PNR201 MED SURG 1 COMPREHENSIVE EXAM AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED

PNR201 MED SURG 1 COMPREHENSIVE EXAM AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED Terms in this set (64) If a nurse assesses a client with a low heart rate, what intervention should be done next? Check vital signs including BP The nurse needs to understand how to assess a client with a low potassium level and the need for replacement therapy. Assess- Dysthymia, Heart rate and rhythm Which symptoms of cellulitis indicate a potentially serious effect of the infection? Fever, chills, malaise, foul odor Know stages of pressure ulcers and best practices for prevention Stage 1- Intact skin that is reddened, deep pink, or mottled and does not blanch. Stage 2- Partial-thickness skin loss involving the dermis and/or epidermis. Shallow crater can feel hot or warmer than normal. Stage 3- Skin is ulcerated. Crater-like ulcer with subcutaneous tissue involved. Stage 4- Deep ulceration and necrosis in deeper underlying muscle and possibly bone. Depth can be determined. Unstageable- Full-thickness wounds with eschar and/or tissue that obscures depth determination. Prevention- Pressure relief (with devices), positioning, padding, adequate nutrition, skin care (keep dry). Causes of psoriasis, when would you suspect this condition in a client Diagnosis is by history, physical examination, and ruling out other skin conditions. Signs- inflamed skin lesions covered with adherent silvery-white scales. What are the causes and interventions related to Stridor? Causes- inflammation or partial obstruction of upper airway passage. In children with croup, adults- obstruction. Interventions- incentive spirometer, monitor pulse ox, review meds and dosages (inhaler), breathing exercises. What is the source used for an allograft? Tissue from the same species, normally obtained from a cadaver. (autograph is the patient's own skin) What is a primary preventative approach for eye health? Education on protective eye equipment, such as goggles. What is Ototoxicity? Caused by drugs or chemicals that damage the inner ear or the vestibulocochlear nerve. Can result in temporary or permanent damage of hearing, balance, or both. (tinnitus can be a sign) What is the organ of Corti and what does it do? Transmits impulses to the cochlear branch of the vestibulocochlear nerve (cranial nerve VIII). This nerve carries the impulses to the medulla oblongata, thalamus, and temporal lobe of the brain, which contains the auditory cortex. Who is at greatest risk for wound dehiscence post -op? Diabetic, obese, malnourished, dehydrated, have had multiple abdominal traumas, infection of the wound, or vomiting. How can impaired ventilation after surgery be identified? (Think gases) Arterial Blood Gas (ABG) Analysis- can have high levels of CO2, CO2 monitoring (can be sublingual) Identify droplet precautions and steps the nurse should take for safety Cohorting (roommates) of patients with same type of infection is acceptable, wear surgical mask when entering patients room, gowns (not usually unless specified), gloves when helping with cough-inducing procedures or disregarding tissues. Isolation precautions, what should the nurse remember? To prevent the transmission of potentially infective microorganisms to any patients. (Specifically constructed rooms with positive airflow, depending on the patient) What are the symptoms of Dehydration? Thirst, poor skin turgor, weight loss, weakness, dizziness, postural hypotension, decreased urine output (dark and concentrated), dry cracked lips, sunken soft eyeballs, dry scaly skin, rapid weak thready pulse. What is the average loss of fluid from the body through expired air each day? 350-400 mL Where is potassium the highest in the body? Intracellular fluid What are the electrolyte concerns for clients with fluid overload? Hyponatremia (sodium), Hyperkalemia (potassium), Hypomagnesemia (magnesium) What is the Acid-base imbalances for individuals with hyperemesis? Metabolic alkalosis What is the teaching plan for a client with pneumonia? Stay hydrated, sputum cultures are used to determine the source of pneumonia, take antibiotics until completed. get vaccinated. What is the priority treatment plan for complicated influenza with evidence of bacterial infection? Azithromycin 500mg IV daily A client currently lacking their gag reflex post-op, how should the client be positioned? Laying on their side What is a Pleural effusion? fluid in the pleural space or lining of the lungs What are the chest tube complications to watch for? If the chest tube is pinched or clogged Client has a deviated nasal septum and chronic allergies; what condition are they at high risk for? Sinusitis What are the signs and symptoms of status asthmaticus? Respiratory distress without wheezing What is Albuterol and its side effects? Asthma S/S-Tachycardia and hypokalemia