MNS 5430 MED-SURG PRACTICE EXAM CONCEPTS |
STUDYGUIDE 2021.
Med-Surg Practice Exam Concepts
o Crutches
▪ Place body weight on crutches
▪ Advance unaffected leg onto the stair
▪ Shift weight from crutches to unaffected leg
▪ Bring crutches and affected leg up to the stair
o Closed-suction drain nursing interventions
▪ Negative-pressure device
▪ Doesn’t require wall suction
▪ *Compress the drain reservoir after emptying (creates negative pressure)
▪ Do not need to put below bed (doesn’t use gravity)
o External fixation device
▪ Surgeon applies the external fixation device directly to the client’s bone to form
a rigid structure around the affected extremity
Casts, boots, or splints are applied directly to the leg for internal fixation
▪ Client should wear external fixation device continuously for a period of 4-6 weeks
Nurse should teach the client to perform care of the wound and pin sites
at home
▪ Use crutches with rubber tips
Prevents the client from slipping and decreases fall risks
▪ Only the provider should adjust the client’s external fixation device in order
to maintain bone alignment
o Long-term mechanical ventilation complications
▪ Decreased cardiac output and hypotension, related to positive pressure
from mechanical ventilation inhibiting blood return to the heart
▪ Fluid retention related to decreased cardiac output
▪ Stress ulcers, related to elevated levels of HCl in the stomach
Increase risk for systemic infection and require pharmacological treatment
▪ Hyponatremia, secondary to fluid retention
o Postoperative nursing interventions following mastectomy
▪ Instruct client that the drain will remain in place for 1-3 weeks after surgery and
will be removed when there is 25 mL of output or less in a 24-hour period
▪ Instruct client to start exercising the arm on side of surgery 24 hours after surgery
▪ Elevate arm on surgical side on a pillow to promote lymphatic fluid return
▪ Nurse should elevate the head of the client’s bed to at least 30 degrees to
promote drainage from the surgical site and facilitate breathing
o Patient teaching for active tuberculosis
▪ Sputum specimens are necessary every 2-4 weeks until there are three
negative cultures
After 3 negative cultures, the client is no longer considered infectious
,▪ Client’s infection is usually no longer contagious after taking TB medications for 2-
3 weeks
▪ Family members do not need to follow airborne precautions because they
have already been exposed to TB
, ▪ A follow-up evaluation of the client’s TB should be performed using a chest x-
ray because the TB skin test is no longer considered accurate after a person has
tested positive
o Nursing interventions following total hip arthroplasty
▪ Assist client to maintain legs in abduction
▪ Client should not flex hip greater than 90 degrees to prevent hip dislocation
▪ Nurse should place a pillow between client’s legs to prevent hip dislocation
▪ Nurse should not keep client’s hip internally rotated, as this can lead to
hip dislocation
o Patient teaching on kidney organ donation
▪ Client who is recipient of organ donation will require lifelong
immunosuppressive therapy to protect against transplant rejection
▪ A healthy donor who has one kidney can manage the body’s urinary
excretion requirements
▪ Client’s nonfunctioning kidney remains in the body until transplant surgery,
unless the client has chronic kidney infection or pain
▪ A client who receives a kidney from live donor has a lower rate of transplant rejection
Client who receives a kidney from a live donor has a lower rate of
transplant rejection because the donor is often more medically compatible
than a donor who is deceased
o Patient teaching about prevention of atherosclerosis
▪ Smoking cessation
▪ Maintain an appropriate weight
▪ Eat a low-fat diet
o MRSA precautions for health care professionals
▪ Client should wear an isolation gown and wash hands before being transported
from the room to prevent spread of micro-organisms
▪ Nurse should bathe client using warm water and a chlorhexidine solution to
prevent the spread of micro-organisms
▪ Use dedicated assessment equipment when assessing the client and leave in room
to prevent cross-contamination with other clients
▪ Mode of transmission = contact
o Nephrostomy expected findings
▪ Red-tinged urine during the first 12-24 hours
▪ Normal BUN
▪ Increased urine output (notify provider for decreased UO)
▪ NOTIFY PROVIDER FOR BACK PAIN
Can indicate the tube is dislodged or clogged
o Nursing interventions for dysrhythmias
▪ Defibrillation for ventricular tachycardia or ventricular fibrillation
▪ Cardioversion for all other dysrhythmias
▪ CPR for a client who is pulseless or not breathing
▪ Lidocaine IV bolus for a client who has ventricular dysrhythmia
o Seizure precautions
▪ Client should limit intake of alcohol or caffeine, minimize stress, fever, and fatigue
to prevent triggering a seizure
, ▪ Nurse should keep 2-3 side rails up to prevent falls
▪ Keep client’s bed in lowest position to prevent falls
▪ Ensure client has patent IV access in the event that the client requires medication
to stop seizure activity
o Nursing interventions for blood transfusions
▪ Priority = check for the type and number of units of blood to administer
▪ Obtain baseline vital signs for comparison
▪ Describe blood transfusion to promote client understanding
▪ Ensure client has a large-bore IV access to prevent hemolysis during transfusion
o Patient teaching for insulin lispro
▪ Rapid-acting insulin that the client can use in conjunction with intermediate or
long- acting insulins
▪ Client should inject the medication subcutaneously into the abdomen, upper thigh,
or arm
▪ Nurse should instruct client that insulin lispro is rapid-acting and the client
should administer immediately before eating or immediately after eating
▪ Instruct the client to continue taking insulin lispro as prescribed during times
of illness, and notify provider of the illness
o Patient teaching for metformin
▪ Decreases the amount of glucose produced in the liver and increases tissue
sensitivity to insulin
▪ Client should take metformin with or immediately following meals to
improve absorption and to minimize GI distress
▪ Clients typically lose weight when beginning metformin due to N/V
▪ Adverse effect = rash
o Evisceration nursing interventions
▪ Priority = call for help
▪ Cover the wound with sterile, saline-moistened dressing to protect organs
▪ Monitor client’s vital signs to monitor for complications
▪ Place client in supine position to promote blood flow to organs
o Blood transfusion complication interventions
▪ Bacterial transfusion reaction = antibiotic
Manifestations: hypotension, tachycardia, shock
▪ Febrile transfusion reaction = antipyretic, acetaminophen
Manifestations: tachycardia, fever, hypotension, chills
▪ Circulatory overload from transfusion: loop-diuretic, furosemide
Manifestations: dyspnea, hypotension, hypertension, distended neck veins
▪ Allergic transfusion reaction: antihistamine, diphenhydramine
Manifestations: urticarial, itching, flushing, bronchospasms, anaphylaxis
o Central venous catheter nursing interventions
▪ Place client in Trendelenburg position with a rolled towel between client’s
shoulder blades
Position facilitates the insertion of the catheter by dilating blood vessels of
the client’s neck and shoulders
▪ Goes into subclavian vein
STUDYGUIDE 2021.
Med-Surg Practice Exam Concepts
o Crutches
▪ Place body weight on crutches
▪ Advance unaffected leg onto the stair
▪ Shift weight from crutches to unaffected leg
▪ Bring crutches and affected leg up to the stair
o Closed-suction drain nursing interventions
▪ Negative-pressure device
▪ Doesn’t require wall suction
▪ *Compress the drain reservoir after emptying (creates negative pressure)
▪ Do not need to put below bed (doesn’t use gravity)
o External fixation device
▪ Surgeon applies the external fixation device directly to the client’s bone to form
a rigid structure around the affected extremity
Casts, boots, or splints are applied directly to the leg for internal fixation
▪ Client should wear external fixation device continuously for a period of 4-6 weeks
Nurse should teach the client to perform care of the wound and pin sites
at home
▪ Use crutches with rubber tips
Prevents the client from slipping and decreases fall risks
▪ Only the provider should adjust the client’s external fixation device in order
to maintain bone alignment
o Long-term mechanical ventilation complications
▪ Decreased cardiac output and hypotension, related to positive pressure
from mechanical ventilation inhibiting blood return to the heart
▪ Fluid retention related to decreased cardiac output
▪ Stress ulcers, related to elevated levels of HCl in the stomach
Increase risk for systemic infection and require pharmacological treatment
▪ Hyponatremia, secondary to fluid retention
o Postoperative nursing interventions following mastectomy
▪ Instruct client that the drain will remain in place for 1-3 weeks after surgery and
will be removed when there is 25 mL of output or less in a 24-hour period
▪ Instruct client to start exercising the arm on side of surgery 24 hours after surgery
▪ Elevate arm on surgical side on a pillow to promote lymphatic fluid return
▪ Nurse should elevate the head of the client’s bed to at least 30 degrees to
promote drainage from the surgical site and facilitate breathing
o Patient teaching for active tuberculosis
▪ Sputum specimens are necessary every 2-4 weeks until there are three
negative cultures
After 3 negative cultures, the client is no longer considered infectious
,▪ Client’s infection is usually no longer contagious after taking TB medications for 2-
3 weeks
▪ Family members do not need to follow airborne precautions because they
have already been exposed to TB
, ▪ A follow-up evaluation of the client’s TB should be performed using a chest x-
ray because the TB skin test is no longer considered accurate after a person has
tested positive
o Nursing interventions following total hip arthroplasty
▪ Assist client to maintain legs in abduction
▪ Client should not flex hip greater than 90 degrees to prevent hip dislocation
▪ Nurse should place a pillow between client’s legs to prevent hip dislocation
▪ Nurse should not keep client’s hip internally rotated, as this can lead to
hip dislocation
o Patient teaching on kidney organ donation
▪ Client who is recipient of organ donation will require lifelong
immunosuppressive therapy to protect against transplant rejection
▪ A healthy donor who has one kidney can manage the body’s urinary
excretion requirements
▪ Client’s nonfunctioning kidney remains in the body until transplant surgery,
unless the client has chronic kidney infection or pain
▪ A client who receives a kidney from live donor has a lower rate of transplant rejection
Client who receives a kidney from a live donor has a lower rate of
transplant rejection because the donor is often more medically compatible
than a donor who is deceased
o Patient teaching about prevention of atherosclerosis
▪ Smoking cessation
▪ Maintain an appropriate weight
▪ Eat a low-fat diet
o MRSA precautions for health care professionals
▪ Client should wear an isolation gown and wash hands before being transported
from the room to prevent spread of micro-organisms
▪ Nurse should bathe client using warm water and a chlorhexidine solution to
prevent the spread of micro-organisms
▪ Use dedicated assessment equipment when assessing the client and leave in room
to prevent cross-contamination with other clients
▪ Mode of transmission = contact
o Nephrostomy expected findings
▪ Red-tinged urine during the first 12-24 hours
▪ Normal BUN
▪ Increased urine output (notify provider for decreased UO)
▪ NOTIFY PROVIDER FOR BACK PAIN
Can indicate the tube is dislodged or clogged
o Nursing interventions for dysrhythmias
▪ Defibrillation for ventricular tachycardia or ventricular fibrillation
▪ Cardioversion for all other dysrhythmias
▪ CPR for a client who is pulseless or not breathing
▪ Lidocaine IV bolus for a client who has ventricular dysrhythmia
o Seizure precautions
▪ Client should limit intake of alcohol or caffeine, minimize stress, fever, and fatigue
to prevent triggering a seizure
, ▪ Nurse should keep 2-3 side rails up to prevent falls
▪ Keep client’s bed in lowest position to prevent falls
▪ Ensure client has patent IV access in the event that the client requires medication
to stop seizure activity
o Nursing interventions for blood transfusions
▪ Priority = check for the type and number of units of blood to administer
▪ Obtain baseline vital signs for comparison
▪ Describe blood transfusion to promote client understanding
▪ Ensure client has a large-bore IV access to prevent hemolysis during transfusion
o Patient teaching for insulin lispro
▪ Rapid-acting insulin that the client can use in conjunction with intermediate or
long- acting insulins
▪ Client should inject the medication subcutaneously into the abdomen, upper thigh,
or arm
▪ Nurse should instruct client that insulin lispro is rapid-acting and the client
should administer immediately before eating or immediately after eating
▪ Instruct the client to continue taking insulin lispro as prescribed during times
of illness, and notify provider of the illness
o Patient teaching for metformin
▪ Decreases the amount of glucose produced in the liver and increases tissue
sensitivity to insulin
▪ Client should take metformin with or immediately following meals to
improve absorption and to minimize GI distress
▪ Clients typically lose weight when beginning metformin due to N/V
▪ Adverse effect = rash
o Evisceration nursing interventions
▪ Priority = call for help
▪ Cover the wound with sterile, saline-moistened dressing to protect organs
▪ Monitor client’s vital signs to monitor for complications
▪ Place client in supine position to promote blood flow to organs
o Blood transfusion complication interventions
▪ Bacterial transfusion reaction = antibiotic
Manifestations: hypotension, tachycardia, shock
▪ Febrile transfusion reaction = antipyretic, acetaminophen
Manifestations: tachycardia, fever, hypotension, chills
▪ Circulatory overload from transfusion: loop-diuretic, furosemide
Manifestations: dyspnea, hypotension, hypertension, distended neck veins
▪ Allergic transfusion reaction: antihistamine, diphenhydramine
Manifestations: urticarial, itching, flushing, bronchospasms, anaphylaxis
o Central venous catheter nursing interventions
▪ Place client in Trendelenburg position with a rolled towel between client’s
shoulder blades
Position facilitates the insertion of the catheter by dilating blood vessels of
the client’s neck and shoulders
▪ Goes into subclavian vein
