NCLEX Prep Questions 2021

NCLEX Prep Questions 2021 Leave the first rating Students also studied Terms in this set (16) Save

Activity and Movement: Assess and ...

35 terms kiblerk3Preview

ANALYZE CUES

12 terms OoAbbyPreview

Exam 1: ECT Therapy questions

20 terms QWERTY3995 Preview Cardiac 98 terms kna Infiltration vs. ExtravasationIn: non-vesicant (non-irritating) leaks into surrounding tissue

Ex: vesicant leaks into surrounding tissue

Infiltration Prevetion (3)1. use smallest catheter for prescribed Rx

• stabilize port access
• assess blood return

Infiltration: Nursing Interventions (5)1. stop infusion

• remove IV
• apply COLD compress
• elevate extremity
• insert new catheter in opposite extremity

Extravasation treatment (5)1. stop infusion

• d/c administration set
• aspirate drug if possible
• apply cold compress
• document condition of site (may photograph)

Phlebitis/thrombophlebitis: Prevention (3)1. rotate sites every 72 to 96 hours

• use aseptic technique
• secure catheter

Phlebitis/thrombophlebitis Treatment (4)1. stop infusion

• remove PIV
• apply HEAT compress
• insert new catheter in opposite extremity

Catheter embolus treatmentimmediately apply tourniquet high on extremity to limit venous flow; prepare for removal under XR

Cx of CVC: air embolism: treatment (2)1. place pt in left lateral Trendelenburg

• administer O2

Cx of CVC: lumen occlusion: treatmentuse 10 mL syringe with a pulsing motion Cx of CVC: Pneumothorax (during insertion): Treatment (2)

• Give O2
• Assist PCP w/chest tube insertion

Cx of CVC: Bloodstream infection: Prevention (1) and Treatment (4)

Prevention: maintain sterile technique

Treatment:

• Change entire infusion system
• notify PCP
• Obtain cultures
• administer antibiotics

Cx of PICC: catheter dislodges: nursing interventions (3) Assess:

• blood return
• discomfort in jaw, chest, or ear
• Contact PCP

Cx of PICC: phlebitis: nursing interventionapply low degree heat, d/c if not resolved Cx of PICC: Catheter embolism: Nursing intervention (3) 1. secure catheter

• avoid pulling
• follow safe practices for catheter removal

TPN: define, (what type of solution is it? components?),

and what type of IV can it be given through (3 subtypes)?Hypertonic solution containing dextrose, proteins, electrolytes, minerals, trace elements, and insulin;

Requires CVC device: PICC line, subclavian, or internal jugular veins)

Nursing care and management of TPN (9)1. Before adminstering, verify Rx and solution with another RN

• Administer via infusion pump
• monitor daily weight
• Monitor and record I&O, noting fluid balance
• Monitor serum glucose level q 4 to 6 hours
• Monitor for signs of infection
• Change dressing q 48 to 72 hr
• Change IV tubing and fluid q 24 hrs
• If TPN solution is temporarily unavailable, give D10W to prevent hypoglycemia