Medical-Surgical Nursing Flashcards

Which assessment finding in a post-thyroidectomy patient requires immediate nursing action?

Answer: Tetany, tingling around the mouth, and positive Trousseau's sign

Tetany and positive Trousseau's sign indicate hypocalcaemia due to accidental parathyroid gland damage during thyroidectomy, a life-threatening emergency requiring immediate intervention.

What is the primary purpose of incentive spirometry in post-operative patients?

Answer: To encourage deep breathing and prevent atelectasis

Incentive spirometry promotes sustained maximal inspiration, expanding alveoli and preventing atelectasis—a common post-operative pulmonary complication.

A patient with a chest tube to water-seal drainage shows continuous bubbling in the water-seal chamber. What does this indicate?

Answer: Air leak in the system or lung

Continuous bubbling in the water-seal chamber (not during respiration only) suggests an ongoing air leak, either from the patient's lung or a break in the drainage system.

Which finding indicates fluid volume excess (hypervolaemia) in a medical-surgical patient?

Answer: Bounding pulse, crackles in lung bases, and peripheral oedema

Fluid volume excess causes increased vascular pressure, leading to a bounding pulse, pulmonary oedema heard as crackles, and peripheral oedema from fluid shifting into tissues.

Before administering a blood transfusion, which nursing action is the most critical safety step?

Answer: Two-nurse verification of patient identity and blood product compatibility

Two-nurse identity and blood product verification is the critical safety check that prevents transfusion reactions caused by administering incompatible blood.

Which position should a patient be placed in after a lumbar puncture to help prevent a post-procedure headache?

Answer: Supine (flat) for 1–4 hours as instructed

Lying supine after a lumbar puncture reduces CSF pressure at the puncture site and helps prevent post-lumbar puncture headache caused by CSF leakage.