NURS 120 Med Surg. Final Exam Study Guide
NG tube placement & verification:
o Review the prescription & purpose of the procedure, understand the need for
placement. Identify client, explain the procedure.
o Review history of nasal problems, anticoagulants, previous trauma, & past history of
aspiration.
o Evaluate the clients ability to cooperate & make a hand signal w/ the client.
o Perform hand hygiene, tape or use commercial fixation device to secure the dressing.
o Use clean gloves, water soluble lube, topical anesthetic, cup of water & straw, catheter &
syringe (30-60 mL), basin, pH strip (>4), clamp or plug to close the tubing after insertion.
o Steps: ATI
1. Auscultate bowel sounds, palpate abdomen for distention, pain & rigidity.
2. Raise head of bed (high fowlers if possible).
3. Assess nares, look for deviation/obstruction.
4. Measure tube from tip of the nose to the earlobe, down to the xiphoid process.
5. Give client water & when they swallow continue to insert tubbing.
If client vomits clear the airway & provide comfort before continuing care.
6. Check for placement w/ pH strip (<4) & assess color, odor, consistency & amount.
7. Verify placement w/ X-RAY.
If the tube is not in the stomach, advance it 5 cm (2 in.) & repeat
placement check.
Wound Evisceration – Nursing actions – what to do if you see evisceration?
1. Call for help, ask the surgeon to be notified & that needed supplies be brought to
the room of the client.
2. Stay with the client.
3. While waiting for supplies, place the client in low fowlers w/ the knees bent.
4. Cover the wound with sterile wet normal saline dressing & keep the dressing moist. Do
not attempt to reinsert organs.
5. Take vital signs & monitor the client closely for signs of shock.
6. Prepare the client for surgery as necessary.
7. Document the occurrence, actions taken, and the clients response.
Perioperative teaching, informed consent.
o Preparing a client for surgery:
1. Assist the client to void before transfer to the operating room.
2. Check all surgeon's prescriptions to ensure they have been carried out.
3. Review the client's record for a history & physical report & laboratory reports.
o Obtaining informed consent- The surgeon is responsible for explaining the surgical
procedure to the client & answering the clients questions. The nurse is responsible for
obtaining the clients signature on the consent form & needs to make sure the client
understood the surgeon’s explanation.
, o The nurse needs to document the witnessing of the signing of the consent form after the
client acknowledges the procedure. The nurse must also document any questions the client
has, reinforce teaching, get an interpreter.
o Minors younger than 18 need a parent or legal guardian. Some older adult clients may need
a legal guardian to sign consent.
o Psychiatric clients have the right to refuse a treatment until the court has legally determined
that they are unable to make a decision for themselves.
o You only need 2 nurses if you’re getting consent over the phone, when the patient
is unable to give it themselves.
o Two witnesses are required if the client is
1. Able to only sign with an “X”
2. Blind, deaf
3. English is a second language.
o Nutrition- NPO status pre-op. Withhold solid foods & liquids as prescribed to avoid aspiration,
6-8 hr. for general anesthesia, & 3 hr. for local anesthesia (as prescribed).
1. Verify NPO status: (to avoid aspiration) for at least: 6 hr.
for solid foods.
2 hr. (clear liquids) before general anesthesia. 3 to 4
hr. (clear liquids) before local anesthesia Chart the
last time the client ate/drank.
o Insert IV line & administer IV fluids as prescribed. The IV catheter should be large
enough to administer blood products if needed. (a large-bore 18-gauge catheter)
Obtaining a detailed health history:
o Diagnosed medical conditions (previous & current)
o Allergies: Banana or Kiwi – indicative of latex allergy
o Eggs/Soybean – Don’t give propofol
o Shellfish & Seafood = No Iodine
o Previous surgeries & problems, medication use, substance abuse.
Reactions/problems to anesthesia (patient/family)
o Assess anxiety level & support systems.
o Lab results. Venous Thromboembolism risk. Head to toe assessment, Vital signs, & O2 sat.
Pregnancy status, Chronic diseases etc.
Post-Operative comfort:
, Who can transfer a client from OR to PACU? o
Anesthesia provider (anesthesiologist or CRNA)
Circulating nurse gives the verbal “hand-of” report to PACU nurse.
Postoperative care is provided initially in the PACU by a ACLS certified RN.
Initial postoperative care: assessments, administering medications, managing client’s pain,
preventing complications, & determining when a client is ready to be discharged from the
PACU.
PRIORITIES During the immediate postoperative stage: o
airway patency
o ventilation
o circulatory status
Vital Signs: Until stable (every 15 min) and assess for trends.
Atropine- Decrease risk of Bradycardia during surgery & at times vagal slowing of the heart due
to parasympathetic response to surgical manipulation. Block Muscarinic response to
acetylcholine by salivation, bowel movement & GI secretions. Slow mobility of GI system.
• salivation, Pancreatic juices & gastric juices
• risk of aspiration
• A/E: Mad as a hatter, dry as a bone, red as a bee, can’t shit, can’t spit, can’t pee.
• Urinary retention
• Tachycardia
• Dry mouth
• Decreased levodopa effects
• Contraindicated w/ glaucoma & urinary problems.
NG tube placement & verification:
o Review the prescription & purpose of the procedure, understand the need for
placement. Identify client, explain the procedure.
o Review history of nasal problems, anticoagulants, previous trauma, & past history of
aspiration.
o Evaluate the clients ability to cooperate & make a hand signal w/ the client.
o Perform hand hygiene, tape or use commercial fixation device to secure the dressing.
o Use clean gloves, water soluble lube, topical anesthetic, cup of water & straw, catheter &
syringe (30-60 mL), basin, pH strip (>4), clamp or plug to close the tubing after insertion.
o Steps: ATI
1. Auscultate bowel sounds, palpate abdomen for distention, pain & rigidity.
2. Raise head of bed (high fowlers if possible).
3. Assess nares, look for deviation/obstruction.
4. Measure tube from tip of the nose to the earlobe, down to the xiphoid process.
5. Give client water & when they swallow continue to insert tubbing.
If client vomits clear the airway & provide comfort before continuing care.
6. Check for placement w/ pH strip (<4) & assess color, odor, consistency & amount.
7. Verify placement w/ X-RAY.
If the tube is not in the stomach, advance it 5 cm (2 in.) & repeat
placement check.
Wound Evisceration – Nursing actions – what to do if you see evisceration?
1. Call for help, ask the surgeon to be notified & that needed supplies be brought to
the room of the client.
2. Stay with the client.
3. While waiting for supplies, place the client in low fowlers w/ the knees bent.
4. Cover the wound with sterile wet normal saline dressing & keep the dressing moist. Do
not attempt to reinsert organs.
5. Take vital signs & monitor the client closely for signs of shock.
6. Prepare the client for surgery as necessary.
7. Document the occurrence, actions taken, and the clients response.
Perioperative teaching, informed consent.
o Preparing a client for surgery:
1. Assist the client to void before transfer to the operating room.
2. Check all surgeon's prescriptions to ensure they have been carried out.
3. Review the client's record for a history & physical report & laboratory reports.
o Obtaining informed consent- The surgeon is responsible for explaining the surgical
procedure to the client & answering the clients questions. The nurse is responsible for
obtaining the clients signature on the consent form & needs to make sure the client
understood the surgeon’s explanation.
, o The nurse needs to document the witnessing of the signing of the consent form after the
client acknowledges the procedure. The nurse must also document any questions the client
has, reinforce teaching, get an interpreter.
o Minors younger than 18 need a parent or legal guardian. Some older adult clients may need
a legal guardian to sign consent.
o Psychiatric clients have the right to refuse a treatment until the court has legally determined
that they are unable to make a decision for themselves.
o You only need 2 nurses if you’re getting consent over the phone, when the patient
is unable to give it themselves.
o Two witnesses are required if the client is
1. Able to only sign with an “X”
2. Blind, deaf
3. English is a second language.
o Nutrition- NPO status pre-op. Withhold solid foods & liquids as prescribed to avoid aspiration,
6-8 hr. for general anesthesia, & 3 hr. for local anesthesia (as prescribed).
1. Verify NPO status: (to avoid aspiration) for at least: 6 hr.
for solid foods.
2 hr. (clear liquids) before general anesthesia. 3 to 4
hr. (clear liquids) before local anesthesia Chart the
last time the client ate/drank.
o Insert IV line & administer IV fluids as prescribed. The IV catheter should be large
enough to administer blood products if needed. (a large-bore 18-gauge catheter)
Obtaining a detailed health history:
o Diagnosed medical conditions (previous & current)
o Allergies: Banana or Kiwi – indicative of latex allergy
o Eggs/Soybean – Don’t give propofol
o Shellfish & Seafood = No Iodine
o Previous surgeries & problems, medication use, substance abuse.
Reactions/problems to anesthesia (patient/family)
o Assess anxiety level & support systems.
o Lab results. Venous Thromboembolism risk. Head to toe assessment, Vital signs, & O2 sat.
Pregnancy status, Chronic diseases etc.
Post-Operative comfort:
, Who can transfer a client from OR to PACU? o
Anesthesia provider (anesthesiologist or CRNA)
Circulating nurse gives the verbal “hand-of” report to PACU nurse.
Postoperative care is provided initially in the PACU by a ACLS certified RN.
Initial postoperative care: assessments, administering medications, managing client’s pain,
preventing complications, & determining when a client is ready to be discharged from the
PACU.
PRIORITIES During the immediate postoperative stage: o
airway patency
o ventilation
o circulatory status
Vital Signs: Until stable (every 15 min) and assess for trends.
Atropine- Decrease risk of Bradycardia during surgery & at times vagal slowing of the heart due
to parasympathetic response to surgical manipulation. Block Muscarinic response to
acetylcholine by salivation, bowel movement & GI secretions. Slow mobility of GI system.
• salivation, Pancreatic juices & gastric juices
• risk of aspiration
• A/E: Mad as a hatter, dry as a bone, red as a bee, can’t shit, can’t spit, can’t pee.
• Urinary retention
• Tachycardia
• Dry mouth
• Decreased levodopa effects
• Contraindicated w/ glaucoma & urinary problems.
