MEDICAL SURGICAL NURSING

MEDICAL SURGICAL NURSING

RESPIRATORY SYSTEM:

• List 4 common symptoms of pneumonia the nurse might note on a physical

exam.

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

• State 4 nursing interventions for assisting the client to cough productively.
• Deep breathing, fluid intake increased to 3 liters/day, use humidity to loosen

secretions, suction airway to stimulate coughing.

• What symptoms of pneumonia might the nurse expect to see in an older client?
• Confusion, lethargy, anorexia, rapid respiratory rate.

• What should the O2 flow rate be for the client with COPD?
• 1-2 liters per nasal cannula, too much O2 may eliminate the COPD client’s stimulus

to breathe, a COPD client has hypoxic drive to breathe.

• How does the nurse prevent hypoxia during suctioning?
• Deliver 100% oxygen (hyperinflating) before and after each endotracheal suctioning.

• During mechanical ventilation, what are three major nursing intervention?
• Monitor client’s respiratory status and secure connections, establish a communication

mechanism with the client, keep airway clear by coughing/suctioning.

• When examining a client with emphysema, what physical findings is the nurse

likely to see?

• Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in

lung fields.

• What is the most common risk factor associated with lung cancer?
• Smoking

• Describe the pre-op nursing care for a client undergoing a laryngectomy.
• Involve family/client in manipulation of tracheostomy equipment before surgery, plan

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

• List 5 nursing interventions after chest tube insertion.
• Maintain a dry occlusive dressing to chest tube site at 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 on outside of drainage unit. Encourage use of incentive spirometry every 2 hours.

• What immediate action should the nurse take when a chest tube becomes

disconnected from a 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 an occlusive dressing and notify

physician STAT.

• What instructions should be given to a client following 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 TB when placed on respiratory

isolation?

• Mask for anyone entering room; private room; client must wear mask if leaving room.

• List 4 components of teaching for the client with tuberculosis.
• Cough into tissues and dispose immediately into special bags. Long-term need for

daily medication. Good handwashing technique. Report symptoms of deterioration, i.e., blood in secretions.

RENAL SYSTEM:

• Differentiate between acute renal failure and chronic renal failure.
• Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic

renal failure: irreversible, slow deterioration of kidney function characterized by increasing BUN and creatinine. Eventually dialysis is required.

• During the oliguric phase of renal failure, protein should be severely restricted.

What is the rationale for this restriction?

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

from protein catabolism.

• Identify 2 nursing interventions for the client on hemodialysis.
• Do NOT take BP or perform venipunctures on the arm with the A-V shunt, fistula, or

graft. Assess access site for thrill or bruit.

• What is the highest priority nursing diagnosis for clients in any type of renal

failure?

• Alteration in fluid and electrolyte balance.

• A client in renal failure asks why he is being given antacids. How should the

nurse reply?

• Calcium and aluminum antacids bind phosphates and help to keep phosphates from

being absorbed into blood stream thereby preventing rising phosphate levels, and must be taken with meals.

• List 4 essential elements of a teaching plan for clients with frequent urinary tract

infections.

• Fluid intake 3 liters/day; good handwashing; void every 2-3 hours during waking

hours; take all prescribed medications; wear cotton undergarments.

• What are the most important nursing interventions for clients with possible

renal calculi?

• Strain all urine is the MOST IMPORTANT intervention. Other interventions include

accurate intake and output documentation and administer analgesics as needed.

• What discharge instructions should be given to a client who has had urinary

calculi?

• Maintain high fluid intake 3-4 liters per day. Follow-up care (stones tend to recur).

Follow prescribed diet based in calculi content. Avoid supine position.

• Following transurethral resection of the prostate gland (TURP), hematuria

should subside by what post-op day?

• Fourth day

• After the urinary catheter is removed in the TURP client, what are 3 priority

nursing actions?

• Continued strict I&O; continued observations for hematuria; inform client burning

and frequency may last for a week.

• After kidney surgery, what are the primary assessments the nurse should make?
• Respiratory status (breathing is guarded because of pain); circulatory status (the

kidney is very vascular and excess bleeding can occur); pain assessment; urinary assessment most importantly, assessment of urinary output.

CARDIOVASCULAR SYSTEM:

• How do clients experiencing angina describe that pain?
• Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or

prolonged.

• Develop a teaching plan for the client taking nitroglycerin.
• Take at first sign of anginal pain. Take no more than 3, five minutes apart. Call for

emergency attention if no relief in 10 minutes.

• List the parameters of blood pressure for diagnosing hypertension.
• >140/90

• Differentiate between essential and secondary hypertension.
• Essential has no known cause while secondary hypertension develops in response to

an identifiable mechanism.

• Develop a teaching plan for the client taking 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 while initiating therapy.

• Describe intermittent claudication.
• Pain related to peripheral vascular disease occurring with exercise and disappearing

with rest.

• Describe the nurse’s discharge instructions to a client with venous peripheral

vascular disease.

• Keep extremities elevated when sitting, rest at first sign of pain, keep extremities

warm (but do NOT use heating pad), change position often, avoid crossing legs, wear unrestrictive clothing.

• What is often the underlying cause of abdominal aortic aneurysm?
• Atherosclerosis.

• What lab values should be monitored daily for the client with thrombophlebitis

who is undergoing anticoagulant therapy?

• PTT, PT, Hgb, and Hct, platelets.

• When do PVCs (premature ventricular contractions) present a grave danger?
• When they begin to occur more often than once in 10 beats, occur in 2s or 3s, land

near the T wave, or take on multiple configurations.

• Differentiate between the symptoms of left-sided cardiac failure and right-sided

cardiac failure.

• Left-sided failure results in pulmonary congestion due to back-up of circulation in the

left ventricle. Right-sided failure results in peripheral congestion due to back-up of circulation in the right ventricle.

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

• What condition increases the likelihood of digitalis toxicity occurring?
• When the client is hypokalemic (which is more common when diuretics and digitalis

preparations are given together).

• What life style changes can the client who is at risk for hypertension initiate to

reduce the likelihood of becoming hypertensive?

• Cease cigarette smoking if applicable, control weight, exercise regularly, and

maintain a low-fat/low-cholesterol diet.