Sensory
What is the last sense to leave the body?
Hearing
True or False: Patients that receive local anesthesia for a suture repair need to have a ride home?
False - General/moderate sedation must have a ride home from procedure
True or False: You should instruct the patient to close their mouths and breath through their noses when assessing lung sounds
False
What is the priority nursing intervention when performing a sterile procedure and the field becomes contaminated?
Start over with new materials
True or False: The RAS system monitors and regulates incoming sensory stimuli
True
Describe two interventions you would take to decrease the risk of sensory overload
Offer care consisting of rest/comfort/sleep
Allow time alone
Reduce noise around the patient
What are two teaching points the nurse should describe to the patient regarding PRN pain control post op?
They must ask for the medication
They should ask for the medication before it becomes severe
Pain control prior to exercises
What is the optimal positioning for performing breathing exercises and taking nebulized medications?
Fowlers
When removing PPE, which item will be removed first?
Gloves
Name a consideration the nurse would take when a patient going to surgery in one week for a knee replacement reports that he takes a daily anticoagulant medication.
Discuss with team regarding pausing anticoagulant until surgery.
A patient responds "what" over and over again when interviewing a patient. What are three interventions the nurse can take for better communication?
Decrease background sounds
Check hearing aids if they have them
Position self with light on your face
Face the patient when speaking with them
Sign language/writing
A patient that has broken her arms discusses how nervous she will be that she will be awake during the reduction and casting of her forearm. What teaching should the nurse provide regarding moderate sedation?
While you will be conscious, you will be altered and medically sedated so you are in a depressed state and probably will not remember much of anything
The respiratory therapist is obtaining an ABG study on a patient with COPD. Your orientee asks why they are doing that? You anticipate their response to include...
Measure oxygenation/carbon dioxide and pH.
Decide whether further interventions need to be taken, see how well the patient is ventilating, and assess for acid-base imbalance
A patient going to surgery soon for a femur repair. What fluids would you anticipate the surgeon ordering so that the patient maintains fluid/electrolyte balance?
Lactated Ringers
Your patient comes in with an 02 sat of 80% on room air with a history of asthma. They are confused, tachypneic, wheezing, and having difficulty formulating sentences. What medical term would you use to describe their lack of oxygen and perfusion to tissues?
Hypoxia
A patient that is confused keeps coming out of their room wandering around the nurses station. Name two interventions the nurse can take to redirect the patient.
Orient/reorient to environment
Offer diversional activities
Offer explanations when warranted
Face to face communication
Speak calm + simply to patient
You are preparing a patient for surgery and performing teaching on what they should expect afterwards. They ask you what some interventions are to decrease the risk of post op injury. What are five interventions you would include in your teaching?
Cough/deep breathing
Incentive Spirometer
Turning in bed
Leg exercises
Early ambulation
SCD's
There are four aspects of a respiratory physical exam. In what order would these assessments go in?
Inspection
Palpation
Percussion
Auscultation
A nurse is doing a fall risk assessment on an 85 year old patient here for abdominal pain that lives alone at home. What are questions the nurse should prioritize when assessing fall risk?
Stairs
Medications they are on
History of falls
A patient is going in to the OR for a appendectomy and describes that they ate a bacon, egg, and cheese prior a few hours ago on their way to the hospital. What is the priority nursing intervention?
Notify the provider/OR of PO status
A patient asks you to describe the senses involved in sensory reception. Name four different senses and briefly describe them.
Visual
Auditory
Olfactory
Gustatory
Tactile
Kinesthetic
Stereognosis
Proprioception
You are a PACU nurse and your orientee is asking you what your priority assessments are on a patient newly transferred from the OR. What are at least four priority nursing assessments you would tell them?
Respiratory status
Cardiovascular status
Fluid status
Temperature
CNS
Wound status
GI status
What is the difference between oxygenation and ventilation?
oxygenation = deliverance of oxygen to tissues
ventilation = inspiration and exhalation
What is the priority nursing intervention when a patient comes in with a wound dehiscence?
Cover with a sterile dressing/0.9 saline solution and notify provider
What are three different oxygen delivery systems and describe a situation in which you might use each?
Nasal Cannula
Nasopharyngeal catheter
Transtracheal catheter
Simple face mask
Partial nonrebreather
Nonrebreather
Tent
Venturi mask