NUR 242 Med/Surg Exam 1 Complete
questions and correct verified answers
(detailed answers) already graded A+
Post-Op - {✔✔ANSWER✔✔}-DVT is the most common type of
thrombophlebitis. High risk for pulmonary embolism. Develops most often in the
legs but can occur in the upper arms
,Interventions: patient education regarding leg exercises, early ambulation,
adequate hydration, compression stockings, sequential compression devices
(SCD's)
Post-Op
wound healing and prevention of infections - {✔✔ANSWER✔✔}-assess the
surgical incision at least every 8 hours for redness, increases warmth, swelling,
tenderness or pain, and the type/amount of drainage
sanguineous (bloody) to serosanguineous to serous (yellow) drainage is normal
during the first few days after surgery. Drainage should gradually decrease
Crusting on the incision line, pink colour to the incision line, and slight swelling
under the sutures/staples is normal
Post-op Risk for post surgical wound
DEHISCENCE - {✔✔ANSWER✔✔}-Obesity
diabetes
corticosteriod use
immune deficiency
malnutrition
Post-op
wound EVISCERATION - {✔✔ANSWER✔✔}-Call for help and stay with
patient
cover wound with sterile gauze soaked in sterile water
do not attempt to reinsert the protruding organ
place the patient in supine position with hips and knees bent
, raise the HOB no more than 15-20 degrees
provide support and reassurance to the patient
Sequence of inflammation - {✔✔ANSWER✔✔}-Stage 1 - injured tissue and
the leukocytes mast cells in this area secrete histamine, serotonin and kinins that
constrict the small veins and dilate the arterioles in the area of injury. These
changes cause redness and warmth to the tissues
Stage 2 - An increased number of circulating neutrophils occurs. Exudate in the
form of pus occurs, containing dead WBC's, necrotic tissue, and fluids that escape
from the damaged cells. Thus, you will see an increase in the neutrophil count
Stage 3 - tissue repair and replacement occur
MIDLINE catheters - {✔✔ANSWER✔✔}-peripheral IV access
utilized for short -term therapy (4 weeks or less)
the tip of the midline ends in the axillary vein
should not be used to draw labs
DOES NOT require x-ray for placement
complications of PIV
(peripheral IV) Infiltration - {✔✔ANSWER✔✔}-IV becomes dislodged
fluid leaks from the vein to surrounding tissue
discontinue IV and elevate the extremity
apply ice or heat therapy
vesicant medications can cause extravasation if IV infiltrates
Complication of PIV
questions and correct verified answers
(detailed answers) already graded A+
Post-Op - {✔✔ANSWER✔✔}-DVT is the most common type of
thrombophlebitis. High risk for pulmonary embolism. Develops most often in the
legs but can occur in the upper arms
,Interventions: patient education regarding leg exercises, early ambulation,
adequate hydration, compression stockings, sequential compression devices
(SCD's)
Post-Op
wound healing and prevention of infections - {✔✔ANSWER✔✔}-assess the
surgical incision at least every 8 hours for redness, increases warmth, swelling,
tenderness or pain, and the type/amount of drainage
sanguineous (bloody) to serosanguineous to serous (yellow) drainage is normal
during the first few days after surgery. Drainage should gradually decrease
Crusting on the incision line, pink colour to the incision line, and slight swelling
under the sutures/staples is normal
Post-op Risk for post surgical wound
DEHISCENCE - {✔✔ANSWER✔✔}-Obesity
diabetes
corticosteriod use
immune deficiency
malnutrition
Post-op
wound EVISCERATION - {✔✔ANSWER✔✔}-Call for help and stay with
patient
cover wound with sterile gauze soaked in sterile water
do not attempt to reinsert the protruding organ
place the patient in supine position with hips and knees bent
, raise the HOB no more than 15-20 degrees
provide support and reassurance to the patient
Sequence of inflammation - {✔✔ANSWER✔✔}-Stage 1 - injured tissue and
the leukocytes mast cells in this area secrete histamine, serotonin and kinins that
constrict the small veins and dilate the arterioles in the area of injury. These
changes cause redness and warmth to the tissues
Stage 2 - An increased number of circulating neutrophils occurs. Exudate in the
form of pus occurs, containing dead WBC's, necrotic tissue, and fluids that escape
from the damaged cells. Thus, you will see an increase in the neutrophil count
Stage 3 - tissue repair and replacement occur
MIDLINE catheters - {✔✔ANSWER✔✔}-peripheral IV access
utilized for short -term therapy (4 weeks or less)
the tip of the midline ends in the axillary vein
should not be used to draw labs
DOES NOT require x-ray for placement
complications of PIV
(peripheral IV) Infiltration - {✔✔ANSWER✔✔}-IV becomes dislodged
fluid leaks from the vein to surrounding tissue
discontinue IV and elevate the extremity
apply ice or heat therapy
vesicant medications can cause extravasation if IV infiltrates
Complication of PIV
