Medical-Surgical Nursing Concepts – NURS 242 –
Complete Exam Prep with Solved Questions,
Clinical Scenarios, and Lab Answers
What is the MET call criteria for children? - -Resp rate 5 or below
-Heart rate 50 or below
-Blood pressure 55 or below
-Unresponsive
-Airway threatened
-Apnea
-Seizure
-Bleeding
-You are worried about the patient
What are normal vital signs for children? - Resps: 15-30
02: 93% and above
Temp: 35.5-37.5
Heart Rate: 80-130
What should you do if you patients ADDS score between 1-3? - -Inform shift coordinator
-Increase obs to 4 hourly
-Manage, fever, pain distress
-Review 02 needs
What should you do if you patients ADDS score between 4-5? - -Request review
-RMO in 30 mins
-Obs increase to hourly
-Patient must have escort if they have to leave the ward
,What should you do if you patients ADDS score between 6-7? - -Registrar must review in
30 mins
-Shift coordinator must review
-Half hourly observations
-Escort required
What should you do if you patients ADDS score of 8 - -MET call
-Continuous monitoring
It is recommended that patients fast for 6 hours from food and 2 hours from clear fluids. List 5
possible side effects of prolonged fasting? - confusion, irritability, dehydration,
headaches, hypoglycaemia, electrolyte imbalance, nausea and vomiting
Venous thromboembolism (VTE) is a major risk factor for patients undergoing surgical
procedures. Explain why - DVT is common after an operation because patients will
usually stay in bed for long periods of time while they recover. When they stop moving, blood
flows more slowly in the deep veins, which can lead to a clot.
List 6 contraindications to the application of anti-embolic stockings. - -Suspected or
proven peripheral arterial disease, including history of peripheral arterial bypass grafting
-Severe peripheral neuropathy or other cause of sensory impairment
-Allergy to stocking material
-Massive leg edema or pulmonary edema from congestive cardiac failure
-Local skin or soft-tissue condition, including recent skin graft, fragile "tissue paper" skin,
gangrene, oozing dermatitis and severe cellulitis
-Extreme deformity of the leg, or unusual leg shape or size preventing correct fit
When should jewellery be removed prior to a procedure and what are the nursing actions to
take? - Jewellery must be removed if it is likely to cause:
A risk of alternate site burns when using electrosurgery
Difficulty with intubation or a possibility of inhalation. Oral tissue piercing can cause trauma to
tongue and difficult airway management due to bleeding and tongue oedema 3 [Level IV]
Interference to the operative site e.g. remove jewellery from operative limb
, A pressure injury when positioning the patient
A risk of jewellery getting caught in surgical drapes, being pulled from skin or mislaid
Obstruction when inserting a urinary catheter
Prior to any procedure the Nurse must perform a urinalysis on all patients who have not had
one completed within 24 hours of admission. Why? - Urinalysis may exclude underlying
causes or bladder dysfunction
When does urinary retention occur? - when patients are unable to void at bladder
volumes exceeding 400 - 600mL as the bladder threshold
List 10 points that should be covered during post-procedure handover - • Name of the
patient
• Procedure performed (including any adverse events)
• Relevant medical, surgical and psychosocial history (past and present) including
allergies
• Vital sign status
• Nausea and vomiting (PONV is addressed and anti-emetics are prescribed) • All medications
administered (including anaesthetic agent, e.g. general/local
anaesthesia)
• Pain management plan in place, analgesia last administered and effect
• Wound status/drains
• Invasive access devices (such as venous access, indwelling catheters)
• Fluids, medications infusing
• Urine output
• Post-procedure instructions/parameters
• Requirement for transmission based precautions as applicable (e.g. micro alert and
transmissible diseases). Refer to Infection Control Manual for further information
The optimum frequency of observation is an unresolved issue. What is the frequency protocol
for post-operative observations at RPH? - • On return to the ward
• 1⁄2 hourly x 2 hours
Complete Exam Prep with Solved Questions,
Clinical Scenarios, and Lab Answers
What is the MET call criteria for children? - -Resp rate 5 or below
-Heart rate 50 or below
-Blood pressure 55 or below
-Unresponsive
-Airway threatened
-Apnea
-Seizure
-Bleeding
-You are worried about the patient
What are normal vital signs for children? - Resps: 15-30
02: 93% and above
Temp: 35.5-37.5
Heart Rate: 80-130
What should you do if you patients ADDS score between 1-3? - -Inform shift coordinator
-Increase obs to 4 hourly
-Manage, fever, pain distress
-Review 02 needs
What should you do if you patients ADDS score between 4-5? - -Request review
-RMO in 30 mins
-Obs increase to hourly
-Patient must have escort if they have to leave the ward
,What should you do if you patients ADDS score between 6-7? - -Registrar must review in
30 mins
-Shift coordinator must review
-Half hourly observations
-Escort required
What should you do if you patients ADDS score of 8 - -MET call
-Continuous monitoring
It is recommended that patients fast for 6 hours from food and 2 hours from clear fluids. List 5
possible side effects of prolonged fasting? - confusion, irritability, dehydration,
headaches, hypoglycaemia, electrolyte imbalance, nausea and vomiting
Venous thromboembolism (VTE) is a major risk factor for patients undergoing surgical
procedures. Explain why - DVT is common after an operation because patients will
usually stay in bed for long periods of time while they recover. When they stop moving, blood
flows more slowly in the deep veins, which can lead to a clot.
List 6 contraindications to the application of anti-embolic stockings. - -Suspected or
proven peripheral arterial disease, including history of peripheral arterial bypass grafting
-Severe peripheral neuropathy or other cause of sensory impairment
-Allergy to stocking material
-Massive leg edema or pulmonary edema from congestive cardiac failure
-Local skin or soft-tissue condition, including recent skin graft, fragile "tissue paper" skin,
gangrene, oozing dermatitis and severe cellulitis
-Extreme deformity of the leg, or unusual leg shape or size preventing correct fit
When should jewellery be removed prior to a procedure and what are the nursing actions to
take? - Jewellery must be removed if it is likely to cause:
A risk of alternate site burns when using electrosurgery
Difficulty with intubation or a possibility of inhalation. Oral tissue piercing can cause trauma to
tongue and difficult airway management due to bleeding and tongue oedema 3 [Level IV]
Interference to the operative site e.g. remove jewellery from operative limb
, A pressure injury when positioning the patient
A risk of jewellery getting caught in surgical drapes, being pulled from skin or mislaid
Obstruction when inserting a urinary catheter
Prior to any procedure the Nurse must perform a urinalysis on all patients who have not had
one completed within 24 hours of admission. Why? - Urinalysis may exclude underlying
causes or bladder dysfunction
When does urinary retention occur? - when patients are unable to void at bladder
volumes exceeding 400 - 600mL as the bladder threshold
List 10 points that should be covered during post-procedure handover - • Name of the
patient
• Procedure performed (including any adverse events)
• Relevant medical, surgical and psychosocial history (past and present) including
allergies
• Vital sign status
• Nausea and vomiting (PONV is addressed and anti-emetics are prescribed) • All medications
administered (including anaesthetic agent, e.g. general/local
anaesthesia)
• Pain management plan in place, analgesia last administered and effect
• Wound status/drains
• Invasive access devices (such as venous access, indwelling catheters)
• Fluids, medications infusing
• Urine output
• Post-procedure instructions/parameters
• Requirement for transmission based precautions as applicable (e.g. micro alert and
transmissible diseases). Refer to Infection Control Manual for further information
The optimum frequency of observation is an unresolved issue. What is the frequency protocol
for post-operative observations at RPH? - • On return to the ward
• 1⁄2 hourly x 2 hours
