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