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PN 2006 - INTEGRATED NURSING PRACTICE POST MIDTERM EXAM
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PN 2006 - INTEGRATED NURSING PRACTICE POSTMIDTERM EXAM
history: ask about last bowel movement, normal pattern, any changes, diet, nausea,
vomiting, diarrhea; assess mouth, teeth, tongue, swallowing ability, abdomen:
inspect distention? auscultate bowel sounds: 4 quadrants (5-20 sec), palpate 1/2" -
ANSWER focused GI assessment
high fowlers (min 30 degrees), flush tube 30 MLS air, aspirate 5-10ml gastric
contents (ph), flush with 15-30mls water, check GRV, attach feeding set, set rate as
per orders, flush 30 MLS after feeding (or q4h if continuous), high fowlers
30mins-2 hrs post-feed - ANSWER enteral feeding
nasogastric, mesenteric (nasoduodenal, nasojejunal), gastronomy, percutaneous
endoscopic gastronomy tube, jejunostomy tube - ANSWER 5 types of tube feeds
- ANSWER placement of tube feeds
- ANSWER tube feed site care
pouching a bowel diversion, assemble supplies, cut hole to fit stoma (2mm larger
than stoma), wash peristomal skin with warm water, dry area, apply powder/paste,
press and hold as adhesive is activated by warmth - ANSWER ostomy care
left side Sims position, stool check (10cm from anus), pt to lay flat for 5 mins -
ANSWER administration of suppositories
left side Sims position, stool check (10cm from anus), - ANSWER administration
of fleet enema
vs; history:history of respiratory disease, smoking, and environmental exposures,
chest pain, cough?, meds?; look: rate (inspirations&expirations), rhythm, depth
(deep, normal, shallow), skin colour, O2 sat; feel: palpate for chest expansions;
listen: 8 front, 4 each side, 10 back; - ANSWER focused respiratory assessment
high fowlers, deep breath through nose, hold for 3 sec, out through pursed lips, on 3
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