Reduction of

Risk Potential
Archer Review

© USMLE Galaxy LLC

Reduction of Risk Potential

(RN and PN 9 - 15%)

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Key Topics
▪ Vital sign changes
▪ Diagnostics and labs
▪ Change in condition
▪ Complications/Alterations
▪ Focused Assessments
▪ Procedure Complications
o Preoperative, intraoperative, and postoperative

Vital Signs

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Vital Signs: How to take/trends

● The 5th vital sign is pain!

○ Normal: Varies for each client
○ Important to set pain goals with client

Temperature
● Temperature methods
○ Rectal - best for core temperature
○ Axillary
○ Temporal
○ Oral
○ Tympanic

Temperature is too high

● Fever - infection
● Hyperthermia - exposure to extreme temperatures / medications

Temperature is too low

● Hypothermia - exposure to extremely cold elements

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Blood Pressure
Client position: Feet on floor, legs not crossed

Sizing

● Width of the bladder should 40% of the size of the arm

● The length of the bladder should be about 80% of the circumference of
the arm
○ Cuff size too small - falsely elevated reading
○ Cuff size too big - falsely lowered reading
● Low: Hypotension

● High: Hypertension

Respirations
● Respiratory rate
○ Normal 12-18 breaths per minute
○ Low: Opioid overdose
○ High: Anxiety attack
● Count for one full minute
● In babies, look at abdomen to count respirations
● Respiratory rate low
○ Bradypnea
○ Can cause respiratory acidosis
● Respiratory rate high
○ Tachypnea
○ Can cause respiratory alkalosis

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Pulse
● If any abnormalities, take for a full minute
● Newborns
○ Always take an apical pulse for a full minute because of irregular rate
● Adult
○ Radial pulse
● Strength
○ 0 = weak and absent
○ 1+ = thready and diminished
○ 2+ = normal
○ 3+ = bounding
● High pulse
○ Tachycardia
● Low pulse
○ Bradycardia

Pain
The 5th Vital Sign

● Types of scales
○ Numerical
○ Wong Baker
○ Cries Scale
○ Nonverbal pain scale
● PCA
○ Patient controlled analgesia
○ Pump
○ Client should be the only one to
push the PCA

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Invasive Monitoring
● Intracranial pressure
○ Normal 5 - 15
○ Measured by implantable transducers (probes)
○ Too high implement measure to decrease ICP and start seizure precautions.
● Pulmonary artery pressure
○ Normal 8 - 20
○ Measured by Doppler Echo
○ Too high - pulmonary artery hypertension
■ Affects right side of the heart and the arteries going to the lungs

Diagnostics and Labs

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Magnetic Resonance Imaging (MRI)
● Noninvasive imaging method
○ Uses magnetic fields and radio waves to determine anatomy
○ Lasts 15 - 60 minutes
○ May show soft tissue/organ changes
○ Great to see the brain, spinal cord, and nerves
○ May or may not use contrast

● Before MRI
○ Ensure that client has no metal objects in/on them (watches/jewelry)
○ Assess for claustrophobia
○ Assess if client has pacemaker
■ Old MRI machines may deactivate them
■ Some newer machines are safe for pacemakers

● Contraindications
○ Agitation/old tattoos (contain lead)

Computerized Tomography (CT)

● This uses many x-rays to form three dimensional anatomical pictures
○ Donut shaped scanner
○ May or may not use contrast (contrast is helpful for tumor identification)
○ Client must remain still
○ Each set of scans takes 5 - 10 minutes

● Best way to see the bones

● Ensure renal function checked before giving contrast
○ Increase fluids post-contrast
○ Monitor urine output closely after CT
○ Hold Metformin 24 hours prior and up to 48 hours after

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Ultrasound
● Uses sound waves to produce an image
○ Examples:
■ Bladder
■ Uterus
■ Kidneys
■ Abdomen
■ Ovaries/Testes
■ Vasculature
● Non-invasive
● No food or fluid
- Looking at digestive system
● Drink water for full bladder
- Scan of pelvis or fetus

Lab Values
● Client education
● Critical lab values
○ Know when to report
● Most important
○ Understand what the lab results indicate

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Diagnostics
● Gathering Samples:
○ Blood Culture
■ Take before starting antibiotics
■ 10 mL/bottle
● Not enough = false negative results
● Too much = inaccurate results
○ Wound
■ Take from clean tissues
■ Gathering:
● Rotate swab for at least 5 seconds
● Zig Zag Method
○ Urine
■ Don’t get out of the indwelling catheter bag.
■ Make sure to maintain sterile technique if from catheter
■ Clean catch technique
○ Stool
● Label right after getting the specimen.

Order of Lab Collection with Central Line

1. Gather all supplies
2. Wash hands
3. Scrub the lumen with alcohol swab
4. Flush central line with 10 mL of NS
5. Draw 10 mL of blood and discard
6. Draw 10 mL of blood and put into tubes for labs.
7. Flush with 10 - 20 mL of NS (per facility protocol)
8. Label tubes with name/DOB/time collected and send to lab
9. Document collect

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Complete Blood Count (CBC)
● Hemoglobin (Hgb)
○ Female: 12-16 g/dL
○ Male: 14-18 g/dL
● Hematocrit (Hct)
○ Female: 37-47%
○ Male: 42-52%
● Red Blood Cells (RBCs)
○ 4.5-5.5 million
● White Blood Cells (WBCs)
○ 5,000 - 10,000
● Platelets
○ 150,000 - 400,000

Coagulation Panel
● Activated partial thromboplastin time (aPTT)
○ Tests the intrinsic coagulation cascade
○ Not on anticoagulants: 30 - 40 seconds
○ On Heparin, ‘therapeutic aPTT’ is 1.5-2.5x
normal
● Prothrombin Time (PT)
○ Tests the extrinsic coagulation cascade
○ 10 - 12 seconds
● International Normalized Ratio (INR)
○ It is calculated from a PT and is used to
monitor how well warfarin is working
○ Not on anticoagulants: 0.9-1.2
○ Taking warfarin, therapeutic INR - 2-3

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 Metabolic Panel
● Sodium - 135-145
● Total protein - 6.4 - 8.3
● ● Albumin - 3.5 - 5
Potassium - 3.5 - 5

● Calcium - 9 -10.5
● Bilirubin - <1
● ● Ammonia - 15 - 110
Magnesium - 1.5 - 2.5

● ● AST - 0 - 35
Chloride - 98 - 106

● ● ALT - 4 - 36
Phosphorus - 2.5 - 4.5

● Glucose 70-110
● ALP - 30 - 120

● BUN - 10 - 20

● Creatinine - 0.6-1.2

● GFR - >90

Renal labs

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Liver Function Tests (LFTs)

Cardiac Labs
● Troponin
○ Troponins are a group of proteins found in skeletal and cardiac muscle fibers that regulate
muscular contraction
○ Test measures the level of cardiac-specific troponin in the blood to help detect heart injury
○ Several types of troponin
○ Normal = 0-0.4

● BNP
○ When there is fluid retention, the heart
senses the need to pump harder to move
fluid forward, and releases BNP
○ Test for CHF
○ Normal <100

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Lipid Panel
● Total cholesterol <200 mg/dL
● HDL > 45 mg/dL
● LDL < 130 mg/dL
● Triglycerides 40-160 mg/dL

Misc.
● D-dimer
○ <500 ng/mL
● CRP
○ <1 mg/dL
● HbA1C
○ Non-diabetic: 4-5.6%
○ Pre-diabetes: 5.7-6.4%
○ Diabetic - >6.5%
○ Target level for diabetics - <7%

Glucometer
How to use:

1. Wash hands

2. Introduce self

3. Insert test strip

4. Ensure number on the glucometer matches the test strips

5. Collect blood

6. Apply blood to strip

7. Check result
a. Normal should be 70 -110 mg/dL

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Amniocentesis
● Looks at genetic disorders and neural tube defects
● Invasive
○ Requires informed consent
○ Risk to fetus
● Done on outpatient basis
○ Long thin needle is inserted to remove a small amount of amniotic fluid

● Assess if rhogam is needed for the mother

Changes in Condition

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Identifying Client Risk
● Aspiration
○ Diagnosis that can cause risk:
■ Parkinson's disease
■ Stroke
○ Always assess a gag reflex
○ If questionable, refer to speech language pathologist
● Skin breakdown
○ Braden scale
○ Friction
○ Shearing
● Poor Perfusion
○ Skin color
○ Capillary refill

Friction & Shear

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Output Monitoring
● Urine
○ Normal 30 mL/hr or greater
○ Should be light yellow
○ Indicator of kidney function

● Wounds
○ Report odor, purulent drainage - indicates infection
○ Clean from the inside to the outside of the wound

● NG tubes
○ Normal output <500 mL

● Stool
○ Know clients regular habits
○ Check for bowel sounds
○ If no sounds for 5 minutes = absent

Neurological Complication Prevention

● Foot Drop
○ Caused by nerve injury
○ Can occur when the nerves/muscles in the foot aren’t used
○ Passive range of motion can be beneficial in prevention
○ May require physical therapy
● Posturing
○ Decorticate
○ Decerebrate
● Babinski Reflex
○ Stroke sole of foot
○ Positive - toes fan outward
○ Negative - toes curl in
○ Positive Babinski - abnormal after 2 years of age

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 Lack of Blood Components
● Thrombocytopenia
○ Lack in platelet levels
○ Bleeding risk
● Neutropenia
○ Lack of neutrophils
○ Infection risk
● Pancytopenia
○ Lack in all major blood components platelets, white blood cells, and red blood cells
○ Infection and bleeding risk

Education for Complication Prevention

● Diabetes foot care
○ Inspect feet daily
○ Close-toed shoes
○ Do not put lotion between the toes
○ Ensure to change/socks or shoes if they become wet
○ Massage can be beneficial
● Below the knee amputation
○ Prone several times a day
■ Prevention of contractures
○ Do not place pillow under the knee/residual limb after the first 24 hours
○ Wrap post op bandage in a figure 8

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 Complications

Cardiac Catheterization Complications

● Thin tube into the blood vessel in order to
look at the heart muscle and vasculature
○ Helps us to visualize the heart's
function
● Complications
○ Bleeding - Bruising
○ Blood clots - Stroke
○ Arrhythmias
○ Infection
○ Ensure no allergy/prior reaction to
contrast dye

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Central Line Associated Bloodstream Infection
● Risk Factors
○ Multiple lumens
○ Femoral insertion site
○ TPN

● Prevention
○ Wash hands
○ Scrub the hub
○ Wear gloves
○ Change caps every shift
○ Sterile central line dressing change

● Signs and symptoms

○ Fever, redness, and/or pain around central line insertion site
○ Increase in white blood cell count

Bleeding/Hemorrhage
● Hematocrit/Hemoglobin
○ Will trend down
● Nursing interventions
○ Trendelenburg client
○ Give fluids
○ Prepare to give blood, clotting factor, and plasma volume expanders
● Hypovolemic shock
○ Hypotension and tachycardia

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Shock

What is Shock?
● A state where the vital organs are not receiving adequate oxygenation
○ This lack of oxygenation causes organ damage
○ Forces the cells to use anaerobic metabolism to create energy, producing lactate
● The cardiovascular system is composed of
○ The blood
○ The vasculature
○ The heart
● A disruption in any of these three components can cause a lack of oxygen delivery to
the organs, causing shock
● Which component is ‘broken’ determines the type of shock

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 Phases of Shock
● Initial stage - is the first stage, which occurs in all types of shock—this stage is characterized by hypoxia and
anaerobic cell respiration leading to lactic acidosis.

● Hyperdynamic - occurs in the early or compensated stage of septic shock. Blood pressure may still be within
normal limits, but the heart rate and temperature increase due to increased cardiac output and systemic
vasodilation.

● Progressive stage - occurs in all types of shock and is characterized by decreased cardiac output, hypotension,
and anasarca (generalized edema). During this stage, the compensatory mechanisms begin failing to meet
tissue metabolic needs.

● Hypodynamic phase - is the final/irreversible phase of septic shock, characterized by decreased cardiac
output, decreased blood pressure, and vasoconstriction.

Treatment
● Dopamine: first line in shock ● Vasopressin: third line
○ Used in trauma clients and cold shock ○ Antidiuretic hormone (ADH)
○ Low doses used in kidney failure to increase ○ ANTI-diuresis…. Less diuresis
renal blood flow ■ More volume IN the
○ Low doses increase contractility
vascular system
■ Increases CO
○ Higher doses cause vasoconstriction ■ More volume → more
■ Increases SVR pressure!
○ Raises BP
○ Second line in distributive shock
○ Third line in septic shock
● Phenylephrine: second line
○ Used for anesthesia-induced hypotension
○ Second line agent in some shock clients
○ Only acts on alpha-1 receptors
○ Causes only vasoconstriction - no inotropy
○ Vasoconstriction → Increased BP

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Question
The nurse is caring for a client with septic shock presenting with a temperature of 102 degrees
F (38.9C), heart rate 98 beats/minute, and blood pressure of 126/84 mmHg. Which phase of
septic shock is this client experiencing?

A. Progressive
B. Hypodynamic
C. Initial stage
D. Hyperdynamic

Answer: D
Choice D is correct. The hyperdynamic phase occurs in the early or compensated stage of septic shock. In this phase, the blood
pressure may still be within normal limits, but the heart rate and temperature increase due to increased cardiac output and systemic
vasodilation. During this phase, nursing interventions include intravenous fluids to increase the peripheral vascular resistance and
administration of prescribed antibiotics as soon as possible. Addressing septic shock appropriately at this stage significantly improves
the outcomes.

Choice A is incorrect. The progressive stage occurs in all types of shock and is characterized by decreased cardiac output, hypotension,
and anasarca (generalized edema). During this stage, the compensatory mechanisms begin failing to meet tissue metabolic needs.
Elevated catecholamine production increases peripheral vascular resistance as the body attempts to shunt blood away from non-vital
organs (gastrointestinal tract, kidneys, muscle, and skin) to the vital organs (brain and heart). This phase is also described as a cold
shock.

Choice B is incorrect. The hypodynamic phase is the final/irreversible phase of septic shock, characterized by decreased cardiac output,
decreased blood pressure, and vasoconstriction. At this stage, the shock becomes unresponsive to therapies and hence, fatal.

Choice C is incorrect. The initial stage is the first stage, which occurs in all types of shock—this stage is characterized by hypoxia and
anaerobic cell respiration leading to lactic acidosis. Almost immediately, the compensatory stage follows as the body initiates neural,
hormonal, and biochemical compensation efforts to maintain homeostasis. Clinically, the initial stage of shock may not show any
manifestations. As soon as the compensatory stage of septic shock begins, tachycardia is noticed.

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 Tubes & Drains

Tubes/Drains
● NG tube
● Foley catheter
● Chest tube
● Airways
○ ETT
○ Tracheostomy

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Nasogastric tube
● Tube inserted in the nare that terminates in the
stomach
● Uses
○ Enteral nutrition
○ Decompression
○ Medication administration
○ Removal of stomach contents after an overdose

NGT Insertion
1. Perform hand hygiene
2. Explain the procedure to the client
3. Measure from the earlobe of the client to the nose, then to the xiphoid process.
This is how deep you will insert the NG tube.
4. Mark the depth of insertion on the NG tube
5. Lubricate the tip of the tube.
6. Insert the tube to the nasopharynx, and ask the client to swallow and tuck their
chin to their chest.
7. Continue advancing the tube to the predetermined depth.
8. Secure the tube.
9. Verify placement of the NG tube.

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Measurement

Placement verification
● Gold standard - x-ray visualization
● Aspiration of gastric contents
● Auscultation of air over the epigastrium
● Residuals
○ The amount of feeding that remains in the
stomach at the time of your assessment
○ Typically checked as you are preparing to start
the next feed
○ If it is greater than 500 mL, the feed should be
held

Image source: creative comments. View here

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Foley catheters
● Catheter placed into the urethra and
up to the client's bladder
● Foley catheters are ‘indwelling’ or left
for an extended period of time
● Urine drains into a drainage bag

Inserting a foley catheter

1. Wash your hands and don sterile gloves

2. Place the tip of the catheter in lubricant

3. Clean with betadine

a. Females: Use the non-dominant hand to spread the labia. Use three swabs: one on
the left, one on the right, and the last one down the middle.
b. Male: Clean the peri-urethral opening with three swabs.
4. Using the dominant hand, insert the catheter into the urethral opening

5. Once urine is observed, advance the catheter another one to two inches

6. Attach the pre-filled syringe to the port and inflate the balloon

7. Connect the drainage system to the catheter and secure per facility protocol.

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Nursing Must Know
● There should never be dependent loops in the tubing
○ This can lead to urine backing up in the bladder
● Inserting a foley catheter requires sterile technique to prevent infection
● CAUTIs (catheter acquired urinary tract infections) are UTIs caused by a catheter
○ The hospital is not reimbursed for these infections, so there is a lot of emphasis on
preventing them
○ Most facilities use a bundle to prevent CAUTIs
○ Always remove as soon as possible
○ Daily cleaning and care
● You can collect a urine sample directly from the port on the foley!

Collecting a urine sample

1. Collect supplies.

2. Wash hands, put on gloves.

3. Wipe genitals with a towelette

4. Allow urine for flow for two seconds, then place sterile container to collect sample.

5. Client can finish urinating.

6. Replace lid on specimen container and label according to policy. Place in a specimen bag.

7. Remove gloves, wash hands.

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 NGN Question
The nurse is removing an indwelling urinary catheter

Drag words from the choices below to fill the blank in the following sentence

Prior to attempting to remove the catheter again, the nurse should __________________.

Answer:
Drag words from the choices below to fill the blank in the following sentence

Prior to attempting to remove the catheter again, the nurse should further deflate the catheter balloon.

Rationale: The amount of fluid removed from the balloon (this secures the catheter in place inside of the bladder) was
inadequate. 10 mL of fluid is typically used to inflate the catheter balloon to keep it secure inside the bladder. The nurse
should further deflate the catheter balloon by passively allowing the fluid to fill the syringe. The nurse may gently pull back
on the syringe plunger if this does not work. By removing the residual volume, the nurse should then remove the catheter.

Cutting the balloon inflation valve would negate the closed system. Cutting the valve is not standard practice and should
not be done. Positioning the client 45 degrees is not appropriate for discontinuing an indwelling urinary catheter. The
correct approach for positioning a client to remove an indwelling catheter is having a male client supine and a female in the
dorsal recumbent position.

Placing a warm compress over the perineum may give the client comfort, but this will not effectively troubleshoot the
problem with the catheter. The issue is not with a bladder spasm, yet an indwelling urinary catheter that has not been
entirely deflated.

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Chest tube
● Tube inserted into the pleural space
of the lungs
● Helps to remove air or fluid that has
caused the lung to collapse
● Also placed after cardiac surgery into
the pericardial space to help drain
blood and fluid from around the heart

Why would our client need a chest tube?

● There is something in the pleural space….and

we need to get it out
○ Air - pneumothorax
○ Fluid - pleural effusion
○ Blood - hemothorax
● This allows the lung to fully expand

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Drainage System Chambers

Nursing Considerations
● Positioning
○ Always keep the drainage system below the level of the
client's chest
○ Ensure the tubing is free of kinks and draining freely
○ There should be no dependent loops in the tubing
● Monitor the drainage
○ Color: Serous-serosanguinous. Know WHY the client has a CT!
○ Odor: none
○ Consistency: thin-thick
○ Amount - no more than 100ml/hr
■ More? Call the doc!!
■ Mark hourly

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What to do if the chest tube comes out
● Cover the site with a sterile dressing
● Tape on three sides
○ Air can escape this way
○ If taped on 4 sides you might cause
a tension pneumothorax
● Call the primary healthcare provider
● STAY WITH THE CLIENT

What to do if the
tube disconnects from
the drainage
collection system?
● Chest tube is still in the client, but becomes disconnected from
the collection chamber
● Place the end of the chest tube in a bottle of sterile water

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Tracheostomy Tube
● Suctioning
○ Assess need for suctioning at least every 2 hours
■ Abnormal lung sounds
■ Signs of distress
■ Decrease in pulse oximetry
○ Limit to 10 - 15 seconds

1. Perform hand hygiene and identify the client

2. Hyperoxygenate the client, if required
3. Insert the suction catheter without suctioning to the pre-measured depth
4. Apply intermittent suction and rotate the suction catheter as it is removed from the tracheostomy
5. Replace the cap, mist collar, oxygen mask, or other apparatus to the tracheostomy and monitor the
client to ensure they return to baseline

Always keep the same size and one size small tracheostomy tube at bedside

Focused Assessments

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 Hypoglycemia: Hyperglycemia:

● Cold ● Increase thirst

● Clammy ● Increase urination
● Confused ● Blurred vision
● Shakey ● Fatigue
● Nervous ● Weakness
● Nausea ● Headache
● Headache ● Tingling
● Hungry ● Polyphagia
● Blurry vision
*Warning sign DM client may have
*Beta Blockers may mask infection if levels start rising
symptoms of hyperglycemia

Peripheral Edema
● Pitting Edema
○ Caused by fluid accumulation in tissues
○ +1: 2 mm depression bounces back immediately
○ +2: 3 to 4 mm depression bounces back in 15 seconds
○ +3: 5 to 6 mm depression bounces back in 1 minute
○ +4: 7 to 8 mm depression bounces back in several minutes
● Non-Pitting Edema
○ Causes
■ Protein, sodium, and water accumulation
● Treatment
○ Find underlying cause and treat it
○ Chronic cases use compression stockings

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Venous Return
● Antiembolic Stockings
○ Use for edema, DVT, varicose veins
○ Ensure no wrinkles
○ Remove every 8 hours to assess the extremity
○ Have client elevate legs often
● Sequential Compression Devices (SCDs)
○ Prevent blood clots
○ Ensure no pain/discomfort
○ Remove every 8 hours to assess extremities

Delayed Wound Healing

● At-risk clients
○ Poor nutrition (lack of vitamin C, zinc, and protein)
○ Diabetes mellitus
○ Poor oxygenation to the tissues
○ Elderly population
● Nursing interventions
○ Educate on smoking cessation
○ Nutrition changes
○ Infection prevention
○ Wound care

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Fall Risk
● Ensure call light is in reach
● Have client wear non-skid socks
● Place closer to the nurses station
● Do hourly rounding
● Adhere fall risk bracelet to client

Seizure Risk
● Pad side rails of the bed
● Set up suction at bedside

If seizure occurs:

● Turn client on their side

● Loosen clothing around the neck
● Do not put anything in their mouth
● Remain with the client
● Ensure safety

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Aspiration Risk
● Clients at risk for aspiration
○ Parkinson's disease
○ Stroke
● If they have impaired swallowing abilities
○ NG/OG tube
○ Refer to a speech language pathologist
● Client teaching
○ No distractions while eating
○ Sit up (>45 degrees) while eating and 30 minutes
after
○ Swallow with chin down
● Contact Provider
○ Fever
○ Trouble breathing/wheezing

Neutropenic Precautions
● Clients who made need neutropenic precautions
○ Chemotherapy clients
○ Post transplantation
○ HIV positive clients
● Practices to follow
○ No fresh fruits or vegetables
○ No plants or flowers
○ Keep doors closed
○ Client may wear a surgical mask or N95
● Infection prevention
○ Hand washing
○ Look for signs of infection in the client

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 Procedures

Electroconvulsive Therapy
● Treatment for severe depression/bipolar/schizophrenia.
● Induces a brief seizure during the treatment
● Typically 6 - 12 treatments
○ May need maintenance treatments
● Informed consent required
● Postprocedure:
○ Reorient client when they wake
○ Someone else must drive home
○ Normal to have some short term memory loss

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 Anesthesia Response/Sedation
● Local
○ Ointment or injection
○ Client is awake
○ Causes numbness in small area of the body

● Regional
○ Spinal block, nerve block, epidural
○ Client is awake/alert
○ Causes numbness/pain blocking over a large area

● General
○ Entire body anesthesia
○ Cause loss of consciousness
○ Used for major operations

● Moderate Sedation
○ Person is sedated but can still respond (sleepy)
○ Usually pain medication will also be given
○ May not remember procedure

Preoperative and Postoperative

● Preoperative
○ Informed consent signed
○ NPO
○ Hold anticoagulants
○ Assess
■ Allergies
■ Support systems
■ Religion/cultural practices
● Time out process
● Postoperative
○ Stabilization of vital signs
○ Pain management
○ Client teaching

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Hip Arthroplasty
Damaged bone/joints are removed and replaced with a prosthetic

● Education and nursing interventions

○ Do not internally or externally rotate the hip
○ Use abduction pillow
○ Do not place on surgical side
● Discharge
○ Raised toilet seats
○ Grab bars in the bathroom
○ Sleep on non affected hip with pillow between legs

Casts
● Types
○ Plaster
○ Fiberglass
○ Spica Cast
■ Keep the cast dry, diaper should go under the cast
● Nursing Actions
○ Elevate limb
○ Proper hygiene
○ Teach client to report hot spots on the cast
● Complications
○ Compartment syndrome
■ Pain, pulselessness, pallor, paresthesia, poikilothermia, and paralysis
○ Never put anything in the cast
○ Ensure good circulation

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Pin Site Care
● Pin Site Care
○ Use of Saline/Vaseline Dressings (facility protocol may differ)
○ No current evidence based standard
○ Done every 8-12 hours
○ Use one cotton swab per pin
○ Infection prevention
● Signs of pin site infection
○ Loose pins
○ Purulent drainage from pins
■ Clear drainage is an expected finding
○ Odor
○ Fever

NGN Practice
The nurse in the intensive care unit (ICU) is caring for an 85-year-old male

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 Select

NGN Practice Continued promethazine

ondansetron
The nurse reviews the physician's orders from 1900 and 2000
pantoprazole
➢ Complete the following sentence from the list of options

Select

Select Hypotension

Arterial Blood Gas. Respiratory Acidosis

Blood Pressure. Fever

Temperature.

Select

NGN Answer promethazine

ondansetron
The nurse reviews the physician's orders from 1900 and 2000
pantoprazole
➢ Complete the following sentence from the list of options

Select

Hypotension
Select

Arterial Blood Gas. Respiratory

Acidosis
Blood Pressure.
Fever
Temperature.

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