What was Victoria Gonzalez's diagnosis? primary- respiratory distress syndrome secondary- failure to thrive
What was Isabelle Capstone's diagnosis? primary- bronchiolitis secondary- rule out RSV
What precautions are needed for RSV? contact droplet
What are the steps to PCA pump medication admini...
NUR 436 Final Exam Review Questions
and Answers
What was Victoria Gonzalez's diagnosis? ✅primary- respiratory distress syndrome
secondary- failure to thrive
What was Isabelle Capstone's diagnosis? ✅primary- bronchiolitis
secondary- rule out RSV
What precautions are needed for RSV? ✅contact droplet
What are the steps to PCA pump medication administration? ✅1. Verify prescription on
patient chart, unit standing orders/protocol. Review facility policy-may include use of
C02 monitor and/or pulse oximetry.
2. Compare the patient prescription for drug, dose, route, and time to patient MAR.
3. Assemble equipment: Medication syringe, PCA pump, key, and tubing, alcohol wipes,
saline flush.
4. Verify medication infusion rate, volume to be infused, and compatibility with the
primary IV solution or any other drugs infusing in the same IV line to drug reference
manual. Ascertain precautions for administration procedures.
5. Perform drug dosage calculations (if required).
6. Wash hands and follow standard precautions as appropriate
Procedure Steps
7. Select correct medication and compare medication label with doctor orders to check
for 5 rights
8. Note any instructions on the syringe concerning prescribed duration of flow.
9. Check the expiration date of the IV medication.
Administration of medication by PCA
10. Provide privacy and perform hand hygiene.
11. Introduce self to client. State purpose of nurse/ client interaction. Identify client with
name/ birth date/ medical record number on the MAR. Check client allergies
12. Discuss the drug's purpose, its action, and possible adverse effects. Explain that
you will be administering medication through the IV line. Assure that the patient and
family, if present, understand safety precautions related to patient controls.
13. Assess the IV site for redness or swelling. Check for patency, phlebitis, or
infiltration. Determine if patient has any symptoms of discomfort at the IV site.
14. Check medication with MAR and verify 5 rights before you spike and hang the IV
bag; Or place Syringe into PCA pump.
15. Verify Medication and dosage with 2nd RN.
16. Scan the patient armband and medication barcode. .
17. Wash hands. Don gloves if needed.
18
, What are the steps for giving a medication via IV push? ✅1. Verify prescription on
patient chart, unit standing orders/protocol. Review facility policy
2. Assemble equipment: alcohol wipes, tape, pen, gloves, sharps container
3. Compare the patient prescription for drug, dose, route, and time to patient MAR.
4. Check drug reference manual to determine how quickly the medication can be given
and to ensure that it is compatible with the primary IV solution or any other drugs
infusing in the same IV line. Ascertain precautions for administration procedures.
5. Perform drug dosage calculations (if required).
6. Wash hands and follow standard precautions as appropriate
Procedure Steps
7. Select correct medication and compare label on container with patient MAR to check
for 5 rights (1stCheck)
8. Check the expiration date of the medication.
9. Using aseptic technique clean top of vial with alcohol in a circular motion for 30
seconds with firm friction and allow to air dry.
10. Draw air into the syringe to equal the amount of medication being withdrawn.
(Needle cap can be left on for this) Remove cap from needle (out and away from you).
Insert needle through the center of the vial stopper). Inject air into vial (above the fluid
level) THEN invert vial and make sure the tip of the needle is in the solution. Withdraw
the correct amount of solution, examining for and removing any air bubbles before
removing needle from vial and replacing needle cap using the scoop method and
maintaining sterility.
11. If needed: Dilute the medication in normal saline.
a. Obtain vial of normal saline.
b. Check expiration date on vial.
c. Using aseptic technique clean top of vial with alcohol wipe in a circular motion for 30
seconds with firm friction and allow to air dry.
d. Draw air into a new syringe equal to the amount of saline required for medication
dilution (needle cap can be left on for this).
What is included in the titration of medications? ✅Titration of medications are used in
critical care situations when the patient is unstable.
•When titrating meds-the nurse can use their clinical judgment to quickly adjust the
dosage of the medication according to the patient response!
•Doses can be adjusted either up or down depending on the patient response.
The nurse would stay at the bedside with the patient until they were stable and monitor
the patient blood pressure/HR every 5 minutes to determine if the nurse will need to
increase the medication until the patient blood pressure stabilized
You started the Heparin Protocol at 0800; what time will you need to draw labs for the
APTT for your patient? ✅You would draw labs at 1400-this is 6 hours after you started
the Heparin infusion
At 1400 the patients APTT = 44 sec-what do you do?
Weight Based Heparin Protocol
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