Question | Answer |
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. |