NUR 2050: Final exam study guide!!
Antidote for coumadin and heparin - correct answer--Coumadin: vitamin K
-Heparin: protamine sulfate
characteristics of stage 1 pressure injury - correct answer--nonblanchable erythema
of intact skin
characteristics of stage 2 pressure injury - correct answer-partial thickness skin loss
with exposed dermis. can appear as serum filled blister. wound bed is viable,
pink/red and moist
characteristics of stage 3 pressure injury - correct answer-full thickness skin loss thru
subcutaneous tissue. eschar and slough may be present. no fascia, muscle, tendon,
ligament seen.
characteristics of stage 4 pressure injury - correct answer-full thickness skin loss thru
fascia, muscle, tendon, bone, or ligament. slough and eschar may be present.
tunneling may be present
For NG and PEG- how can you prevent aspiration, what value is a high residual?
What does it mean to have a high residual? - correct answer--Do tube checks
-Keep HOB no lower than 30* during continuous feeding and 1 hour after bolus
feeding
-Hold feeding when turning pt or during hygiene care
,high post residual value= non-absorption/slow absorption of tube feeds
(200-250=high PVR)
How to prevent shear and friction forces from causing pressure injuries? - correct
answer--using lifting devices, transfer sheets, and transparent films. (friction is
caused from pulling of the skin from transferring and shearing is from displaced skin
from sliding down into bed caused from increased bed incline.)
metabolic acidosis manifestations - correct answer-Nausea
Anorexia
Abdominal pain
Diarrhea
Decreased LOC
Muscle twitching (hypercalcemia)
Tremors
Convulsions
Increased rate and depth of respirations
Skin warm and flushed
metabolic alkalosis manifestations - correct answer-symptoms related to decreased
calcium, respiratory depression, tachycardia, symptoms of hypokalemia, hypertonic
muscles
NREM: Physiology Summary - correct answer--Low steady metabolic rate
-HR/BP/R/Brain temp/Cerebral blood flow decreased
, -Peripheral blood volume dilated->low BP
Nursing interventions to prevent pressure ulcers and DVT? - correct answer-DVT
Prevention: -TED hoses-sequential compression device, ambulation/range of motion
Pressure injuries: Repositioning every 2 hours, use of wedges/pillows under bony
prominences, preventative dressings over bony prominences.
Peri-operative patient teaching regarding medication - correct answer-Prescribed
medications that will most likely be stopped for surgery:
---anticoagulants, diuretics, adrenal steroids, antibiotics, ASA, NSAIDs, herbal
supplements
Preoperative medications:
---Use: decrease anxiety/amount of general anesthesia/pain, promote
relaxation/sedation/comfort
---Side Effects: decrease BP and pulse, resp. depression
---Ex: antianxiety, sedatives, opioid analgesics
Peri-operative patient teaching regarding pain management - correct answer-Teach
patient that prescribed pain meds will help
-They have very low chance of addiction (think opioid crisis)
-Set realistic goals and have good regimen
-Pain is not a weakness!
Antidote for coumadin and heparin - correct answer--Coumadin: vitamin K
-Heparin: protamine sulfate
characteristics of stage 1 pressure injury - correct answer--nonblanchable erythema
of intact skin
characteristics of stage 2 pressure injury - correct answer-partial thickness skin loss
with exposed dermis. can appear as serum filled blister. wound bed is viable,
pink/red and moist
characteristics of stage 3 pressure injury - correct answer-full thickness skin loss thru
subcutaneous tissue. eschar and slough may be present. no fascia, muscle, tendon,
ligament seen.
characteristics of stage 4 pressure injury - correct answer-full thickness skin loss thru
fascia, muscle, tendon, bone, or ligament. slough and eschar may be present.
tunneling may be present
For NG and PEG- how can you prevent aspiration, what value is a high residual?
What does it mean to have a high residual? - correct answer--Do tube checks
-Keep HOB no lower than 30* during continuous feeding and 1 hour after bolus
feeding
-Hold feeding when turning pt or during hygiene care
,high post residual value= non-absorption/slow absorption of tube feeds
(200-250=high PVR)
How to prevent shear and friction forces from causing pressure injuries? - correct
answer--using lifting devices, transfer sheets, and transparent films. (friction is
caused from pulling of the skin from transferring and shearing is from displaced skin
from sliding down into bed caused from increased bed incline.)
metabolic acidosis manifestations - correct answer-Nausea
Anorexia
Abdominal pain
Diarrhea
Decreased LOC
Muscle twitching (hypercalcemia)
Tremors
Convulsions
Increased rate and depth of respirations
Skin warm and flushed
metabolic alkalosis manifestations - correct answer-symptoms related to decreased
calcium, respiratory depression, tachycardia, symptoms of hypokalemia, hypertonic
muscles
NREM: Physiology Summary - correct answer--Low steady metabolic rate
-HR/BP/R/Brain temp/Cerebral blood flow decreased
, -Peripheral blood volume dilated->low BP
Nursing interventions to prevent pressure ulcers and DVT? - correct answer-DVT
Prevention: -TED hoses-sequential compression device, ambulation/range of motion
Pressure injuries: Repositioning every 2 hours, use of wedges/pillows under bony
prominences, preventative dressings over bony prominences.
Peri-operative patient teaching regarding medication - correct answer-Prescribed
medications that will most likely be stopped for surgery:
---anticoagulants, diuretics, adrenal steroids, antibiotics, ASA, NSAIDs, herbal
supplements
Preoperative medications:
---Use: decrease anxiety/amount of general anesthesia/pain, promote
relaxation/sedation/comfort
---Side Effects: decrease BP and pulse, resp. depression
---Ex: antianxiety, sedatives, opioid analgesics
Peri-operative patient teaching regarding pain management - correct answer-Teach
patient that prescribed pain meds will help
-They have very low chance of addiction (think opioid crisis)
-Set realistic goals and have good regimen
-Pain is not a weakness!
