Med Surg I #1

Which is the most appropriate priority nursing intervention when a patient experiences a wound evisceration?

• Place a sterile, saline soaked towel over the area and call the rapid response team

• elevate the patient's knees

• increase the IV fluids

How will the nurse instruct the patient to splint their surgical incision when coughing?

• Interlace fingers snugly, putting both hands together and placing hands across the incision site

• Placing both palms on incision and applying deep pressure

• There are no special precautions that need to be taken

What is an Aldrete score?

• 0-10 scoring system used to determine when people can be safely discharged from the PACU

• This is made up

• 0-10 functional screen assessment tool

Which of the following are common expectations for a 12 hour post-op THA? (select all that apply)

• use of adduction pillow

• use of abduction pillow

• serosanguineous drainage in the hemovac

• order for antibiotics

Which degree of sprain does the nurse anticipation the patient will have the longest recovery time?

• 1st degree – mild sprain, slight pain

• 2nd degree – moderate sprain, partial tear of ligaments, swelling and more pain

• 3rd degree – severe rupture of ligaments, popping noise heard, more swelling and pain

Which of the following is the least serious type of strain?

• First degree: limited pain, mild tenderness.

• Second degree: moderate pain; limited range of motion; swelling and bruising possible.

• Third degree: severe pain, limited or no movement, muscle tissue severely damaged and torn.

Which of the following instructions will the nurse give a patient to decrease the risk of fracture due to osteoporosis? (select all that apply)

• Participate in regular, weight-bearing exercises

• take calcium and vitamin d as prescribed

• stop smoking

• eat more protein

Which of the following are included in the 6 P's and are concerns in assessing neurovascular status? (select all that apply)

• Poikilothermia

• Paresthesias

• Pulselessness

• Panic

Pallor, cool moist skin, tachypnea, tachycardia, concentrated urine, hypotension are all symptoms of what?

• hypovolemic shock

• anaphylactic shock

• neurogenic bladder

• pneumonia

In which stage of anesthesia could the nurse assess a patient to be excited, talkative, and trying to get out of bed.

• I

• II

• III

• IV