HESI Medical Surgery Final Exam
Terms in this set (94)
*Thoracentesis What Position you going to place them in?
Upright leaning over table to increase lung expansion
What should the nurse expect for a client who has unstable Angina who had a cardiac catheter?
Metabolic Acidosis Respirations
are short high pitched sounds made on expiratory
*Abnormal Breathe sounds
used to describe bronchial or bronchovesicular sounds heard in the peripheral lung fields.
are extra breath sounds that are abnormal.
After procedure keep the patient NPO until gag reflux returns.
*What to report with a Bronchoscopy?
monitor for: bloody sputum.
complications include: bronchospasm or bronchial perforation. (facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax)
(Saunders N-CLEX Review)
PaO2 is at 55% and SpO2 is 88
What test do you use to verify pulmonary embolus?
A patient with an SaO2 of 85% has a PaO2 of 50mm Hg. This indicates?
shift to the left in the oxygen-hemoglobin dissociation curve that could be caused by hypothermia.
Normal Arterial Blood Gases
pH 7.35-7.45, PaO2 80-100mm Hg, SaO2 >95%, PaCO2 32-48 mm Hg, HCO3- 22-26 mEq/L
To determine when the patient with a tracheostomy tube can be effectively swallow, the nurse deflates the cuff and?
has the patient drink a small amount of blue-colored water, observing for coughing and colored secretions.
When obtaining a health history from a patient with possible cancer of the mouth, the nurse would expect the patient to report?
Heavy tobacco and alcohol use.
The most normal functioning method of speech restoration in the patient with a total larynectomy is
a voice presthesis
A patients tracheostomy tube becomes dislodged with vigorous coughing. The first action by the nurse is to?
attempt to replace the tube
What will the nurse teach a patient with pneumonia?
Deep breathing and coughing
short-duration, discontinuous, high pitched sounds heard just before the end of inspiration. In pneumonia or heart failure.
long duration, discontinuous, low pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; evident with inspiration. COPD, heart failure, and pneumonia.
Absent breath sounds
no sound evident over entire lung or area of lung. Pleural effusion or lobectomy
is a complication of acute pharyngitis or acute tonsillitis when bacterial infection invades one or both tonsils. The tonsil may enlarge sufficiently to threaten airway patency. Also known as the hot potato voice. The patient experience a high fever, leukocytosis, and chills.
Sputum Test for TB
3 seperate sputum test over 3 days. Airborne precautions until 3 negative sputum samples. HEPA mask required.
latent TB and treat 6 to 9 months.
Rifampin side effects and considerations
Hepatitis, thrombocytopenia, orange discoloration of bodily fluids (Sputum, urine, sweat, tears).
BCG or Bacille Calmette-Guerin
Immigrants have been vaccinate in parts of the world with high TB. Do not give TB test only chest x-ray.
A patient with pneumonia has a nursing diagnosis pf ineffective airway clearance related to pain, fatigue, and thick secretions. An appropriate nursing intervention for the patient is to
Encourage fluid intake of 3L/day
*Diagnose Pulmonary Emboli
with at CAT scan or MRI
SPO2 96%. What is the nurse going to do? Turn oxygen up.
Symptom of primary pulmonary hypertension
dyspnea with exertion.
2 blood draws from 2 different sites before start ABT.
thick green mucous.
Proventil side effects
tachycardia, BP changes, nervousness, palpitations, muscle tremors, nausea, vomiting, vertigo, insomnia, dry mouth, headache, hypokalemia.
On examining a patient 8 hours after formation of a colostomy, the nurse would expect to find
a brick-red, puffy stoma that oozes blood.
*A patient is admitted to the emergency department with acute abdominal pain. The nursing intervention that should be implemented first is
measurement of vital signs
The nurse identifies a need for additional teaching when a patient with acute infectious diarrhea states,
"I may use over-the-counter lopermide (Immodium) or Parepectolin as need to control the diarrhea."
Following a Billroth II procedure, a patient develops dumping syndrome. The nurse explains that the symptoms associated with this problem are caused by
movement of fluid into the small bowel because concentrated food and fluids move rapidly into the intestine.
Nursing management of the patient with chronic gastritis includes teaching the patient to
Maintain a non irritating diet with six small meals a day
Following a patient's esophagogastrostomy for cancer of the esophagus, it is important for the nurse to
maintain the patient in sem-fowler's or fowler's position
The nurse teaches the patient with a hiatal hernia or GERD to control symptoms by
Sleeping with the head of the bed elevated on 4 to 6 inch blocks
A patient treated for vomiting for several days from an unknown cause is admitted to the hospital. The nurse anticipates collaborative care to include
IV replacement of fluid and electrolytes.
The nurse is caring for a patient receiving 1000mL of PN solution over 24 hours. When it is time to change the solution, 150mL remain in the bottle. The most appropriate action by the nurse is to
Hang a new solution and discard the unused solution.
Before administering a bolus of intermittent tube feeding to a patient with percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220mL of gastric contents. The nurse should
return the aspirate to the stomach and continue with the tube feeding as planned.
The nurse evaluates that patient teaching about a high-calorie, high protein diet has been effective when the patient selects for breakfast from the hospital menu
two poached eggs, hash brown potatoes, and whole milk
While receiving a unit of packed RBCs, the patient develops chills and a temperature of 102.2 F. The priority action for the nurse to take is
Stop the transfusion and removes the IV catheter
A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which of the following actions is most important for the nurse to implement?
Monitoring the patient for headaches, vertigo, or confusion
A patient has a platelet count of 50,000/uL and is diagnosed with immune thrombocytopenia purpura. The nurse anticipates that initial treatment will include
*The strict vegetarian is at highest risk for the development of ?
cobalamin deficiency anemia
*During the assessment of a patient with cobalamin deficiency, the nurse would expect to find that the patient has?
Paresthesia of the hands and feet
Endoscopic retrograde cholangiopanceatography (ERCP)
Nursing responsibility is to explain procedure to patient, including patients role. Keep patient NPO 8 hour before procedure. Ensure consent is signed. Administer sedation. Administer ABT. Check VS and check for perforation or infection. Check Gag reflex.
After procedure you keep the patient NPO until gag reflex returns. Gently tickle back of throat to determine reflex. Use warm saline gargles for relief of throat. Check temp for 15-30min for 1-2hr.
Nursing responsibility for ultrasound
Instruct patient to be NPO 8-12 hour before ultrasound. Air or gas can reduce quality of images. Food intake can cause gallbladder contraction, resulting in suboptimal study.
Abdomen auscultation need further evaluation
If bowel sounds are absent
Palpate the liver
place your left hand behind the patient to support the right eleventh and twelfth ribs. Press the left hand forward and place the right hand on patients right abdomen later to the rectus muscle.
Need for patient teaching inf they take tylenol.
*After Procedure colonoscopy
Be aware patient may experience abdominal cramping. Observe for rectal bleeding and signs of perforation (e.g., malaise, abdominal distension, tenesmus). Check vital signs.
*Before procedure colonoscopy
Bowel preparation is done. May be on clear liquid diet for 1-2 days. Enema given the night before. 1 gallon of GoLYTELY evening before. Explain the that the flexible scope will be inserted in side lying position. Sedation will be given.
PRBCS develops chills, fever, anxiety 30 minutes after infusion started. What does the nurse do?
stop the transfusion.
*Blood transfusion reactions the following steps need to be taken
1. stop transfusion. 2. maintain patent IV line with saline solution. 3. notify blood bank and the healthcare provider immediately; 4. recheck identifying tags and numbers; 5. monitor VS and urine output; 6. treat symptoms per physician order; 7. save the blood bag and tubing and send them to the blood bank for examination; 8. complete transfusion report; 9. collect required blood and urine specimens at intervals stipulated by hospital policy to evaluate hemolysis and 10. document on transfusion reaction form and patient chart.
*Delegation of Blood transfusions
NAP can obtain blood products from the blood bank as directed by RN. Take VS before the transfusion and after the first 15 minutes.
Patients fear of death
can be extremely detrimental. Attitude and emotional state influence the stress response, and thus the surgical outcome.
Ambulatory Center day of surgery
explain to the patient events such as patient registration, parking, what to wear, what to bring, and the need to have a responsible adult present for transportation home after the surgery.
Genitourinary System Review prior to surgery
Consider women of childbearing age, you need to determine if they are pregnant or think they could be pregnant. The Surgeon should be informed immediately if the patient states that she might be pregnant because maternal and subsequent fetal exposure to anesthetic during first trimester should be avoided.
Non Drug Allergies
specifically food and environmental allergies such as latex. You want to make sure they do not use latex prior to surgery and schedule them first for surgery so no latex dust in the air.
St. John's Wort
May prolong the effects of anesthetic agents. Increases the waking time after surgery.
The patient who smokes should be encouraged to stop at least 6 weeks preoperatively to decrease the risk of intraoperative and postoperative respiratory complications. Draw ABGs prior and after. Assess lung sounds.
may have additive effects with other hormone therapies.
When the nurse prepares to administer preoperative medication to a patient, the patient tells the nurse that she really does not understand what the surgeon plans to do.
Notify the healthcare provider because the patient needs further explanation of the planned surgery.
Blood Glucose prior to surgery
to check their metabolic status, blood sugar, and their diabetes mellitus. Determine if insulin needs to be given prior to surgery.
A client presents with the s/s of Diabetes type 2 and feeling shaky. What is the nurse priority?
Obtain glucose level
Day of Surgery and Wedding Ring
If the patient does not want to remove their wedding ring if can be taped securely to the finger to prevent loss.
decrease oral and respiratory secretions
decrease anxiety, induce sedation, amnesic effects
Histamine (H2)-receptor antagonist (Pepcid)
decrease HCL acid secretion, increase pH, and decrease gastric volume. Taken to prevent stress ulcers
may increase bleeding, especially in patients taking anticoagulants
Nurse anethetist role
Performing and documenting a preanesthetic assessment and evaluation. Developing and implementing a plan for delivering anesthesia. Anesthetic technique. Administer the anesthesia, adjuvant drugs, and fluids. Noninvasive and invasive monitoring devices. Manage pt. airway and pulmonary status. Manage emergence and recovery from anesthesia. Pain relief. Responding to emergency situations.
Scrub nurse sterile activities
Scrubs, gowns, and gloves self and other members of surgical team. Prepares instruments. Counts sponges, needles, and instruments. Monitors practices of aseptic technique in self and others.
Hearing aides and glasses to surgical suite
bring to the nurses desk so when the patient awakes he will not feel as disorientated without having his glasses and hearing aides.
A break in sterile technique during surgery would occur then the scrub nurse touches
the mask with gloved hands
How anethetist puts somebody to sleep
picture a relaxing place and push medications through the IV.
*Because of rapid elimination of volatile liquids used for general anesthesia, the nurse should anticipate that early in the anesthesia recovery period, the patient will need
Sedative medication prior to surgery
given by the anesthesiologist
post surgery monitor for respiratory depression, hypotension, and hallucinations.
The primary advantage of the use of (Versed) as an adjunct to general anesthesia is its
RN VS First assistant
First assistant can open and close an incision site
RN delegate to a surgical technologist
the surgical technologist can pass instruments to the doctor
NG tube removal after surgery
first priority is to ambulate
To promote effective coughing, deep breathing, and ambulation in the postoperative patient, it is most important for the nurse to
provide adequate and regular pain medication.
normal color is green bile
A person who has petechiae on skin what are you going to ask that they use?
When somebody is taking Heparin what test are you going to use to monitor it?
If a patient is taking Heparin infusion and Coumadin and diagnosed with heparin-induced thrombocytopenia (HIT). What are you as the nurse going to do?
Flush all the IV lines with normal saline
While receiving a unit of packed RBCs. the patient develops chills and a temperature of 102.2F. The priority action for the nurse to take is?
stop the transfusion and removes the IV catheter.
A patient who has had a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). How do you reduce the reaction?
Transfuse only leukocyte-reduced PRBCs.
While administering and infusion of packed RBCs. the RN may delegate which of the following actions to nursing assistive personnel
1. Obtain blood products from the bank and 2. Obtain VS before and after the first 15 minutes.
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