NURS 4526 Final Exam (Adult section Week 9 (disability): 1
-53 Week 10 (DKA/HHS/hypoglycemia) 54-88 Week 10
(CVAD): 89-103 Week 10 (Pre/intra/postoperative): 104-181
Week 12 Shock: 182-227 Week 12 Code blue: 228-246
Pediatric section Week 7 Sickle cell + DKA: 247-297 Week 8
Neuro dysfunction) Questions With Complete Solutions
Nursing care assessment of neuro status postop
LOC
-AVPU
-GCS
-Orientation
-Ability to follow commands
-Size reactivity and equality of pupils
-Sensory and motor status
GCS
Eye opening
4 = eyes open spontaneously
3 = eyes open to verbal command or speech
2 = eyes open to pain
1 = no eye opening
Verbal
5 = Oriented x3
4 = Confused conversation but able to answer questions
3 = Inappropriate response
,2 = Incomprehensible sound or speech
1 = no verbal response
Motor
6 = Obeys commands for movement
5 = purposeful movement to painful stimulus
4 = withdraws from pain
3 = Abnormal flexion or decorticate posturing
2 = Extensor response or decerebrate posturing
1 = No motor response
Potential alterations in temperature
Hypothermia may be present in immediate postop period
-Fever can occur at any time
Etiologies of temp alterations
Mild elevation
-Can result from stress response
Moderate elevation
-Usually caused by resp congestion or ateleactsis, rarely caused
by dehydration
If temp elevation remains after 48 hrs, is usually indicative of
infection.
-Can signial C. dificl if accompanied by diarrhea + pain
---
,Hypothermia can occur
-When heat loss exceeds production
-Loss of heat to cold OR from body organs exposed to the air
There is an increased risk associated with
-Age
-Debility
-Intoxication
-Prolonged anesthetic admin
Potential alterations in urinary function postop
Low urine output is EXPECTED in the first 24 hours regardless
of intake
Anticholinergic and opioid drugs can also interfere with ability
to intitiate voiding or fully emptying bladder
Progression of drainage of course of recovery
Should change from snguineous (bloody) to serosanguineous to
serous (clear) with decreasing output
Signs of wound dihiscence
A sudden brown, pink, or clear discharge can precede wound
dehisence
Principals of discharge from the clinical unit
-Prep for discharge should be an ongoing process throughout the
surgical experience
-Client is prepared as events unfold
, -They will gradually assume greater responsibility for self care
in the postop period
Information that the client and caregiver should be provided at
discharge
-Care of the wound site
-Dressing, bathing recommendations
-Activities that can be allowed and restricted
-Dietary restrictions
-Symptoms to be reported
-Instructions on follow-up care
-Answers to questions, or concerns
Components that contribute to the stroke volume of the heart
-Preload
-Afterload
-Contractility
Components that contribute to cardiac output
CO = HR x SV
So a change in preload, afterload, contractility affects stroke
volume, which in turn affects the cardiac output
Frank starling law
There is an optimal length between sarcomeres at which the
tension in the muscle fibre is greatest, resulting in the greatest
force of contraction
-53 Week 10 (DKA/HHS/hypoglycemia) 54-88 Week 10
(CVAD): 89-103 Week 10 (Pre/intra/postoperative): 104-181
Week 12 Shock: 182-227 Week 12 Code blue: 228-246
Pediatric section Week 7 Sickle cell + DKA: 247-297 Week 8
Neuro dysfunction) Questions With Complete Solutions
Nursing care assessment of neuro status postop
LOC
-AVPU
-GCS
-Orientation
-Ability to follow commands
-Size reactivity and equality of pupils
-Sensory and motor status
GCS
Eye opening
4 = eyes open spontaneously
3 = eyes open to verbal command or speech
2 = eyes open to pain
1 = no eye opening
Verbal
5 = Oriented x3
4 = Confused conversation but able to answer questions
3 = Inappropriate response
,2 = Incomprehensible sound or speech
1 = no verbal response
Motor
6 = Obeys commands for movement
5 = purposeful movement to painful stimulus
4 = withdraws from pain
3 = Abnormal flexion or decorticate posturing
2 = Extensor response or decerebrate posturing
1 = No motor response
Potential alterations in temperature
Hypothermia may be present in immediate postop period
-Fever can occur at any time
Etiologies of temp alterations
Mild elevation
-Can result from stress response
Moderate elevation
-Usually caused by resp congestion or ateleactsis, rarely caused
by dehydration
If temp elevation remains after 48 hrs, is usually indicative of
infection.
-Can signial C. dificl if accompanied by diarrhea + pain
---
,Hypothermia can occur
-When heat loss exceeds production
-Loss of heat to cold OR from body organs exposed to the air
There is an increased risk associated with
-Age
-Debility
-Intoxication
-Prolonged anesthetic admin
Potential alterations in urinary function postop
Low urine output is EXPECTED in the first 24 hours regardless
of intake
Anticholinergic and opioid drugs can also interfere with ability
to intitiate voiding or fully emptying bladder
Progression of drainage of course of recovery
Should change from snguineous (bloody) to serosanguineous to
serous (clear) with decreasing output
Signs of wound dihiscence
A sudden brown, pink, or clear discharge can precede wound
dehisence
Principals of discharge from the clinical unit
-Prep for discharge should be an ongoing process throughout the
surgical experience
-Client is prepared as events unfold
, -They will gradually assume greater responsibility for self care
in the postop period
Information that the client and caregiver should be provided at
discharge
-Care of the wound site
-Dressing, bathing recommendations
-Activities that can be allowed and restricted
-Dietary restrictions
-Symptoms to be reported
-Instructions on follow-up care
-Answers to questions, or concerns
Components that contribute to the stroke volume of the heart
-Preload
-Afterload
-Contractility
Components that contribute to cardiac output
CO = HR x SV
So a change in preload, afterload, contractility affects stroke
volume, which in turn affects the cardiac output
Frank starling law
There is an optimal length between sarcomeres at which the
tension in the muscle fibre is greatest, resulting in the greatest
force of contraction
