NUR242 / NUR 242 Exam 1, 2, 3, 4 & 5 Review Medical-Surgical Nursing Concepts 100% Guarantee passing score

NUR242 / NUR 242 Exam 1, 2, 3, 4 & 5 Review ss ss ss ss ss ss ss ss ss ss ss ss ss




Medical-Surgical Nursing Concepts ss ss




100% Guarantee passing score ss ss ss ss




Exam 1 ss




1. Cane:: -Appropriate height (at wrist level when arm is at side)
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-Pt strong hand on cane
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*MOVE CANE WITH WEAKER LEG*
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2. At risk for falls due to:: incontenience
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3. Transferring pt to WC:: -Place WC on strong side angled to bed
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-Strong hand to armrest, then pivot
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4. Safe pt handling:: -Keep pt directly in front of you and as close as
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ss possible to prevent back injuries
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5. Skin integrity:: -dont wear restrictive clothing
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-WC pt lift themselves off buttock for 10 seconds q1hr
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,6. Pressure Ulcer stages:: *Stage 2- skin is not intact; open or fluid blister*
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7. Wet-to-damp wound care:: mechanically removes necrotic tissue ss ss ss ss ss ss




does more damage than good bc it removes the good tissue as well
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8. Informed consent:: -surgeon is responsible for having consent signed
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-Pt who can not sign can sign with an "X" but must be witnessed by two
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ss people
-If the pt doesn't understand the surgery, the surgeon has to be notified
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-A blind pt can sign the consent, has to be witnessed by 2 people
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-Nurses DO NOT clarify orders/procedure/risks, must call the MD to explain to
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ss pt


9. Pre-OP:: -Report these to surgeon: ss ss ss ss




-increased PT/INR/aPTT/Creatinine ss




-Verify operative permit is signed
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-Side rails up, bed down, call light within reach
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10. Intra-OP:: -Pts are lifted into position onto the OR table to prevent
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shearing
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-Gel pads are placed on the OR table to prevent pressure ulcers
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-Warming blankets are used ss ss ss

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,-Cover the pts head and feet (decrease hypothermia)
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*If saving is necessary, hair should be removed using disposable sterile
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supplies immediately before the start of the procedure*
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-Sterile scrubbing from fingertips to elbow for 3-5 minutes
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11. Post-OP:: -in PACU, nurse immediately assess pt airway, LOCss ss ss ss ss ss ss ss




-RR <10 may indicate respiratory depression due to anesthesia
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-Sanguineous to serosanguineous drainage is normal ss ss ss ss ss




-Crusting at incision line and swelling is normal
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12. Malignant hyperthermia:: -life threatening ss ss ss




-you will see HIGH TEMPERATURE
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-early sign is tachycardia, muscle rigidity
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-Dantrolene is used to treat ss ss ss ss




13. Pain Management:: *Pain management referral for pts in chronic pain
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-Pain after abdominal sx is from trapped carbon dioxide, ambulate pt as soon
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ss as possible
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-Use FACES scale in pts with dementia
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14. PCA Pump:: -Lockout interval of 5-15 minutes
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-Pt cannot be cognitively impaired
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-Only the pt can press the button
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, 15. If incision opens:: -cover with wet sterile gauze
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-Do not try to reinsert protruding organ
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-Reassure pt ss




-Supine position with knees bentss ss ss ss




16. IV:: -20G 1-1.5" needle is adequate for most therapies
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-Huber needle should be placed at 90 degree angle to access port (chemo
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17. TPN:: - Check each bag twice ss ss ss ss ss




-If TPN is unavailable, hang 10% dextrose/water or 20% D/W until TPN is
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ss available
-If TPN not administered on time, do not increase the rate
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-Change IV tubing q24 hours when new bag is hung
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-Dressing change around IV site changed 2 48-72 hours
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18. Sickle Cell:: -Pain is the most common problem
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-Requires large doses of opioid analgesics ss ss ss ss ss




-Hydrate with NS IV fluids, encourage oral fluids without caffeine
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-Administer O2 ss




-Remove restrictive clothing, No BP with external cuff
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-Sickle Cell crisis: pain meds and IV fluids
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19. Vitamin B12 Deficiency:: -Smooth, beefy red tongue
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