VN 15 Study Guide Test 6- DONE

Question 1

1. Homecare client education for PCA use

Answer 1

-Only pt can press pca
-constant level of relief
-no nurse is needed to give dose
-cant overdose on pca
-don’t wait until pain is too late to administer meds

Question 2

2. Nurse post-op assessment (pg.603)

Answer 2

-Level of consciousness
-Vital signs
-Effectiveness of respirations
-Presence or need for supplemental oxygen
-Condition of the wound and dressing
-Location of drains and drainage characteristics
-Location, type, and rate of intravenous fluid
-Level of pain and need for analgesia
-Presence of a urinary catheter and urine volume

Question 3

3. Client education included with discharge post op (pg.605)

Answer 3

-How to care for the incision site
-Signs of complications to report
-What drugs to use to relieve pain
-How to self-administer prescribed drugs
-When normal activity can be resumed
-If and how much weight can be lifted
-Which foods to consume or avoid
-When and where to return for follow-up appointments
-The nurse gives information both verbally and in written form.

Question 4

4. Steps to Gastro Intubation(pp slide12)

Answer 4

-gather set up equipment (if tube is stiff put in warm water)
-inspect nasal(look for polyps,deviated septums, narrow passageway)
-measure(nose,earlobe,xiphoid)
-assess bowel sounds
-raise head of bed (high fowlers)
-lubricate tip & insert
-stop at first mark(ear-nose) & inspect throat
-lower chin & swallow while advancing tube 3-5 inches w/each swallow
-secure tube
-confirm placement: definitive only x-ray
-12. Auscultation of the abdomen while instilling air or aspirate w/PH to monitor for placement after verification

Question 5

5. Pre insertion assessment of GI tubes and the exclusions (pg.646)

Answer 5

-Level of consciousness
-Weight
-Bowel sounds
-Abdominal distention
-Integrity of nasal and oral mucosa
-Ability to swallow, cough, and gag
-Any nausea and vomiting
-exclusions: polyps, fractures, deviated septums, narrow passageway

Question 6

6. Signs of someone choking (pg.829)

Answer 6

-Coughing or gagging while eating
• Audibly wheezing
• Persistently attempting to clear throat
• Making hoarse or wet vocal sounds
• Resisting efforts to be fed
• Being unable to speak
• Holding throat
• Being unable to breathe
• Exhibiting cyanosis

Question 7

4 types of drainage

Answer 7

Sanguineous: fresh bleeding
Serous: clear, thin, watery plasma (normal during inflammatory stage of wound healing)
serosanguinous: light pink (small amounts of blood)
Purulent: thick,tan,yellow,green or brown (puss)