3020 Exam 2
open angle glaucoma
Wide angle between cornea and iris (Most common/ treatable with drugs) -S&S: none at first... loss of peripheral vision (edges are dark) -The door is "open" for the outflow of aqueous humor -Treat: Cholinergic agents
Signs of transfusion-associated Circulatory overload (TACO)?
blood is infused too quick S&S: HTN, bonding pulse, JVD, SOB, restless, confusion Reduce: monitor I&O, infuse slow, diuretics
What vascular changes happen with a burn?
circulation is disrupted at first -> vasoconstriction -> fluid shifts from vascular space to interstitial space (3rd spacing) -> edema ALL OVER Leads to... hypovolemia, metabolic acidosis (from circulating dead cells), hyperkalemia, and hyponatermia
Hyperopia
farsightedness - far is clear Fix = convex lens -> move light in front of retina
stage 3 pressure injury
full thickness loss, looks like deep crater extend to fascia, subtaneous tissue damged/necrpticfat visable undermining/tunneling may be present damage to surrounding tissue
Unstageable pressure injury
full-thickness wound covered by nonviable slough tissue. Unable to stage wound due to this.
A client with sickle cell anemia has a low hematocrit. high hematocrit. normal hematocrit. normal blood smear.
low hematocrit
Iron foods
meats, chicken, fish, liver, legumes, green leafy veggies, raisins
Myopia
nearsightedness - close is clear Fix = biconcave lenses -> move light back to retina
stage 1 pressure injury
non-blanchable erythema of intact skin
stage 2 pressure injury
partial thickness skin loss with exposed dermis/ blisters
deep tissue pressure injury
persistent non-blanchable deep red, maroon, or purple discoloration
Meinere's disease
rare disorder characterized by progressive deafness, vertigo, and tinnitus
osteomalacia
softening of the bone
strain vs sprain
strain: musculo-tendon sprain: ligamentous
astigmatism
uneven curved surfaces of eye = distorted vision (not focused on retina)
Common cause of vitamin B12 deficiency anemia?
vegan diet or pernicious anemia (failure to absorb VB12 b/c not enough intrinsic factors in GI mucosa)
A 60-year-old patient with chronic myeloid leukemia will be treated in the home setting and the nurse is preparing appropriate health education. What topic should the nurse emphasize? A) The importance of adhering to the prescribed drug regimen B) The need to ensure that vaccinations are up to date C) The importance of daily physical activity D) The need to avoid shellfish and raw foods
A
An unresponsive Caucasian patient has been brought to the emergency room by EMS. While assessing this patient, the nurse notes that the patient's face is a cherry-red color. What should the nurse suspect? A)Carbon monoxide poisoning B)Anemia C)Jaundice D)Uremia
A
Following a serious thermal burn, which complication will the nurse take action to prevent first? A. Infection B. Renal failure C. Hypovolemia D. Tissue hypoxia
C
The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of otitis externa? A) Tophi on the pinna and ear lobe B) Dark yellow cerumen in the external auditory canal C) Pain on manipulation of the auricle D) Air bubbles visible in the middle ear
C
A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage? A) Rinsing the ears with normal saline after swimming B) Avoiding loud environmental noises C) Instilling antibiotic ointments on a regular basis D) Avoiding the use of cotton swabs
D
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? A. 9% B. 18% C. 27% D. 36%
D 1 leg = 9% front/ 9% back... both legs entirely so 36% total
Signs of transfusion-related acute lung injury (TRALI)?
Donor blood has antibodies against recipient blood (Life threatening!) S&S: rapid SOB, hypoxia (within 6 hours)
dry vs wet macular degeneration
Dry - progressive and slow in one or both eyes (gradual blockage of retina capillaries) -S&S: "drusen" aka yellow spots beneath retina Wet - rapid with visions of wavy lines and loss of central vision usually in one eye. (quickly getting splashed in one eye) -S&S: abrupt vision disturbance "lines are crooked" or "word letters are broken"
Heparin-induced thrombocytopenia (HIT)
Extreme decrease in platelets after heparin treatment- Development of IgG antibodies against heparin- bound platelet factor 4 (PF4). Antibody-heparin-PF4 complex activates platelets -> thrombosis and thrombocytopenia. S&S: VTE, bleeding, skin necrosis -Thrombocytopnea -Thrombosis -Timing of platelet count fall (usually 50% 5-5 days after therapy)
stage 4 pressure injury
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.
What is the most common cause for anemia in adults?
GI bleeding
Bone Mineral Density (BMD) DEXA Scan
Gives a "T" score - shows # of standard deviations above/ below average BMD for young adults Healthy = 0 Osteopenia = -1 - -2.5 Osteoporosis = < -2.5
What cardiac changes occur with a burn?
HR increase/ CO decrease (from hypovolemia) -> more workload -> shock
Iron deficiency anemia nursing interventions
Increase Iron -Food! (meat, eggs, green leafy) -Pharm: ferrous sulfate pills & iron dextran
TBSA Rule of 9's
Total Body Surface Area head: 4.5% anterior/ 4.5% posterior Chest: 18% anterior/ 18% posterior Abdomen: 4.5% anterior/ 4.5% posterior Arms: 4.5% full anterior/ 4.5% full posterior Legs: 9% full anterior/ 9% full posterior Remember- legs and arms could be further divided to upper and lower areas
What is the MOST sensitive assessment for CO in a burn?
Urine output
Signs of allergic transfusion reaction?
Urticaria, itch, bronchospasm, anaphylaxis (24 hours after infusion) Reduce: give leukocyte reduced blood, or just RBC
What type of VB12 would the pt. get if they have pernicious anemia?
VB12 injections (body can't absorb oral intake)
Iron deficiency anemia S&S
Weak, pallor, tired, fissures in mouth corners, brittle nails, Pica Low Hgb, Hct, MCV, Serum iron
A young student comes to the school nurse and shows the nurse a mosquito bite. As the nurse expects, the bite is elevated and has serous fluid contained in the dermis. How would the nurse classify this lesion?
Wheal- elevated with fluid in the dermis
Disseminated Intravascular Coagulation (DIC)
abnormal blood clotting in small vessels throughout the body that cuts off the supply of oxygen to distal tissues, resulting in damage to body organs. (the blocked organs -> widespread clotting -> less clotting factors -> extensive bleeding) Nurse: prevent infections! also early = heparin, later = give clotting factors
Vitamin B12 foods
animal products, nuts, dairy, dried beans, citrus fruits, leafy green veggies
ABCDEs of melanoma
asymmetry (shape) border (undefined) color (variations) diameter (>6mm) evolution (changing)
Bacterial conjunctivitis S&S + treatment
- blood vessel dilation, redness -Edema -Burning -Discharge: watery -> thick -Eye crust Treat: ophthalmic antibiotics / teach to wash hands
otitis External Treatment
-Heat on ear 20 minutes 3X day -Topical antibiotic drops -Minimize head movement -X water sports for 7-10 days -Home remedy- 50% rubbing ETOH, 25% white vinegar, 25% distilled H20
Otitis Media Treatment
-Quit environment, low heat application -X head move -PO antibiotics -antipyretics for fever -Surgery: tube placement if recurrent
Retinal tear S&S
-Sudden onset/ painless -Bright flash of light -Floating ark spots Shade or curtain effect
Foods that influence calcium absorbtion
-X Calcium or vitamin D = Ca released from bone (From PTH stimulation) -high Phosphorus = Ca loss -High carbonation = Ca loss -X protein = Ca loss (50% Ca is protein bound)
Cataracts S&S
-early = slightly blurred vision/ less color perception -double vision
Allergic Conjunctivitis S&S + treatment
-edema -Burning -"bloodshot eyes" -Tears -Itchy -Photophobia Treat: cool compress, artificial tears, NSAIDS, antihistamines, Corticosteroid eyedrops
Signs of cellulitis
-red, warm, tender, edematous skin -inflammation -localized or entire limb (lymph involvement) -increased WBC
Glaucoma education
1. DO NOT combine eyedrops 2. Wait 5-10 minutes between drops 3. Punctual occlusion: put pressure on inner eye corner near the nose to prevent systemic absorption of the drug
Nurse Care for hip arthroplasty
1. Prevent Adduction (DON'T have legs together, use pillow) 2. NEVER flex hip > 90° 3. DO NOT elevate legs when sitting
Skin cancer prevention tips
1. X sun exposure 11-3 PM 2. Sunscreen 3. wear hat/ clothes that cover/ sunglasses 4. examine body monthly
Braden scale categories
1. sensory perception (1-4) 2. moisture (1-4) 3. activity (1-4) 4. mobility (1-4) 5. nutrition (1-4) 6. friction/shear (1-3)
pediculosis treatment
1. topical permethrin/ piperonyl butoxide 2. dip comb in vinegar/ manually remove lice 3. Teach: its not uncleanly, clean linens, treat family
Diet change to prevent osteoporosis
3 glasses VD Milk (1 cup = 300 mg Ca) or other dairy products Protein- Salmon Broccoli Mg Vitamin K Men 50-70 = 1000 mg Women > 51/ men > 70 = 1200 mg
When does the diuretic stage occur after a burn?
48-72 hours (day 3 = start to pee) -capillary membrane integrity returned so fluid goes back-> blood volume increase -> more kidney flow + diuresis
A 6-year-old child is brought to the pediatric clinic for the assessment of redness and discharge from the eye and is diagnosed with viral conjunctivitis. What is the most important information to discuss with the parents and child? A) Handwashing can prevent the spread of the disease to others. B) The importance of compliance with antibiotic therapy C) Signs and symptoms of complications, such as meningitis and septicemia D) The likely need for surgery to prevent scarring of the conjunctiva
A
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? A. inflammatory B. neuroendocr C. ineintravascular fluid excess D. hypertension
A
A nurse is caring for a patient who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. Which of the following measures will best achieve these goals?* A) Encouraging the patient to turn from side to side and to assume a prone position B) Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C) Minimizing movement of the flexor muscles of the hip D) Encouraging the patient to sit in a chair for at least 8 hours a day
A
A nurse is caring for a patient who has a diagnosis of acute leukemia. What assessment most directly addresses the most common cause of death among patients with leukemia?* A) Monitoring for infection B) Monitoring nutritional status C) Monitor electrolyte levels D) Monitoring liver function
A
A nurse is teaching a patient with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the patient to perform what action? A) Instill the medication in the conjunctival sac. B) Maintain a supine position for 10 minutes after administration. C) Keep the eyes closed for 1 to 2 minutes after administration. D) Apply the medication evenly to the sclera
A
A nurse is writing a care plan for a patient admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a patient with an open fracture of the radius? A) Risk for Infection B) Risk for Ineffective Role Performance C) Risk for Perioperative Positioning Injury D) Risk for Powerlessness
A
A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding? A) This is a normal aging process of the eye. B) Glasses will minimize this phenomenon. C) The patient may be exhibiting signs of glaucoma. D) This may be a result of weakened ciliary muscles.
A
A patient who has undergone a lower limb amputation is preparing to be discharged home. What outcome is necessary prior to discharge? A) Patient can demonstrate safe use of assistive devices. B) Patient has a healed, nontender, nonadherent scar. C) Patient can perform activities of daily living independently. D) Patientis free of pain.
A
Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Pulmonary system B. Nutrition C. Pain D. Cardiovascular system
A
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A. A urine output consistently above 40 ml/hour B. A weight gain of 4 lb (2 kg) in 24 hours C. Body temperature readings all within normal limits D. n electrocardiogram (ECG) showing no arrhythmias
A
The health care team is caring for a patient with osteomalacia. It has been determined that the osteomalacia is caused by malabsorption. What is the usual treatment for osteomalacia caused by malabsorption? A) Supplemental calcium and increased doses of vitamin D B) Exogenous parathyroid hormone and multivitamins C) Colony-stimulating factors and calcitonin D) Supplemental potassium and pancreatic enzymes
A
The nurse in the ED is caring for a 4 year-old brought in by his parents who state that the child will not stop crying and pulling at his ear. Based on information collected by the nurse, which of the following statements applies to a diagnosis of external otitis? A) External otitis is characterized by aural tenderness. B) External otitis is usually accompanied by a high fever. C) External otitis is usually related to an upper respiratory infection. D) External otitis can be prevented by using cotton-tipped applicators to clean the ear.
A
The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient, what characteristic symptom would the nurse expect to find? A) Flashing lights in the visual field B) Sudden eye pain C) Loss of color vision D) Colored halos around lights
A
The nurse is providing discharge education for a patient with a new diagnosis of Ménière's disease. What food should the patient be instructed to limit or avoid? A) Sweet pickles B) Frozen yogurt C) Shellfish D) Red meat
A
The nurse should recognize the greatest risk for the development of blindness in which of the following patients? A) A 58-year-old Caucasian woman with macular degeneration B) A 28-year-old Caucasian man with astigmatism C) A 58-year-old African American woman with hyperopia D) A 28-year-old African American man with myopia
A
The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? A. Liquid blood component is lost into extravascular space B. Fluid loss C. Decreased renal blood flow D. Sodium and water retention caused by increase adrenocortical activity
A
The patient scheduled for a Syme amputation is concerned about the ability to eventually stand on the amputated extremity. How should the nurse best respond to the patients concern? A)You will eventually be able to withstand full weight-bearing after the amputation. B) You will have minimal weight-bearing on this extremity but you'll be taught how to use an assistive device. C) You likely will not be able to use this extremity but you will receive teaching on use of a wheelchair. D) You will be fitted for a prosthesis which may or may not allow you to walk.
A
The surgical nurse is admitting a patient from post-anesthetic recovery following the patients below-the- knee amputation. The nurse recognizes the patients high risk for postoperative hemorrhage and should keep which of the following at the bedside? A) A tourniquet B) A syringe preloaded with vitamin K C) A unit of packed red blood cells, placed on ice D) A dose of protamine sulfate
A
When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? A.1 B.2 C.3 D.4
A
Which of the following is considered an antidote to heparin? A. Protamine sulphate B. Vitamin K C.Narcan D. Ipecac
A
The nurse is performing an assessment on a patient with acute myeloid leukemia (AML) and observes multiple areas of ecchymosis and petechiae. What laboratory study should the nurse be concerned about? A) Platelet count of 9,000/mm3 B) WBC count of 4,200 cells/mcL C) Hematocrit of 38% D) Creatinine level of 1.0 mg/dL
A Complications of AML include bleeding and infection, which are the major causes of death. The risk of bleeding correlates with the level and duration of platelet deficiency (thrombocytopenia).
The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption? A. Eating calf's liver with a glass of orange juice B. Eating leafy green vegetables with a glass of water C. Eating apple slices with carrots D. Eating a steak with mushrooms
A Iron foods: organ meats (e.g., beef or calf's liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.
A nurse is explaining a patients decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply. A) Thyroid hormone B) Growth hormone C) Estrogen D) Vitamin B12 E) Luteinizing hormone
A B C
The nurse is assessing a patient for dietary factors that may influence her risk for osteoporosis. The nurse should question the patient about her intake of what nutrients? Select all that apply. A) Calcium B) Simple carbohydrates C) Vitamin D D) Protein E) Soluble fiber
A C
Acute Compartment Syndrome (ACS)
A serious condition in which increased pressure within a compartment compromises circulation to the area. • Blood or fluid accumulate in compartment • Causes: reduction of compartment size (i.e. cast too tight, bulky dressings), an increase in muscle compartment contents because of edema or hemorrhage i.e. crushing injuries • Forearm and leg- most often involved • Neuromuscular damage is irreversible in 4-6 hours; limb useless in 24-48 hours S&S: less sensation
Signs of Febrile Transfusion reaction
Anti WBC antibodies cause reaction S&S: chills, high HR, tachypnea, fever, HTN Reduce risk: give leukocyte reduced blood, give HLA matched plts., WBC filters
Which type of sickle crisis occurs as a result of infection with the human parvovirus? Sequestration crisis Aplastic crisis Sickle cell crisis Acute chest syndrome
Aplastic crisis Aplastic crisis results from infection with the human parvovirus. Sequestration crisis results when other organs pool the sickled cells. Sickle cell crisis results from tissue hypoxia and necrosis due to inadequate blood flow to a specific region of tissue or organ.
A clients health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patients increased risk for what hematologic disorder? A) Leukemia B) Anemia C) Thrombocytopenia D) Lymphoma
B
A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis? A) Hot skin with a capillary refill of 1 to 2 seconds B) Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin C) Pain, diaphoresis, and erythema D) Jaundiced skin, weakness, and capillary refill of 3 seconds
B
A nurse is planning preoperative teaching for a patient with hearing loss due to otosclerosis. The patient is scheduled for a stapedectomy with insertion of a prosthesis. What information is most crucial to include in the patient's preoperative teaching? A) The procedure is an effective, time-tested treatment for sensory hearing loss. B) The patient is likely to experience resolution of conductive hearing loss after the procedure. C) Several months of post-procedure rehabilitation will be needed to maximize benefits. D) The procedure is experimental, but early indications suggest great therapeutic benefits.
B
A patient has sustained a long bone fracture and the nurse is preparing the patients care plan. Which of the following should the nurse include in the care plan? A) Administer vitamin D and calcium supplements as ordered. B) Monitor temperature and pulses of the affected extremity. C) Perform passive range of motion exercises as tolerated. D) Administer corticosteroids as ordered.
B
A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents? A)The child's scalp should be monitored for 48 to 72 hours before starting treatment. B)Nits may have to be manually removed from the child's hair shafts. C)The disease is self-limiting and symptoms will abate within 1 week. D)Efforts should be made to improve the child's level of hygiene.
B
An older adult patient has fallen in her home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the patients presurgical care, the nurse should be aware of the patients heightened risk of what complication? A) Osteomyelitis B) Avascular necrosis C) Phantom pain D) Septicemia
B
Assessment of a patient's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion? A)Keloid B)Ulcer C)Fissure D)Erosion
B
Clinical assessment of a patient with AML includes observing for signs of infection, the major cause of death for AML. The nurse should assess for indicators of: A) Thrombocytopenia. B) Splenomegaly. C) Bone marrow expansion. D) Neutropenia.
B
The nurse and a colleague are performing the Epley maneuver with a patient who has a diagnosis of benign paroxysmal positional vertigo. The nurses should begin this maneuver by performing what action? A) Placing the patient in a prone position B) Assisting the patient into a sitting position C) Instilling 15 mL of warm normal saline into one of the patient's ears D) Assessing the patient's baseline hearing by performing the whisper test
B
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patients physician. B) Stop the transfusion immediately. C) Remove the patients IV access. D) Assess the patients chest sounds and vital signs.
B
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A. A urinary output of 10 mL/hr B. A urinary output of 30 mL/hr C. A urinary output of 80 mL/hr D. A urinary output of 100 mL/hr
B
The nurse is providing care for a patient who has had a below-the-knee amputation. The nurse enters the patients room and finds him resting in bed with his residual limb supported on pillow. What is the nurses most appropriate action? A) Inform the surgeon of this finding. B) Explain the risks of flexion contracture to the patient. C) Transfer the patient to a sitting position. D) Encourage the patient to perform active ROM exercises with the residual limb.
B
The nurse is providing health education to a patient newly diagnosed with glaucoma. The nurse teaches the patient that this disease has a familial tendency. The nurse should encourage the patient's immediate family members to undergo clinical examinations how often? A) At least monthly B) At least once every 2 years C) At least once every 5 years D) At least once every 10 years
B
The nurse on the medical-surgical unit is reviewing discharge instructions with a patient who has a history of glaucoma. The nurse should anticipate the use of what medications? A) Potassium-sparing diuretics B) Cholinergics C) Antibiotics D) Loop diuretics
B
Which of the following is the most appropriate nursing intervention to facilitate healing in a patient who has suffered a hip fracture? A) Administer analgesics as required. B) Place a pillow between the patients legs when turning. C) Maintain prone positioning at all times. D) Encourage internal and external rotation of the affected leg.
B
While assessing a patient who has had knee replacement surgery, the nurse notes that the patient has developed a hematoma at the surgical site. The affected leg has a decreased pedal pulse. What would be the priority nursing diagnosis for this patient? A) Risk for Infection B) Risk for Peripheral Neurovascular Dysfunction C) Unilateral Neglect D) Disturbed Kinesthetic Sensory Perception
B
A patient has just returned to the surgical floor after undergoing a retinal detachment repair. The postoperative orders specify that the patient should be kept in a prone position until otherwise ordered. What should the nurse do? A) Call the physician and ask for the order to be confirmed. B) Follow the order because this position will help keep the retinal repair intact. C) Instruct the patient to maintain this position to prevent bleeding. D) Reposition the patient after the first dressing change
B Air bubble will keep retina in place!
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? A. Prevent infection B. Fluid resuscitation C. Endotracheal tube placement D. Strict intake and output
B Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? A. Ca: 9 mg/dL B. BUN: 28 mg/dL C. Na+: 145 mEq/L D. K+: 5.0 mEq/L
B Possible renal failure would be an issue
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? A. The client's heart rate is rapid and regular. B. The client's urinary output is 0.5 to 1 mL/kg/hour. C. The client's breathing is unlabored, and skin is clammy. D. The client is alert and conscious.
B We want to replace fluids from fluid shift!
A nurse in a busy emergency department provides care for many patients who present with contusions, strains, or sprains. Treatment modalities that are common to all of these musculoskeletal injuries include which of the following? Select all that apply. A) Massage B) Applying ice C) Compression dressings D) Resting the affected extremity E) Corticosteroids F) Elevating the injured limb
B C D F
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? A. AlbuminDextrose 5% in water (D5W) B. Lactated Ringer's solution C. Normal saline solution with 20 mEq of potassium per 1,000 ml
C
A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem? A. A hemolytic reaction to mismatched blood B. A hemolytic reaction to Rh-incompatible blood C. A hemolytic allergic reaction caused by an antigen reaction D. A hemolytic reaction caused by bacterial contamination of donor blood
C
A nurse in a dermatology clinic is reading the electronic health record of a new patient. The nurse notes that the patient has a history of a primary skin lesion. What is an example of a primary skin lesion? A)Crust B)Keloid C)Pustule D)Ulcer
C
A nurse is caring for a patient who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the patient does which of the following in order to prevent common complications associated with a hip fracture? A) Avoid requesting analgesia unless pain becomes unbearable. B) Use supplementary oxygen when transferring or mobilizing. C) Increase fluid intake and perform prescribed foot exercises. D) Remain on bed rest for 14 days or until instructed by the orthopedic surgeon.
C
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: A. planning for the client's rehabilitation and discharge. B. providing emotional support to the client and family. C. maintaining the client's fluid, electrolyte, and acid-base balance. D. preserving full range of motion in all affected joints.
C
A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)? A)Teaching participants to improve their overall health through nutrition B)Encouraging participants to identify their family history of cancer C)Teaching participants to limit their sun exposure D)Teaching participants to control exposure to environmental and occupational radiation
C
A nurse is performing a shift assessment on an elderly patient who is recovering after surgery for a hip fracture. The nurse notes that the patient is complaining of chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the patient is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this patient is likely demonstrating symptoms of what complication? A) Avascular necrosis of bone B) Compartment syndrome C) Fat embolism syndrome D) Complex regional pain syndrome
C
A patient has been diagnosed with hearing loss related to damage of the end organ for hearing or cranial nerve VIII. What term is used to describe this condition? A) Exostoses B) Otalgia C) Sensorineural hearing loss D) Presbycusis
C
A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patient's health status? A) For some patients, these recurrent infections constitute an age-related physiologic change. B) The patient would benefit from a temporary mobility restriction to facilitate healing. C) The patient needs to be assessed for nasopharyngeal cancer. D) Blood cultures should be drawn to rule out a systemic infection.
C
A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patients consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance? A) Vitamin E B) Vitamin D C) Iron D) Magnesium
C
A patient has informed the home health nurse that she has recently noticed distortions when she looks at the Amsler grid that she has mounted on her refrigerator. What is the nurse's most appropriate action? A) Reassure the patient that this is an age-related change in vision. B) Arrange for the patient to have her visual acuity assessed. C) Arrange for the patient to be assessed for macular degeneration .D) Facilitate tonometry testing.
C
An elderly patient's hip joint is immobilized prior to surgery to correct a femoral head fracture. What is the nurse's priority assessment? A) The presence of leg shortening B) The patient's complaints of pain C) Signs of neurovascular compromise D) The presence of internal or external rotation
C
An older adult patient has been diagnosed with macular degeneration and the nurse is assessing him for changes in visual acuity since his last clinic visit. When assessing the patient for recent changes in visual acuity, the patient states that he sees the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response? A) Ask if the patient has been using OTC vasoconstrictors. B) Instruct the patient to repeat the test at different times of the day when at home. C) Arrange for the patient to visit his ophthalmologist. D) Encourage the patient to adhere to his prescribed drug regimen.
C
Six weeks after an above-the-knee amputation (AKA), a patient returns to the outpatient office for a routine postoperative checkup. During the nurses assessment, the patient reports symptoms of phantom pain. What should the nurse tell the patient to do to reduce the discomfort of the phantom pain? A) Apply intermittent hot compresses to the area of the amputation. B) Avoid activity until the pain subsides. C) Take opioid analgesics as ordered. D) Elevate the level of the amputation site.
C
The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies? A. Hypernatremia B. Hypokalemia C. Hyperkalemia D. Hypercalcemia
C
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? A. Diverticulitis B. Hematemesis C. Paralytic ileus D. Ulcerative colitis
C
Which of the following vitamins enhance the absorption of iron? C A D E
C OJ or Vitamin C tablets with iron tabs.
A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as A. 36%. B. 27%. C. 18%. D. 9%.
C Rule of nines: Abdomen 4.5% anterior + 4.5% posterior + 9% anterior leg = 18%
A patient is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The patient has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this patient? Select all that apply. A) Systemic infection B) Complex regional pain syndrome C) Deep vein thrombosis D) Compartment syndrome E) Fat embolism
C D E
A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered? A) Ossiculoplasty B) Insertion of a cochlear implant C) Stapedectomy D) Insertion of a ventilation tube
D
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? A. silvadene application B. debridement C. allograft D. escharotomy
D
A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client? A. Ventilator assisted breathing B. Endotracheal tube insertion C. Tracheostomy D. Escharotomy
D
A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? A. Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician. B. Slow the transfusion and monitor the client closely. C. Stop the transfusion, notify the blood bank, and administer antihistamines. D. Immediately stop the transfusion, infuse normal saline solution, call the physician, and notify the blood bank.
D
A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what? A) Slight morning discharge from the eye B) Any appearance of redness of the eye C) A "scratchy" feeling in the eye D) A new floater in vision
D
A patient is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. Which of the following is the most plausible explanation for this patients signs and symptoms? A) Subluxated right hip B) Right hip contusion C) Hip strain D) Traumatic hip dislocation
D
An 82-year-old patient is being treated in the hospital for a sacral pressure ulcer. What age-related change is most likely to affect the patient's course of treatment? A)Increased thickness of the subcutaneous skin layer B)Increased vascular supply to superficial skin layers C)Changes in the character and quantity of bacterial skin flora D)Increased time required for wound healing
D
An African American is admitted to the medical unit with liver disease. To correctly assess this patient for jaundice, on what body area should the nurse look for yellow discoloration? A)Elbows B)Lips C)Nail beds D)Sclerae
D
An emergency department patient is diagnosed with a hip dislocation. The patients family is relieved that the patient has not suffered a hip fracture, but the nurse explains that this is still considered to be a medical emergency. What is the rationale for the nurses statement? A) The longer the joint is displaced, the more difficult it is to get it back in place. B) The patients pain will increase until the joint is realigned. C) Dislocation can become permanent if the process of bone remodeling begins. D) Avascular necrosis may develop at the site of the dislocation if it is not promptly resolved
D
The nurse is administering eye drops to a patient with glaucoma. After instilling the patient's first medication, how long should the nurse wait before instilling the patient's second medication into the same eye? A) 30 seconds B) 1 minute C) 3 minutes D) 5 minutes
D
The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? A. Document the findings and instruct the client to report numbness of the extremity. B. Apply an elastic stocking to the extremity and administer SQ heparin per order. C. Elevate the leg on pillows and reassess the leg in 1 hour. D. Contact the primary care provider and prepare for an escharotomy.
D
Your client has just been prescribed oral iron. Why would you advise this client to avoid taking their medication with coffee, tea, eggs, or milk? A) Untoward reactions may occur. B) Coffee, tea, eggs, and milk interact with oral iron. C) Grand mal seizures may result. D) Absorption of iron will decrease.
D
What does a nurse do if patient develops HIT?
Heparin-induced thrombocytopenia (HIT) = very low platelets 1. STOP heparin 2. Start different anticoagulation therapy (direct thrombin inhibitors) 3. Teach X heparin 3-4 months after (can have increased risk of recurrence)
The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the physician. What type of anemia is the nurse concerned the co-worker may have? Iron deficiency anemia Megaloblastic anemia Sickle cell anemia Aplastic anemia
Iron deficiency anemia Explanation: People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.
angle closure glaucoma
Narrow angle between cornea and iris where iris is pushed forward and aqueous humor outflow is stopped -EMERGENCY -S&S: severe eye pain, redness, decreased/ blurred vision, seeing halos or rainbows, HA, N/V
Parkland Formula*
PF = 4ml X weight (kg) X TBSA % -Give 1/2 in first 8 hours -Give 2nd 1/2 in next 16 hours -Use "dry weight" (weight before burn edema) -Calculate from TIME OF INJURY not when they arrived to the hospital
Where to assess for jaundice in African Americans?
Sclera and hard palate
A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patients health history would most likely predispose her to this deficiency? A) The patient has irregular menstrual periods. B) The patient is a vegan. C) The patient donated blood 60 days ago. D) The patient frequently smokes marijuana.
B
A patient with diabetes is attending a class on the prevention of associated diseases. What action should the patient perform to reduce the risk of osteomyelitis? A) Increase calcium and vitamin intake. B) Perform meticulous foot care. C) Exercise 3 to 4 times weekly for at least 30 minutes. D) Take corticosteroids as ordered.
B
The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A) Myocardial muscle tissue B) All body fluids C) Cerebral tissue D) Venous and arterial vessel walls
B
Things to do during blood transfusion?
1. Check blood for gas bubbles/ cloudiness 2. Verify with another nurse @ bedside 3. Start with ONLY NS 4. Stay with pt. first 15-30 minutes 5. Infuse at prescribed rate & slow for the first 15 minutes (keep < 4 hours) 6. monitor vitals/ sign of reactions
Ways to prevent Osteoporosis
1. More calcium (diet/ supplements) 2. Vitamin D (sun/ supplements) 3. weight bearing exercise- MOST effective if walking 2-5 times a week 4. Lifestyle (X smoke, X carbonation, X caffeine, X ETOH) 5. Pharm (if T-score < -2)
An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A) Stool for occult blood B) Bone marrow biopsy C) Lumbar puncture D) Urinalysis
A
An older adult patient has symptoms of osteoporosis and is being assessed during her annual physical examination. The assessment shows that the patient will require further testing related to a possible exacerbation of her osteoporosis. The nurse should anticipate what diagnostic test? A) Bone densitometry B) Hip bone radiography C) Computed tomography (CT) D) Magnetic resonance imaging (MRI)
A
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? A. Beans, dried fruits, and leafy, green vegetables B. Fruits high in vitamin C, such as oranges and grapefruits C. Berries and orange vegetables D. Dairy products
A
Which medication is the antidote to warfarin? A. Vitamin K B. Protamine sulfate C. Aspirin D. Clopidogrel
A
You are caring for a client with thalassemia who is being transfused. What your role during a transfusion? A. To closely monitor the rate of administration B. To administer vitamin B12 injections C. To instruct the client to rest immediately if chest pain develops D. To assess for enlargement and tenderness over the liver and spleen
A
A client is prescribed 325 mg/day of oral ferrous sulfate. The nurse includes in client teaching, "Take your iron pill... A. 1 hour before breakfast" B. with dairy products" C. and decrease fruits and juices in your diet" D. along with a decreased amount of dietary fiber"
A Explanation: Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation.
S/S of Non-Hodgkin's Lymphoma
All lymphoid cancers without "Reed-strenberd cells" that starts in less orderly fasion 1. Lymphadenopathy: painless swelling of nodes (upper body) 2. tumor spreads elsewhere (GI, skin, bone marrow) 3. B symptoms in 1/3 of cases (fever > 101.5° F, night sweats, > 10% weight loss
A nurse is assessing a patient who is receiving traction. The nurse's assessment confirms that the patient is able to perform plantar flexion. What conclusion can the nurse draw from this finding? A) The leg that was assessed is free from DVT. B) The patient's tibial nerve is functional. C) Circulation to the distal extremity is adequate. D) The patient does not have peripheral neurovascular dysfunction.
B
A nurse is reviewing a patient's activities of daily living prior to discharge from total hip replacement. The nurse should identify what activity as posing a potential risk for hip dislocation? A) Straining during a bowel movement B) Bending down to put on socks C) Lifting items above shoulder level D) Transferring from a sitting to standing position
B
A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client? A. Limit visits by family members. B. Encourage the client to use a wheelchair. C. Use the smallest needle possible for injections. D. Maintain accurate fluid intake and output records.
C
A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What risk factor of the following should the educator describe? A) Recurrent infections and prolonged use of NSAIDs B) High alcohol intake and low body mass index C) Small frame, female gender, and Caucasian ethnicity D) Male gender, diabetes, and high protein intake
C
A patient is complaining of pain in her casted leg. The nurse has administered analgesics and elevated the limb. Thirty minutes after administering the analgesics, the patient states the pain is unrelieved. The nurse should identify the warning signs of what complication? A) Subcutaneous emphysema B) Skin breakdown C) Compartment syndrome D) Disuse syndrome
C
A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patients vital signs to establish baselines. D) Facilitate insertion of a central venous catheter.
C
Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education? A) Infection risks associated with FFP administration B) Physiologic functions of plasma C) Signs and symptoms of a transfusion reaction D) Strategies for managing transfusion-associated anxiety
C
The results of a nurses musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? A) Osteoporosis B) Kyphosis C) Lordosis D) Scoliosis
C
he nurse is caring for a patient who underwent a total hip replacement yesterday. What should the nurse do to prevent dislocation of the new prosthesis? A) Keep the affected leg in a position of adduction. B) Have the patient reposition himself independently. C) Protect the affected leg from internal rotation. ) Keep the hip flexed by placing pillows under the patient's knee.
C
A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the childs muscles have greater-than-normal tone. The nurse should document the presence of which of the following? A) Tonus B) Flaccidity C) Atony D) Spasticity
D
A nurse is assessing the neurovascular status of a patient who has had a leg cast recently applied. The nurse is unable to palpate the patient's dorsalis pedis or posterior tibial pulse and the patient's foot is pale. What is the nurse's most appropriate action? A) Warm the patient's foot and determine whether circulation improves. B) Reposition the patient with the affected foot dependent. C) Reassess the patient's neurovascular status in 15 minutes. D) Promptly inform the primary care provider.
D
Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, Im terrified of getting AIDS from a blood transfusion. How can the nurse best address the patients concerns? A) All the donated blood in the United States is treated with antiretroviral medications before it is used. B) That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility. C) HIV was eradicated from the US blood supply in the early 2000s. D) The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low.
D
A clinic patient is being treated for polycythemia vera and the nurse is providing health education. What practice should the nurse recommend in order to prevent the complications of this health problem? A) Avoiding natural sources of vitamin K B) Avoiding altitudes of ³1500 feet (457 meters) C) Performing active range of motion exercises daily D) Avoiding tight and restrictive clothing on the legs
D Because of the risk of DVT, patients with polycythemia vera should avoid tight and restrictive clothing
A nurse is caring for a patient who is recovering in the hospital following orthopedic surgery. The nurse is performing frequent assessments for signs and symptoms of infection in the knowledge that the patient faces a high risk of what infectious complication? A) Cellulitis B) Septic arthritis C) Sepsis D) Osteomyelitis
D Osteomyelitis = bone infection
6 Ps for Poor circulation
Pain Pallor (Cyanosis) Poikilothermia (cold) Paresthesia (X sensation) Paralysis Pulselessness
Signs of Hemolytic Transfusion Reaction
blood type/ Rh incompatibility = antigen antibody complexes -> inflammatory response and coagulation S&S: DIC (disseminated IV coagulation), circulatory collapse, HA, apprehension, Low back pain, tachycardia/ tachypnea, hypotension, impending doom
A 50-year-old woman was recently diagnosed with non-Hodgkin's lymphoma (NHL) and has begun a treatment regimen that includes simultaneous radiation therapy and chemotherapy. The combination of severe symptoms and aggressive therapy has necessitated admission to the hospital. When providing care for this patient, which of the following actions should the nurse implement? A) Applying standard precautions conscientiously to reduce the patient's risk of infection B) Monitoring the patient's bowel pattern and facilitating a high-fiber diet C) Encouraging frequent mobilization and independence in activities of daily living D) Providing meticulous skin care and turning the patient at least once every 2 hours
A
A nurse is caring for a patient who is postoperative day 1 right hip replacement. How should the nurse position the patient? A) Keep the patient's hips in abduction at all times. B) Keep hips flexed at no less than 90 degrees. C) Elevate the head of the bed to high Fowler's. D) Seat the patient in a low chair as soon as possible.
A
A patient with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the patient's care plan? A) Protective isolation and vigilant use of standard precautions B) Provision of a high-calorie, low-texture diet and appropriate oral hygiene C) Including the family in planning the patient's activities of daily living D) Monitoring and treating the patient's pain
A
An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The patient should undergo diagnostic testing for what health problem? A) Osteomyelitis B) Osteoporosis C) Osteomalacia D) Septic arthritis
A
An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A) Ensure that blood components are never infused at a rate greater than 125 mL/hr. B) Administer prophylactic antihistamines prior to all blood transfusions. C) Establish baseline vital signs for all patients receiving transfusions. D) Be vigilant in identifying the patient and the blood component.
D
Sickle cell crisis nursing interventions
1. O2 therapy = less sickling 2. pain manage (morphine / hydromorphone IVP or PCA) 3. hydration: oral/ IV 4. remove constrictive clothes 5. DO NOT raise knee poition of bed 6. Elevate HOB no more than 30° 7. Warm room temperature
Nurse treatment for osteomyelitis
1. Prevention- check your feet! 2. Antibiotics ASAP - > 3 months (PICC may be needed) 3. Irrigate wound
A nurse is collaborating with the physical therapist to plan the care of a patient with osteomyelitis. What principle should guide the management of activity and mobility in this patient? A) Stress on the weakened bone must be avoided. B) Increased heart rate enhances perfusion and bone healing. C) Bed rest results in improved outcomes in patients with osteomyelitis. D) Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.
A
A nurse is teaching a patient with osteomalacia about the role of diet. What would be the best choice for breakfast for a patient with osteomalacia? A) Cereal with milk, a scrambled egg, and grapefruit B) Poached eggs with sausage and toast C) Waffles with fresh strawberries and powdered sugar D) A bagel topped with butter and jam with a side dish of grapes
A
A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for? A. The onset of a bacterial infection B. Bleeding C. Abdominal pain D. Diarrhea
A
A nurse is caring for an older adult patient who is preparing for discharge following recovery from a total hip replacement. Which of the following outcomes must be met prior to discharge? A) Patient is able to perform ADLs independently. B) Patient is able to perform transfers safely. C) Patient is able to weight-bear equally on both legs. D) Patient is able to demonstrate full ROM of the affected hip.
B
A nurse is caring for a patient who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the patient's statements would indicate to the nurse that the patient requires further teaching? A) "I'll need to keep several pillows between my legs at night." B) "I need to remember not to cross my legs. It's such a habit." C) "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D) "I will need my husband to assist me in getting off the low toilet seat at home."
D
A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patients consequent risk of what complication of treatment? A) Hypovolemia B) Vitamin B12 deficiency C) Thrombocytopenia D) Iron overload
D
A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. The most important action of the nurse is to A. Continue with the present infusion rate of heparin. B. Consult with the physician about discontinuing heparin. C. Begin treatment with the prescribed warfarin (Coumadin). D. Increase the heparin infusion by 100 units per hour.
B Explanation: Platelet counts may decrease with heparin therapy, and this client's platelet count has decreased. The client may have heparin-induced thrombocytopenia (HIT). Treatment of HIT includes discontinuing the heparin. The question asks about the most important action of the nurse and that is to consult with the physician about discontinuing heparin therapy. The nurse may continue with the current rate and should not increase the heparin dose until consulting with the physician. Warfarin is not administered until the platelet count has returned to normal levels.
A patient with diabetes has been diagnosed with osteomyelitis. The nurse notes that the patients right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis? A) Hematogenous osteomyelitis B) Osteomyelitis with vascular insufficiency C) Contiguous-focus osteomyelitis D) Osteomyelitis with muscular deterioration
B
Muscle Strength Grades
0 = no contraction 1 = palpable or observable contraction 2 = moves without gravity over the full ROM 3 = moves against gravity/ less ROM 4= moves against gravity and moderate resistance over full ROM 5 = moves against gravity at maximum resistance
A client with idiopathic thrombocytopenic purpura (ITP), an autoimmune disorder, is admitted to an acute care facility. Concerned about hemorrhage, the nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below: 10,000/?l. 20,000/?l. 75,000/?l. 135,000/?l.
10,000/?l.
Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse? "Most likely, the father is the carrier of the gene." "The trait is passed down through the mother." "The child must inherit two defective genes, one from each parent." "It is an acquired, not a hereditary disorder."
"The child must inherit two defective genes, one from each parent."
Things to do before blood transfusion?
1. Verify prescription 2. Verify pt. consent 3. Assess labs (plt < 20,000 & Hbg < 6 g/dL) 4. Obtain blood cross match (lasts 3 days) 5. Assess vitals (X fever), output, skin color (X jaundice), lung sounds, and X JVD 6. Explain procedure 7. Assess if previous transfusion reaction 8. Obtain venous access 9. Make sure medications are given (can't for 2 hours during transfusion) 10. Obtain blood from bank (we have < 30 minutes to hang!)
Things to do after blood transfusion?
1. Vitals, breath sounds (X fluid overload) 2. Discontinue infusion materials 3. monitor if treatment was effective 4. document
How to prevent sickle cell crisis?
1. drink 3-4 L a day 2. X ETOH/ Smoking 3. Flu/pneumonia shots 4. X temp. extremes 5. X high altitudes 6. X crazy physical activities
Sickle cell crisis interventions
1. oxygen (helps cause less sickling) 2. pain: morphine/ hydromorphone (give on a schedule to control pain) 3. IV hydration
A patient was brought to the emergency department after a fall. The patient is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A) "Make sure you don't bring your knees close together." B) "Try to lie as still as possible for the first few days." C) "Try to avoid bending your knees until next week." D) "Keep your legs higher than your chest whenever you can."
A
A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention? A. Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential B. Monitoring the client's breathing and reviewing the client's arterial blood gases C. Monitoring the client's heart rate and reviewing the client's hemoglobin D. Monitoring the client's blood pressure and reviewing the client's hematocrit
A Explanation: Clients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. No definite symptoms of neutropenia appear until the client develops an infection. A routine CBC with differential can reveal neutropenia before the onset of infection.
A client has hereditary hemochromatosis. Laboratory test results indicate an elevated serum iron level, high transferrin saturation, and normal complete blood count (CBC). It is most important for the nurse to A. Remove the prescribed one unit of blood. B. Instruct the client to limit iron intake in the diet. C. Inform the client to limit ingestion of alcohol. D. Educate about precautions to follow after a liver biopsy.
A. Treatment for hemochromatosis is phlebotomy or removal of whole blood from a vein to reduce iron. Limiting dietary intake of iron is not an effective treatment.
Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? A. Implement neutropenic precautions B. Eliminate direct contact with others who are infectious C. Apply prolonged pressure to needle sites or other sources of external bleeding D. Monitor temperature at least once per shift
C Explanation: For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? A. Elevated hematocrit concentration B. Enlarged mean corpuscular volume (MCV) C. Low ferritin level concentration D. Elevated red blood cell (RBC) count
C Explanation: The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration.
A nurse is caring for a patient who is being treated for leukemia in the hospital. The patient was able to maintain her nutritional status for the first few weeks following her diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, the nurse should implement what intervention? A) Arrange for total parenteral nutrition (TPN). B) Facilitate placement of a percutaneous endoscopic gastrostomy (PEG) tube. C) Provide the patient with several small, soft-textured meals each day. D) Assign responsibility for the patient's nutrition to the patient's friends and family.
C This option would be trialed before resorting to tube feeding or TPN.
A patient is being prepared for a total hip arthroplasty, and the nurse is providing relevant education. The patient is concerned about being on bed rest for several days after the surgery. The nurse should explain what expectation for activity following hip replacement? A) "Actually, patients are only on bed rest for 2 to 3 days before they begin walking with assistance." B) "The physical therapist will likely help you get up using a walker the day after your surgery." C) "Our goal will actually be to have you walking normally within 5 days of your surgery." D) "For the first two weeks after the surgery, you can use a wheelchair to meet your mobility needs."
B
A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action? A) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. C) Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D) Administer the remaining PRBCs by the IV direct (IV push) route.
B
A patient with a total hip replacement is progressing well and expects to be discharged tomorrow. On returning to bed after ambulating, he complains of a new onset of pain at the surgical site. What is the nurse's best action? A) Administer pain medication as ordered. B) Assess the surgical site and the affected extremity. C) Reassure the patient that pain is a direct result of increased activity. D) Assess the patient for signs and symptoms of systemic infection.
B
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia? A) Provide a clear liquid, low-sodium diet. B) Put on a mask, gown, and gloves when entering the client's room. C) Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing. D) Have the client use a soft toothbrush and electric razor, avoid using enemas, and watch for signs of bleeding.
C Low bacterial diet