Medical-Surgical Nursing Certification Flashcards

A patient is receiving a blood transfusion and develops fever, chills, and flank pain 15 minutes after starting. The nurse's priority action is:

Answer: Stop the transfusion, maintain IV access with NS, and notify the provider

These symptoms suggest an acute hemolytic transfusion reaction; stopping the transfusion immediately is the priority to prevent further harm.

A patient with chronic kidney disease has a potassium level of 6.3 mEq/L and peaked T-waves on ECG. Which intervention is most urgent?

Answer: Administer calcium gluconate IV to stabilize cardiac membranes

Calcium gluconate is the fastest intervention to stabilize cardiac membrane potential and prevent life-threatening arrhythmia from hyperkalemia.

Post-op day 1 after a right hemicolectomy, a patient's ostomy stoma appears pale and dusky. What is the correct interpretation?

Answer: Possible stoma ischemia requiring immediate provider notification

A healthy stoma should be beefy red; a pale or dusky stoma suggests ischemia or necrosis requiring urgent assessment.

A patient has serum sodium of 118 mEq/L and is symptomatic with seizures. Which IV solution is indicated?

Answer: 3% Hypertonic saline

Severe symptomatic hyponatremia with seizures requires hypertonic (3%) saline to rapidly correct sodium and resolve neurologic symptoms.

A patient with a chest tube develops subcutaneous emphysema around the insertion site. What does this indicate?

Answer: Air is leaking into the subcutaneous tissue, possibly indicating tube displacement

Subcutaneous emphysema (crepitus around the insertion site) suggests the chest tube has become dislodged or there is an air leak.

Which preoperative nursing intervention most reduces the risk of surgical site infection (SSI)?

Answer: Administering prophylactic antibiotics within 60 minutes before incision

Evidence-based SSI prevention bundles include prophylactic antibiotics given within 60 minutes before surgical incision.