Medical Surgical nursing

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  1. List 4 common symptoms of pneumonia the
    nurse might note on a physical exam.

    Tachypnea, fever with chills, productive cough, bronchial breath sounds.
  2. What symptoms of pneumonia might the
    nurse expect to see in an older client?
    Confusion, lethargy, anorexia, rapid respiratory rate.
  3. 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.
  4. How does the nurse prevent hypoxia during
    Deliver 100% oxygen (hyperinflating) before and after each endotracheal suctioning.
  5. During mechanical ventilation, what are
    three major nursing intervention?
    Monitor client’s respiratory status and secureconnections, establish a communication mechanism with the client, keep airway clear bycoughing/suctioning
  6. When examining a client with emphysema,
    what physical findings is the nurse likely to
    Barrel chest, dry or productive cough,decreased breath sounds, dyspnea, crackles in lung fields.
  7. What is the most common risk factor
    associated with lung cancer?
  8. 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.
  9. List 5 nursing interventions after chest tube
    • 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.
  10. 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
    Place end in container of sterile water. Apply an occlusive dressing and notify physician STAT.
  11. 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.
  12. What precautions are required for clients
    with TB when placed on respiratory
    Mask for anyone entering room; private room; client must wear mask if leaving room.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. What is the highest priority nursing
    diagnosis for clients in any type of renal
    Alteration in fluid and electrolyte balance.
  18. 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.
  19. List 4 essential elements of a teaching plan
    for clients with frequent urinary tract
    Fluid intake 3 liters/day; good handwashing; void every 2-3 hours during waking hours; take all prescribed medications; wear cotton undergarments.
  20. What are the most important nursing
    interventions for clients with possible renal
    Strain all urine is the MOST IMPORTANT intervention. Other interventions include accurate intake and output documentation and administer analgesics as needed.
  21. What discharge instructions should be
    given to a client who has had urinary
    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.
  22. Following transurethral resection of the
    prostate gland (TURP), hematuria should
    subside by what post-op day?
    Fourth day
  23. After the urinary catheter is removed in the
    TURP client, what are 3 priority nursing
    Continued strict I&O; continued observations for hematuria; inform client burning and frequency may last for a week.
  24. 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.
  25. How do clients experiencing angina
    describe that pain?
    Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged.
  26. 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.
  27. List the parameters of blood pressure for
    diagnosing hypertension.
  28. Differentiate between essential and
    secondary hypertension.
    Essential has no known cause while secondary hypertension develops in response to an identifiable mechanism.
  29. Develop a teaching plan for the client taking
    antihypertensive medications.
    Explain how and when to take med, reason formed, necessary of compliance, need for follow-up visits while on med, need for certain lab tests, vital sign parameters while initiating therapy.
  30. Describe intermittent claudication.
    Pain related to peripheral vascular disease occurring with exercise and disappearing with rest.
  31. Describe the nurse’s discharge instructions
    to a client with venous peripheral vascular
    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.
  32. What is often the underlying cause of
    abdominal aortic aneurysm?
  33. What lab values should be monitored daily
    for the client with thrombophlebitis who is
    undergoing anticoagulant therapy?
    PTT, PT, Hgb, and Hct, platelets.
  34. 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.
  35. 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.
  36. List 3 symptoms of digitalis toxicity.
    Dysrhythmias, headache, nausea and vomiting
  37. 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).
  38. 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 lowfat/ low-cholesterol diet.
  39. What immediate actions should the nurse
    implement when a client is having a myocardial
    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).
  40. 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
  41. Bradycardia is defined as a heart rate
    below ___ BPM. Tachycardia is defined as
    a heart rate above ___ BPM.
    bradycardia 60 bpm; tachycardia 100 bpm
  42. What precautions should clients with valve
    disease take prior to invasive procedures
    or dental work?
    Take prophylactic antibiotics.
  43. 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.
  44. List 3 categories of medications used in the
    treatment of peptic ulcer disease.
    Antacids, H2 receptor-blockers, mucosal healing agents, proton pump inhibitors.
  45. List the symptoms of upper and lower
    gastrointestinal bleeding.
    Upper GI: melena, hematemesis, tarry stools. Lower GI: bloddy stools, tarry stools. Similar: tarry stools.
  46. What bowel sound disruptions occur with an
    intestinal obstruction?
    Early mechanical obstruction: high-pitched sounds; late mechanical obstruction: diminished or absent bowel sounds.
  47. 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.
  48. List the common clinical manifestations of
    • Sclera-icteric (yellow sclera), dark urine, chalky
    • or clay-colored stools
  49. What are the common food intolerances for
    clients with cholelithiasis?
    Fried/spicy or fatty foods.
  50. List 5 symptoms indicative of colon cancer.
    Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss.
  51. In a client with cirrhosis, it is imperative to
    prevent further bleeding and observe for
    bleeding tendencies. List 6 relevant nursing
    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.
  52. What is the main side effect of lactulose,
    which is used to reduce ammonia levels in
    clients with cirrhosis?
  53. How should the nurse administer pancreatic
    Give with meals or snacks. Powder forms should be mixed with fruit juices.
  54. What diagnostic test is used to determine
    thyroid activity?
    T3 and T4
  55. What condition results from all treatments
    for hyperthyroidism?
    Hypothyroidism, requiring thyroid replacement
  56. State 3 symptoms of hyperthyroidism and 3
    symptoms of hypothyroidism.
    Hyperthyroidism: weight loss, heat intolerance, diarrhea. Hypothyroidism: fatigue, cold intolerance, weight gain.
  57. 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
  58. Describe the physical appearance of clients
    who are Cushinoid.
    • Moon face, obesity in trunk, buffalo hump in
    • back, muscle atrophy, and thin skin.
  59. Which type of diabetic always requires
    insulin replacement?
    • Type I, Insulin-dependent diabetes mellitus
    • (IDDM)
  60. What type of diabetic sometimes requires
    no medication?
    • Type II, Non-insulin dependent diabetes
    • mellitus (NIDDM)
  61. List 5 symptoms of hyperglycemia.
    • Polydipsia, polyuria, polyphagia, weakness,
    • weight loss
  62. List 5 symptoms of hypoglycemia.
    • Hunger, lethargy, confusion, tremors or shakes,
    • sweating
  63. 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)
  64. 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.
  65. 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.
  66. 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 longacting insulin to peak.
  67. 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.
  68. 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.
  69. Differentiate between rheumatoid arthritis
    and degenerative joint disease in terms of
    joint involvement.
    Rheumatoid arthritis occurs bilaterally. Degenerative joint disease occurs asymmetrically.
  70. 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).
  71. What measures should the nurse encourage
    female clients to take to prevent
    Estrogen replacement after menopause, high calcium and vitamin D intake beginning in early adulthood, calcium supplements after menopause, and weight-bearing exercise.
  72. What are the common side effects of
    GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation
  73. What is the priority nursing intervention
    used with clients taking NSAIDs?
    Administer or teach client to take drugs with food or milk.
  74. List 3 of the most common joints that are
    Hip, knee, finger.
  75. 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.
  76. Describe nursing care for the client who is
    experiencing phantom pain after
    Be aware that phantom pain is real and will eventually disappear. Administer pain medication; phantom pain responds to medication.
  77. 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.
  78. 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.
  79. List 3 problems associated with immobility.
    Venous thrombosis, urinary calculi, skin integrity problems.
  80. List 3 nursing interventions for the
    prevention of thromboembolism in
    immobilized clients with musculoskeletal
    Passive range of motion exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return.
  81. What are the classifications of the
    commonly prescribed eye drops for
    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.
  82. Identify 2 types of hearing loss.
    Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to 8th cranial nerve)
  83. Write 4 nursing interventions for the care of
    the blind person and 4 nursing
    interventions for the care of the deaf person.
    Care of the blind: announce presence clearly, call by name, orient carefully to surroundings, 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.
  84. 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.
  85. 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.
  86. State 4 independent nursing interventions
    to maintain adequate respirations, airway,
    and oxygenation in the unconscious client.
    Position for maximum ventilation (prone or semi-prone and slightly to one side), insert airway if tongue obstructing; suction airway efficiently, monitor arterial pO2 and pCO2 and hyperventilate with 100% oxygen before suctioning.
  87. Who is at risk for cerebral vascular
    Persons with history of hypertension, previous TIAs, cardiac disease (atrial flutter/fibrillation), diabetes, oral contraceptive use, and the elderly.
  88. 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.
  89. List 4 rationales for the appearance of
    restlessness in the unconscious client.
    Anoxia, distended bladder, covert bleeding, or a return to consciousness
  90. What nursing interventions prevent corneal
    drying in a comatose client?
    Irrigation of eyes PRN with sterile prescribed solution, application of opthalmic ointment q8h, close assessment for corneal ulceration/drying
  91. 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.
  92. What is the most important principle in a
    bowel management program for a
    neurologic client?
    Establishment of REGULARITY
  93. Define cerebral vascular accident.
    A disruption of blood supply to a part of the brain, which results in sudden loss of brain function.
  94. 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?
  95. What are the symptoms of spinal shock?
    Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion.
  96. What are the symptoms of autonomic
    Hypertension, bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia
  97. What is the most important indicator of
    increased ICP?
    A change in the level of responsiveness
  98. What vital sign changes are indicative of
    increased ICP?
    Increased BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities and temperature increase.
  99. 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.
  100. 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.
  101. How do Hyperosmotic agents (osmotic
    diuretics) used to treat intracranial pressure
    Dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent reabsorption, and by drawing fluid from the extravascular spaces into the plasma.
  102. Why should narcotics be avoided in clients
    with neurologic impairment?
    • Narcotics mask the level of responsiveness as
    • well as pupillary response.
  103. 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.
  104. How should the head of the bed be
    positioned for post-craniotomy clients with
    infratentorial lesions?
    Infratentorial – FLAT; Supratentorial – elevated
  105. Is multiple sclerosis thought to occur
    because of an autoimmune process?
  106. Is paralysis always a consequence of spinal
    cord injury?
  107. 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.
  108. 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
  109. Write 2 nursing diagnoses for the client
    suffering from anemia.
    Activity intolerance and altered tissue perfusion
  110. What is the only intravenous fluid compatible with blood products?
    What is the only intravenous fluid compatible with blood products?
  111. 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.
  112. List 3 interventions for clients with a
    tendency to bleed.
    Use a soft toothbrush, avoid salicylates, do not use suppositories.
  113. Identify 2 sites, which should be assessed
    for infection in immunosuppressed clients.
    Oral cavity and genital area.
  114. Name 3 food sources of vitamin b12.
    Glandular meats (liver), milk, green leafy vegetables.
  115. Describe care of invasive catheters and
    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.
  116. List 3 safety precautions for the
    administration of antineoplastic
    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.
  117. Describe the use of Leucovorin.
    Leucovorin is used as an antidote with methotrexate to prevent toxic reactions.
  118. Describe the method of collecting the
    trough and peak blood levels of antibiotics.
    Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of peak: draw blood 30 minutes after administration of antibiotic.
  119. What is the characteristic cell found in
    Hodgkin’s disease?
  120. 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.
  121. 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.
  122. What are the indications for a hysterectomy
    in the client who has fibromas?
    Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain.
  123. 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.
  124. What are the most important nursing
    interventions for the postoperative client
    who has had a hysterectomy with an A&P
    Avoid rectal temps and/or rectal manipulation; manage pain; and encourage early ambulation
  125. 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.
  126. 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.
  127. Cite 2 nursing diagnoses for a client
    undergoing a hysterectomy for cervical
    Altered body image related to uterine removal. Pain related to postoperative incision.
  128. What are the 3 most important tools for
    early detection of breast cancer? How often
    should these tools be used?
    Breast self-exam monthly; mammogram baseline at age 35 followed by exams every 1 to 2 years in 40s and every year after age 50; physical examination by a professional skilled in examination of the breast.
  129. 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.
  130. Name 3 priorities to include in a discharge
    plan for the client who has had a
    Arrange for Reach-to-Recovery visit. Discuss the grief process with the client. Have physician discuss with the client the reconstruction options.
  131. What is the most common cause of
    nongonococcal urethritis?
    Chlamydia trachomatis
  132. What is the causative agent for syphilis?
    Treponema pallidum (spirochete bacteria)
  133. Malodorous, frothy, greenish-yellow vaginal
    discharge is characteristic of which STD?
    Trichomonas vaginalis
  134. Which STD is characterized by remissions
    and exacerbations in both males and
    Herpes Simplex Type II
  135. Outline a teaching plan for the client with an
    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.
  136. List 4 categories of burns.
    Thermal, radiation, chemical, electrical
  137. Burn depth is a measure of severity. Describe the characteristics of superficial partial thickness, deep partial-thickness, and full thickness 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
  138. 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.
  139. 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.
  140. 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
  141. 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.
  142. Describe the method of extinguishing each of
    the following burns: thermal, chemical and
    Thermal: remove clothing, immerse in tepid water. Chemical: flush with water or saline. Electrical: separate client from electrical source.
  143. 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.
  144. 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.
  145. Describe an autograft.
    Use of client’s own skin for grafting.
  146. State 4 nursing interventions for assistingthe client to cough productively
    Deep breathing, fluid intake increased to 3 liters/ day, use humidity to loosen secretions, suction airway to stimulate coughing
Card Set:
Medical Surgical nursing
2014-04-30 01:58:24
Med surg

All systems
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