Medsurg 5 Flashcards
A ____ transfer is appropriate only for a patient who has at least one leg that’s strong enough to bear weignt, such as a patient with hemiplegia or a single-leg amputation.
weight bearing
____ (voiding of 30 to 60 ml of urine every 15 to 30 minutes) is a sign of bladder distention.
Overflow incontinence
The ____ is reddened skin that blanches when pressure is applied.
first sign of a pressure ulcer
____ include tachycardia, cardiomegaly, systolic and diastolic murmurs, chronic fatigue, hepatomegaly, and splenomegaly.
Late signs and symptoms of sickle cell anemia
A ____ , which can maintain ventilation automatically for an extended period, is indicated when a patient can’t maintain a safe PaO2 or PaCo2 level.
mechanical ventilator
_____ exist: negative-pressure ventilators, which apply negative pressure around the chest wall, and positive-pressure ventilators, which deliver air under pressure to the patient.
Two types of mechanical ventilators
____ is characterized by substernal pain that lasts for 2 to 3 minutes. The pain, which is caused by myocardial ischemia, may radiate to the neck, shoulders, or jaw; is described as viselike, or constricting and may be accompanied by severe apprehension or a feeling of impending doom
Angina pectoris
The ____ is based on the patient’s signs and symptoms, electrocardiogram tracings, troponin level, and cardiac enzyme studies
diagnosis of an acute myocardial infarction
The ____ is to reduce the heart’s workload, thereby reducing the myocardial demand for oxygen and preventing myocardial infarction.
goal of treatment for a patient with angina pectoris
____ decreases the amount of blood that returns to the heart by increasing the capacity of the venous bed.
Nitroglycerin
The patient should take ____ in a 15-minute period.
no more than three nitroglycerin tablets
Hemodialysis is usually performed 24 hours ____
before kidney transplantation
____ are progressive enlargement and tenderness at the transplant site, increased blood pressure, decreased urine output, élevated serum creatinine level, and fever
Signs and symptoms of acute kidney transplant rejection
____ , the patient’s arm should be elevated (with the hand above the elbow) on a pillow to enhance circulation and prevent edema.
After a radical mastectomy
____ care includes teaching the patient arm exercises to facilitate lymph drainage and prevent shortening of the muscle and contracture of the shoulder joint (frozen shoulder)
Postoperative mastectomy
____ , the patient should help prevent infection by making sure that no blood pressure readings, injections, or venipunctures are performed on the affected arm.
After radical mastectomy
For a patient who ____ and is susceptible to lymphedema, a program of hand exercises can begin shortly after surgery, if prescribed. The program consists of opening and closing the hand tightly six to eight times per hour and performing such tasks as washing the face and combing the hair
has undergone mastectomy
Signs and symptoms of ____ include vomiting, restlessness, and an apical pulse rate of more than 200 beats/minute.
theophylline toxicity
The nurse ____ in a person who has ingested poison and is having seizures or is semiconscious or comatose.
shouldn’t induce vomiting
___ , which is the pressure in the right atrium and the great veins of the thorax, is normally 2 to 8 mm Hg (or 5 to 12 cm H20). CVP is used to assess right sided cardiac function,
Central venous pressure (CVP)
___ is monitored to assess the need for fluid replacement in seriously ill patients, to estimate blood volume deficits, and to evaluate circulatory pressure in the right atrium
CVP
To ____ after surgery, the nurse should administer 5,000 units of heparin subcutaneously every 8 to 12 hours, as prescribed.
prevent deep vein thrombosis
___ , such as warfarin (Coumadin) and dicumarol, disrupt natural blood clotting mechanisms, prevent thrombus formation, and limit the extension of a formed thrombus.
Oral anticoagulants
___can’t dissolve a formed thrombus.
Anticoagulants
___ is contraindicated in a patient who has liver or kidney disease or Gl ulcers or who isn’t likely to return for follow-up visits
Anticoagulant therapy
The nurse can assess a patient for ____ by measuring the affected and unaffected legs and comparing their sizes. The nurse should mark the measurement locations with a pen so that the legs can be measured at the same place each day.
thrombophlebitis
Drainage of more than 3,000 ml of fluid daily from a nasogastric tube may suggest ____ . Yellow drainage that has a foul odor may indicate small-bowel obstruction
intestinal obstruction
Preparation for _____ includes administering an enema 1 hour before the examination, warming the scope in warm water or a sterilizer (if using a metal sigmoidoscope). and draping the patient to expose the perineum
sigmoidoscopy
Treatment for a patient with _____ includes administering vasopressin (Pitressin), giving an ice water lavage, aspirating blood from the stomach, using esophageal balloon tamponade, providing parenteral nutrition, and administering blood transfusions, as needed,
bleeding esophageal varices
A ___ shouldn’t be moved until a patent airway is established and the cervical spine is immobilized.
trauma victim
____, lymphedema may cause a feeling of heaviness in the affected arm.
after a mastectomy,
____ shouldn’t be told exactly how long he’s expected to live, but should be told something more general such as “Some people live 3 to 6 months, but others live longer.”
A dying patient
___ a patient should avoid using makeup until otherwise instructed.
after eye surgery
___ the patient should wear an eye shield when engaging in activities such as playing with children or pets.
After corneal transplant
____ , the patient shouldn’t lie on the affected site, bend at the waist, or have sexual intercourse for 1 week. The patient must avoid getting soapsuds in the eye,
After a corneal transplant
A _____ is used for patients who have structural scoliosis. The brace helps to halt the progression of spinal curvature by providing longitudinal traction and lateral pressure. It should be worn 23 hours a day.
Milwaukee brace
Short-term measures used to treat ____ include stool softeners, irrigation, and stomal dilatation
stomal retraction
A patient who has a _____ should be advised to eat a low-residue diet for 4 to 6 weeks and then to add one food at a time to evaluate its effect.
colostomy
To relieve _____ , the patient should breathe into a paper bag,
postoperative hiccups
If a patient with an ____ has a blocked lumen as a result of undigested high-fiber food, the patient should be placed in the knee-chest position and the area below the stoma should be massaged.
ileostomy
During the initial interview and treatment of a patient with _____ , the patient’s sexual contacts should be identified.
syphilis
The nurse shouldn’t administer ____ to a patient whose respiratory rate is less than 12 breaths/minute
morphine
To _____, oxygen should be administered with hydration.
prevent drying of the mucous membranes
