Surgery
One of these would be priority 3 hr postop:
Decreased pain level
Hgb 15 & Hct 40%
Total UOP 50ml since surgery
Serosanguineous drainage
What is Total UOP of 50 ml
A client is regurgitating their enteral nutrition. This would be a priority due to the risk of this complication
What is aspiration
This type of drainage is pink in color
What is serosanguineous
An external female catheter must be attached to this to operate effectively
What is continuous suction
These are the five right of safe medication administration
What are right Patient, right Time, right Dose, right Route, right Drug
These should be assessed during a peripheral vascular assessment following knee surgery
What is skin color and temperature, equal bilateral pulses of the lower extremities, and edema
This the "A" of the ABCDE priority framework
What is airway
A client postop abdominal surgery has an evisceration, this is the priority intervention
What is cover the area with saline soaked gauze
This is the purpose of a serum creatinine level
What is to check a client's kidney function
These are appropriate client identifiers
What are name, DOB, MRN, telephone number
To minimize postop anxiety, this should be completed during preop
What is client education
This oxygen delivery device that delivers a precise oxygen saturation to the patient
What is a Venturi Mask
These are some expected manifestations of an infection
What is Edema (swelling), Erythema (redness), heat at site, pain, fever, increased WBC, foul odor
Implementing this intervention for a confused client with frequent urinary incontinence should be the first action
What is provide a 2 hour toileting schedule
These are some actions to reduce medication errors
What are check med against the MAR, Ensure proper ID of patient, prepare medications for one client at a time, be aware of look alike sound alike drugs, follow correct procedure of medication administration
A client postop abdominal surgery should do this when coughing and deep breathing
What is splinting with a pillow
These are priority education points for client being discharged home with oxygen
What Post "no smoking" signs, check the top of the ears for skin breakdown, make sure all straps on the mask are secure, clean mask or collar with clear warm water every 4-8 hrs.
A nurse should do this to prevent skin breakdown on a client with urinary incontinence
Apply a moisture barrier to the skin, wash with mild soap and warm water, assess skin every 2 hours
A client with an ostomy should have a stoma of this color
What is rosy red
This is a way to implement a safe patient transfer
What is keep your back straight
Client education on leg exercises postop to prevent DVT should include these movements
1Point the toes toward the foot of the bed, 2Rotate the feet in a circular motion, 3Point toes toward the head, 4Perform every 1-2 hrs, 5Repeat 5x's per session
This is a common cause of wheezing in breath sounds
What is narrowed or obstructed airways
A wound that extends to the subcutaneous fat layer is considered what stage
What is stage 3
Nurses should do this prior to sealing an ostomy bag
What is clean the bag
To prevent falls, client education should include these topics at discharge
Visual deficits, tripping hazards (throw rugs), musculoskeletal disease, low blood pressure