MEDICAL SURGICAL NURSING
1. List 4 common symptoms of pneumonia the nurse might note on a physical
– Tachypnea, fever with chills, productive cough, bronchial breath sounds.
2. State 4 nursing interventions for assisting the client to cough productively.
– Deep breathing, fluid intake increased to 3 liters/day, use humidity to loosen
secretions, suction airway to stimulate coughing.
3. What symptoms of pneumonia might the nurse expect to see in an older client?
– Confusion, lethargy, anorexia, rapid respiratory rate.
4. What should the O2 flow rate be for the client with COPD?
– 1-2 liters per nasal cannula, too much O2 may eliminate the COPD client’s stimulus
to breathe, a COPD client has hypoxic drive to breathe.
5. How does the nurse prevent hypoxia during suctioning?
– Deliver 100% oxygen (hyperinflating) before and after each endotracheal suctioning.
6. During mechanical ventilation, what are three major nursing intervention?
– Monitor client’s respiratory status and secure connections, establish a communication
mechanism with the client, keep airway clear by coughing/suctioning.
7. When examining a client with emphysema, what physical findings is the nurse
likely to see?
– Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in
8. What is the most common risk factor associated with lung cancer?
9. Describe the pre-op nursing care for a client undergoing a laryngectomy.
– Involve family/client in manipulation of tracheostomy equipment before surgery, plan
acceptable communication method, refer to speech pathologist, discuss rehabilitation
10. List 5 nursing interventions after chest tube insertion.
– Maintain a dry occlusive dressing to chest tube site at all times. Check all
connections every 4 hours. Make sure bottle III or end of chamber is bubbling.
Measure chest tube drainage by marking level on outside of drainage unit. Encourage
use of incentive spirometry every 2 hours.
11. What immediate action should the nurse take when a chest tube becomes
disconnected from a bottle or a suction apparatus? What should the nurse do if
a chest tube is accidentally removed from the client?
– Place end in container of sterile water. Apply an occlusive dressing and notify
12. What instructions should be given to a client following radiation therapy?
– Do NOT wash off lines; wear soft cotton garments, avoid use of powders/creams on
13. What precautions are required for clients with TB when placed on respiratory
– Mask for anyone entering room; private room; client must wear mask if leaving room.
14. List 4 components of teaching for the client with tuberculosis.
– Cough into tissues and dispose immediately into special bags. Long-term need for
daily medication. Good handwashing technique. Report symptoms of deterioration,
i.e., blood in secretions.