Exam 1

NPO Status

Nothing by mouth after midnight before surgery to reduce aspiration risk during anesthesia

Informed Consent Rule

A signed consent form does not override a patient's expressed doubt — stop and notify the provider immediately to reassess capacity

Surgical Site Marking

The surgical site must be marked before the procedure to prevent wrong-site surgery

Pre-Op Lab Panel

CBC, BMP, coagulation studies, and urinalysis are the standard pre-operative labs

Incentive Spirometry

A device used post-op every 1–2 hours to prevent atelectasis and pneumonia by promoting deep lung expansion

Splinting Technique

Patient holds a pillow firmly against the incision while coughing to reduce pain and protect the wound

Malignant Hyperthermia (MH)

A life-threatening reaction to general anesthesia characterized by rising temperature, generalized muscle rigidity, and tachycardia — treat by activating the MH protocol immediately

Dantrolene

The antidote for malignant hyperthermia; it works by inhibiting calcium release in skeletal muscle

PACU Urine Output Goal

Urine output must be ≥30 mL/hr in the PACU to indicate adequate renal perfusion

PACU Vital Sign Frequency

Vital signs are monitored every 5–15 minutes in the post-anesthesia care unit

Post-Op Hemorrhage Signs

Decreased BP, increased HR, cool/clammy skin — apply pressure and notify the physician

Post-Op DVT Prevention

Sequential compression devices (SCDs), early ambulation, and prescribed anticoagulants

Wound Evisceration Management

Cover exposed bowel immediately with sterile saline-moistened gauze, position patient supine with knees slightly bent, and call the provider — NEVER attempt to push bowel back in

Paralytic Ileus

Absence of bowel sounds and failure to pass flatus post-op — treated with NPO status, NG tube, and IV fluids

Post-Op Urinary Retention

If patient has not voided within 8 hours post-op or has a distended bladder, catheterization is indicated

Post-Op Pneumonia Prevention

Incentive spirometry every 1–2 hours, turning, coughing, and deep breathing exercises

Hypotonic IV Fluid

Fluid with lower solute concentration than blood (e.g., 0.45% NS); shifts water into cells; used for hypernatremia; caution: cerebral edema risk

Isotonic IV Fluid

Fluid with same solute concentration as blood (e.g., 0.9% NS, LR, D5W); no fluid shift; expands extracellular volume; caution: fluid overload

Hypertonic IV Fluid

Fluid with higher solute concentration than blood (e.g., 3% NS, D10W); pulls water out of cells; used for severe hyponatremia; must be given slowly

Hypovolemia Signs

Decreased BP, weak thready pulse, dry mucous membranes, poor skin turgor, sunken eyes, urine output

Hypervolemia Signs

Elevated BP, bounding pulse, crackles, shortness of breath, orthopnea, pitting edema, JVD, weight gain, dilutional hyponatremia

Hypervolemia Treatment

Diuretics, fluid restriction, elevate head of bed; priority intervention is oxygenation when crackles and low SpO₂ are present

Hyponatremia

Serum sodium

Hypernatremia

Serum sodium >145 mEq/L; caused by water loss exceeding sodium loss; signs include thirst, dry mouth, restlessness, seizures; treat with slow hypotonic fluid replacement

Hypokalemia

Serum potassium

IV Push Potassium Rule

Potassium must NEVER be given IV push — it causes fatal cardiac dysrhythmias; always dilute and infuse slowly with continuous cardiac monitoring

Hyperkalemia

Serum potassium >5.0 mEq/L; caused by renal failure, ACE inhibitors, acidosis; signs include muscle weakness, paralysis, diarrhea; EKG shows peaked T waves

Hyperkalemia Treatment

IV calcium gluconate (cardiac protection), insulin + glucose (shift K⁺ into cells), diuretics or dialysis for elimination

SIADH

Syndrome of Inappropriate Antidiuretic Hormone — causes water retention and dilutional hyponatremia; treat with fluid restriction

Severe Symptomatic Hyponatremia

Sodium

Ischemic Stroke

Most common type (85%); caused by arterial blockage leading to brain infarction; treated with tPA if within 3–4.5 hours of onset

Hemorrhagic Stroke

Less common (15%); caused by vessel rupture with bleeding into brain; tPA is absolutely contraindicated

TIA (Transient Ischemic Attack)

Temporary neurological deficit that resolves within 24 hours (usually

FAST Acronym

Stroke recognition tool: Face drooping, Arm weakness, Speech difficulty, Time to call 911

CT Without Contrast — Stroke Priority

Must be the FIRST action in suspected stroke to rule out hemorrhage before any treatment is given

tPA (Alteplase)

Thrombolytic drug for ischemic stroke; must be given within 3–4.5 hours of symptom onset; contraindicated in hemorrhagic stroke or history of recent hemorrhagic stroke

tPA Contraindications

Recent hemorrhagic stroke, active bleeding, severe uncontrolled hypertension, recent major surgery

Left Hemisphere Stroke

Causes right-sided weakness/paralysis, aphasia (expressive or receptive), apraxia, and slow/cautious behavior

Right Hemisphere Stroke

Causes left-sided weakness/paralysis, left neglect syndrome, spatial-perceptual deficits, impulsive behavior, and agnosia

Dysphasia vs. Dysphagia

Dysphasia = Speech difficulty (language); Dysphagia = Swallowing difficulty (GI/aspiration risk)

Stroke Nursing Priority — Airway

HOB at 30°, supplemental O₂, suction

Status Epilepticus

A seizure lasting >5 minutes continuously OR recurrent seizures without regaining consciousness — a neurological emergency requiring IV benzodiazepines

Seizure Intervention — During

Lower patient to floor, protect head, do NOT restrain, do NOT put anything in the mouth, time the seizure, loosen restrictive clothing

Seizure Intervention — Postictal

Place in side-lying (recovery) position, reorient patient, monitor vital signs, document

Tension Headache

Most common headache type; dull, band-like bilateral pressure; related to stress/muscle tension; treated with OTC analgesics and relaxation

Migraine Headache

Unilateral throbbing pain with nausea, photophobia, phonophobia; sometimes preceded by aura; treated with triptans, dark quiet room, anti-emetics

Cluster Headache

Severe unilateral periorbital pain; known as the "suicide headache"; associated with red/watery eye; treated with high-flow O₂ for 15–20 minutes and triptans

Multiple Sclerosis (MS)

Demyelinating disease with relapse/remission pattern; symptoms include fatigue, visual changes, spasticity, bladder dysfunction; nursing focus: energy conservation, fall safety, toileting schedule

Parkinson's Disease — TRAP

Four cardinal signs: Tremor (resting), Rigidity, Akinesia, Postural instability; caused by dopamine depletion in the basal ganglia

Levodopa-Carbidopa (Sinemet)

Key medication for Parkinson's disease; must be given on a consistent schedule; high-protein meals reduce absorption by competing with levodopa; monitor for "on-off" effects

ALS (Amyotrophic Lateral Sclerosis)

Progressive motor neuron degeneration with no sensory or cognitive loss; respiratory failure is the terminal cause; nursing focus: respiratory monitoring, aspiration prevention, advance directives

Left-Sided Heart Failure

Results in pulmonary congestion; signs include crackles, shortness of breath, orthopnea, and decreased cardiac output

Right-Sided Heart Failure

Results in systemic venous congestion; signs include peripheral pitting edema, JVD, and hepatomegaly

Heart Failure Daily Weight Rule

Patients should weigh daily at the same time; report a gain of more than 2 lbs in a day or 1 kg/day as this indicates fluid retention

Heart Failure — Pulmonary Edema Priority

Crackles not clearing + SpO₂ 89% = pulmonary edema; priority is immediate oxygenation + IV diuretics

Furosemide (Lasix)

First-line diuretic for heart failure; reduces fluid overload by promoting renal sodium and water excretion

Heart Failure Diet

Low sodium diet (2 g/day) and fluid restriction to prevent fluid overload

Stable Angina

Chest pain with exertion; relieved within 5 minutes by nitroglycerin; predictable pattern; not an emergency but managed with MONA + lifestyle changes

Unstable Angina

Chest pain at rest or with minimal activity; lasts >20 minutes; NOT relieved by nitroglycerin; represents ACS risk — hospitalize immediately

MONA Protocol

M = Morphine (pain relief, reduce O₂ demand); O = Oxygen if SpO₂

Nitroglycerin Storage

Must be stored in original dark glass bottle in a cool, dry, dark place — heat and light degrade the medication

12-Lead EKG — ACS Nursing Priority

Obtain immediately along with troponin levels and IV access for continuous cardiac monitoring

Hypertension Stage 1

BP ≥130/80 mmHg

Hypertension Stage 2

BP ≥140/90 mmHg

Hypertensive Crisis

BP >180/120 mmHg — a medical emergency with risk of end-organ damage to heart, brain, kidneys, and eyes

HTN Patient Education Priority

Patients must be taught to continue antihypertensive medications even when blood pressure feels normal — stopping medications causes rebound hypertension

DASH Diet

Dietary Approaches to Stop Hypertension; emphasizes fruits, vegetables, whole grains, low-fat dairy, low sodium (

PAD (Peripheral Arterial Disease)

Arterial insufficiency: diminished/absent pulses, cold/pale/shiny/hairless skin, deep punched-out ulcers on toes, pain worsens with leg elevation; keep legs dependent

Venous Insufficiency

Venous disease: normal pulses, brown skin discoloration, pitting edema, shallow irregular ulcers at medial ankle, pain improves with leg elevation; elevate legs and use compression stockings

PAD vs. Venous — Positioning Rule

PAD: keep legs dependent (gravity aids arterial flow); Venous Insufficiency: elevate legs (promotes venous return and reduces edema)

===== KEY PRIORITIZATION RULES =====

ABCs Priority Framework

Always address Airway → Breathing → Circulation before any other intervention

Consent Priority Rule

If a patient expresses any doubt about consent before surgery — even with a signed form — stop and notify the provider immediately

MH Protocol Trigger

Muscle rigidity + rising temperature + tachycardia after general anesthesia = activate Malignant Hyperthermia protocol and administer dantrolene

Stroke Treatment Sequence

CT without contrast FIRST → if ischemic and within 3–4.5 hours → administer tPA → NEVER give tPA for hemorrhagic stroke

Seizure Safety Rules

NEVER restrain the patient; NEVER insert anything into the mouth; lower to floor and protect head as the first action

K⁺ Administration Safety

Potassium is NEVER given IV push; always diluted and administered slowly with continuous EKG monitoring

Sodium Imbalance Treatment Summary

Hyponatremia → fluid restriction ± slow 3% NS for severe cases; Hypernatremia → slow 0.45% NS infusion

DVT Prevention — Most Effective

Combination of anticoagulants + early ambulation is more effective than SCDs alone; NEVER massage the calves (can dislodge a clot → PE)

Calf Massage Contraindication

Bilateral calf massage is contraindicated post-operatively because it can dislodge an existing thrombus and cause a pulmonary embolism