NRSG258 exam || QUESTIONS WITH ALL PASSED
ANSWERS!!
Benefits for using Patient Controlled Analgesia (PCA) pump correct answers -Empowering
patients to have control over their pain will in turn help to alleviate anxiety which will in turn
reduce pain experience.
-immediate and effective and the patient does not have to wait to have analgesia
administered.
-Extremely useful for incident pain e.g. dressing changes, physiotherapy
-The treatment regimen can be tailored to the needs of the individual
-Improved quality of recovery and care
-Decreased bed occupancy time with resultant economic benefit
-More positive perception of hospital stay
Nursing interventions if patient on PCA is drowsy correct answers -Assess vitals and A-G
-If vitals are below range, stop the infusion
- Give oxygen 15l/min
-Inform medical staff
What to do if patient during blood transfusion has an allergic reaction (8 steps) correct
answers -STOP THE TRANSFUSION.
- Start IV line (0.9% NaCl)
- Place the client in Fowler's position (upright 90 degrees) if with Shortness of Breath and
administer O2 therapy.
- Observe patient and monitor vital signs as often as every 5 minutes.
- Notify the physician.
- The nurse prepares to administer emergency drugs such as antihistamines, vasopressor,
fluids, and steroids as per physician's order or protocol.
- Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as
a result of RBC hemolysis.
- Blood container, tubing, attached label, and transfusion record are saved and returned to the
laboratory for analysis.
Advantages of using enteral feeding tube correct answers cheaper
simpler
fewer complications
for efficient use of nutrients
stimulates intestinal blood flow
maintain GI mucosal barrier (prevents bacterial translocation and portal endotoxaemia)
reduced gut associated lymphatoid system (GALT) -> becomes a source of activated cells
and proinflammatory stimulants
prevents disuse atrophy
Assessment on admission to PACU correct answers Physical Assessment
Airway, Breathing, Circulation & Disability Assessment (link to Nursing Assessment
Guideline)
Baseline Observations including, RR, Respiratory effort, SpO2, HR, BP and Temperature
Oxygen requirements
IV Fluids
, Analgesia
Urine Output
Reportable Blood Loss
Assessment of Wound Sites / Dressings
Presence of drains and patency of same
NGT In situ
Patient outcomes that need to be met before transferring patient from PACU to ward
"Discharge Criteria" correct answers -Clinical Observations within age appropriate limits
-Observations which fall within shaded areas of clinical observation chart, MET
modifications must be completed (if appropriate) as per the Medical Emergency response
procedure. Anaesthetist must notify PICU outreach, bed card consultant of any MET
modification and plan.
-Core temperature 36 degrees or 36.6 degrees for neonates
-Sedation score 2 or less (UMSS)
-No active vomiting
-Pain Managed
- Observe every 15 mins if there is a delay in transfer
5 Factors for effective documentation correct answers • factual
• accurate
• complete
• current (timely)
• organized
• compliant with standards
Interventions that may assist recovery of post-operative patient and prevent adverse events
correct answers Encourage early mobilization:
o Deep breathing and coughing
o Active daily exercise
o Joint range of motion
o Muscular strengthening
o Make walking aids such as canes, crutches and walkers available
and provide instructions for their use
• Ensure adequate nutrition
• Prevent skin breakdown and pressure sores:
o Turn the patient frequently
o Keep urine and faeces off skin
• Provide adequate pain control
Post-operative complications for obese patient correct answers Risk of VTE; prevent it by::
early postoperative mobilisation; mechanical compression devices; thromboembolic device
(TED) stockings; anticoagulant drugs; and vena caval filters.
Continuous positive airway pressure (CPAP) and NIV have been used to prevent and treat
acute respiratory failure after surgery or to treat acute respiratory failure
4 key elements required for informed consent surgery correct answers
examine and label ECG tracing and label PQRST waves correct answers
ANSWERS!!
Benefits for using Patient Controlled Analgesia (PCA) pump correct answers -Empowering
patients to have control over their pain will in turn help to alleviate anxiety which will in turn
reduce pain experience.
-immediate and effective and the patient does not have to wait to have analgesia
administered.
-Extremely useful for incident pain e.g. dressing changes, physiotherapy
-The treatment regimen can be tailored to the needs of the individual
-Improved quality of recovery and care
-Decreased bed occupancy time with resultant economic benefit
-More positive perception of hospital stay
Nursing interventions if patient on PCA is drowsy correct answers -Assess vitals and A-G
-If vitals are below range, stop the infusion
- Give oxygen 15l/min
-Inform medical staff
What to do if patient during blood transfusion has an allergic reaction (8 steps) correct
answers -STOP THE TRANSFUSION.
- Start IV line (0.9% NaCl)
- Place the client in Fowler's position (upright 90 degrees) if with Shortness of Breath and
administer O2 therapy.
- Observe patient and monitor vital signs as often as every 5 minutes.
- Notify the physician.
- The nurse prepares to administer emergency drugs such as antihistamines, vasopressor,
fluids, and steroids as per physician's order or protocol.
- Obtain a urine specimen and send to the laboratory to determine presence of hemoglobin as
a result of RBC hemolysis.
- Blood container, tubing, attached label, and transfusion record are saved and returned to the
laboratory for analysis.
Advantages of using enteral feeding tube correct answers cheaper
simpler
fewer complications
for efficient use of nutrients
stimulates intestinal blood flow
maintain GI mucosal barrier (prevents bacterial translocation and portal endotoxaemia)
reduced gut associated lymphatoid system (GALT) -> becomes a source of activated cells
and proinflammatory stimulants
prevents disuse atrophy
Assessment on admission to PACU correct answers Physical Assessment
Airway, Breathing, Circulation & Disability Assessment (link to Nursing Assessment
Guideline)
Baseline Observations including, RR, Respiratory effort, SpO2, HR, BP and Temperature
Oxygen requirements
IV Fluids
, Analgesia
Urine Output
Reportable Blood Loss
Assessment of Wound Sites / Dressings
Presence of drains and patency of same
NGT In situ
Patient outcomes that need to be met before transferring patient from PACU to ward
"Discharge Criteria" correct answers -Clinical Observations within age appropriate limits
-Observations which fall within shaded areas of clinical observation chart, MET
modifications must be completed (if appropriate) as per the Medical Emergency response
procedure. Anaesthetist must notify PICU outreach, bed card consultant of any MET
modification and plan.
-Core temperature 36 degrees or 36.6 degrees for neonates
-Sedation score 2 or less (UMSS)
-No active vomiting
-Pain Managed
- Observe every 15 mins if there is a delay in transfer
5 Factors for effective documentation correct answers • factual
• accurate
• complete
• current (timely)
• organized
• compliant with standards
Interventions that may assist recovery of post-operative patient and prevent adverse events
correct answers Encourage early mobilization:
o Deep breathing and coughing
o Active daily exercise
o Joint range of motion
o Muscular strengthening
o Make walking aids such as canes, crutches and walkers available
and provide instructions for their use
• Ensure adequate nutrition
• Prevent skin breakdown and pressure sores:
o Turn the patient frequently
o Keep urine and faeces off skin
• Provide adequate pain control
Post-operative complications for obese patient correct answers Risk of VTE; prevent it by::
early postoperative mobilisation; mechanical compression devices; thromboembolic device
(TED) stockings; anticoagulant drugs; and vena caval filters.
Continuous positive airway pressure (CPAP) and NIV have been used to prevent and treat
acute respiratory failure after surgery or to treat acute respiratory failure
4 key elements required for informed consent surgery correct answers
examine and label ECG tracing and label PQRST waves correct answers
