Medical-Surgical Nursing Flashcards

A 58-year-old male patient in a Riyadh tertiary care hospital is post-operative day 2 following an open cholecystectomy. He develops sudden onset of dyspnea, pleuritic chest pain, and his SpO₂ drops to 89% on room air. His HR is 118 bpm and BP is 100/70 mmHg. The Wells score is calculated at 7. According to SCFHS nursing standards, which immediate nursing action takes priority BEFORE the physician's order is received?

Answer: Administer supplemental oxygen via non-rebreather mask at 10–15 L/min

In a suspected massive or submassive pulmonary embolism with hypoxemia (SpO₂ 89%), the nurse's first independent action is to restore oxygenation — administering high-flow O₂ via non-rebreather mask at 10–15 L/min is within nursing scope and is the most life-saving immediate step. Positioning supine with legs elevated is contraindicated as it worsens RV strain and can increase thrombus propagation. ECG and ABGs are important but are concurrent physician-driven orders, not the first independent nursing priority. Surgical embolectomy is a physician/surgical decision.

A nurse in a Saudi MOH hospital is managing a patient with diabetic ketoacidosis (DKA). The patient's serum potassium on admission is 5.8 mEq/L. After 3 hours of IV insulin infusion at 0.1 units/kg/hr and normal saline resuscitation, the repeat potassium level is 3.2 mEq/L. Blood glucose has decreased from 28 mmol/L to 14 mmol/L. Which action is MOST appropriate at this point?

Answer: Continue the insulin infusion and add IV potassium chloride replacement to the fluid

At a serum K⁺ of 3.2 mEq/L, the protocol requires continuing insulin (to resolve ketoacidosis) while initiating potassium replacement — typically 20–40 mEq/hr IV KCl. Insulin must NOT be stopped unless K⁺ falls below 3.0 mEq/L (per Saudi/international DKA protocols). Switching to dextrose-containing fluid is indicated when glucose approaches 11 mmol/L (250 mg/dL) to prevent hypoglycemia but does not address the hypokalemia. Simply reducing the insulin rate without replacing potassium would allow ketoacidosis to persist while hypokalemia remains uncorrected.

A patient admitted to a NGHA hospital has a history of chronic liver disease and presents with upper GI bleeding. He is started on octreotide infusion. After endoscopy reveals esophageal varices with active bleeding, band ligation is performed. On day 3, the patient develops fever of 38.9°C, abdominal pain, and ascitic fluid analysis shows: WBC 420 cells/mm³ with >70% polymorphonuclear cells, protein 12 g/L, LDH 180 U/L, glucose 5.1 mmol/L. What is the MOST likely diagnosis and the nurse's priority intervention?

Answer: Spontaneous bacterial peritonitis (SBP); ensure IV albumin is administered alongside antibiotic therapy as prescribed

The ascitic fluid PMN count ≥250 cells/mm³ with clinical signs confirms spontaneous bacterial peritonitis (SBP), a common and life-threatening complication in cirrhotic patients with ascites. The protein level of 12 g/L is consistent with SBP (not secondary peritonitis, which typically shows higher protein, LDH > serum LDH, and glucose <2.8 mmol/L). The critical nursing priority, alongside ensuring prescribed antibiotic therapy (e.g., cefotaxime), is to ensure IV albumin (1.5 g/kg on day 1) is administered as it significantly reduces renal impairment and mortality — a distinction unique to SBP management per EASL and SCFHS-aligned guidelines. Surgical drainage is for secondary peritonitis. TB peritonitis would require further workup and the fluid profile differs.

A medical-surgical nurse in a Saudi hospital is caring for a patient on warfarin therapy for atrial fibrillation who undergoes an elective knee replacement. On post-op day 1, the patient's INR is 1.1. The orthopedic surgeon prescribes low molecular weight heparin (LMWH) for DVT prophylaxis. The patient's renal function shows a GFR of 22 mL/min/1.73m². Which action should the nurse take?

Answer: Withhold the LMWH and contact the physician, as severe renal impairment (GFR <30) requires dose adjustment or alternative anticoagulation

LMWH (e.g., enoxaparin) is predominantly renally cleared. In patients with GFR <30 mL/min, there is significant accumulation risk leading to over-anticoagulation and major bleeding. The Saudi Commission for Health Specialties (SCFHS) and international pharmacovigilance standards require dose reduction (e.g., enoxaparin 0.5 mg/kg once daily) or switching to unfractionated heparin, which is not renally cleared. The nurse's professional obligation is to withhold and clarify before administration — a critical patient safety act. Monitoring anti-Xa is appropriate if LMWH is continued after adjustment, not before addressing the contraindication. Restarting warfarin immediately post-operatively without bridging is inappropriate and not indicated here.

A 45-year-old female patient in a Saudi hospital ICU step-down unit has been on mechanical ventilation via tracheostomy for 18 days following ARDS. She is being weaned and tolerating pressure support of 8 cmH₂O. The nurse notes that during tracheostomy tube cuff deflation trial, the patient develops audible stridor and increasing respiratory distress within 90 seconds. SpO₂ drops to 92%. Which complication is MOST likely and what is the priority nursing response?

Answer: Subglottic or tracheal stenosis causing post-deflation upper airway obstruction; immediately re-inflate the cuff, call the physician, and prepare for bronchoscopy evaluation

Stridor with respiratory distress immediately upon cuff deflation in a long-term tracheostomy patient is a hallmark of subglottic or tracheal stenosis — a known complication of prolonged intubation/tracheostomy, particularly with high cuff pressures exceeding 25–30 cmH₂O. The correct priority response is to re-inflate the cuff to restore the airway seal and oxygenation, then notify the physician urgently. Bronchoscopy (fibre-optic) is the gold standard for diagnosis and planning treatment (e.g., laser resection, stenting, or surgical reconstruction). Tracheomalacia presents with dynamic collapse on expiration — not immediate post-deflation stridor. TEF manifests as food/secretion in the airway, not isolated stridor. Vocal cord paralysis would not respond to cuff deflation in this manner.

A nurse is caring for a Saudi patient with sickle cell disease (SCD) who is admitted with a vaso-occlusive pain crisis. The patient has been receiving IV morphine via PCA for 36 hours. The nurse notes the patient is increasingly drowsy, respiratory rate has decreased to 8 breaths/min, and SpO₂ is 88% on 4L nasal cannula. The patient's pain score is 3/10. Which intervention is CONTRAINDICATED in this situation?

Answer: Administering an additional IV bolus dose of morphine to preemptively prevent pain escalation during the opioid reversal period

Administering an additional morphine bolus in a patient showing clear signs of opioid-induced respiratory depression (RR 8, SpO₂ 88%, excessive sedation) is absolutely contraindicated and could result in apnea and death. The clinical picture mandates opioid reversal. In SCD, naloxone must be titrated carefully in small increments (0.04 mg aliquots every 2 minutes) rather than as a full 0.4 mg bolus, because abrupt opioid reversal can precipitate severe vaso-occlusive crisis and acute chest syndrome — but the reversal process itself is necessary and indicated. Oxygen supplementation and positioning are appropriate supportive measures. Saudi SCFHS nursing standards align with international guidelines for opioid toxicity management.