MEDICAL SURGICAL NURSING
FLASH CARDS
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.
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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.
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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.
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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.
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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.
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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.
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Differentiate between the symptoms of leftsided 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.
What immediate actions should the nurse
implement when a client is having a
myocardial infarction?
Place the client on immediate strict bedrest to lower
oxygen demands of heart, administer oxygen by 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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What symptoms should the nurse expect
to find in the client with hypokalemia?
Dry mouth and thirst, drowsiness and lethargy, muscle
weakness and aches, and tachycardia.
Bradycardia is defined as a heart rate
below ___ BPM. Tachycardia is defined as
a heart rate above ___ BPM.
bradycardia 60 bpm; tachycardia 100 bpm
What precautions should clients with valve
disease take prior to invasive procedures
or dental work?
Take prophylactic antibiotics.
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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.
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 of the
client with a colostomy.
Irrigate daily at same time; use warm water for
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
jaundice
Sclera-icteric (yellow sclera), dark urine, chalky or
clay-colored stools.
What are the common food intolerances for
clients 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 of
incomplete evacuation, abdominal pain with nausea,
weight loss.
In a client with cirrhosis, it is imperative to
prevent further bleeding and observe for bleeding
tendencies. List 6 relevant nursing interventions.
Avoid injectons, use small bore needles for IV
insertion, maintain pressure for 5 minutes on all
venipuncture sites, use electric razor, use 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.
How should the nurse administer pancreatic
enzymes?
Give with meals or snacks. Powder forms should be
mixed with fruit juices
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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
symptoms of hypothyroidism.
Hyperthyroidism: weight loss, heat intolerance,
diarrhea. Hypothyroidism: fatigue, cold intolerance,
weight gain.
List 5 important teaching aspects for clients who
are beginning corticosteroid therapy.
Continue medication until weaning plan is 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
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 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
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.
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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, the
nurse teaches the client the relationship between
stress, exercise, bedtime snacking, and glucose
balance. State the relationship between each of
these.
Stress and stress hormones usually increase glucose
production 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); bedtime
snacking can prevent insulin reactions while waiting
for long-acting insulin to peak.
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.
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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, selfhypnosis, biofeedback), and medications.
What measures should the nurse encourage
female clients to take to prevent osteoporosis?
Estrogen replacement after menopause, high calcium
and vitamin D intake beginning in early adulthood,
calcium supplements after menopause, and weightbearing 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
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 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.
What are the immediate nursing actions if fat
embolization is suspected in a fracture/orthopedic
client?
Notify physician STAT, draw blood gas results, assist
with endotracheal intubation and 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.
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