AH TEST #1

Which factor refers to a client's experiential readiness to learn?

Educational history and life experience

Nurses role in Pre-op

Having the knowledge of the nature of the disorder for surgery, identifying the patients response to stress, assessing the results of pre-op tests, and providing a baseline or risks and complications

Post-op Phase 1

Immediate recovery and intensive nursing care

Which statement by the client indicates the client's experiential readiness to learn?

"Do you have a video about my disease? I don't like to read."

Which statement made by the client indicates understanding of the Centers for Disease Control and Prevention and U.S. Preventive Services Task Force recommendation for prostate screening frequency?

"I will see you next year for my prostate exam."

Responsibilities of the nurse in the PACU:

-Airway -VS compared to the baseline VS -Asses the pain last (if they are in pain you need to make sure everything else is in the baseline then asses their pain)

Patient education pre-op:

-Deep breathing, coughing, and incentive spirometry -Get the patient out of bed, motility is important -Pain management -Coping strategies

When maintaining a patent airway...

-Maintain ventilation: oxygenation (keep oxygen above 92% unless the patients baseline is lower) -Keep head of bed elevated 15-30 degrees unless told other wise

Maintaining Cardiovascular stability:

-Monitor skin along with blood pressure and heart rate -Watch for hypotension, hemorrhage, shock, and arrhythmias

Types of Diabetes

-Type 1 -Type 2 -Gestational Diabetes -Prediabetes -Latent autoimmune diabetes of adults (LADA)

Make sure to look for signs of hypovolemic shock

-pallor, cool, moist skin -cyanosis -rapid, weak, thread pulse -concentrated urine (normal output 1mL/kg)

Creatine values

0.4-1.0mg/dL- Females 0.6-1.2mg/dL- Males

INR values

0.8-1.2

type 1 diabetes

Decrease insulin production, insulin-producing beta cells in the pancreas are destroyed

Mg values

1.8-2.5mg/dL

PT values

11-12.5 seconds

Na values

135-145mEq/L

Platelet values

140,000-400,000/mm3

How long before surgery does the patient need to stop taking herbal medication?

2 weeks before the surgery

PTT values

25-35 seconds

K values

3.5-5.0mEq/L

WBC

5,000-10,000/mm3

BUN values

8-20 mg/dL

Ca values

8.5-10.5mg/dL

eGFR values

>60

What happens during the inflammatory stage of wound healing?

A blood clot forms

Therapeutic Regimen

A routine that promotes health and healing

In the PACU what is the first thing you need to assess?

Airway -Always check the airway first

Latent autoimmune diabetes in adults (LADA)

Autoimmune beta cell destruction in the pancreas is slower than in type 1 and type 2. Not insulin dependent in the initial 6 months.

Preoperative Phase:

Begins when the decision to proceed with surgical intervention is made and ends with he transfer of the patient onto the operating room bed -Decide to have surgery to the transfer of patient to the OR bed

Intaoperative Phase:

Begins when the patient is transferred onto the OR bed and ends with admission to the PACU

Postoperative Phase:

Begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or home

Stress reduction and stress management

Behaviors and techniques used to strengthen a person's resources against stress

Local Anesthesia:

Blocks sensation for surgery, given in combination with epinephrine

What medication classification must be assessed during the per-op period because it can cause an electrolyte imbalanced during surgery?

Diuretics

General Anesthesia:

Inhalation- liquid agents and gases, always combined with oxygen Intravenous- onset is pleasant, patent awakes with little nausea and vomiting

A nurse is taking care of a patient who has type 1 diabetes and is in need of long-acting insulin preparation. The nurse anticipates giving what type of insulin?

Insulin glargine

type 2 diabetes

Insulin resistance and impaired insulin secretion

Informed consent:

It is very important!!! -Surgeon must explain the procedure -Nurse just clarifies information and witnesses the signature -Must be signed before given any medications

Health Education

Learning experiences designed to promote behaviors that facilitate health

When a person works to prevent relapse and to sustain the gains made from actions taken, he or she is in which stage of the Transtheoretical Model of Change?

Maintenance

Discharge:

Make sure you are giving directions that the patients understand. Give them a schedule they are used too. Provide written, verbal instructions, with follow-up care, complications, meds, diet, and activity.

Hgb values

Male: 13-18g/dL Female: 12-16g/dL

Hct values

Males: 42-52% Females: 36-48%

Gerotologic Considerations: hydration

Older adults lose their feeling of thirst. The nurse will need to keep reminding them to drink so they do not become dehydrated.

Which factor is a leading health indicator used to measure the health of the nation?

Overweight and obesity

Self-responsiblity

Personal accountability for one's actions and behaviors

Which phase of the nursing process encompasses the establishment of expected outcomes?

Planning

Post-op Phase 2

Preparing to transfer to an inpatient nursing unit, an extended care setting, or discharge

Which is an example of a behavior that facilitates health?

Self-monitoring for signs and symptoms of illness

Gerontologic Considerations: Increased likelihood of delirium

Someone with infections, UTI, Alzheimers, long duration of stay, and meds can cause some delirium in the older adults.

Function of insulin

Stimulate the storage of glucose in the liver and muscle as glycogen. Signals the lier to stop the release of glucose

Stage one of Transtheoretical Model of Change: Precontemplative

Te person is not thinking about making a change

Changing a post-op dressing

The first dressing change can be done by the nurse, you need to use sterile technique, assessing the wound and any drainage, applying the new dressing, document it and the patients response, and education

Stage three of Transtheoretical Model of Change: Decision making

The person constructs a plan to change behavior

The termination stage of the Transtheoretical Model of Change begins when which action occurs?

The person has the ability to resist relapsing back to unhealthy behavior

Stage two of Transtheoretical Model of Change: Contemplative

The person is only thinking about change in the near future

Stage four of Transtheoretical Model of Change: Action

The person takes a step to operationalize the plan of action

Stage five of Transtheoretical Model of Change: Maintenance

The person works to prevent relapse and to sustain the gains made form the actions taken

Stage six of Transtheoretical Model of Change: Termination

The persons has the ability to resist relapse back to unhealthy behaviors

T/F The circulating nurse is responsible for monitoring the surgical team.

True

T/F? The nurse should intervene at the patient's first report of nausea to control the problem rather than wait for it to progress to vomiting?

True- The nurse should intervene at any first report of nausea rather than waiting for vomiting to prevent other potential problems

The nurse is preparing to administer a premedication. Which of the following actions should the nurse take first?

You should have the patient void to protect the patients safety.

Third-intention wound healing

deep wounds not sutured early or break down & are resutured later; pack w/ moist gauze & cover w/ dry sterile dressing

First-intention wound healing

granulation not visible & scar formation minimal; cover w/ dry sterile dressing

Second-intention wound healing

granulation occurs in infected wounds or wounds with edges not approximated; pack w/ moist sterile dressing & cover w/ dry sterile dressing

Health education of a client by the nurse

is an independent function of nursing practice.

Physical fitness

the condition of being physically healthy as a result of proper exercise and nutrition

The role of the nurse is

to advocate for the patient

Nutritional Awareness

understanding the importance of a healthy diet; as well as the relationship between diet and disease

Regional Anesthesia:

Epidural-need a larger dose, no headache, blocks sensory, motor, and automatic functions Spinal- gets a headache, provides autonomic, sensory, and motor blockage

Which step of the nursing process determines whether the client understands the health teaching that is provided?

Evaluation