Medsurgical quiz 2

wound dehiscence

separation of the layers of a surgical wound; may be partial, or superficial only, or complete, with disruption of all layers

Types of wound drainage

serous, purulent, serosanguineous, sanguineous

purulent drainage

thick green, yellow, or brown drainage Concerning

Neuromuscular blocking agents

usually administered during anesthesia to facilitate endotracheal intubation and/or to improve surgical conditions. ex. succinylcholine

post-op complications

wound dehiscence, wound infection, pulmonary embolism, shock, DVT

A nurse is caring for a client who is due to receive general anesthesia. The client asks the nurse, "What is the difference between an analgesic & anesthesia?" Which of the following statements should the nurse make?

"Anesthesia can cause loss of consciousness."

A nurse is teaching a client who is posted about the importance of turning, coughing, and breathing deeply. Which of the following statements would the nurse identify as an indication that the client understands the instructions?

"If I do this often, I won't get pneumonia"

complications of anesthesia

-Malignant Hyperthermia -Overdose -Hypoventilation -Complications of Intubation -Anaphylaxis -Nerve Damage

Minimum urine output

30 mL/hr

Actelectasis

A collapsed or airless state of all or part of the lung

sanguineous drainage

Bright red; indicates active bleeding. Concerning

A nurse is caring for client who was transferred to the surigical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediantely following the transfer?

Check the client's vital signs

A nurse is caring for a postop client who has an indwelling catheter for gravity drainage. The nurse notes no urine output in the past 2 hours. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked

CSMTs

Color Sensation Motion Temperature

complications of epidural anesthesia

Common: urinary retention, backache, postspinal headache, hypotension

A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicate which of the following?

Confirms the client appears competent to provide consent

A nurse is preparing to administer dantrolene to a client who has muscle spasticity. Which of the following findings from the client's medical history should the nurse identify as a contranindication to the administration of this medication?

History of cirrhosis

A nurse is teaching a group of nurses about the effects of a client receiving spinal anesthesia. Which of the following pieces of information should the nurse include in the teaching?

Hypotension is an adverse effect of spinal anesthesia.

A nurse is providing teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching?

Instruct the client about the use of sequential compression device

A nurse is teaching group of nursing students about the experiences of clients who are having surgery. Which phase of case is the client transferred to the surgical suite table before being transferred to PACU?

Intraoperative

S/S of paralytic ileus

No bowel sounds x 4 q No flatus abd distention Abd pain

Informed consent

Nurse verfies, surgeon obtains. verify correct patient and if pt is competent enough to give IC

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop teaching and check with the surgeon about informed consent

A nurse on a med-sure unit is caring for a Clint who is posted following a hip replacement surgery. The client reports filing apprehensive and restless. Which of the following findings should the nurse recognize as indication of a PE?

Sudden onset of dyspnea

A nurse is teaching a newly licensed nurse about informed consent for a client who is scheduled for a surgical procedure. Which of the following pieces of information should the nurse include in teaching?

The person performing the procedure is responsible for obtaining informed consent

What should you have on hand when administering NMBAs?

analgesic or anesthesia, pt must have airway support and requires mechanical ventilation after administration

What assessment is key in a patient who is having a surgery related to an extremity?

assess for pain, decreased temp, color (pallor or redness)

What condition can lead to dyspnea, tachypnea, hypoxia, and decreased breath sounds or possible crackles?

atelectasis

wound evisceration

protrusion of internal organs and tissues through incision

Intraoperative Care

care involving intense focus and assessment of the patient during surgery

preoperative care

care provided before the surgery

Postoperative care

care provided following surgery

perioperative care

care that clients receive before, during, and after surgery

serous drainage

clear, watery plasma normal

paralytic ileus

complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction

PCA evaluation

conducts a thorough in-home assessment of an older adult's physical, mental, social and functional abilities and needs

When your patient's leg displays redness, unilateral swelling, pain, and warmth to the touch, what might you suspect?

deep vein thrombosis (DVT)

S/S of atelectasis

dyspnea, cough, fever, leukocytosis

types of anesthsia

general local regional conscious sedation

complications of spinal anesthesia

hypotension, nausea, vomiting, low-frequency hearing loss, postdural puncture headache

low hematology labs can predict...

hypoxemia

serosanguineous drainage

mixture of serum and red blood cells normal

How to best perform a GI assessment post-op? (what are you looking for)

monitor for abdominal distention monitor for nausea/vomiting advance diet as ordered and tolerated assess for constipation

This agent may cause total flaccid paralysis, blocking all muscles including diaphragm & respiratory system. When using it, the nurse must have a bag-mask available in case of affected breathing.

neuromuscular blocking agent

What assessment findings would indicate hypovolemic shock?

pallor, cool moist skin, rapid breathing (tachydyspnea) , cyanosis, fast weak pulse, hypotension, concentrated urine

What condition is charcterized by absence of bowel sounds, abdominal distention, and no passing of flatus?

paralytic ileus