Final Exam: NSG223/ NSG 223 (Latest 2024/ 2025 Update) Med Surg 2 Exam| Questions and Verified Answers| 100% Correct| Grade A- Herzing
Final Exam: NSG223/ NSG 223 (Latest 2024/
2025 Update) Med Surg 2 Exam| Questions
and Verified Answers| 100% Correct| Grade
A- Herzing
Q: infection in a patient with a cast most commonly occurs from what?
Answer:
breakdown of skin under the cast also called pressure necrosis
Q: signs of pressure necrosis
Answer:
hot spot under the cast, musty smell, fever
Q: how should a patient with an arm cast position their arm
Answer:
elevate it above the heart to reduce swelling
Q: nursing care for a leg cast
Answer:
elevate the leg on several pillows to reduce swelling and apply ice for first 24 hours as prescribed
Q: good diet for healing
Answer:
high in protein, iron, vitamins, carbs
Q: monitor pts in a body/spica cast for what serious complication?
Answer:
cast syndrome
Q: fracture patient’s pain must be immediately reported to the HCP to avoid what
Answer:
paralysis and necrosis
Q: how to monitor for potential cast syndrome
Answer:
note bowel sounds every 4-8 hours and report distention, nausea, and vomiting
Q: treatment for cast syndrome
Answer:
try to relieve pressure, window in cast
Q: goal for post knee replacement- flexion beyond how many degrees
Answer:
90 degrees
Q: patient after TKA should avoid pressure on what?
Answer:
heel
Q: greatest concern after TKA and THA
Answer:
contractures
Q: what is done to prevent contractures
Answer:
maintaining limb extension and CPM
Q: acute compartment syndrome is caused by
Answer:
reduced circulation to the area causing increased pressure from cast that is put on too early or too
tight
Q: most common complication of lower extremity surgery
Answer:
DVT
Q: earliest manifestation of fat embolism syndrome
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what is the most common surgery
hip replacement
what labs (electrolytes) will you ask about with musculoskeletal system
calcium, phosphorus
what happens to calcium concentration if calcitonin is increased beyond normal level
it deceases and inceases renal excretion of calcium and phosphorus in the body
what will you see in a compound fracture?
bone through the skin
the patient with a fracture often has trauma to what??
other body systems
what is the FIRST thing you do when a patient has a fracture
assess all major body systems for life threatening complication
when a pelvic fracture occurs, what should the nurse assess for and how should she do it
hypovolemic shock
how to assess for hypovolemic shock
assess vital signs, skin color, level of consciousness
what is a sign that the bladder or urethra has been damaged with a fracture
blood in the urine, inability to void,
what will you see in a closed fracture if there is bleeding under the skin
ecchymosis
what is the greatest risk associated with a fracture?
the potential for it to injury nerves, blood vessels, and muscles that surround it
infection in a patient with a cast most commonly occurs from what?
breakdown of skin under the cast also called pressure necrosis
signs of pressure necrosis
hot spot under the cast, musty smell, fever
how should a patient with an arm cast position their arm
elevate it above the heart to reduce swelling
nursing care for a leg cast
elevate the leg on several pillows to reduce swelling and apply ice for first 24 hours as prescribed
good diet for healing
high in protein, iron, vitamins, carbs
monitor pts in a body/spica cast for what serious complication?
cast syndrome
fracture patient’s pain must be immediately reported to the HCP to avoid what
paralysis and necrosis
how to monitor for potential cast syndrome
note bowel sounds every 4-8 hours and report distention, nausea, and vomiting
treatment for cast syndrome
try to relieve pressure, window in cast
goal for post knee replacement- flexion beyond how many degrees
90 degrees
patient after TKA should avoid pressure on what?
heel
greatest concern after TKA and THA
contractures
what is done to prevent contractures
maintaining limb extension and CPM
acute compartment syndrome is caused by
reduced circulation to the area causing increased pressure from cast that is put on too early or too tight
most common complication of lower extremity surgery
DVT
earliest manifestation of fat embolism syndrome
altered mental status, then dyspnea and chest pain
what is traction
pulling force to a part of the body to provide reduction, alignment, and rest.
how often is circulation monitored after traction is applied
every hour for first 24 hours and every 4 hours afterward
what must the nurse assess for traction
circulation, sensation, and motor function of the limb
pink nailbeds indicates what
arterial pressure
white nailbeds indicates
decreased arterial supply
blue nailbeds indicates what
circulatory compromise
nurses primary focus for amputation patient
monitor for signs indicating that there is sufficient tissue perfusion and no hemorrhage
nursing priorities after amputation
preventing edema, observing for bleeding, preventing contractures
postop complications after amputation
hemorrhage, infection, phantom limb pain, contractures
what is phantom limb pain
pain felt in amputated part of body after surgery\
proper positioning of limb after amputation
adduction, external rotation, flexion, prone
5 P’s of neurovascular assessment
pain, pulses, pallor, paresthesia, paralysis
full thickness burns destroy what kinds of glands
sweat glands- leads to decrease in excretory ability
severity of burns depends on what?
how much surface area is involved and the depth of the burn
the degree of tissue damage is related to
to the agent causing the burn and the temperature of the heat source, thickness of the skin and how long the skin was exposed
who is at high risk for burns
elderly people and children
most burns occur in what setting?
the home
water heater temperature in the home should be below what temp?
140
what happens to heart rate when patient is burned
increases
what happens to blood pressure when patient is burned
decreases
electrolyte imbalances that occur with burns
hypovolemia, hyponatremia, hyperkalemia, metabolic acidosis
Burns- an airway obstruction is caused by?
heat that reaches the upper airway and causes edema of the mouth and throat
Burns-
GI changes?
decrease in motility causing abdominal distention
what is Curling’s Ulcer
peptic ulcer of duodenum that leads to ischemia and cell necrosis
Burns-
what happens to the patient’s calorie and oxygen needs
increases
Burns-
what happens to patient’s risk of infection
it increases
Burns-
what happens to blood concentration
blood becomes viscous and reduces blood flow to small vessels causing hypoxia
Burns-
what happens to cardiac output
decreases
Burns-
what happens to cardiac output after fluid resuscitation?
increases
Burns-
what treatment prevents cardiac complications
fluid resuscitation and oxygen therapy
Burns-
what is the most common type of burn
thermal burn
Burns-
thermal burns are caused by what?
flames, flash, scalding, or contact with hot objects
Burns-
nursing interventions for thermal burns
smother flame, remove smoldering clothing and metal
Burns-
what kind of substances cause chemical burns?
acids, alkali, and organic compounds
Burns-
examples of acids
rust remover, bathroom cleaner
Burns-
examples of alkali substances
oven cleaners and fertilizers
Burns-
examples of organic compounds
gasoline, chlorine, bleach, ammonia
Burns-
what kind of injury results from an electrical burn?
tissue injury and necrosis
Burns-
what is the iceberg effect?
burn damage that is difficult to see due because most of it is below the skin
Burns-
with which type of burn does the iceberg effect happen
electrical burns
Burns-
patient with electrical burns is at risk for?
dysrythmias, metabolic acidosis, myoglobinuria
Burns-
nursing interventions for patient with electrical burns
seperate patient from electrical current, initiate CPR
Burns-
indications of pulmonary injury with smoke inhalation
hoarseness, brassy cough, drool, difficulty swallowing, wheezes, cough, stridor, singed nasal hair
Burns-
signs of impending airway obstruction
wheezing that suddenly stops
Burns-
what is needed if smoke inhalation patient has an obstructed airway
intubate immediately!!
Burns-
what will a person with carbon monoxide poisoning look like?
cherry red skin
Burns-
treatment for carbon monoxide poisoning
100% oxygen
Burns-
smoke inhalation injury above the glottis can result from?
hot air, steam, smoke
Burns-
injury below glottis can lead to
pulmonary edema
Burns-
injury above glottis can lead to
airway obstruction
Burns-
1st manifestations of pulmonary edema
ulcerations, redness, edema of the mouth and epiglottis
Burns-
what toxoid should be administered?
tetanus
Burns-
the emergent phase occurs when?
24-48 hours after the burn
Burns:-
late signs of pulmonary edema?
crackles, orthopnea, SOB
Burns-
nursing priorities for emergent phase of burns
continuous airway assessment , fluid replacement, pain management, maintain body temp, monitor urine output
Burns-
emergent phase- tell the patient to do what?
cough and deep breathe
Burns-
greatest threat during emergent phase
hypovolemic shock
Burns-
acute phase occurs when?
36-48 hours after burn
Burns-
priority nursing interventions for acute phase?
assess and maintain CV and resp systems, hand hygiene, meticulous wound care
Burns-
greatest threat during acute phase?
burn wound sepsis
Burns-
rehab phase begins when?
with wound closure
Burns-
priority management for rehab phase
adjustment of patient, prevention of scars and contractures, resumption of activity
Burns-
patient education for burns rehab phase
signs of infection, wound dressing changes
Burns-
common lab findings
hyperglycemia, initial increase then decrease of WBCs, hypoxia, metabolic acidosis, decreased albumin
Burns-
which chart is considered the most accurate assessment for determining total body surface area
Lund-browner chart
Burns-
rule of nines is considered accurate for what?
inital first assessment of adults
\
Burns-
nursing interventions for chemical burns
quickly remove chemical from skin, remove clothing containing chemical
Burns-
fluid resuscitation: maintain BP at how much?
100 systolic
Burns-
fluid resuscitation: maintain urine output at how much?
30-50 mL/hr
Burns-
foley catheter is inserted during which phase?
emergent
cellulitis is caused by which bacteria?
staphylococcus and streptococcus
manifestations of cellulitis
localized area of inflammation that may enlarge if not treated, redness, warmth, edema, tenderness
cellulitis is often spread to other areas of the body by what?
scratching or rubbing the skin with fingernails that have organisms under them
treatment for cellulitis
obtain culture and administer broad spectrum IV antibiotics for at least 14 days
nonpharmacological interventions for cellulitis
warm compresses to promote circulation and decrease discomfort, erythema, and edema
herpes zoster – manifestations
eruption of multiple lesions in a dermatone pattern that doesnt cross the midline, usually occurs after several days of discomfort and lasts several weeks
common complication of herpes zoster
postherpetic neuralgia which is severe pain persisting after the lesions have resolved
treatment for herpes zoster
early diagnosis and prompt treatment with acyclovir
herpes zoster is contagious until?
lesions have crusted over
what type of precautions for herpes zoster
contact precautions
herpes zoster is contagious to?
people who have not previously had chicken pox or been vaccinated
hypovolemic shock is caused by
hemorrhage, or any loss of blood volume from the vascular space
hypovolemic shock can be reversible if treated within how long?
1-2 hours
the initial stage of shock is present when the patient’s baseline MAP is decreased by how much?
less than 10
what may be the only objective manifestation of the initial stage of shock?
increase in HR, RR, diastolic BP
the nonprogressive/compensatory stage shock is present when the patient’s baseline MAP is decreased by how much?
10-15 from baseline
manifestations in the nonprogressive/compensatory stage of shock
moderate vasoconstriction, thirst, decreased urine output, acidosis, hyperkalemia, hypoxia to non vital organs, restlessness, decrease in o2 sat
the progressive stage of shock is present when the patient’s baseline MAP is decreased by how much?
more than 20 from baseline
manifestations of progressive stage of shock
hypoxia to vital organs, acidosis, hyperkalemia, sense of impending doom, rapid weak pulse, cyanosis of oral mucosa, anuria
the endotracheal tube should rest where?
2 cm above the carina
each intubation attempt should last no longer than?
30 seconds
how is placement of an endotracheal tube verified
by checking end tidal carbon dioxide levels and chest xray
a bipap machine is what kind of ventilator?
pressure cycled
benefits of positive pressure ventilation
forced/enhanced lung expansion, improved gas exchange, decreased work of breathing
what is tidal volume
the volume of air the patient receives with each breath
an increased peak airway pressure reading means?
increased airway resistance
how often should ventilated patient’s respiratory status be assessed?
every 4 hours
air temperature should be maintained at what temp?
body temp
mouth care on ventilated patient should be done how often?
every 2 hours
cardiac problems caused by mechanical ventilation
hypotension and fluid retention
main reason for failure to wean off ventilator
malnutrition
examples of internal disasters
fire, explosion, violence, building collapse
examples of category A Biological Terrorism Agents
anthrax, small pox
example of category B biological terrorism agent
Ricin
example of category c bioterrorism agent
avian flu, pandemic flu
what kind of precautions for bioterrorism agents?
isolation
Nerve agents cause what?
loss of consciousness, seizures, copious secretions, apnea, death