Medical Surgical Nursing Bullet II (Belajar KMB itu mudah)

? Before angiography, the nurse should ask the patient whether he’s allergic to the dye, shellfish, or iodine and advise him to take nothing by mouth for 8 hours before the procedure.

? During myelography, approximately 10 to 15 ml of cerebrospinal fluid is removed for laboratory studies and an equal amount of contrast media is injected.

? After angiography, the puncture site is covered with a pressure dressing and the affected part is immobilized for 8 hours to decrease the risk of bleeding.

? If a water-based medium was used during myelography, the patient remains on bed rest for 6 to 8 hours, with the head of the bed elevated 30 to 45 degrees. If an oil-based medium was used, the patient remains flat in bed for 6 to 24 hours.

? The level of amputation is determined by estimating the maximum viable tissue (tissue with adequate circulation) needed to develop a functional stump.

? Heparin sodium is included in the dialysate used for renal dialysis.

? Paroxysmal nocturnal dyspnea may indicate heart failure.

? A patient who takes a cardiac glycoside, such as digoxin, should consume a diet that includes high-potassium foods.

? The nurse should limit tracheobronchial suctioning to 10 to 15 seconds and should make only two passes.

? Before performing tracheobronchial suctioning, the nurse should ventilate and oxygenate the patient five to six times with a resuscitation bag and 100% oxygen. This procedure is called bagging.

? Signs and symptoms of pneumothorax include tachypnea, restlessness, hypotension, and tracheal deviation.

? The cardinal sign of toxic shock syndrome is rapid onset of a high fever.
? A key sign of peptic ulcer is hematemesis, which can be bright red or dark red, with the consistency of coffee grounds.

? Signs and symptoms of a perforated peptic ulcer include sudden, severe upper abdominal pain; vomiting; and an extremely tender, rigid (boardlike) abdomen.

? Constipation is a common adverse reaction to aluminum hydroxide.

? For the first 24 hours after a myocardial infarction, the patient should use a bedside commode and then progress to walking to the toilet, bathing, and taking short walks.

? After a myocardial infarction, the patient should avoid overexertion and add a new activity daily, as tolerated without dyspnea.

? In a patient with a recent myocardial infarction, frothy, blood-tinged sputum suggests pulmonary edema.

? In a patient who has acquired immunodeficiency syndrome, the primary purpose of drugs is to prevent secondary infections.

? In a patient with acquired immunodeficiency syndrome, suppression of the immune system increases the risk of opportunistic infections, such as cytomegalovirus, Pneumocystis carinii pneumonia, and thrush.

? A patient with acquired immunodeficiency syndrome may have rapid weight loss, a sign of wasting syndrome.

? If the body doesn’t use glucose for energy, it metabolizes fat and produces ketones.

? Approximately 20% of patients with Guillain-Barré syndrome have residual deficits, such as mild motor weakness or diminished lower extremity reflexes.

? Hypertension and hypokalemia are the most significant clinical manifestations of primary hyperaldosteronism.
? After percutaneous aspiration of the bladder, the patient’s first void is usually pink; however, urine with frank blood should be reported to the physician.

? A urine culture that grows more than 100,000 colonies of bacteria per milliliter of urine indicates infection.

? A patient who is undergoing dialysis should take a vitamin supplement and eat foods that are high in calories, but low in protein, sodium, and potassium.

? In a patient who has chronic obstructive pulmonary disease, the most effective ways to reduce thick secretions are to increase fluid intake to 2,500 ml/day and encourage ambulation.

? The nurse should teach a patient with emphysema how to perform pursed-lip breathing because this slows expiration, prevents alveolar collapse, and helps to control the respiratory rate.

? Clubbing of the digits and a barrel chest may develop in a patient who has chronic obstructive pulmonary disease.

? A stroke (“brain attack”) disrupts the brain’s blood supply and may be caused by hypertension.

? In a patient who is undergoing dialysis, desired outcomes are normal weight, normal serum albumin level (3.5 to 5.5 g/dl), and adequate protein intake (1.2 to 1.5 g/kg of body weight daily).

? Intermittent peritoneal dialysis involves performing three to seven treatments that total 40 hours per week.

? In a patient with chronic obstructive pulmonary disease, the best way to administer oxygen is by nasal cannula. The normal flow rate is 2 to 3 L/ minute.

? Isoetharine (Bronkosol) can be administered with a handheld nebulizer or by intermittent positive-pressure breathing.

? Brain death is irreversible cessation of brain function.

? Continuous ambulatory peritoneal dialysis requires four exchanges per day, 7 days per week, for a total of 168 hours per week.

? The classic adverse reactions to antihistamines are dry mouth, drowsiness, and blurred vision.

? Because of the risk of paralytic ileus, a patient who has received a general anesthetic can’t take anything by mouth until active bowel sounds are heard in all abdominal quadrants.

? The level of alpha-fetoprotein, a tumor marker, is elevated in patients who have testicular germ cell cancer.

? Clinical manifestations of orchitis caused by bacteria or mumps include high temperature, chills, and sudden pain in the involved testis.

? The level of prostate-specific antigen is elevated in patients with benign prostatic hyperplasia or prostate cancer.

? The level of prostatic acid phosphatase is elevated in patients with advanced stages of prostate cancer.

? Phenylephrine (Neo-Synephrine), a mydriatic, is instilled in a patient’s eye to dilate the eye.

? To promote fluid drainage and relieve edema in a patient with epididymitis, the nurse should elevate the scrotum on a scrotal bridge.

? Fluorescein staining is commonly used to assess corneal abrasions because it outlines superficial epithelial defects.

? Presbyopia is loss of near vision as a result of the loss of elasticity of the crystalline lens.

? Transient ischemic attacks are considered precursors to strokes.
? A sign of acute appendicitis, McBurney’s sign is tenderness at McBurney’s point (about 2″ [5 cm] from the right anterior superior iliac spine on a line between the spine and the umbilicus).

? When caring for a patient with Guillain-Barré syndrome, the nurse should focus on respiratory interventions as the disease process advances.

? Signs and symptoms of colon cancer include rectal bleeding, change in bowel habits, intestinal obstruction, abdominal pain, weight loss, anorexia, nausea, and vomiting.

? Symptoms of prostatitis include frequent urination and dysuria.

? A chancre is a painless, ulcerative lesion that develops during the primary stage of syphilis.

? During the tertiary stage of syphilis, spirochetes invade the internal organs and cause permanent damage.

? In total parenteral nutrition, weight gain is the most reliable indicator of a positive response to therapy.

? The nurse may administer an I.V. fat emulsion through a central or peripheral catheter, but shouldn’t use an in-line filter because the fat particles are too large to pass through the pores.

? If a patient who has a prostatectomy is using a Cunningham clamp, instruct him to wash and dry his penis before applying the clamp. He should apply the clamp horizontally and remove it at least every 4 hours to empty his bladder to prevent infection.

? If a woman has signs of urinary tract infection during menopause, she should be instructed to drink six to eight glasses of water per day, urinate before and after intercourse, and perform Kegel exercises.

? If a menopausal patient experiences a “hot flash,” she should be instructed to seek a cool, breezy location and sip a cool drink.

? Cheilosis causes fissures at the angles of the mouth and indicates a vitamin B2, riboflavin, or iron deficiency.

? Tetany may result from hypocalcemia caused by hypoparathyroidism.

? A patient who has cervical cancer may experience vaginal bleeding for 1 to 3 months after intracavitary radiation.

? Ascites is the accumulation of fluid, containing large amounts of protein and electrolytes, in the abdominal cavity. It’s commonly caused by cirrhosis.

? Normal pulmonary artery pressure is 10 to 25 mm Hg. Normal pulmonary artery wedge pressure is 5 to 12 mm Hg.

? After cardiac catheterization, the site is monitored for bleeding and hematoma formation, pulses distal to the site are palpated every 15 minutes for 1 hour, and the patient is maintained on bed rest with the extremity extended for 8 hours.

? Hemophilia is a bleeding disorder that’s transmitted genetically in a sex-linked (X chromosome) recessive pattern. Although girls and women may carry the defective gene, hemophilia usually occurs only in boys and men.

? Von Willebrand’s disease is an autosomal dominant bleeding disorder that’s caused by platelet dysfunction and factor VIII deficiency.

? Sickle cell anemia is a congenital hemolytic anemia that’s caused by defective hemoglobin S molecules. It primarily affects blacks.

? Sickle cell anemia has a homozygous inheritance pattern. Sickle cell trait has a heterozygous inheritance pattern.

? Pel-Ebstein fever is a characteristic sign of Hodgkin’s disease. Fever recurs every few days or weeks and alternates with afebrile periods.

? Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited metabolic disorder that’s characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis.

? Preferred sites for bone marrow aspiration are the posterior superior iliac crest, anterior iliac crest, and sternum.

? During bone marrow harvesting, the donor receives general anesthesia and 400 to 800 ml of marrow is aspirated.

? A butterfly rash across the bridge of the nose is a characteristic sign of systemic lupus erythematosus.

? Rheumatoid arthritis is a chronic, destructive collagen disease characterized by symmetric inflammation of the synovium that leads to joint swelling.

? Screening for human immunodeficiency virus antibodies begins with the enzyme-linked immunosorbent assay. Results are confirmed by the Western blot test.

? The CK-MB isoenzyme level increases 4 to 8 hours after a myocardial infarction, peaks at 12 to 24 hours, and returns to normal in 3 days.

? Excessive intake of vitamin K may significantly antagonize the anticoagulant effects of warfarin (Coumadin). The patient should be cautioned to avoid eating an excessive amount of leafy green vegetables.

? A lymph node biopsy that shows Reed-Sternberg cells provides a definitive diagnosis of Hodgkin’s disease.

? Bell’s palsy is unilateral facial weakness or paralysis caused by a disturbance of the seventh cranial (facial) nerve.

? During an initial tuberculin skin test, lack of a wheal after injection of tuberculin purified protein derivative indicates that the test dose was injected too deeply. The nurse should inject another dose at least 2″ (5 cm) from the initial site.

? A tuberculin skin test should be read 48 to 72 hours after administration.

? In reading a tuberculin skin test, erythema without induration is usually not significant.

? Death caused by botulism usually results from delayed diagnosis and respiratory complications.

? In a patient who has rabies, saliva contains the virus and is a hazard for nurses who provide care.

? A febrile nonhemolytic reaction is the most common transfusion reaction.

? Hypokalemia (abnormally low concentration of potassium in the blood) may cause muscle weakness or paralysis, electrocardiographic abnormalities, and GI disturbances.

? Beriberi, a serious vitamin B1 (thiamine) deficiency, affects alcoholics who have poor dietary habits. It’s epidemic in Asian countries where people subsist on unenriched rice. It’s characterized by the phrase “I can’t,” indicating that the patient is too ill to do anything.

? Excessive sedation may cause respiratory depression.

? The primary postoperative concern is maintenance of a patent airway.

? If cyanosis occurs circumorally, sublingually, or in the nail bed, the oxygen saturation level (Sao 2) is less than 80%.

? A rapid pulse rate in a postoperative patient may indicate pain, bleeding, dehydration, or shock.

? Increased pulse rate and blood pressure may indicate that a patient is experiencing “silent pain” (pain that can’t be expressed verbally, such as when a patient is recovering from anesthesia).

? Lidocaine (Xylocaine) exerts antiarrhythmic action by suppressing automaticity in the Purkinje fibers and elevating the electrical stimulation threshold in the ventricles.

? Cullen’s sign (a bluish discoloration around the umbilicus) is seen in patients who have a perforated pancreas.

? During the postoperative period, the patient should cough and breathe deeply every 2 hours unless otherwise contraindicated (for example, after craniotomy, cataract surgery, or throat surgery).

? Before surgery, a patient’s respiratory volume may be measured by incentive spirometry. This measurement becomes the patient’s postoperative goal for respiratory volume.

? The postoperative patient should use incentive spirometry 10 to 12 times per hour and breathe deeply.

? Before ambulating, a postoperative patient should dangle his legs over the side of the bed and perform deep-breathing exercises.

? During the patient’s first postoperative ambulation, the nurse should monitor the patient closely and assist him as needed while he walks a few feet from the bed to a steady chair.

? Hypovolemia occurs when 15% to 25% of the body’s total blood volume is lost.

? Signs and symptoms of hypovolemia include rapid, weak pulse; low blood pressure; cool, clammy skin; shallow respirations; oliguria or anuria; and lethargy.

? Acute pericarditis causes sudden severe, constant pain over the anterior chest. The pain is aggravated by inspiration.

? Signs and symptoms of septicemia include fever, chills, rash, abdominal distention, prostration, pain, headache, nausea, and diarrhea.

? Rocky Mountain spotted fever causes a persistent high fever, nonpitting edema, and rash.

? Patients who have undergone coronary artery bypass graft should sleep 6 to 10 hours per day, take their temperature twice daily, and avoid lifting more than 10 lb (4.5 kg) for at least 6 weeks.

? Claudication pain (pain on ambulation) is caused by arterial insufficiency as a result of atheromatous plaque that obstructs arterial blood flow to the extremities.

? Pacemakers can be powered by lithium batteries for up to 10 years.

? The patient shouldn’t void for 1 hour before percutaneous suprapubic bladder aspiration to ensure that sufficient urine remains in the bladder to make the procedure successful.

? Left-sided heart failure causes pulmonary congestion, pink-tinged sputum, and dyspnea. (Remember L for left and lung.)

? The current recommended blood cholesterol level is less than 200 mg/dl.

? When caring for a patient who is having a seizure, the nurse should follow these guidelines: (1) Avoid restraining the patient, but help a standing patient to a lying position. (2) Loosen restrictive clothing. (3) Place a pillow or another soft object under the patient’s head. (4) Clear the area of hard objects. (5) Don’t force anything into the patient’s mouth, but maintain a patent airway. (6) Reassure and reorient the patient after the seizure subsides.

? Gingival hyperplasia, or overgrowth of gum tissue, is an adverse reaction to phenytoin (Dilantin).

? With aging, most marrow in long bones becomes yellow, but it retains the capacity to convert back to red.

? Clinical manifestations of lymphedema include accumulation of fluid in the legs.

? Afterload is ventricular wall tension during systolic ejection. It’s increased in patients who have septal hypertrophy, increased blood viscosity, and conditions that cause blockage of aortic or pulmonary outflow.

? Red blood cells can be stored frozen for up to 2 years; however, they must be used within 24 hours of thawing.

? For the first 24 hours after amputation, the nurse should elevate the stump to prevent edema.

? After hysterectomy, a woman should avoid sexual intercourse for 3 weeks if a vaginal approach was used and 6 weeks if the abdominal approach was used.

? Parkinson’s disease characteristically causes progressive muscle rigidity, akinesia, and involuntary tremor.

? Tonic-clonic seizures are characterized by a loss of consciousness and alternating periods of muscle contraction and relaxation.

? Status epilepticus, a life-threatening emergency, is a series of rapidly repeating seizures that occur without intervening periods of consciousness.

? The ideal donor for kidney transplantation is an identical twin. If an identical twin isn’t available, a biological sibling is the next best choice.

? Breast cancer is the leading cancer among women; however, lung cancer accounts for more deaths.

? The stages of cervical cancer are as follows: stage 0, carcinoma in situ; stage I, cancer confined to the cervix; stage II, cancer extending beyond the cervix, but not to the pelvic wall; stage III, cancer extending to the pelvic wall; and stage IV, cancer extending beyond the pelvis or within the bladder or rectum.

? One method used to estimate blood loss after a hysterectomy is counting perineal pads. Saturating more than one pad in 1 hour or eight pads in 24 hours is considered hemorrhaging.

? Transurethral resection of the prostate is the most common procedure for treating benign prostatic hyperplasia.

? In a chest drainage system, the water in the water-seal chamber normally rises when a patient breathes in and falls when he breathes out.

? Spinal fusion provides spinal stability through a bone graft, usually from the iliac crest, that fuses two or more vertebrae.

? A patient who receives any type of transplant must take an immunosuppressant drug for the rest of his life.

? Incentive spirometry should be used 5 to 10 times an hour while the patient is awake.

? In women, pelvic inflammatory disease is a common complication of gonorrhea.

? Scoliosis is lateral S-shaped curvature of the spine.

? Signs and symptoms of the secondary stage of syphilis include a rash on the palms and soles, erosion of the oral mucosa, alopecia, and enlarged lymph nodes.

? In a patient who is receiving total parenteral nutrition, the nurse should monitor glucose and electrolyte levels.

? Unless contraindicated, on admission to the postanesthesia care unit, a patient should be turned on his side and his vital signs should be taken.

? Edema is treated by limiting fluid intake and eliminating excess fluid.

? A patient who has had spinal anesthesia should remain flat for 12 to 24 hours. Vital signs and neuromuscular function should be monitored.

? A patient who has maple syrup urine disease should avoid food containing the amino acids leucine, isoleucine, and lysine.

? A severe complication of a femur fracture is excessive blood loss that results in shock.

? To prepare a patient for peritoneal dialysis, the nurse should ask the patient to void, measure his vital signs, place him in a supine position, and using aseptic technique, insert a catheter through the abdominal wall and into the peritoneal space.

? If more than 3 L of dialysate solution return during peritoneal dialysis, the nurse should notify the physician.

? Hemodialysis is the removal of certain elements from the blood by passing heparinized blood through a semipermeable membrane to the dialysate bath, which contains all of the important electrolytes in their ideal concentrations.

? Gangrene usually affects the digits first, and begins with skin color changes that progress from gray-blue to dark brown or black.

? Kidney function is assessed by evaluating blood urea nitrogen (normal range is 8 to 20 mg/dl) and serum creatinine (normal range is 0.6 to 1.3 mg/dl) levels.

? A weight-bearing transfer is appropriate only for a patient who has at least one leg that’s strong enough to bear weight, such as a patient with hemiplegia or a single-leg amputation.

? Overflow incontinence (voiding of 30 to 60 ml of urine every 15 to 30 minutes) is a sign of bladder distention.

? The first sign of a pressure ulcer is reddened skin that blanches when pressure is applied.

? Late signs and symptoms of sickle cell anemia include tachycardia, cardiomegaly, systolic and diastolic murmurs, chronic fatigue, hepatomegaly, and splenomegaly.

? A mechanical ventilator, which can maintain ventilation automatically for an extended period, is indicated when a patient can’t maintain a safe PaO2 or PaCO2 level.

? Two types of mechanical ventilators exist: negative-pressure ventilators, which apply negative pressure around the chest wall, and positive-pressure ventilators, which deliver air under pressure to the patient.

? Angina pectoris is characterized by substernal pain that lasts for 2 to 3 minutes. The pain, which is caused by myocardial ischemia, may radiate to the neck, shoulders, or jaw; is described as viselike, or constricting; and may be accompanied by severe apprehension or a feeling of impending doom.

? The diagnosis of an acute myocardial infarction is based on the patient’s signs and symptoms, electrocardiogram tracings, troponin level, and cardiac enzyme studies.

? The goal of treatment for a patient with angina pectoris is to reduce the heart’s workload, thereby reducing the myocardial demand for oxygen and preventing myocardial infarction.

? Nitroglycerin decreases the amount of blood that returns to the heart by increasing the capacity of the venous bed.

? The patient should take no more than three nitroglycerin tablets in a 15-minute period.

? Hemodialysis is usually performed 24 hours before kidney transplantation.

? Signs and symptoms of acute kidney transplant rejection are progressive enlargement and tenderness at the transplant site, increased blood pressure, decreased urine output, elevated serum creatinine level, and fever.

? After a radical mastectomy, the patient’s arm should be elevated (with the hand above the elbow) on a pillow to enhance circulation and prevent edema.

? Postoperative mastectomy care includes teaching the patient arm exercises to facilitate lymph drainage and prevent shortening of the muscle and contracture of the shoulder joint (frozen shoulder).

? After radical mastectomy, the patient should help prevent infection by making sure that no blood pressure readings, injections, or venipunctures are performed on the affected arm.

? For a patient who has undergone mastectomy and is susceptible to lymphedema, a program of hand exercises can begin shortly after surgery, if prescribed. The program consists of opening and closing the hand tightly six to eight times per hour and performing such tasks as washing the face and combing the hair.

? Signs and symptoms of theophylline toxicity include vomiting, restlessness, and an apical pulse rate of more than 200 beats/minute.

? The nurse shouldn’t induce vomiting in a person who has ingested poison and is having seizures or is semiconscious or comatose.

? Central venous pressure (CVP), which is the pressure in the right atrium and the great veins of the thorax, is normally 2 to 8 mm Hg (or 5 to 12 cm H2O). CVP is used to assess right-sided cardiac function.

? CVP is monitored to assess the need for fluid replacement in seriously ill patients, to estimate blood volume deficits, and to evaluate circulatory pressure in the right atrium.

? To prevent deep vein thrombosis after surgery, the nurse should administer 5,000 units of heparin subcutaneously every 8 to 12 hours, as prescribed.

? Oral anticoagulants, such as warfarin (Coumadin) and dicumarol, disrupt natural blood clotting mechanisms, prevent thrombus formation, and limit the extension of a formed thrombus.

? Anticoagulants can’t dissolve a formed thrombus.

? Anticoagulant therapy is contraindicated in a patient who has liver or kidney disease or GI ulcers or who isn’t likely to return for follow-up visits.

? The nurse can assess a patient for thrombophlebitis by measuring the affected and unaffected legs and comparing their sizes. The nurse should mark the measurement locations with a pen so that the legs can be measured at the same place each day.

? Drainage of more than 3,000 ml of fluid daily from a nasogastric tube may suggest intestinal obstruction. Yellow drainage that has a foul odor may indicate small-bowel obstruction.

? Preparation for sigmoidoscopy includes administering an enema 1 hour before the examination, warming the scope in warm water or a sterilizer (if using a metal sigmoidoscope), and draping the patient to expose the perineum.

? Treatment for a patient with bleeding esophageal varices includes administering vasopressin (Pitressin), giving an ice water lavage, aspirating blood from the stomach, using esophageal balloon tamponade, providing parenteral nutrition, and administering blood transfusions, as needed.

? A trauma victim shouldn’t be moved until a patent airway is established and the cervical spine is immobilized.

? After a mastectomy, lymphedema may cause a feeling of heaviness in the affected arm.

? A dying patient shouldn’t be told exactly how long he’s expected to live, but should be told something more general such as “Some people live 3 to 6 months, but others live longer.”

? After eye surgery, a patient should avoid using makeup until otherwise instructed.

? After a corneal transplant, the patient should wear an eye shield when engaging in activities such as playing with children or pets.

? After a corneal transplant, the patient shouldn’t lie on the affected site, bend at the waist, or have sexual intercourse for 1 week. The patient must avoid getting soapsuds in the eye.

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