NCLEX Practice Questions

Neutropenia

- ANC <1000 cells/mm3 - Severe: <500 CRITICAL EMERGENCY -- mask and separate from other pts in private room w/ HEPA filtration, avoid raw fruits/veggies, standing H2O, undercooked meat

Ferrous sulfate pt education

- AVOID Ca supplements or antacids within 1 hr of ferrous sulfate (decreases absorption) - Vit. C can enhance absorption - Best 1 hr pre or 2 hrs post meal (best in acidic environment)

Alzheimer Pt Management

- Acknowledgement - Reassurance - Distraction - Redirection Note: antipsychotics are associated w/ increased mortality when used for agitation in pts w/ dementia

Increased risk for falls

- Age: >65-75 - Lying pulse 80/min, standing 110/min - Osteoarthritis -Carbidopa /levodopa - Ambulatory aid

Afib bradycardia - what meds should be held?

- All beta blockers, including eye drops (metoprolol, timolol, atenolol), CCBs (VND)

Preventions of SIDS

- Alt. position of infant's head - ALWAYS supine when sleeping - Tummy time 30-60 min/day

Anorexia Nervosa sx

- Amenorrhea - Fluid & electrolyte imbalances - Wt loss 25% norm. - Cold intolerance -Lengthy & vigorous exercise - Lanugo in extreme cases

Education to postpartum pt experiencing breast engorgement who exclusively formula feeds

- Apply chilled, fresh cabbage leaves (b/c of phytoestrogens from leaves) or ice packs to both breasts for 15-20 mins every 3-4 hrs - Take anti-inflammatory analgesic (ibuprofen) as directed - Maintain firm breast support (ex. supportive bra, breast binder) until milk flow is diminished

Suctioning Technique

- Apply suction no longer than 5-10 sec. - Wait 1-2 mins btw suction passes - Should be set at medium pressure (adults: 100-120 mmHg, kids: 50-75 mmHg)

Prevent aspiration for pt who is receiving tube feeding @ 30 mL/hr

- Assess for gastric intolerance (residual, abd. dissension q4h - Keep HOB >=30 degrees - If intubated keep endotracheal cuff inflated & suction appropriately - Use caution when giving sedatives

Cyclosporine education

- Avoid large crowds bc it's an immunosuppressant - Monitor or SE, incidence of secondary malignancies ex. skin cancer, lymphoma is increased in these pts - Can cause hirsutism, associated w/ HTN and nephrotoxicity

Don't elevate

- BKA >24h - femoral approach percutaneous coronary intervention - hip fracture

Liquid iron supplement education

- Best absorbed on empty stomach, may be given w/ meals to avoid gastric irritation - Vit. C can increase iron absorption - Milk products and antacids should be avoided - May cause constipation and black or dark green, tarry stools - Liquid iron supplements can stain teeth and are administered w/ medicine dropper toward back of infant's cheek (may be diulted w/ water or juice)

Hypothyroidism CM

- Bradycardia - Wt gain, constipation - Fatigue/muscle aches, joint pains - Lethargy/apathy, forgetfulness, depression - Decreased libido - Cold intolerance, dry & thick skin, brittle nails & hair, hair loss, facial & generalized interstitial edema - Anemia (pallor)

Neuro assessment requiring immediate follow-up

- Can't flex chin toward chest (meningitis) - New onset of arm drift - Pupils >8mm in diameter bilaterally

Meds for open fracture

- Cefazolin (ABX) - Cyclobenzaprine (musc. relaxant) - Tetanus/diptheria toxoid (immunization if not up to date) - Ketorolac (NSAID) - Opioids

Acute glomerulonephritis CM

- Complex immune disease commonly induced by GABHS infection - Latent period of 2-3 wks and sx - Sx: periorbital & facial/generalized edema, SEVERE HTN, oliguria, tea-colored urine bc of protein & blood in urine - MONITOR BP

Age-related changes that increase older adults' risk for respiratory infections

- Decrease in force of cough - Chest wall stiffening - Diminished immune response - Drier mucous membranes - Decrease in # & motility of cilia

IM sites

- Deltoid - Vastus lateralis - Ventrogluteal (preferred: fewer large BV & nerves)

Iron-rich foods

- Eggs - Green leafy veggies - Meats - Shellfish Eating w/ foods rich in vit. C (citrus, potatoes, tomatoes, green veggies) enhances iron absorption (coffee & tea interferes)

Weaning from breastfeeding

- Exclusive breastfeeding for first 6 months - Introduction of pureed foods @ 6 months + breast milk - Introduction of cow's milk @ 1 yr

Fetal alcohol syndrome sx

- Facial characteristics: indistinct philtrum, thin upper lip, short palpebral fissures - Intellectual disability - Developmental delay

Skin cancer risk factors

- Family hx - High # of moles - Immunosuppressants - Outdoor occupation - Aging - Celtic ancestry traits (ex. light skin, red/blonde hair, blue/green eyes, many freckles)

What increases likelihood of pt to experience atypical sx of MI?

- Female gender - Advanced age - Diabetes/neuropathy

Neuroleptic Malignant Syndrome

- Fever - Rigidity - Mental status changes - Autonomic instability

Causes of trace amounts of proteinuria

- Fever - Strenuous exercise - Prolonged standing

How parents can help w/ hospitalization of toddler

- Follow home routines - Stay with kid (including overnight) - Using playroom

Large bowel obstruction

- Gradual onset of sx - Absolute constipation (later) - Lack of flatus (later)

Foods high in potassium

- Green leafy veggies - Melons, bananas, strawberries - Milk - Beef, fish, & shellfish - Whole grains

NG tube feeding actions

- HOB 30-45 degrees - Assess tube marking - Confirm tube placement (gastric aspirate - return to stomach) - Auscultate BS - If cramps, slow feeding - Flush tube w/ 30 mL of H2O pre & post feeding

HPV education

- HPV increases risk of genital warts & cerv. cancer - Warts that have been treated can reoccur @ any time - Teens & HAs should be vaccinated - Women should receive cervical cancer screening @ age 21 - Barrier methods can reduce risk but don't eliminate it

Digoxin education

- Held for pulse <90-110/min for infants + younger children or <70/min for an older child - Oral liquid is administered in side/ back of mouth - Do not mix w/ food or liquids - Never give extra doses (vomiting = toxicity) - Give water/brush teeth after to remove sweetened liquid

HELLP syndrome

- Hemolysis, - Elevated liver enzymes, - Low platelets

Contraindications for epidurals

- Hypotension - Coagulopathies (extremely low platelets, clotting disorders) - Infection

Nephrotic Syndrome

- Increased permeability of glomerulus to proteins - Affects ages 2-7 yo - Sx: hypoalbuminemia, generalized edema, wt gain, loss of appetite (from ascites), decreased urine output - Tx: corticosteroids, loss of appetite management, infection prevention

IV vancomycin nursing actions

- Infuse for @ least 60 mins - Monitor BP (for hypotension) - Assess for hypersensitivity - Monitor for anaphylaxis - Observe IV site q 30 mins - Draw prescribed trough level (10-20 mg/dL)

Pediculosis Capitis education

- Launder in hot H2O -Items that can't be washed/dry cleaned- sealed plastic bag for 14 days to kill lice -Vacuuming

Billroth II surgery education

- Lie down after eating to avoid dumping syndrome - Avoid fluids w/ eating to delay (@ least 30 mins before/after meals

Fentanyl patch usage

- Mod.-severe CHRONIC pain - Question HCP if it's being used post-op, temporarily or for intermittent pain - Why? bc it doesn't provide immediate pain relief, systemic & may take up to 17 hrs to reach full effect

Interventions for pt w/ bipolar disorder w/ acute manic episode

- Private room - Choose clothing for pt - Physical exercise - One-on-one interactions -High-protein, high-cal meals and easy to eat snacks

Preventing skin breakdown in infants

- Raise HOB <= 30 degrees to reduce pressure and prevent sliding - Moisture barriers - Pulse ox sites should be changed q4h

What questions should be asked with birth is imminent?

- Recent meds or illicit drug use - Current preg. dx & how many babies - Color of amniotic fluid - Due date

Prevent air embolism when discontinuing central venous catheter

- Supine - Bear down - Air-occlusive dressing - Never pull if resistance

Cardioversion

- Tachyarrythmias w/ pulse (Afib or flutter) - Requires synchronization (delivers during R wave) - Sedative given if non emergent

Hemophilia education

- Vaccines should be administered subs to prevent IM hematoma - Smallest gauge needle is used, firm & continuous pressure is applied to site for 5 mins - Avoid aspirin and NSAIDs due to risk of bleeding (acetaminophen is recommended) - Superficial bleeding can be controlled w/ ice packs

Cataracts education

- Vision can remain blurry for several hours up to several days - Causes mild discomfort not pain typically (report) - Avoid activities that increase IOP ex. sex, straining, heavy lifting) - Wear eye patch at night to prevent corneal abrasions

HF pt management

- Weigh self daily @ same time, same amt of clothing, same scale - Avoid meals with Na >400 mg/serving - Take diuretics in morning - Encourage cardiac rehabilitation (exercise plan) - Avoid NSAIDs

Best time to take statin drugs

- With evening meal (to lower cholesterol since most is synthesized at night)

HIV education

- always use protection even w/ HIV+ partner (multiple strains - coinfection - superinfection) - latex/synthetic condoms/dental dams - NO lambskin

Polycythemia Vera

- chronic disease: bone marrow overproduces RBCs, WBCs, & platelets - Increased Hct >53%, blood volume, enhanced blood viscosity & abnormal clotting is normal

MI sx in older pts

- nausea - upper back and shoulder pain - pts taking COX-2 inhibitors are associated w/ increased risk of MI

Acute Cholecystitis Sx

- pain in r upper quadrant of abd referred to r scapula - indigestion, N/V, restlessness - fever, leukocytosis

Immune thrombocytopenia purpura

- platelets <150,000/mm3 - petechiae is common

Do elevate extremity in pts w/

- weeping cellulitis - DVT

IM newborn and infant injections

1 in needle in anterolateral thigh in VASTUS LATERALIS

Tracheal deviation, absent lung sounds, severe hypotension & dyspnea & tx

Spontaneous tension pneumothorax Tx: 20-gauge needle insertion at mid-axillary line for pleural aspiration

How long is strep contagious for?

Starts @ onset of sx through first 24 hrs of beginning ABX tx

Psychomotor retardation

decreased movement, inability/decreased ability to talk, impaired cog. function

Emphysema CM

due to loss of elasticity in lungs due to permanently enlarged alveoli -- hyperinflation of lungs - Activity intolerance, anxiety - Barrel chest - Hyper-resonance on percussion - Prolonged expiration

Stage 3 pressure injury

full thickness skin loss, may see subq fat

Assault

Threat of battery

Most important health hx info for pt w/ bladder cancer

Tobacco use Most common sx: painless hematuria

Pt has chest pain and transdermal nitroglycerin patch peeled off

Tx acute angina: rapid-acting sublingual nitroglycerin (Transdermal patches have delayed onset & are used prophylactically)

Benztropine

Tx for some EPS 1. Pseudoparkinsonism ex. muscle rigidity & shuffling gait 2. Dystonia (SE of antipsychotic meds)

Why are beta blockers given to pts w/ thyrotoxicosis?

Tx symptoms ex. tachycardia, HTN

Hypertonic fluid therapy

Tx: cerebral swelling: increased ICP, hyponatremia

Isotonic fluid therapy

Tx: extracellular fluid deficits ex. dehydration - gastroenteritis

Factors that influence bone healing

nutrition, adequate circulation, age (overwt BMI puts pt @ risk for fractures but doesn't impact healing)

Norm. Mg levels

1.5-2.5 mEq/L

Detection of FHR

10-12 wks

Phenytoin therapeutic range and sx of toxicity

10-20 mcg/mL Toxicity sx: horizontal nystagmus, gait unsteadiness, slurred speech, decreased alertness, ataxia

Normal fetal heart rate baseline

110-160/min

Measuring fundal ht

12 wks: just above symphysis pubis 16 wks: halfway btw symphysis pubis & umbilicus 20 wks: at level of umbilicus 36 wks: diploid process After 20 wks, fundal ht is measured in cm from symphysis pubis to top of funds

Which telemetry pt is the priority for the nurse to assess first? 1. Adolescent pt with coarctation of the aorta and diminished femoral pulses 2. Infant with ventricular septal defect with reported grunting during feeding 3. Newborn pt with patent ductus arteriosus and a loud machinery-like systolic murmur 4. Preschool pt with tetralogy of Fallot who has finger clubbing and irritability

2 VSD places the pt at risk of CHF because the defect causes a septal opening and left to right shunting leading to excess blood flow to the lungs. This places the patient at risk for congestive heart failure and pulmonary hypertension. CM include systolic murmur near the 3rd or 4th intercostal space and CHF signs (diaphoresis, tachypnea, dyspnea). COA - elevated pulse pressure in upper extremities, diminished in lower TOF - cyanotic, congenital heart defect (CM: irritability, clubbing of fingers)

Tx for constipation during infancy

2 oz of pear or apple juice added to diet + high-fiber foods

Heparin flush for CCV lumen

2-3 mL containing 100 units/mL using a 10 mL syringe (smaller syringes create more pressure, more potential for damage)

When should a toddle achieve bowel & bladder control

24 months

The nurse is instructing a female client how to collect a clean catch urine specimen. Place in order the steps indicating that client teaching has been effective. All options must be used. 1. Cleanses vulva from front to back with single-use aseptic towelettes 2. Initiates urinary stream before passing container into stream for collection 3. Performs hand hygiene and removes container lid, with sterile side placed upward 4. Removes specimens container from the stream before stopping urinary flow 5. Spreads labia using index finger and thumb of non-dominant hand

3, 5, 1, 2, 4 A female client performs a clean catch urine specimen by completing hand hygiene and opening the specimen container, spreading the labia using the index finger and the thumb of the nondominant hand, and cleansing the vulva in a front-to-back motion. The client then initiates a urine stream before introducing the container midstream for urine collection. The container is removed when well filled (30-60 mL) and before urinary flow ends.

Long-acting insulin peak (Detemir)

3-14 hrs

Normal pupils

3-5mm in diameter

The nurse in an emergency department is assigned to triage clients coming to the ED for tx on the evening shift. The nurse whorls assign priority to which patient? 1. A pt complaining of muscle aches, a headache, history of seizures 2. Twisted ankle when rollerblading, requesting pain meds 3. Minor laceration on index finger sustained while cutting eggplant 4. Chest pain who just ate pizza made with a very spicy sauce

4 Patients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits or who have sustained chemical splashes to eyes, are classified as emergent..

Time frame for closing laceration for pt receiving radiation therapy

6-8 hrs

Normal MAP

70-105 mmHg

Normal serum fasting blood glucose

70-99 mg/dL

Normal serum glucose

70-99 mg/dL

JP Drain

80-120 mL/hr expected in first 24 hrs

What amount of residual urine in the bladder should be reported?

> 100 mL

Heel-to-shin test

Assesses cerebellar function

When should the ventrogluteal area be used for injections & what size needle should be used?

At least age 3 1 1/2 in. needle

CM of neurogenic shock

Bradycardia

Phenazopyridine HCl (Pyridium) side effect

Bright red-orange urine discoloration - Suggest sanitary napkins & wearing eyeglasses while on medication - Provides symptomatic relief but no antibiotic action, so it's important to take full course of ABX

Meds for wheezing due to bronchospasm (ex. asthma, COPD)

Bronchodilators (albuterol, ipratropium) and systemic corticosteroids (ex. methylprednisolone)

Leg swelling and calf pain from 15-hour flight 2 days ago

DVT -> PE

Priority sx post CVA

Decorticate posturing (sx of worsening neuro function)

SE of long-term use of PPIs (-azoles)

Decreased bone density (calcium malabsorption) & increased risk for Cdiff-associated diarrhea & pneumonia

Schizophrenia sx

Delusions, tangentiality, waxy flexibility

Vaccine Administration Contraindications

Do not administer live vaccines to severely immunocompromised (ex. corticosteroid therapy, chemo, AIDS) Live vaccines: - Varicella-zoster - MMR - Rotavirus - Yellow fever - Local rxns, minor illness, exposure to infectious source, and allergies to non vaccine components are NOT contraindications

When is a hem occult test performed?

When occult (hidden) blood is suspected due to dark & tarry stool

Normal contraction frequency and duration

Every 2-3 minutes or 3-5 contractions/10 minutes lasting 45-80 seconds during active labor - Intensity: 25-50 mmHg - Resting tone: should not exceed 20 mmHg SHOULD NOT EXCEED 90 SECONDS

How often should use of restraints be reassessed?

Every hour (also hourly neuro checks & check for skin integrity q2h)

Aminoglycosides and serious rxns

Ex. gentamicin, tobramycin, amikacin OTOTOXICITY & NEPRHOTOXICITY

Most concerning for pt w/ blurred vision & reduced visual fields

Extreme eye pain (acute angle-closure glaucoma) can lead to permanent blindness from IOP Other CM: sudden onset of severe eye pain, reduced central vision, blurred vision, ocular redness, report of seeing halos around lights

Which CVC placement has highest possibility for infection?

Femoral (inguinal)

Primigravida

First pregnancy

Prolonged vomiting

Gastroenteritis - assess for orthostatic hypotension, hypokalemia, hyponatremia, cardiac dysrthymias, metabolic acidosis

Nephrotic syndrome physiologic process

Glomerular injury

68 yo M had laparoscopic cholecystectomy 8 hrs ago & has not urinated since surgery

Help pt OOB to help with normal position for urinating - if unable to urinate, use bladder scanner

Painful genital lesions can be indicative of... Significance for pregnant women & tx

Herpes Simplex Virus - Neonatal HSV has serious morbidity & mortality Tx: IMMEDIATE ANTIVIRAL THERAPY ex. acyclovir & C/S

Diet for pts with cirrhosis

High calorie, high carb, low sodium, low fat, moderate protein intake

Pericardial friction rub

High-pitched scratchy sound @ apex of heart

deep tissue injury

purple or maroon, intact, caused by pressure

How often should a stoma pouch be changed?

q5-10 days

Cushing's Triad

r/t increased ICP Early sx: LOC changes Late sx: 1.bradycardia, 2. increased systolic blood pressure, widening pulse pressure (diff. btw systolic & diastolic), 3. irregular resp.

Priority for accidental eye exposure

Immediately flush eye w/ water or saline for @ least 10 minutes

Stevens-Johnson syndrome

Immune-mediated rxn triggered by certain classes of drugs (sulfonamide ABX, allopurinol, anticonvulsants Sx: blistered lesions on face, trunk, and palms (MAY BE FATAL IF LEFT UNTREATED)

Peritonitis

rebound tenderness, birdlike abd. rigidity, shallow breathing

Trismus

Inability to open mouth due to tonic contraction of muscles (sx of peritonsillar or retropharygneal abscess - implication of tonsillitis)

Rhonci indicates

secretions in larger airways

Toddle head circumference growth

Increases by 1 in. during the 2nd yr, then slows to growth rate of 0.5 in per yr till age 5

Afib

Ineffective atrial contraction - Increased risk for clots (could cause stroke or PE)

Education for pts w/ asthma who exercise

Inhaled bronchodilator should be taken 20 mins before athletic activity

Priority for Wilms tumor

Instruct NOT to palpate abdomen until after dx is suspected or confirmed - CAN DISRUPT TUMOR & CAUSE DISSEMINATION OF CELLS

Battery

Intentional touching w/o the person's consent even w/o physical injury

Pt who smokes has intermittent leg pain worsens w/ walking, eases w/ rest

Intermittent claudication

Med for HF w/ wt gain & low Na

Loop diuretics (furosemide), ACE inhibitors (-prils), fluid restriction

Multiple people involved in submersion injury, who should be evaluated first?

Marked decrease in RR or work of breathing (may indicate resp. fatigue - impending resp. failure) - Observe for @ least 6 hrs

Barium contrast education

May make stool white for up to 3 days (should be encouraged to drink fluids to assist in expulsion of contrast)

C. diff. tx

Metronidazole Vancomycin

Candida Albicans tx

Miconazole 3-7 days - refrain from sex for duration of tx - partner does not need to be tested

Which assessments are essential for clopidogrel, prasugrel, and ticagrelor?

Monitor for bruising, sx of bleeding (ex. tarry stools, hematuria) and decreased platelet counts

Fetal station +1> below maternal ischial spines

N/V & trembling/shivering

What should never be done during an operative vaginal birth with vacuum extractor or forceps?

NEVER PUSH ON FUNDUS - may cause uterine rupture

Meds contraindicated for HF

NSAIDs ex. ibuprofen (contributes to sodium retention, therefore fluid retention)

Preeclampsia

New-onset HTN + proteinuria or end-organ dysfunction after 20 wks Sx: - Systolic >=140 or diastolic >= 90 on 2 occasions at least 4 hrs apart or S: >=160 or D: >= 110 confirmed on repeat check - >= 300 mg of protein in 24 hr urine collection or protein to cr ratio of 0.3, or dipstick >= +1 - End-organ dysfunction: thrombocytopenia, renal/liver impairment, pulmonary edema, persistent headaches, vision changes - edema is not diagnostic, but is common CM

Sx of blood dyscrasia

unblanchable small red pinpoint rash (severe drug response - systemic)

ABG concern for COPD

PaO2 <60 mmHg (sig. hypoxemia requiring intervention)

Expected lab finding for COPD

Polycythemia

Cervical cerclage usage

Prevent preterm delivery with suture (usually in pts with hx of 2nd trimester loss or preterm birth at 12-14 weeks gestation - Pts should be educated abt signs of preterm labor (ex. low back aches, contractions, pelvic pressure and rupture of membranes) and should understand activity restrictions (bed rest for a short time after placement)

Purpose of IVIG & high dose aspirin for Kawasaki disease tx

Prevention of coronary disease - coronary artery aneurysms are the most serious potential sequelae leading to MI and death

First degree heart block

Prolonged PR - Asymptomatic (usually)

Dietary restrictions for patients receiving hemodialysis

Renal diet: low sodium, low potassium (avoid raw carrots, tomatoes, OJ), low phosphorus (chicken, turkey, dairy), low protein (0.6-0.8 g/kg/day), fluid intake monitoring

NSAIDs Risk (naproxen, ibuprofen, celecoxib)

#1: increase risk of thrombotic events ex. MI, stroke (esp. w/ cardiovascular disease)

Adenosine administration

- 6 mg IV rapidly over 1-2 seconds followed by 20 mL saline flush - For SVT - Half life <5 sec. - Repeat boluses of 12 mg may be given 2x if rapid rhythm persists - Brief systole can be common - Flushing from vasodilation is frequent

Fall risk precautions w/ altered mental status

- Bed alarm - Room close to station - Bedside commode close to bed - Well-lit room - No restraints initially, will only increase agitation

Breastfeeding Education

- Breastfeed: q2-3h, "on demand" when newborn exhibits hunger cues - Position "tummy to tummy" with mouth in front of nipple & head in alignment w/ body - Ensure proper latch (nipple & areola) - At least 15-20mins each breast or until newborn appears satisfied - Insert clean finger beside gums to break suction - Alternate which breast is offered at each feeding

Healthy snacks for toddlers

- Cheese - Whole-wheat crackers - Banana slices - Yogurt - Cooked veggies - Cottage cheese w/ thinly sliced fruit

Folliculitis

- Due to staph in moist areas with friction - Tx: medicated soap, topical ABX, warm compress

When might postmortem care be delayed or not performed?

- Family has certain cultural or religious beliefs OR - The death is considered to be non-natural, traumatic, or associated w/ criminal activity

Acute otitis media CM

- Frequent pulling on affected ear - Loss of appetite - Restlessness & irritability - High fever - Ear pain S: Bulging & very red tympanic membrane

Herbal supplements that increase risk for bleeding (should be discontinued pre-major surgery

- Ginkgo biloba - Ginseng - Garlic - Ginger - Saw palmetto - Feverfew

Reasons for returning blood to blood bank

- Green, black, white, or dusky discoloration - Accumulation of air - Evidence of clotting - Malodor

Allergic rhinitis interventions

- HEPA filters - Keeping windows closed - Hypoallergenic pillow and mattress covers - Eliminating carpet - Mopping and vacuuming regularly w/ HEPA filter system - Damp-dusting furniture frequently

Infant feeding education

- Held in semi-reclining position - Meds given in small ants directed toward back and inside of cheek - Open mouth by applying gentle pressure to chin or cheeks - One hand holds infants free arm

Nonurgent Triage

- Infections - Minor burns/lacerations - Closed fractures

Teaching about bed bug bites for parents

- It's a misconception that bed bugs are only drawn to dirty environments. They can inhabit any environment and spread easily in clothing, bags, furniture and bedding. - They don't pose significant harm, but can cause an uncomfortable rash. - The entire house should be exterminated since just washing a single pillowcase or blanket won't stop the infestation and all family members and pets can be affected. - Minimize itching to prevent secondary infections.

Retinal detachment sx

- Lightning flashes - Floaters - Curtain-like/gnats/hairnet/cobweb effect could result in permanent blindness w/o intervention

Pt w/ splenectomy reporting headache & chills

- Needs immediate intervention: minor infections w/o functioning spleen can become life-threatening - Cultures, imaging, ABX

How often should continuous IV tubing be changed ?

- No earlier than every 72 hours unless contaminated - Intermittent & hypertonic infusions ex TPN, propofol, blood require changes 4-24 hrs

Urgent Triage (tx needed in 30 mins-2 hrs)

- Open fractures w/ palpable distal pulse - Large wounds

Post-op cleft palate interventions

- Pain management: uncontrolled pain leads to crying which stresses surgical site and promotes hemorrhage - Positioned in an upright, supine position to prevent airway obstruction - Elbow restraints to prevent child from disrupting surgical site, while removing restraints per hospital policy to monitor skin and neurovascular status PREVENT HEMORRHAGE = no hard objects placed in mouth

Hypoalbuminemia sx

- Pitting edema - Periorbital edema - Ascites

Reasons for prophylactic antibiotics pre-dental op to prevent infective endocarditis?

- Prosthetic heart valve - Previous hx of IE - Unrepaired cyanotic congenital heart defect - Cardiac transplant

Expectant Triage

- Pulselessness - Apnea - Severe Neuro Trauma - Burns to >60% TBSA

Small bowel obstruction CM & nursing actions

- Rapid onset of N/V - Colicky intermittent abd. pain - Abd. distension Nursing actions: - NPO -NG - IV fluids - Pain control

Priority pts

- Seizures (risk for aspiration, implement seizure precautions) - Blood transfusion 15 and 30 mins to monitor rxn - Pt receiving chemo w/ fever & neutropenia (can turn into sepsis) - CHF w/ SOB & recent prescription of furosemide - Compartment syndrome (limb threatening emergency - 6 P's) - Older, women, and diabetic pts w/ atypical angina sx - Orthopedic pt w/ resp. distress sx, altered mental status, petechial hemorrhage indicating fat embolus - Older pt w/ s3 sound (indicated HF) - Bronchoscopy or any procedure performed under sedation (risk for instability) - Stops wheezing (airway obstruction could lead to resp. failure) - Head injuries - <1 yr w/ fever, lethargy, and vomiting (sepsis or meningitis) - Fluid overload (w/ increased infusion rates to prevent resp. or cardiac compromise) - Amenorrhea, pelvic/abd. pain and/or subsequent vaginal bleeding/spotting (ectopic pregnancy) - Pacemaker infection

Buck's traction nursing actions

- Supine/semi-Fowler's position (MAXL 20-30 degrees) - Assess neurovasc. status q30min - Wts should be free-hanging at all times (never placed on bed or floor) How does it work? Skeletal traction is applied directly to bone with metal wire or pin to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible WTS SHOULD NEVER BE REMOVED, can cause serious injury

Pavlik Harness for DDH

- Usually worn for 3-5 mos - Most successful started during 1st 6 mos of life - Shirt, knee socks, & diaper under straps (skin protection) - Avoid lotions & powders (excess moisture) - Lightly massage skin under straps qday (circ.) - Should stay in place for diaper changes - Straps should be assessed q1-2 wks by HCP, NEVER ADJUSTED BY PARENTS - Assess skin 2-3x daily

Skeletal traction interventions

- WTS SHOULD NOT BE REMOVED unless prescribed by HCP - Intake of >/= 2L of clear fluids - Wts hang freely - Monitoring pin insertion sites, freq. neuro checks, inspect rope

Capsaicin administration education

- Wait at least 30 mins after massaging before washing to ensure adequate absorption - 3-4x daily - Local irritation (burning, stinging, erythema is quite common)

Home Safety hazards

- open wood burning stove - built pre-1978 (lead paint)

Best place to apply pressure if bleeding occurs

1 inch above puncture site

3 point gait w/ crutches to go up stairs

1. Assume tripod position, put body wt on crutches 2. Step up w/ unaffected leg 3. Transfer body wt to unaffected leg & raise body onto stair 4. Advance affected leg & crutches up stair

During central line tubing change, pt suddenly begins gasping for air & writhing

1. Clamp catheter tubing 2. Place pt in Trendelenburg pos. on l side 3. Admin O2 PRN 4. Notify HCP 5. Stay w/ pt & provide reassurance

Colonoscopy prep

1. Clear liquid day before 2. NPO 8-12 hrs before exam 3. Bowel cleansing agent day before (cathartic, enema, or polyethylene glycol)

Pt w/ diabetes receiving peritoneal dialysis experiencing chills and abdominal discomfort and rebound tenderness. Most recent blood glucose is 210 mg/dL

1. Collet peritoneal fluid for culture and sensitivity - pt sx indicate peritonitis , get ABX based on culture and sensitivity

CBT components

1. Education abt specific disorder 2. Self-observation & monitoring 3. Relaxation techniques 4. Desensitization activities 5. Changing neg. thoughts

Priority for burn pt

150 mL/hr of IV LR continuously to STABILIZE CIRCULATION

When can pregnant women feel fetal movement (quickening)?

18-20 wks

Which intervention is appropriate while caring for a pt on life support who has been declared brain dead? 1. Ask family members about funeral service 2. Call the local organ procurement services representative 3. Discontinue nursing care and provide postmortem care 4. Remove life support as requested by the spouse and family

2 All pt deaths are reported to local organ procurement services, per hospital protocol

Tornado protocol? Select all that apply 1. Open doors to pt rooms 2. Move beds away from windows 3. Close window shades and curtains 4. Place blankets over pts who are confined to bed 5. Relocate ambulatory pts from hallways back into room

2, 3, 4 Focus on what can protect pts from flying debris. Ambulatory pts should be moved into hallways from their rooms, away from windows.

Regular insulin peak

2-5 hrs

Normal Albumiin levels

3.5-5.0 g/dL

How long can blood products be left at room temperature?

30 mins

Rapid-acting insulin peak

30 minutes - 3 hrs - given in pt will eat within 15 mins - can be scheduled prandial (prevent unless BS <70) or correctional (unless BS<150)

The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? 1. "I have been seeing small flashes of light." 2. "I have trouble threading my sewing needle. I have to hold it far away to see it." 3. "I notice that my peripheral vision is becoming worse." 4. "I see a blurry spot in the middle of the page when I read."

4 Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact (Option 4). (Option 1) Seeing small flashes of light is associated with retinal detachment. (Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age and therefore unable to adjust to near and far vision. (Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma.

Insulin NPH peak

4-12 hrs

Time needed for heparin bridge to transfer to warfarin

5 day overlap

Pt w/ HR who is SOB & coughing up pink, frothy sputum

Acute pulmonary edema - needs immediate assessment

First action for pt in VT

Assess for pulse (can be pulseless or have a pulse) If unstable: synchronized cardioversion If stable: anti arrhythmic meds ex. amiodarone

Infants <30 days old are at risk for...

Bacteremia (immature immune system - blunted response), FEVER CAN BE ONLY SX (other sx: hypothermia, lethargy, poor feeding, decreased urine) Rectal temp >100.4 or <96.8 is concerning

Late decelerations

Bad (placental insufficiency)

Complication of PEEP

Barotrauma (from high levels: 10-20 cm H2O) can lead to pneumothorax & decreased venous return can cause hypotension

Contraindication for Dicyclomine HCl (Bentyl) for IBS

Bladder scanner showing 500 mL of urine (urge to urinate normally at 300 mL, pain usually ~500 mL) Any meds that have anticholinergic SEs: pupillary dilation, dry mouth, urinary retention, constipation: CLOSED-ANGLE GLAUCOMA, BOWEL ILEUS, URINARY RETENTION (e.x. BPH)

Intoxicated pt found lying on sidewalk when admitted has LOC changes, bradycardia, increased BP & widening pulse pressure - action?

CT to rule out intracranial bleed

Priority when pt has acute change in VS or staff member is worried abt pt's condition

Call rapid response team

Why shouldn't parents put their kids to bed with a bottle of milk?

Can lead to extensive and rapid dental caries in developing teeth aka baby bottle tooth decay (carbohydrate-rick fluid pools around teeth and nourishes decay producing bacteria)

DNR but HCP writes prescription for life-saving intervention

Can provide comfort measures but cannot give life-saving intervention, must advocate for pt's wishes

Complication of pericardial effusion

Cardiac tamponade

How often should stoma bags be changed & emptied?

Changed: q 5-10 days Emptied: 1/3 full

4,800 mL of urine during shift, receiving TPN

Check blood glucose for hyperglycemia (xs: polydipsia, polyuria, headaches, blurred vision)

Priority for pt w/ new trach

Checking tightness, allowing 1 finger to fit under ties

After witnessing child collapse, not breathing but has pulse, and delivers rescue breaths for 2 mins w/o change what should be done?

Chest compressions alternating w/ rescue breathing & checking pulse every 2 mins

How can itching be relieved under a cast?

Cool setting of hair dryer - NOTHING should be placed in cast (can cause skin breakdown & infection)

IUDs & length of contraception

Copper - 10 yrs Levonorgestrel - 3 of 5 yrs

Sumatriptan contraindications

Coronary artery disease and ischemic uncontrolled HTN

Most important lab value to monitor w/ Vancomycin administration

Creatinine levels (can cause nephrotoxicity)

Barking cough, stridor, & resp. distress & tx

Croup Tx: racemic epinephrine

Bruising behind the ears (Battle sign)

EMERGENT - Basilar Skull Fracture: pose risk of severe intracranial injury (most common cause of traumatic death in kids) other sx: periorbital hematoma (raccoon eyes), blood behind tympanic membrane, CSF leaking from nose or ears Tx: IMMEDIATE C-SPINE IMMOBILIZATION, neuro assessment, ABCs

Most important lab value to report abt pt with DM type I

Elevated serum creatinine (@ risk for diabetic nephropathy)

What should you do if chest tube dislodges?

Firmly cover insertion site with palm of clean, gloved hand - sterile occlusive dressing is better aka PETROLEUM GAUZE (prevent pneumothorax)

Priority for pt w/ ineffective airway clearance r/t pain

Give pain meds before performing coughing exercises so exercises are more effective

How to stand up from chair w/ crutches

Hold hand grips of both crutches in hand on affected side, move to chair's edge, & hold armrest w/ hand on unaffected side

Common SE of potassium-wasting diuretics ex. furosemide, bumetanide

Hypokalemia - muscle cramps, weakness, or paresthesia - can lead to lethal cardiac arrhythmia & paralysis

SE of PPV

Hypotension b/c of the increased intrathoracic pressure and reduced venous return and CO

Elevated TSH indicates... Tx?

Hypothyroidism (insufficient T3 & T4) - Tx: increase levothyroxine

A pt is hypertensive, tachycardic, and has low central venous pressure, what does this indicate?

Hypovolemic shock

Priority for pt w/ alc. intoxication

IV thiamine (vitamin B1) before or with IV glucose to prevent Wernicke encephalopathy. Note: untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis)

When do you give Rhogam?

If mom isn't Rh sensitized (neg. Coombs (antibody) test to prevent antibody formation within 72 hours of birth

Heart Failure CM

Left HF: pulmonary congestion - cardiomegaly - pulmonary edema: CRACKLES, dyspnea Right HF: systemic venous congestion - JVD - EDEMA, ascites

Fondaparinux administration

NOT administered until more than 6 hours after any surgery and NOT w/ epidural catheter

Most important nursing action for pt with UTI and sx of agitation, confusion, and disorientation

One-on-one supervision & freq. reorientation

Pt education for postop pain after invasive MIDCAB grafting

Overall recovery time is expected to be shorter, but initial postop pain can actually be higher b/c incisions were made btw ribs

Acute pancreatitis complications

Pancreatic abscess/necrosed pancreas: high fever, leukocytosis, increasing abd. pain - TX IMMEDIATELY W/ ABX TO PREVENT SEPSIS

Syphillis in pregnancy w/ penicillin allergy

Penicillin desensitization

Pre-op assessment for open abd. aneurysm repair

Peripheral pulses (to determine if graft becomes occluded post-op)

Priority post-op concern

Post-op hypotension (could indicate bleeding, hypovolemia, sepsis)

Pursed lip breathing technique for COPD pts

Relax neck and shoulders. Inhale for 2 second through nose keeping mouth closed. Exhale for 4 seconds through pursed lips. How? Pursed lips create pressure which prolongs expiration and decreased SOB Pts should practice 5-10 minutes 4 times daily

Constipation post barium enema 3 days ago

Retention of barium can cause fecal impaction or bowel obstruction resulting in severe complications such as bowel perforation and peritonitis

Grapefruit + CCB (VND)

Severe hypotension

Pulsus Paradoxus

Systolic BP decrease >10 mmHg

TORCH infections

Toxoplasmosis Other [parovirus B19, varicella-zoster] Rubella Cytomegalovirus Herpes simplex cause fetal abnormalities - preg. HCW can safely care for pts w/ contact precautions ex. MRSA & should not care for pts receiving radioactive therapy or w/ teratogenic infections

2nd degree AV block intervention (consistent PR intervals & dropped QRS complexes)

Transcutaneous pacemaker IMMEDIATELY

Best assessment indication that bladder irrigation flow is productive after TURP

Urine is light pink, no clots

Meds drawn from glass ampule

Use filter needle to draw up med, then change to injection needle

Pt's radiation implant has dislodged, what do you do?

Use long-handled forceps to secure implant in a lead container

A pt who is 6 cm dilated with recurrent variable decelerations gets an IUPC placed and is prescribed an amnioinfusion, what finding should be reported to the HCP immediately?

Uterine resting baseline tone above 20 mmHg and minimal to absent fluid return. Why? Indication of uterine overdistension b/c of too much fluid infused. Pause infusion and notify HCP.

What should be done if the pt remains hypotensive after a fluid bolus?

Vasopressor or isotropic medications (norepinephrine, dopamine) should be initiated. Circulatory fluid volume must be restored first

Best site for newborn & infant IM injections & needle length

Vastus lateralis muscle Newborns: 5/8 in. 5/8-1 in. infants 22-25 gauge <12 months

What dysrhythmia can hyperkalemia cause? What meds make it worse?

Vfib - ACE Inhibitors (-prils) and ARBS (-sartans)

PVCs

Wide distorted QRS - Usually in response to stimulants (caffeine, nicotine, alc, electrolyte imbalances)

Normal aPTT & aPTT with heparin

aPTT: 25-35 seconds Heparin aPTT: 46-70 seconds

immunosenescence

age-related decline of immune responses that increases older pts risk of infection & sepsis ATYPICAL SX OF INFECTION (ex. hypothermia, altered mental status, leukopenia) should be reported immediately

Duchenne Muscular Dystrophy (DMD)

most common form of childhood MD due to lack of protein dystrophin - onset: 2-5 yrs - Gower sx *NO EFFECTIVE CURE* - most kids are wheelchair bound & die by age 20-30 from resp. failure - differs from cerebral palsy (abnormal muscle tone & lack of coordination w/ spasticity) DMD - weak muscles - encouraged to do GENTLE exercise & swimming

Grapefruit + statins

possible myopathy

Palifermin

prevents oral mucositis, doesn't help w/ pain (lidocaine does)

Pediculosis Pubis Tx

"Crabs" aka pubic lice - Use lice tx shampoo (1% permethrin) - Remove nits w/ fine-toothed nit comb, fingernails, or tweezers - Wash & dry clothes w/ hot H2O & hot dryer setting - Sexual partners should also receive tx - May be passed through close contact & sharing linens - ALL HOUSEHOLD MEMBERS are @ risk

How to best respond to parents who don't believe in ABX to tx kid

"Please tell me your understanding of your child's condition." Assess parental knowledge deficit

Correcting vasooclusion in sickle cell pts

#1: High-flow IV fluids then supplemental O2 - only if they don't respond to tx can you transfuse RBCs

Tx for CKD w/ urosepsis

- IV fluid bolus - IV broad-spectrum ABX - Urine & blood cultures are obtained before 1st ABX dose - Continuous VS & cardiac monitoring - Stop ACEs & ARBs - Clarify CT w/ contrast (can be toxic w/ CKD)

Meds for rhonci (resembles snoring) - upper resp. infections or chronic bronchitis

Guaifenisin

Variable decelerations

HR up or down, cord compression = VERY BAD Prolapsed cord= push head up, change mom position

Stridor

Harsh or high-pitched breathing due to obstruction or constriction of airway - indicates LIFE THREATENING AIRWAY COMPROMISE

St. John's wort interactions

- Depression meds: TCAs, SSRIs/SNRIs, MAOIs

Morning sickness interventions

- Several small meals during day (high in protein or carbs & low in fat) - Drinking fluids (clear, cold, carbonated) btw rather than during meals - High protein snack before bed & on awakening - Ginger - B6 (nuts, seeds, legumes)

Emergent Triage

- Shock - Compromised airway - Unstable wounds - Chest trauma

Beck Triad

1. Hypotension 2. Muffled heart sounds 3. Neck vein distension

How is effectiveness for TB treatment determined?

3 negative sputum cultures and chest X-ray Entire course of therapy must be completed (6-9 months)

Priority for GCS

Report neg. neurological trend in GCS scale

Normal albumin levels

3.5-5 g/dL

30 month old wt gain since birth

4 times initial birth wt

Sodium polystyrene sulfonate

Kayexalate - tx of hyperkalemia

Complications of placenta accreta (placenta adheres to myometrium instead of endometrium)

LIFE-THREATENING HEMORRHAGE & SHOCK Prevent: 2 large 18-gauge IVs, blood type & crossmatch in case blood transfusion is needed

Nagle's Rule

LMP +7 days -3 months +1 yr

Tx for dog bite resulting in pain, edema, and redness

ABX, possibly rabies vaccine

1st step if child ingests poisonous substance

ASSESS to determine if emergency care or poison control are needed

Pt w/ pleural effusion normal finding

Absent breath sounds in base of lung b/c of fluid collecting in pleural space preventing lung from expanding

Carotid Endarterectomy concern

Stroke

Intervention for newborn with NAS

Swaddle & gently rock to prevent skin damage from excessive movement & minimize stimulation

What should be reported immediately with AVF?

Sx of impaired distal extremity perfusion: - skin pallor - pain - numbness - diminished pulses - poor cap. refill distal to AVF

6 mo. crying and grabbing intermittently at abd. w/ red, currant jelly appearance

Give air (pneumatic) enema

After turning pt w/ chest tube 125 mL of dark bloody drainage rushes out

Document & continue to monitor drainage - Immediately following thoracotomy, chest tube drainage (50-500 mL for first 24 hrs) is expected to be sanguineous for sev. hrs then change to serosanguineous followed by serous over a period of a few days - Not concerning - most likely r/t retained blood b/c of partial tube blockage

Priority for pt w/ memory loss post ECT

Document (expected finding)

Phalen's manuver

Dx for carpel tunnel

Cardiac tamponade tx

Emergency pericardiocentesis

3-7 yo w/ acute resp. distress, drooling & dysphagia, fever & tx

Epiglottitis Tx: Intubation - possible trach - NO O2 (can close trachea)

Hemoglobin <11g/dL in 2nd trimester, <10.5 in 3rd trimester

Evaluate for anemia & possible iron supplementation (Fetus depletes iron stores)

Why is enteral nutrition preferred?

Maintain integrity of gut, prevent stress ulcers, prevent translocation of bacteria into bloodstream

Priority dx for schizophrenic pt

Risk for dehydration & malnutrition

Cervical Cancer risk factors

#1: HPV - STIs - oral contraceptive use - multiple sexual partners - sexual activity <18 - weakened immunity

Marfan Syndrome education

#1: NO competitive/contact sports (risk for cardiac injury & sudden death: aortic root disease is major cause of death) - monitor for scoliosis - annual eye exams - preventive ABX may be needed

Priority for pregnant pt @38 wks w/ contractions, severe abd. pain, & dark vag. bleeding

#1: Palpate abd. & apply FHR monitor -- indicates placental abruption (can interrupt fetal O2 & cause maternal hemorrhage) - then IV for fluids & blood, possible C-section

Trach care steps

1. Gather supplies & pos. pt in semi-Fowler's 2. Don PPE 3. Remove soiled dressing & clean gloves 4. Don sterile glove; remove old cannula & replace 5. Clean around stoma w/ sterile H2O, dry & replace gauze

When are prophylactic ABX given to pregnant women?

1. Pos. GBS test 2. When GBS status is unknown + a. ROM >= 18 hrs b. maternal temp. >= 100.4 c. gestation <37 wks

Characteristics of nephrotic syndrome

1. Proteinuria 2. Edema 3. Hypoalbuminemia 4. Hyperlipidemia (cholesterol >200)

DKA protocol

1. Rehydration (NS) 2. Insulin

Rhythms for cardioversion

1. Supraventricular tachycardia 2. Ventricular tachycardia w/ pulse 3. Afib w/ rapid ventricular response MUST BE ABLE TO SYNC W/ R WAVE

Tetracycline Education

1. Take on empty stomach 2. Avoid antacids or dairy products 3. Take w/ full glass of H2O 4. Photosensitivity - use sunblock 5. Can decrease use of oral contraceptives

Dressing change for surgical incision

Clean gloves when removing existing dressing changing to sterile gloves when applying new dressing

Normal Hct

Males: 42-52% Females: 37-47%

Normal Hgb

Men: 14-18 Women: 12-16

IV Potassium Warning

NEVER ADMINISTER BY GRAVITY - may cause lethal arrhythmias - requires pump

Contraindicated med for pt w/ HTN

NSAIDs ex. ibuprofen can cause CV SE including MI, stroke, high BP, and HF - can decrease effectiveness of diuretics and other BP meds - long term use is associated w/ peptic ulcers and CKD

Lithium

Narrow therapeutic index 0.6-1.2 - Interaction w/ #1: thiazide diuretics, NSAIDs, & antidepressants

Best position for newborn resuscitation

Neck slightly extended (not hyperextended) + blanket or towel under newborn's shoulders

Negative contraction test

Normal — no late or variable decelerations

IUD pt education

Notify HCP if string feels longer or shorter after menses (assess weekly for first 4 wks & then after each menses - Report PAINS sx (period abnormalities, abd. pain, infection, not feeling well, strings length)

Priority for craniotomy w/ wound drainage saturating the incision

Notify HCP of color and amt of drainage

Oropharyngeal candidiasis tx

Nystatin (antifungal)

Best room placement for pt with autism

Private room away from nurses' station (calm environment, minimal stimulation)

Nitrazine test for ROM

Probable rupture - Blue (amniotic fluid is alkaline) Probably intact membranes - Yellow (vaginal fluids are acidic) NOTE: PRESENCE OF BLOOD OR SEMEN CAN RESULT IN FALSE POS. (alk)

Placenta previa

Sx: painless, bright red vaginal bleeding RISK FOR HEMORRHAGE -- VAGINAL EXAMS CONTRAINDICATED, pelvic rest recommended, C/S after 36 wks

Malignant hyperthermia sx and tx

Sx: tacycardia, tachypnea, rigid jaw/generalized rigidity, fever later Tx: IV DANTROLENE - Discontinue succinylcholine - Cooling blankets - Tx high potassium levels (triggered by certain drugs used for anesthesia)

Malfunctioning BP machine

Take out of service to prevent pt injury & measure manually

Best action for suspected frostbite

Thaw in warm water bath 98.6-102.2F and administer analgesics (Manual friction is contraindicated as it could damage the tissue) Frostbite - vasoconstriction restricts blood flow, intracellular fluid freezes and cell membranes rupture

Priority for failing pacemaker

Transcutaneous pacemaker to stabilize pt till internal pacemaker can be repaired/replaced

Sx of VP shunt malfunction

Vomiting, headaches, changes in vision & mental status (same sx as increased ICP)

Pt receiving blood transfusion gets new prescription for Amphotericin B

Wait 1 hr after transfusion finishes before administering Amphotericin B (similar SEs)

Best way to walk next to blind pt

Walk slightly ahead of pt w/ pt's hand resting on nurse's elbow

RSV

causes bronchiolar swelling & excess mucus in infants & kids Tx: resp. support & admin of antipyretics & IV fluids - Contact and droplet isolation - Palivizumab is given IM once monthly during winter for kids @ high risk (ex. prematurity, chronic lung disease)

How to measure cane length & pt education

Greater trochanter to floor - Hold cane on stronger side - Place cane several in. in front of and to side - Move weaker leg forward - 2 points of support on floor at all times

Normal central venous pressure

2-8 mm Hg

When should epoetin alfa be given?

- Combat effects of chemo and/or kidney disease

Priority for sickle cell pt who received blood transfusion w/ pain all over, anxiety, SOB, and crackles in bilateral lower lobes

- Administer prescribed diuretics due to circulatory overload and provide additional resp. support - Slow infusion rate and pt should be put in sitting position

Assessment based on pt's developmental age

- As young as 3 can tell and/or show where they hurt or how they feel - 10 yr olds are capable of understanding & assisting in physical exam, also becoming modest & don't want parent in the room w/ them

Pt w/ crushing substernal chest pain

- Assess ABCs & pain - Dx: 12-lead, blood work: cardiac markers, electrolytes, CXR - O2 if needed <90%, dyspnea - 2 IVs & prescribed meds (nitro, aspirin, morphine) - Continuous cardiac monitoring

Systemic lupus erythematosus pt education

- Avoid situations that cause physical & emotional stress - Avoid sun exposure & UV light when possible - Notify HCP if you have fever

Reactive Nonstress Test (NST)

- Baseline 110-160/min - Moderate variability (6-25/min) - >=2 accelerations in 20 mins, each peaking >= 15/min above baseline lasting >= 15 s

Lactase deficiency dietary management

- Can still eat cheese and yogurt in moderation if tolerated well - Should take daily Ca + Vit. D supplements - Enzyme supplements (Lactaid) should be taken w/ meals containing dairy

Parent education for feeding kids

- Chopped whole fruit instead of juice (b/c fiber) - H2O btw meals - Space introducing new foods by ~a wk

Parent education for strep A pharyngitis

- Complete all ABX (can lead to glomerulonephritis or rheumatic fever if untreated) - Cool liquids and soft diet are recommended - Replace toothbrushes 24 hrs after starting ABX since bristles can harbor bacteria (can cause reinfection) - May return to school after 24 hrs of ABX

Vitamin K-rich foods

- Decrease anticoagulant effects of warfarin - Ex. green leafy veggies & liver - Note: Don't confuse K+ w/ vitamin K

Tumor lysis syndrome sx

- Hyperkalemia - Hyperuricemia - Hyperphosphatemia

Brachtherapy nursing actions

- Limit time (30 mins/day: cluster care & wear dosimeter badge) - Maximize distance (6ft from source) - Use shielding, TURNING BACK IS RISK FOR EXPOSURE) - Linens must remain in pts room till implant is removed - Body fluids are generally not radioactive (can normally dispose)

tPA ( tissue plasminogen activator - thrombolytic therapy)

- MUST be given 3-4.5 hrs from onset of ischemic stroke - Contraindications: recent surgery (14 days), thrombocytopenia (<100,000/mm3), coag. disorders

Cardiac tamponade sx requiring immediate intervention

- Muffled/distant heart tones - Narrowed pulse pressure - JVD - Pulsus paradoxus - Dyspnea, tachypnea - Tacycardia

Hypokalemia

- Muscle weakness/paralysis, soft flabby muscles - Paralytic ileus - Cardiac arrhythmias

Priority for bipolar pt w/ mania

- Prioritize physiological needs Ex. High calorie snacks the pt can eat while on the move and during tasks b/c they may refuse to sit still long enough to finish meal

Most concerning lab values for pt w/ systemic lupus erythematous

- Serum Creatinine: >1.3 - BUN >20 - Abnormal UA can indicate presence of lupus nephritis (inflammation of kidney - can lead to serious kidney injury)

PEG tube expected finding

- Slight in/out movement <= 0.25 in - Should always be secured loosely against skin

Administration of IV hydromorphone

- Slowly over 2-3 minutes - With stool softener to prevent constipation - Reasses pain and sedation level every 15-30 minutes - Helps with deep breathing exercised when pt is in pain

Priority hypothermia interventions

- Warm blankets - Warm IV fluids - Cardiac monitor (as core temp. decreases, prone to dysrhythmias) -- handle gently: could go into spontaneous Vfib - Anticipate defibrillation

Acute Appendicitis Sx

- excruciating pain in lower abd. above r hip (McBurney's point) - N/V, anorexia - rebound tenderness & guarding - r leg flexed to decrease pain

Diverticulitis Sx

- pain in lower l quadrant (sigmoid) - palpable, tender mass - systemic sx of infection

Actions for pt w/ nystatin oral suspension

- soak dentures in nystatin oral suspension - assess affected area frequently - instruct pt to swish suspension in mouth for several minutes and then SWALLOW - shake before - continued for at least 48 hrs

Digoxin toxicity sx

1. GI 2. Neuro 3. Visual 4. Cardiac (potassium doesn't need to be increased only if pt is taking digoxin w/ diuretics supplementation may be needed)

The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV. Which of the following statements by the client indicates a need for further education? Select all that apply: 1. "I don't have to use protection if my sexual partner is also HIV positive." 2. "I have to make sure my family knows not to borrow my razors." 3. "I need to avoid eating raw or undercooked meats and eggs." 4. "I started to use lambskin condoms during sex, as I have a latex allergy." 5. "I won't reuse or share any needles or syringes that I use to inject heroin."

1, 4 Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive immune system impairment. When educating clients with HIV, the nurse should discuss health promotion and infection transmission prevention strategies, particularly safe sex practices. Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections (STIs). Protected sex is important even with HIV-positive partners as HIV has multiple strains and coinfection results in HIV superinfection, which may hasten progression to AIDS (Option 1). Clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous membrane exposure (ie, oral, vaginal, anal) to semen or vaginal secretions. Natural barriers (eg, lambskin) do not prevent transmission of STIs due to the presence of small pores (Option 4). (Option 2) Sharing personal hygiene devices that may have been exposed to blood (eg, toothbrushes, razors) increases HIV transmission risk and should be avoided. (Option 3) Immunosuppressed clients should be educated to avoid raw or undercooked foods (eg, eggs, meats, seafood) to avoid foodborne illnesses. (Option 5) To prevent transmission of HIV, hepatitis B virus, and other bloodborne diseases, IV drug users should be taught to avoid reusing or sharing needles or syringes.

Positions for procedures 1. Paracentesis 2. Liver biopsy 3. Catheterization via femoral artery 4. Enema 5 Lumbar puncture

1. Upright (Semi-high Fowler's) 2. Right side-lying position 3. Flat or low-Fowler's position w/ affected extremity straight ~4-6hrs 4. Sims 5. Fetal or hunched for procedure (supine for 4-12 hrs in bed )

Hypomagnesemia sx

1. Ventricular arrhytmias 2. Neuromuscular excitability (same as hypocalcemia): tremors, hyperactive reflexes, pos. Trousseau & Chvostek sx & seizures

Toilet training

18-24 months - When able to communicate urge to go and follow simple commands like pulling clothing up and down & walking to and sitting on toilet

Norm. Neutrophil Count

2200-7700 cells/mm3

A health care provider prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 34 lb. Based on the available concentration of cefuroxime, how many mL would the nurse administer per dose? Click the exhibit button for additional information. Record your answer using one decimal place. Medication concentration: 250mg/5ml

4.6 To calculate the volume of cefuroxime in milliliters per dose, the nurse should first identify the prescribed dose (eg, 30 mg/kg/day) and available medication (eg, 250 mg/5 mL) and then convert to volume in milliliters per dose (eg, 4.6 mL).

Normal Calcium levels

8.6-10.2 mg/dL <8.6 hypocalcemia is complication of parathyroidectomy - Check for Trousseau's and Chvostek's sx

Normal systemic vascular resistance

800-1200 dynes

Angle of SubQ injection

90 degrees in 2 in. of subq fat can be grasped or 45 degrees if only 1 in. can be grasped

Normal temp

96.8-100.4 F (36-38 C)

Abnormal urine culture results

>10,000 organisms/mL indicates UTI

Critical value for potassium

>5.5 mEq/L

STEMI

>=1 of coronary arteries supplying blood to myocardium is occluded PROMPT Tx: thromolytics, percutaneous coronary intervention

Adequate urine output

@ least 30 mL/hr or 0.5 mL/kg/hr

When does chest circumference exceed abdominal circumference?

After age 2

Radiation contamination monitoring

Anywhere with rapidly proliferating cells ex. oral mucosa, GI tract, bone marrow

Complication of endoscopic retrograde cholangiopancreatogrophy

Appendicitis manifesting as epigastric of l upper quadrant pain often radiating to back & rapid rise in pancreatic enzymes (amylase, lipase)

Purulent drainage & crusting of eyelid & tx

Bacterial conjunctivitis (pink eye) Tx: ABX, warm soaks/cool compresses

Post-tonsillectomy/adenoidectomy concern

Bleeding may occur up to 14 days post surgery can lead to LIFE-THREATENING AIRWAY COMPROMISE so kids should not resume contact sports earlier - Teach parents to observe for sx of bleeding: freq. swallowing or throat clearing, restlessness, vomiting blood, pallor - Teach to limit coughing, gargling, clearing throat

Gestational Diabetes

Blood glucose >=130-140 mg/dL

Priority sx to report for pt taking rituximab

Bronchospasm, dyspnea, tachypnea, hypotension, angioedema

Meds for coarse crackles

Bumetanide, furosemide - loop diuretic (indicates fluid or mucus in l resp. tract ex. PE or pulm. fibrosis)

DIC (disseminated intravascular coagulation)

Clotting within micro vessels which leads to bleeding complications - REQUIRES IMMEDIATE ATTN & EMERGENT REPLACEMENT OF CLOTTING FACTORS, BLOOD, & PLATELETS

First action when pt has difficulty swallowing large pill

Consult w/ pharmacist to see if other forms of med. are available

Sickle cell crisis pain management if previous interventions have been ineffective

Contact HCP for PCA at higher dose (morphine or hydromorphone aka Dilaudid) NO MEPERIDINE - can cause tremors resulting in seizure

Clopidogrel concern for surgery

DISCONTINUE 5-7 days before surgery (same w/ NSAIDs, anticoags, anti platelets, herbal drugs)

Pt reports headache after nitroglycerin

Document & administer acetaminophen (expected finding b/c vasodilator)

Bullimia Nervosa

Eating disorder: binge-eating followed by actions to prevent wt gain (laxative overuse, self-induced vomiting, excessive diarrhea) - wt within or above normal range compared to anorexia nervosa

Priority follow-up for Sulfasazline prescribed for pt with IBD

Elevated urine specific gravity (norm. 1.003-1.030) bc IBD pts are at risk of dehydration and sulfa can crystalize in the kidney if dehydrated Expected findings: elevated erythrocyte sedimentation rate, C-reactive protein, and WBC, mild-moderate anemia, yellow-orange discoloration of pt's skin and urine is expected SE

Priority action in providing care for PTSD pt

Encourage the pt to talk about their trauma at their own pace, listen actively to build trust, and allow pts to vent

Foul-smelling lochia post- prolonged vag. delivery of term infant

Endometrial infection Other sx: fever, achy, uterine pain/tenderness Note: WBC is normally elevated during first 24 hrs postpartum up to 30,000/mm3

Tx for hypovolemic shock

Fluid resuscitation - isotonic fluids (LR, NS)

Botulism tx

IV botulism immune globulin (BIG-IV) + supportive care

The best intervention to reduce the risk of drug interactions

Have pt bring all meds to each appt

Early decelerations

Head pressed on. This is ok.

Sx precipitating seizure activity (eclampsia) in preeclamptic pts

Hyperreflexia, clonus (assessed by dorsiflexing foot & observing rhythmic, jerking "beats" as foot is released)

What vaccines can be administered to a pregnant pt @ 30 wks gestation

Inactivated vaccines: - Influenza injection regardless of trimester during flu season - Tetanus, diphtheria, and pertussis (provides newborns w/ passive immunity against whooping cough) Live virus vaccines are contraindicated

Liver biopsy complication & sx to look for

Internal bleeding (highly vast. organ) - watch for tachycardia

Concern for those experiencing pica

Iron deficiency anemia (due to insufficient nutritional intake or impaired iron absorption

Best action to visualize airway w/ extensive injuries to head & upper back

Jaw-thrust maneuver in supine position on backboard when there's any suspicion of spinal injury (Head-tilt chin-lift doesn't stabilize alignment of head and neck, can cause spinal damage)

Absence seizures

Occur in children ages 4-12 lasting less than 10 seconds, often multiple times a day where it appears the child is daydreaming or inattentive due to a brief loss of consciousness - no postictal period

Ovarian cancer sx

Often vague: bloating, early satiety, urinary urgency/frequency, pelvic pressure, abd/back/leg pain, GI disturbances

Pt receiving vancomycin reports discomfort at IV site

Phlebitis: IMMEDIATELY REMOVE catheter to prevent thrombophlebitis, emboli, or bloodstream infection

18 month old is consuming small amounts of food

Physiologic anorexia: NORMAL - decreased metabolic needs: very high demands of infant slow to keep pace w/ moderate growth of toddlerhood- intake over several days meets nutritional & energy needs

First action for pt w/ suspected meningitis

Place pt on droplet precautions

How to help pt experiencing auditory hallucinations

Provide earphones & a DVD player and have pt sing along w/ music (increasing amp of external sound makes it easier to ignore hallucinations)

Discharge instructions to parents of kid with Kawasaki disease

REPORT FEVER IMMEDIATELY (check q6h for first 48 hrs following the last fever till follow-up visit)

Max infusion rate & concentration for KCl

Rate: 10 mEq/hr [ ]: 40 mEq/L

Pain during defecation

Rectal problem: inflammation, anal fissure, or thromboses hemorrhoids

Why give heparin/enoxaparin/aspirin 24 hrs before and after surgery?

Reduce risk of venous thromboembolism (validate if Hgb and Hct are low)

Botulism

Result of ingesting improperly canned or stored food - DON'T use can w/ bulging end - Kids <1 yr should not be given honey b/c immature gut - results in LIFE-THREATENING MUSCLE PARALYSIS through blocking ACH can progress to RESP. FAILURE & ARREST Sx: constipation, difficulty feeding, decreased head control, diminished deep-tendon reflexes

Pts who undergo coronary intervention & stent placement are at risk for...

Retroperitoneal hemorrhage Sx: hypotension, back pain, flank ecchymosis, hematoma, diminished distal pulses

Side effects of TB treatment

Rifampin: hepatotoxicity, red-orange discoloration of body fluids, increased metabolism of some drugs Isoniazid: hepatotoxicity and peripheral neuropathy Ethambutol: ocular toxicity

Atypical Antipsychotics

Risperidone, Olanzapine, Quetiapine -SE: EPS, NMS, anticholinergic effects, orthostatic hypotension, sedation

Linezolid teaching

SSRIs are contraindicated (increased risk of serotonin syndrome)

New-onset anemia for 50 yo

Screening colonoscopy for colon cancer + annual fecal occult blood test

Fever, vomiting, irritability, high-pitched cry may indicate...

Serious underlying infection and increased ICP - SUSPECTED BACTERIAL MENINGITIS Tx: Prompt initiation of ABX & droplet precautions

Incident Reporting

Should be filed when action results in harm OR has potential to cause harm to pt, visitor, or employee ex. falls, mislabeled specimens, med. & communication errors

Unstageable pressure injury

Slough/eschar preventing visualization of wound base - debridement necessary

Shortly after initiating infusion of KCl, pt reports burning & discomfort @ IV site, priority action?

Slow rate of KCl infusion (recommended 5-10 mEq/hr) Concentrations: 20-40 mEq/100 mL Max rate: 40 mEq/hr Continue with IV rather than oral bc lowered risk for dysthymias

Priority monitoring for dopamine

VS for dangerous tachycardia and tachyarrhythmias

Pregnant pt arrives with mild contractions and painless vaginal bleeding, 7-8 months pregnant, what should be done?

1. Blood draw for type and screen 2. Electronic fetal monitoring 3. Initiation of 2 large-bore IV catheters 4. Pad counts to assess bleeding CONDITION: PLACENTA PREVIA Dx: Ultrasound Vaginal examinations are contraindicated - risk for hemorrhage

ASA (aspirin) toxicity tx

1ST - Activated charcoal (inhibits absorption) THEN IV sodium bicarb (excretes salicylate)

The nurse is preparing to administer medications to a client with an asthma exacerbation. Which prescription should the nurse confirm with the health care provider prior to administration? Click on the exhibit button for additional information. Day 1, Day 5 Hematocrit: 37% (0.37), 36% (0.36) Platelets: 250,000/mm3 (250 × 109/L), 96,000/mm3 (96 × 109/L) White blood cells: 9,100/mm3 (9.1 × 109/L), 15,000/mm3 (15.0 × 109/L) Potassium: 3.8 mEq/L (3.8 mmol/L), 3.6 mEq/L (3.6 mmol/L) 1. Albuterol 2. Enoxaparin 3. Methylprednisone 4. Potassium chloride

2 A significant reduction in platelets after initiation of heparin or low-molecular-weight heparin (eg, enoxaparin [Lovenox]) therapy can indicate heparin-induced thrombocytopenia (HIT), a severe, potentially lethal complication. HIT is an immune reaction to heparin-based anticoagulants that causes a drastic decrease in platelet count (ie, ≤50% of pretreatment levels and/or platelet count <150,000/mm3 [150 × 109/L]) and a paradoxical increase in risk for arterial and venous thrombosis (eg, deep venous thrombosis, pulmonary embolism). The nurse should notify the health care provider immediately of decreased platelet levels and anticipate stopping enoxaparin therapy and initiating a nonheparin anticoagulant (eg, rivaroxaban, argatroban) (Option 2). (Option 1) Beta-2 adrenergic agonists (eg, albuterol, salmeterol) are medications used to dilate the airways. The nurse should clarify the prescription if hypokalemia or tachycardia, common adverse effects, are present. (Option 3) Methylprednisolone is a glucocorticoid medication used to reduce airway inflammation in asthma. Glucocorticoids can cause an expected, transient elevation in the white blood cell count during initiation of treatment. (Option 4) Potassium chloride is an electrolyte replacement drug used to prevent and treat hypokalemia (<3.5 mEq/L [3.5 mmol/L]). The nurse should clarify the prescription if hyperkalemia or kidney injury is present. This client has an additional risk for low potassium due to the continued use of albuterol.

What concern for post-op pts would be priority? 1. Post cholecystectomy reporting increased nausea 2. Post myomectomy with mild oozing blood from surgical site 3. Post spinal surgery requesting additional pain meds 4. Post transurethral resection of prostate with reddish-pink drainage

2 Increased risk of vomit aspiration due to nausea and altered level of consciousness (caused by anesthesia). These pts should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications.

The nurse cares for a client with aortic stenosis who was admitted due to syncope on exertion and dyspnea. Identify the area where the nurse would best auscultate the client's heart murmur.

2nd ICS to the right sternal border Aortic stenosis (AS) is a type of valvular heart disease characterized by narrowing of the aortic valve opening, which limits the left ventricle's ability to eject blood into the aorta. AS may occur from hardening (ie, calcification) of the valves, congenital heart disorders, or inflammation. If left untreated, AS may result in heart failure and pulmonary hypertension as compensatory mechanisms fail. When assessing a client with AS, the nurse should auscultate in the aortic area (ie, second intercostal space at the right sternal border) for a loud, systolic ejection murmur heard following the first heart sound. The aortic area, rather than directly over the heart valve, is the preferred location for auscultation as the heart sounds travel in the direction the blood flows. Additional clinical manifestations of aortic stenosis include chest pain, shortness of breath, and/or syncope that are worsened by exertion.

Post-Op Tramadol Administration

50-100 mg q 4-6h mod-sev. pain

Stage 2 pressure injury

shallow, partial-thickness skin loss

The parent of a 5-year-old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? Select all that apply: 1. Apply a cold cloth to the bridge of the nose 2. Apply continuous pressure to the nose for 10 minutes 3. Attempt to keep the child calm and quiet 4. Have the child lie down and turn to the left side 5. Take the child to the emergency department

1, 2, 3 Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury (eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home management. Home management of epistaxis includes: - Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 10 minutes to promote clot formation (Option 2) - Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding (Option 1) - Attempting to keep the client with epistaxis quiet and calm as emotional outbursts and noncooperation create a challenge to implementing interventions and stopping bleeding (Option 3) (Option 4) Positioning a child with epistaxis in a horizontal position or with the head tilted backward promotes drainage of blood into the throat, which increases the risk of swallowing or aspirating blood. Clients with epistaxis should sit upright and tilt the head forward. (Option 5) Epistaxis is typically managed at home. However, the caregiver should seek emergency care if the client's breathing is impaired, or the bleeding is excessive or uncontrollable with home measures or resulted from a traumatic injury.

A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care? Select all that apply: 1. Assess for skin breakdown of the limb in traction 2. Ensure adequate pain relief 3. Keep the limb in a neutral position 4. Perform frequent neuromuscular checks on the limb in traction 5. Reposition the client and use a wedge pillow

1, 2, 3, 4 Buck traction is a type of skin traction used to immobilize hip fractures and reduce pain and spasmuntil the client can undergo surgical repair of the fracture. A traction boot is applied to the leg, below the fracture site. A weight gently and continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should ensure that the traction boot is fitted properly and that the limb remains straight in a neutral position (Option 3). Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess neurovascular status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the limb to which the boot is applied (Options 1 and 4). Overall pain level and efficacy of administered pain medications should be monitored closely, as increasing pain in the limb in traction may indicate neurovascular compromise (Option 2). (Option 5) Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute to neurovascular and orthopedic compromise.

The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply: 1. Administer O2 via NRB face mask 2. Change maternal position to the left side 3. Discontinue oxytocin infusion 4. Notify the health care provider 5. Perform a nitrazine test

1, 2, 3, 4 The mnemonic VEAL CHOP may help nurses recall causes of fetal heart rate (FHR) changes noted on monitor tracings. A late deceleration is a decrease in FHR that begins after a contraction, reaches its lowest point (nadir) after the contraction peak, and then gradually returns to baseline. Late decelerations indicate impaired fetal oxygenationassociated with decreased uteroplacental perfusion (eg, due to maternal hypotension after epidural placement or uterine tachysystole). Chronic uteroplacental insufficiency (eg, intrauterine growth restriction, preeclampsia, diabetes) may also cause late decelerations. Nursing actions to improve fetal perfusion and oxygenation include: - Discontinuing uterotonics (eg, oxytocin [Pitocin]) to reduce uterine activity (Option 3) - Changing maternal position to the left side to relieve compression of the inferior vena cava. If the FHR tracing does not improve, a right-side position may be attempted (Option 2) - Administering oxygen at 8-10 L/min via nonrebreather face mask to promote fetal oxygenation (Option 1) - Giving prescribed IV bolus of lactated Ringer solution or normal saline to improve placental perfusion, especially during maternal hypotension - Notifying the health care provider (Option 4) (Option 5) Nitrazine pH tests are used to detect leaking amniotic fluid, most often if premature (prelabor) rupture of membranes is suspected. This client is at term and in active labor.

The nurse is delegating client care tasks to a licensed practical nurse (LPN) and unlicensed assistive personnel. Which of the following assignments are most appropriate to assign to the LPN? Select all that apply: 1. Administer a client's daily dose of subcutaneous insulin glargine 2. Administer a scheduled oral analgesic to a 2 days postoperative client 3. Complete an admission nursing interview for a client admitted for elective hysterectomy 4. Reinforce teaching on self-administration of insulin to a client with diabetes mellitus 5. Tally the shift's intake and outputs for the entire unit

1, 2, 4 The LPN can monitor and care for stable clients who have been initially evaluated by a registered nurse (RN). Interventions LPNs may perform include: - Administering oral and parenteral medications, but excluding administering IV medications, which vary by state legislation (Options 1 and 2) - Reinforcing teaching and skills that have been initially taught by the RN (Option 4) - Focused assessments (eg, bowel sounds) after the RN's initial assessment (Option 3) Performing admission or initial assessments is outside the scope of the LPN and UAP. The RN must perform initial assessments in order to analyze the findings and formulate the client's plan of care before delegating tasks. (Option 5) The LPN is capable of performing routine care (eg, calculating daily intake and output, toileting). However, the UAP may also perform these tasks, which frees the LPN to perform more complex duties. Therefore, the most appropriate staff member to assign the task of calculating intake and output to is the UAP.

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply: 1. Administers 100% oxygen prior to suctioning the client 2. Applies suction while withdrawing the catheter from the airway 3. Instills sterile normal saline into tracheostomy prior to suctioning 4. Limits suctioning to 20 seconds during each suction pass 5. Uses sterile gloves and technique throughout the procedure

1, 2, 5 Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET suctioning to reduce the risk of complications (ex. pneumonia, hypoxemia) or tracheal injury (ex. trauma, bleeding), the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique, and limits each suction pass to ≤10 seconds (Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways. (Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%).

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? Select all that apply: 1. Change in lacrimation on the affected side 2. Electric shock-like pain in the lips and gums 3. Flattening of the nasolabial fold 4. Inability to smile symmetrically 5. Severe pain along the cheekbone

1, 3, 4 Bell palsy is peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (cranial nerve VII) in the absence of a stroke or other causative agent/disease. Paralysis of the motor fibers innervating the facial muscles results in flaccidity on the affected side. Manifestations of Bell palsy include: - Inability to completely close the eye on the affected side - Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option 1) - Flattening of the nasolabial fold on the side of the paralysis (Option 3) - Inability to smile or frown symmetrically (Option 4) - Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue. (Options 2 and 5) Electric shock-like pain in the lips and gums and severe pain along the cheekbone are symptoms of trigeminal neuralgia (cranial nerve V). With Bell palsy, the trigeminal nerve may become hypersensitive and cause facial pain, but this is uncommon and typically more indicative of trigeminal neuralgia.

The registered nurse (RN) is discussing care of shared clients with the licensed practical nurse. Which of the following clients require intervention by the RN? Select all that apply: 1. A client receiving a blood transfusion who reports severe anxiety and has blood pressure 90/60 mm Hg and pulse 110/min 2. A client receiving oral metoprolol whose heart rate has decreased to 60/min after administration 3. A client whose blood pressure decreased from 130/80 mm Hg to 110/70 mm Hg following administration of 1 mg hydromorphone IV 4. A client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered 5. A client whose pulse increased from 70/min to 100/min after albuterol administration

1, 4 Clients receiving blood products are at risk for acute transfusion reactions (eg, hemolytic reaction), which may be life-threatening without prompt recognition and intervention. Clients with symptoms of a blood transfusion reaction (eg, anxiety, hypotension, tachycardia) require immediate assessment (Option 1). Nifedipine is a calcium channel blocker often used to treat hypertension. Administration of nifedipine is contraindicated in clients whose blood pressure is already low (ie, systolic <90 mm Hg), as this may cause potentially life-threatening hypotension. Therefore, the nurse should promptly assess the client with a blood pressure 90/65 mm Hg who received nifedipine for hemodynamic stability (Option 4).

The nurse is assigned to care for clients with assistance from unlicensed assistive personnel (UAP). Which of the following tasks are appropriate for the nurse to assign to UAP? Select all that apply: 1. Emptying a urinary drainage bag and recording the output volume 2. Emptying and verifying the potency of an accordion drain 3. Escorting a disgruntled family member off the unit 4. Providing perineal care around an indwelling urinary catheter 5. Reapplying bilateral sequential compression devices

1, 4, 5 Obtaining a clean-catch urine specimen, emptying a urinary drainage bag, providing perineal care around an indwelling urinary catheter, and reapplying sequential compression devices are all routine tasks that can be safely performed by UAP (Options 1, 4, and 5). (Option 2) UAP can measure, empty, and document the output of a drain, but the registered nurse is responsible for assessing proper drain function and the type, amount, color, and odor of drainage. (Option 3) With a disgruntled family member, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by a security officer.

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediateintervention by the nurse? 1. Client reports chest pain that is worse with deep inspiration 2. Distant heart tones and jugular venous distention 3. ECG showing ST-segment elevations in all leads 4. Pericardial friction rub auscultated at the left sternal border

2 Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). Increased pericardial fluid places pressure on the heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-threatening without immediate intervention. When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest. (Option 1) In acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep breathing or when positioned supine. The client should be placed in the Fowler position with a support (eg, bedside table) to lean on for comfort. (Option 3) ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in only localized leads (depending on which vessel is occluded). (Option 4) Pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium rubbing together to create a characteristic high-pitched, leathery, and grating sound.

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first? 1. Administer 0.25 mg hydromorphone IV push for pain 2. Draw blood for complete blood count and electrolyte levels 3. Initiate IV access and infused normal saline 4. Obtain urine specimen for urinalysis

2 Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3). (Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO status in case of emergency surgery. However, circulation takes priority over pain medication. (Options 2 and 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining laboratory specimens.

The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am I going to die?" Which statement by the nurse is appropriate? 1. "I know how anxious you must be. Watching some television might help you relax." 2. "Tell me more about your thoughts and feelings regarding the situation." 3. "The biopsy results show that you have cancer, but many cancers are treatable." 4. "Waiting for test results can be stressful. I am sorry I cannot tell you anymore."

2 Clients with life-limiting diagnoses often experience anxiety, frustration, and the phases of grief. The nurse must assess the client's knowledge and feelings regarding the illness. Use of therapeutic communication (eg, active listening, reflection, focusing) allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the client cope with difficult information (Option 2). (Option 1) Indicating knowledge of the client's feelings and changing the subject weaken the nurse-client relationship by making the nurse seem uncomfortable with the situation, minimizing the client's feelings, and disregarding client concerns. (Option 3) The HCP should be involved in informing the client about the biopsy results. It is best that both the HCP and nurse be present to address all questions and concerns the client may have. (Option 4) An automatic response is a nontherapeutic communication technique that deflects the client's feelings, thereby weakening the nurse-client relationship. The nurse should encourage the client to share their thoughts.

The charge nurse is assisting with a nonemergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene? 1. Administers a one-time dose of IV midazolam 2. Disengages the "sync" function on the defibrillator 3. Places defibrillator pads on upper right and lower left chest 4. Turns off the client's oxygen and moves it away from the bed

2 Synchronized cardioversion is a procedure used to convert tachyarrhythmias (eg, supraventricular tachycardia, ventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The shock in cardioversion is timed by the defibrillator ("sync" feature enabled) to be delivered only during the R wave of the QRS complex, when the ventricles depolarize. Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, causes R-on-T phenomenon, which frequently results in lethal arrhythmias (eg, ventricular fibrillation). The nurse must ensure that the defibrillator's "sync" feature is enabled when preparing to perform synchronized cardioversion. Disabling or failing to enable the "sync" feature may result in a potentially lethal, asynchronous shock being delivered to the client (Option 2). (Option 1) During nonemergent cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. (Option 3) Defibrillator pads should be placed on the right upper chest next to the sternum and on the left lower chest. (Option 4) Prior to delivery of electrical shock (eg, cardioversion, defibrillation), oxygen should be turned off and moved away. Oxygen is flammable and may explode when subjected to electric currents.

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply: 1. Bradycardia 2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation

2, 3, 4, 5 Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac strain due to congested blood flow in the pulmonary arteries. Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: - Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2) - Dyspnea and hypoxemia (Options 3 and 4) - Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option 5) - Tachycardia - Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis (Option 1) Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular cardiac output. (Option 6) Tracheal deviation is a sign of tension pneumothorax (not PE), which occurs when pressure on the side of the collapsed lung pushes organs toward the unaffected lung.

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? Select all that apply: 1. Blue, cyanotic toes 2. Calf pain 3. Dry, shiny, hairless skin 4. Lower leg warmth and redness 5. Unilateral leg edema

2, 4, 5 Although clients with a DVT may have no symptoms, typical clinical manifestations include unilateral edema, localized pain (eg, calf pain) or tenderness to touch, warmth, erythema, and occasionally low-grade fever (Options 2, 4, and 5). Recognition of a potential DVT is critical because the thrombus can dislodge from the vessel and cause life-threatening pulmonary embolism. (Option 1) Blue, cyanotic toes is an indicator of impaired arterial blood perfusion to the extremity, which may occur with acute arterial occlusion (eg, arterial embolism) or severely reduced blood flow (eg, vasopressor-induced vasoconstriction, atherosclerosis). (Option 3) Dry, shiny, hairless skin are common clinical manifestations of chronic peripheral arterial disease. These characteristic skin alterations occur from long-term impairment of blood flow to the extremity.

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up? 1. Edema of the scalp crossing the suture lines 2. Flat, bluish, discolored area on the buttocks 3. Small tuft of hair at the base of the spine 4. White, waxy substance in the axillae and labial folds

3 Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially allows spinal cord contents to protrude through the opening. The mildest formis spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss) of varying severity. Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of the spine. The nurse should notify the health care provider because further assessment and surgical repair may be required (Option 3). (Option 1) Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to prolonged pressure of the presenting part against the cervix during labor, resolves in a few days. (Option 2) Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal melanocytosis (ie, Mongolian spots). (Option 4) Vernix caseosa, a protective substance covering the fetus, is secreted by the sebaceous glands. This white, cheesy/waxy substance is most likely seen in the axillary and genital areas of term newborns.

The telemetry nurse is reviewing the cardiac monitors of 4 clients. Which cardiac rhythm is the priority for intervention by the nurse? 1. Atrial fibrillation 2. Premature Ventricular Contractionss 3. Ventricular Fibrillation 4. Ventricular tachycardia

3 Ventricular fibrillation (VF) is a lethal arrhythmia characterized by disorganized electrical activity in the heart ventricles. Because of this erratic electrical activity, the heart's muscles lose the ability to contract, resulting in loss of blood flow and pulse (eg, cardiac arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation (Option 3). (Option 1) Atrial fibrillation is a cardiac arrhythmia characterized by disorganized electrical activity in the atria and an irregular pulse rate. Clients may experience this condition chronically or in response to other medical conditions (eg, electrolyte imbalance). However, a client with VF has no pulse and is the priority for care. (Option 2) Premature ventricular contractions are abnormal electrical impulses in the ventricles that may occur spontaneously or in response to heart irritants (eg, stimulant medications, electrolyte alterations, pain). This arrhythmia is typically not harmful but requires monitoring by the nurse. (Option 4) Ventricular tachycardia, a potentially lethal dysrhythmia characterized by organized, rapid firing of electrical activity within the ventricles, may impair perfusion and often leads to cardiac arrest and/or VF. However, clients may have a pulse with ventricular tachycardia, making the client with VF and no pulse the priority.

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply: 1. Applies sterile gloves before performing client care 2. Ensures surgical masks are worn by staff in client's room 3. Requests that the client be assigned to a single-client room 4. Uses alcohol-based sanitizers for hand hygiene 5. Wears a single-use, disposable gown during client care

3, 5 Contact precautions Organisms: - MDR organisms (eg, MRSA, VRE) - Enteric organisms (eg, Clostridium difficile) - Scabies Infection-control measures: -Hand hygiene (soap & water for C difficile) - Nonsterile gloves - Gown - Private room preferred - Use dedicated medical equipment that always stays in the patient's room (Option 1) Clean, rather than sterile, gloves are required during care of a client with C difficile to prevent transmission of infection to other individuals. (Option 2) Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound care). (Option 4) When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore-forming bacteria (eg, C difficile, anthrax).

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. 1. Bruising easily, especially on the arms 2. Fatigue 3. Feeling depressed 4. Muscle cramps in the legs

4 Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia (Option 4). Additional causes of hypokalemia include gastrointestinal losses (eg, vomiting, diarrhea, nasogastric suctioning) and medications (eg, insulin). To combat hypokalemia in clients receiving potassium-wasting diuretics, supplemental potassium and/or a high-potassium diet may be required. (Option 1) Bruising is common with the use of antiplatelet agents (eg, aspirin, clopidogrel). However, the nurse should monitor for and report signs of uncontrolled bleeding, such as bloody stools and signs of stroke (eg, headache, slurred speech). (Option 2) Myocardial infarction and heart failure often cause activity intolerance and fatigue due to decreases in heart muscle function. In addition, fatigue is a common side effect experienced on initiation of beta blocker (eg, metoprolol) therapy, but typically improves over time. (Option 3) Feelings of depression are common after an acute health-related event such as a myocardial infarction. The nurse should further explore and evaluate feelings of depression; however, these symptoms are not immediately life-threatening unless the client exhibits suicidal ideation.

A pt with DKA is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse be expected to implement? 1. Check serum BUN and creatinine levels every hour 2. Discontinue insulin infusion where blood glucose is <350 mg/dL 3. Increase insulin infusion rate when blood glucose level decreases 4. Initiate potassium IV when serum potassium is 3.5-5.0 mEq/L

4 Hypokalemia often occurs with the resolution of acidosis and administration of insulin so potassium is given even if pt is normokalemic to prevent hypokalemia and subsequent life-threatening arrhythmias. - If blood glucose levels are <250 mg/dL D5W is administered to prevent hypoglycemia until ketoacidosis is reversed - IV insulin infusion may be discontinued with resolution of acidosis and ketosis which generally occurs with blood glucose level of <200 mg/dL - Management includes fluid resuscitation, IV insulin and hourly blood glucose monitoring

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis. Which nursing action is the priority? 1. Ensuring that the drainage collection bag is below the level of the abdomen 2. Placing the client in the semi-Fowler position 3. Recording the characteristics of the output dialysate 4. Using sterile technique when spiking and attaching the bag of dialysate

4 In peritoneal dialysis (PD), the abdominal lining (peritoneum) is used as a semipermeable membrane to dialyze clients with decreased kidney function. A catheter is placed in the peritoneal cavity for infusing and draining dialysate (dialysis fluid). Dialysate is infused and dwells in the abdomen, which allows waste products and electrolytes to cross the peritoneum into the dialysate for removal. After the prescribed dwell time, the dialysate, electrolytes, and wastes are drained via gravity. When administering PD, it is essential to use sterile technique when spiking and attaching bags of dialysate to the client's PD catheter to prevent contamination and infection (Option 4). Bacterial peritonitis, an infection of the peritoneum, is a potential complication of PD that may lead to sepsis. Signs of peritonitis should be reported to the health care provider. (Options 1 and 2) Proper positioning of the catheter drainage bag (ie, below the abdomen) and the client (eg, Fowler or semi-Fowler position) promotes effluent outflow but is not a priority over infection prevention. (Option 3) Cloudy effluent may indicate infection, whereas bloody or brown effluent may indicate bowel perforation. Documenting effluent characteristics is important but not a priority over maintaining asepsis.