GNRS 555 Med/Surg Care Adult/Geriatric
Weeks 1-5 Questions and Answers
ventilation movement of air in and out of the lungs
diffusion movement of O2 and CO2 between alveoli and RBC
perfusion the distribution of red blood cells to and from the pulmonary capillaries
bradypnea abnormally slow breathing; below 12/min
Tachypnea abnormally high rate of breathing; above 20/min
hypocarbia reduced CO2 in blood
hypercarbia CO2 retention
Cheyne-Stokes respiration alternating periods of apnea and hyperventilation
Characteristics of Hypotension - systolic <90 mm Hg
- dilation of arteries
- loss of blood volume
,- decrease of blood flow to vital organs
- orthostatic
Characteristics of Hypertension - more common than hypotension
- thickening of walls
- loss of elasticity
Nursing Process A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation
Stages of pressure ulcers Stage 1 - intact skin with nonblanchable redness
Stage 2 - partial thickness skin loss involving epidermis, dermis, or both
Stage 3 - full thickness tissue loss with visible fat
Stage 4 - full thickness tissue loss with exposed blood muscle or tendon
Characteristics of Primary Intention - Surgical incisions
,- skin edges are approximated, closed
- low risk of infection
- quick healing, minimal scar
Characteristics of Secondary Intention - Wound involving loss of tissue (burn, pressure
ulcer, laceration)
- wound left open until it becomes filled by scar tissue
- takes longer to heal
- higher chance of infection
Braden Scale A tool for predicting/measuring pressure ulcer risk
How to prevent pressure injuries: turn the patient every 2 hours
Risk factors of pressure ulcers - friction & shearing
- immobility
- inadequate nutrition
- fecal & urinary incontinence
- decreased mental status
- diminished sensation
- age
, T/F: It is the nurse's responsibility to make sure informed consent is obtained and put into
patient's file True
Pressure injuries form primary as a result of: Tissue Ischemia
The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The
nurse should classify this stage of pressure injury formation as: Stage II
A 43-year-old client is scheduled to have a gastrectomy. Which of the following is a major
preoperative concern?
a. The client's brother had a tonsillectomy at age 11.
b. The client smokes a pack of cigarettes a day.
c. The client has an intravenous (IV) infusion.
d. The client has a history of employment as a computer programmer. b. The client
smokes a pack of cigarettes a day
As obese client is admitted for abdominal surgery. The nurse recognizes that this client is more
susceptible to the postoperative complication of: Dehiscence
Define dehiscence When surgical wound reopens partially or completely. Wounds can
reopen either internally or externally.
Weeks 1-5 Questions and Answers
ventilation movement of air in and out of the lungs
diffusion movement of O2 and CO2 between alveoli and RBC
perfusion the distribution of red blood cells to and from the pulmonary capillaries
bradypnea abnormally slow breathing; below 12/min
Tachypnea abnormally high rate of breathing; above 20/min
hypocarbia reduced CO2 in blood
hypercarbia CO2 retention
Cheyne-Stokes respiration alternating periods of apnea and hyperventilation
Characteristics of Hypotension - systolic <90 mm Hg
- dilation of arteries
- loss of blood volume
,- decrease of blood flow to vital organs
- orthostatic
Characteristics of Hypertension - more common than hypotension
- thickening of walls
- loss of elasticity
Nursing Process A - Assessment
D - Diagnosis
P - Planning
I - Implementation
E - Evaluation
Stages of pressure ulcers Stage 1 - intact skin with nonblanchable redness
Stage 2 - partial thickness skin loss involving epidermis, dermis, or both
Stage 3 - full thickness tissue loss with visible fat
Stage 4 - full thickness tissue loss with exposed blood muscle or tendon
Characteristics of Primary Intention - Surgical incisions
,- skin edges are approximated, closed
- low risk of infection
- quick healing, minimal scar
Characteristics of Secondary Intention - Wound involving loss of tissue (burn, pressure
ulcer, laceration)
- wound left open until it becomes filled by scar tissue
- takes longer to heal
- higher chance of infection
Braden Scale A tool for predicting/measuring pressure ulcer risk
How to prevent pressure injuries: turn the patient every 2 hours
Risk factors of pressure ulcers - friction & shearing
- immobility
- inadequate nutrition
- fecal & urinary incontinence
- decreased mental status
- diminished sensation
- age
, T/F: It is the nurse's responsibility to make sure informed consent is obtained and put into
patient's file True
Pressure injuries form primary as a result of: Tissue Ischemia
The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The
nurse should classify this stage of pressure injury formation as: Stage II
A 43-year-old client is scheduled to have a gastrectomy. Which of the following is a major
preoperative concern?
a. The client's brother had a tonsillectomy at age 11.
b. The client smokes a pack of cigarettes a day.
c. The client has an intravenous (IV) infusion.
d. The client has a history of employment as a computer programmer. b. The client
smokes a pack of cigarettes a day
As obese client is admitted for abdominal surgery. The nurse recognizes that this client is more
susceptible to the postoperative complication of: Dehiscence
Define dehiscence When surgical wound reopens partially or completely. Wounds can
reopen either internally or externally.
