NURSING > EXAM > NURS 120 Med Surg Final Exam Study Guide LATEST 2022 (All)

NURS 120 Med Surg Final Exam Study Guide LATEST 2022

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NG tube placement & verification: o Review the prescription & purpose of the procedure, understand the need for placement. Identify client, explain the procedure. o Review history of nasal problems, anticoagulants, previous trauma, & past history of aspiration. o Evaluate the clients ability to cooperate & make a hand signal w/ the client. o Perform hand hygiene, tape or use commercial fixation device to secure the dressing. o Use clean gloves, water soluble lube, topical anesthetic, cup of water & straw, catheter & syringe (30-60 mL), basin, pH strip (>4), clamp or plug to close the tubing after insertion. o Steps: ATI 1. Auscultate bowel sounds, palpate abdomen for distention, pain & rigidity. 2. Raise head of bed (high fowlers if possible). 3. Assess nares, look for deviation/obstruction. 4. Measure tube from tip of the nose to the earlobe, down to the xiphoid process. 5. Give client water & when they swallow continue to insert tubbing. • If client vomits clear the airway & provide comfort before continuing care. 6. Check for placement w/ pH strip (<4) & assess color, odor, consistency & amount. 7. Verify placement w/ X-RAY. • If the tube is not in the stomach, advance it 5 cm (2 in.) & repeat placement check. • Wound Evisceration – Nursing actions – what to do if you see evisceration? 1. Call for help, ask the surgeon to be notified & that needed supplies be brought to the room of the client. 2. Stay with the client. 3. While waiting for supplies, place the client in low fowlers w/ the knees bent. 4. Cover the wound with sterile wet normal saline dressing & keep the dressing moist. Do not attempt to reinsert organs. 5. Take vital signs & monitor the client closely for signs of shock. 6. Prepare the client for surgery as necessary. 7. Document the occurrence, actions taken, and the clients response. • Perioperative teaching, informed consent. o Preparing a client for surgery: 1. Assist the client to void before transfer to the operating room. 2. Check all surgeon's prescriptions to ensure they have been carried out. 3. Review the client's record for a history & physical report & laboratory reports. o Obtaining informed consent- The surgeon is responsible for explaining the surgical procedure to the client & answering the clients questions. The nurse is responsible for obtaining the clients signature on the consent form & needs to make sure the client understood the surgeon’s explanation.

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