HR Test Review 6

The client has been taking divalproex for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test?

Alanine aminotransferase (ALT) Rationale: ALT levels will increase primarily in liver damage/disorders. A SE of administering divalproex is drug-induced hepatitis.

Intermittenet self catheterization

Clean procedure

What data would indicate that the clients nadolol should be help and the HCP notified?

HR of 56/min

If doctor leaves computer with client info on screen what should you do?

Minimize or hide screen so info is no longer visible, then inquire whether the user will be returning to the computer work station.

Parenting classes for first time parents in an attempt to decrease child abuse in the community is an example of what level of prevention?

Primary

Naegeles rule?

To calcuate the expected date of confinement. Take the first day of last menstrual period, add seven days, subtract 3 months, add one year.

What is true about violence when the victim tries to leave?

You are at greatest risk when you leave. Violence is likely to escalate and may become lethal when the spouse leaves the abusive partner.

Ataxic respirations

irregular, random pattern of deep and shallow respirations w/ irregular apneic periods.

What nursing interventions should be implemented for a client dx w/ new onset grand mal seizures?

- Pad side rails w/ blankets - Place bed in low position - Instruct client to call for help when ambulating - Place call light in reach - Put client close to nurses station - Maintain bedrest until seizures controlled, or ambulate w/ assistance to protect from injury.

When is the pt at greatest risk for hypoglycemia following an 8:00am dose of regular insulin?

11:00 Rationale: Regular insulin peaks 2-3 hrs after administration. - Regular insulin onset is 30 min after administration.

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse see first? 1) Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2) Diagnosed with early onset of Alzheimer's disease with confusion. 3) Post operative internal fixation of the femur with crust forming on the Steinman pins. 4) Receiving treatment for dehydration, and is now picking at bedding and IV tubing.

4) Receiving treatment for dehydration, and is now picking at bedding and IV tubing. Rationale: Being restless is an early sign of hypoxia. Oxygen may be necessary. Remember the ABCs.

A new born is admitted to the nursery w/ a diagnosis of r/o cytomegalovirus. What RN should NOT be assigned to this baby?

A nurse who is 10 weeks pregnant. Rationale: CMV is a viral infection that can be devastating to a fetus, esp. in the first trimester.

S/S of Parkinsons disease

Blank affect Decreased ability to swing arms Pill-rolling tremor Stiff muscles Shuffling gait

Clang association

Involves the choice of words governed by soudns, often taking the form of rhyming. Ex: "It is hot. I am a hot tot in a lot. I sit all day on a cot drinking a pop."

Diazepam

- Do not mix w/ any other med. - Administer w/ food - Increased risk of falls

Kosher diet

- No pork (bacon, ham, sausage) - Milk is not allowed at the same time as meat. There should be at least 3 hrs separating the two. - All traces of blood must be gone from steak. - Fish is allowed if it has fins and scales. - Shellfish is NOT kosher.

A nurse who has never had varicella has been exposed to a client diagnosed w/ herpes zoster. What actions should the nurse take?

- Notify infection control nurse. - Recieve the varicella-zoster immune globulin within 96 hours of exposure. Rationale: Varicella is chickenpox and herpes zoster is shingles. Both are closely related. Exposure to herpes zoster by someone who has not had varicella places the person at risk for developing herpes zoster. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin.

Administering ear drops?

- Position client supine, with affected ear up (not prone). - Client should remain supine for 5 min after medication is instilled. - Nurse should pull the pinna up and back on adults or down and back for children 3 years of age and younger. - Administer med at room temp. - Educate on mild adverse reactions including ear irritation, local stinging or burning, dizziness.

What interventions should be done if a late fetal heart rate deceleration occurs when monitoring the external fetal monitor?

- Turn the client to the left side. - Administer oxygen. - Notify the primary HCP. - Turn the client to the left side Rationale: Late FHR decelerations are associated w/ fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increase maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary HCP are deviations from the standard of care.

The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would most likely be based on what?

Lack of a sense of wholeness, purpose, and life well lived.

Priority nursing action for a pregnant client in labor who is having an epidural catheter inserted for pain managment?

Monitor maternal BP Rationale: Epidural anesthesia may result in distal vasodilation and a precipitous drop in maternal BP, which will adversely affect placental blood flow. - Obtaining consent is the responsbility of the primary HCP. - Preparing the insertion site is the responsibility of the primary HCP. - Residual effects of epidural anesthesia include infeciton and headache.

What are the peak times for NPH insulin and Lente insulin?

NPH: 6-8 hrs Lente: 8-12 hrs

The nurse is caring for a client who is scheduled to receive furosemide 40 mg IVP twice daily, as well as 20 meq (20 mmol/l) of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.7 mEq/L (2.7 mmol/L) this morning. How should the nurse proceed?

Notify the primary HCP of the K+ level immediatly. Rationale: This is a very low level. Normal K+ is 3.5-5.0 mEq/L - Do not delay care (i.e., do not assess for signs of hypokalemia). - Do not decide to give K+ and hold furesemide, this delays care and confuses the issue of how much K+ needs to be administered now.

Chenye-Stokes

Rhythmic crescendo and decrescendo of rate and depth of respirations with brief periods of apnea.