NUR 242 Med Surg Exam 1 final for 2024 latest update with detailed
questions and answers/ NUR 242 Med Surg Exam 1 final for 2024
latest update with detailed questions and answers
Post-OP - CORRECT ANSWER-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 - CORRECT ANSWER-
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 color to the incision line, and slight
swelling under the sutures/staples is normal
Post-op Risk for post surgical wound
DEHISCENCE - CORRECT ANSWER-Obesity
diabetes
corticosteriod use
,immune deficiency
malnutrition
Post-op
wound EVISCERATION - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-inflammation of
the vein (redness, edema, warmth, pain at site)
discontinue IV
notify physician for treatment
restart IV in the opposite extremity
Central Line Access Devices - CORRECT ANSWER-All central line access
devices terminate in the superior vena cava (PICC line, implantable
ports, tunneled and non-tunneled catheters, and central lines)
insertion requires informed consent
need to have a chest x-ray prior to use
questions and answers/ NUR 242 Med Surg Exam 1 final for 2024
latest update with detailed questions and answers
Post-OP - CORRECT ANSWER-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 - CORRECT ANSWER-
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 color to the incision line, and slight
swelling under the sutures/staples is normal
Post-op Risk for post surgical wound
DEHISCENCE - CORRECT ANSWER-Obesity
diabetes
corticosteriod use
,immune deficiency
malnutrition
Post-op
wound EVISCERATION - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-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 - CORRECT ANSWER-inflammation of
the vein (redness, edema, warmth, pain at site)
discontinue IV
notify physician for treatment
restart IV in the opposite extremity
Central Line Access Devices - CORRECT ANSWER-All central line access
devices terminate in the superior vena cava (PICC line, implantable
ports, tunneled and non-tunneled catheters, and central lines)
insertion requires informed consent
need to have a chest x-ray prior to use
