SE5l, Medical-Surgical Review curse PowerPoint.pdf
Medical-Surgical Nursing
Certification Review
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SE5l, Medical-Surgical Review curse PowerPoint.pdf
CMSRN Exam
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Given four times a year –
– Spring (usually May)
– Fall (usually October)
– AMSN Annual Convention
(usually September)
– Nursing 200x Symposium in the
Spring
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AMSN Nursing Practice Roles

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Helping Role 17% (32-36)
Teaching/coaching role 17% (32-36)
Diagnostic and Patient Monitoring Role
25% (38-42)
Administering and Monitoring
Therapeutic Intervention 25% (58-62)
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AMSN Nursing Practice Roles
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Effective Management of Rapidly
Changing Situations 10% (18-22)
Monitoring/Ensuring Quality Health
Care Practice 3% (4-7)
Organizational and Work-Role
Competencies 3% (4-7)
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Distribution Patient Problem
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GI – 19% (36-40)
Pulmonary – 19% (36-40)
Cardiovascular – 15% (28-32)
Diabetes/Other endocrine – 15% (28-32)
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Distribution Patient Problem
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Renal/GU-12%(22-29)
Musculoskeletal/Neuro – 11%
(20-24)
Hematological / Immune /
Integumentary – 9% (16-20)
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Preparing for the Test
Medsurg Nursing Certification
Board Requirements – CMSRN
credential
Minimum of 3,000 hours in Medsurg
nursing as a staff nurse, clinical nurse
specialist, clinical educator, faculty,
manager, or supervisor.
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Practice in medical-surgical nursing
for at least two full years of the past
five years
Registered Nurse
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Preparing for the Test
Contacting Medical- Surgical
Nursing Certification Board
MSNCB Home Office
East Holly Avenue, Box 56, Pitman, NJ
08071-0056
Phone: 856-256-2323 or Toll free 866877-2676
Fax: 856-589-7463 (fax)
E-mail: msncb@ajj.com
http://www.medsurgnurse.org
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Publications to review
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Scope and Standards for MedicalSurgical Nursing Practice
ANA Code for Nurses
Human Rights Guidelines for Nurses in
Clinical and other Research
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Preparing for the Test
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AMSN Core Curriculum for MedicalSurgical Nursing
Medical Surgical Nursing Review
Questions
Review Course
Examination Prep Guide
Your nursing experience
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Test Taking Tips
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Read questions all the way through
Eliminate obvious wrong answers
Take moment to relax occasionally
Have good reason to change answers
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Stress Reduction

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Review prior to exam, but don’t “cram”
especially the night before (raises
stress levels making it more difficult)
Take time during the exam to take deep
breaths and relax.
You will have 4 hours to take the exam
which has 200 questions – plenty of
time!
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A patient begins to experience a severe GI
bleed. The plan of care to meet the
patient’s fluid needs should include, as a
priority, planning for which of the following?
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A. Provision for skin care
B. Monitoring vital signs frequently
C. Decreasing PH of gastric fluids
D. Rapid infusion of IV blood and fluids
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To prevent complications on the third day
after an uncomplicated acute MI, the nurse
would implement which action?
A. Monitor the patient’s ability to perform
activities of daily living without shortness
of breath
B. Accompany the patient ambulating for a
short distance at least each shift
C. Apply anti-embolic hose to the legs
D. Give the patient a nitroglycerin sublingual
to prevent chest pain before all out of bed
activities
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A patient is having a seizure activity. What
should the nurse do during this activity?
A. Insert an oropharyngeal airway
B. Promote safety of body systems
C. Protect the patients head on a pillow
D. Observe the length and after effects of the
seizure
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A patient in acute renal failure developed
acute pulmonary edema. Which of the
following interventions would be
inappropriate to include in the patient’s
care?
A. Administration of oxygen at 3 L/min per
nasal cannula
B. Administration of morphine and
Furosemide (Lasix)
C. Place the patient in high Fowler’s position
D. Replace fluids with normal saline
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Fluids and Electrolytes
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Fluid
•Intracellular
–¾ Body water
• Extracellular
–¼ Body water
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Electrolytes
Same electrolytes in
intracellular space as
in extracellular space
Always measure
extracellular space
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Sodium
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
Necessary for protein synthesis
Fluid volume in extracellular spaces
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Hyponatremia

Dilutional – most common
–
Excessive fluid intake
 – Edema, confusion
 – Treatment – decrease fluid intake

• True
–
Fluid and sodium loss
 – Dry tissue
 – Treatment – replace both sodium and
water
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Hypernatremia

Most common, fluid loss without loss
of sodium
–
Dry tissue
 – Treatment – replace fluids

Increased sodium with diet rare – could
occur with full strength high protein
tube feeding
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Potassium
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Irritant at neuromuscular junction
Increased muscular irritability
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Hyperkalemia

Causes – cell wall destruction,
increased intake, renal failure

Symptoms – irritable muscles

Treatment – Kayexalate, calcium
gluconate, insulin
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Hypokalemia

• Increased loss of potassium
or increased fluid
 –Muscle
flaccidity
 – Treatment – potassium supplements
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
• IV
• Oral
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Calcium
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Sedative at the neuro level
Necessary for coagulation
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Hypercalcemia
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Increased intake, hyperparathyroidism
• Symptoms
–

Sedation
• Treatment
–
Decrease calcium intake
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Hypocalcemia
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Decreased calcium intake, increased
phosphate levels, renal disease
Hyperactive deep tendon reflexes
– Chvostek’s
– Trousseau’s
–Laryngospasm
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Phosphate

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Informal inverse relationship with
calcium
• Symptoms may be opposite of
calcium (hypophosphatemia looks like
hypercalcemia, etc)
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Magnesium

Hypermagnesemia
–Usually poor renal excretion
–Muscular depression
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Hypomagnesemia
 –Hyperactive
deep tendon reflexes
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Serum Osmolality
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• 2(Na) + BUN/5 + glucose/20 = 275-295
mOsm/l
• Quick and dirty 2(Na)
• Higher the number, dryer the patient
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IV Fluids

• Hypertonic = above 295 mOsm/L
–
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• Isotonic = 275 – 295 mOsm/L
–

D5LR, D5NS
NS, LR
• Hypotonic = below 275 mOsm/L
 –¼
NS
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A patient experiencing a sodium imbalance
must be assessed for which of the following
symptoms?
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A. Changes in level of consciousness
B. Irritability of skeletal muscles
C. Depression of deep tendon reflexes
D. Evidence of acid-base imbalances
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A patient who is severely dehydrated would
most likely be treated initially with which of the
following IV solutions?
A. Hypertonic
B. Isotonic
C. Hypotonic
D. Colloidal
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Which of the following assessment data are
consistent with hypovolemia?
A. Increased pulse and a swollen tongue
B. Neck vein distention and dry skin
C. Weight loss and thirst
D. Increased blood pressure and a fever
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Which of the following sets of signs and
symptoms would be exhibited by a patient with
a serum potassium of 6.8 mEq/L?
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A. Bradycardia and constipation
B. Confusion and muscle cramps
C. Paralytic ileus and paresthesias
D. Diarrhea and spastic paralysis
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Immune System
Leukocytes
A. Granulocytes
1. Neutrophils – first line of
defense against bacteria
2. Eosinophils –phagocytize
antigen-antibody complexes
3. Basophils- contain
histamine and heparin
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Immune System
B. Nongranulocytes
1) Monocytes – phagocytize
bacteria
2) Lymphocytes – provide
immunity against foreign
invaders including transplants
C. Immune Response
1) Humoral – B lymphocytes,
memory
2) Cellular – T lymphocytes,
foreign invaders
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Compromised
Immune System
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
Steroids
suppression of system
Chemotherapy
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Acquired Immune
Deficiency Syndrome
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In 2009
33.3 million people worldwide living
with AIDS
2.6 million new infections this year
Women and those 15-24 accounted for
50% of infections
Project that by 2012 100 million people
will be infected
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Transmission of AIDS
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Blood
Semen
Vaginal fluids
Breast milk
Transplacental ?
Transmitted even when asymptomatic
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Pathophysiology
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Retrovirus, part of the Lentivirius family
Infects CD4 lymphocytes
Carries genetic information on RNA into
the cell’s DNA
CD4 cells, necessary to immune function,
decrease in numbers in acute phase
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CD 4 Classification of AIDS
> 500 CD4 cells /micro L
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Category I:
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Category II: 200-400 CD4 cells/ micro L
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Category III:
< 200 CD4 cells/ micro L
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Clinical Classification of AIDS
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Clinical Category A= asymptomatic or
have persistent generalized
lymphadenopathy or symptoms of primary
HIV infection
Clinical category B= symptoms of immune
deficiency not serious enough to be AIDS
defining
Clinical Category C= AIDS-defining illness
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Treatment of AIDS
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Prevention
Optimal treatment includes combination of
at least 3 drugs, often referred to as
HAART
Reverse transcriptase inhibitors
Protease inhibitors
Fusion inhibitors
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Hematologic System
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Erythrocytes: 120 day life span
Requires erythropoietin from kidneys
(80%) and liver (20%)
Thrombocytes: 7.5 day life span, 1/3
sequestered in spleen. Increased blood
platelet level following splenectomy
a. Clotting cascade
Extrinsic
Intrinsic
Enzymes
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White blood cells
Neutrophils- first line of defense against
bacteria
 Immature
cells are Bands
Eosinophils- break down antigen/antibody
complex
Basophils- work to keep blood flowing
through micro-vascular system
Monocytes-effective bacterial macrophage
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Lymphocytes:
T-lymphocytes-react against foreign or
abnormal cells
B-lymphocytes- becomes antibodies when
exposed to something seen as a long term
threat
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Assessment
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
History
Objective information
 Physical
assessment
 Diagnostic studies
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Hematologic concerns
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Anemia
Blood loss, Hemolytic
Sickle cell
Iron deficiency
Pernicious
Disseminated Intravascular coagulation
Hodgkins
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Sam Andrew had just been diagnosed with
pernicious anemia following his gastric
resection. He asked how long he will need to
take the vitaminnB12. You tell him he’ll need to
continue:
A. Until his anemia is corrected
B. For the rest of his life
C. It depends on his physician’s assessment of
him
D. It’s different in everyone
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
A.
B.
C.
D.
Which of the following laboratory results
would be considered the most indicative of
DIC?
High platelet count
Elevated blood glucose
Increased bleeding times
Presence of fibrin degradation products
(FDP)
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Cardiovascular system
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Anatomy and Physiology
A. Heart: atria, ventricles, valves,
coronary circulation, cardiac,
conduction system
B. Cardiac Cycle: Systole, diastole
C. Peripheral vascular system:
Veins, arteries, arterioles, venioles,
capillaries
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 CO=HR
SV
 Stroke
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volume
 Preload
 Afterload
 Contractility
Heart Rate
Impact of the ANS
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Assessment:
Nursing History
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Past medical
Diet
Medication
Pain
Edema
Other
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Chest Pain
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
Description?
Location?
Does it radiate?
What causes it?
What causes it worse?
What makes it better?
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Physical Assessment


Inspection
–Edema, skin assessment, hair
growth
Palpation
–Peripheral pulses, PMI
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Heart sounds

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Normal
–S1
–S2
Abnormal
–S3 – lub DUB dub
–S4 – lub dub DUB
Murmurs
Friction rub
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Diagnostic studies
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Cardiac enzymes & proteins
–Troponins
–CPK-MB, myoglobin, troponins
–LDH
• Doppler ultrasound
• ECHO:TEE
• Thallium imaging
• Pericardial fluid analysis
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Diagnostic procedures
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Electrocardiogram
Electrophysiology
Echocardiography
Stress test
Doppler Ultrasound
Cardiac Catheterization
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Acute Coronary Syndromes (ACS)
Sudden Death
Stable Angina
Coronary
Arterial
Thrombosis
Non-ST-Elevation
MI
STElevation MI
Sudden Death
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ECG Changes Consistent with
ACS
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Anti- ischemic Options
Nitrates
Dilate blood vessels; relaxes and expands
artery, increasing blood flow
Morphine
Pain relief, Dilate blood vessels; relaxes and
expands artery, including blood flow
Beta blockers
ACE inhibitors
Calcium blockers
Slows pumping action of the heart, reduce
oxygen requirements
Dilate blood vessels, prevent fluid retention, and
ease the workload of the heart
Dilate blood vessels and reduce vascular
smooth-muscle contraction
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Antiplatelets and Antithrombin Agents
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Salicylates: Aspirin
ADP-receptor inhibitors: Clopidogrel
Glycoprotein(GP) Iib-IIIa receptor antagonists
Heparin-unfractionated heparin (UFH)
Low- Molecular weight heparins (LMWH) with
UA/NSTEMI indications
 Enoxaparin
 Dalteparin
Direct- acting Antithrombins
 Bivalirudin
 Argatrobran
 Lepirudin
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CV Conditions

CHF
 Diuretics,
ACE Inhibitors, Digitalis, Beta
Blockers
 BNP- Brain Naturetic Peptide
Hypertension
Highest Risk: African American males in
southeast United States
Weight loss- diet management; exercise,
Diuretics, Ace inhibitors, Beta blockers,
Angiotensin 2 receptor blockers
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CV conditions
Chronic Peripheral Circulatory Disease
 Arterial(
PAD-peripheral arterial disease):
Thrombolytics, antiplatelet aggregates,
revascularization-stents, arterioplasty,
bypass grafting
 Venous )PVD-peripheral venous disease):
elevation, wound prevention- assessmentmanagement, antiplatelet aggregates
 DVT: Heparin, LMWH, warfarin, labs:
PT/PTT/INR, D-dimer: SVC filter
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Which of the following complications would
likely to happen in a client receiving both a
calcium channel blocker and Lanoxin?
A.
B.
C.
D.
A change in the blood pressure
A decrease in the pulse rate
An increase in respiratory rate
Presence of a systolic murmur
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You are caring for a patient post MI, who
suddenly develops bradycardia and
hypotension. What is the likely cause?
A.
B.
C.
D.
Anxiety reaction
Cardiogenic shock
Medication overdose
Pulmonary edema
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Mr. Jones, just returning from a coronary
angiogram, develops bradycardia and a
narrowing pulse pressure. What is the
most likely cause?
 A. Cardiac tamponade
 B. Positional hypotension
 C. Myocardial infarction
 D. Anaphylactic shock
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Which of the following antihypertensive
should be avoided in a person with
diabetes?
A.
B.
C.
D.
Calcium channel blockers
Beta Blockers
ACE inhibitors
Nitrates
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Cancer

Uncontrolled growth of cells Due
to alteration in cell’s genes
 Immune system fails to destroy

Etiologic factors
 Chemicals
 Radiation
 Viruses
 Host-related
factors (tobacco use etc)
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Cancer Prevention






Age
Sex
Geographical
location
Racial or ethnic
origin
Familial tendency
Environmental

Lifestyle







Tobacco use
Diet
Alcohol
Occupational risks
Biological risks
Iatrogenic risks
Psychosocial
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Cancer screening and early
Detection



Early detection-attempt to diagnose at
a curable stage
Secondary prevention- to identify and treat
before disease is symptomatic thus halting
the disease
Health promotion requires consumer
involvement
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Therapeutic modalities




Surgery- for staging and treatment
Radiation-Side effects at site of radiation
Biologic therapy-alter host responses to
malignant cells
Chemotherapy- use of chemical agents
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Sue Lynn, a 50 year old diagnosed with an
autoimmune disorder, asks what that
means. You tell her:
1.
2.
3.
4.
The body’s ability to fight off infections has been
lost
She is experiencing an increase in one white
cell line
Her immune system is attacking her own body
cells
It is a short lived event which will make her
susceptible to bruising
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Which of the following sets of signs and
symptoms would be exhibited by a patient
with a serum potassium of 6.8 MEq/l?
A.
B.
C.
D.
Bradycardia and constipation
Confusion and muscle cramps
Paralytic ileus and paresthesia
Diarrhea and GI spasms
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A patient on your unit has been diagnosed
with AIDS. He expresses concerns for
your safety during his am care. You would
state:
1. let’s talk about what we can call body
substance isolation
2. You’re not bleeding so there’s no risk
3. It’s just part of my job, so I don’t think
about it.
4. It is scary, but you deserve my care
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Gastrointestinal system
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History and subjective assessment






Past history of GI disorders, Surgery, allergy,
lactose intolerance
Pain: location and r/t eating (full or empty
stomach)
Condition of teeth, tongue, oral mucosa
Dysphagia, belching, indigestion/heart burn,
nausea, vomiting
Weight loss, anorexia
Bowel movement frequency: Diarrhea,
constipation, laxative or enema use, presence of
dark stools or frank blood
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Objective Assessment




Inspection: Weight, spider angioma
on trunk, visible peristalsis, distention,
jaundice, icterus, ecchymosis or
petechiae
2. Auscultation: Bowel sounds
3. Palpation: Distention, as, cites,
hepatomegaly (firm ridge below the rib
cage.
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Diagnostic Studies


Lab tests: Electrolytes, LFTs, fecal
studies, analysis of gastric secretions
2. Radiography: Barium swallow,
barium enema, ultrasound, ERCP,
endoscopy, arteriography,
colonoscopy, nuclear medicine
imaging, CT scan
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Liver Disease

Cirrhosis- Hardening of the liver
 Medical
treatment-paracentesis, Transjugular
intra-hepatic Porto-systemic shunting (TIPS),
organ transplant
 Nursing interventions: Monitor for bleeding,
albumin, B vitamin levels, serum ammonia;
treat alcoholism (refer to rehab); teach
avoidance of hepatotoxic substances and use
of OTC meds; control ammonia related
encephalopathy-neomycin, lactulose, reduced
protein intake
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Esophageal varices


Medical treatment- Banding, sclerosing,
esophageal balloon tamponade,
transfusion of RBCs and clotting factors
(FFP)
Nursing interventions: monitor VS, S&S of
bleeding, PT, PTT, platelets, refer to
treatment for alcoholism
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Viral Hepatitis

Transmission
 A-
Fecal-oral, contaminated food
 B and C-Blood and body fluid

Medical treatment
 Hepatitis
A- supportive treatment, antdiarrhea and anti ememitics
 Hepatitis B gamma globulin, prevention with
hepatitis vaccine
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Hepatitis C initial infection is rarely treated
due to flu-like symptoms. Chronic state is
treated with antiviral therapy(ribavirin,
interferon injections) treatment similar to
cirrhosis when fibrosis develops
Nursing interventions
Teach hand washing and safe food handling,
safe sex, and recommend hepatitis A and
B vaccines
Monitor LFTs
Provide symptom management

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Bowel disease

Inflammatory bowel disease
 Medical
treatment- corticosteroids, azulvidine,
surgery( Colectomy/Colostomy or ileostomy)
 Nursing Interventions: monitor for S&S of
bleeding, test stools for occult blood, ostomy
care including diet teaching and address body
image
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Irritable bowel syndrome


Conventional medical treatment-imodium for
diarrhea; tegaserod maleate (Zelnorm) for
constipation; Alosetron hydrochloride ( Lotronex)
for diarrhea if conventional therapy is not
effective
Nursing intervention: Teach avoidance of the
individual’s triggers- large meals, wheat, rye,
barley, chocolate, milk products, alcohol, drinks
with caffeine; stress or emotional upsets. Teach
avoidance of overusing saline enemas and OTC
laxatives
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Bowel Disease
Obstruction


Medical treatment- NG tube, NPO, surgery
Nursing interventions: Monitor bowel
sounds, IV fluids, TPN, prepare for
diagnostic studies and surgery, treat N&V
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Colon Cancer


Medical Treatment- polypectomy, tumor
resection, colectomy/ostomy, chemo and
or radiation
Nursing Interventions: Bowel prep, ostomy
care, diet teaching, teach effects of chemo
and radiation
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Pancreatitis



Acute: NPO, fluids, possibly TPN.
Monitor glucose, acid balance, K, Ca,
Serum Co2, and amylase, lipase. Pain
management, I7O monitoring; be alert for
signs of hemorrhage, renal and respiratory
failure
Chronic: Pancreatic enzymes, teach low
fat diet, pain management
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Peptic Ulcer disease



Causes: Helicobter pylori has been found
to be the cause in most ulcers, 50% of the
population is colonized
NASAIDS are another significant factor for
gastric and duodenal ulcers in individuals
over 60
Corticosteroids cause erosion of gastric
mucosa
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Peptic Ulcer disease

Interventions:
 Assess
VS for signs of blood loss, assess
emesis for coffee ground appearance, and
test stools for occult blood
 During acute bleeding-NG tube, NPO, IV
fluids, Monitor Hgb & Hct, RBC transfusions
may be necessary
 Teach patient bland diet and medication
regimen
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Peptic Ulcer disease




Antibiotics
Histamine 2 blockers
proton pump inhibitors
Barrier medications
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Peritonitis



Nursing assessment
Monitor VS, WBCs, assess pain level,
assess firmness of the abdomen(rebound
tenderness)
Treatment:
 Antibiotics(
intraperitoneal in peritoneal
dialysis patient)
 Pain management
 Antiemetics PRN
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Mrs. Stone, 68, is on your unit with
ascites, as a complication of her liver
cancer. Her potassium level is elevated
and would most likely be related to:




A. Hypomagnesemia
B. Increased ammonia levels
C. Decreased albumin levels
D. Poor lymphatic system
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A client with advanced cirrhosis is
admitted to your unit from the E.D.
Which of the following orders should
you question?
A. Phenobarbital 100 mg HS
B. Neomycin sulfate 300 mg
Q6 x 4 doses
C. Low protein diet
D. Serum ammonia levels daily
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





Jerry Thomas, 22, is being treated with
dexamethasone (Decadron) for an
acute head injury caused by a skiing
accident. He is also receiving ranitidine
(Zantac) because of dexamethasone’s
propensity to:
A. Increase peristalsis
B. Erode gastric mucosa
C. Decrease secretions
D. Irritate mucous membranes
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Nutrition
Essential for adequate functioning of all
body systems





Calculating nutrition intake is based on kcalKilocalories
Carbohydrates 4 Kcal/gram
Protein
4 Kcal/gram
Fat
9 Kcal/gram
Enteral feeding is preferred over parenteral
feeding because it is important to maintaining a
functioning GI tract
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