Acute Care Exam #3 - Pre/Intra/Post-Operative Care, Musculoskeletal Trauma/Management, Biliary Disorders (Q & A) Latest (100%)
If an infection is present in an extremity that is about to be amputated, what must first be prescribed?
What type of assessment needs to be performed on both the a...
if an infection is present in an extremity that is about to be amputat
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Chamberlain College Of Nursing
HESI ACUTE (HESI2A)
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Acute Care Exam #3 - Pre/Intra/Post-Operative Care,
Musculoskeletal Trauma/Management, Biliary Disorders (Q &
A) Latest (100%)
Quiz:> If an infection is present in an extremity that is about to be amputated, what must
first be prescribed?
{{{Answer}}} (Prophylactic antibiotics to clear up infection followed by more definitive
surgery)
Quiz:> What type of assessment needs to be performed on both the affected and
unaffected extremity before amputation is considered?
{{{Answer}}} (Neurovascular assessment - 5 P's)
Quiz:> This type of pain is felt at the site post amputation of an extremity
{{{Answer}}} (Phantom limb pain)
Quiz:> Nursing alert: If the elastic dressing falls off on stump (amputation site) what is
the nurses immediate next action?
{{{Answer}}} (Wrap the limb with an elastic compression bandage ASAP, if not, edema
will develop; Notify physician if edema develops)
Quiz:> What types of drugs are given to treat phantom pain?
{{{Answer}}} (BB, anti-epileptics and TCA's)
Quiz:> What is the HALLMARk sign of peritonitis?
{{{Answer}}} (Board like abdomen (extremely rigid))
Quiz:> In what instances will pain perception be diminished? (think meds & comorbid
conditions)
{{{Answer}}} (Patients taking corticosteroids, analgesic agents
Patients with diabetes (advanced neuropathy), patients with cirrhosis (experiencing
ascites))
Quiz:> Defined as a complication of trauma or perforation of bowel; Extremely serious;
IV antibiotics and surgery may be required
{{{Answer}}} (Peritonitis)
Quiz:> What nursing interventions/assessments are required for peritonitis?
{{{Answer}}} (Position patient side-lying or semi-fowlers position (position for comfort)
Monitor respiratory status
Maintain patient NPO
Monitor pulse ox
,Monitor temperature)
Quiz:> What are the s/s associated with cholecystisis?
{{{Answer}}} (Pain
Tenderness
Rigidity of RUQ that may radiate to shoulder)
Quiz:> Defined as stones in gallbladder
{{{Answer}}} (Cholelithiasis)
Quiz:> If pus develops in the gallbladder due to infection, what complication can this
lead to?
{{{Answer}}} (Empyema)
Quiz:> When are ERCP and PTC procedures used?
{{{Answer}}} (For cholelithiasis --> Removal of gallstones)
Quiz:> What type of sedation is used for ERCP and PTC interventions?
{{{Answer}}} (Moderate sedation)
Quiz:> During acute pancreatitis, what should the nurse monitor for specifically?
{{{Answer}}} (HYPOXIA)
Quiz:> During assessment of suspected pancreatitis, what are positive signs of
diagnosis?
{{{Answer}}} (Cullen's sign - ecchymosis around umbilicus
Turner's sign - ecchymosis on flanks)
Quiz:> What diagnostic tests are used to confirm diagnosis of pancreatitis?
{{{Answer}}} (Amylase and lipase ("Ases are high"))
Quiz:> In this typeof pancreatitis, the benchmark of pain is met and the patient is able to
more easily cope with the pain; "Burnout."
{{{Answer}}} (Chronic pancreatitis)
Quiz:> Under moderate sedation, what does the nurse need to monitor?
{{{Answer}}} (RR, temp and BP)
Quiz:> After epidural anesthesia, what will be continuously monitored along with
continuous o2 sat monitoring?
{{{Answer}}} (End tidal co2 - little bubble underneath nasal cannula; monitors co2 levels
& recirculates the co2 the patient breaths out. Ensures that their levels are between 35-
45)
Quiz:> In a patient with chronic lung disease, what is the highest priority post-op for this
patient?
,{{{Answer}}} (Respiratory status
-Depth, rate and characteristics of respirations, use of accessory muscles, identifying
respiratory distress early)
Quiz:> If a wound is dehiscing post-operatiely, what is the nurse's first action?
{{{Answer}}} (IMMEDIATELY put sterile soaked gauze on the open wound & notify
physician because this patient will need to go back to the OR)
Quiz:> What lab values need to be specifically examined pre-op? If these lab values are
off, is surgery postponed?
{{{Answer}}} (PT/INR --> Monitoring for coagulation problems
CBC --> WBC count need to be examined to monitor for contraction of infection
If any of these values are off, surgery will be postponed)
Quiz:> For patients with a PCA pump, what does the nurse need to continuously
monitor?
{{{Answer}}} (RR, level of consciousness, pain level)
Quiz:> If a patient becomes suddenly dizzy upon ambulation post-op, what is the
nurse's first action?
{{{Answer}}} (Stabilize patient, sit them down ASAP to reduce risk of falls)
Quiz:> If a patient becomes suddenly restless in the PACU post surgery, what is the first
thing the nurse should examine?
{{{Answer}}} (PULSE OX - lack of o2 can cause confusion and restlessness)
Quiz:> What are the s/s of hypovolemia and hypovolemic shock?
{{{Answer}}} (Drop in BP
Weak, rapid, thready pulse
Altered LOC
Cool, clammy skin)
Quiz:> How does the nurse prevent post-op atelectasis/pneumonia?
{{{Answer}}} (Encouraging deep breathing/coughing
Encourage use of incentive spirometer
Encouraging ambulation day 1 post-op
Encouraging position changes)
Quiz:> A score of what or higher on the Aldrete test indicates that the patient is ready to
be discharged from the PACU?
{{{Answer}}} (8 or higher)
, Quiz:> When a nurse suspects compartment syndrome, how should they keep the
extremity positioned?
{{{Answer}}} (Keep extremity aligned and DO NOT elevate)
Quiz:> For patients with a spica cast (typically children) what does the nurse need to
assess for concerning bowel movements/constipation?
{{{Answer}}} (Need to assess for a paralytic ileus - auscultate bowel sounds)
Quiz:> How often does the nurse need to inspect the pin sites for patients in traction?
{{{Answer}}} (q8hr)
Quiz:> What is important for the nurse to do in the post-op period?
{{{Answer}}} (Treat pain
Treat constipation due to opiate pain medication
Positon patient for comfort (depending on surgical procedure)
Encourage deep breathing techniques (coughing, incentive spirometer)
Prevent infection)
Quiz:> What is the emergency management of fractures?
{{{Answer}}} (IMMOBILIZATION, followed by reduction via surgical procedure)
Quiz:> Defined as preparing the patient for every step of a surgical experience as a
whole
{{{Answer}}} (Peri-operative care)
Quiz:> This type of surgery would be necessary for a patient that came into the ER post
a traumatic accident; Life would be threatened if surgery was not performed
{{{Answer}}} (Emergent surgery)
Quiz:> How can a nurse evaluate empirical knowing for a patient potentially needing a
colostomy?
{{{Answer}}} (The patient may experience body image disturbances & depression and
the nurse will need to address these concerns)
Quiz:> What are nursing considerations associated with older adult patients going under
anesthesia?
{{{Answer}}} (They have:
- Ineffective temperature control
- Decompensating physiologically
- Do not tolerate anesthesia well (Anesthesia binds to protein in which they lack))
Quiz:> Why do older adult patients not tolerate anesthesia well? (Think body make up)
{{{Answer}}} (Due to older adults not having lower protein concentrations in the body &
higher fat, the anesthesia binds to protein molecules)
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