NUR 242 Med/Surg Exam 1 Complete
questions and correct verified RESOLUTION
RESULT VERIFIEDs (detailed RESOLUTION
RESULT VERIFIEDs) already graded A+
Post-Op - {✔✔RESOLUTION RESULT VERIFIED✔✔}-DVT is the most common
type of
thrombophlebitis. High risk for pulmonary embolism. Develops most often in the
legs but can occur in the upper arms
Interventions: patient education regarding leg exercises, early ambulation,
adequate hydration, compression stockings, sequential compression devices
(SCD's)
Post-Op
wound healing and prevention of infections - {✔✔RESOLUTION RESULT
VERIFIED✔✔}-assess the surgical incision at least every 8 hours for redness,
increases warmth, swelling, tenderness or pain, and the type/amount of drainage
,sanguineous (bloody) to serosanguineous to serous (yellow) drainage is normal
during the first few days after surgery. Drainage should gradually decrease
Crusting on the incision line, pink colour to the incision line, and slight swelling
under the sutures/staples is normal
Post-op Risk for post surgical wound
DEHISCENCE - {✔✔RESOLUTION RESULT
VERIFIED✔✔}-Obesity diabetes
corticosteriod use immune deficiency
malnutrition
Post-op
wound EVISCERATION - {✔✔RESOLUTION RESULT VERIFIED✔✔}-Call for
help and stay with patient
cover wound with sterile gauze soaked in sterile water do
not attempt to reinsert the protruding organ place the
patient in supine position with hips and knees bent raise the
HOB no more than 15-20 degrees provide support and
reassurance to the patient
Sequence of inflammation - {✔✔RESOLUTION RESULT VERIFIED✔✔}-Stage 1
- injured tissue and the leukocytes mast cells in this area secrete histamine,
serotonin and kinins that constrict the small veins and dilate the arterioles in the
area of injury. These changes cause redness and warmth to the tissues
Stage 2 - An increased number of circulating neutrophils occurs. Exudate in the
form of pus occurs, containing dead WBC's, necrotic tissue, and fluids that escape
, from the damaged cells. Thus, you will see an increase in the neutrophil count
Stage 3 - tissue repair and replacement occur
MIDLINE catheters - {✔✔RESOLUTION RESULT VERIFIED✔✔}-peripheral IV
access
utilized for short -term therapy (4 weeks or less) the
tip of the midline ends in the axillary vein should
not be used to draw labs
DOES NOT require x-ray for placement
complications of PIV
(peripheral IV) Infiltration - {✔✔RESOLUTION RESULT VERIFIED✔✔}-
IV becomes dislodged fluid leaks from the vein to surrounding tissue
discontinue IV and elevate the extremity apply ice or heat therapy
vesicant medications can cause extravasation if IV infiltrates
Complication of PIV
phlebitis and thrombophlebitis - {✔✔RESOLUTION RESULT VERIFIED✔✔}-
inflammation of the vein
(redness, edema, warmth, pain at site) discontinue
IV
notify physician for treatment restart
IV in the opposite extremity
questions and correct verified RESOLUTION
RESULT VERIFIEDs (detailed RESOLUTION
RESULT VERIFIEDs) already graded A+
Post-Op - {✔✔RESOLUTION RESULT VERIFIED✔✔}-DVT is the most common
type of
thrombophlebitis. High risk for pulmonary embolism. Develops most often in the
legs but can occur in the upper arms
Interventions: patient education regarding leg exercises, early ambulation,
adequate hydration, compression stockings, sequential compression devices
(SCD's)
Post-Op
wound healing and prevention of infections - {✔✔RESOLUTION RESULT
VERIFIED✔✔}-assess the surgical incision at least every 8 hours for redness,
increases warmth, swelling, tenderness or pain, and the type/amount of drainage
,sanguineous (bloody) to serosanguineous to serous (yellow) drainage is normal
during the first few days after surgery. Drainage should gradually decrease
Crusting on the incision line, pink colour to the incision line, and slight swelling
under the sutures/staples is normal
Post-op Risk for post surgical wound
DEHISCENCE - {✔✔RESOLUTION RESULT
VERIFIED✔✔}-Obesity diabetes
corticosteriod use immune deficiency
malnutrition
Post-op
wound EVISCERATION - {✔✔RESOLUTION RESULT VERIFIED✔✔}-Call for
help and stay with patient
cover wound with sterile gauze soaked in sterile water do
not attempt to reinsert the protruding organ place the
patient in supine position with hips and knees bent raise the
HOB no more than 15-20 degrees provide support and
reassurance to the patient
Sequence of inflammation - {✔✔RESOLUTION RESULT VERIFIED✔✔}-Stage 1
- injured tissue and the leukocytes mast cells in this area secrete histamine,
serotonin and kinins that constrict the small veins and dilate the arterioles in the
area of injury. These changes cause redness and warmth to the tissues
Stage 2 - An increased number of circulating neutrophils occurs. Exudate in the
form of pus occurs, containing dead WBC's, necrotic tissue, and fluids that escape
, from the damaged cells. Thus, you will see an increase in the neutrophil count
Stage 3 - tissue repair and replacement occur
MIDLINE catheters - {✔✔RESOLUTION RESULT VERIFIED✔✔}-peripheral IV
access
utilized for short -term therapy (4 weeks or less) the
tip of the midline ends in the axillary vein should
not be used to draw labs
DOES NOT require x-ray for placement
complications of PIV
(peripheral IV) Infiltration - {✔✔RESOLUTION RESULT VERIFIED✔✔}-
IV becomes dislodged fluid leaks from the vein to surrounding tissue
discontinue IV and elevate the extremity apply ice or heat therapy
vesicant medications can cause extravasation if IV infiltrates
Complication of PIV
phlebitis and thrombophlebitis - {✔✔RESOLUTION RESULT VERIFIED✔✔}-
inflammation of the vein
(redness, edema, warmth, pain at site) discontinue
IV
notify physician for treatment restart
IV in the opposite extremity
