NUR 2900 Exam #1 Revised UPDATED ACTUAL Questions
and CORRECT Answers
Guidelines of prioritizing - Systemic manifestation before local manifestations
- Acute manifestations before chronic manifestations
- What must be addressed now vs. later
- Unexpected vs. expected
Three Tier System of Prioritizing 1. ABCC I/I: Airway, Breathing, Cardiac, Circulation, prevention of
Injury/Infection
2. Patients with specific focus on pain/mobility/nutrition/etc.
3. Self-esteem issues including health education
How often should temperature be taken post-op? Every 4 hours for the first 24 hours
How often should vitals be taken post-op? HR/BP/RR - every 15 minutes for the 1st hour and every 30 mins for the next 2
hours
Temp - Every 4 hours for the first 24 hours
How long should you wait for a post-op patient's first Patient is expected to void within 8 hours after surgery
void?
What should be done with a post-op patient's first - Patient should pee into a hat so nurse can measure the amount of urine for
void? the purpose of knowing the bladder is emptying (> 30 mL/hour = 240 mL after
8 hrs)
- Used to measure amount, appearance, and consistency
, Nursing Interventions to Promote Cardiac Output - Early ambulation
- Leg exercises and frequent position changes are initiated to stimulate
circulation (use of anti-embolism stockings and early ambulation)
+ Patients should avoid positions that compromise venous return (raising the
bed's knee gatch, placing a pillow under knees, sitting for long periods and
dangling the legs with pressure at the back of the knees)
- Assessing patency of IV lines and ensuring correct fluids are given at
prescribed rate
- Intake and output ➔ including emesis and output from wound drainage
systems are recorded separately and totaled to determine fluid balance
- Electrolyte levels and hemoglobin and hematocrit levels are monitored
Benefits of Early Ambulation - Increases metabolism and pulmonary aeration
- Promoting normal bowel function and voiding
- Prevention of DVT (circulatory problems), hypostatic pneumonia, atelectasis,
and GI discomfort
- Will assist with return of GI function
- Improve circulation
- Prevent venous stasis
- Helps prevent complications
- Exercise of extremities (extension and flexion of knee and hip joints)
- Proper body mechanics
Who are at risk for wound dehiscence? - Obese patients
- Pts who get abdominal surgery
- Diabetes bc of problems healing
- Pts getting their sutures removed
What happens when a pt is experiencing wound - Position the patient is a low fowlers position (don't want to be sitting up or
dehiscence? lying flat) and instruct to lie quietly
- Sterile saline and abdominal pad goes over wound
- Contact physician and/or surgeon
What is the assessment priority for a PICC? Verify placement with an x-ray
Patient teaching for PICC - Keeping PICC covered
- Ensure dressing patency, caps are secured, and clamps are closed
- How to take care of dressings (clean hands, sterility, changing caps)
- How to take care of the PICC (saline flushes, assessing site)
Complications of a PICC - Infection (local at site and systemic inside the body)
- Vein with PICC is sore and irritated
- Bleeding
- Break or leak in PICC
- Leakage of drugs under the skin
- Tip of PICCC moves out of place
When should you seek medical attention for a PICC? - Signs of infection (systemic or local)
- Sudden shortness of breath or sudden onset of chest pain (could be a sign
that a blood clot has traveled to the lungs)
- Not able to flush the PICC or difficulty in flushing
- Not able to draw blood from the PICC
- PICC breaks, falls out, or comes out part of the way
- Bleeding from the PICC line
- If caps are lost
and CORRECT Answers
Guidelines of prioritizing - Systemic manifestation before local manifestations
- Acute manifestations before chronic manifestations
- What must be addressed now vs. later
- Unexpected vs. expected
Three Tier System of Prioritizing 1. ABCC I/I: Airway, Breathing, Cardiac, Circulation, prevention of
Injury/Infection
2. Patients with specific focus on pain/mobility/nutrition/etc.
3. Self-esteem issues including health education
How often should temperature be taken post-op? Every 4 hours for the first 24 hours
How often should vitals be taken post-op? HR/BP/RR - every 15 minutes for the 1st hour and every 30 mins for the next 2
hours
Temp - Every 4 hours for the first 24 hours
How long should you wait for a post-op patient's first Patient is expected to void within 8 hours after surgery
void?
What should be done with a post-op patient's first - Patient should pee into a hat so nurse can measure the amount of urine for
void? the purpose of knowing the bladder is emptying (> 30 mL/hour = 240 mL after
8 hrs)
- Used to measure amount, appearance, and consistency
, Nursing Interventions to Promote Cardiac Output - Early ambulation
- Leg exercises and frequent position changes are initiated to stimulate
circulation (use of anti-embolism stockings and early ambulation)
+ Patients should avoid positions that compromise venous return (raising the
bed's knee gatch, placing a pillow under knees, sitting for long periods and
dangling the legs with pressure at the back of the knees)
- Assessing patency of IV lines and ensuring correct fluids are given at
prescribed rate
- Intake and output ➔ including emesis and output from wound drainage
systems are recorded separately and totaled to determine fluid balance
- Electrolyte levels and hemoglobin and hematocrit levels are monitored
Benefits of Early Ambulation - Increases metabolism and pulmonary aeration
- Promoting normal bowel function and voiding
- Prevention of DVT (circulatory problems), hypostatic pneumonia, atelectasis,
and GI discomfort
- Will assist with return of GI function
- Improve circulation
- Prevent venous stasis
- Helps prevent complications
- Exercise of extremities (extension and flexion of knee and hip joints)
- Proper body mechanics
Who are at risk for wound dehiscence? - Obese patients
- Pts who get abdominal surgery
- Diabetes bc of problems healing
- Pts getting their sutures removed
What happens when a pt is experiencing wound - Position the patient is a low fowlers position (don't want to be sitting up or
dehiscence? lying flat) and instruct to lie quietly
- Sterile saline and abdominal pad goes over wound
- Contact physician and/or surgeon
What is the assessment priority for a PICC? Verify placement with an x-ray
Patient teaching for PICC - Keeping PICC covered
- Ensure dressing patency, caps are secured, and clamps are closed
- How to take care of dressings (clean hands, sterility, changing caps)
- How to take care of the PICC (saline flushes, assessing site)
Complications of a PICC - Infection (local at site and systemic inside the body)
- Vein with PICC is sore and irritated
- Bleeding
- Break or leak in PICC
- Leakage of drugs under the skin
- Tip of PICCC moves out of place
When should you seek medical attention for a PICC? - Signs of infection (systemic or local)
- Sudden shortness of breath or sudden onset of chest pain (could be a sign
that a blood clot has traveled to the lungs)
- Not able to flush the PICC or difficulty in flushing
- Not able to draw blood from the PICC
- PICC breaks, falls out, or comes out part of the way
- Bleeding from the PICC line
- If caps are lost
