health alterations exam 2

Which pulse pressure indicates shock? 130/80 mm HG 100/60 mm HG 90/70 mm HG 120/90 mm HG

90/70 mm HG Explanation: Pulse pressure correlates with stroke volume. Elevation of the diastolic BP with the release of catecholamines and attempts to increase venous return through vasoconstriction is an early compensatory mechanism in response to decreased stroke volume. A narrowed or decreased pulse pressure is an early indicator of shock. A normal pulse pressure is 40 mm Hg (120 mm Hg systolic blood pressure minus 80 mm Hg diastolic blood pressure); thus 90/70 = 20 mm HG, indicates a narrowed pulse pressure. 130 mm HG -80 mm HG = 50 mm HG, a normal pulse pressure. 100 mm HG- 60 mm HG = 40 mm HG- a normal pulse pressure

normal I/Os (urine output)

30 ml/hr or 240mL/8 hr

blood transfusion:

4 hour duration; time sensitive needs to be administered 30 minutes after receiving from blood bank -20 G needle should be used since better for smaller veins -2 nurses must verify ABO group, Rh factor, pt ID, expiration time; check for bubbles, cloudiness, colors -first 15 minutes= infusion rate no faster than 5mL/min -never add any medications to blood transfusions

A client refuses to remove her wedding band when preparing for surgery. What is the best action for the nurse to take? Discuss the risk for infection caused by wearing the ring. Discuss the risk for infection caused by wearing the ring. Allow the client to wear the ring and cover it with tape. Cancel the surgery take it off after the client is sedated

Allow the client to wear the ring and cover it with tape. Explanation: Most facilities will allow a client to wear a wedding band during a surgical procedure. The nurse must secure the ring with tape. Although it is appropriate to discuss the risk for infection, the client has already refused to remove the ring. The surgery should not be canceled and the ring should not be removed without permission.

A client admitted with a massive myocardial infarction rapidly develops cardiogenic shock. Ideally, the physician would use the intra-aortic balloon pump (IABP) to support the injured myocardium. However, this client has a history of unstable angina pectoris, aortic insufficiency, hypertension, and diabetes mellitus. Which condition is a contraindication for IABP use? Unstable angina pectoris Aortic insufficiency Diabetes mellitus Hypertension

Aortic insufficiency Explanation: A history of aortic insufficiency contraindicates use of the IABP. Other contraindications for this therapy include aortic aneurysm, central or peripheral atherosclerosis, chronic end-stage heart disease, multisystemic failure, chronic debilitating disease, bleeding disorders, and a history of emboli. Unstable angina pectoris that doesn't respond to drug therapy is an indication for IABP, not a contraindication. Hypertension and diabetes mellitus aren't contraindications for IABP

allergic reaction to blood transfusion

Caused by hypersensitivity. S/S include itching, fever, anaphylactic shock (if severe) -reactions usually mild -diphenhydramine=antihistamine

COLDSPA

Character Onset Location Duration Severity Pattern Associated factors

What is the major purpose of withholding food and fluid before surgery?

Prevent aspiration Explanation: The major purpose of withholding food and fluid before surgery is to prevent aspiration. Decreasing overhydration, decreasing urine output, and decreasing constipation are not major purposes of withholding food and fluid before surgery. Until recently, fluid and food were restricted preoperatively overnight and often longer. Currently, specific recommendations depend on the age of the client and the type of food eaten.

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? Wound dehiscence Contractures Hypotension Phlebitis

Wound dehiscence Explanation: Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia. This client is not at increased risk for hypotension, contractures, or phlebitis.

NG tube insertion

X ray confirmation initially after placement, then aspirate q shift to confirm Want grey-brown gastric juice, acidic, test pH -placement must be confirmed prior to meds/feeding admin, measurement of tube length

scrub nurse

a nurse who assists surgeons during surgery, wearing sterile attire and handling sterile equipment and supplies

circulating nurse

a nurse who assists the scrub nurse and the surgeons during surgery, positioning the patient and equipment, obtaining additional supplies, and adjusting lighting as needed; documents

Fowler's position

a semi-sitting position; the head of the bed is raised between 45 and 60 degrees shoulder, breast reconstruction

prealbumin

a thyroxin-binding protein measured to evaluate the nutrition status of critically ill patients who are at high risk for malnutrition 12-42 dL (half life of 2 days)= earlier signifier of malnutrition versus albumin (has 20 day half life)

Intermittent bolus feedings

admin into stomach usually via g tube -designated intervals -3-4 times per day -end of tube is capped when not in use

post-operative period

after surgery admit to PACU--> hospitalization--> home--> ends at last followup appt

adverse effects of anesthesia

anaphylaxis, hypoxia, malignant hyperthermia, seizure, respiratory arrest, cardiac arrest, stroke, nerve damage, hematoma, abscess

Gastrostomy feedings are preferred to nasogastric feedings in the comatose patient, because the: Digestive process occurs more rapidly as a result of the feedings not having to pass through the esophagus. Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Feedings can be administered with the patient in the recumbent position. The patient cannot experience the deprivational stress of not swallowing.

Gastroesophageal sphincter is intact, lessening the possibility of regurgitation and aspiration. Explanation: Gastrostomy is preferred over NG feedings in the patient who is comatose because the gastroesophageal sphincter remains intact. Regurgitation and aspiration are less likely to occur with a gastrostomy than with NG feedings.

Nursing students are reviewing information about agents used for anesthesia. The students demonstrate understanding when they identify which of the following as an inhalation anesthetic? Succinylcholine Halothane Fentanyl Propofol

Halothane Explanation: Halothane is an example of an inhalation anesthetic. Fentanyl, succinylcholine, and propofol are commonly used intravenous agents for anesthesia.

persistent pain

baseline pain; treated around the clock

important consideration when checking for hemorrhage

check under patient/blankets for bleeding

hematoma post-op

concealed bleeding under the skin -usually bleeding stops spontaneously (clot) -large clot may require evacuation

urinary retention post-op

due to anticholinergics, opiooids, anesthetics pt should void within 8 hours post-op, if not voiding bladder scanner to view retained amt of urine, straight cath may be needed noninvasive measures--> peppermint oil, running water, ambulation, after void scan bladder to assess post void residual (<250 acceptable volume, if more= cath)

lithotomy position

lying on back with legs raised and feet in stirrups, hips and knees flexed, thighs abducted and externally rotated vaginal, rectal, obstetrical, urological resections of groin and rectal areas

VTE

venous thromboembolism stress response from surgery makes blood hyper-coagulable--> dehydration--> low CO--> immobility--> blood pooling in extremities--> DVT

Three Phases of Perioperative Period

-Preoperative: Decision to have surgery to Operating room -Intraoperative: Admission to surgical department to PACU (Post-Anesthesia Care Unit) -Postoperative: PACU to complete recovery from surgery

Acute hemolytic transfusion reaction

-Type II hypersensitivity reaction. -Intravascular hemolysis (ABO blood group incompatibility) or extravascular hemolysis (host antibody reaction against foreign antigen on donor RBCs). -Presents with fever, hypotension, tachypnea, tachycardia, flank pain, hemoglobinuria (intravascular hemolysis), jaundice (extravascular), heat sensation in tranfused vein -most rapid with ABO incompatibility (as little as 10mL) -treatment= stop transfusion, maintain blood volume/renal perfusion, prevent DIC

Febrile nonhemolytic transfusion reaction

-Type II hypersensitivity reaction. Host antibodies against donor HLA antigens and WBCs. -Presents with fever, headaches, chills, flushing, muscle stiffness -most common rxn; 90% -non-life threatening-- stop transfusion and notify

MODS (multiple organ dysfunction syndrome)

-complication of an form of shock due to inadequate tissue perfusion -often starts in lungs (ARDS)--> renal system--> liver--> GI system -failure of 3 or more organ systems= 80-90% mortality rate -cardiac and neuro= 100% mortality rate -end result if shock isn't stopped

NG tube monitoring/maintenance

-record I/Os every 8 hours -irrigate q4-6 hours -tap water/sterile saline/NS used when admin feedings or meds -frequent oral and nasal care -nasal tape changed daily

nurses role in reducing dumping syndrome

-using room temp feedings -changing from bolus to continuous feedings if appropriate -having pt stay in semi-fowlers for 1 hr after feeding -slowing rate of feeding to allow more time for digesting -instill minimal amt of water needed to flush tube

When vasoactive medications are administered, the nurse must monitor vital signs at least how often? 15 minutes 45 minutes 30 minutes Hourly

15 minutes Explanation: When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).

A patient is receiving a continuous tube feeding. The nurse notes that the feeding tube was last irrigated at 2 p.m. The nurse would plan to irrigate the tube again at which time? 6 p.m. to 8 p.m. 4 p.m. to 6 p.m. 8 p.m. to 10 p.m. 10 p.m. to 12 a.m.

6 p.m. to 8 p.m. Explanation: The recommendation is to irrigate the feeding tube of patients receiving continuous tube feedings every 4 to 6 hours. For this patient, the nurse would irrigate the tube next at 6 p.m. to 8 p.m.

A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery? 2 to 3 days 7 to 10 days 2 weeks 4 weeks

7 to 10 days Explanation: Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery; otherwise, the client may be at increased risk for bleeding.

hypovolemic shock

A condition in which low blood volume, due to massive internal or external bleeding or extensive loss of body water, results in inadequate perfusion. total body fluid decreased

distributive shock

A condition that occurs when there is widespread dilation of the small arterioles, small venules, or both. can be sepsis, anaphylaxis, or neurogenic

The nurse is caring for a client in septic shock. The nurse knows to closely monitor the client. What finding would the nurse observe when the client's condition is in its initial stages?

A rapid, bounding pulse Explanation: A rapid, bounding pulse is observed in a client in the initial stages of septic shock. In case of hypovolemic shock, the pulse volume becomes weak and thready and circulating volume diminishes in the initial stage. In the later stages when the circulating volume has severely diminished, the pulse becomes slow and imperceptible, and pulse rhythm changes from regular to irregular.

What measurement should the nurse report to the physician in the immediate postoperative period? A systolic blood pressure lower than 90 mm Hg A temperature reading between 97°F and 98°F A hemoglobin of 13.6 Respirations between 20 and 25 breaths/min

A systolic blood pressure lower than 90 mm Hg Explanation: A systolic blood pressure of less than 90 mm Hg is usually considered immediately reportable. However, the patient's preoperative or baseline blood pressure is used to make informed postoperative comparisons. A previously stable blood pressure that shows a downward trend of 5 mm Hg at each 15-minute reading should also be reported. The other findings are normal or close to normal.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: auscultate bowel sounds. change the client's position. insert a rectal tube. palpate the abdomen.

auscultate bowel sounds. Explanation: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

The nurse recognizes that the most common cause of iron deficiency anemia in an adult is

bleeding. Explanation: Iron deficiency in adults generally indicates blood loss (e.g., from bleeding in the gastrointestinal (GI) tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer.

MODS Signs and Symptoms

brain swelling and ischemia cardiovascular instability vena cava flattening increased peak pressure, difficult ventilation and oxygenation (ARDS) anuria/ARF (acute renal failure) increased gut ischemia, impending necrosis further worsening of acidosis

Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency? Thyroid Adrenal Parathyroid Pituitary

Adrenal Patients who have received corticosteroids are at risk of adrenal insufficiency. Insufficiency related to corticosteroids does not occur to the pituitary, thyroid, or parathyroid glands

Which colloid is expensive but rapidly expands plasma volume? Albumin Lactated Ringer solution Dextran Hypertonic saline

Albumin Explanation: Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. Dextran interferes with platelet aggregation and is not recommended for hemorrhagic shock. Lactated Ringer solution and hypertonic saline are crystalloids, not colloids.

A client arrives in the orthopedic clinic with complaints of twisting the right ankle while playing softball. The nurse collects data including complaints of pain and swelling in the right ankle. What intervention will the nurse provide that will decrease vasodilation and reduce localized swelling? Injection of a steroid into the joint space Warm compresses Ice bag Elevation of the extremity

Ice bag Explanation: Pain associated with injury is best treated initially with cold applications such as an ice bag or chemical pack. The cold decreases vasodilation which reduces localized swelling, which may be useful for minor or moderate pain. Heat will increase vasodilation. Elevation of the extremity will not decrease vasodilation. It is beyond the scope of practice for the nurse to inject steroids into the joint space.

dressing on drain management

If you have a dressing on a drain, trace the drainage on the dressing with a pen. Doing so will not increase the risk of infection-- tracing it is a necessary step to show seepage.

A nurse is planning preoperative teaching for an older client. Which structural or functional changes in the older adult impact the surgical experience?

Increased fatty tissue prolongs elimination of anesthesia. Decreased ability to compensate for hypoxia increases the risk of an embolism. Loss of collagen increases the risk of skin complications. Reduced tactile sensitivity can lead to assessment and communication problems. Explanation: The older adult has increased fatty tissue which prolongs elimination of anesthesia, decreased ability to compensate for hypoxia increases the risk of an embolism, loss of collagen increases the risk of skin complications, and reduced tactile sensitivity can lead to assessment and communication problems. The older adult has decreased plasma proteins, and no enlarged liver unless there is an underlying disease.

A client is lethargic with a systolic blood pressure of 74, heart rate of 162 beats/min, and rapid, shallow respirations. Crackles are audible in the lungs. The nurse assesses frequently for which of the following? Select all answers that apply. Reports of chest pain Ecchymoses and petechiae Increased paCO² levels Loss in consciousness Decreases in liver enzymes

Increased paCO² levels Reports of chest pain Loss in consciousness Ecchymoses and petechiae Explanation: The client is in the progressive stage of shock. Continuation of shock leads to organ systems decompensating. The client will retain and exhibit increased levels of carbon dioxide. Because of the dysrhythmias and ischemia, the client may experience chest pain and suffer a myocardial infarction. As the client's lethargy increases, the client will begin to lose consciousness. Metabolic activities of the liver are impaired, and liver enzymes will increase.

A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following? Increased anxiety level Increased tissue elasticity Impaired thermoregulation Decreased lean tissue mass

Decreased lean tissue mass Explanation: Elderly patients require lower doses of anesthetic agents because of decreased tissue elasticity and reduced lean tissue mass. An increased amount of anesthetic would be needed with an increased anxiety level. Impaired thermoregulation increases the patient's susceptibility to hypothermia.

The health care provider prescribes a vasoactive agent for a patient in cardiogenic shock. The nurse knows that the drug is prescribed to increase blood pressure by vasoconstriction. Which of the following is most likely the drug that is ordered?

Levophed Explanation: The vasopressor agents that increase blood pressure by vasoconstriction are Levophed, Intropin, Neo-Synephrine, and Pitressin. Other vasopressors act by reducing preload and afterload and oxygen demands of the heart, and by increasing contractility and stroke volume.

Which position is used for perineal surgical procedures?

Lithotomy Explanation: The lithotomy position is used for nearly all perineal, rectal, and vaginal surgeries. The Trendelenburg position is usually used for surgery on the lower abdomen and pelvis. The Sims or lateral position is used for renal surgery. The dorsal recumbent position is the usual position for surgical procedures.

Which positioning strategy should be used for a client diagnosed with hypovolemic shock? Prone Semi-Fowlers Modified Trendelenburg Supine

Modified Trendelenburg Explanation: A modified Trendelenburg position is recommended in hypovolemic shock. Elevation of the legs promotes the return of venous blood and can be used as a dynamic assessment of a client's fluid responsiveness.

The nurse cares for a client who receives continuous enteral tube feedings and who is at low risk for aspiration. The nurse assesses the gastric residual volume to be 350 mL. The nurse determines which action is correct? Flushing the feeding tube. Monitoring the feeding closely. Increasing the feeding rate. Lowering the head of the bed.

Monitoring the feeding closely. Explanation: High residual volumes (>200 mL) should alert the nurse to monitor the client more closely. Increasing the feeding rate will increase the residual volume. Lowering the head of the bed increases the client's risk for aspiration.

adverse effects of meds

NSAIDs= renal toxicity, GI ulceration, issues with bleeding time (risk for clotting and bleeding issues) Acetaminophen= hepatotoxicity opioids= constipation, N/V, pruritus, HoTN , resp/CNS depression

The nurse is assessing a patient complaining of severe pain. What physiologic indicator does the nurse recognize as significant of acute pain? Bradycardia Diaphoresis Decreased respiratory rate Hypotension

Diaphoresis Explanation: Observe behavioral signs, e.g., facial expressions, crying, restlessness, diaphoresis (sweating), and changes in activity. A pain behavior in one patient may not be in another. Try to identify pain behaviors that are unique to the patient ("pain signature"). Increased heart rate, blood pressure, and respiratory rate would be more likely to be associated with pain rather than decreased levels of these measures.

Informed consent from the surgical client is essential in all of the following categories of surgery except: Elective surgery Emergent surgery Urgent surgery Required surgery

Emergent surgery Explanation: In an emergency, a physician may perform surgery without a client's informed consent in order to save the client's life.

Which stage of surgical anesthesia is also known as excitement?

II Explanation: Stage II is the excitement stage, which is characterized by struggling, shouting, and laughing. Stage II is often avoided if the anesthetic is administered smoothly and quickly. Stage I is the beginning of anesthesia, during which the client breathes in the anesthetic mixture and feelings of warmth, dizziness, and detachment occur. Stage III is surgical anesthesia, which is achieved by continued administration of anesthetic vapor and gas. Stage IV is medullary depression, in which the client is unconscious and lies quietly on the table.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also reports unpleasant tastes and odors. Which measure should be included in the client's plan of care? Keep the feeding formula refrigerated. Provide frequent mouth care. Ensure adequate hydration with additional water. Flush the tube with water before adding the feedings.

Provide frequent mouth care. Explanation: Frequent mouth care helps to relieve the discomfort from dryness and unpleasant odors and tastes. It can be done with the help of ice chips and analgesic throat lozenges, gargles, or sprays. Adequate hydration is essential. If urine output is less than 500 mL/day, formula and additional water can be given as ordered. Keeping the feeding formula refrigerated and unopened until it is ready for use and flushing the tube with water before adding feedings are measures to protect the client from infections.

An older adult client presents to the health care provider's office and reports exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?

RBC count Explanation: A decreased red blood cell count is indicative of anemia, a common condition in older adults that results in fatigue.

dumping syndrome

Rapid emptying of gastric contents into small intestines (due to high osmolality taken in large amounts). Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia. HoTN also

The nurse observes that a postsurgical client has hemorrhaged and is in hypovolemic shock. Which nursing intervention will manage and minimize hemorrhage and shock? Encouraging the client to breathe deeply Rubbing the back Reinforcing dressings or applying pressure if bleeding is frank Elevating the head of the bed

Reinforcing dressings or applying pressure if bleeding is frank

Sudden withdrawal of which of the following may result in seizures? Tranquilizers Steroids Thiazide diuretics Monoamine-oxidase inhibitors

Tranquilizers Explanation: Abrupt withdrawal of tranquilizers may result in anxiety, tension, and even seizures if withdrawn suddenly. Abrupt withdrawal of steroids may precipitate cardiovascular collapse. Monoamine oxidase inhibitors increase the hypotensive effects of anesthetics. Thiazide diuretics may cause excessive respiratory depression during anesthesia due to an associated electrolyte imbalance.

The nurse is caring for a client 6 hours post surgery. The nurse observes that the client voids urine frequently and in small amounts. The nurse knows that this most probably indicates what? Requirement of intermittent catheterization Calculus formation Urine retention Urinary infection

Urine retention Explanation: Voiding frequent, small amounts of urine indicates retention of urine with elimination of overflow. The nurse should assess the volume of first voided urine to determine adequacy of output. If the client fails to void within 8 hours of surgery, the nurse should consult with the physician regarding instituting intermittent catheterization until voluntary voiding returns and is not required in this case. Frequent and small amounts of urine voiding does not indicate urinary infection nor does it indicate the formation of a calculus.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? inhale longer than exhale use diaphragmatic breathing exhale through your mouth use chest breathing

Use diaphragmatic breathing. Explanation: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

first 24 hours post-op goals

VS q15 first hour, then q30 x4 then as ordered (usually Q4) -moving towards self care controlling pain symptoms -mobilize pt and regain their independence

The nurse is reviewing diagnostic lab work of a client developing shock. Which laboratory result does the nurse note as a key in determining the type of shock? WBC: 42,000/mm3 Potassium: 4.8 mEq/L Hemoglobin: 14.2 g/dL ESR: 19 mm/hour

WBC: 42,000/mm3 Explanation: Septic shock has the highest mortality rate and is caused by an overwhelming bacterial infection; thus, an elevated WBC can indicate this type of shock. The other lab values are within normal limits.

At what point does the preoperative period end? When the client signs the consent form When the client is admitted to the PACU When the decision is made to proceed with surgery When the client is transferred onto the operating table

When the client is transferred onto the operating table Explanation: The preoperative phase begins when the decision to proceed with surgical intervention is made and ends with the transfer of the client onto the OR table. The intraoperative phase begins when the client is transferred onto the operating table and ends with admission to the PACU.

informed consent and surgery

Written permission signed by the patient, guardian, or whoever holds power of attorney must be obtained. Written consent protects the surgeon against claims of unauthorized surgery and provides the patient an opportunity to exercise the right of informed consent. RN can sign consent form as a witness needs to be signed before any pre-op meds can be given necessary for all non-emergent surgeries

Gastrostomy tube

a surgically placed feeding tube from the exterior of the body into the stomach -ideal for prolonged enteral nutrition support >4 weeks -regurg and aspiration less likely -PEG tube= feeding tube placed through abd wall into stomach -LPEG tube= used to replace g tube that has been removed from an established stoma; cannot assess residuals (nutrition directly to jejunum)

iron deficiency anemia

anemia resulting when there is not enough iron to build hemoglobin for red blood cells -most common type -usually due to blood loss, inadequate iron intake from diet, iron malabsorption (celiac, H2 inhibitors, antacids, meds, g-tube) -S/S (specifically for IDA)= smooth red tongue, pica (craving for non-edible things), koilonychias (depressed flat nailbeds)

unclogging NG tube

aspirate what you can warm water back and forth smaller syringes clog zapper: pancreatic enzymes and sodium bicarbonate

adverse medications before surgery

aspirin--> needs to be stopped 10 days before surgery Lisinopril/ACEs--> may cause HoTN during surgery stop aleve, ibuprofen and celebrex 1 week before surgery no blood thinners before surgery, no MAIO either

airway post-op

assess for hypopharyngeal obstruction -choking, nosy/irregular resp, decreased Sp02 -movement of thorax doesn't mean air is moving -head tilt chin lift maneuver -may need to insert oral/nasal airway

older adults and pain meds

at risk for NSAID induced GI toxicity -reduce dose by 25-30% in adults over 70 -pain is expected and normal; may be fear of what pain means -symptoms may differ: restlessness, confusion, aggression, loss of appetite

Hierarchy of Pain Measures

attempt to get self report (consider underlying patho or conditions/procedures that may be painful)--> assess behaviors--> evaluate physiological factors--> conduct an analgesic trial

clinical characteristics/effects of malnutrition

characteristics: insufficient food intake, weight loss overtime, loss of muscle and fat mass, fluid accumulation, measurably diminished grip strength effects: delayed wound healing, increased susceptibility to infections, decreased immunity, anemia, sickness and inflammation

atelectasis

collapsed lung; incomplete expansion of alveoli crackles heard on auscultation along with cough if not treated can lead to pneumonia treatment= TCDB q2hr (turn, cough, deep breath), clear secretions, incentive spirometry, splinting of abdominal incision, treat pain

1 unit of blood =

contains 450 ml of blood, 50 ml anticoagulant -separated RBCs (250-300 mL); rest platelets, plasma (can admin each individually or together) 1 unit of blood will raise the hemoglobin by 1g/dL and HCT by 3% if the pt is not bleeding or hemolyzing

The nurse collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest? cyclic feedings intermittent feedings continuous feedings bolus feedings

continuous feedings Explanation: Continuous feedings should be administered to a client who is at risk of diarrhea due to hypertonic feeding solutions. Bolus or intermittent feedings cause sudden distention of the small intestine, and cyclic feedings are not advised

skin features of shock

cool--> cold, pale--> mottled--> cyanotic moist, clammy, dry mouth, increased cap refill

Sepsis Bundle

cultures for antibiotic administration, 2 large bore IVs (NS IVF for HoTN or lactate levels above 4 mmol/L) antibiotics started within the hr- can prevent septic shock vasopressors if HoTN during or after fluids • CVP 8-12, MAP >65 UPO >0.5 mL/kg, SCVO2 >70%

cardio features of shock

decreased CO, increased pulse, thready pulse, decreased BP, postural HoTN, flat neck veins, slow cap refill, diminished peripheral pulses

kidney features of shock

decreased UOP, increased specific gravity

GI features of shock

decreased motility, diminished/absent BS, N/V, constipation

DVT

deep vein thrombosis (blood clot) S/S= pain/cramping in calf, painful swelling of entire leg, fevers, chills, diaphoresis prophylaxis treatment--> TED hose/SVDs, anticoagulants (low dose heparin or enoxaparin), ambulation, hourly leg exercises, adequate hydration avoid: blankets/rolls under knees, any forms of constricting elevation

dosing for pain

demand (PRN) and around the clock (ATC) -PRN appropiate for intermittent pain prior to procedures, breakthrough pain -ATC for 12+ hours of persistent pain

opioid naive

describes patients who are receiving opioid analgesics for the first time and who therefore are not accustomed to their effects -needs smallest dose possible to function (lightweight, sensitive, hasn't had a lot of opioids in past)

DIC

disseminated intravascular coagulation--bleeding disorder marked by reduction of blood clotting factors due to their use and depletion for intravascular clotting. "death is coming" clots in microvasculature, bleeding everywhere increased d-dimer (indicates clotting and breakdown), decreased platelets, prolonged PTT

megaloblastic anemia

due to inadequate B12 and folic acid -B12 deficit= diet rare, faulty absorption in GI tract most common (lack of intrinsic factor) -folic acid deficit= diet rare, ETOH, malabsorption -same S/S with anemia; may see more neuro effects (neuropathy, AMS, depression, visual disturbances, balance issues, dementia=late sign)

neuro features of shock

early: restlessness, anxiety late: lethargy--> coma, generalized muscle weakness, sluggish pupillary response to light

admin meds with enteral feedings

ensure pills can be crushed and capsules can be opened -crush pills thoroughly to prevent clogging -flush with 20/30 ml of tap water/sterile water/NS -consult pharmacy to convert meds to liquid form

continuous infusion feedings

enteral feedings delivered by an infusion pump at a slow rate over a 16- to 24-hour period -preferred for aspiration risk pts and those who tolerate feeding poorly -less risk for ab distention, nausea, gastric residuals and risk for aspiration -expensive, less flexible

wound infection post-op

exposure of deep body tissue to pathogens S/S= increased pulse/temp/WBCs, wound swelling, warmth, tenderness, discharge (local S/S may be absent if incision is deep) -may not be present until POD 5 -treatment= insertion of drain, I+D procedure, culture sensitivity, ABX

A nurse is caring for a client who underwent a skin biopsy and has three stitches in place. This wound is healing by: fourth intention. third intention. first intention. second intention.

first intention. Explanation: Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

PACU nurse role

frequent q15 monitoring of vitals, drains/dressings, LOC, CSMTs ensure IVF infusing per orders assess effects of anesthesia (ex: is pt spontaneously breathing? responding to commands?) assess for post-op complications (airway, cardiovascular, pain/anxiety, N/V, PE, hypovolemic shock, infection, dehiscence, evisceration, paralytic ileus, GI dilation, atelectasis, urinary retention, pnemonia) provide comfort and pain relief

The client is taking oxycodone (Oxycontin) for chronic back pain and reports decreased pain relief when he began taking a herb to improve his physical stamina. The nurse asks if the herb is

ginseng Explanation: Ginseng may inhibit the analgesic effects of an opioid, such as oxycodone. The other herbs listed (valerian, kava-kava, and chamomile) may increase central nervous system depression.

iron supplements

give 1 hr before or 2 hr after antacid to prevent malabsorption vitamin C aides in absorption N/D and constipation common at start of therapy use straw for liquid iron to prevent staining of teeth -side effects: tarry stools (dark in color), epigastic pain, heart burn PO= take on empty stomach with OJ IM= may stain skin (z-track method) IV= monitor for anaphylaxis rxn

Enteral feedings

given to meet nutritional requirements when oral intake is inadequate or not possible -several advantages vs TPN= low cost, safer, well tolerated, easy to use at home, physiologic benefits -delivered to stomach via NG or gastrostomy

complete blood count

hemoglobin-- males= 13-18 gl/mL; females= 12-16 gl/mL hematocrit-- males= 43-49%; females= 38-44% look at these levels closely for need of transfusion

multimodal, preemptive analgesia

hopefully less need for narcotics for pain relief post op if all these meds are given methocarbamol/roboxin--> muscle relaxant acetaminophen--> pain reliever celecoxib--> COX-2 inhibitor/NSAID corticosteroids--> physician preference

Malignant hyperthermia

hypermetabolic crisis (sustained muscle contractions) due to exposure of volatile gas anesthetic or succinylcholine generally genetic, important to get possible family hx about condition pre-op S/S= tachycardia, skeletal muscle rigidity (early sign; especially masseter muscle contraction), dark brown urine from muscle breakdown, hyperthermia (later sign) treatment= dantrolene, cooling pt pt can die if not diagnosed/treated early

when do blood transfusion reactions usually occur?

in first 10-15 minutes of first 50 cc of blood

respiratory features of shock

increased RR--> rapid/shallow RR, decreased Co2--> increased CO2, oxygen sat decreases, cyanosis goes from respiratory alkalosis to respiratory acidosis

cyclic tube feedings

infusion given at faster rate over shorter period of time; can be infused at night then done by daytime -used for weaning from tube feedings to oral intake as tolerated, supplement for pts who cannot eat enough, who need daytime hours free from pump

shock and glucose levels

insulin may be needed for pts in sepsis due to high inflammation high inflammation= high blood glucose levels

Low lithotomy position

lap surgeries vaginal procedures

The nurse understands that the purpose of the "time out" is to: verify all necessary supplies are available. maintain the safety of the client. clarify the roles of the OR personnel. identify the client's allergies.

maintain the safety of the client. Explanation: Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client.

Supine Surgical Position

most freq used & natural procedures on anterior surface abd, Abd/thoracic, vascular, orthopedic, head/neck, ophthalmic

Bowel function post-op

nausea common d/t temporarily decreased peristalsis flatus = 1st sign of bowel function check 4 ileus constipation is very common usually pt cannot go home until 1 post-op BM no BM 2-3 days--> notify provider

antibiotics with surgery

needs to be given within 60 minutes of first incision; if not surgery needs to be delayed

tolerance with opioids

normal response occurs with regular admin of opioids; occurs first 2 days-2 weeks of therapy

physical dependence w/ opioids

normal response with opioid admin over 2 weeks; withdrawal s/s with sudden stop

A client is experiencing vomiting and diarrhea for 2 days. Blood pressure is 88/56, pulse rate is 122 beats/minute, and respirations are 28 breaths/minute. The nurse starts intravenous fluids. Which of the following prescribed prn medications would the nurse administer next?

ondansetron Explanation: An antiemetic medication, such as ondansetron (Zofran), is administered for vomiting. It would be administered before loperamide (Imodium) for diarrhea so the client would be able to retain the loperamide. There is no indication that the client requires medication for pain (meperidine [Demerol]) or heartburn (magnesium hydroxide [Maalox]).

A client is to receive general anesthesia with sevoflurane. What does the nurse anticipate would be given with the inhaled anesthesia? rocuronium alfentanil lidocaine oxygen

oxygen Explanation: Sevoflurane is an inhalation anesthetic always combined with oxygen to decrease the risk of coughing and laryngospasm. It would not be combined with alfentanil, rocuronium, or lidocaine. Alfentanil and rocuronium are intravenous anesthetics. Lidocaine is a local anesthetic.

nociceptive pain

pain from a normal process that results in noxious stimuli being perceived as painful -somatic= bone, joint, muscle, skin, CT; aching, throbbing, well localized -visceral= organs (GI tract, pancreas, tumors, IBS, UC) treatment--> opioids, nonopioids (tylenol, NSAIDs), local anesthetics

neuropathic pain

pain from damage to neurons of either the peripheral or central nervous system lasts months to years -central-- stroke, parkinsons, MS -peripheral-- phantom limb syndrome -allodynia-- typically non-noxious stimuli is excruciating -treatment: dilaudid, opioids, lidocaine patch; antidepressants (SNRIs, tricyclic), anticonvulsants (gabapentin)

possible reasons for tachypnea post-op

pain, constricting dressing, abdominal distention, bad position, obesity, etc

PCA

patient controlled analgesia -IV (PCA) or epidural (PCEA) -pt controls admin of meds with safety limits -predetermined dose and time (lockout interval) -only pt can push button -continuous infusion (basal), on demand (bolus) -pain should be under control prior to starting -don't wait for pain to get severe to push button (stay on top of pain control) -constant rate of serum opioid -for PCAs-- monitor for CNS effects/depression -for PCEAs-- combo of opioid and analgesia (hydromorphone and levocain); monitor respiratory status, UOP, pruritus, peripheral neuro status, BP, site assessment

jacknife position

prone with hips over break in table and feet below level of head gluteal and anorectal procedures

pre op shower

pt uses CHG (chlorhexidine gluconate) to cleanse skin in order to prevent risk of surgical site infections

what changes first in shock, pulse or BP?

pulse Pulse will ALWAYS compensate first. It is a lot of work to make the heart listen to you, so the body tries to work on distant vessels like arterioles, venules, arteries, veins, all that stuff to tighten up and send blood back to the heart. Pulse can compensate in seconds, BP compensates in minutes. loss of peripheral pulses may be the first sign of shock

narcan with opioid overdose

reverses adverse effects of opioids -use lowest dose possible, should be diluted (short duration of action= 1 hr) -low dose to maintain pain control but regain LOC

time out during surgery

right pt? right location? right procedure? check history, documents, pt ID, etc. mark procedure site with surgeon inititals timeout for the team

how often to assess pain

start of shift, reports of new pain, q4hrs minimum, before/after analgesics, end of shift

breakthrough pain

temporary flare-up of moderate to severe pain -meds wearing off

The most significant complication related to continuous tube feedings is the interruption of GI integrity. a disturbance of intestinal and hepatic metabolism. an interruption in fat metabolism and lipoprotein synthesis. the increased potential for aspiration.

the increased potential for aspiration. Explanation: Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the client receiving continuous tube feedings. Tube feedings preserve GI integrity by intraluminal delivery of nutrients. Tube feedings preserve the normal sequence of intestinal and hepatic metabolism. Tube feedings maintain fat metabolism and lipoprotein synthesis.

Post op complications

this chart is v amazing, memorize this shit

Lateral Surgical Position

thoracic renal and hip procedures

residual tube assessment

tolerance is measured -easily assessed with large bore G tubes -small tubes collapse with suction -volume indicates rate of digestion -volumes less than 200-500 ml more well tolerated -Q4 or as ordered -discarding= no evidence that returning gastric aspirates provides more benefits than discarding them without increased potential complications

Sepsis

toxic inflammatory condition arising from the spread of microbes, especially bacteria or their toxins, from a focus of infection disease state cause poor vasculature tone--> vasodilation (pseudo state of hypovolemia

NG tubes

use: decompression (bowel), lavage; admin feedings, fluids, meds Very short amount of time, irritating to nasal mucosa, r/o aspiration contras: facial and head trauma, severe coagulopathy, deviated septum, esophageal strictures, diverticula caution: esophageal varices, post gastric bypass, lap bands, cervical injuries

Trendelenburg surgical position

used for lower Abd pelvic procedures move Abd viscera away from pelvic area for better exposure lung volume Dec pressure of organs against diaphragm mechanically compresses the heart

Modified Trendelenburg position

used in the treatment of shock; the patient is positioned lying flat on the back with the legs elevated 12-16 inches above the head in an effort to improve the blood flow to the brain

A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control? wound healing liver dysfunction nutrient deficiencies respiratory complications

wound healing

A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?

wound healing Explanation: In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor. There is no direct correlation between blood glucose levels and nutrient deficiencies, respiratory complications, or liver dysfunction.

general indications for shock

MAP less than 65 high levels of lactate SBP< 90 mmHg (or changes in BP over 40 mmHg) low HCT/HgB effects entire body hypoperfusion/tissue hypoxia

Malnourishment, vs Undernourishment

Mal: An imbalance of vitamins and nutrients Under: Not taking in enough calories

Midazolam

Benzodiazepine used adjunctively in anesthesia can help to decrease anxiety since stress can negatively impact healing process

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound; sutures gave way avoid by: abdominal binder, pillow splint when coughing, using leg muscles not abdominal muscles

The nurse is inserting a nasogastric tube for a patient with pancreatitis. What intervention can the nurse provide to allow facilitation of the tube insertion? Allow the patient to sip water as the tube is being inserted. Spray the oropharynx with an anesthetic spray. Have the patient maintain a backward tilt head position. Have the patient eat a cracker as the tube is being inserted.

Allow the patient to sip water as the tube is being inserted. Explanation: During insertion, the patient usually sits upright with a towel or other protective barrier spread in a biblike fashion over the chest. The nostril may be swabbed or the oropharynx sprayed with an anesthetic agent to numb the nasal passage and suppress the gag reflex. The tip of the patient's nose is tilted upward, and the tube is aligned to enter the nostril. When the tube reaches the nasopharynx, the patient is instructed to lower the head slightly and, if able, to begin to swallow as the tube is advanced. The patient may also be encouraged to sip water through a straw to facilitate advancement of the tube if this action is not contraindicated.

The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure? Elevate the head of the bed to 45 degrees Administer a topical analgesic to control pain at the site Apply pressure over the site for 5-7 minutes Pack the wound with half-inch sterile gauze

Apply pressure over the site for 5-7 minutes Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the client's platelet count is low or if the client has been taking a medication (e.g., aspirin) that alters platelet function. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing.

A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority? Monitoring vital signs Putting the client on nothing-by-mouth (NPO) status Applying a sterile, moist dressing Inserting a nasogastric (NG) tube

Applying a sterile, moist dressing Explanation: Evisceration involves separation of all layers of the abdominal wall, resulting in protrusion of abdominal contents. The nurse's first priority should be to protect the client's abdominal contents. She should apply warm, sterile saline dressings over the protruding viscera. Next, the nurse should institute NPO status because the client will ultimately need surgery. The client is at risk for shock, so the nurse should monitor vital signs frequently after applying the sterile, moist dressing. The nurse doesn't need to make inserting an NG tube an immediate priority, especially because the physician may not order one.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to Auscultate lung sounds every 4 hours. Change the nasal tape every 2 to 3 days. Apply water-based lubricant to the nares daily. Inspect the nose daily for skin irritation.

Auscultate lung sounds every 4 hours. Explanation: Pulmonary complications may occur as a result of nasogastric intubation. It is a high priority according to Maslow's hierarchy of needs and takes a higher priority over assessing the nose, changing nasal tape, or applying a water-based lubricant.

A nurse administered a full strength feeding with an increased osmolality through a jejunostomy tube to a client. Immediately following the feeding, the client expelled a large amount of liquid brown stool and exhibited a blood pressure of 86/58 and pulse rate of 112 beats/min. The nurse

Consults with the physician about decreasing the feeding to half-strength Explanation: The osmolality of normal body fluids is 300 mOsm/kg. A feeding with a higher osmolality may cause dumping syndrome. The client may report a feeling of fullness, nausea, or both and may exhibit diarrhea, hypotension, and tachycardia. The nurse needs to take steps to prevent dumping syndrome. Increasing the amount of the feeding, administering the feeding at an extreme temperature, or increasing the osmolality of the feedings will continue dumping syndrome. The nurse needs to decrease the osmolality of the feeding as in administering a half-strength solution.

The nurse is assessing a postoperative patient's abdominal wound and observes a portion of intestines protruding through the wound. What is the priority intervention for the nurse to provide? Approximate the wound edges with adhesive tape so that the intestines can be gently pushed back into the abdomen. Carefully push the exposed intestines back into the abdominal cavity. Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Apply an abdominal binder snugly so that the intestines can be slowly pushed back into the abdominal cavity.

Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution. Explanation: If disruption of a wound occurs, the patient is placed in the low Fowler's position and instructed to lie quietly. These actions minimize protrusion of body tissues. The protruding coils of intestine are covered with sterile dressings moistened with sterile saline solution, and the surgeon is notified at once. A binder may be applied over the dressing, but not directly on the intestines. The nurse should not push the intestines back into the abdomen.

A nurse asks a client who had abdominal surgery 1 day ago if he has moved his bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene? Administer a tap water enema. Apply moist heat to the client's abdomen. Notify the physician. Encourage the client to ambulate as soon as possible after surgery.

Encourage the client to ambulate as soon as possible after surgery. Explanation: The nurse should encourage the client to ambulate as soon as possible after surgery. Ambulating stimulates peristalsis, which helps the bowels to move. It isn't appropriate to apply heat to a surgical wound. Moreover, heat application can't be initiated without a health care provider's order. A tap water enema is typically administered as a last resort after other methods fail. A health care provider's order is needed with a tap water enema as well. Notifying the health care provider isn't necessary at this point because the client is exhibiting bowel function by passing flatus.

management of shock

Ensure adequate lung ventilation and provide extra oxygen Restore blood volume by infusion of blood or other fluids (NS, colloids, blood products) Use interventions that improve cardiac performance (vasoactive meds such as vasopressin/epi,

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? Filgrastim Epoetin alfa Eltrombopag Sargramostim

Epoetin alfa Explanation: Erythropoietin (epoetin alfa) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis. Filgratism ( Neupogen) and Sargramostim stimulate granulocytosis( increasing WBC count) , Eltrombopag (Promacta) is used to treat aplastic anemia and thrombocytopenia.

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? Provide oral hygiene. Remove the tape from the nose of the client. Withdraw the tube gently for 6 to 8 inches. Flush with 10 mL of water.

Flush with 10 mL of water. Explanation: Before a nasogastric tube is removed, the nurse flushes the tube with 10 mL of water or normal saline to ensure that the tube is free of debris and away from the gastric tissue. The tape keeps the tube in the correct position while flushing is occurring and is then removed from the nose. The nurse then withdraws the tube gently for 6 to 8 inches until the tip reaches the esophagus, and then the remainder of the tube is withdrawn rapidly from the nostril. After the tube is removed, the nurse provides oral hygiene.

Residual content is checked before each intermittent tube feeding. The patient would be reassessed if the residual, on two occasions, was: About 100 mL. Between 50 and 80 mL. Greater than 200 mL. About 50 mL.

Greater than 200 mL. Explanation: Research demonstrates that residual volumes of less than 200 mL appear to be well tolerated without risk of aspiration.

A client, who had an above the knee amputation of the left leg related to peripheral vascular disease from uncontrolled diabetes, complains of pain in the left lower extremity. What type of pain is the client experiencing? Referred pain Neuropathic pain Visceral pain Breakthrough pain

Neuropathic pain Explanation: An example of neuropathic pain is phantom limb pain or phantom limb sensation, in which individuals with an amputated arm or leg perceive that the limb still exists and that sensation such as burning, itching, and deep pain are located in tissues that have been surgically removed. Chronic pain sufferers may have periods of acute pain, which is referred to as breakthrough pain. Visceral pain arises from internal organs such as the heart, kidneys, and intestine that are diseased or injured. Referred pain is a term used to describe discomfort that is perceived in a general area of the body but not in the exact site where an organ is anatomically located.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment:

Oxygen at 2 L/min by nasal cannula Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

Routes of Pain Meds:

PO, IV, rectal, topical, transdermal (avoid heat, 12-18 hours for effect), intraspinal, epidural

Which phase of pain transmission occurs when the brain experiences pain at a conscious level? Transmission Transduction Perception Modulation

Perception Explanation: Perception is the phase of impulse transmission during which the brain experiences pain at a conscious level, but many concomitant neural activities occur almost simultaneously. Transmission is the phase during which peripheral nerve fibers form synapses with neurons in the spinal cord. Modulation is the last phase of pain impulse transmission, during which the brain interacts with the spinal nerves in a downward fashion to alter the pain experience. Transduction is the conversion of chemical information in the cellular environment to electrical impulses that move toward the spinal cord.

Which is a symptom of severe thrombocytopenia? Inflammation of the mouth Dyspnea Petechiae Inflammation of the tongue

Petechiae Explanation: Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply. Assess for hypoxia. Assess urine output. Reorient the client. Apply wrist restraints. Ambulate the client. Administer opioid pain medication per orders.

Reorient the client. Assess for hypoxia. Assess urine output. Explanation: The nurse should provide reassurance and reorient the client as needed. Hypoxia and urinary retention may cause acute confusion in the older adults postoperatively, so it would be appropriate for the nurse to assess for hypoxia and urine output. Opioid pain medications may cause further confusion; the physician should be consulted about the type and dosage of the pain medication. Ambulating the client may present safety concerns, especially if the client is bleeding or hypoxic.

Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out? Review the scheduled procedure, site, and client. Confirm that informed consent has been obtained. Ensure that sufficient surgical supplies are available. Check that all surgical personnel are properly attired.

Review the scheduled procedure, site, and client. Explanation: According to the 2016 National Patient Safety Goals, accurate identification of the client, procedure, and operative site is essential.

Hemorrhage (post-op complication)

S/S= apprehension, rapid thready pulse, disorientation, restlessness, oliguria, cold/pale skin, increased pulse/RR, decreased CO, hypothermic Severe, rapid blood loss *Control bleeding *Adminsister IV fluid *Replace blood if loss >500 mL hold pressure if bleeding from surgical site

Which zone of the surgical area only requires attire in the form of scrub clothes and caps? Semi-restricted zone Operative zone Unrestricted zone Restricted zone

Semi-restricted zone Explanation: The semi-restricted zone is where attire consists of scrub clothes and caps. The unrestricted zone is where street clothes are allowed. The restricted zone is where scrub clothes, shoe covers, caps, and masks are worn. The surgeons and other surgical team members wear additional sterile clothing and protective devices during the operation.

A client is undergoing thoracic surgery. What priority education should the nurse provide to assist in preventing respiratory complications? Deep breathing and coughing exercises may be used as relaxation techniques. Pain medication should be taken before completing deep breathing and coughing exercises. Splint the incision site using a pillow during deep breathing and coughing exercises. Deep breathing and coughing exercises should be completed every 8 hours.

Splint the incision site using a pillow during deep breathing and coughing exercises. Explanation: Splinting the incision site will help decrease pain and support the incision. This will increase compliance with the deep breathing and coughing exercises that assist in preventing respiratory complications. Pain medication should be taken regularly, not only before deep breathing and coughing exercises. Deep breathing and coughing exercises should be done at least every 2 hours, more frequently if possible. While some clients will find the exercises relaxing, most clients find it painful to complete them.

A nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primary action?

Stop the infusion. Explanation: A client with impaired renal function is at increased risk for transfusion-associated circulatory overload (TACO). Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. If the symptoms are mild, the nurse may be able to slow the infusion and administer diuretics; however, sudden shortness of breath should clue the nurse to immediately stop the infusion and sit the client upright with feet dangling. Next, the nurse will notify the health care provider after normal saline is infused into the site. Only after stopping the infusion will the nurse obtain the client's vital signs.

Which clinical manifestation is often the earliest sign of malignant hyperthermia?

Tachycardia (heart rate >150 beats per minute) Explanation: Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops quickly. Scant urinary output is a later sign of malignant hyperthermia.

A physician calls the nurse for an update on his client who underwent abdominal surgery 5 hours ago. The physician asks the nurse for the total amount of drainage collected in the Hemovac since surgery. The nurse reports that according to documentation, no drainage has been recorded. When the nurse finishes on the telephone, she goes to assess the client. Which assessment finding explains the absence of drainage? The Hemovac drain isn't compressed; instead it's fully expanded. The client has been lying on his side for 2 hours with the drain positioned upward. There is a moderate amount of dry drainage on the outside of the dressing. The client has a nasogastric (NG) tube in place that drained 400 ml.

The Hemovac drain isn't compressed; instead it's fully expanded. Explanation: The Hemovac must be compressed to establish suction. If the Hemovac is allowed to fully expand, suction is no longer present, causing the drain to malfunction. The client who requires major abdominal surgery typically produces abdominal drainage despite the client's position. An NG tube drains stomach contents, not incisional contents. Therefore, the NG tube drainage of 400 ml is normal in this client and is not related to the absence of Hemovac drainage. Dry drainage on the dressing indicates leakage from the incision; it isn't related to the Hemovac drainage.

A postoperative client is being evaluated for discharge and currently has an Aldrete score of 8. Which of the following is the most likely outcome for this client? The client should be transferred to an intensive care area. The client can be discharged from the PACU. The client must be put on immediate life support. The client must remain in the PACU.

The client can be discharged from the PACU. Explanation: The Aldrete score is usually 8 to 10 before discharge from the PACU. Clients with a score of less than 7 must remain in the PACU until their condition improves or they are transferred to an intensive care area, depending on their preoperative baseline score.

Evisceration

The displacement of organs outside of the body. -moist NS dressings over organs (cover intestinal loops, do not try to force contents back into body) -remain in bed with knees bent -will return to OR

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? A length of 50 cm (20 in) The distance determined by measuring from the tragus of the ear to the xiphoid process A point that equals the distance from the nose to the xiphoid process The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process Explanation: Before inserting the tube, the nurse determines the length that will be needed to reach the stomach or the small intestine. A mark is made on the tube to indicate the desired length. This length is traditionally determined by (1) measuring the distance from the tip of the nose to the earlobe and from the earlobe to the xiphoid process, and (2) adding up to 15 cm (6 in) for NG placement or at least 20 to 25 cm (8 to 10 in) or more for intestinal placement.

The physician requests lidocaine 2% with epinephrine for use in local infiltration anesthesia. What does the nurse understand is the purpose of adding epinephrine to the lidocaine? (Select all that apply.) The epinephrine prevents rapid absorption of the anesthetic drug. The lidocaine will not anesthetize the area locally without the epinephrine. The epinephrine prolongs the local action of the anesthetic agent. The epinephrine causes vasoconstriction. The epinephrine will prevent the patient from having an allergic reaction to the lidocaine.

The epinephrine causes vasoconstriction. The epinephrine prevents rapid absorption of the anesthetic drug. The epinephrine prolongs the local action of the anesthetic agent. Explanation: Local anesthesia is often administered in combination with epinephrine. Epinephrine constricts blood vessels, which prevents rapid absorption of the anesthetic agent and thus prolongs its local action and prevents seizures.

Reverse Trendelenburg's position

The head of the bed is raised and the foot of the bed is lowered procedures on head and neck; Dec blood supply