Fundamentals Exam #3

characteristics of feces

-color -consistency -shape -amount -odor -constituents

Which of the following are used to perform wound irrigation? SATA 1. Clean gloves 2. Sterile gloves 3. Refrigerated irrigation solution 4. 60 mL syringe 5. Forceps

1. Clean gloves 2. Sterile gloves 4. 60 mL syringe

A client's arterial blood gas values are as follows: pH, 7.32; PaCO2 58; HCO3 32. The nurse knows that the client is experiencing which acid-base imbalance? 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis

2. Respiratory acidosis

The client is most likely to require the greatest amount of analgesia for pain during which period? 1. Immediately after surgery 2. 4 hours after surgery 3. 12 to 36 hours after surgery 4. 48 to 60 hours after surgery

3. 12 to 36 hours after surgery

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. Alginate 2. Dry gauze 3. Hydrocolloid 4. No dressing indicated

3. Hydrocolloid

A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority? 1. Renal 2. Cardiac 3. GI 4. Neuromuscular

4. Neuromuscular

Hypervolemia

Increased blood volume capable of causing hypertension and edema

pressure ulcer stage 1

Intact kin with non-blanchable redness of a localized area, usually over a bony prominence; skin is not broken but is red or discolored; partial thickness skin loss; skin can be warm or cool

major surgery

Involves extensive reconstruction or alteration in body parts; poses great risks to well being

Ablative procedure

Involves removal of or destruction of tissue

minor surgery

Procedure without significant risk; often done with local anesthesia

Palliative procedure

Relieves symptoms without curing the cause

conscious sedation

a decreased level of consciousness in which the patient is not completely asleep

Hypovolemia

decreased blood volume

topical anesthesia

numbs only the tissue surface and is applied as a liquid, ointment, or spray (lidocaine)

emergency surgery

surgery that must be performed immediately to save the person's life or a body organ

primary intention healing

tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring

incision

to cut

regional anesthesia

Loss of sensation in an area of the body supplied by sensory nerve pathways.

pressure ulcer stage 2

Partial-thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed.

chyme

Partially digested, semiliquid food mixed with digestive enzymes and acids in the stomach.

abrasion

Scrape of the skin due to something abrasive

Alginate dressing

Soft, absorbent, cotton like, for wounds with exudate, require packing and absorption, absorb a TON

clean wounds

Uninfected wounds with minimal inflammation. Primarily closed wounds.

puncture

a small hole made by a sharp object

hematoma

a solid swelling of clotted blood within the tissues.

anuria

absence of urine

nursing diagnoses for postoperative phase

acute pain risk for infection risk for injury risk for deficient fluid volume ineffective breathing pattern delayed surgical recovery disturbed body image

contusion

bruise, injury

acidosis

excessive acidity of body fluids

Hypercalcemia

excessive calcium in the blood

Hyperphosphatemia

excessive phosphate in the blood

hyperkalemia

excessive potassium in the blood

regeneration

renewal of tissues

cleansing enemas

tap water, normal saline, hypertonic solutions, soapsuds promote the complete evacuation of feces from the colon (done before colonoscopy)

Braden Scale

Pressure ulcer risk score lower the number, higher the risk 4-23 less than 17 = risk for pressure ulcers

haustral churning

(shuffling) movement of the chyme back and forth within the haustra in the large intestine

Transparent film dressing

* adhesive plastic, semipermeable, nonabsorbent * allow exchange of oxygen between atmosphere and wound bed * impermeable to bacteria and water * provide protection against contamination and friction * prevents evaporation * indications - IV dressing, central line dressing, superficial wounds, pressure ulcers (S1)

Norton's Pressure Area Risk Assessment Form Scale

* categories - general physical condition, mental state, activity, mobility, and incontinence (medication category may be added) * 24 possible points * scores of 15 or 16 indicate risk for pressure ulcers

collagen dressings

* gel, past, powder, granules, sheets, sponges derived from animal sources (cow or pig) * assists with stopping bleeding * helps recruit cells into the wound and stimulates their proliferation to facilitate healing * indications - clean moist wounds * examples - Biostep, Cellerate RX, NU-GEL, Promogran

Assessing surgical wounds

-Appearance -Size -Drainage -Swelling -Pain -Drains or tubes

nursing diagnoses for fecal elimination

-bowel incontinence -constipation -risk for constipation -perceived constipation -diarrhea -dysfunctional gastrointestinal motility

characteristics of urine

-color -odor -turbidity -pH -specific gravity -constituents

Postoperative Assessment

-comfort -fluid balance -dressing and bedclothes -drains and tubes -vital signs

Preoperative Assessment

-current health status -allergies. -medications. -previous surgeries -mental status -understanding of the surgical procedure and anesthesia -smoking. -alcohol and other mind-altering substances. -coping -social resources -cultural and spiritual considerations.

nursing diagnoses related to fluid balance

-deficient fluid volume -excess fluid volume -risk for imbalanced fluid volume -risk for deficient fluid volume -impaired gas exchange

factors that affect defecation

-developmental competence -diet -fluid intake/output -activity -psychological factors -defecation habits -medications -diagnostic procedures -anesthesia and surgery -pathologic conditions -pain

factor effecting wound healing

-developmental considerations - nutrition -lifestyle -medications (anti-inflammatory drugs interfere with wound healing)

factors affecting urinary voiding

-developmental considerations -psychosocial factors -fluid and food intake -medications -muscle tone -pathologic conditions -surgical and diagnostic procedures

risk factors for pressure ulcers

-friction and shearing -immobility -inadequate nutrition -fecal and urinary incontinence -decreased mental status -diminished sensation -excessive body heat -advanced age -presence of certain chronic conditions

Nursing Diagnosis for urinary elimination

-impaired urinary elimination -disturbed body image -urinary retention -sensory impairment -urgency due to obstructions -toileting self care deficit

Assessing wounds

-location and extent of damage -measure length, width, and depth -inspect for exudate

urinary habit factors

-social culture -personal habits -physical abilities

purulent exudate

Pus: indicates a bacterial infection

Which nursing diagnosis is/are most applicable to a client with fecal incontinence? SATA 1. Bowel incontinence 2. Risk for Deficient Fluid Volume 3. Disturbed body image 4. Social isolation 5. Risk for Impaired Skin integrity

1. Bowel incontinence 3. Disturbed body image 4. Social isolation 5. Risk for Impaired Skin integrity

Proper technique for performing a wound culture includes which of the following? 1. Cleansing the wound before obtaining specimen 2. Swabbing for the specimen in thee area with the largest collection of drainage 3. Removing crusts or scabs with sterile forceps and then culturing the site beneath 4. Waiting 8 hours following a dose of antibiotic to obtain the specimen

1. Cleaning the wound before obtaining specimen

Clients should be taught that repeatedly ignoring sensation of needing to defecate could result in which of the following? 1. Constipation 2. Diarrhea 3. Incontinence 4. Hemorrhoids

1. Constipation

The intake and output record of a client with a nasogastric tube that has been attached to suction for two days shows greater output and input. Which nursing diagnoses are most applicable? Select all that apply. 1. Deficient fluid volume 2.Risk for deficient fluid volume 3.Impaired oral mucous membranes 4.Impaired gas exchange 5.Decreased cardiac output

1. Deficient fluid volume 3.Impaired oral mucous membranes 5.Decreased cardiac output

The client's postoperative orders state "diet as tolerated." The client has been NPO. The nurse will advance the client's diet to clear liquids based on which assessment? Select all that apply. 1. Does not complain of nausea or vomiting. 2. Pain level is maintained at a rating of 2-3 out of 10. 3. States passing flatus. 4. Ambulates with minimal assistance. 5. Expresses feeling "hungry."

1. Does not complain of nausea or vomiting. 3. States passing flatus.

30 minutes after application is initiated the client requests the nurse leave the heating pad in place. The nurse explains which of the following to the client? 1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation) 2. It will be acceptable to leave the pad in place if the temperature id reduced 3. It will be acceptable to leave the pad in place for another 30 minutes if site appears satisfactory when assessed 4. It will be acceptable to leave the pad in place as long as it is moist heat

1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation)

The catheter slips into the vagina during a straight catheterization of a female. The nurse does which action? 1. Leaves the catheter in place and gets a new sterile catheter 2. Leaves the catheter in place and asks another nurse to attempt procedure 3. Removes the catheter and redirects it to the urinary meatus 4. Removes the catheter, wipes it with sterile gauze, and redirects it to the urinary meatus

1. Leaves the catheter in place and gets a new sterile catheter

Which of the following are primary risk factors for pressure ulcers? SATA 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1. Low-protein diet 3. Lengthy surgical procedures 4. Fever

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? SATA 1. Perineal skin irritation 2. Fluid intake of less than 1500 mL/day 3. History of antihistamine intake 4. History of frequent urinary tract infections 5. A fecal impaction

1. Perineal skin irritation 2. Fluid intake of less than 1500 mL/day 4. History of frequent urinary tract infections 5. A fecal impaction

Your client is only comfortable lying on the right or left side. List four potential sites of pressure ulcers you must assess from the side position

1. ankles 2. knees 3. trochanter/ilea 4. shoulders/ears

Ostomy sites

1. ileostomy- mostly liquid 2. cecostomy- liquid 3. ascending colostomy- liquid 4. transverse colostomy- soft 5. descending colostomy- firm 6. sigmoidostomy- similar to normal bowel movement

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1. "I need to drink one and a half to two quarts of liquid every day." 2. "I need to take a laxative such as milk of magnesia if I don't have a BM every day." 3. "If my bowel pattern changes on its own, I should call you." 4. "Eating my meals at regular times is likely to result in regular bowel movements."

2. "I need to take a laxative such as milk of magnesia if I don't have a BM every day."

The nurse would assess for signs of hypomagnesemia in which of the following clients? SATA 1. A client with real failure 2. A client with pancreatitis 3. A client taking magnesium-containing antacids 4. A client with excessive nasogastric drainage 5. A client with chronic alcoholism

2. A client with pancreatitis 4. A client with excessive nasogastric drainage 5. A client with chronic alcoholism

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? 1. Prepare to irrigate the colostomy 2. After assessing the stoma and surrounding skin, notify the surgeon 3. Asses bowel sounds and administer antiemetic 4. Administer a bulk-forming laxative, and encourage increased fluids and exercise

2. After assessing the stoma and surrounding skin, notify the surgeon

Which action represents the appropriate nursing management of a client wearing a condom catheter? 1. Ensure the tip of the penis fits snugly against the end of the condom 2. Check the penis for adequate circulation 30 minutes after applying 3. Change the condom every 8 hours 4. Tape the collecting tube to the lower abdomen

2. Check the penis for adequate circulation 30 minutes after applying

The nurse plans to remove the client's sutures. Which action demonstrates appropriate standards of care? Select all that apply. 1. Use clean technique. 2. Grasp the suture at the knot with a pair of forceps. 3. Place the curved tip of the suture scissors under the suture as close to the skin as possible. 4. Pull the suture material that is visible beneath the skin during removal. 5. Remove alternate sutures first.

2. Grasp the suture at the knot with a pair of forceps. 3. Place the curved tip of the suture scissors under the suture as close to the skin as possible. 5. Remove alternate sutures first.

A client who is having a mastectomy expresses sadness about losing her breast. Based on this information, the nurse would identify that the client is at risk for which nursing diagnosis? 1. Disturbed body image 2. Grieving 3. Fear 4. Ineffective coping

2. Grieving

The nurse assess a postoperative client who has a rapid, weak pulse; urine output of less than 30 mL/h; and decreased blood pressure. The client's skin is cool and clammy. What complication can the nurse suspect this is? 1. Thrombophlebitis 2. Hypovolemic shock 3. Pneumonia 4. Wound dehiscence

2. Hypovolemic shock

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is 1. Risk for Impaired skin integrity 2. Impaired skin integrity 3. Impaired tissue integrity 4. Risk for infection

2. Impaired skin integrity

Your client has a Braden scale score of 17. Which is the most appropriate nursing action? 1. Assess the client again in 24h; the score is within normal limits. 2. Implement a turning schedule; the client is at increased risk for skin breakdown. 3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk for skin breakdown. 4. Request an order for a special low-air-loss bed; the client is at very high risk for skin breakdown.

2. Implement a turning schedule; the client is at risk for skin breakdown.

The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? 1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy

2. Kock pouch

An older man is admitted to the medical unit with a diagnosis of dehydration. Which sign or symptom is most representive of a sodium imbalance? 1. Hyperreflexia 2. Mental confusion 3. Irregular pulse 4. Muscle weakness

2. Mental confusion

Which of the following behaviors indicates that the client on a bladder training program has met the expected outcome? SATA 1. Voids each time there is an urge 2. Practices slow, deep breathing until the urge decreases 3. Uses adult diapers for "just in case" 4. Drinks citrus juices and carbonated beverages 5. Performs pelvic muscle exercises

2. Practices slow, deep breathing until the urge decreases 5. Performs pelvic muscle exercises

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to this client? SATA 1. Limit fluids to avoid burning sensation on urination 2. Review symptoms of UTI with the client 3. Wipe the perineal area from back to front 4. Wear cotton underclothes 5. Take baths rather than showers

2. Review symptoms of UTI with the client 4. Wear cotton underclothes

A man bring his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first? 1. Start an IV 2. Review the results of serum electrolytes 3. Offer the woman foods high in sodium and potassium content 4. Administer an antiemetic

2. Review the results of serum electrolytes

Which goal is most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? 1. The client will wear a medical bracelet for antibiotic allergy 2. The client will return to his or her own previous fecal elimination pattern 3. The client will verbalize the need to take an antidiarrheal medication PRN 4. The client will increase intake of insoluble fiber such as grains, rice, and cereals

2. The client will return to his or her own previous fecal elimination pattern

Which of the following indicates proper use of a triangle arm sling? 1. The elbow is kept flexed at 90 degree angle or more 2. The knot is placed on either side of the vertebrae of the neck 3. The sling extends to the proximal of the hand 4. The sling is removed every 2 hours to check for circulation and skin integrity

2. The knot is placed on either side of the vertebrae of the neck

An older nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding? 1. Increased BP 2. Weak, rapid pulse 3. Moist mucous membranes 4. Jugular vein distention

2. Weak, rapid pulse

An older client comes to the emergency department experiencing chest pain and SOB. An arterial blood gas is ordered. Which of the following ABG results indicates respiratory acidosis? 1. pH 7.54; PaCO2 28 mmHg; HCO3 22 mEq/L 2. pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L 3. pH 7.31; PaCO2 35 mmHg; HCO3 20 mEq/L 4. pH 7.50; PaCO2 37 mmHg; HCO3 28 mEq/L

2. pH 7.32; PaCO2 46 mmHg; HCO3 24 mEq/L

Which statement indicates a need for further teaching of the home care client with a long term indwelling catheter? 1. "I will keep collection bag below the level of the bladder at all times." 2. "Intake of cranberry juice may help decrease risk of infection" 3. "Soaking in a warm tub bath may ease the irritation associated with the catheter 4. "I should use clean technique when emptying the collection bag"

3. "Soaking in a warm tub bath may ease the irritation associated with the catheter

Which test is the best resource for determining the perioperative status of a client's liver function? 1. Serum electrolytes 2. Blood urea nitrogen (BUN), creatinine 3. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin 4. Serum albumin

3. Alanine aminotransferase (ALT), aspirate aminotransferase (AST), bilirubin

Which focus is the nurse most likely to teach for a client with a flaccid bladder? 1. Habit training: attempt voiding at specific time periods. 2. Bladder training: delay voiding according to a preschedule timetable. 3. Credé's maneuver: apply gentle manual pressure to the lower abdomen. 4. Kegel exercises: contract the pelvic muscles.

3. Credé's maneuver: apply gentle manual pressure to the lower abdomen.

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? 1. Soapsuds 2. Retention 3. Return flow 4. Oil retention

3. Return flow

Which of the following is most likely to validate that a client is experiencing intestinal bleeding? 1. Large quantities of fat mixed with pale yellow liquid stool 2. Brown, formed stools 3. Semisoft black colored stools 4. Narrow, pencil-shaped stool

3. Semisoft black colored stools

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy? 1. The stoma extends 1/2 inch above the abdomen 2. The skin under the appliance looks red briefly after removing the appliance 3. The stoma color is deep red-purple 4. The ascending colostomy delivers liquid feces

3. The stoma color is deep red-purple

Which client statement indicates need for further teaching regarding treatment for hyperkalemia? 1. "I will use avocado in my salads." 2. "I will be sure to check my heart rate before I take my digoxin." 3. "I will take my potassium in the morning after eating breakfast." 4. "I will stop using my salt substitute."

4. "I will stop using my salt substitute."

Which statement by the client indicates that the preoperative teaching regarding gallbladder surgery has been effective? 1. "I cannot eat or drink anything after midnight." 2. "I am not going to cough after surgery because it could open my incision." 3. "I might have a stroke if I stop taking my anticoagulant." 4. "The nurse showed me how to contract and relax my calf muscles."

4. "The nurse showed me how to contract and relax my calf muscles."

Which statement if made by the client or family member would indicate need for further teaching? 1. "If a skin area gets red, but then the red goes away after turning, I should report it to the nurse." 2. "Putting foam pads under my heels or bony areas can help decrease pressure." 3. "If my father cannot turn himself in bed, I should help him change position every 4 hours."" 4. "The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet."

4. "The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet."

A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema? 1. Oil retention 2. Return flow 3. High, large volume 4. Low, small volume

4. Low, small volume

A semiconscious client in the postanesthetic care unit (PACU) is experiencing dyspnea (difficulty breathing). Which action should the nurse perform first? 1. Place a pillow under the client's head. 2. Remove the oropharyngeal airway. 3. Administer oxygen by mask. 4. Reposition the client to keep the tongue forward.

4. Reposition the client to keep the tongue forward.

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? 1. The bladder distends and its capacity increases 2. Older adults ignore the need to void 3. Urine becomes more concentrated 4. The amount of urine retained after voiding increases

4. The amount of urine retained after voiding increases

During a shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? 1. Stress urinary incontinence 2. Reflex urinary incontinence 3. Functional urinary incontinence 4. Urge urinary incontinence

4. Urge urinary incontinence

respiratory acidosis

A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2.

elective surgery

A surgical procedure that may be scheduled in advance, is not an emergency, and is discretionary on the part of the physician and patient

Aldrete Post-Anesthetic Recovery Score

ACTIVITY 2- moves all extremities voluntary/on command 1- some weakness in movement of extremities 0- unable to move extremities RESPIRATION 2- breathes deeply and coughs freely 1- dyspneic, shallow or limited breathing 0- apneic CIRCULATION 2- BP+-20 mmHg of preanesthetic level 1- BP +-20-50 mmHg of preanesthetic level 0- BP+-50mmHg of preanesthetic level CONSCIOUSNESS 2- fully awake 1- arousable on calling 0- not responding OXYGEN SATURATION 2- maintains value > 90% on room air 1- requires oxygen to maintain value > 90% 0- value < 90% with supplemental oxygen

respiratory alkalosis

Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.

Lasix (furosemide)

Classification: Loop Diuretic Therapeutic Effects: Diuresis. Lowering of blood pressure Adverse Reactions & side effects: Dehydration, hypochloremia, hypokalemia, hypomagnesaemia, hyponatremia, hypovolemia, metabolic alkalosis Nursing Implications & teaching: Monitor for thirst, dry mouth, lethargy, weakness, hypotension, oliguria and notify physician. Monitor K+, Ca++, Mg. Can increase BUN, glucose and creatinine, TAKE WITH FOOD

physiological effects of cold

Decrease in tissue temperature Vasoconstriction Decrease in muscle spasms Decrease in pain perception

oliguria

Decreased urine output

Composition of Body Fluids

Extracellular & Intracellular fluids contain: oxygen from the lungs, nutrients from Gastrointestinal tract, waste of metabolism (CO2) Ions - electrolytes cations (-) anions (+)

wound irrigation

Flushing of an open wound using a medicated solution, water, sterile saline, or an antimicrobial liquid preparation Nurse should use 30-60 mL syringe with 19 gauge catheter to deliver ideal pressure

pressure ulcer stage 3

Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.

pressure ulcer stage 4

Full-thickness pressure ulcer involves all skin layers and extends into supporting tissue. Exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue).

Hydrogel dressing

Gel used to regulate fluid exchange and relieve pain during wound healing

psychological effects of heat

Increased circulation 1.5-2 times normal resting blood flow Increased metabolism Increased inflammation Increased phagocytosis and wound healing Decreased pain (analgesia) Sedative effect that helps patient relax Great for soreness, aches, and pains but not for removing acute injury pain Decreased muscle spasm Decreased tissue stiffness Will cause collagen cross-bonds to release, facilitating elongation of connective tissue

preoperative teaching

Instructions regarding a patient's anticipated surgery and recovery given before the surgery. Instruction includes, but is not limited to, dietary and activity restrictions, anticipated assessment activities, postoperative procedures and pain relief measures.

contaminated wounds

Open, fresh, accidental wounds and surgical wounds that involve a major break in sterile technique or a large amount of spillage from the GI tract. Show evidence of inflammation

Potential postoperative complications

RESPIRATORY -pneumonia -atelectasis -pulmonary embolism CIRCULATORY -hypovolemia -hemorrhage -hypovolemic shock -thrombophlebitis -thrombus -embolus URINARY -retention -UTI GI -nausea and vomiting -constipation -tympanites -postoperative ileus WOUND -wound infection -wound dehiscence -wound evisceration PSYCHOLOGICAL -postoperative depression

Constructive surgery

Restores function lost or reduced as result of congenital anomalies

Nursing Diagnosis for Skin Integrity

Risk for Impaired Skin Integrity Impaired Skin Integrity Impaired Tissue Integrity Risk for Impaired Tissue Integrity

The overall goal of nursing care during the intraoperative phase is the client's

Safety

A postoperative client who had abdominal surgery is holding a pillow against his abdomen during deep-breathing and coughing exercises. Which term does the nurse use to describe this technique?

Splinting

Alkalosis

The buildup of excess base (lack of acids) in the body fluids.

serous exudate

Watery exudate: indicates early inflammation

fecal impaction

a mass of dry, hard stool that remains packed in the rectum and cannot be expelled

compress

a moist gauze dressing applied frequently to an open wound, sometimes medicated, can be cold or hot

arterial blood gases (ABGs)

a test performed on arterial blood to determine levels of oxygen, carbon dioxide, and other gases present

urinary retention

abnormal accumulation of urine in the bladder because of an inability to urinate

informed consent

an ethical principle that research participants be told enough to enable them to choose whether they wish to participate

Hyperchloremia

an excess of chloride in the blood plasma

sanguineous exudate

an exudate containing large amounts of red blood cells; bloody exudate

ischemia

an inadequate blood supply to an organ or part of the body, especially the heart muscles.

penetrating wound

an open wound that breaks the skin and enters a body area, organ, or cavity

how to insert catheter on a female

ask pt to bear down gently and slowly insert catheter through urethral meatus; advance catheter total of 2 - 3 inches or until urine flows out of catheter; when urine appears, advance catheter another 1-2 inches and then inflate the balloon

urine pH

average 6.0; range 4.6-8.0

pressure ulcer unstageable

base of ulcer covered by slough and/or eschar in the wound bed.

Hypophosphatemia

below-normal serum concentration of inorganic phosphorus

local anesthesia

causes the loss of sensation in a limited area by injecting an anesthetic solution near that area

pressure ulcers

compromised circulation secondary to pressure or pressure combined with friction, bony prominences

partial thickness wound

confined to the skin, that is, the dermis and epidermis; heal by regeneration

urostomy

creation of an opening in the urinary tract, normally to divert urine flow away from a diseased bladder

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

metabolic acidosis

decreased pH in blood and body tissues as a result of an upset in metabolism

Hypochloremia

deficiency of chloride in the blood plasma

Hypocalcemia

deficient calcium in the blood

nursing diagnoses for preoperative phase

deficient knowledge anxiety grieving ineffective coping

Hypokalemia

deficient potassium in the blood

Hyponatremia

deficient sodium in the blood

cathartics

drugs that induce defecation (laxatives)

metabolic alkalosis

elevation of HCO3- usually caused by an excessive loss of metabolic acids

acid-base balance

equilibrium between acid and base concentrations in the body fluids

polyuria

excessive production of urine

nocturia

excessive urination at night

return flow enema

expel flatus and relieve abdominal distention

urinary meatus

external opening of the urethra

Extracellular fluid (ECF)

fluid outside the cells; includes intravascular and interstitial fluids

exudate

fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells

Intracellular fluid (ICF)

fluid within cells

irrigation

flushing of a tube, cavity, or area with a fluid

Hydrocolloid dressing

gel forming polymer such as gelatin, pectin, and carboxymethylcellulose with a strong film or foam adhesive backing. absorb exudate by swelling into a gel like mass and vary from being occlusive to semi permeable. does not attach to actual wound itself and is instead anchored to intact skin surrounding the wound.

bladder training

goal is to gain control of urination done as directed by nurse and care plan person uses toilet/pan at frequent regular intervals and is slowly increased. Person has catheter which is clamped to prevent urine flow for periods of time (1-2hrs at first then up to 3-4hrs) to train bladder

Hypermagnesia

high magnesium

Hypernatremia

high sodium

The nurse administers an IV solution of D5 1/2NS to a postoperative client. This is classified as what type of intravenous solution?

hypertonic

gastrocolic reflex

increased peristalsis of the colon after food has entered the stomach

suprapubic catheter

indwelling catheter inserted directly in the bladder through an abdominal incision above the pubic bone that includes a collection system that allows urine to be drained into a bag; used in patients requiring long-term catheterization

nerve block

injection of regional anesthetic to stop the passage of sensory or pain impulses along a nerve path

Hypomagnesemia

insufficient amount of magnesium in the extracellular fluid

retention enema

introduces oil or medication into the rectum and sigmoid colon

enuresis

involuntary discharge of urine

full thickness wound

involves the dermis, epidermis, subcutaneous tissue and possible muscle and bone; requires connective tissue repair

general anesthesia

involves the total loss of body sensation and consciousness induced by anesthetic agents administered primarily by inhalation or intravenous injection

how to insert a catheter on a male

lift penis to a position perpendicular to pts body and apply gently upward traction; ask pt to bear down as if to void and lowly insert catheter; advance catheter 7-9 inches or until urine flows out end of catheter; when urine appears in an indwelling catheter, advance it to bifurcation (advance until the tube turns into 2 lumens)

clear absorbent acrylic dressings

maintain a transparent membrane for easy wound bed assessment, provide bacterial and shearing protection, maintain moist wound healing, and can be used with alginates to provide packing to deeper wound beds.

impregnated non-adherent dressings

materials impregnated with petrolatum, saline, zinc-saline, antimicrobials or other agents -requires secondary dressing to secure them in place, retain moisture, and provide wound protection -used to cover, soothe and protect partial- and full-thickness wounds without exudate -indications - post op, dressing over sutures/staples, superficial burns

electrolytes

minerals that carry electrical charges that help maintain the body's fluid balance

dysuria

painful or difficult urination

dehiscence

partial or total rupture of sutured wound

hematocrit

percentage of blood volume occupied by red blood cells

postoperative phase

period of time that begins with the admission of the patient to the postanesthesia care unit and ends after follow-up evaluation in the clinical setting or home

perioperative phase

period of time that constitutes the surgical experience; includes the preoperative, intraoperative, and postoperative phases of nursing care

evisceration

protrusion of viscera through an incision

edema

puffy swelling of tissue from the accumulation of fluid

skin integrity

refers to the presence of normal skin layers, uninterrupted by wounds

epidural anesthesia

regional anesthesia produced by injecting medication into the epidural space of the lumbar or sacral region of the spine

spinal anesthesia

regional anesthesia produced by injecting medication into the subarachnoid space

debridement

removal of foreign material and dead or damaged tissue from a wound

Transplant surgery

replaces a malfunctioning body part, tissue, or organ

nursing diagnoses for intraoperative phase

risk for aspiration ineffective protection impaired skin integrity risk for perioperative position injury risk for imbalanced body temperature ineffective peripheral tissue perfusion risk for deficient fluid volume

Polyurethane dressing

semipermeable, nonadherent and nonlinting, waterproof outer layer, provides moist wound environment, provides cushioning, easy to remove, provides bacterial barrier

electrolytes and their ranges

sodium: 135-145 potassium: 3.5-50 chloride: 95-108 calcium: 4.5-5.5 or 8.5-10.5 magnesium: 1.5-2.5 or 1.6-2.5 phosphate: 1.8-2.6 or 2.5-4.5 serum osmolarity: 280-300

anaerobic

specimen grow only in absence of oxygen

aerobic

specimen only grows when oxygen is present

vesicostomy

surgical production of an opening into the bladder

clean-contaminated wound

surgical wounds GI, respiratory, genital, or urinary tract entered no evidence of infection

hemmorrhoids

swollen, twisted, varicose veins in the rectal region can be internal or external

Diagnostic Procedures

tests performed to determine the diagnosis

vasoconstriction

the constriction of blood vessels, which increases blood pressure.

meconium

the first bowel movement of the newborn

nephrostomy

the placement of a catheter to maintain an opening from the pelvis of one or both kidneys to the exterior of the body

intraoperative period

time during which the client undergoes surgery

preoperative period

time that starts when the client is informed that surgery is necessary and ends when he or she is transported to the operating room

vasodilation

widening of blood vessels, decreases blood pressure

Secondary intention healing

wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring (pressure ulcer)

dirty/infected wound

wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage

wound irrigation procedure

•Sterile procedure •Position patient with wound exposed •Place waterproof pad under area to be irrigated •Don clean gloves, remove existing dressing, inspect wound •Doff gloves, perform hand hygiene •Prepare supplies •Open syringe container •Pour irrigating solution into sterile container •Open supplies needed for dressing change •Place a collection basin distal to the wound to catch contaminated fluid •Perform hand hygiene, don sterile gloves, consider other personal protective equipment •Fill syringe with sterile solution •Direct solution to all areas of the wound from superior to inferior edges •Allow gravity to drain fluid from superior to inferior edges •Keep tip of syringe at least 1 inch away from wound •Use consistent pressure •Flush until all debris is cleared or until the ordered volume is instilled •Dry surrounding skin with sterile gauze •Apply sterile dressing