client, keep airway clear by
MEDICAL SURGICAL NURSING coughing/suctioning.
PRACTICE QUESTIONS: 7. When examining a client with
emphysema, what physical findings
RESPIRATORY SYSTEM: is the nurse likely to see?
• Barrel chest, dry or productive
1. List 4 common symptoms of cough, decreased breath sounds,
pneumonia the nurse might note on a dyspnea, crackles in lung fields.
physical exam. 8. What is the most common risk factor
• Tachypnea, fever with chills, associated with lung cancer?
productive cough, bronchial breath • Smoking
sounds. 9. Describe the pre-op nursing care for
2. State 4 nursing interventions for a client undergoing a laryngectomy.
assisting the client to cough • Involve family/client in manipulation
productively. of tracheostomy equipment before
• Deep breathing, fluid intake surgery, plan acceptable
increased to 3 liters/day, use communication method, refer to
humidity to loosen secretions, speech pathologist, discuss
suction airway to stimulate rehabilitation program.
coughing. 10. List 5 nursing interventions after
3. What symptoms of pneumonia might chest tube insertion.
the nurse expect to see in an older • Maintain a dry occlusive dressing to
client? chest tube site at all times. Check all
• Confusion, lethargy, anorexia, rapid connections every 4 hours. Make
respiratory rate. sure bottle III or end of chamber is
4. What should the O2 flow rate be for bubbling. Measure chest tube
the client with COPD? drainage by marking level on outside
• 1-2 liters per nasal cannula, too of drainage unit. Encourage use of
much O2 may eliminate the COPD incentive spirometry every 2 hours.
client’s stimulus to breathe, a COPD 11. What immediate action should the
client has hypoxic drive to breathe. nurse take when a chest tube
5. How does the nurse prevent hypoxia becomes disconnected from a bottle
during suctioning? or a suction apparatus? What should
• Deliver 100% oxygen the nurse do if a chest tube is
(hyperinflating) before and after each accidentally removed from the
endotracheal suctioning. client?
6. During mechanical ventilation, what • Place end in container of sterile
are three major nursing intervention? water. Apply an occlusive dressing
• Monitor client’s respiratory status and notify physician STAT.
and secure connections, establish a 12. What instructions should be given to
communication mechanism with the a client following radiation therapy?
, • Do NOT wash off lines; wear soft 4. What is the highest priority nursing
cotton garments, avoid use of diagnosis for clients in any type of
powders/creams on radiation site. renal failure?
13. What precautions are required for • Alteration in fluid and electrolyte
clients with TB when placed on balance.
respiratory isolation? 5. A client in renal failure asks why he
• Mask for anyone entering room; is being given antacids. How should
private room; client must wear mask the nurse reply?
if leaving room. • Calcium and aluminum antacids bind
14. List 4 components of teaching for the phosphates and help to keep
client with tuberculosis. phosphates from being absorbed into
• Cough into tissues and dispose blood stream thereby preventing
immediately into special bags. Long- rising phosphate levels, and must be
term need for daily medication. taken with meals.
Good handwashing technique. 6. List 4 essential elements of a
Report symptoms of deterioration, teaching plan for clients with
i.e., blood in secretions. frequent urinary tract infections.
RENAL SYSTEM: • Fluid intake 3 liters/day; good
1. Differentiate between acute renal handwashing; void every 2-3 hours
failure and chronic renal failure. during waking hours; take all
prescribed medications; wear cotton
• Acute renal failure: often reversible,
undergarments.
abrupt deterioration of kidney
7. What are the most important nursing
function. Chronic renal failure:
interventions for clients with
irreversible, slow deterioration of
possible renal calculi?
kidney function characterized by
increasing BUN and creatinine. • Strain all urine is the MOST
Eventually dialysis is required. IMPORTANT intervention. Other
2. During the oliguric phase of renal interventions include accurate intake
failure, protein should be severely and output documentation and
restricted. What is the rationale for administer analgesics as needed.
this restriction? 8. What discharge instructions should
be given to a client who has had
• Toxic metabolites that accumulate in
urinary calculi?
the blood (urea, creatinine) are
derived mainly from protein • Maintain high fluid intake 3-4 liters
catabolism. per day. Follow-up care (stones tend
3. Identify 2 nursing interventions for to recur). Follow prescribed diet
the client on hemodialysis. based in calculi content. Avoid
supine position.
• Do NOT take BP or perform
9. Following transurethral resection of
venipunctures on the arm with the A-
the prostate gland (TURP),
V shunt, fistula, or graft. Assess
access site for thrill or bruit.
MEDICAL SURGICAL NURSING coughing/suctioning.
PRACTICE QUESTIONS: 7. When examining a client with
emphysema, what physical findings
RESPIRATORY SYSTEM: is the nurse likely to see?
• Barrel chest, dry or productive
1. List 4 common symptoms of cough, decreased breath sounds,
pneumonia the nurse might note on a dyspnea, crackles in lung fields.
physical exam. 8. What is the most common risk factor
• Tachypnea, fever with chills, associated with lung cancer?
productive cough, bronchial breath • Smoking
sounds. 9. Describe the pre-op nursing care for
2. State 4 nursing interventions for a client undergoing a laryngectomy.
assisting the client to cough • Involve family/client in manipulation
productively. of tracheostomy equipment before
• Deep breathing, fluid intake surgery, plan acceptable
increased to 3 liters/day, use communication method, refer to
humidity to loosen secretions, speech pathologist, discuss
suction airway to stimulate rehabilitation program.
coughing. 10. List 5 nursing interventions after
3. What symptoms of pneumonia might chest tube insertion.
the nurse expect to see in an older • Maintain a dry occlusive dressing to
client? chest tube site at all times. Check all
• Confusion, lethargy, anorexia, rapid connections every 4 hours. Make
respiratory rate. sure bottle III or end of chamber is
4. What should the O2 flow rate be for bubbling. Measure chest tube
the client with COPD? drainage by marking level on outside
• 1-2 liters per nasal cannula, too of drainage unit. Encourage use of
much O2 may eliminate the COPD incentive spirometry every 2 hours.
client’s stimulus to breathe, a COPD 11. What immediate action should the
client has hypoxic drive to breathe. nurse take when a chest tube
5. How does the nurse prevent hypoxia becomes disconnected from a bottle
during suctioning? or a suction apparatus? What should
• Deliver 100% oxygen the nurse do if a chest tube is
(hyperinflating) before and after each accidentally removed from the
endotracheal suctioning. client?
6. During mechanical ventilation, what • Place end in container of sterile
are three major nursing intervention? water. Apply an occlusive dressing
• Monitor client’s respiratory status and notify physician STAT.
and secure connections, establish a 12. What instructions should be given to
communication mechanism with the a client following radiation therapy?
, • Do NOT wash off lines; wear soft 4. What is the highest priority nursing
cotton garments, avoid use of diagnosis for clients in any type of
powders/creams on radiation site. renal failure?
13. What precautions are required for • Alteration in fluid and electrolyte
clients with TB when placed on balance.
respiratory isolation? 5. A client in renal failure asks why he
• Mask for anyone entering room; is being given antacids. How should
private room; client must wear mask the nurse reply?
if leaving room. • Calcium and aluminum antacids bind
14. List 4 components of teaching for the phosphates and help to keep
client with tuberculosis. phosphates from being absorbed into
• Cough into tissues and dispose blood stream thereby preventing
immediately into special bags. Long- rising phosphate levels, and must be
term need for daily medication. taken with meals.
Good handwashing technique. 6. List 4 essential elements of a
Report symptoms of deterioration, teaching plan for clients with
i.e., blood in secretions. frequent urinary tract infections.
RENAL SYSTEM: • Fluid intake 3 liters/day; good
1. Differentiate between acute renal handwashing; void every 2-3 hours
failure and chronic renal failure. during waking hours; take all
prescribed medications; wear cotton
• Acute renal failure: often reversible,
undergarments.
abrupt deterioration of kidney
7. What are the most important nursing
function. Chronic renal failure:
interventions for clients with
irreversible, slow deterioration of
possible renal calculi?
kidney function characterized by
increasing BUN and creatinine. • Strain all urine is the MOST
Eventually dialysis is required. IMPORTANT intervention. Other
2. During the oliguric phase of renal interventions include accurate intake
failure, protein should be severely and output documentation and
restricted. What is the rationale for administer analgesics as needed.
this restriction? 8. What discharge instructions should
be given to a client who has had
• Toxic metabolites that accumulate in
urinary calculi?
the blood (urea, creatinine) are
derived mainly from protein • Maintain high fluid intake 3-4 liters
catabolism. per day. Follow-up care (stones tend
3. Identify 2 nursing interventions for to recur). Follow prescribed diet
the client on hemodialysis. based in calculi content. Avoid
supine position.
• Do NOT take BP or perform
9. Following transurethral resection of
venipunctures on the arm with the A-
the prostate gland (TURP),
V shunt, fistula, or graft. Assess
access site for thrill or bruit.
