for Medical-Surgical Nursing is the ultimate reviewer for the NCLEX
. This contains 160 bits of information, all about the concepts of Medical-Surgical Nursing that are easy to digest. You can simply print a copy of this reviewer and carry it all around and read it during your free time.
Other Nursing Bullets
Below are the nursing bullets for Medical-Surgical Nursing.
1. Bone scan
is done by injecting radioisotope per IV and then x-rays are taken.
2. To prevent edema on the site of sprain, apply cold compress
on the area for the first 24 hours.
3. To turn the client after lumbar Laminectomy
, use the logrolling technique.
4. Carpal tunnel syndrome
occurs due to the injury of median nerve.
5. Massaging the back of the head
is specifically important for the client with Crutchfield tong.
6. A one-year-old child has a fracture
of the left femur. He is placed in Bryant’s traction
. The reason for elevation of his both legs at 90º angle is his weight isn’t adequate to provide sufficient countertraction, so his entire body must be used.
7. Swing-through crutch gait
is done by advancing both crutches together and the client moves both legs past the level of the crutches.
8. The appropriate nursing measure to prevent displacement
of the prosthesis after a right total hip replacement
is to place the patient in the position of right leg abducted.
9. Pain on non-use of joints, subcutaneous nodules and elevated ESR are characteristic manifestations of rheumatoid arthritis.
10. Teaching program of a patient with SLE
should include emphasis on walking in shaded area.
is characterized by replacement of normal bones
by spongy and highly vascularized bones.
Eyes and Ears
12. Use of high-pitched voice
is inappropriate for the client with hearing impairment.
13. Rinne’s test
compares air conduction with bone conduction.
is the most characteristic manifestation of Meniere’s disease.
15. Low sodium is the diet
for a client with Meniere’s disease.
16. A client who had cataract surgery
should taught to call his MD if he has eye
17. Risk for Injury
takes priority for a client with Meniere’s disease.
18. Irrigate the eye with sterile saline is the priority nursing intervention when the client has a foreign body protruding from the eye.
19. Snellen’s Test
assesses visual acuity.
is an eye disorder characterized by lessening of the effective powers of accommodation.
21. The primary problem in cataract
is blurring of vision
22. The primary reason for performing iridectomy
after cataract extraction is to prevent secondary glaucoma.
23. In acute glaucoma
, the obstruction of the flow of aqueous humor
is caused by displacement of the iris.
is characterized by irreversible blindness.
is corrected by convex lens.
is caused primarily by exposure to dust.
27. A sterile chronic granulomatous inflammation of the meibomian gland is chalazion.
28. The surgical procedure which involves removal of the eyeball is enucleation
29. Romberg’s test
is a test for balance or gait.
30. If the client with increased ICP demonstrates decorticate posturing, observe for flexion of elbows, extension of the knees, plantar flexion of the feet.
31. The nursing diagnosis
that would have the highest priority in the care of the client who has become comatose following cerebral hemorrhage is Ineffective Airway Clearance
32. The initial nursing action—for a client who is in the clonic phase of a tonic-clonic seizure
—is to obtain equipment for orotracheal suctioning.
33. The first nursing intervention in a quadriplegic client who is experiencing autonomic dysreflexia
is to elevate his head as high as possible.
34. Following surgery for a brain tumor
near the hypothalamus
, the nursing assessment should include observing for inability to regulate body temp.
35.Post-myelography (using metrizamide (Omnipaque) care includes keeping head elevated for at least 8 hours.
36. Homonymous hemianopsia
is described by a client had CVA and can only see the nasal visual field on one side and the temporal portion on the opposite side.
may be prescribed to prevent thromboembolic CVA.
38. To maintain airway patency during a stroke
in evolution, have orotracheal suction available at all times.
39. For a client with CVA, the gag reflex
must return before the client is fed.
40. Clear fluids draining from the nose of a client who had a head trauma 3 hours ago may indicate basilar skull fracture
41. An adverse effect of gingival hyperplasia
may occur during Phenytoin
output increased: best shows that the mannitol
is effective in a client with increased ICP.
43. A client with C6 spinal injury would most likely have the symptom of quadriplegia.
are the leading cause of injury in elderly
45. The client is for EEG this morning
. Prepare him for the procedure by rendering hair
shampoo, excluding caffeine
from his meal and instructing the client to remain still during the procedure.
46. Primary prevention
is true prevention. Examples are immunizations, weight control, and smoking
47. Secondary prevention
is early detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray
48. Tertiary prevention
is treatment to prevent long-term complications.
49. On noticing religious artifacts and literature on a patient’s night stand, a culturally aware nurse
would ask the patient the meaning of the items.
50. A Mexican patient
may request the intervention of a curandero, or faith
healer, who involves the family in healing the patient.
51. In an infant, the normal hemoglobin
value is 12 g/dl.
52. A patient indicates that he’s coming to terms with having a chronic disease when he says something like: “I’m never going to get any better,” or when he exhibits hopelessness
Diet and Nutrition
53. Most of the absorption of water occurs in the large intestine.
54. Most nutrients are absorbed in the small intestine.
55. When assessing a patient’s eating habits, the nurse should ask, “What have you eaten in the last 24 hours?”
56. A vegan diet should include an abundant supply of fiber.
57. A hypotonic enema
softens the feces
, distends the colon
, and stimulates peristalsis
58. First-morning urine
provides the best sample to measure glucose
, ketone, pH
, and specific gravity values.
59. To induce sleep
, the first step is to minimize environmental stimuli.
60. Before moving a patient, the nurse should assess the patient’s physical abilities and ability to understand instructions
as well as the amount of strength required to move the patient.
61. To lose 1 lb (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily).
62. To avoid shearing force injury, a patient who is completely immobile is lifted on a sheet.
63. To insert a catheter from the nose through the trachea
for suction, the nurse should ask the patient to swallow
64. Vitamin C
is needed for collagen production.
65. Bananas, citrus fruits, and potatoes are good sources of potassium
66. Good sources of magnesium include fish, nuts, and grains.
67. Beef, oysters, shrimp, scallops, spinach, beets, and greens are good sources of iron.
68. The nitrogen balance estimates the difference between the intake and use of protein.
69. A Hindu patient
is likely to request a vegetarian diet.
70. No pork or pork products are allowed in a Muslim diet.
71. In accordance with the “hot-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”
72. Milk is high in sodium and low in iron.
is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.
74. Increased gastric motility interferes with the absorption of oral drugs.
75. When feeding an elderly patient, the nurse should limit high-carbohydrate foods because of the risk of glucose intolerance.
76. When feeding an elderly patient, essential foods should be given first.
78. For the patient who abides by Jewish custom, milk and meat shouldn’t be served at the same meal.
79. Only the patient can describe his pain accurately
80. Cutaneous stimulation
creates the release of endorphins that block the transmission of pain stimuli.
81. Patient-controlled analgesia (PCA)
is a safe method to relieve acute pain
caused by surgical incision, traumatic injury, labor
and delivery, or cancer
82. An Asian-American or European-American typically places distance between himself and others when communicating.
83. Active euthanasia
is actively helping a person to die.
84. Brain death
is irreversible cessation of all brain function.
85. Passive euthanasia
is stopping the therapy that’s sustaining life.
86. Voluntary euthanasia
is actively helping a patient to die at the patient’s request.
87. A back rub is an example of the gate-control theory
88. Pain threshold, or pain sensation, is the initial point at which a patient feels pain.
89. The difference between acute pain and chronic pain
is its duration.
90. Referred pain is pain that’s felt at a site other than its origin.
91. Alleviating pain by performing a back massage is consistent with the gate control theory.
92. Pain seems more intense at night because the patient isn’t distracted by daily activities.
93. Older patients commonly don’t report pain because of fear
of treatment, lifestyle changes, or dependency.
review is performed to determine whether the care provided to a patient was appropriate and cost-effective.
95. A value cohort
is a group of people who experienced an out-of-the-ordinary event that shaped their values.
96. A third-party payer is an insurance company.
97. Intrathecal injection is administering a drug through the spine.
98. When a patient asks a question or makes a statement that’s emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked.
99–105. The steps of the trajectory-nursing model are as follows:
- Step 1: Identifying the trajectory phase
- Step 2: Identifying the problems and establishing goals
- Step 3: Establishing a plan to meet the goals
- Step 4: Identifying factors that facilitate or hinder attainment of the goals
- Step 5: Implementing interventions
- Step 6: Evaluating the effectiveness of the interventions
106–107. Two goals of Healthy People 2010 are:
- Help individuals of all ages to increase the quality of life and the number of years of optimal health
- Eliminate health disparities among different segments of the population.
108. A community nurse is serving as a patient’s advocate if she tells a malnourished patient to go to a meal program at a local park.
109. If a patient isn’t following his treatment plan, the nurse should first ask why.
110. When a patient is ill, it’s essential for the members of his family to maintain communication about his health needs.
is the universal belief that one’s way of life is superior to others’.
111. When a nurse is communicating with a patient through an interpreter, the nurse should speak to the patient and the interpreter.
is a hostile attitude toward individuals of a particular group.
113. The three phases of the therapeutic relationship
are orientation, working, and termination.
114. Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.
115. Abdominal assessment
is performed in the following order: inspection, auscultation, palpation, and percussion.
116. When measuring blood
pressure in a neonate, the nurse should select a cuff that’s no less than one-half and no more than two-thirds the length of the extremity that’s used.
117. When administering a drug by Z-track, the nurse shouldn’t use the same needle that was used to draw the drug into the syringe because doing so could stain
118. Sites for intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.
119. When evaluating whether an answer on an examination is correct, the nurse should consider whether the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.
and is an essential component of a therapeutic relationship between a health care provider and his patient.
is the duty to do no harm and the duty to do good. There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.
is the duty to do no harm.
123–128. Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns.
- A: Airway. This category includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction.
- B: Breathing. This category includes everything that affects the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
- C: Circulation. This category includes everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output.
- D: Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.
- E: Everything else. This category includes such issues as writing any incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.
129. Rule utilitarianism
is known as the “greatest good for the greatest number of people” theory.
130. Egalitarian theory
emphasizes that equal access to goods and services must be provided to the less fortunate by an affluent society.
Communication and Patient Education
131. Before teaching any procedure to a patient, the nurse must assess the patient’s current knowledge and willingness to learn.
132. Process recording is a method of evaluating one’s communication effectiveness.
133. Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning).
134. When communicating with a hearing impaired patient, the nurse should face him.
135. When a patient expresses concern about a health-related issue, before addressing the concern, the nurse should assess the patient’s level of knowledge.
136. Passive range of motion
maintains joint mobility. Resistive exercises increase muscle
137. Isometric exercises
are performed on an extremity that’s in a cast.
138. Anything that’s located below the waist is considered unsterile; a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1″ (2.5 cm) around a sterile field is considered unsterile.
139. A “shift to the left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.
140. A “shift to the right” is evident when the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia
141. Before administering preoperative medication
, the nurse should ensure that an informed consent form
has been signed and attached to the patient’s record.
142. A nurse should spend no more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.
143. A nurse shouldn’t be assigned to care for more than one patient who has a radiation implant.
144. Long-handled forceps and a lead-lined container should be available in the room of a patient who has a radiation implant.
145. Usually, patients who have the same infection and are in strict isolation can share a room.
146. Diseases that require strict isolation include chickenpox, diphtheria
, and viral hemorrhagic fevers such as Marburg disease
147–155. According to Erik Erikson
, developmental stages are:
- Trust versus mistrust (birth to 18 months)
- Autonomy versus shame and doubt (18 months to age 3)
- Initiative versus guilt (ages 3 to 5)
- Industry versus inferiority (ages 5 to 12)
- Identity versus identity diffusion (ages 12 to 18)
- Intimacy versus isolation (ages 18 to 25)
- Generativity versus stagnation (ages 25 to 60), and
- Ego integrity versus despair (older than age 60).
156. An appropriate nursing intervention for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system.
157. The most effective way to reduce a fever
is to administer an antipyretic, which lowers the temperature set point.
158–163. The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse
- Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States.
- Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may lead to physical or psychological dependence.
- Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both.
- Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs.
- Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.
164. During lumbar puncture
, the nurse must note the initial intracranial pressure and the color of the cerebrospinal fluid
165. Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite