Download NUR 155 Exam 4 Questions and Verified Answers| 100% Correct| Grade A and more Exams Nursing in PDF only on Docsity!
NUR 155 Exam 4 Questions and
Verified Answers| 100%
Correct| Grade A
What size needle is used for IM injections? What size syringe? 22g 1.5 inch 3ml syringe What size needle do you use for SubQ injections? What size syringe? 25g 5/8 inch 1ml Syringe What is the 5 rights of medication administration? Right medication right dose right pt right route right time frame (are the meds due) DOCUMENTATION Can you administer an IV medication that has been prepared by another nurse? NO!!! no matter how emergent Can you administer a packaged drug (unopened) that another nurse has handed off to you to administer? YES
You make a med error, what is the FIRST and most important step into solving this problem? ASSESS THE PATIENT You are suspecting that your patient is having an allergic reaction to the IV medication, what is the first and most important step into solving this problem? Stop the medication, and asses the pt What are the signs and symptoms of an allergic reaction? Shortness of breath/difficulty breathing If you have an order for a pt that is just for a headache like Tylenol, can you give that medication for a fever? NO you have to call the doctor and get a new order that is for fever If your pt is having a hard time swallowing their PO potassium due to the pill being to large, what can you do to help the pt take their medication? call the pharmacy and have them change the pill from pill form to a liquid form What is the Z track method? This is used for IM injections. Use nondominant hand to pull skin laterally and hold it in position while giving injection. Release skin immediately after withdrawing needle to seal off the injection site. This prevents the medication from leaking through the more sensitive subcutaneous tissue from the muscle. Done at the ventrogluteal or dorsogluteal sites. Are you supposed to aspirate an IM injection? YES! always pull back to see if the syringe has blood in it. What do you do if you aspirate an IM injection and you get blood return? Start over! new injection site, new medication. What is the main thing to remember when giving an IM injection in the deltoid? No more than 1mL of medication If a pt has scheduled mediation, and you go into asses your pt and they are sleeping, do you have to wake that pt to give them their scheduled medication? YES! if the medication is scheduled it can be given within the hour that medication is due! Your pt calls out for their PRN pain medication, you finally get the chance to pull your medication, you walk into the room to asses your pt and they are sleeping, do you have to wake the pt up to give them their PRN medication?
Age and development motivation readiness active involvement relevance feedback nonjudgemental support simple to complex learning repetition timing environment emotions physiological events culture aspects psychomotor ability What should you asses before teaching your pt ANYTHING? Level of consciousness how they learn are they willing to learn can they physically do the task are they developmentally delayed can they physically read the directions What is the difference between acute and chronic pain? Chronic pain is pain that is long-lasting, normally controlled with medication, Acute pain is pain that has suddenly come on and usually is temporary. What is non-pharmacological pain management? pain management consists of a verity of physical, cognitive-behavioral, and lifestyle pain management that targets the mind body and spirit and social interaction. what are examples of non-pharmacological pain management? Body: massages applying heart/Ice electrical stimulation positioning acupuncture sleep Mind: self-hypnosis pain diary
distractions attitude adjustment reducing fear anxiety and stress music therapy Spirt: prayer self-reflection meaningful rituals spiritual healing social interactions: pet therapy family therapy problem-solving support groups What is pharmacological pain management? Pain that is managed by medications Examples of pharmacological pain management opioids coanalegesics NSAIDS can you crush a scored pill? yes Can you crush a pill that is not scored? NO! most of the time pills that are not scored are extended release Why do we flush IVs before and after medication administration? to ensure that all the medication has been cleared from the line. What are the important things to know about putting on patches and ointment make sure the areas are clean and dry alternate areas when replacing patches make sure you remove the old patch before you place the new one. What kind of pain scale do we use? Wong-baker Your pt tells you their pain score is a 3, what is medication will you be giving to that pt for that level of pain?
is experienced in the advanced event Ex: the wife that griefs before her husband dies What is disenfranchised grief? Grief or mourning that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Situations in which this occur often relate to a socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption. What is complicated grief? A form of grief in which the individual's strategies to cope with the loss are maladaptive. The disorder may be said to exist if the preoccupation lasts for more than 6 months and leads to a reduced ability to function formally. what is chronic grief? The same signs are expressed with normal grief, is extended in length and severity. Ex: after 10 years of her husbands death a woman still can not live life normally, she is still very depressed and can not function after a long period of time what are the clinical manifestations of end of life loss of muscle tone Relaxation of the facial tissues difficulty speaking difficulty swallowing loss of gag reflex decreased gastrointestinal tract with nausea feces retention possible urine and fecal incontinence diminished body movement What are the clinical manifestations of end of life slowing of circulation diminished sensation mottling and cyanosis of the extremities cold skin first in feet later in hands ears and nose slower and weaker pulse decreased BP Clinical manifestations changes in reporations rapid, shallow, irregular or abnormally slow noisy breathing due to mucus in the throat mouth breathing dry oral mucous membranes
clinical manifestation of sensory impairment blurred vision impaired senses of taste and smell What are the septs of planning end of life care Maintain physiological and psychological achieve a dignified and peaceful death maintain personal control understand that pt has rights of living person What are the physiological needs of a dying pt BOX 43-5 pg 1002 in the book! READ IT what are the post mortem interventions leave identification bracelet on apply additional identification tags make the body look natural asses the pts religious rituals and make every attempt to comply if family or friends wish to view the body make the environment clean and make the body look natural and comfortable all equipment and soiled lien should be removed wrap the body in a shroud apply identification of the outside of the shroud take the body to the morgue of arrange to have the body removed from the pts room handle the deceased with dignity What are the Kubler-Ross stages of grief?
- Denial- refuses to believe that the loss is happening
- Anger- pt or family direct anger to staff or nurse about matters that normally would not bother them
- Bargaining- bargains to avoid loss "let me just live until my daughter gets married then ill be ready to die"
- Depression- grieves over what happened and what cannot be "may talk freely reviewing past losses such as money or job"
- Acceptance- comes to terms with the loss How do we encourage grieving pts and families? verbally support the client but do not enforce denial help understand that anger is a normal response to feelings of loss and powerlessness provided structure to continuity to promote feelings of security and allow as much control as
