DHA Nursing Medical-Surgical Nursing 2 — Questions and Answers
Question 1: Which assessment finding in a post-thyroidectomy patient requires immediate nursing action?
- Tetany, tingling around the mouth, and positive Trousseau's sign (Correct answer)
- Mild throat soreness
- Slight hoarseness on day one
- Low-grade fever of 37.5°C
Correct 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.
Question 2: What is the primary purpose of incentive spirometry in post-operative patients?
- To encourage deep breathing and prevent atelectasis (Correct answer)
- To measure peak expiratory flow
- To administer inhaled medications
- To monitor carbon dioxide levels
Correct 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.
Question 3: A patient with a chest tube to water-seal drainage shows continuous bubbling in the water-seal chamber. What does this indicate?
- Air leak in the system or lung (Correct answer)
- Normal functioning
- Fluid drainage complete
- Suction level too high
Correct 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.
Question 4: Which finding indicates fluid volume excess (hypervolaemia) in a medical-surgical patient?
- Bounding pulse, crackles in lung bases, and peripheral oedema (Correct answer)
- Dry mucous membranes and poor skin turgor
- Hypotension and tachycardia
- Concentrated urine and thirst
Correct 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.
Question 5: Before administering a blood transfusion, which nursing action is the most critical safety step?
- Two-nurse verification of patient identity and blood product compatibility (Correct answer)
- Taking the patient's blood pressure only
- Hanging normal saline after the blood
- Checking the patient's haemoglobin level
Correct 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.
Question 6: Which position should a patient be placed in after a lumbar puncture to help prevent a post-procedure headache?
- Supine (flat) for 1–4 hours as instructed (Correct answer)
- High Fowler's immediately
- Left lateral Trendelenburg
- Ambulate immediately
Correct 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.
DHA Nursing Medical-Surgical Nursing 2
Which assessment finding in a post-thyroidectomy patient requires immediate nursing action?