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NUR 242 Final Exam Review Galen College Of Nursing - Question and answers verified to pass

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NUR 242 Final Exam Review Galen College Of Nursing - Question and answers verified to pass NUR 242 Final Exam Review Exam 1: - correct answer Cane: - correct answer -Appropriate height (at wrist level when arm is at side) -Pt strong hand on cane *MOVE CANE WITH WEAKER LEG* At ris...

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NUR 242 Final Exam Review
Exam 1: - correct answer ✔


Cane: - correct answer ✔-Appropriate height (at wrist level when arm is at
side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*


At risk for falls due to: - correct answer ✔incontenience


Transferring pt to WC: - correct answer ✔-Place WC on strong side angled
to bed
-Strong hand to armrest, then pivot


Safe pt handling: - correct answer ✔-Keep pt directly in front of you and as
close as possible to prevent back injuries


Skin integrity: - correct answer ✔-dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr


Pressure Ulcer stages: - correct answer ✔*Stage 2- skin is not intact; open
or fluid blister*


Wet-to-damp wound care: - correct answer ✔mechanically removes necrotic
tissue

,does more damage than good bc it removes the good tissue as well


Informed consent: - correct answer ✔-surgeon is responsible for having
consent signed
-Pt who can not sign can sign with an "X" but must be witnessed by two
people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to
pt


Pre-OP: - correct answer ✔-Report these to surgeon:


-increased PT/INR/aPTT/Creatinine


-Verify operative permit is signed
-Side rails up, bed down, call light within reach


Intra-OP: - correct answer ✔-Pts are lifted into position onto the OR table to
prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile
supplies immediately before the start of the procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes

,Post-OP: - correct answer ✔-in PACU, nurse immediately assess pt airway,
LOC
-RR <10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal


Malignant hyperthermia: - correct answer ✔-life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat


Pain Management: - correct answer ✔*Pain management referral for pts in
chronic pain unrelieved*
-Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon
as possible
-Use FACES scale in pts with dementia


PCA Pump: - correct answer ✔-Lockout interval of 5-15 minutes
-Pt cannot be cognitively impaired
-Only the pt can press the button


If incision opens: - correct answer ✔-cover with wet sterile gauze
-Do not try to reinsert protruding organ
-Reassure pt
-Supine position with knees bent


IV: - correct answer ✔-20G 1-1.5" needle is adequate for most therapies

, -Huber needle should be placed at 90 degree angle to access port (chemo pt)


TPN: - correct answer ✔- Check each bag twice
-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is
available
-If TPN not administered on time, do not increase the rate
-Change IV tubing q24 hours when new bag is hung
-Dressing change around IV site changed 2 48-72 hours


Sickle Cell: - correct answer ✔-Pain is the most common problem
-Requires large doses of opioid analgesics
-Hydrate with NS IV fluids, encourage oral fluids without caffeine
-Administer O2
-Remove restrictive clothing, No BP with external cuff
-Sickle Cell crisis: pain meds and IV fluids


Vitamin B12 Deficiency: - correct answer ✔-Smooth, beefy red tongue


MRSA: - correct answer ✔-Sleep in separate beds until infection clears
-Wash clothes in HOT water


Standard precautions: - correct answer ✔-Hand hygiene
-Gloves


Contact precautions: - correct answer ✔-Private room

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