Quiz 1 Flashcards
What is done during the preoperative assessment?
medical hx
food/drug allergies
asses pt emotional state/readiness for sx
baseline data
If a pt has allergies to banana or kiwi, what can this indicate?
risk for reaction to latex
If a pt has allergies to eggs or soybean oil, what can this be a contradiction of?
contraindication to the use of propofol for anesthesia
If a pt has allergies to shellfish, what can this result in?
reaction to povidone-iodine
How long should a pt be NPO before surgery?
at least 8 hours (solid foods)
at least 2 hours (clear liquids)
What are the types of anesthesia techniques?
general anesthesia
local anesthesia
monitored anesthesia
regional anesthesia
Define general anesthesia
loss of sensation with loss of consciousness
Define local anesthesia
smaller area
loss of sensation without loss of consciousness
Define monitored anesthesia care (MAC)
decreased responsiveness, may need airway support
Define regional anesthesia
larger area
loss of sensation to region of body without loss of consciousness
What are examples of catastrophic events in intraoperative care?
anaphylactic reaction
malignant hyperthermia
What are manifestations of anaphylactic reaction?
hypotension + tachycardia = (bleeding somewhere)
What can an anaphylactic reaction reaction cause?
bronchospasm
pulmonary edema
What are the interventions for an anaphylactic reaction?
protect airway
give epinephrine
What are the manifestations of malignant hyperthermia?
increased HR
decreased BP
increased RR
muscle rigidity
hyperthermia (late sign)
What are the interventions of malignant hyperthermia?
stop anesthetic
protect airway (100% oxygen)
administer dantrolene
start iced IV 0.9% NaCl
initiate cooling measures
During postop care, what will be done for the pulmonary assessment?
encourage cough/deep breathing/incentive spirometer
suction prn
assess:
- airway
-respiratory pattern
- O2 sat
During postop care, what will be done for the circulatory assessment?
compare VS to baseline
assess:
- tissue perfusion
- fluid and electrolyte balance
- signs of bleeding
During postop care, what will be done for the neuro assessment?
assess:
- LOC
- reflexes
- movements
During postop care, what will be done for the urinary assessment?
monitor I&O
During postop care, what will be done for the gastrointestinal assessment?
assess:
- bowel sounds
- abdominal distention
During postop care, what will be done for the integument assessment?
assess:
- dressing
- amount of drainage
GCS less than 8….
you must intubate
cal rapid respone!
Describe the glasgow coma scale
EYE OPENING
4. spontaneous
3. to sound
2. to pain
1. never
MOTOR RESPONSE
6. obeys command
5. localizes pain
4. normal flexion (withdrawal)
3. abnormal flexion
2. extension
1. none
VERBAL RESPONSE
5. oriented
4. confused conversation
3. inappropriate words
2. incomprehensible words
1. none
How can a nurse prevent respiratory complications?
positioning (semi-fowlers)
O2 therapy
incentive spirometer
coughing and deep breathing
hydration
mucolytics
How can a nurse prevent neurologic or psychologic complications?
safety precautions
fluid/electrolyte monitoring
sleep
pain management
bowel/bladder function
How can a nurse prevent cardiovascular complications?
VS, LOC, I&O monitoring
antiembolic stockings
promotion of venous flow
IV isotonic fluid to support BP
early ambulation
prophylactic anticoagulant
How can a nurse prevent gastrointestinal complications?
nausea:
- oral care
- antiemetic
- NG tube to decompress stomach
- comfort measures
paralytic ileus:
- ambulation
- prokinetic agent (metoclopramide)
- limiting opiods
- NG tube to decompress stomach
How can a nurse prevent urinary retention?
bladder scan
bedoan
I&O monitoring
no more than 6 hrs w/o pt voiding
What is done when there is wound dehiscence or evisceration?
- position to decrease tension @ suture line
- sterile saline-soaked gauze
- notify surgeon
- no coughing or straining
What is the criteria for discharge?
aldrete score of 8-10
stable VS
no evidence of bleeding
return of reflexes (gag, cough, swallow)
minimal to absent N/V
wound drainage min-mod
urine output at least 30 mL/hr
What is aldrete scoring?
5 factors (scored 0-2):
- activity
- consciousness
- respiration
- O2 sat
- circulation
2 being back to normal
What is IV therapy used for?
administration of
- medications
- fluids
- blood/blood products
- radiologic constrast agents
- nutritional support
- repeated blood sampling
What are the types of IV therapy?
peripheral
central venous access
Describe infiltration
What are the interventions?
cool skin
swelling at site
stop tx, remove catheter, elevate extremity
Describe extravasation
What are the interventions?
pain
burning
redness
swelling
stop tx, notify provider, infuse antidote
Describe phlebitis
What are the interventions?
redness
tenderness
pain
warmth
red streak
stop tx, remove cath, use warm compress
Describe a midline catheter
peripheral venous access
doesn’t last long
good for multiple draws
Where are central venous access devices placed? How is this confirmed?
large blood vessels
- subclavian vein
- jugular vein
Xray to confirm placement
What are examples of central venous access devices?
non tunneled or tunneled
implanted infusion port
peripherally inserted central cath (PICC)
- single or multiple lumen
What is the interventions for an air embolism in a CVAD?
clamp cath
admin oxygen
place client on left side in trendelenburg
What should be assessed when looking at IVs?
insertion site
integrity
signs of complications
connections
solutions
rate
What is the protocol for flushing the catheter?
flush w/ normal saline
use push-pause technique with CVADs
use 10 mL syringe
What are examples of complications of CVADs?
circulatory overload
air embolism
pneumothorax
catheter-related bloodstream infection
What are the symptoms of circulatory overload?
shortness of breath
crackles, cough
hypertension
What are the interventions of circulatory overload?
slow iv rate
elevate HOB
monitor VS
notify provider
administer diuretic
What are the symptoms of an air embolism?
chest pain
increased HR
decreased BP
decreased O2 sat
What are the interventions of an air embolism?
clamp cath
position pt left lateral trendelenburg
give O2
notify provider
What are the symptoms of pneumothorax?
dyspnea
chest pain
decreased breath sounds
What are the interventions for pneumothorax?
elevate HOB
administer O2
discontinue cath
notify provider
chest tube insertion
What are the symptoms for catheter-related bloodstream infection?
redness
tenderness
warmth
edema
purulent drainage
fever
chills
What are the interventions for catheter-related bloodstream infection?
discontinue cath and apply warm compress
culture tip of cath
give antibiotic and antipyretic
apply CRBSI prevention bundle
What does a complete blood count (CBC) include?
RBC
Hgb
Hct
WBC
Platelet
What is the normal range for RBC?
male
4.7-6.1 x10^12/L
female
4.2-5.4 x10^12/L
What is the normal range for Hgb?
male
14-18 g/dL
female
12-16 g/dL
What is the normal range for Hct?
male
42-52%
female
37-47%
What is the normal range for WBC?
5,000-10,000 /mm^3
What is the normal range for platelet count?
150,000-400,000 /mm^3
How long is blood tubing good for?
4 hours
What do RBCs do?
carries oxygen
What does plasma do?
maintains blood pressure
treats bleeding
replaces fluid volume
What do platelets do?
helps clotting process
treat thrombocytopenia
Type A blood can receive / donate to?
receive:
A, O
donate:
A, AB
Type B blood can receive / donate to?
receive:
B, O
donate:
B, AB
Type AB blood can receive / donate to?
receive:
all types
donate:
AB
Type O blood can receive / donate to?
receive:
O
donate: all types
What is the nurse’s responsibility before a blood transfusion?
- assess lab values/verify order/consent
- type and cross match
- initiate large bore IV access
- assess VS and hx of transfusion
- explain reason for transfusion
- inspect blood product
- prime blood administration set with 0.9% NaCl
- verify client and compatibility with 2 nurses
- infuse
What is a nurse’s responsibility during a blood transfusion?
remain with client for first 15 min
monitor VS
complete transfusion
What is a nurse’s responsibility after a blood transfusion?
obtain VS
dispose of blood admin set
monitor blood values
complete transfusion documents
document
What are examples of transfusion reactions?
acute hemolytic reaction
febrile transfusion reaction
allergic transfusion reaction
circulatory overload
What are examples of isotonic IV fluids?
dextrose 5% in water
0.9% sodium chloride
lactated ringers
What do isotonic IV fluids do?
replaces fluid losses
What are examples of hypotonic IV fluids?
0.45% NaCl
0.33% NaCl
Who do hypotonic IV fluids do?
rehydrates cells
What are examples of hypertonic IV fluids?
dextrose 10% in water
3-5% NaCl
dextrose 5% in 0.9% NaCl
dextrose 5% in 0.45% NaCl
dextrose 5% in LR
What do hypertonic IV fluids do?
pulls fluid from cells
What are the expected ranges for sodium?
136-145
What are the expected ranges for potassium?
3.5-5
What are the expected ranges for calcium?
9-10.5
What are the expected ranges for magnesium?
1.3-2.1
What are the expected ranges for phosphorus?
3.0-4.5
What are the expected ranges for chloride?
98-106
