Exam (elaborations)
Quiz 1 Nursing 400
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Exam of 21 pages for the course cardiac exam nursing 400 at cardiac exam nursing 400 (Quiz 1 Nursing 400)
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Quiz 1 Nursing 400Dysphagia - ANS-inability to swallow or difficulty in swallowing
2 key points about Dysphagia - ANS-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 - ANS-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 - ANS-Nasogastric tube
Irrigation tray - 60 ml syringe
A bottle of sterile water
lubricant
NGT insertion - ANS-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 - ANS-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 - ANS-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 - ANS-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
Gastrostomy Tube - ANS-is a tube inserted through the abdomen that delivers nutrition
directly to the stomach.
Requires surgery (sx) - done by MD
Gastrostomy Tube Supplies - ANS-1. 60 mL syringe
2. A bottle of sterile water
Gastrostomy Tube Care - ANS-1. Clean with water and soap if it is healed
2. If the tube is newly inserted, clean the tube with saline solution
3. Flush with 30 mL of water
4. Make sure that the skin around the tube is clean and dry
, 5. Do not put any ointment unless directed by MD **any redness, foul smelling odor, and
drainage must be notified to the provider**
7 Rules about Body mechanics - ANS--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? - ANS-THE SMALLER THE NUMBER, THE
BIGGER THE DIAMETER (GAUGE) OF NEEDLE
Intradermal injections sites - ANS--Ventral forearm
-Upper back
-under the scapula for allergy testing
**make sure is lesion-free, hairless, and lightly pigmented**
**mark the area by drawing a circle around it**
Intradermal syringe lengths - ANS-0.25-0.5 inch
Intradermal syringe gauges - ANS-25 or 27
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