Exam #1 Study Review Week 1

Question 1

Informed consent: what is your role as a nurse

Answer 1

To witness the clients consent
And make sure that they are NPO before midnight

Only the providers job to obtain the consent

Question 2

General anesthesia

Answer 2

Loss of sensation
Loss of consciousness

Question 3

Local Anesthesia

Answer 3

Fully awake
Loss of sensation to localized area

Ex: stitches

Question 4

Monitored anesthesia

Answer 4

Decreased responsiveness
May need airway support

Ex: getting a colonoscopy

Question 5

Regional anesthesia

Answer 5

Loss of sensation to body
Without loss of consciousness

Ex: epidural

Question 6

Anaphylactic reaction (signs and symptoms)

Answer 6

Hypotension
Tachycardia
Bronchospasm
Pulmonary edema

Question 7

Anaphylactic reaction: nursing intervention

Answer 7

Protect airway
Give epinephrine

Question 8

Malignant Hyperthermia manifestations

Answer 8

Increase HR, Decreased BP, dysrhythmia
increased respiratory rate, hypoxia, hypercapnia
Muscle rigidity
Myoglobinuria
Hyperthermia= late sign (bp low)

Question 9

Malignant hyperthermia Nursing interventions

Answer 9

Stop anesthetic
Protect airway
Dantrolene
IV fluid
Initiate cooling measures

Question 10

What to do immediately after patient gets out of surgery

Answer 10

Listen to lungs
ABCs = Airway, breathing, circulation

Question 11

What to do for respiratory depression

Answer 11

Promote coughing and deep breathing
Positioning
O2 therapy
Incentive spirometer

Question 12

Reversing agent for morphine (opioids)

Answer 12

Naloxone

Question 13

Reversing agent for Benzodiazepine

Answer 13

Flumazenil

Question 14

Signs of deep vein thrombosis (Venous thromboembolism)

Answer 14

Edema, redness, and warmth
Calf tenderness or pain

Question 15

Penrose drain

Answer 15

(Looks like a pen)
Is a straight flexible tube that drains fluid from surgery site onto a sponge pad not a regular gauze

Question 16

Jackson Pratt drain

Answer 16

(Bulb looking drain)
This device is used to drain fluids that might collect under or near the incision where the surgeon cut your skin

Question 17

Hemovac Drain

Answer 17

Placed under ur skin during surgery
Removes any blood or other fluids that might build up in the area

Question 18

Post Op : possible GI complications

Answer 18

Might have nausea
Paralytic ileus: Hypoactive or Absent bowel sounds

Question 19

GI complications interventions

Answer 19

Nausea: Antiemetic, NGT to decompress stomach, oral care

Paralytic ileus: ambulation, prokinetic agent, NGT to decompress stomach

Question 20

Dehiscence and Evisceration Nursing Actions

Answer 20

Position patient to supine position with knees flexed
Soak gauze with sterile saline and place on opening to prevent bacteria and infection
Notify surgeon
Make sure patient does not cough

Question 21

Peripheral IV access

Answer 21

Antecubital
Back of hand

Question 22

Central venous IV access

Answer 22

Subclavian vein
Jugular vein

Question 23

Central Line: client education when removing

Answer 23

Tell patient to hold breath and bear down

Use sterile technique when changing IV
(Change dressing with normal gloves then switch to sterile procedure when putting a new dressing back on)

Question 24

IV complications: Infiltration

Answer 24

Edema and discomfort around site
Fluid leaking from site

Stop infusion, elevate extremity and apply warm or cold compress

Question 25

IV complication: Phlebitis

Answer 25

Redness, tenderness, pain Possible red streak and/or palpable cord **stop infusion, use warm compress to relieve pain**

Question 26

Blood transfusion parameters

Answer 26

Need a second nurse to verify vital signs, blood, and allergies Stay with patient for first 15-30 min of transfusion Once blood product is received you have 30 min to begin transfusion and up to 4 hours to transfuse

Question 27

Acute hemolytic reaction

Answer 27

Increase Respiratory rate, dyspnea Increased Heart rate Decreased blood pressure Low back pain Hemoglobinuria

Question 28

Acute hemolytic reaction nursing actions

Answer 28

**Stop infusion and remove blood tubing** Initiate normal saline with new tubing Monitor vital signs and treat symptoms Notify the provider

Question 29

Allergic transfusion reaction

Answer 29

Mild itching, urticaria, flushing Anaphylactic: bronchospasm, hypotension, shock

Question 30

Allergic transfusion reaction nursing action

Answer 30

Stop transfusion and remove tubing Administer normal saline Administer antihistamine Administer epinephrine, vasopressin, corticosteroids, Oxygen for anaphylaxis reaction, and start CPR if needed

Question 31

Blood types

Answer 31

If patient has positive blood they can receive both positive and negative blood If negative then patient can only receive negative blood

Question 32

Hypovolemia

Answer 32

tachypnea Weakness Dry mouth **hematocrit levels: high** **blood osmolality: high**

Question 33

Hypervolemia

Answer 33

Crackles, cough, dyspnea JVD - jugular distended veins Bounding pulse Hypertension Edema

Question 34

Hypokalemia

Answer 34

Flattened T wave Hypoactive bowel sounds Dysrhythmia (for both high and low) **never push IV potassium, very hard on veins (can cause phlebitis)**

Question 35

Hyperkalemia

Answer 35

T waves become peaked Diarrhea Hyperactive bowel sounds- bowel is too tight **administer sodium polystyrene sulfonate**

Question 36

Foods high in potassium

Answer 36

Dried peaches Raisins Oranges Bananas Skin of potatoes

Question 37

Hyponatremia

Answer 37

Can cause seizure, coma, and death - deep tendon reflex **isotonic solution are the best**

Question 38

Hypocalcemia

Answer 38

Tetany, tingling around mouth or fingers Chvostecks sign —> facial twitching when touched by finger Trousseaus sign —> hand and finger spasm

Question 39

Hypercalcemia

Answer 39

Renal cálculo and kidney stones

Question 40

What solution to give for hypernatremia

Answer 40

Dextrose 5% in water

Question 41

Order of what to do client having infiltration

Answer 41

Stop the infusion Remove catheter Apply sterile dressing Elevate extremity Apply warm or cold compress