Medical-Surgical Nursing Flashcards

A 58-year-old male patient in a Saudi hospital is post-operative day 2 following an open cholecystectomy. He develops sudden onset pleuritic chest pain, SpO₂ drops to 89% on room air, and his HR rises to 118 bpm. D-dimer returns elevated at 2.4 mg/L FEU. Which nursing action takes highest priority before the physician arrives?

Answer: Apply high-flow oxygen via non-rebreather mask and elevate the head of bed to 30–45°

The clinical picture — pleuritic chest pain, tachycardia, hypoxia, elevated D-dimer, and recent major abdominal surgery — is highly suspicious for pulmonary embolism (PE). The immediate nursing priority is to correct hypoxia with high-flow oxygen via non-rebreather mask while positioning the patient semi-upright to optimize lung expansion. Morphine is not a first-line priority before oxygenation is secured. Trendelenburg is contraindicated in PE as it increases right-heart workload. Incentive spirometry is insufficient for acute hypoxia.

A nurse in a SCFHS-accredited facility is caring for a patient with chronic kidney disease (CKD) Stage 4 who is prescribed sodium polystyrene sulfonate (Kayexalate) for hyperkalemia. The patient has had no bowel movement for 3 days. What is the most critical assessment finding that should prompt the nurse to withhold this medication and notify the physician immediately?

Answer: Abdominal distension with absent bowel sounds and the patient reporting nausea

Sodium polystyrene sulfonate is contraindicated in patients with reduced or absent intestinal motility (ileus or bowel obstruction) because it can cause intestinal necrosis, a rare but life-threatening complication. Abdominal distension with absent bowel sounds and nausea in a patient who has not had a bowel movement for 3 days indicates possible ileus — an absolute contraindication. Hyperkalemia with ECG changes (option A) is the reason TO give Kayexalate, not withhold it. Options C and D are expected findings in CKD that do not contraindicate the medication.

During a shift in a Saudi general hospital, a nurse is caring for a patient with liver cirrhosis and Grade III hepatic encephalopathy who is receiving lactulose via nasogastric tube. The patient develops 6–8 watery stools per day. Arterial blood gas shows: pH 7.51, PaCO₂ 44 mmHg, HCO₃ 34 mEq/L. Which complication is MOST directly linked to these findings?

Answer: Metabolic alkalosis exacerbating hepatic encephalopathy by promoting ammonia entry into the CNS

The ABG shows metabolic alkalosis (pH 7.51, elevated HCO₃ 34, normal PaCO₂ — no respiratory compensation yet). Excessive lactulose-induced diarrhea causes significant potassium and chloride loss, leading to hypokalemic, hypochloremic metabolic alkalosis. Alkalosis promotes conversion of ammonium (NH₄⁺, a non-diffusible ion) to ammonia (NH₃, a freely diffusible gas) that readily crosses the blood-brain barrier, paradoxically worsening hepatic encephalopathy. The nurse must notify the physician to adjust lactulose dosing to achieve 2–3 soft stools/day — not 6–8.

A nurse working in a SCFHS facility is preparing to administer a unit of packed red blood cells (PRBCs) to a 45-year-old female patient. Fifteen minutes into the transfusion, the patient complains of low back pain, the nurse notes dark reddish-brown urine in the catheter bag, and the patient's temperature rises from 37.0°C to 38.8°C. What is the nurse's PRIORITY action?

Answer: Stop the transfusion immediately, keep the IV line open with normal saline via new tubing, and notify the physician

The triad of low back pain, hemoglobinuria (dark reddish-brown urine), and fever during a blood transfusion is pathognomonic for an acute hemolytic transfusion reaction (AHTR) — a life-threatening ABO incompatibility. The nurse must STOP the transfusion IMMEDIATELY and keep the IV access patent with normal saline through NEW tubing (to avoid infusing any remaining incompatible blood from the existing tubing). The physician must be notified urgently. While sending the blood bag and obtaining specimens are correct subsequent steps, the immediate priority is stopping the transfusion and maintaining IV access. Slowing the rate (option A) is used for febrile non-hemolytic reactions and is dangerous in AHTR.

A nurse in a Saudi tertiary hospital is caring for a patient with SIADH (Syndrome of Inappropriate Antidiuretic Hormone) whose serum sodium is 118 mEq/L. The physician orders 3% hypertonic saline at a controlled rate. Four hours into the infusion, the patient's sodium has risen from 118 to 130 mEq/L (a rise of 12 mEq/L). What is the priority nursing concern?

Answer: Osmotic demyelination syndrome (central pontine myelinolysis) due to overly rapid sodium correction

In chronic hyponatremia, brain cells adapt by extruding osmolytes. Correcting sodium faster than 10–12 mEq/L per 24 hours (or 18 mEq/L per 48 hours) causes rapid osmotic shrinkage of previously adapted brain cells, resulting in osmotic demyelination syndrome (ODS), also called central pontine myelinolysis. A rise of 12 mEq/L in just 4 hours far exceeds the safe rate. The nurse must immediately notify the physician, stop or slow the hypertonic saline, and monitor for ODS signs (dysarthria, dysphagia, paraplegia, altered consciousness appearing 2–6 days later). Cerebral edema (option D) is a risk of hyponatremia itself, not rapid correction.

A 67-year-old male patient with type 2 diabetes is admitted to a Saudi hospital with a serum glucose of 38 mmol/L (684 mg/dL), serum osmolarity of 342 mOsm/kg, pH 7.38, HCO₃ 24 mEq/L, and no ketonemia. He is confused and oliguric. His admission weight is 74 kg. Which nursing intervention requires the most careful monitoring in the first 4 hours?

Answer: IV fluid resuscitation rate and neurological status to detect cerebral edema from rapid osmolarity correction

This presentation is Hyperosmolar Hyperglycemic State (HHS), not DKA — evidenced by markedly elevated glucose and osmolarity without acidosis or ketonemia. The primary danger in HHS management is overly rapid reduction of serum osmolarity through aggressive fluid resuscitation, which can cause fluid to shift rapidly into brain cells, precipitating fatal cerebral edema. Osmolarity should be reduced by no more than 3–4 mOsm/kg/hour. Neurological monitoring (GCS, pupil response) is the most critical nursing parameter in the first 4 hours. While potassium monitoring is important in DKA before insulin, HHS patients are more commonly volume-depleted, and the primary risk is the rate of osmolarity correction.