NUR 242 Final Exam Review

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NUR 242 Final Exam Review Exam 1: Correct Answer: Cane: Correct Answer: -Appropriate height (at wrist level when arm is at side) -Pt strong hand on cane *MOVE CANE WITH WEAKER LEG* At ri... sk for falls due to: Correct Answer: incontenience Transferring pt to WC: Correct Answer: -Place WC on strong side angled to bed -Strong hand to armrest, then pivot Safe pt handling: Correct Answer: -Keep pt directly in front of you and as close as possible to prevent back injuries Skin integrity: Correct Answer: -dont wear restrictive clothing -WC pt lift themselves off buttock for 10 seconds q1hr Pressure Ulcer stages: Correct Answer: *Stage 2- skin is not intact; open or fluid blister* Wet-to-damp wound care: Correct Answer: mechanically removes necrotic tissue does more damage than good bc it removes the good tissue as well Informed consent: Correct Answer: -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 Pre-OP: Correct Answer: -Report these to surgeon: -increased PT/INR/aPTT/Creatinine -Verify operative permit is signed -Side rails up, bed down, call light within reach Intra-OP: Correct Answer: -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 Post-OP: Correct Answer: -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 Malignant hyperthermia: Correct Answer: -life threatening -you will see HIGH TEMPERATURE -early sign is tachycardia, muscle rigidity -Dantrolene is used to treat Pain Management: Correct Answer: *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 PCA Pump: Correct Answer: -Lockout interval of 5-15 minutes -Pt cannot be cognitively impaired -Only the pt can press the button If incision opens: Correct Answer: -cover with wet sterile gauze -Do not try to reinsert protruding organ -Reassure pt -Supine position with knees bent IV: Correct Answer: -20G 1-1.5" needle is adequate for most therapies -Huber needle should be placed at 90 degree angle to access port (chemo pt) TPN: Correct Answer: - Check each bag twice -If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is available -If TPN not administered on time, do not increase the rate -Change IV tubing q24 hours when new bag is hung -Dressing change around IV site changed 2 48-72 hours Sickle Cell: Correct Answer: -Pain is the most common problem -Requires large doses of opioid analgesics -Hydrate with NS IV fluids, encourage oral fluids without caffeine -Administer O2 -Remove restrictive clothing, No BP with external cuff -Sickle Cell crisis: pain meds and IV fluids Vitamin B12 Deficiency: Correct Answer: -Smooth, beefy red tongue MRSA: Correct Answer: -Sleep in separate beds until infection clears -Wash clothes in HOT water Standard precautions: Correct Answer: -Hand hygiene -Gloves Contact precautions: Correct Answer: -Private room -Wear gloves when entering room -Wash hands with soap and water -Dedicated equipment Airborne Precautions: Correct Answer: -Private room with negative airflow -Keep door closed -N95 respirator *Pt wear surgical mask when leaving room for labs/procedure* Droplet precautions: Correct Answer: -Private room preferred -If not, may share a room with pt having same active infection -Surgical mask when working WITHIN 3 FEET OF PT -Pt to wear surgical mask when leaving room Psoriasis: Correct Answer: Treat with UV light but NOT A TANNING BED Skin Cancer: Correct Answer: -Avoid sun exposure from 11-3pm -A=Asymmetry -B=border -C=color -D=diameter -E=evolving -Examine the body monthly for changes Exam 2: Correct Answer: The nurse is teaching a client who has been prescribed alprazolam. Which of [Show More]

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