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PPNC 2, Exam 1 Questions With Complete Solutions •Face Mask: Correct Answers 6-12 L/min =35%-50% FIO •Face tent: Correct Answers 24%-50% FIO •Nasal cannula: Correct Answers 1L to 6L max = 24% to 44% •Partial/Nonrebreather mask: Correct Answers 10- L/min = 60%-90% FIO •Tracheostomy collar: Correct Answers 4 -10 L/min •Venturi mask: Correct Answers 4-12 L/MIN24%-50% FIO Acute hemolytic reaction Correct Answers Transfusion of ABO incompatible red cells in blood; usually caused by misidentification or improper labeling Within minutes of transfusion initiation
Fever with or without chills; tachycardia; hypotension; abdominal, chest, back, and flank pain; dyspnea; red or dark urine; shock Use extreme care during the entire patient identification process; proper labeling of blood sample; meticulous verification of ABO/Rh compatibility between donor and recipient before administration; start transfusion slowly and monitor carefully for the first 15 minutes. Stop the transfusion. Get help immediately. Change administration set and administer 0.9% sodium chloride at rate to maintain patent IV access. Notify health care provider and blood bank. Treat shock. Maintain blood pressure and renal perfusion. Insert Foley catheter. Monitor intake and output hourly. Dialysis may be required. Obtain blood and urine samples and send to laboratory with unused part of unit of blood. Document reaction according to agency policy. Alginates Correct Answers Derived from seaweed, highly absorbent. Form a gel when absorbing wound fluid. Indicated for moderately to heavily draining wounds like surgical sites.
Avoid recapping needles If you are injured, report it Apply the nursing skills associated with venipuncture and intravenous insertion. Correct Answers Vein stabilization - Anchor the vein by applying traction below the insertion site to prevent rolling. Controlled insertion - Insert the catheter at the appropriate angle with a smooth, controlled motion. Confirm placement - Ensure blood return and flush the catheter to verify patency. Secure the line - Use sterile dressings and tape to immobilize the catheter and prevent dislodgement. Patient education - Explain the procedure, purpose of the IV, and instruct on keeping the site immobilized. Ongoing monitoring - Regularly assess the IV site for complications like infiltration, phlebitis, and dislodgement. Proper documentation - Record date/time of insertion, catheter gauge/type, number of attempts, and condition of the site. approximated Correct Answers the edges of a wound being brought close together or into alignment
Autolytic debridement Correct Answers the removal of dead tissue via lysis of necrotic tissue by the WBCs and natural enzymes of the body Bacterial contamination Correct Answers Microorganism contamination of infused product during donation or in preparing component for infusion Highest risk when administering platelets Occurs at time of donation Symptoms may appear during transfusion or within 4 hours of completion High fever, severe chills, hypotension, flushed skin, shock, hemoglobinuria, renal failure, DIC Use good skin antisepsis prior to venipuncture. Inspect blood unit carefully and do not administer if clots, bubbles, bag leaks, or discoloration of unit noted. Stop the transfusion. Treat shock, and administer ordered steroids and antibiotics. Culture patient's blood, blood component, and all intravenous solutions.
Tachypnea - Rapid, shallow breaths over 20 breaths/min Bradypnea - Slow rate below 12 breaths/min Kussmaul (Air hunger) - Deep, rapid breaths seen in metabolic acidosis Cheyne-Stokes - Cyclical pattern of apnea alternating with deep then shallow breaths. 20 sec-2 min cycles Biot's respirations- "Periodic" or "cluster" or "ataxic" Breathing-characterized by periods of apnea (cessation of breathing) followed by clusters of rapid, shallow breaths Apnea - Absence of breathing for 15-20 seconds or longer Stridor - High-pitched crowing sound on inspiration from upper airway obstruction Wheezing - Musical sound from lower airway obstruction
Compare and contrast various the methods of oxygen delivery systems (including L/min equivalents to FiO2, clinical judgment). Correct Answers •Nasal cannula: 1L to 6L max = 24% to 44% •Face Mask: 6-12 L/min = 35%-50% FIO •Venturi mask: 4-12 L/MIN24%-50% FIO •Face tent: 24%-50% FIO •Tracheostomy collar: 4 -10 L/min •Partial/Nonrebreather mask: 10-15 L/min = 60%-90% FIO Consistently demonstrate correct technique in setting up a sterile field and donning sterile gloves. Correct Answers • Prepare a flat surface and cover it entirely with a sterile drape, ensuring the drape is not contaminated (only touch on side/ the side that IS NOT SHINY)
- Open sterile packages and arrange sterile supplies on the field using aseptic technique, only touching the OUTSIDE of packages
- Perform surgical hand antisepsis following proper technique
- Open the outer glove package OUTSIDE of the sterile field, grasping only the outer inch of paper
- Pick up the first glove by the inside of the cuff
- Remove gloves and perform hand hygiene. Demonstrate the steps for performing tracheostomy care. Correct Answers 1. Gather supplies: sterile gloves, sterile saline or water, sterile dressings, tracheostomy ties or holder, and suction equipment.
- Explain the procedure to the patient and position them with their head extended.
- Perform hand hygiene and don sterile gloves using aseptic technique.
- Remove soiled dressing and inspect stoma site for redness, drainage, or skin breakdown.
- Clean the stoma and surrounding skin with sterile saline using a circular motion from the stoma outward.
- Pat dry with sterile gauze and apply new sterile dressing around the tracheostomy tube.
- Ensure the tracheostomy tube is secure with clean ties or holder device.
- Suction the tracheostomy tube if needed using sterile technique.
- Discard supplies, remove gloves, and perform hand hygiene.
- Document the procedure, stoma appearance, characteristics of any secretions, and any complications.
Demonstrate the steps for performing tracheostomy suctioning. Correct Answers 1. Gather supplies: sterile gloves, suction catheter (proper size for tracheostomy tube), sterile saline, suction canister and tubing.
- Explain procedure to patient and position them with head slightly extended.
- Perform hand hygiene and don sterile gloves using aseptic technique.
- Preoxygenate the patient and hyperinflate the lungs if possible.
- Gently insert the sterile suction catheter into the tracheostomy tube without applying suction. Advance until resistance is met.
- Apply suction by occluding the vent and withdrawing the catheter slowly with a rotating motion. Limit continuous suctioning to 10-15 seconds.
- Instill a small amount of sterile saline if needed to loosen secretions.
- Rinse the catheter, allow patient to rest and reoxygenate between passes.
- After suctioning, ensure inner cannula is replaced and ties are secure.
- Monitor respiratory status, oxygen saturation, and document findings.
(such as thin or thick), odor (none or foul), and amount in tablespoons or milliliters Describe nursing care associated with the use of a wound VAC (Vacuum-Assisted Closure), also known as negative-pressure wound therapy (NPWT). Correct Answers • Clip hair on skin around wound (check agency policy).
- Fill uneven skin surfaces with a skin barrier product such as paste or strips.
- Make sure that periwound skin surface is dry.
- Cut transparent film to extend 2.5 to 5 cm (1-2 inches) beyond wound perimeter.
- Frame periwound area with liquid skin barrier, solid skin barrier, or hydrocolloid dressing.
- Cut or mold transparent dressing to fit wound.
- Avoid wrinkles when applying transparent film.
- Identify any air leaks with a stethoscope and repair them with a sealant dressing (e.g., transparent dressing).
- Use only one or two additional layers for large leaks. Multiple layers reduce moisture vapor transmission and cause maceration of wound.
- If an adhesive remover is used, be sure to cleanse periwound well because it leaves a residue that can hinder film adherence.
Describe the appropriate techniques for irrigating a wound. Correct Answers - Using an appropriate solution like normal saline or sterile water. Avoid cytotoxic solutions.
- Positioning the wound to allow fluid drainage.
- Applying enough pressure to dislodge debris without damaging tissue, around 4-15 psi.
- Using a 19-gauge catheter tip or similar device to create a pressurized stream.
- Directing the stream from the clean end of the wound toward the dirtier area.
- Irrigating for sufficient time to thoroughly clean the wound bed.
- Drying the surrounding skin and applying a clean, moist dressing after irrigation. Describe the complications of intravenous insertion. Correct Answers • Minor bleeding
- Infiltration
- Catheter Occlusions
- Catheter-related infections
- Phlebitis (Thrombophlebitis)
- Hematoma and/or bleeding at the site
- Nerve Injury
"springy"
- Common sites: (start with most distal veins of upper extremity 1st)
- Forearm
- Dorsal hand Describe the methods for assessing adequate respiration Correct Answers To assess adequate respiration, observe for an unlabored respiratory pattern with a normal rate of 12-20 breaths per minute in adults. The chest should rise and fall symmetrically with each breath. Breath sounds should be clear on auscultation without adventitious sounds like wheezes or crackles. Oxygen saturation levels should be within normal range. Describe the methods for assessing inadequate respiration. Correct Answers tachypnea or bradypnea, use of accessory muscles, nasal flaring, pursed lip breathing, cyanosis, diminished or absent breath sounds, adventitious lung sounds, restlessness or anxiety, and low oxygen saturation levels. Abnormal breathing patterns like Kussmaul, Cheyne-Stokes, or periods of apnea may also indicate inadequate ventilation.
Describe the nursing care & management of IV insertion. Correct Answers • Avoid placing the tourniquet too tight
- Clean site for 30 seconds
- 10-30 degree angle, bevel up
- Non dominant hand below insertion hand Document
- Date, time, & your initials
- Placement site
of attempts
- Length & Gauge of catheter
- Assessment of site
- Patency
- Patient tolerance
Appliance fit - An ill-fitting appliance that is too tight or loose allows leakage of stomal output onto the peristomal skin. Allergic dermatitis - Some patients may develop allergic reactions to the adhesive or materials used in ostomy appliances. Peristomal moisture - Excessive moisture from perspiration or drainage can macerate the skin around the stoma. Trauma - Improper removal of appliances or accidental injury can damage the delicate peristomal skin. Poor nutrition - Malnutrition impairs wound healing and skin integrity. Infection - Bacterial or fungal overgrowth in the skin folds around the stoma increases risk of breakdown. Discuss nursing care associated with bowel diversions. Correct Answers Stoma care - Monitoring stoma appearance, ensuring proper appliance fit, changing pouching systems regularly, and protecting peristomal skin integrity. Output management - Assessing characteristics and amount of effluent, ensuring adequate pouching supplies, and addressing issues like odor or leakage. Diet and hydration - Providing guidance on dietary modifications, fluid intake recommendations, and
identifying foods that may cause obstructions or irritation. Psychosocial support - Addressing body image concerns, lifestyle adjustments, sexuality issues, and connecting patients with support resources. Complication prevention - Monitoring for stomal complications like prolapse, retraction, stenosis, hernias, and skin breakdown. Early intervention is crucial. Patient education - Thorough ostomy care instruction, appliance management, signs/symptoms requiring medical attention, and strategies for reintegrating into normal activities. Discuss the components of ostomy education. Correct Answers • Stoma care
- Meticulous skin care
- Stoma color
- Use barrier cream
- Resources
- online
- Wound nurse
- Teaching
- Care
