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212 Cards in this Set
- Front
- Back
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What is an Abcess?
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cavity containing pus and surrounded by inflamed tissue,
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An abcess is caused by what?
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formed as a result of suppuration in localized infection
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An Antibacterial does what?
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Kills bacteria or inhibits their growth or replication
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An Antibody is what and produced by what?
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immunoglobulin produced by lymphocytes in response to bacteria, viruses or other antigenic substances
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Antifungal is
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substance the kills fungi or inhibits their growth or reproduction
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An antigen is
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a substance, usually a protein that the body recognizes as foreign and can evoke an immune response
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anti-infective is
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an agent that prevents or treats infections
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Antimicrobial is
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a substance that kills microorganisms or inbibits their growth or replication
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antiviral
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destructive to viruses
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bacteremia is what
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the presence of bacteria in the blood
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The blood brain barrier is
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feature of the brain thought to consist of wall of capillaries in the CNS and surrounding astrocytic glial membranes
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broad spectrum antibiotic is
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antibiotic effective against a wide range of infectious microorganisms
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colony
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a mass of microorganisms in a culture that orginates from a single cell
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culture
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lab test to grow specific microbes of bring tissue cells on a special medium that will encourage the growth
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sensitivity test
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tests the effectivness of antibiotics on a culture.
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viral load
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counts the number of particles in a sample of blood
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epidemiology
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study of determinants of diseas in populations
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glucocorticoid
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an adrenocortical steriod hormone that increases gluconeogensis, exerts an anti-inflammatory effect and influesnces many body functions
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Immunosuppressive
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substance or procedure that lessens or prevents an immune response.
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infiltration
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fluid passes into the tissues
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infusion
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the introduction of a substance, (fluid, elctrolyte, nutrient, drug) directly into the vein or interstitially by means of gravity of flow
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KVO
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keep vein open, IV fluid at slow rate for emergencies
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leukocytosis
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abnormal increase in circulating WBC
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leukipenia
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abnormal decrease in circulating WBC
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lymphadenitis is
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inflammatory condition of the lymph nodes
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lymphadenitis is usually the result of what?
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systemic neoplastic disease, bacterial infection or other inflammatory conditions
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pathogen
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any microorganism that is capable of producing disease.
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peak and trough levels
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highest and lowest blood level concentration of a drug
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phagocytosis
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cells engulf and destroy microorganisms and celluar debris
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phlebitis (throbophlebitis)
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inflammation of a vein and the formation of a clot
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purulence
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producing or discharging pus
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pyrogen
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any substance or agent that tends to cause a rise in body temp like some bacterial toxins
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septic shock
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endotoxins or exotoxins are release from certain bacteria in the bloodstream, occasionally septic shock may be cuased by the presence of funi or viruses
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superinfection
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occurs during antimicrobial treatment for another infection
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urticaria
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pruitic skin eruption, transient wheels of varying shapes an sizes with well defined erythmatous margins and pale centers
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virulence
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power of a microorganism to produce disease
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example of health deviation in actual structure
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broken leg
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example of health deviation in physiologic function
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difficulty breathing
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example of health deviation in behavior
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withdrawn person
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example of health deviation in disruption of human integrated function
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comatose person
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_____ may alter the way a person responds to self care
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health deviation
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4 disorder dervived demands
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illness-headace
injury-broken arm deformity-burned lack of therapeutic care-malnutrition/elderly |
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Universal self care is required to meet a persons ____.
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basic human needs
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3 catagories of self care requirements
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universal self care, developmental
health deviation |
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Health deviations might alter the way a person responds to universal self care. Give example
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amputee to activity and rest
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Health deviations might alter the way a person responds to developmental self care. Give example
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the child who is burned and requires long term stay, loses friends.
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demands arising from illness, injury or deformity, or lack of therapeutic self care are called
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disorder dervived demands
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need for nursing depends on the analysis of self care agency and ____. 3 ways to assess.
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if its
developed, operating and adequate |
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define self care agency
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the power of the individual to engage in self care
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self care agency limitation may occur with regard to the decision making phase, explain
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when a health deviation alters the persons ability to identify requirements for self care, or when a aperson lacks motivation to engage in health deviation self care
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self care agency limitation may occur with regard to the action taking phase, explain
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this limitation can decrease this limitation can decrease abilities that are already part of a persons self-care agency thereby altering developed self care skills.
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the nurses goal in helping a client with health deviation achieve one or more of 6 kinds of goals. list
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Adjust
cope revise routine establish new techniques integrate consider modification to life |
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assessment of self care agency depends on analysis of the following 3 factors
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if self care agency is DEVELOPED,
OPERATING ADEQUATE |
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If self care is not adequate, that means....
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self care deficit exists and nursing is needed.
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Medical or disorder derived?
NPO Toradol CBC IV fluid |
medical
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medical or disorder derived?
pt misses work diarrhea, no meds |
disorder
disorder |
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disorder derived examples
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abdominal pain
temp high vomiting and diarrhea once misses school |
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PQRSTU protocol
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precipitating factors
quality of pain region severity timing affects U |
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What levels of DC4 would be considered AIDS
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< 200
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what is normal WBC
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4.5 - 10.5 WBC X 10^3
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What is normal Hct%
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girls 36-48
males 42-52 |
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What is normal Hb
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girls 12-16
boys 14-17 |
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What is normal platelet
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150-450 X10^3
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Three catagories of HIV/AIDs, what are they and how to tell which stage the pt is in.
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A), asymptomatic CD4 > 500
B) symptomatic CD4 200-499 C) AIDS CD4 , 200 |
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Organ systems affected by HIV?
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CNS, GI, Resp, Skin
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Kaposi Sarcoma is indicative of what?
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AIDs Cat c, stage 3. Purple lesions
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what is the most common resp infection for AIDs pt
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pneumocystic pneumonia PCP, common in end stages
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What are some opportunistic infections that go with AIDs?
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bacterial-TB, pneumonia
fungal-cadidiasis protozoal-PCP, toxoplamosis viral-herpes HIV-kaposi sarcoma |
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if a pt has AIDs what type of food would you instruct him to avoid?
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no fruit, fresh flowers, spinach that has spores on it.
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The higher the catagory level the aids patient has the ____ the protein calories needed.
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higher
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This class of drug prevents the binding of HIV to cells, preventing entry of HIV into healthy cells
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fusion inhibitors
enfurvirtide-Fuzeion (drug) |
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prevents an enzyme from cutting HIV proteins into the proper lengths necessary to allow viable virions to assemble
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protease inhibitors
Saquinavir-fortovase, indinavir-crixivan |
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inserts necleoside into the developing HIV DNA chain to stop development of the chain, leaving the new stransd of HIV DNA incomplete
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NRTI, nucleioside reverse transcriptase inhibitors AZT
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When a central line is inserted it ends up where
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superior vena cava
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fluids used for fluid volume deficit rt diarrhea
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D5W .45 with 20 mEq KCL, 167mL per hour
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if an organism is present on the skin but has not caused infection it is called
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colonization
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if an organism enters the body site and multiplies in tissue, there are s/s of infection, fever, pus, elevated WBC it is called
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infection
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an extended infection that interferes with integrated functioning is called
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disease
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removal of central line in a pt with an infection, a lab test you would probably do is
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send the tip of the cath for culture.
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ANC is what
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absolute neutrophil count (baby wbc) a count of <200 is very significant, REVERSE isolation
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if a pt has C diff, it is okay to use the hand sanitizer to clean hands after contact with pt. T or F
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false...soap and water, hand sanitizer doesn't work
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HAI's
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MRSA, C diff, pneumonia, VCRE, pressure ulcers
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septic shock is usually caused by what
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gram negative bacteria in the blood.
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Assessment data for HIV pt.
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WBC count
CD4 count Viral load – quantity of HIV RNA in blood Opportunistic infections Vital signs (fever) Compliance with medications Sexual activity/risk behaviors |
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Organ systems affected by HIV
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CNS
Dementia Sensory-vision Respiratory Pneumocystic pneumonia Cyanotic pallor GI Dysphagia Weight loss Diarrhea Skin Kaposi Sarcoma |
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Other opportunistic infections for HIV pts
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Bacterial Diseases
Tuberculosis Mycobacterium Avium Complex (MAC) Bacterial Pneumonia and septicemia Fungal infections Candidiasis Cryptococcosis Protozoal diseases Pneumocystitis Carinii pneumonia (PCP) Toxoplasmosis Microsporidiosis Blastomycosis Viral Diseases Herpes Simplex and herpes zoster Cytomegalovirus (CMV) HIV associated malignancies Kaposi sarcoma Lymphoma and squamous cell carcinoma |
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antiretroviral medications should be offered to individuals with a T-cell count of less than
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350 cells/mm3
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This syndrome is one of the most frequent systemic side effects associated with the use of antiretroviral medications
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Fat redistribution syndrome
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antiretroviral agents four classes
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nucleoside/nucleotide reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI), protease inhibitors, and fusion inhibitors (DHHS Panel, 2006). Fusion and entry inhibitors (such as enfuvirtide [T-20]) act by targeting GP120 during
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Nonnucleoside reverse transciptase inhibitors (NNRTI) action
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Combine with reverse transcriptase enzyme to block the process needed to convert HIV RNA into HIV DNA
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Nucleoside Reverse Transcriptase Inhibitors NRTI action
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Inserts nucleoside into the developing HIV DNA chain. This stops further development of the chain, leaving the new strand of HIV DNA incomplete
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NRTI drug
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Zidovudine (AZT, ZVD), didanosine (ddl, Videx), abacavir (Ziagen),Tenofovir (Viread)
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NNRTI drugs
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Nevirapine (Viraimune), delavirdine (Rescriptor)
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Protease inhibitors (PIs) action
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Prevents the protease enzyme from cutting HIV proteins into the proper lengths necessary to allow viable virions to assemble
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Protease inhibitors (PIs) drugs
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Saquinavir (Fortovase), indinavir (Crixivan)
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Fusion Inhibitors action
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Prevent binding of HIV to cells, preventing entry of HIV into healthy cells
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Fusion Inhibitor drugs
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Enfurvirtide (Fuzeon)
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Nutritional support for HIV/AIDS
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higher the category, higher calories, Calories from 3-4000. Protein 1-2 g/kg.
All will benefit from multivitamin |
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Category A
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Asymptomatic HIV, persistent generalized
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Category B
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Symptomatic HIV, complications HIV
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Category C
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CD4 count less than 200, plus the presence of AIDs defining condition and/or Opportunistic infection
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Assessment of IV site
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PERT
P = pain E = edema R = redness T = temperature |
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Risk for infection r/t central line, compromised immune system (WBC < ____
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100, reverse isolation
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Organism is present on the skin but has not caused infection as the skin has not been penetrated
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Colonization-
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Organism enters the body site and multiplies in tissue. There are s/s of infection: fever, pus, elevated wbc
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Infection-
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Extended infection that interefers with integrated functioning.
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Disease:
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ANC- (absolute neutrophil count) less than ______is very signficant-
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200 , neutropenia
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Inflammation/infection at tissue level caused by enzymes produced by bacteria
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cellulitis
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Treatment for septic shock
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Vasopressor (dopamine), IV fluids, antibiotic, 02, treat bleeding- DIC
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Treatment for MRSA
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antibiotics, NOT methicillin. Generally use vancomycin. Requires contact precautions/isolation. Freq dressing change
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Treatment for VRE
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antibiotic therapy- no vancomycin. May use flagyl or linezolid drug class; oxazolidiones. Need contact precautions/isolation
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Treatment for C Diff
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Antibiotic generally oral vancomycin, may use flagyl. Contact preacautions/isolation required.
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Treatment for PRSP- Penicillin Resistant Streptococcus Pneumonia
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Antibiotic usually b-lactam (augmentin) or levaquin (quinolone) and droplet precautions/isolation
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Pre-op phase begins and ends when
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Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the OR table.
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Intraoperative phase begins and ends
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Begins when the patient is transferred onto the OR table and ends with admission to the PACU (Post Anesthesia Care Unit)
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Post operative phase begins and ends
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Begins with the admission of the patient to the PACU and ends with a follow up evaluation in the clinical setting or home.
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Conditions that may increase risk for surgery
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Diabetes
Respiratory disorders Anemia Heart disease Pre-existing infection Pre-existing disability Poor immune function (steroids) Poor nutrition/dehydration Obesity Pregnancy Renal impairment Hepatic impairment Extreme age (old/young) |
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How do you Assess nutritional, fluid needs
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Metabolic Panel (Chem)
BUN, Creatinine, Lytes, albumin, protein CBC Hemoglobin, hematocrit Vital Signs Height and Weight Skin turgor, moisture Urine output |
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Common pre-op labs
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UA
CBC Chemistry panel Glucose Liver (ALT, AST) Kidney (BUN, CR) Nutrition (Protein, albumin) Electrolytes (K+, Na+) ABG’s Pulmonary Function PT/PTT, bleeding times/coag studies Type and Screen/Cross Match Pregnancy Test |
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Current anesthesia guidelines actually allow for liquids up to ______ hours before procedure- don’t often see this
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4
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NPO night before surgery including
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smoking/hard candy
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RN role in consent form
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is to witness patient signature
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Pre-op meds being given
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Anti anxiety (Versed, Ativan, Valium)
Anti cholinergic (Atropine, Scopolomine) Anti emetic (Reglan, Inapsine) Narcotic (Morphine, Demerol, Sublimaze{fentanyl} |
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Cough and Deep Breath (CDB) important to help prevent:
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pneumonia/atelectasis
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What medications a patient takes is important for preop, examples:
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Steroids
OTC (aspirin) Herbal remedies |
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Leukocytosis-
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Elevation of the WBC
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Laparotomy-
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Scope like instrument inserted through and opening
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Transverse incision is an incision the the ____position
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horizontal
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More anesthesia is needed in the obese clinet because
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Fat takes up less of the medication and is released slower into blood stream- thus more anesthesia is required
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A narcotic given pre op will have what effect on anesthesia and how long should it be given over?
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Narcotic- will decrease the anesthetic needed
Given undiluted over 2 minutes |
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An anti-anxiety medication given preop will have what effect on anesthesia?
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Anti-anxiety- will decrease the anesthetic needed, will reduce anxiety. Causes anterograde amnesia.
Dilute with NS or D5W for sedation over 2 minutes. Incompatible with LR, many others |
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Spinal Anesthesia advantages
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resp disease:few adverse effects on the respiratory system,
Patent airway. As control of the airway isn't compromised, there is a reduced risk of airway obstruction or the aspiration of gastric contents. This advantage may be lost if too much sedation is given. Diabetic patients. There is little risk of unrecognized hypoglycemia in an awake patient. Diabetic patients can usually return to their normal food and insulin regime soon after surgery as they experience less sedation, nausea and vomiting. Muscle relaxation. Spinal anesthesia provides excellent muscle relaxation for lower abdominal and lower limb surgery. Bleeding. Blood loss during operation is less than when the same operation is done under general anesthesia. This is because of a fall in blood pressure and heart rate and improved venous drainage with a resultant decrease in oozing. Splanchnic blood flow. Because it increases blood flow to the gut, spinal anesthesia may reduce the incidence of dehiscence. Visceral tone. The bowel is contracted during spinal anesthesia and sphincters are relaxed although peristalsis continues. Normal gut function rapidly returns following surgery. Coagulation. Post-operative deep vein thromboses and pulmonary emboli are less common following spinal anesthesia. |
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Explain what risks are involved with spinal anethesia and:
Respiratory disease Patent Airway |
Respiratory disease. Spinal anesthesia produces few adverse effects on the respiratory system as long as unduly high blocks are avoided.
Patent airway. As control of the airway is not compromised, there is a reduced risk of airway obstruction or the aspiration of gastric contents. This advantage may be lost if too much sedation is given. |
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Explain what risks are involved with spinal anethesia and:
Diabetic pt Muscle relaxation |
Diabetic patients. There is little risk of unrecognized hypoglycemia in an awake patient. Diabetic patients can usually return to their normal food and insulin regime soon after surgery as they experience less sedation, nausea and vomiting.
Muscle relaxation. Spinal anesthesia provides excellent muscle relaxation for lower abdominal and lower limb surgery. |
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Explain what risks are involved with spinal anethesia and:
Bleeding |
Bleeding. Blood loss during operation is less than when the same operation is done under general anesthesia. This is because of a fall in blood pressure and heart rate and improved venous drainage with a resultant decrease in oozing.
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Explain what risks are involved with spinal anethesia and:
Splanchnic blood flow Visceral tone Coagulation |
Splanchnic blood flow. Because it increases blood flow to the gut, spinal anesthesia may reduce the incidence of dehiscence. Visceral tone. The bowel is contracted during spinal anesthesia and sphincters are relaxed although peristalsis continues. Normal gut function rapidly returns following surgery.
Coagulation. Post-operative deep vein thromboses and pulmonary emboli are less common following spinal anesthesia. |
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Explain what risks are involved with spinal anethesia and:
hypotension |
hypotension may occur with higher blocks and the anesthetist must know how to manage this situation with the necessary resuscitation drugs and equipment immediately to hand.
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What does the anesthesiologist assess
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VS
Hypotension common Bradycardia Too high a block may cause respiratory distress/apnea Nausea and vomiting CSF leakage Motor and sensory function |
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Common anesthetic Agents
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Bupivacaine (Marcaine). 0.5% hyperbaric (heavy) bupivacaine is the best agent to use if it is available. 0.5% plain bupivacaine is also popular. Bupivacaine lasts longer than most other spinal anaesthetics: usually 2-3 hours.
Lidocaine/Lignocaine (Xylocaine).. Recently concerns have been raised about the safety of 5% lidocaine (it is said to be potentially neurotoxic) despite it having been used uneventfully for over forty years. Lidocaine from multi-dose vials should not be used for intrathecal injection as it contains potentially harmful preservatives Cinchocaine (Nupercaine, Dibucaine, Percaine, Sovcaine). solution is similar to bupivacaine. Tetracaine (Amethocaine, Pantocaine, Pontocaine, Decicain, Butethanol, Anethaine, Dikain). A 1% solution can be prepared with dextrose, saline or water for injection. Mepivacaine (Scandicaine, Carbocaine, Meaverin). similar to lignocaine. Pethidine/Meperidine. The 5% solution (50mg/ml) A dose of 0.5-1mg/kg is usually adequate for spinal anesthesia. |
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______ from multi-dose vials should not be used for intrathecal injection as it contains potentially harmful preservatives
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Lidocaine
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It is postural, being made worse by standing or even raising the head and relieved by lying down. It is often occipital and may be associated with a stiff neck. Nausea, vomiting, dizziness and photophobia frequently accompany it. It is more common in the young, in females and especially in obstetric patients...what is this?
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Spinal headace thought to be from losing CSF through the hole made in the dura by the spinal needle.
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Prolonged or severe Spinal headaches may be treated with
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epidural blood patch performed by aseptically injecting 15-20ml of the patient's own blood into the epidural space. This then clots and seals the hole and prevents further leakage of CSF.
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An ____ does not enter the CSF and is injected ____.
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Epidural
Injection into epidural space via thoracic or lumbar approach. |
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Sensory pathways blocked, motor pathways intact except in higher doses
Commonly used for hip/knee replacement. May be left in post op for pain control Which type of anesthesia is this? |
Epidural
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Recovery from Spinal/Epidural
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Spinal- Complete return of sensory and motor function
Epidural-Return of sensory function, motor generally not affected |
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Nursing Interventions for spinal/epidural
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Assess LOC
Maintain an open airway and adequate respiratory function Side lying helps keep airway open and reduces risk of aspiration Once conscious patient can be supine with HOB slightly elevated Assess breathing, O2 needs Monitor VS until stable Every 15 minutes first hour Every 30 minutes for next 2 hours Every hour for 4 hours BE THERE TO SEE RESULT ON AUTOMATIC B/P!!!! Maintain fluid balance and document fluids infused or ingested Assess IV site for PERT, IV solution and rate Assess UO, drainage output, wound dressing Assess for changes in HR/B/P Assess skin/mucous membranes Check the operative site for excessive drainage Reinforce surgical dressing DO NOT remove unless directed to do so by MD Frequent checks – ask each time “Can I get you anything” Call light in reach Bed low-side rails?? Personal items near Reminders to call for assistance Reminder that lower extremities may still be under anesthesia |
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Transfer from recovery- Report
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Patient demographics
Medical diagnosis and surgical procedure Co- morbid conditions/history Any unexpected surgical events Medications administered/allergies VS, including pulse oximeter Pain rating-Last medication Dressing condition/location Drains/amount out-estimated blood loss Nausea or vomiting Intake- IV Information about family MD orders |
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Potential complications from surgery
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PC: Hemorrhage
PC: Blood clot PC: Infection |
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IV 1000cc D5LR @ 100cc/hr
ordered why for preop? |
Maintain F&E, Isotonic, initially hypertonic
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Primaxin 500 mg IVPB q 8 h
ordered why for preop? |
Prevent nosocomial infection
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Pepcid 20 mg IVP q 12 h
ordered why for preop? |
H2 blocker, decrease acid- stress, decrease n/v
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NPO-ordered why for preop?
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Prevent N/V which will prevent aspiration
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Mds orders after surgery are NG to LIS (low intermittent suction), what for?
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Decompress stomach to decrease n/v and prevent wound complication (rupture) from vomiting
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Why does the Md order this after surgery? Up in chair q shift
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Movement prevents complications (Resp, skin, GI, clots)
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Why does the Md order this after surgery?I&O
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Assess adequate hydration, Fluid volume & kidney status)
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Why does the Md order this after surgery? Morphine PCA loading dose 5 mg, then 1 mg q 10 minutes lock out; with 30 mg q 4 hour maximum
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Maintain pain control- safe with lockout
Loading- raises analgesic level rapid Lock out- unable to get more than that |
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Post op Complications- Ineffective airway clearance related to inability to clear secretions, anesthetic agents, what are the nursing interventions
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Pneumonia/Atelectasis
Assess resp rate, characteristics, use of accessory muscles Monitor VS, including P OX Auscultate breath sounds Encourage CDB, Incentive spirometer- provide pain relief first Encourage early ambulation, position change Encourage fluid intake ~2000 ml |
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Pulmonary embolism signs and symptoms
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Chest pain, SOB, anxiety
EKG changes, PO changes |
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Assess for DVT..
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DVT
Assess peripheral vascular status- C irculation Color, Temp, pulse, cap refill M otor S ensation Assess circumference of extremity |
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Nursing interventions for DVT
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Encourage leg exercises and early ambulation
Encouraged 10-12 times every hour Flex and extend the legs Tighten buttock/thigh Circular motion ankle Raise leg No cross leg, no pillows under knee, no bending of bed at knee Apply TEDS, sequential compression device, plexi pulse-remove 1 hour q shift for skin assessment Encourage fluid intake Record/report findings Anticoagulant as ordered Lovenox- sub q in lower lateral abdomen (love handles) Coumadin- po- usually given in evening Heparin- sub q |
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What does the nurse monitor for hemorhage after surgery
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Monitor drainage q 1 hour post op then q 4
Monitor dressing Reinforce prn DO NOT CHANGE WITHOUT ORDER Monitor VS q 15 min, q 1 hour, q 4 hour Assess skin color/temp/moisture Assess mental status Monitor CBC H&H, platelet Record/report findings |
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If a patient has Paralytic Ileus (PC) after surgery what might happen as far as interventions.
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NPO until peristalsis returns
May have NG (nasogastric tube) Medicate as ordered with antiemetics, gastric motility agents (Reglan) Frequent oral care |
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I & O should be what per hour for adequate hydration
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Assess I & O**30 ML per hour
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anti-emetics medications
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Compazine (prochlorperazine)
Zofran (ondansetron) Reglan (metoclopramide) Phenergan (promethazine) |
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A patients wound Eviscerates, what do you do?
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EMERGENCY Cover with moist sterile dressing and notify MD
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A client is to take nothing by mouth after 4 am. The nurse recognizes that the client has deficient knowledge when he states he:1. Ate jello at 3:30 am
2. Brushed his teeth at 4:00 am but did not swallow 3. Used a cold washcloth to hold against his lips 4. Smoked a cigarette at 6:00 am |
smoked a cig...no hard candy either
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The nurse should suspect that a client who reports an allergy to shellfish is also allergic to:
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Iodine
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A client who is to receive general anesthesia has a serum potassium level of 5.8 meq/L. What should be the nurse’s first response?
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Notify the anesthesiologist
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On the day of surgery, a diabetic client who takes insulin on a sliding scale is ordered to have nothing by mouth and all medications withheld. Her 6 am glucose level is 300 mg/dL. What is the correct initial nursing intervention regarding the clients high blood glucose level?
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. Call the physician for specific orders based on the glucose
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A client is admitted for an arthroscopy of the right shoulder through same-day surgery. Which nurse is responsible for starting the client’s discharge planning?
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preadmission nurse
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The nurse is preparing to administer a premedication. Which of the following actions should the nurse take first?Have the family present.
2. Ensure that the preoperative shave is completed 3. Have the client empty his bladder 4. Make sure the client is covered with a warm blanket |
3. Have the patient empty his bladder
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An allergy to which of the following would be least likely in clients who are at risk for latex allergies?1. Avocados
2. Apples 3. Kiwi 4. Peaches |
kiwi
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The nurse is teaching a client deep-breathing exercises to expand the alveoli and prevent postoperative atelectasis and pneumonia. What are the steps ?
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Splint or support the incision to promote maximal comfort
2. Inhale slowly through the nostrils, exhale through pursed lips 3. Hold the breath for about 5 seconds to expand the alveoli 4. Repeat the breathing method 5 to 10 times hourly |
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The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which of the following laboratory findings should be reported to the surgeon?1. RBC of 4.5 million/mm3
2. Creatinine of 2.6 mg/dL 3. Hemoglobin of 12.2 g/dL 4. Blood urea nitrogen (BUN) of 15 mg/dl |
2. Creatinine of 2.6 mg/dL
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When the nurse administers intravenous midazolam hydrochloride (Versed), the client demonstrates signs of overdose. Which of the following interventions should the nurse be prepared to implement first?1. Ventilate with an oxygenated Ambu bag
2. Shock with ECG paddles 3. Administer 0.5 mL 1:1000 epinephrine 4. Titrate flumazenil (Romazicon |
1. Ventilate with an oxygenated Ambu bag
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Metoclopramide (Reglan) is ordered as a premedication for a gastroduodenoscopy. The nurse expects which of the following as the primary therapeutic effect?1.Increased gastric pH
2.Increased gastric emptying 3.Reduced anxiety 4.Inhibited respiratory secretions |
Increased gastric emptying
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What therapeutic outcome does the nurse expect for a client who has received a premedication of Glycopyrrolate (Robinul)?
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3. Decreased secretions
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Atropine (atropine sulfate) is contraindicated in all but which one of the following clients?1. A client with diabetes
2. A client with glaucoma 3. A client with urinary retention 4. A client with bowel obstruction |
1. A client with diabetes
Rationale atropine will worsen glaucoma as it dilates the pupil, will worsen urinary retention and bowel obstruction as it relaxes smooth muscle |
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A client has been ordered to receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy (LAVH). Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaprin? 1. Increase in red blood cell production
2. Reduction of postoperative thrombi 3. Decrease in postoperative bleeding 4. Promotion of tissue healing |
2. Reduction of postoperative thrombi
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A client who is scheduled for an open cholecystectomy has a 20 pack year history of smoking. For which postoperative complication is the client most at risk?1. Deep vein thrombosis
2. Atelectasis and pneumonia 3. Delayed wound healing 4. Prolonged immobility |
2. Atelectasis and pneumonia
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Which of the following interventions is most important in preventing postoperative complications?1. Progressive diet planning
2. Pain management 3. Bowel and elimination monitoring 4. Early ambulation |
4. Early ambulation
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In planning a client’s perioperative teaching, the nurse includes an explanation of the circulating nurse as the person who:1. Passes instruments to the surgeon
2. Answers the phone in surgery 3. Provides the nursing process during surgery 4. Ensures sterility of the supplies |
3. Provides the nursing process during surgery
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The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following would the nurse assess next?1. Bladder distention
2. Headache 3. Postoperative pain 4. Ability to move the legs |
1. Bladder distention
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When assessing a client who has had spinal anesthesia, which of the following would the nurse expect to find? Select all that apply?
1. The legs moved before pain was felt 2. Blood pressure was significantly increased 3. Sensation returned to toes but not to the perineal area 4. The client complained of a headache while in the lying position |
1. The legs moved before the pain was felt
3. Sensation returned to toes but not to the perineal area |
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The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals a patent airway and stable vital signs. What is the nurse’s next action?
1. Checking the dressing for signs of bleeding 2. Emptying any peri-incisional drains 3. Assessing the client’s pain level 4. Assessing the client’s bladder |
check dressing for bleeding
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The nurse in the postanesthesia care unit notes that one of the clients pupils is larger than the other. Which of the following actions should the nurse perform next?
1. Rate the client on the Glascow scale 2. Administer oxygen 3. Check the client’s baseline data 4. Call the surgeon |
3. Check the client’s baseline data
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A 250 pound male client recovering from general anesthesia has the following assessment findings: pulse 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate 28 breaths/minute and tympanic temperature 99.8 and rigid muscles. The nurse determines that the client
1. Is recovering as expected from the anesthesia and continues monitoring him 2. Is exhibiting the effects of excessive blood loss experienced in the operating room and increases the rate of his intravenous infusion 3. Is in the early stages of malignant hyperthermia and obtains emergency medications and notifies the anesthesiologist 4. Is in pain and offers him pain medication |
Is in the early stages of malignant hyperthermia and obtains emergency medication and notifies anesthesiologist
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Which of the following clients is expected to retain the anesthesia agents longest?
1. A client who is 6 feet 2 inches tall and weighs 250 pounds 2. A client who is 5 feet 4 inches tall and weighs 110 pounds 3. A client who is 5 feet 1 inch tall and weighs 200 pounds 4. A client who is 5 feet 7 inches tall and weighs 145 pounds |
3. A client who is 5 feet 1 inch tall and weighs 200 pounds
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The nurse monitors the surgical client closely for which clinical manifestation with the administration of naloxone (narcan)?
1. Dizziness 2. Biliary colic 3. Bleeding 4. Urinary retention |
3. Bleeding
Rationale narcan has side effect of abnormal coagulation |
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The nurse anticipates that the client who has received epidural anesthesia is at decreased risk for a spinal headache because
1. A 17 gauge needle is used 2. A subarachnoid injection is made 3. A noncutting needle is used 4. A faster onset occurs |
3. A noncutting needle is used
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A client is admitted to the surgical floor after having bowel surgery. The nurse observes that the client’s urinary output has decreased from 50 to 20 mL/hour. Which of the following is most likely the cause?
1. Bowel obstruction 2. Side effect of opioid analgesics 3. Hemorrhage 4. Hypertension |
3. Hemorrhage
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Which of the following interventions should the nurse implement for pulmonary emboli prophylaxis
1. Have the client perform leg exercises every hour while awake 2. Encourage the client to cough and deep breath 3. Massage the calves of the client’s legs 4. Have the client wear antiembolic stockings when out of bed |
1. Have them perform leg exercises every hour while awake
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The nurse assess a client who has just received morphine sulfate. The client’s blood pressure is 90/50 mm Hg, pulse 58 bpm, respirations, 4 breaths/minute. What drug should the nurse prepare to administer?
1. Flumazenil (Romazicon) 2. Naloxone hydrochloride (Narcan) 3. Doxacurium (Nuromax) 4. Remifentanil (Ultiva |
2. Naloxone hydrochloride (Narcan)
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The initial postoperative assessment is completed on a client who had an arthroscopy of the knee. Assessment of which of the following parameters is not necessary every 15 minutes during the first postoperative hour?
1. Vital signs including pulse oximeter 2. Pain rating of the operative site 3. Urinary output 4. Neurovascular check distal to the operative site |
3. Urinary output
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Which of the following nursing interventions does not aid in meeting the goal of clear breath sounds?
1. Offering pain relief before having the client cough 2. Providing a minimum of 1500 mL fluid per day 3. Monitoring breath sounds 4. Assisting with early ambulation |
2. Providing a minimum of 1500 mL fluid per day
Rationale minimum of 2500 mL |
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The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on his leg. What is the nurse’s best action?
1. Document the prednisone with current medications. 2. Notify the surgeon of the poison ivy. 3. Notify the anesthesiologist of the prednisone administration. 4. Send the client to surgery |
Notify the anesthesiologist of the prednisone administration
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post op After the initial assessment, the patient's vital signs and general physical status are assessed
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at least every 15 minutes
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determine the patient's readiness for discharge from the PACU assess what
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Stable vital signs
Orientation to person, place, events, and time Uncompromised pulmonary function Pulse oximetry readings indicating adequate blood oxygen saturation Urine output at least 30 mL/hour Nausea and vomiting absent or under control Minimal pain |
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Urine specific gravity norms and what they indicate
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1.010 - 1.025
tests the kidneys ability to conserve/excrete water |
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BUN norms and what they indicate
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10-20mm/dL
if they are increased: bleeding, GI, dehydration, fever sepsis if they are decreased: end stage liver disease, low protein diet, starvation |
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Creatine norms and what they indicate
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0.7 - 1.4 mg/dL
creatine is the end product of muscle metabolism. It inrease when renal function decreases. |
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Hct norms and what they indicate
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Volume % of RBC in whole blood.
42-52% male 35-47% female up: dehydration down: overhydration/anemia |
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K norms and what they indicate
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3.5 - 5.0 mEq/L
hypokalemia-cardiac resp.arrest hyper: cardiac arrest mor often signs not seen til <3.0 |
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WBC norms and what they indicate
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4.5- 11.0 WBC x 10^3
Increased: fighting infection decreased: at risk of infection |
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Hgb norms and what they mean
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hemoglobin is ameasure of the oxygen carrying capacity of blood. transports CO2
males: 14-17.4 females:12-16 g/dL <5 g/dl leads to heart failure and death >20.g/dL results in hemoconcentration and clogging of capillaries |
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Platelet norms and what they mean
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140-400 c 10^3/mm3
for clotting and control of bleeding. critical decrease to less than 20 can mean spontaneous bleeding, prolonged bleeding time, petechia(tiny red spots that aren't raised and don't blanch), and ecchymosis |
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Septic shock 8 steps starts with precipitating event with gram - bacteria
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1) have an infection
2) causes vasodilation BP falls 3)activates inflammatory response 4) releases histamines casuse increase in capillary permeability 5) fluid leaking out of capillaries, lowers fluid &BP 6) decrease venous return 7) decrease CO 8) decrease tissue perfusion |
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Which of these preoperative drugs should not be mixed in the same syringe with any other drug?
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VALIUM
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After injecting a client's preoperative Demerol and Atropine, you would:
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not to smoke
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General anesthetics administered by inhalation include:
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Halothane
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The nurse who supervises a client's recovery from general anesthesia should:
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Encourage the client to breathe deeply and exercise his legs as he begins to regain consciousness
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The nurse may prevent parotitis by:
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performing oral care
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