Medical Surgical Nursing Bullet III (Belajar KMB itu mudah)

? A Milwaukee brace is used for patients who have structural scoliosis. The brace helps to halt the progression of spinal curvature by providing longitudinal traction and lateral pressure. It should be worn 23 hours a day.
? Short-term measures used to treat stomal retraction include stool softeners, irrigation, and stomal dilatation.
? A patient who has a colostomy should be advised to eat a low-residue diet for 4 to 6 weeks and then to add one food at a time to evaluate its effect.
? To relieve postoperative hiccups, the patient should breathe into a paper bag.
? If a patient with an ileostomy has a blocked lumen as a result of undigested high-fiber food, the patient should be placed in the knee-chest position and the area below the stoma should be massaged.
? During the initial interview and treatment of a patient with syphilis, the patient’s sexual contacts should be identified.
? The nurse shouldn’t administer morphine to a patient whose respiratory rate is less than 12 breaths/minute.
? To prevent drying of the mucous membranes, oxygen should be administered with hydration.
? Flavoxate (Urispas) is classified as a urinary tract spasmolytic.
? Hypotension is a sign of cardiogenic shock in a patient with a myocardial infarction.
? The predominant signs of mechanical ileus are cramping pain, vomiting, distention, and inability to pass feces or flatus.
? For a patient with a myocardial infarction, the nurse should monitor fluid intake and output meticulously. Too little intake causes dehydration, and too much may cause pulmonary edema.
? Nitroglycerin relaxes smooth muscle, causing vasodilation and relieving the chest pain associated with myocardial infarction and angina.
? The diagnosis of an acute myocardial infarction is based on the patient’s signs and symptoms, electrocardiogram tracings, and serum enzyme studies.
? Arrhythmias are the predominant problem during the first 48 hours after a myocardial infarction.
? Clinical manifestations of malabsorption include weight loss, muscle wasting, bloating, and steatorrhea.
? Asparaginase, an enzyme that inhibits the synthesis of deoxyribonucleic acid and protein, is used to treat acute lymphocytic leukemia.
? To relieve a patient’s sore throat that’s caused by nasogastric tube irritation, the nurse should provide anesthetic lozenges, as prescribed.
? For the first 12 to 24 hours after gastric surgery, the stomach contents (obtained by suctioning) are brown.
? After gastric suctioning is discontinued, a patient who is recovering from a subtotal gastrectomy should receive a clear liquid diet.
? The descending colon is the preferred site for a permanent colostomy.
? Valvular insufficiency in the veins commonly causes varicosity.
? A patient with a colostomy should restrict fat and fibrous foods and should avoid foods that can obstruct the stoma, such as corn, nuts, and cabbage.
? A patient who is receiving chemotherapy is placed in reverse isolation because the white blood cell count may be depressed.
? Symptoms of mitral valve stenosis are caused by improper emptying of the left atrium.
? Persistent bleeding after open heart surgery may require the administration of protamine sulfate to reverse the effects of heparin sodium used during surgery.
? The nurse should teach a patient with heart failure to take digoxin and other drugs as prescribed, to restrict sodium intake, to restrict fluids as prescribed, to get adequate rest, to increase walking and other activities gradually, to avoid extremes of temperature, to report signs of
? The nurse should check and maintain the patency of all connections for a chest tube. If an air leak is detected, the nurse should place one Kelly clamp near the insertion site. If the bubbling stops, the leak is in the thoracic cavity and the physician should be notified immediately. If the leak continues, the nurse should take a second clamp, work down the tube until the leak is located, and stop the leak.
? In two-person cardiopulmonary resuscitation, the rescuers administer 60 chest compressions per minute and 1 breath for every 5 compressions.
? Mitral valve stenosis can result from rheumatic fever.
? Atelectasis is incomplete expansion of lung segments or lobules (clusters of alveoli). It may cause the lung or lobe to collapse.
? The nurse should instruct a patient who has an ileal conduit to empty the collection device frequently because the weight of the urine may cause the device to slip from the skin.
? A patient who is receiving cardiopulmonary resuscitation should be placed on a solid, flat surface.
? Brain damage occurs 4 to 6 minutes after cardiopulmonary function ceases.
? Climacteric is the transition period during which a woman’s reproductive function diminishes and gradually disappears.
? After infratentorial surgery, the patient should remain on his side, flat in bed.
? In a patient who has an ulcer, milk is contraindicated because its high calcium content stimulates secretion of gastric acid.
? A patient who has a positive test result for human immunodeficiency virus has been exposed to the virus associated with acquired immunodeficiency syndrome (AIDS), but doesn’t necessarily have AIDS.
? A common complication after prostatectomy is circulatory failure caused by bleeding.
? In right-sided heart failure, a major focus of nursing care is decreasing the workload of the heart.
? Signs and symptoms of digoxin toxicity include nausea, vomiting, confusion, and arrhythmias.
? An asthma attack typically begins with wheezing, coughing, and increasing respiratory distress.
? In a patient who is recovering from a tonsillectomy, frequent swallowing suggests hemorrhage.
? Ileostomies and Hartmann’s colostomies are permanent stomas. Loop colostomies and double-barrel colostomies are temporary ones.
? A patient who has an ileostomy should eat foods, such as spinach and parsley, because they act as intestinal tract deodorizers.
? An adrenalectomy can decrease steroid production, which can cause extensive loss of sodium and water.
? Before administering morphine (Duramorph) to a patient who is suspected of having a myocardial infarction, the nurse should check the patient’s respiratory rate. If it’s less than 12 breaths/minute, emergency equipment should be readily available for intubation if respiratory depression occurs.
? A patient who is recovering from supratentorial surgery is normally allowed out of bed 14 to 48 hours after surgery. A patient who is recovering from infratentorial surgery normally remains on bed rest for 3 to 5 days.
? After a patient undergoes a femoral-popliteal bypass graft, the nurse must closely monitor the peripheral pulses distal to the operative site and circulation.
? After a femoral-popliteal bypass graft, the patient should initially be maintained in a semi-Fowler position to avoid flexion of the graft site. Before discharge, the nurse should instruct the patient to avoid positions that put pressure on the graft site until the next follow-up visit.
? Of the five senses, hearing is the last to be lost in a patient who is entering a coma.
? Cholelithiasis causes an enlarged, edematous gallbladder with multiple stones and an elevated bilirubin level.
? The antiviral agent zidovudine (Retrovir) successfully slows replication of the human immunodeficiency virus, thereby slowing the development of acquired immunodeficiency syndrome.
? Severe rheumatoid arthritis causes marked edema and congestion, spindle-shaped joints, and severe flexion deformities.
? A patient with acquired immunodeficiency syndrome should advise his sexual partners of his human immunodeficiency virus status and observe sexual precautions, such as abstinence or condom use.
? If a radioactive implant becomes dislodged, the nurse should retrieve it with tongs, place it in a lead-shielded container, and notify the radiology department.
? A patient who is undergoing radiation therapy should pat his skin dry to avoid abrasions that could easily become infected.
? During radiation therapy, a patient should have frequent blood tests, especially white blood cell and platelet counts.
? The nurse should administer an aluminum hydroxide antacid at least 1 hour after an enteric-coated drug because it can cause premature release of the enteric-coated drug in the stomach.
? Acid-base balance is the body’s hydrogen ion concentration, a measure of the ratio of carbonic acid to bicarbonate ions (1 part carbonic acid to 20 parts bicarbonate is normal).
? Amyotrophic lateral sclerosis causes progressive atrophy and wasting of muscle groups that eventually affects the respiratory muscles.
? Metabolic acidosis is caused by abnormal loss of bicarbonate ions or excessive production or retention of acid ions.
? Hemianopsia is defective vision or blindness in one-half of the visual field of one or both eyes.
? Systemic lupus erythematosus causes early-morning joint stiffness and facial erythema in a butterfly pattern.
? After total knee replacement, the patient should remain in the semi-Fowler position, with the affected leg elevated.
? In a patient who is receiving transpyloric feedings, the nurse should watch for dumping syndrome and hypovolemic shock because the stomach is being bypassed.
? If a total parenteral nutrition infusion must be interrupted, the nurse should administer dextrose 5% in water at a similar rate. Abrupt cessation can cause hypoglycemia.
? Status epilepticus is treated with I.V. diazepam (Valium) and phenytoin (Dilantin).
? Disequilibrium syndrome causes nausea, vomiting, restlessness, and twitching in patients who are undergoing dialysis. It’s caused by a rapid fluid shift.
? An indication that spinal shock is resolving is the return of reflex activity in the arms and legs below the level of injury.
? Hypovolemia is the most common and fatal complication of severe acute pancreatitis.
? In a patient with stomatitis, oral care includes rinsing the mouth with a mixture of equal parts of hydrogen peroxide and water three times daily.
? In otitis media, the tympanic membrane is bright red and lacks its characteristic light reflex (cone of light).
? In patients who have pericardiocentesis, fluid is aspirated from the pericardial sac for analysis or to relieve cardiac tamponade.
? Urticaria is an early sign of hemolytic transfusion reaction.
? During peritoneal dialysis, a return of brown dialysate suggests bowel perforation. The physician should be notified immediately.
? An early sign of ketoacidosis is polyuria, which is caused by osmotic diuresis.
? Patients who have multiple sclerosis should visually inspect their extremities to ensure proper alignment and freedom from injury.
? Aspirated red bone marrow usually appears rust-red, with visible fatty material and white bone fragments.
? The Dick test detects scarlet fever antigens and immunity or susceptibility to scarlet fever. A positive result indicates no immunity; a negative result indicates immunity.
? The Schick test detects diphtheria antigens and immunity or susceptibility to diphtheria. A positive result indicates no immunity; a negative result indicates immunity.
? The recommended adult dosage of sucralfate (Carafate) for duodenal ulcer is 1 g (1 tablet) four times daily 1 hour before meals and at bedtime.
? A patient with facial burns or smoke or heat inhalation should be admitted to the hospital for 24-hour observation for delayed tracheal edema.
? In addition to patient teaching, preparation for a colostomy includes withholding oral intake overnight, performing bowel preparation, and administering a cleansing enema.
? The physiologic changes caused by burn injuries can be divided into two stages: the hypovolemic stage, during which intravascular fluid shifts into the interstitial space, and the diuretic stage, during which capillary integrity and intravascular volume are restored, usually 48 to 72 hours after the injury.
? The nurse should change total parenteral nutrition tubing every 24 hours and the peripheral I.V. access site dressing every 72 hours.
? A patient whose carbon monoxide level is 20% to 30% should be treated with 100% humidified oxygen.
? When in the room of a patient who is in isolation for tuberculosis, staff and visitors should wear ultrafilter masks.
? When providing skin care immediately after pin insertion, the nurse’s primary concern is prevention of bone infection.
? After an amputation, moist skin may indicate venous stasis; dry skin may indicate arterial obstruction.
? In a patient who is receiving dialysis, an internal shunt is working if the nurse feels a thrill on palpation or hears a bruit on auscultation.
? In a patient with viral hepatitis, the parenchymal, or Kupffer’s, cells of the liver become severely inflamed, enlarged, and necrotic.
? Early signs of acquired immunodeficiency syndrome include fatigue, night sweats, enlarged lymph nodes, anorexia, weight loss, pallor, and fever.
? When caring for a patient who has a radioactive implant, health care workers should stay as far away from the radiation source as possible. They should remember the axiom, “If you double the distance, you quarter the dose.”
? A patient who has Parkinson’s disease should be instructed to walk with a broad-based gait.
? The cardinal signs of Parkinson’s disease are muscle rigidity, a tremor that begins in the fingers, and akinesia.
? In a patient with Parkinson’s disease, levodopa (Dopar) is prescribed to compensate for the dopamine deficiency.
? A patient who has multiple sclerosis is at increased risk for pressure ulcers.
? Pill-rolling tremor is a classic sign of Parkinson’s disease.
? For a patient with Parkinson’s disease, nursing interventions are palliative.
? Fat embolism, a serious complication of a long-bone fracture, causes fever, tachycardia, tachypnea, and anxiety.
? Metrorrhagia (bleeding between menstrual periods) may be the first sign of cervical cancer.
? Mannitol is a hypertonic solution and an osmotic diuretic that’s used in the treatment of increased intracranial pressure.
? The classic sign of an absence seizure is a vacant facial expression.
? Migraine headaches cause persistent, severe pain that usually occurs in the temporal region.
? A patient who is in a bladder retraining program should be given an opportunity to void every 2 hours during the day and twice at night.
? In a patient with a head injury, a decrease in level of consciousness is a cardinal sign of increased intracranial pressure.

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