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NUR 242 MED SURG EXAM 1 NEWEST 2025 ACTUAL
EXAM COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED
ANSWERS) |ALREADY GRADED A+||LATEST
VERSION!!!
Four Major subgroups of Late Adulthood - Answer- 65 - 74 young old 75 - 84 middle old 85 - 99 old old 100 and older elite old Lifestyle and Practice to Promote Wellness older adults - Answer-Yearly flu vaccine pneumococcal vaccine Shingles vaccine tetanus and booster every 10 years wear seat belts alcohol in moderation avoid smoking smoke detectors prevent falls - waxed floors and scattered rugs
medications as prescribed avoid OTC medications unless primary care phyisican directs Yearly physicial regular exercise socialization reminisce Common health Issues and Concerns older adults - Answer-Decreased nutrition and hydration Decreased mobility Stress and loss Accidents - falls most common/MVA Drug use and misuse Mental health/cognition problems (including substance abuse) Elder neglect and abuse GFTT ( Geriatric Failure To Thrive) Complex Syndrome - Answer-Under nutrition Impaired mobility
Symptoms - inattentiveness, disorganized thinking, and altered level of consciousness Nurse's role in Rehab - Answer-Advocate for the patient and family Create therapeutic rehab milieu provide whole person patient-centered care Collaborate with healthcare team for patient outcome and develop care plan Communicate with effectively with all members of the health care team, patient and family Evaluate effectiveness of plan of care for the patient and family Use Braden scale - skin break down risk Safe Patient Handing and Mobility (SPHM) - Answer-- Maintain a wide, stable base with your feet
- Put the bed at the correct height - waist level while providing direct care and hip level when moving patients
- Keep the patient or work directly in front of you to prevent your spine from rotating
- Keep the patient as close to your body as possible to prevent reaching walker - assisted and cane - assisted procedure - Answer-
- Apply a transfer belt around patients waist
- guide patient to a standing position
- remind patient to place both hands on the walker
- ensure that the patient's body is well balanced walker teaching - Answer-- lift the walker
- move the walker about 2 feet forward and set it down on all legs
- while resting on the walker, take small steps
- check balance
- repeat sequence cane teaching - Answer-- be sure cane is at the height of the patients wrist when the arm is placed at his or her side
- remind patient to place his or her strong hand on cane
- ensure that the patient's body is well balanced
- move the cane and weaker leg forward at the same time
SCIP infection - 3 - Answer-Prophylactic Antibiotics discontinued within 24 hours after surgery end time (provides benefit without risk) SCIP infection - 4 - Answer-Cardiac surgery patients with controlled 6 am postoperative blood glucose (cardiac patients only) To avoid hyperglycemia SCIP infection - 6 - Answer-Surgery patients with appropriate hair removal (removal is performed with electric clippers or chemical depilatories) to avoid skin abrasions and increase risk of surgical site infections SCIP infection - 9 - Answer-Urinary catheter removed on postoperative day 1 or postoperative day 2 with day of surgery being day zero ( to avoid urinary tract infections) SCIP infection - 10 - Answer-Surgery patients with preoperative temperature management (prevent prolonged hyperthermia, which is associated with wound healing, serious cardiac complications, altered drug metabolism, coagulation problems, and higher surgical infections.
SCIP CARD - 2 - Answer-Surgery patients on beta-blocker therapy prior to arrival who received a beta-blocker during the perioperative period ( receive beta-blocker prior and continue immediately after surgery) SCIP Venous Thromboembolism - 1 - Answer-Surgical patients with recommended venous thromboembolism prophylaxis ordered (reduce complications from postoperative VTE) SCIP Venous Thromboembolism - 2 - Answer-Surgery Patients who received appropriate Venous thromboembolism prophylaxis within 24 hours of prior to surgery to 24 hours after surgery ( reduce complications from postoperative VTE particularly among patients undergoing the types of surgeries in which the risk was highest Chapter 24 - skin layers - Answer-- Epidermis
- dermis
- subcutaneous - hypodermis Epidermis - Answer-- protection
Skin assessment - Color - Answer-- is affected by blood flow, gas exchange, body temperature, and pigmentation. describe by their appearance. Are changes general or confined to one body region Skin assessment - ABCDE - Answer-A - Asymmetry B- border irregularity C- color variation within one lesion D- Diameter greater than 6 mm E - Evolving or changing in any feature (shape, size, color, elevation, itching, bleeding, or crusting) Changes in Dark skin - cyanosis - Answer-- examine lips and tongue for gray color
- examine nail beds, palms, and soles for blue tinge
- Examine conjunctiva for pallor Changes in Dark skin - Inflammation - Answer-- Compare effective area with non affected area for increased warmth
- examine skin of affected area to determine whether it is shiny or taut or pits with pressure
- Compare the skin color of affected area with the same area on the opposite side of the body
- palpate the affected area and compare it with unaffected area to determine whether texture is different (affected area may feel hard or "woody" Changes in Dark skin - Jaundice - Answer-- Check for yellow tinge to oral mucous membranes, especially the hard palate
- examine the sclera nearest to the iris rather than the corners of the eye Changes in Dark skin - Bleeding - Answer-- Compare the affected area with the same area on the unaffected body side for swelling or skin darkening
- if the patient has thrombocytopenia, petechiae may be present on the oral mucosa or conjunctiva Nail assessment - nail color - Answer-White - chronic liver disease or kidney disease - shock - anemia - early arteriosclerotic changes (toenails) - myocardial infarction Yellow - brown - Jaundice - peripheral lymphedema - bacterial or fungal infections of the nail - psoriasis -
Stage 2 pressure ulcer - Answer-- skin is not intact
- there partial - thickness skin loss of the epidermis or dermis
- ulcer is superficial and maybe an abrasion, a blister (open or fluid-filled, or a shallow crater) Stage 3 pressure ulcer - Answer-- skin loss is full thickness subcutaneous tissue may be damaged or necrotic
- damage extends to fascia, bone, tendon and muscle
- undermining and tunneling may or may not be present Stage 4 pressure ulcer - Answer--Skin loss is full thickness with exposed or palpable muscle, tendon, or bone
- often excludes undermining and tunneling
- sinus tracts may develop
- slough and eschar are often present or at least part of the wound
Unstageable - Answer-- skin loss is full thickness and the base is completely covered with slough, or eschar, obscurring the true depth of the wound Wet to damp saline moistened gauze - Answer-necrotic debris is mechanically removed but with less trauma to healing tissue Continuous wet gauze - Answer-wound surface continually bathed with wetting agent of choice, promoting dilution of viscous exudate and softening of dry eschar Topical enzyme preparations - Answer-proteolytic action of thick, adherent eschar causes breakdown of denatured protein and more rapid separation of necrotic tissue Moisture - retentive dressing - Answer-Spontaneous separation of necrotic tissue is promoted by autolysis Wound - vac - negative pressure wound therapy - Answer- can reduce and or close chronic injuries by removing fluids or infectious materials, enhancing granulation. Should be changed every 48 to 72 hours.
- observe all skin areas, especially bony prominences and areas in contact with the bed or other firm surfaces
- measure and record any redness or loss of integrity
- photograph areas of concern
- note presence of skin tenting over sternum and forehead
- note moistness of skin and mucous membranes Patient at risk for pressure injury - with wounds - Answer-- remove dressing (noting condition of dressing)
- cleanse wound and remove and compare with previous notations of wound condition
- presence, amount and nature of exudate
- use disposable paper tape measurement to measure wound diameter and depth
- amount (%) and type of necrotic tissue
- presence of granulation/epithelium
- presence or absence of cellulitis presence or absence of odor take patients temperature to assess for fever
Patient at risk for pressure injury - understanding of illness and compliance with treatment - Answer--s/s to report to primary care doctor
- drug therapy plan (correct time and dosing)
- ambulation or positioning schedule
- dressing changes/skin care
- nutrition modifications (24-hr diet recall) Patient at risk for pressure injury - nutritional needs - Answer-- change in muscle mass
- lackluster nails, sparse hair
- recent weight loss or more than 5% of usual weight
- impaired oral intake
- difficulty swallowing
- generalized edema Psoriasis - Answer-Chronic autoimmune disorder affecting the skin with exacerbations and remissions. Results from overstimulation of the immune system. activates T- lymphocytes. This can not be cured, often patients can control symptoms
Hand Hygiene - Answer-wash hands with soap and water when hands are visible soiled or contaminated not visible soiled may use ABHR before direct contact with patients wash or use ABHR Decontaminate hands before putting on sterile gloves, to after contact with patients intact skin (taking a pulse) Standard precautions - Answer-should be used when caring for all patients. includes: hand hygiene between each patient contact, after removing gloves, after touching bloody, body fluids or secretions, when touching mucous membranes and non- intact skin Contact precautions - Answer-private room, wear gloves when entering the room, wash hands with soap and water when leaving the room, dedicated equipment for patient C-diff scabies impetigo respiratory syncytial virus (RSV) in infants and children
Airborne Precautions - Answer-private room with negative pressure airflow, keep door closed, N95 respirator, patient to wear surgical mask when leaving room a clinical reason M - measles T - tuberculosis V - varicella (including disseminated zoster) Droplet precautions - Answer-Private room, if private room not available, may share with patient having the same infectious disease and microorganism, wear mask when working within 3 feet of the patient, patient to wear mask when leaving room for clinical reasons S - sepsis/streptococcal pharyngitis P - pneumonia/pertussis I - influenza D- Diptheria (pharyngeal) E - epiglottitis R - Rubella M - Mumps/meningitis AN _ Adenovirus
