutrition - answerspecialized feeding through a feeding tube to supplement
oral intake or provide total nutritional support,
4 hours and after before and after intermitten feedings and medications - answerhow
often should you irrigate a feeding tube
30 ml - answerhow may mls do you need to flush the length of the tube
diarrhea, vomiting, dehydration - answerwhat are some complications of feeding tubes
feeding too fast, medications, lack offiber and contaminaniation - answerwhat causes
diarrea in feeding tube situations
improper tube placement, delayed gastric emptying, positioning - answerwhat are the
causes of vomiting with an ng tube
high residual volume - answerwhen do you hold your ng tube feedings
Refeeding syndrome - answera metabolic complication occurring when the refeeding of
a client in the starvation state, resumption of insulin production causes the uptake of
glucose and electrolytes from the blood stream depleting serum levels, this resultsin
fluid retention, electrolyte imbalances
Shallow resps, neurological disturbances, weaknesss, acute confusion, seizures,
bleeding and cardiac dysrhythmias - answerwhatare the manfiestations of refeeding
syndrome
Check for infection, irrigation sets should be labeled and only used for 24 hours, only do
four hours of feed at a time, maintain semi fowlers, monitor weght, and I and and do I
and O's - answerhow to care for a feeding tube
Urinary cathertization - answerused to support urinary elimination in clients who are
unable to void naturally, acute retention, accurate urine ouput measurement in a
critically ill client, enahce healing healing of open perineal wounds, prolonged bedrest,
terminal illness or sever eimpairemnt
Urinary catheter insertion for female - answeron back with knees flexed and thighs
relaxed, allowing hips to rotate
, Male client urinary catherization insertion - answersupine position, egs extended and
slightly abducted
Smallest - answerwhat do yo alwaus use for cathether
Urinary cathether insertion procedure - answerDrape client, preventing unnecessary
exposure of body parts 2. Apply clean gloves and wash perineal area 3. Open
catheterization kit and set up sterile field and supplies, don sterile gloves 4. Drape client
with sterile drapes, setting up equipment as needed 5. Clean urethra using antiseptic
cleanest to dirtiest (working outward) 6. Female catheter insertion: slowly and gently
insert, asking client to bear down, until urine appears 7. Male catheter insertion: lift
penis to 90 degrees, ask client to bear down and advance catheter until urine flows 8.
Allow urine to drain, and collect a sample if needed 9. Inflate balloon by injecting total
amount of prefilled syringe 10. Secure and label catheter tubing, position drainage bag
lower than bladder
Catheter associated urinary tract infections - answerassociate with inceased morbidity,
mortality, hospital cost and length of stay
Fever and chills, lethargy, abdominal and back pain,urgency and frequeny of urination,
painful urination, hematuria, mental status changes - answerwhat are some
manifestations of UTI
Sterile technique, use narrowest possible tube size, dialy cleansing, sexure the catheter
and ensure no blockages are present - answerhow do you prevent an UTI
Semi fowlers - answerwhat positiong should a client with a mastectomy be in with
affected arm eleated to prevenedema
Lithotomy position - answerwhat position should perineal and vaginal procedures be in
Semi fowlers - answerwhat position should a client with a thyroidiectomy be in, with
pillows to suppor the head,
Elevate with semi fowlers - answerwhat position should you client be in with
hypophystectomy
Lateral side lying - answerwhat posion should some with their haemorrhoids removed
be in
Reverse trendelenburg's position - answerwhat position should some with GERD be in
Supin with right arm raised behind head - answerwhat position should someone with a
liver bipsoy be in
Circulatory overload transfusion reaction - answer when too much volume or rate, can
lead to pulmonary edema, increase risk with those with cardiovascular or kidney
problems
Cough, dyspnea, pulmonary congestion, hypertension, tachycardia, bounding pulse,
distended jugular veisn, restlessness and confusion - answer what are some
manifestations of circulatory overload blood tx reaction
Slow or stop infusion as ordered, elevate clients head, monitor for resp distress, monito
I and o, admin diruetics - answerwhat should you do with circulatory overload blood tx
reaction
Tracheostomy tube - answertube inserted right into trachea via an incision made into
neck
Endotracheal tube, - answertube inserted into trachea via mouth or nose
Relieves obstruction, route for mechanical ventilation, secretion removal and protects
airway from aspiration - answerwhy are there respiratory tubes
Maintain placement, patency, cuffinflation, oxygenation, oral and skin care - answer
Well established - answerwhat kind of trach can RPN deal with
Ascultate for bilateral breath sounds, observe symmetric chest wall movement, chest
tube placement should be verified by x ray immediately after insertion, adnominal
distention should be observed - answerwhat helps maintain tube placement
Tracheal airway suctioning - answerextends to lower airway and is intended to remove
resp secretions and maintain airway, this is sterile
Decreased o2 sat, anxiousness, tachypnea, gurgling, wheezing, pallor, cyanosis,
fatigue decreased oc - answerindications for tracheal suctioning
Conduct assessment, comfirm patient id, explain to client, set suction to 100-120,
hyperoxygenate with 100 oxygen 30-60 secondsp prior, use aspetic technique, apply
goggles mask and sterile gloves, insert into tube until resistance is felt then pull back 1
cm, suction slowly withdrawing and roatete the cath for no more than 10 seconds,
reapply oxygen inbetween and allow rest, rinse catheter and connect with normal saline
if prescribed - answerhow to tracheal suctioning
,Cuff inflation - answerperform hand hygine and apply clean gloves and face shield,
suction secretions, connect syringe to balloon port, place stethescop on sternal notch
on tracheal and listen for air leak on inspiration, if no leak is aculated remoa la air and
reinfflate as prescrived, if no excessive leak is heard ,slowly add air until leak is minimal,
remove equipemtn ad reposition client to promote comfort, how to inflate a cuff for trach
Unlock and remove inner cannula, immerse non disposalve cannulas in sterile solution,
clean inside and out and dry, replace tracheal oxygen mask as need to prevent hypoxia,
se forcepts to remove soiled ressings around tbe, assess and clean the stoma site, use
gauze pad soaked in sterile solution to remove dried secretons, apply new trachesomty
dressing, replace ties, two fingers should be able to fit between the ties - answerhow to
do trachesomty care
Admin suction, remove old tape and device, remove secretions and provide oral and
nasal care, secure endotracheal tube, remove , clean and reinsert oral airway -
answerhow to do endotracheal tube care
Airway obstruction, stoma inection, haemorrhage, tube displacement, decannculation,
aspiration, tube occlusion - answerwhat are some complications of trachesomty
Less than 7 days old contact physican and maintain ventilation using ambu bag, if 7
days old or greater, call for assistance and replace dislodge cannula, remove inner
cannula and insert obturatory, then gently reinsert the tube at 45 degree angle using
lubricant, if cannot be replaced, assess for resp distress and place in semi fowlers
postion - answerhow to help with accidental decanncualtion
Acidental extubation - answerclient is able to talk or yello still, activationing of ventilator
alarms, diminished breath sounds, resp distress, gastric distention, stay with client and
call for help, maintain and support ventilationg use a bag valve mask and oxygen as
required, prepare for reintubation
Aspiration - answersalivation, client positioning, trachesopahgeal fistula, improper cuff
inflation, preventative measures include frequent suctioning, prevent omitting, maintain
head of bed at 30-45 degrees
Ng tube - answerflexible plastic tubei nserte through the nostrils, down the nasopharynx
and into the stomach, this is used to deiver nutrietns or to remove gastric contents
Gastrostomy - answera stoma created from the abdominal wall into the stomach
thourhg which a short feeding tube is surgicall inserted
PEG - answertubes are placed endoscopically
NG tube insertion - answerHCP order is required, assess the condition of nares and oral
cavities, assess the client for adominadistention, pain, explain procedure and verify
,order, perform hand hygiene, position client in high fowlers position, measure and
moniter vital signs,determine length of tube, test tube for patency and cut tape, lubricate
end of tube and apply cean gloves, insert tuve through the nostril with curved point
poiting down, have the client swallow, assess correct placement of NG, may be gastric
contents esting or x ray
Total enteral nutrition - answerspecialized feeding through a feeding tube to supplement
oral intake or provide total nutritional support,
4 hours and after before and after intermitten feedings and medications - answerhow
often should you irrigate a feeding tube
30 ml - answerhow may mls do you need to flush the length of the tube
diarrhea, vomiting, dehydration - answerwhat are some complications of feeding tubes
feeding too fast, medications, lack offiber and contaminaniation - answerwhat causes
diarrea in feeding tube situations
improper tube placement, delayed gastric emptying, positioning - answerwhat are the
causes of vomiting with an ng tube
high residual volume - answerwhen do you hold your ng tube feedings
Refeeding syndrome - answera metabolic complication occurring when the refeeding of
a client in the starvation state, resumption of insulin production causes the uptake of
glucose and electrolytes from the blood stream depleting serum levels, this resultsin
fluid retention, electrolyte imbalances
Shallow resps, neurological disturbances, weaknesss, acute confusion, seizures,
bleeding and cardiac dysrhythmias - answerwhatare the manfiestations of refeeding
syndrome
Check for infection, irrigation sets should be labeled and only used for 24 hours, only do
four hours of feed at a time, maintain semi fowlers, monitor weght, and I and and do I
and O's - answerhow to care for a feeding tube
Urinary cathertization - answerused to support urinary elimination in clients who are
unable to void naturally, acute retention, accurate urine ouput measurement in a
critically ill client, enahce healing healing of open perineal wounds, prolonged bedrest,
terminal illness or sever eimpairemnt
Urinary catheter insertion for female - answeron back with knees flexed and thighs
relaxed, allowing hips to rotate
, Male client urinary catherization insertion - answersupine position, egs extended and
slightly abducted
Smallest - answerwhat do yo alwaus use for cathether
Urinary cathether insertion procedure - answerDrape client, preventing unnecessary
exposure of body parts 2. Apply clean gloves and wash perineal area 3. Open
catheterization kit and set up sterile field and supplies, don sterile gloves 4. Drape client
with sterile drapes, setting up equipment as needed 5. Clean urethra using antiseptic
cleanest to dirtiest (working outward) 6. Female catheter insertion: slowly and gently
insert, asking client to bear down, until urine appears 7. Male catheter insertion: lift
penis to 90 degrees, ask client to bear down and advance catheter until urine flows 8.
Allow urine to drain, and collect a sample if needed 9. Inflate balloon by injecting total
amount of prefilled syringe 10. Secure and label catheter tubing, position drainage bag
lower than bladder
Catheter associated urinary tract infections - answerassociate with inceased morbidity,
mortality, hospital cost and length of stay
Fever and chills, lethargy, abdominal and back pain,urgency and frequeny of urination,
painful urination, hematuria, mental status changes - answerwhat are some
manifestations of UTI
Sterile technique, use narrowest possible tube size, dialy cleansing, sexure the catheter
and ensure no blockages are present - answerhow do you prevent an UTI
Semi fowlers - answerwhat positiong should a client with a mastectomy be in with
affected arm eleated to prevenedema
Lithotomy position - answerwhat position should perineal and vaginal procedures be in
Semi fowlers - answerwhat position should a client with a thyroidiectomy be in, with
pillows to suppor the head,
Elevate with semi fowlers - answerwhat position should you client be in with
hypophystectomy
Lateral side lying - answerwhat posion should some with their haemorrhoids removed
be in
Reverse trendelenburg's position - answerwhat position should some with GERD be in
Supin with right arm raised behind head - answerwhat position should someone with a
liver bipsoy be in
