med surg flash cards

Topics: Pain, Hypertension, Renal failure Pages: 32 (4469 words) Published: October 14, 2013


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

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

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

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?


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

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


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

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

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



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

Alteration in fluid and electrolyte balance.

A client...
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