Medical-Surgical Nursing Flashcards

A patient with a fractured hip is in Buck's traction. Which nursing action is most important?

Answer: Maintain continuous traction as ordered

Buck's traction must remain continuous to maintain alignment and reduce muscle spasm — weights must never be removed without an order.

A patient post-CABG has a mediastinal chest tube draining 200 mL of bright red blood in 1 hour. The nurse should:

Answer: Notify the surgeon immediately

Drainage of 200 mL/hr of bright red blood post-CABG indicates hemorrhage and requires immediate surgical notification.

Which lab value is most important to monitor in a patient receiving heparin therapy?

Answer: aPTT

The aPTT (activated partial thromboplastin time) is used to monitor the therapeutic effect of heparin.

A patient with cirrhosis develops asterixis (flapping tremor). This finding indicates:

Answer: Hepatic encephalopathy

Asterixis is a hallmark sign of hepatic encephalopathy caused by ammonia accumulation affecting the brain.

A nurse is caring for a patient with a suspected pulmonary embolism. Which action is the priority?

Answer: Administer high-flow oxygen

Oxygenation is the priority intervention for PE because the clot obstructs pulmonary blood flow, causing hypoxemia.

Which dietary instruction is most important for a patient with gout?

Answer: Avoid high-purine foods like red meat and organ meats

Purine-rich foods increase uric acid production, which precipitates gout attacks, so they must be limited.