patient admitted with transmission-based precautions what is the minimum PPI needed to be worn in this room?
Gloves and Gown
isotonic solution
A
... [Show More] solution in which the concentration of solutes is essentially equal to that of the cell which resides in the solution
hypertonic solution
A solution in which the concentration of solutes is greater than that of the cell that resides in the solution
hypotonic solution
A solution in which the concentration of solutes is less than that of the cell that resides in the solution
Heparin antidote
protamine sulfate
INR
International Normalized Ratio - a calculation based on the PT used to monitor patients using blood thinners. 2.0-3.0 is the range for people taking warfarin:Coumadin
Causes of hematoma
poor venipuncture technique, flow clamp left open, tourniquet left on to long, cannula to large, digging into vein
Signs of hematoma
Ecchymosis, immediate swelling at the site & discomfort, leakage of blood at the insertion site- unable to advance cannula
Phlebitis
inflammation of the inner lining of a vein
thrombophlebitis
inflammation of a vein associated with a clot formation
bacterial phlebitis is caused by
Poor hand hygiene, lack of aseptic technique, failure to check equipment, or recognize early signs of phlebitis
Often occurs during insertion
Phlebitis Scale
0 = No symptoms
1 = Erythema at access site with or without pain
2 = Pain at access site with erythema and/or edema
3 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord
4 = Pain at access site with erythema and/or edema, streak formation, palpable venous cord >1 inch in length, and purulent drainage
erythema
redness of the skin
Infiltration
admission of a non-vesicant med or solution into the surrounding tissue
Extravasation
admission of a vesicant into surrounding tissue
CVAD
central vascular access device or indwelling line
treatment of thrombophlebitis
complete bed rest
avoid massage
heat and elevation promote venous return
anticoagulant therapy
treatment of phlebitis
remove catheter, warm compress, elevate extremity, apply analgesic or anti-inflammatory PRN
active immunity
immunity produced by exposure to an antigen, as a result of the immune response
pt has a saline lock in place but it is not being used, what should be done?
call MD to verify it can be removed
which medication is most commonly used to clean an occlusion caused by a blood clot
Activase- Alterplace
Systemic complications of IV therapy
Circulatory overload
Speed shock
Septicemia
Allergic reaction
Catheter embolism
Air embolism
BSI
what set would vancomyacin IVPB be given in
secondary administration set
Circulatory overload is a concern for which patient
Patients with elevated BUN and creatinine level
BUN
10-20 mg/dL
Creatinine
0.6-1.2 mg/dL
what are the LPN duties when assisting with blood transfusion
monitor pt during transfusion
X-ray shows tip of PICC is in the jugular vein
let RN know of x-ray reading
where should broken IV pumps be stored?
Return pump to bio-med engineering dept
Is it okay to use a sharpie on a plastic IV bag?
no, it will seep through
Who can insert PICC lines?
Specially trained nurses
Skin is cool, taunt, edemic, what type of complication may have occurred?
Infiltration
What steps should be take if BSI is suspected
Notify MD
What statement about lorazepam would indicate the nurse needs further teaching?
Used for nausea
Iv was hung by gravity but the tubing was not primed, what action is take by the nurse?
place pt in trendelenburg and left side
signs and symptoms of pulmonary edema from receiving an infusion to quickly
- cough
- dyspnea
- restless
- crackles
What should be included in charting for a grade 3 infiltration iv finding
- assessment of site
- date and time
- notify MD
- treatment ordered
- carry out of treatment
What statement would indicate a nurse needs more teaching for central line dressing change
bio-patches to prevent infections
central line site has purulent drainage, pt also has fever and elevated WBC, what can the LPN legally do?
change dressing
hang ivpb to newly inserted peripheral iv
what statement would indicate a need for further teaching of transmission based precautions
pt in airborne precautions can not come out of their room for any reason
INR-5.5, Pt has been taking 2mg of warfarin daily. What order would be questions?
Increase the coumadin to 4mg daily.
antidote for warfarin
Vitamin K
what can an lpn carry out on a pediatric unit?
report to RN redness of iv site on 10 y/o
what would be done if redness, swelling, and exudate is oozing forming from IV site?
remove catheter, apply a sterile dressing, and call MD
what type of IV complication would we leave the catheter in for
Extravasation, may need and antidote and
Hyperpigmentation
Urokinase
thrombolytic agent to help break down blood clot
Peripheral catheters
Short term use (After surgery or a procedure)
midline catheter
inserted in intermediate sized veins and advanced into large vessels 2-4 weeks
over-the-needle catheter
a plastic catheter that fits over a needle and is used to pierce the wall of a vein to initiate intravenous access
electronic infusion devices
administer exact amounts, have an alarm when IV bag is low, when there is air in tubing or when flow is impeded by an occlusion
SASH guideline
Saline flush
Admin med
Saline flush
Heparin flush
Used for meds given by IV push or bolus
What should you remember when using 3-way stopcocks
use compatible fluids
patient receives education on an ambulatory IV pump, what comment would indicate pt needs further teaching?
I don't have to worry about plugging this in
A nurse is caring for a patient who is receiving an isotonic solution in a plastic container, what statement by the LPN would indicate a need for further teaching?
A plastic container is not easily punctured
A nurse is assessing a pts peripheral IV site and notices redness, warm to touch, swelling and the infusion rate has slowed what is the first action taken by the nurse?
Remove the IV catheter
what should be used to clean a central line
chloaprep
what pt would the nurse be most concerned about that has an IV?
Phlebitis with a red palpable cord
What should the nurse consider when choosing the appropriate infusion catheter for a pt?
- type of sol ordered
- condition of pts vein
- length of time it will be used
The nurse will apply which standard of practice pertaining to an administration set?
- intermediate infusion sets should be changed immediately upon contamination
- secondary intermediate IVPB should be changed every 24 hours
- Primary infusion sets should be changed every 72-96 hours
what nursing actions would prevent vascular assess infection?
- apply sterile gloves when applying a new central line dressing
- remove peripheral iv with redness as soon as noticed
- checking expiration date on tubing of iv fluid
what are local complications?
- phlebitis
- hematoma
- extravasation
what reasons you as a nurse are concerned with preventing HAI's?
- healthcare institutions are not reimbursed for HAI's
- can be life threatening
- NPSG concerning infection prevention
what action would the nurse take to prevent infiltration and extravasation?
- instruct pt to immediately report pain, burning or swelling iv IV site
- do not attempt peripheral iv more than 2 times per nurse
- do not place peripheral iv over a joint- can cause occlusion
what symptoms would indicate septicemia?
- BP of 80/50= hypotensive
-positive blood culture
restlessness
if a pt has jugular vein distention, SOB, 3 lb weight gain in 24 hours, and generalized bilateral edema what nursing intervention would be carried out?
- daily weights
- restriction of oral fluid intake
- sit pt in semi-fowlers position
- listen to lungs for crackles
what action would show and understanding by LPN of a sterile technique?
- only touches sterile to sterile
- takes care to make sure sterile hands do not drop below waist
- does not take outside of 1 inch boarder of sterile field
geriatric pt just had a hip fracture and has history of CHF, what are risks of complications associated with IV site?
- immunity to infection generally declines with age, placing pt at a high risk for infection
- increased risk for infilrtration/extravasation because geriatric pts have fragile veins
- having a fragile vein and being elderly increases pts risk of phlebitis
a newly admitted 60 year old has sever bacterial pneumonia, a pulse ox of 85%, and right side mastectomy 1 year prior. What orders/interventions with eh LPN carry out?
- Monitor pulse of continuously
- hang IVPB with broad spectrum antibiotic until culture and sensitivity tests come back
- Apply O2/ nebulizer treatment as ordered
what can LPN safely delegate to UAP
- Obtain vials Q4H on a stable pt
- Apply non prescription barrier creams
- Notify LPN that IV pump is alarming
LPN caring for a 14 y/o, what intervention can the LPN carry out for the pt who has had N&V&D for the last 3 days?
- obtain stool sample and sent to lab for occult blood
- obtain BP every 30 minutes
- rectal suppository for for N&V
Picc line dressing is wet what should be done?
gather supplies, change to a new sterile dressing that is completely sealed
Lpn needs further teaching if she does this
swipes iv hub with alcohol
what is a bio patch used?
to prevent dressing from being changed as often [Show Less]