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Exam 3
Nursing
| Question | Answer |
|---|---|
| Cachexia | Extreme Malnutrition |
| Functions of the Skin (5 things) | 1. Protection 2. Thermoregulation 3. Sensation 4. Metabolism 5. Communication |
| Reactive blanching hyperemia | No damage if pressure is relieved |
| Non-blanching reactive hyperemia | tissue damage |
| What are the contributing factors of pressure ulcers? (6 things) | Shear, Friction, Moisture, Nutrition, Infection, Age |
| Pathogenesis of Pressure Ulcers(3 things) | Pressure, Duration of Pressure, Tissue Tolerance |
| Wound Classifications for pressure ulcers | Stage 1:Alteration of intact skin, temperature, firm, pain or itching.Stage 2: Partial thickness skin lossStage 3:Full thickness skin loss - subcutaneous tissueStage 4:Full-thickness skin loss, extensive destruction |
| Common site for pressure ulcers | Sacrum, Greater Trochanter, Ischial tuberosites |
| Example of Pressure Ulcers - Intentional or Unintentional | Intentional: SurgeryUnintentional: pressure ulcer |
| What is important about Escar? | needs to be removed before staging the pressure ulcer. |
| Pressure Ulcer | impaired skin integrity |
| Hyperemia | Blanching, Non-Blanching |
| Ischemia | No circulation, dieing tissue |
| Necrosis | Dead Tissue |
| Ulceration | sore has formed |
| How can we prevent pressure ulcers in the older patient? | Turn every 2 hours, including in wheelchairs |
| Braden Scale for Predicting Sore Risk: | Sensory Preception, Moisture, Activity, Mobility, Nutrition, and Friction/Shear |
| Primary Intention | A wound with little or no tissue loss, like a clean incision - edges can come together (approximate) |
| Secondary Intention | A wound with tissue loss like a laceration, pressure ulcer or burns - since the edges cannot come together. |
| Delayed primary dosure | gaping wounds that closed from the inside out. |
| Granulation tissue | Soft, pink, fleshy projections of tissue that form during the healing process in a wound not healing by primary intention. |
| Inflammatory Response | Erythema and edema are the first response. |
| Epidermal Repair | They begin migration across the wound, originating from the epidermal cells on the edges. |
| Dermal Repair | Epidermis thickens, anchors to adjacent cells and resumes normal function. |
| The first phase in the imflammatory phase | Hemostasis |
| Proliferative Phase | new tissue, epithelialization, and contraction |
| Remodeling Phase | last up to 1 year, reorgazines the collagen to produce more elastic and stronger collagen for scar tissue |
| Hemostasis | cessation of bleeding by vasoconstriction and coagulation. |
| Hematoma | collection of a blood clot, localized under skin |
| When does a contaminated or tramatic wound infection develop | 2 to 3 days |
| What about a surgical wound? | 4 - 5 days |
| Dehiscence | the partial or total separation of layers of skin and tissue separate |
| Dehiscence occurs mostly in - | abdominal surgical wounds by straining from coughing, vomiting or sitting up (they feel a pop). |
| Evisceration | wound layers separate below the fascial layer - use sterile towels and sterile saline. |
| Fistula | an abnormal opening between 2 organs - mostly in peri area. |
| What are the types of drainage (4) | Serous - clear watery plasmaSanguineous - fresh, bleedingSerosanguineous - pale, more watery with rbcsPurlent- thick, yellow, green, or brown prescence of dead or living cells. |
| How do you clean a wound? | From the center - out. |
| Types of drains in a wound: | JP (squeeze and suction), Hemovac (suction), Penrose (suction) |
| In Heat/Cold Therapy - what is the order? | cold is first, heat is second. |
| Perioperative nursing - | nursing care before, during and after surgery. |
| What are the Classifcations for Surgery: | Seriousness, Urgency & Purpose |
| In peripoperative nursing always know: | Baseline, Before and After. |
| When assessing the neurological status of a person - what do you ask? | Person, Place and Time. |
| In Diagnostic screening of patient - what tests are done? | CBC, Electrolytes, and Creatnin |
| What Implementation can be done - Pre-Op? | Informed consent, Health Promotion, and Preoperative teaching to relieve stress and anxiety of the "unknown" |
| Physical Preparation before surgery: | NPO - 8-12 hoursSedative and Antianxiety MedsShower with Antiseptic Soap |
| What are the types of Anesthesia? | General, Regional, Local, and Conscious Sedation |
| What is the Timing On Preoperative Teaching? | Started a week before admission and reinforced immediatly before surgery. |
| Circulating Nurse | cares for patient while in OR by completing preoperative assessment. |
| Scrub Nurse | Maintaining a sterile field during the surgical procedure. |
| PACU | Preanestheisa Care Unit |
| PSCU | Presurgical Care Unit |
| PACU - what do they do? | Neurological, Surgical Wound, Urinary, No Bowel Sounds for 24-72 hrs., Fluids IV and I & O |
| Why are older patients at greater surgical risk? | Declining Physiological status. |
| A priority nursing intervention to prevent respiratory complications after surgery in older adults is: | Encourage patient to turn, deep breathe, and cough frequently. |
| You must ask each patient preoperatively for the name and dose of all prescription and over the counter medications taken before surgery because they: | May interact with anesthetic agents. |
| A patient with a prothrombin time (PT) or an activated partial thromboplastin time (APTT) greater than normal needs to be monitored closely for: | Bleeding |
| You review the lab results of the patient you are preparing for surgery. Which lab value interacts with anesthesia to increase the rish of cardiac dysrhymias? | Potassium 3.1 mEq/L |
| You are checking your patient 2 hours after he returns from surgery. Which assessment finding requires immediate attention? | Foley catheter drained 30 ml of urine for past 2 hours. |
| Which factor contributes to the risk of poor wound healing in obese patients? | Fatty tissue has a poor blood supply. |
| Which statement made by the patient having hernia surgery indicates a need for further teaching? | I'll use a clean disposable razor to shave the hair on my lower abdomen before surgery. |
| In the PACU you note that the patient is having difficultly breathing because of an airway obstruction. You would first: | Position the patient so that the tongue falls forward. |
| Which nursing intervention is most effective to prevent the postoperative complication of deep vien thrombosis? | Early ambulation |
| Health is: | A state of complete physical, mental, and social well being. |
| A persons state of health, wellness or illness depends on an indivuals: | Self - Concept |
| According to the health belief model, health beliefs usually influence: | Health Behaviors |
| The health promotion model attempts to explain the: | Reasons indiviuals engage in health activities. |
| Holistic health interventions are used to: | Complement standard medical therapy. |
| The health status of an indiviual or community is: | Multifactorial |
| The internal variable that influence a patients health beliefs and health practices are: | Developmental stage, intellecual background, emotional factors, spiritual factors. |
| Health promotion activities are activities that: | Help maintain or enhance health |
| Primary prevention strategies: | Decrease vunerablilty to an illness |
| The presence of certain risk factors: | Increase the chance that a disease will develop |
| Changing health behaviors: | May be either a cessation of health-damaging behavior or the adoption of a healthy behavior. |
| External variables that influence a patients illness behavior are: | The visibililty of symptoms, social groups, economics, and social support. |
| Mr. Houseff has been hospitalized following an auto accident. He has suffered multiple tramatic injuries & requires complete assistance with bathing. The patient is a Muslim. When providing a bath you should know that: | For a Muslim the left hand is used for cleaning. |
| While assessing a patients skin, you notice flaky, rough texture on exposed areas of the hands, face, and legs. Good skin care for this patient includes: | Increasing fluid intake. |
| Which of the following patients is at greatest risk for having oral hygiene problems? | Ms. Hornbeck who is 62, has been NPO for 3 days following a colon resection, and has a nasogastric (NG) tube. |
| An older adult who has practiced poor oral hygiene and has an impaired gag reflex is at risk for developing pnemonia for which of the following reasons? | Aspirating bacteria that accumulate in the orla cavity. |
| Which of the following patients should not soak his foot or her feet before nail care? | A patient with diabetes mellitus |
| Pressure injury to the skin results from: | Compression of the skin by two surfaces for a prolonged period of time |
| The topical management of a clean, granular wound healing by secondary intention requires: | A moist wound dressing |
| Postoperativly the patient with a closed abdominal wound reports a sudden "pop" after coughing. When you examine the surgucal wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct interve | To cover the area with sterile saline-soaked towels and immediatly notify the surgical team. |
| Serous drainage from a wound is defined as: | Clear, watery plasma |
| Interventions to manage a patient who is experiencing fecal and urinary incontinence include: | Utilzation of an incontience cleanser, followed by application of a moisture-barrier ointment. |
| THe best description of hydrocollid dressing is: | A dressing that forms a gel that interacts with the wound surface. |
| A binder placed around a surgical patient with a new abdominal wound is indicated for: | Reduction of stress on the abdominal incision |
| Application of a warm compress is indicated: | To promote healing by stimulating blood flow |
| Vaccum assisted closure is defined as: | A wound management system that uses negative pressure to the wound to promote and accelerate healing |
| Postive Inotropic Drugs | Increase force of muscular contractions |
| Chronotropic Drugs | + increase h/r & - decrease h/r |
| Dromotropic | Electrical conduction within the heart |
| Inotropic Agents Meds are: | Cardiac Glycosides & Phosphodiesterase Inhibitors |
| CHF (Conjestive Heart Failure) | heart is failing as a pump, sweeling, shortness of breath, edema in body & lungs |
| Ejection fraction | Blood ejected with each contraction (going down) |
| Dysrhythmias | Heart failing as a punp - irractically. |
| Atrial Fibrillation | Rapid heart beat |
| Atrial Flutter | More Rapid beat |
| The AV nodes control what? | how fast the ventricles contract |
| Sodium Potassium Pump | The exchange causes the electrical beat of the heart (SA node and AV node) |
| Automaticity | when the heart depolarizes spontaneously |
| Refractory | When the cardiac cells are readadjusting their sodium and potassium levels |
| Cardiac Glycosides (Lanoxin/Digoxin) - what do they do? | increase myocardial contractibility by inhibiting the sodium pump. Also slows the rate of electrical contraction. SO - increase stroke volume, decrease B/P and increases corornary circulation. |
| So, Lanoxin/Digoxin does breifly does what? | Slows Heart rate & strengthens the heart |
| Before administering Lanoxin/Digoxin, you do what first? | Take Apical pluse, check cap. refill and pulse must be btw 60 - 100 - if under or over, hold it. |
| Normal Theraputic drug range for Lanoxin/Digoxin is: | 0.5 and 2 ng/ml |
| Lanoxin/Digoxin toxicity looks like: | Nausea, Vomiting, Anorexia, Bradycardia & Dysrhythmias |
| What is Hyperkalemia? | Serum potassium level over 5 mEg/L - in a patient with digitoxcity |
| What is the Antibody to Digoxin? | Digoxin immune Fab, and can be used in hyperkalemia. |
| Life-Threatening Digoxin overdose is: | more than 10 mg in adults, more than 4 mg in children |
| Phosphodiesterase Inhibitors - what do they do? | it inhibits phosphodiesterase (an enzyme), and this results in more calcium being present to make the heart beat stronger, and dialtes the blood vessels. |
| What are teh drug effects for Phosphodiesterase Inhibitors? | Postive Inotropic & relaxation of heart wall. |
| What are the side effects of Phosphodiesterase inhibitors? | Thrombocytopenia, GI and Liver enzymes increase with long term use. |
| What is Digitalizing? | Stabilizing fast to get blood level up to achieve the maximum therapeutic effect without producing toxic symptoms - 2 ng/ml |
| What is a Class 1 - block sodium | fast sodium channel blockers - anticonvulsant |
| Class 11 - beta blockers | slow down heart - antihypertensives |
| Class 111 - repolarization | fast - Prolong ERP and myocardial potiental |
| Class IV - block calcium | antihypertensives - reduce influx of calcium ions during action potential. |
| Antidysrhymics - effects and sides effects | effects: decrease dysrhymias, side effects: hypersensitivity to Rx, GI |
| Antianguial Drugs - what are they? | heart must have O2 & coronary arteries supply O2 to the muscle, and without O2 patient will experience angina - thus, 3 classes of drugs keep O2 increased in heart. |
| What are the 3 Antianguial Drugs? | Nitrates/ninites, beta blockers, & calcium channel blockers (vasodialation drugs) |
| Nitrates/Nitrites - action & side effects: | Action: venous dialation, brings blood to venous system.Side Effects: headache, postural hypotension, tachycardia |
| Beta Blockers - action & side effects: | slows heart rate, lowers electrical conduction, - chromo rx & - inotropicSide Effects: breathing disorders worsen |
| Calcium Channel Blockers - action & side effects: | Action: depress automacity of contractions, lowers myocardial contractility, relaxation of artery toneSide effects: few |
Created by:
ambiecomet
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