Med-Surg Test II
Potassium lab values
3.5-5.0 mEq/L
WBC lab value
5,000-10,000/mm3
A nurse is caring for a client who is scheduled for an exploratory laparotomy. The client's temperature is 39 degrees C (102.2 degrees F) orally. Which of the following actions should the nurse take?
A) Inform the surgeon of the elevated temperature.
A nurse is reinforcing preoperative teaching with a client who is to have abdominal surgery. Which of the following statements should the nurse make? (SATA) A)'Take your heart medication with a sip of water before surgery' B)'Splint the abdominal incision with a pillow when coughing and deep breathing' C)'Bed rest is recommended for the first 48 hrs' D)'Anti-embolism stockings are applied before surgery' E)'You can eat solid foods up to 4 hours before surgery'
A)'Take your heart medication with a sip of water before surgery' B)'Splint the abdominal incision with a pillow when coughing and deep breathing' D)'Anti-embolism stockings are applied before surgery'
A nurse us reviewing the medical records of several clients scheduled for a surgical procedure to identify risk factors that can lead to postoperative complications. Which of the following clients are at risk for complications? (SATA) A)A client who has a WBC of 22,500/uL B)A client who uses an insulin pump C)A client who takes warfarin daily D)A client who has heart failure E)A client who has a BMI of 26
A)A client who has a WBC of 22,500/uL B)A client who uses an insulin pump C)A client who takes warfarin daily D)A client who has heart failure
A nurse is caring for a client who reports nausea and vomiting 2 days postoperative following a hysterectomy. Which of the following actions should the nurse perform first? A)Check for bowel sounds. B)Administer antiemetic medication C)Ensure IV fluids are initiated D)Insert a prescribed nasogastric tube.
A)Check for bowel sounds.
A nurse is contributing to the plan of care for a client to prevent postoperative atelectasis. Which of the following interventions should the nurse recommend for inclusion in the plan of care? (SATA) A)Encourage use of the incentive spirometer every 2 hr. B)Instruct the client to splint the incision C)Reposition the client every 2 hr. D)Administer antibiotic therapy E)Assist with early ambulation
A)Encourage use of the incentive spirometer every 2 hr. B)Instruct the client to splint the incision C)Reposition the client every 2 hr. E)Assist with early ambulation
What is the first priority to monitor when patient arrives in PACU?
ABC's Airway, breathing patency and circulation.
What is the first VS assessed when client arrives in the PACU?
Airway patency. ABC's Airway, Breathing & CIrculation
Thromboembolism (page 593)
Apply pneumatic compression devices and/or anti-embolism stockings. Reposition every 2hrs. and ambulate early and regularly. Administer prescribed anticoagulants or antiplatelet medications. Monitor extremities for calf pain, warmth, erythema and edema.
A nurse is caring for a client who is postoperative following a gastric resection. Which of the following actions should the nurse take? (SATA) A)Reposition the client every 4 hrs B)Apply pneumatic compressing stockings bilaterally. C)Place pillows under the client's knees when in the supine position' D) Administer pain medication 30 min prior to ambulation E)Encourage the client to perform leg exercises every 1 hr.
B)Apply pneumatic compressing stockings bilaterally. D) Administer pain medication 30 min prior to ambulation E)Encourage the client to perform leg exercises every 1 hr.
A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (SATA)
C) Ensure the client understands information about the procedure. D) Witness the client signing the informed consent form. E) Determine if the client is capable of understanding the reason for the process.
A nurse is reviewing a client's laboratory values before surgery. Which of the following results should the nurse report to the provider? (SATA) A)Potassium 3.9 mEq/L B)Sodium 145 mEq/L C)Creatinine 2.8mg/dl D)Blood glucose 235 mg/dl E)WBC 17,850/mm3
C)Creatinine 2.8mg/dl D)Blood glucose 235 mg/dl E)WBC 17,850/mm3
A nurse is verifying informed consent for a client who is having a paracentesis. Which of the following actions should the nurse take? (SATA) A)Explain to the client the purpose of having the procedure B)Inform the client of risks to having the procedure C)Ensure the client understand the information about the procedure D)Witness the client signing the informed consent form E)Determine if the client is capable of understanding the reason for the procedure.
C)Ensure the client understand the information about the procedure D)Witness the client signing the informed consent form E)Determine if the client is capable of understanding the reason for the procedure.
DVT (deep vein thrombosis) (page 594)
Caused by dehydration, stress response that leads to hypercoaguiabilty of the blood, immobility, obesity, trauma, malignancy, history of thrombosis, hormones, and ise of indwelling venous catheter.
Wound dehiscence and Evisceration (page 594)
Caused by spontaneous opening of the incisional wound (dehiscence.) Can progress to the protrusion of the internal organs through the incision (evisceration.) Nursing actions: Monitor risk factors (obesity, coughing, moving without splinting, poor nutritional status, diabetes millitus, infection, hematoma, steroid use) If wound dehiscence or evisceration occurs, call for help, stay with the client, cover the wound with a sterile towel or dressing that is moistened with sterile saline, place in a low-Fowler's position with knees bent, monitor for shock and notify the provider immediately. Do not attempt to reinsert organs.
What is dehiscence, what is nursing intervention for an evisceration?
Caused by spontaneous opening of the incisional wound (dehiscence.) Nursing intervention for evisceration: If wound dehiscence or evisceration occurs, call for help, stay with the client, cover the wound with a sterile towel or dressing that is moistened with sterile saline, place in a low-Fowler's position with knees bent, monitor for shock and notify the provider immediately. Do not attempt to reinsert organs.
Serous Sanguineous:
Clear and blood tinged
Serous drainage
Composed of clear, serous portion of the blood and from serous membranes
What is the purpose of splinting the incision before and during cough?
Coughing uses abdominal and accessory respiratory muscles, which may have been cut during surgery. Splinting supports the incision and surrounding tissues and reduces pain during coughing.
A nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? A)Encourage the client to void after preoperative medication administration. B)Administer antibiotics 2 hr prior to surgical incision C)Remove hair using a manual razor D)Remove nail polish on fingers and toes
D)Remove nail polish on fingers and toes
For wound healing what food group is most important to increase? (page 593)
Encourage the client to consume a diet high in calories, protein and vitamin C. If the client has diabetes mellitus, maintain appropriate glycemic control.
What is the frequency for coughing and deep breathing while splinting incision (different from repositioning frequency, don't confuse.)
Every 1 hour while awake.
How often should the patient be repositioned after surgery?
Every 2 hours. Ambulate early and regularly.
How to use IS (incentive spirometer), put steps in order.
Exhale and place mouth piece in mouth, seal lips tightly, inhale deeply, hold breath 2-3 seconds, exhale slowly around the mouthpiece.
Post Op pt with a PCA (patient controlled analgesia) pump states pain med not working?
First thing to do is a pain assessment, rating, where is it, quality and intensity before calling MD)
What are the blankets used for post op?
Hypothermia. Blankets are kept in a warmer and paced on clients for warmth. The OR can be very cold.
Pain (page 592)
If prescribed, provide continuous pain relief. A preventative around the clock approach is more effective than PRN med delivery. Monitor pain frequently. Encourage the pt to ask for pain meds before pain gets to severe. Monitor for manifestations of pain (increased pulse, resp, BP, restlessness, wincing or moaning.) Monitor for adverse effects of opioids (resp depression, urinary retention and constipation.) Provide analgesia prior to ambulation. Monitor for effectiveness of pain med. Incorporate nonpharmacological approaches to pain (relaxation techniques, meditation, noise reduction, listening to music.)
What to do if abnormal VS before surgery especially an elevated temp, who do you notify before the client goes to the OR?
Immediately notify the surgeon of the elevated temperature to determine if canceling the surgery is necessary due to an underlying infection.
What is healing by primary intention? (Give example)
Little or no tissue loss. Edges approximated, as with a surgical incision. Heals rapidly. Low risk of infection. No or minimal scarring. Ex. Closed surgical incision with staples, sutures or liquid glue to seal laceration.
Bowel function (page 592)
Maintain the client NPO until return of gag relfex (risk of aspiration) and peristalsis (risk of paralytic ileus.) Irrigate NG suction tubes with saline as needed to maintain patency. Do not move NG tubes in clients who are postoperative following gastric surgery (risk to incision.) Monitor bowel sounds in all four quadrants as well as ability to pass flatus. Advance diet as prescribed and tolerated (clear liquids to regular.) Encourage gum chewing as a low-cost method to stimulate gastric secretions and promote the return of intestinal peristalsis.
Hematocrit lab values
Male: 42%-52% Female: 37%-47%
Sanguineous drainage
Mixture of serum and red blood cells
What is the minimal U/O for urine production?
Monitor and report U/O less than 30 mL an hour.
S/S hypovolemic shock. BP, HR, Resp., Skin Color, Temp, Call MD stat
Monitor decrease in BP & U/O; increased HR & Resp., Narrowing of pulse pressure and slow cap refill. Skin color, Temp., Call MD stat.
Incision and drain sites (page 593 second bullet monitor the incision site.)
Monitor drainage (should progress from sanguineous to serosanguineous to serous.) Monitor incision site. Monitor wound drains each time vital signs are measured. In most instances the surgeon will perform the first dressing change. Use abdominal binder as prescribed for clients who are obese or debilitated. Encourage splinting with position changes, coughing and deep breathing. Remove sutures or staples in 5-10 days as prescribed. If incision is is secured with would closure tape, instruct the client to keep in place until strips fall off on their own.
What is frequency to monitor post op drains? (under incisions and drains. page 593)
Monitor drainage with every set of vital signs.
S/S DVT (Deep Vein Thrombosis)
Monitor extremities for calf pain, warmth, erythema, and edema.
What to assess if client is constipated and no flatus after surgery and what intervention regarding ambulation should be encouraged?
Monitor for bowel sounds. Encourage ambulation. Advance the diet as tolerated when bowel sounds or flatus are present. Administer prokinetic agents (metoclopramide), as prescribed. The client can have an NG tube inserted to empty stomach contents. Encourage gum chewing.
What to expect with U/O when pt is hypovolemic?
Monitor for decreased bllod pressure and urinary output, increased heart and respiratory rates, narrowing of pulse pressure and slow capillary refill. Administer oxygen. Place client in a supine position with legs elevated. Assist with administration of IV fluids and vasopressors as prescribed.
How many hours does a pt need to be NPO for surgery general anesthesia if client has eaten solid foods?
Not eating solid food for 6 or more hours before surgery can reduce the risk of complications.
Kidney function (page 592)
Output should equal intake within 3 days postoperatively. Report urinary output less than 30mL/hr. Once indwelling catheter is removed, client should void within 8hr. Recommend the use of a bladder scan to monitor for suspected retention of urine.
Who should get the consent for surgery, physician or nurse?
Physician, nurse can witness the signature.
Hypovolemic shock (page 594)
Postoperative shock can result from a massive loss of circulating blood volume.
Nurses responsibility to make sure client had been educated by doctor about procedure before consent is signed if not, nurse needs to call provider.
The provider is responsible for giving clarification. Notify provider if the client has additional questions or appears to not understand any of the information.
What is a TIME OUT?
The surgical "time out" represents the last part of the Universal Protocol and is performed in the operating room, immediately before the planned procedure is initiated. The "time out" represents the final recapitulation and reassurance of accurate patient identity, surgical site, and planned procedure.
Purulent drainage
Thick, yellow, green, tan, or brown drainage
What is the purpose for anti embolism stockings?
To prevent thromboembolism. (blood clots)
Activating/emptying JP drain. (Steps in order page 592)
Wash hands, apply non sterile gloves. Remove cap from collection reservoir (bulb), squeeze bulb to empty contents into container, when empty re-squeeze bulb completely, replace cap in reservoir to reactivate suction, remove gloves, wash hands.
Sodium lab value
135-145 mEq/L
HgB lab values
14-18 g/dL; females 12-16 g/dL