Test 1

Question 1

Nursing interventions for absence of voiding for significant period of time postoperatively

Answer 1

• Normal positioning of the client—sitting for women and standing for men. Providing reassurance to the client regarding the ability to void
• The use of techniques such as running water, drinking water, or pouring warm water over the perineum may also be of assistance.
• Ambulation, preferably to the bathroom, and the use of a bedside com- mode are additional helpful measures to promote voiding.

Question 2

• Reinforce
• replace blood loss
• If large volumes of blood have been transfused then haemorrhage may be exacerbated by consumption coagulopathy. It may also be due to preoperative anticoagulants or unrecognised bleeding diathesis.
• Perform clotting screen and platelet count, ensure good intravenous (IV) access. If there is very significant bleeding and it is safe to do so, consider inserting a central venous pressure (CVP) catheter. Give protamine if heparin has been used. Order cross-matched blood. If the clotting screen is abnormal, give fresh frozen plasma (FFP) or platelet concentrates. Consider surgical re-exploration at all times.
• Late postoperative haemorrhage occurs several days after surgery and is usually due to infection damaging vessels at the operation site. Treat the infection and consider exploratory surgery.

Answer 2

Interventions (in proper order) if postoperative bleeding is assessed at the incision site

Question 3

The blockage of pulmonary arteries by thrombus, fat or air emboli, or neoplastic tissue

Answer 3

PULMONARY EMBOLISM

Definition

Question 4

• The severity of the clinical manifestations of PE depends on the size of the emboli and the size and number of blood vessels occluded.
• The most common manifestations of PE are anxiety and the sudden onset of unexplained dyspnea, tachypnea, or tachycardia.
• Other manifestations are cough, pleuritic chest pain, hemoptysis, crackles, fever, accentuation of the pulmonic heart sound, and sudden change in mental status as a result of hypoxemia.
• Massive emboli may produce sudden collapse of the client with shock, pallor, severe dyspnea, and crushing chest pain. However, some clients with massive PE do not have pain. The pulse is rapid and weak, the BP is low, and an ECG indicates right ventricular strain.
• Death occurs in more than 60% of clients with massive emboli
• Medium-sized emboli often cause pleuritic chest pain, dyspnea, slight fever, and a productive cough with blood-streaked sputum.
• A physical examination may reveal tachycardia and a pleural friction rub.
• Small emboli frequently are undetected or produce vague, transient symptoms.
• The exception to this is the client with underlying
• cardiopulmonary disease, in whom even small or mediumsized emboli may result in severe cardiopulmonary compromise.

Answer 4

PULMONARY EMBOLISM:

CLINICAL MANIFESTATIONS

Question 5

• The client should be kept on bedrest in a semi-Fowler’s position to facilitate breathing.
• An IV line should be maintained for medications and fluid therapy. The nurse should know the side effects of medications and observe for them.
• Oxygen therapy should be administered as ordered.
• Careful monitoring of vital signs, ECG, ABGs, and lung sounds is critical to assess the client’s status.

Answer 5

PULMONARY EMBOLISM:

NURSING INTERVENTIONS - ACUTE CARE

Question 6

A disorder involving a thrombus in a deep vein, most commonly the iliac and femoral veins.

Answer 6

DVT

Question 7

(called Virchow’s triad)

(1) venous stasis
(2) damage to the endothelium (inner lining of the vein)
(3) hypercoagulability of the blood.

The client at risk for the development of venous thrombosis usually has predisposing conditions to these three disorders

Answer 7

DVT ETIOLOGY

Question 8

May have no symptoms or have unilateral leg edema, extremity pain, warm skin, and erythema.

If the calf is involved, tenderness may be present on
palpation.

A positive Homans’ sign (pain on forced dorsiflexion
of the foot when the leg is raised) is a classic but very unreliable sign

If the superior vena cava is involved, there may be symptoms in the upper extremities, the neck, the back, and the face.

Answer 8

DVT CLINICAL MANIFESTATIONS

Question 9

• Nursing care is directed toward the prevention of embolus formation and the reduction of inflammation.
• While the client is receiving nticoagulation therapy, the nurse should closely observe for any indication of bleeding, including epistaxis and bleeding gingivae.
• Urine should be assessed for gross or microscopic hematuria. A smoky appearance to the urine is sometimes noted if blood is present. A Specimen should be checked daily for hematuria.
• Particular attention should be paid to the protection of skin areas that may be traumatized. Surgical incisions should be closely observed for evidence of bleeding.
• Stools should be tested to determine the presence of occult blood from the gastrointestinal tract.
• Mental status changes, especially in the older client, should be assessed as a possible indication of cerebral bleeding. IM injections should not be given

Answer 9

DVT NURSING INTERVENTIONS

Question 10

Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Answer 10

IMPAIRED TISSUE PERFUSION

Question 11

WHAT DOES IMPAIRED TISSUE PERFUSION CAUSE?

Answer 11

SHOCK

Question 12

A syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. This results in an imbalance between the supply of and the demand for oxygen and nutrients. The exchange of oxygen and nutrients at the cellular level is essential to life. When a cell experiences a state of hypoperfusion, the demand for oxygen and nutrients exceeds the supply.

Answer 12

SHOCK

Question 13

WHICH STAGE OF SHOCK?

aerobic switches to anaerobic, build up of lactic acid, metabolic acidoseous

Answer 13

STAGES OF SHOCK - Intital stage

Question 14

WHICH STAGE OF SHOCK ?

neurologic changes, maintaining homeostasis, barrow receptors, vessels general vasoconstriction, trying to be maintained, trying to maintain the function of vital organs, kidneys renetangio rensen cycle, decreases urinary output, increases venus return to the heart, attempting to increase blood pressure, GI tract compromised, impaired motility, skin is cool and clamy.

Answer 14

STAGE OF SHOCK - COMPENSATORY STAGE

Question 15

WHICH STAGE OF SHOCK?

compensating measures in general are failing, proteins leaking through to the interstital space, causes interstitial edema, anascara, blood flow to pulmunary capillaries, leaving vascular space, pulmonary edema, looking for crackles, fluid moves into aveoli, respiratory increase, cardiac input falls further, circulation decreases, cap refil low, temp cold, pulses weak, b/p low, low oxygen, dysrythmea, excemia, MI, complete deteriation of the cardiac system,GI tract mucousa barrier is decreasing, protects lining of bowels, causes major bleeding, increases with shock, ability to absorb nutrietns decreases, immune function compromised

Answer 15

STAGES OF SHOCK - Progressive Stage

Question 16

• vomiting
• hemohharge
• diahhrea
• diabetes
• excessive urine result of high blood sugar acts like salt
* External loss of whole blood (e.g., hemorrhage from trauma, surgery,

* GI bleeding)

* Loss of other body fluids (e.g., vomiting, diarrhea, excessive diuresis, diabetes insipidus, diabetes mellitus - high blood sugar causes oligoria)

Answer 16

Hypovolemic shock symptoms

Absolute Hypovolemia

Question 17

* Pooling of blood or fluids (e.g., bowel obstruction)

* Fluid shifts (e.g., burn injuries, ascites)

* Internal bleeding (e.g., fracture of long bones, ruptured spleen, hemothorax, severe pancreatitis)

* Massive vasodilation (e.g., sepsis)

Answer 17

Hypovolemic shock symptoms

Relative Hypovolemia (3rd spacing)

Question 18

• compensating measures in general are failing
• proteins leaking through to the interstitial space
• causes interstitial edema
• anascara
• blood flow to pulmonary capillaries
• leaving vascular space
• pulmonary edema
• looking for crackles
• fluid moves into alveoli
• respiratory increase
• cardiac input falls further
• circulation decreases
• cap refill low
• temp cold
• pulses weak
• b/p low
• low oxygen
• dysrythmea
• excemia
• MI
• complete deteriation of the cardiac system
• GI tract mucousa barrier is decreasing, protects lining of bowels, causes major bleeding
• increases with shock
• ability to absorb nutrients decreases
• immune function compromised

Answer 18

Common laboratory readings during progressive stage OF SHOCK

Question 19

• Maintain patent airway
• Optimize oxygenation
with supplemental O2
• Intubation, mechanical
ventilation, if necessary

• Aggressive fluid
resuscitation with
colloids

• Antihistamines (e.g.,
diphenhydramine)
• Epinephrine (subQ, IV,
nebulized)
• Bronchodilators:
nebulized (e.g.,
albuterol)
• Corticosteroids (if
hypotension persists)

• Identify and remove
offending cause
• Prevention via avoidance
of known allergens
• Premedication with
history of prior sensitivity
(e.g., contrast media)

Answer 19

Interventions for anaphylactic shock

Question 20

Common fluids used in fluid resuscitation

Answer 20

COLLOIDS & ISOTONIC CRYSTALLOIDS

Question 21

• inflammation
• coagulation increase fibranolysis
• Respiratory failure
• fever
• tachycardic
• hyperventaltion
• hypoxemia
• low blood pressure urine output decreases
• confusion
• agitation

Answer 21

Septic shock manifestations

Question 22

Goal of care for cardiogenic shock

Answer 22

For a client in cardiogenic shock, the overall goal is to restore blood flow to the myocardium by restoring
the balance between oxygen supply and demand

Question 23

Collaborative care for clients with MODS focuses on 4 THINGS

Answer 23

Collaborative care for clients with MODS focuses on

(1) prevention and treatment of infection
(2) maintenance of tissue oxygenation
(3) nutritional and metabolic support
(4) appropriate support of individual failing organs.

Question 24

Dosage adjustment based on assessment of the adequacy of analgesic effect versus the side effects produced

Answer 24

TITRATION

Question 25

What is your part in assessing appropriate pain sedation?

Answer 25

• Anxiety related to pain
• Treatment regiment
• appropriate health teaching to client/ family
• Assist client in identifying there goal in their pain management

Question 26

Preoperative teaching concerns three types of information:

Answer 26

1. Sensory – clients want to know what they will see, hear, smell, and feel during the surgery
2. Process – may not want specific details but desire the general flow of what is going to happen
3. Procedural – desired details are more specific; for example, an intravenous line will be started while clients are in the holding area, and in the OR, clients will be asked to move onto the narrow bed and a safety strap will be put over their thighs

Question 27

Circulating or Nonsterile Activities
The perioperative registered nurse adheres to the following practices:

Answer 27

• Reviews, identifies, and assesses the physical status of the client
• Prioritizes, adjusts, and documents the plan of care to meet the specific needs of the client
• Provides resources required for the health care team to function efficiently
• Provides physical comfort measures specific to each surgical client
• Provides appropriate care during admission, preinduction, induction, intraoperative, and emergence periods
• Performs the count procedure concurrently with the scrub nurse and accurately documents
• Assists in maintaining and monitoring the integrity of the sterile field
• Provides continuous, astute, and vigilant observation of the surgical team throughout the surgical phase while meeting the needs of the health care team and client to reduce risk
• Acts as a client advocate during the perioperative period
• Responds appropriately to complications and unexpected events during the perioperative period
• Provides and assists with procedures and devices required to complete client care following the surgical procedure
• Assists in the client transfer and postoperative positioning
• Documents nursing, surgical, and other health care team activities during the perioperative period
• Utilizes appropriate communication techniques as required to keep noise at a minimum

Question 28

Scrubbed or Sterile Activities
The perioperative registered nurse adheres to the following practices:

Answer 28

• Sets priorities and expedites an efficient aseptic set-up for each surgical procedure
• Applies knowledge and skills and adapts as necessary to the techniques and the procedural steps of the surgical procedure
• Is vigilant and attentive and responds appropriately to complications and unexpected events during the surgical procedure
• Monitors aseptic technique throughout the procedure
• Performs the count procedure with the circulating registered nurse and accounts for all items on the sterile field
• Demonstrates knowledge of instruments and equipment and their function
• Acts as the client’s advocate during the surgical procedure
• Teaches and coaches learners throughout the surgical procedure

Question 29

Types of control measures and purpose of those measures in the OR

Answer 29

• Filters and controlled airflow in the ventilating systems provide dust control
• Positive air pressure in the rooms prevents air from entering the OR from the halls and corridors
• Dust-collecting surfaces such as open shelves, windows, and ledges are omitted.
• Materials that are resistant to the corroding effects of strong disinfectants are used.
• The functional design facilitates the practice of aseptic technique by the OR team
• Physical safety and comfort are aided by the use of OR furniture that is adjustable, easy to clean, and easy to move.
• All equipment is checked frequently to ensure electrical safety.
• The lighting is designed to provide a low- to high-intensity range for a precise view of the surgical site.
• A communication system provides a means for the delivery of routine and emergency messages
• The temperature is controlled to remain between 20°C and 24°C & humidity is regulated at 30 to 60% to facilitate client comfort under the surgical drapes, team comfort during the procedure, and an environment that is unfavourable to bacterial incubation and growth
• There should also be proper ventilation in each room to provide both physical comfort and for proper air exchange, which helps remove toxic fumes and anaesthetic gas fumes
• The privacy of the client is achieved by restricting access by unnecessary hospital personnel and to visitors. In addition, the complexity of an ongoing operative procedure does not permit the presence of extraneous persons

Question 30

OR aseptic considerations

Answer 30

1. Supplies should be opened as close as possible to the surgery start time.
2. Each package should be checked for wrapper integrity and changed chemical indicators (both external and internal).
3. The contents of any package with questionable wrappers or indicators should be considered unsterile.
4. Fabric, plastic, or items wrapped in paper or plastic that are dropped on the floor should be considered unsterile.
5. All materials that enter the sterile field must be sterile.
6. If a sterile item comes in contact with an unsterile item, it is contaminated.
7. If an item is contaminated before passing it to the scrub nurse, it should immediately be discarded.
8. Sterile team members must wear only sterile gowns and gloves. Once dressed for the procedure, they should recognize that the only parts of the gown considered sterile are the front from chest to table level and the sleeves to two inches above the elbow.
9. A wide margin of safety must be maintained between the sterile and the unsterile fields.
10. Tables are considered sterile only at tabletop level; items extending beneath this level are considered contaminated.
11. The edges of a sterile package are considered contaminated once the package has been opened.
12. Bacteria travel on airborne particles and will enter the sterile field with excessive air movements and currents.
13. Bacteria travel by capillary action through moist fabrics, and contamination occurs.
14. Bacteria harbour on the client’s and the team members’ hair, skin, and respiratory tracts and must be confined by appropriate attire.

Question 31

Identification process for OR

Answer 31

Asking the client to state:
• her or his name
• the surgeon’s name
• the operative procedure and location.

Question 32

the loss of sensation with loss of consciousness, skeletal muscle relaxation, analgesia, and elimination of the somatic, autonomic, and endocrine responses, including coughing, gagging, vomiting, and sympathetic nervous system responsiveness.

Answer 32

General anaesthesia

Question 33

the loss of sensation without loss of consciousness. Local anaesthesia may be induced topically or via infiltration intracutaneously or subcutaneously.

Answer 33

Local anaesthesia

Question 34

a minimally depressed level of consciousness with maintenance of the client’s protective airway reflexes. The primary goal of conscious sedation is to reduce the client’s anxiety and discomfort and to facilitate cooperation. Often a combination of sedative–hypnotic and opioid drugs is used. Conscious sedation preserves the client’s ability to maintain her or his own airway and respond appropriately to verbal commands, yet achieves a level of emotional and physical acceptance of a painful procedure (e.g., colonoscopy).

Answer 34

Conscious sedation (“twilight sleep”)

Question 35

the loss of sensation to a region of the body without loss of consciousness when a specific nerve or group of nerves is blocked with the administration of a local anaesthetic (e.g., spinal, epidural, or peripheral nerve block).

Answer 35

Regional anaesthesia

Question 36

• A rare metabolic disease characterized by hyperthermia with rigidity of skeletal muscles that can result in death.

Answer 36

Malignant hyperthermia

Question 37

occurs in affected people exposed to certain anaesthetic agents.

Answer 37

Malignant hyperthermia

Question 38

• When it does occur, it is usually during general anaesthesia, but it may manifest in the recovery period as well.
• It is autosomal dominant in inheritance but is variable in its genetic penetrance, so predictions based on family history are important but inconsistent

Answer 38

Malignant hyperthermia

Question 39

• The fundamental defect is hypermetabolism of skeletal muscle resulting from altered control of intracellular calcium, leading to muscle contracture, hyperthermia, hypoxemia, lactic acidosis, and hemodynamic and cardiac alterations

Answer 39

Malignant hyperthermia

Question 40

• Tachycardia, tachypnea, hypercarbia, and ventricular dysrhythmias are generally seen but are nonspecific to MH.
• MH is generally diagnosed after all other causes of the hypermetabolism are ruled out.
• The rise in body temperature is not an early sign of MH
• Can result in cardiac arrest and death

Answer 40

Malignant hyperthermia

S&S

Question 41

1. Record time of client’s return to unit.
2. Take baseline vital signs.
3. Assess airway and breath sounds.
4. Assess neurological status, including level of consciousness and movement of extremities.
5. Assess wound, wound closure and dressing, and drainage tubes.
   • Note type and amount of drainage.
   • Note any packing to an open wound.
   • Connect tubing to gravity or suction drainage.
6. Assess colour and appearance of skin.
7. Assess urinary status.
   • Note time of voiding.
   • Note presence of catheter, if any, and total output.
   • Check for bladder distension or urge to void.
   • Note catheter patency; check integrity of insertion site and size of Foley catheter.
8. Assess pain and discomfort.
   • Note last dose and type of pain control.
   • Note current pain intensity.
9. Position for comfort, safety (bed in low position, side rails up).
10. Check IV infusion.
    • Note type of solution.
    • Note amount of fluid remaining.
    • Note flow rate.
    Attach call light within client’s reach, and orient client to use of call light.
11. Ensure that emesis basin and tissues are available.
12. Determine emotional condition and support needed.
13. Check for presence of family member or significant other.
14. Orient client and family to immediate environment.
15. Check and carry out postoperative orders.

Answer 41

Appropriate postoperative assessment for various types of anesthesia
General Anaesthetic

Question 42

1. Record time of client’s return to unit.
2. Take baseline vital signs.
3. Assess airway and breath sounds.
4. Assess neurological status, including level of consciousness and movement of extremities.
   • Assess spinal insertion or epidural insertion site; ensure that there is a continuous epidural infusion in place and that the dressing and catheter are secure.
   • Assess motor and sensory blockage from spinal anaesthetic.
5. Assess wound, wound closure, dressing, and drainage tubes.
   • Note type and amount of drainage.
   • Note any packing to an open wound.
   • Connect tubing to gravity or suction drainage.
6. Assess colour and appearance of skin.
7. Assess urinary status.
   • Note time of voiding.
   • Note presence of catheter, if any, and total output.
   • Check for bladder distension or urge to void.
   • Note catheter patency; check integrity of insertion site and size of Foley catheter.
8. Assess pain and discomfort.
   • Note last dose and type of pain control.
   • Note current pain intensity.
9. Position for comfort, safety (bed in low position, side rails up).
10. Check IV infusion.
    • Note type of solution.
    • Note amount of fluid remaining.
    • Note flow rate.
11. Attach call light within client’s reach, and orient client to use of call light.
12. Ensure that emesis basin and tissues are available.
13. Determine emotional condition and support.
14. Check for presence of family member or significant other.
15. Orient client and family to immediate environment.
16. Check and carry out postoperative orders.

Answer 42

Appropriate postoperative assessment for various types of anesthesia

Spinal or Epidural Anaesthetic

Question 43

• characterized by a variety of nonspecific clinical signs and symptoms, ranging from agitation to somnolence, hypertension to hypotension, and tachycardia to bradycardia.
• Pulse oximetry will indicate a low oxygen saturation (below the 90 to 92% range).

Answer 43

Hypoxemia

Question 44

Appropriate postoperative positions for recovery

Answer 44

• Unless contraindicated by the surgical procedure, the unconscious client is positioned in a lateral “recovery” position (keeps the airway open and reduces the risk of aspiration if vomiting occurs)
• Once conscious, the client is usually returned to a supine position with the head of the bed elevated (maximizes expansion of the thorax by decreasing the pressure of the abdominal contents on the diaphragm)

Question 45

• evidenced by signs of hypoperfusion to the vital organs, especially the brain, the heart, and the kidneys.
• Clinical signs of disorientation, loss of consciousness, chest pain, oliguria, and anuria reflect hypoxemia and the loss of physiological compensation.

Answer 45

hypotension

Question 46

• Intervention must be timely to prevent the devastating complications of cardiac ischemia or infarction, cerebral ischemia, renal ischemia, and bowel infarction

Answer 46

hypotension interventions

Question 47

• The most common cause of hypotension in the PACU is ___________ _________ and _________ __________; thus, treatment is directed toward restoring circulating volume. If there is no response to fluid administration, cardiac dysfunction should be presumed to be the cause of hypotension

Answer 47

unreplaced fluid and blood loss

Question 48

Initial nursing actions upon receiving postoperative client on surgical floor from the PACU

Answer 48

• Assess vitals
• Review post-op orders

Question 49

Nursing interventions to promote intestinal motility

Answer 49

• Abdommotilityinal distension may be prevented or minimized by early and frequent ambulation, which stimulates intestinal

Question 50

Use of low-molecular weight heparin (LMWH) or unfractionated heparin

Answer 50

• The use of unfractionated heparin (UH) or low–molecular weight heparin (LMWH) is a prophylactic measure for venous thrombosis and pulmonary embolism
• LMWH has a greater bioavailability, more predictable dose response, and longer half-life than heparin with less risk of bleeding complications