Oxygenation
Which coughing technique will the nurse use to help a patient clear central airways?
Huff
This cough helps stimulate a natural cough reflex and moves secretions to the larger airways for removal.
Types of tissue to assess within a wound bed
Granulation, slough, eschar
presence of exudate (serous, serosanguineous, purulent)- and what do those mean to the wound
A patient is requiring pain medications. You have an order for an opioid, but you know your patient has never had opioids before. What is your greatest concern?
1. O2 of 95%
2. Difficult to arouse
3. RR of 12bpm
4. Pain of a 5 out of 10
Difficult to arouse.
Becuase they are opioid-naive, you must anticipate complications with administering an opioid to them for the first time box 44.13
The nurse is preparing a patient for surgery. Which goal is a priority for assessing the patient before surgery?
Establish a patient’s baseline of normal function.
A baseline must always be established.
The nurse is caring for a patient with pneumonia. The patient is lying in bed, coughing, and cannot clear their secretions. Which action should the nurse take?
1. Notify the healthcare provider
2. Assess the lung sounds
3. Elevate the HOB
4. Encourage incentive spirometry
3- elevate the HOB
this simple intervention will promote secretion expulsion by the patient.
The nurse is teaching about the process of exchanging gases through the alveolar-capillary membrane. Which term will the nurse use to describe this process?
Diffusion
Diffusion is responsible for moving respiratory gases from one area to another
Prevention of skin breakdown
use predictive measures to assess risk (braden scale), mobility/strength, nutritional status, exposure to body fluids, significant pain, prolonged pressure points
A patient is being sent home with opioid medications to manage pain after a surgical procedure. What should the nurse consider teaching this patient?
1. Decrease movement as to not interrupt the healing process
2. Increase coffee intake to help with bowel function
3. Increase water intake to help prevent constipation
4. Take the medication every 4 hours to manage pain approrpriately
Increase water intake ti help prevent constipation
The nurse is caring for a surgical patient when the family member asks what perioperative nursing means. How should the nurse respond?
Perioperative nursing includes activities before, during, and after surgery.
There are pre, intra, and post-operative areas. Nursing is required in all three settings. The nurses carry different responsibilities in each.
What should a diet progression look like for a post-operative patient?
1. Maintain NPO status
2. Clear liquids to high fiber
3. Clear liquids to full liquids to regular
4. Straight to regular
3- clear liquids to full liquids to regular
this is a slow, steady progression of the diet to ensure the patient tolerates it before moving to the next stage.
A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority?
Impaired gas exchange
There are many factors that are hindering this patient's ability to have adequate gas exchange. The patient is very quickly not going to have adequate oxygenation and perfusion to their vital organs. This is a priority diagnosis.
The wound care nurse visits a client in the long-term care unit. The nurse is monitoring a client with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the client’s medical record?
Healing Stage III pressure ulcer
Wounds never progress to the next wound stage down when healing. They remain in their current stage with noted healing.
A patient is receiving medication via a patient controlled analgesia (PCA). What should the nurse include in the teaching instructions?
1. The PCA button is only for you to push.
2. You can only push the button every 30 minutes.
3. The PCA is closely monitored so you do not overdose.
4. The PCA was chosen because other meds didn't work to control your pain.
The PCA button is only for the patient to push. This provides the patient control over their pain and decreases their anxiety that the med is available if/when they need it.
Time-Out
Pre-op verification that all verifications (informed consent, labs, medical/physical findings, allergies) are complete, marking the surgical site, last-minute verification of the right patient, right procedure, right site
Which of the following are measures to reduce tissue damage from shear?
1. Have HOB elevated when moving patient
2. Raise HOB 60 degrees when pt is laying supine
3. Providing hourly pericare
4. Using a transfer board when moving pt from the gurney to the bed.
4-Using a transfer board when moving a pt from the gurney to the bed
This prevents or reducing the chance of a shearing injury from occurring.
Can a nurse delegate applying an oxygen device to a NAP?
True. Box 41.9 states:
The skill of applying a nasal cannula or oxygen mask can be delegated to a NAP. Additionally, a NAP can safely adjust the device making it tighter or looser, inform the nurse when there is a change in vital signs associated with oxygenation, and provide skin care around the oxygen delivery devices.
The nurse is assessing a client for their risk of developing pressure ulcers. The nurse finds the client has a Braden score of 10. What action are appropriate measures for the nurse to take?
Place the client on a pressure-redistribution surface.
A braden scale score of 10 is an indicator that the patient has a high risk for skin breakdown. Preventative measures should be implemented.
Behavioral indicators of pain (box 44.9)
vocalization, facial expressions, body movement, social interaction. It is important to know there are other ways to assess pain.
Post-operative complications
Airway, circulation, musculoskeletal, GI/GU, skin breakdown/infection, nervous system
see box 50.8
What simple, but effective interventions can help prevent these?
Manage pain, encourage ROM/early ambulation, use TED hose or SCD's, monitor VS, assess I&O's, advance diet as tolerated, assess skin/pressure points
Which post-op intervention best prevents atelectasis?
1. Using compression stockings
2. Heel-toe flexion
3. Use of incentive spirometry
4. Abdominal splinting and coughing
3- Use of incentive spirometry
Incentive spirometry will help exercise the lungs and prevent atelectasis or alveolar collapse.
Atelectasis
A collapse of the alveoli that prevents the normal exchange of oxygen and carbon dioxide.
Decreases oxygenation, prolongs recovery, causes discomfort for the patient.
- mobilize - TCD- early ambulation- IS
The nurse is caring for a client with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The client is unconscious and bedridden. The nurse is completing the plan of care and is writing outcomes for the client. Which is the best outcome for this client?
The client will remain free of odorous or purulent drainage from the wound throughout the hospital stay.
Our goal is to have the patient remain free of infection. The absence of infection from their wound should be assessed.
Misconceptions about pain in infants and older adults (table 44.3 and 44.4)
we can't make any assumptions about how pain is perceived.
The nurse is caring for a patient in the operating suite who is experiencing hypercarbia, tachypnea, tachycardia, premature ventricular contractions, and muscle rigidity. Which condition does the nurse suspect the patient is experiencing?
Malignant Hyperthermia
This is a life-threatening complication of anesthesia. The signs/symptoms noted are considered early signs.
A post-op patient experiences tachypnea during the 1st hour of recovery. Which nursing intervention is a priority?
1. Elevate the HOB
2. Give O2
3. Have the pt use the Incentive spirometer
4. Position the pt flat and on their side
1- Elevate the HOB
Maintaining an airway is always a priority. Elevating the head of the bed will help this pt accomplish this.