NCLEX ATI Comprehensive

lithium toxicity

therapeutic: 0.8-1.2 >2 is critical coarse hand tremors, incoordination, ECG changes, sedation, confusion, n/v, polyuria (drink adequate fluids) expected: polyuria, fine hand tremors, lethargy

NG tube insertion

tilt head back then forward, gulp water, use water soluble lubricant

occiptal

vision

18 month old developmental tasks

vocab of 10+ words

metoprolol

beta blocker adverse effect: stuffy nose, blurred vision, hypotension, bradycardia, dizzy, wt gain, edema (heart failure)

incr ICP signs

bradypnea, bradycardia, more stuporous, widened pulse pressure, asymmetric pupils tx: HOB elevated, do not cluster nursing care, monitor BG q4h, keep lights dim, do not flex hips

varicella zoster, herpes zoster (chicken pox, shingles)

fluid filled vesicles on trunk and extremities, neurologic pain, itching, fever, fatigue, lose appetite use antiviral (acyclovir), moist compress, PO/topical analgesic airborne/contact

alzheimers disease

incr fall rx (lock doors to stairs), night light, remove stove knobs early: short term memory loss, misplace items moderate: wandering severe: loss of mobility

fiber

incr fiber = decr constipation/incr diarrhea decr fiber = incr constipation/decr diarrhea high fiber foods: dried peas and beans (black beans), whole grain bread low fiber foods: white rice, canned fruit and juices (accept prune juice)

resuscitation phase of burn injury

incr hct from fluid loss hyperkalemia bc release of potassium from destruction of tissue and red blood cells at the burn site hyponatremia because sodium is drawn to the edematous burn area and lost through plasma leakage decrease in albumin due to a loss of protein from increased permeability of the vascular membranes at the burn site.

IM location

infants & toddlers: vastus lateralis adults: ventrogluteal, deltoid, vastus lateralis

prenatal labs

initial visit: urinalysis, blood type, STI screening 24-28 wk: 1 hr glucose tolerance test, antibody screening if Rh -, hgb/hct 36-38 wk: GBS

intellectual disability

intellectual impairment, impaired language skills

nystagmus

involuntary eye movements and muscle spasticity, which are manifestations of multiple sclerosis

codeine (narcotic)

antitussive - contraindicated with respiratory diseases (COPD)

serotonin syndrome

anxiety, disorientation, agitation, hyperthermia, tremor, muscle rigidity, hyperreflexia, HTN, tachycardia, diaphoresis ex taking St Johns wort

carbon dioxide retention post cholecystectomy

apply heat

cpm machine for knee replacement

apply when knee is extended check device settings q8h place client supine line up frame joints with knee

fundal height

at 20 weeks, fundus is at umbilicus incr ht by 1 cm/week after 20 weeks at 36 weeks, fundus is at xiphoid process ex: 24 wk? 24 cm + or - 2 cm

cataract extraction care

avoid aspirin, expect itching (use cold compress), bend at the knees, avoid lifting >10 lb

thrombocytopenia care

avoid hard foods (cause mouth trauma), use electric shaver, do not blow nose

transdermal fentanyl patch

avoid heat - incr vasodilation and absorption remain for 72 hr, peak 24 hr upper torso for optimal absorption - clean, dry, intact, alternate use short-acting analgesics to treat acute or breakthrough pain

trach tube home care

do not remove outer canula unless Dr says, clean technique at home long term is fine, perform trach care at least 1x/d, secretions should be thin and easily removable (notify Dr if mucus plug or thick secretions)

Catarcts

double vision

preop position for appendicitis

fetal position Pain medications are not given to the client with acute appendicitis because they may mask the symptoms that accompany a ruptured appendix. A nasogastric tube may be necessary postoperatively for gastric decompression or preoperatively if perforation occurs.

Encephalitis is characterized by

fever, nuchal rigidity, and altered mental status

manifestations of bacterial meningitis can include

fever, photophobia, nuchal rigidity, petechial rash, and impaired consciousness

ulcerative colitis s/s

fever, weight loss, liquid bloody stool, elevated WBC

Crohn's s/s

fever, wt loss, frequent soft loose stool without blood, elevated WBC, abd pain RLQ, decreased albumin

vitamin B12 deficiency

glossitis (smooth, beefy red tongue)

non heme iron

grain, legume, veggies

lumbar disk excision care

logroll, slight flexion of knees to relax back puscles, avoid sitting postop unless defecating, report urinary retention, use heating pad to relax muscle spasms, limit stair climbing, walk daily, resume activity gradually, avoid driving for 6 wks

acute lymphocytic leukemia

low RBC, plt, hct high WBC

heme iron

meat, fish, poultry

limbic

memory, learning

hyperkalemia tx

polystyrene sulfonate

tonsilectomy

post op hemorrhage s/s: frequent clearing of the throat, tachycardia, pallor, and decreased blood pressure. Manifestations of airway obstruction include increased respiratory rate, cyanosis, drooling, and stridor. expected findings: dry mouth, bad breath, brown nasal drainage

SLE exacerbating factors

pregnancy, infection, sun exposure

critical pathways

prevent unnecessary expense and implement Evidence based strategies for pt with specific, common diagnoses

car seat use

retainer clip at armpit rear facing in back seat. front seat no airbag shoulder harness at or below shoulders at 45 degree angle

bowel sound order

right lower quadrant

Autism Spectrum Disorder

s/s regression rx: malnutrition, self harm, sleep disturbances, learning difficulties, impaired interpersonal relationships

secondary prevention

screening

histrionic PD

self-focused, melodramatic, attention-seeking, and impulsive. Typically, they do not believe they need mental health counseling.

10 month old

separation anxiety, pull up to standing position, crawl on hands and knees

Garlic

can be used to treat hypertension and elevated cholesterol levels. incr rx of bleeding

self control therapy

this form of therapy can be applied to new situations." "An advantage of this technique is that change is likely to last." "Talking to oneself is a basic component of this form of therapy."

Adalimumab

tx rheumatoid arthritis tumor necrosis factor (TNF) inhibitor - immunosuppressant: do not receive live attenuated vax (instead, inactivated), do not take if have infection, receive TB test first, do not take with abx

secondary intention wound healing

wounds remain open and edges do not mesh, which increases the risk of infection keep moist to facilitate epithelization schedule home health visit for dressing changes and infection monitoring

prednisone adverse effects

wt gain, myopathy, infeciton, hyperglycemia

neonatal abstinence syndrome (NAS) s/s

yawn, sneeze, mottling, sweating, hypertonicity, high-pitched, shrill, persistent cry, and experience a disturbance in sleep patterns, uncoordinated suck, tremors, seizures ex: maternal heroin use

intimacy vs isolation

young adults

ovarian CA s/s

bloating, urinary frequency/urgency, constipation, pelvic/abd pain, early satiety

CKD electrolyte disturbances

hyperkalemia, hyperphosphatemia, hypermagnesemia, incr cr and BUN decr Ca, Bicarb, Hgb, Hct, PaCO2

Hep A vax

1st dose: 12 -23 mo 2nd dose: 6-18 mo after initial dose

varicella vax

1st dose: 12-15 mo 2nd dose: 4-6 yo

nasal canula

2-4L

CVP

2-8 low? hypovolemic shock - adm IV bolus isotonic fluids (NS, LR)

ANC

2500-8000

SIADH

hypervolemia, hyponatremia tx: fl restriction, sodium replacement, vasopressin antagonist (tolvaptan - promotes water excretion)

CN XII

hypoglossal observe ROM tongue weakness of tongue

alkaline phosphatase

30 to 120 units/L

aPTT

30-40 sec 60-80 sec with therapeutic heparin dosing >100? stop heparin

trigylcerides

35 to 135 mg/dL

triglycerides

35-160

hematocrit (Hct) level

37-52% prego >33% child: 32-44

irine osmolality

50 to 1,200 mOsm/kg

PAWP

6-12

blood lead levels

>5? contact social services >20? contact poison control >45? start chelation therapy

pH of NG aspirate

>6 = in respiratory tract!

PEEP and mechanical ventilation adverse effects

hypotension, tension pneumothorax, fluid/sodium retention, barotrauma, subcutaneous emphysema

eye contusion tx

ice

cranial nerve VIII (the acoustic nerve)

A tuning fork would be used

captopril

ACE-i (adverse effect: cough - report) Adequate fluid is important, but 4 quarts (4 liters) of water daily could actually aggravate the hypertension. avoid standing in one position for long periods, to change positions slowly, and to avoid extreme warmth such as with baths, showers, or heat from the sun in warm weather. The client would be instructed to monitor for signs of orthostatic hypotension, such as dizziness, light-headedness, weakness, and syncope.

atenolol

beta blocker, adm up to twice daily, not exceeding 100 mg/day, PO tx HTN and angina

cataracts s/s

blurred vision, halos when looking at lights

pediculosis capitis

boil combs for 10 min vaccuum carpets and upholstered furniture wash linens in hot water, dry in hot dryer for 20 min seal Non washable items in plastic bag for 14 d

information giver

Shares experiences as an authority figure

aplastic anemia diagnosis confirmed with

bone marrow biopsy

wt gain pregnancy

BMI >30? gain 11-20 lb BMI 18.5-25? gain 25-35 lb

measles (rubeola) precautions

airborne precautions - MASK, GLOVES. Any articles that are contaminated would be bagged and labeled.

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. The nurse reviews the client's record and notes that the client is presently taking warfarin. The nurse contacts the primary health care provider (PHCP), anticipating that the PHCP will prescribe which medication?

Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin are enhanced. Therefore, if thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin should be reduced.

pregnancy and constipation

Estrogen and progesterone levels increase leading to decreased peristalsis and relaxation of the smooth muscles of the intestine, which can result in constipation. sm intestines absorb iron and water more readily enlarged uterus compresses intestines

Cimetidine

H2 receptor antagonist most common CNS side effect: confusion

epinephrine adverse effects

HTN, chest pain (angina)

anaphyactic rxn nsg actions

If anaphylaxis occurs, the nurse immediately assesses the client's respiratory status. The medication is also immediately stopped. If the client's airway needs to be established or stabilized, the Rapid Response Team is called. In addition, the PHCP is contacted. The intravenous (IV) line is not removed because IV access is needed to administer emergency medications such as diphenhydramine or epinephrine. The client is positioned appropriately. The legs and feet are elevated. The head of the bed is elevated to improve ventilation; elevate the head of the bed 10 degrees if hypotension is present and 45 degrees or higher if the blood pressure is normal. The nurse stays with the client and monitors the client's status, including the vital signs. The nurse documents the event, actions taken, and the client's response.

peripheral vascular disease

ankle swelling, cellulitis, brown pigmentation

adolescent activity

Listening to music need at least 8h sleep/night

CKD diet

Low protein Low sodium Low Potassium Low phosphate limit meat and dairy fluid restriction

selegiline

MAOI interacts with many meds (ex: methylphenidate) - d/c 2 wks prior

phenelzine

MAOi antidepressant. Avoid tyramine (aged meat/cheese) & caffeine (chocolate) --> HTN crisis expected adverse effects: constipation, hypotension, wt gain good food choices: broccoli, yogurt, cream cheese

intestinal obstruction nursing care

NG tube (decompress, drain fluid and water, reduce pain), NPO, CT/US, semi-fowlers, frequent position changes to promote peristalsis, IV fluids (monitor urine output), assess bowel sounds

The nurse is reviewing the laboratory test results for a client who is receiving filgrastim. Which reported value would indicate an effective response to this medication?

Neutrophil count of 10,000 mm3 (10 × 109/L) filgrastim is used to promote the growth of neutrophils and enhance the function of mature neutrophils

Task of the orienteer

Noting the progress of the group toward assigned goals

Task of the initiator-contributor

Offering new and fresh ideas on an issue

fontanel closure

anterior: 12-18 mo posterior: 2-3 mo

brompheniramine for allergic rhinitis

anticholinergic effects (dry mouth, constipation, urinary retention), GI disturbance, CNS alteration (dizzy, confusion, poor coordination, fatigue)

heroin (opioid) intoxication

Sedation, bradycardia, and hypotension, pinpoint pupils, euphoria, resp acidosis, hypoglycemia, decr bowel sounds

phenobarbital

anticonvulsant, hypnotic agent avoid other CNS depressants like alcohol

Infective Endocarditis (IE)

The client needs to alert any physician about the history of infective endocarditis before invasive dental, oral, or upper respiratory procedures. The physician would place the client with a history of infective endocarditis on prophylactic antibiotics if one of these procedures is needed. Antibiotics need to be taken for the full course of therapy. The client needs to notify the physician if chest pain worsens or if dyspnea or other symptoms occur. The client would use a soft toothbrush and floss carefully to avoid any trauma to the gums, which could provide a portal of entry for bacterial infection.

Cyclophosphamide

The nurse should offer fluids frequently to maintain hydration and prevent hemorrhagic cystitis, which is an adverse effect of this medication.

Which purposes of placental functioning would the nurse include in a prenatal class? Select all that apply.

The placenta provides an exchange of oxygen, nutrients, and waste products between the parent and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

antihistamines

adverse effect: bitter taste

cochlear implants

directly stimulate the auditory nerve

sulfamethoxazole-trimethoprim

adverse effect: vomiting, diarrhea, tinnitus, vertigo, hallucination, seizure

amitriptyline

adverse effects: constipation, blurred vision, urinary retention, dry mouth tx MDD

technique for eye meds

Touching the eye or eyelid during medication administration can contaminate the dropper and cause eye injury. The child needs to be placed in a supine position with the neck slightly hyperextended for administration. Eye drops would be administered before eye ointment is administered. Blinking will increase the loss of medication.

Pheochromocytoma

VMA test to dx

walking with cruthces

When walking upstairs, the client should advance the unaffected leg first. When walking downstairs, the client should advance the crutches and the affected leg first and then follow with the unaffected leg. use a 3 point gait, rubber soled shoes

aminoglycosides

bacterial antibiotics, target gram-negative bacteria. administer via intermittent IV bolus over at least 30 min. toxicity: Nephrotoxicity and ototoxicity (tinnitus) monitor peak and trough serum levels.

newborn bathing

bathe every other day do not attempt to retract foreskin before 3 yo avoid antimicrobial soaps water temp 100-104

vitamin A food

carrot

rotavirus

contact precautions s/s: vomiting, diarrhea, fever 6-12 mo old are most susceptible oral fecal route

cranial nerve V - trigeminal nerve

cotton wisp on face

pseudophedrine

decongestant caution with diabetes mellitus, hyperthyroidism, prostatic hyperplasia, HTN, acute coronary syndrome (can cause vasoconstriction and HTN and tachycardia) contraindicated with glaucoma adverse effects: nonmigraine headaches, insomnia, and anxiety

left sided heart failure s/s

decr cap refill, dyspnea, dizzy (orthopnea)

macular degenration

decr central vision

physiological changes aging

decr lung expansion, CO, oral temp

oxytocin stimulated contraction test (OCT)

electronic fetal monitoring at the start of the OCT to obtain a baseline of the fetal heart rate. The nurse then administers oxytocin via IV infusion pump to initiate uterine contractions to observe the fetus' response to the stress of contractions. The test is negative if there are at least three contractions in 10 min with no late or variable decelerations of the fetal heart rate. empty bladder 1st semi fowlers, slightly tilted to one side to incr uteroplacental perfusion

ypovolemic shock

elevate legs 30 degrees s/s: hypotension, tachycardia, hyperkalemia, acidosis

blood transfusion tubing

in-line filter, macrodrip, no tinting or injection ports

bowel obstruction s/s

nausea, vomiting, abdominal distention, and constipation.

paranoid personality disorder

project blame

aplastic anemia

protective isolation, apply pressure to peripheral punctures for 5 min s/s: petechia, ecchymosis

glomerulonephritis

protein in urine limit strenuous activity limit sodium intake daily wt

Amoxicillin/Clavulanate suspension

shake, refrigerate, discard after 14d, report diarrhea (c diff), give q8-12h

pulmonary edema s/s

tachycardia, clammy, cyanotic skin, crackles, pink/frothy sputum

levodopa-carbidopa

toxicity: dyskinesias - report muscle twitching, tremors, and spastic winking. avoid high protein meals (reduces absorption) can cause urine and sweat to turn dark - normal drink 2-3L/d - avoid hypotension

nitroglycerin

transdermal: rotate site every few days to avoid skin irritation, wear 12-14hr/d (remove at night to avoid tolerance), headache is common, do not dc abruptly contraindicated with ED meds (hypotension) avoid rising quickly, alcohol (hypotension)

CN V

trigeminal clench teeth, palpate masseter

phenytoin

tx seizures adverse effects: measles-like rash (Stevens-Johnson syndrome, or toxic epidermal necrolysis) - report immediately gingival hyperplasia (bleeding and swollen gums), dizzy, nausea

CN X

vagus vocalize

CN VIII

vestibulocochlear Rinne and Weber and whisper tests dizziness, hearing loss

cranial nerve II (optic)

vision

prealbumin

15-36 mg/dL

The nurse is interviewing a 16-year-old client during the initial prenatal clinic visit. The client is beginning week 18 of their first pregnancy. Which statement, if made by the client, indicates an immediate need for further investigation?

"I don't like my face anymore. I always look as if I have been crying." there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. The question identifies an adolescent who has not sought early prenatal care. Such clients are at higher risk for the development of gestational hypertension.

serum lipase level

0 to 160 U/L (0 to 160 U/L)

burn pt IV fluids contraindicated

0.45% NS (risk 3rd spacing bc hypotonic)

creatinine

0.5 to 1.1 mg/dL

fecal impaction

1st: oil retention enema (softens stool first) (Bisacodyl is contraindicated) advance gloved lubricated finger along rectal wall do not stimulate vagal response with rectal stimulation (cardiac dysrhythmias) side lying, knees flexed

true labor

1 ctx/5 min (regular frequency), dilation 2-3 cm/hr, painful, back to abd, no relief with fluids and rest

sterile field

1 in border, open items at least 6 inches above field, open last flap towards self, keep everything in line of vision and above hip level

conversions

1 pint = 480 mL 1 oz = 30 mL

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments?

1) "I would avoid all contact with my family." 2) "I would avoid large crowds for at least 3 weeks." 3) "I cannot give Legionnaires' disease to other people." (CORRECT) 4) "I will have to take antibiotics until my symptoms disappear." Legionnaires' disease is spread through infected aerosolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription; therefore, the remaining options are incorrect.

A client with diabetes mellitus received 20 units of Humulin N insulin subcutaneously at 0800. At what time would the nurse plan to assess the client for a hypoglycemic reaction?

1700 Humulin N is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication?

1) Drowsiness (CORRECT) 2) Hypocalcemia 3) Blurred vision 4) Seizure activity Drowsiness is a common side or adverse effect of phenobarbital, which is a barbiturate and antiseizure medication. Hypocalcemia is a rare effect. Blurred vision is not an associated side effect of this medication. Seizure activity could occur from abrupt withdrawal of this medication therapy or as a toxic reaction.

The nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child's parents to determine their adjustment to their child's chronic illness. Which statement, if made by the parents, would indicate a need for further teaching?

1) Our child sleeps in our bedroom at night." (CORRECT) 2) "We worry about injuries when our child has a seizure." 3) "Our child is involved in a swim program with neighbors and friends." 4) "Our babysitter just completed cardiopulmonary resuscitation training." Parents are especially concerned about seizures that might go undetected during the night. The nurse needs to decrease parental overprotection and would suggest the use of a baby monitor at night. Involvement in a swim program and knowing CPR identify parental understanding of the disorder. Worrying about injuries when a child has a seizure is a common concern. The parents need to be reminded that as the child grows, they cannot always observe their child, but their knowledge of seizure activity and care is appropriate to minimize complications.

The nurse would include which interventions in the plan of care for a client with hypothyroidism? Select all that apply.

1) Provide a cool environment for the client. 2) Instruct the client to consume a high-fat diet. 3) Instruct the client about thyroid replacement therapy. (CORRECT) 4) Encourage the client to consume fluids and high-fiber foods in the diet. (CORRECT) 5) Inform the client that iodine preparations will be prescribed to treat the disorder. 6) Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur. (CORRECT) The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the PHCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. s/s: dry coarse hair, periorbital edema, bradycardia

urine specific gravity

1.005 to 1.030 incr? nausea/vomiting

bun

10-20 child: 5-18 low? malabsorption, liver disease, fluid overload, or nephrotic syndrome high? renal disease, dehydration, shock, excessive protein in the diet, sepsis, glucocorticoid use, gastrointestinal bleeding

wbc

5000-10000

newborn head circumference

33-35 cm

health literacy assurances

5th-6th grade level in client's spoken language, sensitive to their cultural background, given before procedure simple pictures for reinforcement

infant diapers

6-10 in 24hr is normal

Amino acids obtained thru diet

9

Absolute Neutrophil Count (ANC)

<500? rx shock

pregnancy vaccines

recommended: Tdap, flu contraindicated: HPV, MMR, varicella

diverticulosis

high fiber diet

task of the information giver.

sharing experiences as an authority figure

hepatitis A

fecal-oral route avoid raw clams

Romberg test

feet together, arms resting down at sides, once with eyes open and once with eyes closed, test balance

major depressive disorder rx factors

female, >65 yo, tressful life events, chronic medical disorders, and first-degree family members having major depressive disorder.

iron deficiency anemia treatment

ferrous sulfate

vital lung capacity

amt air client can exhale after max inhalation

functional residual capacity

amt air in lungs after normal expiration

preeclampsia

incr Hgb, transient headaches, maybe edema

brace care

avoid lotions and powders which cake and cause irritation

trichomoniasis

avoid sex until 1 wk after therapy with metronidazole (flagyl) use condoms, tx partners to avoid reinfection

St. John's wort

can cause insomnia, restlessness, dry mouth, and headache. St. John's wort can reduce the effectiveness of digoxin and calcium channel blockers

Indicators that fluid volume deficit is resolving would be

capillary refill less than 2 seconds, specific gravity of 1.003 to 1.030, urine output of at least 1 mL/kg/hr, and adequate tear production, no more tachycardia, good skin turgor

misoprostol

causes diarrhea, reduces gastric acid secretion so ulcers can heal and reduces the risk of new ulcer development, avoid mag containing antacids (incr risk diarrhea), r/o pregnancy (causes uterine ctx)

varenicline

chantix smoking cessation

borderline personality disorder

emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation.

SIRS

high then low WBC, low plt, increased lactic acid (5-20 normal range), increased C-reactive protein (1-3 normal range)

ventriculoperitoneal shunt

lay flat (prevent rapid draining) on nonoperative side,

magnesium

legumes, nuts, green veggies have high levels of mag hypermagnesemia: weak DTRs, cardiac dysrhythmias used to tx torsades de pointes

MDMA

lethargy, increased tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects.

sleep hygiene

limit naps to 2, 20 min or less naps/day limit caffeine consumption (incl hot cocoa) at least 4h before bed avoid exercise within 3h before bed avoid fluids before bed (nocturia)

orienteer

notes the progress of the group toward assigned goals

diabetic foot care

pat dry, wash daily (do not soak), lotion on top and sole but not between toes, 105-110 degrees

IV morphine

peaks in 20 min, do adm if RR <12, bolus over 4-5min, resp depression occurs in 7 min

infant activity

peek-a-boo

second trimester care

pelvic tilt exercises, rest, sleep on firm mattress to ease back pain physical exercises (abs) prevent UTI - avoid bubble baths avoid lying on back (rx supine hypotension)

physiotherapy

perform percussions over single layer of clothing with cupped hand, no pain, Trendelenburg to promote drainage

toddler activity

push pull toy, imitative play (jumping), parallel play

osteoporosis meds

raloxifene adv effects: dyspnea (thromboembolism) Teriparatide adv effects: muscle pain, headache Denosumab adv effects: urinary frequency (UTI) zoledronate adv effects: jaw pain increase rx: estrogen deficiency, sedentary, small frame

oxygen toxicity

substernal pain, crackles

Tiotropium

tx COPD adv effect: anticholinergic (dry mouth, urinary retention)

alprazolam

tx GAD adverse effects: orthostatic hypotension, dizziness, confusion, lethargy, constipation (incr fluid)

5 yr old developmental tasks

walk backward, tying shoelaces

exercise EKG

no caffeine, alcohol, smoking day of test no Ca channel blockers or Beta blockers day of test light meal 2 h prior is ok

affordable care act

no lifetime or annual coverage limits covers children until 26 yo covers preexisting conditions

hip frx pain type and location

no pain, groin pain, pain referred to the lower back, or pain referred to the back of the knee

nonstress test

nonreactive after 40 min with no accels despite vibroaccoustic stimulation provide vibroacoustic stimulation after 20 min of no accels

bowel sounds

normal bowel sounds = high-pitched clicks/ gurgles. Loud gurgles (borborygmi) = hyperperistalsis More high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. swishing/buzzing sound represents turbulent blood flow associated with a bruit (abnormal)

varicella

not contagious when all lesions have crusted

radiation therapy

not to remove any temporary ink markings when cleaning the skin until the entire course of radiation therapy is complete. The client should also avoid rubbing, scratching, or scrubbing the skin to prevent a break in skin integrity, which would increase the risk of infection. The client should wash the skin with water and gently pat it dry and should avoid using soaps, deodorants, perfumes, and powders on the site during the duration of treatment. apply only lotions that the provider prescribes. Chemical agents in sunscreens can cause irritation to the radiated skin. wear loose-fitting clothing over the treated area of skin. The client should not wear buckles, belts, straps, or anything that binds or rubs the skin at the radiation site. protect the skin from exposure to sunlight during treatment and for 1 year after the last treatment. The nurse should encourage the client to stay in the shade, such as under an awning when the sun's rays are most intense. Going outside in the early morning or evening to avoid the more intense sun rays allows the client to stay outside for a longer period adv effect: altered taste sensation, dry skin, increased sensitivity skin, hair loss at site of radiation

suicide rx

parental suicide, hx poor decision making, impulsivity, poor judgement, lack of adherence to prescribed meds, lack self care, sudden decline in school performance

Cyclosporine is prescribed for a client who received a kidney transplant. The nurse would be most concerned if a review of the medical record revealed that the client currently is taking which prescribed medication?

phenytoin Cyclosporine is an immunosuppressant medication used to prevent rejection following allogeneic organ transplantation. Medications known to lower cyclosporine levels include phenytoin (anticonvulsive medication), phenobarbital, rifampin, and trimethoprim-sulfamethoxazole. Cyclosporine levels would be monitored and the dosage adjusted in clients taking these medications.

opioid toxicity

pinpoint pupils, respiratory depression, hypoactive bowel sounds, ALOC give naloxone

death views according to age and development

preschoolers - avoid death with magical thinking 6-9 yo - death is final, curious about it, fear 10-12 yo - death is final, affects all, evil, how affect me adolescents - religious and spiritual aspects young adults - interruption of what might have been odler adults - accept death as natural consequence of deteriorating body

inadequate progesterone in pregancy

preterm labor, reduced uterine contractility (maintains lining of uterus)

tertiary prevention

prevent complications

NG tube post surgery

prevent pressure on suture lines, prevent GI distention and vomiting, drains air and fluid in GI tract

hypertonic enema

prior to surgery - cleanse bowel

restraints use

provider must renew a prescription for restraints every 4 hr for clients 18 years or older, every 2 hr for children ages 9 to 17 years, and every 1 hr for children under the age of 9 years. document q15-30 min have staff member remain with patient provider must assess pt within 1 hr of restraint initiation

Aversion therapy

provides a negative reinforcement when the stimulus is produced

EEG

pt lies with eyes closed, hyperventilation, photic stimulation with flashing lights, 45min-2h, documents brain activity (no electrical shock)

ventricular tachycardia

pulse? synchronized cardioversion, amiodarone pulseless? CPR, defib

cardiac tamponade s/s

pulsus paradoxus, a finding in which the systolic BP is 10 mm Hg or greater on expiration than inspiration jugular vein distention, bradycardia, hypotension

acute gastritis s/s

rapid onset of epigastric discomfort, nausea and vomiting, hematemesis (or vomiting blood), gastric hemorrhage, dyspepsia (heartburn), and anorexia

delirium

rapid, inappropriate, incoherent, and rambling speech patterns.

purine foods

red wine, liver, chicken (animal protein) avoid/limit if prone to uric acid calculi formation (instead, eat citrus fruits like oranges)

hearing aid care

remove battery at night, turn volume down when inserting, when new initially start wearing for 20 min and incr time, do not wear when blow drying hair or using heat lamp, clean with soft cloth, do not immerse in water

diaphragm use

replace q2yr clean with mild soap and water, dry gently remain in place 6hr after intercourse

preventing infections

replace toothbrush every 3 mo or after a respiratory infection wash visibly soiled linens separate wash hands for 15 sec

4 month old activities

roll from front to back, no head lag, raise head and chest off a flat surface to a 90° angle when lying prone

nationally notifiable diseases

rubella, listeriosis, Lyme disease, malaria, and measles child mortality due to flu, adult mortality due to varicella, anthrax, TB, chlamydia

neural tube defect

rx: DM, antiepileptics, non daily use of prenatals, previous child with NTD, obesity, bathing in hot water

pancreatitis

rx: hypovolemia (from NPO - give isotonic fluids), pain (give opioids PCA), hypocalcemia (positive Chvostek's and Trousseau's)

mastitis

s/s fever, muscle aches, breast pain, inflammation (warmth, redness, edema) adm abx, warm compress, massage breast, proper latch, NSAIDS, acetaminophen, incr fluids

peritonitis

s/s: fever, abdominal distention, tachycardia, nausea, vomiting, tachypnea, shallow breathing and fetal position bc sudden sharp pain, altered bowel patterns, elevated WBC, generalized abd pain radiating to shoulder or back

scarlet fever

s/s: fever, tonsillitis, and a strawberry tongue characterized by prominent red papillae, rash also appears that begins to desquamate at the end of the first week of the illness, including sloughing of the skin of the soles and palms.

malignant hyperthermia

s/s: tachycardia, tachypnea, hypotension, and irregular heart rhythm, hypercapnia, muscle rigidity correct dysrhythmias, provide oxygen to tissues, correct electrolyte imbalances, and reverse metabolic and respiratory acidosis. administer dantrolene and oxygen, monitor the PCO2 level on the client's ABGs for hypercapnia and observe the client for muscle rigidity of the jaw and chest muscles. cooling blankets, fluid resuscitation

newborn care

set water temp to 120 or less, crib slats should be no more than 5.7 cm (2.25 in) apart, car seat should remain rear-facing until the age of 2 years old, bathe q2-3d, cover body when washing hair to prevent heat loss, place on back to sleep, breastfeed q2-3h, use bulb syringe in mouth then nose

abruptio placentae

severe abdominal pain, uterine tenderness, abdomen feels hard and boardlike on palpation, as the blood penetrates the myometrium and causes uterine irritability.

compartment syndrome

severe pain, paresthesia, cool, no pulses, HTN, no voiding fasciotomy is needed to decrease atrial spasms and increase perfusion within the muscle compartments. contraindicated: elevating the right leg above heart level, and applying ice to the affected extremity

pernicious anemia

signs: weakness, mild diarrhea, wt loss, tachycardia, and a smooth red tongue that is sore (glossitis). The client also may have nervous system signs and symptoms such as paresthesias, difficulty with balance, and occasional confusion give Vitamin B12

thoracentesis

sitting on the side of the bed and leaning over the table (during procedure); affected side up (after procedure). need chest x-ray after to determine no pneumothorax or mediastinal shift local anesthetic is used avoid moving and deep breaths during procedure place the client in an upright position, with arms and shoulders raised and supported on pillows or on an overbed table (facilitates removal of fluid and access to the pleural space)

preschooler activity

skipping

papule

small, solid, elevated lesion with distinct borders less than 10 mm (ex: wart, elevated mole)

PP factors rx thromboembolic disorders

smoking, varicose veins, obesity, a history of thrombophlebitis, pregnant clients older than 35 years or who have had more than three pregnancies, and clients who have had a cesarean birth

schizotypal

social awkwardness

2 yr old developmental tasks

speak in 2-3 sentences, follow and complete simple commands, state own name

4 yr old developmental tasks

speak in 4-5 word sentences, add 3 parts to a stick figure, develop superego (conscience, right and wrong, punishment and reward)

pressure injuries

stage 1: nonblanchable stage 2: partial thickness skin loss, blister stage 3: visible subcutaneous tissue stage 4: muscle damage, tendon exposure

anorexia nervosa care

stay with client 1hr post meal weight daily upon waking and after first void wt gain 2-3 lb/wk manifestations: low BMI, weight loss, food restriction, lanugo, edema, cold extremities Complications: arrhythmias, decreased bone density, muscle weakening, and heart failure.

sublimation

substituting a socially unacceptable behavior for an acceptable behavior: ex: channeling negative feelings over the loss of their job into a new hobby

tracheostomy care

suction 5-15s, surgical asepsis

primary intention wound healing

surgical incisions and sutures, little scarring

paranoid PD

suspicious and distrustful of others. They display jealousy and expect hostility from others.

opioid withdrawal (ex heroin)

sweating, rinorrhea, goosflesh, tremors, irritable, weak, fever, diarrhea, insomnia, pupil dilation, n/v monitor for SI

mononucleosis

swollen lymph nodes, fever, sore throat, headache, fatigue, splenomegaly (LUQ pain)

Calcium supplement

take with large glass of water after meal do not take with grains (decr absorption) take with Vit D 1200 mg daily

aquatheria pad

tell client to report if gets too warm check limb 15-20 min after application for complications do not show the pt how to readjust the temp d/c if redness and report to provider

the carina

the ET tube should lie 2 cm above the carina - the bifurcation of R and L bronchi

5 mo old

turn from abd to back

Islamic death rituals

turn head to right shoulder with body facing Mecca, family member of same gender washes body, wrapped in white, autopsies are forbidden

bed rest care

turn q1-2h deep breath and cough q1h ROM 3-4x/d ankle pump q1-2h

zidovudine

tx HIV anemia and granulocytopenia can occur with this medication, a CBC count will be done periodically side effects: nausea, headache

diltiazem

tx HTN adverse effect: hypotension, dizziness, cardiac dysrhythmia, hyperglycemia, blurred vision

Simvastatin/Ezetimibe

tx hypercholesterolemia adverse effect: myopathy, which can include muscle aches, tenderness, and weakness. Myopathy can progress to rhabdomyolysis, which is a breakdown of muscle cells; hyperglycemia, rashes, pruritis avoid grapefruit juice (raises ALT and AST levels)

methotrexate

tx rheumatoid arthritis adverse effects: infection rx, (kidney damage - dark purple spots on body/petechia, purpura, bleeding (hematemesis, bleeding gums) (drink 2-3L), dermatitis, bone marrow suppression (thrombocytopenia), alopecia, n/v (antiemetic), diarrhea, teratogenic (use birth control) avoid caffeine and folic acid

chlorpromazine

tx schizophrenia 1st gen antipsychotic common adverse effects: headache, dry mouth, blurred vision, photophobia, constipation, leukopenia (report sore throat) dangerous adverse effects: neuroleptic malignant syndrome, a potentially life-threatening adverse effect of chlorpromazine that can cause the client to have a high temperature, dysrhythmia, decreased level of consciousness, and a labile blood pressure avoid alcohol and driving do not d/c abruptly

haloperidol

tx schizophrenia first-generation (typical) antipsychotic medication that helps control the positive manifestations of schizophrenia, such as agitation, hallucinations, delusions, and bizarre behavior. adverse effects: muscle spasms of the tongue, face, neck, and back, mask-like faces, tremors, muscle rigidity, and continuous, restless movement. dry mouth (rinse mouth, sugarless gum, hard candy). have regular eye exams. photosensitivity (wear sunscreen). do not abruptly stop (avoid EPS)

conversion

unconsciously transfers emotional tension into a physical manifestation. (ex: transferring the anxiety caused by viewing a fire on television into stomach pains after experiencing house fire)

oxygen storage in the home

use cotton sheets (don't generate electricity as synthetics do), store away from walls, bedding, drapes, and combustible materials, store upright, 8 ft away from heat source, use water soluble lubricant to soothe mucous membranes, check functioning of equipment daily

continuous bladder irrigation post TURP

use isotonic solution (not sterile wtaer), use 50 mL to clear blockage, subtract irrigation fluid to determine output, secure to thigh

newborn bathing care

use moistened cotton ball or corner of washcloth to clean ear water temp 38-40 C do not remove yellow exudate from circumcision do not use talcum powder (emollient is good)

tetralogy of fallot

ventricular septal defect, pulmonary stenosis, overriding aorta, R ventricular hypertrophy rx: thromboembolic events, infective endocarditis, heart failure (diaphoresis, hypotonia, fl retention (wt gain, periobrbital edema, decr urine output), poor wt gain, failure to thrive, pale cool extremities) require surgery btwn 6-12 mo s/s: systolic heart murmur and palpable thrill, tet spells/hypercyanotic spells when crying, feeding - place infant in knee-chest position first, then morphine, soothing, oxygen, encourage nonnutritive sucking, quiet environment

paracentesis

void first, local anesthetic, upright/high fowlers

albuterol metered dose inhaler use

wait at least 1 min between inhalations clean the mouthpiece every day with warm water and soap take a long, slow inhalation while activating the dispenser take the medication 5 to 20 min prior to exercise medication's effects begin immediately, peak in 30 to 60 min, and can last for up to 5 hr hold breath 5-10 sec breath out away from inhaler first tilt the head slightly back while inhaling med thoroughly/vigorously shake before use (do not shake dry powder inhaler)

genital herpes care

warm compress, no sexual activity when lesions present, use mild soap to clean lesions, 3-4 sitz baths/d

scleral buckling for detached retina

wear eye shield at night 2-6 wk after, do not lift more than 20 lb, avoid reading for 1 wk, vision gradually returns over several weeks

venus insufficiency

wear graduated compression stockings during the day and evening elevate their legs for at least 20 min four or five times per day. When the client is lying down, they should elevate their legs above the level of their heart. avoid prolonged periods of sitting or standing, which keeps the legs from being in a dependent position and helps prevent venous stasis. not to cross their legs while sitting

heart failure

weigh daily, report wt gain >1.4 kg (3 lb) in 1 day or more than 2.3 kg (5 lb) per week. To promote exercise tolerance, the client should wait for 2 hr after eating before engaging in an exercise activity. take diuretics in the morning to avoid having to get up during the night to void. limit sodium intake to 2 to 3 g per day to prevent fluid retention.

Lifestyle modifications for gastroesophageal reflux disease (GERD)

weight reduction if appropriate, decreasing caffeine and alcohol intake, avoiding lying down for at least 3 hours after eating, and eating small, frequent meals.

heroin OD

within 6-8hr muscle aches, insomnia, pupil dilation, diarrhea

older adult diet

1200 mg Ca (incr) limit fat to 20-30% 2.7/3.7 L/d protein 10-35% (incr) incr vitamin D, B12, A

hgb

14-18 male 12-16 female prego >11

Fruit & veggie servings per day

5 servings/d

developmental play

<12 mo: solitary play 1-3 yo: parallel play 3-5 yo (preschoolers): imaginary play, associative play 6-12 yo: cooperative play

thyroid storm

Fever greater than 38.5° C (101.3° F), heart rate greater than 130/min, systolic hypertension, and mental status changes, such as confusion, restlessness, and sleepiness

CT scan

For a CT scan of the head, the client lies on a movable table in a head-holding device. Each set of head scans takes less than 5 minutes to perform. An iodinated contrast medium may or may not be used. No special aftercare is indicated, so the client may resume the usual diet and activity afterward.

task of the evaluator

Measuring the group's work against the assigned objectives

asthma triggers

NSAIDS (ibuprofen- instead use acetaminophen), upper resp infection, dry air, exercise, carpet

initiator-contributor

Offering new and fresh ideas on an issue

Esomeprazole

PPI Constipation, dry mouth, headaches, diarrhea are adverse effects treats gastric ulcers, duodenal ulcers, and GERD - absence of heart burn/burning throat = therapeutic response

The nurse is performing an assessment on a client with a diagnosis of chronic angina pectoris. The client is receiving sotalol orally daily. Which assessment finding indicates to the nurse that the client is experiencing a side or adverse effect related to the medication?

Palpitations Sotalol is a beta-adrenergic blocking agent. Side and adverse effects include bradycardia, palpitations, difficulty breathing, irregular heartbeat, signs of heart failure, and cold hands and feet. Gastrointestinal disturbances, anxiety and nervousness, and unusual tiredness and weakness also can occur.

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse would expect to note which finding on assessment of the client?

Positive Trousseau's sign Hypoparathyroidism is related to a lack of parathyroid hormone secretion or a decreased effectiveness of parathyroid hormone on target tissues. The end result of this disorder is hypocalcemia. When serum calcium levels are critically low, the client may exhibit Chvostek's and Trousseau's signs, which indicate potential tetany

betamethasone

Stimulates fetal lung maturation between 24-32 weeks gestation adv effect: hyperglycemia

Digoxin levels

The normal therapeutic range is 0.5 to 2.0 ng/mL (0.6 to 2.4 nmol/L) 2.4 ng/mL=toxic

tertiary intention wound healing

Wounds remain open for several days to allow edema to resolve or infection to heal. The provider then closes it with staples, sutures, or adhesive skin closures

school-age children activity

hand sewing a picture, catching a ball

coarctation of aorta

incr blood flow to upper extremities, lower blood flow to lower extremities - different pulses and BP

breastfeeding nutrition

incr daily calorie intake by 450-500, drink a full glass of water when breastfeeding (12, 8 oz caffeine free fluids daily), continue prenatals

spina bifida related allergies

latex

enema use

lubricate 2 in of tube, don clean gloves prior, administer fluids slowly and lower container if client experiences fullness/pain, lay in left Sim's position

hypocaclemia

numb, tingling extremities and around the mouth

assess newborn order

observe, auscultate, palpate, invasive (eyes, ears, mouth, nose), then moro last

integrity vs despair

older adults

pain indicators

pale, diaphoresis, dilated pupils, hyperglycemia

acute head injury s/s

pallor, headache, vomiting, confusion, agitation, altered mental status, incr temperature, blurred vision, diplopia, headache, somnolence, incr sleeping

neonatal infection s/s

pallor, jaundice, fever, tachypnea, hypotonia/lethargy

vanco

peak: 18-50 trough: 15-20

Betaxolol eye drops have been prescribed for a client with glaucoma. The nurse monitoring this client for side/adverse effects of the medication would place highest priority on which assessment?

pulse rate Betaxolol is a beta-blocking agent as well as an antiglaucoma medication. Nursing assessments include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. The nurse also assesses for evidence of heart failure as manifested by dizziness, night cough, peripheral edema, and distended neck veins.

amputation

rewrap 3x/d, firm mattress (prevent contractures), prone 20-30 min q3-4h (prevent hip contractures), no lotions or powders

myasthenia gravis

set alarm to take meds at same time each day avoid overheating eat high calorie diet

carboprost

side effects: HTN, tachycardia

8 month old activity

sit unsupported

hyperthyroidism s/s

tachycardia, diaphoresis, weight loss, tremors, insomnia, exophthalmia

verapamil

take with food to reduce gastric discomfort avoid NSAIDS (aspirin) - incr bleeding rx, reduces verapamil's antiHTN action incr fluid and fiber (decr constipation) monitor for wt gain and diarrhea don't take with grapefruit juice (hypotension) adverse effect of verapamil: urinary frequency, drowsy, wt gain

corneal light reflex

tests for strabismus

isoniazid (INH)

tx TB adverse effect: decr Vit B6 (peripheral neuropathy - tingling; take Vit B6)

Divalproex sodium

tx absence seizures most frequent side effects: gastrointestinal (GI) disturbances, such as nausea, vomiting, and indigestion

beclamethasone

tx asthma adverse effect: dry mouth, dysphonia (hoarseness, difficulty speaking) - gargle with water after use to prevent oral candidiasis

Vincristine

tx breast CA can cause peripheral neuropathy, muscle atrophy, and numbness and tingling in the hands and feet, CNS depression, decreased reflexes, and motor difficulties., constipation

timolol

tx glaucoma, HTN contraindicated with asthma (bronchospasm)

Milrinone (Primacor)

tx heart failure (monitor daily wt) side effect: hypotension (monitor BP), incr urinary output use infusion pump through central line (extravasion rx if peripheral)

alendronate sodium

tx paget's disease, postmenopausal osteoporosis - prevents/slows bone weakening wait 30 min after taking med to eat or lie down - decr heart burn and esophageal damage (contraindicated with esophageal achalasia)

post vein ligation or stripping care

walk q5-10 min qhr supine, legs elevated compressions socks for 1wk

INR

with pulmonary embolism: 2.5-3.5

The parent of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the parent?

"The child may return to school in 3 weeks but needs to go half-days for the first few days." the child cannot participate in physical education for 2 months

The nurse provides teaching on how to relieve discomfort to a client in the second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching?

1) "When I get home, I need to lie on my left side with my feet in a dorsiflexed position." 2) "I need to soak in a tub bath of hot water when I get home and then perform pelvic tilt exercises." 3) "When I get home, I need to lie on my right side with my feet elevated on a pillow and with a heating pad on my back." 4)"When I get home, I need to lie on the floor with my legs elevated on a couch and turn my hips and knees at right angles. (CORRECT) Lying on the floor with the legs elevated on a couch with the hips and knees at right angles will produce a posture of pelvic tilt while countering gravity, which is the force that leads to edema of the lower extremities. Lying on the left side with the feet dorsiflexed may help with the reduction of hemorrhoids. Remember that heat needs to be prescribed by a primary health care provider (PHCP).

Which assigned client would the nurse monitor closely for signs of hyperkalemia?

1) A client with ulcerative colitis 2) A client with Cushing's syndrome 3) A client admitted 6 hours ago with a 40% burn injury (CORRECT) 4) A client who has a history of long-term laxative abuse Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings would the nurse expect to note? Select all that apply.

1) Dental decay (CORRECT) 2) Moist, oily skin 3) Loss of tooth enamel (CORRECT) 4) Electrolyte imbalances (CORRECT) 5) Body weight well below ideal range Clients with bulimia nervosa initially may not appear to be physically or emotionally ill. They are often at or slightly below ideal body weight. On further inspection, a client exhibits dental decay and loss of tooth enamel if the client has been inducing vomiting. Electrolyte imbalances are present. Dry, scaly skin (rather than moist, oily skin) is present.

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse would provide which instructions to the client? Select all that apply.

1) Diarrhea may occur secondary to the metformin.(CORRECT) 2) The repaglinide is not taken if a meal is skipped. (CORRECT) 3) The repaglinide is taken 30 minutes before eating. (CORRECT) 4) A simple sugar food item is carried and used to treat mild hypoglycemia episodes. (CORRECT) 5) Muscle pain is an expected effect of metformin and may be treated with acetaminophen. 6) Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide. Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, is to be taken before meals (approximately 30 minutes before meals) and would be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, and the client needs to be prepared by carrying a simple sugar at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin, but it might signify a more serious condition that warrants primary health care provider notification, not the use of acetaminophen.

A client with a new ileostomy is concerned about the odor from stool in the ostomy drainage bag. The nurse would teach the client to include which food in the diet to reduce odor?

1) Eggs 2) Yogurt (CORRECT) 3) Broccoli 4) Asparagus The client needs to be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a gas-forming food as well. Broccoli, asparagus, and eggs are gas-forming foods. There are also optional charcoal filters that can deodorize the ileostomy. change pouch q3-7d, empty when 1/3-1/2 full, fluid intake 1920 mL/d or more no stool 6-12 h? contact PCP

The nurse is performing an admission assessment of a client with a possible right colon tumor. Which sign or symptom would the nurse anticipate the client may report?

1) Frequent diarrhea 2) Crampy gas pains 3) Flat, ribbon-like stools 4) Dull abdominal pain exacerbated by walking (CORRECT) Characteristic symptoms of right colon tumors include vague, dull abdominal pain exacerbated by walking and dark red- or mahogany-colored blood mixed in the stool. The symptoms described in the other options are associated with left colon tumors.

A client with diabetes mellitus is taking Humulin NPH insulin and regular insulin every morning. The nurse would provide which instructions to the client? Select all that apply.

1) Hypoglycemia may be experienced before dinnertime. (CORRECT) 2) The insulin dose needs to be decreased if illness occurs. 3) The insulin should be administered at room temperature. (CORRECT) 4) The insulin vial needs to be shaken vigorously to break up the precipitates. 5) The NPH insulin would be drawn into the syringe first, then the regular insulin. Humulin NPH is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 30 to 60 minutes, it peaks in 1 to 5 hours, and its duration is 6 to 10 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials would never be shaken vigorously. Regular insulin is always drawn up before NPH.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence?

1) Inability to pass flatus (CORRECT) 2) Loss of anal sphincter control 3) Severe, constant pain with rapid onset 4)Firm, nontender mass palpable at the lower right costal margin An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

After the spontaneous rupture of the membranes of a client in labor, the fetal heart rate drops to 85 beats/minute. Which would be the nurse's priority action?

1) Reposition the client to knee-chest. 2) Assess the vagina and cervix with a gloved hand. (CORRECT) 3) Notify the primary health care provider of the need for an amnioinfusion. 4) Document the description of the fetal bradycardia in the nursing notes It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action would be to glove the examining hand and insert two fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the client to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression are the first interventions that need to be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, but not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

A client with gastritis who uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?

1) Resolved diarrhea 2) Relief of epigastric pain (correct) 3) Decreased platelet count 4) Decreased white blood cell count The client who uses NSAIDs is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence in clients taking NSAIDs frequently. Diarrhea can be a side effect. Options 3 and 4 are unrelated to the purpose of misoprostol.

The nurse manager is planning the clinical assignments for the day. Which staff members would not be assigned to care for a client with herpes zoster? Select all that apply.

1) The nurse who never had roseola 2) The nurse who never had mumps 3) The nurse who never had chicken pox (CORRECT) 4) The nurse who never had German measles 5) The nurse who never received the varicella-zoster vaccine (CORRECT) The nurses who have not had chicken pox or did not receive the varicella-zoster vaccine are susceptible to the herpes zoster virus and would not be assigned to care for the client with herpes zoster. Nurses who have not contracted roseola, mumps, or rubella are not necessarily susceptible to herpes zoster. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the causative virus of chicken pox. Individuals who have not been exposed to the varicella-zoster virus or who did not receive the varicella-zoster vaccine are susceptible to chicken pox. Health care workers who are unsure of their immune status would have varicella titers done before exposure to a person with herpes zoster.

Due to an extreme staff shortage, the nurse has been sent to the intensive care unit to assist registered nurses in the care of clients. The nurse understands that which factor is most important to consider when treating a client with cardiogenic shock?

1) Use of diuretics to decrease circulating volume 2) Use of whole blood to easily restore fluid volume 3) Use of intravenous and oral fluids to restore circulating volume 4) Restriction of volume expanders because of secondary pulmonary edema (correct) A client in cardiogenic shock may have secondary issues such as pulmonary edema due to the ineffective pumping mechanism of the heart. Fluid restoration is a key ingredient in treating shock states although it must be used conservatively in clients with cardiogenic shock. Therefore, options 2 and 3 are incorrect. Option 1 is incorrect because the problem is with the pumping action of the heart and not increased blood volume

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action?

1) Wears a turban to cover the incision 2) Indicates that facial puffiness will be a permanent problem (CORRECT) 3) Verbalizes that periorbital bruising will disappear over time 4) States an intention to purchase a hairpiece until hair has grown back After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

older adult client health promotion

10-15 min sun exposure 2-3x/wk (wear hat, long sleeve, sunscreen) dietary fat intake between 20% and 35% of daily caloric intake to prevent weight gain fiber 35 to 50 grams per day. exercise five times per week for 30 min to improve strength and mobility

platelet

150,000-400,000

The nurse is reviewing the laboratory results for a client diagnosed with cirrhosis. Which of the following albumin levels would the nurse anticipate?

2.0 g/dL Cirrhosis is end-stage liver disease related to the degeneration and destruction of liver cells that are replaced by fibrotic tissue. The most common causes of cirrhosis include hepatitis C infection and chronic alcohol use. Common laboratory findings include increased liver function tests (LFTs), such as aspartate aminotransferase (AST) and alanine aminotransferase (ALT), increased bilirubin, increased prothrombin time, and decreased albumin. A normal albumin level ranges from 3.5 to 5.0 g/dL (35 to 50 g/L).

Risperidone

2nd gen tx schizophrenia adverse effect: orthostatic hypotension, constipation, diarrhea, dry mouth (incr fluids), elevated ALT/AST, anemia, thrombocytopenia, leukocytosis, leukopenia (monitor CBC), dyslipidemia

clozapine

2nd gen Antipsychotic med for schizophrenia adverse effect: agranulocytosis (sore throat, malaise, fever), leukopenia - monitor WBCs and ANC closely before tx and during, hypotension, GI upset (take with food), dyslipidemia (elevated trig and cholesterol), hyperglycemia

NG tube suction

80-100 (no more) use water soluble lubricant secure to gown oral hygiene frequently measure drainage qshift

calcium level

9-10.5 high? muscle weakness, decreased deep tendon reflexes, generalized weakness, fatigue, lethargy, confusion, weight loss, bone pain, cardiac dysrhythmias, shortening of the Q-T interval, and kidney stones, constipation low? Muscle spasms, cramps, and tetany, positive Chvostek's sign, numbness around lips, cardiac dysrhythmias (give calcium gluconate)

Ca

9-10.5 hypocalcemia: tetany, Chvostek's, hypotension (bc decr Ca and decr heart contraction) and ventricular dysrhythmias and prolonged QT and ST interval RDA for older adult female: 1200 mg

cholesterol

<200 low cholesterol diet: seafood 2x/wk, remove chicken skin, use liquid oil instead of margarine, low fat milk

CD4 t cells

<200 = HIV stage 3, severely immunocompromised

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis. Peritonitis is a risk associated with breaks in aseptic technique.

A client with diabetes mellitus taking daily NPH insulin has been started on therapy with dexamethasone. The nurse anticipates that which adjustments in medication dosage will be made?

An increased dose of NPH insulin Dexamethasone is a glucocorticoid (corticosteroid) and therefore can elevate the blood glucose level. Diabetic clients may need their dosage of insulin or oral hypoglycemic medications increased during glucocorticoid therapy. This is most often a temporary change, needed to compensate for the actions of the medication. The client would not change to an oral diabetic medication if taking daily insulin. Additional calories would not be required. The client would not take a lower dose of dexamethasone than usual to compensate.

A client has a tumor that is interfering with the function of the hypothalamus. The nurse would monitor for signs and symptoms related to which imbalance?

Antidiuretic hormone (ADH) excess or deficit The hypothalamus exerts an influence on both the anterior and the posterior pituitary gland. Abnormalities can result in excess or deficit of substances normally mediated by the pituitary. ADH could be affected by disease of the hypothalamus because the hypothalamus produces ADH and stores it in the posterior pituitary gland. The pineal gland is responsible for melatonin production. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids.

mineral deficiencies and s/s

Brittle nails, fissures at mouth corners result from an iron deficiency. Protein deficiency leads to hair thinning and loss. Fatty acid deficiency can result in dermatitis vitamin K deficiency results in bruising.

A client is receiving topical corticosteroid therapy for the treatment of psoriasis. What would the nurse include in client teaching to maximize the effects of the treatment?

Cover the application with a warm, moist dressing and an occlusive outer wrap. limited to 12 hours per day to minimize local and systemic adverse effects. The medication is applied but not rubbed into the skin

MDMA use

Diaphoresis, tactile sensitivity, lowered inhibition, chills, muscle cramping, teeth clenching, and mild hallucinogenic effects

Celiac Disease diet

Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

Naegle's rule

EDD = LMP + 7 d - 3 mo

The nurse is providing dietary instructions to help with diabetes control for a client newly diagnosed with diabetes mellitus who will be taking insulin. The nurse would provide the client with which best instruction?

Eat meals at approximately the same time each day.2

24-hour urine collection

Explain the procedure to the client. Save all subsequent voidings after the first void during the 24-hour period. During the collection period, place the main container on ice or in a refrigerator. Have the client void at the end time, and place this specimen in the main container

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

Fluctuation with inspiration and expiration, not continuous bubbling, would be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this would decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse would check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes would be clamped only with a primary health care provider's prescription.

An ambulatory care nurse makes a follow-up telephone call to the parent of a child who underwent a myringotomy with insertion of tympanoplasty tubes on the previous day. The parent of the child tells the nurse that the child is complaining of discomfort. What would the nurse instruct the parent to do?

Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen can be given to relieve the discomfort

IS use

For optimal lung expansion with the incentive spirometer, the client would assume a semi-Fowler's or high-Fowler's position. The mouthpiece would be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client would hold the breath for 2 or 3 seconds and then exhale slowly. clean mouthpiece with water and dry after each use, inhale deeply to elevate balls, cough deeply after each use, use several times every hour when awake

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? Select all that apply.

Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias (a fib), infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism - anemia), pulmonary disease, and hypervolemia.

Crohn's diet

High calorie High protein Low fiber high potassium avoid cafeine and alcohol and carbonated beverages NPO/bowel rest during exacerbation

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the primary health care provider at standard doses and frequencies would the nurse question?

Ibuprofen, morphine sulfate, tramadol, and meperidine are all analgesics. Ibuprofen is a nonsteroidal anti-inflammatory medication and is acceptable for use in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate and meperidine hydrochloride are both opioid analgesics, and both are effective in treating acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it would be used only short term and is not recommended for use in older clients

The primary health care provider (PHCP) is assessing the client for the presence of ballottement. To make this determination, the PHCP would take which action?

Initiate a gentle upward tap on the cervix Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger. Auscultating for fetal heart sounds and palpating the abdomen for fetal movement are a part of fetal assessment. Assessing the cervix for compressibility is determining the presence of Hegar's sign.

Insect in ear

Insects are killed before removal unless they can be coaxed out by a light or a humming noise. The nurse would first look into the ear canal using a headlamp. The ear may also be examined with an otoscope to visualize the insect. A flashlight may also be helpful to coax out the insect. Substances such as viscous lidocaine may be prescribed to be instilled into the ear to suffocate the insect, which then is removed with the use of ear forceps. Irrigation may be necessary to flush the ear canal once the mosquito is killed, but this would not be the first action.

A 10-year-old child with hemophilia A has slipped on the ice and bumped the knee. The nurse would prepare to administer which prescription?

Intravenous infusion of factor VIII4

The nurse provides discharge instructions to a client after skin patch testing to assess for allergies. Which instruction would be included on the discharge sheet for the client?

Keep the test sites dry.2 The nurse also discourages excessive physical activity that will result in sweating. If the client reapplies patches that come loose, this can interfere with an accurate interpretation of the allergic reactions. The nurse reinforces the necessity of removing loose or nonadherent test patches for reapplication at a later date. The initial reading is performed 2 days after application, and the final reading is performed 2 to 5 days later.

evaluator

Measuring the group's work against the assigned objectives is the task of the evaluator.

Moexepril

Moexipril is an ACE-i. The client needs to be instructed to take the medication at least 1 hour before meals. The other ACE inhibitor that needs to be taken 1 hour before meals is captopril

physical manifestations of death

Mottling of the skin, Coolness and pallor, cyanosis of the extremities (alterations in circulation and perfusion), pulmonary congestion, decreased muscle tone, and incontinence, Urine will become scant and appear dark in color due to decreased renal perfusion.

A client undergoing hemodialysis begins to experience muscle cramping. What is the best action by the hemodialysis nurse in this situation?

Muscle cramps during hemodialysis result from either too rapid removal of water and sodium or neuromuscular hypersensitivity. The nurse corrects this situation by either SLOWING DOWN THE ULTRAFILTRATION RATE on the hemodialyzer or administering hypertonic or isotonic normal saline

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How would the nurse assess for this disease?

Palpating for diminished or absent peripheral pulses Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected

Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis. What instruction would the nurse include in the client's teaching plan?

Perform the postural drainage first and then the breathing exercises. performed twice daily, and they are preceded by postural drainage. The postural drainage will mobilize secretions, and the breathing exercises will then assist with expectoration. Exercises to assist in assuming correct postures and in maximizing thoracic mobility, such as swinging the arms and bending and twisting the trunk, are included. The ultimate aim of these exercises is to establish a good habitual breathing pattern.

The nurse discusses plans for future treatment options with a client with symptomatic polycystic kidney disease. Which treatment(s) would be included in this discussion?

Polycystic kidney disease is a genetic familial disease in which the kidneys enlarge with cysts that rupture and scar the kidney, eventually resulting in end-stage renal disease. Treatment options include hemodialysis or kidney transplant. Clients usually undergo bilateral nephrectomy to remove the large, painful, cyst-filled kidneys.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.

Pregnancy needs to be avoided for 1 to 3 months. The vaccine is administered by the subcutaneous route. Exposure to immunosuppressed individuals needs to be avoided. A hypersensitivity reaction can occur if the client has an allergy to eggs.

RIFLE AKI

R (risk) I (Injury): less than 0.5 mL/kg urine output for 12h F (failure): no urine output 12h L (loss): no urine output w/o renal replacement therapy (RRT) for 4-12 wk E (end-stage): no urine output w/o renal replacement therapy (RRT) for more than 3 months

The emergency department nurse is caring for a client admitted with diabetic ketoacidosis. The physician prescribes intravenous (IV) insulin. The nurse plans to prepare which type of insulin for the client?

Regular insulin Regular insulin can be administered by the IV route. Insulin glargine is a long-acting insulin. Insulin isophane and 50% human insulin isophane/50% human insulin are intermediate-acting insulins.

The nurse is creating a care plan for a client with achalasia. Because of the disorder, the client has difficulty swallowing and must follow a semisoft diet. The client expresses anxiety over eating and drinking fluids related to a fear of choking and an inability to hold eating utensils well, which is also contributing to the client's constipation due to decreased fluid intake. Which would the nurse identify as the client's priority problem?

Risk for aspiration Achalasia is a chronic condition with an insidious onset that results in the absence of peristalsis in the distal two-thirds of the esophagus. Clients report a globus sensation in the throat and difficulty swallowing. Clients with this condition have an increased risk of aspiration, which compromises the airway. Since protecting the airway would always be the priority, option 4, risk for aspiration, is the priority client problem. While options 1, 2, and 3 are appropriate problems for this client, the nurse needs to prioritize nursing interventions that minimize the risk of aspiration

The nurse is admitting a client who has a cough, dyspnea, and an abnormal chest x-ray who is otherwise healthy. The client has an elevated serum angiotensin-converting enzyme (SACE) level. Based on this result, what condition is the client at risk for?

Sarcoidosis SACE is found in pulmonary epithelial tissue and is used in the detection of sarcoidosis. It does not diagnose pulmonary fibrosis, bacterial pneumonia, or COPD. Normal SACE levels are 8 to 53 U/L. Elevated SACE levels are found in a high percentage of clients with sarcoidosis (an autoimmune granulomatous disease that affects many organs, especially the lungs). It is also used to monitor the clinical course of the disease.

The nurse is caring for a newborn infant after surgical intervention for imperforate anus. The nurse would place the infant in which position in the postoperative period?

Side-lying with the legs flexed

pregnant integumentary changes

Striae gravidarum, or stretch marks, reflect separation within the underlying connective tissue of the skin. After birth they usually fade, although they NEVER DISAPPEAR COMPLETELY An epulis is a red raised nodule on the gums that bleeds easily. Chloasma, or mask of pregnancy, is a blotchy, browning hyperpigmentation of the skin over the cheeks, nose, and forehead and is especially noticed in dark-complexioned pregnant individuals. Chloasma usually fades after the birth. Telangiectasias, or vascular "spiders," are tiny star-shaped or branch-shaped, slightly raised, and pulsating end arterioles usually found on the neck, thorax, face, and arms. They occur as a result of elevated levels of circulating estrogen. The spiders usually disappear after delivery.

amitryptiline

TCA tx depression, chronic pain (peripheral neuropathy, migraines) common side effects: anticholinergic (dry mouth and skin, constipation, urinary retention, hypoactive bowel, hyperthermia, facial flushing, pupil dilation), hypotension (change positions slowly), drowsy (take at bedtime), blurry vision, urinary retention, tachycardia, prolonged QT, seizure, cardiac arrest give sodium bicarb IV to reduce rx of arrhythmia , activated charcoal within 1-2hr

electronconvulsive therapy (ECT)

The client will receive a short-acting barbiturate and a muscle-paralyzing agent, such as succinylcholine, to promote skeletal muscle relaxation and prevent injury during treatment. two to three treatments of ECT per week for a total of six to 12 treatments. short-term memory loss, confusion, and disorientation can occur immediately following the procedure and can persist for several weeks after the treatments.

A client tells the nurse that the primary health care provider (PHCP) has stated a diagnosis of silicosis. The nurse determines that which finding is consistent with this respiratory disorder?

The client with silicosis has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. This disease is restricted to the respiratory system only.

PICC line home care

The client would be taught that only minor activity restrictions apply with this type of catheter. The client needs to protect the site during bathing and would carry or wear a MedicAlert identification. The client needs to have a repair kit in the home for use as needed because the catheter is for long-term use.

Kick count

The client would lie on the side, not the back, when performing kick counts. Lying on the back increases the risk for vena cava syndrome. The client would use a timer or a clock and needs to record the number of movements felt during that time. The client is advised to count the fetal movements for 30 to 60 minutes 3 times a day. The client is instructed to place the hands on the largest part of the abdomen and concentrate on the fetal movements.

vestibulocochlear nerve (cranial nerve VIII).

The cochlear division of cranial nerve VIII is responsible for hearing. Clients with hearing difficulty may benefit from the use of a hearing aid. The vestibular portion of this nerve controls equilibrium; difficulty with balance caused by dysfunction of this division could be addressed with use of a walker

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes swollen lymph nodes, and laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse provides instruction regarding care of the adolescent. Which statement made by the parent indicates an understanding of the care measures?

The parent needs to be instructed to notify the physician if abdominal pain, especially in the left upper quadrant, or left shoulder pain, occurs because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until splenomegaly resolves. Bed rest is not necessary, and children usually self-limit their activity. No isolation precautions are required, although transmission can occur via saliva, close intimate contact, or contact with infected blood. The child may still feel tired in 1 week as a result of the virus.

breath sounds

The sounds that the nurse hears are bronchial breath sounds. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue, as in a lung mass, atelectasis, or pneumonia. A pleural friction rub is a superficial, low-pitched, coarse rubbing or grating sound that sounds like two rough surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly. These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

hypercoagulability

Thrombocytopenia, increased D-dimer level, Prolonged prothrombin time (PT), Prolonged activated partial thromboplastin time (aPPT), increased fibrinogen

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a loss of variability. What is the initial nursing action?

Turn the client on the side and administer oxygen by face mask at 8 to 10 L/min.2

.The nurse is reviewing the plan of care for a child with a diagnosis of suspected appendicitis. The nurse would question which intervention if noted in the plan of care?

Whenever appendicitis is suspected, the nurse would be aware of the danger of administering laxatives or enemas or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation. The nurse can determine the most intense site of pain, located at McBurney's point, by palpation. McBurney's point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis. There is no contraindication to using an oral thermometer in a child with suspected appendicitis. Obtaining blood for a complete blood count is important to determine the white blood cell count

PVC

abnormal ectopic beats originating in the ventricles characterized by an absence of P waves, the presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.

peripheral arterial disease

absent pedal pulses, thin dry atrophied skin, hair loss

stoma care

activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds. cut the skin barrier opening no more than 0.3 cm (0.13 in) larger than the stoma to reduce the risk of skin irritation cleanse the skin at the stoma site using a washcloth and warm water dry the skin around the stoma using a patting motion

kawasaki disease

acute: high fever that is unresponsive to antibiotics or antipyretics, tachycardia subacute: pain in the weight-bearing joints, peeling of the palms of the hands and soles of the child's feet

rotavirus vax

adm at 2 and 4 mo

Hib vax

adm at 2, 4, 6, 12, 15 mo

PCV vax

adm at 2, 4, 6, 12, 15 mo

PP hemorrhage

administer methylergonovine and oxygen, insert urinary catheter, massage fundus, weigh pads

Fresh frozen plasma

administer over 30-60 min right when received check prothrombin time after administration

metformin

adverse effect: bloating, metallic taste take once a day in the evening

clonidine

adverse effects: dry mouth, dry eyes, constipation, rash indirect-acting antiadrenergic agent used for hypertension, severe pain, and attention deficit disorder

donepezil

adverse effects: frequent urination, bradycardia, dizziness, syncope, n/v, dyspepsia, abd pain, anorexia, diarrhea, hypotension/HTN

interferon beta-1b

adverse effects: hepatotoxicity (monitor LFTs), lymphocytopenia, anemia, dyspnea, myalgia

spironolactone

adverse effects: menstrual irregularities, agranulocytosis (monitor temp), cardiac dysrhythmia (monitor ekg) weigh client before adm

conductive hearing loss L ear rinne test

air conduction less than bone conduction

disulfiram

alcohol abstinence

OCD care

allow time for rituals positive reinforcement for non-ritualistic behaviors reduce environmental stimuli provide a structured schedule all this reduces client's anxiety

Reye syndrome is characterized by

altered mental status and impaired hepatic function

scopolamine

anticholinergic medication adverse effect: dry mouth, urinary retention, dilated pupils, decr sweating

heparin

antidote: protamine sulfate monitor aPTT every 4 hr until the client has reached a therapeutic level. The therapeutic reference range of aPTT is 60 to 80 seconds, which is one and a half to two times the expected reference range monitor the platelet count every 2 to 3 days.

Guillan Barre syndrome

ascending muscle paralysis, absent reflexes - neuromuscular respiratory failure (assess with spirometry)

Hirschsprung's disease

assess infant abd for visible peristalsis and distention

Cranial nerve I (the olfactory nerve)

assessed by testing the sense of smell (using a non-noxious aromatic substance such as coffee beans) in a client who reports the loss of smell.

essential oil possible contraindications

asthma, soy or coconut allergy

MMR vax

at 12/15 mo, and right before entering school (kindergarten, 4-6 yo)

Hep B vax

at birth, at 1-2 mo, and at 6-18 mo

schizophrenia brain structure

atrophy of lateral and or 3rd ventricles

Aripiprazole

atypical antipsychotic tx autism, bipolar, schizophrenia do not abruptly stop (withdrawal - anxiety, dizzy, tachycardia, vomit, diaphoresis, insomnia) side effects: akathisia (restless), dystonic rxn (muscle ctx), parkinsonism (tremor, rigidity, mask face), tardive dyskinesia (involuntary movements - lip smacking)

PKU

autosomal recessive - both mother and father carry

sucralfate

avoid antacids (reduce effect), abx (cipro) interferes with absorption of theophylline, digoxin, warfarin

sickle cell treatment

avoid high altitude and low oxygen environments, avoid overexertion, apply warm compresses, receive pneumococcal vax bc incr rx infection, adequate daily fluid intake (at least 3-4L/d), do not bend extremities or use automated BP cuff, administer humidified oxygen, assess peripheral pulses, assess mouth q8h

stomatits treatment

avoid lemon glycerin swabs remove dentures unless eating use soft toothbrush or foam swab rinse mouth with hydrogen peroxide, warm saline, or baking soda q2-3h

cardiac catheterization care

avoid strenuous exercise for several days avoid tub bath for 3 d, can shower the day after the procedure remove pressure dressing the day after the procedure, then place an adhesive bandage over the insertion site for the next 2 days, observe for redness, swelling, bleeding, or any other drainage and notify provider if occur pt can return to school the day after the procedure, only participate in light to moderate activities at school and home for the next several days.

Hispanic birthing practices

bed rest 3 d after birth, client's mother included in daily care, delay bathing after birth, limit food 2 d after birth

CDC notifiable disease

botulism toxin can develop dysphasia, drooping eyelids, and vision changes, and in 12 to 36 hr can develop neurologic symptoms such as symmetric, flaccid paralysis and cranial nerve impairment. chlamydia, syphilis, gonorrhea, chancroid, and HIV/AIDS to the local health department.

chest tube drainage with water seal chamber

bubbling indicates leak occlusive dressing on insertion site drainage <70 mL/h

immunosuppression client care

change IV tubing q24h, inspect mouth q8h, inspect IV site q4h for infection, monitor WBCs q24h

continuous feeding tube care

change bag q24h water is ok - monitor I&O, monitor for dehydration (dry mucous membranes, decreased urine output) client should not lay on tube (lying on side is ok) HOB at least 30 degrees

erythropoetin

check Hgb first (do not give if >10)

alcohol withdrawal

chlordiazepoxide 12 -72 hr following the last alcohol intake and can last up to 7 days tremors, seizures, hallucinations, disorientation, loss of insight, tachycardia, hypertension, elevated temperature, abdominal cramping, vomiting, cardiovascular collapse and death.

rivastigmine

cholinesterase inhibitor - cholinergic actions such as bradycardia, atrioventricular (AV) block, and cardiac arrest, diaphoresis, anorexia, nausea, vomiting, diarrhea, and abdominal pain, which can lead to weight loss.

vesicle

circumscribed, elevated, contains serous fluid (blister, herpes simplex, poision ivy, chickenpox)

post cleft lip repair

clear liquids for 24 hr and progress to a liquid diet for 2 week upright or side lying elbow restraints (prevent hands and fingers in mouth to damage surgical repair)

TPN

client will require finger stick BG checks check for egg allergy change tubing once every 24h take daily wt

risk factors for 3rd spacing

clients with liver or kidney disease, major trauma, severe burn injuries, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

familial cancers

colorectal, breast, prostate, ovarian

dissociation

compartmentalizing unpleasant thoughts (ex: dissociating from memories of a house fire by watching a movie)

school age

concrete operational thinking, conservation

smoothing

conflict resolution - complimenting, focusing on shared ideas

suppression

conscious decision to avoid thinking about problems at a certain time.

multiple sclerosis

constipation can occur (incr fluid and fiber) vitamin D deficiency difficulty swallowing remissions, vary in length

RSV

contact and droplet precautions private room rx otitis media, pneumonia most sever days 3-6, cough lasts many weeks adm high flow NC, heated and humidified, IV fluids (no abx) s/s: rhinorrhea, fever, cough, crackles, wheezes

living will

contains advance directives to inform medical personnel of care to provide if client is unable to specify

scleroderma

contractures, pedal edema, decreased salivation

gingko biloba

contraindication: seizures therapeutic use: reduce leg pain from peripheral arterial disease interferes with coagulation interacts with medications such as anticonvulsants, antidepressants, decongestants, some antihistamines, and antipsychotics.

PO contraceptive contraindications and therapeutic effects

contraindications: abnormal liver function, breast cancer, abnormal vaginal bleeding, and clients who are older than 35 years of age and smoke tobacco therapeutic effect: decr iron deficiency anemia, decreasing blood flow by regulating cycle irregularity and menorrhagia, improvement premenstrual syndrome (PMS) manifestations, dysmenorrhea, acne, and polycystic ovary syndrome.

rifampin

contraindications: liver dysfunction,

compensation

covers problem ex: drink alcohol to forget pain ex: excel in something else to handle being defined by anxiety

removing sutures

cut the sutures close to the skin on both sides by pulling the knot up with forceps and using a special curved tip scissor cleanse the skin and sutures before removal

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client would be questioned about the use of which medication?

decongestants In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. These medications lessen the voluntary ability to contract the bladder. The client would be questioned about the use of these medications and if experiencing urinary retention

folic acid

decr rx heart disease postmenopausal

finasteride

decrease PSA level in 6 months (tx prostate CA) adverse effect: decreased libido, orthostatic hypotension, gynecomastia, decr ejaculate volume

PP depression manifestations

decreased libido, loss appetite, difficulty sleeping, sadness, anxiety

neuroleptic malignant syndrome

decreased responsiveness, muscle rigidity, posturing, diaphoresis, and vital signs that are outside the expected reference ranges monitor labs and ABGs as multiorgan failure can occur. To evaluate interventions and track the client's condition, monitor temperature, hydration status, and provide for early detection of complications.

phantom limb pain

decreases over time use heat and massage to manage pain

circumcision care

do not wash with soap until healed wrap upper body in blanket for comfort during procedure and offer sucrose artifical nipple apply loose diaper after procedure

iron containing foods

dried fruit, citrus fruit decrease absorption of iron: coffee, tea, milk, whole grains, spinach, swiss chard

pertussis

droplet precautions, humidified oxygen, coughing spasms and mucus plugs and apnea, vomiting, enlarged painful parotid glands

hypernatremia

dry, sticky mucus membranes dry, swollen, red tongue confusion, seizures

morning sickness prevention

eat dry crackers/toast before rising

COPD diet

eat more cold foods (reduces feeling of fullness) do not drink fluids with meals (fluids make you fuller) add high fat foods to increase caloric intake eat convenience, ready to cook meals to decrease tiredness form cooking and increase intake

hyperemesis gravidarum

eat q2 - 3 hr to avoid having an empty stomach, which can increase nausea separate liquids from solids q2 -3 hr to help minimize nausea. eat foods high in protein, low in fat. Warm ginger ale or ginger tea can also decrease nausea.

primary prevention

education, vax

nitrous oxide for labor

effects felt in 1 min no neonatal effect inhale as ctx begins feel relaxed, decr pain (no disorientation)

complete proteins

eggs, meat, seafood, milk, yogurt, cheese, soybeans

gastrostomy tube feeding care

elevate HOB at least 30 degrees - can be sitting or ambulating replace tubing and tube feeding bag q24h clean the top of the formula can before opening it, avoid touching the opening of the feeding container and any part of the tubing that will come into contact with the formula. feeding should be room temp (cold? causes gastric cramping, n/v). store enteral feeding containers away from heat, direct sunlight, and moisture because these can break down the formula. check the pH level of secretions before feedings. They should also observe for changes in the length of the tube, volume of aspirate, and pH of aspirate dissolve meds in 30 mL of sterile water, stop feeding, flush with 15-30 mL sterile water before and after meds

polycythemia vera

elevate legs, drink at least 3L/d, wear support hose when awake, do not floss (decr bleeding rx since taking anticoagulatns) - use soft toothbrush

DVT with hep tx care

encourage ambulation, encourage 2-3L fluid/d, place warm compress on affected extremity, levate effected extremity (reduce edema)

sickle cell anemia chronic vaso occlusive crisis s/s

enlarge heart, enuresis, leg ulcer, retinal detachment, intrahepatic cholestasis, jaundice (enlarged liver - ecchymosis, petechia)

obstructive sleep apnea complications

enuresis, HTN, wt gain, heart failure, cardiac dysrhythmias

anemia secondary to chem tx

epoetin alfa

delusions of reference

events are personal/significant to them - song, newspaper etc with secret message

dark-toned skin client findings

expected: light yellow-colored sclera (Overt yellow or green pigmentation can be an indication of liver disease) plum-colored lips (Pallor of the lips can indicate anemia, and bluish undertones can indicate possible cyanosis) transparent, convex-shaped nails (Spoon-shaped, brittle, or ridged nails can indicate malnutrition) not expected: blue undertones on the palms, foot soles, conjunctiva, nail beds, buccal mucosa - cyanosis

frontal lobe

expression of thoughts

CN VII

facial droop, asymmetrical smile

agoraphobia

fear of leaving the house and experiencing panic attacks when doing so

macule

flat, variably shaped, discolored, small (ex freckles)

retinal detachment

floating dark spots

detached retina s/s

floating dark spots, sudden, painless

care of a tunneled central venous catheter without a pressure sensitive valve

flush daily with heparin when not in use keep clamped to avoid backflow of blood restrict physical activities until the tissue adheres to the cuff change the dressing at least every 5-7d when inserting new infusion set, lie patient flat, perform Valsalva maneuver, turn head away, use asepsis/surgical aspirate for a brisk blood return from the catheter lumen prior to each use and before flushing the catheter to determine patency and confirm placement, flush with NS before use, 15 scrub of catheter hub, apply slow, even pressure to syringe

autonomic dysreflexia

flushing of skin above area of injury, nasal congestion, headache, sudden increase in blood pressure, bradycardia, blurred vision with spots in the visual field

midazolam

for moderate sedation adverse effects: resp depression, cough, hypotension

sodium polystyrene sulfonate enema

for pt high in potassium

lorazepam OD

give flumazenil (benzodiazepine antidote)

mag sulfate

give to preterm labor <32 wk (prevent cerebral palsy) monitor I&O

7 month old activity

grasps small objects with hands, bear wt when someone holds them in standing position

A pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which item would the nurse offer to the child?

green gelatin Following tonsillectomy, cool, clear liquids should be administered. Citrus-flavored, carbonated, and extremely hot or cold liquids would be avoided because they may irritate the throat. Red liquids are avoided because they give the appearance of blood if the child vomits. Milk and milk products, including pudding, are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding.

glaucoma s/s

halo post op: do not strain during bowel movement (incr IOP - eat high fiber and fluids), lie on unaffected side, avoid lifting 10 lb or more, sleep with head elevated

DVT s/s

hardening along affected blood vessel, prominent superficial vein, pain/tenderness, incr circumference,

metronidazole

harmless side effect: dark urine, metallic taste, GI upset avoid alcohol for 3 days after completion tx trichomoniasis

temporal lobe

hearing

vaso-occlusive sickle cell crisis s/s

hematuria, Visual disturbances, Painful swelling of the hands and feet

Disseminated Intravascular Coagulation (DIC) s/s

hematuria, tachycardia, petechiae, GI bleed, bleeding of nose and gums, diaphoresis, bruising decreased platelets, fibrinogen, Factor V, incr D-dimer

CN II

hemianopsia

HELLP

hemolysis (jaundice, anemia = decr Hgb), Elevated Liver enzymes (high AST, ALT = vomit, nausea, epigastric pain), Low Platelets

position after tube feeding

high fowlers, R side 30-60 min (facilitates gastric emptying, prevents vomiting & aspiration)

Mantoux test

high rx individuals should receive annually (those residing in a long-term care facility, health care workers, homeless) read in 48 to 72 hr indurated area (palpable, raised, and hard) that is 10 mm or larger in diameter is a positive reaction (HIV? 5 mm = positive)

management of Cushing syndrome

high-potassium, low-sodium diet (Decreased sodium intake decreases renal retention of sodium and water) daily weights and intake and output and have extremities assessed for edema

Pavlik Harness

hips in flexion and abduction

wheal

hive transient, elevated, irregularly shaped

cane ambulation

hold cane on good side advance cane and then follow with good leg

ADHD

hyperactivity to sensory input, intellectual impairment, interrupting others, losing necessary things meds: methylphenidate (Ritalin) - adm 2-3 divided doses with last one before 6 pm and 30-45 min before food. can cause wt loss, irritable, tachycardia, sleep disturbances, jittery, HTN, avoid caffeine

immobility complications

hypercalcemia, respiratory acidosis, decreased cardiac output, decr peristalsis

stress physical manifestations

hyperglycemia, deceased peristalsis, dry mouth, decreased urinary output

addison's disease

hypotension, wt loss, salt craving, incr skin pigmentation

rheumatoid arthritis

ice joints, allow client to perform own ADLs, allow for frequent rest periods, administer 3g acetaminophen/d to client, administer NSAIDS not opioids, take hot showers for morning stiffness, eat foods high in iron, protein, vitamins

placenta previa

improperly implanted placenta in the lower uterine segment near or over the internal cervical os s/s: painless bright red vaginal bleeding in 2nd or 3rd trimester, Soft, relaxed, nontender uterus, Fundal height may be greater than expected for gestational age

dumping syndrome

include foods with protein, eat only 1-2 foods from each food gropu at once, avoid drinking liquids during meals and wait 30-60 min after meal to drink liquids, avoid simple sugars, maintain supine after meals

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan?

limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, unlike as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse needs to maintain the prescribed activity level. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen

antisocial PD

manipulative, deceitful, and antagonistic, lack remorse. Criminal behavior and substance use are associated with this disorder.

SIDS rx

maternal age younger than 20 years, maternal smoking and alcohol use, blankets or stuffed animals or toys in the crib, co-sleeping, late or no prenatal care, and low birth weight or premature infant.

IUD contraindications

menorrhagia severe dysmenorrhea hx of ectopic pregnancy

furosemide advers effects

metabolic alkalosis (muscle twitching/cramping, incr HR), hyponatremia and hypokalemia and hypomagnesemia (dysrhythmia), hyperglycemia, hypocalcemia ototoxicity

PPH meds

methylergonovine - contraindicated with HTN oxytocin, miso carboprost

generativity vs stagnation

middle age

enoxaparin

monitor Plt

estradiol

monitor for headaches (thromboembolic stroke), swelling and tenderness of an extremity or fluid retention, genitourinary candidiasis, HTN

sulfur sulfadiazine cream for burns

monitor leukopenia adverse effect

intussusception

most common cause of intestinal obstruction in children proximal segment of the bowel slides into the distal segment - blocks food/fluid from passing through, cuts off the blood supply to the part of the intestine that's affected s/s: lethargy, vomiting, distended abdomen, sausage shaped R sided abdominal mass, acute abdominal pain, drawing knees to chest, inconsolable crying, red currant jelly-like stools (air or barium enema), and fever, bilious non projectile vomiting complications: dehydration, intestinal perforation, peritonitis (fever, abd rigidity, guarding, rebound tenderness)

hypokalemia

muscle weakness, decr DTR, hypoactive bowel sounds, U wave on EKG, abd distention, fatigue, and lethargy

myocardial infarction (MI) manifestations

n/v, diaphoresis, dizziness, doom, diminished pulse, tachypnea

durable power of attorney/health care proxy

names surrogate to make health care decisions for client if unable

digoxin toxicity

nausea, anorexia, abdominal pain, bradycardia, visual changes, diarrhea, muscle weakness

Abstience syndrome

nicotine withdrawal manifestations begin within 24 hr of last use, last several months. incr appetite leading to weight gain, craving, nervousness, restlessness, increased agitation, hostility, insomnia, and a decreased ability to concentrate