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EXAM 2: NUR242/ NUR 242 MEDICAL -SURGICAL
NURSING EXAM | QUESTIONS AND VERIFIED
ANSWERS| 100% CORRECT| GRADE A- GALEN
QUESTION: What are the guidelines for using a cane?
Answer: Cane: -Appropriate height (at wrist level when arm is at side) -Pt strong hand on cane MOVE CANE WITH
WEAKER LEG
QUESTION: What puts a patient at risk for falls according to
the text?Answer: At risk for falls due to: incontenience
QUESTION: How should a patient be transferred to a
wheelchair (WC)?Answer: Transferring pt to WC: -Place WC on strong side angled to bed -Strong hand to armrest, then pivot
QUESTION: What is a key principle of safe patient handling?
Answer: Safe pt handling: -Keep pt directly in front of you and as close as possible to prevent back injuries
QUESTION: What are recommendations for maintaining skin
integrity?
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Answer: Skin integrity: -dont wear restrictive clothing -WC pt lift themselves off buttock for 10 seconds q1hr
QUESTION: What characterizes a Stage 2 pressure ulcer?
Answer: Pressure Ulcer stages: Stage 2- skin is not intact; open or fluid blister
QUESTION: What is wet-to-damp wound care, and what is its
drawback?Answer: Wet-to-damp wound care: mechanically removes necrotic tissue does more damage than good bc it removes the good tissue as well
QUESTION: What are the rules for informed consent?
Answer: Informed consent: -surgeon is responsible for having consent signed -Pt who can not sign can sign with an "X" but must be witnessed by two people -If the pt doesn't understand the surgery, the surgeon has to be notified -A blind pt can sign the consent, has to be witnessed by 2 people -Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
QUESTION: What should be done pre-operatively (Pre-OP)?
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Answer: Pre-OP: -Report these to surgeon: -increased PT/INR/aPTT/Creatinine -Verify operative permit is signed - Side rails up, bed down, call light within reach
QUESTION: What occurs intra-operatively (Intra-OP)?
Answer: Intra-OP: -Pts are lifted into position onto the OR table to prevent shearing -Gel pads are placed on the OR table to prevent pressure ulcers -Warming blankets are used -Cover the pts head and feet (decrease hypothermia) If saving is necessary, hair should be removed using disposable sterile supplies immediately before the start of the procedure -Sterile scrubbing from fingertips to elbow for 3-5 minutes
QUESTION: What should be assessed post-operatively (Post-
OP) in the PACU?Answer: Post-OP: -in PACU, nurse immediately assess pt airway, LOC -RR <10 may indicate respiratory depression due to anesthesia -Sanguineous to serosanguineous drainage is normal -Crusting at incision line and swelling is normal
QUESTION: What is malignant hyperthermia, its signs, and
treatment?Answer: Malignant hyperthermia: -life threatening -you will see HIGH TEMPERATURE -early sign is tachycardia, muscle rigidity -Dantrolene is used to treat
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QUESTION: What are considerations for pain management?
Answer: Pain Management: Pain management referral for pts in chronic pain unrelieved -Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon as possible -Use FACES scale in pts with dementia
QUESTION: What are the guidelines for a PCA pump?
Answer: PCA Pump: -Lockout interval of 5-15 minutes -Pt cannot be cognitively impaired -Only the pt can press the button
QUESTION: What should be done if an incision opens?
Answer: If incision opens: -cover with wet sterile gauze -Do not try to reinsert protruding organ -Reassure pt -Supine position with knees bent
QUESTION: What are considerations for IV administration?
Answer: IV: -20G 1-1.5" needle is adequate for most therapies - Huber needle should be placed at 90 degree angle to access port (chemo pt)
QUESTION: What are the guidelines for administering TPN?
Answer: TPN: - Check each bag twice -If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available -If