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Med Surg Flashcards - Med Surg ATI study guide for
2019-2021 school year nursing students
Accounting (Everglades University)
Studocu is not sponsored or endorsed by any college or university
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MEDICAL SURGICAL NURSING
MEDICAL SURGICAL NURSING
RESPIRATORY SYSTEM:
List 4 common symptoms of pneumonia the Tachypnea, fever with chills, productive cough,
nurse might note on a physical exam.
bronchial breath sounds.
State 4 nursing interventions for assisting Deep breathing, fluid intake increased to 3 liters/
the client to cough productively.
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.
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MEDICAL SURGICAL NURSING
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,
Barrel chest, dry or productive cough,
what physical findings is the nurse likely to decreased breath sounds, dyspnea, crackles in
see?
lung fields.
What is the most common risk factor
associated with lung cancer?
Smoking
Describe the pre-op nursing care for a client
Involve family/client in manipulation of
undergoing a laryngectomy.
tracheostomy equipment before surgery, plan
acceptable communication method, refer to
speech pathologist, discuss rehabilitation
program.
List 5 nursing interventions after chest tube Maintain a dry occlusive dressing to chest tube
insertion.
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.
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MEDICAL SURGICAL NURSING
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.
fi
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MEDICAL SURGICAL NURSING
Differentiate between acute renal failure and
Acute renal failure: often reversible, abrupt
chronic renal failure.
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, Toxic metabolites that accumulate in the blood
protein should be severely restricted. What
(urea, creatinine) are derived mainly from
is the rationale for this restriction?
protein catabolism.
Identify 2 nursing interventions for the client Do NOT take BP or perform venipunctures on
on hemodialysis.
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
Calcium and aluminum antacids bind
given antacids. How should the nurse reply? phosphates and help to keep phosphates from
being absorbed into blood stream thereby
preventing rising phosphate levels, and must
be taken with meals.
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MEDICAL SURGICAL NURSING
List 4 essential elements of a teaching plan Fluid intake 3 liters/day; good handwashing;
for clients with frequent urinary tract
void every 2-3 hours during waking hours; take
infections.
all prescribed medications; wear cotton
undergarments.
What are the most important nursing
Strain all urine is the MOST IMPORTANT
interventions for clients with possible renal
intervention. Other interventions include
calculi?
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.
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MEDICAL SURGICAL NURSING
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
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MEDICAL SURGICAL NURSING
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 Keep extremities elevated when sitting, rest at
to a client with venous peripheral vascular first sign of pain, keep extremities warm (but do
disease.
NOT use heating pad), change position often,
avoid crossing legs, wear unrestrictive clothing.
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MEDICAL SURGICAL NURSING
What is often the underlying cause of
abdominal aortic aneurysm?
Atherosclerosis.
What lab values should be monitored daily PTT, PT, Hgb, and Hct, platelets.
for the client with thrombophlebitis who is
undergoing anticoagulant therapy?
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- Left-sided failure results in pulmonary
sided cardiac failure and right-sided
congestion due to back-up of circulation in the
cardiac failure.
left ventricle. Right-sided failure results in
peripheral congestion due to back-up of
circulation in the right ventricle.
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MEDICAL SURGICAL NURSING
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 Cease cigarette smoking if applicable, control
is at risk for hypertension initiate to reduce weight, exercise regularly, and maintain a lowthe likelihood of becoming hypertensive? fat/low-cholesterol diet.
What immediate actions should the nurse
Place the client on immediate strict bedrest to lower
implement when a client is having a myocardial oxygen demands of heart, administer oxygen by
infarction?
nasal cannula at 2-5 L/min., take measures to
alleviate pain and anxiety (administer prn pain
medications and anti-anxiety medications).
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MEDICAL SURGICAL NURSING
What symptoms should the nurse expect to Dry mouth and thirst, drowsiness and lethargy,
find in the client with hypokalemia?
muscle weakness and aches, and tachycardia.
Bradycardia is defined as a heart rate
bradycardia 60 bpm; tachycardia 100 bpm
below ___ BPM. Tachycardia is defined as
a heart rate above ___ BPM.
What precautions should clients with valve Take prophylactic antibiotics.
disease take prior to invasive procedures
or dental work?
GASTROINTESTINAL SYSTEM:
List 4 nursing interventions for the client
with a hiatal hernia.
Sit up while eating and one hour after eating.
Eat small, frequent meals. Eliminate foods that
are problematic.
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MEDICAL SURGICAL NURSING
List 3 categories of medications used in the
treatment of peptic ulcer disease.
Antacids, H2 receptor-blockers, mucosal
healing agents, proton pump inhibitors.
List the symptoms of upper and lower
gastrointestinal bleeding.
Upper GI: melena, hematemesis, tarry stools.
Lower GI: bloddy stools, tarry stools. Similar:
tarry stools.
What bowel sound disruptions occur with an
intestinal obstruction?
Early mechanical obstruction: high-pitched
sounds; late mechanical obstruction:
diminished or absent bowel sounds.
List 4 nursing interventions for post-op care Irrigate daily at same time; use warm water for
of the client with a colostomy.
irrigations; wash around stoma with mild soap/
water after each colostomy bag change; pouch
opening should extend at least 1/8 inch around
the stoma.
List the common clinical manifestations of Sclera-icteric (yellow sclera), dark urine, chalky
jaundice.
or clay-colored stools
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MEDICAL SURGICAL NURSING
What are the common food intolerances for
clients with cholelithiasis?
Fried/spicy or fatty foods.
List 5 symptoms indicative of colon cancer. Rectal bleeding, change in bowel habits, sense
of incomplete evacuation, abdominal pain with
nausea, weight loss.
In a client with cirrhosis, it is imperative to Avoid injectons, use small bore needles for IV
prevent further bleeding and observe for
insertion, maintain pressure for 5 minutes on
bleeding tendencies. List 6 relevant nursing all venipuncture sites, use electric razor, use
interventions.
soft-bristle toothbrush 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 with cirrhosis?
Diarrhea.
List 4 groups who have a high risk of
contracting hepatitis.
Homosexual males, IV drug users, recent ear
piercing or tattooing, and health care workers.
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How should the nurse administer pancreatic
enzymes?
Give with meals or snacks. Powder forms
should be mixed with fruit juices.
ENDOCRINE SYSTEM:
What diagnostic test is used to determine
thyroid activity?
T3 and T4
What condition results from all treatments
for hyperthyroidism?
Hypothyroidism, requiring thyroid replacement
State 3 symptoms of hyperthyroidism and 3 Hyperthyroidism: weight loss, heat intolerance,
symptoms of hypothyroidism.
diarrhea. Hypothyroidism: fatigue, cold
intolerance, weight gain.
List 5 important teaching aspects for clients
Continue medication until weaning plan is
who are beginning corticosteroid therapy. begun by physician, monitor serum potassium,
glucose, and sodium frequently; weigh daily,
and report gain of >5lbs./wk; monitor BP and
pulse closely; teach symptoms of Cushing’s
syndrome
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Describe the physical appearance of clients
who are Cushinoid.
Moon face, obesity in trunk, buffalo hump in
back, muscle atrophy, and thin skin.
Which type of diabetic always requires
insulin replacement?
Type I, Insulin-dependent diabetes mellitus
(IDDM)
What type of diabetic sometimes requires
no medication?
Type II, Non-insulin dependent diabetes
mellitus (NIDDM)
List 5 symptoms of hyperglycemia.
Polydipsia, polyuria, polyphagia, weakness,
weight loss
List 5 symptoms of hypoglycemia.
Hunger, lethargy, confusion, tremors or shakes,
sweating
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Name the necessary elements to include in
teaching the new diabetic.
Teach the underlying pathophysiology of the
disease, its management/treatment regime,
meal planning, exercise program, insulin
administration, sick-day management,
symptoms of hyperglycemia (not enough
insulin)
In less than ten steps, describe the method
for drawing up a mixed dose of insulin
(regular with NPH).
Identify the prescribed dose/type of insulin per
physician order; store unopened insulin in
refrigerator. If opened, may be kept at room
temperature for up to 3 months. Draw up
regular insulin FIRST. Rotate injection sites.
May reuse syringe by recapping and storing in
refrigerator.
Identify the peak action time of the following
types of insulin: rapid-acting regular insulin,
intermediate-acting, long-acting.
Rapid-acting regular insulin: 2-4 hrs. Immediateacting: 6-12 hrs. Long-acting: 14-20 hrs.
When preparing the diabetic for discharge, Stress and stress hormones usually increase
the nurse teaches the client the relationship glucose production and increase insulin need;
between stress, exercise, bedtime snacking, exercise can increase the chance for an insulin
and glucose balance. State the relationship reaction, therefore, the client should always
between each of these.
have a sugar snack available when exercising
(to treat hypoglycemia); bedtime snacking can
prevent insulin reactions while waiting for longacting insulin to peak.
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MEDICAL SURGICAL NURSING
When making rounds at night, the nurse
notes that an insulin-dependent client is
complaining of a headache, slight nausea,
and minimal trembling. The client’s hand is
cool and moist. What is the client most
likely experiencing?
Hypoglycemia/insulin reaction.
Identify 5 foot-care interventions that
should be taught to the diabetic client.
Check feet daily & report any breaks, sores, or
blisters to health care provider, wear well-fitting
shoes; never go barefoot or wear sandals,
never personally remove corns or calluses, cut
or file nails straight across; wash daily with mild
soap & warm water.
MUSCULOSKELETAL SYSTEM:
Differentiate between rheumatoid arthritis
and degenerative joint disease in terms of
joint involvement.
Rheumatoid arthritis occurs bilaterally.
Degenerative joint disease occurs
asymmetrically.
Identify the categories of drugs commonly
used to treat arthritis.
NSAIDs (nonsteroidal anti-inflammatory drugs)
of which salicylates are the cornerstones (used
when arthritic symptoms are severe).
Identify pain relief interventions for clients
with arthritis.
Warm, moist heat (compresses, baths,
showers), diversionary activities (imaging,
distraction, self-hypnosis, biofeedback), and
medications.
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What measures should the nurse encourage Estrogen replacement after menopause, high
female clients to take to prevent
calcium and vitamin D intake beginning in early
osteoporosis?
adulthood, calcium supplements after
menopause, and weight-bearing exercise.
What are the common side effects of
salicylates?
GI irritation, tinnitus, thrombocytopenia, mild
liver enzyme elevation.
What is the priority nursing intervention
used with clients taking NSAIDs?
Administer or teach client to take drugs with
food or milk.
List 3 of the most common joints that are
replaced.
Hip, knee, finger.
Describe post-op stump care (after
amputation) for the 1st 48 hours.
Elevate stump first 24 hours. Do not elevate
stump after 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 is
experiencing phantom pain after
amputation.
Be aware that phantom pain is real and will
eventually disappear. Administer pain
medication; phantom pain responds to
medication.
A nurse discovers that a client who is in
traction for a long bone fracture has a slight
fever, is short of breath, and is restless.
What does the client most likely have?
Fat embolism, which is characterized by
hypoxemia, respiratory distress, irritability,
restlessness, fever and petechiae.
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What are the immediate nursing actions if Notify physician STAT, draw blood gas results,
fat embolization is suspected in a fracture/
assist with endotracheal intubation and
orthopedic client?
treatment of respiratory failure.
List 3 problems associated with immobility.
Venous thrombosis, urinary calculi, skin
integrity problems.
List 3 nursing interventions for the
prevention of thromboembolism 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.
NEUROSENSORY/NEUROLOGICAL SYSTEMS:
What are the classifications of the
commonly prescribed eye drops for
glaucoma?
Parasympathominetics for pupillary
constriction. Beta-adrenergic receptor-blocking
agents to inhibit formation of aqueous humor.
Carbonic anhydrase inhibitors to reduce
aqueous humor production, and prostaglandin
agonists to increase aqueous humor outflow.
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MEDICAL SURGICAL NURSING
Identify 2 types of hearing loss.
Conductive (transmission of sound to inner ear
is blocked) and sensorineural (damage to 8th
cranial nerve)
Write 4 nursing interventions for the care of Care of the blind: announce presence clearly,
the blind person and 4 nursing
call by name, orient carefully to surroundings,
interventions for the care of the deaf person. guide by walking in front of client with his/her
hand in your elbow. Care of deaf: reduce
distraction before beginning conversation, look
and listen to client, give client full attention if
they are a lip reader, face client directly.
In your own words describe the Glasgow
Coma Scale.
An objective assessment of the level of
consciousness based on a score of 3 to 15,
with scores of 7 or less indicative of coma.
List 4 nursing diagnoses for the comatose
client in order of priority.
Ineffective breathing pattern, ineffective airway
clearance, impaired gas exchange, and
decreased cardiac output.
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State 4 independent nursing interventions Position for maximum ventilation (prone or
to maintain adequate respirations, airway,
semi-prone and slightly to one side), insert
and oxygenation in the unconscious client. airway if tongue obstructing; suction airway
efficiently, monitor arterial pO2 and pCO2 and
hyperventilate with 100% oxygen before
suctioning.
Who is at risk for cerebral vascular
accidents?
Persons with history of hypertension, previous
TIAs, cardiac disease (atrial flutter/fibrillation),
diabetes, oral contraceptive use, and the
elderly.
Complications of immobility include the
potential for thrombus development. State
3 nursing interventions to prevent thrombi.
Frequent range of motion exercises, frequent
(q2h) position changes, and avoidance of
positions which decrease venous return.
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MEDICAL SURGICAL NURSING
List 4 rationales for the appearance of
restlessness in the unconscious client.
Anoxia, distended bladder, covert bleeding, or
a return to consciousness
What nursing interventions prevent corneal Irrigation of eyes PRN with sterile prescribed
drying in a comatose client?
solution, application of opthalmic ointment q8h,
close assessment for corneal ulceration/drying.
When a comatose client on IV
hyperalimentation begin to receive tube
feedings instead?
When peristalsis resumes as evidenced by
active bowel sounds, passage of flatus or
bowel movement.
What is the most important principle in a
bowel management program for a
neurologic client?
Establishment of REGULARITY
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Define cerebral vascular accident.
A disruption of blood supply to a part of the brain,
which results in sudden loss of brain function.
A client with a diagnosis of CVA presents
with symptoms of aphasia, right
hemiparesis, but no memory or hearing
deficit. In what hemisphere has the client
suffered a lesion?
Left
What are the symptoms of spinal shock?
Hypotension, bladder and bowel distention,
total paralysis, lack of sensation below lesion.
What are the symptoms of autonomic
dysreflexia?
Hypertension, bladder and bowel distention,
exaggerated autonomic responses, headache,
sweating, goose bumps, and bradycardia
What is the most important indicator of
increased ICP?
A change in the level of responsiveness
M
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What vital sign changes are indicative of
increased ICP?
Increased BP, widening pulse pressure,
increased or decreased pulse, respiratory
irregularities and temperature increase.
A neighbor calls the neighborhood nurse
stating that he was knocked hard to the
floor by his very hyperactive dog. He is
wondering what symptoms would indicate
the need to visit an emergency room. What
should the nurse tell him to do?
Call his physician now and inform him/her of
the fall. Symptoms needing medical attention
would include vertigo, confusion or any subtle
behavioral change, headache, vomiting, ataxia
(imbalance), or seizure.
What activities and situations should be
avoided that increase ICP?
Change in bed position, extreme hip flexion,
endotracheal suctioning, compression of
jugular veins, coughing, vomiting, or straining
of any kind.
How do Hyperosmotic agents (osmotic
Dehydrate the brain and reduce cerebral
diuretics) used to treat intracranial pressure edema by holding water in the renal tubules to
act?
prevent reabsorption, and by drawing fluid from
the extravascular spaces into the plasma.
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Why should narcotics be avoided in clients Narcotics mask the level of responsiveness as
with neurologic impairment?
well as pupillary response.
Headache and vomiting are symptoms of
many disorders. What characteristics of
these symptoms would alert the nurse to
refer a client to a neurologist?
Headache which is more severe upon
awakening and vomiting not associated with
nausea are symptoms of a brain tumor.
How should the head of the bed be
Infratentorial – FLAT; Supratentorial – elevated
positioned for post-craniotomy clients with
infratentorial lesions?
Is multiple sclerosis thought to occur
because of an autoimmune process?
YES
Is paralysis always a consequence of spinal NO
cord injury?
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What types of drugs are used in the
treatment of myasthenia gravis?
Anticholinesterase drugs, which inhibit the
action of cholinesterase at the nerve endings to
promote the accumulation of acetylcholine at
receptor sires, which should improve neuronal
transmission to muscles.
HEMATOLOGY/ONCOLOGY:
List 3 potential causes of anemia.
Diet lacking in iron, folate and/or vitamin B12;
use of salicylates, thiazides, diuretics; exposure
to toxic agents such as lead or insecticides.
Write 2 nursing diagnoses for the client
suffering from anemia.
Activity intolerance and altered tissue perfusion.
What is the only intravenous fluid
compatible with blood products?
Normal saline
What actions should the nurse take if a
hemolytic transfusion reaction occurs?
Turn off transfusion. Take temperature. Send
blood being transfused to lab. Obtain urine
sample. Keep vein patent with normal saline.
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List 3 interventions for clients with a
tendency to bleed.
Use a soft toothbrush, avoid salicylates, do not
use suppositories.
Identify 2 sites, which should be assessed
for infection in immunosuppressed clients.
Oral cavity and genital area.
Name 3 food sources of vitamin b12.
Glandular meats (liver), milk, green leafy
vegetables.
Describe care of invasive catheters and
lines.
Use strict aseptic technique. Change dressings
2 to 3 times/week or when soiled. Use caution
when piggybacking drugs, check purpose of
line and drug to be infused. Use lines for
obtaining blood samples to avoid “sticking”
client when possible.
List 3 safety precautions for the
administration of antineoplastic
chemotherapy.
Double check order with another nurse. Check
for blood return prior to administration to
ensure that medication does not go into tissue.
Use a new IV site daily for peripheral
chemotherapy. Wear gloves when handling
the drugs, and dispose of waste in special
containers to avoid contact with toxic
substances.
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Describe the use of Leucovorin.
Leucovorin is used as an antidote with
methotrexate to prevent toxic reactions.
Describe the method of collecting the
Collection of trough: draw blood 30 minutes
trough and peak blood levels of antibiotics. prior to administration of antibiotic. Collection
of peak: draw blood 30 minutes after
administration of antibiotic.
What is the characteristic cell found in
Hodgkin’s disease?
Reed-Sternberg
List 4 nursing interventions for care of the
client with Hodgkin’s disease.
Protect from infection. Observe for anemia.
Encourage high-nutrient foods. Provide
emotional support to client and family.
List 4 topics you would cover when
teaching an immunosuppressed client
about infection control.
Handwashing technique. Avoid infected
persons. Avoid crowds. Maintain daily hygiene
to prevent spread of microorganisms.
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What are the indications for a hysterectomy Severe menorrhagia leading to anemia, severe
in the client who has fibromas?
dysmenorrhea requiring narcotic analgesics,
severe uterine enlargement causing pressure
on other organs, severe low back and pelvic
pain.
List the symptoms and conditions
associated with cystocele.
Symptoms include incontinence/stress
incontinence, urinary retention, and recurrent
bladder infections. Conditions associated with
cystocele include multiparity, trauma in
childbirth, and aging.
What are the most important nursing
interventions for the postoperative client
who has had a hysterectomy with an A&P
repair?
Avoid rectal temps and/or rectal manipulation;
manage pain; and encourage early ambulation.
Describe the priority nursing care for the
client who has had radiation implants.
Do not permit pregnant visitors or pregnant
caretakers in room. Discourage visits by small
children. Confine client to room. Nurse must
wear radiation badge. Nurse limits time in
room. Keep supplies and equipment within
client’s reach.
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What screening tool is used to detect
cervical cancer? What are the American
Cancer Society’s recommendations for
women ages 30 to 70 with three consecutive
normal results?
Pap smear. Women ages 30 to 70 with 3
consecutive normal results may have pap
smear every 2 to 3 years.
Cite 2 nursing diagnoses for a client
undergoing a hysterectomy for cervical
cancer.
Altered body image related to uterine removal.
Pain related to postoperative incision.
What are the 3 most important tools for
Breast self-exam monthly; mammogram
early detection of breast cancer? How often baseline at age 35 followed by exams every 1
should these tools be used?
to 2 years in 40s and every year after age 50;
physical examination by a professional skilled
in examination of the breast.
Describe 3 nursing interventions to help
decrease edema post mastectomy.
Position arm on operative side on pillow. Avoid
BP measurements, injections, or venipunctures
in operative arm. Encourage hand activity and
use.
Name 3 priorities to include in a discharge
plan for the client who has had a
mastectomy.
Arrange for Reach-to-Recovery visit. Discuss
the grief process with the client. Have
physician discuss with the client the
reconstruction options.
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What is the most common cause of
nongonococcal urethritis?
Chlamydia trachomatis
What is the causative agent for syphilis?
Treponema pallidum (spirochete bacteria)
Malodorous, frothy, greenish-yellow vaginal
discharge is characteristic of which STD?
Trichomonas vaginalis
Which STD is characterized by remissions
and exacerbations in both males and
females?
Herpes Simplex Type II
Outline a teaching plan for the client with an
STD.
Signs and symptoms of STD. Mode of
transmission. Avoid sex while infected.
Provide concise written instructions regarding
treatment and request a return verbalization to
ensure the client understands. Teach “safer
sex” practices.
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List 4 categories of burns.
Thermal, radiation, chemical, electrical
Burn depth is a measure of severity. Describe
the characteristics of superficial partialthickness, deep partial-thickness, and fullthickness burns.
Superficial partial-thickness: 1st degree = pink to red
skin (i.e., sunburn), slight edema, and pain relieved
by cooling. Deep partial-thickness: 2nd degree =
destruction of epidermis and upper layers of dermis;
white or red, very edematous, sensitive to touch and
cold air, hair does not pull out easily. Full-thickness:
3rd degree = total destruction of dermis and
epidermis; reddened areas do not blanch with
pressure, not painful, inelastic, waxy white skin to
brown, leathery eschar.
Describe fluid management in the emergent
phase, acute phase, and rehabilitation phase of
the burned client.
Stage I (Emergent phase): Replacement of fluids is
titrated to urine output. Stage II (Acute phase):
Maintain patent infusion site in case supplemental
IV fluids are needed; heparin lock is helpful; may
use colloids. Stage III (Rehabilitation phase): No
extra fluids needed, but high-protein drinks are
recommended.
Describe pain management of the burned client.
Administer pain medication, especially prior to
dressing wound (usually Morphine 10 mg). Teach
distraction/relaxation techniques. Teach use of
guided imagery.
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Outline admission care of the burned client.
Provide a patent airway as intubation may be
necessary. Determine baseline data. Initiate fluid
and electrolyte therapy. Administer pain
medication. Determine depth and extent of burn.
Administer tetanus toxoid. Insert NG tube.
Nutritional status is a major concern when
caring for a burned client. List 3 specific dietary
interventions used with burned clients.
High-calorie, high-protein, high-carbohydrate diet.
Medications with juice or milk. NO “free” water.
Tube feeding at night. Maintain accurate, daily
calorie counts. Weigh client daily.
Describe the method of extinguishing each of
the following burns: thermal, chemical and
electrical.
Thermal: remove clothing, immerse in tepid water.
Chemical: flush with water or saline. Electrical:
separate client from electrical source.
List 4 signs of an inhalation burn.
Singed nasal hairs, circumoral burns; sooty or
bloody sputum, hoarseness, and pulmonary signs
including: assymetry of respirations, rales or
wheezing.
Why is the burned client allowed NO “free”
water?
Water may interfere with electrolyte balance. Client
needs to ingest food products with highest biological
value.
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Describe an autograft.
Use of client’s own skin for grafting.
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