Medical-Surgical Nursing Flashcards

A patient is receiving a blood transfusion and develops fever, chills, and back pain 15 minutes after the transfusion begins. What is the priority nursing action?

Answer: Stop the transfusion immediately and maintain IV access with normal saline

These symptoms suggest an acute hemolytic transfusion reaction, a potentially fatal immune response. The priority is to stop the transfusion immediately while maintaining IV access with normal saline to prevent hemoglobin from precipitating in the renal tubules.

A patient with heart failure is prescribed furosemide. Which electrolyte level requires monitoring?

Answer: Potassium

Furosemide (a loop diuretic) causes potassium wasting through increased urinary excretion. Hypokalemia is the most significant electrolyte imbalance, increasing the risk of dangerous arrhythmias and digoxin toxicity if the patient is also on digoxin.

The nurse is educating a patient with peptic ulcer disease about diet. Which food should the patient avoid?

Answer: Coffee and alcohol

Coffee (even decaffeinated) and alcohol stimulate gastric acid secretion and damage the gastric mucosal barrier, worsening peptic ulcer disease. Patients should avoid these along with spicy foods, NSAIDs, and smoking.

A patient with asthma is using a peak flow meter. The reading falls in the yellow zone (50–79% of personal best). What should the nurse instruct the patient to do?

Answer: Take rescue bronchodilator and reassess; contact provider if no improvement

The yellow zone (50–79% of personal best) indicates caution — airways are narrowing. The patient should take their rescue bronchodilator and reassess. If the reading does not improve or falls to the red zone, they should contact their healthcare provider.

A patient develops sudden onset of severe 'thunderclap' headache described as 'the worst headache of my life.' The nurse should prioritize:

Answer: Immediate CT scan of the head to rule out subarachnoid hemorrhage

A sudden, severe 'thunderclap' headache — described as the worst ever — is the classic presentation of subarachnoid hemorrhage (SAH) until proven otherwise. Immediate CT scan is required to diagnose or exclude SAH, a medical emergency.

A patient with chronic kidney disease (CKD) asks why they have been prescribed erythropoietin. The nurse explains that this medication:

Answer: Stimulates red blood cell production to treat anemia of CKD

In CKD, the kidneys produce inadequate erythropoietin, leading to anemia. Exogenous erythropoietin (e.g., epoetin alfa) stimulates the bone marrow to produce more red blood cells, correcting the anemia of chronic kidney disease.