prepu combo

pursed liped breathing

Breathe in normally through your nose for 2 counts (while counting to yourself, one, two)." • "Relax your neck and shoulder muscles." • "Pucker your lips as if you were going to whistle." • "Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four)."

trichomonias men

Burning after urination or ejaculation Itching of urethra Slight discharge from urethra

Ankle edema seldom follow

CABG surgery and may indicate right-sided heart failure.

hospice care

Care is provided in the home, independent of physician is wrong the doctor still has input in hospice care

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question?

Change the second I.V. solution to dextrose 5% in water.

nasal surgery nasal packing

Checking the nares for ulcerations is not necessary.

dic sign

Chest pain and shortness of breath if blood clots form in the blood vessels in your lungs and heart.

cause for oral cancer

Chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless tobacco are other significant risk factors

STRESS TEST

Clients need to abstain from eating and drinking for only 4 hours before the test.

Botulism is a rare but serious illness caused by

Clostridium botulinum bacteria.

Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?

Continue the lithium and reassure the client that these temporary side effects will subside.

autoimmune disorders Other common laboratory findings in these clients include

Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins.

meds for crohns disease

Corticosteroids, such as prednisone, reduce the signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation.

A high-fiber diet and milk and milk products are contraindicated in clients wit

Crohn's disease because they may promote diarrhea.

Hypertension is a symptom of

Cushing's disease, and muscle mass is decreased.

Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of

Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline.

Amenorrhea develops in

Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

hyperadrenocorticism

Cushing's syndrome: a glandular disorder caused by excessive cortisol.

Hirsutism, not hair loss, is common in

Cushing's syndrome; therefore, with successful treatment, abnormal hair growth declines.

Osteoporosis occurs in

Cushing's syndrome; therefore, with successful treatment, bone mineralization increases.

Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's:

Decreased cellular demand for oxygen.

ANTITUSSIVES Prototype: Dextromethorphan

Diphenhydramine (Benadryl) Benzonatate (Tessalon) Opioid Antitussives Codeine Hydrocodone

trichomonas in women

Discomfort with intercourse Itching of the inner thighs Vaginal discharge (thin, greenish-yellow, frothy or foamy) Vaginal itching Vulvar itching or swelling of the labia Vaginal odor (foul or strong smell)

side effects of clonidine are

Dry mouth, impotence, and sleep disturbances are possible adverse effects.

The presence of a U-wave may or may not be apparent on a normal

ECG; it represents repolarization of the Purkinje fibers.

The following measures are required for Droplet Precautions

Employees and visitors must wear a surgical mask to enter the room.

pancreatitis risk factor

Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis.

pvd and exercise

Exercise - exercise may improve arterial blood flow to the affected limb. so you need it Exercise is not recommended for people with severe rest pain, venous ulcers, or gangrene.

born at 39 weeks' gestation or later signs

Extensive rugae on the scrotum and coarse, silky scalp hair are typical findings

Bethanechol (Urecholine), a cholinergic drug, may be used in

GERD to increase lower esophageal sphincter pressure and facilitate gastric emptying.

Propantheline bromide is classified as a

GI anticholinergic; the medication inhibits muscarinic actions of acetylcholine at postganglionic parasympathetic neuroeffector sites.

heprin injection

Gentle pressure should be applied after the injection, but the area must not be massaged.

normal findings in tpn

Glycosuria is to be expected during the first few days of therapy until the pancreas adjusts by secreting more insulin.

Quantification of T-lymphocytes is used to monitor the effectiveness of treatment for

HIV.

. A family or personal history of breast cancer or a history of estrogen-dependent dysplasia is an absolute contraindication for

HRT hormone replacement therapy

Polycythemia vera early sign

Headache and dizziness are early symptoms from engorged veins

dic sign

Headaches, speech changes, paralysis (an inability to move), dizziness, and trouble speaking and understanding if blood clots form in the blood vessels in your brain. These signs and symptoms may indicate a stroke.

emergent phase of burn

Hemoconcentration, not hemodilution, is caused by circulatory dehydration as plasma shifts into the extracellular space.

Toilet-training is commonly more difficult for children who have undergone surgery for

Hirschsprung's disease than it is for other children.

folliculitis treatment

Hot, moist compresses may promote drainage of the affected follicles.

The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated. Correct Answer: C

How should the nurse handle linens that are soiled with incontinent feces? A. Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B. Place an isolation hamper in the client's room and discard the linens in it. C. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

burns sodium levels are

Hyponatremia because sodium is trapped in edematous fluid.

emergent phase of burn has what type of sodium

Hyponatremia is another anticipated electrolyte imbalance because sodium is trapped in edematous

After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the

I.V. extension set and restart the infusion.

Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development o

IVH.

chlorothiazide (Diuril). The expected outcome of this drug is:

Improved capillary circulation.

Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D). Correct Answer: B

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area.

In evaluating care, the nurse should first determine if the expected outcomes of the plan of care were achieved (A). As indicated, the nurse may then review the initial nursing actions and the rationales for those actions (B), document successful completion of the care plan goals (C), and revise the plan of care (D). Correct Answer: A

In evaluating client care, which action should the nurse take first? A. Determine if the expected outcomes of care were achieved. B. Review the rationales used as the basis of nursing actions. C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care.

The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D). Correct Answer: C

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Request hospice care for the client. B. Report the client's acuity level to the nursing supervisor. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent.

Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?

Incorporate physical exercise as tolerated into the daily routine.

During the arteriogram, the client reports having nausea, tingling, and dyspnea

Inform the physician, symptoms suggest an allergic reaction. Treatment may involve administering oxygen and epinephrine.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Institute isolation precautions.

men gonorrhea

Irregular menstrual bleeding. Lower abdominal (belly) pain. Fever and general tiredness. Swollen and painful glands at the opening of the vagina (Bartholin glands). Painful sexual intercourse. Sore throat (rare). Pinkeye (conjunctivitis) (rare).

theophylline

It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive.

difficult case of scabies use

Ivermectin is a pill that may be used.

Hyperpigmented lesions are indicators of

Kaposi's sarcoma.

Other AIDS-defining illnesses include

Kaposi's sarcoma; cytomegalovirus of the liver, spleen, or lymph nodes; and Pneumocystis carinii pneumonia.

A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should

Keeping the involved extremity at or below the body's horizontal plane will facilitate tissue perfusion and prevent tissue damage.

The signs and symptoms of diabetic ketoacidosis include

Kussmaul respirations, fruity breath, tachycardia, abdominal pain, nausea, vomiting, headache, thirst, dry skin, and dehydration

genital herpes

Lesions may appear 2 to 12 days after exposure

BRONCHODILATORS BETA2-ADRENERGIC AGONISTS (Inhaled Short-Acting Agents) Prototype: Albuterol (Proventil, Ventolin, Accuneb)

Levalbuterol (Xopenex, Xopenex HFA) Oral Beta2-Adrenergic Agonists Albuterol (generic) tablets or syrup Albuterol (VoSpire ER) Terbutaline (Brethine) (Inhaled beta2 agents are preferred)

macular degeneration for

Loss of central vision

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?

Lubricant jelly

no evidence of distant metastasis is classified as

M0

rifampin (Rifadin) side effects

Maintaining follow-up monitoring of liver enzymes. • Avoiding alcohol intake. • The urine may have an orange color.

gavage feeding steps

Measure the tube distance from the nose to the earlobe, then from the earlobe to midway between the lower tip of the sternum and the belly button. Mark the tube with the piece of tape or a permanent marker.

Imperforate anus signs are

Meconium

oliguric phase

Metabolic acidosis develops because the kidneys cannot excrete hydrogen ions, and bicarbonate is used to buffer the hydrogen. Hypertension may develop as a result of fluid retention. Hyperkalemia develops as the kidneys lose the ability to excrete potassium.

emergent burn phase has what type of acid base?

Metabolic acidosis,commonly develops due to loss of bicarbonate ions.

no abnormal regional lymph nodes

N0,

Normal oral feedings are resumed as soon as the

NG tube is removed, usually within 10 days after surgery.

Mouth care should be provided after

NG tube removal. Auscultating and palpating the abdomen should have been done before tube removal.

Clients with acute necrotizing pancreatitis should remain

NPO with early enteral feeding via the jejunum to maintain bowel integrity and immune function.

Clients with acute necrotizing pancreatitis should remain \

NPO with early enteral feeding via the jejunum to maintain bowel integrity and immune function. TPN is considered if enteral feedings are contraindicated. \

Loop diuretics act on the

Na+-K+-2Cl- symporter (cotransporter) in the thick ascending limb of the loop of Henle to inhibit sodium and chloride reabsorption.

patient with breathing problems what should nurse tell uap to do

Obtaining vital signs. • Applying antiembolic stockings. • Keeping the client oriented.

Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. Correct Answer: B

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate.

osteoarthritis

Opioid analgesics are not used for osteoarthritic pain control. Acetaminophen and selected nonsteroidal anti-inflammatory drugs may be used to achieve pain relief.

FIRST-GENERATION H1 ANTAGONISTS Antihistamines Prototype: Diphenhydramine (Benadryl

Other First-Generation Antihistamines Brompheniramine Chlorpheniramine (Chlor-Trimeton) Dexchlorpheniramine Clemastine (Tavist) Promethazine (Phenergan) Hydroxyzine (Vistaril)

CYCLOOXYGENASE INHIBITORS First Generation—Nonaspirin NSAIDs Prototype: Ibuprofen (Advil, Motrin

Other NSAIDs Fenoprofen (Nalfon) Flurbiprofen (Ansaid) Ketoprofen Naproxen (Aleve, Anaprox, Naprelan, Naprosyn) Oxaprozin (Daypro) Diclofenac (Voltaren, Cataflam)—risk of liver failure

mechanical ventilation problems

Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

A client with primary pulmonary hypertension is being evaluated for a heart-lung transplant. The nurse asks the client what treatments he's currently receiving for his disease. He's likely to mention which treatments? Select all that apply

Oxygen • Diuretics • Vasodilators

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Oxygen saturation of 90%

Inflammation, evidenced by

PAIN , swelling, and redness, is one of the early signs of infection and needs prompt intervention.

PNEUMOVAX 23 is a vaccine indicated for active immunization for the ...

PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons

This vasoconstriction may increase pain in the areas where

PVD is the greatest.

dic sign

Pain, redness, warmth, and swelling in the lower leg if blood clots form in the deep veins of your leg.

men gonorrhea

Painful or frequent urination or urethritis. Anal itching, discomfort, bleeding, or discharge. Sore throat (rare). Pinkeye (conjunctivitis) (rare).

women gonorrhea

Painful or frequent urination. Anal itching, discomfort, bleeding, or discharge. Abnormal vaginal discharge. Abnormal vaginal bleeding during or after sex or between periods. Genital itching.

signs of glomerulonephritis

Periorbital edema,hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting, hypertension ,oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain.

Lubricant jelly is a water-soluble agent that the nurse can apply safely during oxygen therapy to alleviate dryness of the nares.

Petroleum jelly is combustible; it isn't safe to use with oxygen. The nurse shouldn't use sterile water or antibiotic ointment to alleviate dryness in the nares.

extra secretion during sex

Place a thin piece of gauze over the tracheostom

The following measures are required for Droplet Precautions ·

Place the patient in a private room. No special ventilation is required.

drugs that cause hyperglycemia

Prednisone, Lithium may cause transient hyperglycemia,

straight catheter

Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate.

The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment (A) and guides the planning and implementation (C) of care, such as the decision to monitor the client frequently. (D) provides the nurse with information about the effectiveness of the plan of care. Correct Answer: B

Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? A. Assessment. B. Analysis. C. Implementation. D. Evaluation.

CYCLOOXYGENASE INHIBITOR Second-Generation NSAID (COX-2 Inhibitor)

Prototype: Celecoxib (Celebrex)

Polycythemia vera late sign

Pruritus is a late symptom that results from abnormal histamine metabolism

In the oliguric phase of acute renal failure, the nurse should assess the client for:

Pulmonary edema

Right ventricle Pulmonary artery Arterioles and alveoli

Pulmonary vein Left atrium

Procainamide may cause an increased QRS complexes and

QT intervals

RECOMBIVAX HB is a sterile suspension for intramuscular injection. ...

RECOMBIVAX HB Hepatitis B Vaccine

To help control pain during coughing for a client who has had a pulmonary lobectomy, the nurse should:

Raise the bed to semi-Fowler's position and position the client's hands so that the incision is supported anteriorly and posteriorly

Foods that sometimes need to be limited, in order to make it easier to manage your colostomy, include

Raw vegetables Skins and peels of fruit (fruit flesh is OK) Dairy products Very high fiber food such as wheat bran cereals and breads Beans, peas, and lentils Corn and popcorn Brown and wild rice Nuts and seeds Cakes, pies, cookies, and other sweets High fat and fried food such as fried chicken, sausage, and other fatty meats

Vasospasm lasting several minutes is characteristic of

Raynaud's disease.

A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?

Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.

Which of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago?

Restlessness and shortness of breath.

expectorants

Robitussin Mucinex Guaifenesin (generic for Mucinex)

heart Injury results from prolonged ischemia and is reflected by

ST-segment elevation.

Poor peripheral perfusion would cause subnormal

SaO2

With a diagnosis of right rib fracture and closed pneumothorax, the client should be placed in:

Semi- to high-Fowler's position, tilted toward the right side.

Polycythemia vera early sign

Shortness of breath is an early symptom from congested mucous membranes and ineffective gas exchange.

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

Sigmoidoscopy

Anal excoriation is inevitable with profuse diarrhea, and meticulous perianal hygiene is essential.

Sitz baths are comforting and cleansing

gonnorrhea

Some women have no symptoms or vaginal itching and a thick, purulent vaginal discharge.

...

Stopping smoking. • Wearing a face covering and gloves in the winter.

No evidence of primary tumor

T0

According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C). Correct Answer: D

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience.

A 20-pound box is safely lifted by bending the knees (D), holding the box close to the center of gravity, and extending the legs using the quadriceps muscles. (A and B) might be helpful, but the charge nurse should use this opportunity to reinforce proper body mechanics techniques. Pushing the box against the wall (C) does not assist with lifting. Correct Answer: D

The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. Ask another staff member for assistance. B. Request that supplies are delivered in smaller containers. C. Push the box against the wall to provide support while lifting. D. Bend at the knees when lifting heavy objects.

larngetctomy and bath

The client is able to take tub baths with careful instruction on ways to avoid slipping, the need to make sure the water is no more than 6 inches deep, and other safety measures.

o Permanent hypothyroidism is the major complication of RAI 131I treatment. o

The client needs to be educated about the need for lifelong thyroid hormone replacement and watch for signs of hypothyrodism

colostomy care 4 wks post op

The client should be encouraged to discuss any concerns about his sexuality

Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). Depression is a component of normal grieving, and (A) does not represent susceptible adaptation to the developmental crisis of an older adult, Integrity vs despair. (C and D) are judgmental and not therapeutic. Correct Answer: B

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? A. She is almost sure to be less able to adapt than before. B. It's highly likely that she will recover and return to her pre-illness state. C. If you can interest her in something besides religion, it will help her stay well. D. Cultural strains contribute to each woman's tendencies for recurrences of depression.

Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit. Correct Answer: D

The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance.

Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.). Correct Answer: C

The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

creams for scabies

The most commonly used cream is permethrin 5%. Other creams include benzyl benzoate, sulfur in petrolatum, and crotamiton. Lindane is rarely used because of its side effects.

(D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D). Correct Answer: D

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? A. Administer a PRN antihypertensive prescription. B. Provide the client with an additional blanket. C. Encourage additional fluid intake. D. Turn the client q2h.

If resistance is encountered during the initial insertion of an enema tube, the client should be instructed to relax while a small amount of solution runs through the tube into the rectum (D) to promote dilation. (A) is unlikely to resolve the problem. (B) may cause injury. (C) should not be implemented until other, less invasive actions, such as (D) have been taken. Correct Answer: D

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? A. Withdraw the tube and apply additional lubricant to the tube. B. Encourage the client to bear down and continue to insert the tube. C. Remove the tube and check the client for a fecal impaction. D. Ask the client to relax and run a small amount of fluid into the rectum.

The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage, and/or seek out help to maintain health, and is best exemplified in the client belief or understanding about diet and health maintenance (D). (A) indicates noncompliance with an action to be done in the management of diabetes. (B) represents inattentiveness. (C) reflects knowledge deficit. Correct Answer: D

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs or symptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health.

If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion. Correct Answer: B

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A. Check for a blood return. B. Reposition the client's arm. C. Remove the IV site dressing. D. Flush the lock with saline.

Active, rather than passive, ROM is best to restore strength and (B) is an effective schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not performed beyond the point of resistance or pain (D) because of the risk of damage to underlying structures. Correct Answer: B

The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A. Passive ROM exercises to all joints on all extremities four times a day. B. Active ROM exercises to both arms and legs two or three times a day. C. Active ROM exercises with weights twice a day with 20 repetitions each. D. Passive ROM exercises to the point of resistance and slightly beyond.

The nurse should document the client's complaints (A) as subjective data--symptoms only the client can describe. (B) should be documented as objective data, which is collected via the nurse's observation. (C and D) are documented as intervention results. Correct Answer: A

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? A. Complains of inability to empty bladder. B. Temperature of 99.8° F and pulse of 108. C. Post-voided residual volume of 750 ml. D. Specimen collection for culture and sensitivity.

Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure. Correct Answer: B

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? A. Temperature increases from 98.8° to 99.0° F. B. Pulse rate decreases from 78 to 52 beats/min. C. Respiratory rate increases from 16 to 24 breaths/min. D. Blood pressure increases from 110/84 to 118/88 mm/Hg.

Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegtables and fruits. Correct Answer: D

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? A. Fiber. B. Folate. C. Ascorbic acid. D. Vitamin B12.

The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. Correct Answer: A, B, D, F

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Pre-medicate the client with an analgesic. B. Inform the client of the plan for moving to the chair. C. Obtain and place a portable commode by the bed. D. Ask the client to push the IV pole to the chair. E. Clamp the indwelling catheter. F. Assess the client's blood pressure.

A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precise, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size. Correct Answer: B

The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? A. Portable syringe pump. B. Cassette infusion pump. C. Volumetric controller. D. Nonvolumetric controller.

To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. Correct Answer: B

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution.

Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. Correct Answer: D

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel.

Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration (C). Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty (A) or impaired gas exchange (B). Although (D) may be related to an ineffective cough, the client's coughing is an effective response when solids or liquids are taken orally. Correct Answer: C

The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse include in this client's plan of care? A. Ineffective breathing pattern. B. Impaired gas exchange. C. Risk for aspiration. D. Ineffective airway clearance.

The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth--this may be at the family's request (A). (B, C, and D) may be indicated, but first the nurse should confer with the healthcare provider to obtain all needed information. Correct Answer: A

The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? A. Healthcare provider. B. Client's family. C. Case manager. D. Chief of staff.

Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. Correct Answer: C

The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A. Stage 1 pressure sore draining sero-sanguineous drainage. B. Pressure sore at bony prominence with exudate noted. C. One-inch pressure sore draining serous fluid. D. Pressure sore on heel with a small amount of purulent drainage.

blood transfusion signs are

The nurse should assess for signs of impending shock such as diaphoresis. The client would have hypotension, dysuria, and cool skin.

revascularization procedure for arteriosclerosis

The nurse should avoid placing the affected extremity on a hard surface, such as a firm mattress, to avoid pressure ulcers.

Experiences with the same type of pain that has successfully been relieved makes it easier for a client to interpret the pain sensation, and as a result, the client is better prepared to take steps to relieve the pain (D). (A, B, and C) are having new experiences with pain. Correct Answer: D

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A. A 10-year-old who was burned by a camp fire earlier today. B. A 70-year-old who has a postoperative infection from a surgery one week ago. C. A 23-year-old woman who sprained her knee while bicycling. D. A 55-year-old woman who has had moderate low back pain for three months.

The nurse should first slow the IV flow rate to keep vein open (KVO) rate (B) to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started (A) and the appearance of the IV insertion site (C) before contacting the healthcare provider (D) for further instructions. Correct Answer: B

The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? A. Determine when the IV solution was started. B. Slow the IV infusion to keep vein open rate. C. Assess the IV insertion site for swelling. D. Report the finding to the healthcare provider.

pulse wave

The progressive increase of pressure radiating through the arteries that occurs with each contraction of the left ventricle of the heart.

The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit environment with one family member present. What is the primary rationale for these nursing interventions?

To minimize oxygen consumption

A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization or intensity, so pain assessment should focus on any interference with daily activities (D), sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors illicit specific assessment findings, whereas (A, B, and C) are limiting, closed-end questions, and can be answered with a yes, no, or a number. Correct Answer: D

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A. Can you describe where your pain is the most severe? B. What is your pain intensity on a scale of 1 to 10? C. Is your pain best described as aching, throbbing, or sharp? D. Which activities during a routine day are impacted by your pain?

folliculitis treatment

Treatment may include antibiotics applied to the skin (mupirocin) or taken by mouth (dicloxacillin), or antifungal medications to control the infection.

The nurse instructs the unliscensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?

Use a soft toothbrush to brush the client's teeth after each meal.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing.

An adult client has bacterial conjunctivitis. What should the nurse teach him to do? Select all that apply

Use warm saline soaks four times per day to remove crusting. • Apply topical antibiotic without touching the tip of the tube to his eye. • Wash his hands after touching his eyes. • Avoid touching his eyes.

treatment for peripheral vascular disease Promoting

Vasodilation (increasing the diameter of blood vessels) - Vasodilation can be achieved by providing warmth and preventing long periods of exposure to cold. Never apply direct heat to the limb, such as with the use of a heating pad or extremely hot water to reduce the risk of burns

nsaids

Voltaren Gel and Flector Patch Diclofenac Plus Misoprostol (Arthrotec) Diflunisal (Dolobid) Etodolac Indomethacin (Indocin) Ketorolac (Toradol), available IM or IV Mefenamic acid (Ponstel) Meclofenamate Meloxicam (Mobic) Nabumetone Piroxicam (Feldene) Sulindac (Clinoril) Tolmetin (Tolectin

what to do with scabies

Wash underwear, towels, and sleepwear in hot water. Vacuum the carpets and upholstered furniture.

Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates culturally sensitive care. (B, C, and D) do not demonstrate cultural awareness. Correct Answer: A

What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs.

A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the client closer to the nurse when being turned. Correct Answer: A

What action is most important for the nurse to implement when placing a client in the Sim's position? A. Raise the bed to a waist-high working level. B. Elevate the head of the bed 45 degrees. C. Place a pillow behind the client's back. D. Bring the client to one edge of the bed.

The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. Correct Answer: B

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A. Maintain in a lateral position using protective wrist and vest devices. B. Position prone with a small pillow below the diaphragm. C. Raise the head and knee gatch when lying in a supine position. D. Transfer into a wheelchair close to the nurse's station for observation.

Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D). Correct Answer: B

What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field.

In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may occur when client outcomes are achieved, evaluation is best determined by attainment of measurable client outcomes. Correct Answer: D

What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes.

Bathing often makes a client feel weak, and if a client is already feeling weak (B), assistance is required during the bathing process to ensure the client's safety. (A and C) do not pose safety issues. Although (D) may pose a safety issue, further assessment is needed to determine if this in fact poses a safety issue for the client. Correct Answer: B

What client statement indicates to the nurse that the client requires assistance with bathing? A. I wasn't able to pack a bag before I left for the hospital. B. I don't understand why I'm so weak and tired. C. I only bathe every other day. D. I left my eyeglasses at home.

The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D). Correct Answer: A

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A. Check capillary refill of toes on lower extremity with Unna's paste boot. B. Apply dressing to wound area before applying the Unna's paste boot. C. Wrap the leg from the knee down towards the foot. D. Remove the Unna's paste boot q8h to assess wound healing.

C (The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care (C). (A, B, and D) do not support the basis for using the nursing process. Correct Answer: C)

What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals.

Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume (C). Jugular vein distention (A) is a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid volume deficit. Changes in the client's skin integrity are not evident (D). Correct Answer: C

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A. Confirm the finding by further assessing the client for jugular vein distention. B. Offer the client high protein snacks between regularly scheduled mealtimes. C. Continue the planned nursing interventions to restore the client's fluid volume. D. Change the plan of care to include a nursing diagnosis of impaired skin integrity.

Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed. Correct Answer: B

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame.

The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange (B) implies that the client is having trouble with breathing, which has the highest priority of the nursing diagnoses listed. Though an immobilized client presents a multitude of nursing care challenges, (A, C, and D) do not have the priority of (B). Correct Answer: B

When caring for an immobile client, what nursing diagnosis has the highest priority? A. Risk for fluid volume deficit. B. Impaired gas exchange. C. Risk for impaired skin integrity. D. Altered tissue perfusion.

A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics. Correct Answer: D

When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle.

Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication (A), then flush the lumen with saline again. (B and C) are not necessary. The aspirated blood can be flushed back through the closed system into the client's bloodstream, but does not need to be withdrawn (D). Correct Answer: A

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? A. Flush the lumen with the saline solution and administer the medication through the lumen. B. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. D. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

Adequate visualization or palpation of the perineum (A) is essential to ensure correct placement of the catheter. (B) is not necessary to perform self-catheterization. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag (C), and uses a straight catheter without a balloon (D). Correct Answer: A

When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? A. Locate the perineum. B. Transfer to a commode. C. Attach the catheter to a drainage bag. D. Manipulate a syringe to inflate the balloon.

(C) is an open-ended question that encourages the client to discuss personal feelings. (A) devalues the client and hinders further communication. Acting defensively and asking why questions such as (B) are likely to elicit more anger and block communication. By deferring to the client advocate (D), the nurse fails to even address the client's feelings of anger and exasperation. Correct Answer: C

When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A. There is no reason to be so angry. B. Why do I need to leave your room? C. What is concerning you this morning? D. Let me call the client advocate for you.

Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate (A)before ambulation to determine tolerance for activity. (B, C, and D) are also important, but are of lower priority than (A). Correct Answer: A

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating.

Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. Correct Answer: D

Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in reducing the risk of urosepsis. Correct Answer: D

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A. Ensure that the client's perineal area is cleansed twice a day. B. Maintain accurate documentation of the fluid intake and output. C. Encourage frequent ambulation if allowed or regular turning if on bedrest. D. Obtain a prescription for removal of the catheter as soon as possible.

The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time. Correct Answer: A

Which statement best describes durable power of attorney for health care? A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. B. The healthcare decisions made by another person designated by the client are not legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.

An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. (C) is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or more of these elements. Correct Answer: C

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. The nurse will provide client instruction for daily foot care. B. The client will demonstrate proper trimming toenail technique. C. Upon discharge, the client will list three ways to protect the feet from injury. D. After instruction, the nurse will ensure the client understands foot care rationale.

The first part of the nursing diagnosis statement is the diagnostic label and is followed by related to the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's response, which the nurse can provide support, reflection, and dialogue. Correct Answer: D

Which statement is an example of a correctly written nursing diagnosis statement? A. Altered tissue perfusion related to congestive heart failure. B. Altered urinary elimination related to urinary tract infection. C. Risk for impaired tissue integrity related to client's refusal to turn. D. Ineffective coping related to response to positive biopsy test results.

The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems. Correct Answer: C

Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model.

Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications (B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the presence of other family members is not harmful to the client's well-being, (D) is not correct. Correct Answer: A

While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs? A. Speak initially with the oldest family member to show respect. B. Realize that Southeast Asians may not take Western medications. C. Ask the husband to step out during the mother's pelvic examination. D. Tell the family that planning health care is provided in private with the client.

During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C). Correct Answer: D

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down.

When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. (C) should then be implemented to reduce the risk of aspiration. After that, (B and D) can be implemented as indicated. Correct Answer: A

While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? A. Discontinue the administration of the bolus feeding. B. Auscultate the client's breath sounds bilaterally. C. Elevate the head of the bed to a high Fowler's position. D. Administer a PRN dose of a prescribed antiemetic.

Push 2 cc of air quickly into the stomach while listening over the infant's stomach with a stethoscope.

You should hear a "whooshing" sound as the air enters the stomach (see illustration). You should also be able to withdraw the air you pushed in.

acute respiratory distress syndrome is

a non cardiac pulmonary edema

Before amniocentesis, what is done

a routine ultrasound

Four-point gait:

a slow gait pattern in which one crutch is advanced forward and placed on the floor, followed by advancement of the opposite leg; then the remaining crutch is advanced forward followed by the opposite remaining leg; requires the use of two assistive devices (crutches or canes); provides maximum stability with three points of support while one limb is moving.

Vitamin B12, also called cobalamin, is

a water-soluble vitamin with a key role in the normal functioning of the brain and nervous system, and for the formation of blood.

In a strangulated hernia, the hernia cannot be reduced back into the

abdominal cavity.

peritonitis or perforated bowel

abdominal rigidity, a cardinal sign of peritonitis and perforated bowel

Because the client has a peritoneal catheter in place, blood-tinged drainage should not occur. Persistent blood-tinged drainage could indicate damage to the

abdominal vessels, and the physician should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys.

Polycythemia vera is a bone marrow disease that leads to an

abnormal increase in the number of blood cells (primarily red blood cells).

Unless the pouch leaks, the client can wear her ileostomy pouch for

about 4 to 7 days.

Acute angle-closure glaucoma produces

abrupt changes in the angle of the iris.

with terminal ilieum resection surgery vitamin B12 tablet cannot be

absorbed regardless of the amount of oral intake of sources of vitamin B12, such as animal protein or vitamin B12 tablets.

Clients with cirrhosis should not take

acetaminophen (Tylenol), which is potentially hepatotoxic.

The nurse should monitor anesthesia/pain levels every 30 minutes during

active labor to ascertain that this client is comfortable during the labor process and particularly during active labor when pain often accelerates for the client.

Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with

active tuberculosis.

Isolation for 2 to 4 weeks is warranted for a client with

active tuberculosis.

Signs of hip prosthesis dislocation include:

acute groin pain in the affected hip,

The intestinal lumen and the blood supply to the intestine are obstructed, causing an

acute intestinal obstruction. Without immediate intervention, necrosis and gangrene may develop

Hypovolemic shock from fluid shifts is a major factor in

acute pancreatitis

High-carbohydrate foods meet the body's caloric needs during

acute renal failure

Serevent twice daily, it should not be used in

additional doses before exercise; twice daily is the maximum dosage.

Methylxanthine agents inhibit rather than stimulate

adenosine receptors

Swing-to gait: both crutches are

advanced forward together; weight is shifted onto hands for support and both legs are then swung forward to meet the crutches; requires the use of two crutches or a walker; indicated for individuals with limited use of both lower extremities and trunk instability.

Postural drainage may be helpful for respiratory hygiene but will not

affect the nature of secretions.

cytoscopy normal findings

after pink tinged urine

Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal

age-related changes to skin.

Increased urine output is the best indication that the

albumin is having the desired effect.

milk is

alkaline

burns Metabolic acidosis, not

alkalosis, commonly develops due to loss of bicarbonate ions.

It is not necessary to keep the stoma covered at

all times, although a gauze bib can be used to protect the clothes from mucus and to keep irritants from entering the stoma.

intradermally injection Slow diffusion is necessary during diagnostic

allergy testing because rapidly introducing an allergen could cause a life-threatening allergic reaction in a sensitive client.

Elevating the legs above the heart or wearing antiembolism stockings is a strategy for

alleviating venous congestion and may worsen peripheral arterial disease.

More severe strains may cause spasms

along with more intense pain and possible swelling.

Regular exercise for those with claudication helps open up

alternative small vessels (collateral flow) and the limitation in walking often improves.

Acute bone pain and confusion are associated with

aluminum intoxication, another potential complication of dialysis.

In severe cases oligohydramnios may be treated with

amnioinfusion during labor to prevent umbilical cord compression.

An amplitude decrease would support the nurse's suspicion because fluid surrounding the heart, such as in cardiac tamponade, suppresses the

amplitude of the QRS complexes on an ECG.

pulsus pardaxous

an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg.

Clubbing describes an increased

angle between the nail plate and nail base.

The posterior tibial pulse is on the medial surface of the

ankle just behind the medial malleolus.

Allograft tissue, taken from

another person, takes longer to incorporate into the recpient'sr body, but there is no second surgical site to heal. Also, the surgical time and hospital stay may be shorter when allograft tissue is used.

Leads V1 and V2 record electrical events on th

anterior surface of the right ventricle and the anterior surface of the left ventricle.

Leads V1 and V2 record electrical events on the

anterior surface of the right ventricle and the anterior surface of the left ventricle.

A client with COPD typically has a barrel chest in which the

anteroposterior diameter is larger than the transverse chest diameter

treatment of chorioamnionitis

antibiotics (amoxicillin + gentamicin + metronidazole) for the mother, and quickly delivering the baby

Amantadine and diphenhydramine enhance the effects of

anticholinergic agents.

Propantheline is an

anticholinergic, antispasmodic medication that decreases vagal stimulation and pancreatic secretions

Frank hematuria indicates excessive

anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin.

Sulfisoxazole and other sulfonamides are chemically related to oral

antidiabetic agents and may precipitate hypoglycemia.

amphotericin B, an

antifungal agent,

Vitamin E is a powerful

antioxidant that helps to prevent oxidation of the cell membrane.

For gallbladder disease, propantheline has an

antispasmodic effect on the bile duct and gallbladder. Although the medication reduces the production of gastric solutions as well as hypermotility, these aren't the main reasons for the medication.

Other indicators of hypothyroidism are the presence of

antithyroid antibodies and elevation of the creatine phosphokinase (CPK-MM) level.

Dextromethorphan is the most widely used

antitussive in the United States because it produces few adverse reactions while effectively suppressing a cough.

Amantadine, an

antiviral agent

The S2 results from closing of the

aortic and pulmonic valves.

A diastolic, blowing, decrescendo murmur accompanies

aortic insufficiency.

A systolic, harsh, crescendo-decrescendo murmur occurs with

aortic stenosis.

Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with

appendicitis.

subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should:

apply suction continuously — not every hour.

One goal of care for a client with PVD is to decrease anxiety, so as to decrease or prevent vasoconstriction of the:

arteries

as

asa

Normal serum albumin is administered to reduce

ascites

Hypoalbuminemia, a mechanism underlying

ascites formation, results in decreased colloid osmotic pressure.

Broccoli and brussels sprouts are good sources of

ascorbic acid (vitamin C).

Reusing a suction catheter is not consistent with

aseptic technique.

Lozenges will increase saliva production, increasing the client's risk of

aspiration.

Although steroids should be given during surgery to prevent hypocortisolism, the nurse should

assess the client for it.

Indications for Serevent include only

asthma and bronchospasm induced by chronic obstructive pulmonary disease.

Clients who take only one daily dose of ranitidine are usually advised to take it

at bedtime to inhibit nocturnal secretion of acid.

Thickening of the intima and media of the artery is characteristic of

atherosclerosis.

For the client with an ET tube, the most important nursing action is

auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery.

The most common causes of primary adrenocortical insufficiency are

autoimmune destruction (70%) and tuberculosis (20%).

addison process is believed to be

autoimmune in nature.

PKU is an

autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid, phenylalanine, to tyrosine.

pvd Although heat promotes vasodilation, use of a heating pad is to be

avoided to reduce the risk of thermal injury secondary to diminished sensation.

Pelvic rocking helps to relieve

backache during pregnancy and early labor by making the spine more flexible.

It typically results from

bacteria ascending into the uterus from the vagina and is associated with prolonged labor.

When a building's hot water plumbing has water at this temperature, the

bacteria thrive; then they may be transmitted via inhalation from air conditioning, showers, spas, and whirlpools.

When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for

balloon inflation and continuous inflow and outflow of irrigation solution.

A small waxy nodule with pearly borders may indicate a

basal cell carcinoma.

digixin A nurse usually takes a serum sample immediately

before administering the daily maintenance dose, about 24 hours after the previous dose.

check for lice

behind the ear

A nurse should question the order for morphine sulfate because it is believed to cause

biliary spasm. Thus, the preferred opioid analgesic to treat cholecystitis is meperidine (Demerol).

Hyperbilirubinemia refers to an increase in

bilirubin in the blood and is not associated with IVH.

Adult lice usually

bite the scalp behind the ears and along the back of the neck.

A bleeding ulcer produces

black, tarry stools.

There is no need for the client to stay on a

bland diet after a laparoscopic cholecystectomy. The client should, however, avoid excessive fats.

Common examples of vesicles include

blisters and the lesions caused by chickenpox and herpes simplex

Most institutions use tubing especially for platelets instead of tubing for

blood and blood product

Color Doppler imaging ultrasonography identifie

blood flow through the umbilical cord.

The thyroid gland doesn't regulate

blood glucose levels; therefore, signs and symptoms of hypoglycemia aren't relevant for this client. Dehydration is seen in diabetes insipidus.

subdural hematoma is a collection of

blood on the surface of the brain.

To determine pulsus paradoxus, the nurse should measure

blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Unless the client has cardiac tamponade, the two measurements are usually less than 10 points apart.

The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering

blood products that aid clotting. These products include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors.

Hypokinesia refers to decreased

bodily movement

Allograft tissue transplants are not rejected by the

body as with organ transplants, so that it is not necessary to use drugs to suppress

Vitamin D and calcium are necessary for

bone healing

arsenic exposure After the acute phase

bone marrow depression, encephalopathy, and sensory neuropathy occur.

Raloxifene hydrochloride (Evista), an estrogen receptor modulator, increases

bone mineral density without stimulating the endometrium.

Steroid use causes calcium to leave

bone, suppressing parathyroid hormone.

Three-point gait

both crutches and involved leg are advanced together, then uninvolved leg is advanced forward; indicated for use with involvement of one extremity , e.g. lower extremity fracture.

treat botulism You will get

botulinus antitoxin.

Abdominal discomfort secondary to constipation will be relieved after the client has a

bowel movement; an opioid would contribute to the constipation.

Removing the sheath after cardiac catheterization may cause a vasovagal response, including

bradycardia. The nurse should have atropine on hand to increase the client's heart rate if this occurs

Parasympathetic hyperactivity leading to sudden hypotension secondary to

bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope.

Foods high in potassium include

bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.

Gavage (guh-vahj) feeding is a way to provide

breastmilk or formula directly to your baby's stomach. A tube placed through your baby's nose (called a Nasogastric or NG tube) carries breast milk/formula to the stomach.

legionnaires' disease recieved from

breathing in bacteria from aerosols or ac or water

Drainage during the first 6 to 12 hours contains some

bright red blood, but large amounts of blood or excessive bloody drainage should be reported to the physician promptly.

Blood-tinged secretions are common for several hours after

bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.

Bile is created in the liver, stored in the gallbladder, and released into the duodenum giving stool its

brown color. A bile duct obstruction can cause pale colored stools.

About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally

brown, which indicates digested blood

resp acidosis is

build up of acid which can cause heart problems and shock

A common finding of IVH intraventricular hemorrhaging is

bulging fontanel.

Clients with stress incontinence are encouraged to avoid substances, such a

caffeine and alcohol, that are bladder irritants.

PARATHYROID GLAND produce parathyroid hormone, which controls

calcium, phosphorus, and vitamin D levels within the blood and bone.

A SINGLE episode of urinary tract infection is not as likely to lead to

calculi formation as a routinely low fluid intake.

The increase in venous pressure results in an increase in

capillary hydrostatic pressure, which causes a net filtration of fluid out of the capillaries into the interstitial space, resulting in edema.

In metabolic alkalosis, the body tries to compensate by conserving

carbon dioxide, so there is no need to have the client inhale carbon dioxide, as would be the case if hyperventilation were occurring.

The peak incidence of cervical cancer is

carcinoma in situ is 20 to 30 years of age in African-American and Caucasian women.

Adverse effects of pseudoephedrine (Sudafed) are experienced primarily in the

cardiovascular system and through sympathetic effects on the central nervous system (CNS).

Salivary fistula or skin necrosis usually precedes

carotid artery rupture

To compensate for the patient's profoundly diminished plasma volume,

catecholamines increase cardiac output and myocardial contractility. But these effects won't be strong enough to keep his blood pressure up.

mechanical ventilation

cause decreased cardiac output

Decreased RBC production diminishes

cellular oxygen, leading to fatigue and weakness.

The client who cannot assign meaning to sound has

central hearing loss.

Access is also needed for TPN, preferably via a \

central line.

Clonidine (Catapres) is a

central-acting adrenergic antagonist.

Intermittent, painless vaginal bleeding is a classic symptom of

cervical cancer, but given the client's history, bleeding in more likely a result of the radiation.

Human papillomavirus can lead to

cervical cancer.

syphyllis 1st stage

chancres are: On the vulva (outside the vagina) or on the cervix (neck of the womb) in women. On the penis in men. Around the anus and mouth (both sexes).

Ventricular remodeling (or cardiac remodeling)[1] refers to the

changes in size, shape, structure and physiology of the heart after injury to the myocardium mi

note with htn question also

check compliance its leading cause of complications

epidural for L & D, To provide the safest care for this client the nurse should

check if she can walk not dangling she has epidural so see if legs can move

By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without

chest pain. Severe chest pain should not be present on day 2 after and MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program

Hemothorax is a collection of blood in the space between the

chest wall and the lung (the pleural cavity).

Amantadine, digoxin, and diphenhydramine can interact with a

cholinergic blocking agent but not through delayed absorption.

Diaphoresis and increased salivation are not present in

cholinergic crises.

question said someone had hemicolectomy and was having issues with eating what is needed tpn or jejunostomy

choose tpn because its parenteral versus jejunostomy which is enteral not as much nutrients

Additional oral cancer risk factors include

chronic irritation such as a broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis.

burns Hemoconcentration, not hemodilution, is caused by

circulatory dehydration as plasma shifts into the extracellular space.

buerger disease Signs and symptoms include slowly developing

claudication, cyanosis, coldness, and pain at rest.

autograft It is important to keep donor site

clean, dry, and free of pressure.

The radiated skin area needs to be kept

clean, dry, and open to air.

Rehabilitation efforts are implemented as soon as the

client's condition is stabilized.

a fib Because of the poor emptying of blood from the atrial chambers, there is an increased risk for .

clot formation around the valves.

To prevent a photosensitivity reaction, the client should avoid direct sunlight during

co-trimoxazole therapy

heat stroke Cool liquids are easier to drink than

cold liquids.

Vasospastic disorder (Raynaud's disease) is a form of intermittent arteriolar vasoconstriction that results in

coldness, pain, and pallor of the fingertips, toes, or tip of the nose, and a rebound circulation with redness and pain.

The most common cancers that elevate CEA are in the

colon and rectum. Others: cancer of the pancreas, stomach, breast, lung, and certain types of thyroid and ovarian cancer.

Colorectal polyps are common with

colon cancer.

CEA may be elevated in

colorectal cancer but isn't considered a confirming test

An abdominal CT scan is used to stage the presence of

colorectal cancer.

Weight loss — not gain — is an indication of

colorectal cancer.

Stool Hematest detects blood, which is a sign of

colorectal cancer; however, the test doesn't confirm the diagnosis.

gonorrhea The client should avoid sexual intercourse until treatment is

completed, and a follow-up culture confirms that the infection has been eradicated (which usually takes 4 to 7 days).

Curling's ulcer is an acute peptic ulcer of the duodenum resulting as a \

complication from severe burns when reduced plasma volume leads to sloughing of the gastric mucosa

The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation

complications and the audible crackles that may result from fluid overload from the I.V. line

Early emphasis on rehabilitation is important to decrease

complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence

bronchopulmonary dysplasia typically occurs in

compromised very-low-birth-weight neonates who require oxygen therapy and assisted ventilation for treatment of respiratory distress syndrome.

Polyhydramnios is a medical

condition describing an excess of amniotic fluid in the amniotic sac.

Dyshidrotic eczema is a

condition in which small, usually itchy blisters develop on the hands and feet

Contact dermatitis is a

condition in which the skin becomes red, sore, or inflamed after direct contact with a substance.

Dialysis equilibrium syndrome causes

confusion, a decreasing level of consciousness, headache, and seizures.

Arteriovenous malformation or AVM is an abnormal

connection between veins and arteries, usually congenital, congenital malformed blood vessels in the ventricles

Accompanying symptoms of prostate cancer can includ

constipation, weight loss, and lymphadenopathy.

Caring for client infected with vancomycin-resistant enterococci requires

contact precautions.

Bile is not clear and is not green unless it comes in

contact with gastric fluid.

Placing a thin piece of gauze over the tracheostomy during sexual activity will help to

contain the secretions and yet allow ventilation.

The recommended procedure for teaching clients postoperatively to deep breathe includes

contracting (pulling in) the abdominal muscles and taking a slow, deep breath through the nose. This breath is held 3 to 5 seconds, which facilitates alveolar ventilation by improving the inspiratory phase of ventilation.

New laryngectomy clients may find air-conditioning too

cool and dry at first so they should avoid such environments

The recommended emergency treatment for a heat burn is immersion in

cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue.

Droplet transmission occurs when the person

coughs or sneezes and releases large respiratory droplets into the air. these droplets are heavy and fall to surfaces rapidly, usually falling within 3 feet of the patient.

pvd Elevating the extremities

counteracts the forces of gravity and promotes venous return and reduces venous stasis.so its bad

80 year old SPINAL anesthesia and 4,000 ml of room temperature isotonic bladder irrigation it is important to

cover this client with warm blankets because he is at high risk for hypothermia secondary to age, spinal anesthesia,

risk for colorectal cancer

crohns and ulcerative

The client with conjunctivitis can use warm soaks to remove

crusting

Pink-tinged urine and bladder spasms are common after

cystoscopy.

Bloody diarrhea is indicative of

cytomegalovirus infection

Biliary drainage tubes (T tubes) are placed in the common bile duct and drain bile, which is

dark yellow-orange

An alteration in the protective pressure sensation results from a

decline in the number of Meissner's and pacinian corpuscles.

Steroids are used in severe flare-ups because they can

decrease the incidence of bleeding

Hemodilution

decreased concentration (as after hemorrhage) of cells and solids in the blood resulting from gain of fluid

ivh signs are

decreased hematocrit, and increasing hypoxia. Seizures also may occur

A client who is free from infection will most likely have

decreased oxygen requirements versus normal temperature

COPD have CO2 retention and the respiratory drive is stimulated when the PO2

decreases so if have alarming labs like p02 of 70 pco2 of 66 check vitals because you cant give to much oxygen it will stop breathing

Pain in the calf is common with a diagnosis of

deep vein thrombosis.

Oligohydramnios is a condition in pregnancy characterized by a

deficiency of amniotic fluid.

Diabetes insipidus is caused by a

deficiency of antidiuretic hormone, which results in excretion of a large volume of dilute urine, urine specific gravity of less than 1.005 should be reported.

Uterine atony, or relaxed uterus, may occur after

delivery, leading to postpartum hemorrhage.

TIS, N0, M0

denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

Repositioning the client every 2 hours helps prevent secretions from pooling in

dependent lung areas.

For the first few weeks after CABG surgery, clients commonly experience

depression, fatigue, incisional chest discomfort, dyspnea, and anorexia.

Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the

detection of two-thirds of all colorectal cancers.

A prolonged QT interval is significant because it can lead to the

development of polymorphic ventricular tachycardia, also known as torsades de pointes.

Increasing glycosuria is a symptom of poorly managed

diabetes.

The CEA blood test is not reliable for

diagnosing cancer or as a screening test for early detection of cancer

HSV infection is one of a group of disorders that, when diagnosed in the presence of HIV infection, are considered to be

diagnostic for AIDS

An upper GI series, or barium study, usually isn't the

diagnostic method of choice, especially in a client with acute active bleeding who's vomiting and unstable

Trimethoprim-sulfamethoxazole is most likely to cause

diarrhea. Nausea and vomiting are other common adverse effects.

Mitral stenosis causes a

diastolic, rumbling, low-pitched murmur audible at the apex

dic As blood collects in the peritoneal cavity, it causes

dilation and distention, which is reflected in increased abdominal girth. The client would be tachycardic and hypotensive. Petechiae reflect bleeding in the skin.

During the intermediate phase of burn care, the client's hematocrit should

diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues

In emphysema, the anteroposterior diameter of the chest wall is increased. As a result, the client's breath sounds may be

diminished.

a fib The clots become

dislodged and travel through the circulatory system. As a result, cerebrovascular accident is a common complication

The nurse should wrap the client's arms and legs from the

distal to proximal ends and use strict sterile technique throughout the dressing change.

Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience

diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis.

balanced suspension traction The client should be positioned so that the feet

do not press against the footboard. Therefore, elevating the head of the bed no more than 25 degrees is recommended to keep the client from moving down in the bed.

Catheterization isn't routine

done in the 4th stage of deliver to protect the bladder from trauma. It's done, for a postpartum complication of urinary retention.

Constipation lasting 3 days or longer is unusual in this client and warrants immediate action. However, because the client had chemotherapy with

doxorubicin (Adriamycin) 10 days ago, she is susceptible to infection and should avoid rectal medications and treatments

The burn should be kept moist to prevent the

dressing adhering to the wound. Warm, mild soap solutions would be contraindicated because they are irritating to the injured tissue.

nasal surgery, the client has packing in the nose Mouth-breathing

dries the oral mucous membranes. Frequent mouth care is necessary for comfort and to combat the anorexia associated with the taste of blood and loss of the sense of smell.

Immediately after laparoscopic cholecystectomy surgery, the client will

drink liquids. A light diet can be resumed the day after surgery.

legionnaires' disease signs are

dry cough, myalgia, gi issues , diarrhea pneumonia and heart problems

A cholinergic blocking agent may cause

dry mouth and delay the sublingual absorption of nitroglycerin

stomatitits Lemon-glycerin swabs should be avoided because they are

drying and also can promote bacterial growth.

trach tube surgery after A nasogastric (NG) tube is usually inserted

during surgery to allow for enteral feedings postoperatively.

Insufficient secretion of GH causes

dwarfism or growth delay.

complication of deep vein thrombosis is pulmonary embolism

dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis),

The risk of developing chorioamnionitis increases with

each vaginal examination including during labor

Oropharyngeal candidiasis, or thrush, is the most common infection associated with the

early symptomatic stages of HIV infection.

An increased serum albumin level and increase

ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites.

The client taking dexamethasone needs to know the early signs of Cushing's disease, which include

easy bruising, moonface, buffalo hump, and osteoporosis.

hiatal hernina To minimize intra-abdominal pressure and decrease gastric reflux, the client should

eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver).

Wrapping elastic bandages on dependent areas limits

edema formation and bleeding and promotes graft acceptance.

Karaya and Stomahesive are both

effective agents for protecting the skin around a colostomy. They keep the skin healthy and prevent skin irritation from stoma drainage.

radiation care Clients should use an

electric razor, instead of a straight-edge razor, on any skin areas that are receiving radiation.

Leads V3 and V4 record

electrical events in the septal region of the left ventricle.

Leads II, III, and aVF record

electrical events on the inferior surface of the left ventricle.

Bullae are

elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister.

Cysts, such as sebaceous cysts, are

elevated, thick-walled lesions containing fluid or semisolid matter

A complication of balloon valvuloplasty is

emboli resulting in a stroke.

Pain from a kidney stone is considered an

emergency situation and requires analgesic intervention.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

empyema.

A woman with a uterus who takes unopposed estrogen has an increased risk of

endometrial cancer. The addition of progesterone prevents the formation of endometrial hyperplasia.

necrotizing pancreatitis TPN is considered if

enteral feedings are contraindicated. .

Applying pressure against the nose at the inner canthus of the closed eye after administering eyedrops prevents the medication from

entering the lacrimal (tear) duct. If the medication enters the tear duct, it can enter the nose and pharynx, where it may be absorbed and cause toxic symptoms

Anxiety stimulates the sympathetic nervous system, which results in the secretion of

epinephrine, angiotensin, and serum proteins that cause vasoconstriction in the arteries of the peripheral circulatory system. As a result, peripheral vascular resistance is increased.

Because aerobic exercise may increase blood pressure and increased blood pressure can cause

epistaxis, the client with hypertension should avoid it.

The nurse requests an order from the physician to change the dose to an

equianalgesic dose of morphine

Metoclopramide hydrochloride (Reglan) increases

esophageal sphincter tone and facilitates gastric emptying; both actions reduce the incidence of reflux.

Acetone in the urine would indicate

excessive fat catabolism

pku testing the infant before that time

excessive vomiting, or poor intake can yield false-negative results.

Serevent can be used to prevent

exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking

It may be done before or after

exercise.

Squamous cell carcinoma commonly develops on the skin of the

face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas.

Pneumothorax will cause a client to feel extremely short of breath. Semi- or high- Fowler's position will

facilitate ventilation by the unaffected lung. Positioning the client toward the affected side does not compromise the remaining, functional lung.

Clients with autoimmune disorders may have either

false-positive or false-negative serologic tests for syphilis.

pku The infant does not need t

fast 4 hours before the test.

Platelets should be administered as

fast as can be tolerated by the client to avoid aggregation.

Ketosis happens when your body resorts to

fat for energy after your stored carbohydrates have been burned out

In the early stages of cirrhosis, there is no need to restrict

fat, protein, or sodium

Because the client is anesthetized, the client may not

feel the urge to push so bearing-down efforts during the second stage of labor may be less effective.

Herpes simplex may be passed to the

fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature birth.

An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to

fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed.

The taking in phase is the

first period after delivery emphasis on reviewing and reliving the L & D process, concern with self and needing to be mothered.

Gloves are most contaminated, so she should remove them

first when exiting the room to prevent infection transmission.

A prolonged PR-interval is associated with

first-degree atrioventricular block.

Herpes genitalis

flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina

herpes

flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina,vaginal itching and a thick, purulent vaginal discharge.

Warm compresses could also increase

fluid accumulation

Dyspnea and cyanosis are associated

fluid excess, not CRF.

As the emergent period ends and capillary permeability returns to normal, the

fluid in the interstitial compartment will return to the intravascular compartment.

Fine crackles are present when there is

fluid in the lungs

The client is in the taking hold phase

focus on the neonate and learning about and fulfilling infant care and needs

Inflammation of a hair follicle is called

folliculitis

there were 2 question about best position for someone with aspiration risk one was unconscious one was conscious

for the conscious client you can sit them up for the unconscious they need to be turned to the side

Inspiratory and expiratory stridor is a low-pitched crowing sound heard in a client who has a

foreign body obstructing the trachea or mainstem bronchi.

Increased atrial contraction or systemic hypertension can result in a

fourth heart sound.

Cholelithiasis is the medical term for

gallstone disease.

Reglan does not decrease

gastric acid secretion, as do histamine-receptor blockers.

common complication of steroid therapy is

gastric irritation and peptic ulcers.

Oral steroids can cause

gastric irritation and ulcers and should be administered with meals, if possible, or otherwise with an antacid.

Metoclopramide (Reglan), which is prescribed to treat

gastroesophageal reflux disease, acts by stimulating gastric motility and reducing the volume of gastric reflux.

The most common toxicities from NSAIDs are

gastrointestinal disorders (nausea, epigastric pain, ulcers, bleeding, diarrhea, and constipation).

Sulfasalazine can cause

gastrointestinal distress and is best taken after meals and in equally divided doses.

Early clinical manifestations of cirrhosis are subtle and usually include

gastrointestinal symptoms, such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are caused by the liver's altered ability to metabolize carbohydrates, proteins, and fats

botulism Patients who have trouble swallowing may

getintravenous fluids. A feeding tube may be inserted.

Primary Addison's disease refers to a problem in the

gland itself that results from idiopathic atrophy of the glands.

The gag reflex is governed by the

glossopharyngeal nerve, one of the cranial nerves.

Adults and children with gonorrhea may develop

gonococcal conjunctivitis by touching the eyes with contaminated hands

The nurse should wear a

gown, gloves, a mask, and eye protection when entering the client's room.

development of ARDS are

gram-negative septic shock and gastric content aspiration. shock cause permabiity so then there is leakage

Because such lice are tiny (1 to 2 mm) with

grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions.

On digital rectal examination, key signs of prostate cancer are a

hard prostate, induration of the prostate, and an irregular, hard nodule.

Tracheal breath sounds are

harsh, discontinuous sounds heard over the trachea during inhalation or exhalation.

hyptonic labor are

have contraction but there is no effacement of cervix or decent of the baby

dumping syndrome diet

having a diet high in protein and fat and low in carbohydrates,

However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's

head flat; typically, the client with such a hematoma is older and has a less expandable brain

Lying flat and drinking fluids are interventions for client's experiencing

headaches from spinal anesthesia.

Adverse effects of danazol (Danocrine) include

headaches, dizziness, irritability, and decreased libido. Masculinization effects, such as deepened voice, facial hair, and weight gain, also may occur.

Raloxifene adverse effects is increased

headaches.

The tube allows the suture line to

heal adequately, minimizes contamination of the pharyngeal and esophageal suture lines, and prevents fluid from leaking through the wound into the trachea before healing occurs.

The temporal lobe controls

hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain)

dvt The extremity should be kept elevated with

heat applied to treat the inflammation and pain

pad To avoid burns,

heating pads should not be used by anyone with impaired circulation

Removal of the drainage fluids assists in wound healing and is intended to decrease the incidence of

hematoma, abscess formation, and infections

Protamine sulfate is an antidote to

heparin

Hypokalemia is a precipitating factor in

hepatic encephalopathy.

Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be

hepatotoxic

stomatitis Commercial mouthwash is contraindicated because of

high alcohol content that is irritating to inflamed mucosa.

Reserpine is used to treat

high blood pressure by lowering so there is risk it could drop too much

Warm shock characterized by

high cardiac output and low peripheral vascular resistance occurs first.

For clients who have cirrhosis without complications, a

high-calorie, high-carbohydrate diet is preferred to provide an adequate supply of nutrients.

colostomy care 4 wks post op The client will not need to maintain a

high-carbohydrate or high-protein diet. Rather, the client will be encouraged to maintain a normal diet while avoiding any foods that cause odor and flatulence.

Clients with diverticulosis are encouraged to follow a

high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber.

The murmur in aortic insufficiency is

high-pitched and blowing and is heard at the third or fourth intercostal space at the left sternal border.

The client with sensorineural hearing loss has difficulty hearing

high-pitched sounds.

Pinching of the tubing used to deliver oxygen causes a

high-pitched whistling sound. .

Mitral insufficiency has a

high-pitched, blowing murmur at the apex.

A nurse who suspects an air embolism should place the client on

his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system.

warm shock Vasodilation from the effects of

histamine, bradykinins, serotonin, and endorphins dramatically decrease total peripheral vascular resistance

Spontaneously occurring wheals occur in.

hives.

Beau's line is a

horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth.

multiple sclerosis who has an impaired peripheral sensation should avoid

hot because they cant feel well and cold because of it constrictive behavior

ABO compatibility is not a necessary requirement for plasma , but

human leukocyte antigen (HLA) matching of lymphocytes may be completed to avoid development of anti-HLA antibodies when multiple platelet transfusions are necessary.

Ranitidine blocks secretion of

hydrochloric acid.

. Forcing large quantities of fluid may cause

hydronephrosis if urine is prevented from flowing past calculi.

Weakness, tingling, and cardiac arrhythmias suggest

hyperkalemia, which is associated with renal failure.

di has

hypernatremia and siadah has hyponatremia

Bending, lifting, and the Valsalva maneuver can precipitate

hypertensive crises They increase transabdominal pressure and may cause cardiac-stimulating effects

The client with pheochromocytoma should be instructed to avoid activities that precipitate

hypertensive crises or paroxysms, such as The Valsalva maneuver.

The TPN solution is usually

hypertonic dextrose solution.

Pyloric stenosis involves

hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration.

Fat necrosis occurring with acute pancreatitis can cause

hypocalcemia requiring calcium replacement

Fat necrosis occurring with acute pancreatitis can cause \

hypocalcemia requiring calcium replacement.

nephrotic syndrome has what type of calcium

hypocalcemia.

Cool, clammy skin occurs in the .

hypodynamic or cold phase (later phase). of septic shock

When taken in combination with aspirin, glipizide commonly causes

hypoglycemia

With a client in metabolic alkalosis, the nurse should monitor for

hypokalemia

Muscle spasms are not seen in

hypokalemia.

With a client in metabolic alkalosis, the nurse should monitor for

hypokalemia.

Thyroidectomy may lead to

hypoparathyroidism if the parathyroid is also removed during surgery.

The chordee is corrected when the

hypospadias is repaired. Circumcision is performed at the same time.

The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as

hypospadias.

The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe

hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued.

The chief complications of diltiazem are

hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels. Other reported reactions include flushing, nocturia, and polyuria, but not renal failure.

The result of this shift is

hypovolemic shock and edema formation.

Restlessness is an early indicator of

hypoxi

T-wave inversion, ST-segment elevation, and a pathologic Q-wave are all signs of tissue

hypoxia which occur during an MI

tb is airborne spread so

if its in the air you can only getting from coughing sneezing not from plates plates is not air

Water-soluble jelly is not recommended for lubricating a gavage-feeding catheter becaus

if the catheter is inadvertently inserted into the lungs, the jelly could damage the lung tissue or cause pneumonia

Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the

ileum, where it is absorbed into the bloodstream.

Tremors associated with Parkinson's disease are not psychogenic but are related to an

imbalance between dopamine and acetylcholine

When a chest tube becomes disconnected, the nurse should take

immediate steps to prevent air from entering the chest cavity, which may cause the lung to collapse. when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified.

If a central venous catheter becomes disconnected, the nurse should

immediately apply a catheter clamp.

The recommended emergency treatment for a heat burn is

immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue.

autograft donar site A pressure dressing is not needed over the donor site and ca

impair healing.

sensorineural loos

impaired cochlea or 8th cranial nerve failure of sound impulses in inner ear or brain

C. trachomatis infection

in women they can bee asymptomatic, but symptoms are yellowish discharge and painful urination.

Ischemia results from

inadequate blood supply to the myocardial tissue and is reflected by T-wave inversion.

metoclopramide Other common adverse effects

include diarrhea (not constipation) and nausea. Occasionally transient hypertension.

copd Measures that help mobilize secretions

include drinking 2 L of fluid daily, practicing controlled pursed-lip breathing, and engaging in moderate activity.

Valves often becom

incompetent with PVD.

The fluid shift, which occurs between the intravascular and interstitial extracellular compartments, is caused b

increased capillary permeability that allows water, sodium, and protein to shift to the tissues.

In PVD, decreased blood flow can result in

increased venous pressure.

When calcium levels are too low, the body responds by

increasing production of parathyroid hormone

Q-waves may become evident when the injury progresses to

infarction.

Second intention healing occurs in

infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings

A boggy, tender prostate is found with

infection (e.g., acute or chronic prostatitis).

legionnaires' disease

infection caused by gram neg BACTERIA

Abdominal distention is an early sign of

infection hirshsprung and therefore the parents need to report it to the physician.

A fungus that enters the skin surface and causes

infection is a dermatophyte.

Chorioamnionitis is a serious intrapartum

infection that may result in fetal tachycardia and a hypotonic labor pattern.

The major risk factor for cervical cancer is

infection with the human papillomavirus (HPV) that is transmitted sexually.

Chorioamnionitis the infected amniotic fluid in the fetal lungs may result in a

infection, such as pneumonia, during the neonatal period.

Airborne precautions prevent transmission of infectious agents that remain

infectious over long distances when suspended in the air (e.g. mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV).

Leads II, III, and aVF record electrical events on the

inferior surface of the left ventricle

Buerger's disease is characterized by

inflammation and fibrosis of arteries, veins, and nerves. White blood cells infiltrate the area and become fibrotic, which results in occlusion of the vessels.

Chorioamnionitis is an

inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection.

Paronychia refers to an

inflammation of the skinfold at the nail margin

What is Trousseau's sign?

inflate BP cuff 10-20 mm Hg above systolic pressure, capral spasms w/in 2-5 min indicate tetany

The Sengstaken-Blakemore tube has a gastric and an esophageal balloon that are

inflated to compress bleeding esophageal varices. An inflated esophageal balloon prevents swallowing. Therefore, the nurse should provide the client with tissues and encourage him to spit into the tissues or an emesis basin.

The nurse would keep the client's head flat after

infratentorial, not supratentorial, surgery.

The most common complication after an

inguinal hernia repair is the inability to void, especially in men.

Exhalation should be longer than

inhalation to prevent collapse of the bronchioles.

In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with

inhaled bronchodilators, I.V. corticosteroids and, possibly, I.V. theophylline (Theo-Dur).

Drugs administered intradermally

injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local microcapillary system.

Vitamin B12 needs to b

injected every month because the ileum has been surgically removed.

Considering that there is usually 1 L of

insensible fluid loss, this client's output exceeds his intake (intake, 2,000 ml; output, 2,200 ml), indicating deficient fluid volume.

The obturator is inserted into the replacement tracheostomy tube to guide

insertion and is then removed to allow passage of air through the tube.

Goiter attacks and severe laryngotracheitis are associated with

inspiratory stridor only.

Tuberculosis can be controlled but never completely eradicated from the body. Periods of

intense physical or emotional stress increase the likelihood of recurrence.

conductive loss

interrupted sound from external ear to junction of staples and oval window due to wax

Lymphedema after breast cancer It is caused by the

interruption or removal of lymph channels and nodes after axillary node dissection. Removal results in less efficient filtration of lymph fluid and a pooling of lymph fluid in the tissues on the affected side.

Heparin is administered subcutaneously, never

intramuscularly. A 25- or 26-gauge, ½- to 5/8-inch needle is most appropriate for heparin administration.

emergent Fluid shifting into the interstitial space causes

intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine.

Clients taking metoclopramide should be instructed to report any

involuntary movements of the face, eyes, or extremities because adverse effects of the drug include extrapyramidal reactions and parkinsonism-like reactions.

An incarcerated hernia refers to a hernia that is

irreducible but has not necessarily resulted in an obstruction.

Clinical manifestations of hypokalemia include an

irregular pulse, fatigue, muscle weakness, flabby muscles, decreased reflexes, nausea, vomiting, and ileus.

Intestinal cantour tubes are not

irrigated.

Although all the options are associated with hepatitis B, the onset of

irritability and drowsiness suggests a decrease in hepatic function.

A client with metabolic alkalosis may exhibit

irritability or nervousness.

There are two kinds of contact dermatitis:

irritant or allergic.

Intertrigo refers to

irritation of opposing skin surfaces caused by friction.

CEA is tested in blood. The normal range

is <2.5 ng/ml in an adult non-smoker and <5.0 ng/ml in a smoker

DEXAMETHASONE

is a steroid for cushings

if hip is dislocated wiggling toes

is not good indicator if it occured

To prevent the spread of scabies

isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins, wearing gloves when applying the pediculicide and during all contact with the client.

air born precaution The preferred placement is in an

isolation single-patient room that is equipped with special air handling and ventilation.

diarrhea has what type of potassium

it has low potassium because they are losing electrolytes i know you thought since diarrhea has metabolic acidosis it has low potassium the acidosis is from loss of bicarbonate acid loss and potassium loss

If a neck or spine injury is suspected, the

jaw-thrust maneuver should be used to open the client's airway.

Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to

join two or more vertebrae. Supplementary bone tissue, either from the patient (autograft) or a donor (allograft), is used in conjunction with the body's natural bone growth (osteoblastic) processes to fuse the vertebrae.

Clinical findings for osteoarthritis include

joint pain, crepitus, Heberden's nodes (bony growths at the distal interphalangeal joints), Bouchard's nodes (growths involving the proximal interphalangeal joints), and enlarged joints.

autograft donar site Occlusive dressings are not used because they do not

keep the donor site dry and open to the air.

ketonuria is a sign of diabetic

ketoacidosis.

Diabetic nephropathy is

kidney disease or damage that occurs in people with diabetes.

Unilateral hydronephrosis is swelling of one

kidney due to a backup of urine

Anesthesia and analgesia can slow the process o

labor

The normal uterus is only able to distend to a certain point and when that point is reached,

labor may be initiated.

The client will probably not be able to tolerate a full meal comfortably the day after

laparoscopic cholecystectomy surgery.

Hirschsprung's disease is a blockage of the

large intestine due to improper muscle movement in the bowel.

Oral hygiene is an important aspect of self-care for the

laryngectomy client, who is less able to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth care reduces the risk of infection.

Leads I, aVL, V5, and V6 record electrical events on the

lateral surface of the left ventricle

Leads I, aVL, V5, and V6 record electrical events on the

lateral surface of the left ventricle.

warm shock also makes capillaries more permeable causing

leakage and fluid shifting into tissues and fluid shifting into tissues and physiologic third spaces.

The client's highest brachial systolic pressure is divided by the

left ankle systolic blood pressure to get 0.81

The client's highest brachial systolic pressure is divided by the

left ankle systolic blood pressure to get 0.81.

Aphasia is more commonly present when the dominant or

left hemisphere is damaged.

The primary symptoms of a client who experiences a right-sided stroke are

left-sided weakness, impulsiveness, and poor judgment.

Azithromycin is the drug of choice for treatin

legionnaires' disease.

Basal cell carcinoma presents as

lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated

Skin and underlying structures may become anoxic after

less than 2 hours of unrelieved pressure.

under epidural anesthesia, the client states she needs to urinate. The nurse should next:

let them go you dont have to palpate the bladder unless the patient is not peeing

gerd The client should no

lie down until 2 to 3 hours after a meal. The client should sleep with the head of the bed elevated 4 to 6 inches

pacemaker care The client should be instructed to avoid

lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to heal and full range of motion to return.

A splinter hemorrhage is

linear red or brown streak in the nail bed.

Humidified air helps to

liquefy respiratory secretions, making them easier to raise and expectorate

encephalopathy is when

liver can not detoxify blood so ammonia builds up and go to the brain

Because of its location near the xiphoid process, th

liver is the organ most easily damaged from pressure exerted over the xiphoid process during CPR.

Atopic dermatitis is a

long-term (chronic) skin disorder that involves scaly and itchy rashes

An aortic murmur i

loud and rough and is heard over the aortic area.

Bronchial breath sounds are

loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration.

herniated disc Common symptoms include

low back pain, numbness or tingling starting in the rear and radiating down one leg, or numbness or weakness in the chest, neck or arm.

di urine osmolarity is

low because there is high water less solutes

Typical signs of cardiogenic shock include

low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness.

The kidneys are concentrating urine in response to

low circulating volume, as evidenced by a urine output of less than 30 ml/hour. This indicates that increased fluid replacement is needed.

calculi can form with

low fluid intake.

thyrotoxicosis

low thyroid

Mitral stenosis has a

low-pitched rumbling murmur heard at the apex.

Hydralazine acts to

lower blood pressure by peripheral dilation without interfering with placental circulation.

morphine works by

lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand

symptoms of esophageal cancer include

lump in throat dysphagia, substernal pain, regurgitation of undigested food, foul breath, and hiccups.

CT scanning is the standard noninvasive method used in a workup for

lung cancer because it can distinguish small differences in tissue density and can detect nodal involvement.

. Diaphragmatic breathing — not chest breathing — increases

lung expansion.

Lymphatic obstruction is a blockage of the

lymph vessels that drain fluid from tissues throughout the body and allow immune cells to travel where they are needed.

antidote for oxytocin is

mag sulfate

Magnesium is normally excreted by the kidneys. When the kidneys fail,

magnesium can accumulate and cause severe neurologic problems

CT is comparable not better or worse than to

magnetic resonance imaging in evaluating lymph node metastasis.

One nursing goal for a child with febrile seizures is to

maintain the child's temperature at a level low enough to prevent recurrence of seizures.

Salmeterol (Serevent) is a beta2-agonist,

maintenance drug that the asthmatic client uses twice daily, every 12 hours.

dental care for endocarditis is

manual toothbrush

burns Adherence to standard precautions requires the nurse to wear a

mask, eye goggles, gown, and gloves to prevent contamination from the irrigation.

During the emergent phase of burn management, there is a

massive shift of fluid from the blood vessels (intravascular compartment) into the tissues (interstitial compartment).

herniated disc occurs when the inner

material of a disc protrudes through the outer layer.

dont use Plain tap water for gavage because

may be contaminated. If introduced inadvertently into the lungs, it could result in damage or pneumonia.

C. trachomatis infection in women is commonly asymptomatic, but symptoms

may include a yellowish discharge and painful urination.

Urethral meatal stenosis, which can occur in circumcised infants, results from

meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision.

Good sources of vitamin B12 include

meats and dairy products.

Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged

mechanical ventilation because of the development of stress ulcers.

The dorsalis pedis pulse is found on the

medial aspect of the dorsal surface of the foot in line with the big toe.

Bronchovesicular breath sounds are

medium-pitched, continuous sounds that occur during inhalation or exhalation.

Hypertonic dextrose solutions are used t

meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system.

Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest

melanoma.

Elderly clients should not be given

meperidine because of the risk of acute confusion and seizures in this population.

someone with diarrhea has

metabolic acidosis which is associated with loss of bicarbonate which means there is loss of base so then there is more acid

intermediate phase of burn care Loss of serum sodium leads to

metabolic acidosis, not metabolic alkalosis.

This score is between 0.71 and 0.90, which suggests

mild peripheral artery disease.

This score is between 0.71 and 0.90, which suggests .

mild peripheral artery disease.

radiation The skin should be cleaned daily with a

mild soap, not harsh antibacterials.

A client on an acid-ash diet must avoid

milk and milk products because these make the urine more alkaline, encouraging bacterial growth.

The first heart sound (S1) occurs when the

mitral and tricuspid valves close

A pansystolic, blowing, high-pitched murmur characterizes

mitral insufficiency.

Back muscle strains are common, and

moderate strains can cause mild pain and stiffness.

A drainage tube is placed in the wound after a

modified radical mastectomy to help remove accumulated blood and fluid in the area

The burn should be kept

moist to prevent the dressing adhering to the wound.

A wet-to-damp saline dressing should always keep the wound

moist.

Because terbutaline can cause tachycardia, the woman should be taught to

monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute.

Splenomegaly often accompanies

mononucleosis and is present 2 to 4 weeks after contracting the infection. To prevent splenic rupture, contact sports and vigorous exercise should be avoided.

addision Other early signs and symptoms include

mood changes, emotional lability, irritability, weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency. LETHARGY

Peak flow numbers should be monitored daily, usually in the

morning (before taking medication). Peak flow does not need to be monitored after each meal.

Clients who take the Ranitidine twice a day are advised to take it in the

morning and at bedtime.

Glucocorticoids should be taken in the

morning, not at bedtime.

peripheral nervous system is

motor movement and sensory system

heat stroke Treatment consists of

moving the adolescent to a cool environment and giving cool liquids.

airborne

mtv measles varicella tb

Anemia is a common problem with

multiple gestation clients

Other potential complications of mitral stenosis include

mural thrombi, pulmonary hemorrhage, and embolism to vital organs.

A nasal drip pad is not needed after removal of

nasal packing.

Oxytocin is administered as

nasal spray before breast-feeding to stimulate lactation.

Common side effects of lithium are

nausea, dry mouth, diarrhea, thirst, mild hand tremor, weight gain, bloating, insomnia, and light-headedness. Immediately notifying the physician about these common side effects is not necessary.

Increased AFP levels are associated with

neural tube defects, such as spina bifida, anencephaly, and encephalocele.

ivh signs are

neurologic signs such as hypotonia ( low muscle tone, often involving reduced muscle strength. ), lethargy,

: Clindamycin may enhance the action o

neuromuscular blocking agents by blocking neuromuscular transmission.

Clindamycin may enhance the action of

neuromuscular blocking agents by blocking neuromuscular transmission.

abundant wbc is

neutrophil

Green, leafy vegetables are good sources of

niacin, folate, and carotenoids (precursors of vitamin A)

Breast milk has been found to heal nipples when placed on the

nipple at the completion of a feeding.

if one parent dose not have sickle sell hba and other has hbs then

no chance of sickle cell

emergent Little fluctuation in weight suggests that there is

no fluid retention and the intake is equal to output.

The client should receiv

normal saline solution through the second I.V. site until his blood glucose level reaches 250 mg/dl.

White pulmonary secretions are

normal with deep partial-thickness and full-thickness burns on the face, arms, and chest

Cirrhosis Clients are encouraged to eat

normal, well-balanced diets and to restrict sodium to prevent fluid retention. Protein is not restricted until the liver actually fails, which is usually late in the disease.

Bradycardia for the first 7 days in the postpartum period is

normal.

Bile green or cloudy white drainage is

not expected during the first 12 to 24 hours after a subtotal gastrectomy.

In cholinergic crisis, I.V. edrophonium chloride (Tensilon), a cholinergic agent, does

not improve muscle weakness; in myasthenic crisis, it does.

illeostomy Eating six small meals a day is

not necessary.

burns The irrigation is

not painful and sedatives or pain medications are not usually necessary.

note question with pt with spinal anesthesia and 4000 ml of isotonic bladder irrigation

note it says patient is getting irrigation it dosent say that the bag is full

Stridor occurs as a result of a partially

obstructed larynx or trachea; stridor can be heard without auscultation.

Bandages for burns may be elasticized and often are used to form an

occlusive pressure dressing.

Hypertension, not hypotension, is a sign

of hypoxia

The donor twin may become growth restricted and can have

oligohydramnios while the recipient twin may become polycythemic with polyhydramnios and develop heart failure

Pulmonary edema can develop during the

oliguric phase of acute renal failure because of decreased urine output and fluid retention.

I.V. dressing be changed

once or twice per week or when it becomes soiled, loose, or wet.

Two-point gait:

one crutch and opposite extremity move together followed by the opposite crutch and extremity; requires use of two assistive devices (canes or crutches)

Neonates born before 36 weeks' gestation will hav

only an anterior transverse crease on the soles of the feet.

squamous cell carcinoma Early lesions appear are

opaque, firm nodules with indistinct borders, scaling, and ulceration.

Secondary or second intention healing occurs in

open wounds. When the wound edges are not approximated and it heals with formation of granulation tissue, contraction and eventual spontaneous migration of epithelial cells.

Imperforate anus is a defect that is present from birth (congenital) in which the

opening to the anus is missing or blocked.

Sulfasalazine gives alkaline urine an

orange-yellow color, but it is not necessary to stop the drug when this occurs.

Raynaud's disease An adverse effect of reserpine is

orthostatic hypotension. The client should report dizziness and low blood pressure as it may be necessary to consider stopping the drug

Raloxifene hydrochloride (Evista) is useful in preventing

osteoporosis in postmenopausal women

note that steroid use mimics cushing disease and cushings cause

ostoprorosis because takes calcium from the bone so high calcium

Intermittent self-catheterization is appropriate for

overflow or reflux incontinence, but not urge incontinence, because it does not treat the underlying cause.

Therefore, an SaO2 of 90% indicates inadequate

oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen.

pad They should be advised to rest if

pain develops and resume activity when pain subsides

claudication is

pain with walking as seen with peripheral arterial disease

Genital herpes simplex lesions typically ar

painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks

The chancre of syphilis is characteristically a

painless, moist ulcer.

An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by

palpating the pulse.

The use of histamine2 (H2) blockers such as cimetidine can cause

paradoxic central nervous system (CNS) stimulation, resulting in ataxia in the elderly. Impaired vision, gait, and thinking may also occur.

Propantheline is contraindicated in

paralytic ileus, therefore the nurse should be concerned with the absent bowel sounds.

oxytocin is used to treat eclampsia, reduce postpartum bleeding, or treat erythroblastosis fetalis, the drug is administered

parenterally

Interferons (IFNs) are proteins made and released by host cells in response to the presence of

pathogens such as viruses, bacteria, parasites or tumor cells

The Seldinger maneuver is a method of

percutaneous introduction of a catheter into a vessel.

A potent topical corticosteroid may increase the client's risk for injury because it may be absorbed

percutaneously, causing the same adverse effects as systemic corticosteroids

A notched T-wave may indicate

pericarditis in an adult client.

Tailor sitting and squatting help stretch the

perineal muscles in preparation for labor.

A basilar skull fracture commonly causes only

periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function.

There is no need for the client to remain on nothing-by-mouth status after laparoscopic cholecystectomy surgery because

peristaltic bowel activity should not be affected.

The most common site of hemorrhage is the

periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile.

contact isolation The nurse should assemble all needed supplies before putting on

personal protective equipment and entering the client's roo

The frontal lobe influences

personality, judgment, abstract reasoning, social behavior, language expression, and movement.

autograft donar site Single-layer gauze dressings impregnated with

petroleum, scarlet red, or biosynthetic dressings may be used to cover the donor site as it heals

Oversecretion of the adrenal medulla causes

pheochromocytoma

Stress incontinence is losing urine without meaning to during

physical activity, such as coughing, sneezing, laughing, or exercise.

Preventing edema is an appropriate immediate postoperative nursing goal, but attaining it does not affect

physical mobility in the immediate and extended postoperative periods

Prothrombin synthesis in the liver requires vitamin K. In cirrhosis, vitamin K is lacking, precluding prothrombin synthesis and, in turn, increasing the client's PT. An increased PT, which indicates clotting time, increases the risk of bleeding. Therefore, the nurse should expect to administer

phytonadione (vitamin K1) to promote prothrombin synthesis.

Nose drops are not instilled with packing in

place.

SARS, a highly contagious viral respiratory illness, is spread by

placed on airborne and contact precautions

Placenta accreta, a rare phenomenon, refers to a condition in which the

placenta abnormally adheres to the uterine lining

Administering serum albumin increases the

plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma.

Legionellosis is a

pneumonia caused by the bacterium Legionella pneumophilia that thrives in water that is 95° to 115° F (35° to 46° C).

After a bronchoscopy with a lung biopsy, the nurse should monitor the client for signs of

pneumothorax as well as hemorrhage

jaw thrust

position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward.

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:

possible hematologic problem.

emphysema If the client has copious secretions and has difficulty mobilizing secretions, the nurse should teach him and his family members how to perform

postural drainage and chest physiotherapy.

Owing to the massive cellular destruction that occurs in burns,

potassium is released into the extracellular fluid, which leads to hyperkalemia.

emergent phase of burn

potassium is released into the extracellular fluid, which leads to hyperkalemia.

Although loop diuretics block

potassium reabsorption, this isn't a therapeutic action.

The nurse should expect to hold the insulin infusion for 30 minutes until the ]

potassium replacement has been initiated.

Insulin administration causes

potassium to enter the cells, which further lowers the serum potassium level.

Insulin is a required hormone for any client with diabetes mellitus, including the

pregnant client.

Actinic keratosis is a

premalignant skin lesion.

Castor oil can initiate

premature uterine contractions and other adverse effects in pregnant women.

A Foley catheter provides accurate output assessment to monitor for

prerenal acute renal failure that can occur from hypovolemia.

The multiple gestation client is at risk for

preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation

Pneumovax 23, a polyvalent pneumococcal vaccine, is administered prophylactically to

prevent the pneumococcal sepsis that sometimes occurs after splenectomy.

A major focus of nursing care after transsphenoidal hypophysectomy is

prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted.

Letting go is the

process beginning about 6 weeks postpartum when the mother may be preparing to go back to work.

bronchopulmonary dysplasia BPD is a chronic illness that may require

prolonged hospitalization and permanent assisted ventilation.

: All clients exposed to persons with tuberculosis should receive

prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium

renal failure Carbohydrates provide energy and decrease the need for

protein breakdown.

The main goal of nutritional therapy in acute renal failure is to decrease

protein catabolism.

Carcinoembryonic antigen (CEA) is a

protein found in many types of cells but associated with tumors and the developing fetus.

Testosterone is an androgen hormone that is responsible for

protein metabolism as well as maintenance of secondary sexual characteristics; therefore, it is needed by both males and females.

The mother is commonly unable to consume enough

protein, calcium, and iron to supply her needs and those of the fetuses.

pku neonate must have ingested sufficient

protein, such as breast milk or formula, for at least 24 hours.

An inguinal hernia ( /ˈɪŋɡwɨnəl ˈhɜrniə/) is a

protrusion of abdominal-cavity contents through the inguinal canal.

allergic reaction to the dye used during the arteriogram

pruritus and urticaria, which may indicate a mild anaphylactic reaction Decreased alertness may and dyspnea (not hypoventilation).

In a low anorectal anomaly, the rectum has descended normally through the

puborectalis muscle.

A reduction in pulmonary artery pressures should improve the

pulmonary congestion and lung sounds.

Hypotension, not hypertension, would suggest a possible

pulmonary embolism.

A progressive activity regimen may be prescribed to increase

pulmonary function after surgical lung resection

The most accurate method for determining the presence of hypoxia is to evaluate the

pulse oximeter value or arterial blood gas values

Hypotension, hypothermia, and vasoconstriction may alter

pulse oximetry values by reducing arterial blood flow

The client with chronic bronchitis should exhale through

pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping

Exhaling slowly as if trying to blow out a candle is a technique used in

pursed-lip breathing to facilitate exhalation in clients with chronic obstructive pulmonary disease.

Because terbutaline can cause tachycardia, the woman should be taught to monitor her

radial pulse and call the physician for a heart rate greater than 120 beats/minute.

A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if

recirculation is unavoidable.

hiatal hernia to minimize intra-abdominal pressure, the client shouldn't

recline after meals, lift heavy objects, or bend.

Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to

reconstruct the urethra.

Water-soluble lubricants used during sexual intercourse can augment

reduced natural vaginal lubrication caused by ovarian dysfunction and decreased circulating estrogen related to chemotherapy.

Mexiletine, an antiarrhythmic, is used to treat

refractory ventricular arrhythmias; it doesn't cause hypoglycemia.

illeostomy The client is usually placed on a

regular diet but is encouraged to eat high-fiber, high-cellulose foods (e.g., nuts, popcorn, corn, peas, tomatoes) with caution; these foods may swell in the intestine and cause an obstruction.

radiation Lotion should be

removed from the skin before any treatment and then reapplied after the treatment.

Moist heat to the flank area is helpful when

renal colic occurs, but it is less necessary as pain is lessened.

If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as

renal colic.

intermediate phase of burn care Urinary output increases during this phase as

renal perfusion increases.

calculi can form with

repeated urinary tract infections, high doses of vitamin C or D, immobility, and large doses of calcium.

Hyperventilation is a clinical manifestation of

respiratory alkalosis.

Benzonatate is used for cough associated with

respiratory conditions and chronic pulmonary diseases.

Laryngeal stridor is characteristic of

respiratory distress from inflammation and swelling after bronchoscopy. It must be reported immediately.

Vibration and percussion of the chest wall may be helpful for

respiratory hygiene but will not affect the nature of secretions.

A client with COPD is at high risk for development of

respiratory infections

The client with acute pancreatitis is prone to complications associated with the

respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate.

.Intermittent claudication subsides with

rest.

oa The joint pain occurs with movement and is relieved by

rest. As the disease progresses, pain may also occur at rest.

pseudoephedrine (Sudafed) The most common CNS adverse effects include

restlessness, dizziness, tension, anxiety, insomnia, and weakness.

The adolescent is most likely experiencing heat exhaustion or heat collapse, Symptoms

result from loss of fluids and include nausea, vomiting, dizziness, headache, and thirst.

Vitamin A is a vitamin that is needed by the

retina of the eye

The client should review the adcance directive with the physician at every admission because some conditions may be

reversible and temporary, making portions of the advance directive inappropriate.

Overuse of nasal spray containing pseudoephedrine can lead t

rhinitis medicamentosa, which is a rebound effect causing increased swelling and congestion.

Other symptoms associated with cholelithiasis are

right upper quadrant tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal

Group B Streptococcus is a

risk factor for all pregnant women and is not limited to those carrying twins.

Obesity, stress, high intake of sodium or saturated fat, and family history are all

risk factors for primary hypertension.

Passive ROM exercises and isometric exercises do not provide the bone stress necessary to reduce the

risk of osteoporosis.

The bag containing platelets needs to be gently

rotated to prevent clumping.

osteoarthritis Intra-articular corticosteroid injections are not used

routinely; rather, they are cautiously used during periods of acute joint pain.

A salivary fistula is suspected when there i

saliva collecting beneath skin flaps or leaking through the suture line or drain site.

herpes virus 2 Other signs and symptoms during the primary episode may include a

second crop of sores, and flu-like symptoms, including fever and swollen glands.

Cutaneous lesions on the palms and soles and alopecia are signs of

secondary syphilis. Chancres do not bleed sufficiently to alter tissue perfusion.

Propantheline bromide is used to reduce

secretions and spasms of the GI tract in clients with diverticulitis, a condition characterized by bowel inflammation and colonic irritability and spasticity.

drinking water with copd can cause

secretions to be liquidified so it is to mobilize and get rid of secretions

The parietal lobe interprets and integrate

sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.

Aging and ototoxicity are two causes of

sensorineural hearing loss.

Leads V3 and V4 record electrical events in the

septal region of the left ventricle.

Metabolic alkalosis can cause potassium to shift into the cells, resulting in a decrease of

serum potassium

Abrupt withdrawal of endogenous cortisol may lead to

severe adrenal insufficiency.

Clinical manifestations include

severe eye pain, colored halos around lights, and rapid vision loss.

Rectal surgery is accompanied by

severe pain resulting from spasms of sphincters and muscles. Therefore, controlling pain is a priority goal of nursing care.

Ranson's criteria is a clinical predictor scale used to assess the

severity of acute pancreatitis and prognosis

A client with genital herpes lesions should avoid all

sexual contact to prevent spreading the disease.

A client with primary syphilis is at risk for transmitting the disease t

sexual partners if he or she is not knowledgeable about how the disease is spread.

arsenic exposure Dehydration can lead to

shock and death.

acute respiratory distress syndrome aka

shock lung and white lung which is increased permeability of alveolar cap lets the fluid leak out into interstitial space

A dry gauze dressing — not a plastic sheet-type dressing —

should cover the wet dressing.

After the corticotropin-secreting tumor is removed, the client

shouldn't be at risk for hyperglycemia.

siadh has high urine osmolarity

siadh body retains water so there is less water being released meaning more solutes just thing they are inversely related

Lethargy puts the posttonsillectomy client at risk for aspirating blood from the surgical wound. Therefore, placing the client in the \

side-lying position until he's fully awake is best.

postion for buck traction The client can

sit up in bed, remaining in the supine position so that an even, sustained amount of traction is maintained under the bandage used in the Buck's traction and bandage doesnt slip

Hypothyroidism has a metabolic effect on

skeletal muscle. Muscle injury results, causing the CPK-MM to spill out of the damaged cells and into the bloodstream.

Adequate protein intake is necessary for improving

skin integrity.

The stoma does not need to be kept clean and dry; rather the

skin surrounding the stoma needs to be kept clean and dry.

cushings Loss of collagen makes the

skin weaker and thinner; therefore, the client bruises more easily. The nurse should instruct the client to report any of these signs to the physician.

avoid shoes to stop falls

slippers and shoes with deep treads

Raloxifene hydrochloride (Evista) is contraindicated for women who

smoke cigarettes or who have a history of venous thrombosis.

Raynaud's disease The nurse should instruct the client to stop

smoking because nicotine is a vasoconstrictor. \

Benign conditions that can increase CEA include

smoking, infection, inflammatory bowel disease, pancreatitis, cirrhosis of the liver, and some benign tumors

alpha-adrenergic blockers. These drugs relax the

smooth muscle of the bladder neck and prostate, so the urinary symptoms of BPH are reduced in many clients.

in chronic renal failure the kidney cant make vitamin d i

so then it cant make calcium so then then the parathyroid gland begins to increase production negative feed back loop

Lactated Ringer's solution replaces lost

sodium and corrects metabolic acidosis, both of which commonly occur following a burn.

In the intermediate phase of burn care, the client will experience serum

sodium deficits.

Loop diuretics block

sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also dilate renal vessels

Which of the following interventions will be most effective in reducing a client's fluid volume excess?

sodium restriction may be necessary to promote fluid loss. Restricting fluid intake will not reduce retained fluids

Thiazide diuretics, not loop diuretics, promote

sodium secretion into the distal tubule.

Vesicular breath sounds are

soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation.

LBP is commonly associated with overuse or an injury to the

soft-tissue structures Muscle strain

A neonate born at 37 weeks' gestation will have

some cartilage in the ear lobes, fine and fuzzy hair, scant to moderate rugae in the scrotum, and a breast nodule diameter of 4 m

Swelling gradually subsides over several weeks; the client can gently clean the nares as

soon as nasal packing is removed

Spermicidal agents work by destroying the

spermatozoa before they enter the cervix

During spinal anesthesia, medication is injected into you

spinal canal to numb the nerves in the lower half of your body.

If spinal fluid leaks through the tiny puncture site, you may develop a

spinal headache.

Bradycardia, paralytic ileus, and hot and dry skin typically occur during

spinal shock

An abdominal CT scan is used to

stage the presence of colorectal cancer.

Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the

stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure.

suctioning a tracheostomy tube The recommended technique is to use a

sterile catheter each time the client is suctioned.

If a clamp isn't available, the nurse may place a

sterile syringe or catheter plug in the catheter hub.

The catheter used for gavage feeding a neonate should be lubricated with

sterile water before introduction so that if the catheter is inadvertently introduced into the lungs, serious damage would not occur.

Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it

stimulates the development of collateral circulation.

A soft toothbrush, Toothette, or gauze pad should be used to provide oral hygiene at least every 2 hours to promote client comfort and prevent

stomatitis

Daunorubicin The nurse should immediately

stop the medication, apply ice to the site, and notify the physician.

Surgery is required to release the

strangulation.

Isometric, not isotonic, exercises are used to

strengthen muscles

hemorrhoidectomy Positioning in the early postoperative phase should avoid

stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective.

Loss of urine when coughing occurs with

stress incontinence

Emotional stressors do not cause

stress incontinence. It is most commonly caused by relaxed pelvic musculature.

Obesity is a risk factor for osteoarthritis because it places increased

stress on the joints.

. The loss of color vision, or achromatopsia, is a rare symptom that occurs when a

stroke damages the fusiform gyrus. It most often affects only half of the visual field.

In addition, some spermicides alter the vaginal pH to a

strong acidic environment, which is not conducive to survival of spermatozoa.

Pneumothorax signs and symptoms include

sudden, sharp chest pain; tachypnea; and tachycardia, absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side.

Adequate fluid intake of at least 8 glasses a day prevents crystalluria and stone formation during

sulfasalazine therapy.

Stomal stenosis may be present when there is

suprasternal and intercostal retractions and difficult breathing.

The client with a Sengstaken-Blakemore tube cannot

swallow.

Tube feedings do not prevent

swallowing or pain upon swallowing.

When the client advances both crutches together and follows by lifting both lower extremities PAST the level of the crutches, the gait is called a

swing through" gait.

Clonidine (Catapres) reduces of this drug

sympathetic outflow from the central nervous system.

history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen

symptoms mean infection so you need to call doctor not elevate on pillows because the symptoms not from lymph edema or lymph swellng but from infection

The ABI test is a noninvasive test that compares the

systolic blood pressure in the arm with that of the ankle.

Adenosine treats

tachyarrhythmias

complication of deep vein thrombosis is pulmonary embolism

tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub.

pseudoephedrine (Sudafed) Common cardiovascular adverse effects include

tachycardia, hypertension, palpitations, and arrhythmias. Tachycardia,

The blood pressure is very labile with these activities, and paroxysms may be accompanied by

tachycardia, palpitations, angina, or electrocardiographic changes.

: One of the most common adverse effects of the drug hydralazine (Apresoline) is

tachycardia.

Eating and sleep are high priorities during this

taking in phase

A wound (regardless of its size) that contains

tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place.

What is Chovstek's sign?

tap facial nerve 2 cm anterior to the earlobe just below the zygomatic arch, twitching indicates tetany

ivh signs are

temperature instability, nystagmus, apnea, bradycardia

transsphenoidal hypophysectomy The nurse should monitor for signs of infection, including elevated

temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical insufficiency may occur.

question asked if someone with hep b which is worse fatigue when walking or iritability and drowsniness

the answer was irritablity because that implies hepatic encephalthypy from liver having to much ammonia

Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in

the detection of two-thirds of all colorectal cancers

when breast feeding As much of the mother's nipple and areola need to be in

the infant's mouth in order to establish a latch that does not cause nipple cracks or fissures which decreasing pain, cracking and fissures.

in di the low levels of potassium or high calcium cause

the kidneys to not respond to the adh

An automated drug delivery system most effectively reduces

the likelihood of medication errors by automatically dispensing the drug.

If you don't hear anything, check to make sure that all

the other unused openings of the feeding tube are closed.

if one parent has hbs and other has hbs

then there is 100 percent chance sickle cell

high urine osmalarity means

there is high solutes in water means low water

autograph donar Elastic bandages are not used because

they constrict circulation and can impede healing.

if someone has productive cough

they do not need to be suctioned

so if there is impairment in peripheral sensation problems that means that

they have problems with movement and sensation like hot and cold

Whole grains are a good source of

thiamine.

This is achieved by competing for the Cl- binding site. Because magnesium and calcium reabsorption in the

thick ascending limb is dependent on sodium and chloride concentrations they are also lost in the urine

In people with diabetes, the nephrons

thicken and slowly become scarred over time. The kidneys begin to leak and protein (albumin) passes into the urine

shoes to prevent falls

thin nonslip soles

Transcutaneous pads should be placed on the client with

third degree heart block.

the hallmark symptoms of hyperglycemia are increased

thirst, fruity breath, and glycosuria.

Bleeding is related to the degree of

thrombocytopenia, and infection is related to the degree of neutropenia.

Because of the inflammation, a common complication of Buerger's disease is

thrombus formation and potential occlusion of the vessel. Inflammation of the immediate and small arteries and veins is involved in the disease process.

The parathyroid glands are located in the neck, near or attached to the back side of the

thyroid gland.

Primary or first intention healing occurs when

tissue is cleanly incised and re-approximated and healing occurs without complications. The incisional defect re-epithelizes rapidly and matrix deposition seals the defect

Metabolic alkalosis can cause potassium

to shift into the cells, resulting in a decrease of serum potassium.

normally liver transforms ammoina

to urea which the kidney excrete

Diet therapy for peptic ulcer disease Most clients are instructed to follow a diet that they can

tolerate.

The greater the concentration of dextrose in solution, the greater the

tonicity.

Opioid antitussives, such as codeine and hydrocodone, are reserved for

treating unruly coughs usually associated with lung cancer

Chancres often disappear even without

treatment.

cytoscopy is

tube into bladder

Rifampin is used to treat

tuberculosis

The main use of CEA is as a

tumor marker, especially with intestinal cancer

bucks traction the client should not

turn his body to another position because the bandage may slip.

By 4 months, the neonate should

turn his eyes and head toward a sound coming from behind

Twin-to-twin transfusion drains blood from one

twin to the second and is a problem that may occur with multiple gestation.

When taking isoniazid, the client should limit

tyramine-rich foods in his diet because these foods and the drug could interact to cause hypertensio

When a client has one-sided weakness, the nurse should place the wheelchair on the client's

unaffected side. strong side

Herpetic keratoconjunctivitis usually is

unilateral and causes localized symptoms, such as conjunctivitis ( pink eye swelling of conjuctivi) with herpes simplex virus

Hemoglobin and HCT are typically performed first in clients with \

upper GI bleeding to evaluate the extent of blood loss.

In producing urine, the kidneys excrete wastes such as

urea and ammonia

if the kidney is not working in glomnerphritis then it cannot excrete

urea and ammonia so then there is buildup of ammonia which cause encephalthpy

Protein catabolism causes increased levels of

urea, phosphate, and potassium.

Epidural anesthesia is associated with a decreased

urge to void; therefore, catheterization of a full bladder may be necessary.

Propantheline Side effects are

urinary retention, constipation, and tachycardia.

Cholinergic adverse effects may include

urinary urgency, diarrhea, abdominal cramping, hypotension, and increased salivation.

However, it is not as direct an indicator as increase

urine output.

Coffee and tea are considered neutral because they don't alter the

urine pH.

Lomotil, a combination drug containing atropine, has anticholinergic properties. Common side effects include

urine retention, blurred vision, constipation, palpitations, nervousness, and decreased sweating.

Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for

use during pregnancy because these agents may cause fetal harm.

After intracavity radiation, some

vaginal bleeding occurs for 1 to 3 months.

The passage of feces through the vagina, not

vaginal bleeding, is a sign of rectovaginal fistula.

a routine ultrasound is

valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle.

potent topical corticosteroid cause

vasoconstriction, not vasodilation.

Rapid filling of the ventricle causes

vasodilation that a nurse auscultates as an S3.

acid ash diet Other foods to avoid on this diet include all

vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium

Chordee refers to a

ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue.

Angiotensin-converting enzyme-inhibitor drugs,may help to prevent

ventricular remodeling

Epistaxis, or nosebleed significant blood loss, systemic symptoms, such as

vertigo, increased pulse, shortness of breath, decreased blood pressure, and pallor, will occur.

Scabies is an easily spread skin disease caused by a

very small species of mite

Daunorubicin is a

vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates.

Sensorineural hearing loss (SNHL) is a type of hearing loss in which the root cause lies in the

vestibulocochlear nerve (Cranial nerve VIII), the inner ear, or central processing centers of the brain.

When arsenic overexposure occurs, the symptoms include

violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis.

• When arsenic overexposure occurs, the signs and symptoms include

violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis. o Dehydration can lead to shock and death. o After the acute phase, bone marrow depression, encephalopathy, and sensory neuropathy occur.

Endoscopy is then performed to directly

visualize the upper GI tract and locate the source of bleeding.

Signs of hypocortisolism include

vomiting, increased weakness, dehydration, and hypotension.

laryngectomy client should be encouraged to participate in activities such as

walking, golfing, and other moderate recreational sports.

Septic shock can be broken down into two different types of shock:

warm (or hyperdynamic) shock and cold (or hypodynamic) shock.

Other signs and symptoms of early septic shock include

warm and flushed skin fever with restlessness and confusion; decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea.

Raynaud's disease The nurse can teach the client to rewarm exposed extremities by using

warm water or placing them next to the body, such as under the axilla. It is not realistic to ask this client to change jobs at this time.

To maintain enteric precautions, the nurse must

wash her hands after touching the client or potentially contaminated articles and before caring for another client.

Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with

water only and leave the area open to air. No soaps, deodorants, lotions, or powders should be applied.

After removal of nasal packing, the client should be instructed to apply

water-soluble jelly to the nares to lubricate the nares and promote comfort.

Oxygen therapy is drying to the oral and nasal mucosa; therefore, the client should be encouraged to apply a

water-soluble lubricant, such as K-Y jelly, to prevent drying.

In chronic bronchitis the diaphragm is flat and

weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation.

The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when

weaning the client from tracheal support.

For enteric precautions, the nurse need not

wear a mask and must wear a gown only if soiling from fecal matter is likely.

question about imobilized patient and osteoporosis what should you do

weight bearing excersises remember it does not necessarily mean just walking

The "swing through" gait is often used by paraplegic clients because it allows them to place

weight on their legs while the crutches are moved one stride ahead.

Water does not harm the stoma, so the client does not have to worry about getting it

wet.

Expressive aphasia is a condition in which the client understands what is heard or written but cannot say

what he or she wants to say

Acute asthmatic attacks are characterized by

wheezing.

Although an upper GI series might confirm the presence of a lesion, it wouldn't necessarily reveal

whether the lesion is bleeding.

Thrush is characterized by

whitish yellow patches in the mouth

if calcium levels are high then parathyroid gland

will not cause production of calcium because its already high

Skeletal traction is not used to pull weight

with a boot.

During a spinal tap, a sample of cerebrospinal fluid i

withdrawn from your spinal canal.

Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for

wound healing.

Third intention healing (delayed primary) occurs when a

wound is allowed to heal open for a few days and then closed as if primarily. Such wounds are left open initially because of gross contamination.

The bacteria may enter the body through

wounds, or they may live in improperly canned or preserved food

hemophila

x linked genetics

People who are lactose-intolerant usually are able to tolerate dairy products in which lactose has been fermented, such as

yogurt, cheese, and buttermilk

The following measures are required for Droplet Precaution

· If the patient must leave their room, notify the receiving area and have the patient wear a surgical mask when possible to minimize the dispersal of droplets.

discharge plan for a client with multiple sclerosis

• Carefully test the temperature of bath water. • Avoid hot water bottles and heating pads. • Inspect the skin daily for injury or pressure points. • Wear warm clothing when outside in cold temperatures.

tpa on ulcer

• Prevent direct trauma to the ulcer. • Prevent infection. • Reduce pain. • Increase oxygen to the tissues.

inferior wall myocardial infarction (MI). ECG changes associated with an evolving MI?

• T-wave inversion • ST-segment elevation • Pathologic Q-wave

mi

• T-wave inversion • ST-segment elevation • Pathologic Q-wave

A client with jaundice has pruritis What can the nurse discuss to prevent skin breakdown?

• Take baking soda baths. • Keep nails short and clean. • Rub with knuckles instead of nails.

arsenic symptoms

• Violent vomiting. • Severe diarrhea. • Abdominal pain.

Albuterol (Proventil) is used as the

"rescue inhaler" for bronchospasms.

When the client advances both crutches together and follows by lifting both lower extremities to the SAME level as the crutches, the gait is called a

"swing to" gait.

ATTENUVAX*

(Measles Virus Vaccine Live)

Muscle tears or ruptures cause severe pain

, impede the ability to move or walk, and are usually accompanied by swelling and bruising.

What are signs and symptoms of hyperkalemia?

- EKG changes: peaked T waves, wide QRS complexes - dysrhythmias, ventricular fibrillation, heart block - cardiac arrest - muscle twitching and weakness - numbness in hands and feet and around mouth - nausea - diarrhea

What are causes of hypomagnesium?

- alcoholism - GI suction - diarrhea - intestinal fistuals - poorly controlled diabetes mellitus - malabsorption syndrome

What are signs and symptoms of hypokalemia?

- anorexia, nausea, vomiting - weak peripheral pulses - muscle weakness, paresthesias, decreased deep tendon reflexes - impaired urine concentration - ventricular dysrhythmias - increased instance of dig toxicity - shallow respirations

What are signs and symptoms of hypermagnesium?

- depresses the CNS - depresses cardiac impulse transmission - cardiac arrest - facial flushing - muscle weakness - absent deep tendon reflexes - paralysis - shallow reflexes

What are signs and symptoms of hypernatremia?

- elevated temp - weakness - disorientation - irritibility and restlessness - thirst - dry, swollen tongue - sticky mucous mebranes - hypotension - tachycardia

What are causes of hypernatremia?

- hypertonic tube feedings w/o water supplements - hyperventilation - diabetes insipidus - ingestion of OTC drugs such as Alka-Seltzer - inhaling large amount of saltwater - inadequate water ingestion

What are causes of hypocalcemia?

- hypoparathyroidism - pancreatitis - renal failure - steroids and loop diuretics - inadequate intake - post-thyroid surgery

What are signs and symptoms of hypomagnesium?

- increased neuromuscular irritability - tremors - tetany - hyperactive deep tendon reflexes - seizures - dysrhythmias, especially is kypokalemia present - disorientation - confusion

What are signs and symptoms of hypercalcemia?

- lack of coordination - anorexia, nausea, and vomiting - confusion, decreased level of consciousness - personality changes - dysrhythmias, heart block, cardiac arrest

What are causes of hypercalcemia?

- malignant neoplastic diseases - hyperparathyroidism - prolonged immoblization - excessive intake - immobility - excessive intake of calcium carbonate antacids

What are signs and symptoms of hyponatremia?

- nausea - muscle cramps - confusion - muscular twitching, coma - seizures - headache

What are signs and symptoms of hypocalcemia?

- nervous system becomes increasingly excitable - tetany: Trousseau's sign and Chvostek's sign - hyperactive reflexes - confusion - paresthesias - irritability - seizures

What is calcium regulated by?

- parathyroid hormone - vit D

What are causes of hypermagnesium?

- renal failure - excessive magnesium administration

What are causes of hyperkalemia?

- renal failure - use of potassium supplements - burns - crushing injuries - severe infection

What are causes of hyponatremia?

- vomiting - diuretics - excessive administration of dextrose and water IVs - burns, wound drainage - excessive water intake - syndrome of inappropriate anti diuretic hormone secretion

What are causes of hypokalemia?

- vomiting - gastric suction - prolonged diarrhea - diuretics and steroids - inadequate intake

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inh limit foods like

. Foods such as cheese, dairy products, alcohol (red wine and beer), bananas, raisins, caffeine, and chocolate should be limited.

Asymptomatic proteinuria is an initial sign of

. Microscopic proteinuria should be monitored yearly in all clients with diabetes for over 5 years.

Dyspnea and cyanosis are associated with

...

The ABI test is a noninvasive test that compares the systolic blood pressure in the arm with that of the ankle.

...

Red blood cells should measure

0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field.

Severe peripheral artery disease would result in a score of

0.00 to 0.40

Severe peripheral artery disease would result in a score of

0.00 to 0.40.

Moderate peripheral artery disease would yield a score of

0.41 to 0.70.

Vesicles are elevated, sharply defined lesions that are usually less tha

0.5 cm in diameter and contain serous fluid.

Pustules are elevated lesions less than

1 cm in diameter containing purulent material; examples include impetigo and acne lesions.

For maximum absorption, the client should take this drug at least

1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides.

The proper suctioning technique is to insert the suction catheter until resistance is met, withdraw the catheter

1 to 2 cm, then begin applying intermittent suction while withdrawing the catheter. The suction catheter is inserted approximately 5 to 6 inches. It is not necessary to insert the catheter as the client exhales. Coughing by a client does not necessarily indicate when to begin or stop suctioning.

Posterior nasal packing should be left in place for

1 to 3 days.

Urine specific gravity normally ranges from

1.002 to 1.035, making this client's value normal.

The faceplate opening should be no more than

1/8? to 1/6? larger than the stoma

A fetus normally move

10 to 12 times per hour.

The therapeutic serum theophylline concentration ranges from

10 to 20 mcg/ml.

Normally, pressure in the anterior chamber of the eye remains relatively constant at

10 to 20 mm Hg

A sign of digitalis toxicity is atrial fibrillation, sometimes with a heart rate of more than

100 bpm, nurse is to evaluate the cardiac rhythm of the client. Tachycardia can be a sign of digitalis toxicity.

A maternal hemoglobin level below

11 g/dl is considered anemia

Because AFP levels are usually highest at

15 to 18 weeks' gestation, this is the optimum time for testing.

The normal I:E ratio is

1:2, meaning that expiration takes twice as long as inspiration

4 stages of labor

1st stage is latent active transition 2nd stage is pushing 3rd stage is placenta 4 th stage is postpartum

Meperidine is contraindicated in clients with acute pain lasting more than

2 days and in those for whom large daily doses (more than 600 mg) are needed. It would be inappropriate to urge the client to take the acetaminophen and codeine to prevent addiction.

At birth, visual acuity is estimated at approximately

20/100 to 20/150, but it improves rapidly during infancy and toddlerhood.

210-

216

finish

226

if both parents are carriers habas then

25 chance of child getting it

Disconnect the syringe and pull the plunger back to the

2cc mark Attach the syringe to the end of the feeding tube.

In a female client, the nurse should advance an indwelling urinary catheter

2″ to 3″ (5 to 7.5 cm) into the urethra

When the feeding is completed, clear the tube with

3 cc of water. Rinse the syringe and extension tubing with water.

pacemaker care Avoid lifting anything heavier than

3 lb.

quad position

30 degrees

After supratentorial surgery, the nurse should elevate the client's head

30 degrees to promote venous outflow through the jugular veins.

The nurse should instruct the client to take Propantheline bromide

30 minutes before meals and at bedtime to reduce GI motility, thus relieving spasticity.

The correct procedure for wound irrigation includes using

35-ml syringe and 19-French angiocatheter to provide irrigation of about 8 pounds of pressure per square inch to remove necrotic tissue without tissue damage.

Serum CK-MB levels can be detected

4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.

Terbutaline must be taken every

4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor.

Normal urine pH is

4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation.

A nasal cannula can't deliver oxygen concentrations above

44%.

abg apply pressure for

5 minuets and 15 minutes if anticoagulant therapy in the arm but femoral artery you keep pressure for 15 minutes

if carrier hbas and has sickle cell hbs then

50 percent chance of child getting it

The client should receive a fluid bolus of

500 ml of normal saline solution.

Measurements between the

5th and 95th percentiles are considered normal

In a male client, the nurse should advance the catheter

6″ to 8″.

To avoid a falsely elevated serum digoxin level, a nurse shouldn't draw a blood sample for at least

8 hours after administering oral digoxin and at least 6 hours after administering I.V. digoxin

The nurse should instruct a client receiving a sulfonamide such as co-trimoxazole to drink at least eight

8-oz glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits.

Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained. Correct Answer: D

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? A. Review the client's medical record for an advance directive. B. Determine if a do-not-resuscitate prescription has been obtained. C. Document that the client is being discharged against medical advice. D. Evaluate the client's mental status for competence to refuse treatment.

Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the health care team (D). (A) uses language (i.e. 'incision') that could create anxiety for the child. Four-year-olds are in the Initiative vs. Guilt stage (Erikson's psychosocial development), and (B) contributes to guilt when the child hurts. (C) is not helpful because the child may associate being put to sleep with the postoperative throat pain and then become fearful of going to sleep. Correct Answer: D

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, Will it hurt to have my tonsils and adenoids taken out? Which response is best for the nurse to provide? A. It may hurt a little because of the incision made in your throat. B. It won't hurt because you're such a big boy. C. It won't hurt because we put you to sleep. D. It may hurt but we'll give you medicine to help you feel better.

A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be illicited after confirming the client's dietary history. Correct Answer: B

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client.

When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution. Correct Answer: D

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions.

Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B). Correct Answer: B

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life.

An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a rattling sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent (D). Although culturally sensitive care should be observed throughout the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches. Correct Answer: D

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? A. Ensure cultural customs are observed. B. Increase oxygen flow to 4L/minute. C. Auscultate bilateral lung fields. D. Inform the family that death is imminent.

Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. Correct Answer: A

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown.

To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the wound bed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface. Correct Answer: C

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A. Hydrogel. B. Exudate absorber. C. Wet to moist dressing. D. Transparent adhesive film.

A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium. Correct Answer: B

A client is demonstrating a positive Chvostek's sign. What action should the nurse take? A. Observe the client's pupil size and response to light. B. Ask the client about numbness or tingling in the hands. C. Assess the client's serum potassium level. D. Restrict dietary intake of calcium-rich foods.

Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts (D) about past health problems. (A and B) are time consuming, and may require the client's permission to access information about other hospitalizations. (C) may not produce the specific data needed. Correct Answer: D

A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A. Solicit information on hospitalization from the insurance company. B. Look up previous medical records from archived hospital documents. C. Ask the client to discuss previous hospitalizations in the last 5 years. D. Elicit specific facts about past hospitalizations with direct questions.

The nurse should implement (D), because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. Correct Answer: D

A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again.

Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests. Correct Answer: A

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A. Continue gabapentin. B. Discontinue ibuprofen. C. Add aspirin to the protocol. D. Add oral methadone to the protocol.

Biofeedback involves the use of various monitoring devices that help people become more aware and able to control their own physiologic responses, such as heart rate, body temperature, muscle tension, and brain waves. (D) is an accurate statement concerning its use for clients with Raynaud's disease. (A, B, and C) do not provide correct information about biofeedback. Correct Answer: D

A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? A. The responses to biofeedback have not been well established and may be a waste of time and money. B. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. C. Although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms. D. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C). Correct Answer: C

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Transferrin. B. Prealbumin. C. Serum albumin. D. Urine urea nitrogen.

The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading. Correct Answer: C

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A). Correct Answer: A

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A. Sensory pattern, area, intensity, and nature of the pain. B. Trigger points identified by palpation and manual pressure of painful areas. C. Schedule and total dosages of drugs currently used for breakthrough pain. D. Sympathetic responses consistent with onset of acute pain.

Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome. Correct Answer: A

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicoden) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A. Accused of diversion. B. Reported for stealing. C. Reported for a HIPAA violation. D. Accused of unprofessional conduct.

2nd stage syphillis

A flu-like illness, a feeling of tiredness and loss of appetite, accompanied by swollen glands (this can last for weeks or months). A non-itchy rash covering the whole body or appearing in patches. Flat, warty-looking growths on the vulva in women and around the anus in both sexes. White patches on the tongue or roof of the mouth. Patchy hair loss.

normal findings in tpn

A gradual weight gain is to be expected as the client's nutritional status improves.

Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members. Correct Answer: D

A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies.

diet for cirrhosis

A low-protein and high-carbohydrate diet is recommended.

Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. Correct Answer: A, B, C, E

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A. Snack of potato chips, and diet soda. B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C. Breakfast of eggs, bacon, toast, and coffee. D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E. Bedtime snack of crackers and milk.

Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained. Correct Answer: A

A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration.

The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). Correct Answer: D

A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A. Use distraction techniques during times of spiritual stress and crisis. B. Reassure the client that his faith will be regained with time and support. C. Consult with the staff chaplain and ask that the chaplain visit with the client. D. Use reflective listening techniques when the client expresses spiritual doubts.

Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action. Correct Answer: B

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? A. Document the client's request in the medical record. B. Ask the client if this decision has been discussed with his healthcare provider. C. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs. Correct Answer: B

A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A. Low fat and low sodium foods. B. Combination of plant proteins to provide essential amino acids. C. Limited complex carbohydrates and fiber. D. Increased amount of vitamin C and beta carotene rich foods.

When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs when orthostatic hypotension occurs. Correct Answer: B

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A. Bradycardia. B. Increase in pulse rate. C. Peripheral vasodilation. D. Increase in cardiac output.

Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task (B). (A and D) are less respectful of the client's cultural and spiritual preferences. (C) delays the client's care. Correct Answer: B

A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A. May I ask your daughter to help you with your personal hygiene? B. I will ask one of the female nurses to bathe you. C. A staff member on the next shift will help you. D. I will keep you draped and hand you the supplies as you need them.

(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages. Correct Answer: A

A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 0800, 1200, 1600, 2000. B. 800. C. Every other day at 0800. D. 0800, 1200, 1600, 2000, 0000, 0400.

Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is describe by Erikson as the developmental stage of generativity (A), and is characteristic of middle adulthood. (B, C and D) are not stages of this age group according to Erickson's psychosocial developmental theory. Correct Answer: A

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom.

Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the family's needs to care for the client and are not the best ways to cope with the nurse's frustration. Although (D) may be an option, examining one's cultural differences allows the nurse to cope, empathize, and implement culturally specific interventions pertaining to the needs of the client and the family. Correct Answer: B

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client.

The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may cause increased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B). Correct Answer: C

A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa.

The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B)so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information. Correct Answer: D

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical. What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students. B. Notify the student's clinical instructor of the situation. C. Ask the student if permission was obtained from the client. D. Explain that the records are hospital property and may not be removed.

daunorubicin (DaunoXome)

A red, swollen I.V. site indicates possible infiltration.

The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice. Correct Answer: C

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A. A quasi-intentional tort because a similar mistake can happen to anyone. B. Failure to respect client autonomy to choose based on intentional tort law. C. Assault and battery with deliberate intent to deviate from the consent form. D. An unintentional tort because the client benefited from having the myelogram.

The nurse should first assess what the client desires (C). (A) is somewhat judgmental and attempts to solve the problem for the client without eliciting the client's feelings. Though a referral to the social worker (B) may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news (D), but the nurse should first provide support and assess what the client wants to see happen with her children. Correct Answer: C

A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. Your children are old enough to help you make decisions about their futures. B. The social worker can tell you about placement alternatives for your children. C. Tell me what you would like to see happen with your children in the future. D. You have just received bad news, and you need some time to adjust to it.

botulism For breathing trouble,

A tube may be inserted through the nose or mouth into the windpipe to provide an airway for oxygen. You may need a breathing machine.

men chlyamydia

A white/cloudy and watery discharge from the penis that may stain underwear; a burning sensation and/or pain when passing urine; pain and swelling in the testicles.

As a result of cholinergic crisis, the muscles stop responding to the bombardment of

ACh, leading to flaccid paralysis, respiratory failure, increased sweating, salivation, bronchial secretions along with miosis.

Bleeding and infection are the major complications and causes of death for clients with

AML.

men gonorrhea

Abnormal discharge from the penis (clear or milky at first, and then yellow, creamy, and excessive, sometimes blood-tinged).

Postoperatively after a modified radical mastectomy, a client has an incisional drainage tube attached to Hemovac suction. The nurse determines the suction is effective when:

Accumulated serum and blood in the operative area are removed

Hyposecretion of glucocorticoids, aldosterone, and androgens occur with

Addison's disease

Pituitary dysfunction can cause

Addison's disease, but this is not a primary disease process.

sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan

Aerobic activity. • Weight control.

Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent. Correct Answer: A

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.

sars

Airborne and contact precaution

Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:

Altered protective pressure sensation.

tpn complication

An elevated temperature can be an indication of an infection at the insertion site or in the catheter.

women chlamydia

An increase in vaginal discharge caused by an inflamed cervix; the need to urinate more frequently, or pain whilst passing urine; pain during sexual intercourse or bleeding after sex; lower abdominal pains; irregular menstrual bleeding.

A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams. Correct Answer: D

An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint. Correct Answer: D

An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? A. Apply flannel pajamas to provide warmth. B. Administer a PRN dose of ibuprofen. C. Perform range of motion exercises in a warm tub. D. Drape the sheets over the footboard of the bed.

Polyhydramnios treated with

Antacids may be prescribed to relieve heartburn and nausea and amnioreduction, also known as therapeutic Amniocentesis

The treatment for keratoconjunctivitis includes:

Antibiotic eye drops Antibiotic eye ointment Antiviral eye drops Cidofovir Artificial tears Cold compresses Corticosteroid eye drops: Dexamethasone (Ocu-Dex) Fluorometholone (Flarex, FML Forte) Prednisolone (Pred Forte) Rimexolone (Vexol)

meds for crohns disease

Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.

A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before going to the treatment room when the child feels less threatened. Correct Answer: C

As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? A. Take the child back to his room. B. Recruit others to restrain the child. C. Ask the mother to be present to soothe the child. D. Show the child how to manipulate the equipment.

cirrhosis and aspirin

Aspirin also should be avoided if esophageal varices are present.

The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. The nurse should immediately

Assess vital signs

respiratory excursion

Assessment of the movement of the chest during respiration

The "ABCDs" of melanoma are

Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter

The nurse is discussing a treatment plan for mononucleosis with an adolescent. The nurse emphasizes that the client mus

Avoid contact sports and vigorous exercise for 2 to 4 weeks

The nurse took the correct action and should document the events that occurred in the nurses' notes (C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's medical record and should be placed in the chart, (D) when no longer current. Correct Answer: C

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record.