Fundamentals - Focused Review

Question 1

Post-op complication: Paralytic ileus (one cause and one intervention)

Answer 1

• Caused by abdominal surgery or other physical trauma and absent gastrointestinal peristaltic activity
• Monitor bowel sound, encourage ambulation, and insert NG tube to empty stomach contents

Question 2

Post-op complication: Wound evisceration ( one cause and one intervention)

Answer 2

• Protrusion of the abdominal contents through the incisional wound of the abdominal cavity, caused by failure to splint when moving or coughing, delayed healing due to obesity or DM
• Call for help, cover the wound with sterile saline soaked dressings or towel, and position the client in semi-Fowler’s position with hips and knees bent

Question 3

Post-op complication: Airway obstruction (one cause and one intervention)

Answer 3

• Swelling or spasm of the larynx or trachea, mucus in the airway, or relaxation of the tongue into the nasopharynx, can cause airway obstruction, often manifesting as stridor or snoring
• notify the anesthesiologist, provide humidified oxygen, elevate the head of the bed if not contraindicated, perform a head-tilt/chin-lift maneuver to open the airway, and plan for reintubation on the endotracheal tube

Question 4

Annual screenings for the older adult

Answer 4

• Hearing
• Fecal occult blood test
• Digital rectal and prostate-specific antigen (males)
• Dual-energy x-ray absorptiometry (DXA) scanning for osteoporosis
• Eye examination for glaucoma and other disorders

Question 5

Periodic screenings for the older adult

Answer 5

• Mental health screening for depression
• Cholesterol an diabetes screening every 3 years

Question 6

Pressure wound infection manifestations (time and symptoms)

Answer 6

• 2 to 11 days after injury or surgery
• Purulent drainage
• Pain
• Redness, edema (in and around the would)
• Fever
• Chills
• Odor
• Increased pulse, respiratory rate
• Increased in WBC count