Nursing Guide for Wound Care, Skin Integrity, and Urinary Elimination, Exams of Nursing

Download Nursing Guide for Wound Care, Skin Integrity, and Urinary Elimination and more Exams Nursing in PDF only on Docsity! NR 224 Funds Exam 2 Study Guide 2023 Remember think like a nurse to understand of what the nurse should do best. Med Calculations: #24 – A doctor ordered Vancomycin 1 gram po every 12 hours for a patient. Vancomycin comes in 250 mg. How many tablets would the patient take in 24 hours? *How many tablets in mg would the patient take in 24 hours* #50 – You are given a picture of a drug label of Ceclor. You need to identify the generic name of the drug. Chapter 48 Skin Integrity and Wound Care 1. Know the risk factors of pressure ulcers development. a. Know the situations as to where a patient is at risk from developing ulcers i. Decreased mobility ii. Decreased sensory perception iii. Incontinence iv. Poor nutrition 2. Know the nursing diagnoses for skin integrity and the associated ulcers that best describes it. If you know the list associated according to skin underneath Nursing Diagnosis, you will be good. a. Exam ask of i. impaired skin integrity ii. Ineffective peripheral tissue perfusion 3. Know the staging of the pressure ulcer a. The exam asks for the description of Stage II pressure ulcer b. Know how to document a healing stage III pressure ulcer i. Document as “Healing Stage III ulcer” 4. Know primary, secondary, and tertiary intention and what type of wounds are associated with those. a. Primary Intention – wound is closed, no gap, heals quickly, minimal scar, i. Ex. Surgical incision ii. Incision line poorly approximated iii. Drainage present more than 3 days after closure iv. Inflammation increased in first 3-5 days after injury v. No epithelization of wound edges by day 4 b. Secondary Intention – wound is left open, takes longer to heal, bigger scar, risk for infection i. Ex. Burn, pressure ulcer, or severe laceration ii. Pale or fragile granulation tissue, granulation tissue bed excessively dry or moist iii. Purulent exudate present iv. Necrotic or slough tissue present in wound base v. Epithelization not continuous vi. Fruity, earthy, or putrid odor present vii. Presence of fistula (tunneling or undermining) 5. Know the laboratory data that is used to test for impaired skin integrity a. Impaired skin integrity related to malnutrition and pressure ulcers as evidence by disruption of epidermal and dermal tissues 6. What would a nurse to do if a patient has a Pressure Stage III ulcer that has an odor and discharge? a. Complete health assessment – vitals, treatment, and lab results 7. Know what debridement is a. Debridement – is the removal of nonviable, necrotic tissue. Removal of necrotic tissue to rid the wound of a source of infection, enable visualization of wound bed, and provide a clean base necessary for healing 8. Know what a nurse will do if a wound that has a drain and address that need changing first 9. Know the schedule that a nurse should allow to sit in the chair who is at risk of skin impairment. a. Every 1 to 2 hours 10. Know the actions to take that a nurse if a patient is anxious of a wound dressing. 11. SELECT ALL QUESTION – A nurse is caring for a patient with a surgical incision that eviscerates. What actions would the nurse take? a. Place moist sterile gauze over the site b. Contact the surgical team c. Monitor for shock 12. SELECT ALL QUESTION – The nurse is updating the plan of care for a patient with impaired skin. Which findings indicates achievements of goals and outcomes? a. Skin is intact with no redness or swelling. b. Nonblanchable erythema is absent c. No injuries to the skin and tissues are evident d. Granulation tissue is present 13. Which of the following the choices would make the patient the greatest risk for developing a pressure ulcer? Chapter 46 – Urinary Elimination 14. Know what a patient would be at risk (a condition) for if they have hyperkalemia a. Renal tubular acidosis (RTA) type IV, Acute kidney failure or chronic kidney disease 15. SELECT ALL QUESTION - Need to know the aging process of urinary elimination 16. SELECT ALL QUESTION – Need to know what characteristics makes a urine sample abnormal? d. Medical history and breath sounds 6. A patient was alert, awake, aware and an hour later, he was tachynepic, lucid, and confused? What should the nurse do as the best appropriate action? 7. A nurse found her neighborhood not responsive without a pulse. What should do first? It is like a CPR question 8. A nurse is taking care of a patient who complains of sharp chest pain. What is the best intervention made by the nurse? 9. When a nurse would do chest compressions on a patient? 10. A patient has dyspnea. He is lying supine with 2 L of oxygen. What would the nurse to correct his breathing? a. Obtain arterial blood gases b. Perform oral suction to remove pulmonary sections c. Increase the oxygen to 2L d. Change him to Fowler’s 11. Know Ventilation/Perfusion/Diffusion (Two questions) a. Ventilation – process of moving gases into and out of the lungs b. Perfusion – pumping oxygenated blood to the tissues and the return of deoxygenated blood to the lungs c. Diffusion – the exchange of o2 and co2 across the alveoli membrane 12. A nurse is caring a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mmHg and respiration rate of 30 breaths/mind. Which nursing diagnosis is a priority? a. Risk of skin infection b. Impaired gas exchange c. Activity intolerance d. Risk of infection 13. Know the nursing diagnosis of oxygenation a. Impaired gas exchange and ineffective breathing pattern characteristics of dyspnea and nasal flaring 14. A patient has respirations of 44 breaths/min. He is acute distress. What is the best intervention that the nurse can offer the patient? a. Obtain arterial gases b. Bronchodilator via nebulizer c. Provide oxygen d. Complete medical history 15. Know left sided heart failure vs right sided heart failure. Chest pain is left sided Cardiopulmonary physiology involves delivery of deoxygenated blood (blood high in co2 and low o2) to the right side of the heart and then to the lungs, where it is oxygenated Blood begins to “back up” in the pulmonary (left heart failure) Or systemic (right heart failure) circulation Left-sidedheartfailureisanabnormalconditioncharacterizedbydecreasedfunctioningoftheleftventricle.If leftventricularfailureissignificant,theamountofbloodejectedfrom theleftventricledropsgreatly,resulting indecreasedcardiacoutput.Signsandsymptomsincludefatigue,breathlesnes,dizines,andconfusionasa resultoftisuehypoxiafrom thediminishedcardiacoutput.Astheleftventriclecontinuestofail,bloodbegins topolinthepulmonarycirculation,causingpulmonarycongestion.Clinicalfindingsincludecracklesinthe basesofthelungsonauscultation,hypoxia,shortnes ofbreathonexertion,cough,andparoxysmalnocturnal dyspnea. Right-sidedheartfailureresultsfrom impairedfunctioningoftherightventricle.Itmorecommonlyresults from pulmonarydiseaseorasaresultoflong-term left-sidedfailure.Theprimarypathologicalfactorinright- sidedfailureiselevatedpulmonaryvascularresistance(PVR).AsthePVRcontinuestorise,therightventricle worksharder,andtheoxygendemandoftheheartincreases.Asthefailurecontinues,theamountofblood ejectedfrom therightventricledeclines,andbloodbeginsto“backup”inthesystemiccirculation.Clinicaly thepatienthasweightgain,distendedneckveins,hepatomegalyandsplenomegaly,anddependentperipheral edema. Ap earedontheexam 10/08/2018–October08,2018 Decubitusulcer– what’sshouldbeinthelab? What stage of ulcer does not require dressing and leave open to air?