Medical-Surgical Nursing Certification Flashcards

A patient post-op for abdominal surgery develops a fever of 38.5°C on postoperative day 2. What is the most likely cause?

Answer: Pulmonary atelectasis

Pulmonary atelectasis is the most common cause of fever in the first 48 hours after surgery due to hypoventilation.

A patient develops acute respiratory distress with absent breath sounds on the left side after central line placement. What is the priority intervention?

Answer: Prepare for immediate needle decompression or chest tube insertion

Absent breath sounds after central line placement indicate tension pneumothorax, requiring immediate decompression.

Which electrolyte imbalance is most commonly associated with prolonged nasogastric suctioning?

Answer: Hypokalemia and metabolic alkalosis

NG suctioning causes loss of HCl and K+, resulting in hypokalemia and metabolic alkalosis.

A patient with type 1 diabetes presents with Kussmaul respirations, fruity breath, and blood glucose of 480 mg/dL. This presentation is consistent with:

Answer: Diabetic ketoacidosis (DKA)

DKA presents with Kussmaul respirations (compensatory for metabolic acidosis), fruity breath from ketones, and high glucose.

A patient with a history of atrial fibrillation is anticoagulated. The nurse assesses sudden onset of severe right leg pain, pallor, and pulselessness. What is the priority action?

Answer: Notify the provider immediately for suspected acute arterial occlusion

The 6 Ps of arterial occlusion (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia) require immediate provider notification and intervention.

Which finding is most indicative of increased intracranial pressure (ICP) in a patient with a traumatic brain injury?

Answer: Cushing's triad: hypertension, bradycardia, and irregular respirations

Cushing's triad (hypertension, bradycardia, irregular respirations) is a late, ominous sign of severely elevated ICP.