Exam (elaborations)
NUR 160 LAB QUIZ 2 QUESTIONS AND ANSWERS
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NUR 160 LAB QUIZ 2 QUESTIONS AND ANSWERS
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NUR 160 LAB QUIZ 2 QUESTIONS AND ANSWERSCalcium lab value (Ca+) - Answers- 8.5-10 mg/dL
Ionized Calcium (Ca2+) lab value - Answers- 4.5-5.6 mg/dL
Magnesium (Mg) lab value - Answers- 1.5-2.5 mg/dL
Potassium (K+) lab value - Answers- 3.5-5.0 mEq/L
Sodium (Na+) lab value - Answers- 135-145 mEq/L
What can sterile urine be captured with: - Answers- port of indwelling Foley catheter
straight catheter (cannot be left in patient, one time use)
24 hour urine specimen should be placed on: - Answers- ice, in an orange container
only
Sterile Urine Collection steps: - Answers- Clamp tubing
Clean access port
Withdraw urine from tubing
Unclamp
24 hour urine collection steps: - Answers- Check with lab regarding need for additives
Discard first urine and note start time
Collect all voids until 24 hours reached
How many times should the patient wipe with a cleansing wipe to collect a urine sample
- Answers- 3
Patient wait time after giving pain medications prior to a wet-dressing change by PO
and IV - Answers- 30 minutes, PO
15 minutes, IV
What should you document in a wet-to-dry change - Answers- Wound status
Description of drainage
Dressings applied
Patients response to procedure
Patient teaching
What position should you place a patient who wound has dehiscence or evisceration -
Answers- low fowler with the knees slightly flexed, this helps relieve pressure on the
wound and reduce the risk of further evisceration
Steps when responding to a wound evisceration - Answers- 1. remain with patient and
notify doctor, this is considered a medical emergency
, 2. place patient in low fowler with knees slightly flexed
3. protruding organ is covered with sterile dressing moistened with sterile normal saline
solution (helps prevent bacteria)
4. monitor patient and assess vitals, pulse ox reading to make sure patient is not going
into shock
5. make sure patient remains NPO because surgery will be required
6. reassure patient and family
Wound bleeding may indicate: - Answers- a slipped suture, dislodged clot, coagulation
problem, or trauma to blood vessels or tissue
Signs of a hemorrhage when changing a dressing: - Answers- dressing sometimes
remains dry while the abdominal cavity collects blood
signs of internal bleeding when changing a dressing: - Answers- restlessness, rapid
thready pulse, decreased blood pressure, decreased urinary output, cool and clamp
skin
important sign to assess when changing a dressing - Answers- evidence of
serosanguineous drainage because dehiscence sometimes is preceded by this type
signs of an infected wound - Answers- purulent drainage, fever, tenderness and pain at
the wound site, edema, and an elevated WBC
foods that assist in wound repair - Answers- rich in protein, vitamin a, vitamin c, zinc
(dark leafy veggies, yellow and orange fruits, legumes, peanut butter, strawberries,
tomatoes, red meat, seafood)
Verbal assessment of wound drainage - Answers- COCA - color, odor, consistency,
amount
Report to physician during a wet-to-dry change when: - Answers- Fresh/frank bleeding
Sharp increase in pain
Signs of infection
Signs of shock (changes in BP, HR, RR, etc)
Any retention of irrigation solution
Purpose of wet-to-dry dressings - Answers- keeps wound moist; debridement
Wet-to-dry dressing is appropriate for which type of wounds: - Answers- wounds that do
not have a significant amount of ischemic or necrotic tissue, wounds without large
amounts of drainage or exudate
Discard wetting solutions for wet-to-dry changes after: - Answers- 24 hours
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