Exit ATI
Causes of constipation in pregnancy; pt teaching
-*estrogen & progesterone levels increase* during pregnancy leading to decreased peristalsis & relaxation of the smooth muscles of the intestines -*intestines absorb more water from stool* during pregnancy -*small intestines absorbs iron more readily* during pregnancy due to increased maternal needs -during the 2nd & 3rd trimesters, the size & weight of the growing uterus causes both *displacement & compression of the intestines* causing a decrease in motility
Lithium
-NSAIDS such as naproxen and ibuprofen ^ renal absorption of sodium & ____ causing an ^ in ______ levels and poss toxicity; acetylsalicyclic acid & sulindac are NSAIDs that don't affect ___ levels and can be taken for things like a headaches while on _____ -when sodium levels are high, _____ excretion by the kidneys is ^'d SO eating foods w/ larger amts of sodium reduces rather than ^s the R/f _____ toxicity; ^d sodium intake can lead to excretion of ____ & a decrease in the _____ level; its important for pts to eat normal & consistent amts of sodium to maintain ____ levels -vomiting or diarrhea can cause electrolyte imbalances; if serum sodium decreases, _____ is retained by the kidneys & the R/f ______ toxicity ^s -diuretics decrease kidney excretion of _____ causing levels to rise and ^s the chance for potential toxicity
Osteoporosis
-______ is a disorder of weakened bones d/t loss of bone mass & changes in bone structure -immobility can result in _____ -weight-bearing exercise such as walking is 1way for pts to help prevent ______ -appropriate amts of sun exposure increase vitD levels increasing the absorption of calcium = good for pts w/ _____ -eating large amts of protein can result in more calcium loss through kidneys = bad for pts w/ ______ -chronic use of steroid medications (corticosteroid therapy) increase the risk for ______
Chlordiazepoxide
-a long-acting oral benzo -1st line med to use for a pt who's experiencing manifestations of acute alcohol w/drawal -for pts who are nauseated or vomiting d/t withdrawal can be administered another bento such as lorazepam via IV
Cyclosporine
-can be prescribed to pts post-kidney transplant -____ & similar meds taken after kidney transplant must be cont for rest of pts life -have to pts who take ____ develop a 10-15% increase in BP & might need to start antiHTN therapy -causes some hirsutism (unusual hair growth) in many pts who take it but does NOT cause hair loss -is an immunosuppressive agent, which prevents rejection of the transplanted kidney
Prednisone
-corticosteroid -can be used to treat persistent arthritis exacerbations (note: pts who have arthritis often require high doses to help resolve exacerbations) -associated with delayed wound healing
Steatorrhea
-foul, fatty, frothy stools -manifestation of celiac disease (a malabsorption syndrome)
Ginko biloba
-has become a widely used dietary supplement in the US for increasing cognitive functions in elderly ppl (effect has not been proven) -has also been shown to improve leg pain of intermittent claudication and other peripheral arterial disorders
Administering ear drops; parent teaching 1. otic 2. 3
-instruct the parent to allow __1__ meds she stores in the refrigerator to warm up to room temp prior to administration to prevent dizziness & pain -instruct the parent to pull the pinna upward and back in children older than __2__ YOA to straighten the ear canal and allow the meds to reach the entire canal; for children younger than __2__ the parent should gently pull the pinna downward & back -nurse should instruct the parent to gently massage the tragus on the area anterior to the ear to all the meds to reach the entire canal -instruct the parent to have the child remain lying on the unaffected side for a few mins after instilling medication to allow the med to remain in the ear canal
Echinacea
-popular her widely used in the US -primarily used to reduce the manifestations & duration of colds and flu-like illnesses -used for immune system stimulation -effectiveness has not been proven
Misoprostol
-tends to cause diarrhea -can induce uterine contractions; women of childbearing age must first rule out pregnancy -reduces gastric acid secretion so that ulcers can heal & reduces the risk of new ulcer development -magnesium containing antacids increase the risk of diarrhea and the pt should avoid these when taking ________
Turning a pt to her right side
-use a draw sheet to move the pt to the left side of the bed; using the draw sheet to move the pt reduces friction, which protects the pt's skin & reduces workload preventing injury to the nurse and AP -raise the height of the bed to waist level to prevent injury by positioning the bed at the nurse's and AP's center of gravity -should place a pill under the pts left arm to prevent internal rotation of the left shoulder -lower the side rails on the left side of the bed; prevents ap/nurse from straining bodies; the opposite side rail is left up to promote pt safety
Albuterol
-used to treat asthma -doesnt cause any integumentary effects -type of bronchodilator
Chlorpromazine
-used to treat schizophrenia -can cause dermatitis and eczema
Bladder distention
4th stage of labor, _______ S/S: -the uterus will be displaced to the right -the uterus will be well above the umbilicus -the bladder will sound dull with percussion -the bladder will be suprapubic, round, bulging, dull to percussion, and fluctuate as a balloon filled with water would -uterus is usually boggy
*C-instruct clients who are able to ambulate to leave*; pts who are able to ambulate should leave 1st in the evacuation process bc it quickly reduces the # of pts who require evacuation assistance
A charge nurse is coordinating the evacuation of pts from a facility following a bomb threat; which action should the nurse take in evacuation process? A-call in the pts' family members to provide additional help with moving clients B-ask pts who are able to ambulate to assist in moving unstable pts C-instruct clients who are able to ambulate to leave D-direct staff members to close the doors & windows as each room is evacuated
Correct answers: *A-sit with your back supported*; sitting w/ back supported while at the computer helps to prevent back strain, which can lead to lower-back disc disease *B-keep knees at hip level*; helps to prevent unnecessary strain on the hips and lower back *c-use an ergonomically designed keyboard* Incorrect: D-keep your elbows away from your body E-adjust the monitor screen so that you have to tilt your head slightly to look at it
A community health nurse is conducting a class about body mechanics for county office workers. The nurse should include..... (select all that apply) A-"sit with your back supported" B-"keep your knees at hip level" C-"use an ergonomically designated computer keyboard" D-"keep your elbows away from your body" E-"adjust the monitor screen so that you have to tilt your head slightly to look at it"
Estradiol
A hormone given to help tx symptoms of menopause or removal of the ovaries; nurse should instruct pt to monitor & report to provider: -hypertension -headaches (bc med can cause thromboembolism which can result in stroke) -swelling and tenderness of the calf -genitourinary candidiasis (UTIs)
Ventrogluteal
According to EVP the _______ site, is the safest IM injection site for all adolescence/ adults because it contains thick gluteal muscles & it doesn't contain major nerves or blood vessels
Autonomic dysreflexia S/S
Includes: -blurred vision -facial flushing -nasal congestion -severe headach
Flow-oriented incentive spirometer
Instructions include: -instruct pt to inhale deeply to elevate the balls in the device -proper use of the ______ loosens secretions in the pt's lungs; pt should cough deeply to facilitate removal of secretions from their lungs -instruct the pt to clean the mouth piece w/ H2O & dry it after each use -use ______ several times every hr while awake
1. Two-point discrimination test 2. Glascow coma scale 3. Babinski reflex 4. Romberg test
Neurologic assessments for pts: __1__: is tested by touching the skin w/ 2 sharp, pointed objs; the purpose of the test is to determine if the pt can differentiate b/w the 2 points __2__: used to measure a pts LOC __3__: tested by using an obj to strike the sole of the foot; when the test is negative all the toes bend; pos test if the toes spread outward; pos test= bad sign in adults __4__: nurse instructs pt ot stand w/ feet together & arms at sides, 1st w/ his eyes open & then w/ eyes closed; the inability to maintain balance is a positive ______
Correct: *B-decreased blood glucose*; betamethasone causes hyperglycemia in the pt predisposing the newborn to hypoglycemia in the first hrs after delivery; it's important to assess the newborns blood glucose level w/in the first hr following birth & frequently thereafter until BG levels are stable Incorrect: A-hyperthermia; doesnt affect newborns ability to maintain body temp so not an adverse effect C-rapid pulse rate; when administered to antepartum pt doesn't affect the newborns vital signs; if newborn has a rapid apical pulse it is related to another cause such as prematurity or respiratory insufficiency D-irritability; not an adverse effect
Nurse administers betamethasone to a pt at 33 wks of gestation to stimulate fetal lung maturity; when planning care for the newborn, which condition should nurse identify as an adverse effect of this med? A-hyperthermia B-decreased blood glucose C-rapid pulse rate D-irritability
Correct: A- cont observing fetal hr; early decelerations indicate the progression of labor & are a benign finding Incorrect: B- assist the pt to a knee-chest position; should do this if she notes a prolapsed cord C- prepare the pt for cont internal monitoring; no indication D-prepare for emergency cesarean birth; should do this if the monitor indicates late or variable decelerations despite intervention
Nurse caring for a pt who's in labor at 39 wks of gestation; during 2nd stage of labor, nurse observes early decels on monitor tracing; nurse should... A- cont observing fetal hr B- assist the pt to a knee-chest position C- prepare the pt for cont internal monitoring D-prepare for emergency cesarean birth
Correct: *D-a pt who had a right above the knee amputation 24 hrs ago*; nurse from a med unit can care for this pt bc the surgical dressing is usually left in place for 48-72 hrs so the residual limb doesn't require special care at this time Incorrect: A- pt in balanced skeletal traction; an ortho nurse should care for this pt bc they will have experiential knowledge to safely care for this pt B- pt who had a total hip arthroplasty 3 days ago; ortho nurse d/t experiential knowledge of the post-op restrictions for hip arthroplasty required to safely care for this pt C- pt who has a femur fracture w/ a new cast; ortho nurse bc experiential knowledge of the care of a new cast & monitoring required to safely care for this pt
Nurse from a medical unit is asked to work on an orthopedic unit; nurse has no ortho experience; which pt should be assigned? A- pt in balanced skeletal traction B- pt who had a total hip arthroplasty 3 days ago C- pt who has a femur fracture w/ a new cast D-a pt who had a right above the knee amputation 24 hrs ago
Correct: *C-apply a cold pack to the edematous area on the pt's ankle for 30 min every other hr*; nurse should verify prescription for cold back bc T1DM is a contraindication for receiving cold therapy; pt w/ T1DM can have impaired circulation d/t arteriosclerosis & a loss of sensory perception d/t neuropathy Incorrect: A- obtain capillary blood glucose level q2h; nurse should monitor pt BG every 2-4 hr to monitor for hyperglycemia d/t stress on body B-assess the neurovascular status of the pt's lower extremities every hr; nurse should check neurovascular status every hr to monitor further compromise of circulation to extremity D-administer fentanyl 50 mcg IV bolus q2hr for pain; nurse should administer an opioid med, such as fentanyl, hydromorphone, or morphine, PO or IV to manage pts pain
Nurse in ER is reviewing prescriptions of an OA pt who has type 1 diabetes; pt reports severe ankle pain after falling off a step stool at home; which prescription should nurse verify w/ provider A- obtain capillary blood glucose level q2h B-assess the neurovascular status of the pt's lower extremities every hr C-apply a cold pack to the edematous area on the pt's ankle for 30 min every other hr D-administer fentanyl 50 mcg IV bolus q2hr for pain
Correct: *A-unilateral tenderness of the lower extremity*; can indicate pt is developing DVT Incorrect: B-oral temp of 37.7°C (99.8°F); low-grade fever is an expected finding for pt who's post-op following cesarean C-uterine contractions when breastfeeding; expected finding for pt who's postpartum D-abdominal guarding when assessing the fundus; expected finding for a pt who is postpartum
Nurse is assessing a pt who's 18 hrs post-op following cesarean birth & is breastfeeding her newborn; which is the priority finding? A-unilateral tenderness of the lower extremity B-oral temp of 37.7°C (99.8°F) C-uterine contractions when breastfeeding D-abdominal guarding when assessing the fundus
Tonsillectomy
Nurse is caring for a toddler who's post-op following a _____; nurse should: -place the pt in a lateral or prone position w/ the head lower than the chest to avoid aspiration of saliva/blood from surgical site -child should avoid coughing & clearing throat bc these activities can aggravate the throat & cause pain & bleeding -nurse should avoid using a straw & instruct parts of the pt to encourage the use of a cup post-op; straw can cause damage to surgical site and result in bleeding -nurse should administer analgesics to the child q4hrs for the 1st 24-48 hrs to reduce pain & promote comfort
Wear a mask
Nurse should _______ when working w/in 3 ft of a pt who has an infection such as influenza and droplet precautions are required
Passive ROM exercises
Nurse should plan: -to maintain the pt's joint mobility, repeat each motion 3-5 x's -move the joint to the point of slight resistance -stand at the side of the bed closest to the joint being exercised -exercise the larger joints first
Gastrostomy tube feedings
Nurse should remember: -although cold enteral formula could cause cramping its not necessary to warm the feeding prior to administration; formula should be at room temp to improve tolerance of ______; warming in microwave can cause uneven heat distribution & excessive heat so not a safe way to warm enteral feedings -elevate HOB esp in pts w/ brain injury bc typically unable to swallow effectively & thus cannot protect their airway from aspiration; even though this route bypasses the nasopharynx its still poss for pt to cough or vomit enteral feeding into the oral cavity AKA nurse should take actions to prevent aspiration such as elevating HOB prior to initiating the feeding -nurse should flush tube w/ water prior to initiating the feeding to ensure patency of the tube
Glucocorticoids + = brochodilator
Parent teaching for child w/ severe reactive airway disease: -inhaled _____ = tx of choice for long term management -inhaled ______ can cause thrush/oral candidiasis (1 of the most common adverse effects); to prevent this pt should rinse mouth out after inhaling a _______ -at times of stress, such as infection, surgery, or trauma, the pt will need additional oral _____ due to adrenal suppression -chronic use of oral _______ in high doses by children can result in decreased linear growth which is why they are not used for long term management -inhaled _____ deliver the anti-inflammatory agent directly to the local target area (the child's airway) resulting in decreased risk for adrenal suppression -NOTE: inhaled ______ are not rescue medications; for acute bronchospasms related to the severe reactive airway disease the child inhale a __+__
Electroencephalogram (EEG)
Pt teaching includes: -electrodes only monitor brain activity, they do not stimulate it, so the pt won't feel any electrical sensations during the procedure -pt shouldn't fast for an _______ bc hypoglycemia can affect diagnostic results; however, pt shouldn't drink any beverages that contain caffeine the day of the test -painless test that records the activity of the brain -for the test, tech attaches electrodes to the scalp to record the tiny electrical changes the nerve cells in the brain release -so that electrodes will adhere to the scalp, pt's hair has to be clean & free of oil & hair care products
Jaundice
Results from liver dysfunction
S/S that *death is imminent*
S/S indicating ________: -urinary incontinence -cold extremities, first in the feet & hands -hypotension -slow, weak pulse
Digoxin toxicity
Should instruct the pt to monitor for and report manifestations of toxicity such as: -diarrhea -nausea -muscle weakness
Ginger root
Sometimes used to prevent & treat nausea caused by: -sickness -seasickness -& other causes
*Tracheostomy* care
When teaching the parent to provide_____: -nurse should first remove the inner cannula -next, nurse should instruct the parent to remove the soiled dressing -next, they will need to clean the stoma w/ 0.9% sodium chloride (sterile saline) irrigation -finally, nurse should instruct the parent to change the ____ collar
Theopylline
-can be used for relief of chronic bronchitis -toxicity S/S: early manifestation is CNS stimulation often seen as tremors, seizures can occur if blood levels cont to rise, diarrhea, restlessness & irritability, and tachycardia -is a xanthine derivative bronchodilator -is a CNS stimulant
Methadone
-used to treat opioid use disorder (withdrawal) -pt can take this to treat opioid withdrawal symptoms during pregnancy -can develop physical dependency w/ long-term use -sedation and drowsiness are common adverse effects of methadone; sedation most frequently occurs at the beginning of tx or during dosage increases -can cause respiratory depression so pt shouldn't take more than the prescribed dose at any time
Vaso-occlusive sickle cell crisis
Indications include: -painful swelling of the hands and feet -hematuria resulting from ischemia of the kidneys -visual disturbances
Correct: *A-place the BP cuff in a labeled bag to send it for decontamination*; nurse should place BP cuff in labeled bag before removing it from the pt's room & then send it to the proper facility location for decontamination Incorrect: B-immediately rinse the BP cuff in hot running water; nurse should rinse in cold water prior to sending it for decontamination; hot water can cause the vomitus to coagulate & stick to the cuff making it difficult to remove C-dispose of the contaminated BP cuff in the bag lining the trash can; nurse shouldn't dispose of reusable hospital equipment such as a BP cuff D-clean the BP cuff w/ a chlorine bleach solution; nurse should use a chlorine bleach solution to clean blood spills
Nurse is caring for a pt who vomits on a reusable BP cuff; nurse should.... A-place the BP cuff in a labeled bag to send it for decontamination B-immediately rinse the BP cuff in hot running water C-dispose of the contaminated BP cuff in the bag lining the trash can D-clean the BP cuff w/ a chlorine bleach solution
Facilitating acceptance of change
-1st stage of the process is the unfreezing stage=when the nurse manager should inform the staff about current issues; this can increase their understanding of why changes are necessary -2nd stage of process is moving stage= asking staff to participate in trial implementation of the new change; including staff members in the change by encouraging them to offer alternative solutions (this will make staff feel included & less resistant to the new change); & developing goals and objectives to implement the new change/system
Nifedipine
-calcium channel blocker -used to treat HTN -can cause dermatitis and urticaria -also used for angina pectoris -also used for pts in pre-term labor -causes uterine relaxation by blocking the flow of calcium to the myometrial cells of the uterus
Diltiazem
-can be a tx option for essential HTN -med will lower BP & is a contraindication for a pt who is hypotensive -nurse should teach pt taking this to self-monitor BP & keep a record of the readings -_____ & other calcium channel blockers are contraindicated for use in certain conditions where bradycardia is present, such as 2nd or 3rd-degree heart block -used to tx tachydsyrhythmias such as atrial flutter, a-fib, & supraventricular tachycardia -decreased LOC is NOT a contraindication -doesnt interact w/ diuretics so a hx of diuretic use isn't a contraindication
Alosetron
-can be prescribed for IBS w/ diarrhea -has potential fatal adverse effects associated w/ constipation & bowel obstruction -FDA has allowed ______ to be placed on the market only if pt's sign & adhere to a risk management program, which includes signing a pt-provider agreement before starting _____ -pt should be taught to notify provider & stop med if diarrhea isn't controlled after 1 month of starting _____ -pt should notify provider about tachydysrhythmias (an adverse effect of _____) -has few medication interactions & doesnt interact w/ oral contraceptives
Oral Prednisone
-can be used as a long-term asthma med -rash isn't an expected adverse effect of oral glucocorticoids such as _____ -pt should NOT stop taking _____ or other glucocorticoids abruptly if taking ____ for >10 days; dosage should be decreased gradually to prevent w/drawal syndrome during long-term therapy -glucocorticoids such as ______ can cause significant GI distress & lead to ulcer formation; pt shouldn't take steroids on an empty stomach -some of the adverse effects caused by long-term glucocorticoid therapy, such as suppression of the adrenal gland, can be avoided by using alternate-day therapy -oral glucocorticoids, such as ____, are not used as rescue meds; pt might need a short-acting bronchodilator if acute distress occurs
Intranasal calitonin-salmon
-can be used tholepin tx post-menopausal osteoporosis -nurse should instruct pt to administer ____ to one nostril daily, alternating nostrils -instruct the pt that nasal bleeding or ulcerations are indications to discontinue the med & to notify the provider if nasal bleeding occurs -instruct the pt to activate the pump on the initial use by holding the bottle upright & depressing the 2 white side arms toward the bottle 6 x's -is a long-term tx therapy for post-menopausal osteoporosis -med has no documented long-term adverse effects
Hypovolemia (S&S)
-elevated hematocrit (ex=55%) -weak pulse -tachycardia -hypotension -tachypnea -slow cap refill -elevated BUN -increased urine specific gravity -decreased urine output
Metformin
-given to pts w/ T2 diabetes -weight loss is a common finding when beginning _____ (the solfonylurea meds for T2DM, such as glipizide and tolbutamide are likely to cause weight gain) -myalgia, malaise, somnolence, & hyperventilation are manifestations of lactic acidosis which can be a adverse effect while taking _____ d/t blockage of lactic acid oxidation; rarely occurs BUT nurse should instruct pt to report these findings promptly to provider -lowers BS but taking it in prescribed doses as sole med for DM doesnt cause hypoglycemia (other meds for t2dm such as sulfonylureas & glitazones can cause severe hypoglycemia & when used w/ _____ might cause this adverse effect) -can cause N/V/D
Clozapine
-medication used to treat schizophrenia -nurse should recognize antipsychotic meds, such as _____, can cause: urinary retention, polyuria, & orthostatic hypotension -nurse should recognize a temperature as a sign of an adverse effect bc antipsychotic such as ______ can cause agranulocytosis, which is the depletion of WBCs; this increases the pt's risk for infection; fever is an early indication that pt should have WBC count checked to detect agranulocytosis
Newborn safety teaching
-nurse should instruct the client that there should not be blankets, pillows, or stuffed toys in the newborn's crib; these items increase the risk for suffocation; client should dress the newborn in a sleep sack or 1-peice sleeper for naps & nighttime sleeping -nurse should instruct the client that the crib slates should be no more than 5.7 cm (2.25in) apart; slats that are further apart increase the risk of injury -nurse should instruct the client that the newborn's car seat should remain rear-facing until child is 2 YO or exceeds the height and weight limit of the car seat according to the manufacturer; maintaining a rear-facing position decreases the risk of head and neck injuries to the newborn in the event of a collision -nurse should instruct the client to set the max hot water temp to no more than 49°C (120°F); nurse should also instruct the client to test the temp of the newborn's bath water w/ her elbow prior to bathing
Religious traditions related to death
-organ donation is prohibited by ppl who are practicing jehovah's witnesses -cremation is discouraged by ppl who practice roman catholicism -in the jewish faith, a family member often stays w/ the body until burial occurs -some ppl who practice buddhism believe in euthanasia
Spironolaction
-potassium sparing diuretic -can be used for HF -pts taking potassium-sparing diuretic should limit their intake of foods high in potassium (ex; citrus fruits, bananas, potatoes) d/t risk of hyperkalemia -pts taking potassium-sparing diuretic should not use salt substitutes bc they contain potassium & place pt at R/f hyperkalemia -drinking large amts of water can cause dilution hyponatremia which is dangerous when taking ______ since electrolyte imbalances including hyponatremia are common -derived from steroids so can cause adverse endocrine effects such as gynecomastia, impotence in men, & irregular menses & hirsutism in women; nurse should instruct pt that these changes can occur
Amitriptyline
-tricyclic antidepressant -has a sedative effect -med is often prescribed 3x's daily until therapeutic dose has been achieved & then the entire dose is prescribed at bedtime to help pt sleep at night & prevent daytime drowsiness -can cause orthostatic hypotension; nurse should instruct pt to take precautions (ex: move slowly when standing up) to prevent injury d/t falls -should not be taken w/ other CNS depressants such as alc & sedatives bc theres substances can enhance the adverse effects of _____ -_____ & other tricyclic antidepressants have an anticholinergic action & can cause severe constipation as well as adverse effects such as dry mouth, blurred vision, and urinary retention -nurse should reinforce increasing dietary fiber, fluid intake & chewing sugar free gum can alleviate the anticholinergic effects of dry mouth & constipation -pts taking ____ should avoid overheating bc of the lack of an ability to sweat while on medication
Saw palmetto
-used primarily for manifestations r/t prostatic conditions, such as BPH -effectiveness hasn't been scientifically proven -nurse should teach the pt to check w/ the provider about interactions b/w _____ & other meds -used for urinary health promotion
1. Denial; refusing to acknowledge the existence of her substance use disorder 2. Rationalization; attempting to make excuses to justify socially or professionally unacceptable behavior 3.Intellectualization; an attempt to use the intellectual processes to avoid expressing the emotions that stem from stressful situations 4. Suppression; pt is consciously avoiding a discussion of the substance use disorder
A nurse in a substance use disorder program is interacting w/ a pt; identify the coping strategy/defense mechanism used in each statement 1: "I was just using the medication to help me out during a rough time in my life. I can stop whenever I want." 2. "This all happened because my spouse is unemployed. That puts an enormous amt of stress on me" 3. "I have read that problems w/ substances can have a variety of predisposing factors." 4. "I just don't want to talk about it. There's nothing you can do about it anyways."
*A- measure pts daily weight*; daily weights are the most sensitive indicator of fluid balance in clients of all ages, especially critical for infants & children bc fluid accounts for a > portion of body weight INCORRECT: b-checking for the absence of tears is part of the hydration assessment BUT doesn't give the nurse precise information about the degree or severity of the infant's dehydration c-palpating the fontanel is part of the hydration assessment BUT unless fontanel is extremely sunken, this assessment doesn't give the nurse precise info about the degree/severity of the dehydration d-assessing skin turgor is part of hydration assessment BUT unless skin is extremely slow to respond, this isn't precise enough
A nurse is caring for an infant who is experiencing dehydration; which assessment is priority? A- measure the pts daily weight B- check for tears c- palpate the fontanel d-assess skin turgor
Correct: *A-arrange for social services*; appropriate for a pt who faces challenges w/ self-care, as well as w/ paying for medical equipment & supplies *B-initiate a consult w/ an enterostomal therapist*; can assist the pt in learning to care for the colostomy *C-provide the pt w/ information about the American Cancer Society*; pt can learn about helpful resources from the ACS *E-give the pt info about local support groups*; a pt who has cancer & a new colostomy can get help w/ coping from a support group
A nurse is planning discharge teaching for a pt who has colorectal cancer & is post op following a new colostomy. The pt expresses concern about discharge & states "I have no health insurance & cannot pay for the ostomy supplies." Which actions should the nurse take? A- arrange for social services B-initiate a consult w/ an enterostomal therapist C-provide the pt w/ information about the American Cancer Society D-postpone the pt's discharge E-give the pt info about local support groups
Correct: *A-direct stimulation of auditory nerve fibers*; cochlear implants work by directly stimulating nerve fibers in the cochlea Incorrect: B-conduction of sound waves through the mastoid bone to the cochlea; bone conduction hearing aids, not cochlear implants conduct sound waves through to the skull to the inner ear C-processing of digital sound to amplify several sound frequencies; some hearing aids use digital sound processing to help pts who have high-frequency hearing loss, but cochlear implants do not D-conversion of vibrations in the ear's structures to electrical signals; an implantable piezoelectrical device converts vibrations in the eardrum and ossicles to signal a sound processor that then amplifies to a driver that transmits them to the inner ear for sound perception
A nurse is teaching parents of an infant about tx options for profound sensorineural hearing loss; the nurse should include which of the following info about the function of cochlear implants? A- direct stimulation of auditory nerve fibers B-conduction of sound waves through the mastoid bone to the cochlea C-processing of digital sound to amplify several sound frequencies D-Conversion of vibrations in the ear's structures to electrical signals
1. Compromise; CN uses compromise by giving up a demand while asking the staff nurse also to give up a demand 2. Cooperation; CN uses this by giving up her own desires for the desires of the staff nurse 3. Collaboration; CN uses this by putting aside individual desires and focusing on shared decision making 4. Smoothing; CN uses smoothing as a conflict resolution strategy by complimenting or focusing on shared ideas to reduce the emotional component of the conflict
Charge nurse is managing conflict w/ a staff nurse who doesn't agree w/ the client care assignments; what conflict resolution strategy is used in each below: 1. "would you accept the assignment if we reassign your pt who has total care needs and & assign another pt who can provide more self care?" 2. "tell me what changes we need to make so that you'll feel comfortable w/ the assignment" 3. "I didn't mean to make you feel overwhelmed; why don't you look over the assignments w/ me and suggest changes?" 4. "You always complete your work on time & do a great job; I believe you can handle this assignment well"
Older adult patients ^ = aging
Due to physiological changes of __^__, _____ might need dosage adjustments due to: -a decrease in total body water resulting in a smaller-volume distribution of water-soluble medications -changes in tissue composition cause an increase in adipose tissue, a decrease in lean body mass, and a decrease in total body water; the increase in fatty tissue causes increased storage of lipid-soluble meds and lowers plasma levels of those medications (*AKA BODY FAT IS THE MAJOR NEED FOR DOSAGE ADJUSTMENTS*) -splanchnic blood flow decreases resulting in smaller-volume distribution of water-soluble medications -gastric emptying declines slowing the rate of absorption of meds
Correct: *D-abdominal bloating*; early indication of ovarian cancer, as well as increase in abdominal girth, pelvic or abdominal pain, early satiety, & urinary frequency/urgency Incorrect: A-back pain; indication of cervical cancer B-post-coital (after intercourse) bleeding; indication of cervical cancer C-purulent (vaginal) discharge; indication of STI
Nurse in a community center is providing an educational session to a group of women about ovarian cancer; which should the nurse instruct the women to contact their providers about? A-back pain B-post-coital bleeding C-purulent discharge D-abdominal bloating
Correct: *B-Hemoptysis 275 mL/24 hr*; hemoptysis greater than 250mL/24 hr indicates that the pt is at greatest risk for hemorrhage Incomplete: A-decreased activity; nurse should report to provider bc indication of pulmonary function but there's a greater risk to pt C-fever; nurse should report fever to the provider bc it's an indication of pulmonary infection but theres a greater risk to pt D-weight loss 2.3 kg (5lb); nurse should report anorexia & weight loss to provider bc indication of pulmonary infection but theres a greater risk to pt
Nurse is assessing a school-age child w/ cystic fibrosis; what finding is priority to report? A-decreased activity B-Hemoptysis 275 mL/24 hr C-fever D-weight loss 2.3 kg (5lb)
Correct: *B-partial thickness skin loss*; (or blister formation) = stage II pressure ulcer Incorrect; A-muscle damage = stage IV pressure ulcer C-visible subcutaneous tissue = stage II PU D-tendon exposure= stage IV PU
Nurse is assessing pt w/ stage II pressure ulcer; nurse should expect what ulcer/wound characteristics? A- muscle damage B-partial thickness skin loss C-visible subcutaneous tissue D-tendon exposure
Correct: *A- pt who has Alzheimer's dz & is demonstrating aphasia *; aphasia impairs pt's ability to communicate but doesnt interfere w/ nutritional intake/place the pt at a safety risk while eating so assisting the pt at mealtimes is w/in AP's scope of practice Incorrect: B- pt who has asthma and an increase RR; requires assessment by the nurse C- pt who had a stroke & is to start oral intake; requires assessment by the nurse & is at risk for aspiration D- pt who has DKA & is diff to arouse; requires assessment by the nurse
Nurse is caring for 4 pts; which should nurse assign to AP to assist with meals? A- pt who has Alzheimer's dz & is demonstrating aphasia B- pt who has asthma and an increase RR C- pt who had a stroke & is to start oral intake D- pt who has DKA & is diff to arouse
Family-centered care
Nurse is caring for a pt w/ a terminal illness & fam wants to care for pt at home; _______ includes: -fam & pt are the focus -fam must decide w/ the input of the HCT which community resources to contact; nurse should however make suggestions and offer support -nurse should make suggestions and offer support but should NOT make the final decision about changes to the care plan -nurse considered the health of the fam as a unit so pt &fam help determine their outcomes & goals; setting up a meeting to discuss this w/ provider will give them a sense of autonomy & foster the ______ nursing environment
Correct: *A- meperidine*; opioids are more effective for residual limb pain rather than phantom limb pain; additionally, meperidine isn't recommended for chronic pain bc using it long-term can cause accumulation of a toxic metabolite Incorrect: B- amitriptyline; a tricyclic antidepressant that can help manage chronic phantom limb pain C- gabapentin; an anti-epileptic that can help manage chronic phantom limb pain D- propranolol; beta-blockers such as propranolol can reduce the persistent dull, burning sensations of chronic phantom limb pain
Nurse is caring for a pt w/ chronic phantom limb pain following an above-knee amputation; which med prescription should the nurse verify w/ provider A- meperidine B- amitriptyline C- gabapentin D- propranolol
1. Phlebitis or infection 2. Infiltration 3. Phlebitis or infection 4. IV system not intact
Nurse is caring for a pt who is receiving IV therapy via a peripheral catheter; what would each of the following S/S represent? 1. redness at the infusion site? 2. edema d/t fluid entering subcutaneous tissue ? 3. warmth at the infusion site? 4. oozing of blood at the infusion site?
Correct: *D-provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr*; nurse should use an infusion pump when administering TPN solution to ensure accurate dosage and should taper the infusion rate before discontinuing the solution to prevent hypoglycemia; if nurse is unable to cont TPN by infusion pump, nurse should use manual drip tubing to infuse D10W at the same rate as the TPN solution Incorrect: A- administer the TPN solution at the same rate using manual drip tubing; nurse should only administer TPN using an infusion pump to deliver it at a controlled rate B- offer the pt oral fluids in place of TPN; nurse must cont to provide fluids by IV infusion to a pt who's been receiving cont TPN to prevent rebound hypoglycemia C- infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr; nurse should infuse an IV solution that will maintain adequate blood glucose levels
Nurse is caring for a pt who's receiving TPN solution by continuous IV infusion at 60 mL/hr; nurse discovers the infusion pump has stopped working; while waiting for a new infusion pump nurse should...? A- administer the TPN solution at the same rate using manual drip tubing B- offer the pt oral fluids in place of TPN C- infuse 0.9% sodium chloride solution using manual drip tubing at 30 mL/hr D-provide dextrose 10% in water solution using manual drip tubing at 60 mL/hr
Correct: *C-"this herb can result in false low PSA levels"*; the nurse should instruct the pt that saw palmetto can result in false low PSA levels, which can delay diagnosis of prostate cancer Incorrect: A-"this herb can cause GI upset such as bloating and abdominal pain"; flaxseed, which pts can use for migraine prophylaxis can lead to GI symptoms such as bloating, abdominal pain, & flatulence B-"this herb can interact w/ caffeine and cause irritability"; ginseng, which pts can use to stimulate mental activity & increase the appetite, can interact w/ caffeine and cause irritability D-"this herb can lower your BP"; valerian, which pts can use as a tranquilizer or sedative, can lower BP
Nurse is caring for an OA pt who reports taking saw palmetto along w/ his other medications; what response should nurse make? A-"this herb can cause GI upset such as bloating and abdominal pain" B-"this herb can interact w/ caffeine and cause irritability" C-"this herb can result in false low PSA levels" D-"this herb can lower your BP"
Long- leg *fiberglass cast*
Nurse is caring for pt w/ femur fracture and ________: -if pt reports leg itches under the _____ around the mid-upper thigh area; indicates pt's skin is dry & uncomfortable; nurse can offer the pt a hair dryer to use on cool setting to blow air on the skin to relieve the itching -if pt reports increased pain when he lowers leg below the level of heart; increased pain when leg is in dependent position is an expected finding so nurse can recommend the pt keep leg elevated -if pt's ____ becomes wet during sponge bath; _____ is waterproof & water won't affect the integrity of the ______ -*PRIORITY*=pt's heal is reddened & tender; greatest risk to this pt is injury from a pressure ulcer
Correct: *B-tolvaptan*; SIADH is a disorder of water intoxication due to the inappropriate, continuous secretion of antidiuretic hormone by the posterior pituitary gland, causing hypervolemia & hyponatremia; tx of SIADH= fluid restriction, sodium replacement w/ small amounts of 0.9% sodium chloride, and a vasopressin antagonist, such as tolvaptan; tolvaptan promotes the excretion of water, which helps to correct the fluid imbalance in pts who have SIADH Incorrect: A-chlorpropamide: an antidiabetic agent that also has antidiuretic effects that would worsen the manifestations of SIADH; used to treat diabetes insipidus C- vassopressin; an exogenous form of antidiuretic hormone that would worsen the manifestations of SIADH; its use to treat diabetes insidious D-desmopressin; a synthetic form of antidiuretic hormone that would worsen manifestations of SIADH; used to treat diabetes insipidus
Nurse is planning care for a pt who has SIADH (syndrome of inappropriate antidiuretic hormone) with mild manifestations; nurse should expect provider will prescribe: A- chlorpropamide B- tolvaptan C- vasopressin D- desmopressin
Correct: *B-WBC 2,800/mm^3*; clozapine can cause agranulocytosis, which can be life threatening, SO a WBC of less than 3000 is a contraindication; the nurse should w/hold med & notify the provider of the pt's WBC count Incorrect: A- BP 150/87 mm Hg; hypertension isn't a contraindication; BUT, nurse should monitor the pt for hypotension, esp when going from a lying or sitting position to standing C-auditory hallucinations; these are a positive manifestation of psychosis & not an indication for the pt not to receive clozapine D-nausea; not a contraindication; pt can take clozapine w/ food to minimize gastrointestinal upset
Nurse is reviewing the med record of a pt w/ schizophrenia & is starting to take clozapine; which would be a contraindication for the pt to receive clozapine? A- BP 150/87 mm Hg B- WBC 2,800/mm^3 C-auditory hallucinations D-nausea
Correct: *D-notify the incident commander*; 1st action to take when implementing an emergency preparedness plan is to notify the incident commander to initiate the command hierarchy & maintain order Incorrect: A-contact the triage officer; it is important for having personnel available to evaluate incoming pts but isn't first action to take when implementing an emergency preparedness plan B-implement the client tracking system; is important for making pt room assignments & informing fam members but isn't first action to take when implementing an emergency preparedness plan C-request the communications officer to release a press statement; is important to inform the public but isn't first action to take when implementing an emergency preparedness plan
Nurse manager is on a planning committee to develop an emergency preparedness plan; nurse should recommend which action take place FIRST? A-contact the triage officer B-implement the client tracking system C-request the communications officer to release a press statement D-notify the incident commander
Mechanical restraints
Nurse should include following interventions in plan: -shouldnt remove restraints unless pt is calm, in control, & able to follow simple commands -assess the pt for physical needs, safety, comfort, ROM, circulation, &psychological status every 15-30 min & document findings -provider must renew a prescription every 4 hrs for pts 18 years or older, every 2 hrs for children 9-17, & every 1 hr for children under the age of 9 -provider should evaluate the pt w/in 1 hr of applying ____ -provide a staff member to stay with the pt continuously or view the pt via a camera if necessary d/t risk of injury
Laser-assisted in situ keratomileusis (LASIK) surgery pt teaching
Nurse should include: -"you might need glasses after the surgery"; _____ is a type of refractive laser eye surgery opthalmologists perform to correct myopia, hyperopia, & astigmatism which are common causes of nearsightedness; however, over correction or under correction of refractive errors is possible so some pts will need prescription eyeglasses despite having surgery -pt might receive sedation prior to procedure & post-op might have blurry vision, tearing, & hypersensitivity to light so can't drive themselves home after procedure -pt shouldn't wear soft contact lenses for 2-3 wks or hard contact lenses 4 wks prior to ______; they limit O2 intake to the cornea, which can slow post-op healing -for some pts, vision is clear an hr after surgery, however it can take up to 4 wks for complete healing & optimal vision
Fluoxetine
Nurse should instruct the pt to monitor & report to the provider: (adverse effects of med) -rash -dark or tarry stools bc _______ can cause GI bleeding -tremors; can cause serotonin syndrome w/in 2-72 hrs after starting tx; pt can experience tremors, agitation, confusion, anxiety, & hallucinations; instruct these manifestations to provider and stop taking medication -weight gain Note=antidepressant medication
*NG tube* for gastric decompression
Nurse should plan/know that: -single lumen _____ are used for intermittent suction w/ the machine being set at 80-100 mm Hg; higher suction settings can traumatize the gastric lining -frequent oral hygiene provides comfort for the pt since mucous membranes easily become dry & uncomfortable when a pt cannot drink fluids -measuring the draining at least every shift helps provider to calculate the fluid loss & prescribe appropriate replacement therapy -an unsecured ____ can irritate the nares if the tube is pulled or caught on the bed or other equipment so ______ should be secured to the pt's gown; tube can also be dislodged if not secured appropriately -a water-soluble lubricant should be applied to the nares to help prevent/relieve dry skin; don't use petroleum jelly bc pt could aspirate on an oil-based lubricant like petroleum jelly into the lungs which could result in lipid pneumonia
Providing comfort for pt w/ *rheumatoid arthritis*
Nurse should remember: -pain, stiffness, & swelling are worse in the morning for pts who have ______; nurse should postpone assisting the pt to perform ADL's until morning analgesics & anti-inflammatory meds provide relief -allow for frequent rest periods throughout the day; balance rest w/ exercise to maintain muscle strength, joint function, and ROM -pts who have inflamed joints can use moist heat to enhance comfort but getting into a bath tub places pt at risk for falls so nurse should recommend a warm shower -pt w/ ______ should not take more than 4 g acetaminophen each day
*DVT* plan of care += thrombus
Nurse should: -encourage ambulation; walking doesnt increase the risk for pulmonary emboli nor does it worsen the ____ -encourage pt to drink 2-3 L of fluid daily to decrease platelet aggregation & prevent dehydration -place warm compresses on the affected-area to reduce swelling and promote comfort -elevate the affected leg/extremity to reduce edema and minimize the possibility of the __+__ formation & possible pulmonary emboli
Clostridium difficile (C-diff) pt in contact isolation 1. contact isolation 2. c. diff
Nurse should: -wear gloves when handling articles that have the potential to contaminate the hands when caring for a pt who is in __1__ -use soap and water to cleanse the hands; alcohol-based hand sanitizer is ineffective against the spores of __2__ -shouldn't put pt on complete bed rest bc this places them at risk for the hazards of immobility such as impaired skin integrity & retained respiratory secretions; should instruct pt to remain in room but to move, cough, & DB at least q2hr
4-point crutches
Nurse teaching a pt who has extremity weakness how to use ______ would include: -dont put pressure on the axillae bc this increases risk to underlying nerves, which could result in partial paralysis of the arms -pt should keep elbows flexed about 30° -pt should have 3-points on the ground at all times; so must be able to bear weight on both legs -pt should move each leg alternately w/ each opposite crutch so that 3 points of support are on the floor at all times
Correct: *D-recent weight loss*; good nutritional status is essential for preventing the development of pressure ulcers; pt who has recently lost 5% of TBW or 4.5kg (10lb) is at risk for developing a pressure ulcer Incorrect: A- report of persistent constipation; diarrhea and exposure to stool would place pt at risk B-Hgb 14 g/dL; level=indication of nutritional status and is in expected range C-Albumin 4.2 g/dL; level=indication of nutritional status and is in expected range
Nurse working in a long-term care facility is assessing an OA pt; which puts the pt at risk for development of a pressure ulcer? A- report of persistent constipation B-Hgb 14 g/dL C-Albumin 4.2 g/dL D-recent weight loss
Correct: *D-liver damage*; acetaminophen in large doses can be toxic to the liver; daily intake should be limited to 3-4 grams/day for healthy indvs & 2.4 grams/day for OAs & those w/ a history of liver impairment Incorrect: A-constipation; adverse effect of opioid analgesics B-gastric ulcers; adverse effect of aspirin & other nonselective NSAIDS C-respiratory depression; adverse effect of opioid analgesics
OA pt reports he's been taking acetaminophen 500 mg/day for severe joint pain; nurse should instruct the pt that large doses of acetaminophen could cause which of the following adverse effects? A-constipation B-gastric ulcers C-respiratory depression D-liver damage
Hemolytic transfusion reaction
Pt receiving a blood transfusion, nurse should suspect pt is having a ________ if pt experiences: -tachycardia -low back pain -hypotension
Cataract extraction
Pt teaching following surgery: -pt should avoid taking aspirin following ____ bc of its anticoagulant effect -if eye feels itchy, nurse should recommend the use of a cool compress to ease the discomfort of itching -pt should avoid bending at the waist bc this movement increases intraocular pressure; nurse should reinforce that the pt should bend at the knees when picking up an obj -pt should avoid lifting objs that weigh more than 4.5 kg (10 lb) bc it can increase intraocular pressure & damage the suture of the new lens
Myasthenia gravis
_____ is weakness and rapid fatigue of muscles, so to improve nutrition in pt w/ ______ nurse should instruct pt to: -cut food into small bites and eat slowly to prevent aspiration -keep the HOB elevated during meals & for 30-60 mins following meals to prevent aspiration -instruct the pt to weigh daily to monitor nutritional status -take anti cholinesterase medication 45-60 minutes before meals to prevent aspiration -choose snacks high in calories to maintain adequate nutrition
Correct: *C- determine goals and objs*; the nurse attempting to make a change or revision to a policy should first develop the initial plan & then determine the goals & objs; objs define strategies or implementation steps to attain the identified goals Incorrect: A- set target dates for completion B- identify areas of support D- implement recommended strategies ^^ the nurse should do all of these as later steps in the policy revision process
Charge nurse is leading a committee that's revising the policy for pt d/c; after developing the initial plan, what should the nurse do next? A- set target dates for completion B- identify areas of support C- determine goals and objs D- implement recommended strategies
Clubbing
Children who have cardiovascular disorders develop ______ of the fingers & toes due to chronic hypoxemia of the tissues
Sweat chloride
Children who have cystic fibrosis have an elevated....
Correct: *A-Lateral*; a lateral or side-lying position promotes uteroplacental blood flow and thus relieves the symptoms of supine hypotension, including faintness, dizziness, and breathlessness Incorrect: -B: lithotomy; is for gynecological exams & is still a supine position -C: trendelenburg; supine position with the head lower then the pelvis -D: prone: aka facedown = uncomfortable for women who are past the first trimester of pregnancy & it doesn't relieve supine hypotension Note: supine hypotension results from pressure of the gravid uterus on the ascending vena cava
A nurse on the antepartum unit is caring for a pt who is at 28 weeks of gestation and reports dizziness when lying on her back; the nurse should assist the client in which position? A-Lateral B-Lithotomy C-Trendelenburg
Cardiac tamponade
Assessment expected findings: -pulsus paradoxus; a finding in which the systolic BP is 10 mmHg or > on expiration than on inspiration -jugular vein distention -bradycardia -hypotension -muffled heart sounds -fatigue -dyspnea
