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INP Final Exam
Terms in this set (71)
What is a nurse able to do according to current professional practice knowledge, competent practice skills and professional relationships with patients and their families?
document during care which ensures that proper care will take place
What does a nurse assess in a patient who just came out of surgery?
-physical response to surgery
-monitor for post-op complications
-vital sign changes
-level of consiousness
-motor and sensory ability
-drainage (amount and what type)
-urinary and bowel elimination
What is the appropriate procedure for hair removal pre-surgery?
the nurse must choose the least invasive route; the use of an electric razor or clippers would do, and the patient needs to wash the area that is going to lose hair before and after removal with antibacterial soap to prevent infection
What is a priority goal for a patient with impaired gas exchange post-surgery?
keeping the patient's airway open
-position the patient in a position that facilitates breathing (sitting up)
-assess oxygen saturation
occurs when food or a foreign object blocks the airway and prevents air from entering or leaving the lungs
How does the nurse interveine if there is an airway obstruction?
-manual opening of the airway
-assessing whether something is blocking the airway
-suctioning something that is blocking the airway, such as vomit or gastric secretions
How does the nurse interveine if there is atelectasis?
-administer oxygen and analgesics
-position the patient upright
-coughing 2-3 times every two hours
-deep breathing 10 times every hour
-turning every 2 hours
What are lab values associated with fluid overload?
What are lab values associated with fluid deficit?
-altered BUN:creatinine levels
-increased urine specific gravity
-decreased urine output
What are lab values associated with dehydration?
-decrease in blood pressure
the action or crime of making a false spoken statement damaging to a person's reputation
What are nursing actions that prevent slander?
-only using objective information in documentation
-making no judgements
-avoiding judgemental phrases in documentation
-describing exactly what is seen
-open, honest patient communication
What is the goal of patient positioning during surgery?
to prevent injury and pressure ulcers
How does a nurse prevent injury during surgery, in terms of patient positioning?
-the patient is placed in a functional position with good body alignment
-pressure points are padded and an electrical grounding pad is placed under the patient
-proper positioning allows access to the patient's airway and surgical site, as well as permitting the nurse to monitor vital signs, IV lines and comfort level
What are priority nursing diagnoses for a patent with pneumonia?
-impaired gas exchange
-ineffective airway clearance
-ineffective breathing pattern
What are assessment findings that support moving of a patient off of NPO post-surgery?
-active bowel sounds
-passing gas and stool output
-no more feelings of nausea/vomiting
-gag reflex returns
What is the goal when an incentive spirometer is used?
to have a steady rise of a marker in the device to achieve a specific inhilation of volume
What is the proper procedure for incentive spirometer use?
-the patient should be sitting upright
-the patient is told to breathe in slowly as much as possible, and then to hold their breath for 3-5 seconds
-remove the mouthpiece and exhale slowly
-end with two controlled coughs
-repeat 5-12 times every 1-2 hours as ordered
What are ways a nurse can maintain an open airway post-surgery for a patient who is difficult to arouse?
-jaw thrust or chin-lift manuver
-bag-valve mask device
What is the risk associated with emergency surgeries in patients who have not maintained NPO?
aspiration, which can develop into aspiration pneumonia
What are the ways in which nurses can prevent aspiration in a patient who is going to go into surgery and has not maintained NPO?
insert an NG tube, which can assist with gastric emptying to prevent aspiration
What are the signs and symptoms of post-op hemmorhage?
-cold and clammy skin
-a weak, thready and rapid pulse
-respirations that are rapid and deep
-decreased urine output
a document that gives legal authorization for the surgical procedure, and helps to protect the patient from having unauthroized procedures performed
What is the job of the nurse, in terms of informed conscent?
-make sure that the patient is aware of the surgical procedure, benefits, risk factors, potential complications, expected outcome and post-op recovery
-be a witness to the patient's signature
-if the patient is confused, advocate and ask the surgeon to re-explain or answer any questions
How does the nurse assess a patient after a catheterization procedure using the femoral artery?
-always assess before and after insertion
-assess catheter patency
-make sure there are no clots present
-frequently assess circulation, sensation and movement
How does a nurse assess a puncture site after catheterization of the femoral artery?
she looks for signs of bleeding, hematoma, infection and ecchymosis
check pressure drain for oozing or bleeding
swelling, redness, pain and size
heat, pain, redness, increase in temperature, tachycardia
assess skin around site for purple discoloration
the nurse looks at....
-signs of bleeding
How does the nurse treat a patient with congestive heart failure?
-assess with ABG test
-administer diuretic if needed
-EKGs and X-Ray
-reduce fluid in the lungs so the patient can breathe
What are the symptoms of congestive heart failure?
-shortness of breath, lower extremity edema, chest pain, cough, exhaustion, irregular heartbeat, palpatations
-dyspnea, orthopnea, fatigue, abdominal discomfort due to ascites, JVD, fluid imbalance
What are priority interventions for the nurse so she can assist a patient with COPD to breathe easier?
-elevate the patient so they are sitting upright
-create a calming environment
-request oxygen therapy
How does a nurse assess a patient with COPD to determine oxygen and CO2 status?
-AP Lateral Diameter
-auscultate lung sounds
-assess fingernails for clubbing
How can the nurse teach a post-op patient to prevent blood clots?
-blood thinners can be used to decrease the risk
How does a nurse assess a patient for a DVT or PE?
-vital sign changes
-INR (clotting factor)
-venous doppler ultrasound
-assess for shortness of breath and chest pain, which indicate a pulmonary embolism
What are priority interventions for nurses caring for a post-op patient to prevent pneumonia?
-intermittent positive-pressure breathing
-position them upright
-oral care prevents buildup of secretions that cause pneumonia/aspiration
How does the nurse assess a patient who has pneumonia?
-auscultate lung sounds
-make sure the patient does not aspirate
How does a nurse assess a post-op patient for airway and oxygenation?
-assess lung sounds
-vital signs (O2 sat)
-respiratory system assessment (breath sounds, rate, rythym, depth, gag reflex, use of accessory muscles)
How often does a nurse assess a post-op patient?
assess every 15 minutes in the first hour, and then every 30 minutes for the next 2 hours
What are safety measures the nurse takes for patients who are sedated pre-op?
-side rails are kept up during transport so the patient does not fall out of the bed
-the patient is strapped to the operating table
What are safety measures the nurse takes for patients who are sedated post-op?
-when the patient is waking up, the nurse orients them, tells them that the surgery is done and gives them additional information that may be needed
-when the patient is awake, the top two side rails are kept up and the call light is placed within reach
What are some assessment questions that can be used during a pre-op assessment?
-Any allergies to food or drugs?
-Past operations and when they were?
-Have you or any of your family members ever had trouble with ansthesia?
-Current prescription medications?
-Use of any herbal medications or vitamins?
-Are you pregnant?
-How much alcohol do you drink?
-Do you use recreational marijuana or drugs?
What are assessment findings that would be present in a patient with long-standing respiratory disease?
-shortness of breath
-lung sounds heard when auscultated
What is the procedure conducted when a patient will not stay in the hospital despite proper medical advice?
the patient must sign a form (AMA) saying that the hospital is not liable if anything happens
What is the nurse's priority action for a newly opened surgical wound?
-assist the patient in a position that allows minimal strain to be placed on the incision
-the wound is covered with a sterile saline dressing and the surgeon is notified immediatley
What can the UAP do?
anything they cannot
What can the UAP do in terms of tracheostomy and a surgical care?
-report changes of vital signs, respiratory status, levels of consousness, problems or tube position difficulties, pain or discomfort, skin breakdown, excessive secretions and difficulty in procedure
-must be instructed in emergency procedures, appropriate equipment use and appropriate documentation
What is the goal for a patient with COPD?
to allow them to breath easily
to do no harm; the healthcare provider will cause no harm when taking action
the freedom to make decision supported by knowledge and self-confidence
to act fairly and equally
ability to answer for one's own actions
taking action to influence others to address a health-related concern or to support a health-related belief
the act of holding information in confidence, not to be released to unauthorized individuals
keeping promises or agreements made with others
the concept of being dependable and reliable
What does a nurse assess in a post-op patient?
-dressings, drains, tubes
-level of consciousness
What is a nursing priority action in the OR to ensure an accurate procedure?
-prepare and maintain sterile field
-assist surgeon by passing tools and instruments
-act as an advocate and liaison between scrubbed personnel and surgical team
-coordinate the needs of the surgical team by obtaining supplies and carrying out the nursing care plan
-assess patient safety and septs practice
-monitor patient during surgery (VS, level of consciousness etc)
difficulty breathing when lying down
What is a nursing action for a patient with orthopnea?
-position the patient in an upright position
-maximal lung expansion can be achieved by having the patient assume the tripod position (sitting and leaning forward over a raised bedside table with arms resting on the table
What is the proper procedure for a pulse oximitry reading?
place the probe on the patient's finger and look at the number displaying on it
What is a proper intervention for orthostatic hypotension?
-have the patent hydrate
-have the patient wear compression stockings
-have the patient become more active
-have the patient elevate slowly
-have the patient dangle their feet off of the side of the bed before completley getting up to avoid falling
a sudden drop of 20 mmHg systolic and 10 mmHg diastolic blood pressure as a patient goes from laying down to sitting to standing up
What is a priorty assessment of a patient after a report?
the PACU nurse should determine which patient needs the most immediate assessment after the circulating nurse gives the PACU nurse a report of how the patient responded during surgery
What is the proper procedure for post mortem care?
-identify the patient through a complete head-to-toe assessment
-document the time of death, the patient's name, the time the call was made and findings on the physical exam
-say that the death occured without unusual circumstances, unless this was not the case
-if the patient is an organ donor, follow the policies appropriate for this
-if the patient needs an autopsy, keep medical devices inserted
-after death, remove medical equipment or tubes (unless there is an autopsy)
-bathe and dress the patient
-position the body appropriatley
-ask the family about special religious or cultural practices that would need to be followed
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