MEDSURG Exam 2 + Questions

Potassium replacement:

*Increased dietary potassium* (examples include bananas, melon, citrus fruits, fresh and frozen vegetables (avoid canned vegetables), lean meats, milk, and whole grains) or IV for severe deficit

*The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?* A) Atelectasis B) Anemia C) Dehydration D) Peripheral edema

A) Atelectasis

*Which of the following occurs during the inflammatory stage of wound healing?* A) Blood clot forms B) Granulation tissue forms C) Fibroblasts leave wound D) Tensile strength increases

A) Blood clot forms Rationale: The blood clot forms during the inflammatory phase of wound healing. Granulation tissue forms during the proliferative phase. Fibroblasts leave the wound and tensile strength increases during the maturation phase of wound healing, refer to Table 19-5

Gabapentin, Pregabalin

Anticonvulsants Used to treat neuropathy and postoperative to address neuropathic component of surgical pain

*Which type of surgery is being done when lesions that are removed are likely to develop into cancer?* A) Diagnostic B) Palliative C) Prophylactic D) Reconstructive

C) Prophylactic Rationale: The type of surgery being done when lesions that are removed are likely to develop into cancer is called prophylactic surgery. Diagnostic surgery such as a biopsy is usually performed to obtain a tissue sample for analysis of cells suspected to be malignant. Palliative surgery is performed in an attempt to relieve complications of surgery. Reconstructive surgery is carried out in an attempt to improve function or obtain a more desirable cosmetic effect

*Which specific agents or factors are associated with the etiology of cancer?* A) Dietary and genetic factors B) Hormonal and chemical agents C) Viruses D) All of the above

D) All of the above Rationale: Specific agents or factors associated with the etiology of cancer include: viruses and bacteria, physical factors, sunlight, radiation, chronic irritation, chemical agents, tobacco, asbestos, genetic and familial factors, diet, hormones

*What is one of the most common and feared responses by patients to terminal illness?* A) Anorexia B) Cachexia C) Dyspnea D) Pain

D) Pain Rationale: Prevalence of pain is as high as 50% in patients with cancer of any type as well as in terminally ill patients. Dyspnea is an uncomfortable awareness of breathing that is common in patients approaching the end of life. Anorexia and cachexia are common in the seriously ill

*The nurse is admitting a client to the medical-surgical unit from the PACU. In order to help the client clear secretions and help prevent pneumonia, the nurse should encourage the client to* A) Eat a balanced diet that is high in protein. B) Limit activity for the first 72 hours. C) Take medications as prescribed. D) Use the incentive spirometer every 2 hours.

D) use the incentive spirometer every 2 hours.

*When caring for a patient in hypovolemic shock who is receiving large volumes of IV isotonic fluids, the nurse should monitor for symptoms of:* A) Hyperthermia B) Pain C) Pulmonary edema D) Tachycardia

C) Pulmonary edema Rationale: The nurse should monitor for circulatory overload and pulmonary edema when large volumes of fluids are administered intravenously. Hypothermia may occur with large volumes of fluid that are not warmed. Pain would not be seen in hypovolemic shock but may occur with cardiogenic shock. Tachycardia would be expected in hypovolemic shock

Grieving, Mourning, Bereavement of Staff

In many settings, staff members organize or attend memorial services to support families and other caregivers, who find comfort in joining one another to remember and celebrate the lives of patients

*The nurse is checking the informed consent for an older adult client who requires surgery and who has recently been diagnosed with Alzheimer disease. When obtaining informed consent, who is legally responsible for signing?* A) The client's next of kin B) The The client's spouse C) The client D) The surgeon

C) The client **For future reference** When answering a question like this one, unless it is said as a fact that the patient has some sort of cognitive impairment due to any disorder, the client will always be the primary source of information and the one to give consent.

*A client is admitted to the ED complaining of severe abdominal pain, stating that he has been vomiting coffee-ground like emesis. The client is diagnosed with a perforated gastric ulcer and is informed that he needs surgery. When can the client most likely anticipate that the surgery will be scheduled?* A) Within 24 hrs. B) Within the next week C) Without delay because the bleed is emergent D) As soon as all the day's elective surgeries have been completed.

C) Without delay because the bleed is emergent

*The circulating nurse will be participating in a 78-year-old client's total hip replacement. What consideration should the nurse prioritize during the preparation of the client in the OR?* A) The client should be placed in Trendelenburg position. B)The client must be firmly restrained at all times. C)Pressure points should be assessed and well padded. D)The preoperative shave should be done by the circulating nurse.

C)Pressure points should be assessed and well padded.

*The nurse is caring for a male client who has had spinal anesthesia. The client is under a physician's order to lie flat postoperatively. When the client asks to go to the bathroom, you encourage him to adhere to the physician's order. What rationale for complying with this order should the nurse explain to the client?* A)Preventing the risk of hypotension B)Preventing respiratory depression C)Preventing the onset of a headache D)Preventing pain at the lumbar injection site

C)Preventing the onset of a headache

When should Preop teaching be done, and what important exercises should be taught beforehand to avoid complications after the surgery?

Initiated as soon as possible (physician's office, clinic, or during pre-admission testing) Deep breathing, coughing, incentive spirometry

Preadmission Testing initiates what?

Initiates the nursing process S.A.T.A.: Initiate IV, Ensure NPO, Comfort

Renal Function in Older Patients

Reduced Renal function high-normal and minimally elevated serum *creatinine* (BUN is not accurate)

Emergent Surgery

Requires immediate intervention because of life-threatening consequences *(active bleeding is always emergent!)*

Postoperative Assessment

Respiratory

Acute pain

Result of tissue damage; surgery; trauma

Infection in Cancer

Risk for infection related to altered immunologic response

Informed Consent

Sata: Should be in writing before nonemergeny surgery Legal Mandate Surgeon must explain the procedure, benefits, risks, complications, etc. Nurse clarifies information and witnesses signature Consent is valid ONLY when signed before administering psychoactive premedication Consent accompanies patient to OR

Gerontologic pain considerations

Sensitive to agents that produce sedation and CNS effects *(confusion)*

What should the nurse do when shock occurs?

Understand underlying mechanism, identify subtle and obvious signs and perform rapid assessment

Protecting the Patient From Injury

Verification, accessibility of blood

Basic Guidelines for Surgical Asepsis

When sterile barrier is breached, area is considered contaminated Movement at least 1-foot (30 cm) distance from sterile field must be maintained

Cancer Pain

acute or chronic may require higher doses of pain medications

Irreversible Stage of Shock Nursing Interventions

allow family to spend time with client and help them understand Irreversible Stage of Shock

Sentinel lymph node biopsy (SLNB)

also known as sentinel lymph node mapping, is a minimally invasive surgical approach that in many instances has replaced more invasive lymph node dissections (lymphadenectomy) and the associated complications such as lymphedema and delayed healing

Interdisciplinary collaboration in Palliative Care

based on communication and cooperation among the various disciplines

Routes and Dosing for Pain Management

check allergies, reassess the pain and give PRNs

Multimodal Pharmacologic Pain Management

combines drugs with different underlying mechanisms, which allows lower doses of each of the drugs in the treatment plan

Protein found in Malignant cells?

contain proteins called tumor-associated antigens (TAAs)

Pain Assessment Client Teaching

focus on self-care and safety, reinforce the pain scale number system

Carcinogenic Life Style Factors

heavy alcohol use increases the risk of cancers of the mouth, pharynx, larynx, esophagus, liver, colon, rectum, and breast

Hypermagnesemia Clinical Manifestations

hypoactive reflexes, drowsiness, muscle weakness, depressed (shallow) respirations, ECG changes, dysrhythmias, and cardiac arrest

Nutritional impairment in Cancer

i.e. external radiation for a malignant tumor of the neck → Impaired nutritional status

Hematopoietic Chemotherapy Toxicity

i.e. thrombocytopenia → epistaxis

Caring for recipients in HSCT (what should you teach the family/friends/SO?)

instruct family not to visit if they've had a recent infection (during posttransplantation)

Chronic Pain may cause

intense emotional responses. i.e. tears and anger

Palliative surgery

is performed in an attempt to relieve symptoms, such as ulceration, obstruction, hemorrhage, pain, and malignant effusions

In order to achieve the desired learning outcomes in Palliative Care,

The nurse should be sensitive to these ongoing needs and may need to repeat previously provided information or simply be present while the patient and the family react emotionally

Is the following statement true or false? *The most important nursing intervention when vomiting occurs postoperatively is to turn the patient's head to prevent aspiration of vomitus into the lungs*

True Rationale: The most important nursing intervention when vomiting occurs postoperatively is to turn the patient's head to prevent aspiration of vomitus into the lungs

Is the following statement true or false? *Malignant tumors spread by way of blood and lymph channels to other areas of the body*

True Rationale: Malignant tumors spread by way of blood and lymph channels to other areas of the body. Cells bear little resemblance to the normal cells of the tissue from which they arose

Is the following statement true or false? *The most common colloid solution used to treat hypovolemic shock is 5% albumin*

True Rationale: The most common colloid solution used to treat hypovolemic shock is 5% albumin

The role of the nurse in the Surgical Team

Patient Advocate (ex. Client Privacy)

Driving after discharge

Patients are not to drive home or be discharged to home alone

Osmoreceptors

sense changes in sodium concentration which increases the release of ADH

Hypovolemic shock

shock state resulting from decreased intravascular volume due to fluid loss

Neurogenic shock

shock state resulting from loss of sympathetic tone causing relative hypovolemia. i.e. caused by spinal cord injury, spinal anesthesia, or other nervous system damage

What should you do in the case of extravasation?

stop the administration of the drug immediately

Nutritional support needed

to meet increased metabolic and energy requirements to prevent further catabolism due to depletion of glycogen. Applies to all types of shock

What is the relationship between urine-specific gravity and urine volume?

varies *inversely* with urine volume normally, the larger the volume of urine, the lower the specific gravity is

Radiation-associated impairment of skin integrity

→ myelosuppression → provide skin care to maintain skin integrity → avoid rubbing or scratching the area

What is the "cornerstone" or main goal for a nurse when managing physiological responses?

*Anticipating* and planning interventions for symptoms is a cornerstone of both palliative and end-of-life care/ prevent and relieve suffering

Clinical Findings in Stages of Shock

*Compensatory:* Normal BP, HR 100+, RR 20+, Cold clammy skin, Decreased Urine, Confused, Respiratory alkalosis *Progressive:* Low BP, Fluid resuscitation required, HR 150), Crackles in lungs, Shallow breaths, Mottling, Petechiae, Lethargy, Metabolic Acidosis Irreversible: r.i.p. everything

If the patient, the family, and the health care professionals are aware that the patient is dying and openly acknowledge that reality, what kind of awareness is it?

*Open* Rationale: Open awareness occurs when the patient, the family, and the health care professionals are aware that the patient is dying and openly acknowledge that reality. Closed awareness is when the patient is unaware of their terminal state, whereas others are aware. Suspected awareness is when the patient suspects what others know and attempts to find out details about his or her condition. Mutual pretense awareness is when the patient, the family, and the health care professionals are aware that the patient is dying but all pretend otherwise

For All Types of Shock

-Early identification, timely treatment -Identify, treat underlying cause -Early provision of nutritional support

Metastasis occurring in the Liver

-i.e. metastasis to the liver → jaundice → Liver Function Tests

Normal Part of Aging

Age-related thinning of the skin and loss of strength and elasticity

*Which stage of shock is characterized by a normal blood pressure?* A) Initial B) Compensatory C) Progressive D) Irreversible

B) Compensatory Rationale: In the compensatory stage of shock, the BP remains within normal limits. In the second stage of shock, the mechanisms that regulate BP can no longer compensate and the MAP falls below normal limits. Patients are clinically hypotensive; this is defined as a systolic BP of less than 90 mm Hg or a decrease in systolic BP of 40 mm Hg from baseline. The irreversible (or refractory) stage of shock represents the point along the shock continuum at which organ damage is so severe that the patient does not respond to treatment and cannot survive. Despite treatment, BP remains low

*A family is asking why their father with end-stage COPD is being referred to hospice care. The best response from the nurse would be:* A) Hospice care provides complete pain control B) Hospice assists the family and patient to prepare for death C) Hospice will follow the patient's choice for "DNR" status D) Hospice is provided in the home and will allow the family to be involved in the decisions for care

B) Hospice assists the family and patient to prepare for death Rationale: Hospice is an interdisciplinary team approach that provides services to the patient and family to prepare for death. Hospice care provides pain control but cannot guarantee complete pain control. All areas of health care follow the patient's choice for "DNR" status. This is not just a practice of Hospice, but a right for all patients in any setting. Hospice is provided in the home, hospital, nursing home, or hospice home settings. Other services may also be provided in a patients home such as home health or assisted living situations. The statement of hospice being only in the home setting may be confusing to the family and patient. All practice areas of healthcare encourages family involvement if the patient chooses this. This is not a practice followed only in hospice

*The nurse is performing a preoperative assessment on a client going to surgery. The client informs the nurse that he drinks approximately two bottles of wine each day and has for the last several years. What postoperative difficulties should the nurse anticipate for this clients?* A) Non-adherence to prescribed treatment after surgery following surgery. B) Increased risk for postoperative complication C) Alcohol withdrawal syndrome upon administration of general anesthesia D) Increased risk for allergic reactions.

B) Increased risk for postoperative complication

*The OR nurse is taking the client into the OR when the client informs the operating nurse that his grandmother spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?* A)The client may be experiencing presurgical anxiety. B)The client may be at risk for malignant hyperthermia. C)The grandmother's surgery has minimal relevance to the client's surgery. D)The client may be at risk for a sudden onset of postsurgical infection.

B)The client may be at risk for malignant hyperthermia.

Gerontologic Considerations - Preop

Decreased SQ fat, more susceptible to *Temp Changes* Monitor for hypothermia and hyperthermia

Outpatient Surgery/Direct Discharge

Discharge Planning, discharge assessment *Provide written and verbal instructions* regarding follow up care, complications, wound care, activity, medications, diet *Give prescriptions and Phone numbers* Discuss actions to take if complications occur (SATA question)

Acute Organ Dysfunction Cardiac Signs

Drop in systolic BP >40 mm Hg from baseline Serum Lactate >4 mmol/L MAP <65 mm Hg

Is the following statement true or false? *The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of laryngospasms the following statement true or false?*

False Rationale: The primary nursing goal in the immediate postoperative period is maintenance of pulmonary function and prevention of hypoxemia and hypercapnia

Is the following statement true or false? *The primary goal in treating cardiogenic shock is to limit further myocardial damage*

False Rationales: The primary goal in treating cardiogenic shock is not to limit further myocardial damage. The primary goal in treating cardiogenic shock is to treat the oxygenation needs of the heart muscle

How should meds be given to older patients?

Gerontologic Consideration Initiate with low dose and titrate slowly

What are two very dangerous intraoperative complications?

Hypothermia and Malignant Hyperthermia (Dantrolene)

Pain control for Cardiogenic Shock

IV morphine is given for pain relief. In addition to relieving pain, morphine dilates the blood vessels

Advanced Directives Ex.

If a patient wishes to defer decisions to his son, the nurse can work with the team to negotiate informed consent, respecting the patient's right not to participate in decision making and honoring his family's cultural practice

Nutritional support in Shock

Increased metabolic rates during shock increase energy requirements and therefore caloric requirements. Release of catecholamines early in the shock continuum causes rapid depletion of glycogen stores

Opioid Tolerance

Increased usage needed to effect pain relief

What commonly used drug may potentially affect the surgical experience?

Insulin

Head and Jaw Positioning to Open Airway

KNOW THE STEPS To treat hypopharangeal obstruction *A.* A hypopharyngeal obstruction occurs when neck flexion permits the chin to drop toward the chest; obstruction almost always occurs when the head is in the midposition. *B.* Tilting the head back to stretch the anterior neck structure lifts the base of the tongue off the posterior pharyngeal wall. The direction of the arrows indicates the pressure of the hands. *(One hand located on the back of the neck pushing upwards, while the other hand is on the top of the head pushing downwards)* *C.* Opening the mouth is necessary to correct a valve-like obstruction of the nasal passage during expiration, which occurs in about 30% of unconscious patients. Open the patient's mouth (separate lips and teeth) and move the lower jaw forward so that the lower teeth are in front of the upper teeth. To regain backward tilt of the neck, lift with both hands at the ascending rami of the mandible.

Depression

May be a consequent health problem with Chronic Pain

Respiratory Acidosis

May be cause by diseases that impair respiratory muscles. i.e. muscular dystrophy, myasthenia gravis and Guillain-Barre

Malignant Hyperthermia

Muscle Rigidity, High Fever, High HR, High CO2 Production Give Dantrolene

Spinal Anesthesia

Nerve Block Spinal Headache afterwards, so lay patient supine and hydrate

Opioid Maximum

No absolute maximum opioid dose

Transduction

Nociceptors (primary afferent neurons) are activated by noxious stimuli, such as a surgical incision or burn

Preoperative assessment

Nutritional status Drug or alcohol use is associated with a significant mortality rate when it occurs postoperatively.

Distributive (neurogenic, anaphylactic, septic)

Occurs when intravascular volume pools in peripheral blood vessels Pooling of blood in the periphery results in decreased venous return

Preventing perioperative positioning injury

Pads on bony prominences

Pain during End of Life

Preventable or treatable in most cases-patients who are receiving an established regimen of analgesics should continue to receive those medications as they approach the end of life. Inability to communicate pain should not be equated with the absence of pain

Assisted suicide legislation

The ANA position statement further stresses the important role of the nurse in supporting effective symptom management, contributing to the creation of environments for care that honor the patient's and family's wishes, as well as identifying their concerns and fears

Urine-specific gravity

measures the kidneys' ability to excrete or conserve water

Hypercalcemia clinical manifestations

polyuria, thirst, muscle weakness, intractable nausea, abdominal cramps, severe constipation, diarrhea, peptic ulcer, bone pain, ECG changes, dysrhythmias

NSAIDs

produce pain relief primarily by blocking the formation of prostaglandins in the periphery

Characteristics of severe anaphylaxis usually include

rapid onset of hypotension, neurologic compromise, respiratory distress, and cardiac arrest

When performing psychosocial, spiritual care, what can you do?

referral to mental health providers may be helpful to address specific concerns

Grief

refers to the personal feelings that accompany an anticipated or actual loss. *i.e. Depression: sadness, grief, mourning for impending losses*

Nursing care of patients in the progressive stage of shock

requires expertise in assessing and understanding shock and the significance of changes in assessment data

Hydrostatic pressure

results from the pumping action of the heart