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NURS 108: Final Exam Competencies Study
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Describe the nursing responsibilities witnessing informed consent - correct answer The surgeon's responsibility is to provide a clear explanation of the surgery as well as benefits, alternatives, possible risks, complications, and removal of body parts prior to the patient giving consent. The nurse needs to...
- Clarify the information provided
- Notify physician if the patient requests additional information
- Make sure the consent form has been signed before administering any premedication
- Assess if the patient was in sound mind before signing forms (consent is not valid if obtained while the patient is under the influence of medications that can affect judgment and decision) Differentiate the different categories of surgical procedures - correct answer 1. Emergent ~Immediate attention/without delay ~Potentially life threatening
- Urgent ~Requires prompt attention ~Within 24-30hrs
- Required ~Surgery is needed within a few weeks or month
- Elective ~Surgery should be performed
- Optional ~Patient decides
Ambulatory surgery: outpatient, same-day, short-stay ~Nurse quickly assesses patient and prepares for discharge/follow up care Identify the teaching need for the use of postoperative pain medications - correct answer 1. Opioid analgesic agents: ~Commonly prescribed for pain and immediate postoperative restlessness ~Taken on a schedule (ex: Q6hrs)
- PCA pumps: ~Pt can push a button every hour to administer pain meds ~Maintains therapeutic drug levels
- Epidural infusions: ~Used with caution in chest procedures (may affect respiration) **For all postop pain meds, advise the patient to stand up slowly and walk with someone to prevent falls (pt may experience dizziness) Identify the client safety precautions in the preoperative area - correct answer 1. Have all pts in a hospital gown
- Remove jewelry/any metal
- Tie all long hair back
- Remove dentures/plates, glasses, any prosthetic devices
- Have all pts void before going to the OR
- If preanesthetic medication is given, raise all side rails and prevent patient from standing/walking alone
- Assess for medication reactions
- Assist in verifying patient ID, surgical procedure, and surgical site
- Cardiogenic ~Heart is unable to pump enough oxygen rich blood to the body organs
- Neurogenic ~State resulting from loss of sympathetic tone causing hypovolemia
- Anaphylactic ~Allergic reaction causing acute system vasodilation and hypovolemia
- Septic ~Subset of sepsis ~Circulatory/cellular metabolism abnormalities profound enough to increase mortality
*Early phase S&S~ feelings of impending doom, decreased cardiac output, vascular resistance, labored breathing, pt reports "feeling cold", tinnitus *Labs= sharp drop in hemoglobin, hematocrit levels Describe the purpose of pre-admission testing - correct answer The main purpose of pre-admission testing is to insure that the patients do not have any contraindications for surgery Pre-admission tests may include bloodwork, urine analysis, EKG, chest X-ray The nurse will...
- Initiate initial preoperative assessments
- Begin education appropriate to patient
- Verify completion of preoperative diagnostic testing
- Verify understanding of surgeon's orders (emptying bowels, checking NPO status, showers)
- Discuss and review advance directive documents
- Begin discharge planning while assessing patient's need for postoperative care Discuss the nursing considerations of a pre-surgical client on aspirin therapy - correct answer 1. Discontinue aspirin therapy 7-10 days before surgery (lowers risk for post-op bleeding)
- Notify CRNA/surgeon of aspirin use prior to surgery
- Check full medication history and report any possible contraindications (some medications mixed with anesthesia can cause hypotension and circulatory collapse) **The anesthesiologist will evaluate the potential effects of medication therapy, the length of time the patient used the medication, the physical condition of patient, and nature of the surgery Discuss the nursing considerations related to geriatric clients after surgery - correct answer ~Transfer patient slowly to prevent skin tears, bruising, and other injury ~Closely monitor BP and ventilation ~Keep patient warm ~Change patient's position frequently (stimulates respirations; promotes circulation & comfort; reduces risk of sores) ~Assess for cardiovascular, pulmonary, or renal function impairment ~Monitor changes in mental status (confusion, delirium) ~Maintain adequate hydration **Keep in mind that the elderly typically recover much slower than young adults Identify the nursing considerations related to a surgical time out - correct answer The circulation nurse is responsible to document findings and make sure a "time out" occurs to debrief about anticipated problems, potential complications, allergies, and comorbidities
With prompt recognition and rapid treatment, the mortality rate is less than 10% Identify the nursing assessment findings associated with an impaired airway - correct answer 1. Hypopharyngeal obstruction ~Pt supine, lower tongue & jaw fall backward, air passages become obstructed
- S&S ~Choking ~Noisy and irregular respirations ~Decreased O2 sat ~Cyanosis of skin ~Bubbling in water seal chamber (if pt has chest tube) ~Dyspnea ~Abnormal respiratory rate, rhythm, and depth Utilize the Aldrete scoring tool - correct answer The Aldrete score is used to determine the patient's general condition and readiness for transfer from the PACU The pt is assessed at regular intervals to calculate a total score Scores: 7-10= discharge <7= must remain in PACU until condition improves or are transferred to an ICU Discuss the nursing responsibilities related to breaks in sterility in the operating room - correct answer ~Prepare sterile field as close as possible to time of use ~Constantly monitor and maintain sterile field ~Discard any item uncertain that is sterile ~If a drape is torn or punctured, it must be replaced
~Whenever a sterile barrier is breached, the area must be considered contaminated. The sterile process will have to be restarted Identify the assessment findings related to postoperative pain - correct answer
- Pain is extremely common after a surgical procedure. Pain reported: 1/3= severe 1/3= moderate 1/3= little/none ~Pain normally does not completely go away until weeks after surgery ~Many factors influence pain (motivational, affective, cognitive, emotional, cultural). The degree and severity of pain depends on the patient's tolerance ~Intense pain stimulates the stress response which affects cardiac and immune systems *S&S of post-op pain: ~Muscle tension ~Movement pain ~Throat pain ~Grimacing ~Moaning/groaning ~Nausea ~Irritation *The nurse needs to implement pharmaceutical and nonpharmaceutical pain relieving measures and assess the effectiveness periodically Identify the nursing interventions used with client complaining of nausea - correct answer ~Deep breathing ~Aromatherapy (especially peppermint)
Identify the cause of postoperative blood pressure changes - correct answer ~Blood loss ~Hypoventilation ~Position changes ~Pooling of blood in extremities ~Side effects of medications and anesthetics ~Loss of circulating volume through blood and plasma loss (most common) ~Pain **Systolic BP >90 needs to be immediately reported **Previously stable BP now showing a downward trend needs to be reported as well Identify the nursing responsibilities related to complication of a surgical incision - correct answer 1. The surgical site and incision should always be inspected for infection and bleeding ~If bleeding is present, place a sterile gauze pad w/ pressure and elevate site to heart level (if possible) ~Notify doctor immediately
- Would dehiscence and evisceration are serious and need to be reported immediately ~Place patient into low Fowler's and instruct the patient to remain still. Cover wound with sterile dressings moistened with sterile saline solution ~Abdominal binders can be used to provide support and guard against dehiscence Identify the nursing assessment findings related to post-surgical blood loss - correct answer ~Decreased hemoglobin and hematocrit levels ~Hypotension ~Hemorrhage (S&S= low BP, rapid pulse, disorientation, restlessness, oliguria, cold pale skin) ~Shock (S&S= feelings of dread, decreased CO, vascular resistance, labored breathing, hypothermia)
**If shock symptoms are left untreated, the patient will continually grow weaker but can remain conscious until near death Identify the assessment findings associated with postoperative complications - correct answer 1. Respiratory: SOB, shallow breathing, ineffective airway
- Cardiovascular: decreased CO/hemorrhage
- GI: N/V, constipation
- Urinary: urine retention
- Vascular: DVT
- Integumentary: dehiscence (open), evisceration (organs protrude)
- Infection Identify the nursing responsibilities associated with high-risk surgical clients - correct answer 1. Assess which patients are at high risk for complications
- Closely monitor vital signs and new signs and symptoms
- Assess for changes in respiratory rate, HR, BP, consciousness, temperature, and urine output
- Relay information to surgeon Identify the interventions involved in the surgical care improvement project (SCIP) - correct answer SCIP identifies performance measures aimed at preventing surgical complications, including VTE's (venous thromboembolism) and surgical site infection ~If beta-blockers are used, the CRNA must evaluate whether the medication should be administered before or after surgery ~The nurse needs to be alert for appropriate preoperative prescriptions aimed at preventing VTE and SSI Prioritize the care of postoperative clients - correct answer 1. Communicate information regarding patient: ~Vital signs
- Family needs ~Answer questions, explain procedure
- Pre-op teaching ~What to expect, what is being done ~Obtain consent
- Pre-op holding area ~Monitor patient ~Prepare for surgery Identify the nursing interventions to ensure optimal cerebral tissue perfusion - correct answer 1. Assess pt for S&S of decreased cerebral tissue perfusion (dizziness, visual disturbances, aphasia, irritability, restlessness, decreased level of consciousness, weakness)
- Implement measures to improve cerebral tissue perfusion ~Administer thrombolytic agents, anticoagulants, antihypertensive ~Prepare client for surgery
- Report any unusual findings to doctor Develop a discharge plan for clients with cranial nerve damage - correct answer
- Assess which cranial nerve was damaged (smell? taste? vision?)
- Plan surgery if needed (ex: microvascular decompression)
- Teach patient signs and symptoms to look out for, and to contact PCP if symptoms worsen
- Advise appointment w/ specialist
Discuss the techniques used to assess cranial nerve function - correct answer 1. Observation of overall appearance, mental status, posture, movement, balance, and affect
- Sensory test~ assess tactile sensation, superficial pain, temperature, proprioception
- Assess involuntary and voluntary reflexes
- Listen to all subjective data from the patient ** Ex: *Olfactory nerve: have patient smell different scents and describe them *Optic nerve: shine pen light into both eyes to check for dilation/constriction and reaction *Oculomotor/Trochlear/Abducent nerves: ask the patient to follow your finger as you draw letters in the air *Trigeminal nerve: ask patient to clench teeth and open against resistance *Facial motor nerve: have patient raise eyebrows, close eyes, puff cheeks *Vestibulocochlear nerve: Weber/Rinne test *Glossopharyngeal nerve: test gag reflex with tongue depressor *Vagus nerve: have patient say "AH" *Accessory nerve: have patient shrug shoulders and turn head against resistance *Hypoglossal nerve: have patient stick tongue out Identify the nursing considerations associated with CT scans - correct answer 1. Inform patients they will have to lay supine and still for 30 min or less
- Ask patient if they are claustrophobic (if they are, antianxiety meds can be given). If their claustrophobia is severe, inform the HCP performing the scan
- Assess for allergies to iodine or shellfish and pregnancy
- Make sure nothing metal is on the patient before heading to the scan (jewelry, pins in hair, glasses, hearing aids, dentures) Identify the medications utilized in the treatment of cerebral edema - correct answer 1. Mannitol
Identify the adverse reactions related to seizure medications - correct answer Mild: ~Lightheadedness ~Poor coordination/balance ~Sleepiness Severe: ~Respiratory depression ~Potential for postictal cerebral edema ~Bone disease (osteoporosis, osteomalacia, hyperparathyroidism) Develop a plan of care for a client with increased intracranial pressure (ICP) - correct answer ICP~ pressure exerted by the volume of the intracranial contents within cranial vault Main goal: Minimize intracranial pressure to prevent any damage to nerve tissue and prevent long term neurological deficits
- Frequent neuro checks (q1h)
- Monitor temp, MAP, CPP
- Avoid sedatives or CNS depressants if possible (could alter neuro checks)
- Administer ordered medications (osmotic diuretics, hypertonic saline, corticosteroids)
- Prepare patient for surgical intervention (craniectomy, external ventricular drain)
- Monitor electrolytes and urine output
- Perform various interventions (maintain HOB 30-45 degrees, decrease stimuli, keep patient from coughing/bearing down) Identify the assessment tools utilized for clients with ICP - correct answer ~CT scanning ~MRI ~Cerebral angiography
~PET
~SPECT
~Transcranial Doppler studies (provide information about cerebral blood flow) ~Electrophysiologic monitoring (observes cerebral blood flow indirectly) **Lumbar punctures are NOT performed because a sudden release of pressure can cause the brain to herniate Identify the teaching needs of the family caring for a client that has seizures - correct answer 1. Give anti-seizure medications as prescribed (DO NOT STOP TAKING WITHOUT CONSULTING PROVIDER)
- Remove clutter in homes (less for patient to fall on/hit if having a seizure)
- Never lock doors so if needed, people can get to you
- Do not let the patient eat or drink anything after the seizure
- Do not hold the patient still/force anything into their mouth to move their tongue
- Discuss driving limitations
- Loosen tight clothing and place something soft under their head
- Notify their health care provider if seizures persist/increase Identify the medications utilized to treat status epilepticus - correct answer Status epilepticus~ prolonged seizures without recovery of consciousness in the intervals between seizures
- IV diazepam, lorazepam, or fosphenytoin (given slowly to halt seizures immediately)
- Phenytoin and phenobarbital (given to maintain seizure-free states) Identify the high-risk complications associated with neurologic dysfunction - correct answer ~Paralysis ~Loss of sensation or strength ~Seizures ~Altered levels of consciousness
Identify the risk factors associated with stroke - correct answer ~Obesity ~Sedentary lifestyle ~Binge drinking ~Smoking ~Diabetes ~Hypertension ~Hypercholesterolemia ~Family history ~Cardiovascular diseases ~Age (55+) ~Gender (male) ~Race (African Americans) Identify the interventions used in aneurysm precautions - correct answer ~ABR testing (hearing) ~Decrease ICP ~No straining ~DVT prevention ~Decrease extra stimuli Identify the criteria & contraindications for thrombolytic therapy for stroke - correct answer Recombinant t-PA is used for stroke victims as "clot busters" to dissolve blood clots that have suddenly blocked major arteries or veins In other to use thrombolytic therapy, you must... ~Take within 3hrs of initial symptoms ~Not be taking other anticoagulation therapies to prevent bleeding **This therapy is contraindicated with patients who have intracranial hemorrhages or head trauma
Describe the care needs of a client with disturbed sensory perception - correct answer 1. Promote safety by preventing falls
- Frequently monitor patient
- Maintain the client's comfort
- Maintain an environment without extraneous stimuli (turn off TV, keep lights lowered, limit visitors)
- Explain procedures and care activities in a way that patients can understand (pictures, gestures)
- Maintain a consistent medication schedule
- Use close ended questions that require a "yes" or "no" when necessary
- Communicate with the patient at eye level and give them extra time to speak
- Use assistive devices (hearing aid, walker, tools for reaching) Identify the modifiable risk factors associated with stroke - correct answer 1. Obesity ~Promote weight loss
- Sedentary lifestyle ~Promote exercise
- Binge drinking & smoking ~Refrain from cigarettes and alcohol
- Hypertension ~Take antihypertensive to control BP
- Hypocholesteremia ~Follow a low cholesterol diet Identify the non-modifiable risk factors associated with stroke - correct answer ~Family history ~Cardiovascular diseases ~Age (55+) ~Gender (male)
