Wounds
How do you dress a sucking chest wound?
Place a dry dressing over it and secure it on 3 sides.
List 4 signs and symptoms of sepsis!
Shivering, fever, or cold, extreme pain or discomfort, clammy or sweaty skin, confusion or disorientation, SOB, tachycardia
How do you measure for an NG tube?
What is from nose to ear lobe, to xiphoid process
The nurse determines clinical death and initiates CPR immediately. How long is resuscitation considered possible?
If cardiopulmonary arrest has existed for no more than 4 minutes
What should the nurse assess the patient for before administration of contrast media?
Any allergy to iodine
List 5 factors that may impair wound healing!
What is age, malnutrition, obesity, impaired oxygenation, smoking, drugs, diabetes mellitus, radiation, wound stress.
Provide 2 nursing interventions for a patient experiencing shock!
Establish an airway, Control bleeding if present, Provide fluid replacement, Place the patient supine with legs slightly higher than the head, If head, neck, or spinal injuries suspected-keep them flat unless absolutely necessary to prevent further injury, If victim is unconscious or is vomiting or bleeding around the nose and mouth, position on their side to allow the airway to clear and to encourage drainage, Elevate the head and shoulders if they are having problems breathing, Maintain body temperature, Food and fluids withheld in case internal injuries present, Provide moistened cloth to help with dryness of the mouth or mucous membranes, In the hospital-2 large bore IVs are established to allow for rapid infusion of fluids and blood products if necessary, Pain control should be addressed if an injury is present, Essential to give emotional support and reassurance
What should the nurse look for after a foley catheter has been removed?
List the 5 cardinal signs of inflammation!
Pain, heat, redness, swelling, loss of function
The nurse is caring for a patient following a bronchoscopy and maintains NPO status for 2 hours. What additional assessment will indicate to the nurse that this patient’s risk for aspiration has decreased?
Return of gag reflex
Describe the 4 types of drainage?
What is purulent- pus and white/ yellow/ brown
Serous- watery plasma that is mostly clear, but may have some pink or yellow tinge to it
Serosanguineous- pale, red, watery: mixture of serous and sanguineous
Sanguineous- bright red: indicates active bleeding
List 5 signs of anaphylactic shock!
Swelling of conjunctiva, lightheadedness, loss of consciousness, confusion, headache, anxiety, SOB, Wheezing, hoarseness, pain with swallowing, cough, campy abdomen, diarrhea, vomiting, loss of bladder control, pelvic pain, hives, itchiness, flushing, fast or slow HR, low BP, swelling of lips/tongue or throat
If the patient is suspected of having a fecal impaction, which type of enema would the nurse anticipate the healthcare provider to order?
Oil retention enema
How much circulating blood an average adult male is supposed to have?
12 pints
The patient has undergone a lumbar puncture. What position will the nurse place the patient in for up to 12 hours to avoid discomfort from post-puncture spinal headache?
Supine
A wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound. What is the result of this intervention when the dressing is removed?
Mechanical debridement
List 5 symptoms of cardiogenic shock!
Tachycardia, anxiety and delirium, increased preload, pulmonary congestion, decreased cardiac output, dusky skin color, decreased blood pressure, narrow pulse pressure, oliguria, dyspnea.
When initiating a 24-hour urine collection, the nurse asks the patient to void. Which action does the nurse take with the specimen?
Discard it in the patient’s bathroom
What is the correct procedure for the wet-to-dry dressing method?
Place moist gauze into the wound and remove it at prescribed intervals
What should the nurse do when preparing the patient for an exercise tolerance test (treadmill)?
Allow the patient to drink water before the test
NPO 4 hours before the test
Assess for pregnancy
No smoking
Instruct the patient to wear suitable clothing
Obtain a pretest ECG
The nurse observes a loop of bowel protruding from the surgical incision. What is the first intervention the nurse should implement?
Cover the bowel with a sterile saline dressing
List 5 symptoms of hypovolemic shock?
Poor skin turgor, thirst, oliguria, low systemic and pulmonary preloads, rapid heart rate, low BP (late manifestation)
Ileostomy- an opening in the ileum, is semi-liquid stool
Colostomy- Where the colon normally attaches, may be liquid, semi-formed or formed depending on the area
Urostomy is a diversion of urine.
A patient comes to the ER with burns on the front of his torso, entire right arm and face. What percent of his body is burned?
Rule of nines: torso is 18%
Right arm is 9%
Face is 4.5% (head is 9)
31.5% of body is burned
What should the nurse do when preparing the patient for a bronchoscopy?
Reassure the patient that they will be able to breathe during the procedure
Instruct the patient to perform good mouth care
NPO after midnight
Remove contacts, glasses, and dentures
The patient will receive conscious sedation