Medical-Surgical Nursing Notes

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By nclexnursing

Medical Nursing Notes. In a patient with hypokalemia, serum potassium level below 3.5 mEq/L, exhibiting signs and symptoms involve muscle weakness and cardiac arrhythmias.

During cardiac arrest, if an I.V. route is unavailable, epinephrine can be administered endotracheally.

Pernicious anemia results from the failure to absorb vitamin B12 in the G.I. tract and primarily causes G.I. and neurologic signs and symptoms.

A client who has a pressure ulcer should eat a high-protein, high-calorie diet unless contraindicated.

The CK-MB isoenzyme level is used to assess tissue damage in myocardial infarction.

After a 12-hour fast, the average fasting blood glucose level is 80 to 120 mg/dl.

A patient experiencing digoxin toxicity may report nausea, vomiting, diplopia, blurred vision, light flashes, and yellow-green halos around images.

Anuria is daily urine output of fewer than 100 ml.In remittent fever, the body temperature varies over 24 hours but remains elevated. The risk of a fat embolism is most significant in the first 48 hours after the fracture of a long bone. It’s exhibited by respiratory distress.

To help venous blood return in a patient in shock, the nurse should elevate the patient’s legs no more than 45 degrees. This method is contraindicated in a patient with a head injury.

When taken simultaneously by two nurses, the pulse deficit is the difference between the apical and radial pulse rates.

The nurse should schedule postural drainage before meals or 2 to 4 hours after meals to reduce the patient’s risk of vomiting and aspiration.

Blood pressure can be measured directly by intra-arterial insertion of a catheter connected to a pressure-monitoring device.

A positive Kernig’s sign, seen in meningitis, occurs when an attempt to flex the hip of a recumbent patient causes painful spasms of the hamstring muscle and resistance to further extension of the leg at the knee.

In a patient with a fractured, dislocated femur, treatment begins with reducing and immobilizing the affected leg.

Herniated nucleus pulposus (intervertebral disk) most commonly occurs in the lumbar and lumbosacral regions.

Laminectomy is the surgical removal of the herniated portion of an intervertebral disk.

Surgical treatment of a gastric ulcer includes severing the vagus nerve (vagotomy) to reduce gastric acid secreted by the gastric cells.

Valsalva’s maneuver is forced exhalation against a closed glottis, as when taking a deep breath, blowing air out, or bearing down.

When mean arterial pressure falls below 60 mm Hg and systolic blood pressure fall below 80 mm Hg, and vital organ perfusion is seriously compromised.

Lidocaine (Xylocaine) is the drug of choice for reducing premature ventricular contractions.

A patient is at most significant risk of dying during the first 24 to 48 hours after myocardial infarction.

During a myocardial infarction, the left ventricle sustains the most significant damage typically.

The pain of a myocardial infarction results from myocardial ischemia caused by anoxia.

For a patient in cardiac arrest, the priority is to establish an airway.

The universal sign for choking is clutching the hand to the throat.

For a patient with heart failure or cardiogenic pulmonary edema, nursing interventions focus on decreasing venous return to the heart and increasing left ventricular output. These interventions include placing the patient in a high Fowler’s position and administering oxygen, diuretics, and positive inotropic drugs as prescribed.

A positive tuberculin skin test is an induration of 10 mm or greater at the injection site.

The signs and symptoms of histoplasmosis, a chronic systemic fungal infection, resemble those of tuberculosis.

In burn victims, the leading cause of death is respiratory compromise. The second leading cause is infection.

The exocrine function of the pancreas is the secretion of enzymes used to digest carbohydrates, fats, and proteins.

A patient with hepatitis A should consume a diet that’s moderately high in fat and high in carbohydrates and protein and eat the most important meal in the morning.

Esophageal balloon tamponade shouldn’t be inflated greater than 20 mm Hg.

Overproduction of prolactin by the pituitary gland can cause galactorrhea, excessive or abnormal lactation, and amenorrhea absence of menstruation.

Intermittent claudication pain during ambulation or another movement relieved with rest is a classic symptom of arterial insufficiency in the leg.

In bladder carcinoma, the most common finding is gross, painless hematuria.

Parenteral administration of heparin sodium is contraindicated in patients with renal or liver disease, GI bleeding, recent surgery or trauma, pregnant patients, and women older than age 60.

Drugs that potentiate the effects of anticoagulants include aspirin, chloral hydrate, glucagon, anabolic steroids, and chloramphenicol.

For a burn patient, care priorities include maintaining a patent airway, preventing or correcting fluid and electrolyte imbalances, controlling pain, and preventing infection.

Elastic stockings should be worn on both legs.

Active immunization is the formation of antibodies within the body in response to vaccination or exposure to disease.

Passive immunization is the administration of antibodies that were performed outside the body.

A patient receiving digoxin (Lanoxin) shouldn’t accept a calcium preparation because of the increased risk of digoxin toxicity. Concomitant use may affect cardiac contractility and lead to arrhythmias.

Intermittent positive-pressure breathing is inflation of the lung during inspiration with compressed air or oxygen. The goal of this inflation is to keep the lung open.

Wristdrop is caused by paralysis of the extensor muscles in the forearm and hand.

Footdrop results from excessive plantar flexion and are usually a complication of prolonged bed rest.

A patient who has gonorrhea may be treated with penicillin and probenecid (Benemid). Probenecid delays the excretion of penicillin and keeps this antibiotic in the body longer.

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