Wound Care - Study guide questions/ Open Book & Moodle Questions
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| What is surgical asepsis or sterile technique? | Designed to destroy all microorganisms and their spores
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| How does the nurse use sterile techniques when performing a dressing change? | Verify physician orders, assemble all equipment necessary for a sterile procedure before you begin, this way you avoid having to leave sterile area to locate missing supplies
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| What is the 1st principle of sterile technique? | Sterile object remains sterile only when touched exclusively by other sterile objects
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| What is the 2nd principle of sterile technique? | Place only sterile objects on sterile field
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| What is the 3rd principle of sterile technique? | Sterile field out of ranges of vision or an object held below a persons waist is contaminated
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| What is the 4th principle of sterile technique? | Sterile object or field becomes contaminated by prolonged exposure to air
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| What is the 5th principle of sterile technique? | When a sterile surface comes in to contact with a wet, contaminated surface, sterile object/field is contaminated
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| What is the 6th principle of sterile technique? | Fluid flows in direction of gravity
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| What is the 7th principle of sterile technique? | Consider the edges of a sterile field or container to be contaminated
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| What is a sterile field? | Area that is free of microorganisms and has been prepared to receive sterile items
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| Why do pressure ulcers occur? | Sufficient pressure on the skin to cause the blood vessels in an area to collapse
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| What are some ways to prevent, and/or care for, pressure ulcers? | On going assessment & evaluation, observe for signs of hydration, turn patients who are on complete bed rest or unable to reposition themselves.
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| Define clean | Not infected or inflamed wound is free
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| Define clean-contaminated | Was the respiratory, alimentary, or genitourinary tract entered under controlled conditions
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| Define contaminated | Fresh, open and has pus
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| Define infected | Old wound, more than 4-6hrs old, may have green color
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| What are two modifiable factors that may interfere with wound healing? | Nutritional needs/fluids, rest & activity
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| What are two non-modifiable factors that may interfere with wound healing? | Pre-existing conditions, chronic diseases
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| What foods should the nurse offer the patient to assist with wound repair? | Vitamin A, C, foods rich in protein, and zinc
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| What can be done to prevent separation of a wound while coughing? | Splinting - apply a pillow, rolled blanker, or the palms of the hands to the incisional area to lessen intra-abdominal pressure
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| What are the basic principles of wound irrigation? | Cleansing wound & medicating wound
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| What is an abrasion? | Process of scraping or wearing away
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| What is a elective surgery? | Alteration of personal appearance; rhinoplasty, breast augmentation)
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| How does age affect the individual's response to a procedure or surgery? | Young and old patients don't tolerate major surgical procedures because of their metabolism & slower response to physiologic changes and also risk of aspiration, atelectasis, & pneumonia
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| What is appropriate for a LPN to delegate to unlicensed assistive personnel in the perioperative nursing period? | May obtain V/S, weight, and height measurements. Make sure to have instructed proper precautions as well
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| What should the nurse include to ask during the assessment of the pre-op patient? | Use of chemicals, alcohol, recreational substances, allergies, past surgeries, history of disease and/or infection
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| What pre-operative teaching is important for the patient? | Include patient and family & remember to use basic terminology & information that is easier for them to understand rather than complex explanations
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| When are serum electrolytes assessed? | Prior to surgery
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| What happens when your K level is elevated? | Increased HR
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| What happens when your K level is decreased? | Decreased BP and urine output
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| What is the role of the nurse in the informed consent? | Make sure patient understands what physician explained and act as a witness to consent form
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| What is the role of the nurse in emergency contact? | Attempt to locate family & document the attempts / Act as witness
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| What is the role of the nurse for telephone consent? | Ensure family can repeat what physician has explained to them / Act as witness x 2
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| How would you explain the use of IS to your patient? | Spirometer is used to help prevent any type of respiratory issues such as pneumonia after surgery. It promotes deep breathing
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| What is ICP and why would coughing be contraindicated? | Intracranial Pressure - coughing increases ICP, leading to leakage of cerebrospinal fluid
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| What medical devices are routinely ordered to reduce the risk of thrombus formation? | Antiembolism stockings (Ted Hose) and/or sequential compression device's (SCD's) with an intermittent external pneumonic compression system
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| What is a pre-op checklist? | Required list used to ensure all required care has been preformed & the patient is properly prepared for surgery
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| What should the nurse monitor the incision for following surgery? | Assess for bleeding or excessive drainage
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| What should the nurse monitor ventilation for following surgery? | Arterial oxygen saturation (SaO2) monitored by arterial gas measurements or by pulse oximetry
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| What should the nurse monitor pain for following surgery? | Effective pain management allows for early ambulation, promotion of adequate rest & fewer postoperative complications
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| What should the nurse monitor urinary function for following surgery? | Bladder area for distension & changes in renal function (usually takes 6-8hrs for voiding to occur post-op)
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| What should the nurse monitor Venous stasis for following surgery? | Assessment of feet/legs including pedal pulses, notating skin color and temperature
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| What activity should the nurse monitor for following surgery? | Early ambulation is a significant factor in hastening postoperative recovery & preventing postoperative complications; should watch for thrombophlebitis
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| What gastrointestinal status should the nurse monitor for following surgery? | Ausculate for bowel sounds in the abdomen to assess for the return of peristalsis
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| What is the description for pneumonia/atelectasis complication? | Dyspnea & increase respiratory rate, increase in temp, productive cough, chest pains, crackles over involved lung area, delirium in older pt./hyperglycemia in diabetic pt.
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| What is the description for pulmonary embolism complication? | Dyspnea, sudden sharp chest pain or upper abd pain, increase HR, decrease in BP, cyanosis
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| What is the description for hemorrhage complication? | Escape of blood from ruptured blood vessel
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| What is the description for shock complication? | Abnormal condition of inadequate blood flow to the body's peripheral tissues
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| What is the description for urinary retention complication? | Restlessness & diaphoresis, lower abd. pain, inability to void, distended abd. drum like sounds on percussion of bladder, increase in BP
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| What interventions does a nurse perform for complication of pneumonia/atelectasis? | Encourage early ambulation, monitor temp, reposition pt. every two hours, encourage IS, cough & deep breaths, check lung sounds & suction to clear secretions if the pt. is unable to cough, encourage fluid intake
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| What interventions does a nurse perform for complication of pulmonary embolism? | Notify RN and/physician immediately, establish IV access & monitor V/S
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| What interventions does a nurse perform for complication of hemorrhage? | Direct pressure/indirect pressure, apply tourniquet, monitor V/S, notify RN/physician immediately
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| What interventions does a nurse perform for complication of shock? | Elevate legs (unless pt. has spinal anesthesia) Notify RN/physician immediately, establish IV access
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| What interventions does a nurse perform for complication of urinary retention? | Monitor for voiding & check for distended bladder with bladder scanner (ultrasound), encourage fluid intake, provide privacy, pour warm water over perineum
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| What interventions does a nurse perform for complication of wound evisceration? | Notify RN/physician immediately, plate pt. in low fowler's position with knees bent to prevent abd. tension, prevent wound infection by placing warm, moist gauze over exposed tissue and administer antiemetic's
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| What interventions does a nurse perform for complication of wound dehiscence? | Notify RN/physician immediately, place pt. in low fowler's position with knees bent to prevent abdominal tension
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| What interventions does a nurse perform for complication of wound infection? | Monitor temp. incision site for approximate suture line, edema, bleeding, sings of infection, maintain the patency of any drains
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| What is the difference between medical & surgical asepsis? | Medical asepsis is techniques that inhibit growth & transmission of pathogenic microorganisms, while surgical asepsis is techniques destroys all microorganisms & their spores
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| When an inflammation is systemic, what signs besides edema turgor, heat, and pain develop? | Tenderness and loss of function in affected body part
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| What factors affect a person's immunologic defense mechanisms? | Increasing age, extreme young, stress, fatigue, nutritional status, hereditary factors, disease processes, environmental factors, medical therapy, chemo, radiation, lifestyle, occupation, diagnostic procedures, travel history, trauma
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| Describe the goals of the CDC guidelines for transmission-based precautions in hospitals? | To interrupt the chain of infection and reduce transmission of blood-borne pathogens and other potentially infectious materials
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| What determines the method of sterilization or disinfection? | Disinfection is used to destroy microorganisms and sterilization is used to destroy microorganisms and spores. Methods of sterilization depends on the type of microorganism present & type of item that need to be disinfected or sterilized
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| Name possible nursing diagnoses for patients susceptible to or affected by an infection? | Impaired tissue integrity, risk for infection, social isolation
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| How are wounds classified? | Determined based on a series of factors that include cause, the severity of injury, amount of contamination, and size
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| Name the phases of wound healing | Hemostasis, Inflammatory, Reconstruction, and Maturation
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| The extent of the inflammatory response depends of what factors? | Level of injury inflicted, size of the area involved, and the physical condition of the patient
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| Explain the use of gauze, semi-occlusive, and occlusive dressings in the care of surgical wounds | Gauze dressings permit air to reach the wound, semi-occlusive dressings permit O2 but not air impurities to pass, occlusive dressings permit neither air nor O2 to pass
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| What are the advantages of transparent dressings? | Adheres to undamaged skin to contain exudate and minimize wound contamination, serves as a barrier to external fluids and bacteria, yet still allows the wound to breathe, promotes a moist environment that speeds epithelial cell growth
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| What are the two principles of basic wound irrigation? | Cleanse in direction from least contaminated area to most contaminated; When irrigating, be sure all the solution flows from the lease contaminated to most contaminated
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| Wound bleeding may indicate what conditions? | Slipped suture, dislodged clot, coagulation problem, or trauma to blood vessels or tissue
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| Describe the factors that would dictate the use of staples or sutures | Patients history of wound healing, the site of the wound, the tissue involved, and purpose of the sutures
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| List the three drainage systems | Closed drainage, Open drainage, and Suction drainage
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| Describe the closed drainage system | System of tubing and other apparatus attached to the body to remove fluid in an air tight circuit that prevents environmental contaminates from entering wound cavity
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| Describe the open drainage system | System passes through an open-ended tube into a receptacle or out into the dressing
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| Describe the suction drainage system | System uses a pump or other mechanical device to help extract fluid
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| What is elective surgery? | Not necessary to preserve life and may be performed at a time the patient chooses
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| What is urgent surgery? | Required to keep additional health problems from occurring
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| What is emergent surgery? | Performed immediately to save the individuals life or to preserve the function of a body part or system
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| What are the common variations of surgery? | Inpatient, One-day, Outpatient, Short-stay surgical center, Short-stay unit, and mobile surgery unit
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| Describe inpatient surgery | Patient hospitalized for surgery
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| Describe One-day surgery | (Same day surgery) Patient is admitted the day of surgery is scheduled and discharged the same day
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| Describe Outpatient surgery | (Not hospitalized) Patient is admitted to a short stay unit or directly to surgical suite
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| Describe Short stay surgical center | Independently owned agency; Surgery is performed when overnight hospitalization is not required (aka - ambulatory/one-day surgery center)
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| Describe Mobile surgery unit | Moves from place to place it goes to the patient instead of patient traveling to the unit
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| What are the common fears associated with surgery? | Fear of loss of control, unknown, anesthesia, pain or inadequate post-operative analgesia, death, separation disruption, change in body image, detection of cancer
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| What are factors that affect the individual's ability to tolerate surgery? | Age, physical condition, nutritional factors, psychosocial needs, socioeconomic & cultural needs, medications, education & experience
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| Which test are commonly reviewed prior to surgery? | U/A, CBC, Chem profile, serum electrolytes, chest x-ray's, and EKG
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| When diagnosing risk for latex allergy response, what factors influence this diagnosis? | Multiple surgical procedures, food allergies (bananas, avocado's, kiwi, chestnuts), job with daily exposure to latex, history or reactions to latex (balloons, condoms, gloves) children w/spina bifida, history of allergies & asthma
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| Name the four primary purposes for the use of the incentive spirometer (IS) | Prevents atelectasis, improves lung expansion, improves oxygenation & prevents post-operative pneumonia
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| What is the first phase of anesthesia? | Induction - patient is awake and the anesthetic is often given intravenously (IV)
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| What is the second phase of anesthesia? | Maintenance - patient is kept anesthetized at appropriate levels throughout the surgical procedure
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| What is the final phase of anesthesia? | Emergence - when surgery is complete, reversal agents are given
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| What is the difference between spinal & epidural anesthesia? | Spinal is injected into the cerebrospinal fluid in the subarachnoid space, while the epidural is injected into the epidural space outside the dura mater & depth of anesthesia is lighter than spinal
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| How is deep vein thrombosis (DVT) prevented after surgery? | Early and frequent ambulation and leg exercises; antiembolism stockings & pneumatic compression devices (external intermittent compression system, SCD)
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| Patient comes into ER with open wound to R leg with large piece of tissue missing, leaving tendons & muscle exposed. What type of wound is it? | Avulsion
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| Nurse is caring for patient with wound on R arm with bandage, what is 1st priority assessment when inspecting skin that is distal to bandage? | Circulatory impairment
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| Patient with pressure ulcer on sacrum, full thickness skin loss with necrosis tissue; what is the wound classification? | Stage III
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| Physician orders sterile wound change, what is the most appropriate way to cleanse wound & surrounding area? | Use antiseptic swab, start from incision outward, 1 stroke/swab, then allow to dry
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| Patient is admitted to post-anesthetic care unit (PACU), which nursing action is most important during stay in this unit? | Suctioning mucous from respiratory passages
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| Nurse assesses patient for electrolyte imbalance, which clinical manifestation indicates K deficiency? | Muscle weakness
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| Nurse caring for patient who had abdominal hysterectomy, which intervention prevents post-op thrombophlebitis? | Leg exercises 10x/hr.
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| Which of the following is true regarding preoperative medication? | The preoperative phase is the optimal time to introduce the concept of patient controlled analgesia (PCA) to patient
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| What should the nurse do to help prevent respiratory complications in a post-op patient? | Assist patient to ambulate within a few hours of surgery, unless contraindicated
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| When preparing to remove a dressing, the nurse should don _______ gloves? | Clean
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| Abdominal binders can be used to hold dressings in place & they are also used with obese patients for additional support, True or False | True
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| What are the phases of wound healing? | Hemostasis, Inflammation, Reconstruction, Maturation
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| Nurse writes the problem "impaired skin integrity" for a client with stage IV pressure ulcer, which intervention should be included in plan of care? | Obtain order for dietitian, obtain order for an air flow bed
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| What is the nurses first priority when caring for a patient needing wound care? | Check medical record for physicians orders
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| What is the most important assessment made by the nurse after assessing a post-op patient for a patent airway? | Stability of V/S
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| What are true statements regarding medications and surgery? | Seriously ill pt. may receive as many as 20 meds peri-operative setting at one time; Review of pt's current medication regimen is essential to promote safe surg. outcome; Pt chart should be "flagged" for allergy status to alert all health care workers
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