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Med Surg > Tissue Integrity/PeriOp Care > Flashcards

Tissue Integrity/PeriOp Care Flashcards

1
Q

Stage 1 Pressure ulcer

A

Red area that is not blanchable

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2
Q

Stage 2 Pressure ulcer

A

Shallow open wound w/o slough

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3
Q

Stage 3 Pressure ulcer

A

No bone or muscle present
Some slough but does not obscure
Full thickness loss

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4
Q

Stage 4 Pressure ulcer

A

Full thickness tissue loss
See bone or muscle
Slough and eschar may be present
Undermining and tunneling

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5
Q

Suspected deep tissue injury

A

Depth unknown
Purple discolored area of intact skin
Due to pressure or shear

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6
Q

Unstageable Pressure ulcer

A

Depth unknown
Full thickness tissue loss
Ulcer covered by slough and eschar in wound bed
Cannot stage until removed`

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7
Q

Priority screening before surgery

A

Screen for Malignant hyperthermia

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8
Q

What meds would the nurse check for a pt. before a surgery that puts them at a high risk during surgery

A

Aspirin
Antidepressants
Steroids
NSAIDs

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9
Q

What is best practice for marking a surgical site?

A

The physician should mark the site with the involvement of the pt.

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10
Q

Pt. has surgery in 3 hours but take her Beta-blocker every morning. True/False: The nurse should withhold the medication before surgery

A

False: This is a vital medication for heart function. The pt. should have the beta-blocker

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11
Q

Pt. has surgery in 3 hours but take her multivitamin every morning. True/False: The nurse should withhold the medication before surgery

A

True: this is not a vital medication

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12
Q

Surgical Time Out

A

ID right pt., right procedure, right site
Sponge and instrument count
Positioning

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13
Q

What is the last sense to go when a pt. is under anesthegia

A

Hearing

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14
Q

During the surgical procedure who is the advocate for the pt.?

A

Nurse circulator

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15
Q

Where should a ground device be placed?

A

Place over muscle

DO NOT place over bone or extremity with joint replacement

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16
Q

Pt. just under went an abdominal laparoscopic surgery 4 hours ago. The patient is complaining of pain in shoulders and upper chest. What should the nurse suspect?

A

Trapped gas from the surgery

Intervention: Ambulation

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17
Q

General anesthesia

A

Total loss of consciouness

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18
Q

Local anesthesia

A

topical or by local infiltration

Ex. skin cancer removal

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19
Q

Spinal anesthesia

A

Use for pt. that are not good candidates for general anesthesia
Ex. elderly, frailty, heart probs

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20
Q

Regional anesthesia

A

Nerve block

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21
Q

PACU phase 1 priority assessment

A

LOC

Can they maintain their own airway?

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22
Q

PACU Phase 1 handoff

A

anesthesia and circulating RN handoff to PACU RN

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23
Q

PACU Phase 2 and 3 handoff

A

PACU RN handoff to unit RN

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24
Q

What types of things are included in handoff report after surgery

A 
Type of surgery
Type of anesthesia
VS
Estimated blood loss (EBL)
Dressings
Drains
Incisions
Temp
Health Hx
IV fluids
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25
Q

Complication of surgery that the PACU RN should assess

A

Signs of shock

Hemorrhage

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26
Q

PACU RN’s pt. surgical site dressing is beginning to show blood through the dressing. True/False: The nurse should remove the soiled dressing and put a new dressing on to prevent infection and assess bleeding

A

False: the nurse should just “reinforce” the dressing. This means placing a new dressing OVER the old dressing. The first dressing change should be done by the HCP

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27
Q

What drains use negative pressure to drain fluids?

A

Jackson-Pratt

Hemovac

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28
Q

What should the nurse label a dressing with?

A

Date, time, intials

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29
Q

Penrose drains are primarily used for what type of surgery?

A

Abdominal surgeries

30
Q

Gas exchange complication

A

atelectasis

pneumonia

31
Q

Gas exchange interventions

A

Incentive spirometer
Turn, cough, deep breath
ambulation

32
Q

Perfusion Complications

A

Venous stasis
DVT
PE
Hemorrhage

33
Q

Perfusion Interventions

A 
TED
SCD
Ambulation
doriflexsion
anticoagulants
monitor blood loss (H and H)
Dressings
34
Q

Surgical site infection assessment

A 
Drainage
Pain
redness
Heat
tenderness
Odor
Swelling
35
Q

Prevention of surgical site infection

A 
Admin antibiotics
Sterile dressing and changes
Know risk factors for infection
Prevent hypothermia during surgery
Effective preop skin prep
36
Q

Wound Dehiscence

A

Serration of wound edges

37
Q

Wound Evisceration

A

protrusion of intestinal contents through wound
Apply sterile gauze
Notify HC immediately

38
Q

Fever 2 days after surgery can be in indicator of what respiratory complication?

A

Atelactesis

39
Q

GI complications

A

Abd distension
Constipation
Postop ileus

40
Q

GI interventions

A 
Ambulation
Bowel rest
stool softeners
chewing gum
Help control N/V
I and O
41
Q

GU Complications

A

Urinary retention
Decreased urinary output
Incontinence

42
Q

GU interventions

A

I and Os
Bladder scan
Remove foley as appropriate
Encourage fluids

43
Q

Surgical Pt. being discharged. What signs should the nurse teach the pt. about when to call the HCP?

A

Excessive bleeding
yellow/foul smelling drainage
Temp greater than 100.8

44
Q

What type of discharge teaching should the nurse provide to the pt.?

A

Written and verbal

45
Q

Celluitis

A

diffuse infection of the dermis and SQ tissue

Tx: vary depending on causative agent

46
Q

MRSA

A

Decrease risk by giving CHG baths prior to surgery

47
Q

Risk Factors for surgical complications

A 
Pre-existing conditions (COPD, asthma, sleep apnea, smoking)
Kidney issues - excreting anesthesia
Malignant hyperthermia
Age
Obesity
Immunocompromised
Urinary issues - inability to excrete urine
Cardiac Hx
48
Q

Post surgery Issues

A 
Hypovolemic shock
Hemorrhage
Wound infection
DVT, PE
Urinary retention
anesthesia reaction
49
Q

Which lab result is concerning for a pt. going to orthopedic surgery?

a. ) Ca 9.2
b. ) INR 2.6
c. ) Hemoglobin 10.5
d. ) K+ 3.5

A

INR 2.6

50
Q

Pt. going for surgery smokes 2 packs of cigarettes a day. What is this client at greatest risk for?

a. ) Wound infection
b. ) Hemorrhage
c. ) Atelectasis
d. ) Postoperative ileus

A

C Atelectasis: because bad lungs, more at risk for lung probs

51
Q

What is the minimum age a person can consent to surgery in Alabama

A

14 years old can consent to their own surgeries

52
Q

What assessment is most important for the client who has delayed surgical wound healing?

a. ) Family Hx
b. ) Serum albumin and prealbumin
c. ) Hx of Kidney stones
d. ) K+ levels

A

B - Albumin and prealbumin, measure of nutrition

Nutrition effects wound healing

53
Q

What type of anesthesia is used for a pt. undergoing an EGD?

a. ) general
b. ) regional
c. ) local
d. ) Moderate sedation

A

D- moderate sedation

54
Q

What is NOT a risk factor for respiratory depression with PCA?

a. ) obesity
b. ) middle age
c. ) advanced age
d. ) Low body weight

A

B - middle age

55
Q

Moderate Sedation

A

Able to breath on their own

56
Q

Which meds can NOT be used with PCA

a. ) nerve meds
b. ) acetaminophen
c. ) NSAIDS
d. ) Fentanyl

A

D- Fentanyl

57
Q

Which med is NOT acceptable for a NPO patient?

a. ) Aspirin oral
b. ) labetalol
c. ) Digoxin
d. ) pantoprazole

A

D - Pantoprazole

58
Q

Which of these tests is used to r/o pneumonia?

a. ) CT scan
b. ) Chest x ray
c. ) MRI

A

B - Chest X ray

59
Q

RN is talking o client about cellulitis. What description is NOT correct?

a. ) can occur in many different settings, typical unilateral
b. ) Caused by gram positive bacteria such as Staph A or Strep P
c. ) Infection of dermis and SubQ tissues
d. ) Collection of pus within the dermis and subQ tissue

A

D- Collection of pus within the dermis and subQ tissue

60
Q

Client is recieving PO pain med for pain 9/10 at 1100. When is the follow up?

a. ) 1115
b. ) 1215
c. ) 1200
d. ) 1230

A

C - 1200

61
Q

Which population is most likely at risk for inadequate pain control

a. ) AOC X 3
b. ) Current Hx of cocaine use
c. ) Proficient bilingual client

A

b - Current Hx of cocaine use

62
Q

The nurse is assessing the pt. surgical dressing. What is not considered an emergency situation?

a. ) Sx dressing is saturate through multiple reinforcements
b. ) Organ tissue is protruding out of the exposed wound
c. ) Wound bed edges are slightly separated with scarce drainage

A

C

63
Q

Which is NOT a Tx option for malignant hyperthermia?

a. ) meds
b. ) Ice
c. ) fluids
d. ) K+

A

D- K+

64
Q

Client is ready to have a PICC line placed. What is most important task performed in the intra-op phase?

a. ) Assessment of drain tubes placed
b. ) Understanding of surgical procedure
c. ) Surgical time out
d. ) Reviewing previous surgery Hx

A

C- Surgical time out

65
Q

Client is concerned about robotic procedure. What is NOT an advantage of robotic procedures?

a. ) Less dexterity
b. ) Shorter recovery time
c. ) Less puncture wounds
d. ) Less pain

A

A - Less dexterity

66
Q

Pt. jsut came back from oral procedure. What is the priority assessment while in PACU?

a. ) O2 sat
b. ) Pain
c. ) LOC
d. ) RR

A

C - LOC

67
Q

RN assessing surgical site of a pt. from Sx. What is NOT indicative of risk for surgical site infection?

a. ) WBC of 100
b. ) Taking steroids for asthma
c. ) Moderate serosangious output from drain
d. ) Being 100 years old

A

C - Moderate serosangious output form drain

68
Q

Client receiving IV Dilaudid PCA pump. What makes you concerned about pt. potential RASS score?

a. ) Wife hitting button for pt.
b. ) pt moans with deep breaths
c. ) Pt. is easy to arouse

A

A - wife hitting button for pt

69
Q

Client is ready for discharge. What action BEST tells the RN the client can empty the drain properly?

a. ) Reading discharge instructions
b. ) Return demostration
c. ) Have significant other empty the drain

A

B - return demostration

70
Q

RN is assessing arm of pt. What is a major complication of celluitis?

a. ) Overuse and misuse of systemic antibiotics
b. ) Bleeding from biopsy site
c. ) blood culture inaccuracies

A

A - Overuse and misuse of antibiotics

Med Surg (22 decks)

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