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NUR265: Final Exam/39 Questions & Answers 2024
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- NUR265: Final Exam/39 Questions & Answers 2024
NUR265: Final Exam/39 Questions & Answers 2024
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NUR265: Final Exam/39 Questions &Answers 2024
Describe a comprehensive preoperative assessment to identify pertinent
health and surgical risk factors - -Initiates the nursing process
Admission data: demographics, health hx, other information pertinent to the
surgical procedure
Verifies completion of preoperative diagnostic testing
Begins discharge planning by assessing pt's need for postop care
Health hx and physical exam, medications and allergies, nutrition, fluid
status, dentition, drug or alcohol use, respiratory and cardiovascular status,
hepatic and renal function, endocrine function, immune function, previous
medication use, psychosocial factors, spiritual, cultural beliefs
Medications that potentially affect surgical experience: corticosteroids,
diuretics, phenothiazines, tranquilizers, insulin, antibiotics, anticoagulants,
anticonvulsant meds, thyroid hormone, opioids, OTC and herbal
-Identify legal and ethical considerations related to obtaining informed
consent for surgery - -should be written before non emergent surgery, legal
mandate, surgeon must explain the
procedure/benefits/risks/complications/etc, nurse calcifies information and
witnesses signature, consent is valid ONLY when signed before administering
psychoactive premedication, consent accompanied patient to OR
-Describe preoperative nursing measures that decrease the risk for infection
and other postoperative complications - -providing pt education, deep
breathing, coughing, and incentive spirometry, mobility and active body
movement, pain management, cognitive coping strategies, education for pts
undergoing ambulatory surgery, providing psychosocial interventions,
reducing anxiety and decreasing fear, respecting cultural/spiritual/religious
beliefs, maintaining pt safety, managing nutrition, fluids, preparing the
bowels, preparing the skin, pt changes into gown, mouth inspection, jewelry
removed, valuable stored in a secure place, administering preanesthetic
medication, maintaining preoperative record, transporting pt to presurgical
area, attending to family needs
-Describe the responsibilities of the post-anesthesia care nurse in the
prevention of immediate post-operative complications. - -Provide care for
patient until patient has revered from effects of anesthesia. (Resumption of
motor and sensory function, Oriented, Stable VS, shows no evidence of
hemorrhage or other complications or surgery), vital to perform frequent
skilled assessment of patient, review pertinent information, baseline
assessment upon admission to unit, assess airy, respiratory function,
cardiovascular function, skin color, level of consciousness, and ability to
, respond to commands, reassess VS, patient status every 15 minutes or more
frequently as needed, administration of postoperative analgesia, transfer
report, to another unit or discharge patient to home. Discharge planning,
discharge assessment, provide written, kernel instructions regarding
medications, diet, give prescriptions, phone numbers, discuss actions to take
if complications occur. Give instructions to patient, responsible adult who will
accompany patient, patients are not to drive home or be discharged to home
alone, sedation, anesthesia may affect memory, judgement, affect ability.
-Identify assessment parameters appropriate for the early detection of
postoperative complications. - -Assessment: Respiratory, pain, mental
status/LOC, general discomfort, primary consideration: necessary to maintain
ventilation, oxygenation, provide supplemental O2 as indicated, assess
breathing by placing hand near face to feel movement of air. Keep head of
bed elevated 15 to 30 degrees unless contraindicated-may require
suctioning. If vomiting occurs, turn patient, monitor all indicators of
cardiovascular status assess all IV lines, potential for hypotension, shock,
potential for hemorrhage, potential for hypertension, dysrhythmias, Pallor.
Cool, moist skin, rapid respirations, cyanosis, rapid, weak, thready pulse,
decreasing pulse pressure, low blood pressure, concentrated urine, assess
patient comfort, control of environment: quiet, low lights, noise level,
administer analgesics as indicated; usually short-acting Opioids IV. Family
visit, dealing with family anxiety. Intervene at first indication of nausea,
medications, assessment of postoperative nausea, vomiting risk,
prophylactic treatment.
-Plan effective care of patients with the following imbalances: fluid volume
deficit and fluid volume excess, sodium deficit (hyponatremia) and sodium
excess (hypernatremia), and potassium deficit (hypokalemia) and potassium
excess (hyperkalemia). - -Fluid Volume Deficit (hypovolemia) Abnormal fluid
losses, decreased intake, third-space fluid shifts, additional causes: I&O at
least every 8 hours, sometimes hourly, daily weight, vital signs closely
monitored, skin and tongue turgor, mucosa, urine output, mental status,
measures to minimize fluid loss. Administration of oral fluids, administration
of parenteral fluids, Fluid Volume Excess Edema, distended neck veins,
cradles: I&O and daily weights assess lung sounds, edema, other symptoms,
monitor response to medications-diuretics and parenteral fluids, promote
adherence to fluid restrictions, patient teaching related to sodium and fluid
restrictions, monitor, avoid sources of excessive sodium, including
medications, promote rest. Hyponatrimia, hypernatremia(Sodium):
(Hyponatremia). Less than 135mEq/L Treat underlying condition, sodium
replacement, water restriction, medication, assessment: I&O, daily weight,
lab values, CNS changes. Encourage dietary sodium, monitor fluid intake.
Effects of medications (diuretics, lithium) Hypernatremia Higher than
145mEq/L:Gradual lowering of serum sodium level via infusion of hypotonic
electrolyte solution. Diuretics, Assessment for abnormal loss of water and
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