Medical-Surgical Nursing Flashcards

A patient returns from colostomy surgery. What should the nurse teach regarding stoma colour?

Answer: The stoma should be moist and pink or red; a dark or black colour indicates ischaemia

A healthy stoma is moist and pink-to-red due to good blood supply; a dark or black stoma signals ischaemia and requires immediate medical attention.

Which nursing measure is most effective in preventing surgical site infections (SSI)?

Answer: Strict sterile technique during dressing changes and proper hand hygiene

Maintaining sterile technique during wound care and rigorous hand hygiene are the most evidence-based measures to prevent surgical site infections.

What is the most common early sign of increased intracranial pressure (ICP) in a neuro-surgical patient?

Answer: Decreasing level of consciousness / altered mental status

A change in level of consciousness is the earliest and most sensitive indicator of rising intracranial pressure as cerebral perfusion is compromised.

A patient with Cushing's syndrome is most at risk for which metabolic complication?

Answer: Hyperglycaemia and diabetes mellitus

Excess cortisol in Cushing's syndrome promotes gluconeogenesis and insulin resistance, leading to hyperglycaemia and secondary diabetes mellitus.

Which nursing intervention is the priority for a patient in hypovolaemic shock?

Answer: Rapid IV fluid resuscitation to restore circulating volume

Hypovolaemic shock results from inadequate circulating volume; rapid IV fluid resuscitation is the cornerstone treatment to restore perfusion pressure.

Which type of wound healing occurs when wound edges are surgically approximated and closed?

Answer: Primary intention

Primary intention healing occurs when clean wound edges are brought together (e.g., by sutures or staples), allowing rapid healing with minimal scarring.