O2
A nurse is caring for a client who is having trouble breathing. The client is lying in bed and is already receiving O2 therapy via NC. What is the nurses priority intervention?
What is : Raise head of bed to Fowler‘ position. Remember ABC’s.
Name 2 findings that may indicate post op wound infection.
What are: Increased pain, fever, chills, redness.
What is imperative when assessing the weights and pulleys for a patient in traction?
What is: checking that weights hang freely.
Give an example of local anesthesia.
What is: novacaine at dentist appt.
Name 2 s/s of thrombophlebitis.
What are: pain in calf or leg, warmth, swelling.
Why is it dangerous to raise O2 level above 3 L for a COPD pt?
What is: It can decrease the respiratory drive/incentive.
What is a priority intervention if the nurse finds a surgical wound separating and viscera is protubing?
What is: cover the wound with saline soaked sterile gauze.
What is the purpose of a CPM machine after joint replacement surgery?
What is: to exercise the joint.
Who is responsible for obtaining informed consent prior to surgery?
What is: the surgeon.
What Symptom may pt express if a wound dehiscence?
What is: It feels like “ something gave”
What is the most common cause of hypoxia?
What is: airway obstruction.
Name one way debridement occurs.
What is: surgically or with a chemical agent, ie ointment.
How often is a neurovascular assessment performed on an immobilized body part?
What is: q shift or prn.
If your pt has not voided after 8 hrs post surgery, you would first?
What is: obtain an order to catheterize the pt.
You notice the knee incision is opening each time the CPM machine is at max angle. You should :
a- pad the portion of the machine that heel rests on
b- stop the machine and call doc.
c- reassess in 8 hrs
d- increase angle of machine to decrease pressure on heel
What is: b
Name 2 early inactions of hypoxemia.
What are: tachypnea, restlessness, confusion, pallor.
How do cold packs decrease swelling?
What is: by causing vasoconstriction and decreasing bleeding from damaged cells.
Bucks traction is performed before or after surgery?
What is: before.
Which nursing role is responsible for maintaining sterility within the sterile field during surgery?
Who is: scrub nurse.
What is a yankauer suction tip used for?
What is: for oral suctioning of mouth and top of pharynx.
Name 2 teaching items that should be included for the patient going home with O2.
What are: no smoking, no use of petroleum jelly, do not store O2 in closet, be sure tubing is not a tripping hazard.
A 15 yo client with a hx of DM, is s/p appendectomy. He is tolerating a reg diet, ambulating, reports pain level 2/10 after receiving pain meds q 6-8 hrs. His incision is well approximated w scant drainage. What risk factor put him at risk for impaired wound healing?
a- extremes in age
b- impaired circulation
c- impaired/ suppressed immune function
d- malnutrition
e- poor wound care
What is:b and c
Name 2 nursing interventions for the immobilized pt.
What are: ROM (active or passive), specialty beds and mattresses, dietary needs.
Name 2 interventions to prevent atelectasis.
What are: teach deep breathe and cough, use inspirometer, early ambulation, offer splint pillow to abdominal surgery pt.
Name 4 items to document post suctioning a pt.
What are: 1)date, 2)time, 3)reason, 4)size of catheter, 5)type of technique (nasopharyngeal/ oral/ tracheal), 6)amt 7)type of secretions, 8)findings post suctioning, 9)pt response.