NUR326: Final Exam
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QUESTIONS
CHOOSE ONE ANSWER
TIME : 2 HOUR
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NUR326: Final Exam
sorry but I did not finish the cards because the study guide was 30 pages long.
but make sure you study
all of the psych meds bc omg
PAD Manifestations
- paresthesia
- thin, shiny, taut skin
- loss of hair on lower legs
- diminished/absent pulses
- intermittent claudication (muscle pain from mild exertion, relieved by short period of
rest)
- paleness of extremity with elevation
- resting pain
- reactive hyperemia of foot in dependent position (literally turns red when foot is
hanging down)
CVI manifestations
- edema (uni- or bi- lateral)
- hemosiderin staining (brownish skin discoloration due to iron deposition from
broken down RBCs)
- thick hardened skin giving leathery appearance
- wounds 'weep' (leaking excessive fluid)
- skin becomes friable (fragile skin that breaks easily)
PAD collaborative care: cessation of risky behavior, medications,
surgical/radiographic, diagnostic needs
- cessation of risky behavior: DASH diet (1500mg of sodium), stop smoking, weight
management, hygiene
- medications: BP, BG, coagulation, CV and pulmonary care and support
- surgical/radiographic: debridement, angioplasty, bypass
- diagnostic needs: monitoring labs, ultrasound, cultures, Ankle-brachial index (ABI)
CVI collaborative care
- TED hose/ compression thromboembolic deterrent hose
- high protein diet
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- hyperbaric support: angiogenesis
- drugs: anticoagulants
- moist environment dressings
- elevation of extremity
- underlying medical management support
- cessation of risk factors.
PAD nursing management
- positioning: upside down hand peace sign = legs down for pain relief
- teach about daily foot check/foot care
- wound care
- extremity assessment to report changes for: color, temperature, cap refill,
peripheral pulses, sensation and movement
CVI nursing management
- positioning: peace sign = "V" shape, legs up
- monitor skin
- apply and educate compression
- encourage activity/avoid immobility
informed consent
- active, shared decision making process between HCP and patient.
- adequate disclosure
- clear understanding and comprehension
- voluntary decision by pt
- obtained and explained by physician and witnessed by RN
- consider: emergencies, minors, unconscious, mentally incompetent.
Safety measures to prevent surgical errors: universal protocol
- right site
- right procedure
- right surgery
safety measures to prevent surgical errors: surgical timeout
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- identify the right patient
- compare hospital ID number with patient wristband
preventing surgical complications: assessments, labs, and diagnostics
- assessments: wound/surgical incision assessments, head-to-toe. ABC's are
priority
- PACU: initial assessment that includes airway patency, oxygenation, EKG,
LOC/A&O. ABC's are priority
- labs to monitor: WBC (indicates infection/at risk), K+ (cardiac dysrhythmias)
- Nursing diagnoses: acute pain, anxiety
Pressure injury: stage 1
- skin intact
- non-blanchable redness
- may be harder to detect on darker skin tones
pressure injury: stage 2
- partial thickness skin loss
- pink or red tissue may be seen in wound bed
pressure injury: stage 3
- full thickness skin loss with visible adipose tissue
- granulation tissue often seen (new skin that forms on surface of wound)
pressure injury: stage 4
- full thickness skin loss with muscles, tendons, ligaments, or bone visible
- edges are rolled
- tunneling can be present
pressure injury: unstageable
- the full damage of wound cannot be determined due to wound covered in slough or
eschar
pressure injury: prevention and interventions
- identify patients at risk: malnourished, immobile, altered circulation/decreased
sensory. incontinence, general physical or behavioral health issues.
- keep patients clean, dry, Q2H turns. maintain toileting schedules, protect bony
prominences with supportive surfaces (moonboots)
pressure injury: nutrition
- monitor weight and oral intake
- high protein intake essential to help heal
- utilize high calorie, high protein, fortified foods
pressure injury: wound care
- monitor drainage: amount and characteristics (color, clots, infection, odor)
- monitor for pain