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NUR 242 MED SURG EXAM 2 NEWEST 2025 ACTUAL
EXAM COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (100%
VERIFIED ANSWERS) |ALREADY GRADED
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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 -
Care of Patient in Sickle Call Crisis - Answer-Give prescribed pain medication hydrate with normal saline IV, encourage oral intake of fluids without caffeine administer oxygen remove restrictive clothing, no blood pressure with external cuff check circulation in extremities every hour Vitamin B12 Deficiency - Answer-Results from poor intake of foods containing B Vitamin B 12 anemia (pernicious anemia) caused by deficiency of intrinsic factor needed for intestinal absorption of B12. Seen in patients with bowel resections, chronic diarrhea, diverticula, tape worms, or overgrowth of intestinal bacteria s/s: glossitis (a smooth, beefy red tongue) fatigue, weight loss, and pallor or jaundice Methicillin Resistant Staphylococcus Aureus (MRSA) - Answer-Avoid close contact with others until infection clears sleep in separate bed from others
wash all soiled clothing and linens with hot water and laundry detergent do not share any personal items Cellulitis - Answer-generalized infection with either staphylococcus or streptococcus and involves deeper connection tissue infection can spread by scratching or rubbing the skin can result from a secondary bacterial infection of an open wound or unrelated to skin trauma localized area of inflammation that may enlarge rapidly if not treated warm compresses to the area are recommended treatment with IVABT 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)
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 Skin cancer prevention - Answer-avoid sun exposure between 11 - 3pm use sunscreens with the appropriate skin protection factor wear a hat, opaque clothing, and sunglasses keep a body map of skin spots, scars, and lesions to detect when changes have occurred
Deep Tissue Injury (DTI) - Answer--The intact skin appears purple or maroon
- Blood - filled blisters may be present
- Before the previously listed appeared, the tissue in this area may first have been painful
- other changes that may have preceded the discoloration include that area may have felt more firm, boggy, mushy, warmer, or cooler than the surrounding tissue Stage 1 pressure ulcer - Answer-- skin is intact
- area, usually over a bony prominence, red and does not blanch with external pressure 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
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. Hyperbaric - oxygen therapy (HBOT) - Answer- administration of oxygen under high pressure, raising tissue oxygen concentration. Usually received under limb life-threatening wounds such as - burns, necrotizing infections, brown recluse spider bites, osteomyelitis, and diabetic ulcers patient at risk for pressure injury - cardiovascular status - Answer-- presence or absence of peripheral edema
- hand-vein filling in the dependent position
- neck-vein filling in the recumbent and sitting position
- weight gain or loss patient at risk for pressure injury - cognition and mental status - Answer--level of consciousness
- orientation to time, place and person
- can the patient read a seven word sentence containing three syllables or fewer patient at risk for pressure injury - condition of skin - Answer-- assess skin cleanliness
- 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
