MED
SURG[ COMMON CONCEPTS ] FINAL EXAM REVIEW JULY 2014
What are some
important things the nurse asks when she assess the immune system?
How do you feel? Have you had any operations? Ask about
unexplained weightless or fatigue.
Hepatitis B
vaccine is active or passive immunity? Does Hepatitis B last a lifetime?
Active immunity; acquired. Technically it does, but we know now we may need to give boosters. Check titers if not sure to see if high enough level. Titers tell immunity levels. Chicken pox is an example.
Active immunity; acquired. Technically it does, but we know now we may need to give boosters. Check titers if not sure to see if high enough level. Titers tell immunity levels. Chicken pox is an example.
When you talk
about Osteoarthritis and doing teaching with a patient, what will be your focus?
Eating healthy,
weight bearing exercise and remaining active
If somebody is
having trouble sleeping, what do you want to stress to them?
Consistent times
What clinical
assessment finding would you find in a patient with Paget’s disease?
Bowing of legs
How do we help avoid
unusual stress on the joints? What is a lifestyle modification?
Weight and posture. To prevent unequal stress on your
joints so you don’t get degenerative joint disease.
If somebody is
complaining of phantom pain, they had an amputation of their right leg, below
the knee. The patient complains their right foot hurts, what are you going to
do?
Treat the pain
What are the symptoms
of compartment syndrome?
Numbness and tingling
What is
compartment syndrome?
It’s a lot of pressure, usually will be under a cast or a
splint.
If the patient develops lot of pressure (compartment syndrome) under the cast, what are they going to do?
They need to get to a place where they can take the cast
off quickly.
When you have prolonged
immobilization, what happens to your muscles?
Atrophy
Which of these is a priority assessment for someone with
a knee injury and why?
My knee aches.
My feet are cold.
My foot is swollen.
My toes are numb.[Toes
are numb because of nerve compression.]
On
a visit to the family physician, a client is diagnosed with a bunion on the
lateral side of the great toe, at the metatarsophalangeal joint. Which statement
should the nurse include in the teaching session?
a. Bunions are congenital and can't be prevented.
b. Bunions may result from wearing shoes that are too
big, causing friction when the shoes slip back and forth.
c. Some bunions
are congenital; others are caused by wearing shoes that are too short or
narrow.
d. Bunions are caused by a metabolic condition called
gout.
C- Bunions
may be congenital or may be acquired by wearing shoes that are too short or
narrow, which increases pressure on the bursa at the metatarsophalangeal joint.
Acquired bunions can be prevented. Wearing shoes that are too big may cause
other types of foot trauma but not bunions. Gout doesn't cause bunions.
Although a client with gout may have pain in the big toe, such pain doesn't result
from a bunion.
A
patient with a fractured left humerus reports dyspnea and chest pain. Pulse
oximetry is 88%. Temperature is 100.2 degrees Fahrenheit; heart rate is 110
beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects
the client is experiencing:
FAT Embolism
A client undergoes
hip-pinning surgery to treat an intertrochanteric fracture of the right hip.
The nurse should include which priority intervention in the postoperative care
plan?
a) Keeping a pillow between the client's legs at all times
b) Maintaining the client in semi-Fowler's position
c) Turning the client from side to side every 2 hours
d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift
a) Keeping a pillow between the client's legs at all times
b) Maintaining the client in semi-Fowler's position
c) Turning the client from side to side every 2 hours
d) Performing passive range-of-motion (ROM) exercises on the client's legs once each shift
Rationale:
After hip
pinning, the client must keep the affected leg abducted at all times; placing a
pillow between the legs reminds the client not to cross the legs and to keep
the leg abducted. Passive or active ROM exercises shouldn't be performed on the
affected leg during the postoperative period because this could damage the
operative site and cause hip dislocation. Most clients should be turned to the
unaffected side, not from side to side. After hip pinning, the client must
avoid acute flexion of the affected hip to prevent possible hip dislocation;
therefore, semi-Fowler's position should be avoided.
A patient returns
to the clinic 4 hours after being fitted for a cast of a fractured radius. He
states my arm hurts even more than when I broke it. General manipulation of the
fingers by the nurse causes excruciating pain. Which of the following interventions
by the nurse is the priority?
Notify the provider right away. Remove cast asap due to
compartmental syndrome.
A nurse is caring
for a patient with osteomyelitis following wound debridement. IV and antibiotics
have been administered for 7 days and the patient has been discharged with
continued care in a home setting. Which of the following statements can the
nurse include in the home care of osteomyelitis? What are they going to be
doing for about 3 months after discharge if the patient has osteomyelitis?
They will be prescribed IV antibiotics for 3 months. (have a home infnusion nurse come visit).
They will be prescribed IV antibiotics for 3 months. (have a home infnusion nurse come visit).
A
nurse is caring for a client who underwent a total hip replacement. What should
the nurse and other caregivers do to prevent dislocation of the new prosthesis?
a) Prevent internal rotation of the affected leg.
b) Keep the hip flexed by placing pillows under the client's knee.
c) Use measures other than turning to prevent pressure ulcers.
d) Keep the affected leg in a position of adduction.
a) Prevent internal rotation of the affected leg.
b) Keep the hip flexed by placing pillows under the client's knee.
c) Use measures other than turning to prevent pressure ulcers.
d) Keep the affected leg in a position of adduction.
Rationale: The nurse and other caregivers should
prevent internal rotation of the affected leg. However, external rotation and
abduction of the hip will help prevent dislocation of a new hip joint. Postoperative
total hip replacement clients may be turned onto the unaffected side. The hip
may be flexed slightly, but it shouldn't exceed 90 degrees. Maintenance of
flexion isn't necessary.
How do you assess motor response in a
comatose patient?
Eye not opening; 3 on Glasgow coma
scale. Nonverbal; 3 on Glasgow coma scale. Apply painful stimuli. Sternal rub.
Observe arms and legs. Score is based on what they do with their arms and legs.
Do not pinch the nipples, nailbeds, or
squeeze hands. If a patient responds to a verbal command before a physical,
shows a higher level of functioning.
The
nurse is providing care for a patient admitted to the hospital with a head
injury and who requires regular neurologic vital signs. Which of the following
assessments will be components of the patient's score on the Glasgow Coma Scale
(GCS) (select all that apply)?
a. Judgment
b. Eye opening
c. Abstract reasoning
d. Best verbal response
e. Best motor response
f. Cranial nerve function
a. Judgment
b. Eye opening
c. Abstract reasoning
d. Best verbal response
e. Best motor response
f. Cranial nerve function
To maintain airway
patency during a stroke in evolution, which nursing intervention is
appropriate?
A. Thicken all dietary liquids.
B. Restrict
dietary and parenteral fluids.
C. Place client in
supine position.
D. Have tracheal suction available at all
times.
Rationale: Because
of a potential loss of the gag reflex and potential altered level of
consciousness, the client should be kept in Fowler's or a semiprone position
with tracheal suction available at all times. Thickening dietary liquids isn't
done until the gag reflex returns or the stroke has evolved and the deficit can
be assessed. Unless heart failure is present, restricting fluids isn't
indicated
When preparing for
a patient with a suspected lumbar herniated nucleus pulposus for MRI. Which
nursing intervention should be done prior to the test? Ask the patient if they
have any metal implants.
Question the
client about allergy to iodine if using contrast. Ask if claustrophobic. Ask to
remove all jewelry and ask about body piercings. Do not bring the chart into
the room.
A
client is sitting in a chair and begins having a tonic-clonic (general) seizure.
The most appropriate nursing response is to:
carefully move him to a flat surface and
turn him on his side.
A patient has been admitted to Exacerbation of
multiple sclerosis (MS). What’s the priority of nursing care for a patient with
MS?
Pain & risk of
falls
Nurse is assessing
a patient with meningitis. What are the signs of meningitis?
Nuchal rigidity(neck
stiffness), terrible headache
A female client
with Guillain-Barré syndrome has paralysis affecting the respiratory muscles
and requires mechanical ventilation. When the client asks the nurse about the
paralysis, how should the nurse respond?
a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary."
b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss."
c. "It must be hard to accept the permanency of your paralysis."
d. "You'll first regain use of your legs and then your arms."
a. "You may have difficulty believing this, but the paralysis caused by this disease is temporary."
b. "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss."
c. "It must be hard to accept the permanency of your paralysis."
d. "You'll first regain use of your legs and then your arms."
A patient has an embolist
to Right carotid artery that causes the stroke, what kind of stroke do they
have?
Ischemic stroke; disrupted blood flow to the brain.
A nurse is teaching
a community class that those experiencing symptoms of ischemic stroke need to
enter the medical system early. The primary reason for this is which of the
following?
TPA
Thrombolytic therapy has a time window of only 3 hours.
What are contraindications
to TPA?
Hemmorahagic stroke, too long of a time frame(longer you
wait, less effective and more dangerous it is), bleeding disorder,
hypertension. If can’t get blood pressure under 185, we can’t administer TPA.
If blood sugar is
high after ischemic stroke what does
that increase the risk for? What does it do in the brain with high blood sugar?
happens to brain?
Increases swelling because metabolizing sugar in anaerobic
environment and products of anaerobic environment that interferes with lactic
acid, waste products and all the chemicals that rush to the site, causes more
swelling. Very important to control blood sugar after stroke from seizures.
Seizures increase metabolism.
High risk for
seizure after a stroke. What are some things you want to prevent after a
stroke?
High blood sugar, seizures, very low blood pressure, very
high blood pressure, high fever.
A patient with
Parkinson’s is having trouble getting enough nutrition in. What are some
nursing interventions?
High calories,
allow more time to eat, space out protein throughout the day.
How to position a
patient after a stroke?
Semi fowlers; Head 30 degree in neutral position to
prevent CSF flow
When administering
TPA, what is your priority assessment?
Monitor blood
pressure, signs of bleeding for hemorrhage. Heart rate would increase due to
the drop of blood pressure. Level of
consciousness would decrease. Perform frequent neuro assessment. Glasgow Scale can be done every 15 minutes
but you would do a more in depth neuro assessment. if there’s a change in glasgow
scale, it indicates irreversible neurological damage.
A nurse is
assessing a patient with a terminal illness and notices the patient is in
denial about the condition. Which of the following would be the most important
for the nurse to develop patient’s plan of care?
Seek help from help team members to address the patient’s
denial.
Explain to the patient that denial is not healthy
Correct the patient’s misconception about outcome,
treatment and goals
Accept the patient’s denial of the
situation.
Denial is the first stage of the process. As nurses, we know acceptance is important.
A patient has C-dif (Clostridium difficile ) related diarrhea and has been diagnosed with FVD(fluid volume deficit) . The nurse providing the care for the patient should anticipate which of the following?
Decrease level of bun
Increase level of potassium
Administration of hypertonic IV solution
Administration of
hypotonic or isotonic IV solution
Normal Blood PH Range : 7.35-7.45
Al[K]alosis; K-kickin the pH up >7.45
Al[K]alosis; K-kickin the pH up >7.45
Aci[D]osis;
D-slidin the pH DOWN <7 .35="" span="">
Respiratory
problem: CO2 is less
than 35mmHg(alkalosis)
CO2 greater than 45 mmHg(acidosis).
Metabolic problem: HCO3 is less than 22mEq/L (acidosis)
HCO3
greater than 26mEq/L(alkalosis).
If arrows are both in same direction=metabolic; if
opposite direction = respiratory
PH 7.47 =alkalosis
CO2 = 30 respiratory
Study abgs
A nurse is
caring for a post op patient of abdominal surgery, which of the following
nursing interventions should the nurse perform to prevent respiratory
complications?
Assist the client with the use of an incentive
spirometer. Mobilize as soon as possible. Assist the client with coughing and
deep breathing, provide a pillow or folded blanket so that the client can
splint as necessary for abdominal incision.
Do you inhale or exhale using an
incentive spirometere?
Inhale.
How often reposition
surgical patients?
At least every 2 hours
If you’re
administering moderate sedation for bronoschopy, what are you going to tell the
patient , how are they going to feel during the procedure?
Kind of awake but have amnesia with IV, NPO, won’t
remember much during procedure
After procedure: feel groggy, don’t drive.
If patient tells
you that their medicine makes them sick? How should you respond?
How does it make you sick? What do you mean? Tell me what
symptoms you have.
When giving Narcotic
pain meds for older adults, what should you keep in mind?
Need less meds, get confused, can get toxic easily(slow
liver & kidneys).
Where does gas
exchange occur in lung?
Aveolar membrane
Teaching for
obstructive sleep apnea. What are some lifestyle modifications? What should you
tell the patient?
Lose weight, no smoking, avoid alcohol, avoid hypnotic
meds, don’t take naps during the day can cause insomnia at night.
Before performing tracheal
suction, what should you do?
Hyperoxygenate and listen to lung sounds before and after
checking heart rate & stat o2
Patients with TB
get admitted to the hospital, what should we keep in mind?
TB- isolation room with
negative air pressure; use N95 mask
What’s the best
way to deliver medication when someone is having an acute asthma attack?
Give nebulizer
Teaching for COPD, what should you keep in mind?
Have rest periods,
stop smoking, increase calories, if eat too many carbs, can turn into sugar-CO2
levels increase and metabolize. Eat more of high fat, high protein diet.
Position for breathing better. Incentive spirometer. If cold and fever= infection. Inform them of
signs of respiratory infections and to seek help immediately.
With
Atherosclerosis can it cause angina?
Yes, it can. Narrowing cardiac muscles; as it narrow get
vasospasms. Plaques obstruct coronary artery, not veins! Athero means arteries.
How do kidneys
respond to hypertension to help normalize blood pressure?
Excrete sodium and
water.
If someone has
kidney failure, can’t regulate blood pressure like you should; what do you do?
Give ace inhibitors to people who have diabetes to prevent kidneys from getting
bad.
What are ways to
reduce blood pressure if you have been diagnosed with hypertension?
Exercise, diet,
decrease sodium, change position slowly when waking up, smoke cessation
What is the goal
for patient with coronary artery disease and has developed angina from the CAD?
Enhance myocardial
oxygenation;
Where does oxygen travel
to? Where does blood travel to?
Everywhere
You are taking
care of a patient who sudden looses consciousness and you can’t palpate
ceratoid pulse. What is priority action?
Get help and then initiate CPR (cardiopulmonary
resuscitation).
What is your high
priority, assessment for a patient with
heart failure?
Respiratory status due to fluid overloads leading to
pulmonary edema.
If patient has mechanical
valve replacement, take antibiotics before teeth cleaning. Why?
To prevent infection of the heart; valve.
If someone had peripheral
arterial disease, how would you improve circulation to their legs?
Keep legs in
dependent or neutral position.
In arterial flow,
why do you not elevate legs? Don’t get enough arterial blood flow.
In venous flow, why do you keep the head up? Venous blood
comes below to go up; prevent blood clot to the brain.
What are some early
interventions to prevent blood clots in surgical patient?
Early ambulation for venous blood flow(best answer)[,
then SCDs to help patient get out of bed and prevent clots]
A patient with NG
feeding feels full and uncomfortable, what should you do?
Stop feeding and assess placement and patency.
What is gastritis?
Inflammation of gastric mucosa (lining of the stomach)
What causes
gastritis?
Coffee , alcohol, smoking, spices, caffeine, NSAIDS,
aspirin, steroids, bacteria-viral, viruses,steroids
H.plyori loves to
live an environment that has ulcers. Breath testing for h. plyori
Patient has a BMI
for 32. What are they considered?
Obese. 30+ obese 35+ morbidly obese 40+ supra obese
A patient is
considering bariatric surgery. In the time leading up to the surgery, which of
the following nursing diagnoses would be the primary focus intervention?
Altered growth and development r/t obesity
Risk of injury r/t obesity
Knowledge deficit
r/t implications of bariatric surgery
When planning care
for a patient with small bowel obstruction, which should be a priority?
Maintain fluid balance
Which of the
following should be the first priority after a patient recovering from ostomy
surgery?
Stoma care
If you have Fluid retention
from acute glomerulonephritis, what sign and symptom do you expect to see?
High blood pressure, increase of edema of face and body.
What would your
priority assessment be for that patient, everyday?
Daily weights. [daily weigh-in]
What findings
support a diagnosis UTI infection?
WBC, positive Leukocytes
on dipstick, pyuria(pus)
What should you
teach the patient to do if they have kidney stones?
Strain all urine to check if stones are calcium or uric
acid
If patient is
taking Ibuprofen for pain, how do you instruct them to take it?
Take with food.
If patient is on
continuous bladder irrigation and starts complaining of severe spasms. They
just had cystourethroscopy, what should you do?
Check patency and irrigate blood clots to prevent blood clots
from going into the bladder.
Why do we advise young
adults to get HPV?
Prevent cervical cancer and prevent some long term complications
for men
Sign for
hyperglycemia:
3 P’s = polyuria, polyphagia, polydipsia [excessive
urination, excessive hunger, excessive, thirst]
If you’re teaching
a type 1 diabetic, what should you teach them regarding meals?
Don’t skip meals or insulin (take insulin just as
ordered). If diabetic is sick, their insulin needs increases.
Nursing Dx[diagnosis]
for diabetes insipidus:
FVD related to increased urinary output
A patient with Hyperthyroidism
is having trouble maintain weight and have a nursing diagnosis of “less than
body requirement; altered nutrition.” What are some interventions to help this?
Increase calories, small frequent meals
Your patient is
going to MRI, what are some things you are going to check?
Check pacemakers and hearing aids; allergies;
claustrophobic, implants, dentures, medications, patches,
What are the nursing
interventions following a lumbar puncture:
Lay down flat 3 hours, monitor site for swelling and
hematoma, increase fluid intake, finger stick immediately to check blood sugar.
What percent should your blood sugar be in the spinal
fluid? If lower what does it signify?
2/3(two-thirds). If lower
than 2/3, will signify infection.
