ATI Live Review

knee arthroplasty pt 1 week ago. which client statement most concerns nurse?

"I am so glad to be off blood thinners". Client now has decreased mobility and is at an increased risk for DVT. they will be on blood thinners for 3-6 months. keep pillow under calf, need crutches or walker, don't take NSAID (ibuprofen) with blood thinner (acetaminophen)- need narcotic

ibandronate patient. nurse should question which statement by the client?

"I should drink a full glass of juice when I take it." (osteoporosis medication) -they should only drink water -they should sit up for 30 minutes after taking it -they should take 30 mins before eating -call provider if they have joint or muscle pain

a client taking omeprazole needs further instruction when they state:

"This med is taken with each meal" You have to take omeprazole on an empty stomach in the morning

IV infiltration nursing intervention

(this is when fluid leaks out into subq tissue) elevate and apply cold compress

neural tube defects

*protect the sac* -don't let it dry out -STERILE towels and saline -measure head circumference and measure fontanels -repair defect in surgery -PRONE position

central lines

*sterile technique needed -goes into long subclavian vein and into heart -insertion complication= pneumothorax or air embolism

LPN duties

-LPN's CANNOT assess. can only collect data -CANNOT care for unstable patients (ex: client returning from cardiac cath- risk for MI) -LPNs cannot administer blood or blood products. ALBUMIN is a blood product. -LPN's don't do initial teaching, but can verify RN teaching -can give IM injections -no such thing as IV-certified LPN -first bag of anything IV must be hung by RN: requires assessment -LPN's cannot titrate IV drips (pt not stable)

rights of delegation

-UAP isn't trained in therapeutic communication -urine specimen from indwelling catheter= STERILE

nagele's rule

-a means of estimating the EDD or EDC -subtract 3 months, add 7 days, to the first day of the last normal menstrual cycle -adjust for the year as necessary

sickle cell anemia

-abnormal hemoglobin that tends to clump -never want these children to dehydrate- PREVENT CRISIS -chronic anemia, cool extremities, pain, delayed puberty, renal involvement -sickle cell crisis: HOP (hydrate, oxygenate, pain management)

parkland formula burns

-administer lactated ringer's -formula: 4 mL x kg x %TBSA -1/2 total in first 8 hours -1/2 in remaining 16 hours -a central line may be used -deduct any fluids given pre-hospital -urine output must be monitored to determine best fluid administration

prenatal care assess at each visit:

-anticipatory guidance -maternal vital signs and weight -fundal height -fetal heart rate -fetal activity -urine: glucose and protein

hemodialysis

-assess circulation: feel thrill and auscultate bruit at access site *hold medications before dialysis *don't take BP on arm with dialysis access -advantages: more efficient clearance, shorter treatment time -complications: infection, closure, disequilibrium syndrome, hypotension, bleeding

nursing interventions for ischemic and hemorrhagic stroke

-baseline level of function and glasgow coma scale -monitor for aspiration due to risk of dysphagia -establish means of communication -hemiparesis, hemiplegia: will cause safety issues

meds to promote air exchange

-beta 2 adrenergic agonists -methylxanthines -anticholinergics -glucocorticoids -leukotriene modifiers

cleft lip

-breast feeding: football hold -give solid foods normally at 4-5 months -feed slowly over 20-30 minutes -burp after every ounce or every 2-3 minutes

methylxanthines

-cause rapid heart rate -therapeutic range: 10-20

signs and symptoms of ischemic and hemorrhagic stroke

-change in mental status (earliest sign of increasing ICP) -slurred speech and dysphagia -weakness on one side of body -visual disturbance -sudden severe headache

acute schizophrenia

-delusions and hallucinations -alterations in speech, perceptions -altered behavior

antimicrobials

-determine most effective antibiotic with culture and sensitivity -nephrotoxic antibiotics: vancomycin and gentamicin -cranial nerve affected by meds: 8- acoustic/auditory

digoxin

-don't give to children with heart rate less than 70, or infants with heart rate less than 90 -give for heart failure and atrial fibrillation/dysrhythmias -monitor for apical pulse and potassium toxicity -signs of toxicity: GI and CNS effects may lead to dysrhythmias

beta 2 adrenergic agonists

-end in -erol -contraindicated with tachydysrhythmia

order of giving medications

-give antibiotics on a SCHEDULE to maintain therapeutic blood level--give these first -give scheduled meds before prn

prodrome stage of schizophrenia

-gradual onset -milder symptoms -occurs months or years prior to acute phase

nutrition in pregnancy

-increase calories by 300-400/day -iron 30mg/day -folate intake 600mcg/day (any female of childbearing age and sexually active should take)

cardiac catheter pre-procedure

-informed consent -kidney function -allergies -metformin -mark distal pulse -teach: metallic taste, flush

cholesterol lowering meds

-monitor HDL, LDL, total cholesterol, and triglycerides for effect -common adverse effects: reduced liver function, muscle aches (rhabdomyolysis), decreased kidney function -OMIT GRAPEFRUIT

prostate cancer

-older gentleman -TURP -prostate exams starting at 50 -enlargement, can't get a good stream

MI manifestations

-pain: chest pain or discomfort, jaw, neck, arms, back, abdomen -occurs without cause -relieved by opioids -associated with symptoms: N/V, diaphoresis, SOB, fear, anxiety, dizziness, fatigue -older people, women, and diabetics may not have classic symptoms

post-procedure cardiac cath

-positioning (flat 4-6 hours after) -immobilize leg straight -pressure dressing -chest pain (MI risk-report) -vital signs -extremity monitoring

stabilization schizophrenia

-psychosocial treatment participation -improved coping -medication controls symptoms

transurethral resection of the prostate (TURP)

-remove piece of prostate- lots of bleeding- frees up urethra -irrigation solution (3,000mL bag)-titrate solution to keep urine pink

postoperative nursing

-respiratory: deep breathing, incentive spirometry -circulatory: assess pulses, cap refill, temp, ambulation -neuro: LOC, reflexes, glasgow coma scale, pupils, grasp

incident reports info

-risk management investigates incident -reports include description of incident and actions taken -reports are confidential and not shared with noninvolved staff -DON'T chart that incident report was completed

maintenance schizophrenia

-symptom control maintained -medication adherence -quality of life

pregnancy vaccines

-tdap vaccine to protect against whooping cough during pregnancy -influenza vax can be given before or during pregnancy

atropine

-treats bradycardia, anticholinergic effects (dries secretions with 0.3mg dose) -side effects: no effects with emergent use -dose: 1/2-1mg for bradycardia, 3 mg max -assess heart rate (we want it to increase) -monitor urine output

platelets

-used for active bleed, thrombocytopenia, aplastic anemia, bone marrow suppression -monitor platelet count (expected range 150,000-400,000)

fresh frozen plasma

-used for hemorrhage, burns, shock, bleeding from warfarin -monitor PT time (expected range 11-12.5 seconds)

albumin

-used for hypovolemia, burns, hypoalbuminemia, severe nephrosis, newborn hemolytic anemia -monitor albumin level (expected range 3.5-5)

packed red cells

-used for severe or hemolytic anemia, hemoglobinopathies, and erytheoblastalis fetalis -monitor hemoglobin (expected range: 12-18)

nitroglycerin

-vasodilator -reduces preload and afterload -side effects: hypotension, tachycardia, headache, tolerance -call 911 if one tablet doesn't work after 5 mins, can take up to 3 while waiting for emergency services

preoperative nursing

-witness consent -preop meds -NPO status -patient education -history -allergies

what should urine output be maintained at?

0.5mL/kg/hr

normal creatinine

0.6-1.2

normal INR

0.8-1.1

menopause

1 full year with no vaginal bleeding -need DEXA scan for osteoporosis -1200 mg calcium supplements -600 mg vitamin D- helps calcium absorption -increase walking

max amount of pads that should be needed after delivery

1 pad every 2 hours- shouldn't be fully saturated

a nurse assesses a client who has chronic emphysema and hypertension. which ABG should be most consistent with this client's medical history? 1) pH 7.37, PaCO2 62, HCO3 36, PaO2= 65 (compensated respiratory acidosis) 2) pH 7.24, PaCO2 83, HCO3 24, PaO2=58 (uncompensated respiratory acidosis) 3) pH 7.27, PaCO2 44, HCO3 16, PaO2=91 (uncompensated metabolic acidosis) 4) pH 7.36, PaCO2 30, HCO3 19, PaO2=85 (compensated metabolic acidosis)

1) compensated respiratory acidosis

a nurse identifies the client is disposing of sharps at home using unsafe practices. which actions did the nurse observe? select all that apply. 1) placed insulin needles in recycling bin 2) recapped the needle prior to disposal 3) removed the needle before placing syringe in trash 4) used a portable sharps container when traveling 5) requested the provider to dispose of sharps container

1) placed insulin needles in recycling bin 2) recapped the needle prior to disposal 3) removed the needle before placing syringe in trash

a nurse cares for a client who has exacerbation of asthma. order of performance:

1) position in high fowler's 2) assess bilateral breath sounds 3) administer albuterol nebulizer 4) administer methylprednisolone IV 5) administer montelukast po now

metered dose inhaler use:

1) remove mouthpiece cover 2) shake MDI 3) inhale and exhale completely 4) place between teeth and seal lips 5) inhale and depress cannister 6) hold breath 5-10 seconds, exhale

a client has a Glasgow coma scale of 5 and is receiving mechanical ventilation. which actions should the nurse implement to maintain skin integrity? select all that apply. 1) reposition the client every 2 hours 2) inspect bony prominences every 4 hours 3) provide a high intake of protein and vitamin c 4) insert an indwelling urinary catheter if incontinent 5) clean the perineal area with hot soapy water after bowel movements

1) reposition the client every 2 hours 3) provide a high intake of protein and vitamin C

blood administration steps

1) verify client IV access (20g+) and patency 2) obtain unit of packed red blood cells from blood bank 3) verify client ID and compatibility at bedside with 2nd RN 4) obtain baseline vital signs 5) prime Y tubing with NaCl and spike blood 6) initiate transfusion slowly, monitor for 15 minutes 7) complete transfusion within 4 hours after it leaves the blood bank

a nurse provides discharge teaching to a client regarding colostomy care. which instructions should be included? select all that apply. 1) "clip hair surrounding the peristomal site." 2) "empty colostomy bag when one third full." 3) "add cranberry juice and yogurt to your diet." 4) "apply moisturizing soap to cleanse skin surrounding stoma." 5) "avoid use of stoma powder, if peristomal skin becomes raw."

1, 2, 3

a nurse provides teaching to a client who has a WBC of 1,000/mm3. which instructions should be included? select all that apply. 1) rinse toothbrush in bleach solution at least weekly. 2) wash dishes in hot, soapy water or dishwasher. 3) increase intake of fresh fruit and vegetables 4) report fever greater than 100.0 F (37.8 C) immediately 5) avoid fluids that have been unrefrigerated more than 1 hour

1, 2, 3, 4, 5

a nurse cares for a client who is admitted with stage 2 (moderate) alzheimer's disease. which signs and symptoms should be expected? select all that apply. 1) cannot balance a checkbook 2) leaves the stove on after cooking 3) decline in daily basic hygiene needs 4) doesn't recognize family members 5) is unable to grocery shop independently 6) experiences incontinence of bowel/bladder

1, 2, 3, 5

a nurse should recognize that which symptoms are non verbal indications of stress in an adolescent? 1) easily angered 2) change in appetite 3) withdrawing from peers 4) pre menstrual moodiness 5) decreased academic performance

1, 2, 3, 5

lisinopril given to patient allergic to amoxicillin, enalapril and latex. nurse's actions? 1) obtain vital signs 2) monitor for angioedema 3) complete occurrence report 4) assure client lisinopril not one of allergies 5) record dose, time, and route in MAR

1, 2, 3, 5

client with dehydration secondary to vomiting. which lab value is expected to be elevated? 1) serum pH 2) hematocrit 3) urine osmolarity 4) serum K+ 5) urine specific gravity

1, 2, 3, 5 serum pH will increase because you are losing acid (above waist), so pH will increase. hematocrit will increase because of hemoconcentration urine osmolarity follows urine specific gravity urine specific gravity will increase because you are losing fluid so urine will be more concentrated

a nurse cares for a client 48 hrs postpartum who has developed endometritis. which interventions should the nurse anticipate? select all that apply 1) lochia assessment 2) sitz bath as needed 3) cephalosporin IV therapy 4) perineal pads changed every 6 hours 5) abdominal binder when ambulating

1, 2, 3. endometritis is inflammation of the inner lining of the uterus. it is the most common cause of infection after childbirth.

nurse monitors client receiving dopamine (continuous infusion) for which adverse effect? 1) dyspnea 2) dysrhythmias 3) hyperthyroidism 4) decreased urine output 5) numbness in extremities

1, 2, 4, 5 can suppress thyroid hormones, not increase their function. numbness in extremities may be experienced with high doses

a nurse assesses a toddler who has a 36 hr history of vomiting and diarrhea. which of the findings should the nurse report to the provider? select all that apply 1) absence of tears 2) skin cool, clammy 3) heart rate 110/min 4) 6% loss of body weight 5) capillary refill 2 seconds 6) blood pressure 78/52

1, 2, 4, 6 absence of tears indicates severe dehydration. toddler's systolic blood pressure should be at least 90.

a charge nurse prepares end of shift report for a group of clients. which laboratory results require follow up? select all that apply. 1) a client scheduled for surgery: hematocrit 32% 2) a client scheduled for angioplasty: creatinine 1.6mg/dL 3) a client diagnosed with type 1 diabetes mellitus: HbA1c 5.9% 4) a client who has deep vein thrombosis receiving warfarin: INR 2.5 5) a client who has a pulmonary embolus receiving heparin: aPTT 40 sec

1, 2, 5

a nurse cares for a client who has dysphagia following a cerebral vascular accident. which interventions should be implemented? select all that apply. 1) place client in upright position 2) evaluate client's ability to cough 3) instruct to lift chin when swallowing 4) provide liquids once meal is completed 5) select foods from mechanical pureed diet 6) place food at front of mouth on unaffected side

1, 2, 5

client has a 20 gauge catheter in their inner arm. which can be given via peripheral access? 1) 1 unit packed RBC for severe anemia 2) TPN for pancreatitis 3) amiodarone infusion for v fib 4) dextrose 5% in 0.9% sodium chloride with 40 meq KCL/L 5) intermittent infusion of 40mg methylprednisolone for status asthmaticus

1, 3, 4, 5

a nurse cares for a client who is newly diagnosed with autism spectrum disorder. which actions should the nurse implement? select all that apply. 1) introduce new activities slowly 2) monitor level of attention span 3) decrease environmental stimuli 4) administer stimulant medication 5) promote positive reinforcement

1, 3, 5

a nurse provides discharge teaching to parents of a newborn who has a cleft lip. which of the feeding guidelines should be included? select all that apply. 1) provide special feeding devices 2) place nipple toward the cleft lip 3) feed in an upright, sitting position 4) introduce solid foods after 12 months 5) feed slowly over a 20-30 minute period 6) wait to burp until the feeding is complete

1, 3, 5

a nurse cares for a client who is admitted for treatment of opioid addiction. which manifestations of opioid withdrawal should the nurse expect? 1) fever 2) euphoria 3) somnolence 4) diaphoresis 5) irritability 6) vomiting

1, 4, 5, 6

a nurse cares for a client who is 2 hours postpartum. which finding should be of most concern? 1) two perineal pads saturated since delivery 2) fundus 1 cm above the level of the umbilicus 3) painful uterine contractions while infant breastfeeds 4) large amount of dark blood from vagina when standing the first time

1. this is not normal, pads should not be getting saturated. fundus 1cm above umbilicus is normal and it will gradually descend. large amount of blood spilling when standing is normal due to gravity.

urine specific gravity normal

1.005-1.03

normal urine specific gravity

1.005-1.030

normal BUN

10-20

normal PT

11-12.5

normal Hgb

12-18

a nurse reviews the medical record of a client who is admitted with Graves' disease. what time should the nurse have initially intervened. 0800: 110/72 BP, 98.6F temp, 88/min HR, 250 ng/dL serum T3 1200: 130/76 BP, 99.7F temp, 98/min HR, 260 ng/dL serum T3 1600: 140/90 BP, 101F temp, 102/min HR, 300 ng/dL serum T3 2000: 124/68 BP, 98F temp, 68/min HR, 290 ng/dL serum T3

1200. Normal T3 range is 80-220. This client's lab values indicate that they are having thyroid storm. A 20 mmHg elevation in systolic blood pressure is indicative of an issue.

normal sodium level (Na+)

135-145

normal platelet count

150,000-400,000

prenatal care specific assessments

16-18 weeks: screen for neural tube defects 28 weeks: screen for diabetes 35 weeks: test for group B strep

specific prenatal assessments

16-18 weeks: screen for neural tube defects 28 weeks: screen for diabetes 35 weeks: test for group B strep

normal PT when on warfarin therapy

16.5-25

after evaluating a client's rhythm strip who has atrial fibrillation, the nurse recognizes a risk of developing: 1) deep vein thrombosis 2) cerebrovascular accident 3) spontaneous pneumothorax 4) disseminated intravascular coagulation

2) cerebrovascular accident

what is the normal deep tendon reflex measurement?

2+

a woman is in her 38th week of her current pregnancy. she has a 2 year old at home who was born in the 28th week of gestation. what is her GTPAL?

2, 0, 1, 0, 1

umbilical cord has ___ arteries and ___ vein

2, 1

a nurse plans discharge for a client who has dependent personality disorder. which findings indicate a desired response to therapy? select all that apply. the client: 1) demonstrates empathy for others 2) creates a daily list of short term goals 3) gathers information before decision making 4) self administers diazepam to control anger 5) manages delusions of grandiosity with quetiapine

2, 3

client with K+ level 3.2. response therapeutic to prescribed KCL 40 IV infusion over 4 hr? 1) trousseau's sign becomes negative 2) leg cramps are gone 3) K+ is 3.6 4) HR decreased 110-85 5) peaked T waves gone from ECG

2, 3 trousseau's sign may be present with hypocalcemia peaked t waves may be present with hyperkalemia

a nurse should make the following assessments when caring for a client who has a NG tube to low wall suction? select all that apply. 1) bowel control 2) aspirate color 3) throat comfort 4) device stability 5) oral cavity hydration 6) nares mucosa condition

2, 3, 4, 5, 6

a nurse initiates IV nitroprusside. which actions should be implemented? 1) evaluate K+ levels 2) assess BP every 5 mins 3) monitor ECG continuously 4) protect bag and tubing from light 5) obtain serum thiocynate levels daily 6) observe for confusion and mental status changes

2, 3, 4, 5, 6. must obtain serum thiocynate levels daily because you can get cyanide poisoning while taking. antihypertensive medication that lowers blood pressure, so this needs to be monitored. need to monitor potassium levels with digoxin. KEEP AWAY FROM LIGHT

a nurse provides teaching to parents of an infant who has tetralogy of fallot. the nurse should identify these as triggers of hypercyanotic spells. select all that apply. 1) when resting 2) during feeding 3) upon awakening 4) after a crying episode 5) during painful procedures

2, 3, 4, 5- anything that increases need for oxygen can cause a tet spell

a nurse is caring for a patient taking levothyroxine . the med dose should increase if: 1) tachycardia 2) hypotension 3) paresthesia 4) constipation 5) excessive sweating 6) decreased appetite

2, 3, 4, 6

a nurse instructs a client about the use of an incentive spirometer. which instructions should be provided? select all that apply. 1) lie on your left or right side 2) inhale slowly to reach goal volume 3) seal lips tightly around mouthpiece 4) hold breath 10 seconds after inhalation 5) use incentive spirometer every 1 hr while awake

2, 3, 5

levodopa/carbidopa teaching: 1) eat high protein 2) change positions slowly 3) take with food 4) symptoms improve within a week 5) report irregular or fast heart rate 6) potential for hallucinations or paranoia

2, 3, 5, 6 don't eat high protein- will interfere with abdomen symptoms take a long time to improve

INR when on warfarin therapy

2-3

a nurse cares for a toddler who has glomerulonephritis. which intervention should be the priority of care? 1) record intake/output every 2 hours 2) assess blood pressure every 1 hour 3) maintain diet with reduced sodium content 4) plan activities to allow for frequent rest periods

2. glomerulonephritis is inflammation of the glomeruli, which are structures in your kidneys that are made up of tiny blood vessels. these knots of vessels help filter your blood and remove excess fluids. if your glomeruli are damaged, your kidney will stop working and you can go into kidney failure. controlling blood pressure with glomerulonephritis may slow down kidney damage.

a nurse receives report on a group of clients. which client should be assessed first? 1) an infant with an axillary temperature of 100.1 who is tugging at left ear 2) a school age client with sore throat who is sitting upright in tripod position and drooling 3) a preschool aged child with harsh cough, expiratory wheezes, and mild intercostal retractions 4) a toddler with barking cough, infrequent inspiratory stridor, and oxygen saturation 94% on room air

2. this client has acute epiglottitis and is at risk for losing their airway. 1st one is an ear infection, 3rd is chronic asthma, and fourth is whooping cough.

normal HCO3

22-26

aortic stenosis patient: auscultate for aortic valve function where?

2nd intercostal space, r. sternal border

which client should be assessed first? 1) hypertrophic cardiomyopathy with dyspnea 2) cardiac cath about to ambulate for the first time 3) receiving antibiotics reporting anxiety and chest pain 4) 2 days postop (ABG with temp 99.0)

3 1 is an expected finding

a nurse cares for a client with AIDs who is receiving antiviral combination therapy. which finding indicates an effective response to therapy? 1) improved mental status 2) client reports a weight gain 3) no evidence of pulmonary infiltrates 4) western blot analysis converts to negative

3 (lack of opportunistic infection such as pneumonia= effective therapy)

first stage of labor

3 phases of dilation latent: 0-3cm active: 4-7cm transition: 8-10cm

a client is receiving mechanical ventilation and the high pressure alarm sounds. which action should the nurse implement? 1) check for a leak or break in the ventilator system. 2) administer a sedative to decrease the client's anxiety. 3) assess the client to determine the need for suctioning. 4) check for air escaping around the cuff of the endotracheal tube.

3) assess the client to determine the need for suctioning- there is an obstruction. If LOW pressure alarm sounds there is a system disconnect or leak.

an older adult client has been vomiting for the past 4 days. the client is febrile, tachycardic, and has postural hypotension. which ABG results should the nurse recognize as consistent with this client's history? 1) pH 7.24, PaCO2 83, HCO3 42 (partially compensated respiratory acidosis) 2) pH 7.49, PaCO2 29, HCO3 22 (uncompensated respiratory alkalosis) 3) pH 7.48, PaCO2 46, HCO3 32 (partially compensated metabolic alkalosis) 4) pH 7.27, PaCO2 32, HCO3 16 (partially compensated metabolic acidosis)

3) metabolic alkalosis- you are losing fluid above the waist so you are losing ACIDS and are going to become ALKALOTIC

a nurse provides teaching to a client who has systemic lupus erythematosus (SLE). which statement indicates need for further instruction? 1) when gardening, i will plan to wear a large brimmed hate. 2) prescribed antimalarial medication should reduce joint pain. 3) remaining on oral contraceptives will control exacerbations. 4) alternating rest with activity should enhance my immune system.

3) remaining on oral contraceptives will control exacerbations

a nurse is caring for a client who is in labor and assess fetal monitor strip with late decel. which action should the nurse take first? 1) continue to monitor 2) perform a vaginal exam 3) reposition the client and apply oxygen 4) prepare for an immediate cesarean section

3) reposition the client and apply oxygen

a nurse cares for a client who has pancreatitis. total parenteral nutrition was started 24 hours ago. which finding indicates a need for intervention? 1) WBC 9,600 2) albumin level of 3.4 3) urine specific gravity of 1.042 4) weight gain of 1 pound in 24 hours

3) urine specific gravity of 1.042

a nurse provides teaching to a client following a left eye cataract removal with lens implant procedure. which statements indicate effective instruction? select all that apply. 1) "I will have 20/20 vision without glasses." 2) "my vision will be unchanged for several weeks." 3) "I should contact my surgeon if I experience pain." 4) "I will wear a patch on the left eye until my checkup." 5) "My eyelid swelling and bruising will be managed with ice packs."

3, 4

a nurse assists the provider during a bronchoscopy. which actions should the nurse perform for the client? select all that apply. 1) assess return of the gag reflex 2) place in trendelenburg position 3) monitor oxygen saturation levels 4) administer sedatives as prescribed 5) label container for specimen collection

3, 4, 5

a client who has ulcerative colitis is scheduled for discharge following placement of a permanent ileostomy. which instructions should the nurse include? select all that apply. 1) take enteric-coated medications 2) notify the provider if no stool in 24 hours 3) avoid raw cabbage, nuts, and popcorn 4) change the entire pouch system every 3-7 days 5) include an adequate amount of sodium and water in the diet 6) assume knee chest position if abdominal cramping occurs

3, 4, 5, 6

morphine sulfate given to post op patient. the charge nurse should intervene if the nurse: 1) notifies pharmacy that the prefilled syringe was empty 2) med removed without witness signature 3) return unused med to automated dispensary 4) LPN witnesses waste 5) narcotic count in dispensary is incorrect and nurse removes med

3, 5

a client who is prescribed clonzapine prepares for discharge. the nurse evaluates teaching as effective when the client makes which statement? select all that apply. 1) monthly injections will be required 2) orange juice will increase the absorption 3) i should stand up slowly to prevent dizziness 4) the medication should be stopped if i have a headache 5) if flu like symptoms occur i will call the provider immediately

3, 5 clonzapine is an antipsychotic that treats schizophrenia. major side effects are drooling, drowsiness, dizziness, lightheadedness, headache, shaking, tremor, vision problems, constipation, weight gain. can rarely cause neuroleptic malignant syndrome characterized by flu like symptoms.

diabetes mellitus patient with labia irritation and vaginal cheese-like discharge. what med should they use? 1) imiquimod 2) ceftriaxone 3) fluconazole 4) metronidazole

3- fluconazole. this is a yeast infection imiquimod is used for genital warts/herpes ceftriaxone is used for gonorrhea metronidazole is used for trichomoniasis

client 1 hour post cardiac stent placement via L. femoral artery. most concerning? 1) 1-2 PVC's/min 2) discomfort in L. groin "7/10" 3) pulse 120, BP 90/60, RR 22 4) L. pedal pulse 1+; R. pedal pulse 2+; L. leg cooler than right

3- indicative of bleeding internally 1 is expected and 2 is subjective

client with addisonian crisis. question which prescription? 1) sodium polysterene 2) hydrocortisone sodium succinate 3) dextrose 5% water IV @ 30mL/hr 4) ECG with continuous telemetry

3- this is a keep vein open rate, need higher amount of NS- this is a crisis!!! 1 is kayexalate which pulls out potassium 2 is a steroid

teaching to atorvastatin client: 1) don't modify diet 2) take med with lunch 3) notify provider of muscle aches 4) check renal function labs every 6 months

3- this is an indication of rhabdomyolysis which is a severe complication. check LIVER function labs every 6 months. take at nighttime. modify diet to aid in lowering cholesterol.

the axillary temperature of a newborn client is 96.4. which finding should indicate to the nurse the presence of cold stress? 1) apical heart rate of 160/min with shivering 2) moist skin with vernix caseosa in skin folds 3) cool, cyanotic extremities with warm trunk 4) respirations 35/min with sternal retractions

3. 1- newborns do not shiver 2- normal 4- indicates air hunger

a nurse cares for an infant who has cystic fibrosis and is receiving pancrelipase powder. which finding is a desired effect of the medication? 1) clear lung breath sounds 2) skin free of salt crystals 3) steady weight/height gain 4) fewer respiratory infections

3. cystic fibrosis is a digestive issue. pancrelipase is a synthetic enzyme that allows those with CF to digest their food regularly.

nurse teaches about lisinopril. which finding should be reported immediately? 1) persistent dry cough 2) rash on torso or neck 3) swelling of tongue or lips 4) lightheadedness when standing

3. this is angioedema and is life threatening. lisinopril is an ACE inhibitor that can treat high blood pressure and heart failure. expected side effects are dizziness, lightheadedness, tiredness, headache, or dry cough. complications include possible angioedema, liver and kidney impairment

normal potassium level (K+)

3.5-5

how much should a pregnant woman exercise?

30 minutes moderately every day

normal aPTT

30-40

normal PaCO2

35-45

normal Hct

37-52

how many stages of labor are there?

4

tetrology of fallot

4 issues with heart (DROP) Defect of ventricular septum Right ventricular hypertrophy (problem pumping) Overriding aorta (alters cardiac output) Pulmonic stenosis (pulmonic valve between r ventricle and lungs is stenosed) manifestations: cyanosis, hypoxia treatment: complete repair during 1st year

a nurse cares for a client who has acute pyelonephritis. which finding should the nurse recognize as an effective response to therapy? 1) 24 hour urine collection of 1550 mL 2) flank pain decreased since initial treatment 3) clear liquids tolerated without nausea or vomiting 4) WBC changed from 18,000/mm3 to 13,000mm3

4) WBC changed from 18,000mm3 to 13,000mm3

which action should nurse take after drawing blood from client who has implanted venous port? 1) Check for blood return 2) apply 20% benzocaine to injection site 3) access port with non-coring needle 4) flush port with 5mL of 100 units heparin/mL

4) flush port with 5mL of 100 units heparin/mL

a nurse evaluates room assignments. which room assignment requires immediate modification? 1) COPD exacerbation on Prednisone, positive C. difficile stool toxin 2) positive vancomycin resistant enterococcus urine culture in client with a urinary catheter, acute MI and post resuscitation 3) positive H. influenza type B culture, positive H. influenza type B culture 4) positive methicillin-resistant staphylococcus aureus (MRSA) sputum culture, postoperative total knee replacement

4) positive methicillin-resistant staphylococcus aureus (MRSA) sputum culture, postoperative total knee replacement

a nurse cares for a client who has a spinal cord injury. which actions should be implemented to prevent autonomic dysreflexia? select all that apply. 1) perform rectal digital stimulation daily 2) instruct client to wear medic alert bracelet 3) observe for pattern of blood pressure changes 4) promote high fiber diet and use of stool softeners 5) monitor patency of indwelling bladder catheter

4) promote high fiber diet and use of stool softeners 5) monitor patency of indwelling bladder catheter

type 1 diabetes client with glucose of 580. which intervention first? 1) reassess urine for ketones 2) begin continuous IV insulin infusion 3) administer 20mEq K+ IV over 2 hours 4) infuse 1L NaCl 0.9% over 1 hour

4- REHYDRATE THEM. issue is DKA, so their blood is hemoconcentrated and they are dehydrated. you don't know what their true blood sugar is- must lower glucose slowly

normal HbA1c

4-6%

LNMP 4/1/20. what is the EDC?

4/1/20 - 3 months= 1/1/20 + 7 days= 1/8/20, adjust for year: 1/8/21

normal aPTT when on heparin therapy

45-80

normal wbc

5,000-10,000

where is the tricuspid valve?

5th intercostal space on the left side

an apartment fire occurred at 1400 hours. a client is transported to the ED at 1800 hours with 36% TBSA burned. the client weights 187 lb. how much IV fluid should the nurse administer within the first 4 hours after admission?

6,120 4mL x 85 kg x 36%= 12,240 1/2 in first 8 hours after burn= 6,120 1/2 in remaining 16 hours= 6,120

nursing care of infants:

6-8 weeks: posterior fontanel closes 4 months: solid foods introduced 5 months: birth weight doubles, rolls front to back 6 months: first flu shot 8 months: crude pincer grasp, sits unsupported 1 year: birth weight triples, walks with help 12-18 months: anterior fontanel closes infant-2 years: rear facing car seat

normal pH

7.35-7.45

normal glucose fasting

70-105

normal calcium level (Ca2+)

8.5-10

normal PaO2

80-100

what is the maximum time a contraction should be?

90 seconds

normal toddler systolic blood pressure

90-92

normal SaO2

95-100

normal cholesterol level

<200

normal HbA1c when you have diabetes

<7%

addison disease

ADD back hormone- lack of glucocorticoids adrenal hypofunction fluid volume deficit weight loss salt cravings hypotension hyperkalemia hypercalcemia hypoglycemia hyponatremia decreased cortisol and aldosterone hyperpigmentation (increased melanocytes) **add back steroids, sugars, and salt (all S's)

gout diet

Avoid purines anchovies, organ meats, fish/sea food, yeast and yeast products (breads)

pernicious anemia

B12 malabsorption

glomerulonephritis #1 symptom:

BP change, hematuria, proteinuria

best way to measure hydration status

DAILY WEIGHTS 1kg= 1L of fluid

medication for rheumatoid arthritis

DMARDs (disease modifying antirheumatic drugs, methotrexate)

cervical cancer contributing factors

HPV, multiple partners

client exhibiting early signs of hemorrhage. which findings can be anticipated?

HR 120/min- related to compensation late signs: cold, clammy skin, weak thready pulse, decrease in blood pressure

where is the pulmonic valve?

L. side, 2nd intercostal space

which medication might be given to prevent rubella?

MMR vaccine

MI initial interventions

MONA (not in this order) morphine, oxygen, nitroglycerin, aspirin

when mixed with regular insulin, draw this medication up last:

NPH

diet for pancreatitis

NPO, TPN may be used

pancreatitis diet

NPO, TPN may be used

naproxen

NSAID take with water, milk, assess nasal polyps

screening for cervical cancer

Pap test (starting at 21, every 3 years), DNA test

5 P's of labor

Passenger, Passage, Powers, Position, Psyche

who can check bowel sounds? (RN, LPN, or UAP)

RN and LPN

who can establish goals for nursing care? (RN, LPN, UAP)

RN only

who can initiate a client referral? (RN, LPN, UAP)

RN only

who can regulate IV insulin? (RN, LPN, or UAP)

RN only

who can administer the MMR vaccine? (RN, LPN, or UAP)

RN or LPN

who can change a sterile dressing? (RN, LPN, or UAP)

RN or LPN

who can obtain a urine sample from an indwelling catheter? (RN, LPN, UAP)

RN or LPN

scope of practice for RN, LPN, UAP

RN: unstable client, assess, teach, plan care LPN: stable client, data collection, reinforce teaching UAP: routine vitals (NOT admission/assessment), I&O

bronchiolitis

RSV most common cause, droplet/ contact precaution

paroxetine

SSRI- antidepressant interacts with st. john's wort- serotonin syndrome

maconium stained amniotic fluid

SUCTION IMMEDIATELY after birth

periodic fetal heart rate changes

VEAL CHOP MINE variable--cord compression--move patient early decels--head compression--identify labor progress accelerations--okay--none late decels--placental insufficiency--execute action immediately

client with rheumatoid arthritis needs methotrexate therapy. side effects?

WBC 1,200 platelets 5,000 high specific gravity can have mouth sores and weight loss causes pancytopenia

can a UAP administer a tube feeding?

Yes, if they know how

a patient taking phenelzine should avoid what in their diet? a) pepperoni b) fresh fish c) lettuce salad d) cottage cheese e) cheddar cheese

a, e phenelzine is an MAOI, so they need to avoid tyramine. this includes foods that are aged, smoked, pickled, + soy sauce

client prescribed isosorbide mononitrate. which finding should concern the nurse most? a) use of vardenafil b) administration of metoprolol c) report of frequent headaches d) history of MI

a. vardenafil is used for erectile dysfunction and when combined with nitrate can cause life threatening hypotension

a pulmonary embolus client is being treated with 40% oxygen via venturi mask, IV heparin, and bedrest. therapy deemed effective when?

aPTT 70 seconds normal= 30-40, heparin normal 45-80

glucocorticoids (adrenal)

abrupt cessation may cause addisonian crisis chronic use may cause cushing's

2nd trimester of pregnancy

accepting dyspnea, heartburn

guillain-barré syndrome

acute inflammatory polyneuropathy

antidysrhythmic meds

adenosine, amiodarone, atropine

childhood neurodevelopmental disorders

adhd, autism spectrum, intellectual disability, learning disorder

who can ambulate a client with a walker? (RN, LPN, UAP)

all

who can apply lotion to intact skin? (RN, LPN, or UAP)

all

partial compensation of pH

all 3 values are outside normal

obsessive compulsive disorder nursing intervention

allow rituals

acute/short term neurological meds

alprazolam (benzo) lorazepam (benzo) zolpidem tartrate

1 trimester of pregnancy

ambivalence N/V, frequent urination

opioids

analgesic

NSAIDs

analgesic, antipyretic, anti-inflammatory, antiplatelet, renal damage

acetaminophen

analgesic, antipyretic, renal damage, liver damage

Colchicine

anti-inflammatory that treats and prevents gout attacks monitor for sudden muscle pain, get baseline CBC

posterior pituitary gland secretes:

antidiuretic hormone: holds fluid in proper compartment if this hyposecretes- diabetes insipidus (DI)- usually caused by head injury if this hypersecretes- SIADH (dilutional hyponatremia- seizure risk)

chronic kidney disease symptoms

anuria, fluid and electrolyte imbalances

triggers of hypercyanotic spells (tet spells)

anything that increases need for oxygen: feeding, awakening, after crying, during painful procedures

IV hematoma intervention

apply light pressure

IV catheter embolus intervention

apply tourniquet

IV phlebitis intervention

apply warm compress inflammation/warmth...put on warm compress

weak pedal pulses, skin on left lower leg shiny and cool to touch indicates:

arterial insufficiency- not getting enough oxygen. nursing intervention= position left leg dependently LEGS OF CAPITAL A GO DOWN

IV extravasation intervention

aspirate drug if possible

cleft palate

aspiration risk

bronchoscopy intervention

assess gag reflex

4 days after a ventral hernia repair, client who's obese, has history of COPD, vomits and has severe abdominal pain. O2sat 90%. nurse's first action?

assess surgical incision site. dehiscence= biggest risk especially because client is obese. address ACUTE first. 90% O2sat normal for COPD

nurse enters room where client is lying at foot of bed lying on floor. initial nursing action?

assess vitals and level of consciousness

quantiferon GOLD intervention

assign client to private room this is a test that detects tuberculosis- if it is positive, client will have to be on airborne precautions

mechanical ventilation

assist with ventilation, assess breath sounds, maintain ETT tube position, suction as needed HOLD= alarm acronym high pressure alarm=obstruction low pressure alarm= disconnect or leak

amiodarone

assists with vfib and unstable v tach side effects: bradycardia, pulmonary complications -monitor respirations -don't give with heparin

which medication might be given to prevent heart disease?

atorvastatin

myasthenia gravis

autoimmune disease characterized by fatigue and weakness

multiple sclerosis

autoimmune disease. defects in myelin sheath affect nerve conduction.

celiac diet

avoid glutens

diet for celiac's disease

avoid glutens

diet for gout

avoid purines

the client is experiencing severe 'back' labor. what should the nurse do?

back massage. place on all fours-occiput posterior (OP). (POSITION)

pyelonephritis

bacterial infection-client will be put on antibiotics

gout nursing interventions

bed rest, avoid touch, increase fluids, NSAIDs, steroid injection, diet

post-partum depression

begins within 4 weeks of childbirth

medications for mood disorders

benzodiazepines, antipsychotics, antiepileptics, lithium

Hirschsprung disease

bilious vomit

this supplement is an estrogen substitute similar to soy, treats menopause symptoms

black cohosh

cirrhosis symptoms

bleeding (vitamin K affected by liver, bleeding esophageal varices)

manifestations of cervical cancer

bleeding, dyspareunia

when a client is taking glipizide, what should the nurse monitor?

blood glucose- this is an oral hypoglycemic

intussusception

blood stools

newborn hypoglycemia

blood sugar <40

late sign of lithium toxicity

blurred vision

abruptio placentae

board like abdomen, dark red bleeding

asthma main symptom

bronchospasm

medication used for amphetamine withdrawal or abstinence:

bupropion, diazepam

medication used for withdrawal or abstinence of nicotine:

bupropion, varenicline

nurse arrives at work sit explosion. who should they triage first?

burns to the face and respiratory stridor.

ACE inhibitors complication

can cause angioedema ex: enalapril, lisinopril

Calcium channel blockers complication

can increase risk of heart failure ex: amlodipine, diltiazem)

vasodilators complication

can rapidly decrease blood pressure ex: nitroglycerin

antiepileptics

carbamazepine, valproic acid, lamotrigine may reduce effectiveness of contraceptives

diet for nausea/vomiting

celar liquids

a person with afib is at risk for:

cerebrovascular accident because blood is retained in atria and produces thousands of microscopic clots

what is the earliest sign of increasing ICP?

change in mental status

manic phase of bipolar disorder

check thyroid levels- rule out physiological cause -accelerated speech -anorexia -fragmented thoughts -lacks impulsive control -inability to sleep -promiscuous sexual behavior

methotrexate

chemotherapy and immunosuppressive drug inspect mouth and gums daily obtain CBC every 6 months

dutasteride

class: 5-alpha-reductase inhibitor indication: benign prostatic hypertrophy side effects: decreased ejaculate and libido should clients using dutasteride donate blood? no; it is teratogenic

warfarin

class: anticoagulant indication: prophylaxis for thrombosis, TIAs side effects: black box warning: serious/fatal bleeding events should foods containing vitamin K be avoided while taking warfarin? no, consistent intake recommended

adenosine

class: antidysrhythmic indications: paroxysmal svt side effects: bradycardia, dyspnea, hypotension, flushing, chest discomfort what client outcome should the nurse expect? conversion to normal sinus rhythm

phenytoin

class: antiepileptic indication: seizures side effects: gingival hyperplasia, thrombocytopenia is client taking phenytoin susceptible to stevens johnson syndrome? yes, flu like signs and symptoms, skin rash, instruct client to stop taking medication and notify provider

metronidazole

class: antiprotozoal, antimicrobial, amebicide indication: amoebiasis, trichomoniasis, giardiasis, drug of choice for c diff side effects: nausea, headache, metallic taste, dark urine why is alcohol contraindicated with this drug? it can cause disulfiram-like reaction

cyclobenzaprine

class: centrally acting muscle relaxant indication: relief of muscle spasm related to muscle injury side effects: dizziness, dry mouth, drowsiness, urinary retention, constipation should the client take MAOI's? no, may increase risk of hypertensive crisis, seizures

hydrocodone/acetaminophen

class: opioid analgesic indication: moderate to severe pain side effects: respiratory depression, constipation, urinary retention, sedation, cough suppression what should the nurse teach the client? increase fluid and fiber intake; sit or lie down after taking; don't crush or chew; avoid alcohol

nausea/vomiting diet

clear liquids

diet for diverticulitis

clear liquids and then high fiber

diverticulitis diet

clear liquids--->high fiber

screening for breast cancer

clinical breast exam (mammograms starting at age 40)

benzodiazepines

clonazepam, lorazepam short term use due to dependency concerns

which medication might be given to prevent an MI or stroke?

clopidogrel

acute gout medication

colchicine

pneumothorax

collapse lung chest tube=intervention give oxygen, anxiolytics, position, and analgesics

respiratory distress syndrome

common in premature infants, hypoxia

APGAR

completed after 1 and 5 mins after infant birth. determines adjustment to life heart rate, respiratory rate, muscle tone, reflex, and color 0-3: severe distress 4-6: moderate distress 7-10: no distress (normal)

symptoms of fat emboli

confusion, tachypnea, tachycardia, petechiae

if you are unsure of proper enteral feedings technique:

consult unit procedure manual for guidance

complications of alpha 2 agonists

contraindicated with anticoagulants. these medications lower blood pressure ex: clonidine

anticholinergics

contraindicated with peanut allergy max effects take WEEKS

what does adenosine do?

converts SVT to sinus rhythm

cold stress signs and symptoms

cool, cyanotic extremities with warm trunk

prednisone

corticosteroid- treats inflammation severe hypotension if stopped quickly can cause cushing's disease

what to do if client on contact precautions needs to leave the room?

cover the wound

a nurse cares for a client who reports feeling weak and lightheaded. the nurse assesses the cardiac rhythm strip bradycardia. which medication should the nurse expect to administer? a) digoxin b) xylocaine c) verapamil d) atropine sulfate

d) atropine sulfate

a nurse cares for a client 6 hours post total laryngectomy who has a history of hepatitis C and HIV. which equipment is recommended during direct care? a) gloves only b) gloves and gown c) gloves, gown, mask d) gloves, gown, mask, goggles

d) gloves, gown, mask, goggles

a nurse admits a client with symptoms of tachycardia, hypotension, fever and a history of severe diarrhea for the past 2 days. which arterial blood gas (ABG) results should the nurse recognize as being consistent with the client's history and symptoms? a) pH 7.24; PaCo2 83mmHg; HCO3 42mEq/L (respiratory acidosis) b) pH 7.49; PaCo2 29mmHg; HCO3 22mEq/L (respiratory alkalosis) c) pH 7.48; PaCO2 39mmHg; HCO3 32mEq/L (metabolic alkalosis) d) pH 7.27; PaCO2 32mmHg; HCO3 16mEq/L (metabolic acidosis)

d) metabolic acidosis- losing fluid below the waist= losing alkalines making you ACIDIC

client receiving vancomycin IV. which lab should prompt nurse to question med dosage increase? a) WBC 15,000 b) WBC 3,000 c) serum trough lower than expected d) serum peak higher than expected

d. 1 is high, which means immune system is working. increase dose to get them down. 2 is not yet neutropenia, but it is low. if trough was lower than expected, you would increase the dose.

gout medication

daily allopurinol

diet for liver disease

decrease protein

liver disease diet

decrease protein

epidural analgesic patient immediate intervention finding:

decreased level of consciousness (not enough oxygen getting to brain)

intellectual disability

deficits in reasoning, problem-solving

hyperemesis

dehydration; weight loss of >5% prepregnancy weight

third stage of labor

delivery of the placenta. newborn care

collaborative care for diabetes during pregnancy

diet, exercise, monitor blood sugar, insulin PRN

teaching for breast cancer

diet, weight

ADHD manifestation

difficulty following through on tasks

cystic fibrosis

digestion issue -individual with this gets pancrelipase before every meal- synthetic pancreatic enzyme that body doesn't produce naturally

meningitis

dim light, low stimulus environment

if a patient has metabolic acidosis, the nurse might use:

diphenoxylate/atropine OR regular insulin

thrombolytic

dissolves clots alteplase, reteplase give within 4-6 hours of symptoms contraindicated with intracranial hemorrhage, active bleeding, brain tumors

medication used for alcohol withdrawal or abstinence:

disulfiram, diazepam

nonmaleficence

do no harm

colostomy instructions

don't shave hair around colostomy stoma- clip it, empty colostomy bag when 1/3 full or less, add cranberry juice and yogurt to colostomy diet

chest tubes

drainage, water seal TIDALS (increases and decreases with respirations), suction BUBBLES

bariatric surgery risk:

dumping sydrome

cystitis symptoms

dysuria, frequency

early or late symptoms of shock?

early: pallor, tachypnea, confusion**(first sign of not getting enough oxygen), tachycardia late: cold, moist skin, weak, thready pulse, anuria, hypotension, metabolic acidosis

pursed lip breathing is a sign of

emphysema

a nurse admits a client who sustained a burn injury to the entire left arm, left anterior leg, and left anterior surface of the torso. using the rule of nines for an adult, the nurse should calculate the percentage of body surface area burned.

entire left arm=9% left anterior leg=9% left side of anterior torso=9% total body surface burned=27%

which medication might be given to treat GERD?

esomeprazole

which medication might be given to slow the progression of arthritis?

etanercept

euphoria

experienced when under the influence of opioids insomnia is experienced with opioid withdrawal

thalassemia

facial bone deformities

risks of non potassium sparing diuretics

falls related to fluid and electrolyte imbalance

breast cancer contributing factors

family history, sedentary lifestyle

complications of fractures

fat emboli, compartment syndrome

bethamethasone

fetal lung maturity- give 2 doses 24 hours apart

growth factors

filgrastim, oprelvekin

autism spectrum manifestation

fixated interests, insistence on routine

hepatitis symptoms

flu like symptoms

hypertonic solution

fluid moves out of cell D5NS, 3% NaCl

factors that contribute to increased intracranial pressure:

fluid overload, hypertension, seizure activity, encephalitis, brain tumors, hydrocephalus manifestations: LOC changes, increased blood pressure, pupil changes, projectile vomiting, cheyne stokes respirations (late sign)

main side effects of adenosine

flushing, bronchospasms

why would someone have their NG tube to low wall suction?

for decompression

what are signs of hemorrhage after a tonsillectomy?

frequent swallowing, clearing throat, hematemesis

GTPAL

g= gravida- number of pregnancies t= term- births after 37 weeks p- preterm- birth before 37 weeks a- abortions l- living children

this supplement blocks LDL cholesterol, increases HDL, and decreases triglycerides. increases risk of bleeding in those taking NSAIDs, warfarin, and heparin

garlic

mild preeclampsia

gestational hypertension proteinuria of 1-2+ edema in upper extremities and face

4 supplements that interfere with anticoagulants and start with "G"...consult with provider before taking NSAIDs

ginger, gingko, garlic, ginseng

this supplement increases blood flow to brain and improves memory. clients with peripheral artery disease may have reduced pain with walking

gingko biloba

how to administer adenosine

give rapid IV push, flush with NS

this medication is given subcutaneously and has no peak action time:

glargine (long acting)

what is the minimal PPE requirement for contact precautions?

gloves and gown. prn mask and goggles.

medication for osteoarthritis

glucosamine

acute bronchitis

gradual onset, cool air may help

child with heart disease at risk for:

growth failure, respiratory infections, exercise intolerance -conserve energy, promote oxygenation, give digoxin

for there to be negligence, there has to be:

harm

a nurse evaluates room assignments. which room assignments are appropriate? select all that apply. -heart failure exacerbation, hemoccult positive stool -disseminated shingles, suspected TB -accessed implanted port, necrotizing fascitis group A beta hemolytic streptococcus -HIV positive. WBC 5,200, hepatitis B positive -ulcerative colitis, hepatitis A positive

heart failure exacerbation, hemoccult positive stool HIV positive WBC 5,200, hepatitis B positive ulcerative colitis, hepatitis A positive

lung cancer symptom

hemoptysis (bloody sputum)

symptoms of menopause

hot flashes/night sweats, palpitations, vaginal atrophy, osteoporosis

glomerulonephritis symptoms

hypertension, hematuria

eclampsia

hypertension, proteinuria plus seizures or coma magnesium sulfate treatment antihypertensive meds; hydralazine or labetalol

risks of diabetes during pregnancy

hypo or hyperglycemia fetal anomalies abortion/death macrosomia NB hypoglycemia

side effects of non potassium sparing diuretics

hypokalemia, hyponatremia, hyperglycemia

osteoarthritis and rheumatoid nursing interventions

ice/heat ROM rest NSAID steroid joint replacement

ROME

if Respiratory condition, the PCO2 is in the Opposite direction of pH. Metabolic Equal

chest tube client- chest tube has become disconnected from chest drainage system. action?

immerse end of chest tube in bottle of sterile water. recreate temporary water seal, stopping lung from collapse.

teaching for cervical cancer

immunization, delay intercourse

hydroxychloroquine

immunosuppressive drug and anti-parasite take with food monitor for fever, blistering rash biannual eye exam

client with SIADH has serum sodium of 116, what should nurse do?

implement seizure precautions

where is there supposed to be bubbling in a chest tube system?

in suction control chamber.

cervical insufficiency

increased pelvic pressure; pink vaginal discharge

a client receives a transfusion of packed RBCs and tells nurse "My IV site is painful and looks swollen". This indicates:

infiltration. intervention: take out IV, start a new one at another site and resume transfusion. only send blood tubing back to lab if client experiences a transfusion reaction.

a nurse is preparing a client who is in active labor for epidural anesthesia. which action should be implemented at this time? 1) infuse an isotonic IV bolus 2) place indwelling bladder catheter 3) assist client in left side lying position 4) measure bilateral deep tendon reflexes

infuse an isotonic bolus

nursing interventions for hyperbilirubinemia

initiate breast feeding early assess voiding and stooling encourage frequent feedings safety measures with phototherapy

panic disorder nursing intervention

instruct to take slow, deep breaths

anticoagulants

interferes with clotting process heparin, warfarin supplements may increase bleeding risk

antiplatelet

interferes with platelet aggregation aspirin, clopidogrel ecchymosis and tarry stools indicate bleeding

recurring calf pain after walking 1-2 blocks that disappear with rest indicates:

intermittent claudication

club foot

inversion passive exercise cast

chronic/long term neurological meds

isocarboxazid lithium carbonate olanzapine (antipsychotic) sertraline (SSRI)

findings of hyperbilirubinemia

jaundice, increased bilirubin levels

this supplement relieves anxiety and promotes sleep. it can cause livery injury.

kava

fidelity

keeping your word

anergia

lack of energy- seen with depression

major depressive disorder

lasts 2 weeks to 6 months

early signs of lithium toxicity

lethargy, dehydration, slurred speech

meds for hypothyroidism

levothyroxine: take early in the morning

the client should eat as soon as this medication is given

lispro/aspart (RAPID)

hyperemesis gravidarum

losing weight, severe n/v

a nurse admits a client with C3 spinal cord injury. which finding is priority care?

loss of function below injury: lungs and diaphragm/BREATHING--respirations 10/min

cholecystitis diet

low fat

diet for cholecystitis

low fat

LOW SODIUM acronym

low sodium-->Cerebral-->Seizures

persistent depressive disorder

low-level; lasts more than 2 years

atypical antipsychotic meds

lower risk of extrapyramidal symptoms and tardive dyskinesia, increased risk of weight gain, diabetes, dyslipidemia ex: olanzapine, aripiprazole

manifestations of breast cancer

lump, discharge

left sided heart failure

lungs: dyspnea, frothy sputum, crackles, cough

pancreatitis symptoms

malnutrition (autodigestion of amylase and lipase)

what is the first drug given for increasing ICP?

mannitol

what is the minimal PPE requirement for airborne precautions?

mask. prn gloves, gown, and goggles

what is the minimal PPE requirement for droplet precautions?

mask. prn gloves, gown, and goggles

haloperidol

med for schizophrenia

magnesium sulfate IV

medication for preeclampsia toxicity signs: absent DTR's, bradypnea calcium gluconate= REVERSAL

a client is taking rifampin. what should they be taught regarding contact lenses use?

medication turns them orange- inadvisable to wear plastic contacts during treatment

this supplement manages jet lag and insomnia. can cause vivid dreams

melatonin

pH decreased, PCO2 normal, HCO3 decreased

metabolic acidosis

pH elevated, PCO2 normal, HCO3 elevated

metabolic alkalosis

hold this medication 48 hours before and after use of contrast dye

metformin

which oral hypoglycemic is held when contrast dye is given?

metformin

medication used for opioid withdrawal or abstinence:

methadone, clonidine

meds for hyperthyroidism

methimazole *no breastfeeding with this

what does the adrenal gland secrete?

mineralcorticoids *glucocorticoids

hemophilia

missing coagulation factor-bleeding is the issue assess for location of bleeding- make sure not internal give replacement factors RICE (rest, ice, compression, elevation)

neonatal seizures

monitor oxygen and LOC

which medication might be given to prevent bronchospasm?

montelukast

hypotonic solution

moves fluid into cell ex: 0.45% NS

TPN

must be given by central line (PICC, tunneled catheter) hypertonic solution TPN prepared daily TPN dressing change done with surgical asepsis lab value checked every 4-6 hours when TPN initiated: blood glucose TPN=20-50% dextrose new TPN bag hung every 24 hours. new filter hung with each bag

if a patient has respiratory acidosis, the nurse might use:

naloxone OR hydromorphone

gentamycin

nephrotoxic- check creatinine before starting

tuberculosis symptom

night sweats

can LPNs take care of unstable patients?

no

isotonic solution

no fluid crosses cell membrane ex: LR, 0.9% NS

does anything change cognitively in ALS patients?

no- they become trapped in their own bodies but nothing changes cognitively

will something life threatening be localized to one spot?

no.

can you delegate any task to a new RN?

no. must have seen them perform the skill and know they are competent to perform it.

can LPN's give Rhogam?

no. this is a blood product.

what is the minimal PPE requirement for standard precautions?

none. prn gloves, gown, mask and goggles

leukotriene modifiers

not used with acute asthma interacts with warfarin and theophylline

abdominal binder

obese mom with midline c section may use this dehiscence is an emergency

reye syndrome

observe for bleeding

chest tube client's water seal has stopped tidaling. why?

obstruction is present in the tubing

disruptive mood dysregulation

occurs in children; tantrums, irritability

DVT

occurs in vein (clot develops there)

seasonal affective disorder

occurs when there is less daylight

antipsychotics

olanzapine, risperidone, aripiprazole s/e's: hyperlipidemia, hyperglycemia

acute kidney injury symptoms

oliguric phase, followed by diuresis

if a patient has metabolic alkalosis, the nurse might use

ondansetron

sources of vitamin B12

only found in animal products such as yogurt and liver **if person is vegan or vegetarian, they must take vitamin B12 to avoid pernicious anemia

what types of insulin can be mixed?

only regular and NPH. regular is the only one given IV

cane use

opposite of affected side holds cane. advance cane 6-10 inches forward move cane-->left leg-->right leg (good leg) proper height at greater trochanter

hip dysplasia

ortolani sign (positive when a posterior hip dislocation is reducible with this maneuver) pavlik harness cast

which medication might be given to prevent urinary incontinence?

oxybutynin

uncompensated pH

pH and one other value are abnormal

compensated pH

pH is normal, other 2 values are abnormal

blood products

packed red blood cells, platelets, albumin, fresh frozen plasma

symptoms of compartment syndrome

pain, pressure, pallor, paresthesia, paralysis, pulselessness

mastitis

painful, reddened and tender area of breast tissue associated with breast feeding completely empty breast with feeding and good hygiene

placenta previa

painless, bright red bleeding

aplastic anemia

pancytopenia (low WBC, RBC, and platelet)

learning disorder manifestation

persistent difficulty with reading or math

thoracentesis intervention

place chest tube in room

pneumonia symptom

pleuritic pain (lungs)

when a client is taking digoxin, what should the nurse monitor?

potassium- this is an antiarrhythmic

which medication might be given to treat neuropathy?

pregabalin

hemolytic

premature rbc destruction

hyperbilirubinemia contributing factors

prematurity, birth injury, Rh negative mom

the fetus is in a longitudinal lie with FHR above the umbilicus. what should the nurse do?

prepare for ultrasound. evaluate for breech. (PRESENTATION)

3rd trimester of pregnancy

preparing for birth nesting, braxton hicks contractions, disturbed sleep

schizophrenia stages

prodrome, acute, stabilization, maintenance

endometritis

profuse lochia, sitz baths help, cephalosporin because you have an infection

acute epiglottitis

progresses rapidly, possible intubation

parkinson's disease

progressive disease tremor, rigidity, bradykinesia and postural instability missing dopamine; meds increase levels contraindicated with MAOI's, narrow angle glaucoma

pyloric stenosis

projectile vomit

sputum collection intervention

provide oral care

second stage of labor

pushing stage. support and assess fhr

what to do if client on droplet precautions needs to leave the room?

put a mask on them

what to do if client on airborne precautions needs to leave the room?

put a surgical mask on them

congenital GI disorders

pyloric stenosis, hirschsprung's, intussusception, cleft palate

which medication might be given to treat bipolar disorder?

quetiapine

insulin types

rapid (aspart, lispro) short intermediate (NPH, humulin, regular) long acting (glargine, detemir)

hydatiform mole

rapid uterine growth; bleeding, grape like clusters

if a patient has respiratory alkalosis, the nurse might use a:

rebreather bag OR hydromorphone

fourth stage of labor

recovery and bonding. hemorrhage= greatest risk

renal disease symptom

reduced erythropoietin

lithium

reduces bipolar disorder symptoms short term use due to dependency concerns, adverse reaction with diuretics and NSAIDs. levels: therapeutic- 0.4-1.4 toxicity- >2 toxicity is caused by NSAIDs and hyponatremia

generalized anxiety disorder nursing intervention

reframe situation in positive way

which insulin do you give for hyperkalemia?

regular (aka intermediate/NPH/humulin)

this medication might be used to lower serum K+ levels

regular insulin IV

client recently had tracheostomy surgery and is now home. nurse recognizes need for immediate intervention when caregiver:

removes the ties before cleaning the tracheostomy. if they cough, they can decannulate themselves and lose airway. other aspects of trach care: use precut drain sponge around trach, suction trach for 10-15 secs, place air humidifier at bedside

kidney stones (urolithiasis) symptoms

renal colic

pH decreased, PCO2 elevated, HCO3 normal

respiratory acidosis

pH elevated, PCO2 decreased, HCO3 normal

respiratory alkalosis

when a client is taking morphine, what should the nurse monitor?

respiratory rate- this is an opioid

right sided heart failure

rest of body: JVD, weight increases, edema

neurosensory disorders

reye syndrome, meningitis, neonatal seizures, substance exposed infant

clozapine

risk for agranulocytosis antipsychotic that treats schizophrenia

epiglottitis

risk of losing airway -drooling, tripod position

this supplement helps clients with enlarged prostates. pregnant women shouldn't take.

saw palmetto

typical antipsychotic meds

sedation, extrapyramidal symptoms (dystonia, akathisia, parkinsonism, tremor, tardive dyskinesia), anticholinergic effects, seizures, agranulocytosis ex: haloperidol, thiothixene, hydrochloride

what position should you put someone with increasing ICP in?

semi fowler's- this allows for natural drainage

nephrotic syndrome symptoms

severe proteinuria

pulmonary embolus

signs and symptoms: dyspnea, tachypnea, restlessness, chest pain, diaphoresis interventions: respiratory assessment/support, pain management, anticoagulation or thrombolytics, monitor for complications

diet for dumping syndrome

small, frequent meals

dumping syndrome diet

small, frequent meals

2 potassium sparing diuretics

spironolactone and triameterone

this supplement treats mild depression, can cause serotonin syndrome when combined with antidepressants

st. john's wort

oprelvekin

stimulates platelets side effects: cardiac dysrhythmias give after chemo

filgrastim

stimulates white blood cell production side effects: leukocytosis interventions: monitor CBC

contraction frequency is 90 seconds. what should the nurse do?

stop pitocin (tachysystole). check fhr. assess pain and fatigue. (POWERS)

phobias nursing intervention

support desensitization

circumcision

surgical removal of foreskin of the penis contraindicated in hypospadias, epispadias, ambiguous genitalia consent and "time out" post-op education for parents

substance exposed infant

swaddle with hands close to mouth

when a client is taking acetaminophen, what should the nurse monitor?

temperature- this is an analgesic/antipyretic

chronic bronchitis symptom

tenacious sputum

late decelerations

these are a PROBLEM- fetal heart rate decreases at peak of contraction and doesn't come back to normal after the contraction is over

if patient is prescribed 2 sprays of desmopressin acetate, what instructions should you give them?

this is a synthetic form of antidiuretic hormone to treat diabetes that will prevent excess urination. store unused medication in the fridge.

when there is a fire in the hospital, evacuate who first?

those who are ambulatory so that you can get as many people out as possible

which medication might be given to treat COPD?

tiotropium

nursing care of children

toddler 1-3 yrs: ritualism, separation anxiety peaks 15 months: walks independently, uses cup well 3 year old: rides tricycle, alternates feet going up stairs preschooler 3-6 years old: pretend play, magical thinking 4 year old- skips and hops, throws ball overhand, catches reliably 5 year old- jumps rope, ties shoes

cushing's disease

too many glucocorticoids increased steroid production (S) hyperclycemia hypernatremia (water follows sodium leading to reduced serum electrolytes) hypocalcemia hypokalemia osteoporosis (body pulling it out of bones) hypertension and weight gain poor wound healing moonface, buffalo hump, trunkal obesity fragile skin immune suppression (too many steroids) hirsutism *TOO MUCH sugar and salt, steroids

antipsychotic meds

typical: haloperidol, thiothixene, hydrochloride atypical: olanzapine, aripiprazole

prenatal tests

ultrasound- may need full bladder nonstress test- fetal heart rate increases with fetal movement contraction stress test- negative test has no late decels biophysical profile- 5 variables assessed amniocentesis- give Rhogam after test to Rh- client maternal serum alpha fetoprotein- neural tube defect

ectopic pregnancy

unilateral, stabbing abdominal pain

amyotrophic lateral sclerosis (ALS)

upper and lower neuron disease. progressive weakness, wasting, and paralysis.

beta blockers complication

use cautiously with asthma (bronchoconstriction) ex: propranolol, atenolol

peritoneal dialysis

uses belly to filter blood inside the body done at least daily -weigh client before and after -don't have to hold meds -labs don't fluctuate as much -advantages: more mobility, fewer hemodynamic complications -complications: poor outflow, infection, cold shock, bowel perforation

danger signs during pregnancy

vaginal bleeding fever, chills, severe vomiting decreased or absent fetal movement sudden weight gain severe headache preterm labor ROM prior to 37 weeks (deliver within 24 hours)

which medication might be given to decrease symptoms of herpes zoster?

valacyclovir

this supplement prevents insomnia

valerian root

which medication might be given to lower blood pressure?

valsartan

venous insufficiency

veins carry deoxygenated blood- LEGS GO UP LIKE LEGS ON V

venous or arterial insufficiency?

venous: painless ulcers, lower leg edema, hyperpigmentation arterial: claudication, delayed CRT, hair loss on legs, cyanotic extremities (all due to lack of oxygen)

if you are admitting a client from long term care:

verify admission meds prescribed by provider, review current med regimen with client, obtain most recent med list from long term care, and discuss discrepancies with provider. MED RECONCILIATION

what vitamins are given to newborn after birth?

vitamin K injection to start clotting and erythromycin in the eyes

accrocyanosis

warm cyanotic extremities and warm trunk

iron deficiency anemia

weakness and pallor

do you need to get treated for postpartum depression?

yes

with type 1 diabetes, does individual always have a daily injection of insulin?

yes

testicular cancer

younger men: 30s -detection: do testicular exams, shouldn't have any discomfort -heaviness in scrotal sac or nodule on testicle -orchiectomy- surgery to remove testicle -chemo after surgery can destroy sperm-talk about banking