Ethics in Nursing
Ethics is concerned with ‘right and wrong’, although agreeing what is ‘right’ can be challenging. An understanding of ethics is essential to the delivery of skilled professional care. It is vital that nurses appreciate the value of ethics in their work. Ethics is relevant to clinical, practice-based issues and affects all areas of the professional nursing role. To apply ethics effectively, nurses must develop reasoning skills and understand the concepts and principles that assist ethical analysis.
ICN Code of Ethics
An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953. The ICN Code of Ethics for Nurses is a guide for action based on social values and needs. It will have meaning only as aliving document if applied to the realities of nursing and health care in a changing society.
The four elements of the ICN Code of Ethics for Nurses: Nurses and people, nurses and practice, nurses and the profession, and nurses and co-workers, give a framework for the standards of conduct. (International Council for Nurses, 2012).
Elements of the code
Nurses and people
- The nurse's primary professional responsibility is to care people requiring nursing care.
- In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.
- The nurse ensures that the individual receives accurate, sufficient and timely information in a culturally appropriate manner on which to base consent for care and related treatment.
- The nurse holds in confidence personal information and uses judgment in sharing this information.
- The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.
Nurses and practice
- The nurse carries personal responsibility and accountability for nursing practice, and for maintaining competence by continual learning.
- The nurse maintains a standard of personal health such that the ability to provide care is not compromised.
- The nurse uses judgement regarding individual competence when accepting and delegating responsibility.
- The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance its image and public confidence.
- The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.
- The nurse strives to foster and maintain a practice culture promoting ethical behavior and open dialogue.
Nurses and the profession
- The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education.
- The nurse is active in developing a core of research-based professional knowledge that supports evidence-based practice.
- The nurse is active in developing and sustaining a core of professional values.
- The nurse, acting through the professional organization, participates in creating a positive practice environment and maintaining safe, equitable social and economic working conditions in nursing.
- The nurse practices to sustain and protect the natural environment and is aware of its consequences on health.
- The nurse contributes to an ethical organizational environment and challenges unethical practices and settings.
Nurses and co-workers
- The nurse sustains a collaborative and respectful relationship with co-workers in nursing and other fields.
- The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a co-worker or any other person.
- The nurse takes appropriate action to support and guide co-workers to advance ethical conduct.
International Council of Nurses
The International Council of Nurses (ICN) is a federation of national nurses associations in more than 130 countries. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health policies globally. Founded in 1899, ICN is the world's first and widest reaching international organization for health professionals and is headquartered in Geneva, Switzerland.
ICN has identified three key program areas as crucial to the betterment of nursing and health. These are known as ICN's Pillars and they are: Professional practice, regulation, and socioeconomic welfare.
Nepal Nursing Council
Nepal Nursing Council (NNC) is establi-shed under Nepal Nursing Council Act 2052 (1996). It came into force on 2053–03–02 (16th June 1996). First amendment 3of the Act was done on 2058/10/14 (17th January, 2002 AD).
Powers, functions, and duties
- The powers, functions and duties of the council shall be as follows:
- To formulate policy required to operate the nursing profession smoothly.
- To provide recognition to a teaching institution.
- To evaluate and review the curriculum, terms and conditions of admission, examination system and other necessary terms and conditions and infrastructure of a teaching institution which has been granted recognition pursuant to clause (b).
- If a teaching institution is found form the evaluation and review made pursuant to clause (c) to have failed to met the standards determined by the council, to make a recommendation for revoking the approval for operation of such institution.
- To determine the qualifications of the nursing professionals and to issue certification to the qualified nursing professional after registering his/her name in the registration book.
- To determine the work limit of nursing professionals.
- To formulate professional code of conduct of the nursing professionals and to take action against those nursing professionals who violate such code of conduct.
- Prior to granting approval to establish and operate a teaching institution, the concerned body shall consult the council. The council shall provide its opinion on that matter after examining whether such teaching institution has met the required standard and infrastructure or not. The concerned body shall reach to a decision in respect of granting or not granting approval for establishment and operation of teaching institution on the basic of such opinion of the council.The council members (Board of Directors) are responsible to carry out all these powers, functions and duties. There is complies of its members representing different sector. The process of constitution of council is:
- One chairperson nominated by Nepal Government among the nurse meeting criteria decide by Council Act.
- One member nominated by Nepal Government among the nurses who have 12 years experience after at least Bachelors Degree in Nursing Education.
- Two members are nominated by Nepal Government among the Campus Chiefs of Nursing College.
- Ex-office member chairperson of NAN.
- One member designated by Director General of Department of Health.
- One member designated by the Dean of IOM.
- Three members nominated by Nepal Government among the Nursing Chiefs (administrator) working in regional/zonal hospitals and directorate.
- One member nominated by Nepal Government among nationally renowned person on behalf of consumer group.
- One member as a representative of CTEVT.
Tenure of members is 4 years. 15 executive members.
In order to discharge the daily administrative function and activities of Council the Government of Nepal may appoint the post of registrar among the nurses who has met criteria asked by Act.4
Other administrative staffs may be appoint by council according to the need and asked by workload in the council.
National licensure examination
National licensure examination for nurses is defined to be an entrance examination to be qualified to be identified as a nursing professional. This national licensure examination for nurses is applied to all the new graduates from Proficiency Certificate Level (PCL) and Bachelor of Science in Nursing (BSc N). Graduation or completion of nursing education in PCL or BSc N is a requirement to sit the national licensure examination. All the graduates of PCL and BSc N must pass the national licensure examination before they start working as a nursing professional.
Nursing Association of Nepal
Nursing Association of Nepal (NAN) is an only one professional organization of the nurses in Nepal. It is a nonpolitical nonsectoral organization not influenced by class and religion. It is determined to provide quality-nursing service to the people in order to protect and promote the professional rights and interests of all nurses in the kingdom of Nepal. NAN was established in BS 2018 Magh 15 (1962 AD) with the Regd. No. 8/018 and became a member of International Council of Nurses (ICN) Geneva in 1969 AD.
Objectives
- To protect, promote and develop professional code of conduct, right and interest of all nurses in the country.
- To raise the health status of the people and undertake various activity necessary to avail basic health services throughout the country.
- To strengthen the nursing service by upgrading its standard by continual education.
- To remain effortful to develop and extend a scientific nursing system.
- To facilitate and conduct relevant nursing research.
- To establish the nursing standard for the scope of practice and safe care delivery.
Strategies
In order to attain the above-mentioned objectives, NAN shall undertake following strategic activities:
- Remain effortful to make the nursing service more effective, efficient, humanitarian and prestigious.
- Remain engaged in various creative activities that are essential for protection, promotion and develop-ment of professional rights and interests.
- Establish co-ordination with other national and international professional organizations including those related to nursing profession and to exchange ideas with each other.
- Extend co-operation to avail preventive, primitive, curative and restorative health services in a simple accessible and organized manner.
- Remain effortful to make all health related programs successful which is intended to strengthen the existing health services of the country and operating under the assistance of various national and international organizations.
- Create general awareness on health through publications of health-related booklets, pamphlets, bulletins, other information materials and exhibitions.
- Network with other national and international organization and agencies to develop partnership to strengthen nursing and enhance health status of people.
Mission
Nursing Association of Nepal is committed to unite all nursing professionals under one roof and provide continuous support for the professional development and quality nursing service.
Goal
All nurses work together for common goal, interest for social and economical development of the nurses, national health programs and meeting health targets through nursing service and professional activities. The nurses will develop competency skill in their respective areas of practice and deliver safe and quality service to the people.
Nursing process
- Organized framework to guide practice
- Problem-solving method—Client focused
- Systematic—Sequential steps
- Goal oriented—Outcome criteria
- Dynamic—Always changing, flexible
- Utilizes critical thinking processes.
Its purpose is to: “Diagnose and treat human responses to actual or potential health problems”.
Scientific method of problem-solving
- Identifying the problem
- Collect data
- Form hypothesis
- Plan of action
- Hypothesis testing
- Interpret results
- Evaluate findings.
Steps in the nursing process
- Assessment
- – First step of the nursing process gather information/collect data.
- – Primary source—Client/family.
- – Secondary source—Physical exa-mination, nursing history, team members, laboratory reports, diag-nostic tests.
- – Subjective—From the client (symptom).
- – “I have a headache”.
- – Objective—Observable data (sign).
- – Blood pressure 130/80.
Assessment-collecting data- – Nursing interview (history)
- – Health assessment—Review of systems
- – Physical examination
- – Inspection
- – Palpation
- – Percussion
- – Auscultation.
- Nursing diagnosis:
- – Second step of the nursing process. It is composed of 3 parts:
- – Problem statement—The client's response to a problem.
- – Etiology—What's causing/contri-buting to the client's problem.
- – Defining characteristics—What's the evidence of the problem.
Interpret and analyze clustered data - Planning: Begin by prioritizing client problems:
- – Types of goals:
- – Short-term goals
- – Long-term goals
- – Cognitive goals
- – Psychomotor goals
- – Affective goals.
- Implementing:
- – The fourth step in the nursing process. This is the “doing” step. Carrying out nursing interventions (orders) selected during the planning step.
- Evaluating:
- – Final step of the nursing process but also done concurrently throughout client care. A comparison of client behavior and/or response to the established outcome criteria.
Rights of Registered Nurses
- Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care.
- Nurses have the right to practice in environments that allow them to act in accordance with professional standards and legally authorized scopes of practice.
- Nurses have the right to a work environment that supports and facilitates ethical practice, in accor-dance with the Code of Ethics for nurses and its interpretive statements.
- Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution.
- Nurses have the right to fair compensation for their work, consistent with their knowledge, experience and professional responsibilities.
- Nurses have the right to a work environment that is safe for themselves and their patients.
- Nurses have the right to negotiate the conditions of their employment, either as individuals or collectively, in all practice settings.
Principles of medication administration
- “Seven Rights” of drug administration
- The right medication—When administering medications, the nurse compares the label of the medication container with medication form.The nurse does this three times:
- Before removing the container from the drawer or shelf.
- As the amount of medication ordered is removed from the container.
- Before returning the container to the storage.
- Right dose—When performing medication calculation or conversions, the nurse should have another qualified nurse check the calculated dose.
- Right client—An important step in administering medication safely is being sure the medication is given to the right client.
- To identify the client correctly.
- The nurse checks the medication administration form against the client's identification bracelet and asks the client to state his or her name to ensure the client's identification bracelet has the correct information.
- Right route—If a prescriber's order neither does nor designates a route of administration, the nurse consult the prescriber. Likewise, if the specified route is not recommended, the nurse should alert the prescriber immediately.
- Right time—
- Each institution has are commended time schedule for medications ordered at frequent interval.
- Medication that must act at certain times are given priority (e.g. insulin should be given at a precise interval before a meal).
- Right documentation—Documentation is an important part of safe medication administration.
- The documentation for the medication should clearly reflect the client's name, the name of the ordered medication, the time, dose, route and frequency.
- Sign medication sheet immediately after administration of the drug.
- Right to refuse.
Client's right related to medication administration
A client has the following rights:
- To be informed of the medication's name, purpose, action, and potential undesired effects.
- To refuse a medication regardless of the consequences.
- To have a qualified nurses or physicians assess medication history, including allergies.
- To be properly advised of the experimental nature of medication therapy and to give written consent for its use.
- To received labeled medications safely without discomfort in accordance with the six rights of medication administration.
- To receive appropriate supportive therapy in relation to medication therapy.
- To not receive unnecessary medications.
- Practice asepsis
- Wash hand before and after preparing the medication to reduce transfer of microorganisms.
- Nurse who administers the medi-cations is responsible for their own action
- Question any order that you considered incorrect (may be unclear or appropriate).
- Be knowledgeable about the medication that you administer
- A fundamental rule of safe drug administration is: “Never administer an unfamiliar medication”.
- Keep the narcotics in locked place
- Use only medications that are in clearly labeled containers. Relabeling of drugs is the responsibility of the pharmacist.
- Return liquid that is cloudy in color to the pharmacy.
- Before administering medication, identify the client correctly.
- Do not leave the medication at the bedside. Stay with the client until he actually takes the medications.
- The nurse who prepares the drug administers it. Only the nurse prepares the drug. Knows what the drug is? Do not accept endorsement of medication.
- If the client vomits after taking the medication, report this to the nurse in charge or physician.
- Preoperative medications are usually discontinued during the postoperative period unless ordered to be continued.
- When a medication is omitted for any reason, record the fact together with the reason.
- When the medication error is made, report it immediately to the nurse in charge or physician.
Principles of Patients' Rights and Responsibilities
- All patients have the right to informed consent in treatment decisions, timely access to specialty care, and confidentiality protections—Patients should be treated courteously with dignity and respect. Before consenting to specific care choices, they should receive complete and easily understood information about their condition and treatment options. Patients should be entitled to coverage for qualified second opinions; timely referral and access to needed specialty care and other services; confidentiality of their medical records and communications with providers; and, respect for their legal advanced directives or living wills.
- All patients have the right to concise and easily understood information about their coverage—This information should include the range of covered benefits, required authorizations, and service restrictions or limitations (such as on the use of certain health care providers, prescribed drugs, and “experimental” treatments). Plans should also be encouraged to provide information assistance through patient ombudsman knowledgeable about coverage provisions and processes.
- All patients have the right to know how coverage payment decisions are made and how they can be fairly and openly appealed—Patients are entitled to information about how coverage decisions are made, i.e. how “medically necessary” treatment is determined, and how quality assurance is conducted. Patients and their family caregivers should have access to an open, simple, and timely process to appeal negative coverage decisions on tests and treatments they believe to be necessary.
- All patients have the right to complete and easily understood information about the costs of their coverage and care—This information should include the premium costs for their benefits package, the amount of any patient out-of-pocket cost obligations (e.g. deductibles, copayments, and additional premiums), and any catastrophic cost limits. upon request, patients should be informed of the costs of services they've been rendered and treatment options proposed.
- All patients have the right to a reasonable choice of providers and useful information about provider options: Patients are entitled to a reasonable choice of health care providers and the ability to change providers if dissatisfied with their care. information should be available on provider credentials and facility accreditation reports, provider expertise relative to specific diseases and disorders, and the criteria used by provider networks to select and retain providers. the latter should include information about whether and how a patient can remain with a provider who leaves or is not part of a plan network.
- All patients have the right to know what provider incentives or restrictions might influence practice patterns: Patients also have the right to know the basis for provider payments, any potential conflicts of interest that may exist, and any financial incentives and clinical rules (e.g. quality assurance procedures, treatment protocols or practice guidelines, and utilization review requirements) which could affect provider practice patterns.
All patients, to the extent capable, have the responsibility to:
(it is recognized that patients may suffer significant physical and/or mental conditions 9which may limit their ability to fulfill these responsibilities).
- Pursue healthy lifestyles—Patients should pursue lifestyles known to promote positive health results, such as proper diet and nutrition, adequate rest, and regular exercise. Simultaneously, they should avoid behaviors known to be detrimental to one's health, such as smoking, excessive alcohol consumption, and drug abuse.
- Become knowledgeable about their health plans—Patients should read and become familiar with the terms, coverage provisions, rules, and restrictions of their health plans. They should not be hesitant to inquire with appropriate sources when additional information or clarification is needed about these matters.
- Actively participate in decisions about their health care—Patients should seek, when recommended for their age group, an annual medical examination and be present at all other scheduled health care appointments. They should provide accurate information to providers regarding their medical and personal histories, and current symptoms and conditions. They should ask questions of providers to determine the potential risks, benefits, and costs of treatment alternatives. Where appropriate, this should include information about the availability and accessibility of experimental treatments and clinical trials. Additionally, patients should also seek and read literature about their conditions and weigh all pertinent factors in making informed decisions about their care.
- Co-operate on mutually accepted courses of treatment—Patients should co-operate fully with providers in complying with mutually accepted treatment regimens and regularly reporting on treatment progress. If serious side effects, complications, or worsening of the condition occur, they should notify their providers promptly. They should also inform providers of other medications and treatments they are pursuing simultaneously.
Vital Signs
Definition
- These are indices of health, or in determining client's condition. This is also known as cardinal signs and it includes body temperature, pulse, respirations, and blood pressure. These signs have to be looked at in total, to monitor the functions of the body.
Different considerations in taking vital signs
- The frequency of taking TPR and BP depends upon the condition of the client and the policy of the institution.
- The procedure should be explained to the client before taking his TPR and BP.
- Obtain baseline data.
Vital signs or cardinal signs are:
- Body temperature
- Pulse
- Respiration
- Blood pressure
- Pain.
Body temperature
- The balance between the heat produced by the body and the heat loss from the body.
Types of body temperature
- Core temperature—Temperature of the deep tissues of the body.
Alteration in body temperature
- Pyrexia: Body temperature above normal range (hyperthermia).
- Hyperpyrexia: Very high fever, 41°C (105.8° F) and above.
- Hypothermia: Subnormal temperture.
Normal adult temperature ranges
- Oral: 36.5–37.5°C
- Axillary: 35.8–37.0°C
- Rectal: 37.0–38.1°C.
Methods of temperature taking
- Oral: It is the most accessible and convenient method.
- Put on gloves, and position the tip of the thermometer under the patients tongue on either of the frenulun as far back as possible. It promotes contact to the superficial blood vessels and ensures a more accurate reading.
- Wash thermometer before use.
- Take oral temperature 2–3 minu-tes.
- Allow 15 minutes to elapse between client's food intakes of hot or cold food, smoking.
- Instruct the patient to close his lips but not to bite down with his teeth to avoid breaking the thermometer in his mouth.
Contraindications
- Young children and infant.
- Patients who are unconscious or disoriented.
- Who must breathe through the mouth.
- Seizure prone.
- Patient with N/V.
- Patients with oral lesions/surgeries.
- Rectal: It is the most accurate measurement of temperature.
- Position—Lateral position with his top legs flexed and drapes him to provide privacy.
- Squeeze the lubricant onto a facial tissue to avoid contaminating the lubricant supply.
- Insert thermometer by 0.5–1.5 inches.
- Hold in place in 2 minutes.
- Do not force to insert the thermometer.
Contraindications
- Patient with diarrhea.
- Recent rectal or prostatic surgery or injury because it may injure inflamed tissue.
- Recent myocardial infarction.
- Patient posthead injury.
- Axillary: It is the safest and noninvasive
- Pat the axilla dry.
- Ask the patient to reach across his chest and grasp his opposite shoulder. This promote skin contact with the thermometer.
- Hold it in place for 9 minutes because the thermometer isn't close in a body cavity.
Note: Use the same thermometer for repeat temperature taking to ensure more consistent result.
Pulse
- This is a wave of blood created by contraction of the left ventricle of the heart. The heart is a pulsating pump, and the blood enters the arteries with each heartbeat, causing pressure pulses or pulse waves. Generally, the pulse wave represents the stroke volume and the compliance of the arteries.
- Stroke volume is the amount of blood that enters the arteries with each contraction in a healthy adult.
- Compliance of the arteries is their ability to contract and expand. When a person's arteries lose their distensibility, greater pressure is required to pump the blood into the arteries.
Normal pulse rate
- 1 year: 80–140 beats/minute.
- 2 years: 80–130 beats/minute.
- 6 years: 75–120 beats/minute.
- 10 years: 60–90 beats/minute.
- Adult: 60–100 beats/minute.
- Tachycardia: Pulse rate of above 100 beats/minute.
- Bradycardia: Pulse rate below 60 beats/minute.
- Irregular: It is uneven time interval between beats.
Pulse sites (Fig.1.1)
- Temporal: Where the temporal artery passes over the temporal bone of the head. The site is superior and lateral to the eye.
- Carotid: At the side of the neck below the lobe of the ear, where the carotid artery runs between the trachea and the sternocleidomastoid muscle.
- Apical: At the apex of the heart.
- Brachial: At the inner aspect of the biceps muscle of the arm (especially in infants) or medially in the antecubital space (elbow crease).
- Radial: Where the radial artery runs along the radial bone, on the thumb site of the inner aspect of the wrist.
- Femoral: Where the femoral artery passes alongside the inguinal ligament.
- Popliteal: Where the popliteal artery passes behind the knee. This point is difficult to find, but it can be palpated if the client flexes the knee slightly.
- Posterior tibial: On the medial surface of the ankle where the posterior tibial artery passes behind the medial malleolus.
- Pedal (dorsalis pedis): Where the dorsalis pedis artery passes over the bones of the foot. This artery can be palpated by feeling the dorsum of the foot on the imaginary line drawn from the middle of the ankle to the space between the big and second toes.
Respiration
- It is the exchange of oxygen and carbon dioxide between the atmosphere and the body.
Assessing respiration
- Rate—Normal 14–20/minute in adult.
- The best time to assess respiration is immediately after taking client's pulse.
- Count respiration for 60 second.
- As you count the respiration, assess, and record breath sound as stridor, wheezing, or stertor.
- Resting respirations should be assessed when the client is at rest, because exercise affects respirations, and increase their rate and depth as well. Respiration may also need to be assessed after exercise to identify the client's tolerance to activity. Before assessing a client's respirations, a nurse should be aware of:
- – The client's normal breathing pattern.
- – The influence of the client's health problems on respirations.
- – Any medications or therapies that might affect respirations.
- – The relationship of the client's respirations to cardiovascular function.
Characteristics of normal respiration
- Respiratory rate
- This is described in breaths per minute. A healthy adult normally takes between 15 and 20 breaths per minute. Breathing that is normal in rate is eupnea. Abnormally slow respirations are referred to as bradypnea, and abnormally fast respirations are called tachypnea or polypnea.
- Depth
- This can be established by watching the movement of the chest. It is generally described as normal, deep, or shallow.
- Respiratory rhythm or pattern
- This refers to the regularity of the expirations and the inspirations. Normally, respirations are evenly spaced. Respiratory rhythm can be described as regular or irregular.
- Respiratory quality or character
- This refers to those aspects of breathing that are different from normal, effortless breathing. It includes:
- – Amount of effort a client must exert to breathe. Usually, breathing does not require noticeable effort.
- – The sound of breathing—Normal breathing is silent, but a number of abnormal sounds such as a wheeze are obvious to the nurse's ear.
Blood pressure
- This is the force exerted by the blood against a vessel wall. Arterial blood pressure is a measure of the pressure exerted by the blood as it flows through the arteries.There are two blood pressure measures:
- Systolic pressure: This is the pressure of the blood because of contraction of the ventricles, which is the height of the blood wave.
- Diastolic pressure: This is the pressure when the ventricles are at rest. It is the lower pressure present at all times within the arteries.
- – Pulse pressure is the difference between the diastolic and systolic pressures.
- – Blood pressure is measured in millimeters of mercury (mmHg) and recorded as a fraction. The systolic pressure is written over the diastolic pressure. The average blood pressure of a healthy adult is 120/80 mmHg. A number of conditions are reflected by changes in blood pressure. The most common is hypertension, an abnormally high blood pressure. Hypotension is an abnormally low blood pressure below 100 mmHg systolic.Adult:90–132 systolic60–85 diastolicElderly:140–160 systolic70–90 diastolic
- Ensure that the client is rested.
- If too tight and narrow—False high BP.
- If too lose and wide—False low BP.
- Position the patient on sitting or supine position.
- Position the arm at the level of the heart, if the artery is below the heart level, you may get a false high reading.
- Use the bell of the stethoscope since the blood pressure is a low frequency sound.
- If the client is crying or anxious, delay measuring his blood pressure to avoid false high BP.
Pain
How to assess pain
- You must consider both the patient's description and your observations on his behavioral responses.
- First, ask the client to rank his pain on a scale of 0–10, with 0 denoting lack of pain and 10 denoting the worst pain imaginable.
- Ask:
- Where is the pain located?
- How long does the pain last?
- How often does it occur?
- Can you describe the pain?
- What makes the pain worse?
- Observe the patient's behavioral response to pain (body language, moaning, grimacing, withdrawal, crying, restlessness muscle twitching and immobility).
- Also note physiological response, which may be sympathetic or parasympathetic.
Managing pain
- Giving medication as per MD's order.
- Giving emotional support.
- Performing comfort measures.
- Use cognitive therapy.
Oral Administration
Advantages
- The easiest and most desirable way to administer medication.
- Most convenient.
- Safe, does not break skin barrier.
- Usually less expensive.
Disadvantages
- Inappropriate if client cannot swallow and if GIT has reduced motility.
- Inappropriate for client with nausea and vomiting.
- Drug may have unpleasant taste.
- Drug may discolor the teeth.
- Drug may irritate the gastric mucosa.
- Drug may be aspirated by seriously ill patient.
Drug forms for oral administration
- Solid: Tablet, capsule, pill, and powder.
- Liquid: Syrup, suspension, emulsion, elixir, milk, or other alkaline substances.
- Syrup: Sugar-based liquid medication
- Suspension: Water-based liquid medication. Shake bottle before use of medication to properly mix it.
- Emulsion: Oil-based liquid medication
- Elixir: Alcohol-based liquid medication. After administration of elixir, allow 30 minutes to elapse before giving water. This allows maximum absorption of the medication.
“Never crush Enteric-Coated or Sustained Release Tablet”
- Crushing enteric-c-coated tablet—It allows the irrigating medication to come in contact with the oral or gastric mucosa, resulting in mucositis or gastric irritation.
Sublingual Administration
- A drug that is placed under the tongue, where it dissolves.
- When the medication is in capsule and ordered sublingually, the fluid must be aspirated from the capsule and placed under the tongue.
- A medication given by the sublingual route should not be swallowed, or desire effects will not be achieved.
Advantages
- Same as oral.
- Drug is rapidly absorbed in the bloodstream.
Disadvantages
- If swallowed, drug may be inactivated by gastric juices.
- Drug must remain under the tongue until dissolved and absorbed.
Buccal Administration
- A medication is held in the mouth against the mucous membranes of the cheek until the drug dissolves.
- The medication should not be chewed, swallowed, or placed under the tongue (e.g. sustained release nitroglycerine, opiates, antiemetic, tranquilizer, and sedatives).
- Client should be taught to alternate the cheeks with each subsequent dose to avoid mucosal irritation.
Advantages
- Same as oral.
- Drug can be administered for local effect.
- Ensures greater potency because drug directly enters the blood and bypass the liver.
Disadvantages
- If swallowed, drug may be inactivated by gastric juice.
Topical Administration
- Application of medication to a circumscribed area of the body.
- Dermatologic—It includes lotions, liniment, ointments, and powder.
- Before application, clean the skin thoroughly by washing the area gently with soap and water, soaking an involved site, or locally debriding tissue.
- Use surgical asepsis when open wound is present.
- Remove previous application before the next application.
- Use gloves when applying the medication over a large surface (e.g. large area of burns).
- Apply only thin layer of medication to prevent systemic absorption.
- Ophthalmic—It includes instillation and irrigation.
- Instillation—To provide an eye medication that the client requires.
- Irrigation—To clear the eye of noxious or other foreign materials.
- Position the client either sitting or lying.
- Use sterile technique.
- Clean the eyelid and eyelashes with sterile cotton balls moistened with sterile normal saline from the inner to the outer canthus.
- Instill eyedrops into lower conjunctival sac.
- Avoid dropping a solution onto the cornea directly, because it causes discomfort.
- Instruct the client to close the eyes gently. Shutting the eyes tightly causes spillage of the medication.
- For liquid eye medication, press firmly on the nasolacrimal duct (inner cantus) for at least 30 seconds to prevent systemic absorption of the medication.
- Otic instillation—To remove cerumen or pus or to remove foreign body.
- Warm the solution at room temperature or body temperature, failure to do so may cause vertigo, dizziness, nausea, and pain.
- Have the client assume a side-lying position (if not contraindicated) with ear to be treated facing up.
- Perform hand hygiene. Apply gloves if drainage is present.
- Straighten the ear canal:
- 0–3 years old: Pull the pinna downward and backward.
- Older than 3 years old: Pull the pinna upward and backward.
- Instill eardrops on the side of the auditory canal to allow the drops to flow in and continue to adjust to body temperature.
- Press gently bur firmly a few times on the tragus of the ear to assist the flow of medication into the ear canal.
- Ask the client to remain in side-lying position for about 5 minutes.
- At times the MD will order insertion of cotton puff into outermost part of the canal. Do not press cotton into the canal. Remove cotton after 15 minutes.
- Nasal—Nasal instillations usually are instilled for their astringent effects (to shrink swollen mucous membrane), to loosen secretions and facilitate drainage or to treat infections of the nasal cavity or sinuses. Decongestants, steroids, and calcitonin.
- Have the client blow the nose prior to nasal instillation.
- Assume a back-lying position, or sit up and lean head back.
- Elevate the nares slightly by pressing the thumb against the client's tip of the nose. While the client inhales, squeeze the bottle.
- Keep head tilted backward for 5 minutes after instillation of nasal drops.
- When the medication is used on a daily basis, alternate nares to prevent irritations.
- Inhalation—Use of nebulizer and metered-dose inhaler.
- Semi or high-Fowler's position or standing position. To enhance full chest expansion allowing deeper inhalation of the medication.
- Shake the canister several times. To mix the medication and ensure uniform dosage delivery.
- Position the mouthpiece 1–2″ from the client's open mouth. As the client starts inhaling, press the canister down to release one dose of the medication. This allows delivery of the medication more accurately into the bronchial tree rather than being trapped in the oropharynx then swallowed.
- Instruct the client to hold breath for 10 seconds to enhance complete absorption of the medication.
- Wait at least 1 minute before administration of the second dose or inhalation of a different medication by MDI.
- Instruct client to rinse mouth, if steroid had been administered. This is to prevent fungal infection.
- Vaginal—Drug forms tablet liquid (douches), jelly, foam, and suppository.
- Close room or curtain to provide privacy.
- Assist client to lie in dorsal recumbent position to provide easy access and good exposure of vaginal canal, also allows suppository to dissolve without escaping through orifice.
- Use applicator or sterile gloves for vaginal administration of medications.
- Vaginal irrigation—It is the washing of the vagina by a liquid at low pressure. It is also called douche.
- Empty the bladder before the procedure.
- Position the client on her back with the hips higher than the shoulder (use bedpan).
- Irrigating container should be 30 cm (12″) above.
- Ask the client to remain in bed for 5–10 minutes following administration of vaginal suppository, cream, foam, and jelly or irrigation.
Rectal Administration
- It can be use when the drug has objectionable taste or odor.
- Need to be refrigerated so as not to soften.
- Apply disposable gloves.
- Have the client lie on left side and ask to take slow deep breaths through mouth and relax anal sphincter.
- Retract buttocks gently through the anus, past internal sphincter and against rectal wall, 10 cm (4″) in adults, 5 cm (2″) in children and infants. May need to apply gentle pressure to hold buttocks together momentarily.
- Discard gloves to proper receptacle and perform hand washing.
- Client must remain on side for 20 minutes after insertion to promote adequate absorption of the medication.
Parenteral Administration
- Administration of medication by needle intradermal—Under the epidermis.
- The site are the inner lower arm, upper chest and back, and beneath the scapula.
- Indicated for allergy and tuberculin testing and for vaccinations.
- Use the needle gauge 25, 26, 27: Needle length 3/8″, 5/8″ or 1/2 ″.
- Needle at 10–15° angle; bevel up.
- Inject a small amount of drug slowly over 3–5 seconds to form a wheal or bleb.
- Do not massage the site of injection. To prevent irritation of the site, and to prevent absorption of the drug into the subcutaneous.
Subcutaneous
Vaccines, heparin, preoperative medication, insulin, and narcotics.
Sites
- Outer aspect of the upper arms
- Anterior aspect of the thighs
- Abdomen
- Scapular areas of the upper back
- Ventrogluteal
- Dorsogluteal.
- Only small doses of medication should be injected via SC route.
- Rotate site of injection to minimize tissue damage.
- Needle length and gauge are the same as for ID injections.
- Use 5/8 needle for adults when the injection is to administer at 45° angle; 1/2 is use at a 90° angle.
- For thin patients: 45° angle of needle
- For obese patient: 90° angle of needle
- For heparin injection: Do not aspirate.
- Do not massage the injection site to prevent hematoma formation.
- For insulin injection: Do not massage to prevent rapid absorption which may result to hypoglycemic reaction.
- Always inject insulin at 90° angle to administer the medication in the pocket between the subcutaneous and muscle layer. Adjust the length of the needle depending on the size of the client.
- For other medications, aspirate before injection of medication to check if the blood vessel had been hit. If blood appears on pulling back of the plunger of the syringe, remove the needle and discard the medication and equipment.
Intramuscular
- Needle length is 1″, 1 1/2″, 2″ to reach the muscle layer.
- Clean the injection site with alcoholized cotton ball to reduce microorganisms in the area.
- Inject the medication slowly to allow the tissue to accommodate volume.
Sites
- Ventrogluteal site:
- The area contains no large nerves, or blood vessels and less fat. It is farther from the rectal area, so it less contaminated.
- Position the client in prone or side-lying.
- When in prone position, curl the toes inward.
- When side-lying position, flex the knee and hip. These ensure relaxation of gluteus muscles and minimize discomfort during injection.
- To locate the site, place the heel of the hand over the greater trochanter, point the index finger toward the anterior superior iliac spine, and then abduct the middle (third) finger. The triangle formed by the index finger, the third finger and the crest of the ilium is the site.
- Dorsogluteal site:
- Position the client similar to the ventrogluteal site.
- The site should not be use in infant under 3 years because the gluteal muscles are not well developed yet.
- To locate the site, the nurse draw an imaginary line from the greater trochanter to the posterosuperior iliac spine.
- The injection site is lateral and superior to this line.
- Another method of locating this site is to imaginary divide the buttock into four quadrants. The uppermost quadrant is the site of injection. Palpate the crest of the ilium to ensure that the site is high enough.
- Avoid hitting the sciatic nerve, major blood vessel or bone by locating the site properly.
- Vastus lateralis:
- Recommended site of injection for infant.
- Located at the middle-third of the anterior lateral aspect of the thigh.
- Assume back-lying or sitting position.
- Rectus femoris site—It is located at the middle-third, anterior aspect of thigh.
- Deltoid site:
- Not used often for IM injection because it is relatively small muscle and is very close to the radial nerve and radial artery.
IM injection – Z tract injection- Used for parenteral iron preparation. To seal the drug deep into the muscles and prevent permanent staining of the skin.
- Retract the skin laterally, inject the medication slowly. Hold retraction of skin until the needle is withdrawn.
- Do not massage the site of injection to prevent leakage into the subcutaneous.
Intravenous
- The nurse administers medication intravenously by the following method:
- As mixture within large volumes of IV fluids.
- By injection of a bolus, or small volume, or medication through an existing intravenous infusion line or intermittent venous access (heparin or saline lock).
- By “piggyback” infusion of solution containing the prescribed medication and a small volume of IV fluid through an existing IV line.
- Most rapid route of absorption of medications.
- Predictable, therapeutic blood levels of medication can be obtained.
- The route can be used for clients with compromised gastrointestinal function or peripheral circulation.
- Large dose of medications can be administered by this route.
- The nurse must closely observe the client for symptoms of adverse reactions.
- The nurse should double-check the six rights of safe medication.
- If the medication has an antidote, it must be available during administration.
- When administering potent medications, the nurse assesses vital signs before, during, and after infusion.
Nursing interventions in IV infusion
- Verify the doctor's order.
- Know the type, amount, and indication of IV therapy.
- Practice strict asepsis.
- Inform the client and explain the purpose of IV therapy to alleviate client's anxiety.
- Prime IV tubing to expel air. This will prevent air embolism.
- Clean the insertion site of IV needle from center to the periphery with alcoholized cotton ball to prevent infection.
- Shave the area of needle insertion if hairy.
- Change the IV tubing every 72 hours. To prevent contamination.
- Change IV needle insertion site every 72 hours to prevent thrombophlebitis.
- Regulate IV every 15–20 minutes. To ensure administration of proper volume of IV fluid as ordered.
- Observe for potential complications.
Types of IV fluids
- Isotonic solution—It has the same concentration as the body fluid
- D5 W
- NaCl 0.9%
- Plain Ringer's lactate
- Plain normosol M.
- Hypotonic—It has lower concentration than the body fluids
- NaCl 0.3%.
- Hypertonic—It has higher concentration than the body fluids
- D10W
- D50W
- D5LR
- D5NM.
Listed below is a table which may serve as your quick reference guide on the different intravenous solutions.19
Description of osmolarity is given in Table 1.1
Complications of IV infusion
- Infiltration—The needle is out of vein, and fluids accumulate in the subcutaneous tissues.
- Assessment:
- – Pain, swelling, skin is cold at needle site; pallor of the site, flow rate has decreases or stops.
- Nursing intervention:
- – Change the site of needle.
- – Apply warm compress. This will absorb edema fluids and reduce swelling.
- Circulatory overload—It results from administration of excessive volume of IV fluids.
- Assessment:
- – Headache
- – Flushed skin
- – Rapid pulse
- – Increase BP
- – Weight gain
- – Syncope and faintness
- – Pulmonary edema
- – Increase volume pressure
- – SOB (shortness of breath)
- – Coughing
- – Tachypnea
- – Shock.
- Nursing interventions:
- – Slow infusion to KVO.
- – Place patient in high Fowler's position. To enhance breathing.
- – Administer diuretic, bronchodilator as ordered.
- Drug overload—The patient receives an excessive amount of fluid containing drugs.
- Assessment:
- – Dizziness
- – Shock
- – Fainting.
- Nursing interventions:
- – Slow infusion to KVO
- – Take vital signs
- – Notify physician.
- Superficial thrombophlebitis—It is due to overuse of a vein, irritating solution or drugs, clot formation, and large bore catheters.
- Assessment:
- – Pain along the course of vein.
- – Vein may feel hard and cordlike.
- – Edema and redness at needle insertion site.
- – Arm feels warmer than the other arm.
- Nursing intervention:
- – Change IV site every 72 hours.
- – Use large veins for irritating fluids.
- – Stabilize venipuncture at area of flexion.
- – Apply cold compress immediately to relieve pain and inflammation; later with warm compress to stimulate circulation and promotion absorption.
- – “Do not irrigate the IV because this could push clot into the systemic circulation”.
- Air embolism—Air manages to get into the circulatory system; 5 ml of air or more causes air embolism.
- Assessment:
- – Chest, shoulder, or back pain
- – Hypotension
- – Dyspnea
- – Cyanosis
- – Tachycardia
- – Increase venous pressure
- – Loss of consciousness.
- Nursing intervention:
- – Do not allow IV bottle to “run dry”.
- – “Prime” IV tubing before starting infusion.
- – Turn patient to left side in the Trendelenburg position. To allow air to rise in the right side of the heart. This prevent pulmonary embolism.
- Nerve damage—It may result from tying the arm too tightly to the splint.
- Speed shock—It may result from administration of IV push medication rapidly.
- To avoid speed shock, and possible cardiac arrest, give most IV push medication over 3–5 minutes.
General Principles of Parenteral Administration
- Check doctor's order.
- Check the expiration for medication—Drug potency may increase or decrease if outdated.
- Observe verbal and nonverbal responses toward receiving injection. Injection can be painful; client may have anxiety, which can increase the pain.
- Practice asepsis to prevent infection. Apply disposable gloves.
- Use appropriate needle size to minimize tissue injury.
- Plot the site of injection properly to prevent hitting nerves, blood vessels, and bones.
- Use separate needles for aspiration and injection of medications to prevent tissue irritation.
- Introduce air into the vial before aspiration. To create a positive pressure within the vial and allow easy withdrawal of the medication.
- Allow a small air bubble (0.2 ml) in the syringe to push the medication that may remain.
- Introduce the needle in quick thrust to lessen discomfort.
- Either spread or pinch muscle when introducing the medication. Depending on the size of the client.
- Minimized discomfort by applying cold compress over the injection site before introduction of medication to numb nerve endings.
- Aspirate before the introduction of medication. To check if blood vessel had been hit.
- Support the tissue with cotton swabs before withdrawal of needle. To prevent discomfort of pulling tissues as needle is withdrawn.
- Massage the site of injection to haste absorption.
- Apply pressure at the site for few minutes. To prevent bleeding.
- Evaluate effectiveness of the procedure and make relevant documentation.
Blood Transfusion Therapy
It involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in patient). One unit of whole blood consists of 450 ml of blood collected into 60–70 ml of preservative or anticoagulant. Whole blood stored for more than 6 hours does not provide therapeutic platelet transfusion, nor does it contain therapeutic amounts of labile coagulation factors (factors V and VIII).
Blood components include:
- Packed RBCs (100% of erythrocyte, 100% of leukocytes, and 20% of plasma originally present in one unit of whole blood), indicated to increase the oxygen-carrying capacity of blood with minimal expansion of blood.
- Leukocyte-poor packed RBCs, indicated for patients who have experience previous febrile no hemolytic reactions.
- Granulocytes (basophils, eosinophils, and neutrophils).
- Fresh frozen plasma, containing all coagulation factors, including factors V and VIII (the labile factors).
- Single donor plasma, containing all stable coagulation factors but reduced levels of factors V and VIII; the preferred product for reversal of Coumadin-induced anticoagulation.
- Albumin, a plasma protein.
- Cryoprecipitate, a plasma derivative rich in factor VIII, fibrinogen, factor XIII, and fibronectin.
- Factor IX concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
- Factor VIII concentrate, a concentrated form of factor IX prepared by pooling, fractionating, and freeze-drying large volumes of plasma.
- Prothrombin complex, containing prothrombin and factors VII, IX, X, and some factor XI.
Advantages of blood component therapy
- Avoids the risk of sensitizing the patients to other blood components.
- Provides optimal therapeutic benefit while reducing risk of volume overload.
- Increases availability of needed blood products to larger population.
Principles of blood transfusion therapy
- Whole blood transfusion
- Generally indicated only for patients who need both increased oxygen-carrying capacity and restoration of blood volume when there is no time to prepare or obtain the specific blood components needed.
- Packed RBCs
- Should be transfused over 2–3 hours; if patient cannot tolerate volume over a maximum of 4 hours, it may be necessary for the blood bank to divide a unit into smaller volumes, providing proper refrigeration of remaining blood until needed. One unit of packed red cells should raise hemoglobin approximately 1%, hematocrit 3%.
- Platelets
- Administer as rapidly as tolerated (usually 4 units every 30–60 minutes). Each unit of platelets should raise the recipient's platelet count by 6000–10,000/mm3: however, poor incremental increases occur with alloimmunization from previous transfusions, bleeding, fever, infection, autoimmune destruction, and hypertension.
- Granulocytes
- May be beneficial in selected population of infected, severely granulocytopenic patients (less than 500/mm3) not responding to antibiotic therapy and who are expected to experienced prolonged suppressed granulocyte production.
- Plasma
- Because plasma carries a risk of hepatitis equal to that of whole blood, if only volume expansion is required, other colloids (e.g. albumin) or electrolyte solutions, (e.g. Ringer's lactate) are preferred. Fresh frozen plasma should be administered as rapidly as tolerated because coagulation factors become unstable after thawing.
- Albumin
- Cryoprecipitate
- It indicated for treatment of hemophilia A, von Willebrand's disease, disseminated intravascular coagulation (DIC), and uremic bleeding.
- Factor IX concentrate
- It indicated for treatment of hemophilia B; carries a high-risk of hepatitis because it requires pooling from many donors.
- Factor VIII concentrate
- It indicated for treatment of hemophilia A; heat-treated product decreases the risk of hepatitis and HIV transmission.
- Prothrombin complex
- It indicated in congenital or acquired deficiencies of these factors.
Objectives
- To increase circulating blood volume after surgery, trauma, or hemorrhage.
- To increase the number of RBCs and to maintain hemoglobin levels in clients with severe anemia.
- To provide selected cellular components as replacements therapy (e.g. clotting factors, platelets, and albumin).
Nursing interventions
- Verify doctor's order. Inform the client and explain the purpose of the procedure.
- Check for cross matching and typing. To ensure compatibility.
- Obtain and record baseline vital signs.
- Practice strict asepsis.
- At least 2 licensed nurse check the label of the blood transfusion.
- Check the followings:
- – Serial number
- – Blood component
- – Blood type
- – Rh-factor
- – Expiration date
- – Screening test (VDRL, HBsAg, and malarial smear)—This is to ensure that the blood is free from blood-carried diseases and therefore, safe from transfusion.
- Warm blood at room temperature before transfusion to prevent chills.
- Identify client properly. Two nurses check the client's identification.
- Use needle gauge 18 and 19. This allows easy flow of blood.
- – Use BT set with special micron mesh filter. To prevent administration of blood clots and particles.
- Start infusion slowly at 10 gtts/minute. Remain at bedside for 15–30 minutes. Adverse reaction usually occurs during the first 15–20 minutes.
- Monitor vital signs. Altered vital signs indicate adverse reaction.
- Do not mix medications with blood transfusion. To prevent adverse effect.
- Do not incorporate medication into the blood transfusion.
- Do not use blood transfusion lines for IV push of medication.
- Administer 0.9% NaCl before; during or after BT. Never administer IV fluids with dextrose. Dextrose causes hemolysis.
- Administer BT for 4 hours (whole blood, packed RBC). For plasma, platelets, cryoprecipitate, transfuse quickly (20 minutes) clotting factor can easily be destroyed.
- Observe for potential complications. Notify physician.
Complications of blood transfusion
Allergic reaction
It is caused by sensitivity to plasma protein of donor antibody, which reacts with recipient antigen.24
- Assessments:
- – Flushing
- – Rush and hives
- – Pruritus
- – Laryngeal edema, and difficulty of breathing.
Febrile, nonhemolytic
It is caused by hypersensitivity to donor white cells, platelets or plasma proteins. This is the most symptomatic complication of blood transfusion.
- Assessments:
- – Sudden chills and fever
- – Flushing
- – Headache
- – Anxiety.
Septic reaction
It is caused by the transfusion of blood or components contaminated with bacteria.
- Assessment:
- – Rapid onset of chills
- – Vomiting
- – Marked hypotension
- – High fever.
Circulatory overload
It is caused by administration of blood volume at a rate greater than the circulatory system can accommodate.
- Assessment:
- – Rise in venous pressure
- – Dyspnea
- – Crackles or rales
- – Distended neck vein
- – Cough
- – Elevated BP.
Hemolytic reaction
It is caused by infusion of incompatible blood products.
- Assessment:
- – Low back pain (first sign). This is due to inflammatory response of the kidneys to incompatible blood.
- – Chills
- – Feeling of fullness
- – Tachycardia
- – Flushing
- – Tachypnea
- – Hypotension
- – Bleeding
- – Vascular collapse
- – Acute renal failure.
Assessment findings
- Clinical manifestations of transfusions complications vary depending on the precipitating factor.
- Signs and symptoms of hemolytic transfusion reaction include:
- Fever
- Chills
- Low back pain
- Flank pain
- Headache
- Nausea
- Flushing
- Tachycardia
- Tachypnea
- Hypotension
- Hemoglobinuria (cola-colored urine).
- Clinical signs and laboratory findings in delayed hemolytic reaction include:
- Fever
- Mild jaundice
- Gradual fall of hemoglobin
- Positive Coombs' test.
- Febrile nonhemolytic reaction is marked by:
- Temperature rise during or shortly after transfusion
- Chills
- Headache
- Flushing
- Anxiety.
- Signs and symptoms of septic reaction include:
- Allergic reactions may produce:
- Hives
- Generalized pruritus
- Wheezing or anaphylaxis (rarely).
- Signs and symptoms of circulatory overload include:
- Dyspnea
- Cough
- Rales
- Jugular vein distension.
- Manifestations of infectious disease transmitted through transfusion may develop rapidly or insidiously, depending on the disease.
- Characteristics of GVH disease include:
- Skin changes (e.g. erythema, ulce-rations, and scaling)
- Edema
- Hair loss
- Hemolytic anemia.
- Reactions associated with massive transfusion produce varying manifes-tations.
Planning and implementation
- Help prevent transfusion reaction by:
- Meticulously verifying patient identification beginning with type and cross match sample collection and labeling to double check blood product and patient identification prior to transfusion.
- Inspecting the blood product for any gas bubbles, clothing, or abnormal color before administration.
- Beginning transfusion slowly (1–2 ml/minute) and observing the patient closely, particularly during the first 15 minutes (severe reactions usually manifest within 15 minutes after the start of transfusion).
- Transfusing blood within 4 hours, and changing blood tubing every 4 hours to minimize the risk of bacterial growth at warm room temperatures.
- Preventing infectious disease transmission through careful donor screening or performing pretest available to identify selected infectious agents.
- Preventing GVH disease by ensuring irradiation of blood products containing viable WBC's (i.e. whole blood, platelets, packed RBC's and granulocytes) before transfusion; irradiation alters ability of donor lymphocytes to engraft and divide.
- Preventing hypothermia by warming blood unit to 37°C before transfusion.
- Removing leukocytes and platelets aggregates from donor blood by installing a microaggregate filter (20–40 µm size) in the blood line to remove these aggregates during transfusion.
- On detecting any signs or symptoms of reaction:
- Stop the transfusion immediately and notify the physician.
- Disconnect the transfusion set, but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion.
- Send the blood bag and tubing to the blood bank for repeat typing and culture.
- Draw another blood sample for plasma hemoglobin, culture, and retyping.
- Collect a urine sample as soon as possible for hemoglobin determination.
- Intervene as appropriate to address symptoms of the specific reaction:
- Treatment for hemolytic reaction is directed at correcting hypotension, DIC, and renal failure associated with RBC hemolysis and hemoglobinuria.
- In septic reaction, treat septicemia with antibiotics, increased hydration, steroids, and vasopressors as prescribed.
- Intervene for allergic reaction by administering antihistamines, steroids, and epinephrine as indicated by the severity of the reaction (if hives are the only manifestation, transfusion can sometimes continue but at a slower rate).
- For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen, and aminophylline may be prescribed.
Nursing interventions when complications occurs in blood transfusion
- If blood transfusion reaction occurs, stop the transfusion.
- Start IV line (0.9% NaCl).
- Place the client in fowler's position if with SOB and administer O2 therapy.
- The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.
- Notify the physician immediately.
- The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per physician's order or protocol.
- Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis.
- Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.
Evaluation
- The patient maintains normal breathing pattern.
- The patient demonstrates adequate cardiac output.
- The patient reports minimal or no discomfort.
- The patient maintains good fluid balance.
- The patient remains normothermic.
- The patient remains free of infection.
- The patient maintains good skin integrity, with no lesions or pruritus.
- The patient maintains or returns to normal electrolyte and blood chemistry values.
Immune Response
- The immune response involves specific reactions in the body to antigens or foreign material.
- This specific response is the body's attempt to protect itself, the body protects itself by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes.
- Cell-mediated immunity: T-lymphocytes are responsible for cellular immunity.
- When fungi, protozoa, bacteria, and some viruses activate T-lymphocytes, they enter the circulation from lymph tissue and seek out the antigen.
- Once the antigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to the area and keep them there to kill the antigen.
- After the antigen is gone, the lymphokines disappear.
- Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if the antigen appears again.
- Humoral response: The ability of the body to develop a specific antibody to 27a specific antigen (antigen-antibody response).
- B-lymphocytes provide humoral immunity by producing antibodies that convey specific resistance to many bacterial and viral infections.
- Active immunity is produced when the immune system is activated either naturally or artificially.
- – Natural immunity involves acquisition of immunity through developing the disease.
- – Active immunity can also be produced through vaccination by introducing into the body a weakened or killed antigen (artificially acquired immunity).
- – Passive immunity does not require a host to develop anti-bodies, rather it is transferred to the individual, passive immu-nity occurs when a mother passes antibodies to a newborn or when a person is given antibodies from an animal or person who has had the disease in the form of immune globulins; this type of immunity only offers temporary protection from the antigen.
Types of immunity
Active immunity
- Host produces antibodies in response to natural antigens or artificial antigens.
- Natural active immunity
- – Antibodies are formed in presence of active infection in the body.
- – Duration lifelong.
- Artificial active immunity
- – Antigens administered to stimulate antibody formation.
- – Lasts for many years.
- – Reinforced by booster.
Passive immunity
- Host receives natural or artificial antibodies produced from another source.
- Natural passive immunity
- – Antibodies transferred naturally from an immune mother to baby through the placenta or in colostrums.
- – Lasts 6 months to 1 year.
- Artificial passive immunity
- – Occurs when immune serum (antibody) from an animal or another human is injected.
- – Lasts 2–3 weeks.
Nosocomial Infection
- Nosocomial Infections: These are those that are acquired as a result of a health care delivery system.
- Iatrogenic infection: These nosocomial infections are directly related to the client's treatment or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning.
- Exogenous Infection: These are a result of the health care facility environment or personnel; an example would be an upper respiratory infection resulting from contact with a caregiver who has an upper respiratory infection.
- Endogenous Infection: It can occur from clients themselves or as a 28reactivation of a previous dormant organism such as tuberculosis; an example of endogenous infection would be a yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are always present in the vagina, but with the elimination of the normal bacterial flora, the yeast flourish.
Hot and Cold Applications (Table 1.2)
Heat and cold are applied to the body for local and systemic effects.
Local effects of heat
- Vasodilatation and increases blood flow to the affected area.
- Bringing (oxygen, nutrients, antibodies, and leukocytes).
- Promote soft tissue healing.
- Used for client with (joint stiffness, and low back pain).
- Sedative effect.
- Increase inflammation.
Disadvantage of heat application
Local effects of cold
- Lowers the temperature of the skin and underlying tissue
- Vasoconstriction
- Decrease capillary permeability
- Slow bacterial growth
- Decrease inflammation
- Local anesthetic effect.
Systematic effects of heat
Systematic effects of cold
Contraindications to the use of heat
- The first 24 hours after traumatic injury (heat increase bleeding and swelling).
- Active hemorrhage (heat causes vaso-dilatation and increase bleeding).
- Non inflammatory edema (heat increases capillary permeability and edema).
- Skin disorder (heat can burn or cause further damage to the skin).
- Localized malignant tumor (heat increase cell growth and accelerate metastases).
Contraindications to the use of cold
- Open wound (cold can increase tissue damage by decreasing blood flow to an open wound).
- Impaired circulation (cold can further impair nourishment of the tissue).
- Allergy and hypersensitive to cold application.
- Some people react by decrease blood pressure.
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Basic First Aid
- What is first aid?
- – The immediate care given to an injured or suddenly ill person.
- – Does not take the place of proper medical treatment.
Initial assessment:
- Goal of the initial assessment:
- – Visually determine whether there are life-threatening or other serious problems that require quick care.
- – Determine if victim is conscious by tap and shout. Check for ABC as indicated:
- – A = Airway Open?—Head-tilt/Chin-lift.
- – B = Breathing?—Look, listen, and feel.
- – C = Circulation?—Check for signs of circulation.
Note: These step-by-step initial assessment should not be changed. It takes less than 1 minute to complete, unless first aid is required at any point.
Victim assessment sequence:
- Assessment sequence components:
- – If victim is responsive
- – Ask them what injuries or difficul-ties they are experiencing.
- – Check and provide first aid for these complaints as well as others that may be involved.
- – If victim is not responsive (unconscious or incoherent).
- – Observe for obvious signs of injury or illness:
- Check from head to toe.
- – Provide first aid/CPR for injuries or illness observed.
Bleeding control
- Control methods for external bleeding:
- – Direct pressure stops most bleeding.
- – Wear medical examination gloves (if possible).
- – Place a sterile gauze pad or a clean cloth over wound.
- – Elevation injured part to help reduce blood flow.
- – Combine with direct pressure over the wound (this will allow you to attend to other injuries or victims).
- – If bleeding continues, apply pressure at a pressure-point to slow blood flow.
- – Pressure-point locations:
- Brachial (top of elbow)
- Femoral (inside upper thigh).
- Control methods for internal bleeding:
- – Signs of internal bleeding:
- – Bruises or contusions of the skin.
- – Painful, tender, rigid, and bruised abdomen.
- – Vomiting or coughing up blood.
- – Stools that are black or contain bright red blood.
- – What to do?
For severe internal bleeding, follow these steps:
- Monitor ABC's (airway breathing circulation).
- Keep the victim lying on his/her left side. (This will help prevent expulsion of vomit from stomach, or allow the vomit to drain and also prevent the victim from inhaling vomit).
- Treat for shock by raising the victim's legs 8″ – 12″.
- Seek immediate medical attention.
Shock
- Shock refers to circulatory system failure that happens when insufficient amounts of oxygenated blood is provided for every body parts. This can be as the result of:
- – Loss of blood due to uncontrolled bleeding or other circulatory system problem.
- – Loss of fluid due to dehydration or excessive sweating.
- – Trauma (injury).
Occurrence of an extreme emotional event:
- What to look for?
- – Altered mental status.
- – Anxiety and restlessness.
- – Pale, cold, and clammy skin, lips, and nail beds.
- – Nausea and vomiting.
- – Rapid breathing and pulse.
- – Unresponsiveness when shock is severe.
- What to do?
- – After first treating life-threatening injuries such as breathing or bleeding, the following procedures shall be performed:
- – Lay the victim on his or her back.
- – Raise the victim's legs 8″ – 12″ to allow the blood to drain from the legs back to the heart.
- – Prevent body heat loss by putting blankets and coats under and over the victim.
Burns
Burns have been described as:
- First-degree burns (superficial)
- – Only the skin's outer layer (epidermis) is damaged.
- – Symptoms include redness, mild swelling, tenderness, and pain.
- – Usually heals without scarring.
- What to do?
- – Immerse in cold water 10–45 minutes or use cold and wet clothes.
- – Cold stops burn progression
- – May use other liquids—Aloe, moisturizer lotion.
- Second-degree burns (partial thickness)
- – Epidermis and upper regions of dermis are damaged.
- – Symptoms include blisters, swelling, weeping of fluids, and severe pain.
- What to do?
- – Immerse in cold water/wet pack
- – Aspirin or ibuprofen
- – Do not break blisters
- – May seek medical attention.
- Third-degree burns (full thickness)
- – Severe burns that penetrate all the skin layers, into the underlying fat and muscle.
- – Symptoms include: The burned area appears gray-white, cherry- red, or black; there is no initial edema or pain (since nerve- endings are destroyed).
- What to do?
- Burn injuries can be classified as follow:
- – Thermal (heat) burns caused by:
- – Flames
- – Hot objects
- – Flammable vapor that ignites
- – Steam or hot liquid.
- What to do?
- – Stop the burning.
- – Remove victim from burn source.
- – If open flame, smoother with blanket, coat or similar item, or have the victim roll on ground.
- – Determine the depth (degree) of the burn.
- Chemical burns
- – The result of a caustic or corrosive substance touching the skin caused by:
- – Acids (batteries)
- – Alkalis (drain cleaners—Often more extensive)
- – Organic compounds (oil products)
- What to do?
- – Remove the chemical by flushing the area with water
- – Brush dry powder chemicals from the skin before flushing
- – Take precautions to protect yourself from exposure to the chemical.
- – Remove the victim's contaminated clothing and jewelry while flushing with water.
- – Flush for 20 minutes all chemical burns (skin, and eyes).
- – Cover the burned area with a dry, and sterile dressing.
- – Seek medical attention.
- Electrical burns
- – A mild electrical shock can cause serious internal injuries.
- – There are three types of electrical injuries:
- – Thermal burn (flame)—Objects in direct contact with the skin are ignited by an electrical current.Mostly caused by the flames produced by the electrical current and not by the passage of the electrical current or arc.
- – Arc burn (Flash)—It occurs when electricity jumps, or arcs, from one spot to another.Mostly cause extensive superficial injuries.
- – True electrical injury (contact)— Occurs when an electric current truly passes through the body.
- What to do?
- – Make sure the scene is safe.
- – Unplug, disconnect, or turn off the power.
- – If that is impossible, call the power company or EMS for help.
- – Do not contact high voltage wires.
- – Consider all wires live.
- – Do not handle downed lines.
- – Do not come in contact with person if the electrical source is live.
- – Check ABCs. (airway breathing circulation).
- – If the victim fell, check for a spinal injury.
- – Treat the victim for shock by elevating the legs 8″ – 12″ if no spinal injury is suspected.
- – Seek medical attention immediately.
Choking
- What is it?
- – Obstruction in the airway.
- General precaution
- – If someone is coughing, leave the person alone.
- – Do not perform the Heimlich maneuver.
- – Keep eyes on that person.
- – Ask the person if he/she needs help.
- What to do?Perform Heimlich maneuver if you are properly trained.
- – Conscious victim:
- – Approach from behind and wrap arms around the victim's waist.
- – Place one fist just above the victim's navel with the thumb side against the abdomen.
- – Second hand over the fist.
- – Press into the victim's abdomen with one upward thrust.
- – Repeat thrust if necessary.
- – Try to pop the obstruction out with swift thrusts in and up.
- – Continue until the obstruction is relieved or victim collapses.
- – Have someone call for help.
Note: Always stay calm.
- What to do?
- – Unconscious victim:
- – Ask someone for help.
- – Lower victim to floor on back or left side and perform Heimlich maneuver.
- – Open airway with tongue-jaw lift.
- – Look inside mouth—If you cannot see anything, do not do a finger sweep.
- – Try to give two full rescue breaths.
- – If these do not go in, reposition the head and give another breath.
- – Perform abdominal thrusts.
- – Continue until successful or help arrives.
Fractures
- There are two categories of fractures:
- – Closed (simple) fracture
- – The skin is intact and no wound exists anywhere near the fracture site.
- – Open (compound) fracture
- – The skin over the fracture has been damaged or broken.
- – The wound may result from bone protruding through the skin.
The bone may not always be visible in the wound.
- What to look for:
- – General signs and symptoms:
- – Tenderness to touch.
- – Swelling.
- – Deformities may occur when bones are broken, causing an abnormal shape.
- – Open wounds break the skin.
- – A grating sensation caused by broken bones rubbing together.
- Can be felt and sometimes even heard.
- Do not move the injured limb in an attempt to detect it.
- Loss of use
- – Additional signs and symptoms include:
- – The history of the injury can lead to suspect a fracture whenever a serious accident has happened.
- The victim may have heard or felt the bone snap.
Amputation
- What to do?
- – Control the bleeding.
- – Treat the victim for shock.
- – Recover the amputated part and whenever possible take it with the victim.
- – To care for the amputated body part:
- – The amputated part does not need to be cleaned.
- – Wrap the amputated part with a dry sterile gauze or other clean cloth.
- – Keep the amputated part cool, but do not freeze.
- – Place the bag or container with the wrapped part on a bed of ice.
- – Seek medical attention immedia-tely.
Bites and stings
Insect stings and bites
- What to look for:
- – Check the sting site to see if a stinger and venom sac are embedded in the skin.
- – Bees are the only stinging insects that leave their stingers and venom sacs behind.
- – Scrape the stinger and venom sac away with a hard object such as a long fingernail, credit card, scissor edge, or knife blade.
- – Reactions generally localized pain, itching, and swelling.
- – Allergic reaction (anaphylaxis) occurs will be a life-threatening.
Insect stings and bites control.
- What to do?
- – Ask the victim if he/she has had a reaction before.
- – Wash the sting site with soap and water to prevent infection.
- – Apply an ice-pack over the sting site to slow absorption of the venom and relieve pain.
- – Because bee venom is acidic, a paste made of baking soda and water can help.
- – Seek medical attention if necessary.
Tick bites
- Tick can remain embedded for days without the victim's realizing it.
- Most tick bites are harmless, although ticks can carry serious diseases.
Symptoms usually begin 3–12 days after a tick bites.
Tick bites control.
- What to do?
- – The best way to remove a tick is with fine-pointed tweezers. Grab as closely to the skin as possible and pull straight back, using steady but gentle force.
- – Wash the bite site with soap and water.
- – Apply rubbing alcohol to further disinfect the area.
- – Apply an ice-pack to reduce pain.
- – Calamine lotion may provide relief from itching.
- – Keep the area clean.
- – Continue to watch the bite site for about one month for a rash.
- – If rash appears, see a physician.
Also watch for other signs such as fever, muscle aches, sensitivity to bright light, and paralysis that begins with leg weakness.
First aid treatment of snake bite
Aims of first-aid
- Attempt to retard systemic absorption of venom.
- Preserve life and prevent complications before the patient can receive medical care.
- Control distressing or dangerous early symptoms of envenoming.
- Arrange the transport of the patient to a place where they can receive medical care.
- Above all, aim to do no harm!
- – The greatest fear is that a snake-bite victim might develop fatal respiratory paralysis or shock before reaching a place where they may be resuscitated.As far as the snake is concerned— Do not attempt to kill it as this may be dangerous.
- – Most traditional first aid methods should be discouraged : they do more harm than good !
- – Antivenom is the only specific antidote to snake venom. A most important decision in the management of a snake-bite victim is whether or not to administer antivenom.
Communication
- It means to establish a helping-healing relationship. All behavior communication-influences behavior.
- Communication is essential to the nurse-patient relationship for the following reasons:
- – It is the vehicle for establishing a therapeutic relationship.
- – It means by which an individual influences the behavior of another, which leads to the successful outcome of nursing intervention.
Basic elements of the communication process
- Sender—This is the person who encodes and delivers the message.
- Messages—This is the content of the communication. It may contain verbal, nonverbal, and symbolic language.
- Receiver–This is the person who receives the decodes the message.
- Feedback—This is the message returned by the receiver. It indicates whether the meaning of the sender's message was understood.
Modes of communication
- Verbal communication—It is the use of spoken or written words.
- Nonverbal communication—It is the use of gestures, facial expressions, posture/gait, body movements, physical appearance, and body language.
Characteristics of good communication
- Simplicity: It includes uses of commonly understood, brevity, and completeness.
- Clarity—It involves saying what is meant. The nurse should also need to speak slowly and enunciate words well.
- Timing and relevance: It requires choice of appropriate time and consideration of the client's interest and concerns. Ask one question at a time and wait for an answer before making another comment.
- Adaptability: It involves adjustments on what the nurse says and how it is said depending on the moods and behavior of the client.
- Credibility: It means worthiness of belief. To become credible, the nurse requires adequate knowledge about the topic being discussed. The nurse should be able to provide accurate information, to convey confidence and certainly in what she says.
Aseptic and Antisepic Techniques
- Aseptic technique: The prevention of microbial contamination of tissues and sterile materials by excluding, removing or killing micro-organisms.
- Disinfection: It involves the killing or removal of sufficient microbes to render an inanimate object safe for its intended purpose.
- Cross infection: The transfer of microbes in hospitalized patients to other patients.
- Autoinfection: Infection caused by organisms already colonizing the patient's body or in septic lesions.
Use of antiseptics and aseptic techniques
Prevention of infection in surgical wounds
For prevention of infection in surgical wounds one has to identify the sources and routes of infection.
The source of infection in surgical wounds can be:
- The patient.
- Staff (a healthy carrier, incubating an infectious disease or with overt clinical illness).
- The operation room.
- Occasionally instruments.
The routes of infection are:
- Personal contact: Patient-to-patient, patient-to-staff, and staff-to-patient.
- Airborne.
Ward and OPD
Ward
Patient
Common organisms in the absence of infection are gram-positives like staphylococcus and streptococcus found on the skin resisting dryness.
Gram-negatives are not resistant and are not common causes in clean wounds.
- Preventative measures
- – Short hospital stay preoperatively.
- – Shower a day before surgery.
- – Treatment of any infectious site before surgery.
- – Aseptic methods with sterile equip-ment for all procedures.
- Special preparations, e.g. bowel preparation for colonic surgery.
Staff
- Preventative measures to be taken
- – Skin disinfection between contact with patients by detergent (soap and water) in the wards or OPD and use of antiseptic in intensive care and neonatal units.
- – Treatment for identified carriers and full blown cases, e.g. boils.
- – Prophylactic antibiotics when indicated.
Operating theater
- Most bacteria-infecting surgical incisions are implanted during the operation. Therefore strict asepsis has to be maintained.
Staff
- Wear clean clothes, shoes or covers, mask and cap or hood beyond the green line.
- Scrubbing up of all operating team before each operation for at least 5 minutes with an antiseptic soap or detergent. To prevent skin damage, brushes should be used only to clean under the nails. Finally, dry with sterile towel and apply 70% alcohol or povidone-iodine if available.
- Put on sterile gloves and gowns in an aseptic manner.
Patient
- Shave hair immediately before surgery.
- Clean the operation field with antiseptic containing:
- – Chlorhexidine and 2.5% iodine for adults.
- – 70% alcohol for children.
- – Povidone iodine for all ages if available.
- – Finally, cover with sterile drapes.
Operating room
There are few bacteria in the air of an empty theater but every individual liberates about 10,000 organisms per minute into the air. Therefore, to decrease airborne infections, keep the number of personnel reduced to a minimum. Unnecessary movement should also be discouraged. There should be adequate ventilation for most procedures. If there is no system to provide this, windows should be open to allow ingress of fresh outside air and escape of anesthetic gases.
Keep all doors closed except as needed for passage of equipment and personnel.
Clean operating rooms between operations. At regular intervals, conduct a more thorough cleaning by mopping the floor and washing the walls with detergents.
Instruments
All instruments and garments to be used in surgical procedures must be sterile and this is attained by sterilization.
Sterilization
It is a process by which inanimate objects are made free of all micro-organisms. Widely used methods of sterilization in a hospital are:
- Autoclaving: This is the preferred method of sterilization. It uses steam at a pressure of 750 mmHg above atmospheric pressure and temperature of 120°C for 15–30 minutes. The steam is helpful for penetration even into spores. Appropriate indicators must be used each time to show that the sterilization is accomplished.
- Dry heat: This is a poor alternative but suitable for metal instruments. It uses a temperature of 170°C for 2 hours.
Note: Boiling is an unreliable means of sterilization and it is not recommended.
Appendix
- Properties of commonly used anti-septics.
- Alcohols (e.g. ethyl and isopropyl): Broad spectrum, rapid action, mode-rately expensive, most active against bacteria at 70% concentration.
- Chlorhexidine: Good activity against staphylococci and streptococci, moderate activity against gram-negative bacteria, persistent action, moderately expensive, nontoxic, and unpleasant taste.
- Iodine (Lugol's solution): Broad spectrum, cheap, stains, and hyper-sensitive.
- Povidone iodine: Broad spectrum, moderately expensive, some hypersensitivity, and rapid inactivation by blood.
Suture Materials and Suturing
Suture
Suture is a thread-like material used to close surgical wounds and unite two edges of cut tissue.
Types of suture materials
Suture materials can generally be classified as absorbable and nonabsorbable.
Absorbable
This is a type of suture material that gets absorbed by the tissue, e.g. catgut (natural or biologic type) and vicryl (synthetic).
Nonabsorbable
This is a type of suture material that remains unabsorbed by the tissue, e.g. silk (natural or biologic type) and nylon (synthetic).37
Anesthesia
Diagnostic tests
- Preanesthetic patient evaluation and preparation: The purpose of pre- anesthetic assessment is to present the patient for surgery in the best possible condition. Preanesthetic assessment and preparation should include:
- – Medical history.
- – Relevant physical examination.
- – Checking the results of tests or investigation.
- – Correct or improve any medical conditions before surgery.
- – Prescribing any drugs for pre-medication (if needed).
- – Explaining to the patient the procedure of anesthesia.
Systemic (general) anesthesia
Definition
Several different types of drugs with different properties can produce the state of anesthesia.
General anesthesia— The method of making the patient pain-free and unaware about what is going on during the surgery.
Regional anesthesia— A method of blocking of nerve impulses before they reach the central nervous system using local acting drugs in order to induce analgesia and /or relaxation.
Advantages of general anesthesia
- It can be given quickly.
- It makes the patient's whole body insensitive to pain.
- It makes the patient unconscious.
A general anesthesia may cause both respiratory and cardiovascular complications, which will require intervention. To fight against the complications, one should:
- Keep a vein open before anesthesia.
- Have to prepare equipments for securing airway and possible venti-lation.
Steps of general anesthesia
- Premedication
- Induction
- Maintenance
- Recovery.
Maintenance of anesthesia— The anesthesia can be maintained with:
- Inhalation agent halothane or ether ± muscle relaxant.
- Inhalation agent + ketamine ± muscle relaxant.
- Intermittent ketamine or ketamine drip ± muscle relaxant.
- Muscle relaxants for maintenance which usually are long-acting ones (e.g. pancuronium, and vecuronium).
Monitoring— During anesthesia it is important to do strict monitoring of heart beat, blood pressure, respiration, temperature, fluid balance, and urine output.
Regional anesthesia
Before performing conduction block, full facilities for resuscitation should be available.
Toxicity of local anesthetics
All local anesthetic drugs are potentially toxic due to:
- Allergic reactions
- Systemic toxicity due to accidental intravascular injection or overdose.
- – CNS-toxicity
- – Drowsiness.
This presents with unconsciousness, which progresses to convulsion, cardio-vascular toxicity, hypotension and cardiac dysrhythmia.
Types of conduction blocks
Spinal anesthesia
- Definition: Spinal anesthesia is a conduction block of nerve roots, 38achieved by injecting a small volume of concentrated local anesthetic solution into the subarachnoidal space through the lumbar puncture. The level of lumbar puncture is at the interspaces between the 3rd and 4th lumbar vertebrae. The procedure should be performed with strict aseptic technique.
- Indications: Spinal anesthesia is appropriate for procedures involving below the level of umbilicus like in the lower extremities, hip, perineum, lower abdomen, and lumbar spine.
- Complications of spinal anesthesia and measures to take:
- – Drop in blood pressure—Due to high spinal block.
- – Give oxygen—Make faster the drip, if that does not help.
- – Bradycardia
- – Give atropine 0.01 mg/kg IV.
- – Total spinal block with anesthesia and paralysis of the whole body.
- – Intubate and ventilate
- – Treat hypotension
- – Postspinal headache
- – Bed rest
- – Hydration.
Nerve block
- Definition: Nerve block is injection of a solution of local analgesic drug near the nerve or nerves supplying the area to be operated on. The commonly used local anesthetic drug is lidocaine with concentration of 1–2%.
- Commonly performed nerve blocks:
- – Digital nerve block
- – Axillary block of the brachial plexus
- – Wrist-block.
Field block
- Definition: Field block is injection of local analgesic so as to create a zone of analgesia around the operative field. It can be used for:
- – Repair of an inguinal hernia
- – Cesarean section
- – Circumcision.
Infiltration
- Definition: Infiltration is direct injection of drugs into the area to be incised and between bone-ends in fractures. Lidocaine 0.5% is adequate for simple infiltration.
Topical anesthesia
- Definition: This can be performed simply by applying 4% lidocaine to the mucous membrane, for minor surgery and instrumentation of:
- – Nose
- – Mouth
- – Eye
- – Pharynx and larynx
- – Urethral procedures.
PPD test
- Read result 48–72 hours after injection.
- For HIV positive clients, in duration of 5 mm is considered positive.
Bronchography
- Secure consent.
- Check for allergies to seafood or iodine or anesthesia.
- NPO 6–8 hours before the test.
- NPO until gag reflex return to prevent aspiration.
Thoracentesis—(aspiration of fluid in the pleural space)
- Secure consent, take V/S.
- Position upright leaning on over bed table.
- Turn to unaffected side after the procedure to prevent leakage of fluid in the thoracic cavity.
- Check for expectoration of blood. This indicate trauma and should be reported to MD immediately.
Holter monitor
- It is an ambulatory technique with device used to detect cardiac arrhythmia, abnormal changes in cardiac rate and silent myocardial ischemia.
- Holter monitoring also called 24 hour ambulatory ECG monitoring and is useful test for monitoring cardiac arrhythmias.
Purposes
- To detect suspected rhythm disturbances.
- To evaluate chest pain.
- To evaluate other signs and symptoms which may be related to heart disease such as fatigue, shortness of breath, dizziness, fainting attacks, palpitations, etc.
Note: Prevent the holter monitor from getting wet.
Echocardiogram
- It is a diagnostic procedure using ultra-sonic waves to study the structure and function of the heart.
- It is important diagnostic tool for detecting pericardial effusion, vulvular abnormalities, enlargement of the chambers of the heart and wall motion abnormality of left ventricle.
Electrocardiograph
An electrocardiograph is the graphic representation of the electric activity of the heart muscles that forms a series of waves and complexes known as the P wave, QRS complexes, and T wave.
- P wave: The sequential activation (depolarization) of the right and left atria.
- QRS complex: Right and left ventricular depolarization (normally the ventricals are activated simultaneously).
- ST –T: Ventricular repolarization.
- U wave: Origin for this wave is not clear, but probably represents “after depolarization” in the ventricles.
- PR interval: Time interval from onset of atrial depolarization (P wave) to onset of ventricular depolarization (QRS complex).
- QRS interval: Duration of ventricular muscle depolarization.
- QT interval: Duration of ventricular depolarization and repolarization.
- RR interval: Duration of ventricular cardiac cycle (an indicate of ventricular rate).
- PP interval: Duration of atrial cycle (an indicator of atrial rate).
12 lead ECG consists 4 limb lead and 6 chest lead which give 12 ECG pattern in ECG paper.
- – Bipolar limbs leads (frontal plane)
- Lead I: RA (–) to LA (+) (right left or lateral).
- Lead II: RA (–) to LF (+) (superior inferior).
- Lead III: LA (–) to LF (+) (superior inferior).
- – Augmented unipolar limb leads (frontal plane):
- Lead aVR: RA (+) to (LA and LF) (–) (rightward).
- Lead AVL: LA (+) to (RA and LF) (–) (leftward).
- Lead aVF (+) to (RA and LA) (–) (inferior) V1 to v6.
Cardiac catheterization
It is the study of the heart and blood vessels (anatomy and hemodynamics) by 40passing small tubes known as vascular catheters through the peripheral vessels by percutaneous approach. Femoral artery and veins are the preferred sites although radial arterial approach is also being popular for coronary studies.
- Secure consent
- Assess allergy to iodine and shellfish.
- V/S and weight for baseline information.
- Have client void before the procedure.
- Monitor PT, PTT, and ECG prior to test.
- NPO for 4–6 hours before the test.
- Shave the groin or brachial area.
- After the procedure—Bed rest to prevent bleeding on the site, do not flex extremity.
- Elevate the affected extremities on extended position to promote blood supply back to the heart and prevent thrombophlebitis.
- Monitor V/S especially peripheral pulses (feel distal pulse).
- Apply pressure dressing over the puncture site.
- Monitor extremity for color, tempe-rature, tingling to assess for impaired circulation.
MRI
- Secure consent.
- The procedure will last 45–60 minutes.
- Assess client for claustrophobia.
- Remove all metal items.
- Client should remain still.
- Tell client that he will feel nothing but may hear noises.
- Client with pacemaker, prosthetic valves, implanted clips, and wires are not eligible for MRI.
- Client with cardiac and respiratory complication may be excluded.
- Instruct client on feeling of warmth or shortness of breath if contrast medium is used during the procedure.
UGIS – barium swallow
- Instruct client on low-residue diet 1–3 days before the procedure.
- Administer laxative evening before the procedure.
- NPO after midnight.
- Instruct client to drink a cup of flavored barium.
- X-rays are taken every 30 minutes until barium advances through the small bowel.
- Film can be taken as long as 24 hours later.
- Force fluid after the test to prevent constipation/barium impaction.
LGIS – barium enema
- Instruct client on low-residue diet 1–3 days before the procedure.
- Administer laxative evening before the procedure.
- NPO after midnight.
- Administer suppository in AM.
- Enema until clear.
- Force fluid after the test to prevent constipation/barium impaction.
Liver biopsy
- Secure consent.
- NPO 2–4 hours before the test.
- Monitor PT and vitamin K at bedside.
- Place the client in supine at the right side of the bed.
- Instruct client to inhale and exhale deeply for several times and then exhale and hold breath while the MD insert the needle.
- Right lateral postprocedure for 4 hours to apply pressure and prevent bleeding.
- Bed rest for 24 hours.
- Observe for S/S of peritonitis.
Paracentesis
- Secure consent, and check V/S.
- Check for serum protein. Excessive loss of plasma protein may lead to hypovolemic shock.
Lumbar puncture
- Obtain consent.
- Instruct client to empty the bladder and bowel.
- Position the client in lateral recumbent with back at the edge of the examining table.
- Instruct client to remain still.
- Obtain specimen per MDs order.
Laboratory and diagnostic examination
Urine specimen
- Clean-catch midstream: It is urine specimen for routine urinalysis, culture, and sensitivity test.
- Best time to collect is in the morning, first voided urine.
- Provide sterile container.
- Do perineal care before collection of the urine.
- Discard the first flow of urine.
- Label the specimen properly.
- Send the specimen immediately to the laboratory.
- Document the time of specimen collection and transport to the laboratory.
- Document the appearance, odor, and usual characteristics of the specimen.
- 24-hour urine specimen
- Discard the first voided urine.
- Collect all specimens thereafter until the following day.
- Soak the specimen in a container with ice.
- Add preservative as ordered accor-ding to hospital policy.
- Second-voided urine—It is required to assess glucose level and for the presence of albumen in the urine.
- Discard the first urine.
- Give the patient a glass of water to drink.
- After few minutes, ask the patient to void.
- Catheterized urine specimen
- Clamp the catheter for 30 minutes to 1 hour to allow urine to accumulate in the bladder and adequate specimen can be collected.
- Clamping the drainage tube and emptying the urine into a container are contraindicated after a genito-urinary surgery.
Stool specimen
- Fecalysis: It is to assess gross appearance of stool and presence of ova or parasite.
- Secure a sterile specimen container.
- Ask the patient to defecate into a clean, dry bedpan or a portable commode.
- Instruct client not to contaminate the specimen with urine or toilet paper (urine inhibits bacterial growth and paper towel contain bismuth) which interfere with the test result.
- Stool culture and sensitivity test
- To assess specific etiologic agent causing gastroenteritis and bacterial sensitivity to various antibiotics.
- Fecal occult blood test
- These are valuable test for detecting occult blood (hidden) which may be present in colorectal cancer, detecting melena stool
- Hematest (an Orthotolidin reagent tablet).
- Hemoccult slide (filter paper impregnated with guaiac).Note: Both test produces blue reaction id occult blood lost exceeds 5 ml in 24 hours.
- Colocare—It is a newer test, requires no smear.
Instructions
- Patient is advice on a high residue diet.
- Avoid dark food and bismuth compound.
- If client is on iron therapy, inform the MD.
- Make sure the stool is not contaminated with urine, soap solution or toilet paper.
- Test sample from several portion of the stool.
Venipuncture
Pointers
- Never collect a venous sample from the arm or a leg that is already being used for IV therapy or blood administration because it may effect the result.
- Never collect venous sample from an infectious site because it may introduce pathogens into the vascular system.
- Never collect blood from an edematous area, AV shunt, site of previous hematoma, or vascular injury.
- Don't wipe off the povidineiodine with alcohol because alcohol cancels the effect of povidone iodine.
- If the patient has a clotting disorder or is receiving anticoagulant-coagulant therapy, maintain pressure on the site for at least 5 minutes after withdrawing the needle.
- Arterial puncture for ABG test: Blood gas analysis, also called arterial blood gas (ABG) analysis. It is a procedure to measure the partial pressure of oxygen (O2), carbon dioxide (CO2) gases and pH (hydrogen ion concentration) in arterial blood.
Purpose
- To diagnose and evaluate respiratory diseases.
- To assess the integrity of the ventilator control system.
- To evaluate the efficiency of pulmonary gaseous exchange.
- To monitor the respiratory therapy.
- To evaluate the acid base level in the blood.
Indication
- Postoperative cardiac surgery.
- The significant change in ventilation mode or FiO2.
- After extubation.
- Following cardiac arrest.
- Any deterioration inpatient, e.g. change in conscious level.
- Any problem with ventilation.
- Any sign of respiratory distress.
- Syringe should be heparinized before sample is collected (clotting should be avoided).
- Syringe should be free from air both before and after the sample is collected.
- If the patient has just received a nebulizer treatment, wait about 20 minutes before collecting the sample.
Normal values— The following results are for arterial blood at sea level (at altitude of 3,000 feets and above, the values of oxygen are lower).
Partial pressure of oxygen (PO2 75–100 millimeters of mercury (mmHg).
Note: That PO2 values normally decline with age.
- Partial pressure of carbon dioxide PCO2 35–45 mmHg.
- pH: 7.35–7.45.
- Oxygen content (O2CT): 15–23 volume%
- Oxygen saturation (SaO2): 94–100%.
- Concentration of bicarbonate (HCO3): 22–26 milimols per liter (mEq/l).
Note: 1 ml of blood is enough for ABG.
Blood specimen
- No fasting for the following tests:
- CBC, Hgb, Hct, clotting studies, enzyme studies, and serum electrolytes.
- Fasting is required:
- FBS, BUN, creatinine, and serum lipid (cholesterol and triglyceride).
Sputum specimen
- Gross appearance of the sputum:
- Sputum culture and sensitivity test:
- Use sterile container.
- Collect specimen before the first dose of antibiotic.
- Acid-fast bacilli:
- To assess presence of active pulmonary tuberculosis.
- Collect sputum in three consecutive mornings.
- Cytologic sputum examination:
- To assess for presence of abnormal or cancer cells.
Procedures
- ECG monitoring: An electrocardiogram (ECG) is a graphical representation of the heart's electrical activity. The ECG monitor is a machine that displays the current electrical activity in the patient's heart. Leads—Red = minus (–) yellow = plus (+); black = Earth.
- Water-sealed drainage: It is a process of inserting drain tube in the chest to drain serogenous fluid, air, pus, and blood. Drain could not be obtained by applying negative pressure through chest tube in release space occupying content. The drain may be obtained by spontaneously or within negative pressure suction. The negative pressure is kept for those whose lungs collapsed and pressure is kept in between 5–15 mmHg. There is special type of negative suction which measures in cm. of water, it should be 10–15 cm H2O.
The level of water must be above the tip of drain tube. check the position of tube by X-ray. Always place the chest drainage bottles 2–3 fit below the patient side. Check the tube for pressed or kink, stressed and any leakage. Check the tube fluctuation as per respiration.
Arterial line
It is the method of direct continuous monitoring of systemic arterial pressure by inserting a catheter into a peripheral artery either in arm or leg. The catheter is connected to a transducer. The transducer is kept in midauxiliary line at the heart level of the patient. The pressurized bag is filled with heparinized normal saline and maintain a continuous pressure of 300 mmHg.
Purpose
- To access continuous measurement of arterial blood pressure.
- To access for multiple blood sampling and blood gas analysis.
Common site of arterial line
- Radial and femoral.
- Others: Brachial, dorsalis pedis, and axillary artery.
Complications
- Peripheral ischemia and gangrene
- Thromboembolism
- Damage to peripheral nerves.
Points to remember:
- Never give any medicine through an arterial line.
- Always check pressure of the pressurized bag and maintain a pressure of 300 mmHg.
- Always compress the site after removal of arterial line for 5 minutes.
- Inspect the area distal and proximal to the insertion site for changes in color, redness, cyanosis and changes in temperature and perfusion.
Central venous pressure
CVP is defined as the pressure of blood in central venous system. Arbitraily this location is superior vena cava to right atrium junction. CVP is usually measured by assessing a peripheral vein and inserting 44a catheter through it and placed in SVC- RA junction. This procedure usually done under aseptic technique. The normal CVP level is 5–12 cm of H2O.
Purpose
- To determine the filling pressure in the heart.
- To evaluate the effectiveness of the pumping mechanism of the heart.
- To evaluate vascular tone.
- To administer drugs.
- To provide total parenteral nutrition for a long time period.
Suctioning the patient
Suctioning is a method to remove excessive secretion from a patient's airway to facilitate breathing and keep it clear and patent.
Points to remember
- Make sure that all equipment are at functioning.
- Regulate the pressure.
- Never use the oily substance to lubricate the tube.
- Never cut the suction tube.
- Oropharyngeal suctioning and nasopharyngeal suctioning.
- Check the equipment for proper functioning and regulate the pressure with adjustment knob.
- – 50–95 mmHg (5–9.5 cm) for infant.
- – 100–115 mmHg (10–11.5 cm) for children.
- – 150–200 mmHg (15–20 cm) for adult.
- Estimate the catheter length. Measure the distance from middle of the chin to tragus of the ear.
- Insert the catheter into oral cavity without closing the control vent or ‘Y’ connector or thumb pressure.
- Close the control vent with thumb and withdraw the catheter slowly with rotating motion between index finger in thumb finger.
- Apply suction not more than 10 seconds at a time.
- Clear the connecting tube by sucking water about 50–100 ml.
- Endotracheal suction: Endotracheal suctioning is a sterile procedure and all the precautions should be taken to prevent the use of contaminated equipment during suction procedure.Sterile suction technique should be used on intubated patient and clean technique on all other patients.
- Ventilate the patient with 100% oxygen for one or two minutes.
- Catheter size is choosen, for the intubated patient the catheter size must be no bigger than half of the internal diameter of the endotracheal tube (take the size of the ET tube and multiply by 3 and divide by 2). For nasopharyngeal and oropharyngeal suction the smallest catheter size is used usually 10, 12, and 14.
- Suction system is turned on and the pressure set between 70–120 mmHg in adults.
- The catheter is inserted until a cough is stimulated, if no cough, then feed the catheter down until you hit the carina, then withdraw about 1 cm pull the catheter backward-little.
- Apply suction by closing Y-vent.
- Remember it should be within 10–15 seconds.
- After ET suction do an oral suction with following principles.
Endotracheal (ET) tube
Endotracheal tube is a C-shaped tube and is commonly made of polyvinyl chloride which provides passage into the trachea through the nose (nasotracheal) or mouth (orotracheal) in order to keep the upper airway patent.45
- Size:
- Diameter:Newborn2.5 mm–4 mmInfant4 mm – 4.5 mmChildren under 6Age/3 + 3.5 mmChildren above 6Age/4 + 4.5 mmAdult (men)8 mm – 9 mmAdult (women)7 mm – 8 mm
- Length:Children aged > 2 years12 cmAdult men22 – 23 cmAdult women20 – 21 cm
Mechanical ventilation (Table 1.3)
Ventilator —Ventilator is a device designed to augment or provide spontaneous respiration.
Ventilation—Ventilation is the process by which the gas is exchanged in the lungs between the blood and inspired air. This need arises as a direct result of cellular aerobic metabolism, which creates a constant demand for uptake of oxygen and elimination of the carbon dioxide. Oxygen is utilized for muscle contraction, protein synthesis, ion pumps, cellular secretion, etc.
Purpose
- To maintain gas exchange in case of acute or chronic respiratory failure.
- To maintain ventilator support after CPR.
- To reduce pulmonary vascular resistance.
- To exchange O2 and CO2 and excrete increases CO2 production.
- To give general anesthesia when muscle relaxant or intermittent positive pressure ventilation are required.
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Weaning of ventilator
It is a process of detaching ventilator and removing endotracheal tube from trachea of a patient.
- Mechanical criteria for weaning
- – Inspiratory pressure : < 30 cm H2O.
- – Tidal volume > 5 ml/ kg.
- – Minute ventilation:< 10 l.
- – Reduced RR by 1–2 as long as RR :< 30/min and paCO2:<45 mmHg.
- – Reduced pressure support 5–8 cm of H2O.
- – Vital Capacity :> 10ml/kg and PEEP is reduced to 3–5 cm of H2O.
- – FiO2 is reduced to less than 40% and PO2 on it more than 65%.
- – Stable cardiovascular and respiratory parameters for 1 hour at least.
- – Rapid shallow breathing index (RSBI)< 100.
- Medication CalculationD = Desired doseQ = Quantity of solutionH = Strength on handX = Unknown quantity of drug
- – Sample: Physician orders 500 mg of ibuprofen (desired dose) for a patient and you have 250 mg. (Quantity on 47Hand) tablets (Quantity of solution) on hand.
- – Solution: D ÷ H × Q = X 500 mg ÷ 250 mg × 1 tablet = 2 tablets. Answer: 2 tablets.
- – Sample: Physician orders 1500 mg of liquid ibuprofen for a patient. Quantity of ibuprofen is 500 mg in 1 cc, how much will you administer?
- – Solution: 1500 mg ÷ 500 mg × 1cc = 3 cc. Answer: 3 cc.
- Dosage and conversions
- – Sample: MD orders 300 mg of Ibuprophen to be taken by a 6 kg infant every 4 hours. Label shows 75 – 150 mg/kg per day. Is the physician's order within normal range?
- – Solution: 6× 75 = 450 mg (minimum dosage per day); 150 × 6 = 900 (maximum dosage per day) 24 ÷ 4 = 6 dosages : 300 × 6 = 1800. Answer: Dosage is not within range.
- Conversion Table
- – 1 kilogram (kg) = 1000 grams (gm)
- – 1 gram (gm) = 1000 milligrams (mg)
- – Convert grams to milligrams by multiplying grams by 1,000.
- – Convert milligrams to grams by dividing milligrams by 1,000.
- – 1 milligram (mg) = 1000 micrograms (mcg).
- – Grains (gr) 15 = 1 gram (gm) or 1000 milligrams (mg).
- – To convert gm to gr multiply by 15
- – To convert gr to g divide by 15.
- – 1 Grain (gr) = 60 milligrams (mg).
- – To convert gr to mg multiply gr. by 60.
- – To convert mg to gr divide mg. by 60.
- – 1ml = 1 cc.
- – 1 ounce = 30 ml.
- – 1 tablespoon (T or tbsp) = 15 ml.
- – 1 teaspoon (t or tsp) = 5 ml.
- – 2.2 lb = 1 kg.
- – To convert pounds to kg divide pounds by 2.2.
- – To convert kg to pounds multiply by 2.2.
- Normal Values
Bleeding time | 1–9 minutes |
Prothrombin time | 10–13 second |
Hematocrit | Male: 42–52% Female: 36–48% |
Hemoglobin | Male:13.5–16 gm/dl Female: 12–16 gm/dl |
Platelet | 150,000–400,000 |
RBC | Male: 4.5–6.2 million/l Female: 4.2–5.4 million/l |
Amylase | 80–180 IU/l |
Bilirubin (serum) | Direct: 0–0.4 mg/dl Indirect: 0.2–0.8 mg/dl Total: 0.3–1.0 mg/dl |
pH | 7.35–7.45 |
PaCO2 | 35–45 |
HCO3 | 22–26 mEq/l |
Contd… | |
Contd… | |
PaO2 | 80–100 mmg |
SaO2 | 94–100% |
Sodium | 135–145 mEq/l |
Potassium | 3.5–5.0 mEq/l |
Calcium | 4.2–5.5 mg/dl |
Chloride | 98–108 mEq/l |
Magnesium | 1.5–2.5 mg/dl |
BUN | 10–20 mg/dl |
Creatinine | 0.4–1.2 |
CPK-MB | Male: 50–325 µm/ml; Female: 50–250 µm/ml |
Fibrinogen | 200–400 mg/dl |
FBS | 80–120 mg/dl |
Glycosylated Hgb (HbA1c) | 4.0–7.0% |
Uric acid | 2.5 –8 mg/dl |
ESR | Male:15–20 mm/hour Female: 20–30 mm/hour |
Cholesterol | 150–200 mg/dl |
Triglyceride | 140–200 mg/dl |
Lactic dehydrogenase | 100–225 µm/ml |
Alkaline phosphokinase | 32–92 U/l |
Albumin | 3.2–5.5 mg/dl |
- Florence nightingale was born in:
- 12th May 1820
- 13th May 1820
- 12th May 1920
- 13th May 1920
- All schools of nursing were placed under Tribhuwan university in:
- 1972 AD
- 1973 AD
- 1960 AD
- 1958 AD
- Developement of goals and plans for care is a step of nursing process, which falls under:
- Nursing assessment
- Planning
- Implementation
- Nursing diagnosis
- First school of nursing under the HMG was opened in:
- 1956 AD
- 1954 AD
- 1960 AD
- 1958 AD
- Which of the following steps in nursing process includes “putting plans into action”:
- Assessment
- Planning
- Implementation
- Evaluation
- Which of the following theory best describe the environmental factors:
- Which of the following is the contraindication of hot water bag?
- Paralysis patient
- Patient having swollen ankle
- Patient having swollen knee
- Patient having chills and rigor
- A code of ethics provides guidelines for:
- Philosophical idea
- Safe and compassionate care
- Motives
- Good character
- Ethics is the study of good conduct character and motives. So it deter-mines:
- What is code of ethics
- What is good or valuable for all people
- Guidelines for safe
- Moral
- Mr Suresh having difficulty of breathing is placed in follower's position. The head of the bed is elevated at angle of:
- 45°
- 50°
- 55°
- 90°
- Which of the following factors is helped in promoting effective?
- Privacy
- Nurse focus
- Conducive environment
- Using judgemental comment
- Standard size of needle used for intramuscularly injections is:
- 18–20 gm
- 21–23 gm
- 25–27 gm
- 27–29 gm
- While giving the regular insulin for a diabetic client the most appropriate angle would be:
- 15°
- 23°
- 9°
- 27°
- In physical examination, when assessing the chest, which assessment technique should be conducted after palpation?
- Inspection
- Auscultation
- Percussion
- Sequence required
- A patient having Foley's catheter has developed urinary tract infection. This type of infection is known as:
- A viral infection
- A chronic infection
- A iatrogenic infection
- An opportunistic infection
- Reporting is an information about the patient either written or oral. A good report is:
- For immediate use and not for performance
- Clear, concise, and complete
- Type of written report
- More of permanent value
- Complete destruction of pathogenic and nonpathogenic micro-organisms including spores is known as:
- Disinfection
- Isolation
- Sterilization
- Medical association
- It is accepted that Minu is often stressed while she is alone in hospital because of alone, fear, and worries. To deal with such patient's need requires:
- Communication
- Assessment
- Sufficient nursing care
- Solving the problem
- Ms Mana is having pain, redness, and swelling around the wound as well as increased body temperature, and purulent drainage after 4 days of appendectomy operation. These are the symptoms of:
- Ms Rita has 70% burn due to hot liquid, it could be classified as:
- Chemical burn
- Thermal burn
- Electrical burn
- Radiation
- Which of the following is subject data?
- “I could not sleep at night”
- His blood pressure is 140/90
- He has swelling of both leg
- My leg are swollen
- Systematic and continues collection of data is one of the major step of nursing process, which comes under:
- Nursing diagnosis
- Planning
- Nursing assessment
- Implementation
- Which laboratory test indicates that a client is at risk for poor nutritional status?
- Decreased serum albumin level
- Increased lymphocyte count
- Decreased blood urea nitrogen level
- Increased platelet count
- The percentage of sodium chloride in normal saline is:
- 0.3%
- 0.6%
- 0.9%
- 0.12%
- The normal respiratory rate of an adult is:
- 6–10 breaths/ minute
- 8–10 breaths/minute
- 16–20 breaths/minute
- 20–24 breaths/minute
- Dorsal recumbent position is best for:
- Examination of rectum
- Examination of chest and abdomen
- Back care
- Taking rectal temperature
- Heart sounds are the results of:
- Blood flow through the heart
- Movement of blood into the heart from the aorta
- Closure of the heart valves
- Contraction of cardiac muscle
- A client is having dyspnea. To facilitate respirations, the nurse would:
- Remove pillows from under the head
- Elevate the head of the bed
- Elevate the foot of the bed
- Take the blood pressure
- Blood pressure is the measurement of:
- The flow of blood through circulation
- The force of the blood against arterial walls
- The force of blood against venous wall
- The flow of blood through the heart
- Most of the drugs are metabolized in:
- Lungs
- Liver
- Kidneys
- Intestine
- In drug administration the abbreviation of PRN means
- At bed time
- In empty stomach
- Four times daily
- When required
- Mr Shyam is 14-year-old. He is going for surgery tomorrow. Dr has asked to give soap water enema before surgery. You should prepare ________ of solution for enema.
- 250–500 ml
- 500–1000 ml
- Less than 1000 ml
- More than 1000 ml
- While collecting specimen for hemoglobin percentage, you will select:
- Plain vial
- EDTA vial
- Culture vial
- PT vial
- Washing out of the stomach with liquid either plain water or medicated water is:
- The process of killing all micro-organisms including spores is called:
- Cleaning
- Washing
- Disinfecting
- Sterilization
- Fluid loss from the skin is:
- An average 400–500 ml/day
- An Average 300–400 ml/day
- An average 200–300 ml/day
- An average 500–600 ml/day
- Admission and discharge procedure is very important in hospital setting. While attending client during this procedure care should be focused on:
- Nurses needs
- Clients needs
- Generalized care need
- Individualized care need
- Nepal Nursing Council has started officially functioning since:
- 2050 BS
- 2052 BS
- 2053 BS
- 2051 BS
- Movement of a limb away from the body is called:
- Adduction
- Abduction
- Abrasion
- Absorption
- The ICN code of ethics include all except:
- Nurses and people
- Doctor and co-workers
- Nurses and practice
- Nurses and profession
- A nursing diagnosis represents the:
- Proposed plan of care
- Client's health problems
- Assessment of client data
- Actual nursing intervention
- The effectiveness of nurse-client communication is best validated by:
- Client feedback
- Health team conferences
- Medical assessment
- Client's physiologic adaptations
- The fundamental responsibility of the nurse is:
- To promote health
- To promote health and to prevent illness
- To promote health, to prevent illness, to restore health and to alleviate suffering
- To promote health, to prevent illness and to restore health
- The needs for shelter and freedom from harm, and danger are presented in which topics of Maslow hierarchy?
- Self- esteem
- Love and belonging needs
- Self-esteem need
- Safety and security needs
- According to Maslow's hierarchy the need for safety and security is an essential_______for an individual.
- Basic need
- Physiological need
- Physical need
- Demand
- A nurse is a:
- A woman who took care of the sick, injured, and dying persons without any formal knowledge
- A person who provides total care to an individual or community in the problematic situation
- A person who provides care to an sick individual
- A woman who provides care to a healthy individuals
- Nursing Association of Nepal is established on:
- BS 2016 Magh
- BS 2018 Magh
- BS 2015 Falgun
- BS 2019 Falgun
- The Nursing ethics is the:
- Science of morals that can guide to nurse in taking moral action
- Science of moral that guide nurse to take disciplinary action
- Science that guide to do action
- Science that provide right track to nurses
- Adduction means:
- The normal height of IV infusion is:
- 18″
- 20″
- 3.15″
- 22″
- The primary purpose for regulating nursing practice is to protect:
- The public
- The practicing nurses
- The employing agency
- Professional standards
- Nurses are protected from all legal action when they:
- Offer health teaching regarding family planning
- Offer first aid at scene of an automobile bus accident
- Administer CPR measures on an unconscious child pulled from a swimming pool
- Report incidents of suspected child abuse to the appropriate authorities identified in legislation and policies
- The nursing process can be defined as the:
- Implementation of nursing care by the nurses
- Steps the nurse employs to provide nursing care
- Process the nurse uses to determine nursing goals
- Activities of a nurse employs to identify a client problems
- To utlilize the nursing process, the nurse must first:
- Identify goals for nursing care
- State the client's nursing needs
- Obtain information about the client
- Evaluate the effectiveness of nursing action
- A nursing diagnosis represents the
- Proposed plan of care
- Client's health problems
- Assessment of client data
- Actual nursing intervention
- The determining factor in the revision of a nursing plan is the:
- Time available for care
- Validity of the diagnosis
- Method for providing care
- Effectiveness of the intervention
- A 9-year-old baby is to have surgery. The physician order meperidine (demerol), 20 mg IV preoperatively. The container have 50 mg/ml. The nurse should administer:
- 0.4 ml
- 0.6 ml
- 0.8 ml
- 1.0 ml
- The position in which a client with dyspnea should be placed is:
- Sims
- Supine
- Orthopneic
- Trendelenburg
- A client begins to expectorate blood. The nurse describes this episode as:
- Hematuria
- Hematoma
- Hemoptysis
- Hematemesis
- The major role in maintaining fluid balance in the body is performed by the:
- Liver
- Heart
- Lungs
- Kidney
- The most important electrolyte of intracellular fluid is:
- Sodium
- Calcium
- Chloride
- Potassium
- The nurse must assess the client with gastric lavage or prolonged vomiting for:
- The nurse should position a client recovering from general anesthesia in a:
- Supine position
- Side-lying position
- High Fowler's position
- Trendelenburg position
- During the immediate postoperative period the nurse should give the highest priority to:
- Observing for hemorrhage
- Maintaining a patent airway
- Recording the intake and output
- Checking the vital signs every 15 minutes
- When assessing a client experiencing pain, the nurse should be alert for a sign of an involuntary reaction to pain, which is:
- Crying
- Splinting
- Grimacing
- Perspiration
- The Primary Health Care mainly focuses on:
- Solving the health problems in the community by providing promotional, preventive, curative and rehabilitative services to individuals, communities and the country as a whole
- Solving the health problems of the community
- Solving the health problems by providing preventive, curative and rehabilitative services to the individual
- Providing the health services to the community people
- A nurse is:
- A person who provides total care to an individual or community in the problematic situation as well as in healthy conditions
- A woman who provides care to the sick, injured, and dying person.
- A person who provides care to the disable person
- A woman who provides care to the sick or well person without any formal knowledge
- The Nursing Association of Nepal was established in:
- Poush 2018 BS
- Magh 2018 BS
- Poush 2016 BS
- Magh 2016 BS
- The founder of ICN (The International Council of Nurses) was:
- Ms Bedford Fenwick
- Ms Lystra E Gretter
- Ms Florence Nightingle
- Ms Alice Price
- The Maslow's hierarchy of human needs is:
- Physiological, love, and belongingness, self-esteem and self-actualization
- Physiological, security and safety, love and belongingness, self-esteem, and self-actualization
- Security and safety, love, self- esteem, and self-actualization
- Physiological, security, and safety, love and belongingness, and self- esteem
- The Nursing Process is defined as:
- An organized, systematic method of giving individualized care within the scope of nursing practice
- A systematic method of giving nursing care to the people
- An organized, systematic method of giving nursing care to the individualized people
- A method of giving nursing care to the people
- The main steps of the nursing process are:
- The formula of conversion of temperature from centigrade to frenheight and vice versa:
- f= cx9/5+32
- f=fx9/5+32
- c=fx9/5+32
- c=cx9/5+32
- Remittent fever means:
- When the elevated temperature fluctuates widely but doesn't reach normal levels between fluctuations
- When the elevated temperature remains near the same level throughout a period of days
- When the temperature falls generally to normal
- When the body temperature rises and falls to normal everyday
- Anuria means:
- Difficulty in voiding urine
- Decreased urinary output
- Presence of pus in urine
- Absence of urinary secretion
- The normal specific gravity of CSF (cerebrospinal fluid) is:
- 1.003–1.008
- 1.015–1.015
- 1.000–1.002
- 1.012–1.013
- Lithotomy position is used for:
- Giving back care or enema
- Instrumental examination of vagina and rectal and for vaginal delivery
- Rectal examination and cord prolapsed
- Drainge from abdomen or pelvic cavity
- Forms of fluid loss in human body:
- Respiration, perspiration, urine, and feces
- Low fluid intake, urine, and feces
- Respiration, perspiration, and urine
- Perspiration, urine, and feces
- The normal height of enema can from patient's anus:
- 45 cm or 18″
- 40 cm or 16″
- 50 cm or 20″
- 55cm or 22″
- Normal temperature of enema fluid is:
- About 105°F
- About 100°F
- About 110°F
- About 108°F
- The main responsibility of nurses in Foley catheter patient for keeping the drainage system patent is:
- Check for kinks or bends in the tubing
- Teach the patient about good perineal hygiene
- Empty the drainage bag at least everyday
- Wash hands before and after procedure
- Sedatives are those drugs which use in:
- Induce sweating
- Reduce body temperature
- Depress CNS and allow sleep
- Induce deep sleep and relieve pain
- Instillation means:
- The administration liquid medication by drop
- The administration medicine locally
- Drugs administration through inhalation
- Drugs administration through injection
- If a patient is getting 4 pints IV infusion in 24 hours the number of drops per minute is:
- 21 drops/minute
- 20 drops/minute
- 18 drops/minute
- 22 drops/minute
- Practices that restrict micro-organisms in the environment and on equipment and supplies and prevents normal body flora from contaminating the surgical wound is:
- During sterilization by autoclaving, for how long do we need to autoclave when 15 lbs pressure is applied under 121°C:
- 3 minutes
- 5 minutes
- 10 minutes
- 15 minutes
- Surgical handwashing last from:
- 5–10 minutes
- 1–3 minutes
- 3–5 minutes
- 5–7 minutes
- A nurse responsible for helping with preparations before the operation starts, taking care of the requirements in the room but outside the sterile field and helping with the end of operation requirement and getting the patient to recovery is known as:
- Theater nurse
- Recovery nurse
- Scrub nurse
- Circulatory nurse
- One of the major responsibility of recovery nurse on the immediate arrival of patient after operation is:
- Maintain BAC (breathing, airway, and circulation)
- Informing the relatives about the operation
- Regulating drips
- securing drains
- Consent is necessary for except.
- To protect patient from unwanted procedure
- To protect surgeon and medical professionals
- To protect the hospital
- To protect the relatives of the patients
- Which techniques can be applied while gloving?
- Direct and indirect technique
- Closed and open technique
- Closed and straight technique
- Sterile and unsterile technique
- Agent that kills micro-organisms on an inanimate surface is:
- Disinfectant
- Antiseptics
- Chemicals
- Spirit
- What is the backbone of operation theater to optimize primary wound healing to promote the efficiency of patient care?
- Efficient anesthetic team
- Effective communication
- Effective infection control program
- Efficient management of resources
- Who is responsible for counting the sponges and all other equipments/materials used during surgery?
- Circulatory nurse
- Scrub nurse
- Recovery nurse
- Both a and b
- Prolene is an _______ suture.
- Natural absorbable
- Synthetic absorbable
- Natural nonabsorbable
- Synthetic nonabsorbable
- Kochers is needed to:
- Hold skin and tough tissues
- Hold delicate parts like intestines
- Hold peritoneum and blood vessels
- Cut delicate tissues
- The appropriate way to minimize the sources of contamination via skin is:
- Gowning
- Gloving
- Covering
- Scrubbing
- Which is not the type of anesthesia?
- General anesthesia
- Local anesthesia
- Peripheral anesthesia
- Spinal anesthesia
- Rubber goods are best sterilized through:
- Boiling
- Chemical sterilization
- Autoclaving
- Radiation
- Among the following, which is not the principle of sterilization?
- Which of the following is the commonest poisoning in Nepal?
- Organochlonine
- Organ phosphorus
- Morphine
- Kerosene
- All the following are aim of first-aid except:
- To preserve life
- To promote recovery
- To prevent further damage
- To cure the disease
- Vomiting is induced in all of the following poisoning except:
- Organophosporus
- Arganochllorine
- Cyanide
- Kerosene
- In case of cardiac arrest, which of the following is a preferred immediate action?
- CPR
- DC shock
- ECG
- Checking temperature
- Qualities of good first aider include all except:
- Observant
- Nondiscriminating
- Sympathetic
- Preserving
- Rings, bracelets, shoes of a burn victim should be removed immediately because:
- They might be stolen
- They obstruct blood flow
- Swelling may occur
- Airway will be blocked
- Drowning is related to:
- Children and teenagers
- Excessive alcohol intake
- Unfamiliar rivers and ponds
- All of the above
- The process by which victims are divided according to agency or security of injuries or illness is called:
- Mitigation
- Triage
- Tagging
- Classification
- The airway is opened by:
- Tilting the head and lifting the chin
- Flexing head towards the chest
- Tilting the head laterally
- Compressing the chest
- In adults IV is given if burn exceeds:
- 2%
- 10%
- 5%
- 15%
- An agent which counteracts a poison is:
- Antibiotic
- Antidote
- Ethanol
- Noloxone
- Paracetamol poisoning should be treated with:
- Nacetylcystine
- Humanceneial
- Ethanol
- Naloxone
- In the management of poisoning, activated charcoal is given:
- IM
- IV
- NG
- Orally
- The rate of heart compression of newborn infant should be at least:
- 100–120/minute
- 70–80/minute
- 50–70/minute
- 30–40/minute
- Don't use direct heat during frostbite as they can:
- Cause sudden increase in body temperature
- Increase blood circulation
- Cause burn
- Cause vasodilatation
- In brain death all are seen except:
- Diabetes incipidus
- Apnea
- Constricted pupils
- Pulse rate unresponsive to atropine
- Which is not seen in hyperventilation?
- Which nursing intervention is appro-priate to prevent pulmonary embolus in a patient who is prescribed bed rest?
- Limit the client's fluid intake
- Encourage deep breathing and coughing
- Use the knee gatch when the client is in bed
- Teach the patient to move legs in bed
- Application of force to another person without lawful justification is:
- Battery
- Negligence
- Tort
- Crime
- “Health is a state of complete physical, mental, and social well-being and not merely the absence of disease and infirmity”. This was stated by:
- United States Health Agency
- National Institute of Health
- National League for Nursing (NLN)
- World Health Organization
- The name of the nursing diagnosis is linked to the etiology with the phrase:
- “As manifested by ”
- “Related to”
- “evidenced by”
- “Due to”
- Which of the following clinical findings is expected in a patient who has undergone gastric lavage and prolonged vomiting?
- Decreased serum pH
- Increased serum bicarbonate level
- Increased serum oxygen level
- Decreased serum osmotic level
- What is the priority nursing intervention for a patient during the immediate postoperative period?
- Observing for hemorrhage
- Maintaining a patent airway
- Recording the intake and output
- Checking the vital signs every 15 minutes
- What is the maximum duration of time the nurse allows an IV bag of solution to infuse into a patient?
- 6 hours
- 12 hours
- 18 hours
- 24 hours
- Which of the following clinical finding indicates the patient is experiencing hypokalemia?
- Edema
- Muscle spasms
- Kussaumal breathing
- Abdominal distension
- Which of the following is an appropriate nursing action when caring a patient who has a radium implant for cancer of cervix?
- Restrict the visitors to a 10 minutes stay
- Store urine in a lead-lined container
- Wear a lead apron when giving care
- Avoid giving IM injections to gluteal region
- Which of the following assessment data is expected in a patient admitted with extracellular fluid excess?
- Elevated hematocrit level
- Rapid and thready pulse
- Distended jugular pressure
- Increased serum sodium level
- Anaphylactic reaction after administering penicillin indicates:
- An acquired atopic sensitization
- Passive immunity to penicillin allergen
- Antibodies to penicillin developed after earlier use of the drug
- Developed potent bivalent antibodies when the IV administration was started
- Which of the following intervention is not recommended in watery diarrhea?
- Which of the following is considered as an indication for administering serum albumin?
- Clotting of blood
- Formation of WBCs
- Formation of RBCs
- Maintenance of oncotic pressuer
- Lactated Ringer's solution is contraindicated in:
- Hypovolemia
- Burns
- Lactic acidosis
- Fluid lost as bile or diarrhea
- Physical signs indicative of poor nutrition are all, except:
- Dental caries, mottled appearance (fluorosis), malpositioned
- Brittle, depigmented, easily pluck-ed; thin and sparse hair
- Tongue—Deep red in appearance; surface papillae present
- Spongy, bleed easily, marginal redness, and recession gums
- What is the term used for normal respiratory rhythm and depth in a client?
- Eupnea
- Apnea
- Bradypnea
- Tachypnea
- What is the term used for a high-pitched musical sound in clients during a respiratory assessment?
- Crowing
- Wheezing
- Stridor
- Sigh
- A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:
- Pulmonary egophony
- Amniotic fluid embolism
- Anaphylaxis
- Bronchospasm
- Which of the following nursing interventions would be most important for determining fluid balance in a client with end-stage renal failure?
- Monitor urine specific gravity
- Measure fluid intake and output
- Weigh daily
- Record frequency of bowel movements
- Priorities of Planning in Nursing Process is done by:
- Information processing model
- Interpersonal theory
- Stages of illness model
- Maslow's hierarchy of human needs
- The scene suggests that a victim has suffered an electrical shock. The first thing to do is _______.
- Cover all burns with a dry loose dressing
- Ask a bystander to help you move the victim
- Place the victim on one side with the head down
- Make sure the power is turned off
- You are caring for a victim with a burned hand. Put the hand in cool water if _______.
- The burns are very deep
- There are burns with open blisters
- The burns are minor with no open blisters
- You should put the hand in cool water for all of the above
- In general a splint should be _______.
- Loose, so that the victim can still move the injured limb
- Snug, but not so tight that it slows circulation
- Tied with cravats over the injured area
- None of the above
- A victim has lost a lot of blood through a deep cut in his leg. He is breathing fast and seems pail and restless. He is probably _______.
- Which would you do when caring for a seizure victim?
- Remove nearby objects that might cause injury
- Place a small object, such as a rolled up piece of cloth, between the victim's teeth
- Try to hold the person still
- All of the above
- A 15-year-old boy has just splashed a chemical on his face. After sending someone to call for an ambulance, you would _______.
- Cover the burned area
- Have the victim stay calm until ambulance arrives
- Flush the burned area with large amounts of water until the ambulance arrives
- Immediately drive the victim to the hospital
- Why should you cover burns with a clean or sterile dressing?
- To prevent infection
- To cool burned area
- To keep the burned area warm
- Both a and c
- Which of the following should be done for a person experiencing a heat related illness?
- Keep the victim warm
- Force the victim to drink fluids
- Apply cool wet cloths
- Place the victim in warm water
- Which should be part of your care for a severely bleeding open wound?
- Allow the wound to bleed in order to minimize infection
- Apply direct pressure and elevate the injured area (if no broken bones)
- Use a tourniquet to stop all blood flow
- Both b and c
- What should you do if you think a victim has serious internal bleeding?
- Apply heat to the injured area
- Call your local emergency phone number for help
- Place the victim in a sitting position
- Give fluids to replace blood loss
- Which of the following behaviors reduces your risk for injury?
- Always wearing a safety belt when riding in automobiles
- Limiting intake of alcohol
- Limiting intake of foods high in cholesterol
- Both a and b
- Which is the first step when caring for bleeding wounds?
- Apply direct pressure with a clean or sterile dressing
- Apply pressure at the pressure point
- Add bulky dressings to reinforce blood soaked bandages
- Elevate the wound
- How can you reduce the risk of disease transmission when caring for open, bleeding wounds?
- Wash your hands immediately after giving care
- Avoid direct contact with blood
- Use protective barriers such as gloves or plastic wrap
- All of the above
- Dressing and bandages are used to _______.
- Reduce the victim's pain
- Reduce internal bleeding
- Help control bleeding and prevent infection
- Make it easier to take the victim to the hospital
- Where is the carotid artery located?
- On an infant, where would you check the pulse?
- Inside the wrist just above the hand
- On the neck to the right or left side of the windpipe
- Behind the kneecap
- Inside the arm between the elbow and shoulder
- For an infant who is choking, you would perform _______.
- The Hiemlick maneuver
- CPR
- Back blows and chest thrusts
- Hold the infant upside down and strike between the shoulder blades
- Breathing emergencies may be caused from _______.
- Asthma or allergic reaction
- Hyperventilation
- Injury to a muscle or bone in the chest
- All of the above
- A people, who is unconscious, not breathing, has a weak pulse, needs _______.
- CPR
- Hiemlick maneuver
- Rescue breathing
- Back blows and chest thrusts
- Which is not a symptom of heart attack?
- Chest pain
- Red, hot or dry skin
- Pale or bluish in color
- Profuse sweating
- A wound where there is damage to the soft tissue and blood vessels under the skin is called _______.
- A scrape
- A cut
- A bruise
- An avulsion
- When giving care for external bleeding, what should you do first?
- Elevate the injury
- Apply direct pressure
- Apply a loose dressing
- Apply a tourniquet
- Bandages are used for _______.
- Applying directly to a wound to soak up blood
- To hold dressings in place, apply pressure and control bleeding
- Ease pain
- Small cuts only
- Dressings and pads _______.
- Should be removed when blood soaked. New ones should be applied
- Are used to help control bleeding and keep germs out
- Are not included in a first aid kit
- Should be applied to a sucking chest wound
- Elastic bandages are used _______.
- To control bleeding
- Control swelling and support injuries such as sprains or strains
- To allow circulation to a severed limb
- When applying a splint
- When caring for a victim with a bloody nose you would not _______.
- Apply an ice pack to the bridge of the nose
- Apply pressure to upper lip just beneath nose
- Have the victim sit with head tilted slightly backward while pinching the nostrils together
- Have the victim sit with head tilted slightly forward while pinching the nostrils together
- Which symptoms would indicate internal bleeding?
- Which is not a symptom of shock _______.
- Strong thirst, nausea, or vomiting.
- Chest or abdominal pain, breathing difficulty
- Restless or irritability
- Rapid breathing or rapid pulse
- A first degree burn _______.
- Involves only the top layer of skin
- Is red and blistered
- Destroys all layers of skin
- Is the most serious of burns
- When caring for someone who has suffered an electrical burn, you would not _______.
- Check breathing and pulse
- Check for possible fractures
- Cool the burned area
- Treat for shock
- You should suspect that a victim has head and spine injuries for _______.
- An incident involving a lightning strike
- A person found unconscious for unknown reasons
- A fall from the height greater than the victim's height
- All of the above
- You may suspect that a student has been poisoned if they _______.
- Are experiencing nausea, vomiting or diarrhea
- Have chest or abdominal pain, breathing difficulty
- Burns around the lips, tongue, or on the skin
- All of the above
- When caring for someone who is suffering from frostbite, you shouldnot _______.
- Soak effected part in warm water 100–105°
- Rub vigorously until skin appears red and feels warm
- Handle area gently
- Avoid breaking blisters
- Hypothermia _______.
- Is not life-threatening
- Victims must be heated up as fast as possible
- Is caused by exposure to temperatures below freezing
- Can be caused by swimming in waters below 70°
- Snakebites can be very serious. When caring for a snakebite victim, which should you not do?
- Wash wounds
- Apply ice
- Keep bitten part still and below the heart
- Get professional medical care within 30 minutes
- When should you give rescue breathing?
- Conscious choking victim
- Unconscious choking victim
- Unconscious, no pulse, not breathing
- Unconscious, not breathing, but has a pulse
- When caring for a choking infant, what position is the infant held in?
- Upside down by the ankles and shoulders
- Face up on a flat surface
- Face down on your forearm with head lower than the body
- Face down on your knee, with head lower than the body
- Soft tissue wounds should be cared for by:
- Heat and elastic bandages
- Ice and elevation
- Apply direct pressure on the area to cut down on bleeding under skin
- Both b and c
- What do you do for a chemical burn?
- Diarrhea is a condition when an individual have:
- Hard and small stool
- Soft and regular stool
- Watery stool
- Frequent watery stool 3 times a day
- The purpose of the enema is:
- To relieve the constipation
- To relieve flatulence, or distention
- To prevent involuntary escape of fecal matter during surgical procedure and deliver
- All of the above
- What is more serious?
- Heat stroke
- Heat exhaustion
- Heat cramps
- Heat rash
- Signals of head and spine injuries are:
- Blood or other fluids in the ears or nose
- Unusual bumps or depressions on the head or over the spine
- Has seizures, severe headaches, or slurred speech
- Both a and b
- Shock is a condition where _______.
- The respiratory system fails to deliver air to the lungs
- The cardiovascular system fails to deliver blood to the heart
- The circulatory system fails to deliver blood to all parts of the body
- All of the above
- A girl at one of your bus stops indicates that she was bitten by a snake, what do you do?
- Apply ice to the wound and take to the nearest fire station or hospital
- Wash the wound, keeping injured area lower than the heart; get professional medical care within 30 minutes
- Cut a 1″ cross at the site if injury and suck the poison out, apply ice
- Elevate injured area, apply ice, and get professional medical care within 30 minutes
- When performing CPR on a child, how deep should the chest compressions be?
- 1½″
- 2″
- 2½″
- 3″
- While providing enema to the adult client the tube should be inserted:
- 2.5–3.73 cm
- 3.5–4.5 cm
- 5.5–8.5 cm
- 7.5–10 cm
- When performing CPR on an adult, how deep should the chest compressions be?
- 1½″
- 2″
- 2½″
- 3″
- A victim is coughing up blood with bleeding from the mouth and is tender in the abdomen. Pulse is weak and rapid. The victim is having signs of:
- Massive head injuries
- Internal bleeding
- Drug overdose
- Possible poisoning
- The proper height of the enema can the nurse should maintain while administering enema is:
- 35 cm
- 45 cm
- 55 cm
- 65 cm
- Using the principles of standard precautions, the nurse would wear gloves in what nursing interventions?
- Providing a back massage
- Feeding a client
- Providing hair care
- Providing oral hygiene
- A nurse obtained a client's pulse and found the rate to be above normal. The nurse document this findings as:
- Tachypnea
- Hyperpyrexia
- Arrhythmia
- Tachycardia
- Which of the following actions should the nurse take to use a wide base support when assisting a client to get up in a chair?
- A client who is unconscious needs frequent mouth care. When performing a mouth care, the best position of a client is:
- Fowler's position
- Side lying
- Supine
- Trendelenburg
- A client is hospitalized for the first time, which of the following actions ensure the safety of the client?
- Keep unnecessary furniture out of the way
- Keep the lights on at all time
- Keep side rails up at all time
- Keep all equipment out of view
- A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client's vital sign hereafter. What phrase of nursing process is being implemented here by the nurse?
- Assessment
- Diagnosis
- Planning
- Implementation
- It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community
- Assessment
- Nursing process
- Diagnosis
- Implementation
- Which of the following cluster of data belong to Maslow's hierarchy of needs?
- Love and belonging
- Physiologic needs
- Self-actualization
- All of the above
- This is characterized by severe symptoms relatively of short duration.
- Chronic illness
- Acute illness
- Pain
- Syndrome
- Which of the following is the meaning of PRN?
- When advice
- Immediately
- When necessary
- Now
- Which of the following is the appropriate meaning of CBR?
- Cardiac board room
- Complete bathroom
- Complete bed rest
- Complete board room
- 20 cc is equal to how many ml?
- 2
- 20
- 2000
- 20000
- The nurse must verify the client's identity before administration of medication. Which of the following is the safest way to identify the client?
- Ask the client his name
- Check the client's identification band
- State the client's name aloud and have the client repeat it
- Check the room number
- The nurse prepares to administer buccal medication. The medicine should be placed _______.
- On the client's skin
- Between the client's cheeks and gums
- Under the client's tongue
- On the client's conjuctiva
- The nurse administers cleansing enema. The common position for this procedure is _______.
- Sims left lateral
- Dorsal recumbent
- Supine
- Prone
- A client complains of difficulty of swallowing, when the nurse try to administer capsule medication. Which 64of the following measures the nurse should do?
- Dissolve the capsule in a glass of water
- Break the capsule and give the content with an apple sauce
- Check the availability of a liquid preparation
- Crash the capsule and place it under the tongue
- Which of the following is the appropriate route of administration for insulin?
- Intramuscular
- Intradermal
- Subcutaneous
- Intravenous
- Which of the following technique involves the sense of sight?
- Inspection
- Palpation
- Percussion
- Auscultation
- The first techniques used examining the abdomen of a client is:
- Palpation
- Auscultation
- Percussion
- Inspection
- A technique in physical examination that is use to assess the movement of air through the trachea bronchial tree:
- Palpation
- Auscultation
- Inspection
- Percussion
- Resonance is best described as:
- Sounds created by air-filled lungs
- Short, high pitch and thudding
- Moderately loud with musical quality
- Drum-like
- The best position for examining the rectum is:
- Prone
- Sim's
- Knee-chest
- Lithotomy
- The nurse asked the client to read the Snellen chart. Which of the following is tested?
- Optic
- Olfactory
- Oculomotor
- Troclear
- The nurse prepares IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication?
- Use a small gauge needle
- Apply ice on the injection site
- Administer at a 45° angle
- Use the Z-track technique
- If a patient's blood pressure is 150/96, his pulse pressure is:
- 54
- 96
- 150
- 246
- A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 am is 99.8°F (37.7°C). This temperature reading probably indicates:
- Infection
- Hypothermia
- Anxiety
- Dehydration
- Which of the following parameters should be checked when assessing respirations?
- Rate
- Rhythm
- Symmetry
- All of the above
- A 38-year-old patient's vital signs at 8 am are axillary temperature 99.6°F (37.6°C); pulse rate, 88; respiratory rate, 30. Which findings should be reported?
- Respiratory rate only
- Temperature only
- Pulse rate and temperature
- Temperature and respiratory rate
- Palpating the midclavicular line is the correct technique for assessing:
- Baseline vital signs
- Systolic blood pressure
- Respiratory rate
- Apical pulse
- The absence of which pulse may not be a significant finding when a patient is admitted to the hospital?
- Which of the following patients is at greatest risk for developing pressure ulcers?
- An alert, chronic arthritic patient treated with steroids and aspirin
- An 88-year old incontinent patient with gastric cancer who is confined to his rest at home
- An apathetic 63-year-old COPD patient receiving nasal oxygen via cannula
- A confused 78-year-old patient with congestive heart failure (CHF) who requires assistance to get out of bed
- The most common deficiency seen in alcoholics is:
- Thiamine
- Riboflavin
- Pyridoxine
- Pantothenic acid
- To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is:
- Less than 30 ml/hour
- 64 ml in 2 hours
- 90 ml in 3 hours
- 125 ml in 4 hours
- Mrs Limbu begins to cry as the nurse discusses hair loss. The best response would be:
- “Don't worry. It's only temporary”
- “Why are you crying? I didn't get to the bad news yet”
- “Your hair is really pretty”
- “I know this will be difficult for you, but your hair will grow back after the completion of chemotherapy”
- An additional vitamin C is required during all of the following periods except:
- Infancy
- Young adulthood
- Childhood
- Pregnancy
- A prescribed amount of oxygen is needed for a patient with COPD to prevent:
- Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
- Circulatory overload due to hypervolemia
- Respiratory excitement
- Inhibition of the respiratory hypoxic stimulus
- The most common injury among elderly persons is:
- Atheroscleotic changes in the blood vessels
- Increased incidence of gallbladder disease
- Urinary tract infection
- Hip fracture
- The most common psychogenic disorder among elderly person is:
- Depression
- Sleep disturbances (such as bizarre dreams)
- Inability to concentrate
- Decreased appetite
- Which of the following vascular system changes results from aging?
- Increased peripheral resistance of the blood vessels
- Decreased blood flow
- Increased workload of the left ventricle
- All of the above
- The nurse's most important legal responsibility after a patient's death in a hospital is:
- Obtaining a consent of an autopsy
- Notifying the coroner or medical examiner
- Labeling the corpse appropriately
- Ensuring that the attending physician issues the death certification
-
- A patient with leukopenia
- A patient receiving broad-spec-trum antibiotics
- A postoperative patient who has undergone orthopedic surgery
- A newly diagnosed diabetic patient
- After routine patient contact, hand washing should last at least:
- 30 seconds
- 1 minute
- 2 minutes
- 3 minutes
- Which of the following procedures always requires surgical asepsis?
- Vaginal instillation of conjugated estrogen
- Urinary catheterization
- Nasogastric tube insertion
- Colostomy irrigation
- Sterile technique is used whenever:
- Strict isolation is required
- Terminal disinfection is performed
- Invasive procedures are performed
- Protective isolation is necessary
- When removing a contaminated gown, the nurse should be careful that the first thing she touches is the:
- Waist tie and neck tie at the back of the gown
- Waist tie in front of the gown
- Cuffs of the gown
- Inside of the gown
- Which of the following nursing interventions is considered the most effective form or universal precautions?
- Cap all used needles before removing them from their syringes
- Discard all used uncapped needles and syringes in an impenetrable protective container
- Wear gloves when administering IM injections
- Follow enteric precautions
- All of the following measures are recommended to prevent pressure ulcers except:
- Massaging the reddened are with lotion
- Using a water or air mattress
- Adhering to a schedule for positioning and turning
- Providing meticulous skin care
- Which of the following blood tests should be performed before a blood transfusion?
- Prothrombin and coagulation time
- Blood typing and cross-matching
- Bleeding and clotting time
- Complete blood count (CBC) and electrolyte levels
- The primary purpose of a platelet count is to evaluate the:
- Potential for clot formation
- Potential for bleeding
- Presence of an antigen-antibody response
- Presence of cardiac enzymes
- Which of the following white blood cell (WBC) counts clearly indicates leukocytosis?
- 4,500/mm³
- 7,000/mm³
- 10,000/mm³
- 25,000/mm³
- The appropriate needle gauge for intradermal injection is:
- 20G
- 22G
- 25G
- 26G
- Parenteral penicillin can be administered as an:
- IM injection or an IV solution
- IV or an intradermal injection
- Intradermal or subcutaneous injection
- IM or a subcutaneous injection
- Which of the following is a sign or symptom of a hemolytic reaction to blood transfusion?
- Which of the following conditions may require fluid restriction?
- Fever
- Chronic obstructive pulmonary disease
- Renal failure
- Dehydration
- All of the following are common signs and symptoms of phlebitis except:
- Pain or discomfort at the IV insertion site
- Edema and warmth at the IV insertion site
- A red streak exiting the IV insertion site
- Frank bleeding at the insertion site
- An infected patient has chills and begins shivering. The best nursing intervention is to:
- Apply iced alcohol sponges
- Provide increased cool liquids
- Provide additional bedclothes
- Provide increased ventilation
- Clay colored stools indicate:
- Upper GI bleeding
- Impending constipation
- An effect of medication
- Bile obstruction
- In which step of the nursing process would the nurse ask a patient if the medication she administered relieved his pain?
- Assessment
- Analysis
- Planning
- Evaluation
- The ELISA test is used to:
- Screen blood donors for antibodies to human immunodeficiency virus (HIV)
- Test blood to be used for transfusion for HIV antibodies
- Aid in diagnosing a patient with AIDS
- All of the above
- Immobility impairs bladder elimination, resulting in such disorders as:
- Increased urine acidity and relaxation of the perineal muscles, causing incontinence
- Urine retention, bladder distention, and infection
- Diuresis, natriuresis, and decreased urine specific gravity
- Decreased calcium and phosphate levels in the urine
- The nurse is to insert an NG Tube when suddenly, she accidentally dip the end of the tube in the client's glass containing distilled drinking water which is definitely not sterile. As a nurse, what should you do?
- Don't mind the incident, continue to insert the NG Tube
- Obtain a new NG Tube for the client
- Disinfect the NG Tube before reinserting it again
- Ask your senior nurse what to do
- All of the following are principle of surgical asepsis except:
- Micro-organism travels to moist surfaces faster than with dry surfaces
- When in doubt about the sterility of an object, consider it not sterile
- Once the skin has been sterilized, considered it sterile
- If you can reach the object by overreaching, just move around the sterile field to pick it rather than reaching for it
- In putting sterile gloves, which should be gloved first?
- The dominant hand
- The nondominant hand
- The left hand
- No specific order, its upto the nurse for her own convenience
- The stage of gas where the adaptation mechanism begins:
- Stage of gas characterized by adaptation:
- Stage of alarm
- Stage of resistance
- Stage of homeostasis
- Stage of exhaustion
- Stage of gas wherein, the level of resistance are decreased:
- Stage of alarm
- Stage of resistance
- Stage of homeostasis
- Stage of exhaustion
- Wherein stages of gas does a person moves back into homeostasis?
- Stage of alarm
- Stage of resistance
- Stage of homeostasis
- Stage of exhaustion
- Which of the following is a not a correct statement of an outcome criteria?
- Ambulates 30 feet with a cane before discharge
- Discusses fears and concerns regarding the surgical procedure
- Demonstrates proper coughing and breathing technique after a teaching session
- Re-establishes a normal pattern of elimination
- Which of the following is a objective data?
- Dizziness
- Chest pain
- Anxiety
- Blue nails
- A patient's chart is what type of data source?
- Primary
- Secondary
- Tertiary
- Can be a and b
- A type of heat loss that occurs when the heat is dissipated by air current:
- Convection
- Conduction
- Radiation
- Evaporation
- Hyperpyrexia is a condition in which the temperature is greater than:
- 40°C
- 39°C
- 100°F
- 105.8°F
- Hari has a fever of 38.5°C. It surges at around 40°C and go back to 38.5°C 6 times today in a typical pattern. What kind of fever is Hari having?
- Relapsing
- Intermittent
- Remittent
- Constant
- Hari has a fever of 39.5°C 2 days ago. But yesterday, he has a normal temperature of 36.5°C. Today, his temperature surges to 40°C. What type of fever is Hari having?
- Relapsing
- Intermittent
- Remittent
- Constant
- Which of the following is a contraindication in taking rectal temperature?
- Unconscious
- Neutropenic
- NPO
- Very young children
- How long should the rectal thermometer be inserted to the clients anus?
- 1–2 inches
- 5–1.5 inches
- 3–5 inches
- 2–3 inches
- Which of the following statement is true about pulse?
- Young person have higher pulse than older persons
- Males have higher pulse rate than females after puberty
- Digitalis has a positive chronotropic effect
- In lying position, pulse rate is higher
- The following are correct actions when taking radial pulse except:
- Which of the following is true about respiration?
- I:E 2:1
- I:E 4:3
- I:E 1:1
- I:E 1:2
- Which of the following is more life- threatening?
- BP = 180/100
- BP = 160/120
- BP = 90/60
- BP = 80/50
- Refers to the pressure when the ventricles are at rest:
- Diastole
- Systole
- Preload
- Pulse pressure
- Which of the following is true about the blood pressure determinants?
- Hypervolemia lowers BP
- Hypervolemia increases GFR
- HCT of 70% might decrease or increase BP
- Epinephrine decreases BP
- How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?
- 5
- 10
- 15
- 30
- Too narrow cuff will cause what change in the client's BP?
- True high reading
- True low reading
- False high reading
- False low reading
- Which is a preferable arm for BP taking?
- An arm with the most contraptions
- The left arm of the client with a CVA affecting the right brain
- The right arm
- The left arm
- In assessing the abdomen, which of the following is the correct sequence of the physical assessment?
- Inspection, auscultation, percussion, palpation
- Palpation, auscultation, percussion, inspection
- Inspection, palpation, auscultation, percussion
- Inspection, auscultation, palpation, percussion
- When is the best time to collect urine specimen for routine urinalysis and C/S?
- Early morning
- Later afternoon
- Midnight
- Before breakfast
- Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?
- Use a clean container
- Discard the first flow of urine to ensure that the urine is not contaminated
- Collect around 30–50 ml of urine
- Add preservatives, refrigerate the specimen or add ice according to the agency's protocol
- The primary factor responsible for body heat production is the:
- Metabolism
- Release of thyroxin
- Muscle activity
- Stress
- The heat regulating center is found in the:
- Medulla oblongata
- Thalamus
- Hypothalamus
- Pons
- A process of heat loss which involves the transfer of heat from one surface to another is:
- Radiation
- Conduction
- Convection
- Evaporation
- Which of the following is a primary factor that affects the BP?
- The following are social data about the client except:
- Patient's lifestyle
- Religious practices
- Family home situation
- Usual health status
- The best position for any procedure that involves vaginal and cervical examination is:
- Dorsal recumbent
- Side lying
- Supine
- Lithotomy
- Measure the leg circumference of a client with bipedal edema is best done in what position?
- Dorsal recumbent
- Sitting
- Standing
- Supine
- In palpating the client's abdomen, which of the following is the best position for the client to assume?
- Dorsal recumbent
- Side lying
- Supine
- Lithotomy
- Rectal examination is done with a client in what position?
- Dorsal recumbent
- Sims position
- Supine
- Lithotomy
- Which of the following is a correct nursing action when collecting urine specimen from a client with an indwelling catheter?
- Collect urine specimen from the drainage bag
- Detach catheter from the connecting tube and draw the specimen from the port
- Use sterile syringe to aspirate urine specimen from the drainage port
- Insert the syringe straight to the port to allow self sealing of the port
- When palpating the client's neck for lymphadenopathy, where should the nurse position himself?
- At the client's back
- At the client's right side
- At the client's left side
- In front of a sitting client
- Which of the following is the best position for the client to assume if the back is to be examined by the nurse?
- Standing
- Sitting
- Side lying
- Prone
- In assessing the client's chest, which position best show chest expansion as well as its movements?
- Sitting
- Prone
- Side lying
- Supine
- Cardiovascular disease is a common health problem in _______.
- Middle adulthood
- Adulthood
- Older hood
- Childhood
- Glaucoma is a common health problem in _______.
- Middle adulthood
- Young adulthood
- Older adult
- Childhood
- Accidents are common during:
- Middle adulthood
- Young adulthood
- Older adult
- Childhood
- Ram Bhadur, the Nepali prime minister, is depressed due to the enormous loss of influence, power, fame and fortune. What type of crisis is Ram Bahadur experiencing?
- Situational
- Maturational
- Social
- Phenomenal
- Sita, the Philippine president, has been unexpectedly impeached and 71was out of office before the end of his term. She is in what type of crisis?
- Situational
- Maturational
- Social
- Phenomenal
- The Tsunami in Thailand and Indonesia took thousands of people and change million lives. The people affected by the Tsunami are saddened and do not know how to start all over again. What type of crisis is this?
- Situational
- Maturational
- Social
- Phenomenal
- Which of the following is a objective data?
- Dizziness
- Chest pain
- Anxiety
- Blue nails
- A patient's chart is what type of data source?
- Primary
- Secondary
- Tertiary
- Can be a and b
- All of the following are characteristic of the nursing process except:
- Dynamic
- Cyclical
- Universal
- Intrapersonal
- Which of the following is true about the nursing care plan?
- It is nursing centered
- Rationales are supported by interventions
- Verbal
- At least 2 goals are needed for every nursing diagnosis
- The nurse should take a rectal temperature of a patient who has:
- His arm in a cast
- Nasal packing
- External hemorrhoids
- Gastrostomy feeding tubes
- Blood pressure measurement is an important part of the patient's data base. It is considered to be:
- The basis of the nursing diagnosis
- Objective data
- An indicator of the patient's well- being
- Subjective data
- Postural drainage to relieve respiratory congestion should take place:
- Before meals
- After meals
- At the nurse's convenience
- At the patient's convenience
- A patient states that he has difficulty sleeping in the hospital because of noise. Which of the following would be an appropriate nursing action?
- Administer a sedative at bedtime, as ordered by the physician
- Ambulate the patient for 5 minutes before he retires
- Give the patient a glass of warm milk before bedtime
- Close the patient's door from 9 pm to 7 am
- Practices that restrict micro-organisms in the environment and on equipment and supplies and prevents normal body flora from contaminating the surgical wound is:
- Aseptic technique
- Septic technique
- Sterilization
- Cleanlines
- During sterilization by autoclaving, for how long do we need to autoclave when 15 lbs pressure is applied under 121°C.
- 3 minutes
- 5 minutes
- 10 minutes
- 15 minutes
- Surgical handwashing last from:
- 5–10 minutes
- 1–3 minutes
- 3–5 minutes
- 5–7 minutes
- Steps of surgical handwashing:
- 4
- 5
- 6
- 7
- A nurse responsible for helping with preparations before the operation starts, taking care of the requirements in the room but outside the sterile field and helping with the end of 72operation requirement and getting the patient to recovery is known as:
- Theater nurse
- Recovery nurse
- Scrub nurse
- Circulatory nurse
- One of the major responsibility of recovery nurse on the immediate arrival of patient after operation is:
- Maintaining BAC (breathing, airway and circulation)
- Informing the relatives about the operation
- Regulating drips
- Securing drains
- Consent is necessary for except:
- To protect patient from unwanted procedure
- To protect surgeon and medical professionals
- To protect the hospital
- To protect the relatives of the patients
- Which techniques can be applied while gloving ?
- Direct and indirect technique
- Closed and open technique
- Closed and straight technique
- Sterile and unsterile technique
- Agent that kills micro-organisms on an inanimate surface is:
- Disinfectant
- Antiseptics
- Chemicals
- Spirit
- What is the backbone of operation theater to optimize primary wound healing to promote the efficiency of patient care?
- Efficient anesthetic team
- Effective communication
- Effective infection control program
- Efficient management of resources
- Who is responsible for counting the sponges and all other equipments/materials used during surgery?
- Circulatory nurse
- Scrub nurse
- Recovery nurse
- Both a and b
- Prolene is an _______ suture.
- Natural absorbable
- Natural nonabsorbable
- Synthetic absorbable
- Synthetic nonabsorbable
- Kochers is needed to:
- Hold skin and tough tissues.
- Hold delicate parts like intestines
- Hold peritoneum and blood vessels
- Cut delicate tissues
- The appropriate way to minimize the sources of contamination via skin is:
- Gowning
- Gloving
- Covering
- Scrubbing
- Which is not the type of anesthesia?
- General anesthesia
- Local anesthesia
- Peripheral anesthesia
- Spinal anesthesia
- Rubber goods are best sterilized through:
- Boiling
- Chemical sterilization
- Autoclaving
- Radiation
- Among the following, which is not the principle of sterilization?
- Sterile field should have only sterile item
- Sterile field is created as close as possible to the time of use
- Gown is sterile in all the front part
- Micro-organisms must be kept to minimum
- Infusing or discarding medication or solution within:
- 24 hours
- 48 hours
- 72 hours
- 7 days
- Changing primary and secondary continuous administration sets every:
- (a) 12th May 1820.
- (a) 1972 AD.
- (a) Nursing assessment.
- (b) 1954 AD.
- (c) Implementation.
- (c) Nightingale's theory.
- (a) Paralysis patient.
- (b) Safe and compassionate care.
- (b) What is good or valuable for all people.
- (c) 55°.
- (d) Using judgemental comment.
- (b) 21–23 gm.
- (b) 23°.
- (b) Auscultation.
- (d) An opportunistic infection.
- (b) Clear, concise, and complete.
- (c) Sterilization.
- (a) Communication.
- (c) Infection.
- (b) Thermal burn.
- (a) “I could not sleep at night”.
- (c) Nursing assessment.
- (a) Decreased serum albumin level.
- (c) 0.9%.
- (c) 16–20 breaths/minute.
- (b) Examination of chest and abdomen.
- (c) Closure of the heart valves.
- (b) Elevate the head of the bed.
- (b) The force of the blood against arterial walls.
- (b) Liver.
- (d) When required.
- (a) 250–500 ml.
- (b) EDTA vial.
- (a) Gastric lavage.
- (d) Sterilization.
- (a) An average 400–500 ml/day.
- (c) Generalized care need.
- (d) 2051 BS.
- (b) Abduction.
- (b) Doctor and co-workers.
- (b) Client's health problems.
- (a) Client feedback.
- (d) To promote health, to prevent illness and to restore health.
- (d) Safety and security needs.
- (a) Basic need.
- (b) A person who provides total care to an individual or community in the problematic situation.
- (b) BS 2018 Magh.
- (a) Science of morals that can guide to nurse in taking moral action.
- (a) Movement of body parts towards the midline of the body.
- (a) 18″.
- (a) The public.
- (d) Report incidents of suspected child abuse to the appropriate authorities identified in legislation and policies.
- (d) Activities a nurse employs to identify a client problems.
- (c) Obtain information about the client.
- (b) Client's health problems.
- (d) Effectiveness of the intervention.
- (a) 0.4 ml.
- (c) Orthopneic.
- (c) Hemoptysis.
- (d) Kidney.
- (d) Potassium.
- (b) Alkalosis.
- (b) Side-lying position.
- (b) Maintaining a patent airway.
- (d) Perspiration.
- (a) Solving the health problems in the community by providing promotional, preventive, curative, and rehabilitative services to individuals, communities and the country as a whole.
- (a) A person who provides total care to an individual or community in the problematic situation as well as in healthy conditions.
- (b) Magh 2018 BS.
- (b) Physiological, security and safety, love and belongingness, self esteem and self-actualization.
- (a) An organized, systematic method of giving individualized care within the scope of nursing practice.
- (b) Assessment, planning, implementation and evaluation.
- (a) f = c × 9/5 + 32.
- (a) When the elevated temperature fluctuates widely but doesn't reach normal levels between fluctuations.
- (d) Absence of urinary secretion.
- (a) 1.003–1.008.
- (b) Instrumental examination of vagina and rectal and for vaginal delivery.
- (a) Respiration, perspiration, urine and feces.
- (a) 45 cm or 18″.
- (a) About 105°F.
- (a) Check for kinks or bends in the tubing.
- (c) Depress CNS and allow sleep.
- (a) The administration liquid medication by drop.
- (a) 21 drops/minute.
- (a) Aseptic technique.
- (d) 15 minutes.
- (b) 1–3 minutes.
- (d) Circulatory nurse.
- (a) Maintaning BAC (breathing, airway and circulation).
- (d) To protect the relatives of the patients.
- (b) Closed and open technique.
- (a) Disinfectant.
- (c) Effective infection control program.
- (d) Both (a) and (b).
- (d) Synthetic nonabsorbable.
- (a) Hold skin and tough tissues.
- (c) Covering.
- (c) Peripheral anesthesia.
- (c) Autoclaving.
- (c) Gown is sterile in all the front part.
- (b) Organ phosphorus.
- (d) To cure the disease.
- (d) Kerosene.
- (a) CPR.
- (b) Nondiscriminating.
- (c) Swelling may occur.
- (d) All of the above.
- (b) Triage.
- (a) Tilting the head and lifting the chin.
- (d) 15%.
- (b) Antidote.
- (a) Nacetylcystine.
- (d) Orally.
- (a) 100–120/minute.
- (c) Cause burn.
- (c) Constricted pupils.
- (d) Hypocalcemia and hyper phosphatemia.
- (d) Teach the patient to move legs in bed.
- (a) Battery.
- (d) World Health Organization.
- (b) “Related to”.
- (b) Increased serum bicarbonate level.
- (b) Maintaining a patent airway.
- (d) 24 hours.
- (d) Abdominal distension.
- (a) Restrict the visitors to a 10 minutes stay.
- (c) Distended jugular pressure.
- (c) Antibodies to penicillin developed after earlier use of the drug.
- (a) Intravenous albumin.
- (d) Maintenance of oncotic pressuer.
- (c) Lactic acidosis.
- (c) Tongue—Deep red in appearance; surface papillae present.
- (a) Eupnea.
- (b) Wheezing.
- (c) Weigh daily.
- (d) Maslow's hierarchy of human needs.
- (d) Make sure the power is turned off.
- (d) You should put the hand in cool water for all of the above.
- (b) Snug, but not so tight that it slows circulation.
- (c) In shock.
- (a) Remove nearby objects that might cause injury.
- (c) Flush the burned area with large amounts of water until the ambulance arrives.
- (a) To prevent infection.
- (c) Apply cool wet cloths.
- (b) Apply direct pressure and elevate the injured area (if no broken bones).
- (b) Call your local emergency phone number for help.
- (d) Both a and b.
- (a) Apply direct pressure with a clean or sterile dressing.
- (d) All of the above.
- (c) Help control bleeding and prevent infection.
- (b) On the neck to the right or left of the windpipe.
- (d) Inside the arm between the elbow and shoulder.
- (c) Back blows and chest thrusts.
- (d) All of the above.
- (c) Rescue breathing.
- (b) Red, hot or dry skin.
- (c) A bruise.
- (b) Apply direct pressure.
- (b) To hold dressings in place, apply pressure and control bleeding.
- (b) Are used to help control bleeding and keep germs out.
- (b) Control swelling and support injuries such as sprains or strains.
- (c) Have the victim sit with head tilted slightly backward while pinching the nostrils together.
- (d) All of the above
- (b) Chest or abdominal pain, breathing difficulty
- (a) Involves only the top layer of skin.
- (c) Cool the burned area.
- (d) All of the above.
- (d) All of the above.
- (d) Avoid breaking blisters.
- (d) Can be caused by swimming in waters below 70°.
- (b) Apply ice.
- (d) Unconscious, not breathing, but has a pulse.
- (c) Face down on your forearm with head lower than the body
- (d) Both b and c.
- (d) Flush with large amounts of cool water until help arrives.
- (d) Frequent watery stool 3 times a day
- (d) All of the above.
- (a) Heat Stroke.
- (d) Both a and b.
- (c) The circulatory system fails to deliver blood to all parts of the body.
- (b) Wash the wound, keeping injured area lower than the heart; get professional medical care within 30 minutes.
- (a) 1½″.
- (d) 7.5–10 cm.
- (b) 2″.
- (b) Internal bleeding.
- (b) 45 cm.
- (d) Providing oral hygiene.
- (d) Tachycardia.
- (b) Face the client, bend knees and place hands on client's forearm and lift.
- (b) Side-lying.
- (c) Keep side rails up at all time.
- (a) Assessment.
- (d) All of the above.
- (b) Acute illness.
- (c) When necessary.
- (c) Complete bed rest.
- (b) 20.
- (a) Ask the client his name.
- (b) Between the client's cheeks and gums.
- (a) Sims left lateral.
- (c) Check the availability of a liquid preparation.
- (c) Subcutaneous.
- (a) Inspection.
- (d) Inspection.
- (b) Auscultation.
- (a) Sounds created by air filled lungs.
- (c) Knee-chest.
- (a) Optic.
- (d) Use the Z-track technique.
- (a) 54.
- (d) Dehydration.
- (d) All of the above.
- (d) Temperature and respiratory rate.
- (d) Apical pulse.
- (c) Pedal.
- (b) An 88-year-old incontinent patient with gastric cancer who is confined to his rest at home.
- (a) Thiamine.
- (a) Less than 30 ml/hour.
- (d) “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy”.
- (b) Young adulthood.
- (d) Inhibition of the respiratory hypoxic stimulus.
- (d) Hip fracture.
- (a) Depression.
- (d) All of the above.
- (c) Labeling the corpse appropriately
- (a) A patient with leukopenia.
- (a) 30 seconds.
- (b) Urinary catheterization.
- (c) Invasive procedures are performed.
- (a) Waist tie and neck tie at the back of the gown.
- (b) Discard all used uncapped needles and syringes in an impenetrable protective container.
- (a) Massaging the reddened are with lotion.
- (b) Blood typing and cross-matching
- (a) Potential for clot formation.
- (d) 25,000/mm³.
- (d) 26G.
- (a) IM injection or an IV solution.
- (a) Hemoglobinuria.
- (c) Renal failure.
- (d) Frank bleeding at the insertion site.
- (c) Provide additional bedclothes.
- (d) Bile obstruction.
- (d) Evaluation.
- (d) All of the above.
- (b) Urine retention, bladder distension, and infection.
- (a) Don't mind the incident, continue to insert the NG tube.
- (c) Once the skin has been sterilized, considered it sterile.
- (b) The nondominant hand.
- (a) Stage of alarm.
- (b) Stage of resistance.
- (a) Stage of alarm.
- (b) Stage of resistance.
- (d) Re-establishes a normal pattern of elimination.
- (d) Blue nails.
- (b) Secondary.
- (a) Convection.
- (d) 105.8°F.
- (c) Remittent.
- (a) Relapsing.
- (b) Neutropenic.
- (b).5–1.5″.
- (a) Young person have higher pulse than older persons.
- (b) Use the thumb to palpate the artery.
- (b) BP = 160/120.
- (a) Diastole.
- (d) Epinephrine decreases BP.
- (d) 30.
- (c) False high reading.
- (d) The left arm.
- (a) Inspection, auscultation, percussion, palpation.
- (a) Early morning.
- (b) Discard the first flow of urine to ensure that the urine is not contaminated.
- (a) Metabolism.
- (c) Hypothalamus.
- (b) Conduction.
- (c) Stress.
- (a) Patient's lifestyle.
- (d) Lithotomy.
- (a) Dorsal recumbent.
- (a) Dorsal recumbent.
- (b) Sims position.
- (c) Use sterile syringe to aspirate urine specimen from the drainage port.
- (a) At the client's back.
- (a) Standing.
- (a) Sitting.
- (a) Middle adulthood.
- (c) Older adult.
- (b) Young adulthood.
- (b) Maturational.
- (a) Situational.
- (c) Social.
- (d) Blue nails.
- (b) Secondary.
- (d) Intrapersonal.
- (a) It is nursing centered.
- (b) Nasal packing.
- (b) Objective data.
- (a) Before meals.
- (c) Give the patient a glass of warm milk before bedtime.
- (a) Aseptic technique.
- (d) 15 minutes.
- (c) 3–5 minutes.
- (c) 6.
- (d) Circulatory nurse.
- (a) Maintaining BAC (breathing, airway, and circulation).
- (d) To protect the relatives of the patients.
- (b) Closed and open technique.
- (a) Disinfectant.
- (c) Effective infection control program.
- (d) Both a and b.
- (d) Synthetic nonabsorbable.
- (a) Hold skin and tough tissues.
- (c) Covering.
- (c) Peripheral anesthesia.
- (c) Autoclaving.
- (c) Gown is sterile in all the front part.
- (a) 24 hours.
- (c) 72 hours.