Postoperative Care and Nursing Interventions, Exams of Nursing

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FUNDS FINAL EXAM

What are the 3 things to do when an incorrect medication has been administered in terms of urgency? - ANS 1. Reassess the patient for adverse reactions. 2. Notify the provider. 3. Document A patient complains of nausea while on an oral medication. What should the nurse assess? - ANS Assess the patient and look for the pill in the emesis. Risk for vomiting and expelling the medication. Notes: Pt complains of nausea - oral medication. Assess the pt and look for the pill in the emesis. What should the nurse do if the patient is complaining of pain, tingling, and itching at the IM site? - ANS Assess the patient for other reactions. Notes: Pt complains of pain, tingling, and itching at the IM site. Assess for adverse reactions. What is a time out period? - ANS Confirm pt ID, surgical procedure, and surgical site. Notes: Before surgical procedure confirmation of correct Patient ID, correct surgical procedure, and correct surgical site. If a patient is taking an anti-coagulant before surgery what should be done? Why? - ANS Postpone surgery due to bleeding risk Notes: Patient should also be NPO What should the nurse do if the patients vitals are HR:120bpm and BP: 80/50mmHg postoperatively? - ANS Notify the provider for cause of concern. Notes: Post op - vitals are 120bpm, bp is 80/50. Notify provider for cause of concern. What complications should be looked for in a post-operative patient? - ANS Impaired wound healing. Check the patient's clotting factor, nutrition, and other health concerns. Notes: Obese people would be more at risk for post-op impaired wound healing. Monitor albumin levels. What kind of patient would be more at risk for impaired wound healing? - ANS An obese patient, with poor nutrition, who smokes. Notes: Monitor labs, nutrition, and wound care. What are the signs of infection? (SATA) - ANS Increased pain, incisional pain, serosanguineous drainage, fever, and chills. Pus, redness, and swelling. What findings are present with purulent drainage? - ANS Pus, thick yellow/green odorous drainage.

Notes: thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. What findings are consistent with serous drainage? - ANS Generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. What findings are consistent with serosanguineous drainage? - ANS Pale to Pink drainage. Mixture of serum and red blood cells. It is light pink to blood tinged. What findings are consistent with sanguineous drainage? - ANS Consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. What should the nurse monitor for a post-op patient after surgery on the GI? - ANS Patient should pass gas (indicative of return of peristalsis). Monitor patient for a bowel movement. Notes: Auscultate the abdominal sounds. If patient is unable to pass gas have the patient walk down the hallway. Which HCP is responsible for receiving consent from the patient prior to surgery? - ANS The doctor receives informed consent. Notes: The nurse verifies that consent has been obtained. What should the nurse do for a terminally ill cancer patient? - ANS Provide effective pain management Notes: Palliative care is a dignified death What should be done to improve the sleep pattern of a patient with insomnia? - ANS Do not disturb the pts sleep pattern, remove electronics, and turn off lights, shower/bath may help, retain bedtime routine, sleep diary created by partner to monitor sleep patterns. What is a risk associated with sleepwalking? - ANS Risk of falls and safety What is the best way to prevent infections? - ANS Hand hygiene

What are standard precautions? - ANS Hand hygiene and gloves Notes: Wear clean nonsterile gloves when touching blood, body fluids, excretions or secretions, contaminated items, mucous membranes, and nonintact skin. Change gloves between tasks on the same patient as necessary and remove gloves promptly after use. If the patient has a bug in the stool, what precautions should be taken by the nurse? - ANS Contact precautions Notes: Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Change gloves after having contact with infective material. Remove PPE before leaving the patient environment, and wash hands with an antimicrobial or waterless antiseptic agent. Limit movement of the patient out of the room. Avoid sharing patient-care equipment. What are airborne precautions? - ANS patients who have infections that spread through the air such as tuberculosis, varicella (chicken pox), and rubeola (measles). Notes: Patient is sneezing. Place patient in a private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour, and appropriate discharge of air outside, or monitored filtration if air is recirculated. Keep door closed and patient in room. Wear a respirator when entering room of patient with known or suspected tuberculosis. If patient has known or suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless the person entering room is immune to these diseases. What are droplet precautions? - ANS Patients with an infection that is spread by large-particle droplets such as rubella, mumps, diphtheria, and the adenovirus infection in infants and young children. Notes: Patient is coughing and sneezing. Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patient's environment. Transport patients out of the room only when necessary and place a surgical mask on the patient if possible. Keep visitors 3 ft from the infected person. Except for hand hygiene, what other method is used to prevent infection? - ANS Identifying which patients are at high risk

What should you do if you find out a patient is at risk for infection? (SATA) - ANS Proper hand hygiene, proper PPE, contact precautions, identify the pt that is at risk, take prescribed ABX until completed. What is phlebitis? - ANS Inflammation, hot, warm, sign of infection Notes: Local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site What is infiltration? - ANS Swelling, pallor, coldness, or pain around the infusion site; significant decrease in the flow rate What is an embolism? - ANS inflammation of a blood vessel and formation of a thrombus [blood clot] What are the steps to administer a blood transfusion? (SATA) - ANS Don clean gloves while spiking the bag. Confirm the right patient, dosage, and drop rate with 2 RNS. Verify informed consent from the patient. Monitor vitals 30 minutes prior, 15 minutes during, and 30 minutes after. Notes: DO NOT run blood for over 4 HOURs. What should the nurse remember when monitoring intake and output? - ANS Document over 24 hours What should be the priority when monitoring fluid deficit? - ANS Weight loss Notes: Dehydration and weight loss. Skin turgor is affected. What should be the priority when monitoring fluid excess? - ANS Edema/swelling in the legs and crackles in the lungs. What should be done for a patient with +4 pitting edema? - ANS Elevate the legs, fluid restriction, and monitor urine output if the patient is on diuretics. What should be done for a patient at risk for heart failure? - ANS Fluid restriction What is the TEACH acronym? - ANS T: Tune into patient E: Edit patient information

A: Act on every teaching moment C: Clarify often H: Honor the patient What is the RACE acronym for fires? - ANS R: Rescue anyone in immediate danger A: Activate the fire code system and notify the appropriate person C: Confine the fire by closing doors and windows. E: Evacuate patients and other people to a safe area What is the nursing care plan? - ANS Illustrates each phase of the nursing process and a sample documentation of nursing assessment or intervention. Notes: Nursing process ADPIE - assessing, diagnosing, planning, implementing, and evaluating What method should be used to confirm the patient's knowledge on ostomy care or a process? - ANS The patient should use the teach back method. Notes: If patient cannot do the teach back method watch patient do the method of ostomy care or process. What are the signs of impending death? - ANS Cheyne-stokes respirations, Low BP (decreasing BP), weak or irregular pulse, restlessness, agitation, bowel incontinence, nausea, flatulence, malnutrition If a patient has a DNR, what should you NOT do? - ANS Do not do CPR or call a CODE. How should the nurse assist in the dying process? - ANS Be aware of cultural beliefs and grant time for the grieving process. How should you ask what are a patient's spiritual beliefs? - ANS Be direct and ask What are the basic needs of everyone? - ANS Love and relatedness/belongingness What is ineffective and effective coping? - ANS Ineffective - more than 6 months after death. Effective - less than 6 months

What are the stages of grief? - ANS Denial and isolation, anger, bargaining, depression, and acceptance. Notes: Denial: The patient denies the reality of death and may repress what is discussed. The patient may think, "They made a mistake in the diagnosis. Maybe they mixed up my records with someone else's." Anger: The patient expresses rage and hostility and adopts a "why me?" attitude: "Why me? I quit smoking and I watched what I ate. Why did this happen to me?" Bargaining: The patient tries to barter for more time: "If I can just make it to my son's graduation, I'll be satisfied. Just let me live until then." Many patients put their personal affairs in order, make wills, and fulfill last wishes, such as trips, visiting relatives, and so forth. It is important to meet these wishes, if possible, because bargaining helps patients move into later stages of dying. Depression: The patient goes through a period of grief before death. The grief is often characterized by crying and not speaking much: "I waited all these years to see my daughter get married. And now I may not be here to see her walk down the aisle. I can't bear the thought of not being there for the wedding—and of not seeing my grandchildren." Acceptance: When the stage of acceptance is reached, the patient feels tranquil. The patient has accepted the reality of death and is prepared to die. The patient may think, "I've tied up all the loose ends: made the will, made arrangements for my daughter to live with her grandparents. Now I can go in peace knowing everyone will be fine." What is an urgent priority assessment with unconscious patients? - ANS Risk for aspiration. Put bed in semi/high fowlers. Notes: skin breakdown and pressure ulcers What should you do if a patient wants to take a bath and has an unsteady gait? - ANS Assist the patient in and out of the bath What is indicative of a properly functioning hearing aid? - ANS A whistling sound me ANS the hearing aid is functioning properly How should the nurse communicate effectively with a patient with hearing issues? - ANS Communicate with them by sitting face to face and turn off the TV What safety measures should be taken with a patient that is on anti-coagulants? - ANS Males should use electric razors to prevent nicks and cuts. Notes: Do not use manual razors

What is passive range of motion? - ANS Lifting or moving the patient What is active range of motion? - ANS Patient is mobile. Patient goes to the gym. What should be remembered when cleaning and assessing an obese patient? - ANS Make sure to clean under folds, rolls, flaps, and breasts. At risk for skin integrity. How should you help dry a patient after shower or bath? - ANS Pat the patient dry What are the 4 wound stages? - ANS Stage 1 - nonblanchable erythema of intact skin Stage 2 - partial thickness loss of the dermis Stage 3 - full thickness loss Stage 4 - full thickness dermis loss and tissue loss Unstageable - obscured full thickness skin and tissue loss. Tissue damage cannot be confirmed. Don't know what the condition is, dark and hard skin Presents as - black, dark, eschar Deep tissue pressure injury - Persistent nonblanchable deep red, maroon, or purple discoloration. A patient has a fracture and has non-blanchable redness on the heel, what is the priority? - ANS Immediately intervene for the heel What should you do after changing and performing wound care? - ANS Document the findings What should you assess when changing a wound? - ANS Color and amount of drainage How should you treat inflammation in a patient? - ANS With an ice pack to the injury site What is evisceration of a wound? - ANS Protrusion of the wound. Protrusion of intra-abdominal organ What is dehiscence? - ANS Partial or total separation of wound layers because of excessive stress on unhealed wounds.

Notes: partial or total separation of wound layers as a result of excessive stress on unhealed wounds. Patients at greater risk include obese or malnourished individuals; tobacco smokers; and those taking anticoagulants, who have infected wounds, or who experience excessive coughing, vomiting, or straining What is the first action the nurse should do before treating a patient? - ANS hand hygiene How should you prevent infection when changing a wound? - ANS Hand hygiene How should the nurse assess DVT? - ANS Assess DVT bilaterally and measure the thigh How should you prevent injury while lifting? - ANS Proper body mechanics - lifting correctly How should you prepare a patient to be ambulated? - ANS Move patient slowly to the end of the bed and dangle their legs before moving. What should the nurse do to prevent choking? - ANS Put the patient in high fowlers What is abduction? - ANS Moving away from the body What is adduction? - ANS Moving towards thee body What is TPN? What should be monitored? - ANS Total Parenteral Nutrition via IV. Monitor glucose levels 3 times a day. Notes: TPN should be administered via pump and tubing should be changed every 24 hours to prevent infection. Why would a patient be NPO pre-operatively? - ANS To prevent the risk of aspiration What is an NG tube? How should it be measured before placement? - ANS Nasogastric tube. Measure from the ear to the nose and then to the xiphoid process. Confirm placement with x-ray and check aspirated content to confirm stomach pH.

How would the nurse assist the patient to alleviate heartburn? - ANS Place the patient in high fowlers What is indicative of poor nutrition? - ANS Skin turgor/texture, dry skin, albumin levels How should the nurse intervene with a patient with dark, cloudy, and foul smelling urine and has burning, pain, and itching? - ANS Most likely signs of UTI Notes: Treat with cranberry juice if pt has burning or frequency during urination. If on antibiotics, eliminate garlic from meals. What is micturition? - ANS Voiding or urinating. Process of emptying the bladder. How would the nurse assess the bladder? - ANS Palpate the bladder above the symphysis pubis. Check the contents of the bladder with bladder scanner for urinary retention. What should the nurse recommend to a patient with dark urine in the foley bag? - ANS Tell the patient to hydrate well. What is urgency? - ANS Strong desire to urinate and feeling goes away. What is polyuria? - ANS Frequent urination What is dysphagia? - ANS Difficulty swallowing What is proteinuria? - ANS Protein in the urine What does the patient risk with placement of an indwelling catheter? - ANS Catheter associated UTI (CAUTI) SATA question: What should you remember when placing a foley catheter? - ANS - Wash from front to back

• Clean the perineal area from front to back
• Bag should be placed on the bed frame

• NEVER put bag on SIDE RAIL If the patient is not able to produce a urine sample, what should the RN do to intervene? - ANS Straight catheter SATA question: When should the RN intervene? - ANS - Donning gloves before providing patient care
• Clean the perineal area from front to back
• UAP is measuring urine output from the foley bag
• The foley bag is on the side rail Where should the foley bag be placed? - ANS Below the bladder and at an unmovable area How should the perineal area be cleaned? - ANS From front to back How is a sterile urinalysis performed? - ANS Straight catheter into the bladder What should the nurse hear when auscultating bowel sounds of a patient with diarrhea? - ANS Hyperactive bowel sounds What should the nurse hear when auscultating bowel sounds of a patient with constipation? - ANS Hypoactive bowel sounds What should be a priority when the nurse auscultates absent bowel sounds for 5 minutes? - ANS Paralytic ileus How should the nurse assess the abdomen? - ANS Inspection, Auscultation, Percussion, Palpation Notes: PALPATION ALWAYS LAST FOR ABDOMEN (light then deep) How will a nurse properly measure the stoma? - ANS Use the face plate. ½ - 1/8 inch from the stoma for the face plate. Notes: The Stoma should be moist

How do you maintain patient bowel habits? - ANS Enforcing and monitoring the patient's bowel routine How should you respect a Jehovah's witnesses beliefs? - ANS Understand that they cannot receive blood transfusions. Respect their faith What should the nurse do if the patient says, "we are going to pray." - ANS Don't leave the room, just stay to respect their beliefs The patient experiences fever, redness, and rash during the blood transfusion. What should the nurse do? - ANS STOP the TRANSFUSION What is the normal frequency for bowel movements? - ANS At least once a day What should the nurse do to educate the patient on spiritual pain and narcotics? - ANS Explain that narcotics don't always relieve the pain. Religion can help with pain. How should the nurse intervene if a patient exhibits spiritual pain? - ANS Call a spiritual leader to help them and provide privacy for them. The nurse needs to administer HIV medication and the patient has visitors present, what should the nurse do? - ANS Ask visitors to leave and then administer. Maintain confidentiality of patient's illness. Notes: Some patients do not want company when meds are administered. Some family members not aware of illness. What does spiritual distress look like? - ANS Person crying, holding bible, and praying. What western medication should be avoided when taking anticoagulants? - ANS Gingko biloba What type of food should be avoided when taking antibiotics? - ANS Garlic What can RNs NOT delegate? - ANS UAPS cannot EAT. EAT (evaluate, assess, teach).

• Cannot delegate evaluations

• Cannot delegate assessments
• Cannot delegate teaching patients
• Cannot delegate administration of meds
• Cannot delegate removal of anything
• UAPS CAN collect urine if it isn't a sterile process. If a patient declines a certain food item, what should the nurse do? - ANS Remove the entire tray and ask the patient for their food preferences. Notes: Especially Jewish patients, once the plate is unclean, it cannot be kosher after. How should you care for a culturally sensitive patient? - ANS Nutrition, religion, cleaning up the room. How do you maintain cultural self-awareness? - ANS Examine your own self beliefs What should the nurse remember with a patient's culture? - ANS Beliefs, values, religion, and physical appearance are never the same. What should you do for a patient that is on a narcotic? - ANS To Prevent constipation: Increase fluids, fiber, and exercise How do artificial nails affect the risk of infection? - ANS Artificial nails increase the risk of infection because bacteria under the fingernails. What kind of medication would an overweight patient be taking typically? - ANS A diuretic What are signs of pulmonary edema? - ANS Rales and wheezing upon lung auscultation. Bloody thin sputum. What are the rights of medication administration? - ANS - Right medication
• Right patient
• Right dosage
• Right route

• Right time
• Right reason
• Right assessment
• Right documentation
• Right response to patient - Right to education - Right to refuse What are the 3 checks of medication administration? - ANS - When nurse reaches for the unit dose package/container
• After retrieval from the drawer and compared with the eMAR/MAR or compared with the eMAR/MAR immediately before poured from a multidose container.
• Just before giving the medication to the patient, or when returning the multidose container. What is the purpose of an IM injection? Where is it administered and how? - ANS Deltoid, Ventrogluteal, and Vastus Lateralis
• IM angle 90 degrees
• Needle size - 18-25G
• Intramuscular injections like vaccinations etc., How should you help an unconscious patient that is an NPO? - ANS You can help them with oral hygiene Notes: Oral hygiene can help with the feeling of dry mouth. How do you obtain a clean catch from the foley catheter? - ANS Directly from the port on the catheter never from the bag. When should colostomy and foley bags be emptied? - ANS When they are half full What are signs of a healthy stoma? - ANS Stoma should be pink. How do you clean the stoma? - ANS Clean the skin around the stoma with mild skin cleanser and water or a cleansing agent and a washcloth. Remove all old adhesive from the skin; additional adhesive remover may be used. Do not apply lotion to the peristomal area. Cleaning the skin removes excretions and old adhesive and skin protectant. Excretions or a buildup of other substances can irritate and damage the skin. Lotion will prevent a tight adhesive seal. Gently pat the

area dry. Make sure the skin around the stoma is thoroughly dry. Assess the stoma and the condition of the surrounding skin. What should patients with Obstructive Sleep Apnea (OSA) use while sleeping? - ANS Continuous positive airway pressure (CPAP) What is REM sleep? - ANS Rapid eye movement sleep- irregular respirations and appears to be asleep. Non-rem - non rapid eye movement When would sleep medications usually be administered? - ANS PRN - as needed. Melatonin and Ambien What can increase the risk of insomnia? - ANS Smoking and caffeine What is stage 4 sleep? - ANS BP is decreased, pulse and respirations decrease. Greatest depth of sleep. Delta sleep. Notes: arousal from sleep is difficult. Muscles are relaxed. Body temp low, metabolism slows. What are the elements of spirituality? - ANS relationships, values, and life purpose How do you respect patient's beliefs system? - ANS - When assessing for spirituality: ask "how can I maintain your spiritual practices"

• Spiritual pain: Narcotics don't always relieve pain - religion can help with pain.
• Person in spiritual distress - may be crying, requesting bible, praying - Respect pts dietary restrictions
• Listen to pt that are culturally sensitive
• (SATA) nutrition, religion, how they clean up. When a patient says, "I miss this person." What is this an example of? - ANS Need for love and belongingness When a patient says, "I wish I could've spent more time with the patient." What is this an example of? - ANS Need for forgiveness

What are the parts of holistic nursing? - ANS Mind, body, spirit What should you do immediately if a patient falls? - ANS Report it and document it DO NOT BREAK HIPAA - ANS can include unauthorized access, use, or disclosure of Protected Health Information (PHI), failure to provide patients with access to their PHI, lack of safeguards to protect PHI, failure to conduct regular risk assessments, or insufficient employee training on HIPAA rules. What should you consider when administering medication to a palliative care patient? - ANS Conditions of ethical distress, whether to medicate the patient. What is patient autonomy? - ANS Patient decides what they want What is beneficence? - ANS Nurse performs actions intended to benefit others, with the patient's best interests in mind What is maleficence? - ANS Deliberate infliction of a negative act or effect on another individual or a group. What are moral values? - ANS Right vs Wrong What is appropriate when performing CPR on a patient with asystole? - ANS Stop CPR because it is not ethical. What should you do to treat constipation? - ANS Increase fibrous foods like fruits and increase fluids What are the precautions for C. diff? - ANS Hand hygiene before and after contact. Contact precautions. What is fecal occult blood? - ANS Blood in the stool that cannot be seen What should the nurse do if the patient does not have an escort home after surgery? - ANS Postpone or cancel the surgery

What are the injection angles of ID, IM, SQ, and IV - ANS - ID - 10-15 degrees - needle size 25-27G

• IM - 45-90 degrees - needles size 18-25G
• SQ - 45-90 degrees - needle size 25-27G
• IV (fastest) - 25 degrees - needle size 16, 18, 22 -24G Deltoid (least invasive), Vastus Lateralis (children), and Ventrogluteal What is the Z track method and why is it used? - ANS Used to promote absorption of the medication and prevent leakage of the medication. Pulling the skin and subcutaneous tissue to the side of the injection site before inserting the needle Notes: pulling the skin and subcutaneous tissue to the side of the injection site before inserting the needle