Ms Flash Cards

8/22/2019 Ms Flash Cards

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MEDICAL SURGICAL NURSINGFLASH CARDS

List 4 common symptoms of pneumonia thenurse might note on a physical exam.

Tachypnea, fever with chills, productive cough,bronchial breath sounds.

State 4 nursing in terventions for assisting theclient to cough productively.

Deep breathing, fluid intake increased to 3liters/day, use humidity to loosen secretions, suction

airway to stimulate coughing.

What symptoms of pneumonia might the nurseexpect to see in an older client?

Confusion, lethargy, anorexia, rapid respiratory rate.

What should the O2 flow rate be for the clientwith COPD?

1-2 liters per nasal cannula, too much O2 mayeliminate the COPD clients stimulus to breathe, a

COPD client has hypoxic drive to breathe.

How does the nurse prevent hypoxia duringsuctioning?

Deliver 100% oxygen (hyperinflating) before andafter each endotracheal suctioning.

During mechanical ventilation, what are threemajor nursing intervention?

Monitor clients respiratory status and secureconnections, establish a communication mechanism

with the client, keep airway clear by

coughing/suctioning.

When examining a client with emphysema, whatphysical findings is the nurse likely to see?

Barrel chest, dry or productive cough, decreasedbreath sounds, dyspnea, crackles in lung fields.


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What is the most common r isk factor associatedwith lung cancer?

Smoking

Describe the pre-op nursing care for a clientundergoing a laryngectomy.

Involve family/client in manipulation of tracheostomyequipment before surgery, plan acceptable

communication method, refer to speech pathologist,discuss rehabilitation program.

List 5 nursing interventions after chest tubeinsertion.

Maintain a dry occlusive dressing to chest tube siteat all times. Check all connections every 4 hours.Make sure bottle III or end of chamber is bubbling.

Measure chest tube drainage by marking level onoutside of drainage unit. Encourage use of

incentive spirometry every 2 hours.

What immediate action should the nurse takewhen a chest tube becomes disconnected froma bottle or a suction apparatus? What should

the nurse do if a chest tube is accidentally

removed from the client?

Place end in container of sterile water. Apply anocclusive dressing and notify physician STAT.

What instructions should be given to a clientfollowing radiation therapy?

Do NOT wash off lines; wear soft cotton garments,avoid use of powders/creams on radiation site.

What precautions are required for clients with TBwhen placed on respiratory isolation?

Mask for anyone entering room; private room; client mustwear mask if leaving room.

List 4 components of teaching for the client withtuberculosis .

Cough into tissues and dispose immediately into specialbags. Long-term need for daily medication. Good

handwashing technique. Report symptoms ofdeterioration, i.e., blood in secretions.


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Differentiate between acute renal failure andchronic renal failure.

Acute renal failure: often reversible, abruptdeterioration of kidney function. Chronic renal failure:

irreversible, slow deterioration of kidney functioncharacterized by increasing BUN and creatinine.

Eventually dialysis is required.

During the oliguri c phase of renal failure,protein should be severely restricted. What is

the rationale for this restrict ion?

Toxic metabolites that accumulate in the blood (urea,creatinine) are derived mainly from protein

catabolism.

Identify 2 nurs ing interventions fo r the clienton hemodialysis.

Do NOT take BP or perform venipunctures on the armwith the A-V shunt, fistula, or graft. Assess access

site for thrill or bruit.

What is the highest priority nurs ing diagnosisfor cli ents in any type of renal failure?

Alteration in fluid and electrolyte balance.

A c lient in renal failure asks why he is beinggiven antacids. How should the nurse reply?

Calcium and aluminum antacids bind phosphates andhelp to keep phosphates from being absorbed intoblood stream thereby preventing rising phosphate

levels, and must be taken with meals.

List 4 essential elements of a teaching plan forclients with f requent urinary tract infections

Fluid intake 3 liters/day; good handwashing; voidevery 2-3 hours during waking hours; take all

prescribed medications; wear cotton undergarments.


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What are the most important nursinginterventions for cli ents with possible renal

calculi?

Strain all urine is the MOST IMPORTANTintervention. Other interventions include accurateintake and output documentation and administer

analgesics as needed.

What discharge instruc tions should be givento a client who has had urinary calculi?

Maintain high fluid intake 3-4 liters per day. Follow-upcare (stones tend to recur). Follow prescribed diet

based in calculi content. Avoid supine position.

Following transurethral resection of theprostate gland (TURP), hematuria should

subside by what post -op day?

Fourth day

Af ter the ur inary catheter is removed in theTURP client, what are 3 priorit y nurs ing

actions?

Continued strict I&O; continued observations forhematuria; inform client burning and frequency may

last for a week.

Af ter k idney surgery, what are the p rimaryassessments the nurse should make?

Respiratory status (breathing is guarded because ofpain); circulatory status (the kidney is very vascularand excess bleeding can occur); pain assessment;

urinary assessment most importantly, assessment ofurinary output.


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How do c lients experiencing anginadescribe that pain?

Described as squeezing, heavy, burning, radiates toleft arm or shoulder, transient or prolonged.

Develop a teaching plan for the clienttaking nitroglycerin.

Take at first sign of anginal pain. Take no more than 3,five minutes apart. Call for emergency attention if no reliefin 10 minutes.

List the parameters of blood pressure fordiagnosing hypertension

>140/90.

Differentiate between essential andsecondary hypertension. Essential has no known cause while secondaryhypertension develops in response to an identifiablemechanism.

Develop a teaching plan for the clienttaking antihypertensive medications

Explain how and when to take med, reason for med,necessary of compliance, need for follow-up visits while on

med, need for certain lab tests, vital sign parameters whileinitiating therapy.


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Describe in termittent claudication. Pain related to peripheral vascular disease occurring withexercise and disappearing with rest.

Describe the nurses dischargeinstruct ions to a client with venousperipheral vascular disease.

Keep extremities elevated when sitting, rest at first sign ofpain, keep extremities warm (but do NOT use heatingpad), change position often, avoid crossing legs, wearunrestrictive clothing.

What is often the underlying cause ofabdominal aortic aneurysm?

Atherosclerosis.

What lab values should be monitored dailyfor the client with thrombophlebitis who isundergoing anticoagulant therapy?

PTT, PT, Hgb, and Hct, platelets.

When do PVCs (premature ventr icularcontractions) present a grave danger?

When they begin to occur more often than once in 10beats, occur in 2s or 3s, land near the T wave, or take onmultiple configurations.


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Differentiate between the symptoms of left-sided cardiac failure and r ight-sidedcardiac failure

. Left-sided failure results in pulmonary congestion due toback-up of circulation in the left ventricle. Right-sidedfailure results in peripheral congestion due to back-up ofcirculation in the right ventricle.

List 3 symptoms of digitalis toxicity. Dysrhythmias, headache, nausea and vomiting

What condi tion increases the likelihood ofdigitalis toxicity occurring?

When the client is hypokalemic (which is more commonwhen diuretics and digitalis preparations are giventogether)

What life style changes can the client whois at risk for hypertension initiate to reducethe likelihood of becoming hypertensive?

Cease cigarette smoking if applicable, control weight,exercise regularly, and maintain a low-fat/low-cholesteroldiet.

What immediate actions should the nurseimplement when a client is having amyocardial infarction?

Place the client on immediate strict bedrest to loweroxygen demands of heart, administer oxygen by nasalcannula at 2-5 L/min., take measures to alleviate pain andanxiety (administer prn pain medications and anti-anxietymedications)


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What symptoms should the nurse expectto find in the client with hypokalemia?

Dry mouth and thirst, drowsiness and lethargy, muscleweakness and aches, and tachycardia.

Bradycardia is defined as a heart ratebelow ___ BPM. Tachycardia is defined asa heart rate above ___ BPM.

bradycardia 60 bpm; tachycardia 100 bpm

What precautions should c lients with valvedisease take prior to invasive proceduresor dental work?

Take prophylactic antibiotics.


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GASTROINTESTINAL SYSTEM:

List 4 nursing interventions for the client with ahiatal hernia.

Sit up while eating and one hour after eating. Eatsmall, frequent meals. Eliminate foods that are

problematic.

List 3 categories of medications used in thetreatment of peptic ulcer d isease

Antacids, H2 receptor-blockers, mucosal healingagents, proton pump inhibitors.

List the symptoms of upper and lowergastrointestinal bleeding.

Upper GI: melena, hematemesis, tarry stools. LowerGI: bloddy stools, tarry stools. Similar: tarry stools.

What bowel sound disrupt ions occur with anintestinal obstruction?

Early mechanical obstruction: high-pitched sounds;late mechanical obstruction: diminished or absent

bowel sounds.

List 4 nursing interventions for post-op care of theclient with a colostomy.

Irrigate daily at same time; use warm water forirrigations; wash around stoma with mild soap/waterafter each colostomy bag change; pouch openingshould extend at least 1/8 inch around the stoma.

List the common cl inical manifestations ofjaund ice

Sclera-icteric (yellow sclera), dark urine, chalky orclay-colored stools.

What are the common food intolerances forclients with cholelithiasis?

Fried/spicy or fatty foods.


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List 5 symptoms indicative of colon cancer Rectal bleeding, change in bowel habits, sense ofincomplete evacuation, abdominal pain with nausea,

weight loss.

In a client with ci rrhosis, it is imperative toprevent further bleeding and observe for bleedingtendencies. List 6 relevant nursing interventions.

Avoid injectons, use small bore needles for IVinsertion, maintain pressure for 5 minutes on all

venipuncture sites, use electric razor, use soft-bristletoothbrush for mouth care, check stools and emesis

for occult blood.

What is the main side effect of lactulose, which is

used to reduce ammonia levels in clients w ithcirrhosis?

Diarrhea

List 4 groups who have a high risk of contractinghepatitis.

Homosexual males, IV drug users, recent ear piercingor tattooing, and health care workers.

How should the nurse administer pancreaticenzymes?

Give with meals or snacks. Powder forms should bemixed with fruit juices


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ENDOCRINE SYSTEM:

What diagnostic test is used to determine thyroidactivity?

T3 and T4

What condition results from all treatments forhyperthyroidism?

Hypothyroidism, requiring thyroid replacement

State 3 symptoms of hyperthyroidism and 3symptoms of hypothyroidism.

Hyperthyroidism: weight loss, heat intolerance,diarrhea. Hypothyroidism: fatigue, cold intolerance,

weight gain.

List 5 important teaching aspects for clients whoare beginning corticos teroid therapy.

Continue medication until weaning plan is begun byphysician, monitor serum potassium, glucose, andsodium frequently; weigh daily, and report gain of>5lbs./wk; monitor BP and pulse closely; teach

symptoms of Cushings syndrome

Describe the physical appearance of clients who

are Cushinoid.

Moon face, obesity in trunk, buffalo hump in back,

muscle atrophy, and thin skin.


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Which type of diabetic always requires insulinreplacement?

Type I, Insulin-dependent diabetes mellitus (IDDM)

What type of diabetic sometimes requires nomedication?

Type II, Non-insulin dependent diabetes mellitus(NIDDM)

List 5 symptoms o f hyperglycemia. Polydipsia, polyuria, polyphagia, weakness, weight

loss

List 5 symptoms of hypoglycemia. Hunger, lethargy, confusion, tremors or shakes,sweating

Name the necessary elements to include inteaching the new diabetic.

Teach the underlying pathophysiology of the disease,its management/treatment regime, meal planning,exercise program, insulin administration, sick-daymanagement, symptoms of hyperglycemia (not

enough insulin)

In less than ten steps, describe the method fordrawing up a mixed dose of insulin (regular with

NPH).

Identify the prescribed dose/type of insulin perphysician order; store unopened insulin in refrigeratorIf opened, may be kept at room temperature for up to

3 months. Draw up regular insulin FIRST. Rotateinjection sites. May reuse syringe by recapping and

storing in refrigerator.


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Identify the peak action time of the following typesof insulin: rapid-acting regular insulin,

intermediate-acting, long-acting.

Rapid-acting regular insulin: 2-4 hrs. Immediate-acting: 6-12 hrs. Long-acting: 14-20 hrs.

When preparing the diabetic for discharge, thenurse teaches the client the relationship betweenstress, exercise, bedtime snacking, and glucosebalance. State the relationship between each of

these.

Stress and stress hormones usually increase glucoseproduction and increase insulin need; exercise can

increase the chance for an insulin reaction, therefore,the client should always have a sugar snack available

when exercising (to treat hypoglycemia); bedtimesnacking can prevent insulin reactions while waiting

for long-acting insulin to peak.

When making rounds at night, the nurse notesthat an insulin-dependent client is complaining ofa headache, slight nausea, and minimal trembling.

The clients hand is cool and moist. What is theclient most likely experiencing?

Hypoglycemia/insulin reaction.

Identify 5 foot-care interventions that should betaught to the diabetic c lient.

Check feet daily & report any breaks, sores, or blistersto health care provider, wear well-fitting shoes; nevergo barefoot or wear sandals, never personally remove

corns or calluses, cut or file nails straight across;wash daily with mild soap & warm water.


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MUSCULOSKELETAL SYSTEM:

Differentiate between rheumatoid arthritis anddegenerative joint disease in terms of join t

involvement.

Rheumatoid arthritis occurs bilaterally. Degenerativejoint disease occurs asymmetrically.

Identify the categories of drugs commonly used totreat arthritis .

NSAIDs (nonsteroidal anti-inflammatory drugs) ofwhich salicylates are the cornerstones (used when

arthritic symptoms are severe).

Identify pain relief interventions for clients witharthritis.

Warm, moist heat (compresses, baths, showers),diversionary activities (imaging, distraction, self-

hypnosis, biofeedback), and medications.

What measures should the nurse encouragefemale clients to take to prevent osteoporosis?

Estrogen replacement after menopause, high calciumand vitamin D intake beginning in early adulthood,

calcium supplements after menopause, and weight-bearing exercise.

What are the common side effects of salicylates? GI irritation, tinnitus, thrombocytopenia, mild liverenzyme elevation.

What is the priority nurs ing intervention used withclients taking NSAIDs?

Administer or teach client to take drugs with food ormilk.

List 3 of the most common joints that are Hip, knee, finger.


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replaced.

Describe post-op stump care (after amputation)for the 1st 48 hours.

Elevate stump first 24 hours. Do not elevate stumpafter 48 hours. Keep stump in extended position and

turn prone three times a day to prevent flexion

contracture.

Describe nursing care for the client who isexperiencing phantom pain after amputation.

Be aware that phantom pain is real and will eventuallydisappear. Administer pain medication; phantom pain

responds to medication.

A nurse discovers that a cl ient who is in tract ionfor a long bone fracture has a slight fever, is short

of breath, and is restless. What does the clientmost likely have?

Fat embolism, which is characterized by hypoxemia,respiratory distress, irritability, restlessness, fever and

petechiae.

What are the immediate nursing actions if fat

embolization is suspected in a fracture/orthopedicclient?

Notify physician STAT, draw blood gas results, assist

with endotracheal intubation and treatment ofrespiratory failure.

List 3 problems associated with immob ility. Venous thrombosis, urinary calculi, skin integrityproblems.

List 3 nursing in terventions for the prevention ofthromboembolism in immobilized clients with

musculoskeletal problems.

Passive range of motion exercises, elastic stockings,and elevation of foot of bed 25 degrees to increase

venous return.

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