I just finished my first semester, only to be told that I cannot move on to the next semester because I did not make an 80 average on my test grades. I had a strong clinical evaluation, and made an 81 on my comprehensive final. i also did a paper, but it does not count unless my test avg is an 80 (got a 97 on my paper). There have been a few questions this semester that I have gotten wrong, and really disagreed with the answers. I am attaching a few of those that I am challenging... any input is appreciated!
- Question pertaining to the care of a Hemovac Drain with no drainage:
The answer was to check for kinks. I selected the answer pertaining to inspecting the insertion site as the first best action for the nurse. This would have been followed by checking the tubing as outlined in the steps listed below.
From Fundamentals of Nursing, Wilkinson and Van Leuven, page 836, top left paragraph:
“Monitor the amount and character of the drainage and the condition of the collection apparatus. Record this information in your nursing notes as well as on the I&O record. Report to the surgeon any change in the amount or character of the drainage. If you suspect that a drain is occluded, check the drain line from the insertion site to the collection device. Remove any kinks in the tubing. If this does not correct the problem, notify the physician of the blockage.”
- Pertaining to the PACU patient who’s respirations are 8 and they have received Morphine:
The answer was to prepare to administer Narcan. While I realize that Narcan is the reversal agent for opioid analgesics, I selected the first action of the Nurse would be to auscultate lung fields. This action would be followed by preparation for the Narcan administration as the reversal agent.
From Medical-Surgical Nursing, Ignatavicius Workman, page 287, right side of page
“Assess the rate, pattern, and depth of breathing to determine adequacy of air exchange. A respiratory rate of less than 10 breaths per minute may indicate anesthetic- or opioid analgesic-induced depression. Rapid, shallow respirations may signal shock, cardiac problems, increased metabolic, or pain.”
“Listen to the lungs over all lung fields to assess breath sounds. Also check symmetry of breath sounds and chest movement.”
-- The next few paragraphs give further instructions as to how to distinguish between the different signs and what their implications may be. Simply administering Narcan, without doing an assessment could cause the Nurse to overlook an additional complication (such as retained secretions, laryngeal spasm (as evidenced by sounds of stridor) or edema).
- Pertaining to the explanation to the post-op patient about why it is important to remain NPO. Patient has absent bowel sounds and had morphine: The answer was to prevent nausea and vomiting. I selected to prevent constipation.
From Fundamentals of Nursing, Wilkinson and Van Leuven, page 947, 2nd, under Diagnosis.
Interventions: “Encourage and assist to move in bed, ambulate, and increase fluid and fiber intake after
bowel sounds return.”
Absent bowel sounds and the opioid analgesic make this patient’s risk for constipation high. Patient should not have anything to eat or drink until peristalsis returns. It may be necessary to first assess for paralytic ileus.
This was also addressed during class 27- under GI- assess date of last b/m. Patient may be NPO until peristalsis returns.
- Pertaining to the question about Atelectasis and hypoxia: I selected aspiration as most common cause of hypoxia (may have been hypoxemia). Correct answer was Atelectasis.
From Medical-Surgical Nursing, Ignatavicius Workman, page 294, left side of page
Instructions for Impaired Gas Exchange under the heading Positioning.
“In the PACU, immediately position the patient in a side-lying position or turn his head to the side to prevent aspiration.”
From Medical-Surgical Nursing, Ignatavicius Workman, page 299, right side of page
Potential for Hypoxemia:
“Interventions: The key to preventing hypoxemia is to follow the nursing interventions for the nursing diagnosis of Impaired Gas Exchange (p. 294).”
- Pertaining to promote venous return to which client: choices were 48 yr old woman having ovarian removal surgery and has cancer as the correct answer. I chose man with INR of 2.2.
My rationale was that a patient who had a lab value done to measure INR was already at risk for DVT prior to surgery.
Further: From Medical-Surgical Nursing, Ignatavicius Workman, page 258, left side of page
Patients at greater risk for DVT: see page…
Older male patient had more risk factors than female. Female’s only risk was cancer and over 40.
- Pertaining to the question with select all that apply: I selected all correct answers except to ground the medical equipment. This topic was not outlined in our notes. In the OR, with Mrs. Kearney, we were told to look for the grounding pad on the patient as a safety precaution.
Further: Further: From Medical-Surgical Nursing, Ignatavicius Workman, page 267, left side of page , 3rd paragraph.
“The nurse ensures electrical safety through proper placement of grounding pads.”
- Pertaining to Post-op client day 2 with a fever of 100.9. Answer was to ambulate, I chose to provide for patient comfort first. Nothing in the questions or answers mentioned atelectasis.
Further: Further: From Medical-Surgical Nursing, Ignatavicius Workman, page 292, right side of page , 3rd paragraph.
“Plan the patient’s activities around the timing of analgesics to promote mobility.”
On Final EXAM…. I may need to review this again, I am certain that there were more questions that I had issues with, but could not recall them at this time.
1. The question pertaining to what does PACU nurse do, assess vitals or assess respiratory? I chose vitals, but wrote next to it that respiratory status was included in the vitals assessments.
From Fundamentals of Nursing, Wilkinson and Van Leuven, page 943, bottom left bullet point:
“Vital signs, including respiratory rate, respiratory competence, and breath sounds…etc “
This same section reinforces my issue with the Atelectasis vs. Aspiration question.