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NUR 242 FINAL EXAM REVIEW
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NUR 242 FINAL EXAM REVIEW
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NUR 242 FINAL EXAM REVIEWExamd1:d-d
Cane:d-d-Appropriatedheightd(atdwristdleveldwhendarmdisdatdside)
-Ptdstrongdhanddondcane
*MOVEdCANEdWITHdWEAKERdLEG*
Atdriskdfordfallsdduedto:d-dincontenience
TransferringdptdtodWC:d-d-PlacedWCdondstrongdsidedangleddtodbed
-Strongdhanddtodarmrest,dthendpivot
Safedptdhandling:d-d-
Keepdptddirectlydindfrontdofdyoudanddasdclosedasdpossibledtodpreventdbackdinjuries
Skindintegrity:d-d-dontdweardrestrictivedclothing
-WCdptdliftdthemselvesdoffdbuttockdford10dsecondsdq1hr
PressuredUlcerdstages:d-d*Staged2-dskindisdnotdintact;dopendordfluiddblister*
Wet-to-dampdwounddcare:d-dmechanicallydremovesdnecroticdtissue
doesdmoreddamagedthandgooddbcditdremovesdthedgooddtissuedasdwell
Informeddconsent:d-d-surgeondisdresponsibledfordhavingdconsentdsigned
-Ptdwhodcandnotdsigndcandsigndwithdand"X"dbutdmustdbedwitnesseddbydtwodpeople
-Ifdthedptddoesn'tdunderstanddthedsurgery,dthedsurgeondhasdtodbednotified
-Adblinddptdcandsigndthedconsent,dhasdtodbedwitnesseddbyd2dpeople
-NursesdDOdNOTdclarifydorders/procedure/risks,dmustdcalldthedMDdtodexplaindtodpt
Pre-OP:d-d-Reportdthesedtodsurgeon:
-increaseddPT/INR/aPTT/Creatinine
-Verifydoperativedpermitdisdsigned
-Sidedrailsdup,dbedddown,dcalldlightdwithindreach
Intra-OP:d-d-PtsdaredlifteddintodpositiondontodthedORdtabledtodpreventdshearing
-GeldpadsdaredplaceddondthedORdtabledtodpreventdpressuredulcers
,-Warmingdblanketsdaredused
-Coverdthedptsdheaddanddfeetd(decreasedhypothermia)
*Ifdsavingdisdnecessary,dhairdshoulddbedremoveddusingddisposabledsteriledsuppliesdimmedi
atelydbeforedthedstartdofdthedprocedure*
-Steriledscrubbingdfromdfingertipsdtodelbowdford3-5dminutes
Post-OP:d-d-indPACU,dnursedimmediatelydassessdptdairway,dLOC
-RRd<10dmaydindicatedrespiratoryddepressiondduedtodanesthesia
-Sanguineousdtodserosanguineousddrainagedisdnormal
-Crustingdatdincisiondlinedanddswellingdisdnormal
Malignantdhyperthermia:d-d-lifedthreatening
-youdwilldseedHIGHdTEMPERATURE
-earlydsigndisdtachycardia,dmuscledrigidity
-Dantrolenedisduseddtodtreat
PaindManagement:d-d*Paindmanagementdreferraldfordptsdindchronicdpaindunrelieved*
-Paindafterdabdominaldsxdisdfromdtrappeddcarbonddioxide,dambulatedptdasdsoondasdpossible
-UsedFACESdscaledindptsdwithddementia
PCAdPump:d-d-Lockoutdintervaldofd5-15dminutes
-Ptdcannotdbedcognitivelydimpaired
-Onlydthedptdcandpressdthedbutton
Ifdincisiondopens:d-d-coverdwithdwetdsteriledgauze
-Dodnotdtrydtodreinsertdprotrudingdorgan
-Reassuredpt
-Supinedpositiondwithdkneesdbent
IV:d-d-20Gd1-1.5"dneedledisdadequatedfordmostdtherapies
-Huberdneedledshoulddbedplaceddatd90ddegreedangledtodaccessdportd(chemodpt)
TPN:d-d-dCheckdeachdbagdtwice
-IfdTPNdisdunavailable,dhangd10%ddextrose/waterdord20%dD/WduntildTPNdisdavailable
-IfdTPNdnotdadministereddondtime,ddodnotdincreasedthedrate
-ChangedIVdtubingdq24dhoursdwhendnewdbagdisdhung
-DressingdchangedarounddIVdsitedchangedd2d48-72dhours
SickledCell:d-d-Paindisdthedmostdcommondproblem
-Requiresdlargeddosesdofdopioiddanalgesics
-HydratedwithdNSdIVdfluids,dencouragedoraldfluidsdwithoutdcaffeine
-AdministerdO2
-Removedrestrictivedclothing,dNodBPdwithdexternaldcuff
-SickledCelldcrisis:dpaindmedsdanddIVdfluids
, VitamindB12dDeficiency:d-d-Smooth,dbeefydreddtongue
MRSA:d-d-Sleepdindseparatedbedsduntildinfectiondclears
-WashdclothesdindHOTdwater
Standarddprecautions:d-d-Handdhygiene
-Gloves
Contactdprecautions:d-d-Privatedroom
-Weardglovesdwhendenteringdroom
-Washdhandsdwithdsoapdanddwater
-Dedicateddequipment
AirbornedPrecautions:d-d-Privatedroomdwithdnegativedairflow
-Keepddoordclosed
-N95drespirator
*Ptdweardsurgicaldmaskdwhendleavingdroomdfordlabs/procedure*
Dropletdprecautions:d-d-Privatedroomdpreferred
-Ifdnot,dmaydsharedadroomdwithdptdhavingdsamedactivedinfection
-SurgicaldmaskdwhendworkingdWITHINd3dFEETdOFdPT
-Ptdtodweardsurgicaldmaskdwhendleavingdroom
Psoriasis:d-dTreatdwithdUVdlightdbutdNOTdAdTANNINGdBED
SkindCancer:d-d-Avoiddsundexposuredfromd11-3pm
-A=Asymmetry
-B=border
-C=color
-D=diameter
-E=evolving
-Examinedthedbodydmonthlydfordchanges
Examd2:d-d
Thednursedisdteachingdadclientdwhodhasdbeendprescribeddalprazolam.dWhichdofdthedfollowin
gdstatementsdbydthednursedwoulddbedappropriatedtodmake?d-
dYoudshoulddinformdyourdprimarydhealthdcaredproviderd(PHCP)dbeforedtakingdanydherbaldsu
pplement.
Thednursedisdcaringdfordadclientdwhodisdscheduleddtodhavedadminordproceduredunderdconsci
ousdsedation.dWhichdofdthedfollowingdmedicationsdshoulddthednursedanticipatedwilldbedpres
cribed?d-dPropofol
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