Med/surg Final

Front 1

A patient has a nursing diagnosis of disturbed sensory perception related to sleep deprivation. Which action will the nurse include in the plan of care?

Back 1

Cluster nursing activities so that the patient has uninterrupted rest periods.

Front 2

When caring for a patient who has an intraaortic balloon pump in place, which action will be included in the place of care?

Back 2

Measure the patient's urinary output every hour

Front 3

Indicated for persons with acute MI with hear failure

Back 3

Assist ratio can be 1:1, 1:2, or 1:3

Front 4

Ventricular assist devices are designed to Temporarily

Back 4

partially or totally support circulation until a donor heart can be obtained

Front 5

Early signs of inadequate oxegen transport

Back 5

is confusion and restlessness

Front 6

While waiting for cardiac translplantation, a patient with severe feart failure has a ventricular assist device (VAD) implanted, Include in Plan of care..

Back 6

Monitoring the surgical incision for signs of infection

Front 7

Head and Neck Cancers 90% occur

Back 7

in individuals 50 and older after prolonged use of tabacco and alcohol

Front 8

Late Stage of head and neck cancers

Back 8

Decreased mobility of the tongue

Front 9

Radiation treatment

Back 9

keep water bottle with you secondary to dry mouth

Front 10

Pt asks "How will I talk after surgery?"

Back 10

Response: "you will have a permanent opening into your neck and will need to have rehab for some type of voice restoration

Front 11

Pt with total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care

Back 11

The patient asks how to clean the trach stoma and tube will indicate that the problem identified is resolving

Front 12

Ater completing discharge instructions you determine that addtional instruction is needed whent he pt says

Back 12

I must keep the stoma covered with a lose sterile dressing at all times

Front 13

Radical Neck dissection- 1st 24 hours S/P surgery, the priority nursing action is to

Back 13

assess breath sounds

Front 14

Modified Neck disscetion
Nutrition

Back 14

Parenteral fluids are given for the first 24 to 48 hours-Thick white secretions-add H2O to enteral feedings

Front 15

Trach, Cuffed Tube with disposable Inner Cannula

Back 15

Prior to deflating suction pt mouth and trachea

Front 16

Cuffed tube with reusable inner cannula

Back 16

to assess safety of eating with cuff deflated defate cuff and have pt drink small amt grape juice and observe for coughing

Front 17

Cuffless tube with Disposable Inner Cannula- Pt coughs violently during suctioning and dislodges the tube:

Back 17

1st action, insert the obturator and attempt toreinsert the trach tube

Front 18

Fenestrated Cuffed Tracheostomy Tube

Back 18

Assess abitlity to swallow before using

Front 19

Trach: Speaking

Back 19

Use finger to block the stoma to speak

Front 20

Respiratory tracheostomy care:
PVC's occur

Back 20

Stop and give 100% O2

Front 21

You are working in Long Term Care, you may delegate suctioning to

Back 21

an experienced LPN

Front 22

After determining that the patient is breathing and has an unobstructed airway

Back 22

observe the patient's respiratory effort

Front 23

Primary Survey: emergancy nursing

Back 23

1st: Insert two large-bore IV catheters
Initiate aggressive fluid resuscitation using normal saline or lactated Ringer's Solution

Front 24

Primary Survery: glasgow Coma Scale

Back 24

Pupils

Front 25

Most immediate deaths from trauma occur because of problems with ventilation,

Back 25

so the patient with a sucking chest wound should be treated first

Front 26

Death in the Emergency Department- patient has a cardiac arrest and resuscitation measures are started.

Back 26

Ask the family members about whether they would prefer to remain in the patient room of wait outside the room

Front 27

Heat Exhaustion:

Back 27

Place moist sheet patient to decrease core temperature
Replace electrolytes

Front 28

Hypothermia: Core temperature <95 degrees

Back 28

When rewarming a patient sufficient rewarming has occurred when the core temperature has reached 89.6-93.2

Front 29

Hypothermina: Dysrhythmias

Back 29

plan to attach a cardica monitor as rewarming can produce dysrhythmias

Front 30

Submersion Injury

Back 30

Initial evaluation: ABCD-Lung Sounds

Front 31

Tylonol overdose

Back 31

Tx with N-acetylcysteine (Mucomyst)

Front 32

Screening for domestion violence is reuired in ED

Back 32

When suspected ask: "Is someone at home hurting you?"

Front 33

Smallpox infection can be prevented by the administation of

Back 33

vaccine given rapidly after exposure

Front 34

Radiologic Terrorism: Ionizing radiation

Back 34

place the pateint in a shower first