NCLEX PN

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock?

-Apply defibrillator pads to bare skin -continue CPR until advised to deliver shock -stop CPR while machine analyzes the rhythm -shout "clear" prior to activating shock button

instill eyedrops

-don't touch the dropper to any part of the eye -instill one drop at a time, wait 5 mins then instill next drop

When auscultating heart sounds where should the nurse place the stethoscope

-fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area -second intercostal space to the right of the sternum to hear sounds from the aortic valve area -the 2nd intercostal space left of the sternum to hear sounds from the pulmonic valve area -5th intercostal space midclavicular line -the first heart sound is best heard at this location

Minimize ICP contributing factors by

-maintaining a calm environment -administer stool softener as prescribed -instruct family not to wake client if sleeping

Administration of eardrops

-position supine w affected ear up -administer drops to fall along inside of ear and flow into ear by gravity. -remain supine for several minutes -instill at room temperature -0-3 yrs open ear canal by drawing back on the pinna and slightly downward -3+ years draw back on the pinna and slightly upward

Cirrhosis patients should

-use a shower chair when performing hygiene; to conserve energy -stop any activity that causes dizziness, chest pain, increased SOA, extreme fatigue or weakness. -monitor sodium intake (high sodium promotes fluid volume excess.) -proper hand hygiene (prevent infections)

WNL range of Bicarb (HCO3)

22-26

RA - rheumatoid arthritis

Autoimmune disease causing inflammation of the synovial membrane and other parts of the joints, as well as the organs.

Vaccines that adults 65 yrs + should receive

Influenza Herpes Zoster Diphtheria Pertussis Pneumococcal vaccine

Biot's respirations

a pattern of bradypnea and shallow respirations which change to tachypnea and deep respirations followed by apnea.

Cheyne-Stokes

abnormal pattern of breathing. The respirations pattern is characterized by rhythmic increase and decrease in respirations and brief periods of apnea

ataxic respirations

an irregular, random pattern of deep and shallow respirations with irregular apneic periods

common side effect of topical anticholinergic medication for treatment of glaucoma

blurred vision

sx/ss of cholecystitis

chills fever nausea/vomiting rigidity of upper right abdomen

cluster breathing

closely grouped series of respirations is followed by apnea.

low residue foods recommended for clients w inflammatory bowel diseases: Crohn's Disease diverticulitis Ulcerative Colitis this diet is designed to decrease fiber in order to limit bowel peristalsis while still including nutritional elements for clients

cooked oatmeal pasta fruits w NO skin and little pulp Cantaloupe

ABG Rule

if both values of the pH and bicarb/HCO3 are going the same way (both up or down)......then it's metabolic X Otherwise it's respiratory X

sx/ss Cystitis

incontinence urgency frequency hematuria (blood in urine) Nocturia (frequent urination at night)

Cystitis

inflammation of the bladder (wall of the bladder)

A client who has been receiving enteral tube feedings for the past three days, has begun having diarrhea. Which interventions should the nurse employ?

observe for abdominal pain, cramping, frequency, urgency, loose, or liquid stools and hyperactive bowel sounds. monitor hydration status with input and output. diarrhea ca n lead to profound dehydration and electrolyte imbalance, poor skin turgor, and dry mucous membrane check for fecal impaction by digital examination. liquid stool may seep past a fecal impaction monitor condition of perianal skin

promethazine

prevents and treat nausea and vomiting

sx/ss of Promethazine

sedation blurred vision medicine also works as an antianxiety agent drug typically lasts for 2-8 hrs following administration