NUR265: Final Exam || Guaranteed Pass.
Describe a comprehensive preoperative assessment to identify pertinent health and surgical risk
factors correct answers Initiates the nursing process
Admission data: demographics, health hx, other information pertinent to the surgical procedure
Verifies completion of preoperative diagnostic testing
Begins discharge planning by assessing pt's need for postop care
Health hx and physical exam, medications and allergies, nutrition, fluid status, dentition, drug or
alcohol use, respiratory and cardiovascular status, hepatic and renal function, endocrine function,
immune function, previous medication use, psychosocial factors, spiritual, cultural beliefs
Medications that potentially affect surgical experience: corticosteroids, diuretics, phenothiazines,
tranquilizers, insulin, antibiotics, anticoagulants, anticonvulsant meds, thyroid hormone, opioids,
OTC and herbal
Identify legal and ethical considerations related to obtaining informed consent for surgery correct
answers should be written before non emergent surgery, legal mandate, surgeon must explain the
procedure/benefits/risks/complications/etc, nurse calcifies information and witnesses signature,
consent is valid ONLY when signed before administering psychoactive premedication, consent
accompanied patient to OR
Describe preoperative nursing measures that decrease the risk for infection and other
postoperative complications correct answers providing pt education, deep breathing, coughing,
and incentive spirometry, mobility and active body movement, pain management, cognitive
coping strategies, education for pts undergoing ambulatory surgery, providing psychosocial
interventions, reducing anxiety and decreasing fear, respecting cultural/spiritual/religious beliefs,
maintaining pt safety, managing nutrition, fluids, preparing the bowels, preparing the skin, pt
changes into gown, mouth inspection, jewelry removed, valuable stored in a secure place,
administering preanesthetic medication, maintaining preoperative record, transporting pt to
presurgical area, attending to family needs
Describe the responsibilities of the post-anesthesia care nurse in the prevention of immediate
post-operative complications. correct answers Provide care for patient until patient has revered
from effects of anesthesia. (Resumption of motor and sensory function, Oriented, Stable VS,
shows no evidence of hemorrhage or other complications or surgery), vital to perform frequent
,skilled assessment of patient, review pertinent information, baseline assessment upon admission
to unit, assess airy, respiratory function, cardiovascular function, skin color, level of
consciousness, and ability to respond to commands, reassess VS, patient status every 15 minutes
or more frequently as needed, administration of postoperative analgesia, transfer report, to
another unit or discharge patient to home. Discharge planning, discharge assessment, provide
written, kernel instructions regarding medications, diet, give prescriptions, phone numbers,
discuss actions to take if complications occur. Give instructions to patient, responsible adult who
will accompany patient, patients are not to drive home or be discharged to home alone, sedation,
anesthesia may affect memory, judgement, affect ability.
Identify assessment parameters appropriate for the early detection of postoperative
complications. correct answers Assessment: Respiratory, pain, mental status/LOC, general
discomfort, primary consideration: necessary to maintain ventilation, oxygenation, provide
supplemental O2 as indicated, assess breathing by placing hand near face to feel movement of
air. Keep head of bed elevated 15 to 30 degrees unless contraindicated-may require suctioning. If
vomiting occurs, turn patient, monitor all indicators of cardiovascular status assess all IV lines,
potential for hypotension, shock, potential for hemorrhage, potential for hypertension,
dysrhythmias, Pallor. Cool, moist skin, rapid respirations, cyanosis, rapid, weak, thready pulse,
decreasing pulse pressure, low blood pressure, concentrated urine, assess patient comfort, control
of environment: quiet, low lights, noise level, administer analgesics as indicated; usually short-
acting Opioids IV. Family visit, dealing with family anxiety. Intervene at first indication of
nausea, medications, assessment of postoperative nausea, vomiting risk, prophylactic treatment.
Plan effective care of patients with the following imbalances: fluid volume deficit and fluid
volume excess, sodium deficit (hyponatremia) and sodium excess (hypernatremia), and
potassium deficit (hypokalemia) and potassium excess (hyperkalemia). correct answers Fluid
Volume Deficit (hypovolemia) Abnormal fluid losses, decreased intake, third-space fluid shifts,
additional causes: I&O at least every 8 hours, sometimes hourly, daily weight, vital signs closely
monitored, skin and tongue turgor, mucosa, urine output, mental status, measures to minimize
fluid loss. Administration of oral fluids, administration of parenteral fluids, Fluid Volume Excess
Edema, distended neck veins, cradles: I&O and daily weights assess lung sounds, edema, other
symptoms, monitor response to medications-diuretics and parenteral fluids, promote adherence
to fluid restrictions, patient teaching related to sodium and fluid restrictions, monitor, avoid
sources of excessive sodium, including medications, promote rest. Hyponatrimia,
hypernatremia(Sodium): (Hyponatremia). Less than 135mEq/L Treat underlying condition,
sodium replacement, water restriction, medication, assessment: I&O, daily weight, lab values,
CNS changes. Encourage dietary sodium, monitor fluid intake. Effects of medications (diuretics,
lithium) Hypernatremia Higher than 145mEq/L:Gradual lowering of serum sodium level via
, infusion of hypotonic electrolyte solution. Diuretics, Assessment for abnormal loss of water and
low water intake, assess for over-the counter sources of sodium. Monitor for CNS changes.
Hypokalemia, hyperkalemia (potassium): Hypokalemia less thean 3.5 mEq/L:Potassium
replacement: Increased dietary potassium or IV for severe deficit. Monitor ECG for changes,
monitor ABG's, monitor patients receiving digitalis for toxicity. Monitor for early signs and
symptoms, administer IV potassium only after adequate urine output has been established.
Hyperkalemia:Greater than 5.0. Monitor ECG, assess labs, monitor I&O, obtain apical pulse.
Limitation of dietary potassium and dietary teaching. Administration of cation exchange resins
Interpret arterial blood gas measurements correct answers Normal Levels:
PH-7.35-7.45
OaCI 35-45 mm H
HCO3 22-26 mEq/L (assumes average values for ABG interpretation)
Pa)2 80-100 mm Hg 02 sat greater than 94% Base excess/deficit +/-2 mEq/L.
Metabolic Acidosis: low PH <7.35
Low Bicarbonate <22 mEq/L
Metabolic Alkalosis: High pH >7,45
Bicarbonate >26 mEq/L
Respiratory Acidosis: Low pH <7.35 paCO2>42 mm Hg
Respiratory Alkalosis: High pH>7,45 PaCO2<35
Use the nursing process as a framework for care of patients with Stevens-Johnson syndrome
correct answers A: skin and oral inspection, VS (fever, rest status, tachycardia), fatigue, pain
levels, urine--volume/specific gravity/color, local s/s infection at IV site, daily weight, evaluate
anxiety and coping mechanism
DX: impaired tissue integrity, deficient fluid volume and electrolyte loss related to loss of fluids
from denuded skin, risk for imbalanced body temp--hypothermia--related to heat loss secondary
to skin loss, acute pain related to denuded skin/oral lesions/possible infections, anxiety related to
physical appearance.
Describe a comprehensive preoperative assessment to identify pertinent health and surgical risk
factors correct answers Initiates the nursing process
Admission data: demographics, health hx, other information pertinent to the surgical procedure
Verifies completion of preoperative diagnostic testing
Begins discharge planning by assessing pt's need for postop care
Health hx and physical exam, medications and allergies, nutrition, fluid status, dentition, drug or
alcohol use, respiratory and cardiovascular status, hepatic and renal function, endocrine function,
immune function, previous medication use, psychosocial factors, spiritual, cultural beliefs
Medications that potentially affect surgical experience: corticosteroids, diuretics, phenothiazines,
tranquilizers, insulin, antibiotics, anticoagulants, anticonvulsant meds, thyroid hormone, opioids,
OTC and herbal
Identify legal and ethical considerations related to obtaining informed consent for surgery correct
answers should be written before non emergent surgery, legal mandate, surgeon must explain the
procedure/benefits/risks/complications/etc, nurse calcifies information and witnesses signature,
consent is valid ONLY when signed before administering psychoactive premedication, consent
accompanied patient to OR
Describe preoperative nursing measures that decrease the risk for infection and other
postoperative complications correct answers providing pt education, deep breathing, coughing,
and incentive spirometry, mobility and active body movement, pain management, cognitive
coping strategies, education for pts undergoing ambulatory surgery, providing psychosocial
interventions, reducing anxiety and decreasing fear, respecting cultural/spiritual/religious beliefs,
maintaining pt safety, managing nutrition, fluids, preparing the bowels, preparing the skin, pt
changes into gown, mouth inspection, jewelry removed, valuable stored in a secure place,
administering preanesthetic medication, maintaining preoperative record, transporting pt to
presurgical area, attending to family needs
Describe the responsibilities of the post-anesthesia care nurse in the prevention of immediate
post-operative complications. correct answers Provide care for patient until patient has revered
from effects of anesthesia. (Resumption of motor and sensory function, Oriented, Stable VS,
shows no evidence of hemorrhage or other complications or surgery), vital to perform frequent
,skilled assessment of patient, review pertinent information, baseline assessment upon admission
to unit, assess airy, respiratory function, cardiovascular function, skin color, level of
consciousness, and ability to respond to commands, reassess VS, patient status every 15 minutes
or more frequently as needed, administration of postoperative analgesia, transfer report, to
another unit or discharge patient to home. Discharge planning, discharge assessment, provide
written, kernel instructions regarding medications, diet, give prescriptions, phone numbers,
discuss actions to take if complications occur. Give instructions to patient, responsible adult who
will accompany patient, patients are not to drive home or be discharged to home alone, sedation,
anesthesia may affect memory, judgement, affect ability.
Identify assessment parameters appropriate for the early detection of postoperative
complications. correct answers Assessment: Respiratory, pain, mental status/LOC, general
discomfort, primary consideration: necessary to maintain ventilation, oxygenation, provide
supplemental O2 as indicated, assess breathing by placing hand near face to feel movement of
air. Keep head of bed elevated 15 to 30 degrees unless contraindicated-may require suctioning. If
vomiting occurs, turn patient, monitor all indicators of cardiovascular status assess all IV lines,
potential for hypotension, shock, potential for hemorrhage, potential for hypertension,
dysrhythmias, Pallor. Cool, moist skin, rapid respirations, cyanosis, rapid, weak, thready pulse,
decreasing pulse pressure, low blood pressure, concentrated urine, assess patient comfort, control
of environment: quiet, low lights, noise level, administer analgesics as indicated; usually short-
acting Opioids IV. Family visit, dealing with family anxiety. Intervene at first indication of
nausea, medications, assessment of postoperative nausea, vomiting risk, prophylactic treatment.
Plan effective care of patients with the following imbalances: fluid volume deficit and fluid
volume excess, sodium deficit (hyponatremia) and sodium excess (hypernatremia), and
potassium deficit (hypokalemia) and potassium excess (hyperkalemia). correct answers Fluid
Volume Deficit (hypovolemia) Abnormal fluid losses, decreased intake, third-space fluid shifts,
additional causes: I&O at least every 8 hours, sometimes hourly, daily weight, vital signs closely
monitored, skin and tongue turgor, mucosa, urine output, mental status, measures to minimize
fluid loss. Administration of oral fluids, administration of parenteral fluids, Fluid Volume Excess
Edema, distended neck veins, cradles: I&O and daily weights assess lung sounds, edema, other
symptoms, monitor response to medications-diuretics and parenteral fluids, promote adherence
to fluid restrictions, patient teaching related to sodium and fluid restrictions, monitor, avoid
sources of excessive sodium, including medications, promote rest. Hyponatrimia,
hypernatremia(Sodium): (Hyponatremia). Less than 135mEq/L Treat underlying condition,
sodium replacement, water restriction, medication, assessment: I&O, daily weight, lab values,
CNS changes. Encourage dietary sodium, monitor fluid intake. Effects of medications (diuretics,
lithium) Hypernatremia Higher than 145mEq/L:Gradual lowering of serum sodium level via
, infusion of hypotonic electrolyte solution. Diuretics, Assessment for abnormal loss of water and
low water intake, assess for over-the counter sources of sodium. Monitor for CNS changes.
Hypokalemia, hyperkalemia (potassium): Hypokalemia less thean 3.5 mEq/L:Potassium
replacement: Increased dietary potassium or IV for severe deficit. Monitor ECG for changes,
monitor ABG's, monitor patients receiving digitalis for toxicity. Monitor for early signs and
symptoms, administer IV potassium only after adequate urine output has been established.
Hyperkalemia:Greater than 5.0. Monitor ECG, assess labs, monitor I&O, obtain apical pulse.
Limitation of dietary potassium and dietary teaching. Administration of cation exchange resins
Interpret arterial blood gas measurements correct answers Normal Levels:
PH-7.35-7.45
OaCI 35-45 mm H
HCO3 22-26 mEq/L (assumes average values for ABG interpretation)
Pa)2 80-100 mm Hg 02 sat greater than 94% Base excess/deficit +/-2 mEq/L.
Metabolic Acidosis: low PH <7.35
Low Bicarbonate <22 mEq/L
Metabolic Alkalosis: High pH >7,45
Bicarbonate >26 mEq/L
Respiratory Acidosis: Low pH <7.35 paCO2>42 mm Hg
Respiratory Alkalosis: High pH>7,45 PaCO2<35
Use the nursing process as a framework for care of patients with Stevens-Johnson syndrome
correct answers A: skin and oral inspection, VS (fever, rest status, tachycardia), fatigue, pain
levels, urine--volume/specific gravity/color, local s/s infection at IV site, daily weight, evaluate
anxiety and coping mechanism
DX: impaired tissue integrity, deficient fluid volume and electrolyte loss related to loss of fluids
from denuded skin, risk for imbalanced body temp--hypothermia--related to heat loss secondary
to skin loss, acute pain related to denuded skin/oral lesions/possible infections, anxiety related to
physical appearance.
