ATI practice questions

A child is admitted after being diagnosed with Wilms tumor. The admitting nurse knows to place a sign that says:

"Do not palpate abdomen"

A patient who is withdrawn says, "When I have the opportunity, I am going to commit suicide." What response by the nurse is of the highest priority?

"Do you have a plan in place?"

The mother of a child with hemophilia asks the nurse how long her child will need to be treated for hemophilia. What is the best response to this question?

"Hemophilia is a life-long blood disorder"

Drug tolerance

"I don't get the same relief as I used to with this pain medicine"

Which of the following statements made by a school-age girl indicates the need for further teaching about the prevention of urinary tract infections?

"I really like taking bubble baths every night"

Pt on Digoxin (Lanoxin) and Furosemide (Lasix) teaching:

"I will eat fruits and veges that have high-potassium content in them"

What is the best response to a parent who asks the nurse whether her 5-month-old infant can have cow's milk?

"Infants younger than 12 months need iron-rich formula to get the iron they need"

What is the nurse's best response to a mother whose child has a diagnosis of acute lymphoblastic leukemia and is expressing guilt about not having responded sooner to her child's symptoms?

"It is not uncommon for parents not to notice the subtle changes in their children's health"

The nurse is caring for a child with Wilms tumor. The child is scheduled for a MRI of the lungs. The parents ask the reason because Wilms involves the kidneys. What is the best response?

"The test is dont to check to see if the disease has spread to the lungs"

The parents of a child with Duchenne muscular dystrophy have just learned that children with this disease have a limited life expectancy. They ask what this means for how they will raise their son. What is the nurse's best response?

"Throughout his disease, we will focus on maximizing his abilities and keeping him comfortable"

Which of the following statements made by parents of a child with leukemia, indicates an understanding of teaching related to home care associated with the disease?

"We will take our son's temperature daily and report any fevers"

The nurse is teaching the parents of a child recently diagnosed with ADHD who has been prescribed methyphenidate (Ritalin). Which of the following should the nurse include in teaching about the side effects of methylphenidate?

"Your child may experience a sense of nervousness"

Addison's disease: Cushing's syndrome:

"add" hormone have extra "cushion" of hormone

ALS

(amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems

After infratentorial surgery

(incision at the nape of neck) position pt flat and lateral on either side.

After supratentorial surgery

(incision behind hairline on forhead) elevate HOB 30-40 degrees

Kawasaki disease

(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.

Woman in labor (un-reassuring FHR)

(late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!

To prevent dumping syndrome

(post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals.

Autonomic Dysreflexia

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

Meningitis Expected findings

-Nuchal Ridgity -Red Macular Rash -photophobia -HA -Avoid raising legs above level of the heart -Avoid crossing legs, hip flexion

NI for pulmonary embolism

-administer oxygen (position high fowlers) -provide emotional support, comfort and control anxiety -monitor changes in LOC and mental status

med interactions with metronidazole

-alcohol causes disulfiram-like reaction -it inhibits inactivation of warfarin

suicide priority actions

-always have client in sight and physically close -always check hands -only use plastic utensils

anorexia nervosa

-ammenoreha (missed periods) -fear of being fat -preoccupied with food and the rituals of eating

reducing fever

-antibiotics -fluids and rest -aspirin -cooling blanket -oral hygiene and dry clothing -control environmental temp, maintaining it between 70-80 degrees

promoting venous return

-check legs every 8hrs -skin care with moisturizing lotion

monitoring chemotherapy related to mucositis

-examine mouth 7 times a day -avoid using glycerin-based mouthwashes or mouth swabs -discourage salty, acidic, or spicy foods -offer mouth care before and after meals -rinse mouth with sodium chloride and half peroxide twice a day and brush with soft-bristles toothbrush

client teaching about external radiation

-fatigue is common -wash skin with mild soap and water, dry thoroughly using patting motions -do not remove radiation tattoos -do not apply powders, ointments, lotions, or perfumes -wear soft clothing over skin -avoid tight clothing -do not expose skin to sun or heat sources

chest tube: reporting complications

-if constant bubbling (its ok in suction chamber) there is an air leak (check connections and call for assistance, cross clamp close to clients chest) -disconnection from chest (cover insertion site, notify provider) -disconnection from drainage (place end of tube in sterile water, keep drainage system below the level of the chest) -tension pneumothorax due to clamping, kinks, or obstruction of tube -Monitor the fluid in the suction control chamber and maintain the fluid level

discharging client with diabetes mellitus and home management

-monitor glucose -check glucose before meal and at bedtime -hypoglycemia warrants immediate evaluation of glucose -monitor foot injuries

s/s of cystic fibrosis

-poor wt gain (failure to thrive) -meconium ileus at birth (abdomen distention, vomiting, inability to pass stool) -no pancreatic enzymes -fatugue -dry, nonproductive cough -thick yellow gray mucus -positive sputum culture -fever -shortness of breath, dyspnea, wheezing -clubbed fingers

client teaching about internal radiation

-remain in position to prevent dislodgement of radiation implant -call nurse for assistance with elimination -maintain precautions at home if discharged

client teaching about Digoxin

-report signs of hypokalemia (N/V, general weakness) -increase potassium (spinach, bananas, potatoes) -monitor GI and CNS effects

bupropion hydrochloride (Wellbutrin) for varies antidepressants; used for pts who have ...

-seasonal affective disorder (reduce light winter) -smoking addiction -depression

Order of post-mortem care?

1) call organ procurement team 2) collect necessary specimens 3) remove tubes and vascular lines 4) cleanse the body 5) apply tags to clients body after all care is provided

proper steps of crutches while climbing stairs

1) stand in tripod position 2) place body weight on crutches 3) place unaffected e.g. on stair 4) move affected leg and crutches up to the stair

Eviscerated bowel resection interventions-

1) stay with the client and call for help 2) cover wound with saline-soaked gauze. 3) place in supine position with knees bent. 4) take client's vitals

Nitroglycerin order

1) stop activity 2) Place tab under tongue 3) wait 5 min 4) call 911 if pain is not relieved

What to report with preeclampsia?

1) swelling of the hands and face 2) rest in side-lying position 3) notify the provider of decreased urinary output 4) perform daily fetal kick counts

Nursing Care of the Newborn Breastfeeding

1. 30-40 minutes a day

Nursing Care of the Newborn Reinforcing Teaching about Breastfeeding

1. 6 to 8 Diapers a day 2. Will have loose pale yellow stools 3. Cover part of Areolar

A two year old child comes to the hospital with anorexia, abdominal distention, chronic constipation, foul-smelling and ribbonlike stools. Which orders might the nurse anticipate for this child? (Select all that apply)

1. Administer enemas to clean bowel 2. Preoperative care for a surgical removal of affected portion of bowel 3. IV antibiotics

Urinary Elimination Needs and Specimen Collection Catheterization for Residual Urine

1. Alcohol clean side port to Withdraw

Mechanical Ventilation Planning Care

1. Asses cuff pressure every 8 hours

Cancers caring for Clients who are Immunocompromised

1. Avoid Fresh Fruit 2. Fresh Flowers 3. Avoid Sick Visitors

Peripheral Vascular Disease, Data Collection

1. Bruit over femoral and aortic arteries

Contraception Appropriate Use of Contraception

1. Can use spermicide gel/cream 2. No male and female condoms 3. Refitted every 2 years/ Keep in place for 6hrs after intercourse

Oxygen Therapy Monitoring Delivery

1. Change water every 24 hours 2L Vpulse 2. Clean Nose

Cognitive Disorders Planning Care in an Adult Day Care Setting

1. Check Mental Status

Diabetes Management Hypoglycemia*

1. Clammy Pale Skin 2. Irrability 3. Weakness 4. Tremors

Management of Varicella

1. Crust over

Which of the following suggestions are important to include when teaching parents of an 18-month-old with iron-deficiency anemia? (select all that apply)

1. Decrease the toddler's daily milk intake to 24 ounces or less 2. Give oral iron supplement between meals with orange juice 3. Include apricots, dark-green leafy veggies and Cream of Wheat in diet

Bacterial Viral and Fungal Infection, Nationally Notifiable Infectious Disease

1. E coli

Head injury ICP expected finding *

1. Early sign Restlessness 2. Late sign Dilated Pupils

Cerebrovascular Accident

1. Eat in upright position / Swallow with head and neck flexed slightly forward 2. Place food in back of mouth on unaffected side 3. Avoid extreme flexion or extension of the neck 4. Give sour/tart food 5. Meet with Speech Therapist

Asthma emergency management of bee sting allergies

1. Epi Pen

Meeting Nutritional Needs of Newborns Breastfeeding

1. Every 2 to 3 hours 2. Freeze 3 to 6 months

Living Will*

1. Express patient's wishes

A mom comes to the clinic that her 2-year-old child has begun to repetitively flap his arms when agitated and echo's words or phrases said to him. What additional findings might the nurse discover when completing the history and assessment? (Select all that apply)

1. Eye contact avoidance 2. Insists on a routine 3. Difficulty with understanding other people's feelings

Disaster Planning and Emergency Management Recommending Clients to Discharge

1. Fever has to stay

Hyperglycemia

1. Flushed Skin 2. Fruity Breath 3. Rapid Breathing 4. Thirst

Breast Self-Examination

1. Following Menstrual Cycle Monthly a Week After

A 5-year-old is being evaluated for a lower UTI. Which symptoms is she likely to be displaying to warrant evaluation? (Select all that apply)

1. Frequency or urgency 2. Strong smelling urine 3. Incontinence in a toilet-trained child

Legal Responsibilities Securing Client Valuables

1. Give money to Security

Medical and Surgical Asepsis Hand Hygiene

1. Hands Above Elbows is wrong 2. Elbows up and Hands down Correct

A 7 year old child experiences intracranial pressure secondary to malignancy. Which assessment findings will the nurse anticipate? (select all that apply)

1. Headache 2. Blurred vision 3. Vomiting especially in the morning

The parents of a child who is disruptive in the classroom consults with the school nurse for ideas concerning behavior modification. Which findings lead the nurse to refer the parent to take the child for an assessment for ADHD? (Select all that apply)

1. Inability to stay on task 2. Frequent shifts from one uncompleted activity to another 3. Fidgeting, squirming when seated

Contraception Appropriate Methods for an Adolescent

1. Injectable Progestin (Depo Prevea)

Phototherapy

1. Jaundice on Head Sclera 2. Maculopapular Rash 3. Dehydration 4. Green liquid stools 5. Feed every 3-4 hours 6. Vital Signs every 4 hours 7. Mask The Eyes 8. Keep Infants Undressed 9. Remove baby from light every 4 hours

Right Sided Heart Failure

1. Jungular Vein Distention 2. Ascending Dependent Edema 3. Weight Gain 4. Hepatomegaly (Liver Enlargement)

Amputation Body Image Change

1. Monitor Anger, 2. Withdrawal 3. Sadness 4. Assist with residue limb Prepation

Nursing care of all infants who have had a myelomeningocele repair includes which of the following interventions? (select all that apply)

1. Monitor for skin breakdown 2. Frequent neurological checks 3. Monitor intake and output

Testicular Examination

1. Monthly after warm shower

Clients Understanding of Organ Donation

1. Must be made by patient

A parent brings his 4-month-old to the ED. Upon assessing the infant, the nurse knows which of the following signs indicate the need for prompt treatment? (Select all that apply)

1. Nasal flaring 2. Respiratory rate of 10 breaths/minute 3. Grunting 4. Oxygen saturation of 90%

Tuberculosis Transmission Precautions

1. Negative air pressure room 2. Transferring Patient needs a Surgical Mask

Spinal Cord Injury Client Referral

1. OTA 2. PT 3. Social Service

An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which of the following interventions should be included in the child's postoperative care? (select all that apply)

1. Observe closely for signs of infection 2. Maintain an accurate record of intake and output 3. Monitor for abdominal distention

Hypocalcemia

1. Paresthesia fingers and lips 2. Tetany 3. Muscle Twitching

Left Sided Heart Failure

1. Pnea, SOB 2. Crackles 3. Oliguria 4. Frothy Sputum 5. Displaced Apical Pulse (Hypertrophy)

Childhood Immunization Contraindication

1. Pregnancy 2. Allergies to gelatin 3. Can be contraindicated if child is sick

Amputation Discharge Teaching

1. Prone position, 6x a day for 20-30 min

Wound Evisceration, Emergency management

1. Saline cover wound

Electrolyte Imbalance Report

1. Severe H/A 2. Blurred Vision 3. Epigastric Pain

Systemic Lupus Erythematosus (Medrol Meds)

1. Should Limit Contact With People With Possible Infection 2. Avoid Large Group Of People

Cerebrovascular Accident Appropriate Referrals

1. Speech Therapist

Respiratory Illness Contagious Common

1. Stay away until 24 Hours after Antibiotics

Female Cancers Appropriate Referrals

1. Support Group

Which of the following factors indicates a potentially, undetected cardiac defect when assessing a 1 month old infant? (Select all that apply)

1. Tachypnea 2. Tachycardia 3. Poor nutritional intake

Urinary Tract Infection Reinforcing Teaching

1. Void 3-4 hours 2. Wipe front to the back 3. Drink plenty of fluids 4. Wear cotton underwear 5. Avoid bubble baths

Peripheral Arterial Disease, Monitoring Circulation

1. Walk 8 times a day 2. Avoid Cold 3. Monitor q 8 hours 4. Skin care with warm water 5. Mild Soap

Benign Hypertrophy

1. While Catheter in place, will feel the urge to void 2. Calculate urine output every 2 hours 3. Should get up in a chair ASAP 4. Avoid heavy lifting 5. Avoid Sex/Intercourse 2-6 weeks 6. Expected output 150-200 ml every 3-4 hours

Disaster Planning and Emergency Management Responding to a fire

1. remove Patient First

magnesium

1.3-2.1

1 g (gram)

1000 mg

Normal 6 - 12 years old HGB level

11.5 - 15.5 g/dL

Normal 12 - 18 years old HGB level

12 - 16 g/dL

normal sodium

136-145

I lb

16 oz

anterior fontanelle closes by...posterior by..

18 months, 6-8 weeks

Kidney glucose threshold

180

Digoxin (lanoxin) was given instead of furosemide (lasix)

1st assess pt Apical pulse

1 pint

2 cups

1 quart

2 pints

Developmental

2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup

1 kg

2.2 lbs

Normal 2 month old Hct level

28% - 42%

COPD patients and O2

2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less

phosphorus

3.5-4.5

normal potassium

3.5-5.0

A patient with irritable bowel syndrome should increase fiber to at least ___g per day.

30

Infant drink 2oz, 3oz, 2.5oz

30 *7.5=225mL (30mL/oz)

1 oz

30 mL

Normal 6 - 12 years old Hct level

35% - 45%

Normal 12 - 18 years old Hct level

37% - 49% males 36% - 46% females

Expected aPTT values in child with hemophilia A?

45- above the expected range

1 tsp

5 mL

hungtington's

50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure

Alzheimer's

60% of all dementias, chronic, progressive degenerative cognitive disorder.

Tidal volume is

7-10 ml/kg

Stranger anxiety is greatest at what age?

7-9 months..separation anxiety peaks in toddlerhood

Report chest tube drainage greater than ___ mL/hr.

70

1 cup

8 oz

Normal 2 month old HGB level

9.0 - 14.0 g/dL

normal calcium

9.0-10.5

normal chloride

98-106

Reasons to withold vaccines

> Any anaphylactic reaction to a vaccine or vaccines containing that substance. > allergies to contents in the vaccine > Moderate or severe illnesses with/without symptoms. (with common cold and other minor illnesses are not contraindicted) > inmmunocompromised individuals as defined by the CDC: those with hematologic or solid tumors, congenital immunodeficiency, or immunosuppressive therapy.

Signs and symptoms of MODERATE dehydration

> Capillary refill between 2-4 seconds > thirst and irritability > pulse slightly increased with orthostatic hypotension > mucous membranes are dry and tears and skin turgor are decreased > urine specific gravity 1.020

Pain Management for burns

> Establish ongoing monitoring of pain and effectiveness of pain treatment. > Avoid IM or subcutaneous injections. > Use intravenous opioid analgesics, such as morphine sulfate, hydromorphone (Dilaudid), and fentanyl(Sublimaze). > Monitor for respiratory depression when using opioid analgesics. > Administer pain medications prior to dressing changes or procedures. >Use nonpharmacologic methods for pain control (guided imagery, music therapy, therapeutic touch) to enhance the effects of analgesic medications and lead to more effective pain management.

Nutritional support for burns

> Increase caloric intake to meet increased metabolic demands and prevent hypoglycemia. > Increase protein intake to prevent tissue breakdown and promote healing. > Provide enteral therapy or total parenteral nutrition (TPN) if necessary due to decreased gastrointestinal motility and increased caloric needs.

Signs and symptoms of MILD dehydration

> Normal: behavior, mucous membranes, anterior fontanel, pulse, and blood pressure. > Capillary refill is between 2 and 4 seconds > slight thirst may be experienced > urine specific gravity 1.020

Signs and symptoms of Digoxin toxicity

> bradycardia > dysrhythmias > nausea, > vomiting > anorexia

Signs and symptoms of severe dehydration

> capillary refill is greater than 4 seconds > tachycardia and orthostatic hypotension, may progress to shock > mucous membranes are very dry and skin is tented > anterior fontanel is sunken > oliguria or anuria is present

End-of-life decisions require

> honest information regarding prognosis > disease progression > treatment options > the impact of the treatments These decisions are made during a highly stressful time. It is important that all health care personnel are aware of the child and family's decisions.

NPH insulin (Humulin N)

> intermediate acting > onset 1-2hr > peak 4-12 hr > duration 18-24hr

Insulin glargine (Lantus)

> long acting > onset 1hr > peak none > duration 10.4 -24 hr

Insulin lispro (Humalog)

> rapid acting > onset is less than 15min > peak 0.5-1hr > Duration 3-4hr

Appropriate toys for an infant

> rattles > mobiles > teething toys > nesting toys > playing pat-a-cake > playing with balls > reading books

Regular insulin (Humulin R)

> short acting > onset 0.5-1hr > peak 2-3hr > duration 5-7hr

Appropriate activities for toddlers

>filling empty containers > plaing with blocks > looking at books > playing with toys that can be pushed or pulled > tossing balls

Skin breakdown

A 5% loss of total body weight in 30 days or a 10% loss of total body weight in 6 month indicates poor nutrition which places a pt at risk for skin breakdown. A pre albumin level of 5mg/dL also places a pt at risk for skin breakdown.

Ibuprofen

A common side effect of ibuprofen is GI bleeding

HIV treatment

A decreased viral load indicates a positive response to prescribed HIV treatment, because viral load testing measures the presence of HIV viral genetic material

Pt with CHF taking Spironolactone (Aldactone) teaching:

A potassium-sparing diuretic should not use salt substitute as it contain potassium and put pt at risk for hyperkalemia

The nurse is caring for a child with a diagnosis of ALL who is receiving chemotherapy. The patient's platelet count is 20,000. Based on this laboratory finding, what information should the nurse provide to the child and parents?

A soft toothbrush should be used for mouth care

Alkalosis/ Acidosis and K+

ALKalosis=al K= low sis. Acidosis (K+ high)

Verifying NG tube placement?

ASPIRATE contents from the tube and verify the pH. Gastric aspirate should be between 1-4 to assess for proper placement prior to bolus feedings.

Which of the following is the best nursing diagnosis for a child with anemia?

Activity intolerence r/t generalized weakness

A child with sickle cell disease is seen in the ED with paleness, fatigue, decreased BP and increased pulse. What is this child potentially experiencing?

Acute sequestration crisis

Addison's & Cushings

Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia

Which of the following should the nurse include when teaching the mother of a 9-month-old about administering liquid iron preparations?

Adequate dosage will turn the stools a tarry green color

Client is to receive IV pyelogram the next day. Which action should the nurse take?

Administer a laxative to remove feces, liquid, and air from the system.

What will be included in the discharge plan for a three-year old with sickle cell disease?

Administration of penicillin daily as ordered

CPM machine

Affected extremity should maintain neutral alignment. Turn off machine during meals to promote comfort and dietary intake.

Lumbar Puncture

After the procedure, the pt should be supine for 4-12 hours as prescribed.

draw up regular and NHP?

Air into NHP, air into Regular. Draw regular, then NHP

Child with asthma rescue meds:

Albuterol (proventil) beta 2-adrenergic agonist used for immediate relief for acute asthma attack

Who should receive Rhogam shots?

An O negative woman following a spontaneous abortion. The abortion may have been carrying an rH-positive fetus.

A 10-year-old with severe hemophilia falls, injures his elbow and is brought to the ER. The nurse should prepare which of the following?

An intravenous infusion of factor VIII

Early detection of prostate cancer?

Annual measurement of PSA levels should be performed for men over 50.

Theophylline toxicity-

Anorexia. Also hypotension, albuminuria, tachycardia.

An adolescent is scheduled for a leg amputation in 2 days for treatment of osteosarcoma. The nurse's approach should include which of the following?

Answer questions with straightforward honesty

Antiinflammatory agents for Asthma

Antiinflammatory agents decrease airway inflammation for long-term management. ■ Corticosteroids (fluticasone [Flovent] and prednisone [Deltasone]) ■ Leukotriene modifiers (montelukast [Singulair]), mast cell stabilizers (cromolyn sodium [Intal]), and monoclonal antibodies (omalizumab [Xolair])

The nurse assesses a 15 year old boy who has just returned to the recovery area after undergoing a cardiac catheterization. Which of the following is of most concern?

Apical pulse is 150 beats/min and regular

APGAR

Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent)

Rheumatoid arthritis

Application of heat and cold decreases joint inflammation and pain

Rheumatoid arthritis management-

Apply cold therapy to edematous joints.

A young girl has just injured her ankle at school. In addition to assessing the ankle and calling the child's parents, what intervention has the highest priority?

Apply ice and elevate extremity

Peripheral artery disease:

Apply lubricating lotion to feet.

The nurse notes skin breakdown on a neutopenic child with leukemia. What is the nurse's priority action?

Assess the child's vital signs for symptoms of infection

Hepatitis b

B= blood and body fluids (hep c is the same)

(benzodiazepine) alprazolam (Xanax); adverse effects

Benzodiazepine "-pam, -lam" tolerance, anxiety, sedation, respiratory depression benzodiazepines (D/V)

(Benzodiazepine) alprazolam (Xanax); questions the use when pt

Benzodiazepine "pam, -lam" drinks 2 glasses of wine each night respiratory depression

(Beta Blocker) betaxolol (Betoptic) eye drops for glaucoma; adverse effect

Beta Blocker "OLOL, LOL" bradycardia because of the blockage of cardiac beta 1 receptors

(Beta Blocker) betaxolol (Betoptic) eye drops for glaucoma; expect following reactions

Beta Blocker "OLOL, LOL" ocular stinging beta-adrenergic blocker; short term

Babinski reflex (stroke the infant's foot and their toes fan out)

Birth to 1 year

moro reflex (startle)

Birth to 4 months

sucking and rooting reflex

Birth to 4 months

palmar grasp

Birth to 6 months

Client w/ iron deficiency anemia and elevated cholesterol. Good food choice?

Black beans. Beans are both high in iron and low in fat; therefore, the client should include this in his diet.

Homonymous Hemianopsia is what?

Blindness in the same visual field of both eyes

A pre-school aged child is hospitalized for leukemia. The nurse should anticipate which fears when planning nursing care for this patient?

Body mutilations and being left alone, and the dark

A nurse is assessing a client q15min during the immediate postpartum period- which requires immediate action?

Boggy uterus. This indicates that the client is at greatest rush for uterine atony; therefore, the nurse should immediately massage the fundus to prevent blood loss.

A 10 year old girl sustained a fracture in the epiphyseal plate of her right fibula when she fell out a tree. When discussing this injury with her parents, the nurse considers which of the following?

Bone growth can be affected by this type of fracture

The nurse understands that the most important precautions needed for children receiving chemotherapy is based on which of the following actions of chemotherapeutic agent?

Bone marrow suppression

Which of the following is true about the genetic transmission of sickle cell disease?

Both parents must carry the sickle cell trait

Pt with anxiety disorder and panic attack, given Diazepam (valium)

BuSpar delayed onset of action. Buspirone an effective nonbenzodiazepine anianxiety but not for acute anxiety attack. Its effect in 7-10 days.

Hypocalcemia

CATS Convulsions, Arrythmias, Tetany, spasms and stridor

Hypo-parathyroid

CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet

laparoscopy

CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup

Myxedema coma

COLD (hypothermia)

Levothyroxine

Calcium supplements can interfere with levothyroxine

Discharged with warfarin (coumadin) teaching:

Carry medic alert ID. Avoid aspirin (antiplatelets effect) Get regular exercise to prevent venous stasis & thrombophlebitis Don't take dark green vege high in vit K will decrease effectiveness of warfarin.

Cholinergic Crisis

Caused by excessive medication ---stop giving Tensilon...will make it worse.

Pt taking Lithium (Eskalith)

Caution of FASTING behavior or crash dieting can lead to Lithium Toxicity.

When assessing a multiparous client following a vacuum-assisted birth, the nurse should be alert for what complication?

Cervical laceration. Maternal complications with vacuum-assisted birth are rare but can include perineal, vaginal, or cervical lacerations.

Which of the following is a characteristic of children with depression?

Change in appetite, resulting in weight loss or gain

Discharge teaching on Albuterol (proventil) for asthma

Check fine motor control, @ risk if inability to administer medication.

After a Tensilon shot patient shows increased muscle weakness and twitching. Probably cause is what?

Cholinergic Crisis...myasthenia gravis

Pt prescribed Ciprofloxacin Hydrochloride (Cipro) and Phenazopyridine (Pyridium) to tx UTI why use both meds...

Cipro treats the infection and Pyridium treats the pain & discomfort

It is important to surgically correct hypospadias prior to which procedure?

Circumcision

Client has two different types of eye drops- what to include in teaching?

Close eyes for 1 min following administration of each medication to allow for absorption. Wait 10-15 min between administration of each med to prevent diluting the medication.

Intussusception

Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements

Which of the following would cause to suspect that a child's cast is too tight?

Complaint of numbness and tingling

Young people with anorexia nervosa are often described as being which of the following?

Conforming

Hypoglycemia

Cool, clammy skin is an indication of hypoglycemia

Propranolol adverse effects:

Coughing at night, subsequent of heart failure.

Prednisone toxicity

Cushings (buffalo hump, moon face, high blood sugar, HTN)

Tetrology of Fallot

DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis)

An adolescent patient tells the nurse that he is experiencing a change in sleeping patterns, irritability, fatigue, and anxiety. His mother reports all his grades dropped 2 letter grades. Given the symptoms, what diagnosis might the nurse suspect?

Depression

Child who has FTT (failure to thrive)- what to include in the plan of care?

Develop a structured routine. A structured routine creates a positive feeding response and limits the number of disruptions in other activities of daily living.

Disseminated herpes zoster localized herpes zoster

Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered!

LLQ

Diverticulitis

Patient is in active labor and is recording Pitocin. FHR shows variability with accelerations. Appropriate nursing response?

Document and continue to monitor. Variable accelerations are a reassuring FHR pattern indicating an intact fetal CNS and a healthy placental/fetal exchange of oxygen. The nurse should continue to monitor the client.

When does idiopathic scoliosis become most noticable?

During preadolescent growth spurt

39 weeks gestation- during second phase of labor, nurse observes early decels on the monitor. What action to take?

Early decels are associated with the progression of labor and are benign. The nurse should continue to observe the fetal heart rate.

What is the priority outcome of mandatory newborn screening for hypothyroidism?

Early identification of the disorder

Hepatitis A

Eating contaminated food increases the risk of contracting Hep A

Better peripheral perfusion?

EleVate Veins, DAngle Arteries

Hepatitis A

Ends in a vowel, comes from the bowel

Adolescents with bulimia may experience which of the following complications as a result of the frequent vomiting?

Erosion of tooth enamel

A 6 year old comes to the clinic and is diagnosed with precocious puberty. Which intervention is important when considering risks associated with this disorder?

Explain the importance of having the child foster relationships with same-age peers

S/S of hip fx

External rotation, shortening adduction

centigrade to Fahrenheit conversion

F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40

Children with spina bifida are at low risk for development of a latex allergy

False

Congenital hypothyroidism is treated only during childhood with thyroid replacement therapy?

False

Johnny is a 5 year old in the ED after a traumatic motor vehicle accident. The physician calls out Glasgow scare of 15. The nurse knows this means she has an altered LOC

False

Which of the following is the most commonly used method in completed suicides?

Firearms

IV with discomfort and coolness

First action the nurse should take is to compare the site to the opposite extremity

Turner's sign

Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis

Nursing manager is having difficulty staffing weekend shifts. What should he do to successfully implement changes?

Form a staff task force to investigate current staffing issues.

A neonate is born with mild clubfeet. When the parents as the nurse how this will be corrected, what will the nurse explain to the parents?

Frequent, serial casting is tried first

SE of vitamins, minerals, and supplements

GI distress (nausea, constipation, heart burn) teeth and skin staining prophylaxis risk hypo-tension Iron toxicity

A neonate is displaying tremors, twitching, weak-high pitched cry and diaphoresis. The nurse knows which of the following labs levels, if low, will indicate the cause?

Glucose

CABG

Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart.

CSF meningitis

HIGH protein LOW glucose

Ventilatory alarms

HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc

Thyroid storm

HOT (hyperthermia)

Apgar measures

HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate

Estradiol (Climara) adverse reaction to report-

Headache, hypertension.

A clinical manifestation of growth hormone deficiency is:

Height less than 5th percentile for age and sex

Pt with DVT, to produce fastest anticoagulation effect:

Heparin sodium IV immediate effects

if HR is <100 (children)

Hold Dig

Meds change from Hydralazine (Apresoline) to Metoprolol (Lopressor)

Hydralazine can trigger reflex stimulation of the heart, Metoprolol used to tx reflex tachycardia but blocking beta adrenergic stimulation to the heart

What are the nursing priorities for a child with sickle cell disease in vaso-occulusive crisis?

Hydration and pain management

When a 2 week-old infant is seen for irritability, poor appetite, and rapid head growth with an observable distended scalp vein, the nurse recognizes these signs as indicative of which condition?

Hydrocephalus

Cushings

Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump

Addison's

Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress.

Trousseau and Chvostek's signs observed in

Hypocalcemia

Pt wt CHF given Furosemide (lasix) monitor for:

Hypokalemia. Furosemide a potent loop diuretic.

shock

Hypotension, tachypnea, tachycardia

Prevent discomfort of breast engorgement?

I've packs on the breasts for 15 mins, 3-4 times per day to reduce swelling and relieve pain.

ICP and Shock

ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp

What is used to treat malignant hyperthermia?

IV Dantrolene Sodium (Dantrium) a skeletal muscle relaxant

never give K+ in

IV push

COPD

If pt has SOB, cough and fatigue along with thick mucus secretions, nurse should administer guaifenesin (mucolytic med that thins secretions and promotes airway clearance) as prescribed Pt should be drinking 2-3L/day to thin mucus secretions

Peritoneal dialysis

If the fluid is sluggish in draining, nurse should turn the pt onto their side to reposition the catheter (if it's against the peritoneal wall) or move the catheter (if it's kinked)

What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting from hemophilia?

Immobilization and elevation of the affected joint

Child from emergency department with fever and fluid filled vesicles on the trunk and extremities. What intervention is the highest priority?

Implement transmission-based precautions. The child most likely has varicella, an infectious disease, which indicates the child is at greatest risk for transmitting the infectious agent to others. Therefore, the priority intervention is to implement transmission-based precautions.

Diabetic ketoacidosis

Improvement in condition would be a glucose of under 300mg/dL

Right hemisphere stroke

Impulsive behavior is an indication

Angiotenson II

In the lungs...potent vasodialator, aldosterone attracts sodium.

Which of the following is a symptom of a brain tumor in an infant?

Increased head circumference

Tension pneumothorax

Indicated by chest asymmetry. The air that is forced into the chest cavity causes the affected lung to collapse, and the air that enters the pleural space during inspiration does not exit during expiration.

Fluid volume overload

Indicated by distended neck veins

Hemolytic transfusion reaction

Indicated by low back pain and apprehension

Cholecystitis

Indicated by pain that radiates to the right shoulder

Increased ICP

Indicated by sleepiness, widening pulse pressure and decerebrate/decorticate posturing

An infant arrives in the ED with a fever, bulging fontanel, and lethargy. The lumbar puncture reveals cloudy CSF. What intervention has the highest priority?

Institute droplet isolation

Which of the following is the primary method of treating osteomyelitis?

Intravenous antibiotic therapy

VP shunt- what to report the the provider?

Irritability when being held. This is a manifestation of increased ICP.

Tonic-clonic seizure

It is not unusual for a pt to become cyanotic and it is generally self-limiting. In the event of a tonic-clonic seizure, nurse should turn the pt onto their side

Peritoneal dialysis

Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok

valproic acid (Depakote) which side effects should nurse monitor and report?

Jaundice!! pulmonary edema

Meningitis--check for

Kernig's/ brudinski's signs

Prolapsed cord

Knee to chest or Trendelenburg

Which assessment is most indicative of neurological dysfunction and should be reported immediately?

Lack of response to painful stimuli

Expected finding on a child with autism?

Lack of responsiveness.

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with diagnosis of bacterial meningitis?

Large amount of leukocytes present

An assessment of a 7-month-old with hemoglobin level of 6.5 is likely to reveal which of the following symptoms?

Lethargic, pale and irritable

A child with a history of fever of unknown origin, excessive bruising, lymphadenopathy, and fatigue is exhibiting symptoms most suggestive of which condition?

Leukemia

Use ___ for Tx of premature ventricular contractions.

Lidocaine

Autism- manage behavioral outbursts by:

Limiting external stimuli and using a calming approach

Which of the following symptoms would the nurse expect to observe dring the physical assessment of an adolescent girl with severe weight loss and disrupted metabolism associated with anorexia nervosa?

Lowered body temperature and brittle nails

Contact precaution

MRS WEE Multidrug resistant organism Rresiratory infection Skin infection Wound infection Enteric infection (C diff) Eye infection (conjunctivitis)

Hyperkalemia

MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes

Cytoxan teaching-

Maintain hydration with liberal fluid intake. Should consume 1-1.5 times more than the recommended daily fluid requirement to maintain hydration and prevent hemorrhagic. Cystitis.

How should the nurse manager evaluate a new nurse's time management skills?

Maintain regular notes about the nurse's time management skills. This provides a comprehensive view of the nurse's abilities.

Which of the following is descriptive of attention deficit hyperactivity disorder (ADHD)?

Manifestations affect every aspect of the child's life but are most obvious in the classroom

12 yr old bacterial meningitis which finding indicates client is experiencing increased intracranial pressure (ICP)

Memory Loss

Which of the following explains why iron deficiency anemia is common during toddlerhood?

Milk is a poor source of iron

Which of the following analgesics is most effective for a child with sickle cell pain crisis?

Morphine

Munchausen syndrome vs munchausen by proxy

Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child

Weighted NI (naso intestinal tubes)

Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris

Airborne precautions

My chicken hez tb (measles, chickenpox (varicella) Herpes zoster/shingles TB

Addesonian crisis

N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP

3-4 cups of milk a day for a child?

NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA

Cardiac cath

NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr

Myelogram

NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site

Dig toxicity?

Nausea

Morphine

Nausea and vomiting are common adverse effects

PE

Needs O2!

what to check with pregnancy

Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope.

Glaucoma

No atropine

Client with thrombocytopenia should avoid:

Nose blowing- which increases the risk for bleeding or hemorrhaging.

CABG

Nurse should assess for a decrease in the pt't temp in the immediate post-op period- during a CABG the pt is cooled to decrease metabolic needs. After the procedure the pt is warmed but body temp can fall again and rewarming may be required

SBO and NG tube

Nurse should assess for the passage of flatus because that indicates that the intestines are resuming appropriate function

Left sided heart failure

Nurse should expect to see oliguria during the day because of decreased blood flow to the kidneys

Radical mastectomy

Nurse should include the presence of one or more surgical drains the the plan of care. Pt should start exercise of the arm 24hr after surgery

Conscious sedation

Nurse should intervene if pt's O2 is 90% because respiratory depression is a side effect of the meds used during conscious sedation

Hypothyroidism

Nurse should monitor for constipation which is a clinical manifestation of hypothyroidism as a result of decreased metabolism causing slow motility of the GI tract

Nontunneled percutaneous central venous catheter (CVC)

Nurse should place pt in Trendelenburg position

Tracheostomy suctioning

Nurse should pre oxygenate the pt with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia

Chemo

Nurse should report a high temp. because it can indicate an infection due to myelosuppression

Wound irrigation

Nurse should use a 30-60mL syringe with a 19 gauge catheter to deliver ideal pressure when irrigating a wound

Priority assessment in a seizing patient is ____ saturation.

O2

Regular insulin (Humulin R) and NPH (Humulin N) at 0730

Onset action at 0800 Onset action of regular insulin is 30-60 min, peak 2-4hr

Failure to thrive

Organic causes may include cerebral palsy, chronic renal failure, congenital heart disease, and/or gastroesophageal reflux. However, factors related to nonorganic failure to thrive (NFTT) may include:

McBurney's point

Pain in RLQ with appendicitis

Murphy's sign

Pain with palplation of gall bladder (seen with cholecystitis)

Which of the following clinical manifestations should the nurse expect when a child with sickle cell anemia experience an acute vaso-occlusive crisis?

Painful swelling of hands and feet; painful joints

Characteristics of stage II pressure ulcer?

Partial thickness skin loss.

Diabetes and illness

Patient should continue medication regimen (insulin) when ill to prevent hyperglycemia

Following a delivery- notes heavy lochia and a boggy fundus. What meds should the nurse administer?

Pitocin. This stimulates uterine contractions, and prevents bleeding.

Arterial line

Place a pressure bag around the flush solution While recording values obtained from arterial line the best position for the pt is supine with head elevated 60% degrees

The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. Which of the following should be included?

Place diaper under harness, preferably using a superabsorbent disposable diaper that is relatively thin

Considering both safety and development, which of the following is the best play activity for a 3 year old child with a spica cast?

Playing with a toy telephone

Which of the following clinical manifestations of developmental dysplasia of the hip are seen in the newborn?

Positive Ortolani click

Position of the baby by fetal heart sounds

Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis.

A 15 year old with spina bifida is seen in the clinic for a well-child checkup. The teen uses leg braces and crutches to ambulate. Which of the following nursing diagnoses takes priority?

Potential body image disturbance

Preload/Afterload

Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.

Increased forgetfulness and disorientation, given LORAZEPAM (Ativan) an Antianxiety & sedative effect, monitor for:

Profound sedation.

The nurse will preoperatively position a neonate born with myelomeningocele in which of the following positions?

Prone

Infant with Spina Bifida

Prone so that sac does not rupture

Teaching home care to a family of a child who has a large wound?

Provide a diet high in protein to promote tissue repair. Also eat foods high in vitamin A, and do NOT cleanse with Betadine because it is toxic to open wounds.

Stage II Lyme disease

Pt can experience joint pain, cardiac and neurological complications. If not treated during this state the disease can become chronic and cause arthritis, peripheral neuropathy, vasculitis and myocarditis.

Cholinergic crisis

Pt exhibits increase muscle weakness and twitching after administration of a cholinesterase inhibitor

Tube feeding with decreased LOC

Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration)

AIDS teaching

Pt should avoid raw fruits and vegetables since they are immunocompromised Pt should get an influenza vaccine each year

Iron supplements

Pt should eat more high-fiber foods to help prevent constipation, which is a common side effect of oral iron supplements

Gastric lavage

Pt should lie on the left side to decrease the amount of 0.9% sodium chloride that leaves the stomach and to prevent aspiration. Nurse should insert a large-bore NG tube

Hormone replacement

Pt should notify provider of calf pain (indication of DVT), numbness in the arms (indication of a CVA) and intense headache (indication of CVA)

Above-the-knee amputation with temporary prosthesis

Pt should sleep on a firm mattress. Pt should keep the residual limb in extension to prevent hip flexion contracture

Implantable cardioverter/defirbrillator (ICD)

Pt should tell dentist about ICD Pt should avoid airport metal detectors

External fixation device

Pt should use crutches with a rubber tip. The device is applied by the surgeon directly to the bone to form a rigid structure on the affected extremity.

Prednisone inhaler

Pt should wait at least 20-30 seconds between puffs

Pt on renal transplant given Cyclosporin (Sandimmune)

Pt will have to take sandimmune for the rest of their life, prevent organ rejection.

Detached retina

Pts who have a retinal detachment typically report the sensation of a curtain being pulled over part of the visual field

codes for pt care

Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival

New prescription for warfarin-

Report changes in color of stools- it could indicate bleeding. Do not use NSAIDS. Should have blood tests taken every day for the first five days.

Magnesium sulfate

Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate

CF chief concern?

Respiratory problems

Anorexia nervosa may best be described as which of the following?

Results in severe weight loss in the absence of obvious physical cause

Non Dairy calcium

Rhubarb sardines collard greens

Cor pumonae

Right sided heart failure caused by left ventricular failure (edema, jugular vein distention)

Hypernatremia

S (Skin flushed) A (agitation) L (low grade fever ) T (thirst)

Air or Pulmonary Embolism

S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.)

Autonomic Dysreflexia/Hyperreflexia

S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!

Cranial nerves

S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More

SSRI's chlorpromazine (Thorazine) for schizophrenia. Pt in ER w/spasms of face, tongue and back...(adverse effects)

SSRI's "-pram, -ine" acute dystonia -treat s/s w/anticholinergic meds (benadryl)

(SSRI's) venlafaxine (Effexor) for major depression..which drug causes serotonin syndrome when taken with venlafaxine?

SSRI's "-pram, -ine" phenelzine (Nardil) (MAOIs) Interaction-not to take within 14d- life threatening complication (anxiety, confusion hallucinations, fever)

(SSRI"s) fluoxetine (Prozac); depression report to PCP...

SSRI's "-pram, -ine" sucidal thoughts SSRI's

SSRI's fluoxetine (Prozac) pt admitted to ER w/agitation, confusion, . ? should PCP suspect (s/s of ...)

SSRI's "-pram,-ine" serotonin syndrome begins 2-72hrs. (SSRI's)

Long-term use of Glucocorticosteroid for asthma teaching:

Schedule meds on alternate days to decrease side effect.

Pericardial friction rub

Scratchy, high-pitched sound associated with acute pericarditis

Which of the following factors predisposes a child to urinary tract infections?

Short urethra in young girls

Quad cane

Should always be placed on the unaffected side of the body.

Sildenafil (viagra)

Should be discontinued if also taking isosorbide mononitrate because the concurrent use can result in severe hypotension

IV blood transfusion

Should be done with 0.9% sodium chloride

Client w/ amputation-

Should lie prone q4hours.

Person with aids:

Should not work in the garden

Thorazine teaching-

Sip fluids throughout the day to relieve dry mouth symptoms. Minimize exposure to sun to prevent photosensitivity reactions.

Magnesium sulfate in labor?

Smooth muscle relaxant. Decreases contractions during preterm labor.

An active 13 year old boy is complaining of swelling and pain at the tibial tubercle. He is prohibited from playing outside with his friends. Which nursing problems would be most appropriate?

Social isolation

Hypotonic dehydration?

Someone experiencing hypotonic dehydration will have a sodium level of less than 130. A level of 136 indicates a positive response to oral rehydration solution.

Transfusion of packed red blood cells >>VS pt is febrile, tachycardic, flushed, chills

Stop the infusion, pt exhibiting hemolytic transfusion reaction.

____ ____ are a complication of long term mechanical ventilation.

Stress ulcers

Naegelle's rule:

Subtract 3 months and add 7 days to last missed period.

An 8-month-old being evaluated for a UTI. A urinalysis and urine culture are ordered. Which of the following is the best way to obtain the urine samples?

Suprapubic aspiration with bladder catheterization after excluding first few milliliter from collection

_____ is a clinical manifestation of malignant hyperthermia.

Tachycardia

INH can cause peripheral neuritis

Take vitamin B6 to prevent. Hepatotoxic

An important nursing consideration when caring for a child with juvenile rheumatoid arthritis would be which of the following?

Teach the child and family about correct administration of medications

shilling test

Test for pernicious anemia

Guthrie test

Tests for PKU. Baby should have eaten protein first

Hearing aids

The amplification of background noise is often a challenging aspect of adjusting the a hearing aid

What is the most important factor for a nurse to consider when teaching a child with cerebral palsy?

The child's developmental level

Acute pancreatitis

The highest priority finding is absent bowel sounds

The nurse is teaching the parents of a child with vesicoureteral reflux. What is the most important instruction to include?

The importance of taking prophylactic antibiotics

The nurse is caring for a 4-year-old who weighs 15 kg. At the end of a 10 hour period, the nurse notes the urine output is 150 ml. What action should the nurse take?

The nurse records the patient's urine output in the chart

Pacemaker

The pacemaker should discharge to maintain the programmed heart rate

Nursing care for meningitis

The presence of petechia or a purpuric-type rash requires immediate medical attention. • Isolate the child as soon as meningitis is suspected. • Initiate and maintain isolation precautions (droplet precautions) per facility protocol. This requires a private room or a room with cohorts, the wearing of a surgical mask when within 3 feet of the child, appropriate hand hygiene, and the use of designated equipment, such as blood pressure cuff and thermometer. Continue for 24 hr after the first antibiotic has been administered. • Continue frequent monitoring of vital signs, urine output, fluid status, pain level, neurologic status, and head circumference (for infants). • Initiate IV fluids to maintain hydration. Continue fluid and electrolyte replacement as indicated by laboratory values. • Maintain NPO status if the child has a decreased level of consciousness. As the child's condition improves, advance to clear liquids and then to a diet that the child can tolerate. • Decrease environmental stimuli., Provide for a quiet environment, Minimize the child's exposure to bright light (natural and electric). • Provide for comfort. (Keep the child's room cool. Position the child without a pillow and slightly elevate the head of the bed, The child may prefer a side-lying position to take pressure off his neck) • Maintain safety (keep the bed in a low position, take seizure precautions). • Keep the family informed of the child's condition.

Which is true concerning the girls/women who have bulimia?

They are mostly within to slightly higher than above average weight

A newborn develops tetany and a seizure just prior to discharge for the nursery. The newborn is diagnosed with hypocalcemia secondary to hypoparathyroidism and is started on calcium and vitamin D. What would be important to teach the parents?

They should observe for signs of vitamin D toxicity: weakness, nausea, vomiting, and diarrhea

FHR patterns for OB

Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill

Valporic acid (Depakote)

This medication may cause hepatic toxicity. Therefore, serum liver enzyme levels are monitored.

Accident report for a med error- what should be documented in the medical record?

Time the medication was given.

Dumping syndrome

To prevent dumping syndrome the pt should lie in a supine position after meals to slow the movement of food within the intestines. Pt should not drink fluids with meals and for 1 hour prior to and following meals

Hypo Mg

Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity)

Place Pt in modified ____ position to place a nontunneled percutaneous centralized catheter in the subclavian vein.

Trendelenburg

(tricyclic antidepressant) amitriptyline (Elavil) for depression instructions taking meds

Tricyclic antidepressant "tyline" chg position slowly don't stop taking abruptly drowsy increase fiber/fluids

Before surgery the neonate with a myelomeningocele is at greatest risk for infection

True

Folic acid deficiency in the mother has been linked to neural tube defects

True

Prenatal screening involves measurement of maternal serum alpha-fetoprotein

True

The degree of impairment is related to the level of the defect on the spinal cord

True

The pupils dilate as intracranial pressure increases

True

Client receiving Pitocin for labor induction and notes frequent decels-

Turn the client on her left side immediately to relieve cord compression.

Metformin

Used for type II diabetes Should be taken with a meal

Skin infection

VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies

infants IM site

Vastus lateralis

Toddler 18 months+ IM site

Ventrogluteal

Given Verapamil (Calan) for pt with Angina Pectoris

Verapamil has more than one action and is used to tx angina pain. A calcium channel blocker that use for both HTN and anginal pain

Before administering blood-

Verify the client and blood product information with another licensed nurse.

Do not delegate

What you can EAT E-evaluate A-assess T-teach

Which breakfast selection indicates that parents understand the nurse's instructions about the dietary management for a child diagnosed with Phenylketonuria (PKA)?

White bread toast and orange juice

Lactulose

Works by stimulating the production of excess stools to rid the body of excess ammonia- these excessive stools can result in hypokalemia and dehydration

Ruptured appendix, taking Dexamethasone (Decadron) before surgery

a glucocorticosteroid has an immunosuppressant effect, increase risk of INFECTION.

Pt in Labor unit has a premature rupture of membranes given Betamethasone (Celestone)

a glucocoticoid used for development of fetal lung maturity

Myesthenia Gravis

a positive reaction to Tensilon---will improve symptoms

eclampsia is

a seizure

Grave's Disease/ hyperthyroidism

accelerated physical and mental function. Sensitivity to heat. Fine/soft hair.

DKA

acetone and keytones increase! once treated expect postassium to drop! have K+ ready

Liver biopsy

administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk

appropriate action for intravenous pyelogram for next day

administer laxative, npo, econurage fluids

MMR and varicella immunizaions

after 15 months!

what to ask before flu shot

allergy to eggs

what to ask before MMR

allergy to eggs or neomycin

buspirone (Buspar); teach

allow 2-4 w feel therapeutic effects

Diazepam (valium)

an Antianxiety agent, drinking Alcohol would potentiates CNS depression effect of valium, could produce sedation >> potentially lethal overdose.

Hydroxyzine (vistaril)

an Anticholinergic, can cause DRY MOUTH

who should receive rhogam

an o- woman following spontaneous abortion

Contraindication for Hep B vaccine

anaphylactic reaction to baker's yeast

early detection of men's prostate cancer

annual measurement of prostate specific antigen (PSA) should be performed for men over 50

Biliary colic pain relief meds include what?

anticholinergics

Glucagon increases the effects of?

anticoagulants

Pt give 5-FU (Fluorouracil) an antineoplastic drug

antimetabolites

Pt with PUD on Bismuth subsalicylate (pepto-bismol)

antimicrobial action. treating ulcer caused by bacteria H. pylori, coats the stomach and ulcer providing protection from gastric juices.

RLQ

appendicitis watch for peritonitis

teaching for peripheral artery disease

apply lubricating lotion to the feet to pre even cracting of the skin. don't elevate feet above heart

ARDS and DIC

are always secondary to another disease or trauma

detached retina

area of detachment should be in the dependent position

gullian-barre syndrome

ascending muscle weakness

Gullian -Barre syndrome

ascending paralysis. watch for respiratory problems.

Pt taking Isoniazid (INH) need freq monitoring

aspartate aminotransferase (AST) liver enzymes to detect INH toxicity

Latex allergies

assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches

Dehydration 2dry to diuretic therapy

assessment finding: Dry mucous membrane

timolol (Timoptic); PCP should ? which disorder?

asthma beta-adrenergic antagonist; bronchospasm

lithium carbonate (Lithobid); teach r/f lithium toxicity

avoid NSAID's (increases renal reabsorption of lithium and sodium)

Sign of a hemolytic transfusion reaction is lower ___ ___.

back pain

emphysema

barrel chest

planning care for heart failure

bed rest monitor daily wt, I&O administer oxygen as perscribed high fowlers check ABG's restrict sodium report 3 lbs or more weight gain

Shock

bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)

perform amniocentesis

before 20 weeks to check for cardiac and pulmonary abnormalities

pathological jaundice occurs: physiological jaundice occurs:

before 24 hours (lasts 7 days) after 24 hours

(benzodiazepine) alprazolam (Xanax) for anxiety (long term); teach pt if abruptly stopping... results in

benzodiazepine "-pam,-lam" withdrawals benzodiazepine; taper over weeks slowly

Cold stress and the newborn

biggest concern resp. distress

Tonic neck reflex

birth to 3-4 months

plantar grasp

birth to 8 months

chlorpromazine (Thorazine); schizo affective disorder; monitor for

blood pressure r/f hypotension; should stay supine for 30 minutes; while monitoring BP

Fat embolism

blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids.

15 min immediate postpartum period requires immediate action by nurse?

bobby uterus

Hypervolemia

bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's

IVP requires

bowel prep so bladder can be visualized

when phenylaline increases

brain problems occur

Side effect of propranolol hydrochloride (Inderal) is ___.

bronchoconstriction

antiplatelet drug hypersensitivity

bronchospasm

Addison's

bronze like skin pigmentation

Lymes disease

bullseye rash

sle (systemic lupus)

butterfly rash

Thorazine and Haldol

can cause EPS

PVC's

can turn into V fib.

Hodgkin's disease

cancer of the lymph. very curable in early stages

Withhold _____ _____ 48 hours prior to a cardioversion procedure.

cardiac glycosides...digoxin

retino blastoma

cat's eye reflex

echothiophate (Phospoline Iodine) for glaucoma; adverse effects

cataracts, halo's cholinesterase inhibitor

during Continuous Bladder Irrigation (CBI)

catheter is taped to the thigh. leg must be kept straight.

Nifedipine (adalat) to suppress uterine contraction

cause Uterine Relaxation by blocking flow of calcium to myometrial cells

Isoniazid

causes peripheral neuritis

Addison's

causes sever hypotension!

CVA

cerebriovascular accident. brain tissue dies.

SIADH (increased ADH)

change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics

nephrotic syndrome

characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay

before IV antibiotics?

check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose.

After endoscopy

check gag reflex

priority for postopertive bleeding due to an angiography

check groin as needed hold pressure notify provider monitor peripheral circulation

acid ash diet

cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread

bryant's traction

children <3 y <35 lbs with femur fx

NCLEX answer tips

choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment.

s/s of respiratory cancer

clubbed fingers kassmaul respiration anorexia dyspnea foul breath

appropriate action for early decelerations

continue observing the fetal heart rate

esophagogastroduodenoscopy (EGD) findings to report

cool, clammy skin

cognitive therapy

counseling

Sucking stab wound

cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo!

MI

crushing stabbing chest pain unrelieved by nitro

angina

crushing, stabbing chest pain relieved by nitro

up stairs with crutches?

crutches first followed by good leg

when on nitroprusside monitor:

cyanide. normal value should be 1.

fractured ankle ice applied every 20 min report what finding to provider?

cyanosis of nail beds

Myasthenia gravis

decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration.

Iron toxicity reversal

deferoxamine

IM site for children

deltoid and gluteus maximus

Hyper Mg

depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY

myasthenia gravis

descending musle weakness

failure to thrive

develop a structured routine

Hirschprung's

diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools

caput succedaneum

diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days

using nitroglycerin patch

do not cut patch apply at the same time once a day remove at night keep on for 12-14hrs

active labor receiving oxytocin. fur shows variability with accelerations. nursing action?

document and continue to monitor

After total hip replacement

don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows.

birth weight

doubles by 6 months triples by 1 year

A 5 day post Op gastrectomy Pt should be instructed to lie down after consuming a meal to help prevent ___ ___.

dumping syndrome

Basophils reliease histamine

during an allergic response

Hydrochlorothiazide (oretic) for HTN

eat food rich in potassium. This meds may cause a loss of potassium. Food rich in K+ ex: bananas, raisins, baked potatoes, pumpkin, milk

Cullen's sign

ecchymosis in umbilical area, seen with pancreatitis

Head Injury

elevate HOB 30 degrees to decrease ICP

Buck's Traction (skin)

elevate foot of bed for counter traction

AKA (above knee amputation)

elevate for first 24 hours on pillow. position prone daily to maintain hip extension.

wilm's tumor

encapsulated above kidneys...causes flank pain

discharge teaching with personality disorder

encourage group, family and psychotherapy

pt with leukemia may have

epistaxis due to low platelets

Transesophageal fistula

esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis)

Diabetes insipidus (decreased ADH)

excessive urine output and thirst, dehydration, weakness, administer Pitressin

hyperthyroidism/ grave's disease

exophthalmos

Glasgow coma scale

eyes, verbal, motor Max- 15 pts, below 8= coma

Hyper-parathyroid

fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet

otitis media

feed upright to avoid otitis media!

russell traction

femur or lower leg

lumbar puncture

fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache.

pneumonia

fever and chills are usually present. For the elderly confusion is often present.

crohns disease decrease what in diet?

fiber

when a pt comes in and is in active labor

first action of nurse is to listen to fetal heart tones/rate

pancreatitis

first pain relief, second cough and deep breathe

laboring mom's water breaks?

first thing--worry about prolapsed cord!

Pt with heat stroke

flat with legs elevated

retinal detachment

floaters and flashes of light. curtain vision

manifestations of bipolar disorder

fluctuation in mood

BKA (below knee amputation)

foot of bed elevated for first 24 hours. position prone to provide hip extension.

nurse difficulty staffing weekend shifts. which actions should nurse manager take first to successfully implement staffing changes

form a staff task force to investigate current staffing issues

lithium carbonate (Lithobid) bipolar disorder; what drug interaction (lithium toxicity) could occur?

furosemide (Lasix) for HTN -increases sodium loss and can cause lithium reabsorption

nurses documents dressing change that was not performed what should charge nurse do first?

gather more info about staff nurse's actions ASSESSSSS

assessing newborn immediate intervention

grunting, tachypnea, nasal flaring

burns rule of Nines

head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1%

Reportable side effect of mannitol is ____.

headache

estradiol monitor and report what to provider

headaches, hypertension

s/s of meds affecting coagulation

hemorrage hep overdose thrombocytopenia hypersensitivity hepatitis hypotension bradycardia

TB drugs are

hepatotoxic!

heat/cold

hot for chronic pain; cold for accute pain (sprain etc)

Hyponatremia will manifest with ____ bowel sounds.

hyperactive

Pheochromocytoma

hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor)

increased ICP

hypertension, bradypnea,, bradycarday (cushing's triad)

phenelzine (Nardil) advise pts to avoid tyramine-riched foods cause of r/f adverse reactions

hypertensive crisis tyramine foods (aged cheese, processed meats) triggors severe HTN, while taking phenelzine (htn, ha,n)

s/s of fluid volume deficit

hyperthermia tachycardia threaded pulse orthostatic hypotension dizziness, confusion, weakness oliguria sunken eye balls flat neck veins scaly skin

Cardinal sign of ARDS

hypoxemia

adverse reaction of orthostatic hypotension occurs in which med

imipramine (Tofranil) tricyclic antidepressant

Spinal shock occurs

immediately after injury

DKA is rare

in DM II (there is enough insulin to prevent fat breakdown)

Edema is located

in the interstitial space, not the cardiovascular space (outside of the circulatory system)

Chest tubes are placed

in the pleural space

Dumping syndrome

increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink

s/s hyperemesis gravidarum

increased pulse rate decreased blood pressure poor skin turgor

the first sign of ARDS

increased respirations! followed by dyspnea and tachypnea

Thyroid storm

increased temp, pulse and HTN

Hypovolemia

increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030

Hypernatremia

increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution.

Digitalis

increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion

Toddlers need to express

independence!

Mantoux skin test for tuberculosis (TB)

insert needle with bevel up. TB syringe should be held close to skin, reduces needle angle at the skin surface facilitates inj just beneath the surface of the skin in order to form wheal.

thyroid med side effects

insomnia. body metabolism increases

nurse assisting with thoracentesis for a client who has pleurisy nurse should plan to do what

instruct the client to avoid deep breathing during procedure

appropriate action for client who will need physical therapy

involve client in selection of pt provider

ventriculoperitoneal shunt post op for infant with hydrocephalus report what to provider

irritability when being held

Heroin withdrawal neonate

irritable, poor sucking

normal PCWC (pulmonary capillary wedge pressure)

is 8-13 readings 18-20 are considered high

orange tag in psych

is emergent psych

MMR

is given SQ not IM

When pt is in distress....medication administration

is rarely a good choice

discharging a client

is started by the nurse at addmission 1. set follow up plans 2. notify s/s of meds 3. give home instructions 4. type of discharge, time and date and where they are being discharged 5. clients condition at discharge 6. copy of discharge instructions

aldactone with blood pressure meds

its a pottasium sparing diuretic that will increase risk of hyperkalcemia and decrease your blood pressure so....... avoid salt (will lead to lithium toxicity) monitor BP and WT

buck's traction

knee immobility

measles

koplick's spots

DKA

kussmal's breathing (deep rapid)

antisocial personality disorder

lack of remorse

acute anxiety

last 4-6 weeks client expresses emotional response that cannot be managed with clients normal coping mechanism 1. actual or perceived loss 2. decrease in communication 3. displacement

positioning for pneumonia

lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!)

pain with diverticulitis

located in LLQ

appendicitis pain

located in RLQ

PTB

low grade afternoon fever

after Thyroidectomy

low or semi-fowler's position, support head, neck and shoulders.

method to evaluate nurse's time management skills

maintain regular notes about the nurse's time management skills

Clonidine (catapress)

may cause orthostatic hypotension, change position clowly.

Iatragenic

means it was caused by treatment, procedure or medication

early sign of cystic fibrosis

meconium in ileus at birth

community mental health clinic which group is appropriate for nurse to lead?

medication education group

alk ash diet

milk, veggies, rhubarb, salmon

Procainamide (Pronestyl) IVP for paroxymal atrial tachycardia

monitor BP if drops >15mm Hg discontinue med

Cushing's

moon face, buffalo hump

bowel obstruction

more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids)

multiple sclerosis

motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia

hypokalemia

muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery)

Hypercalcemia

muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency!

Liver biopsy (prior)

must have lab results for prothrombin time

multiple sclerosis

myelin sheath destruction. disruptions in nerve impulse conduction

Pt with Hx of hypothyroidism has slow speech and decreased temp. What might be happening?

myxedema coma

opiod agonists that prevents SE

narcan

hyperemesis gravidarum

nausea and vomiting beyond 12 weeks of gestation that can result in -weight loss -electrolyte imbalances -ketonuria -ketosis -and could be present in liver dysfunction

digoxin toxicity

nausea!!! diarrhea

Hyponatremia

nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids

for neutropenic pts

no fresh flowers, fresh fruits or veggies and no milk

Neutropenic pts

no fresh fruits or flowers

Head injury or skull fx

no nasotracheal suctioning

ECG

no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure.

with allopurinol

no vitamin C or warfarin!

S3 sound

normal in CHF. Not normal in MI

thrombocytopenia instruct nurse to avoid what

nose blowing

Unstable Angina

not relieved by nitro

Before starting IV antibiotics

obtain cultures!

chest tube pulled out?

occlusive dressing

intraosseous infusion

often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist.

client to see first?

older client who is confused and attempting to pull on IV

pyloric stenosis

olive like mass

During internal radiation

on bed rest while implant in place

urine output 15 ml/hr what additional assessment data is indicative of fluid volume deficit

orthostatic hypotension! inc bun, tachy,

SE of endocrine disorders with synthroid

over medication can lead to hyperthroidism (anxiety, tachycardia, palpitations, altered apitite, abdominal cramping, hear intolerance, WT loss, menstral irregulatities

glaucoma

painful vision loss. tunnel vision. halo

Bladder CA

painless hematuria

s/s panic attack

palpitations shortness of breath chest pain nausea agoraphobia chills hot flashes

hemophilia is x linked

passed from mother to son

In an emergency

patients with a greater chance to live are treated first

Autonomic dysreflexia

patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above)

Glaucoma patients lose

peripheral vision.

first trimester routine prenatal exam when checking if fetal heart can be detected nurse should

place scope midline just above the symphysis pubis and apply firm pressure

complications of mechanical ventilation

pneumothorax, ulcers

post spelectomy

pneumovax 23 is administered to prevent pneumococcal sepsis

risperidone (Risperdal) for schizophrenia; monitor adverse effects

polyuria -atypical antipsychotic; can cause new-onset hyperglycemia

DM

polyuria, polydipsia,polyphagia

Cleft Lip

position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.

After Myringotomy

position on the side of AFFECTED ear, allows drainage.

Thoracentesis:

position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing

CHF pt with Digoxin (lanoxin), reports nausea

possibly dogoxin toxicity, check apical pulse

after receiving report assess who first?

post op client with abdominal distention and no bowel sounds because of paralytic ileus

IM Iron dextran (Infed)

preferred site dorsogluteal. Iron should be admin into deep large muscle using the Z-tract method

Airborne precautions protective equip

private room, neg pressure with 6-12 air exchanges/hr mask N95 for TB

Koplick's spots

prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth

downs syndrome

protruding tongue

diptheria

pseudo membrane formation

After lumbar puncture and oil based myelogram

pt is flat SUPINE (prevent headache and leaking of CSF)

administration of enema

pt should be left side lying (Sim's) with knee flexed.

After Cateract surgery

pt sleep on UNAFFECTED side with a night shield for 1-4 weeks

WBC left shift

pt with pyelo. neutrophils kick in to fight infections

brachial pulse

pulse area on an infant

when drawing an ABG

put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2

pancreatitis pts

put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids

Cushing's triad

r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)

Cushings ulcers

r/t brain injury

pernicious anemia

red beefy tongue

patients with hallucinations patients with delusions

redirect them distract them

BPH

reduced size and force of urine

SE of nitroglycerin (nitro-dur)

reflex tachycardia headache orthostatic hypotension

epinephrine adverse effects

report of chest pain!

TPN, if marked separation of oil droplet from the rest of solution

return the solution to the pharmacy

cholera

rice watery stool

typhoid

rose spots on the abdomen

pneumonia

rusty sputum

five interventions for psych patients

safety setting limits establish trusting relationship meds least restrictive methods/environment

Central line catheters should be flushed with ____.

saline

cystic fibrosis

salty skin

risk for osteoporosis

sedentary lifestyle

bupropion hydrochloride (Wellbutrin) for depression. Contra in recent head injury...causes?

seizures

William's position

semi Fowler's with knees flexed to reduce low back pain

Paracentesis

semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia

Post-Thyroidectomy

semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside

children 5 and up

should have an explanation of what will happen a week before surgery

dunlap traction

skeletal or skin

Myxedema/ hypothyroidism

slowed physical and mental function, sensitivity to cold, dry skin and hair.

Droplet precautions

spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room or cohort mask!)

malaria

stepladder like fever--with chills

kawasaki syndrome

strawberry tongue

TPN given in

subclavian line

first sign of PE

sudden chest pain followed by dyspnea and tachypnea

chlorpromazine (Thorazine); teach

sunscreen antipychotic, photosenitivity

supervising AP

supervise after delegation and determine 1. completion 2. performance 3. make sure findings were documented 4. if assistance is needed 5. reevaluate 6. provide feedback

bethamethasone (celestone)

surfactant. premature babies

SSRI's

take about 3 weeks to work

a nurse makes a mistake?

take it to him/her first then take up the chain

milieu therapy

taking care of pt and environmental therapy

lead poisoning

test at 12 months of age

client with depression which if most important finding to report to an interdisciplinary conference

the client's appetite has diminished over the last week

glomuloneprhitis

the most important assessment is blood pressure

placenta previa s/s placental abrution s/s

there is no pain, but there is bleeding there is pain, but no bleeding (board like abd)

lithium carbonate (Eskalith); bipolar disorder; monitor diagnostic tests

thyroid function adverse effect hypothyroidism

Paget's disease

tinnitus, bone pain, elnargement of bone, thick bones

No phenylalanine

to a kid with PKU. No meat, dairy or aspartame

never give potassium

to a pt who has low urine output!

Rh mothers receive Rhogam

to protect next baby

Pt taking Theophylline (Theo-Dur) for chronic bronchitis

toxicity > Tremors. Theophylline is a xanthine derivative bronchodilator. SNS stimulation tremors, insomnia, confusion, irritability.

TIA

transient ischemic attack....mini stroke, no dead tissue.

lithium carbonate (Eskalith); bipolar disorder; caution pt watch for lithium toxicity levels

tremors, confusion, nausea, muscle weakness

Hospitalized for major depression tx with Amitriptyline (Elavil)

tricyclic antidepressant should be avoided during pregnancy, esp 1st trimester associated with fetal anomalies.

nursing action for a client who is receiving continuous passive motion (CPM) following a total knee arthroplasty

turn off the CPM mating during meal time

Peritoneal Dialysis (when outflow is inadequate)

turn pt from side to side BEFORE checking for kinks in tubing

nitrazine paper

turns blue with alkaline amniotic fluid. turns pink with other fluids

sickle cell crisis

two interventions to prioritize: fluids and pain relief.

cryptorchidism

undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence

18 hr post op client following cesarean birth, highest priority finding

unilateral tenderness of the left lower extremity

Hyper reflexes absent reflexes

upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue

mental client becoming increasingly loud and belligerent nurse action

use calm and clear statements to set limits

dumping syndrome?

use low fowler's to avoid. limit fluids

for phobias

use systematic desensitization

Tensilon

used in myesthenia gravis to confirm diagnosis

Saw palmetto

used primarily for symptoms related to prostatic conditions like benign prostatic hypertrophy (BPH)

Parathyroid relies on

vitamin D to work

ventriculoperitoneal shunt

watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees

Tamoxifen

watch for visual changes--indicates toxicity

the best indicator of dehydration?

weight---and skin turgor

Cerebral angio prep

well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids.

asthma

wheezing on expiration

COPD and O2

with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe.

pancreatic enzymes are taken

with each meal!

Osmotic laxative

work by pulling water into colon and feces, increasing bulk and stimulating peristalsis

Myesthenia Gravis

worsens with exercise and improves with rest

Assessment for maltreatment

• Assess for unusual bruising on the abdomen, back, and/or buttocks. • Assess the mechanism of injury, which may not be congruent with the physical appearance of the injury. Many bruises at different stages of healing may indicate continued beatings. Observe for bruises or welts that have taken on the shape of a belt buckle or other objects. • Observe for burns that appear glove- or stocking-like on hands or feet, which may indicate forced immersion into boiling water. Small, round burns may be caused by lit cigarettes. • Note fractures with unusual features, such as forearm spiral fractures, which could be caused by twisting the extremity forcefully. The presence of multiple fractures is suspicious. • Check the child for head injuries. Assess the child's level of consciousness, making sure to note equal and reactive pupils. Also, monitor the child for nausea/vomiting.

For nutrition, advise parents to:

• Avoid using food as a reward. • Emphasize physical activity. • Ensure that a balanced diet is consumed. Healthy food recommendations are posted by the United States Department of Agriculture • Teach children to make healthy food selections for meals and snacks.

Rotavirus clinical manifestations

• Commonly causes diarrhea in young children • Induces fever and vomiting for 2 days • Produces watery diarrhea for 5 to 7 days (transmitted oral-fecal and is intubated in 48 hours)

Nursing interventions for a child with club foot

• Encourage parents to hold and cuddle the child. • Encourage parents to meet the developmental needs of the child. • Assess and maintain the cast or harness used to treat clubfoot or DDH. • Perform neurovascular and skin integrity checks after cast or harness placement.

Subjective and objective data of maltreatment

• Inconsistency between nature of injury and developmental level of the child. • Repeated injuries requiring emergency treatment • Inappropriate responses from the parents or child • Physical signs such as growth failure, bruises, burns, fractures, poor hygiene, and foul odors or discharge from the genital area • Inappropriate knowledge of or interest in sexual acts • Seductive behavior • Avoidance of anything related to sexuality or genitals and the body • Withdrawn behaviors or excessive aggression towards others • Fear of a particular person or family member

Signs of symptoms of failure to thrive

• Less than the fifth percentile on the growth chart for weight • Malnourished appearance • Signs of dehydration • Decreased activity level • Developmental delays • Negative interactions between the child and parents (no eye contact, irritability, pushing parents away) • Difficulty being soothed

Lab values for Reye's Syndrome

• Liver enzymes (alanine aminotransferase [ALT], aspartate aminotransferase [AST]) - Elevated • Serum ammonia level - Elevated • Serum electrolytes - Metabolic alkalosis, hypocalcemia, hyponatremia, and hypernatremia • Serum blood glucose - Hypoglycemia • CBC may indicate low Hgb, Hct, and platelets. • Coagulation times may be extended.

Nursing care after a seizure

• Maintain the child in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions. • Check vital signs. • Assess for injuries • Perform neurologic checks. • Allow the child to rest if necessary. • Reorient and calm the child (she may be agitated or confused). • Institute seizure precautions, including placing the bed in the lowest position and padding the side rails to prevent future injury.

Maltreatment

• Maltreatment of infants and children is attributed to a variety of predisposing factors, which include parental, child, and environmental characteristics. Child maltreatment can occur across all economic and educational backgrounds and racial/ethnic/religious groups

Risk factors of failure to thrive

• Parental neglect, lack of parental knowledge, or a disturbed maternal-child attachment • Poverty • Health or childrearing beliefs • Family stress • Feeding resistance • Insufficient breast milk

Therapuetic interventions for club foot

• Passive exercise should be performed for a minor deformity • Serial casting is begun after birth before the newborn is discharged home. Weekly casting to stretch the skin and other structures of the foot is done until maximum correction is accomplished. • Surgical intervention should occur if maximum correction is not achieved by 3 months of age.

Nursing Care during a seizure

• Protect the child from injury (move furniture away, hold head in lap if on the • floor). • Position the child to provide a patent airway. • Be prepared to suction oral secretions. • Turn the child to the side (decreases risk of aspiration). • Loosen restrictive clothing. • Do not attempt to restrain the child. • Do not attempt to open the jaw or insert an airway during seizure activity (this may damage teeth, lips, or tongue). Do not use padded tongue blades.

Car safety for an infant

•Should be placed in rear facing car seat in the back seat. •Should be placed in the back until 1 year of age or until they weigh 9.1kg.

Status asthmaticus (A life-threatening episode of airway obstruction that is often unresponsive to common treatment)

■ Prepare for emergency intubation. ■ Administer humidified oxygen. ■ Administer three nebulizer treatments of a beta2 agonist, 20 to 30 min apart. Ipratropium bromide may be added to the nebulizer to increase bronchodilation. ■ Obtain IV access. ■ Monitor ABGs and serum electrolytes. ■ Administer corticosteroid (oral, IM, IV).

Agents that trigger asthma

☐ Smoke ☐ Dust ☐ Mold ☐ Sudden weather changes (especially warm to cold) ☐ Seasonal allergens (grass, tree and weed pollens) ☐ Animal dander ☐ Stress