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NUR 133 ( LATEST 2024 / 2025 ) EXAM 2 STUDY GUIDE | QUESTIONS AND ANSWERS INCLUDED
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NUR 133 ( LATEST 2024 / 2025 ) EXAM 2 STUDY GUIDE | QUESTIONS AND ANSWERS INCLUDED
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NUR 133 Exam 2 Study Guide1. Post-op care
Answer
includes immediate care and ongoing care
2. immediate care (post-op)
o PACU hand-off report or data
o Gather supplies, hand hygiene, PPE if needed, supplies on overbed table or nightstand
o Identify pt , close curtains and door if possible
o Place pt in safe position (semi-fowlers, side lying, high fowlers, etc)
o Monitor and record Vital signs (every 15 mins first hr, every 30 mins next 2 hr, every hr next 4
hrs, and every 4 hrs after)
o Assess respiratory status, oxygen saturation, provide supplemental O2 if pre- scribed
o Assess cardiovascular
o Assess neurovascular based on surgery
o Provide warmth, assess skin
Answer
color and condition
o Gloves, assess surgical site, assess dressings
color, odor, presence drains, amount drainage
§ Mark drainage on dressing by circling amount and put time
o Check tubes and drains all present and working
o Note drainage amount in collection device
o Urinary catheter in place = check output
o Assess pain, check use of analgesic med use and or prescription, review effec- tiveness
o Nonpharmacologic pain management interventions if able
o Assess nausea and vomiting, give antiemetic if prescribed
o Provide safe environment, bed low position, side rails up if policy, call light in reach
o Remove PPE, hand hygiene
,3. ongoing care (post-op)
Answer
promote optimal function of
- respiratory
- cardiovascular
- neurologic
- renal, urinary, fluid, electrolyte
- GI and nutritional
- wound healing
- comfort and pain relief
- psychosocial
4. respiratory (post-op)
Answer
o Assess respiratory
rate, depth, quality, color, cap refill, ask SOB
o Assist coughing and deep breathing
o Incentive spirometry if ordered
o Early ambulation if possible
o Frequent position change
o Supplemental O2 if ordered
o Monitor pulse ox
5. cardiovascular (post-op)
Answer
o Assess apical rate, rhythm, quality, compare w peripheral, color, BP
, o Ask if chest pain or SOB present
o Freq. position change
o Early ambulation
o Compression stockings or pneumatic compression device, if ordered - check skin integrity
o Leg and ROM exercises
6. neurologic (post-op)
Answer
o Assess consciousness, movement, sensation
o Determine orientation
o Test motor ability via moving each extremity 1 at a time
o Evaluate sensation via touch on extremity 1 at time
7. renal, urinary, fluid, electrolyte (post-op)
Answer
o Assess and measure I/O
o Evaluate urinary retention and monitor serum electrolyte levels
o Promote voiding - bedpan, bedside commode, assistance to restroom at regular intervals
o Note frequency, amount, and burning/ other symptoms affecting
o Monitor urinary catheter drainage if present
8. GI and nutritional (post-op)
Answer
o Assess abdomen (distention, firmness)
o Ask nausea, vomiting, passing flatus
o Auscultate bowel sounds
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