In each blank, try to type in the
word that is missing. If you've
typed in the correct word, the
blank will turn green.
If your not sure what answer should be entered, press the space bar and the next missing letter will be displayed. When you are all done, you should look back over all your answers and review the ones in red. These ones in red are the ones which you needed help on. Question: What is the Hand Off ?Answer: Used to exchange vital information between the OR nurse/anesthesiologist and the PACU Question: Four of information in the Hand-Off ReportAnswer: Two patient identifiersType of anesthesia used, reversal agents blood/fluid lossVital signs (baseline, most recent, problems) Question: Four types of information in the Hand-Off Answer: IntraOp complicationsHealth hx (allergies, )Considerations (pain mgmt, reversals, vent settings)Language barriers Question: Elements of PACU Foucused Answer: Airway; Breathing; Circulation; Mental Status/LOC/Responsiveness; Examination of site; Pain Assessment; IV Fluids; Other intubation. Question: Concepts of AssessmentAnswer: Patient artificial airway or can maintain his/her own; Is the neck in proper alignment? Snoring and/or stridor indicates a non-patent airway; Use of accessory muscles indicates the patient is struggling to breathe Question: Concepts of Breathing Answer: Unlabored respirations between 12-20; Skin WNL; Pulse ox >95% or meet baseline; Clear bilateral lung sounds; Chest movement symetrical; O2 administration Question: Concepts of Circulation Answer: B/P within 25% of baseline; Apical pulse 60-100; Cardiac monitoring at baseline; Temperature at baseline; Peripheral assessment according to procedure compared bilaterally and to baseline. Question: Concepts of AssessmentAnswer: AAO x 3; Lethargy; ; Irritability; Glasgows Coma Scale Question: What is considered normal CNS depression on Glasgows Coma ?Answer: <13 Question: What is moderate CNS depression on Glasgows Coma Scale?Answer: 9-12 Question: What is considered severe CNS on Glasgows Coma Scale?Answer: 3-8 Question: What does AVPU of consciousness stand for?Answer: AlertVerbal stimuliUnresponsiveness Question: What are types of abnormal posturing?Answer: (Decorticate)Extensor (Decerebrate)Flacid Question: What is posturing?Answer: the cord Question: What is extensor ?Answer: Toes in, out Question: Concepts of site assessment?Answer: Is the site C/D/I; if not type and amount of drainage; Look underneath patient for /drainage; Drains? Type? Question: Concepts of pain ?Answer: Numerical scale; Faces scale; scale; PCA pump according to orders; Did pt have epidural or spinal anesthesia? Question: What does pain scale represent?Answer: Face; Legs; ; Cry; Consolability Question: of IV fluids?Answer: Correct solutions/additives/rate; How much is present whent pt arrives in PACU. Question: Concepts of ?Answer: NG/gastric-color, consitency, amountSuction-setting-color, consitency, amountFoley-patent (assess for distension) color, clarity and amount Question: Name PACU complications.Answer: Loss of patent airway; Respiratory failure/difficulty; Hypotension; Shock; Hemmorage; ; Disrhytmias Question: List interventions.Answer: Tilt head back, push angle of jaw forward; If this doesn’t fix the , may need an artificial airway; Suction PRN (oral or pharyngeal); assess risk of aspiration (nausea) Question: List respiratory failure/difficulty .Answer: May need support with oxygen; Keep aroused with normal tone of voice; May need to contact anesthesiologist or surgeon for meds if resp 10 or below and does not respond to stimuli; Encourage to cough and deep breathe Question: List /shock interventions.Answer: IV fluids and/or blood/blood products; Meds that B/P; O2; Position patient supine, legs elevated; Thorough assessment, vital signs monitored continuously; Keep patient warm Question: What are the of shock?Answer: Hypovolemic most common; Pallor; Skin cool and ; Tachycardia, weak & thready pulse; Cyanosis; Hypotension; Concentrated urine (dark color) Question: What are the symptoms of ?Answer: Apprehensive, restless; Thirsty; Cold, moist, pale skin; ; Tachypnea (even gasping); Pale mucous membranes and conjunctivae; Weakness Question: List common hemorrhage .Answer: Blood/blood product transfusions; Figuring out where the patient is ; Inspect surgical site; Apply pressure c sterile gauze; Elevate bleed site above heart level; position supine c legs elevated Question: different types of blood products used.Answer: Whole blood; Packed RBC's (pRBC); Autologous RBC's (donated by pt); Platelets; Fresh frozen plasma (FFP); Albumin; factors/Cryoprecipitate Question: of blood donations are?Answer: Blood donor-unpaid ; Autologous donor-obtained from pt receiving the blood; Plasma donor-paid donors Question: of type A blood.Answer: A antigens and B antibodies. Question: Characteristics of type B .Answer: Contains B and A antibodies. Question: of type AB blood.Answer: Contains A & B an no antibodies. Question: Characteristics of type O .Answer: Contains no antigens and both A & B . Question: What is Rh ?Answer: An that may or may not be present on the RBC. Question: What makes one Rh+?Answer: When the Rh is present. Question: Which blood type is the donor?Answer: O- Question: Which blood type is the recipient?Answer: AB+ Question: List the symptoms of a Febrile Transfusion reaction.Answer: Chills; Fever; Headache; ; Tachycardia; Increased anxiety Question: List the symptoms of a Hemolytic Blood Transfusion .Answer: Low back pain; Hypotension; Tachycardia; Fever and chills; pain; Tachypnea; Hemoglobinuria; May have immediate onset Question: List the of an Allergic Blood Transfusion reaction.Answer: Hives; Pruritis; Facial flushingSevere SOB; ; Anxiety Question: What are some nursing interventions for transfusion reations?Answer: Stop the infusion and the physician; change the IV tubing; treat the symptoms presented; recheck crossmatch record with blood product. Question: What must be done for reations?Answer: 2 samples distal to infusion site; obtain UA for hemoglobinuria test; monitor F & E balance; evaluate serum Ca levels Question: What are pre-procedural of blood administration?Answer: Check pt. ID; Allergies; Previous reactions; Dr. order; Check labels on blood for type and expiration; Baseline vitals; Obtain supplies. Question: What must be checked by 2 nurses proir to blood product administration?Answer: ABO group; Rh type; Pt. identifiers; ID blood band; #; Expiration date Question: When blood be warmed?Answer: Only when pt is at risk for shock. Question: What needle is used to administer blood products?Answer: #18G or #20G Question: Severe reactions to blood products usually when?Answer: Within the 15 minutes or 50cc's. Question: What does the nurse know tubing for blood infusions?Answer: It must be changed 4 hours. Question: How long does it take for products to be infused?Answer: 2-4 hours but over 4. Question: What steps does the take after a blood infusion?Answer: Flush the IV with normal saline and tubing in neccessary; document final V/S in chart; obtain post-procedural labs, if ordered. Question: (buterphanol tartrate)Answer: Used to treat moderate to severe painIV, caution in patients taking MAOIsUsual dose: 0.5 – 2mg q3-4h PRNDo not give if respirations < 10Has lower potential for dependence than other opioids Question: (morphine sulfate)Answer: Opioid Analgesicmoderate to severe painIV, IM, subcut, PO, PR (IV & epidural PCA)Use caution in patients taking MAOIsUsual dose: Parenteral, 1-15mg, low and go slow. Higher PO, PRDo not give if respirations <10 Question: (naloxone)Answer: Used for of opioid analgesics Question: (promethazine)Answer: used for sickness and nauseaPO, IM, IVAbsorbed well PO and IM; use caution IV (may cause severe tissue damage)Usual dosage: PO 6.25-12.25mg tid; IM & IV 25mg q2h Question: (ondansetron)Answer: Used for nausea and vomitting preventionPO, IM & IVUsual dosage: PO 16mg 1hr; 4mg IM & IV pre 100% Question: (hydroxine)Answer: Used to treat anxiety; antiemetic adjucnt to opioid and IMAbsorbs wellUsual dosage: PO 25-100mg daily, IM (z-track only)25-100mg q4-6h PRN Question: Name some post-PACU .Answer: Hematoma; Hemorrhage; DVT; Pulmonary embolism; Wound infection/sepsis; Evisceration; Dehiscence; ; Paralytic Ileus Question: NANDA Acute Answer: Pain is whatever the pt says it is. Is subjective. Question: NANDA Decreased OuptutAnswer: Inadequate volume of blood pumped by the per minute to meet metabolic demands of the body Question: Impaired Skin IntegrityAnswer: Altered epidermis and/or Question: Ineffective ThermoregulationAnswer: Temperature fluctuation hypo- and hyperthermia Question: NANDA Ineffective Airway Answer: Inability to clear secretions or obstructions from the respiratory to maintain airway clearance Question: ConstipationAnswer: Decrease in the normal frequency of defecation, accompanied by difficult or incomplete of stool and/or passage of excessively hard, dry stool Question: NANDA Risk for Answer: At risk of injury as a result of the interaction of environmental conditions interacting c the adaptive and defensive resources. Question: Answer: |
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