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PN BN2 Test 5

fundamentals ch31,37,38

QuestionAnswer
Pain may be accompanied by what other changes in vitals? Increased heart rate, blood pressure, and respiratory rate
_________ pain may worsen in the presence of anxiety or fear Acute
Cloths wrapped around a limb or body part are __________;they are effective in relieving pain associated with strains, sprains, and surgical incisions Binders
What organization established standards related to pain that focus on the patient? The Joint Commission
Regarding pain, patients have the right to what? Appropriate assessment and management of pain
When is pain assessment performed? It is considered the fifth vital sign
An aquathermia K-pad is used to help relieve ________. Pain
What kind of patients have skin that is more sensitive to heat damage? the very young and very old
What other patients are at risk for burns from heating pads? Patients with altered level of consciousness, impaired movement and feeling, poor circulation (they may not be aware something is too hot)
What is another term for therapeutic suggestion? Hypnosis
This trance-like state focuses on what? Relaxation techniques
What technique is used to assist the patient to form mental images of a pleasant environment where they are comfortable and happy? Guided imagery
Reading from a script that helps patient visualize a restful place is an example of what? Guided imagery
A non-traditional therapy likely to help with back pain may include: Chiropractic therapy
What non-traditional therapy does not involve machinery or equipment of any kind? hypnosis
What techniques are often used for back pain? chiropractic,acupuncture, and accupressure
What are some examples of narcotic pain medication? Codeine, oxycodone, morphine
Continuous infusion of _______ is less effective at pain control and may more easily result in overmedication Opiods
What are some benefits of the PCA pump? Patients have greater control and less anxiety about pain control
When cleaning around an epidural catheter site, what technique should be remembered? Cleanse in a circular motion, starting in the center and working out
For a patient with baseline vitals of B/P 120/80 and pulse of 72; what example of vitals may indicate a need for more pain medication? B/P 140/90, pulse 90
The shortest analgesic effect will be medication given via which route? Intravenously
Stage 3 of sleep presents what changes in the body? Heart rate slows, respiratory rate slows, body become immobile
Regular exercise can help a person sleep, but should not be close to bedtime due to why? It may over-stimulate and keep a person awake
What is the condition in which the person will stop breathing for brief periods during sleep? Sleep apnea
How can eating patterns affect sleep? Going to bed overly full or hungry can interfere with sleep
Many children patients may sleep better in the hospital if they have what from home? favorite pillow or blanket
Lysis removal or destruction of
Anastomosis joining of two part
-ectomy cutting out or off
-oma tumor
-ostomy creating an outlet
-plasty revision,molding, or repair of tissue
-plexy fixation,anchoring in place
What is very important for the calculations of anesthetic agents and medication dosages for the elderly? Accurate height and weight
If the patient is a minor, who can sign the consent? A legal guardian or parent
Can consents be given over the phone? In an emergency, with two witnesses on extension lines
Prior to surgery, as you finish the preoperative checklist, what should you have the patient do first? empty their bladder
Is shaving hair from the operative site recommended? Usually just clip the hair
Can jewelry be worn into surgery? All jewelry should be removed; if a wedding bad cannot be removed, it should be taped to the finger
When the patients goes to surgery, how should the nurse prepare the patients room? connect oxygen and suctioning equipment and make sure it works;gather emesis basin, tissues, make the bed
Recovery time for same-day surgery usually takes how long? 1-3 or 1-4 hours
Vital signs post-operatively should be done how often? every 15 mins for 1 hour, every 30 mins for 2 hours, every hour for 4 hours, then every 4 hours until fully recovered
What is a priority measure to protect the patient? Maintain an open airway
How should the surgical dressing be handled post op? Keep it dry; if it is stained, the area is outlined with pen and the time noted so bleeding can be assessed later. If bleeding has saturated the dressing, reinforce with more dressings;check each hour for 4 hours;excessive bleeding is reported to surgeon
What position is best for maintaing airway for a patient who has just returned from surgery? Side lying
Coughing and deep breathing is import post op to prevent stasis of secretions and expand lungs when would coughing be contradicted? for PTs who have had hernia repair, eye, ear, or brain surgery
SCD's do what for the legs? alternate compression and release, squeezing the vessels and propelling blood along them
What instructions would a nurse give post surgically for preventing respiratory complications, for a patient who had surgical removal of a brain tumor? Deep breathing and incentive spirometer
When monitoring urine output post op, what amount should be reported to the surgeon? <60mL over a 2 hour period
After surgery, post op patients can be offered a few ice chips or water unless what? there is an order to maintain NPO status
A newly arrived post-surgical patient is after for water, what should the nurse do first? Check for a physicians order
What is the term for a skin opening described as: the traumatic scraping away of surface layers of skin? Abrasion
What is the first phase of wound healing and how long does it last? The inflammatory phase begins immediately after injury and lasts about 4 days
Clinical signs of inflammatory process are what? Swelling or edema of the injured part, erythema (redness), heat, pain
What is the second stage of wound healing and how long does it last? Proliferation stage begins on the third and fourth day after injury and lasts 2-3 weeks
What is the final stage of wound healing? The final stage of healing is maturation,beginning about 3 weeks after injury
A wound with little tissue loss such as a surgical incision, heals by what intention? First (closure); the edges of the wound approximate
If a wound is left open and fills with scar tissue, it heals by what intention? Second; (such as torn ragged laceration or a pressure ulcer)
What intention of wound healing is known or delayed or secondary closure? Third intention
If internal hemorrhage is extensive, hypovolemic shock may occur; signs would be: Fall in B/P, rapid thready pulse, increased resp rate, restlessness, diaphoresis, and cold clammy skin
What is the best way to prevent wound infection? To maintain strict asepsis when performing wound care; used sterile equipment, meticulous hand washing, keep hair for swinging forward
What term for the spontaneous opening of an incision involves the separation of layers beneath the skin as well; pt may state "something has given way" Dehiscence
What term describes the protrusion of an internal organ through incision Evisceration
What is the first thing nurse should do is she is ambulating a pt in the hallway and the pt says " I think something just let go" Have patient lay down in a supine position
If evisceration occurs, what should the nurse do? Notify surgeon, prepare for pt to go back to operating room
What technique is used when emptying closed wound drainage unit? Clean the pouring spout and plug using separate alcohol sponge for each
What type of dressing has a shiny,non-adherent surface on one side that is applied to the wound? Telfa
What is transparent dressing that does not require the use of tape and is less bulky than a gauze dressing? Opsite
What types of wound could opsite be used for? Iv catheter sites, stage 1 pressure ulcer
Why are thin film dressing used on stage 1 ulcers? to protect from shearing forces and keep them moist
What kind of bandage or tapes would be useful for a dressing that needs to be changed frequently, to help prevent skin irritation from removing and reapplying tape? Montgomery straps
What is another term for bruise? Ecchymosis
When removing tape from dressing over a wound, what techniques should be used? Pull the tape towards the wound while stabilizing the skin with the other hand
When applying a hydrocollid dressing, what tip will help with adhesion? Use skin prep around the edges of the skin to make the skin tachy
What technique will help make sure staple removal is pulled free of the skin? Press the handles of the staple remover together all the way to depress the center of the staple
When a soak is ordered, the part to be treated is submerged in warm water or solution for how long? 15-20 minutes
A hypothermia blanket is used to do what? Lower body heat for patients who are running a persistently high fever
Chilling to the point of shivering should be avoided because of what? Shivering causes the temperature to rise.
Created by: kellisteward