and Correct Detailed Answers Already Graded A+
Standard precautions: - CORRECT ANSWER--Hand hygiene
-Gloves
Contact precautions: - CORRECT ANSWER--Private room
-Wear gloves when entering room
-Wash hands with soap and water
-Dedicated equipment
Airborne Precautions: - CORRECT ANSWER--Private room with negative airflow
-Keep door closed
-N95 respirator
*Pt wear surgical mask when leaving room for labs/procedure*
Droplet precautions: - CORRECT ANSWER--Private room preferred
-If not, may share a room with pt having same active infection
-Surgical mask when working WITHIN 3 FEET OF PT
,-Pt to wear surgical mask when leaving room
Cane: - CORRECT ANSWER--Appropriate height (at wrist level when arm is at
side)
-Pt strong hand on cane
*MOVE CANE WITH WEAKER LEG*
At risk for falls due to: - CORRECT ANSWER-incontenience
Transferring pt to WC: - CORRECT ANSWER--Place WC on strong side angled to
bed
-Strong hand to armrest, then pivot
Safe pt handling: - CORRECT ANSWER--Keep pt directly in front of you and as
close as possible to prevent back injuries
Skin integrity: - CORRECT ANSWER--dont wear restrictive clothing
-WC pt lift themselves off buttock for 10 seconds q1hr
Pressure Ulcer stages: - CORRECT ANSWER-*Stage 2- skin is not intact; open or
fluid blister*
,Wet-to-damp wound care: - CORRECT ANSWER-mechanically removes
necrotic tissue
does more damage than good bc it removes the good tissue as well
Informed consent: - CORRECT ANSWER--surgeon is responsible for having
consent signed
-Pt who can not sign can sign with an "X" but must be witnessed by two people
-If the pt doesn't understand the surgery, the surgeon has to be notified
-A blind pt can sign the consent, has to be witnessed by 2 people
-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to pt
Pre-OP: - CORRECT ANSWER--Report these to surgeon:
-increased PT/INR/aPTT/Creatinine
-Verify operative permit is signed
-Side rails up, bed down, call light within reach
, Intra-OP: - CORRECT ANSWER--Pts are lifted into position onto the OR table to
prevent shearing
-Gel pads are placed on the OR table to prevent pressure ulcers
-Warming blankets are used
-Cover the pts head and feet (decrease hypothermia)
*If saving is necessary, hair should be removed using disposable sterile supplies
immediately before the start of the procedure*
-Sterile scrubbing from fingertips to elbow for 3-5 minutes
Post-OP: - CORRECT ANSWER--in PACU, nurse immediately assess pt airway,
LOC
-RR <10 may indicate respiratory depression due to anesthesia
-Sanguineous to serosanguineous drainage is normal
-Crusting at incision line and swelling is normal
Malignant hyperthermia: - CORRECT ANSWER--life threatening
-you will see HIGH TEMPERATURE
-early sign is tachycardia, muscle rigidity
-Dantrolene is used to treat