EMOTIONAL NEEDS
HTT
WOUNDS
PRE OP
POST OP
100
A nursing diagnosis represents a)proposed plan of care b)clients health problems c)assessment of data d)actual nursing interventions
What is b, the actual or potential health problem faced by a client
100
Assessing vital signs includes (include the "fifth" vital sign)
What is BP, RR, TEMP, HR, PAIN
100
Edema, drainage, broken skin, abrasion, blister, or shallow crater describe this stage of pressure ulcer
What is STAGE II
100
Anuria, oliguria, ARF, renal insufficiency, acute hepatitis and UTI, obstructive uropathy
What are contraindications for surgery
200
The determining factor in the revision of a nursing care plan is the a)time available for care b)validity of diagnosis c)method for providing care d)effectiveness of the interventions
What is d) effectiveness
200
Name the lobes of the lungs that can be auscultated on posterior view
What are the LLL, RLL, RUL, LUL
200
The proliferative phase of wound healing occurs between what times frame and is defined by what events?
What is days 5-20 Collagen produced, Granulation of tissue forms, tensile strength increases
200
Can increase the risk of bleeding intra-operatively, are discontinued for surgery relative to INR or PTT.
What are anticoagulants
200
dehydration, hyppoxia, hypercarbia, infection, blood loss, urinary retention, fecal impaction, infection, nervous system depressants are all causes of what?
What is postoperative delerium
300
A patient becomes openly hostile when learning a toe is to be amputated. The response that indicates the nurse's interaction has been therapeutic is? a)patient has no more outbursts b)patient states i dont need to talk anymore c)patients tense muscles relax
What is c) patient shows signs of nonverbal behaviour of acceptance as nonverbal indicates unconsciously controlled behavior
300
These Lung sounds have a high frequency and shrill or hissing quality
What are wheezes
300
Name the 3 phases of wound healing
What is Inflammatory, Proliferative, maturation
300
Psychosocial preoperative teaching includes
What is Pain management techniques, imagery, distraction, optimistic reflection
300
Name 5 nutrients important for wound healing
What are thiamine, protein, calories, calcium, vit K, vitamin D...
400
While receiving a preop enema a patient starts to cry and states "I'm sorry you have to do this mess", your response should be a)I dont mind b)This is my job, you get use to it c)You seem upset?
What is c) this identifies patients feelings
400
Name 5 causes of crackles auscultated in the lung fields
What is pneumonia, cystic fibrosis, left sided congestive heart failure, bronchiectasis, asthma, atelectasis, pulmonary edema
400
Name the 3 types of wound healing and describe there differences
What is First, Second and Third intention 1st-aseptically clean incision made, minimal scar 2nd-infected wounds produce granulation, not approximated,may be packed or drain provided 3rd-deep wounds, wide scar, packed
400
Name 3 possible diagnosis for the preoperative patient
What are Anxiety r/t surgical experience, fear r/t perceived threat of procedure, knowledge deficit of procedure r/t expectations of procedural outcome
400
What are the signs and symptoms of severe anaphylaxis and what is the treatment?
What is vasodilation, hypotension, laryngeal edema, rash, drooling, wheezing, flushing, anxiety, edema... 1)asess pt and vs 2)inform RN... possible MD 3)with pt on monitor admin 0.3cc 1:1000 EPI IM
500
When helping a patient immobilized by chronic pain from arthritis toward self reliance the nurse should approach the problem with a)understanding that little can be accomplished b)recognition that a facility of LTC is needed c)a positive attitude toward any future outcome
What is c
500
The second right intercostal space and the second left intercostal space are locations to auscultate what respectively?
What are the aortic and the pulmonic regions
500
Describe wound dehiscence and name 3 causes
What is disruption or opening of surgical wound... causes include infection, increasing age, poor nutrition, cardiac or pulmonary disease, stress or friction to wound surface
500
Mrs. White is pre-op for an ORIF in 8 hours of her L # femur, her leg has been reduced and is in Bucks traction at 5lb, her left leg pallor distally is dusky, a portable xray has been completed and shows femoral head and long bone displacement. What are your nursing priorities at this time? (discuss pt status, vs, assessment and communications)
What is 1)notify buddy nurse of dusky pallor who should thn notify charge and MD 2)assess CSMT of both limbs followed by complete head to toe ensuring renal, lung, cardiac, musculoskeletal and liver function 3)complete full set of vs including temp 4)ensure pt remains NPO 5)ensure consent is on chart 6)prepare pt for OR 7)con't vs q1H, CSMT q15min
500
Mrs White returns from an ORIF of left femur she is "lethargic" sitting in bed with a CPNBI and IV LR infusing at 75 cc/hr, BP 86/57, HR 54, RR 12, T 35.3, she reports no pain and has a noticed ptosis to left eye. List your concerns, interventions and describe immediate post-op protocol
1)inform RN of hypotension, hypothermia, and borderline bradypnea as well as ptosis 2)reposition pt to supine or reverse trendellenberg and repeat vs 3) complete HTT focusing on bowels, lungs, cardiac, renal system, neuro and musculoskeletal 4) warm bed bath of pt 5) if bowel sounds present encourage warm po fluids and coughing 6) see if increase of IV rate is possible 7) continue assessment and vs q15 x 2, q30 x2, q1h x 4, or remain at q15 if BP continues to decline
M
e
n
u