Medical-Surgical Nursing Flashcards

A patient with type 1 diabetes is found unconscious with a blood glucose of 38 mg/dL. What is the priority intervention?

Answer: Administer IV dextrose 50% (D50W)

An unconscious patient with severe hypoglycemia cannot take oral glucose — IV dextrose (D50W) must be administered immediately.

A patient with a spinal cord injury at T4 develops sudden hypertension, pounding headache, and diaphoresis above the level of injury. The nurse recognizes this as:

Answer: Autonomic dysreflexia

Autonomic dysreflexia is a hypertensive emergency in spinal cord injury above T6, triggered by a noxious stimulus below the injury level.

A nurse assesses a patient's chest tube drainage system and notices continuous bubbling in the water-seal chamber. This indicates:

Answer: An air leak in the system or patient's lung

Continuous bubbling in the water-seal chamber indicates an air leak either in the patient's lung or in the drainage system connections.

A patient taking warfarin has an INR of 5.8 and no active bleeding. What is the priority nursing action?

Answer: Hold the next warfarin dose and notify the provider

For supratherapeutic INR without bleeding, the warfarin dose is held and the provider is notified to adjust dosing.

Which assessment finding in a patient with acute appendicitis indicates perforation has occurred?

Answer: Sudden relief of pain followed by diffuse abdominal rigidity

A sudden brief relief of pain followed by diffuse, board-like rigidity suggests the appendix has ruptured and peritonitis is developing.

A nurse is teaching a patient about signs of infection at a surgical wound. Which finding should be reported to the provider?

Answer: Purulent drainage with increasing redness

Purulent drainage and worsening redness are signs of wound infection requiring provider notification and possible antibiotic therapy.