NUR 133 Exam 2 Study Guide

NUR 133 Exam 2 Study Guide

• Post-op care

Answer

includes immediate care and ongoing care

• immediate care (post-op)

• PACU hand-off report or data
• Gather supplies, hand hygiene, PPE if needed, supplies on overbed table or nightstand
• Identify pt , close curtains and door if possible
• Place pt in safe position (semi-fowlers, side lying, high fowlers, etc)
• 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)

• Assess respiratory status, oxygen saturation, provide supplemental O2 if pre- scribed
• Assess cardiovascular
• Assess neurovascular based on surgery
• Provide warmth, assess skin

Answer

color and condition

• Gloves, assess surgical site, assess dressings

color, odor, presence drains, amount drainage § Mark drainage on dressing by circling amount and put time

• Check tubes and drains all present and working
• Note drainage amount in collection device
• Urinary catheter in place = check output
• Assess pain, check use of analgesic med use and or prescription, review effec- tiveness
• Nonpharmacologic pain management interventions if able
• Assess nausea and vomiting, give antiemetic if prescribed
• Provide safe environment, bed low position, side rails up if policy, call light in reach
• Remove PPE, hand hygiene 1 / 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

• respiratory (post-op)

Answer

• Assess respiratory

rate, depth, quality, color, cap refill, ask SOB

• Assist coughing and deep breathing
• Incentive spirometry if ordered
• Early ambulation if possible
• Frequent position change
• Supplemental O2 if ordered
• Monitor pulse ox

• cardiovascular (post-op)

Answer

• Assess apical rate, rhythm, quality, compare w peripheral, color, BP
• / 3

• Ask if chest pain or SOB present
• Freq. position change
• Early ambulation
• Compression stockings or pneumatic compression device, if ordered - check skin integrity
• Leg and ROM exercises

• neurologic (post-op)

Answer

• Assess consciousness, movement, sensation

• Determine orientation
• Test motor ability via moving each extremity 1 at a time
• Evaluate sensation via touch on extremity 1 at time

• renal, urinary, fluid, electrolyte (post-op)

Answer

• Assess and measure I/O

• Evaluate urinary retention and monitor serum electrolyte levels
• Promote voiding - bedpan, bedside commode, assistance to restroom at regular intervals
• Note frequency, amount, and burning/ other symptoms affecting
• Monitor urinary catheter drainage if present

• GI and nutritional (post-op)

Answer

• Assess abdomen (distention, firmness)

• Ask nausea, vomiting, passing flatus
• Auscultate bowel sounds
• / 3