Exam (elaborations)
Nurs 172 Exam 2: Questions & Proper Solutions
Nurs 172 Exam 2: Questions & Proper Solutions
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Nurs 172 Exam 2: Questions & Proper SolutionsWhat is sepsis? Right Ans - toxic inflammatory condition arising from the
spread of microbes, especially bacteria or their toxins, from a focus of
infection
What do we culture when someone is septic? Right Ans - we remove the iv
and cut the tip for culture. then they will do a lab stick culture.
What is the first thing we do for high BP? Right Ans - IV bolus
What are the 4 stages of phlebitis Right Ans - 0- none
1- erythema
2- pain, edema, redness
3- red lines from injection site (all of above)
4-pruluent drainage (all of above)
infiltration Right Ans - escape of non-vesicant medication/ solution from
the vein into the surrounding tissue
extravasion- Right Ans - escape of a vesicant medication solution form the
vein into the surrounding tissue.
infiltrated treatment: Right Ans - stop infusion immediately
remove iv catheter
notify hcp of the infiltration if there is pain, numbness, or significant swelling.
heat or cold compress to site, depends on the kind of fluid infiltrated.
extravasation Right Ans - stop the iv immediate
call pharmacist if there is an antidote for the medication before removing the
IV catheter.
check with pharmacist or physician regarding whether to elevate the
extremity or not
monitor patient closely
types of vesicant medication Right Ans - promethazine and vancomycin
Nerve injury Right Ans - avoid placement at the cephalic vein for 3-5 inches
above the thumb
, venous spasm Right Ans - a spasm is sudden involuntary contraction of a
vein or artery resulting in temporary cesation of blood flow through a vessel.
causes of venous spasm: Right Ans - -Infusing cold solutions
-Infusing irritating solutions
-Infusing solutions too fast
venous spasm treatment Right Ans - -apply warm compress to site
-restart infusion in new site if spasm continues
-notify RN
circulatory overload Right Ans - an excess in intravascular fluid volume -
infused too much fluid
problems of circulatory overload? Right Ans - pulmonary edema, heart
failure, shock, and cardiac arrest
air embolism: air in vein Right Ans - direct communication between the
source of air and vaculatore
pressure gradient favoring passage into the circulation
air embolism happens: Right Ans - placement of a central line,
catheter fractures
disconnect of the iv adminstered set and the catheter without a clamp
failure to prime the administration set
adding a new IV bag to a line that has run in dry without clearing out the air
loose connections that allow air to enter the system
venous air embolism s/s Right Ans - light headedness, dyspnea, cyanosis,
tachypnea, expiratory wheezes, cough, chest pain, hypotension, changes in
mental status, pulmonary edema, high heart rate
weak thready pulse
impending sense of doom
speed shock Right Ans - caused by rush of IV fluid administered;
med races to blood-rich heart and brain and floods them w/toxic levels of med
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