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Exam (elaborations) NUR 2356 MDC 1 Final Exam Re.iew (NUR2356)

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Exam (elaborations) NUR 2356 MDC 1 Final Exam Review (NUR2356) Managing open fractures, how to prevent infection Frequent dressing changes with aseptic technique, monitor temperature and heart rate, administer broad spectrum antibiotics as ordered (Clindamycin and Gentamycin), irrigate open wound (clean to dirty) Managing ambulation with client who has cancer Ask the patient to wear nonskid footwear. Place the bed in low position and lock the wheels. Assist the patient to dangle at the side of the bed If two nurses are available, each nurse should stand facing the patient on opposite sides of the patient. Brace your feet and knees against the patient. Bend your hips at the knees and hold onto the transfer belt. Pay attention to any known weakness. Instruct the patient to place her arms around you between your shoulders and waist (the location depends on the height of the patient and the nurses). Ask the patient to stand as you move to an upright position by straightening your legs and hips. Allow the patient to steady herself for a moment. One nurse: Stand at the patient’s side, placing both hands on the transfer belt. If the patient has weakness on one side, position yourself on the weaker side Slowly guide the patient forward. Observe for signs of fatigue or dizziness. If the patient must transport an IV pole, allow the patient to hold onto the pole on the side where you are standing. Assist the patient to advance the pole as you ambulate OA/RA OA: Degenerative condition. Wear and tear. Loss/wear down of articular cartilage in the joint which causes pain, stiffness, and crepitus (cracking/popping sound). Aggravates with weight- bearing joint use (weight loss, physical exercise, ice) RA: Chronic, inflammatory, autoimmune disorder that causes bone erosion, joint deformity, and painful swelling. Aggravates with weight-bearing joint use. Inflammation and pain with no activity. Ice and heat. Adequate rest. NSAID’s. Stretching. Knee pain assessment Client history, knee inspection for joint effusion/swelling/warmth/deformity, palpate for point tenderness, AROM/PROM, neurovascular assessment Discharge instructions for osteomyelitis Importance of medication adherence and taking full-course, signs/symptoms/re-infection detection, importance of hand hygiene, proper irrigation techniques, assistive device use, assistance with ADL’s

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MDC 1 Final Exam Review


MDC 1 Final Exam Review

Managing open fractures, how to prevent infection
Frequent dressing changes with aseptic technique, monitor temperature and heart rate,
administer broad spectrum antibiotics as ordered (Clindamycin and Gentamycin), irrigate open
wound (clean to dirty)

Managing ambulation with client who has cancer
➤Ask the patient to wear nonskid footwear.
> Place the bed in low position and lock the wheels.
> Assist the patient to dangle at the side of the bed
> If two nurses are available, each nurse should stand facing the patient on opposite sides
of the patient.
> Brace your feet and knees against the patient. Bend your hips at the knees and hold onto
the transfer belt. Pay attention to any known weakness.
> Instruct the patient to place her arms around you between your shoulders and waist (the
location depends on the height of the patient and the nurses). Ask the patient to stand as
you move to an upright position by straightening your legs and hips.
> Allow the patient to steady herself for a moment.
> One nurse: Stand at the patient’s side, placing both hands on the transfer belt. If the
patient has weakness on one side, position yourself on the weaker side
Slowly guide the patient forward. Observe for signs of fatigue or dizziness.
> If the patient must transport an IV pole, allow the patient to hold onto the pole on the
side where you are standing. Assist the patient to advance the pole as you ambulate

OA/RA
OA: Degenerative condition. Wear and tear. Loss/wear down of articular cartilage in the
joint which causes pain, stiffness, and crepitus (cracking/popping sound). Aggravates with
weight- bearing joint use (weight loss, physical exercise, ice)

RA: Chronic, inflammatory, autoimmune disorder that causes bone erosion, joint deformity,
and painful swelling. Aggravates with weight-bearing joint use. Inflammation and pain with no
activity. Ice and heat. Adequate rest. NSAID’s. Stretching.

Knee pain assessment
Client history, knee inspection for joint effusion/swelling/warmth/deformity, palpate for point
tenderness, AROM/PROM, neurovascular assessment

Discharge instructions for osteomyelitis
Importance of medication adherence and taking full-course, signs/symptoms/re-
infection detection, importance of hand hygiene, proper irrigation techniques, assistive
device use, assistance with ADL’s



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, MDC 1 Final Exam Review

Total knee repair management
DVT/PE prevention/monitoring (TED hoses, anti-embolic/anti-thrombotic stockings) , surgical




dressing changes and monitoring of incision site for infection, observation of mobility
and
sensation, ABC’s, no excessive blood/fluid loss, monitor tissue perfusion
90 degree ROM- elbow




Assessment for patient on bedrest w/pain in leg
PROM, neurovascular assessment for DVT/PE, pain
assessment

Importance of ROM
Improves joint function, balance and muscle strength, flexibility, reduces pain and stiffness,
improves circulation, reduces injury potential

Abduction/adduction

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, MDC 1 Final Exam Review

AB: away from
ADD: towards the body

Type of order from provider for acute flank pain
Possible reasons for pain: dehydration, kidney problems (kidney stones), UTI
Orders: WILDA assessment, blood tests, ultrasound, x-ray, abdominal CT scan, urinalysis/culture,
cystoscopy, IV fluids, pain medication

ADL limitations for client with limited motion of hands
Eating, toileting, bathing, dressing, personal hygiene, weight-bearing activities, medication
adherence

Priorities for immobility
Perform PROM, reposition every 2 hours, encourage independent activity as possible even in
bed rest/AROM, provide assistance devices as needed

Potential impacts of stress on arthritis
Exacerbates symptoms, increases pain and muscle tension, increases risk for development of
inflammatory arthritis

Response to client reporting fatigue and joint pain
Encourage rest, complete pain assessment (WILDA), complete
assessment/inspection/medical history, assess ROM

Halo traction: pin site red and inflamed
Treat with daily pin care, increase dressing changes, culture as needed if pus presents,
determine pain level

Response to confused client climbing out of bed
Move client to room closer to nurses station, implement use of bed alarm, refrain from raising
bed rails

First action when client falls: check vital signs and for any injuries sustained

Priorities for new femur fracture
Dependent on the Control any bleeding.
extent of the injuries Expose the area of Apply direct pressure to
assess BAC and injury to assure bleeding site or pressure to
provide as needed accurate assessment artery above the fracture.




To prevent
Manage pain with an
shock position Splint the injury opioid medication
patient in a
supine.
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BKA symptoms: phantom pain, decreased ROM, localized swelling

Colors of drainage and meaning
Serous: watery consistency, clear
Sanguineous: bloody drainage,
red
Serosanguineous: combination of blood and clear serum, pink/blood
tinged Purulent: thick, malodorous, pus, yellow, green

Priorities for homeless client
Physiologic needs and safety needs met, case management/social worker collaboration

How to avoid shearing injuries
Position bed to 30 degrees or below, use assistive devices when repositioning

Narcolepsy management
Regular sleep schedule, planned short naps, sleep-inducing environment/hygiene, wake
promoting medications, antidepressants

Wound healing stages
Hemostasis: clotting
Inflammatory phase: cleaning/phagocytosis
Proliferative phase: granulation/regeneration/fibroblasts form collagen
Maturation phase: epithelialization/remodeling/scar tissue/collagen broken down into
organized structures/healing

Potential harms from low platelet count: thrombocytopenia
Cannot form clots, delayed wound healing, severe bleeding, higher risk for infections

How to prevent heel skin breakdown
Elevate heels using pillows, pressure redistributing devices, reposition every 2 hours

Extensive burn assessment
ABC’s, inspection (wound drainage, depth of burn injury, wound complications)
culture/biopsy/wood’s light exam/diascopy, pain, wound care




FRO M TO E CO LO R, M O ISTU RE
H EAD TO TEM PER ATU RE,

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