Med-Surg - Cardiac -Prep U -on Meth

Seconal 0.1 gram PRN at bedtime is prescribed for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer?

1 tablet

The proper suctioning technique is to insert the suction catheter until resistance is met, withdraw the catheter

1 to 2 cm, then begin applying intermittent suction while withdrawing the catheter. The suction catheter is inserted approximately 5 to 6 inches. It is not necessary to insert the catheter as the client exhales. Coughing by a client does not necessarily indicate when to begin or stop suctioning.

A client has acute angle-closure glaucoma. The family is concerned that the client may lose sight. The nurse advises that the window in which this problem can progress to permanent sight loss is: a) 1 to 2 weeks b) 1 to 2 months c) 1 to 2 hours d) 1 to 2 days

1 to 2 days Explanation: Acute angle-closure glaucoma is an emergency. The nurse refers the client for medical treatment immediately because vision can be permanently lost in 1 to 2 days.

Posterior nasal packing should be left in place for

1 to 3 days.

As the emergent period ends and capillary permeability returns to normal, the

fluid in the interstitial compartment will return to the intravascular compartment.

Fine crackles are present when there is

fluid in the lungs

The client is in the taking hold phase

focus on the neonate and learning about and fulfilling infant care and needs

Increased atrial contraction or systemic hypertension can result in a

fourth heart sound.

Chorioamnionitis is a serious intrapartum

infection that may result in fetal tachycardia and a hypotonic labor pattern.

The major risk factor for cervical cancer is

infection with the human papillomavirus (HPV) that is transmitted sexually.

Chorioamnionitis the infected amniotic fluid in the fetal lungs may result in a

infection, such as pneumonia, during the neonatal period.

Airborne precautions prevent transmission of infectious agents that remain

infectious over long distances when suspended in the air (e.g. mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV).

Clients who take the Ranitidine twice a day are advised to take it in the

morning and at bedtime.

Anemia is a common problem with

multiple gestation clients

Other potential complications of mitral stenosis include

mural thrombi, pulmonary hemorrhage, and embolism to vital organs.

Vibration and percussion of the chest wall may be helpful for

respiratory hygiene but will not affect the nature of secretions.

A client with COPD is at high risk for development of

respiratory infections

Cholinergic adverse effects may include

urinary urgency, diarrhea, abdominal cramping, hypotension, and increased salivation.

What is the primary actions of drugs to treat hypertension?

-reduce systemic vascular resistance -Reduce volume of circulating blood

Pulmonary Embolism Etiology Thrombus forms when there is what???? a) whats the most common cause ? 1. ________________ 2. __________________ 3._______________________ 4._____________________________________

1. Venous stasis 2. Vessel wall injury 3. Hypercoagulability of the blood 4.**** Emboli originating from DVT most common cause*****

=Pneumothorax Treatment= 1. Removal of.... 2. Correction of 3. Minimize 4. Re-....... 5.______________ insertion 6. give the patient what ? 7. Maintain....

1. air and fluid from pleural space 2. acid-base balance 3. further damage 4. Re-expansion of lung 5. Chest tube 6. Oxygen 7. infection control practice

Pathophysiology of pneumonia 1. Spread of microbes in..... 2. Alveoli, interstitial tissue, and bronchioles become...... 3. The lungs become......

1. alveoli activates the inflammatory and immune response 2. fluid filled (with fluid or blood) as a result of inflammation 3. congested, then air flow and blood flow decrease (V/Q =silent unit) -If no complications, healing occurs as the exudate gets absorbed and macrophages process debris. Lung function resumes.

Pyrazinamide (PZA) 1. Action: 2. Dose: ____to _____ mg/kg children and adults 3. Interactions: 4. Major adverse effects:

1. bactericidal 2. 20-25 mg/kg 3. oral contraceptives, seizure medications and, anticoagulants 4. hepatitis, gastrointestinal distress, rash, joint aches, and hyperuricemia (gout)

How does HTN contribute to systolic HF?

increase afterload

The fluid shift, which occurs between the intravascular and interstitial extracellular compartments, is caused b

increased capillary permeability that allows water, sodium, and protein to shift to the tissues.

In PVD, decreased blood flow can result in

increased venous pressure.

emergent Fluid shifting into the interstitial space causes

intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine.

warm shock also makes capillaries more permeable causing

leakage and fluid shifting into tissues and fluid shifting into tissues and physiologic third spaces.

The client's highest brachial systolic pressure is divided by the

left ankle systolic blood pressure to get 0.81

The client's highest brachial systolic pressure is divided by the

left ankle systolic blood pressure to get 0.81.

Aphasia is more commonly present when the dominant or

left hemisphere is damaged.

The primary symptoms of a client who experiences a right-sided stroke are

left-sided weakness, impulsiveness, and poor judgment.

Azithromycin is the drug of choice for treatin

legionnaires' disease.

Basal cell carcinoma presents as

lesions that are lightly pigmented. As they enlarge, their centers become depressed and their borders become firm and elevated

Skin and underlying structures may become anoxic after

less than 2 hours of unrelieved pressure.

A client with Parkinson disease is taking carbidopa-levodopa (Sinemet). Which observation by the nurse would indicate that the desired outcome of the medication is being achieved?

lessing of tremors

under epidural anesthesia, the client states she needs to urinate. The nurse should next:

let them go you dont have to palpate the bladder unless the patient is not peeing

gerd The client should no

lie down until 2 to 3 hours after a meal. The client should sleep with the head of the bed elevated 4 to 6 inches

Lymphatic obstruction is a blockage of the

lymph vessels that drain fluid from tissues throughout the body and allow immune cells to travel where they are needed.

antidote for oxytocin is

mag sulfate

Magnesium is normally excreted by the kidneys. When the kidneys fail,

magnesium can accumulate and cause severe neurologic problems

CT is comparable not better or worse than to

magnetic resonance imaging in evaluating lymph node metastasis.

One nursing goal for a child with febrile seizures is to

maintain the child's temperature at a level low enough to prevent recurrence of seizures.

Oversecretion of the adrenal medulla causes

pheochromocytoma

Stress incontinence is losing urine without meaning to during

physical activity, such as coughing, sneezing, laughing, or exercise.

The most common site of hemorrhage is the

periventricular subependymal germinal matrix, where there is a rich blood supply and where the capillary walls are thin and fragile.

contact isolation The nurse should assemble all needed supplies before putting on

personal protective equipment and entering the client's roo

The frontal lobe influences

personality, judgment, abstract reasoning, social behavior, language expression, and movement.

autograft donar site Single-layer gauze dressings impregnated with

petroleum, scarlet red, or biosynthetic dressings may be used to cover the donor site as it heals

Preventing edema is an appropriate immediate postoperative nursing goal, but attaining it does not affect

physical mobility in the immediate and extended postoperative periods

Overuse of nasal spray containing pseudoephedrine can lead t

rhinitis medicamentosa, which is a rebound effect causing increased swelling and congestion.

Rectal surgery is accompanied by

severe pain resulting from spasms of sphincters and muscles. Therefore, controlling pain is a priority goal of nursing care.

Ranson's criteria is a clinical predictor scale used to assess the

severity of acute pancreatitis and prognosis

A client with genital herpes lesions should avoid all

sexual contact to prevent spreading the disease.

A client with primary syphilis is at risk for transmitting the disease t

sexual partners if he or she is not knowledgeable about how the disease is spread.

arsenic exposure Dehydration can lead to

shock and death.

acute respiratory distress syndrome aka

shock lung and white lung which is increased permeability of alveolar cap lets the fluid leak out into interstitial space

A dry gauze dressing — not a plastic sheet-type dressing —

should cover the wet dressing.

After the corticotropin-secreting tumor is removed, the client

shouldn't be at risk for hyperglycemia.

This is achieved by competing for the Cl- binding site. Because magnesium and calcium reabsorption in the

thick ascending limb is dependent on sodium and chloride concentrations they are also lost in the urine

Vesicular breath sounds are

soft, low-pitched sounds normally heard over the lower lobes of the lung. They're prolonged on inhalation and shortened on exhalation.

LBP is commonly associated with overuse or an injury to the

soft-tissue structures Muscle strain

A neonate born at 37 weeks' gestation will have

some cartilage in the ear lobes, fine and fuzzy hair, scant to moderate rugae in the scrotum, and a breast nodule diameter of 4 m

Swelling gradually subsides over several weeks; the client can gently clean the nares as

soon as nasal packing is removed

Beta 1 receptors are responsible for what?

speeding up HR

Spermicidal agents work by destroying the

spermatozoa before they enter the cervix

During spinal anesthesia, medication is injected into you

spinal canal to numb the nerves in the lower half of your body.

If spinal fluid leaks through the tiny puncture site, you may develop a

spinal headache.

Bradycardia, paralytic ileus, and hot and dry skin typically occur during

spinal shock

What is preload?

the pressure generated in the LV at the end of diastole

What are the clinical manifestations of primary HTN?

the symptoms are often secondary to target organ disease but can include -Fatigue/activity intolerance -Dizziness -Palpitation/angina -DOE

if one parent has hbs and other has hbs

then there is 100 percent chance sickle cell

high urine osmalarity means

there is high solutes in water means low water

autograph donar Elastic bandages are not used because

they constrict circulation and can impede healing.

if someone has productive cough

they do not need to be suctioned

so if there is impairment in peripheral sensation problems that means that

they have problems with movement and sensation like hot and cold

Whole grains are a good source of

thiamine.

In people with diabetes, the nephrons

thicken and slowly become scarred over time. The kidneys begin to leak and protein (albumin) passes into the urine

shoes to prevent falls

thin nonslip soles

Transcutaneous pads should be placed on the client with

third degree heart block.

the hallmark symptoms of hyperglycemia are increased

thirst, fruity breath, and glycosuria.

Valves often becom

incompetent with PVD.

if both parents are carriers habas then

25 chance of child getting it

Diet therapy for patients diagnosed with IBS include which of the following?

High-fiber diet

Toilet-training is commonly more difficult for children who have undergone surgery for

Hirschsprung's disease than it is for other children.

Initial antibiotic treatment for pneumonia is usually based on

History and physical examination and characteristics chest radiographic findings

A white male, age 43, with a tentative diagnosis of infective endocarditis is admitted to an acute care facility. His medical history reveals diabetes mellitus, hypertension, and pernicious anemia; he underwent an appendectomy 20 years earlier and an aortic valve replacement 2 years before this admission. Which history finding is a major risk factor for infective endocarditis?

History of aortic valve replacement

Which of the following is a modifiable risk factor for transient ischemic attacks and ischemic strokes?

History of smoking

The nurse is administering a nystatin suspension (Mycostatin) for stomatitis. Which instruction will the nurse provide to the client when administering this medication?

Hold the medication in the mouth for a few minutes before swallowing it.

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?

Homan's---->A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.

folliculitis treatment

Hot, moist compresses may promote drainage of the affected follicles.

Which of the following would not be included as a marker of medication effectiveness in glaucoma control? a) Visual field b) Appearance of optic nerve head c) Lowering intraocular pressure (IOP) to target pressure d) Opacity of the lens

Opacity of the lens Explanation: Opacity of the lenses relates to cataract formation. The main markers of the efficacy of the medication in glaucoma control are lowering of the IOP to the target pressure, appearance of the optic nerve head, and the visual field.

osteoarthritis

Opioid analgesics are not used for osteoarthritic pain control. Acetaminophen and selected nonsteroidal anti-inflammatory drugs may be used to achieve pain relief.

The nurse is observing an unlicensed assistive personnel (UAP) who is performing morning care for a bedfast client with Huntington disease. Which care measure is most important for the nurse to supervise?

Oral care

A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?

Osteoporosis resulting from declining hormone levels

Over secretion of ADH

SIADH

pku The infant does not need t

fast 4 hours before the test.

Platelets should be administered as

fast as can be tolerated by the client to avoid aggregation.

The pt with a fractured left humerus reports dyspnea and chest pain, pulese ox 88%, temp 100.2, HR 110, resp 32. the nurse suspects the client is experiencing

fat embolism syndrome

Ketosis happens when your body resorts to

fat for energy after your stored carbohydrates have been burned out

In the early stages of cirrhosis, there is no need to restrict

fat, protein, or sodium

Because the client is anesthetized, the client may not

feel the urge to push so bearing-down efforts during the second stage of labor may be less effective.

Herpes simplex may be passed to the

fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature birth.

An infected chest tube site, lobar pneumonia, and P. carinii pneumonia can lead to

fever, chills, and sweating associated with infection. However, in this case, turbid drainage indicates that empyema has developed.

The taking in phase is the

first period after delivery emphasis on reviewing and reliving the L & D process, concern with self and needing to be mothered.

Gloves are most contaminated, so she should remove them

first when exiting the room to prevent infection transmission.

A prolonged PR-interval is associated with

first-degree atrioventricular block.

Herpes genitalis

flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina

herpes

flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina,vaginal itching and a thick, purulent vaginal discharge.

Warm compresses could also increase

fluid accumulation

Dyspnea and cyanosis are associated

fluid excess, not CRF.

Inflammation of a hair follicle is called

folliculitis

there were 2 question about best position for someone with aspiration risk one was unconscious one was conscious

for the conscious client you can sit them up for the unconscious they need to be turned to the side

Inspiratory and expiratory stridor is a low-pitched crowing sound heard in a client who has a

foreign body obstructing the trachea or mainstem bronchi.

Cholelithiasis is the medical term for

gallstone disease.

Reglan does not decrease

gastric acid secretion, as do histamine-receptor blockers.

common complication of steroid therapy is

gastric irritation and peptic ulcers.

Oral steroids can cause

gastric irritation and ulcers and should be administered with meals, if possible, or otherwise with an antacid.

Metoclopramide (Reglan), which is prescribed to treat

gastroesophageal reflux disease, acts by stimulating gastric motility and reducing the volume of gastric reflux.

The most common toxicities from NSAIDs are

gastrointestinal disorders (nausea, epigastric pain, ulcers, bleeding, diarrhea, and constipation).

Sulfasalazine can cause

gastrointestinal distress and is best taken after meals and in equally divided doses.

The result of this shift is

hypovolemic shock and edema formation.

Restlessness is an early indicator of

hypoxi

T-wave inversion, ST-segment elevation, and a pathologic Q-wave are all signs of tissue

hypoxia which occur during an MI

Therapeutic positioning for adequate breathing

identifies the best position for the patient assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation is patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

tb is airborne spread so

if its in the air you can only getting from coughing sneezing not from plates plates is not air

Water-soluble jelly is not recommended for lubricating a gavage-feeding catheter becaus

if the catheter is inadvertently inserted into the lungs, the jelly could damage the lung tissue or cause pneumonia

What should someone with chronic unstable angina be worried?

if they are having pain at rest

Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the

ileum, where it is absorbed into the bloodstream.

Tremors associated with Parkinson's disease are not psychogenic but are related to an

imbalance between dopamine and acetylcholine

When a chest tube becomes disconnected, the nurse should take

immediate steps to prevent air from entering the chest cavity, which may cause the lung to collapse. when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified.

If a central venous catheter becomes disconnected, the nurse should

immediately apply a catheter clamp.

The recommended emergency treatment for a heat burn is

immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue.

autograft donar site A pressure dressing is not needed over the donor site and ca

impair healing.

sensorineural loos

impaired cochlea or 8th cranial nerve failure of sound impulses in inner ear or brain

C. trachomatis infection

in women they can bee asymptomatic, but symptoms are yellowish discharge and painful urination.

Ischemia results from

inadequate blood supply to the myocardial tissue and is reflected by T-wave inversion.

metoclopramide Other common adverse effects

include diarrhea (not constipation) and nausea. Occasionally transient hypertension.

This score is between 0.71 and 0.90, which suggests

mild peripheral artery disease.

This score is between 0.71 and 0.90, which suggests .

mild peripheral artery disease.

radiation The skin should be cleaned daily with a

mild soap, not harsh antibacterials.

A client on an acid-ash diet must avoid

milk and milk products because these make the urine more alkaline, encouraging bacterial growth.

The first heart sound (S1) occurs when the

mitral and tricuspid valves close

A pansystolic, blowing, high-pitched murmur characterizes

mitral insufficiency.

Back muscle strains are common, and

moderate strains can cause mild pain and stiffness.

A drainage tube is placed in the wound after a

modified radical mastectomy to help remove accumulated blood and fluid in the area

The burn should be kept

moist to prevent the dressing adhering to the wound.

A wet-to-damp saline dressing should always keep the wound

moist.

Because terbutaline can cause tachycardia, the woman should be taught to

monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute.

Splenomegaly often accompanies

mononucleosis and is present 2 to 4 weeks after contracting the infection. To prevent splenic rupture, contact sports and vigorous exercise should be avoided.

addision Other early signs and symptoms include

mood changes, emotional lability, irritability, weight loss, muscle weakness, fatigue, nausea, and vomiting. Most clients experience a loss of appetite. Muscles become weak, not spastic, because of adrenocortical insufficiency. LETHARGY

Peak flow numbers should be monitored daily, usually in the

morning (before taking medication). Peak flow does not need to be monitored after each meal.

Glucocorticoids should be taken in the

morning, not at bedtime.

peripheral nervous system is

motor movement and sensory system

heat stroke Treatment consists of

moving the adolescent to a cool environment and giving cool liquids.

airborne

mtv measles varicella tb

A nasal drip pad is not needed after removal of

nasal packing.

Oxytocin is administered as

nasal spray before breast-feeding to stimulate lactation.

Common side effects of lithium are

nausea, dry mouth, diarrhea, thirst, mild hand tremor, weight gain, bloating, insomnia, and light-headedness. Immediately notifying the physician about these common side effects is not necessary.

Clients with cirrhosis should not take

acetaminophen (Tylenol), which is potentially hepatotoxic.

The nurse should monitor anesthesia/pain levels every 30 minutes during

active labor to ascertain that this client is comfortable during the labor process and particularly during active labor when pain often accelerates for the client.

210

-216

What two things does the degree of altered function depend on?

-area of the heart involved -size of the infarct.

The normal I:E ratio is

1:2, meaning that expiration takes twice as long as inspiration

When the feeding is completed, clear the tube with

3 cc of water. Rinse the syringe and extension tubing with water.

Mole (definition)

Amount of matter

sars

Airborne and contact precaution

Botulism is a rare but serious illness caused by

Clostridium botulinum bacteria.

How is rejection detected in a heart transplant patient?

Endomyocardial biopsies (EMB)

What type of HTN is common in older adults?

ISH - isolated systolic hypertension

Which of the following is the most common and most fatal primary malignant bone tumor?

Osteogenic sarcoma

Polycythemia vera late sign

Pruritus is a late symptom that results from abnormal histamine metabolism

What is stage 1 and stage 2 HTN?

Stage 1= 140-159/90-99 Stage 2= >160/100

The primary treatment for cor pulmonale is directed toward:

Treating the underlying pulmonary condition

Beta 2 receptors are responsible for what?

Vasodilation/ bronchodilation

milk is

alkaline

as

asa

What is the major cause of coronary artery disease? (CAD)?

atherosclerosis

Salmeterol (Serevent) is a beta2-agonist,

maintenance drug that the asthmatic client uses twice daily, every 12 hours.

dental care for endocarditis is

manual toothbrush

Alpha1 blockers are what?

the -osins sympatholitics

An older female client with dementia is transferred from a long-term care unit to an acute care unit. The client's children express concern that their mother's confusion is worsening. How should the nurse respond?

"Confusion in an older person often follows relocation to new surroundings."

The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations the client is likely to experience?

"Have you ever been 'frozen' in one spot, unable to move?

A nurse working in the clinic is seeing a client who has just been prescribed a new medication for hypertension. The client asks why hypertension is sometimes called the "silent killer." The nurse's correct response is which of the following?

"Hypertension often causes no symptoms."

mi

• T-wave inversion • ST-segment elevation • Pathologic Q-wave

A nurse and a nursing student are caring for a client with pericarditis and perform the physical assessment together. The client has a pericardial friction rub audible on auscultation. When the nurse and student leave the room, the student asks how to distinguish a pericardial from a pleural friction rub. The nurse's best response is which of the following

"Ask the client to hold the breath while you auscultate; the pericardial friction rub will continue, while the pleural friction rub will stop.

A nurse is teaching a client with gastritis about the need to avoid the intake of caffeinated beverages. The client asks why this is so important. Which of the following explanations from the nurse would be most accurate?

"Caffeine stimulates the central nervous system and thus gastric activity and secretions, which need to be minimized to promote recovery."

Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome?

"Change your tampon frequently."

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures

"I have my wife look at the soles of my feet every day"

Your patient is ready to be discharged home after a cataract extraction with intraocular lens implant. You are teaching your patient about signs and symptoms that need to be reported to the ophthalmologist immediately. You know that the patient understands when he says what?

"I need to call the doctor if I see flashing lights." Explanation: Postoperatively, the patient who has undergone cataract extraction with intraocular lens implant should report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the ophthalmologist. Slight morning discharge and a scratchy feeling can be expected for a few days. Blurring of vision may be experienced for several days to weeks.

Your patient is ready to be discharged home after a cataract extraction with intraocular lens implant. You are teaching your patient about signs and symptoms that need to be reported to the ophthalmologist immediately. You know that the patient understands when he says what? a) "I need to call the doctor if I have a light morning discharge." b) "I need to call the doctor if I get nauseated." c) "I need to call the doctor if I get a scratchy feeling." d) "I need to call the doctor if I see flashing lights."

"I need to call the doctor if I see flashing lights." Explanation: Postoperatively, the patient who has undergone cataract extraction with intraocular lens implant should report new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness to the ophthalmologist. Slight morning discharge and a scratchy feeling can be expected for a few days. Blurring of vision may be experienced for several days to weeks.

A nurse is teaching an elderly client about good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?

"I need to use laxatives regularly to prevent constipation"

A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

"I'll avoid eating or drinking anything 6 to 8 hours before the test.

The nurse plans to help an 18-year-old developmentally disabled female client ambulate on the first postoperative day. When the nurse tells her it is time to get out of bed, the client becomes angry and yells at the nurse, "Get out of here! I'll get up when I'm ready." Which response should the nurse provide?

"I'll be back in 30 minutes to help you get out of bed and walk around the room."

A 23-year-old college athlete is recovering in the postanesthesia care unit from a tonsillectomy. After an overnight stay in the hospital due to increased secretions and vomitting, you deliver his client education and accompanying paperwork. Which of the client's comments, listed below, indicates a need for additional education? a) "If I'm vomiting, I'll drink lemon-lime soda to keep myself hydrated." b) "I'll sleep on 2 - 3 pillows." c) "I promise I won't blow my nose." d) "I'll gargle with weak salt water 3 - 4 times a day.

"If I'm vomiting, I'll drink lemon-lime soda to keep myself hydrated." Explanation: Instruct the client to avoid carbonated fluids and fluids high in citrus content. Such fluids are caustic to the surgical site and may traumatize tissue, disrupting the suture line. (less)

The nurse is giving preoperative instructions to a 14-year-old female client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates learning has taken place?

"Let me show you the method of turning I will use after surgery."

A client with hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which instruction is most important for the nurse to include in the client's teaching plan?

"Maintain a moderate exercise program."--->The nurse should instruct the client to maintain a moderate exercise program. Such a program helps strengthen bones and prevents the bone loss that occurs from excess parathyroid hormone. Walking or swimming provides the most beneficial exercise. Because of weakened bones, a rigorous exercise program such as jogging is contraindicated. Weight loss might be beneficial but it isn't as important as developing a moderate exercise program.

A patient with a 40-pack-year history of smoking has recently stopped because of the fear of developing lung cancer. The patient asks the nurse what he can do to learn about whether he develops lung cancer. The best response for the nurse is,

"Screening measures for lung cancer are controversial, but we can discuss the advantages and disadvantages of various measures."

During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?

"You must avoid hyperextending your neck after surgery" --->To prevent undue pressure on the surgical incision after subtotal thyroidectomy, the nurse should advise the client to avoid hyperextending the neck. The client may elevate the head of the bed as desired and should perform deep breathing and coughing to help prevent pneumonia. Subtotal thyroidectomy doesn't affect swallowing

The nurse is caring for a client with atrial fibrillation. The client's symptoms started about 1 week ago, but he is just now seeking medical attention. The client asks the nurse why he has to wait several weeks before the cardioversion takes place. The best answer by the nurse is which of the following?

"Your atrial chambers may contain blood clots now, so you must take an anticoagulant for a few weeks before the cardioversion."---> Because of the high risk of embolization of atrial thrombi, cardioversion of atrial fibrillation that has lasted longer than 48 hours should be avoided unless the client has received warfarin for at least 3 to 4 weeks prior to cardioversion.

Albuterol (Proventil) is used as the

"rescue inhaler" for bronchospasms.

When the client advances both crutches together and follows by lifting both lower extremities to the SAME level as the crutches, the gait is called a

"swing to" gait.

ATTENUVAX*

(Measles Virus Vaccine Live)

Atomic mass unit

(amu) smaller unit of mass 1 amu= 1.66x 10(-24)g

What are signs and symptoms of hypokalemia?

- anorexia, nausea, vomiting - weak peripheral pulses - muscle weakness, paresthesias, decreased deep tendon reflexes - impaired urine concentration - ventricular dysrhythmias - increased instance of dig toxicity - shallow respirations

What are some strategies for adherence to drug regimen?

-Empathy to increase patient trust, motivation, and adherence to therapy -Consider cultural beliefs and individual attitudes

Nursing Management 1. what should the nurse promote ?

-Promote emergency care -Promote measures to maintain adequate chest expansion -Promote coping

Muscle tears or ruptures cause severe pain

, impede the ability to move or walk, and are usually accompanied by swelling and bruising.

What might you discover when assessing your patient diagnosed with pneumonia?

- Changed in temperature and pulse. - Secretions - Cough - Tachypnea and SOB - Changes in physical assessment, especially inspection and auscultation of the chest. - Changes in mental status, fatique, dehydration, and concomitant heart failure (especially in elderly patients).

What are the risk factors for TB?

- Close contact with someone who has TB - Immunocompromised status - Substance abuse - Any person without adequate health care - Immigrations from countries with a high prevalence of TB - Living in overcrowded, substandard housing - Being a health care worker performing high risk activities

What are signs and symptoms of hyperkalemia?

- EKG changes: peaked T waves, wide QRS complexes - dysrhythmias, ventricular fibrillation, heart block - cardiac arrest - muscle twitching and weakness - numbness in hands and feet and around mouth - nausea - diarrhea

What are the main symptoms of SARS?

- High fever - Headache - Overall discomfort - Body aches - Dry cough - Progressive hypoxemia (leads to pneumonia)

What are the first line medications for TB?

- INH - Rifampin - Pyrazinamide - Ethambutol

What are causes of hypomagnesium?

- alcoholism - GI suction - diarrhea - intestinal fistuals - poorly controlled diabetes mellitus - malabsorption syndrome

What are the signs and symptoms of TB?

- Low grade fever - Cough - Night sweats - Fatique - Weight loss

What are some collaborative problems with pneumonia?

- Shock - Respiratory Failure - Atelectasis - Pleural Effusion - Confusion - Superinfection

What are signs and symptoms of hypermagnesium?

- depresses the CNS - depresses cardiac impulse transmission - cardiac arrest - facial flushing - muscle weakness - absent deep tendon reflexes - paralysis - shallow reflexes

What are signs and symptoms of hypernatremia?

- elevated temp - weakness - disorientation - irritibility and restlessness - thirst - dry, swollen tongue - sticky mucous mebranes - hypotension - tachycardia

What are causes of hypernatremia?

- hypertonic tube feedings w/o water supplements - hyperventilation - diabetes insipidus - ingestion of OTC drugs such as Alka-Seltzer - inhaling large amount of saltwater - inadequate water ingestion

What are causes of hypocalcemia?

- hypoparathyroidism - pancreatitis - renal failure - steroids and loop diuretics - inadequate intake - post-thyroid surgery

What are signs and symptoms of hypomagnesium?

- increased neuromuscular irritability - tremors - tetany - hyperactive deep tendon reflexes - seizures - dysrhythmias, especially is kypokalemia present - disorientation - confusion

What are signs and symptoms of hypercalcemia?

- lack of coordination - anorexia, nausea, and vomiting - confusion, decreased level of consciousness - personality changes - dysrhythmias, heart block, cardiac arrest

What are causes of hypercalcemia?

- malignant neoplastic diseases - hyperparathyroidism - prolonged immoblization - excessive intake - immobility - excessive intake of calcium carbonate antacids

What are signs and symptoms of hyponatremia?

- nausea - muscle cramps - confusion - muscular twitching, coma - seizures - headache

What are signs and symptoms of hypocalcemia?

- nervous system becomes increasingly excitable - tetany: Trousseau's sign and Chvostek's sign - hyperactive reflexes - confusion - paresthesias - irritability - seizures

What is calcium regulated by?

- parathyroid hormone - vit D

What are causes of hypermagnesium?

- renal failure - excessive magnesium administration

What are causes of hyperkalemia?

- renal failure - use of potassium supplements - burns - crushing injuries - severe infection

What are causes of hyponatremia?

- vomiting - diuretics - excessive administration of dextrose and water IVs - burns, wound drainage - excessive water intake - syndrome of inappropriate anti diuretic hormone secretion

What are causes of hypokalemia?

- vomiting - gastric suction - prolonged diarrhea - diuretics and steroids - inadequate intake

What are side effects that you have to watch out for pretty much all antihypertensives?

-**ortho hypo -Sexual dysfunction -Dry mouth -Frequent urination

Because of fluid shifts, weight monitoring is extremely important with someone who has chronic HF, what should be reported to the HCP?

-3 lb gain in 2 days -3 to 5lb gain over a week

Collateral circulation in the heart is a result/dependent on which two things?

-A person's genetic predisposition for angiogenesis -Chronic ischemia

Diagnostic Tests -what are three of them ?

-ABGs -EKG -CXR

Pulmonary Embolism Diagnostic Studies

-ABGs -Ventilation-perfusion scan -Pulmonary angiogram -Spiral CT -D-dimer -Prevention -Rapid recognition -Treatment

What are some collaborative problems from primary hypertension?

-Adverse drug effects -Hypertensive crusis -Stroke -MI

When would a CABG be indicated?

-After Failed medical management -Presence of left main coronary artery or three-vessel disease -Not a candidate for PCI (e.g., lesions are long or difficult to access) -Failed PCI with ongoing chest pain -History of diabetes mellitus

What are non modifiable risk factors of CAD?

-Age -Gender -Ethnicity -Family hx -Genetic inheritance

What are risk factors for primary HTN?

-Age -Smoking -Diabetes Mellitus -hyperlipidemia -Excess Na+ -M Gender -Family Hx -Obesity -Stress -Sedentary life style -Ethnicity -Socioeconomic status

What types of things increase your oxygen demand?

-Anxiety -HTN -Hyperthyroidism -Substance abuse -exercise -Aortic stenosis -Cardiomyopathy -Dysrhythmia -Tachycardia

What are assessments for a patient following CABG?

-Assessing the patient for bleeding (e.g., chest tube drainage, incision sites) -Monitoring fluid status -Replacing electrolytes PRN -Restoring temperature (e.g., warming blankets)

What are common complications for someone who was on bypass?

-Bleeding and anemia from damage to RBCs and platelets -Fluid and electrolyte imbalances -Hypothermia as blood is cooled as it passes through the bypass machine

How does HTN manifest in the heart?

-CAD -LVH -HF

How does HTN manifest int he brain?

-CVA -TIA

What are the two primary risk factors for HF?

-CVD (HTN, CAD, MI) -Advancing age Contributing risk factors: -Diabetes - **predisposes a person to HF regardless of CAD or HTN -Tobacco use -Obesity -High serum cholesterol

How are unstable and stable angina different?

-Change in usual pattern -New in onset -*Occurs at rest -Has a worsening pattern -UA is unpredictable and represents a medical emergency

=Assessment Findings/ what do you see during Pulmonary Embolism=

-Chest pain -Sense of impending doom -Tachycardia -Dyspnea -Anxiety/restlessness -Decreased breath sounds -Signs of circulatory collapse -Decreased SaO2 -Progressive decreasing LOC, caused by shock

High Risk Indicators of pneumonia

-Chronic illnesses -Diabetes -Sickle cell anemia -CHF -Resides in ECF -Over 50 years old & infants 6 to 23 months old -Weakened immune system -Long term steroids -Cancer (chemo)

What are the 3 goals in treating primary HTN?

-Control BP -Reduce CVD risk factors -Promote Medication adherence

What are the three main goals of drug therapy with someone who has chronic HF and what drugs accomplish this?

-Correction of sodium and water retention and volume overload -Reduction of cardiac workload -Improvement of myocardial contractility Diuretic, RAAS inhibitors (ACE, ARB, Spironolactone) Vasodilator (Nitro/hydralazine) Beta blocker positive Inotrope

What are overall goals in the nursing planning for a patient with chronic HF?

-Decrease in symptoms (e.g., shortness of breath, fatigue) -Decrease in peripheral edema -Increase in exercise tolerance ***Compliance with the medical regimen -No complications related to HF

What 6 things are involved in the immediate collaborative management of ADHF?

-Decrease intravascular volume -Decrease preload -Decrease afterload -Improve gas exchange -Improve cardiac function -Reduce anxiety

What are the goals of therapy for patients with ADHF and chronic HF?

-Decrease patient symptoms -Improve LV function -Reverse ventricular remodeling -Improve quality of life -Decrease mortality and morbidity

What nutritional recommendations can be made to high risk CAD patients?

-Decrease saturated fat and cholesterol -Increase complex carbohydrates (fruit, whole grain, veg) -increase omega-3 fatty acid intake

How do you reduce anxiety in patients with ADHF?

-Distraction, imagery -Sedative medications (e.g., morphine sulfate, benzodiazepines)

What are the classifications of drugs used to treat HTN?

-Diuretics -Adrenergic inhibitors -Vasodilators -ACE-inhibitors -Angiotensin blockers -Ca Channel blockers

What is the line of treatment for a patient with confirmed MI?

-Emergent PCI In most severe cases: CABG

What are the clinical manifestations of chronic heart failure?

-Fatigue -Dyspnea -Tachycardia -Edema -Nocturia -Skin changes -Behavior changes -Chest pain -Weight changes

What are other complications of an MI?

-HF -Papillary muscle dysfunction -ventricular aneurysm -Acute pericarditis

What are diagnostic studies for angina?

-Health history/physical examination -Laboratory studies -12-lead ECG -Chest x-ray -Echocardiogram -Exercise stress test -Cardiac cath/angiography

What are the diagnostic studies for HF?

-History and physical examination -Chest x-ray -ECG -Lab studies (e.g., cardiac enzymes, BNP) -Hemodynamic assessment -Echocardiogram -Stress testing -Cardiac catheterization -Ejection fraction

What are modifiable risk factors of CAD?

-Hyperlipidemia -HTN -smoking -sedentary lifestyle -obesity -diabetes

What are the actions for someone hospitalized with a hypertensive crisis?

-IV drugs titrated to MAP -Monitor CV and renal function -Neuro checks -Determine cause -Education to avoid future crisis

How can you decrease afterload in a patient with ADHF and why would we want that?

-IV sodium nitroprusside (Nipride) -Morphine sulfate -Nesiritide (Natrecor) *it will improve CO and decrease pulmonary congestion

What are the most common complications of heart transplant?

-Infection is the primary complication, followed by -acute rejection, in the first year after transplantation. -Malignancy (especially lymphoma) and coronary artery vasculopathy are major causes of death after the first year.

What are the risk factors for SCD?

-Left ventricular dysfunction (EF 30%) -Ventricular dysrhythmias following MI

What are the emergent things to do for someone with ACS?

-MONAB -ECG monitoring -Monitor VS and pulsox -Bedrest and limitation of activity for 12-24 hours -Possible PCI or Fibrinolytic therapy

Molar mass (definition/calculating)

-Mass (in grams) of 1 mol of substance -Molar mass of compound found by adding atomic masses of each element

Atomic mass (unit/location)

-Measured in amu (atomic mass unit) -Found using periodic table

What is important patient education for patient with HF?

-Medication adherence -Daily weights -Know when drugs (e.g., digitalis, b-adrenergic blockers) should be withheld and reported to health care provider. (take pulse for 1 full minute, withhold if pulse below 60) -Home BP monitoring -Signs of hypokalemia and hyperkalemia if taking diuretics that deplete or spare potassium

What are 5 suggestions that we can make to patients with HTN?

-Nutrition -Drug therapy -Exercise -Home BP monitoring -Quit Smoking

What is the order of action for acute intervention of an MI?

-O2 -VS/Pulsox -ECG -Pain relief (NTG then MSO4) -Auscultate heart sounds listening for S3 or S4

What are the clinical manifestations of an MI and why?

-Pain - ischemia -SNS stimulation (ashen, clammy, and cool skin, diaphoresis) -CV problems (BP and HR elevated at first. BP lowered later due to decreased cardiac output, crackles, Jugular venous distention, Abnormal heart sounds, S3 or S4, new murmur) -N/V- from severe pain -Fever up to 100.4 as the body's normal response to the inflammatory process from cell death

What are complications of heart failure?

-Pleural effusions -Dysrhythmias (afib most common) -Left ventricular thrombus (causes emboli) -Hepatomegaly (Especially RV failure) -Renal failure

What are 4 things that affect cardiac output?

-Preload (right side) -Afterload (left side) -Myocardial contractility -Heart rate

Nursing care for cardiac transplants focused on what? Read

-Promoting patient adaptation to the transplant process -Monitoring cardiac function -Managing lifestyle changes -Providing relevant teaching

Someone after CABG will have what things on/in/coming out of them after surgery?

-Pulmonary artery catheter for measuring CO, other hemodynamic parameters -Intraarterial line for continuous BP monitoring -Pleural/mediastinal chest tubes for chest drainage -Continuous ECG monitoring to detect dysrhythmias (esp. atrial dysrhythmias) -Ventilator (Extubation within 12 hours) -Epicardial pacing wires (pacemaker) for emergency pacing of the heart -Foley -NG tube for gastric decompression

What are the nursing goals for someone experiencing an MI? Read them

-Relief of pain -Preservation of myocardium -Immediate and appropriate treatment -Effective coping with illness-associated anxiety -Participation in a rehabilitation plan -Reduction of risk factors -Health promotion

How will you evaluate a patient's management of HF?

-Respiratory status -Fluid balance -Activity tolerance -Anxiety control -Knowledge of disease process

Disadvantages of CABG?

-Sternotomy -Longer hospitalization -longer recovery

How can we improve gas exchange and oxygenation in a patient with ADHF?

-Supplemental oxygen -Morphine sulfate -Noninvasive ventilatory support (BiPAP)

What are the clinical manifestations of acute decompensated heart failure (ADHF) (heart failure in an acute stage)?

-The patient usually is anxious, pale, and possibly cyanotic. -The skin is clammy and cold from vasoconstriction caused by stimulation of the SNS. -Cough with frothy, blood-tinged sputum -Breath sounds: Crackles, wheezes, rhonchi -Tachycardia -Hypotension or hypertension

What are the goals in treating someone with chronic HF?

-Treat the underlying cause and contributing factors. -Maximize CO. -Provide treatment to alleviate symptoms. -Improve ventricular function. -Improve quality of life. -Preserve target organ function. -Improve mortality and morbidity.

What three things are covered under ACS?

-Unstable Angina (UA) -non-ST elevated MI (NSTEMI) -ST elevated MI (STEMI)

HF is characterized by what 4 things?

-Ventricular dysfunction -Reduced exercise tolerance -Diminished quality of life -Shortened life expectancy

What are the 4 major contributors to primary HTN?

-Water/Na retention -Stress/increased SNS activity -Insulin resistance -Endothelial dysfunction

What are lifestyle modifications that are important to suggest to someone suffering from HTN?

-Weight reduction -DASH eating plan -Na reduction -Increase physical activity -Avoid tabacco -Reduce stress -Moderate alcohol consumption (M-2, F-1)

When are the two points that an older adult might consider a lifestyle change?

-When they are hospitalized from their CAD -When their symptoms are from CAD and not normal aging

What types of things decrease your oxygen supply?

-anemia -asthma -COPD -hypovolemia -hypoxemia -pneumonia -coronary artery spasm or thrombosis -dysrhythmia -HF -valve disorders

How can you decrease intravascular volume in a patient with ADHF?

-diuretics - furosemide (Lasix) -Sometimes they will do ultrafiltration to pull some of the fluid out

What are the different stages of atherosclerosis?

-fatty streaks -Fibrous plaque -Complicated lesion - most severe

What are HTN issues with older adults?

-isolated systolic HTN -Ausculatory gap -white coat HTN

Beta blockers are the what?

-olols

A diagnosis of diastolic HF is based on what?

-presence of pulmonary congestion, -pulmonary hypertension, -ventricular hypertrophy (due to aortic stenosis), -normal EF, -backs up into lungs

Ace inhibitors are what?

-prils

How can you decrease the venous return in a patient with ADHF?

-put them in high fowler's -IV nitro (vasodilate)

What are drugs that lower cholesterol?

-statins (Lipitor, Zocor) -bile sequestrants (Welchol) -decrease cholesterol absorption (Zetia)

What is the pain like with chronic stable angina?

-usually lasts 3-5 minutes and abates when the precipitating factor is relieved

What nursing action is necessary for the client with a flail chest?

. Encourage coughing and deep breathing.

inh limit foods like

. Foods such as cheese, dairy products, alcohol (red wine and beer), bananas, raisins, caffeine, and chocolate should be limited.

Asymptomatic proteinuria is an initial sign of

. Microscopic proteinuria should be monitored yearly in all clients with diabetes for over 5 years.

Dyspnea and cyanosis are associated with

...

Prep U Head & Neck dysfunction

...

The ABI test is a noninvasive test that compares the systolic blood pressure in the arm with that of the ankle.

...

Red blood cells should measure

0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field.

Severe peripheral artery disease would result in a score of

0.00 to 0.40

Severe peripheral artery disease would result in a score of

0.00 to 0.40.

Moderate peripheral artery disease would yield a score of

0.41 to 0.70.

Vesicles are elevated, sharply defined lesions that are usually less tha

0.5 cm in diameter and contain serous fluid.

Pustules are elevated lesions less than

1 cm in diameter containing purulent material; examples include impetigo and acne lesions.

For maximum absorption, the client should take this drug at least

1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides.

Find the empirical formula of a compound by...

1- Change elements' % to g 2- Use molar masses to convert to mol 3- Divide all by the smallest # 4- Put those #s into the forrmula as subscripts *if the # ends up being a decimal (2.5) multiply all #s by 2*

Drug Resistance 1. Occurs when treatment is inadequate due to: 2. Or what else can cause it ?

1. Non-adherence to prescribed drug regimen Malabsorption Inadequate dosage Incorrect medication 2. Occurs when a susceptible host is infected with drug-resistant organisms. The growing incidence of this is an alarming world-wide health problem.

=Pneumothorax Etiology & Pathophysiology= 1. Risk factors:

1. -Smoking -Family history -Trauma -Pulmonary disease

Pulmonary Embolism Management 1. Medications =Supportive care= 2. Administer what ? 3. what position should you place them in 4. If patient goes into shock, what kind of med do you give? 5. If patient goes into heart failure, what kind of med do you give ? 6.___________ hygiene 7. Provide_____________support ? 8. what can you put on their legs 9. the patient may need ?

1. Heparin, LMWH, then warfarin Fibrinolytic agents, like tPA 1st 3-4 hours) Thrombolytic agents--streptokinase 2. O2, how depends on ABG's 3. High Fowler's position 4. vasopressors 5. diuretics 6. Pulmonary 7. emotional 8. Teds/P-Cuffs 9. Surgery

Nursing Process TB 1. Assess for 2. Nursing diagnoses 3. Goals

1. Productive cough Night sweats Afternoon temperature elevation Weight loss 2. Ineffective health maintenance Activity intolerance Ineffective breathing pattern Imbalanced nutrition: Less than body requirements Noncompliance 3. Comply with therapeutic regimen Have no recurrence of disease Have normal pulmonary function Take appropriate measures to prevent spread of disease

Treating Culture-Positive Pulmonary TB 1. The continuation phase must be extended to ____________for patients with______________ and when sputum specimens are still positive after____months of treatment. 2. Use _______________once/week in the continuation phase for selected patients 3. To prevent acquired resistance in patients with advanced HIV, do what ? 4. * Total length of treatment

1. 7 months..... cavitary disease...... 2 months of treatment * 2. INH, Rifapentine 3. , use daily or thrice-weekly regimens 4. * 9 months rather than 6 months

Pneumonia 1. _________ or __________ 2. One or..... 3. Caused by.... 4. ____________ process 5. 4th leading cause of..... 6. Risk factors.....

1. Acute or chronic 2. both lungs 3. bacteria, viruses, or chemical irritants 4. Inflammatory. 5. death among elderly 6. increased age, alcoholism, CHF, malignancies, immunosuppression

Chest Trauma 1. ________or_____________trauma 2._____________ fractures 3. Flail_______ 4.___________ contusion 5. this can cause it by means of Spontaneous, simple, Traumatic or Tension

1. Blunt or Penetrating 2. Sternal, rib 3. Flail chest 4. Pulmonary 5. ****Pneumothorax***** -Spontaneous or simple -Traumatic -Tension pneumothorax

pneumonia Pharmacology 1. if organism not identified, what meds do you use? 2. what route should meds be given in the outpatient setting? a) give examples of the outpatient meds ? 3. what route should meds be given to hospitalized patient b) give examples of these meds ?

1. Broad spectrum 2. Oral in outpatient setting a) Macrolides recommended—Biaxin, Zithromax 3. IV in hospitalized patient b) A quinolone—one of the "floxin's" or a beta-lactam agent—one of the "cef's" (cefuroxime). For MRSA, add vancomcin -other medications Antipyretics Analgesics Supportive meds—decongestants, cough medicines, expectorants, inhalers, bronchodilators

=Nursing care of chest tubes= 1. Check tubing for_______, check connections, keep it _______, make sure it's stabilized against being _______ 2. Keep below... 3. ________________when changing drainage apparatuses 4. Check site....

1. Check tubing for kinks, check connections, keep it straight, make sure it's stabilized against being dislodged 2. level of patient's chest 3. Clamp briefly 4. q shift, dressing changes as ordered Know institution policy if disconnected

1. Atelectasis....what is it? 2. what does it Cause ? 3. what are symptoms ? 4. Best treatment is ? 5. Management includes ?

1. Collapse of alveoli 2. inadequate lung expansion, localized airway obstruction, inadequate surfactant, increased elastic recoil 3. dyspnea, cough, increased HR and respirations, increased work of breathing, decreased O2 sat 4. prevention 5. methods to improve ventilation

What are the four major types of pneumonia?

1. Community Acquired Pneumonia (CAP) 2. Hospital Acquired Pneumonia (HAP) 3. Pneumonia in the Immunocompromised Host 4. Aspiration Pneumonia

Assessment Findings with pneumonia 1. __________ with percussion 2. Sudden onset of..... 3. this happens with (bacterial) pneumonia ? 4. Chest pain aggravated by.... 5. Dyspnea....along with what ? 6. Increased.... 7. Abnormal...... 8_________ sputum 9. ___________and ___________

1. Dullness 2. fever greater than 100F (37.8 C) 3. Shaking and chills (bacterial) 4. coughing 5. Dyspnea, respiratory grunting, and nasal flaring 6. respiratory rate, tachycardia 7. lung sounds, diminished 8. Purulent 9. Anxiety and agitation

Pneumothorax Clinical Manifestations 1..Dyspnea* 2. Tracheal deviation...... 3. Diminished...... 4. Percussion of...... 5. Unequal..... 6. Diminished __________expansion—simple Pneumothora 7. _________often first symptom in simple Pneumothora 8. if severe

1. Dyspnea 2. toward unaffected side with tension Pneumothora 3. breath sounds with tension Pneumothora 4. dullness on affected side 5. chest expansion with tension Pneumothora 6. chest 7. Pain 8. Tachypnea/tachycardia/air hunger/diaphoresis/use of accessory muscles.

Pneumococcal vaccine 1. used in what population ? 2. Important because of.... 3. _____to ____% effective 4. Can be given at same time as...... 5. Given every ____years.

1. For at-risk population: over 65, chronic disease, like diabetes, resides in ECF. 2. increasing drug-resistant S. pneumoniae rate. 3. 50-80% 4. influenza vaccine. Medicare covers it, and other insurances usually do (somewhat expensive). 5. five years.

Collaborative Care TB 1. _______________ not necessary for most patients. -Active disease 2. Four drugs are used in initial phase for maximum effectiveness....which ones are they. Directly observed therapy (DOT) 3. Drug therapy may last..... 4. Meds may cause what ?

1. Hospitalization.... Active disease 2. INH, rifampin, pyrazinamide, and Myambutol. Directly observed therapy (DOT) 3. 4-7 months, prophylaxis 6-12 months 4. liver failure

HAP occurs when at least one of three conditions exists. What are the three conditions?

1. Host defenses are impaired 2. An inoculum of organisms reaches the patient's lower respiratory tract and overwhelms host defenses 3. A highly virulent organism is present

Clinical Manifestations of viral pneumonia =Viral= 1.__________ fever 2.________________ cough 3._____________white count 4.__________________ on Chest X ray

1. Low grade 2. Non-productive 3. Normal/low 4. Minimal changes

Isoniazid (INH) 1. Action: bactericidal - highly active against, what ? 2. Dose: Adult - __to___ mg/kg ____ mg QD (max) 3. Pediatric - ___to ___ mg/kg 4. Interactions: 5. Major adverse effects:

1. M. tuberculosis 2. 5-15 mg/kg 300 mg QD (max) 3. 10-15 mg/kg 4. Phenytoin 5. hepatitis, GI distress, rash, peripheral neuropathy, elevated LFT's, mild CNS effects

TB 1. Infectious disease caused by.... 2. Involves what parts of the body ? 3. High rates of TB with.... 4. Multidrug-resistant what?

1. Mycobacterium tuberculosis 2. Lungs, larynx, kidneys, meninges, bones, adrenal glands, lymph nodes 3. HIV infection 4. strains of M. tuberculosis

Hospital acquired pneumonia (HAP) 1. whats another name for it ? 2. when do Symptoms occur ? HAP Occurs when what happens? 3. Host... 4. Inoculum of ...... 5. Highly.......

1. Nosocomial 2. more than 48 hours after admission -VAP . Occurs when 3. defenses are impaired 4. organisms reaches the lower tract and overwhelms host's defenses 5. virulent organism is present

Percussion Notes and Their Meaning 1. Flat or Dull...... 2. Resonant.... 3. Hyperresonant.......

1. Pleural Effusion or Lobar Pneumonia 2. Healthy Lung or Bronchitis 3. Emphysema or Pneumothorax

Rifampin (RIF) 1. Action: 2. Dose: Adult- ___ mg/kg ____ mg QD (max) 3. Pediatric - ___to ____ mg/kg 4. Interactions: 5. Major adverse effects: 6. Note: RIF may result in body fluid....

1. bactericidal 2.10 mg/kg 600 mg QD (max) 3. 10-20 mg/kg 4. oral contraceptives, seizure medications, anticoagulants, methadone, steroids, protease inhibitors (PIs) 5. gastrointestinal upset, hepatitis, skin rash, bleeding problems, flu-like symptoms 6. discoloration (red/orange) and permanent discoloration of contact lenses

Ethambutol (EMB) 1. Action 2. Dose: ____to ____mg/kg for children and adults 3. Interactions 4. Major adverse effects

1. bacteriostatic 2. 15-25 mg/kg 3. oral contraceptives, seizure medications, and anticoagulants 4. optic neuritis—may cause decreased visual acuity and/or decreased red-green color discrimination

community acquired Pneumonia (CAP) 1. Occurs in 2. some organisms that cause it are ? 3. whats Identified in approximately 50% of cases

1. community setting or within first 48 hours after hospitalization 2. S.Pneumoniae H. influenzae Legionella 3. Gram negative rods Identified in approximately 50% of cases

=Chest Tubes= 1. Used to..... 2. Reestablishes...... 3. Facilitates...... 4. Restores normal....

1. drain fluid, blood, or air 2. negative pressure 3. lung expansion 4. intrapleural pressure

INH, RIF, PZA, and EMB 1. All patients should be started on these 4 drugs, until what ? 2. Initiation phase (first___weeks) using 4 drugs 3. Continuation phase...... 4. Treatment may need to be extended for patients whose sputum does not do what ?

1. drug susceptibility results are known 2. (first 8 weeks) using 4 drugs 3. (next 4 months of a 6-month pansensitive regimen) using INH and RIF 4. does not convert within 2 months or if there is cavitation on CXR after 2 months

Types of Pneumothorax Injuries = Closed (simple)= 1. No.... 2. Most common is _______________________, rupture of ______________ on the visceral pleura, cause unknown. 3. Can also be from..... =Open (traumatic)= 4. Air enters from a..... 5. Often called a.... 6. Needs to be covered immediately with a.........

1. external wound 2. spontaneous pneumothorax............. small blebs 3. mechanical vent., central line insertion, injury from broken ribs 4. wound—gunshots, knives, etc 5. sucking chest wound 6. vented dressing—taped on 3 sides, with 4th side left open. (called a flutter dressing)

Clinical Manifestations of Bacterial pneumonia =Bacterial = 1. High _____ 2.____________ cough 3._________ white count 4.____________ on chest X ray

1. fever 2. Productive 3. Elevated 4. Infiltrates

Pulmonary Embolism Risk Factors 1. Prolonged ______________ 2. Chronic....... 3. what conditions of the heart can cause it ? 4. what kind of surgeries can cause it ? 5. can Pregnancy cause it ? 6. what bad habit can cause it? 7. Most common sites:

1. immobility 2. lung disease 3. Heart failure/atrial fibrillation 4. Lower extremity surgery/abdominal surgery/trauma 5. yes 6. Smoking 7. Legs Pelvic, hepatic, renal veins Right side of heart Upper extremities

Pleural Conditions 1. Pleurisy... 2. Pleural effusion.... 3. Empyema..... 4. Pulmonary edema.....

1. inflammation of the parietal and visceral pleura 2. fluid in the pleural space 3. prurulent fluid accumulation in the pleural space 4. accumulation of fluid in alveolar spaces and lung tissue.

Actions of Anti-Tuberculosis Medications 1. Bacteriostatic agents, how do they work ? 2. what do they do to bacteria ?

1. inhibit the growth of bacteria 2. destroy bacteria

Pneumothorax 1. Injury to chest wall/lungs that interfere with...... 2. Normal intrapleural pressure is ___________ compared to atmospheric pressure 3. Pressure difference is stimulant for ________ 4. Disruption of the _________ causes air accumulation within______________ 5. A pneumothorax Causes the lung to_________?

1. inspiration, gas exchange, or expiration 2. negative 3. breathing 4. Disruption of the pleura causes air accumulation within pleural space 5. collapse

Planning & Implementation (TB) 1. TB suspects must be reported to.... 2. Upon discharge, patient's care should continue to be... 3. All patients should have monthly what collected

1. local or state health department -This ensures safe and effective treatment after discharge as well as initiates contact investigation for family, friends, co-workers at risk 2. managed by an experienced TB provider 3. sputum collected for smear, culture, and drug susceptibility

Contributing Factors to pneumonia 1. Inability to do what ? 2. Aspiration ___________ 3. Frequent__________or ___________ 4. Depressed what ? 5. Prolonged........ 6. __________ providers!!

1. move pulmonary secretions 2. Aspiration pneumonia 3. ETOH intoxication or Cigarette smoking 4. cough reflex 5. immobility 6. Healthcare providers

Flail Chest 1. Caused from what ?

1. multiple rib fractures, causing unstable thoracic cage

Nursing Management pneumonia 1. Administer..... 2._____________ control measures 3. Prevent....... 4. Positioning 5. Nutrition 6. Promote..... 7. Promote _________ hygiene

1. prescribed medications 2. Promote infection control measures 3. aspiration pneumonia in a client receiving tube feeding 4. Positioning 5. Nutrition 6. fluid intake 7. bronchial

Priority Patients -Candidates for DOT 1. Smear-positive ________ TB 2. Previous treatment for..... 3. __________ illness 4. __________and___________ 5. ___________________ (current or prior) 6. ____________resistance 7. _____ infection 8. Previous...... 9. __________ impairment

1. pulmonary TB 2. active TB or LTBI 3. Psychiatric 4. Children and adolescents 5. Substance abuse 6. drug 7. HIV 8. nonadherence to therapy 9. Memory

Pulmonary Embolism 1. Obstruction of 1 or more....... 2. Originates in.....

1. pulmonary arteries by a thrombus or thrombi 2. the venous system/right side of the heart

Actions of Anti-Tuberculosis Medications 1. Tubercle bacilli killed..... 2. Combination _____________ minimizes potential for drug resistance 3. Sufficient length of treatment does what ? 4. Patient is.....

1. rapidly 2. chemotherapy 3. sterilizes host tissues 4. cured with very small likelihood of relapse

Etiology/ Patho TB 1. Replicates.... 2. If cellular immune system is activated 3. Favorable environments for growth

1. slowly and spreads via the lymphatic system 2. -Tissue granuloma forms -Contains the bacteria and prevents replication and spread of disease 3. -Upper lobes of lungs -Kidneys -Epiphyses of bone -Cerebral cortex -Adrenal glands

Patient Education =Prepare patient for continued treatment after discharge:= 1. Teach how to obtain and care for what ? 2. Cover nose and mouth with what ? 3. Hand washing after handling what ? 4. Reinforce importance of..... 5. Reinforce importance of uninterrupted______________? 6. Explain medications what 7. Ensure.... 8. Arrange for.....

1. sputum specimens 2. tissue when coughing, sneezing, or producing sputum 3. sputum-soiled tissues 4. hand washing and good hygiene 5. drug regimen 6. dosages, frequency, potential adverse effects, and evaluate patient's understanding 7. adequate supply of medications 8. follow-up visit and DOT if indicated

Planning & Implementation (TB) 1. Hospitalization of the patient with active TB requires..... 2. what kind of room should be used ? 3. Wear _______ mask, which can filter..... 4. Wear ______ and _____ 5. Provide client with ______ if necessary to transport

1. strict adherence to guidelines of respiratory isolation and use of an airborne infection isolation room 2. (negative-pressure room) 3. Wear N 95 mask—filter 95% particulates 4. gown and gloves 5. mask

=Tension Pneumothorax= 1. A rapid accumulation of air in......... 2. May result from...... 3. Can also be caused by...... 4. As pressure increases : what happens to the lungs and mediastinal? 5. ___________________ compromised 6. whats inserted to release the trapped air 7. There can also be....

1. the pleural space causing high intrapleural pressures and tension on the heart and great vessels. 2. open or closed pneumothorax 3. CPR, central line placement, bronchoscopy, barotrauma 4. lung collapses and mediastinal shift to the unaffected side 5. Cardiac output 6. large bore needle ! 7. hemothorax, usually occurring with pneumo. Called hemopneumothorax. Treatment the same, except stop the bleeding. (from trauma, anticoagulants, malignancy, PE)

Clinical Manifestations TB 1. Early stages........ 2. Later....... 3. Cough becomes frequent a) Produces white..... b) Hemoptysis..... 4. Acute symptoms (generalized flu symptoms)

1. usually asymptomatic 2. fatigue, malaise, anorexia, weight loss, low grade fevers, night sweats 3. a) white, frothy sputum b) is not common and is usually associated with advanced disease 4. -High fever -Chills -Pleuritic pain -Productive cough

TB Etiology and Pathophysiology 1, how is it Spread? =Spread= 2. Not by..... 3. Brief exposure..... 4. Transmission requires..... =Spread= 5. Inhaled bacilli...... 6. Multiply with.....

1. via airborne droplets when infected person Coughs, Speaks, Sneezes, Sings 2. hands or objects 3. rarely causes infection 4. close, frequent, or prolonged exposure Spread 5. pass down bronchial system and implant themselves on bronchioles or alveoli 6. no initial resistance

Urine specific gravity normally ranges from

1.002 to 1.035, making this client's value normal.

The faceplate opening should be no more than

1/8? to 1/6? larger than the stoma

A fetus normally move

10 to 12 times per hour.

A client with peptic ulcer disease must begin triple medication therapy. For how long will the client follow this regimen?

10 to 14 days

The therapeutic serum theophylline concentration ranges from

10 to 20 mcg/ml.

Normally, pressure in the anterior chamber of the eye remains relatively constant at

10 to 20 mm Hg

A sign of digitalis toxicity is atrial fibrillation, sometimes with a heart rate of more than

100 bpm, nurse is to evaluate the cardiac rhythm of the client. Tachycardia can be a sign of digitalis toxicity.

A maternal hemoglobin level below

11 g/dl is considered anemia

What blood pressure is prehypertensive?

120-139/80-89

quad position

30 degrees

After supratentorial surgery, the nurse should elevate the client's head

30 degrees to promote venous outflow through the jugular veins.

Because AFP levels are usually highest at

15 to 18 weeks' gestation, this is the optimum time for testing.

The nurse should instruct the client to take Propantheline bromide

30 minutes before meals and at bedtime to reduce GI motility, thus relieving spasticity.

4 stages of labor

1st stage is latent active transition 2nd stage is pushing 3rd stage is placenta 4 th stage is postpartum

An individual is considered obese when his or her BMI is:

30-39; Person's with BMI of less than 24 are at risk for poor nutritional status Persons with BMI of 25 to 29 are overweight. BMI greater than 40 are extremely obese

Meperidine is contraindicated in clients with acute pain lasting more than

2 days and in those for whom large daily doses (more than 600 mg) are needed. It would be inappropriate to urge the client to take the acetaminophen and codeine to prevent addiction.

At birth, visual acuity is estimated at approximately

20/100 to 20/150, but it improves rapidly during infancy and toddlerhood.

210-

216

finish

226

How long will someone who has had a CABG be in the ICU?

24-36 hours

Disconnect the syringe and pull the plunger back to the

2cc mark Attach the syringe to the end of the feeding tube.

In a female client, the nurse should advance an indwelling urinary catheter

2″ to 3″ (5 to 7.5 cm) into the urethra

pacemaker care Avoid lifting anything heavier than

3 lb.

What is the formula for blood pressure?

Cardiac output multiplied by systemic vascular resistance

The correct procedure for wound irrigation includes using

35-ml syringe and 19-French angiocatheter to provide irrigation of about 8 pounds of pressure per square inch to remove necrotic tissue without tissue damage.

Serum CK-MB levels can be detected

4 to 6 hours after the onset of chest pain. These levels peak within 12 to 18 hours and return to normal within 3 to 4 days.

Terbutaline must be taken every

4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor.

How long does it take for full thickness MI?

4-6 hours

Daily oral doses of isoniazid and rifampin for 6 months to 2 years are appropriate for the client with

active tuberculosis.

Normal urine pH is

4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation.

nurse is receiving report from the emergency room regarding a new client being admitted to the medical-surgical unit with a diagnosis of peptic ulcer disease. The nurse expects the age of the client will be between

40 and 60 years

A nasal cannula can't deliver oxygen concentrations above

44%.

abg apply pressure for

5 minuets and 15 minutes if anticoagulant therapy in the arm but femoral artery you keep pressure for 15 minutes

if carrier hbas and has sickle cell hbs then

50 percent chance of child getting it

The client should receive a fluid bolus of

500 ml of normal saline solution.

Measurements between the

5th and 95th percentiles are considered normal

How long does it take for scar tissue to replace necrotic tissue after an MI?

6 weeks - far less compliant afterward

Mole conversions...1 mol=

6.022 x 10²³ representative particles (Avogadro's #) 22.4 L Atomic mass in grams Molar mass of an element or compound

Avogadro's number

6.022x10(23) units of that substance

What is a normal ejection fraction?

60%

In a male client, the nurse should advance the catheter

6″ to 8″.

To avoid a falsely elevated serum digoxin level, a nurse shouldn't draw a blood sample for at least

8 hours after administering oral digoxin and at least 6 hours after administering I.V. digoxin

The nurse should instruct a client receiving a sulfonamide such as co-trimoxazole to drink at least eight

8-oz glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum, and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A) Hyperthermia related to infectious illness B) Ineffective thermoregulation related to chilling C) Ineffective breathing pattern related to pneumonia D) Ineffective airway clearance related to thick secretions

A

Which of the following physical assessment findings in a patient with a lower respiratory problem best supports the nursing diagnosis of ineffective airway clearance? A) Basilar crackles B) Respiratory rate of 28 C) Oxygen saturation of 85% D) Presence of greenish sputum

A

Isolation for 2 to 4 weeks is warranted for a client with

active tuberculosis.

A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection?

A 17-year-old who is sexually active with numerous partners

Signs of hip prosthesis dislocation include:

acute groin pain in the affected hip,

Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained. Correct Answer: D

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? A. Review the client's medical record for an advance directive. B. Determine if a do-not-resuscitate prescription has been obtained. C. Document that the client is being discharged against medical advice. D. Evaluate the client's mental status for competence to refuse treatment.

Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the health care team (D). (A) uses language (i.e. 'incision') that could create anxiety for the child. Four-year-olds are in the Initiative vs. Guilt stage (Erikson's psychosocial development), and (B) contributes to guilt when the child hurts. (C) is not helpful because the child may associate being put to sleep with the postoperative throat pain and then become fearful of going to sleep. Correct Answer: D

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, Will it hurt to have my tonsils and adenoids taken out? Which response is best for the nurse to provide? A. It may hurt a little because of the incision made in your throat. B. It won't hurt because you're such a big boy. C. It won't hurt because we put you to sleep. D. It may hurt but we'll give you medicine to help you feel better.

Debilitating anginal pain can be decreased in some clients by the administration of beta-blocking agents such as nadolol (Corgard). Which client requires the nurse to use extreme caution when administering Corgard?

A 47-year-old kindergarten teacher diagnosed with asthma 40 years ago

A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be illicited after confirming the client's dietary history. Correct Answer: B

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client.

When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution. Correct Answer: D

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions.

Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B). Correct Answer: B

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. Help the client to accept the final stage of life. B. Assist and support the client in establishing short-term goals. C. Encourage the client to make future plans, even if they are unrealistic. D. Instruct the client's family to focus on positive aspects of the client's life.

An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a rattling sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent (D). Although culturally sensitive care should be observed throughout the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches. Correct Answer: D

A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? A. Ensure cultural customs are observed. B. Increase oxygen flow to 4L/minute. C. Auscultate bilateral lung fields. D. Inform the family that death is imminent.

Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. Correct Answer: A

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown.

To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the wound bed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface. Correct Answer: C

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A. Hydrogel. B. Exudate absorber. C. Wet to moist dressing. D. Transparent adhesive film.

A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium. Correct Answer: B

A client is demonstrating a positive Chvostek's sign. What action should the nurse take? A. Observe the client's pupil size and response to light. B. Ask the client about numbness or tingling in the hands. C. Assess the client's serum potassium level. D. Restrict dietary intake of calcium-rich foods.

Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts (D) about past health problems. (A and B) are time consuming, and may require the client's permission to access information about other hospitalizations. (C) may not produce the specific data needed. Correct Answer: D

A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A. Solicit information on hospitalization from the insurance company. B. Look up previous medical records from archived hospital documents. C. Ask the client to discuss previous hospitalizations in the last 5 years. D. Elicit specific facts about past hospitalizations with direct questions.

The nurse should implement (D), because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. Correct Answer: D

A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again.

Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests. Correct Answer: A

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A. Continue gabapentin. B. Discontinue ibuprofen. C. Add aspirin to the protocol. D. Add oral methadone to the protocol.

Biofeedback involves the use of various monitoring devices that help people become more aware and able to control their own physiologic responses, such as heart rate, body temperature, muscle tension, and brain waves. (D) is an accurate statement concerning its use for clients with Raynaud's disease. (A, B, and C) do not provide correct information about biofeedback. Correct Answer: D

A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? A. The responses to biofeedback have not been well established and may be a waste of time and money. B. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. C. Although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms. D. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

Serum albumin has a long half-life and is the best long-term indicator of the body's entry into a catabolic state following protein depletion from malnutrition or stress of chronic illness (C). While (A) is a good indicator of iron-binding capacity in a healthy adult, it is an unreliable measure in the client with a chronic illness. (B) has a short half-life, and is a sensitive indicator of recent catabolic changes, but it is not as effective as (C) in indicating long-term protein depletion. While (D) is a good indicator of a negative nitrogen balance, it is not as good an indicator of long-term protein catabolism as is (C). Correct Answer: C

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A. Transferrin. B. Prealbumin. C. Serum albumin. D. Urine urea nitrogen.

Which of the following diagnostic tests are done to determine suspected pituitary tumor?

A computer tomography scan CT-->A computed tomography or magnetic resonance imaging scan is done to detect a suspected pituitary tumor. Radiographs of the chest or abdomen are taken to detect tumors. Radiographs also determine the size of the organ and their location. However, measuring blood hormone levels helps determine the functioning of endocrine glands. A radioimmunoassay determines the concentration of a substance in plasma.

During change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first?

A continuous epidural infusion of morphine

What dietary recommendations should a nurse provide a patient with a lung abscess?

A diet rich in protein; For a patient with pleural effusion, a diet rich in protein and calories is pivoral. A charboydrate-dense diet or diets with limited fats are not advisable

The current availability of many herbal supplements lacks federal regulation, research, control and standardization in the manufacture of its purity and dose. Manufacturers that provide evidence of quality control (C), such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide. (A, B, and D) are misleading. Correct Answer: C

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A). Correct Answer: A

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A. Sensory pattern, area, intensity, and nature of the pain. B. Trigger points identified by palpation and manual pressure of painful areas. C. Schedule and total dosages of drugs currently used for breakthrough pain. D. Sympathetic responses consistent with onset of acute pain.

Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome. Correct Answer: A

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicoden) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A. Accused of diversion. B. Reported for stealing. C. Reported for a HIPAA violation. D. Accused of unprofessional conduct.

2nd stage syphillis

A flu-like illness, a feeling of tiredness and loss of appetite, accompanied by swollen glands (this can last for weeks or months). A non-itchy rash covering the whole body or appearing in patches. Flat, warty-looking growths on the vulva in women and around the anus in both sexes. White patches on the tongue or roof of the mouth. Patchy hair loss.

normal findings in tpn

A gradual weight gain is to be expected as the client's nutritional status improves.

Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members. Correct Answer: D

A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies.

Left untreated a HTN emergency can lead to what?

A hypertensive emergency - severe HTN with acute impairment of one or more organ systems (CNS, CV, renal) that can result in irreversible organ damage. CAN CAUSE: -hypertensive encephalopathy -Cerebral hemorrhage -ARF -MI -HF with pulmonary edema

diet for cirrhosis

A low-protein and high-carbohydrate diet is recommended.

Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. Correct Answer: A, B, C, E

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A. Snack of potato chips, and diet soda. B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C. Breakfast of eggs, bacon, toast, and coffee. D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E. Bedtime snack of crackers and milk.

Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained. Correct Answer: A

A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration.

The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). Correct Answer: D

A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A. Use distraction techniques during times of spiritual stress and crisis. B. Reassure the client that his faith will be regained with time and support. C. Consult with the staff chaplain and ask that the chaplain visit with the client. D. Use reflective listening techniques when the client expresses spiritual doubts.

Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider (B). (A) is insufficient to implement the client's request without legal consequences. Although (C and D) provide legal protection of the client's wishes, the present request needs additional action. Correct Answer: B

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? A. Document the client's request in the medical record. B. Ask the client if this decision has been discussed with his healthcare provider. C. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

A macrobiotic diet is high in whole-grain cereals, vegetables, sea vegetables, beans, and vegetarian soups, and the client needs essential amino acids to provide complete proteins to heal the infected wound. Although a macrobiotic diet contains no source of animal protein, essential amino acids should be obtained by combining plant (incomplete) proteins to provide complete (all essential amino acids) proteins (B) for anabolic processes. (A, C, and D) do not provide the client with food choices consistent with a macrobiotic diet and protein needs. Correct Answer: B

A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A. Low fat and low sodium foods. B. Combination of plant proteins to provide essential amino acids. C. Limited complex carbohydrates and fiber. D. Increased amount of vitamin C and beta carotene rich foods.

When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs when orthostatic hypotension occurs. Correct Answer: B

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A. Bradycardia. B. Increase in pulse rate. C. Peripheral vasodilation. D. Increase in cardiac output.

Many female Muslim clients are very modest and prefer to receive personal care from another female because of their religious and cultural beliefs. The most culturally sensitive response is for the male nurse to ask a female colleague to perform this task (B). (A and D) are less respectful of the client's cultural and spiritual preferences. (C) delays the client's care. Correct Answer: B

A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? A. May I ask your daughter to help you with your personal hygiene? B. I will ask one of the female nurses to bathe you. C. A staff member on the next shift will help you. D. I will keep you draped and hand you the supplies as you need them.

(A) provides the best schedule, because QID means four times per day. (B, C, and D) provide incorrect dosages. Correct Answer: A

A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 0800, 1200, 1600, 2000. B. 800. C. Every other day at 0800. D. 0800, 1200, 1600, 2000, 0000, 0400.

Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is describe by Erikson as the developmental stage of generativity (A), and is characteristic of middle adulthood. (B, C and D) are not stages of this age group according to Erickson's psychosocial developmental theory. Correct Answer: A

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom.

What is the definition of pneumonitis?

A more general term that describes an inflammatory process in the lung tissue that may predispose a patient to or place a patient at risk for microbrial invasion.

Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the family's needs to care for the client and are not the best ways to cope with the nurse's frustration. Although (D) may be an option, examining one's cultural differences allows the nurse to cope, empathize, and implement culturally specific interventions pertaining to the needs of the client and the family. Correct Answer: B

A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client.

The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may cause increased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B). Correct Answer: C

A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa.

The nurse should deal with the issue immediately and explain that a client's records are the property of the hospital and cannot be removed (D), even with the client's permission (C). Next, the clinical instructor should be notified (B)so that all students can be educated regarding copying and removing clinical records from the healthcare agency. The nursing supervisor (A) should also be alerted to ensure appropriate supervision of students as well as protection of client information. Correct Answer: D

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical. What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students. B. Notify the student's clinical instructor of the situation. C. Ask the student if permission was obtained from the client. D. Explain that the records are hospital property and may not be removed.

A female client, aged 82, visits the clinic for a blood pressure (BP) check. Her hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about her blood pressure medicine?

A possible adverse effect of blood pressure medicine is dizziness when you stand.------>A possible adverse effect of all antihypertensive drugs is postural hypotension, which can lead to falls. Teaching should include tips for managing syncope and dizziness. You would not teach the client to take the medicine on an empty stomach. (less)

daunorubicin (DaunoXome)

A red, swollen I.V. site indicates possible infiltration.

The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery (C). (A) is injury to economics and dignity, such as invasion of privacy or defamation of character. This is not an incident of failure to respect the client's autonomy (B). An unintentional tort (D) is an act in which the outcome was not expected, such as negligence or malpractice. Correct Answer: C

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A. A quasi-intentional tort because a similar mistake can happen to anyone. B. Failure to respect client autonomy to choose based on intentional tort law. C. Assault and battery with deliberate intent to deviate from the consent form. D. An unintentional tort because the client benefited from having the myelogram.

The nurse should first assess what the client desires (C). (A) is somewhat judgmental and attempts to solve the problem for the client without eliciting the client's feelings. Though a referral to the social worker (B) may be indicated, the nurse should first offer support. Time is likely to help the client cope with this news (D), but the nurse should first provide support and assess what the client wants to see happen with her children. Correct Answer: C

A single mother of two teenagers, ages 16 and 18, was just told that she has advanced cancer. She is devastated by the news, and expresses her concern about who will care for her children. Which statement by the nurse is likely to be most helpful at this time? A. Your children are old enough to help you make decisions about their futures. B. The social worker can tell you about placement alternatives for your children. C. Tell me what you would like to see happen with your children in the future. D. You have just received bad news, and you need some time to adjust to it.

What is the process of TB infection?

A susceptible person inhales mycobacterium bacilli and becomes infected. The bacteria are transmitted through the airways to the alveoli, where they are deposited and begin to multiply.

The nurse is preparing a teaching plan for healthy adults. Which individual is most likely to maintain optimum health?

A teacher whose blood glucose levels average 126 daily with oral antidiabetic drugs

botulism For breathing trouble,

A tube may be inserted through the nose or mouth into the windpipe to provide an airway for oxygen. You may need a breathing machine.

The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants the most immediate intervention by the nurse?

A unilateral pupil that is dilated and nonreactive to light

What is SARS?

A viral respiratory illness cause by a coronavirus, called SARS-associated cornavirus.

men chlyamydia

A white/cloudy and watery discharge from the penis that may stain underwear; a burning sensation and/or pain when passing urine; pain and swelling in the testicles.

To promote airway clearance in a patient with pneumonia, the nurse instructs the patient to do which of the following (select all that apply)? A) Maintain adequate fluid intake B) Splint the chest when coughing C) Maintain a high Fowler's position D) Maintain a semi-Fowler's position E) Instruct patient to cough at end of exhalation

A, B, E

When admitting a 45-year-old female with a diagnosis of pulmonary embolism, the nurse will assess the patient for which of the following risk factors (select all that apply)? A) Obesity B) Pneumonia C) Hypertension D) Cigarette smoking E) Recent long distance travel

A, C, D, E

During admission of a patient diagnosed with non-small cell carcinoma of the lung, the nurse questions the patient related to a history of which of the following risk factors for this type of cancer (select all that apply)? A) Asbestos exposure B) Cigarette smoking C) Exposure to uranium D) Chronic interstitial fibrosis E) Geographic area in which he was born

A,B,C

Which content about self-care should the nurse include in the teaching plan of a client who has genital herpes? (Select all that apply.)

A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condoms to avoid transmission to others. D. Warm sitz baths may relieve itching.

As a result of cholinergic crisis, the muscles stop responding to the bombardment of

ACh, leading to flaccid paralysis, respiratory failure, increased sweating, salivation, bronchial secretions along with miosis.

What role does endothelin play in increasing the workload of a heart in HF?

ADH, catecholamines, and angiotensin II stimulate the production of endothelin from the vascular endothelial cells. It's a vasoconstrictor and also increases the heart's contractility and it hypertrophies the heart.

Bleeding and infection are the major complications and causes of death for clients with

AML.

The intestinal lumen and the blood supply to the intestine are obstructed, causing an

acute intestinal obstruction. Without immediate intervention, necrosis and gangrene may develop

Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?

Incorporate physical exercise as tolerated into the daily routine.

What is the most common cause of pulmonary edema?

acute left ventricular failure secondary to CAD.

Six days after a heart-lung transplant, the patient develops a low-grade fever and a decreased SpO2 with exercise. The nurse recognizes that this may indicate:

Acute rejection that can be treated with corticosteroids

During discharge teaching for a 65-year-old patient with COPD and pneumonia, which of the following vaccines should the nurse recommend that this patient receive? A) a. Staphylococcus aureus B) Haemophilus influenzae C) Pneumococcal D) Bacille-Calmette-Guérin (BCG)

C

Hypovolemic shock from fluid shifts is a major factor in

acute pancreatitis

When a patient with asthma is admitted to the emergency department in severe respiratory distress, the nurse anticipates that initial drug treatment will most likely include administration of

Aerosolized albuterol

High-carbohydrate foods meet the body's caloric needs during

acute renal failure

tpn complication

An elevated temperature can be an indication of an infection at the insertion site or in the catheter.

hospice care

Care is provided in the home, independent of physician is wrong the doctor still has input in hospice care

Serevent twice daily, it should not be used in

additional doses before exercise; twice daily is the maximum dosage.

Chronic interstitial fibrosis is associated with the development of

adenocarcinoma of the lung

Methylxanthine agents inhibit rather than stimulate

adenosine receptors

If a stent is put in place, what is the patient given?

Antiplatelets (Plavix, ASA) because plaque can build up on the stent. This is taken until the intimal layer of the vasculature grows over the stent *sometimes drug-eluting stents are put in place that prevent the overgrowth of the intimal layer, which is the main cause for stent restenosis

Which of the following clients is at highest risk for peptic ulcer disease?

Client with blood type O

What happens during a ballon angioplasty (PTCA)?

After catheterization (PCI) and location of the blockage, a balloon is inflated at the area of blockage to compress the atherosclerotic plaque, thus dilating the vessel. After this unfractionated or low molecular weight heparin is given to maintain the open vessel. Often a stent is put in place to resist vasoconstriction

STRESS TEST

Clients need to abstain from eating and drinking for only 4 hours before the test.

Which of the following digestive enzymes aids in the digesting of starch?

Amylase

In assessing a patient with pneumococcal pneumonia, the nurse recognizes that clinical manifestations of this condition include (select all that apply):

An abrupt onset of fever Productive cough with rust-colored sputum

When obtaining a health history from a patient at the clinic with suspected CAP, the nurse expects the patient to report:

An abrupt onset of fever and chills

What is acute tracheobronchitis?

An acute inflammation of the mucous membranes of the trachea and the bronchial tree.

What is pulmonary edema?

An acute, life threatening situation in which the lung alveoli become filled with serosanguineous fluid as a result of acute decompensated heart failure (ADHF)

In taking health histories of the following individuals, which client would have the greatest potential for development of head and neck cancer?

An alcoholic, tobacco-chewing auctioneer

The nurse is reviewing the routine medications taken by a client with chronic angle closure glaucoma. Which medication prescription should the nurse question?

An anticholinergic with a side effect of pupillary dilation

The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately?

Ability to spontaneously open the eyes before any tactile stimuli are given

men gonorrhea

Abnormal discharge from the penis (clear or milky at first, and then yellow, creamy, and excessive, sometimes blood-tinged).

A client reports to the clinic, stating that she rapidly developed headache, abdominal pain, nausea, hiccuping, and fatigue about 2 hours ago. For dinner, she ate buffalo chicken wings and beer. Which of the following medical conditions is most consistent with the client's presenting problems?

Acute gastritis

What is sudden cardiac death?

Abrupt disruption in cardiac function, resulting in loss of CO and cerebral blood flow Death usually within 1 hour of onset of acute symptoms

Postoperatively after a modified radical mastectomy, a client has an incisional drainage tube attached to Hemovac suction. The nurse determines the suction is effective when:

Accumulated serum and blood in the operative area are removed

Over secretion of GH- growth hormone

Acromegaly

A 74-year-old male client is admitted to the ICU with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent with settings of tidal volume (VT) 750 ml and intermittent mandatory ventilation (IMV) rate of 10. ABG results are pH 7.48; PaCO2 30; PaO2 64; HCO3 25; and FiO2 0.80. Which intervention should the nurse implement first?

Add 5 cm positive end-expiratory pressure (PEEP).

Hyposecretion of glucocorticoids, aldosterone, and androgens occur with

Addison's disease

Pituitary dysfunction can cause

Addison's disease, but this is not a primary disease process.

Under secretion of ACTH

Addisons

A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer?

Adenocarcinoma

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

Adminiistering 1 ampule of 50 % dextrose solution per physcian order

A hospitalized client is found to be comatose and hypoglycemic with a blood sugar of 50 mg/dL. Which of the following would the nurse do first?

Administer 50% glucose intravenously-->The unconscious, hypoglycemic client needs immediate treatment with IV glucose. If the client does not respond quickly and the blood glucose level continues to be low, glucagon, a hormone that stimulates the liver to release glycogen, or 20 to 50 mL of 50% glucose is prescribed for IV administration. A dose of 1,000 mL D5W over a 12-hour period indicates a lower strength of glucose and a slow administration rate. Checking the client's urine for the presence of sugar and acetone is incorrect because a blood sample is easier to collect and the blood test is more specific and reliable. An unconscious client cannot be given a drink. In such a case glucose gel may be applied in the buccal cavity of the mouth.

A central venous catheter has been inserted via a jugular vein and a radiograph has confirmed placement of the catheter. A prescription has been received for a stat medication, but IV fluids have not yet been started. What action should the nurse take prior to administering the prescribed medication?

Administer a bolus of normal saline solution

The patient with lung cancer needs to receive influenza vaccine and pneumococcal vaccines. The nurse will

Administer both vaccines at the same time in different arms

Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent. Correct Answer: A

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature.

A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority? a) Provide the client with oral penicillin that will last for 5 days. b) Provide emphatic oral instructions for the client. c) Ask an accompanying homeless friend to monitor the client's follow-up. d) Administer one intramuscular injection of penicillin.

Administer one intramuscular injection of penicillin. Explanation: If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy.

A client in the emergency department complains of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.---->Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the physician before completing the initial assessment is premature

A client with hypertension has been receiving ramipril (Altace) 5 mg PO daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830 the client's blood pressure is 120/70. What action should the nurse take?

Administer the dose as prescribed.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure?

Administering large doses of IV antibiotics as ordered

A client with a history of alcohol abuse comes to the emergency department and complains of abdominal pain. Laboratory studies help confirm a diagnosis of acute pancreatitis. The client's vital signs are stable, but the client's pain is worsening and radiating to his back. Which intervention takes priority for this client?

Administering morphine IV as ordered

The nurse is providing care to a client following a knee arthroscopy. Which of the following would the nurse expect to include in the client's plan of care?

Administering the prescribed analgesic-->After an arthroscopy, the client's entire leg is elevated without flexing the knee. A cold pack is placed over the bulky dressing covering the site where the arthroscope was inserted. A prescribed analgesic is administered as necessary. The client is allowed to resume his or her usual diet as tolerated.

A patient diagnosed with active TB 1 week ago is admitted to the hospital with symptoms of chest pain. Initially, the nurse gives the highest priority to

Admitting the patient to an airborne-infection isolation room

A patient diagnosed with class 3 TB 1 week ago is admitted to the hospital with symptoms of chest pain. Initially, the nurse gives the highest priority to:

Admitting the patient to an airborne-infection isolation room

The sounds of sirens announce the arrival of the latest trauma to address the trauma center where you practice nursing. Your heart is pounding, your mouth is dry. What gland is responsible for your physiologic response?

Adrenal glands-->The adrenal medulla secretes epinephrine and norepinephrine. These two hormones are released in response to stress or threat to life. They facilitate what has been referred to as the fight-or-flight response

Which of the following hormones controls secretion of adrenal androgens?

Adrenocorticotropic hormone ACTH--->ACTH controls the secretion of adrenal androgens. When secreted in normal amounts, the adrenal androgens appear to have little effect, but when secreted in excess, as in certain inborn enzyme deficiencies, masculinization may result. The secretion of T3 and T4 by the thyroid gland is controlled by TSH. Parathormone regulates calcium and phosphorous metabolism. Calcitonin reduces the plasma level of calcium by increasing its deposition in bone.

A 58-year-old female client tells the nurse that she feels a sense of loss since she has stopped having menstrual periods. She then states, "At least I will no longer have to suffer through those horrible Pap smear tests every year." Which action should the nurse implement?

Advise the client that Pap smear tests should be continued.

sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan

Aerobic activity. • Weight control.

Vasospasm lasting several minutes is characteristic of

Raynaud's disease.

Prevention of skin breakdown and maintenance of skin integrity among older clients is important because they are at greater risk secondary to:

Altered protective pressure sensation.

women chlamydia

An increase in vaginal discharge caused by an inflamed cervix; the need to urinate more frequently, or pain whilst passing urine; pain during sexual intercourse or bleeding after sex; lower abdominal pains; irregular menstrual bleeding.

What is pulmonary tuberculosis?

An infectious disease that primarily affects the lung parenchyma.

What is pneumonia?

An inflammation of the lung parenchyma caused by various microorganisms.

When assigning clients on a medical-surgical floor to a registered nurse (RN) and a practical nurse (PN), it is best for the charge nurse to assign which client to the PN?

An older adult client with pneumonia and viral meningitis

A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams. Correct Answer: D

An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint. Correct Answer: D

An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? A. Apply flannel pajamas to provide warmth. B. Administer a PRN dose of ibuprofen. C. Perform range of motion exercises in a warm tub. D. Drape the sheets over the footboard of the bed.

The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which client condition is most likely to have contributed to this finding?

Anorexia and vomiting for the past 2 days

A patient with active TB continues to have positive sputum cultures ater 6 months of treatment because she says she cannot remember to take the medication all the time. The best action by the nurse is to:

Arrange for directly observed therapy by a responsible family member of a public health nurse

A patient with active TB continues to have positive sputum cultures after 6 months of treatment because she says she cannot remember to take the medication all the time. The best action by the nurse is to

Arrange for directly observed therapy by a responsible family member or a public health nurse.

Other than cholesterol lowering drugs, what is another group of drugs used to treat atherosclerosis?

Antiplatelet drugs (ASA, Plavix)

The "ABCDs" of melanoma are

Asymmetry of the lesion, Borders that are irregular, Colors that vary in shades, and increased Diameter

Polyhydramnios treated with

Antacids may be prescribed to relieve heartburn and nausea and amnioreduction, also known as therapeutic Amniocentesis

The treatment for keratoconjunctivitis includes:

Antibiotic eye drops Antibiotic eye ointment Antiviral eye drops Cidofovir Artificial tears Cold compresses Corticosteroid eye drops: Dexamethasone (Ocu-Dex) Fluorometholone (Flarex, FML Forte) Prednisolone (Pred Forte) Rimexolone (Vexol)

Which statement best describes the treatment of lung abscess?

Antibiotics given for a prolonged period are the usual treatment of choice

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an:

Anticoagulant

meds for crohns disease

Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.

One day after a Billroth II surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed at blood pressure 100/80, pulse 110 beats/min, and respirations 36 breaths/min. What action is most important for the nurse to take?

Apply oxygen at 2 L per nasal cannula.

A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before going to the treatment room when the child feels less threatened. Correct Answer: C

As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? A. Take the child back to his room. B. Recruit others to restrain the child. C. Ask the mother to be present to soothe the child. D. Show the child how to manipulate the equipment.

Types of Pneumonia =Aspiration pneumonia= 1. Usually has history of what ? 2. whats suppressed in these patients ? 3. whats a risk factor for this type ? 4. Name some Forms of aspiration pneumonia

Aspiration pneumonia 1. loss of consciousness 2. Gag and cough reflexes 3. Tube feeding 4. -Mechanical obstruction -Chemical injury -Bacterial infection

cirrhosis and aspirin

Aspirin also should be avoided if esophageal varices are present.

Twelve hours after chest tube insertion for hemothorax, the nurse notes that the client's drainage has decreased from 50 ml/hr to 5 ml/hr. What is the best initial action for the nurse to take?

Assess for kinks or dependent loops in the tubing.

A patient is on a continuous epoprostenol infusion pump. The alarm goes off indicating an obstruction in the intravaneous line downstream. The nurse should:

Assess the central line immediately for any obstruction or accidental clamping of tubing

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment?

Assess the client's level of pain and administer prescribed analgesics.

How can you help determine the target organ damage in your assessment of a patient with HTN?

Assess their functional health patterns: -Health Perception and Management -Nutritional metabolic -Elimination -Activity exercise -Sleep rest -Cognitive-perceptual -Self perception/self concept -Role relationship -Sexuality reproductive -Coping-stress tolerance -Value-Belief Pattern

The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. The nurse should immediately

Assess vital signs

respiratory excursion

Assessment of the movement of the chest during respiration

Which condition most commonly results in coronary artery disease?

Atherosclerosis--->Atherosclerosis (plaque formation), is the leading cause of CAD. Diabetes mellitus is a risk factor for CAD, but it isn't the most common cause. Myocardial infarction is a common result of CAD. Renal failure doesn't cause CAD, but the two conditions are related.

Which medication is the drug of choice for sinus bradycardia?

Atropine

Treatment of symptompatic bradycardia includes which of the following?

Atropine--->Treatment of symptomatic bradycardia includes transcutaneous pacing and atropine. Lidocaine may be used in the treatment of ventricular fibrillation. Cardioversion and Adenocard may be used in patients diagnosed with atrial flutter.

The nurse is preparing a 45-year-old female client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan?

Attend an ostomy support group within 2 weeks.

A nonresponsive client has a nasogastric tube to low intermittent suction due to gastrointestinal bleeding. It is most important for the nurse to

Ausculate lung sounds every 4 hours

An older male client comes to the geriatric screening clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?

Auscultate the client's breath sounds.

Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns?

Average daily census

The nurse is discussing a treatment plan for mononucleosis with an adolescent. The nurse emphasizes that the client mus

Avoid contact sports and vigorous exercise for 2 to 4 weeks

A dietary modification that helps meet the nutritional needs of patients with COPD is

Avoiding foods that require a lot of chewing

After admitting a patient to the medical unit with a diagnosis of pneumonia, the nurse will verify that which of the following physician orders have been completed before administering a dose of cefotetan (Cefotan) to the patient? A) Orthostatic blood pressures B) Sputum culture and sensitivity C) Pulmonary function evaluation D) Serum laboratory studies ordered for am

B

When planning appropriate nursing interventions for a patient with metastatic lung cancer and a 60-pack-per-year history of cigarette smoking, the nurse recognizes that the smoking has most likely decreased the patient's underlying respiratory defenses because of impairment of which of the following? A) Cough reflex B) Mucociliary clearance C) Reflex bronchoconstriction D) Ability to filter particles from the air

B

A client with a gastrojejunostomy is beginning to take solid food. Which finding would lead the nurse to suspect that the client is experiencing dumping syndrome?

Diarrhea

The nurse is planning the care for a client who is admitted with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client's plan of care? (Select all that apply.)

B. Quiet environment C. Deep tendon reflex assessments D. Neurologic checks E. Daily weights

Before doing anything else, a chemical equation must always be ...

BALANCED!!!

If a patient has dyspnea, what test will be done if HF is suspected?

BNP level will tell if it is being caused by HF.

How is a HTN crisis defined clinically?

BP over 220/140

Pneumonia Etiology -what is it typically caused by ?

Bacterial/typical Viral Atypical Opportunistic Aspiration—can be obstruction, chemical pneumonitis, or bacterial CAP HAP

TB Bacteriologic studies 1. Stained....... 2. Required...... 3. three separate........ Bacteriologic studies 4. On different days, three consecutive samples are collected from 5. QuantiFERON-TB (QFT)

Bacteriologic studies 1. sputum smears examined for acid-fast bacilli Required for diagnosis ********* 3. samples on 3 consecutive days required for confirmation to stop meds Bacteriologic studies 4. -Gastric washings -CSF -Fluid from an abscess or effusion 5. QuantiFERON-TB (QFT) -New test -Rapid blood test (few hours) -Does not replace cultures

Why would someone after an MI be given a stool softener?

Because after an MI you are on bedrest and have been on opioids

The nurse took the correct action and should document the events that occurred in the nurses' notes (C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's medical record and should be placed in the chart, (D) when no longer current. Correct Answer: C

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record.

A nurse is explaining the action of insulin to a client with diabetes mellitus. During client teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when she states that insulin is secreted from the:

Beta cells of the pancreas-->The beta cells of the pancreas secrete insulin. The adenohypophysis, or anterior pituitary gland, secretes many hormones, such as growth hormone, prolactin, thyroid-stimulating hormone, corticotropin, follicle-stimulating hormone, and luteinizing hormone, but not insulin. The alpha cells of the pancreas secrete glucagon, which raises the blood glucose level. The parafollicular cells of the thyroid secrete the hormone calcitonin, which plays a role in calcium metabolism.

A patient with a lung mass found on chest x-ray is undergoing further testing. The nurse explains that a diagnosis of lung cancer can be confirmed by:

Biopsy positive for malignant cells

A patient has been declared legally blind. This means that the patient has a best corrected visual acuity (BCVA) that does not exceed what in the better eye?

Blindness is defined as a best corrected visual acuity (BCVA) that can range from 20/400 to no light perception (NLP). The clinical definition of absolute blindness is the absence of light perception. Legal blindness is a condition of impaired vision in which a person has a BCVA that does not exceed 20/200 in the better eye or whose widest visual field diameter is 20 degrees or less. This makes options A, C, and D incorrect.

What is the major disadvantage of ophthalmologic ointments? a) Hard to administer b) Patients don't like them c) They ooze out of the eye d) Blurred vision

Blurred vision Correct Explanation: The major disadvantage of ointments is the blurred vision that results after application. Therefore options A, B, and C are incorrect.

What is the major disadvantage of ophthalmologic ointments?

Blurred vision Explanation: The major disadvantage of ointments is the blurred vision that results after application. Therefore options A, B, and C are incorrect.

A nurse is caring for an elderly female client with osteoporosis. When teaching the client, the nurse should include information about which major complication?

Bone Fracture

A nurse in the free clinic is assessing a patient diagnosed with conjunctivitis who has presented for a follow-up examination. What finding would lead the nurse to conclude that the treatment for conjunctivitis was effective? a) The patient's eye pain is unrelieved. b) The patient is photophobic. c) Preauricular adenopathy is decreased. d) Both eyes have purulent discharge.

Both eyes have purulent discharge. Explanation: After effective treatment for conjunctivitis, the patient's eye pain should be relieved, preauricular adenopathy should be decreased or completely resolved, and purulent discharge resolved. Further therapy is needed for the patient who has purulent drainage in both eyes. Photophobia is not associated with conjunctivitis.

Does pneumonia affect ventilation or diffusion?

Both! (lol)

pursed liped breathing

Breathe in normally through your nose for 2 counts (while counting to yourself, one, two)." • "Relax your neck and shoulder muscles." • "Pucker your lips as if you were going to whistle." • "Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four)."

Acromegaly Evaluation of an adult client reveals oversecretion of growth hormone. Which of the following would the nurse expect to find?

Buldging forehead-->Oversecretion of growth hormone in an adult results in acromegaly, manifested by coarse features, a huge lower jaw, thick lips, thickened tongue, a bulging forehead, bulbous nose, and large hands and feet. Excessive urine output, weight loss, and constant thirst are associated with diabetes insipidus.

trichomonias men

Burning after urination or ejaculation Itching of urethra Slight discharge from urethra

The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea?

By questioning how many pillows the client normally uses for sleep-->The nurse should ask the client about nocturnal dyspnea by questioning how many pillows the client normally uses for sleep. This is because being awakened by breathlessness may prompt the client to use several pillows in bed. Collecting the client's urine output, observing the client's diet, or measuring the client's abdominal girth does not help assess for nocturnal dyspnea

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been most effective when the patient states which of the following measures to prevent a relapse? A) "I will seek immediate medical treatment for any upper respiratory infections." B) "I will increase my food intake to 2400 calories a day to keep my immune system well." C) "I should continue to do deep-breathing and coughing exercises for at least 6 weeks." D) "I must use home oxygen therapy for 3 months and then will have a chest x-ray to reevaluate."

C

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following should the nurse first suspect as the etiology of this episode? A) New onset of angina pectoris B) Septic embolus from the knee joint C) Pulmonary embolus from deep vein thrombosis D) Pleural effusion related to positioning in the operating room

C

Which of the following clinical manifestations would the nurse expect to find during assessment of a patient admitted with pneumococcal pneumonia? A) Hyperresonance on percussion B) Vesicular breath sounds in all lobes C) Increased vocal fremitus on palpation D) Fine crackles in all lobes on auscultation

C

Which of the following nursing interventions is most appropriate to enhance oxygenation in a patient with unilateral malignant lung disease? A) Positioning patient on right side B) Maintaining adequate fluid intake C) Positioning patient with "good lung down" D) Performing postural drainage every 4 hours

C

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which of the following nursing interventions is most appropriate based upon these findings? A) Continue with ambulation since this is a normal response to activity. B) Obtain a physician's order for arterial blood gas determinations to verify the oxygen saturation. C) Obtain a physician's order for supplemental oxygen to be used during ambulation and other activity. D) Move the oximetry probe from the finger to the earlobe for more accurate monitoring during activity.

C

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: a) match the room temperature to the client's body temperature. b) maintain room temperature at 78° F (25.6° C). c) keep the client warm. d) keep the client uncovered.

C) keep the client warm. Explanation: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

What is a nonspecific marker of inflammation that can be measured and is elevated in many patients with CAD?

C-Reactive protein (CRP)

The classification of pneumonia as community-acquired pneumonia (CAP) or hospital- acquired pneumonia (HAP) is clinically useful because

Causative agents can be predicted, and empiric treatment is often effective

pvd Elevating the extremities

counteracts the forces of gravity and promotes venous return and reduces venous stasis.so its bad

You are caring for a client with a damaged tricuspid valve. You know that the tricuspid valve is held in place by which of the following?

Chordae tendineae

Ankle edema seldom follow

CABG surgery and may indicate right-sided heart failure.

Diagnostic Tests pneumonia

CXR CBC—leukocytosis common in bacterial Serum lytes—especially for the dehydrated Sputum gram stain/ cultures—before treatment if possible Blood cultures-for severely ill, can identify sepsis O2 sats/blood gases—can determine treatment for hypoxia/hypercapnia

After undergoing a thyroidectomy, a client develops hypocalcemia and tetany. Which electrolyte should the nurse anticipate administering?

Calcium gluconate--->Immediate treatment for a client who develops hypocalcemia and tetany after thyroidectomy is calcium gluconate. Potassium chloride and sodium bicarbonate aren't indicated. Sodium phosphorus wouldn't be given because phosphorus levels are already elevated.

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in 2 hours is dated 2 years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action would be best for the nurse to implement?

Call for an ECG to be performed immediately.

A client with chronic asthma is admitted to postanesthesia complaining of pain at a level of 8 of 10, with a blood pressure of 124/78, pulse of 88 beats/min, and respirations of 20 breaths/min. The postanesthesia recovery prescription is, "Morphine 2 to 4 mg IV push while in recovery for pain level over 5." What intervention should the nurse implement?

Call the anesthesia provider for a different medication for pain.

A patient with advanced lung cancer refuses pain medication saying, "I deserve everything this cancer can give me." The nurse's best response to the patient is:

Can you tell me what the pain means to you?

A patient has been receiving high-dose corticosteroids and broad-spectrum antibiotics for treatment secondary to a traumatic injury and infection. The nurse plans care for the patient knowing that the patient is most susceptible to:

Candidiasis

As a compensatory mechanism for HF, how does the reduced CO and bloodflow affect the brain?

Cerebral perfusion pressure drops as a result of low CO, and the pp-gland secretes antidiuretic hormone to increase water reabsorption in the renal tubules, increasing blood volume, and therefore workload of the failing heart.

The nurse initiates neuro checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neuro function?

Change in level of consciousness

A client is ready for discharge following creation of an ileostomy. Which instruction should the nurse include in discharge teaching?

Change the bag when the seal is broken.

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question?

Change the second I.V. solution to dextrose 5% in water.

How does HTN manifest in the kidneys?

Changes in urine output nephrosclerosis

nasal surgery nasal packing

Checking the nares for ulcerations is not necessary.

dic sign

Chest pain and shortness of breath if blood clots form in the blood vessels in your lungs and heart.

The nurse is taking a health history from a client admitted with the medical diagnosis of cardiovascular disease (CVD). Identify which of the following symptoms indicate CVD.

Chest pain, weight gain, fatigue-->Chest pain, weight gain, fatigue, dizziness, ascites, and confusion are all symptoms of CVD. Rash, extra-ocular eye movements, ecchymosis, and petechiae are not usually indicative of CVD.

cause for oral cancer

Chronic and excessive use of alcohol can lead to oral cancer. Smoking and use of smokeless tobacco are other significant risk factors

A client is admitted with a diagnosis of chronic obstructive pulmonary disease (COPD). What is the nurse's rationale for keeping the client's oxygen administration level at 3 L/min or less?

Chronic hypoxemia creates the urge to breathe in COPD.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

Cirrhosis

An older client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?

Confusion and tachycardia

Osteoporosis occurs in

Cushing's syndrome; therefore, with successful treatment, bone mineralization increases.

Over secretion of ACTH

Cushings

A nurse is teaching a patient with glaucoma how to administer eyedrops to achieve maximum absorption. Where should the nurse teach the patient to instill the eyedrops? a) Sclera b) Vitreous humor c) Conjunctival sac d) Pupil

Conjunctival sac Correct Explanation: The nurse should instill the eyedrops into the conjunctival sac, where absorption can best take place. The pupil permits light to enter the eye. The sclera maintains the eye's shape and size. The vitreous humor maintains the retina's placement and the shape of the eye.

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling BP

A nurse is providing dietary instructions to a client with hypoglycemia. To control hypoglycemic episodes, the nurse should recommend:

Consuming a low carb- high protein diet and avoiding fasting--->To control hypoglycemic episodes, the nurse should instruct the client to consume a low-carbohydrate, high-protein diet, avoid fasting, and avoid simple sugars. Increasing saturated fat intake and increasing vitamin supplementation wouldn't help control hypoglycemia.

The home health nurse is assessing a male client being treated for Parkinson disease with levodopa-carbidopa (Sinemet). The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement?

Document the presence of these assessment findings.

Assessment of a client taking lithium reveals dry mouth, nausea, thirst, and mild hand tremor. Based on an analysis of these findings, which of the following should the nurse do next?

Continue the lithium and reassure the client that these temporary side effects will subside.

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a patient with closed chest tube drainage. The nurse should

Continue to monitor this normal finding

During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being "floated" to the other unit. What is the best immediate action for the charge nurse to take?

Continue with shift report and talk to the nurse about the incident at a later time.

When treating hypertensive emergencies, the nurse identifies the most appropriate route of administration for antihypertensive agents as being which of the following?

Continuous IV infusion-->The medications of choice in hypertensive emergencies are best managed through the continuous IV infusion of a short-acting titratable antihypertensive agent. The nurse avoids the sublingual and IM routes as their absorption and dynamics are unpredictable. The oral route would not have as quick an onset as a continuous IV infusion

autoimmune disorders Other common laboratory findings in these clients include

Coombs-positive hemolytic anemia, thrombocytopenia, leukopenia, immunoglobulin excesses or deficiencies, antinuclear antibodies, antibodies to deoxyribonucleic acid and ribonucleic acid, rheumatoid factors, elevated muscle enzymes, and changes in acute phase-reactive proteins.

A client comes to the Emergency Department (ED) complaining of precordial chest pain. In describing the pain, the client describes it as pressure with a sudden onset. What disease process would you suspect in this client?

Coronary artery disease

When obtaining a health history from a patient suspected of having early TB, the nurse asks the patient about experiencing

Fatigue, low grade fever and night sweats

meds for crohns disease

Corticosteroids, such as prednisone, reduce the signs and symptoms of diarrhea, pain, and bleeding by decreasing inflammation.

We typically measure by...

Count, mass, volume

A high-fiber diet and milk and milk products are contraindicated in clients wit

Crohn's disease because they may promote diarrhea.

Hypertension is a symptom of

Cushing's disease, and muscle mass is decreased.

Hyperglycemia, which develops from glucocorticoid excess, is a manifestation of

Cushing's syndrome. With successful treatment of the disorder, serum glucose levels decline.

Amenorrhea develops in

Cushing's syndrome. With successful treatment, the client experiences a return of menstrual flow, not a decline in it.

hyperadrenocorticism

Cushing's syndrome: a glandular disorder caused by excessive cortisol.

Hirsutism, not hair loss, is common in

Cushing's syndrome; therefore, with successful treatment, abnormal hair growth declines.

A 71-year-old patient is admitted with acute respiratory distress related to cor pulmonale. Which of the following nursing interventions is most appropriate during admission of this patient? A) Perform a comprehensive health history with the patient to review prior respiratory problems. B) Complete a full physical examination to determine the effect of the respiratory distress on other body functions. C) Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. D) Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

D

The actions of parathyroid hormone (PTH) are increased in the presence of which vitamin?

D

The nurse is caring for a 73-year-old patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient complains of shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4o F, blood pressure 130/88, respirations 36, and oxygen saturation 91% on room air. Which of the following actions should the nurse take first? A) Notify the physician. B) Administer a nitroglycerine tablet sublingually. C) Conduct a thorough assessment of the chest pain. D) Sit the patient up in bed as tolerated and apply oxygen.

D

Which of the following is the priority nursing intervention in helping a patient expectorate thick lung secretions? A) Humidify the oxygen as able B) Administer cough suppressant q4hr C) Teach patient to splint the affected area D) Increase fluid intake to 3 L/day if tolerated

D Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful, but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful, but does not liquefy the secretions so that they can be removed.

Under secretion of ADH

Diabetes insipidus

is high in fruits and vegetables, moderate in low-fat dairy products, and low in animal protein.

DASH diet

What is the collaborative care of chronic stable angina?

Decrease O2 demand and increase O2 supply -Nitrates -beta blockers -calcium channel blockers -reduce risk factors -antiplatelet (ASA) -cholesterol-lowering drugs

What is a hallmark of systolic dysfunction?

Decrease in LV ejection fraction

Which change in lab values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy?

Decrease in hemoglobin

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority?

Decreased cardiac output

During assessment of a client admitted for cardiomyopathy, the nurse notes the following symptoms: dyspnea on exertion, fatigue, fluid retention, and nausea. The initial appropriate nursing diagnosis is which of the following?

Decreased cardiac output

Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's:

Decreased cellular demand for oxygen.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit are decreased. What additional change in lab data should the nurse expect?

Decreased serum ammonia

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention?

Deep, unrelenting pain in the right arm

A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of:

Deficient knowledge----> The client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client's health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn't warranted.

Latent TB Infection Definition 1. Presence of the tubercle bacilli without...... Characteristics 2. Positive _______result 3. Negative _______ result 4.No.... 5. LTBI can be treated with one drug, what is it ?

Definition 1. symptoms or radiographic evidence of TB disease Characteristics 2. TST 3. Chest X ray 4. symptoms or physical findings suggestive of disease 5. isoniazid (INH) because the number of TB bacilli is low (except HIV positive pts. who need 2 drugs)

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?

Demonstrate hoe to apply and remove elastic support stockings

A 77-year-old female client is admitted to the hospital. She is confused and has had no appetite for several days. She has been nauseated and vomited several times prior to admission. She is currently complaining of a headache. Her pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to what medication?

Digitalis (Lanoxin)

What two things happen as a result of the failing heart's compensatory mechanisms

Dilation Hypertrophy - result of ventricular remodeling

ANTITUSSIVES Prototype: Dextromethorphan

Diphenhydramine (Benadryl) Benzonatate (Tessalon) Opioid Antitussives Codeine Hydrocodone

trichomonas in women

Discomfort with intercourse Itching of the inner thighs Vaginal discharge (thin, greenish-yellow, frothy or foamy) Vaginal itching Vulvar itching or swelling of the labia Vaginal odor (foul or strong smell)

An adult resident in a long-term care facility is diagnosed with hepatitis B. Which intervention should the nurse implement with the staff caring for this client?

Discuss the importance of all employees starting the hepatitis B vaccine series.

When obtaining a health history from a patient suspected of having early TB, the nurse asks the patient about experiencing

Fatigue, low-grade fever, and night sweats

Which suggestion would be most important to give a client who has a mild case of bunions?

Don prper footweat

side effects of clonidine are

Dry mouth, impotence, and sleep disturbances are possible adverse effects.

Which of the following is an early warning symptom of acute coronary syndrome (ACS) and heart failure (HF)?

Fatigue---> is an early warning symptom

Under secretion of GH- growth hormone

Dwarfism

What is the most common complication of an MI?

Dysrhythmia

The presence of a U-wave may or may not be apparent on a normal

ECG; it represents repolarization of the Purkinje fibers.

When is BP highest?

Early morning

Which of the following is the correct advice regarding food for a patient who underwent a cataract surgery? a) Eat spinach or collard greens two to four times per week. b) Eat red meat two to four times per week. c) Increase intake of vitamins A and C. d) Eat soft, easily chewed foods.

Eat soft, easily chewed foods. Correct Explanation: The nurse should advise patients recovering from cataract surgery to eat soft, easily chewed foods until healing is complete to avoid tearing from excessive facial movements. Eating spinach or collard greens two to four times per week reduces the risk of macular degeneration and increasing the intake of vitamins A and C is essential for preventing cataracts; however, these have no implications on recovery from cataract surgery.

Which diagnostic is the recommended method of determining whether left ventricular hypertrophy has occurred?

Echocardiogram--->An echocardiogram is recommended method of determining whether hypertrophy has occurred. ECG and blood chemistry are part of the routine work up. Renal damage may be suggested by elevations in BUN and creatinine levels.

The diagnosis of aortic regurgitation (AR) is confirmed by which of the following?

Echocardiography

A 65-year-old client has come to the emergency department reporting lightheadedness, chest pain, and shortness of breath. As you finish your assessment, the physician enters and orders tests to ascertain what is causing the client's problems. In your client education, you explain the tests. Which test is used to identify cardiac rhythms?

Electrocardiogram

% composition=

Element molar mass/compound molar mass x 100

The nurse is to administer a cyclic feeding through a gastric tube. It is most important for the nurse to

Elevate the head of bed to 45 degrees

A 55-year-old male client is admitted to the coronary care unit having suffered an acute myocardial infarction (MI). Within 24 hours of the occurrence, the nurse can expect to find which systemic sign?

Elevated CM-MB level

Which of the following nursing action would the nurse include when caring for a client with endemic goiter and experiencing respiratory symptoms?

Elevating the head of the bed-->The nurse should monitor the respiratory status and elevate the head of the bed to relieve respiratory symptoms. A high-iodine diet does not relieve respiratory distress. Although proper air circulation in the room and avoiding physical exertion may be important, these actions do not address the respiratory symptoms.

Which dietary modification is utilized for a patient diagnosed with acute pancreatitis?

Elimination of coffee

What occurs if the etiologic agent is not identified?

Empiric Antibiotic Therapy

The following measures are required for Droplet Precautions

Employees and visitors must wear a surgical mask to enter the room.

A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue and thick secretions. An appropriate nursing intervention for the patient is to

Encourage a fluid intake of at least 3L/day

A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. An appropriate nursing intervention for the patient is to:

Encourage a fluid intake of at least 3L/day

A client who is receiving an ACE inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. What action should the nurse implement?

Encourage the client to keep taking the drug until seen by the healthcare provider.

The nurse is providing care for a client who has had a cervical cord injury. Following reduction of the cervical fracture, a halo vest is placed to maintain realignment of the spinal canal. What intervention is needed to ensure client safety while the halo vest is in place?

Ensure that a set of wrenches are kept in close proximity

You are monitoring the results of laboratory tests performed on a client admitted to the cardiac ICU with a diagnosis of myocardial infarction. Which test would you expect to show elevated levels?

Enzymes---->When tissues and cells break down, are damaged, or die, great quantities of certain enzymes are released into the bloodstream. Enzymes can be elevated in response to cardiac or other organ damage. After an MI, RBCs and platelets should not be elevated. WBCs would only be elevated if there was a bacterial infection present.

Idiopathic elevated HTN is called what?

Essential or Primary HTN *there are contributing factors, but no direct cause

Which of the following is important for the nurse to consider during the preinterview period with an adult?

Establish rapport with the patient and family members

How can people who are predisposed to CAD reduce their risk?

Even though they have nonmodifiable risk factors, they can still lower their risk at developing by reducing their modifiable risk factors

Which assessment finding would confirm the specific location of an enteral feeding tube?

Examination of portable radiograph taken after the tube was inserted

A 76-year-old client has a significant history of congestive heart failure. During his semiannual cardiology examination, for what should you, as his nurse, specifically assess? Choose all correct options.

Examine the client's neck for distended veins, monitor the client for signs of lethargy or confusion---->During a head-to-toe assessment of a client with congestive heart failure, the nurse checks for dyspnea, auscultates apical heart rate and counts radial heart rate, measures BP, and documents any signs of peripheral edema, lethargy, or confusion

pancreatitis risk factor

Excessive alcohol intake and gallstones are the greatest risk factors. Abdominal trauma can potentiate inflammation. Hyperlipidemia is a risk factor for recurrent pancreatitis.

pvd and exercise

Exercise - exercise may improve arterial blood flow to the affected limb. so you need it Exercise is not recommended for people with severe rest pain, venous ulcers, or gangrene.

Which of the following would the nurse expect to find in a client with severe hyperthyroidism?

Exopthalmos--->Exophthalmos that results from enlarged muscle and fatty tissue surrounding the rear and sides of the eyeball is seen in clients with severe hyperthyroidism. Tetany is the symptom of acute and sudden hypoparathyroidism. Buffalo hump and striae are the symptoms of Cushing's syndrome.

The nurse prepares to auscultate heart sounds. Which nursing interventions would be most effective to assist with this procedure?

Explain to the client that the nurse will be listening to different areas of the chest and may listen for a long time, but that does not mean that anything abnormal is heard

A 64-year-old patient with chronic open-angle glaucoma is being taught to self-administer pilocarpine. After the patient administers the pilocarpine, the patient states that her vision is blurred. Which nursing action is most appropriate? a) Suggesting that the patient put on her glasses b) Explaining that this is an expected adverse effect c) Treating the patient for an allergic reaction d) Holding the next dose and notifying the physician

Explaining that this is an expected adverse effect Correct Explanation: Pilocarpine, a miotic drug used to treat glaucoma, achieves its effect by constricting the pupil. Blurred vision lasting 1 to 2 hours after instilling the eyedrops is an expected adverse effect. The patient may also note difficulty adapting to the dark. Because blurred vision is an expected adverse effect, the drug doesn't need to be withheld, nor does the physician need to be notified. Likewise, the patient doesn't need to be treated for an allergic reaction. Wearing glasses won't alter this temporary adverse effect.

Which of the following exposures accounts for the majoirty of cases withr egard to risk factors for COPD?

Exposure to tobacco smoke

born at 39 weeks' gestation or later signs

Extensive rugae on the scrotum and coarse, silky scalp hair are typical findings

Which of the following features should a nurse observe during an ophthalmic assessment?

External eye appearance Explanation: During an ophthalmic assessment, the nurse should examine the external eye appearance and the pupil responses of the patient. A qualified examiner determines the internal eye function, the visual acuity, and the intraocular pressure. Reference: Timby, B.K., & Smith, N.E. (2010). Introductory Medical-Surgical Nursing, 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 42: Caring for Clients with Eye Disorders, p. 614.

Which assessment finding in a client with an acute small bowel obstruction requires the most immediate intervention by the nurse?

Fever of 102° F

Aneurysm rebleeding occurs most frequently during which timeframe after the initial hemorrhage?

First 2 weeks

The nurse is admitting a 55-year-old male patient diagnosed with a retinal detachment in his left eye. While assessing this patient what characteristic symptom would the nurse expect to find? a) Sudden eye pain b) Loss of color vision c) Colored halos around lights d) Flashing lights in the visual field

Flashing lights in the visual field Explanation: Flashing lights in the visual field are a common symptom of retinal detachment. Patients may also report spots or floaters or the sensation of a curtain being pulled across the eye. Retinal detachment isn't associated with eye pain, loss of color vision, or colored halos around lights.

What does the supportive treatment for pneumonia include?

Fluids, oxygen for hypoxia, antipyretics, antussives, decongestants, and antihistamines.

A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information for the nurse to provide this client's family?

Follow exposure precautions.

How do you improve cardiac function in a patient with ADHF and who is it for?

For patients who don't respond to other pharm treatments (diuretics, morphine, vasodilators) Give them positive inotropes (Digoxin, dopamine, milrinone) dopamine ONLY in hospital setting *need to monitor blood levels

What is the correct procedure for performing an ophthalmoscopic examination on a client's right eye?

From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil.

Bethanechol (Urecholine), a cholinergic drug, may be used in

GERD to increase lower esophageal sphincter pressure and facilitate gastric emptying.

Propantheline bromide is classified as a

GI anticholinergic; the medication inhibits muscarinic actions of acetylcholine at postganglionic parasympathetic neuroeffector sites.

heprin injection

Gentle pressure should be applied after the injection, but the area must not be massaged.

Molecular formula

Gives composition of the molecules present/ can be simplified to empirical formula

Which of the following is the leading cause of blindness in the United States? a) Macular degeneration b) Glaucoma c) Cataracts d) Retinal detachment

Glaucoma Correct Explanation: Glaucoma is one of the leading causes of irreversible blindness in the world and is the leading cause of blindness among adults in the United States.

Which of the following is the leading cause of blindness in the United States?

Glaucoma Explanation: Glaucoma is one of the leading causes of irreversible blindness in the world and is the leading cause of blindness among adults in the United States.

Which hormone would be responsible for increasing blood glucose levels by stimulating glycogenolysis?

Glucagon--->Glucagon is a hormone released by the alpha islet cells of the pancreas that raises blood glucose levels by stimulating glycogenolysis (the breakdown of glycogen into glucose in the liver). Somatostatin is a hormone secreted by the delta islet cells that helps to maintain a relatively constant level of blood glucose by inhibiting the release of insulin and glucagons. Insulin is a hormone released by the beta islet cells that lowers the level of blood glucose when it rises beyond normal limits. Cholecystokinin is released from the cells of the small intestine that stimulates contraction of the gall bladder to release bile when dietary fat is ingested.

In assessing a client for complications of total parenteral nutrition, it is most important for the nurse to monitor which lab value regularly?

Glucose

normal findings in tpn

Glycosuria is to be expected during the first few days of therapy until the pancreas adjusts by secreting more insulin.

How is the appropriate antibiotic determined to be appropriate for pneumonia?

Gram stain results.

What microorganism is another cause of CAP, and frequently affects elderly people or those with comorbid illnesses?

H. Influenzae

Quantification of T-lymphocytes is used to monitor the effectiveness of treatment for

HIV.

. A family or personal history of breast cancer or a history of estrogen-dependent dysplasia is an absolute contraindication for

HRT hormone replacement therapy

Which of the following would be included as a responsibility of the scrub nurse?

Handing instruments to the surgeon and assistants

Polycythemia vera early sign

Headache and dizziness are early symptoms from engorged veins

dic sign

Headaches, speech changes, paralysis (an inability to move), dizziness, and trouble speaking and understanding if blood clots form in the blood vessels in your brain. These signs and symptoms may indicate a stroke.

Diet therapy for patients diagnosed with IBS include which of the following?

High fiber diet

Which of the following therapies are for patient who have advanced heart failure (HF) after all other therapies have failed

Heart transplant

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the unlicensed assistive personnel (UAP) to quickly relieve the client's pain?

Help the client to dangle his legs.

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken into his head. What nursing intervention is indicated?

Help the client to determine ways to increase his fluid intake.

emergent phase of burn

Hemoconcentration, not hemodilution, is caused by circulatory dehydration as plasma shifts into the extracellular space.

Which of the following is the most common complication associated with peptic ulcer?

Hemorrhage

Jack Donohue, a 62-year-old stock broker, attends his annual physical appointment and indicates physical changes since his last examination. He reports chest pain and palpitation during and after his morning jogs. Jack's family history reveals includes coronary artery disease. His lipid profile reveals his LDL level to be 122 mg/dl. Which of the following correctly states the Jack's condition?

High LDL level----->LDL levels above 100 mg/dl are considered high. The goal is to decrease the LDL level below 100 mg/dl

The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated. Correct Answer: C

How should the nurse handle linens that are soiled with incontinent feces? A. Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B. Place an isolation hamper in the client's room and discard the linens in it. C. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

A female client with diabetes mellitus type 2 has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from this client?

How the client examines her feet

Over secretion of TSH

Hyper thyroid

Over secretion of PTH

Hyperparathroidism

Wallace Guterman, a 36-year-old construction manager, is being seen by a physician in the primary care group where you practice nursing. He presents with a huge lower jaw, bulging forehead, large hands and feet and frequent headaches. What could be causing his symptoms?

Hyperpituitarism--->Acromegaly is a condition in which GH is oversecreted after the epiphyses of the long bones have sealed. A client with acromegaly has coarse features, a huge lower jaw, thick lips, a thickened tongue, a bulging forehead, a bulbous nose, and large hands and feet. When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica are common.

A blood pressure of 140/90 mm hg is considered to be

Hypertension--->A BP of 140/90 mm Hg or higher is hypertension. A blood pressure of less than 120/80 mm Hg is considered normal. A BP of 120 to 129/80 to 89 mm Hg is prehypertension. Hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage.

A patient is admitted to the hospital with fever, chills, a productive cough with rusty sputum, and pleuritic chest pain. Pneumococcal pneumonia is suspected. An appropriate nursing diagnosis for the patient based on the patient's manifestations is:

Hyperthermia related to acute infections process

Under secretion of PTH

Hypo parathyroidism

Under secretion of TSH

Hypo thyroid

An elderly patient diagnosed with diarrhea is taking digoxin (Lanoxin). Which of the following electrolyte imbalances should the nurse be alert to?

Hypokalemia

burns sodium levels are

Hyponatremia because sodium is trapped in edematous fluid.

emergent phase of burn has what type of sodium

Hyponatremia is another anticipated electrolyte imbalance because sodium is trapped in edematous

The pharmacology instructor is diagramming the nervous and endocrine systems. What organ would the instructor diagram as the connector between the nervous and endocrine systems?

Hypothalamus-->The hypothalamus is the coordinating center for the nervous and endocrine responses to internal and external stimuli. The pituitary, thyroid, and parathyroid glands all play an important role in hormones, but do not connect the nervous and endocrine systems

Why does a ventilation-perfusion mismatch occur in the affected area of the lung during pneumonia?

Hypoventilation

After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the

I.V. extension set and restart the infusion.

When describing abdominal hernias to a group of nursing students, the instructor would identify which type as most common?

INguinal

Rapid volume expansion, hypercarbia, and hypoglycemia contribute to the development o

IVH.

The nurse is receiving report from PACU about a client with a Penrose drain who is to be admitted to the surgical nursing unit. Before choosing a room for this client, which information is most important for the nurse to obtain?

If the client's wound is infected

You enter your client's room and find them pulseless and unresponsive. What would be the treatment of choice for this client?

Immediate defibrillation--->Defibrillation is used during pulseless ventricular tachycardia, ventricular fibrillation, and asystole (cardiac arrest) when no identifiable R wave is present.

A 64-year-old client reports symptoms consistent with a transient ischemic attack (TIA) to the physician in the emergency department. After completing ordered diagnostic tests, the physician indicates to the client what caused the symptoms that brought him to the hospital. What is the origin of the client's symptoms?

Impaired cerebral circulation

A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide (Norcuron) 0.04 mg/kg every 12 hours IV is prescribed. What is the priority nursing diagnosis for this client?

Impaired communication related to paralysis of skeletal muscles

chlorothiazide (Diuril). The expected outcome of this drug is:

Improved capillary circulation.

When was SARS first reported?

In Asia, February 2003.

When would fibrinolytics be used?

In a hospital setting without a cath lab or where one is too far away.

Which assessment findings would the nurse expect in a client diagnosed with osteomyelitis?

Leukocytosis and localized bone pain

Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D). Correct Answer: B

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area.

In evaluating care, the nurse should first determine if the expected outcomes of the plan of care were achieved (A). As indicated, the nurse may then review the initial nursing actions and the rationales for those actions (B), document successful completion of the care plan goals (C), and revise the plan of care (D). Correct Answer: A

In evaluating client care, which action should the nurse take first? A. Determine if the expected outcomes of care were achieved. B. Review the rationales used as the basis of nursing actions. C. Document the care plan goals that were successfully met. D. Prioritize interventions to be added to the client's plan of care.

The nurse's first priority is to notify the family of the resident's impending death (C). The family may request that hospice care is initiated (A). Reporting the client's acuity level (B) does not have the priority of informing the family of the client's condition. Once the family is contacted, the nurse can also contact the chaplain (D). Correct Answer: C

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? A. Request hospice care for the client. B. Report the client's acuity level to the nursing supervisor. C. Notify family members of the client's condition. D. Inform the chaplain that the client's death is imminent.

Where does CAP occur?

In the community setting or within the first 48 hours of hospitilation or institutionalization.

A patient diagnosed with a pericarditis and pericardial effusion. Based on the physiologic mechanisms of increased pericardial fluid and its effect on the heart, which of the following effects would be expected?

Inability of the ventricles to distend and fill adequately---->An increase in pericardial fluid raises the pressure within the pericardial sac and compresses the heart. This causes increased right and left ventricular end-diastolic pressures, decreased venous return, and inability of the ventricles to distend and fill adequately

What is diastolic heart failure?

Inability of the ventricles to relax and fill during diastole, resulting in decreased stroke volume and cardiac output

Which of the following is the most important postoperative assessment parameter for patients undergoing cardiac surgery?

Inadequate tissue perfusion

A nurse is discussing pharmacologic therapy used in the treatment of coronary vascular disease with a nursing student. The nurse would be correct in identifying the use of a positive inotrope as having which of the following functions?

Increase in myocardial contractility--> A positive inotrope is a medication that increases myocardial contractility (force of contraction). Medications that increase the heart rate are positive chronotropes. Negative chronotropic medications decrease the heart rate. Negative chronotropes decrease myocardial contractility

A nurse is discussing pharmacologic therapy used in the treatment of coronary vascular disease with a nursing student. The nurse would be correct in identifying the use of a positive inotrope as having which of the following functions?

Increase in myocardial contractility-->A positive inotrope is a medication that increases myocardial contractility (force of contraction). Medications that increase the heart rate are positive chronotropes. Negative chronotropic medications decrease the heart rate. Negative chronotropes decrease myocardial contractility

A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. What action should the nurse take based on this observation?

Increase oxygen flow via nasal cannula.

Margaret Lawson, a 52-year grocery clerk, has been experiencing a decrease in serum calcium. She has undergone diagnostics and her physician proposes her calcium level fluctuation is due to altered parathyroid function. What is the role of parathormone?

Increase serum calcium level--->The parathyroid glands secrete parathormone, which increases the level of calcium in the blood when there is a decrease in the serum level

The nurse is caring for a client who is 1 day post acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight PVCs per minute. Which intervention should the nurse implement first?

Increase the client's oxygen flow rate.

Which of the following clinical manifestations of hemorrhage is related to carotid artery rupture? a) Shallow respirations b) Dry skin c) Increased pulse rate d) Increased blood pressure

Increased Pulse Rate Explanation: The nurse monitors vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid, deep respirations. Cold, clammy, pale skin may indicate active blee

Which assessment finding indicates that the expected outcome of administering donepezil (Aricept) to a client with Alzheimer disease has been accomplished?

Increased ability to solve simple problems

How does HTN manifest in the eyes?

Increased pressure - retinal damage

A client is receiving an I.V. infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

Increased urine output

A nurse who works in the OR is required to assess the patient continuously and protect the patient from potential complications. Which of the following would not be included as a symptom of malignant hyperthermia?

Increased urine output; symptoms of malignant hyperthermia include tachycardia, tachypnea, cyanosis, fever, muscle rigidity, diaphoresis, mottled skin, hypotension, irregulr heart rate, decreased urine output and cardiac arrest

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of:

Increasing fluid intake to prevent dehydration

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is a) Acute pain related to upper airway irritation b) Deficient fluid volume related to increased fluid needs c) Deficient knowledge related to prevention of upper respiratory infections d) Ineffective airway clearance related to excess mucus production

Ineffective airway clearance related to excess mucus production Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.

The nurse is assessing a 75-year-old male client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?

Infection

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?

Infection

What causes alterations in endothelial lining of vascular system?

Inflammation and injury to the intimal wall

During the arteriogram, the client reports having nausea, tingling, and dyspnea

Inform the physician, symptoms suggest an allergic reaction. Treatment may involve administering oxygen and epinephrine.

An emaciated homeless client presents to the emergency department complaining of a productive cough with blood-tinged sputum and night sweats. What action is most important for the emergency department triage nurse to implement for this client?

Initiate airborne infection precautions.

FIRST-GENERATION H1 ANTAGONISTS Antihistamines Prototype: Diphenhydramine (Benadryl

Other First-Generation Antihistamines Brompheniramine Chlorpheniramine (Chlor-Trimeton) Dexchlorpheniramine Clemastine (Tavist) Promethazine (Phenergan) Hydroxyzine (Vistaril)

A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?

Inserts the catheter until resistance or coughing occurs

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Institute isolation precautions.

Other teaching to decrease community infection: =Instruct patient to:= 1. Cover.... 2. Wear.... 3. Open..... 4. Do not go to..... 5. Avoid public..... 6. Limit.... 7. When sputum cultures negative after______________ of treatment, patient is no longer considered infectious.

Instruct patient to: 1. mouth when coughing or sneezing 2.mask as instructed 3. windows to assure proper ventilation 4. work or school until instructed by physician 5. transportation 6. visitors 7. 2-3 weeks .

A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites?

Insulin is absorbed more rapidly at abdominal injection site then others

The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes?

Insulin production insuficent

NPH is an example of which type of insulin?

Intermediate acting

What is chronic stable angina?

Intermittent chest pain that occurs over a long period with the same pattern of onset, duration, and intensity of symptoms

Guillain-Barre syndrome causes respiratory problems primarily by:

Interrupting nerve transmission to respiratory muscles

signs of glomerulonephritis

Periorbital edema,hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting, hypertension ,oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain.

men gonorrhea

Irregular menstrual bleeding. Lower abdominal (belly) pain. Fever and general tiredness. Swollen and painful glands at the opening of the vagina (Bartholin glands). Painful sexual intercourse. Sore throat (rare). Pinkeye (conjunctivitis) (rare).

What is silent ischemia?

Ischemia that occurs in the absence of any subjective symptoms *likely due to diabetic neuropathy

What is chronic heart failure?

It is characterized as progressive worsening of ventricular function and chronic neurohormonal activation (compensation) that result in ventricular remodeling. This process involves changes in the size, shape, and mechanical performance of the ventricle.

Home care for hospitalization with pneumonia

It is important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks until all of the infection has cleared from the lungs. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. Increased fluid intake, not caloric intake, is required to liquefy secretions. Home O2 is not a requirement unless the patient's oxygenation saturation is below normal.

theophylline

It makes the central respiratory center more sensitive to carbon dioxide and stimulates the respiratory drive.

What is the FITT program and what does it mean?

It's a way to help work out: Frequency (4-5 days a week) Intensity (moderate, brisk walking, hiking, biking, swimming) Type (weight training/cardio) Time (30 min)

difficult case of scabies use

Ivermectin is a pill that may be used.

A new client has been admitted with right-sided heart failure. The nurse knows to look for which of the following assessment findings when assessing this client?

Jugular vein distention--->When the right ventricle cannot effectively pump blood from the ventricle into the pulmonary artery, the blood backs up into the venous system and causes jugular venous distention and congestion in the peripheral tissues and viscera. All the other choices are symptoms of left-sided heart failure.

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client?

Just above the xiphoid process on the lower third of the sternum

How does pneumonia normally occur?

Normally present flora in a patient whose resistance has been altered, or it results from aspiration of flora present in the oropharynx.

Hyperpigmented lesions are indicators of

Kaposi's sarcoma.

Other AIDS-defining illnesses include

Kaposi's sarcoma; cytomegalovirus of the liver, spleen, or lymph nodes; and Pneumocystis carinii pneumonia.

A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should

Keeping the involved extremity at or below the body's horizontal plane will facilitate tissue perfusion and prevent tissue damage.

Which of the following are common primary sites of tumors that metastasize to the bone? Select all that apply.

Kidney, prostate, lung, breast, ovary

As a compensatory mechanism for HF, how does the reduced CO and bloodflow affect the kidneys?

Kidneys sense reduced blood flow and trigger the RAAS system to produce aldosterone, which promotes sodium retention and is a potent vasoconstrictor, in order to raise BP, which increases the workload of the failing heart.

The signs and symptoms of diabetic ketoacidosis include

Kussmaul respirations, fruity breath, tachycardia, abdominal pain, nausea, vomiting, headache, thirst, dry skin, and dehydration

Which of the following surgical procedures involves flattening the anterior curvature of the cornea by removing a stromal lamella layer?

LASIK Explanation: LASIK involves flattening the anterior curvature of the cornea by removing a stromal lamella or layer. PRK is used to treat myopia and hyperopia with or without astigmatism. Keratoconus is cone-shaped deformity of the cornea. Keratoplasty involves replacing abnormal host tissue with healthy donor (cadaver) corneal tissue. Reference: Timby, B.K., & Smith, N.E. (2010). Introductory Medical-Surgical Nursing, 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 42: Caring for Clients with Eye Disorders, p. 607.

An 83-year-old client is undergoing lipid profile studies in an effort to determine a proper nutritional balance for his CAD. In his lipid profile, his LDL is greater than his HDL. Why is this a risk factor for this client?

LDL sticks to arteries

Which type of lipoprotein contains more cholesterol than any of the others and is the most closely correlated with incidence of atherosclerosis?

LDLs - low serum LDLs are desirable

A 68-year-old resident at a long-term care facility lost the ability to swallow following a stroke 4 years ago. She receives nutrition via a PEG tube. The client remains physically and socially active and has adapted well to the tube feedings. Occasionally, the client develops constipation that requires administration of a laxative to restore regular bowel function. Which of the following is the most likely cause of this client's constipation?

Lack of free water intake

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for receiving oxygenated blood from the lungs

Left atrium--> The left artrium receives oxygenated blood from the lungs

Within the physiology of the heart, each chamber has a particular role in maintaining cellular oxygenation. Which chamber of the heart is responsible for pumping blood to all the cells and tissues of the body?

Left ventricle

What is the difference between left and right-sided HF?

Left-sided failure usually manifests as pulmonary congestion and edema due to the blood backing up on the left side of the heart into the lungs. Right-sided failure causes the back up of blood into the right atrium and therefore venous circulation resulting in peripheral edema.

Which of the following is an inaccurate clinical manifestation of a fracture?

Lengthening

genital herpes

Lesions may appear 2 to 12 days after exposure

What is another name for HAP?

Nosocomial Pneumonia

BRONCHODILATORS BETA2-ADRENERGIC AGONISTS (Inhaled Short-Acting Agents) Prototype: Albuterol (Proventil, Ventolin, Accuneb)

Levalbuterol (Xopenex, Xopenex HFA) Oral Beta2-Adrenergic Agonists Albuterol (generic) tablets or syrup Albuterol (VoSpire ER) Terbutaline (Brethine) (Inhaled beta2 agents are preferred)

The preferred preparation for treating hypothyroidism includes which of the following?

Levothyroxine (Synthroid)

What is the easiest way a patient can improve their HTN?

Lifestyle modification

Which client statement indicates a good understanding of the nutritional modifications needed to manage hypertension?

Limiting my salt intake to 2 grams per day will improve my blood pressure."

The nurse is caring for an 82-year-old male client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP?

Loss of arterial elasticity

macular degeneration for

Loss of central vision

Which area of the spinal column is subject to the greatest mechanical stress and degenerative changes?

Lower lumbar

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?

Lubricant jelly

no evidence of distant metastasis is classified as

M0

What is the most common initial cardiac event for a man with CAD?

MI more than angina

A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54. Based on these findings, which IV medication should the nurse administer?

Magnesium sulfate

A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?

Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound

rifampin (Rifadin) side effects

Maintaining follow-up monitoring of liver enzymes. • Avoiding alcohol intake. • The urine may have an orange color.

The primary objective in the immediate post operative period is?

Maintaining pulmonary ventilation

An antacid (Maalox) is prescribed for a client with peptic ulcer disease. What is the therapeutic action of this medication which is effective in treating the client's ulcer?

Maintenance of a gastric pH of 3.5 or above

What is the name of the major tuberculin skin test?

Mantoux Test

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine

gavage feeding steps

Measure the tube distance from the nose to the earlobe, then from the earlobe to midway between the lower tip of the sternum and the belly button. Mark the tube with the piece of tape or a permanent marker.

Imperforate anus signs are

Meconium

Following a thoracotomy, the patient has a nursing diagnosis of ineffective airway clearance related to inability to cough as a result of pain and positioning. The best nursing interventionfor this patient is to

Medicate the patient with analgesics 20-30 min before assisting to cough and deep-breathe

Swallowing is regulated by which area of the central nervous system (CNS)?

Medulla oblongata

oliguric phase

Metabolic acidosis develops because the kidneys cannot excrete hydrogen ions, and bicarbonate is used to buffer the hydrogen. Hypertension may develop as a result of fluid retention. Hyperkalemia develops as the kidneys lose the ability to excrete potassium.

emergent burn phase has what type of acid base?

Metabolic acidosis,commonly develops due to loss of bicarbonate ions.

When preparing a patient for a cardiac catheterization, the patient states that she has allergies to seafood. Which of the following medications may give to her prior to the procedure?

Methylprednisolone (Solu-Medrol)---->Prior to cardiac catheterization, the patient is assessed for previous reactions to contrast agents or allergies to iodine-containing substances, as some contrast agents contain iodine. If allergic reactions are of concern, antihistamines or methylprednisolone (Solu-Medrol) may be administered to the patient before angiography is performed. Lasix, Ativan, and Dilantin do not counteract allergic reactions.

Which abnormal lab finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy?

Microalbuminuria

Complications TB Miliary TB 1. Large numbers of organisms do what ? Pleural effusion and empyema 2. Caused by..... 3. Inflammatory reaction with..... TB pneumonia 4. Large amounts of bacilli.......

Miliary TB 1. invade the bloodstream and spread to all organs -Acute or chronic symptoms Pleural effusion and empyema 2. bacteria in pleural space 3. pleural exudates of protein-rich fluid TB pneumonia 4. discharging from granulomas into lung or lymph nodes

What is the benefit of a MIDCAB?

Minimally invasive and doesn't need a bypass machine

A nurse is teaching about ischemic stroke prevention to a community group and emphasizes that control of hypertension, which is the major risk factor for stroke, is key to prevention. Ways to control hypertension include the Dietary Approaches to Stop Hypertension (DASH) diet. This diet includes which of the following?

Moderate amounts of low-fat dairy products

Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Based on the clinical manifestations of Cushing syndrome, which nursing intervention would be appropriate for a client who is newly diagnosed with Cushing syndrome?

Monitor blood glucose levels daily.

Promoting Adherence

Monitor for medication adverse effects that could cause patient to discontinue the regimen Offer solutions to management of unpleasant adverse effects Implement the use of DOT whenever possible Provide effective patient education with regular reinforcement of messages and written materials in the patient's primary language

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which assessment should the nurse complete first?

Monitor the client's serum potassium and blood glucose.

Which of the following would be most important to ensure that a client does not retain any barium after a barium swallow?

Monitoring stool passage and its color

A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit?

Moon face---->Clients who are receiving long-term high-dose corticosteroid therapy often develop a cushingoid appearance, manifested by facial fullness and the characteristic moon face. They also may exhibit weight gain, peripheral edema, and hypertension due to sodium and water retention. The skin is usually thin, and ruddy.

Upon discharge from the hospital, patients diagnosed with a myocardial infarction (MI) must be placed on all of the following medications except:

Morphine IV-->Upon patient discharge, there needs to be documentation that the patient was discharged on a statin, an ACE or angiotensin receptor blocking agent (ARB), and aspirin. Morphine IV is used for these patients to reduce pain and anxiety. The patient would not be discharged with IV morphine.

A severe thunderstorm has moved into a small community, and the tornado warning alarm has been activated at the local hospital. Which action should the charge nurse in the surgical department implement first?

Move clients and visitors into the hallways and close all doors to client rooms.

What do the inflamed mucosa of the bronchi produce, in acute tracheobronchitis?

Mucopurulent Sputum

What is the primary infectious agent of TB?

Mycobacterium Tuberculosis

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following? a) Myopia b) Astigmatism c) Emmetropia d) Hyperopia

Myopia Correct Explanation: Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which can affect both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly, but sees near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?

Myopia Explanation: Myopia, or nearsightedness, refers to the condition in which the client can see near objects but has blurred distant vision. Astigmatism is an irregularity in the curve of the cornea, which can affect both near and distant vision. Hyperopia, or farsightedness, refers to the client's ability to see distant objects clearly, but sees near objects as blurry. Emmetropia refers to normal eyesight in which the image focuses precisely on the retina.

no abnormal regional lymph nodes

N0,

Normal oral feedings are resumed as soon as the

NG tube is removed, usually within 10 days after surgery.

Mouth care should be provided after

NG tube removal. Auscultating and palpating the abdomen should have been done before tube removal.

Clients with acute necrotizing pancreatitis should remain

NPO with early enteral feeding via the jejunum to maintain bowel integrity and immune function.

Clients with acute necrotizing pancreatitis should remain \

NPO with early enteral feeding via the jejunum to maintain bowel integrity and immune function. TPN is considered if enteral feedings are contraindicated. \

What is the difference between an NSTEMI and a STEMI?

NSTEMI- partially occluded artery STEMI- fully occluded artery

Loop diuretics act on the

Na+-K+-2Cl- symporter (cotransporter) in the thick ascending limb of the loop of Henle to inhibit sodium and chloride reabsorption.

A patient is being discharged home from the ambulatory surgical center after cataract surgery. In reviewing the discharge instructions with the patient, the nurse instructs the patient to immediately call the office if the patient experiences what?

New floater in vision Explanation: Cataract surgery increases the risk of retinal detachment and the patient must be instructed to notify the surgeon if new floaters in vision, flashing lights, decrease in vision, pain, or increase in redness occurs. Slight morning discharge, some redness, and a scratchy feeling may be expected for a few days after surgery.

=To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treating inflammatory conditions of the eyes? a) Miotics b) Cycloplegics c) Mydriatics d) Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) Correct Explanation: NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.

=To avoid the side effects of corticosteroids, which medication classification is used as an alternative to treating inflammatory conditions of the eyes? a) Miotics b) Cycloplegics c) Mydriatics d) Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) Explanation: NSAIDs are used as an alternative in controlling inflammatory eye conditions and postoperatively to reduce inflammation. Miotics are used to cause the pupil to constrict. Mydriatics cause the pupil to dilate. Cycloplegics cause paralysis of the iris sphincter.

In assessing a client with an arteriovenous shunt who is scheduled for dialysis today, the nurse notes the absence of either a thrill or a bruit at the shunt site. What action should the nurse take?

Notify the healthcare provider of the findings.

Where is the most common place of MI?

Occlusion in the left anterior descending coronary artery

In assessing an older client with dementia for sundowning syndrome, what assessment technique is best for the nurse to use?

Observe for tiredness at the end of the day

Which type of sleep apnea is charcterized by lack of airflow due to pharyngeal occlusion?

Obstructive

The nurse assesses a postoperative client. Oxygen is being administered at 2 L/min and a saline lock is in place. Assessment shows cool, pale, moist skin. The client is very restless and has scant urine in the urinary drainage bag. What intervention should the nurse implement first?

Obtain IV fluids for infusion per protocol.

During an annual health assessment of a 65 y/o clinic patient, the patient tells the nurse he had the pneumonia vaccine when he was 58. The nurse advises the patient that the best way from him to prevent pneumonia now is to:

Obtain the pneumococcal vaccine this year with an annual influenza vaccine

During an annual health assessment of a 65 year old clinic patient, the patient tells the nurse he had the pneumonia vaccine when he was age 59. The nurse advises the patient that the best way for him to prevent pneumonia now is to

Obtain the pneumococcal vaccine this year with an annual influenza vaccine

patient with breathing problems what should nurse tell uap to do

Obtaining vital signs. • Applying antiembolic stockings. • Keeping the client oriented.

Who is more likely to have white coat hypertension?

Older adults

A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. The nurse should explain which pathophysiologic consequence that supports the need for temporary dialysis until acute tubular necrosis subsides?

Oliguria

Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. Correct Answer: B

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate.

CYCLOOXYGENASE INHIBITORS First Generation—Nonaspirin NSAIDs Prototype: Ibuprofen (Advil, Motrin

Other NSAIDs Fenoprofen (Nalfon) Flurbiprofen (Ansaid) Ketoprofen Naproxen (Aleve, Anaprox, Naprelan, Naprosyn) Oxaprozin (Daypro) Diclofenac (Voltaren, Cataflam)—risk of liver failure

mechanical ventilation problems

Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

A client with primary pulmonary hypertension is being evaluated for a heart-lung transplant. The nurse asks the client what treatments he's currently receiving for his disease. He's likely to mention which treatments? Select all that apply

Oxygen • Diuretics • Vasodilators

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Oxygen saturation of 90%

According to the American Society of Anesthesiology Physical Status Classification System, a patient with severe systemic disease that is not incapacitating is noted to have the physical status classification of which of the following?

P3; classification P3 pateints are those who have compensated heart failure, cirrhosis or poorly controlled diabetes. Classification P4 pateints have an incapacitating system disease that is a constant threat to life. Classification P1 is healthy. Classification P2 reflects patient with mild systemic disease

Inflammation, evidenced by

PAIN , swelling, and redness, is one of the early signs of infection and needs prompt intervention.

PNEUMOVAX 23 is a vaccine indicated for active immunization for the ...

PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons

What type of assessment is used when assessing angina?

PQRST P- precipitating events Q- quality of pain R- radiation of pain S- severity of pain T- timing

This vasoconstriction may increase pain in the areas where

PVD is the greatest.

During a health fair, a male client with emphysema tells the nurse that he fatigues easily. Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest diameter. Which instruction is best to provide the client?

Pace your activities and schedule rest periods

Which of the following would be an inaccurate clinical manifestation of a retinal detachment? a) Pain b) Bright flashing lights c) Cobwebs d) Sudden onset of a greater number of floaters

Pain Explanation: Patient may report the sensation of a shade or curtain coming across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great number of floaters. Patients do no complain of pain.

What is prinzmetal's angina?

Pain that often occurs at rest due to a spasm of the coronary artery *not usually precipitated by physical activity *often happens in the REM cycle, or as a result of certain substances (tobacco and histamine)

dic sign

Pain, redness, warmth, and swelling in the lower leg if blood clots form in the deep veins of your leg.

men gonorrhea

Painful or frequent urination or urethritis. Anal itching, discomfort, bleeding, or discharge. Sore throat (rare). Pinkeye (conjunctivitis) (rare).

women gonorrhea

Painful or frequent urination. Anal itching, discomfort, bleeding, or discharge. Abnormal vaginal discharge. Abnormal vaginal bleeding during or after sex or between periods. Genital itching.

Which of the following is a classic sign of hypovolemic shock?

Pallor

The nurse identifies a flail chest in a trauma patient when:

Paradoxic chest movement occurs during respiration

Following a motor vehicle accident, the nurse assesses the driver for which distinctive sign of flail chest?

Paradoxical chest movement

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?

Participate in regular walking program-->Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with conventional wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find?

Pedal pulses will be weak or absent in the left foot.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse question as possibly inappropriate for this client?

Pentobarbital (Nembutal sodium) 50 mg at bedtime for rest

A client who is being monitored with telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates administering which treatment?

Perform synchronized cardioversion

Postpericardiotomy syndrome may occur in patients who undergo cardiac surgery. The nurse should be alert to which of the following clinical manifestations associated with this syndrome?

Pericardial friction rub

Postpericardiotomy syndrome may occur in patients who undergo cardiac surgery. The nurse should be alert to which of the following clinical manifestations associated with this syndrome?

Pericardial friction rub--->The syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR.

Lubricant jelly is a water-soluble agent that the nurse can apply safely during oxygen therapy to alleviate dryness of the nares.

Petroleum jelly is combustible; it isn't safe to use with oxygen. The nurse shouldn't use sterile water or antibiotic ointment to alleviate dryness in the nares.

extra secretion during sex

Place a thin piece of gauze over the tracheostom

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority

Place the client on NPO status.

What is pain from reversible (temporary) myocardial ischemia?

angina - results when O2 demand is greater than O2 supply

The following measures are required for Droplet Precautions ·

Place the patient in a private room. No special ventilation is required.

Which of the following term is used to describe fluid acccumulating within the pleural space?

Pleural effusion; a pneumothrax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature due to collapse alveoli or infectious process

What is the leading cause of death from infection in Canada?

Pneumonia

What is lobar pneumonia?

Pneumonia that includes a substantial part portion of one or more lobes.

What is the definition of bronchopneumonia?

Pneumonia that is more distributed in a patchy fashion, having originated in one or more localized areas within the bronchi and extending to the adjacent surrounding lung parenchyma.

A 36-year-old mother of six has been recently diagnosed with type 2 diabetes. She reports increased hunger and food consumption while continuing to lose weight. What is the term used to describe this condition?

Polyphagia

The resurgence in TB resulting from the emergence of multidrug-resistant strains of Mycobacterium tuberculosis was primarily the result of

Poor compliance with drug therapy in patients with TB

The resurgence in tuberculosis (TB) resulting from the emergence of multidrug-resistan strains of Mycobacterium tuberculosis was primarily the result of:

Poor compliance with drug therapy in patients with TB

During an acute exacerbation of COPD, the patient is severely short of breath and the nurse identifies a nursing diagnosis of ineffective breathing pattern related to obstruction of airflow and anxiety. The best action by the nurse is to

Position the patient upright with the elbows resting on the over the bed table.

In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?

Potassium

What is important to monitor on any patient receiving an antihypertensive that affects the RAAS system? (ACE, ARB, etc.)?

Potassium levels. All can cause hyperkalemia

the nurse is conducting an admission history of a client admitted with a fracture. The nurse recognizes that which of the client's medications placed the client at risk for fractures

Prednisone (Deltasone)

drugs that cause hyperglycemia

Prednisone, Lithium may cause transient hyperglycemia,

straight catheter

Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows

During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear upon auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?

Prepare the client for a pericardial tap.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate.

Laurie Sharples, a 45-year-old teacher, is being seen at the ophthalmic group where you practice nursing due to a vision change. She's noticed an inability to see reading material as she had previously, needing to extend her arms to make the print readable. What is the term used to describe her visual condition? a) Emmetropia b) Myopia c) Presbyopia d) Hyperopia

Presbyopia Correct Explanation: Presbyopia is associated with aging and results in difficulty with near vision. People with presbyopia hold reading material or handwork at a distance to see it more clearly.

The nurse knows that clients taking diuretics must be assessed for the development of hypokalemia, and that hypokalemia will create changes in the client's normal ECG tracing. Which ECG change would be an expected finding in the client with hypokalemia?

Presence of a U wave

The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the mid-foot. Which goal should be included in this client's plan of care?

Prevent infection

Resistance to one of the first-line antituberculoic agents in people who have not had previous treatment is:

Primary drug resistance; Primary drug resistance to one of the first-line antituberculoic agents is people who have not had previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculoic agents in patients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin

What is the etiology of chronic stable angina?

Primary reason for ischemia is insufficient blood flow is narrowing of coronary arteries (atherosclerosis)

The nurse is analyzing (B) data to establish an individualized nursing diagnosis, such as, "Risk for injury related to side effects of drugs." This analysis is based on assessment (A) and guides the planning and implementation (C) of care, such as the decision to monitor the client frequently. (D) provides the nurse with information about the effectiveness of the plan of care. Correct Answer: B

Prior to administering a newly prescribed medication to a client, the nurse reviews the adverse effects of the medication listed in a drug reference guide and determines the priority risks to the client. While performing this action, the nurse is engaged in which step of the nursing process? A. Assessment. B. Analysis. C. Implementation. D. Evaluation.

What contributes to HF after an MI or cardiac cell injury?

Proinflammatory cytokines are released, which further depresses cardiac function by causing hypertrophy, contractile dysfunction, and myocyte cell death. Over time this leads to a systemic inflammatory response that affects cardiac and skeletal muscle and is responsible for the fatigue that accompanies advanced HF

CYCLOOXYGENASE INHIBITOR Second-Generation NSAID (COX-2 Inhibitor)

Prototype: Celecoxib (Celebrex)

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)?

Provide a room that can be kept warm.

The nurse observes dry mucous membranes in a client who is receiving tube feedings after an oral surgery. The client also complains of unpleasant tastes and odors. Which of the following measures should be included in the client's plan of care?

Provide frequent mouth care

A client is being assessed for his semiannual examination and you hear crackles bilaterally in his lungs. Which of the following could be a cause of crackles in the bases of his lungs

Pulmonary congestion--> crackles heard in the bases of the lungs are signs of pulmonary congestion

What does aspiration pneumonia refer to?

Pulmonary consequences resulting from the entry of endogenous or exogenous substances into the lower airway.

In the oliguric phase of acute renal failure, the nurse should assess the client for:

Pulmonary edema

A common complication of many types of environmental lung diseases is:

Pulmonary fibrosis

Right ventricle Pulmonary artery Arterioles and alveoli

Pulmonary vein Left atrium

A female practical nurse (PN) who is a valued employee tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?

Reassign the PN until the resident can be assessed more completely for reality orientation.

Procainamide may cause an increased QRS complexes and

QT intervals

Which two things affect renal fluid volume control?

RAAS natriuretic peptides

RECOMBIVAX HB is a sterile suspension for intramuscular injection. ...

RECOMBIVAX HB Hepatitis B Vaccine

To help control pain during coughing for a client who has had a pulmonary lobectomy, the nurse should:

Raise the bed to semi-Fowler's position and position the client's hands so that the incision is supported anteriorly and posteriorly

Two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. The first action the nurse should take is to:

Raise the head of the bed

A nursing measure that should be instituted after a pneumonectomy is:

Range-of-motion exercises on the affected upper extremity

You are the clinic nurse doing assessments on your clients before they have outpatient diagnostic testing done. What would you document when assessing the client's pulse?

Rate, quality, and rhythm

Foods that sometimes need to be limited, in order to make it easier to manage your colostomy, include

Raw vegetables Skins and peels of fruit (fruit flesh is OK) Dairy products Very high fiber food such as wheat bran cereals and breads Beans, peas, and lentils Corn and popcorn Brown and wild rice Nuts and seeds Cakes, pies, cookies, and other sweets High fat and fried food such as fried chicken, sausage, and other fatty meats

Which of the following terms is given to hypertension in which blood pressure that is controlled with therapy becomes uncontrolled (abnormally high) with the discontinuation of therapy?

Rebound-->Rebound hypertension may precipitate a hypertensive crisis. Essential or primary hypertension denotes high blood pressure from an unidentified source. Secondary hypertension denotes high blood pressure from an identified cause, such as renal disease.

If someone's triglycerides are high, what nutritional recommendation would be wise?

Reduce or eliminate your alcohol and simple sugar consumption (it lowers triglycerides)

Decreased pulse pressure reflects

Reduced stroke volume

Medical management of cardiac failure, whether it is right-sided or left-sided, demonstrates similar methodology. Measures such as dietary modifications, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. What is the primary goal in the medical management of heart failure?

Reducing cardiac workload

A client with non-insulin-dependent diabetes mellitus (NIDDM) takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates the use of which approach to best manage the client's diabetes while the client is NPO during the perioperative period?

Regular insulin subcutaneously per sliding scale

When caring for a postsurgical patient, the nurse observes that the client has hemorrhaged and is in hypovolemic shock. Which of the following nursing interventions will manage and minimize hemorrhage and shock?

Reinforcing dressing or applying pressure if bleeding is frank

Which of the following is the most successful treatment for gastric cancer?

Removal of tumor

A patient receiving chemotherapy for breast cancer develops a Cryptococcus infection of the lungs and is treated with IV amphotericin B. The nurse monitors the patient carefully during the drug's administration with the knowledge that this drug increases the patient's risk for (select all that apply)

Renal impairment Nausea and vomiting Malignant hyperthermia reaction

Which of the following nursing interventions is most appropriate when caring for a client with a nursing diagnosis of risk for injury related to side effects of medication (enoxaparin [Lovenox])?

Report any incident of bloody urine, stools, or both---->The client who takes an anticoagulant, such as a low-molecular-weight heparin, is routinely screened for bloody urine, stools, or both.

A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions. Which intervention helps meet this goal?

Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions.

Risk factors for pulmonary embolism

Research has demonstrated an increased risk of pulmonary embolism in women associated with obesity, heavy cigarette smoking, and hypertension. Other risk factors include immobilization, surgery within the last 3 months, stroke, history of DVT, and malignancy.

How is SARS transmitted?

Respiratory Droplets and Contact

A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse?

Respiratory rate of 12 per minute with O2 saturation of 85%

Which of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago?

Restlessness and shortness of breath.

What is an MI?

Result of sustained ischemia (>20 minutes), causing irreversible myocardial cell death (necrosis)

Which of the following is a true statement regarding a total laryngectomy?

Results in a permanent loss of voice; When a patient undergoes a total laryngectomy, there is a permanent loss of the voice. A larygnectomy results in permanent tracheostomy and the removal of the laryngeal structures, and is performed for most advanced State IV laryngeal cancer

The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. What action should the nurse implement first?

Review the medication actions and interactions.

What is the most common cause of mitral stenosis

Rheumatic endocarditis

Typically would a patient have JVD in R or L sided HF?

Right

Which are the most common vessels used for CABG?

Right internal mammary artery Radial artery Saphenous vein

While caring for a patient with primary pulmonary hypertension, the nurse observes that the patient has exertional dyspnea and chest pain, in addition to fatigue. The nurse knows that these symptoms are related to:

Right ventricular hypertrophy and dilation

Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia?

Risk for injury related to syncope and confusion

expectorants

Robitussin Mucinex Guaifenesin (generic for Mucinex)

As a compensatory mechanism for HF, how is the activation of the SNS counterproductive?

SNS is activated due to reduced stroke volume and CO, then it releases Epi and Nepi, which initially increase HR and contractility. However, that increases the heart's workload and need for O2.

heart Injury results from prolonged ischemia and is reflected by

ST-segment elevation.

Poor peripheral perfusion would cause subnormal

SaO2

Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following may occur as a result of vitamin C deficiency?

Scurvy

Which of the following terms describes high blood pressure from an identified cause, such as renal disease?

Secondary hypertension

With a diagnosis of right rib fracture and closed pneumothorax, the client should be placed in:

Semi- to high-Fowler's position, tilted toward the right side.

The nurse is assessing a client who presents with jaundice. Which assessment finding is the most significant indication that further follow-up is needed?

Serum amylase and lipase levels are twice their normal values

After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias?

Serum potassium level-->The nurse should monitor the client's potassium level because during periods of acidosis, potassium leaves the cell, causing hyperkalemia. As blood glucose levels normalize with treatment, potassium reenters the cell, causing hypokalemia if levels aren't monitored closely. Hypokalemia places the client at risk for cardiac arrhythmias such as ventricular tachycardia. DKA has a lesser affect on serum calcium, sodium, and chloride levels. Changes in these levels don't typically cause cardiac arrhythmias.

To determine whether a tension pneumothorax is developing in a patient with chest trauma, the nurse assesses the patient for:

Severe respiratory distress and tracheal deviation

The patient is on a continuous tube feeding. The tube placement should be checked every

Shift

The human body has 206 bones, which are classified into four categories. Which types of bones are located in the digits?

Short bones

Polycythemia vera early sign

Shortness of breath is an early symptom from congested mucous membranes and ineffective gas exchange.

In which position would a patient undergoing a lumbar punction be placed?

Side-lying, knee to chest

A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?

Sigmoidoscopy

The nurse is providing care to a client who has had a percutaneous liver biopsy. The nurse would monitor the client for which of the following?

Signs and symptoms of bleeding

A client with diabetes mellitus is receiving an oral antidiabetic agent. Which of the following aspects should the nurse observe when caring for the client?

Signs of hypoglycemia

A patient with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which of the following symptoms when caring for this patient

Signs of hypoglycemia--->The nurse should observe the patient receiving an oral antidiabetic agent for the signs of hypoglycemia. The time when the reaction might occur is not predictable and could be from 30 to 60 minutes to several hours after the drug is ingested. Polyuria, polydipsia, and blurred vision are the symptoms of diabetes mellitus.

A male client is to have an amputation. He is acutely ill and diagnosed with a gangrenous limb and related fever, disorientation, and electrolyte imbalances. Which of the following would be most important for the nurse to monitor in this client?

Signs of sepsis--->If the client is acutely ill with a gangrenous limb, related fever, disorientation, and electrolyte imbalances, the nurse should monitor for signs of sepsis and circulation in the limb for any changes such as severe pain, color changes, and lack of peripheral pulses. It is crucial for the nurse to inform the physician about the problems as they occur or else the surgery may become an emergency. Monitoring for signs of nausea and vomiting, occurrence of allergic reactions, and reduced urine output, although necessary, is not as crucial for the client

Emperical formula

Simplest formula of a compound

What is the best health promotion for CAD?

Since clinical manifestations usually don't happen until there is a severe cardiac event, identifying high risk patients and trying to manage their modifiable risk factors is the best health promotion

A 26-year-old client is returning for diagnostic followup. Her Holter monitor strip reveals a heart rate with normal conduction but with a rate consistently above 105 beats per minutes. What type of dysrhythmia would you expect the cardiologist to diagnose?

Sinus tachycardia---->Sinus tachycardia is a dysrhythmia that proceeds normally through the conduction pathway but at a faster than usual rate (100-150 beats/min)

Anal excoriation is inevitable with profuse diarrhea, and meticulous perianal hygiene is essential.

Sitz baths are comforting and cleansing

A client is recovering from gastric surgery. Toward what goal should the nurse progress the client's enteral intake?

Six small meals daily with 120 ml fluid between meals

Diagnostic testing TB Skin testing 1. what kind of injection ? 2. Induration at.....what does it show ? 3. how long does Sensitivity last ? 4. Response is less in what kind of person ? 5. Reactions greater than or equal to...... Chest x-ray 6. Cannot...... 7. Upper lobe infiltrates.......

Skin testing 1. Intradermal administration of tuberculin 2. injection site indicates exposure 3. Sensitivity remains for life, and individual should not be tested again 4. immunocompromised patients 5. 5 mm=positive Chest x-ray 6. make diagnosis solely on x-ray 7. cavitary infiltrates, and lymph node involvement suggest TB

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: a) Sleep with the head of bed elevated. b) Do not perform saline irrigations to the nares. c) You may drink 1 glass of alcohol daily. d) Caffeinated beverages are allowed.

Sleep with the head of bed elevated. Explanation:General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses

Smoking and ciliary action

Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions, chronic cough, and frequent respiratory infections.

gonnorrhea

Some women have no symptoms or vaginal itching and a thick, purulent vaginal discharge.

Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange based on the findings of:

SpO2, of 86%

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first?

Turn off the continuous feeding pump.

A pulmonary embolus is suspected in a patient with a deep-vein thrombosis who develops hemoptysis, tachycardia, and pleuritic chest pain, and diagnostic testing is scheduled. The nurse plans to teach the patient about:

Spiral (helical) CT scan

Of the following diuretic medications, which conserves potassium?

Spironolactone (Aldactone)---->Aldactone is known as a potassium-sparing diuretic. Lasix causes loss of potassium from the body. Diuril causes mild hypokalemia. Hygroton causes mild hypokalemia.

After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written, Which will the nurse implement first?

Sputum specimen for Gram stain and culture and sensitivity

After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which will the nurse implement first?

Sputum specimen for Gram stain and culture and sensitivity

The nurse observes ventricular fibrillation on telemetry and upon entering the client's bathroom finds the client unconscious on the floor. What intervention should the nurse implement first?

Start cardiopulmonary resuscitation

The registered nurse is taking shift report and finds that one of her assigned patients is blind. The nurse recalls that the best way to approach a patient who is blind is to what?

State your name and role after entering the patient's room. There are several guidelines to consider when interacting with a person who is blind or has low vision. Identify yourself my stating your name and role, before touching or making physical contact with the patient. When talking to the person, speak directly at him or her using a normal tone of voice. There is no need to raise your voice unless the person asks you to do so. Do not approach or distract the guide dog unless the owner has given permission or instructed you to do so.

To decrease the patient's sense of panic during an acute asthma attack, the best action of the nurse is to

Stay with the patient and encourage slow, pursed-lip breathing

Parathyroid hormone (PTH) has which effects on the kidney?

Stimulation of calcium reabsorption and phosphate excretion--->PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D. PTH doesn't have a role in the metabolism of vitamin E

...

Stopping smoking. • Wearing a face covering and gloves in the winter.

A client is being treated for glaucoma. What is the rationale for the nurse's instruction to maintain regular bowel habits? a) Straining at stool increases intraocular pressure. b) The client's medications may lead to diarrhea. c) The client's medications may cause constriction of all blood vessels, contributing to hemorrhoids. d) Problems with constipation may compound problems with lens clarity.

Straining at stool increases intraocular pressure. Correct Explanation: The client should maintain regular bowel habits because straining at stool can raise intraocular pressure (IOP). The other answers are distracters for this question.

When caring for the patient with a chest tube, the nurse should intervene when the nursing assistant is

Stripping or milking the chest tube to promote drainage

You are part of a group of nursing students who are making a presentation on chronic hypertension. What is one subject you would need to include in your presentation as a possible consequence of untreated chronic hypertension?

Stroke

What is the most common initial cardiac event for a woman with CAD?

angina more than MI

Which description of symptoms is characteristic of a client diagnosed with trigeminal neuralgia (tic douloureux)?

Sudden, stabbing, severe pain over the lip and chin

The nurse is preparing to examine the abdomen of a client complaining of a change in his bowel pattern. The nurse would place the client in which position?

Supine with knees flexed

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse implement first?

Support the client to a sitting position.

In chronic osteomyelitis, antibiotics are adjunctive therapy in which of the following situations?

Surgical debridement

A patient has bee told he has cataracts in both eyes. The patient wants to know what the treatment options are. What should the nurse tell the patient is the most appropriate treatment option for patients with age-related cataracts that are affecting the patient's ability to function? a) Eyeglasses or magnifying lenses b) Surgical intervention c) Corticosteroid eye drops d) Antioxidant supplements, vitamin C and E, beta-carotene, and selenium

Surgical intervention Explanation: Surgery is the treatment option of choice when the patient's functional and visual status is compromised. No nonsurgical (medications, eyedrops, eyeglasses) treatment cures cataracts or prevents age-related cataracts. Studies recently have found no benefit from antioxidant supplements, vitamins C and E, beta-carotene, or selenium. Corticosteroid eyedrops are prescribed for use after cataract surgery, but in fact, increase the risk for cataracts if used long-term or in high doses. Eyeglasses and magnification may improve vision in the patient with early stages of cataracts, but have limitations for the patient with impaired functioning.

Clubbing describes an increased

angle between the nail plate and nail base.

What are the qualifications for HTN?

Sustained systolic >140 OR Sustained diastolic >90 OR On a HTN medication

A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?

Sweating, tremors and tachycardia

After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices, and makes what additional recommendation?

Switch to skim milk.

No evidence of primary tumor

T0

A patient with TB has been admitted to the hospital and is placed in an airborne infection isolation room. Which of the following should the patient be taught (select all that apply)?

Take all medications for full length of time to prevent multidrug-resistant TB Wear a standard isolation mask if leaving the airborne infection isolation room Maintain precautions in airborne infection isolation room by coughing into a paper tissue

larngetctomy and bath

The client is able to take tub baths with careful instruction on ways to avoid slipping, the need to make sure the water is no more than 6 inches deep, and other safety measures.

An appropriate nursing intervention for a patient with pneumonia with the nursing diagnosis of ineffective airway clearance related to thick secretions and fatigue would be to:

Teach the patient how to cough effectively to bring secretions to the mouth

When preparing a male client who has had a total laryngectomy for discharge, what instruction would be most important for the nurse to include in the discharge teaching?

Tell the client to carry a medic alert card that explains his condition.

If someone's medicine makes them drowsy, what consideration can you make to the patient?

Tell them to take their one dose at night to minimize the side effect

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

Tetany-->Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstructio

A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and where the furniture and the bathroom are in order to move around independently. What must the nurse monitor in the patient's room? a) That the bathroom floor is always dry b) That all furniture remains in the same position c) That visitors don't leave items on the bedside table d) That the patient's slippers stay under the bed

That all furniture remains in the same position Correct Explanation: All articles and furniture must remain in the same positions throughout the patient's hospitalization.

According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C). Correct Answer: D

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience.

A 20-pound box is safely lifted by bending the knees (D), holding the box close to the center of gravity, and extending the legs using the quadriceps muscles. (A and B) might be helpful, but the charge nurse should use this opportunity to reinforce proper body mechanics techniques. Pushing the box against the wall (C) does not assist with lifting. Correct Answer: D

The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. Ask another staff member for assistance. B. Request that supplies are delivered in smaller containers. C. Push the box against the wall to provide support while lifting. D. Bend at the knees when lifting heavy objects.

Your client has had laryngeal surgery. What is as expected outcome in this client? a) The client's breathing patterns improve. b) The client can swallow without difficulty. c) The client's suture line remains intact. d) The client maintains an adequate caloric intake.

The client maintains an adequate caloric intake. Explanation: The caloric and fluid intake of a client undergoing laryngeal surgery should be adequate. The suture line and swallowing abilities are evaluated in clients undergoing tonsillectomy and adenoidectomy. Improved breathing patterns are evaluated in the case of clients with trauma in the upper airway.

o Permanent hypothyroidism is the major complication of RAI 131I treatment. o

The client needs to be educated about the need for lifelong thyroid hormone replacement and watch for signs of hypothyrodism

colostomy care 4 wks post op

The client should be encouraged to discuss any concerns about his sexuality

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD?

The client smokes 1 to 2 packs of cigarettes per day.

Which of the following is a true statement regarding regional enteritis (Crohn's disease)?

The clusters of ulcers take on a cobble stone appearance

Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65-years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others (B). Depression is a component of normal grieving, and (A) does not represent susceptible adaptation to the developmental crisis of an older adult, Integrity vs despair. (C and D) are judgmental and not therapeutic. Correct Answer: B

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? A. She is almost sure to be less able to adapt than before. B. It's highly likely that she will recover and return to her pre-illness state. C. If you can interest her in something besides religion, it will help her stay well. D. Cultural strains contribute to each woman's tendencies for recurrences of depression.

A class of beginning nursing students is learning about heart failure in their pathophysiology class. What should the students be taught is the reason for heart failure?

The heart cannot pump sufficient blood to meet the body's metabolic needs

Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit. Correct Answer: D

The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance.

Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.). Correct Answer: C

The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. B. The client tells the nurse that she does not have much of an appetite today. C. The nurse notes that there are numerous scatter rugs throughout the house. D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

A 58-year-old client, who has no health problems, asks the nurse about taking the pneumococcal vaccine (Pneumovax). Which statement given by the nurse would offer the client accurate information about this vaccine?

The immunization is administered once to older adults or persons with a history of chronic illness."

What is systolic heart failure?

The inability of the heart to pump blood effectively

Which of the following statements describe the management of a patient following lung transplantation (select all that apply)?

The lung is biopsied using a transtracheal method The use of a home spirometer will help to monitor lung function Immunosuppressant therapy usually involves a three-drug regimen

Every shift you work in the hospital unit where you practice nursing, blood pressures are measured as a component of your policy-scheduled assessments. Much information can be gleaned from comparing blood pressure measurements. What does a blood pressure reading indicate

The measured BP reflects the ability of the arteries to stretch and fill with blood, the efficiency of the heart as a pump, and the volume of circulating blood.

creams for scabies

The most commonly used cream is permethrin 5%. Other creams include benzyl benzoate, sulfur in petrolatum, and crotamiton. Lindane is rarely used because of its side effects.

(D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated, but this intervention does not have the priority of (D). Correct Answer: D

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? A. Administer a PRN antihypertensive prescription. B. Provide the client with an additional blanket. C. Encourage additional fluid intake. D. Turn the client q2h.

If resistance is encountered during the initial insertion of an enema tube, the client should be instructed to relax while a small amount of solution runs through the tube into the rectum (D) to promote dilation. (A) is unlikely to resolve the problem. (B) may cause injury. (C) should not be implemented until other, less invasive actions, such as (D) have been taken. Correct Answer: D

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? A. Withdraw the tube and apply additional lubricant to the tube. B. Encourage the client to bear down and continue to insert the tube. C. Remove the tube and check the client for a fecal impaction. D. Ask the client to relax and run a small amount of fluid into the rectum.

The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage, and/or seek out help to maintain health, and is best exemplified in the client belief or understanding about diet and health maintenance (D). (A) indicates noncompliance with an action to be done in the management of diabetes. (B) represents inattentiveness. (C) reflects knowledge deficit. Correct Answer: D

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs or symptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health.

If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion. Correct Answer: B

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A. Check for a blood return. B. Reposition the client's arm. C. Remove the IV site dressing. D. Flush the lock with saline.

Active, rather than passive, ROM is best to restore strength and (B) is an effective schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not performed beyond the point of resistance or pain (D) because of the risk of damage to underlying structures. Correct Answer: B

The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A. Passive ROM exercises to all joints on all extremities four times a day. B. Active ROM exercises to both arms and legs two or three times a day. C. Active ROM exercises with weights twice a day with 20 repetitions each. D. Passive ROM exercises to the point of resistance and slightly beyond.

The nurse should document the client's complaints (A) as subjective data--symptoms only the client can describe. (B) should be documented as objective data, which is collected via the nurse's observation. (C and D) are documented as intervention results. Correct Answer: A

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? A. Complains of inability to empty bladder. B. Temperature of 99.8° F and pulse of 108. C. Post-voided residual volume of 750 ml. D. Specimen collection for culture and sensitivity.

Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure. Correct Answer: B

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? A. Temperature increases from 98.8° to 99.0° F. B. Pulse rate decreases from 78 to 52 beats/min. C. Respiratory rate increases from 16 to 24 breaths/min. D. Blood pressure increases from 110/84 to 118/88 mm/Hg.

Vitamin B12 is normally found in liver, kidney, meat, fish and dairy products. A vegan who consumes only vegetables without careful dietary planning and supplementation may develop peripheral neuropathy due to a deficiency in vitamin B12 (D). (A, B, and C) are commonly adequate in vegtables and fruits. Correct Answer: D

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? A. Fiber. B. Folate. C. Ascorbic acid. D. Vitamin B12.

The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage the client to participate by pushing the IV pole when walking to the chair (D). The nurse should assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. Correct Answer: A, B, D, F

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A. Pre-medicate the client with an analgesic. B. Inform the client of the plan for moving to the chair. C. Obtain and place a portable commode by the bed. D. Ask the client to push the IV pole to the chair. E. Clamp the indwelling catheter. F. Assess the client's blood pressure.

A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precise, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size. Correct Answer: B

The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? A. Portable syringe pump. B. Cassette infusion pump. C. Volumetric controller. D. Nonvolumetric controller.

To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. Correct Answer: B

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution.

Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. Correct Answer: D

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel.

Coughing during or after meals is a manifestation of dysphagia, or difficulty swallowing, which places the client at risk for aspiration (C). Dysphagia can lead to aspiration pneumonia, but the client is not currently exhibiting any symptoms of breathing difficulty (A) or impaired gas exchange (B). Although (D) may be related to an ineffective cough, the client's coughing is an effective response when solids or liquids are taken orally. Correct Answer: C

The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse include in this client's plan of care? A. Ineffective breathing pattern. B. Impaired gas exchange. C. Risk for aspiration. D. Ineffective airway clearance.

The nurse should address the healthcare provider with the written report and discuss why he/she did not tell the client the truth--this may be at the family's request (A). (B, C, and D) may be indicated, but first the nurse should confer with the healthcare provider to obtain all needed information. Correct Answer: A

The nurse overhears the healthcare provider explaining to the client that the tumor removed was non-malignant and that the client will be fine. However, the nurse has read in the pathology report that the tumor was malignant and that there is extensive metastasis. Who should the nurse consult with first regarding the situation? A. Healthcare provider. B. Client's family. C. Case manager. D. Chief of staff.

Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. Correct Answer: C

The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A. Stage 1 pressure sore draining sero-sanguineous drainage. B. Pressure sore at bony prominence with exudate noted. C. One-inch pressure sore draining serous fluid. D. Pressure sore on heel with a small amount of purulent drainage.

blood transfusion signs are

The nurse should assess for signs of impending shock such as diaphoresis. The client would have hypotension, dysuria, and cool skin.

revascularization procedure for arteriosclerosis

The nurse should avoid placing the affected extremity on a hard surface, such as a firm mattress, to avoid pressure ulcers.

Experiences with the same type of pain that has successfully been relieved makes it easier for a client to interpret the pain sensation, and as a result, the client is better prepared to take steps to relieve the pain (D). (A, B, and C) are having new experiences with pain. Correct Answer: D

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A. A 10-year-old who was burned by a camp fire earlier today. B. A 70-year-old who has a postoperative infection from a surgery one week ago. C. A 23-year-old woman who sprained her knee while bicycling. D. A 55-year-old woman who has had moderate low back pain for three months.

The nurse should first slow the IV flow rate to keep vein open (KVO) rate (B) to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started (A) and the appearance of the IV insertion site (C) before contacting the healthcare provider (D) for further instructions. Correct Answer: B

The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? A. Determine when the IV solution was started. B. Slow the IV infusion to keep vein open rate. C. Assess the IV insertion site for swelling. D. Report the finding to the healthcare provider.

What is afterload?

The pressure that the chambers of the heart must overcome in order to eject blood out of the heart.

pulse wave

The progressive increase of pressure radiating through the arteries that occurs with each contraction of the left ventricle of the heart.

What do the coefficients of a balanced chemical equation represent?

The ratio of parts relationship (for example in C (s) + O₂ (g)→ CO₂ (g), coefficients= 1 part C needs 1 part O₂ in order to make 1 part CO₂.)

A nurse is caring for a client with an intracapsular hip fracture. Identify the area where this client's fracture occurred

The round head

What is the definition of miliary TB?

The spread of TB to other parts of the body.

When developing a care plan for a client who has recently suffered a stroke, a nurse includes the nursing diagnosis Risk for imbalanced body temperature. What is the rationale for this diagnosis?

The stroke may have impacted the body's thermoregulation centers.

A client with cirrhosis states that his disease was caused by a blood transfusion. What information should the nurse obtain first to provide effective client teaching?

The year the blood transfusion was received

The nurse should check for leaks in the chest tube and pleural drainage system when:

There is continuous bubbling in the water-seal chamber

What happens to the aveoli in pneumonia?

They become inflammed, producing an exudate that intereres with the diffusion of oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate and fill normally air-containing spaces.

Which statement best describes the therapeutic action of loop diuretics?

They block sodium reabsorption in the ascending loop and dilate renal vessels.---> Loop diuretics block sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also dilate renal vessels. Although loop diuretics block potassium reabsorption, this isn't a therapeutic action. Thiazide diuretics, not loop diuretics, promote sodium secretion into the distal tubule.

Why are antihistamines not usually prescribed for acute tracheobronchitis?

They may cause excessive drying and make secretions more difficult to expectorate.

A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?

Thinning of the skin with loss of elasticity

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the healthcare provider before the chest tube is removed?

Tidaling of water in water seal chamber

What is the definition of consolidation?

Tissue that solidifies as a result of collapsed alveoli or pneumonia.

The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit environment with one family member present. What is the primary rationale for these nursing interventions?

To minimize oxygen consumption

A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization or intensity, so pain assessment should focus on any interference with daily activities (D), sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors illicit specific assessment findings, whereas (A, B, and C) are limiting, closed-end questions, and can be answered with a yes, no, or a number. Correct Answer: D

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A. Can you describe where your pain is the most severe? B. What is your pain intensity on a scale of 1 to 10? C. Is your pain best described as aching, throbbing, or sharp? D. Which activities during a routine day are impacted by your pain?

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first-aid treatment? a) To hasten formation of scar tissue b) To eliminate the need for medical care c) To prevent vision loss d) To serve as a stopgap measure until help arrives

To prevent vision loss Correct Explanation: Prolonged eye irrigation after a chemical burn is the most effective way to prevent formation of permanent scar tissue and thus help prevent vision loss. After a potentially serious eye injury, the victim should always seek medical care. Eye irrigation isn't considered a stopgap measure.

Which of the following instructions should a nurse provide a patient with a history of rheumatic fever before the patient has any dental work done

To take prophylatic antibiotics

A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set

Which of the following are assoicated with compartment syndrome

Trauma from accidents Surgery Casts Tight bandages crushing injuries

folliculitis treatment

Treatment may include antibiotics applied to the skin (mupirocin) or taken by mouth (dicloxacillin), or antifungal medications to control the infection.

What labs are usually ordered when someone comes in with suspected ACS?

Troponin CK-MB

The nurse is awaiting results of cardiac biomarkers for a patient with severe chest pain. The nurse would identify which cardiac biomarker as remaining elevated the longest when myocardial damage has occurred

Troponin T and I---->After myocardial injury, these biomarkers rise early (within 3 to 4 hours), peak in 4 to 24 hours, and remain elevated for 1 to 3 weeks. These early and prolonged elevations may make very early diagnosis of acute myocardial infarction (MI) possible and allow for late diagnosis in patients who have delayed seeking care for several days after the onset of acute MI symptoms. CK-MB returns to normal within 3 to 4 days. Myoglobin returns to normal within 24 hours. BNP is not considered a cardiac biomarker. It is a neurohormone that responds to volume overload in the heart by acting as a diuretic and vasodilator.

In evaluating the effects of lactulose (Cephulac), which outcome would indicate that the drug is performing as intended?

Two or three soft stools per day

Which of the following is also termed preinfarction angina?

Unstable angina

A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. What area contains the older person's center of gravity?

Upper torso

The nurse knows that normal lab values expected for an adult may vary in an older client. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall?

Urinalysis reveals slight protein in the urine and bacteriuria with pyuria.

The nurse instructs the unliscensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?

Use a soft toothbrush to brush the client's teeth after each meal.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching?

Use diaphragmatic breathing.

An adult client has bacterial conjunctivitis. What should the nurse teach him to do? Select all that apply

Use warm saline soaks four times per day to remove crusting. • Apply topical antibiotic without touching the tip of the tube to his eye. • Wash his hands after touching his eyes. • Avoid touching his eyes.

To reduce the risk for most occupation lung diseases, the most important measure promoted by the occupational nurse is:

Using masks and effective ventilation systems to reduce exposure to irritants

What is the cause of most SCD?

V-tach *occurs less commonly with aortic stenosis

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?

Vagus

treatment for peripheral vascular disease Promoting

Vasodilation (increasing the diameter of blood vessels) - Vasodilation can be achieved by providing warmth and preventing long periods of exposure to cold. Never apply direct heat to the limb, such as with the use of a heating pad or extremely hot water to reduce the risk of burns

What happens in the heart after an MI in an attempt to compensate for the infarcted muscle?

Ventricular remodeling - Normal myocardium will hypertrophy and dilate *takes a long time

The primary treatment for cystic fibrosis is

Vigorous and consistent chest physiotherapy.

What is the most common cause of pneumonia in children?

Viruses

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A

client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A

nsaids

Voltaren Gel and Flector Patch Diclofenac Plus Misoprostol (Arthrotec) Diflunisal (Dolobid) Etodolac Indomethacin (Indocin) Ketorolac (Toradol), available IM or IV Mefenamic acid (Ponstel) Meclofenamate Meloxicam (Mobic) Nabumetone Piroxicam (Feldene) Sulindac (Clinoril) Tolmetin (Tolectin

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following actions?

Walk or perform weight-bearing exercises outdoors

what to do with scabies

Wash underwear, towels, and sleepwear in hot water. Vacuum the carpets and upholstered furniture.

A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the client closer to the nurse when being turned. Correct Answer: A

What action is most important for the nurse to implement when placing a client in the Sim's position? A. Raise the bed to a waist-high working level. B. Elevate the head of the bed 45 degrees. C. Place a pillow behind the client's back. D. Bring the client to one edge of the bed.

Which findings should a nurse expect to assess in client with Hashimoto's thyroiditis?

Weight gain, decreased appetite, and constipation--->Hashimoto's thyroiditis, an autoimmune disorder, is the most common cause of hypothyroidism. It's seen most frequently in women older than age 40. Signs and symptoms include weight gain, decreased appetite; constipation; lethargy; dry cool skin; brittle nails; coarse hair; muscle cramps; weakness; and sleep apnea. Weight loss, increased appetite, and hyperdefecation are characteristic of hyperthyroidism. Weight loss, increased urination, and increased thirst are characteristic of uncontrolled diabetes mellitus. Weight gain, increased urination, and purplish-red striae are characteristic of hypercortisolism.

Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates culturally sensitive care. (B, C, and D) do not demonstrate cultural awareness. Correct Answer: A

What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs.

The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. Correct Answer: B

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A. Maintain in a lateral position using protective wrist and vest devices. B. Position prone with a small pillow below the diaphragm. C. Raise the head and knee gatch when lying in a supine position. D. Transfer into a wheelchair close to the nurse's station for observation.

Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D). Correct Answer: B

What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field.

In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may occur when client outcomes are achieved, evaluation is best determined by attainment of measurable client outcomes. Correct Answer: D

What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes.

Bathing often makes a client feel weak, and if a client is already feeling weak (B), assistance is required during the bathing process to ensure the client's safety. (A and C) do not pose safety issues. Although (D) may pose a safety issue, further assessment is needed to determine if this in fact poses a safety issue for the client. Correct Answer: B

What client statement indicates to the nurse that the client requires assistance with bathing? A. I wasn't able to pack a bag before I left for the hospital. B. I don't understand why I'm so weak and tired. C. I only bathe every other day. D. I left my eyeglasses at home.

The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D). Correct Answer: A

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A. Check capillary refill of toes on lower extremity with Unna's paste boot. B. Apply dressing to wound area before applying the Unna's paste boot. C. Wrap the leg from the knee down towards the foot. D. Remove the Unna's paste boot q8h to assess wound healing.

C (The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care (C). (A, B, and D) do not support the basis for using the nursing process. Correct Answer: C)

What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals.

When are Calcium channel blockers indicated for use in angina?

When Beta blockers are contraindicated or for Prinzmetal's angina

Skin turgor is assessed by pinching the skin and observing for tenting. This finding confirms the diagnosis of fluid volume deficit, so the nurse should continue interventions to restore the client's fluid volume (C). Jugular vein distention (A) is a sign of fluid volume overload. High protein snacks (B) will not resolve the fluid volume deficit. Changes in the client's skin integrity are not evident (D). Correct Answer: C

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A. Confirm the finding by further assessing the client for jugular vein distention. B. Offer the client high protein snacks between regularly scheduled mealtimes. C. Continue the planned nursing interventions to restore the client's fluid volume. D. Change the plan of care to include a nursing diagnosis of impaired skin integrity.

Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed. Correct Answer: B

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame.

The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange (B) implies that the client is having trouble with breathing, which has the highest priority of the nursing diagnoses listed. Though an immobilized client presents a multitude of nursing care challenges, (A, C, and D) do not have the priority of (B). Correct Answer: B

When caring for an immobile client, what nursing diagnosis has the highest priority? A. Risk for fluid volume deficit. B. Impaired gas exchange. C. Risk for impaired skin integrity. D. Altered tissue perfusion.

What is acute coronary syndrome (ACS)?

When ischemia is prolonged and is not immediately reversible

A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle (D). A client using a bed cradle may still be able to ambulate independently (A) and does not require raised side rails (B). (C) causes the nurse to use poor body mechanics. Correct Answer: D

When making the bed of a client who needs a bed cradle, which action should the nurse include? A. Teach the client to call for help before getting out of bed. B. Keep both the upper and lower side rails in a raised position. C. Keep the bed in the lowest position while changing the sheets. D. Drape the top sheet and covers loosely over the bed cradle.

Aspiration of a blood return in the lumen of a central venous catheter indicates that the catheter is in place and the medication can be administered. The nurse should flush the tubing with the saline solution, administer the medication (A), then flush the lumen with saline again. (B and C) are not necessary. The aspirated blood can be flushed back through the closed system into the client's bloodstream, but does not need to be withdrawn (D). Correct Answer: A

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? A. Flush the lumen with the saline solution and administer the medication through the lumen. B. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. C. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. D. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

Adequate visualization or palpation of the perineum (A) is essential to ensure correct placement of the catheter. (B) is not necessary to perform self-catheterization. During a self-catheterization, the client typically allows the urine to drain into an open collection device, rather than a drainage bag (C), and uses a straight catheter without a balloon (D). Correct Answer: A

When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? A. Locate the perineum. B. Transfer to a commode. C. Attach the catheter to a drainage bag. D. Manipulate a syringe to inflate the balloon.

How do you treat someone in a HTN crisis?

You bring their BP down over a sustained period of time (8 hours). You can't drastically reduce their BP all at one time

(C) is an open-ended question that encourages the client to discuss personal feelings. (A) devalues the client and hinders further communication. Acting defensively and asking why questions such as (B) are likely to elicit more anger and block communication. By deferring to the client advocate (D), the nurse fails to even address the client's feelings of anger and exasperation. Correct Answer: C

When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? A. There is no reason to be so angry. B. Why do I need to leave your room? C. What is concerning you this morning? D. Let me call the client advocate for you.

How does chronic ischemia influence collateral circulation?

When there is ischemia in a vessel due to an occlusion, your body compensates by creating its own anastomoses around the occlusion.

Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate (A)before ambulation to determine tolerance for activity. (B, C, and D) are also important, but are of lower priority than (A). Correct Answer: A

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A. Respiratory rate. B. Wound location. C. Pedal pulses. D. Pain rating.

Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. Correct Answer: D

Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

The best intervention to reduce the risk for urosepsis (spread of an infectious agent from the urinary tract to systemic circulation) is removal of the urinary catheter as quickly as possible (D). (A, B, and C) are helpful to reduce the risk of infection, but are of less priority than (D) in reducing the risk of urosepsis. Correct Answer: D

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A. Ensure that the client's perineal area is cleansed twice a day. B. Maintain accurate documentation of the fluid intake and output. C. Encourage frequent ambulation if allowed or regular turning if on bedrest. D. Obtain a prescription for removal of the catheter as soon as possible.

The durable power of attorney is a legal document or a form of advance directive that designates another person to voice healthcare decisions when the client is unable to do so. A durable power of attorney for health directives is legally binding (A). (B, C and D) do not include the legal parameters that must be determined by the client in the event the client is unable to make a healthcare decision, which can be changed by the client at any time. Correct Answer: A

Which statement best describes durable power of attorney for health care? A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. B. The healthcare decisions made by another person designated by the client are not legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.

An objective should contain four elements: who will perform the activity or acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under which the behavior is to be demonstrated, and the specific criteria to be used to measure success. (C) is a concise statement that is a learning objective that defines exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or more of these elements. Correct Answer: C

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. The nurse will provide client instruction for daily foot care. B. The client will demonstrate proper trimming toenail technique. C. Upon discharge, the client will list three ways to protect the feet from injury. D. After instruction, the nurse will ensure the client understands foot care rationale.

The first part of the nursing diagnosis statement is the diagnostic label and is followed by related to the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's response, which the nurse can provide support, reflection, and dialogue. Correct Answer: D

Which statement is an example of a correctly written nursing diagnosis statement? A. Altered tissue perfusion related to congestive heart failure. B. Altered urinary elimination related to urinary tract infection. C. Risk for impaired tissue integrity related to client's refusal to turn. D. Ineffective coping related to response to positive biopsy test results.

The posterior tibial pulse is on the medial surface of the

ankle just behind the medial malleolus.

The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems. Correct Answer: C

Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model.

Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan (A). Southeast Asians do not necessarily refuse Western medications (B). Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known, so the husband should be allowed to remain with his wife during the pelvic exam (C). Provided that the presence of other family members is not harmful to the client's well-being, (D) is not correct. Correct Answer: A

While caring for a child and mother from Cambodia, what action should the nurse implement to accommodate the clients' cultural needs? A. Speak initially with the oldest family member to show respect. B. Realize that Southeast Asians may not take Western medications. C. Ask the husband to step out during the mother's pelvic examination. D. Tell the family that planning health care is provided in private with the client.

During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C). Correct Answer: D

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down.

When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. (C) should then be implemented to reduce the risk of aspiration. After that, (B and D) can be implemented as indicated. Correct Answer: A

While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? A. Discontinue the administration of the bolus feeding. B. Auscultate the client's breath sounds bilaterally. C. Elevate the head of the bed to a high Fowler's position. D. Administer a PRN dose of a prescribed antiemetic.

The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?

While the nurse is taking the client's blood pressure, he has a carpal spasm.

Who is most likely to have CAD?

White, middle-aged men

Push 2 cc of air quickly into the stomach while listening over the infant's stomach with a stethoscope.

You should hear a "whooshing" sound as the air enters the stomach (see illustration). You should also be able to withdraw the air you pushed in.

Because HF is a progressive disease, how are interventions planned?

With quality of life goals

TB Without sufficient immune response 1. Organism is not___________ 2. Active........ 3. ____________________ & ____________ patients are at higher risk for disease Dormant TB organisms persist for years 4. Few...... Classes 0, 1, 2, 3, 4,.....name these.

Without sufficient immune response 1. maintained 2. primary disease results 3. Immunosuppressed and diabetic Dormant TB organisms persist for years 4. ever develop TB Reasons for reactivation are not well understood Classes 0 = No TB exposure 1 = Exposure, no infection 2 = Latent TB, no disease 3 = TB, not clinically active 4 = TB suspected

During a health-promotion program, the nurse plans to target women in a discussion of lung cancer prevention because (select all that apply)

Women develop lung cancer at a younger age than men More women die of lung cancer than die from breast cancer Women who smoke are at greater risk to develop lung cancer than men who smoke Women are more likely to develop small cell carcinoma than men

Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur?

Worsening angina

Which type of graft is utilized when a heart valve replacement is made of tissue from an animal heart valve?

Xenograft

The nurse is proving discharge instruction for a patient with a new arrhythmia. Which of the following should the nurse include?

Your family and friends may want to take a CPR class-->Having friends and family learn to take a pulse and perform CPR will help patients to manage their condition. Antiarrhythmic medication should be taken on time. Lightheadedness and dizziness are symptoms which should be reported to the provide

acute respiratory distress syndrome is

a non cardiac pulmonary edema

Before amniocentesis, what is done

a routine ultrasound

Four-point gait:

a slow gait pattern in which one crutch is advanced forward and placed on the floor, followed by advancement of the opposite leg; then the remaining crutch is advanced forward followed by the opposite remaining leg; requires the use of two assistive devices (crutches or canes); provides maximum stability with three points of support while one limb is moving.

When a building's hot water plumbing has water at this temperature, the

bacteria thrive; then they may be transmitted via inhalation from air conditioning, showers, spas, and whirlpools.

Vitamin B12, also called cobalamin, is

a water-soluble vitamin with a key role in the normal functioning of the brain and nervous system, and for the formation of blood.

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? a) "I have my wife look at the soles of my feet each day." b) "I like to soak my feet in the hot tub every day." c) "I stopped smoking and use only chewing tobacco." d) "I walk only to the mailbox in my bare feet."

a) "I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment? a) 5 b) 2 c) 3 d) 4

a) 5 Explanation: Beginning warfarin concomitantly with heparin can provide a stable INR by day 5 of heparin treatment, at which time the heparin maybe discontinued.

A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? a) Assess the client's level of pain and administer prescribed analgesics. b) Ensure that the client's family is kept informed of his status. c) Prepare the client for pulmonary artery catheterization. d) Assess the client's level of anxiety and provide emotional support.

a) Assess the client's level of pain and administer prescribed analgesics. Explanation: The cardinal symptom of MI is persistent, crushing substernal pain or pressure. The nurse should first assess the client's pain and prepare to administer nitroglycerin or morphine for pain control. The client must be medically stabilized before pulmonary artery catheterization can be used as a diagnostic procedure. Anxiety and a feeling of impending doom are characteristic of MI, but the priority is to stabilize the client medically. Although the client and his family should be kept informed at every step of the recovery process, this action isn't the priority when treating a client with a suspected MI.

For a client with an endotracheal (ET) tube, which nursing action is most essential? a) Auscultating the lungs for bilateral breath sounds b) Turning the client from side to side every 2 hours c) Monitoring serial blood gas values every 4 hours d) Providing frequent oral hygiene

a) Auscultating the lungs for bilateral breath sounds

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? a) Homans' b) Rinne c) Romberg's d) Phalen's

a) Homans' Explanation: A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/min. These signs are associated with which condition? a) Hypoxia b) Delirium c) Hyperventilation d) Semiconsciousness

a) Hypoxia

The nurse is caring for a client with chest trauma. Which nursing diagnosis takes highest priority? a) Impaired gas exchange b) Anxiety c) Decreased cardiac output d) Ineffective cardiopulmonary tissue perfusion

a) Impaired gas exchange

When caring for a client with a diagnosis of aortic aneurysm scheduled for surgery, what would be most important for the nurse to monitor? a) Level of consciousness, characteristics of pain, and signs of hemorrhage or dissection b) Intake and output, nutrition level, respirations, and characteristics of pain c) Cultural needs, characteristics of pain, and signs of hemorrhage or dissection d) BP, pulse, respirations, and signs of hemorrhage or dissection

a) Level of consciousness, characteristics of pain, and signs of hemorrhage or dissection Explanation: The nurse monitors BP, pulse, hourly urine output, skin color, level of consciousness, and characteristics of pain for signs of hemorrhage or dissection. Assessing respirations, nutritional levels, and cultural needs are important but not the most important assessments for the nurse to make.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? a) Partial pressure of arterial oxygen (PaO2) b) Partial pressure of arterial carbon dioxide (PaCO2) c) pH d) Bicarbonate (HCO3-)

a) Partial pressure of arterial oxygen (PaO2)

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: a) dependent pallor. b) elevational rubor. c) a 30-second filling time for the veins. d) no rubor for 10 seconds after the maneuver.

a) dependent pallor. Explanation: If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.

When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for

balloon inflation and continuous inflow and outflow of irrigation solution.

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? a) Participate in a regular walking program. b) Massage the calf muscles if pain occurs. c) Use a heating pad to promote warmth. d) Keep the extremities elevated slightly.

a) Participate in a regular walking program. Explanation: Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.

Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that apply. a) Reduces circulation to the extremities b) Impairs transport and cellular use of oxygen c) Causes vasospasm d) Increases blood viscosity e) Decreases blood viscosity

a) Reduces circulation to the extremities b) Impairs transport and cellular use of oxygen c) Causes vasospasm d) Increases blood viscosity Explanation: Nicotine from tobacco products causes vasospasm and can dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity.

A nurse should be prepared to manage complications following abdominal aortic aneurysm resection. Which complication is most common? a) Renal failure b) Graft occlusion c) Hemorrhage and shock d) Enteric fistula

a) Renal failure Explanation: Renal failure commonly occurs if clamping time is prolonged, cutting off the blood supply to the kidneys. Hemorrhage and shock are the most common complications before abdominal aortic aneurysm resection, and they occur if the aneurysm leaks or ruptures. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? a) Shock b) Stroke c) Seizures d) Hyperglycemia

a) Shock

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. b) The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. c) The client exhibits restlessness and confusion. d) The client exhibits bronchial breath sounds over the affected area.

a) The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects to administer an: a) anticonvulsant. b) antihypertensive. c) anticoagulant. d) antibiotic.

a) anticoagulant. Explanation: During PTCA, the client receives heparin, an anticoagulant, as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses don't routinely give antibiotics during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive may cause hypotension, which should be avoided during the procedure. An anticonvulsant isn't indicated because this procedure doesn't increase the risk of seizures.

A small waxy nodule with pearly borders may indicate a

basal cell carcinoma.

When caring for a client with a diagnosis of aortic aneurysm scheduled for surgery, what would be most important for the nurse to monitor? a) Level of consciousness, characteristics of pain, and signs of hemorrhage or dissection b) BP, pulse, respirations, and signs of hemorrhage or dissection c) Cultural needs, characteristics of pain, and signs of hemorrhage or dissection d) Intake and output, nutrition level, respirations, and characteristics of pain

a)Level of consciousness, characteristics of pain, and signs of hemorrhage or dissection Explanation: The nurse monitors BP, pulse, hourly urine output, skin color, level of consciousness, and characteristics of pain for signs of hemorrhage or dissection. Assessing respirations, nutritional levels, and cultural needs are important but not the most important assessments for the nurse to make.

Two days after surgery to amputate his left lower leg, a client states that he has pain in the missing extremity, which action by the nurse is most appropriate

administer medication as ordered for the reported discomfort

with terminal ilieum resection surgery vitamin B12 tablet cannot be

absorbed regardless of the amount of oral intake of sources of vitamin B12, such as animal protein or vitamin B12 tablets.

In a strangulated hernia, the hernia cannot be reduced back into the

abdominal cavity.

peritonitis or perforated bowel

abdominal rigidity, a cardinal sign of peritonitis and perforated bowel

Because the client has a peritoneal catheter in place, blood-tinged drainage should not occur. Persistent blood-tinged drainage could indicate damage to the

abdominal vessels, and the physician should be notified. The bleeding is originating in the peritoneal cavity, not the kidneys.

Polycythemia vera is a bone marrow disease that leads to an

abnormal increase in the number of blood cells (primarily red blood cells).

Unless the pouch leaks, the client can wear her ileostomy pouch for

about 4 to 7 days.

Acute angle-closure glaucoma produces

abrupt changes in the angle of the iris.

Swing-to gait: both crutches are

advanced forward together; weight is shifted onto hands for support and both legs are then swung forward to meet the crutches; requires the use of two crutches or a walker; indicated for individuals with limited use of both lower extremities and trunk instability.

Postural drainage may be helpful for respiratory hygiene but will not

affect the nature of secretions.

cytoscopy normal findings

after pink tinged urine

Yellow, waxy deposits on the lower eyelids, bright red moles on the hands, and areas of dry, scaly skin are normal

age-related changes to skin.

Increased urine output is the best indication that the

albumin is having the desired effect.

burns Metabolic acidosis, not

alkalosis, commonly develops due to loss of bicarbonate ions.

It is not necessary to keep the stoma covered at

all times, although a gauze bib can be used to protect the clothes from mucus and to keep irritants from entering the stoma.

intradermally injection Slow diffusion is necessary during diagnostic

allergy testing because rapidly introducing an allergen could cause a life-threatening allergic reaction in a sensitive client.

Elevating the legs above the heart or wearing antiembolism stockings is a strategy for

alleviating venous congestion and may worsen peripheral arterial disease.

More severe strains may cause spasms

along with more intense pain and possible swelling.

Regular exercise for those with claudication helps open up

alternative small vessels (collateral flow) and the limitation in walking often improves.

Acute bone pain and confusion are associated with

aluminum intoxication, another potential complication of dialysis.

What is ABPM?

ambulatory BP monitoring - necessary for those with white coat phenomenon. It's a noninvasive system that measures BP at specific intervals over a 24 hour period

In severe cases oligohydramnios may be treated with

amnioinfusion during labor to prevent umbilical cord compression.

An amplitude decrease would support the nurse's suspicion because fluid surrounding the heart, such as in cardiac tamponade, suppresses the

amplitude of the QRS complexes on an ECG.

pulsus pardaxous

an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mm Hg.

Allograft tissue, taken from

another person, takes longer to incorporate into the recpient'sr body, but there is no second surgical site to heal. Also, the surgical time and hospital stay may be shorter when allograft tissue is used.

Leads V1 and V2 record electrical events on th

anterior surface of the right ventricle and the anterior surface of the left ventricle.

Leads V1 and V2 record electrical events on the

anterior surface of the right ventricle and the anterior surface of the left ventricle.

A client with COPD typically has a barrel chest in which the

anteroposterior diameter is larger than the transverse chest diameter

treatment of chorioamnionitis

antibiotics (amoxicillin + gentamicin + metronidazole) for the mother, and quickly delivering the baby

Amantadine and diphenhydramine enhance the effects of

anticholinergic agents.

Propantheline is an

anticholinergic, antispasmodic medication that decreases vagal stimulation and pancreatic secretions

Frank hematuria indicates excessive

anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin.

Sulfisoxazole and other sulfonamides are chemically related to oral

antidiabetic agents and may precipitate hypoglycemia.

amphotericin B, an

antifungal agent,

Vitamin E is a powerful

antioxidant that helps to prevent oxidation of the cell membrane.

For gallbladder disease, propantheline has an

antispasmodic effect on the bile duct and gallbladder. Although the medication reduces the production of gastric solutions as well as hypermotility, these aren't the main reasons for the medication.

Other indicators of hypothyroidism are the presence of

antithyroid antibodies and elevation of the creatine phosphokinase (CPK-MM) level.

Dextromethorphan is the most widely used

antitussive in the United States because it produces few adverse reactions while effectively suppressing a cough.

Amantadine, an

antiviral agent

The S2 results from closing of the

aortic and pulmonic valves.

A diastolic, blowing, decrescendo murmur accompanies

aortic insufficiency.

A systolic, harsh, crescendo-decrescendo murmur occurs with

aortic stenosis.

Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with

appendicitis.

subtotal gastrectomy 24 hours ago. The client has a nasogastric (NG) tube. The nurse should:

apply suction continuously — not every hour.

One goal of care for a client with PVD is to decrease anxiety, so as to decrease or prevent vasoconstriction of the:

arteries

Normal serum albumin is administered to reduce

ascites

Hypoalbuminemia, a mechanism underlying

ascites formation, results in decreased colloid osmotic pressure.

Broccoli and brussels sprouts are good sources of

ascorbic acid (vitamin C).

Reusing a suction catheter is not consistent with

aseptic technique.

Lozenges will increase saliva production, increasing the client's risk of

aspiration.

Although steroids should be given during surgery to prevent hypocortisolism, the nurse should

assess the client for it.

Indications for Serevent include only

asthma and bronchospasm induced by chronic obstructive pulmonary disease.

Clients who take only one daily dose of ranitidine are usually advised to take it

at bedtime to inhibit nocturnal secretion of acid.

Thickening of the intima and media of the artery is characteristic of

atherosclerosis.

For the client with an ET tube, the most important nursing action is

auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery.

The most common causes of primary adrenocortical insufficiency are

autoimmune destruction (70%) and tuberculosis (20%).

addison process is believed to be

autoimmune in nature.

PKU is an

autosomal recessive disorder involving the absence of an enzyme needed to metabolize the essential amino acid, phenylalanine, to tyrosine.

pvd Although heat promotes vasodilation, use of a heating pad is to be

avoided to reduce the risk of thermal injury secondary to diminished sensation.

A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? a) "See the physician if complications occur." b) "Practice meticulous foot care." c) "Consider cutting down on your smoking." d) "Reduce your level of exercise."

b) "Practice meticulous foot care." Explanation: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.

Usually why are women more likely to die of CAD?

because angina is usually their precursor symptom, they are less likely to report it, which results in more frequent sudden cardiac death

What is the normal pH range for arterial blood? a) 7 to 7.49 b) 7.35 to 7.45 c) 7.50 to 7.60 d) 7.55 to 7.65

b) 7.35 to 7.45

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? a) Instruct the client to breathe into a paper bag. b) Administer oxygen by nasal cannula as prescribed. c) Auscultate breath sounds bilaterally every 4 hours. d) Encourage the client to deep-breathe and cough every 2 hours.

b) Administer oxygen by nasal cannula as prescribed.

Which of the following diagnostic tests are used to quantify venous reflux and calf muscle pump ejection? a) Lymphangiography b) Air plethysmography c) Lymphoscintigraphy d) Contrast phlebography

b) Air plethysmography Explanation: Air plethysmography is used to quantify venous reflux and calf muscle pump action. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at present intervals. Lymphoangiography provides a way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.

A 29-year-old client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? a) Droplet precautions b) Airborne and contact precautions c) Contact and droplet precautions d) Contact precautions

b) Airborne and contact precautions

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? a) Neither venous nor arterial b) Arterial insufficiency c) Trauma d) Venous insufficiency

b) Arterial insufficiency Explanation: Characteristics of arterial insuffiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterier tibial area.

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a) Immediately before a meal b) At least 2 hours after a meal c) When bronchospasms occur d) When secretions have mobilized

b) At least 2 hours after a meal

Which of the following is a characteristic of an arterial ulcer? a) Brawny edema b) Border regular and well demarcated c) Ankle-brachial index (ABI) > 0.90 d) Edema may be severe

b) Border regular and well demarcated Explanation: Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.

When a client's ventilation is impaired, the body retains which substance? a) Sodium bicarbonate b) Carbon dioxide c) Nitrous oxide d) Oxygen

b) Carbon dioxide

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? a) Slow heart rate and high blood pressure b) Constant, intense back pain and falling blood pressure c) Constant, intense headache and falling blood pressure d) Higher than normal blood pressure and falling hematocrit

b) Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. The nurse performs the initial physical assessment. Which signs and symptoms should the nurse expect to find? a) Decreased respiratory rate b) Dyspnea on exertion c) Barrel chest d) Shortened expiratory phase e) Clubbed fingers and toes f) Fever

b) Dyspnea on exertion c) Barrel chest e) Clubbed fingers and toes

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? a) Elevation of the legs above the heart b) Keeping the legs in a neutral or dependent position c) Application of ace wraps from the toe to below the knees d) Use of antiembolytic stockings

b) Keeping the legs in a neutral or dependent position Explanation: Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations? a) Simple mask b) Nonrebreather mask c) Face tent d) Nasal cannula

b) Nonrebreather mask

Postpericardiotomy syndrome may occur in patients who undergo cardiac surgery. The nurse should be alert to which of the following clinical manifestations associated with this syndrome? a) Decreased white blood cell (WBC) count b) Pericardial friction rub c) Decreased erythrocyte sedimentation rate (ESR) d) Hypothermia

b) Pericardial friction rub Explanation: The syndrome is characterized by fever, pericardial pain, pleural pain, dyspnea, pericardial effusion, pericardial friction rub, and arthralgia. Leukocytosis (elevated WBCs) occurs, along with elevation of the ESR.

An elderly client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? a) Septicemia b) Pneumonia c) Meningitis d) Pulmonary edema

b) Pneumonia

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a) Check for an apical pulse. b) Suction the client's artificial airway. c) Increase the oxygen percentage. d) Ventilate the client with a handheld mechanical ventilator.

b) Suction the client's artificial airway.

The patient has had biomarkers drawn after complaining of chest pain. Which diagnostic of myocardial infarction remains elevated for as long as 3 weeks? a) Total CK b) Myoglobin c) Troponin d) CK-MB

b) Troponin Explanation: Troponin remains elevated for a long period, often as long as 3 weeks, and it therefore can be used to detect recent myocardial damage. Myoglobin returns to normal in 12 hours. Total CK returns to normal in 3 days. CK-MB returns to normal in 3 to 4 days

The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: a) helping him communicate. b) keeping his airway patent. c) encouraging him to perform activities of daily living. d) preventing him from developing an infection.

b) keeping his airway patent.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: a) loss of hair on the lower portion of the left leg. b) left calf circumference 1" (2.5 cm) larger than the right. c) pallor and coolness of the left foot. d) a decrease in the left pedal pulse.

b) left calf circumference 1" (2.5 cm) larger than the right. Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

Raloxifene hydrochloride (Evista), an estrogen receptor modulator, increases

bone mineral density without stimulating the endometrium.

Steroid use causes calcium to leave

bone, suppressing parathyroid hormone.

Pelvic rocking helps to relieve

backache during pregnancy and early labor by making the spine more flexible.

It typically results from

bacteria ascending into the uterus from the vagina and is associated with prolonged labor.

Nitrous oxide is a potent vasodilator released by the vascular endothelium in response to the body's compensatory mechanisms, why is this a good thing for patients with HF?

because vasodilators decrease afterload, which decreases the workload of the LV

digixin A nurse usually takes a serum sample immediately

before administering the daily maintenance dose, about 24 hours after the previous dose.

check for lice

behind the ear

How should BP be taken in an assessment?

bilaterally, use arm with higher reading for subsequent measurement

A nurse should question the order for morphine sulfate because it is believed to cause

biliary spasm. Thus, the preferred opioid analgesic to treat cholecystitis is meperidine (Demerol).

Hyperbilirubinemia refers to an increase in

bilirubin in the blood and is not associated with IVH.

Adult lice usually

bite the scalp behind the ears and along the back of the neck.

What is the most severe type of HF?

biventricular HF

A bleeding ulcer produces

black, tarry stools.

There is no need for the client to stay on a

bland diet after a laparoscopic cholecystectomy. The client should, however, avoid excessive fats.

What is the major adverse effect of fibrinolytic therapy?

bleeding

Common examples of vesicles include

blisters and the lesions caused by chickenpox and herpes simplex

Most institutions use tubing especially for platelets instead of tubing for

blood and blood product

Color Doppler imaging ultrasonography identifie

blood flow through the umbilical cord.

The thyroid gland doesn't regulate

blood glucose levels; therefore, signs and symptoms of hypoglycemia aren't relevant for this client. Dehydration is seen in diabetes insipidus.

subdural hematoma is a collection of

blood on the surface of the brain.

To determine pulsus paradoxus, the nurse should measure

blood pressure in either arm as the client slowly exhales and then as the client breathes normally. Unless the client has cardiac tamponade, the two measurements are usually less than 10 points apart.

The liver is vital in the synthesis of clotting factors, so when it's diseased or dysfunctional, as in hepatitis C, bleeding occurs. Treatment consists of administering

blood products that aid clotting. These products include fresh frozen plasma containing fibrinogen and cryoprecipitate, which have most of the clotting factors.

Hypokinesia refers to decreased

bodily movement

Allograft tissue transplants are not rejected by the

body as with organ transplants, so that it is not necessary to use drugs to suppress

Vitamin D and calcium are necessary for

bone healing

arsenic exposure After the acute phase

bone marrow depression, encephalopathy, and sensory neuropathy occur.

Three-point gait

both crutches and involved leg are advanced together, then uninvolved leg is advanced forward; indicated for use with involvement of one extremity , e.g. lower extremity fracture.

treat botulism You will get

botulinus antitoxin.

Abdominal discomfort secondary to constipation will be relieved after the client has a

bowel movement; an opioid would contribute to the constipation.

Removing the sheath after cardiac catheterization may cause a vasovagal response, including

bradycardia. The nurse should have atropine on hand to increase the client's heart rate if this occurs

Parasympathetic hyperactivity leading to sudden hypotension secondary to

bradyrhythmia causes vasovagal syncope. That is, bradyrhythmia leads to cerebral ischemia which, in turn, leads to syncope.

What lab level is checked to determine the level of HF?

brain natriuretic peptide (BNP) would be high because they are endothelin and aldosterone agonists, and the heart wants to block their actions as a counterregulatory mechanism.

Foods high in potassium include

bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.

Gavage (guh-vahj) feeding is a way to provide

breastmilk or formula directly to your baby's stomach. A tube placed through your baby's nose (called a Nasogastric or NG tube) carries breast milk/formula to the stomach.

legionnaires' disease recieved from

breathing in bacteria from aerosols or ac or water

Drainage during the first 6 to 12 hours contains some

bright red blood, but large amounts of blood or excessive bloody drainage should be reported to the physician promptly.

Blood-tinged secretions are common for several hours after

bronchoscopy, especially if a biopsy was obtained. A respiratory rate of 13 breaths/minute is within normal limits.

Bile is created in the liver, stored in the gallbladder, and released into the duodenum giving stool its

brown color. A bile duct obstruction can cause pale colored stools.

About 12 to 24 hours after a subtotal gastrectomy, gastric drainage is normally

brown, which indicates digested blood

resp acidosis is

build up of acid which can cause heart problems and shock

A common finding of IVH intraventricular hemorrhaging is

bulging fontanel.

A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction? a) "I will have to take the medication for up to a year." b) "This disease may come back later if I am under stress." c) "I will stay in isolation for at least 6 weeks." d) "I will always have a positive test for tuberculosis."

c) "I will stay in isolation for at least 6 weeks."

A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? a) "Reduce your level of exercise." b) "See the physician if complications occur." c) "Practice meticulous foot care." d) "Consider cutting down on your smoking."

c) "Practice meticulous foot care." Explanation: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.

In a patient with a bypass graft, the distal outflow vessel must be at least what percentage patent for the graft to remain patent? a) 40 b) 30 c) 50 d) 20

c) 50 Explanation: The distal outflow vessel must be at least 50% patent for the graft to remain patent.

When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction? a) Avoid using cornstarch on the feet. b) Avoid using a nail clipper to cut toenails. c) Avoid wearing canvas shoes. d) Avoid wearing cotton socks.

c) Avoid wearing canvas shoes. Explanation: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, and perspiration can cause skin irritation and breakdown. Cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

Which task can be safely delegated to a licensed practical nurse (LPN)? a) Teaching a newly diagnosed diabetic about insulin administration. b) Admitting a client who underwent a thoracotomy to the nursing unit from the postanesthesia care unit. c) Changing the dressing of a client who underwent surgery two days ago. d) Administering an I.V. bolus of morphine sulfate to a client experiencing incisional pain

c) Changing the dressing of a client who underwent surgery two days ago.

A recent immigrant from Vietnam is diagnosed with pulmonary tuberculosis (TB). Which intervention is most important for the nurse to implement with this client? a) Client teaching about the cause of TB b) Reviewing the risk factors for TB c) Developing a list of people with whom the client has had contact d) Client teaching about the importance of TB testing

c) Developing a list of people with whom the client has had contact

Which of the following are characteristics of arterial insufficiency? a) Aching, cramping pain b) Superficial ulcer c) Diminished or absent pulses d) Pulses are present, may be difficult to palpate

c) Diminished or absent pulses Explanation: A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a) Elevated blood pressure and rapid respirations b) Decreased pulse rate and blood pressure c) Increased abdominal and back pain d) Retrosternal back pain radiating to the left arm

c) Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

A client who sustained a pulmonary contusion in a motor vehicle accident develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? a) Excess fluid volume related to excess sodium intake b) Acute pain related to tissue trauma c) Ineffective breathing pattern related to tissue trauma d) Activity intolerance related to insufficient energy to carry out activities of daily living

c) Ineffective breathing pattern related to tissue trauma

A client is receiving conscious sedation while undergoing bronchoscopy. Which assessment finding should receive the nurse's immediate attention? a) Absent cough and gag reflexes b) Blood-tinged secretions c) Oxygen saturation of 90% d) Respiratory rate of 13 breaths/min

c) Oxygen saturation of 90%

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) Bicarbonate (HCO3-) c) Partial pressure of arterial oxygen (PaO2) d) Partial pressure of arterial carbon dioxide (PaCO2)

c) Partial pressure of arterial oxygen (PaO2)

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? a) Bleeding time b) Platelet count c) Prothrombin time (PT) d) Partial thromboplastin time (PTT)

c) Prothrombin time (PT) Explanation: PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose appoximately 99% of bleeding disorders on the basis of PT and PTT values.

Intermittent, painless vaginal bleeding is a classic symptom of

cervical cancer, but given the client's history, bleeding in more likely a result of the radiation.

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? a) Increasing blood pressure and monitoring fluid intake and output b) Decreasing blood pressure and increasing mobility c) Stabilizing heart rate and blood pressure and easing anxiety d) Increasing blood pressure and reducing mobility

c) Stabilizing heart rate and blood pressure and easing anxiety Explanation: For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.

The nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority? a) Avoid contact with fur-bearing animals. b) Change filters on heating and air conditioning units frequently. c) Take prescribed medications as scheduled. d) Avoid goose down pillows.

c) Take prescribed medications as scheduled.

Which of the following is the most common site for a dissecting aneurysm? a) Cervical area b) Sacral area c) Thoracic area d) Lumbar area

c) Thoracic area Explanation: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Vital capacity b) Functional residual capacity c) Tidal volume d) Maximal voluntary ventilation

c) Tidal volume

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? a) Make inhalation longer than exhalation. b) Exhale through an open mouth. c) Use diaphragmatic breathing. d) Use chest breathing.

c) Use diaphragmatic breathing.

or a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a) Encouraging the client to drink three glasses of fluid daily b) Keeping the client in semi-Fowler's position c) Using a high-flow Venturi mask to deliver oxygen as prescribed d) Administering a sedative as prescribed

c) Using a high-flow Venturi mask to deliver oxygen as prescribed

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: a) pleural effusion. b) pulmonary edema. c) atelectasis. d) oxygen toxicity.

c) atelectasis.

Human papillomavirus can lead to

cervical cancer.

syphyllis 1st stage

chancres are: On the vulva (outside the vagina) or on the cervix (neck of the womb) in women. On the penis in men. Around the anus and mouth (both sexes).

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: a) elevate the affected leg as high as possible. b) place a heating pad around the affected calf. c) keep the affected leg level or slightly dependent. d) shave the affected leg in anticipation of surgery.

c) keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

A late complication of radiation therapy includes a) xerostomia. b) dysphasia. c) laryngeal necrosis. d) pain.

c) laryngeal necrosis. Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy..

Weight loss — not gain — is an indication of

colorectal cancer.

Stool Hematest detects blood, which is a sign of

colorectal cancer; however, the test doesn't confirm the diagnosis.

Increased AFP levels are associated with

neural tube defects, such as spina bifida, anencephaly, and encephalocele.

Clients with stress incontinence are encouraged to avoid substances, such a

caffeine and alcohol, that are bladder irritants.

PARATHYROID GLAND produce parathyroid hormone, which controls

calcium, phosphorus, and vitamin D levels within the blood and bone.

A SINGLE episode of urinary tract infection is not as likely to lead to

calculi formation as a routinely low fluid intake.

The increase in venous pressure results in an increase in

capillary hydrostatic pressure, which causes a net filtration of fluid out of the capillaries into the interstitial space, resulting in edema.

In metabolic alkalosis, the body tries to compensate by conserving

carbon dioxide, so there is no need to have the client inhale carbon dioxide, as would be the case if hyperventilation were occurring.

The peak incidence of cervical cancer is

carcinoma in situ is 20 to 30 years of age in African-American and Caucasian women.

Adverse effects of pseudoephedrine (Sudafed) are experienced primarily in the

cardiovascular system and through sympathetic effects on the central nervous system (CNS).

Salivary fistula or skin necrosis usually precedes

carotid artery rupture

To compensate for the patient's profoundly diminished plasma volume,

catecholamines increase cardiac output and myocardial contractility. But these effects won't be strong enough to keep his blood pressure up.

mechanical ventilation

cause decreased cardiac output

How does valve disease contribute to systolic HF?

causes mechanical problems in the heart

Decreased RBC production diminishes

cellular oxygen, leading to fatigue and weakness.

The client who cannot assign meaning to sound has

central hearing loss.

Access is also needed for TPN, preferably via a \

central line.

Clonidine (Catapres) is a

central-acting adrenergic antagonist.

Ventricular remodeling (or cardiac remodeling)[1] refers to the

changes in size, shape, structure and physiology of the heart after injury to the myocardium mi

note with htn question also

check compliance its leading cause of complications

epidural for L & D, To provide the safest care for this client the nurse should

check if she can walk not dangling she has epidural so see if legs can move

By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without

chest pain. Severe chest pain should not be present on day 2 after and MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehabilitation program

Hemothorax is a collection of blood in the space between the

chest wall and the lung (the pleural cavity).

Amantadine, digoxin, and diphenhydramine can interact with a

cholinergic blocking agent but not through delayed absorption.

Diaphoresis and increased salivation are not present in

cholinergic crises.

question said someone had hemicolectomy and was having issues with eating what is needed tpn or jejunostomy

choose tpn because its parenteral versus jejunostomy which is enteral not as much nutrients

Additional oral cancer risk factors include

chronic irritation such as a broken tooth or ill-fitting dentures, poor dental hygiene, overexposure to sun (lip cancer), and syphilis.

burns Hemoconcentration, not hemodilution, is caused by

circulatory dehydration as plasma shifts into the extracellular space.

buerger disease Signs and symptoms include slowly developing

claudication, cyanosis, coldness, and pain at rest.

autograft It is important to keep donor site

clean, dry, and free of pressure.

The radiated skin area needs to be kept

clean, dry, and open to air.

Rehabilitation efforts are implemented as soon as the

client's condition is stabilized.

a fib Because of the poor emptying of blood from the atrial chambers, there is an increased risk for .

clot formation around the valves.

To prevent a photosensitivity reaction, the client should avoid direct sunlight during

co-trimoxazole therapy

heat stroke Cool liquids are easier to drink than

cold liquids.

Vasospastic disorder (Raynaud's disease) is a form of intermittent arteriolar vasoconstriction that results in

coldness, pain, and pallor of the fingertips, toes, or tip of the nose, and a rebound circulation with redness and pain.

The most common cancers that elevate CEA are in the

colon and rectum. Others: cancer of the pancreas, stomach, breast, lung, and certain types of thyroid and ovarian cancer.

Colorectal polyps are common with

colon cancer.

CEA may be elevated in

colorectal cancer but isn't considered a confirming test

An abdominal CT scan is used to stage the presence of

colorectal cancer.

gonorrhea The client should avoid sexual intercourse until treatment is

completed, and a follow-up culture confirms that the infection has been eradicated (which usually takes 4 to 7 days).

Curling's ulcer is an acute peptic ulcer of the duodenum resulting as a \

complication from severe burns when reduced plasma volume leads to sloughing of the gastric mucosa

The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation

complications and the audible crackles that may result from fluid overload from the I.V. line

Early emphasis on rehabilitation is important to decrease

complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence

bronchopulmonary dysplasia typically occurs in

compromised very-low-birth-weight neonates who require oxygen therapy and assisted ventilation for treatment of respiratory distress syndrome.

Polyhydramnios is a medical

condition describing an excess of amniotic fluid in the amniotic sac.

Dyshidrotic eczema is a

condition in which small, usually itchy blisters develop on the hands and feet

Contact dermatitis is a

condition in which the skin becomes red, sore, or inflamed after direct contact with a substance.

Dialysis equilibrium syndrome causes

confusion, a decreasing level of consciousness, headache, and seizures.

Arteriovenous malformation or AVM is an abnormal

connection between veins and arteries, usually congenital, congenital malformed blood vessels in the ventricles

Accompanying symptoms of prostate cancer can includ

constipation, weight loss, and lymphadenopathy.

Caring for client infected with vancomycin-resistant enterococci requires

contact precautions.

Bile is not clear and is not green unless it comes in

contact with gastric fluid.

Placing a thin piece of gauze over the tracheostomy during sexual activity will help to

contain the secretions and yet allow ventilation.

The recommended procedure for teaching clients postoperatively to deep breathe includes

contracting (pulling in) the abdominal muscles and taking a slow, deep breath through the nose. This breath is held 3 to 5 seconds, which facilitates alveolar ventilation by improving the inspiratory phase of ventilation.

New laryngectomy clients may find air-conditioning too

cool and dry at first so they should avoid such environments

The recommended emergency treatment for a heat burn is immersion in

cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue.

Droplet transmission occurs when the person

coughs or sneezes and releases large respiratory droplets into the air. these droplets are heavy and fall to surfaces rapidly, usually falling within 3 feet of the patient.

80 year old SPINAL anesthesia and 4,000 ml of room temperature isotonic bladder irrigation it is important to

cover this client with warm blankets because he is at high risk for hypothermia secondary to age, spinal anesthesia,

risk for colorectal cancer

crohns and ulcerative

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?

cross country skiing

The client with conjunctivitis can use warm soaks to remove

crusting

Pink-tinged urine and bladder spasms are common after

cystoscopy.

Bloody diarrhea is indicative of

cytomegalovirus infection

Which of the following medications is considered a thrombolytic? a) Heparin b) Lovenox c) Coumadin d) Alteplase

d) Alteplase Explanation: Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots.

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? a) Nonproductive cough and abdominal pain b) Hypertension and lack of fever c) Bradypnea and bradycardia d) Chest pain and dyspnea

d) Chest pain and dyspnea

The nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? a) Nonproductive cough and normal temperature b) Sore throat and abdominal pain c) Hemoptysis and dysuria d) Dyspnea and wheezing

d) Dyspnea and wheezing

The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the client is using the spirometer properly. During each waking hour, the client should perform a minimum of how many sustained, voluntary inflation maneuvers? a) One to two b) Three to four c) Five to seven d) Eight to ten

d) Eight to ten

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hypotension, hyperoxemia, and hypercapnia b) Hyperventilation, hypertension, and hypocapnia c) Hyperoxemia, hypocapnia, and hyperventilation d) Hypercapnia, hypoventilation, and hypoxemia

d) Hypercapnia, hypoventilation, and hypoxemia

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? a) Fever b) Tachypnea c) Tachycardia d) Hypotension

d) Hypotension

The burn should be kept moist to prevent the

dressing adhering to the wound. Warm, mild soap solutions would be contraindicated because they are irritating to the injured tissue.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? a) Vertigo b) Dizziness c) Acute limb ischemia d) Intermittent claudication

d) Intermittent claudication Explanation: The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a) Nausea or vomiting b) Abdominal pain or diarrhea c) Hallucinations or tinnitus d) Light-headedness or paresthesia

d) Light-headedness or paresthesia

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? a) Respiratory alkalosis b) Respiratory acidosis c) Metabolic alkalosis d) Metabolic acidosis

d) Metabolic acidosis

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? a) An active daily walking program b) A history of diabetes mellitus c) History of increased aspirin use d) Recent pelvic surgery

d) Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

When the patient diagnosed with angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing which type of angina? a) Variant b) Refractory c) Intractable d) Unstable

d) Unstable Explanation: Unstable angina is also called crescendo or preinfarction angina and indicates the need for a change in treatment. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment. Variant angina is described as pain at rest with reversible ST-segment elevation and is thought to be caused by coronary artery vasospasm. Intractable or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? a) Trauma b) Arterial insufficiency c) Neither venous nor arterial insufficiency d) Venous insufficiency

d) Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: a) lung vibrations b) vocal sounds c) breath sounds d) chest movements

d) chest movements

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: a) place a heating pad around the affected calf. b) elevate the affected leg as high as possible. c) shave the affected leg in anticipation of surgery. d) keep the affected leg level or slightly dependent.

d) keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

Bandages for burns may be elasticized and often are used to form an

occlusive pressure dressing.

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a) pH, 7.5; PaCO2 30 mm Hg b) pH, 7.40; PaCO2 35 mm Hg c) pH, 7.35; PaCO2 40 mm Hg d) pH, 7.25; PaCO2 50 mm Hg

d) pH, 7.25; PaCO2 50 mm Hg

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: a) metabolic acidosis. b) metabolic alkalosis. c) respiratory acidosis. d) respiratory alkalosis.

d) respiratory alkalosis.

The nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? a) Inspection b) Chest X-ray c) Arterial blood gas (ABG) levels d)Auscultation

d)Auscultation

Abrupt withdrawal of endogenous cortisol may lead to

severe adrenal insufficiency.

Biliary drainage tubes (T tubes) are placed in the common bile duct and drain bile, which is

dark yellow-orange

An alteration in the protective pressure sensation results from a

decline in the number of Meissner's and pacinian corpuscles.

What is the goal for someone with systolic HF?

decrease afterload

Steroids are used in severe flare-ups because they can

decrease the incidence of bleeding

Hemodilution

decreased concentration (as after hemorrhage) of cells and solids in the blood resulting from gain of fluid

ivh signs are

decreased hematocrit, and increasing hypoxia. Seizures also may occur

A client who is free from infection will most likely have

decreased oxygen requirements versus normal temperature

COPD have CO2 retention and the respiratory drive is stimulated when the PO2

decreases so if have alarming labs like p02 of 70 pco2 of 66 check vitals because you cant give to much oxygen it will stop breathing

Pain in the calf is common with a diagnosis of

deep vein thrombosis.

Oligohydramnios is a condition in pregnancy characterized by a

deficiency of amniotic fluid.

Diabetes insipidus is caused by a

deficiency of antidiuretic hormone, which results in excretion of a large volume of dilute urine, urine specific gravity of less than 1.005 should be reported.

Uterine atony, or relaxed uterus, may occur after

delivery, leading to postpartum hemorrhage.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation. Explanation: Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.

TIS, N0, M0

denotes carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis

Repositioning the client every 2 hours helps prevent secretions from pooling in

dependent lung areas.

For the first few weeks after CABG surgery, clients commonly experience

depression, fatigue, incisional chest discomfort, dyspnea, and anorexia.

Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the

detection of two-thirds of all colorectal cancers.

A prolonged QT interval is significant because it can lead to the

development of polymorphic ventricular tachycardia, also known as torsades de pointes.

Increasing glycosuria is a symptom of poorly managed

diabetes.

The CEA blood test is not reliable for

diagnosing cancer or as a screening test for early detection of cancer

HSV infection is one of a group of disorders that, when diagnosed in the presence of HIV infection, are considered to be

diagnostic for AIDS

An upper GI series, or barium study, usually isn't the

diagnostic method of choice, especially in a client with acute active bleeding who's vomiting and unstable

Trimethoprim-sulfamethoxazole is most likely to cause

diarrhea. Nausea and vomiting are other common adverse effects.

Mitral stenosis causes a

diastolic, rumbling, low-pitched murmur audible at the apex

Dopamine is responsible for what?

dilating renal blood vessels

dic As blood collects in the peritoneal cavity, it causes

dilation and distention, which is reflected in increased abdominal girth. The client would be tachycardic and hypotensive. Petechiae reflect bleeding in the skin.

During the intermediate phase of burn care, the client's hematocrit should

diminish as a result of hemodilution, which occurs as the fluids shift back into the circulating blood volume from the tissues

In emphysema, the anteroposterior diameter of the chest wall is increased. As a result, the client's breath sounds may be

diminished.

a fib The clots become

dislodged and travel through the circulatory system. As a result, cerebrovascular accident is a common complication

The nurse should wrap the client's arms and legs from the

distal to proximal ends and use strict sterile technique throughout the dressing change.

Because the contrast medium used in PTCA acts as an osmotic diuretic, the client may experience

diuresis with resultant fluid volume deficit after the procedure. Additionally, potassium levels must be closely monitored because the client may develop hypokalemia due to the diuresis.

balanced suspension traction The client should be positioned so that the feet

do not press against the footboard. Therefore, elevating the head of the bed no more than 25 degrees is recommended to keep the client from moving down in the bed.

Catheterization isn't routine

done in the 4th stage of deliver to protect the bladder from trauma. It's done, for a postpartum complication of urinary retention.

Constipation lasting 3 days or longer is unusual in this client and warrants immediate action. However, because the client had chemotherapy with

doxorubicin (Adriamycin) 10 days ago, she is susceptible to infection and should avoid rectal medications and treatments

Clinical manifestations include

severe eye pain, colored halos around lights, and rapid vision loss.

nasal surgery, the client has packing in the nose Mouth-breathing

dries the oral mucous membranes. Frequent mouth care is necessary for comfort and to combat the anorexia associated with the taste of blood and loss of the sense of smell.

Immediately after laparoscopic cholecystectomy surgery, the client will

drink liquids. A light diet can be resumed the day after surgery.

legionnaires' disease signs are

dry cough, myalgia, gi issues , diarrhea pneumonia and heart problems

A cholinergic blocking agent may cause

dry mouth and delay the sublingual absorption of nitroglycerin

stomatitits Lemon-glycerin swabs should be avoided because they are

drying and also can promote bacterial growth.

Which diagnostic test does the nurse expect the client with psteoporosis to undergo

dual-energy x ray absorption

trach tube surgery after A nasogastric (NG) tube is usually inserted

during surgery to allow for enteral feedings postoperatively.

Insufficient secretion of GH causes

dwarfism or growth delay.

complication of deep vein thrombosis is pulmonary embolism

dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis),

The risk of developing chorioamnionitis increases with

each vaginal examination including during labor

Oropharyngeal candidiasis, or thrush, is the most common infection associated with the

early symptomatic stages of HIV infection.

An increased serum albumin level and increase

ease of breathing may indirectly imply that the administration of albumin is effective in relieving the ascites.

The client taking dexamethasone needs to know the early signs of Cushing's disease, which include

easy bruising, moonface, buffalo hump, and osteoporosis.

hiatal hernina To minimize intra-abdominal pressure and decrease gastric reflux, the client should

eat frequent, small, bland meals that can pass easily through the esophagus. Meals should be high in fiber to prevent constipation and minimize straining on defecation (which may increase intra-abdominal pressure from the Valsalva maneuver).

Wrapping elastic bandages on dependent areas limits

edema formation and bleeding and promotes graft acceptance.

Karaya and Stomahesive are both

effective agents for protecting the skin around a colostomy. They keep the skin healthy and prevent skin irritation from stoma drainage.

radiation care Clients should use an

electric razor, instead of a straight-edge razor, on any skin areas that are receiving radiation.

Leads V3 and V4 record

electrical events in the septal region of the left ventricle.

Leads II, III, and aVF record

electrical events on the inferior surface of the left ventricle.

What is secondary HTN?

elevated bp with a specific cause

Bullae are

elevated, fluid-filled lesions greater than 0.5 cm in diameter; an example is a 0.5 blister.

Cysts, such as sebaceous cysts, are

elevated, thick-walled lesions containing fluid or semisolid matter

A complication of balloon valvuloplasty is

emboli resulting in a stroke.

Pain from a kidney stone is considered an

emergency situation and requires analgesic intervention.

A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

empyema.

Pneumothorax will cause a client to feel extremely short of breath. Semi- or high- Fowler's position will

facilitate ventilation by the unaffected lung. Positioning the client toward the affected side does not compromise the remaining, functional lung.

Clients with autoimmune disorders may have either

false-positive or false-negative serologic tests for syphilis.

A woman with a uterus who takes unopposed estrogen has an increased risk of

endometrial cancer. The addition of progesterone prevents the formation of endometrial hyperplasia.

necrotizing pancreatitis TPN is considered if

enteral feedings are contraindicated. .

Applying pressure against the nose at the inner canthus of the closed eye after administering eyedrops prevents the medication from

entering the lacrimal (tear) duct. If the medication enters the tear duct, it can enter the nose and pharynx, where it may be absorbed and cause toxic symptoms

Anxiety stimulates the sympathetic nervous system, which results in the secretion of

epinephrine, angiotensin, and serum proteins that cause vasoconstriction in the arteries of the peripheral circulatory system. As a result, peripheral vascular resistance is increased.

Because aerobic exercise may increase blood pressure and increased blood pressure can cause

epistaxis, the client with hypertension should avoid it.

The nurse requests an order from the physician to change the dose to an

equianalgesic dose of morphine

Metoclopramide hydrochloride (Reglan) increases

esophageal sphincter tone and facilitates gastric emptying; both actions reduce the incidence of reflux.

Acetone in the urine would indicate

excessive fat catabolism

pku testing the infant before that time

excessive vomiting, or poor intake can yield false-negative results.

Serevent can be used to prevent

exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking

It may be done before or after

exercise.

Squamous cell carcinoma commonly develops on the skin of the

face, the ears, the dorsa of the hands and forearms, and other sun-damaged areas.

Early clinical manifestations of cirrhosis are subtle and usually include

gastrointestinal symptoms, such as anorexia, nausea, vomiting, and changes in bowel patterns. These changes are caused by the liver's altered ability to metabolize carbohydrates, proteins, and fats

botulism Patients who have trouble swallowing may

getintravenous fluids. A feeding tube may be inserted.

molecular formula

gives the composition of the molecules that are present

Primary Addison's disease refers to a problem in the

gland itself that results from idiopathic atrophy of the glands.

The gag reflex is governed by the

glossopharyngeal nerve, one of the cranial nerves.

Adults and children with gonorrhea may develop

gonococcal conjunctivitis by touching the eyes with contaminated hands

The nurse should wear a

gown, gloves, a mask, and eye protection when entering the client's room.

development of ARDS are

gram-negative septic shock and gastric content aspiration. shock cause permabiity so then there is leakage

Because such lice are tiny (1 to 2 mm) with

grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions.

On digital rectal examination, key signs of prostate cancer are a

hard prostate, induration of the prostate, and an irregular, hard nodule.

Tracheal breath sounds are

harsh, discontinuous sounds heard over the trachea during inhalation or exhalation.

In caring for a client with acute diverticulitis, which assessment data warrant immediate nursing intervention? The client

has a rigid hard abdomen and elevated white blood cell count (WBC).

hyptonic labor are

have contraction but there is no effacement of cervix or decent of the baby

dumping syndrome diet

having a diet high in protein and fat and low in carbohydrates,

copd Measures that help mobilize secretions

include drinking 2 L of fluid daily, practicing controlled pursed-lip breathing, and engaging in moderate activity.

However, after supratentorial surgery to remove a chronic subdural hematoma, the neurosurgeon may order the nurse to keep the client's

head flat; typically, the client with such a hematoma is older and has a less expandable brain

Lying flat and drinking fluids are interventions for client's experiencing

headaches from spinal anesthesia.

Adverse effects of danazol (Danocrine) include

headaches, dizziness, irritability, and decreased libido. Masculinization effects, such as deepened voice, facial hair, and weight gain, also may occur.

Raloxifene adverse effects is increased

headaches.

The tube allows the suture line to

heal adequately, minimizes contamination of the pharyngeal and esophageal suture lines, and prevents fluid from leaking through the wound into the trachea before healing occurs.

The temporal lobe controls

hearing, language comprehension, and storage and memory recall (although memory recall is also stored throughout the brain)

What is an abnormal clinical syndrome involving impaired cardiac pumping or filling?

heart failure

dvt The extremity should be kept elevated with

heat applied to treat the inflammation and pain

pad To avoid burns,

heating pads should not be used by anyone with impaired circulation

How is pain from an MI described?

heaviness, constriction, tightness, burning, pressure, crushing

Removal of the drainage fluids assists in wound healing and is intended to decrease the incidence of

hematoma, abscess formation, and infections

Protamine sulfate is an antidote to

heparin

Hypokalemia is a precipitating factor in

hepatic encephalopathy.

Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be

hepatotoxic

stomatitis Commercial mouthwash is contraindicated because of

high alcohol content that is irritating to inflamed mucosa.

Reserpine is used to treat

high blood pressure by lowering so there is risk it could drop too much

Warm shock characterized by

high cardiac output and low peripheral vascular resistance occurs first.

For clients who have cirrhosis without complications, a

high-calorie, high-carbohydrate diet is preferred to provide an adequate supply of nutrients.

colostomy care 4 wks post op The client will not need to maintain a

high-carbohydrate or high-protein diet. Rather, the client will be encouraged to maintain a normal diet while avoiding any foods that cause odor and flatulence.

Clients with diverticulosis are encouraged to follow a

high-fiber diet. Bran, broccoli, and navy beans are foods high in fiber.

The murmur in aortic insufficiency is

high-pitched and blowing and is heard at the third or fourth intercostal space at the left sternal border.

The client with sensorineural hearing loss has difficulty hearing

high-pitched sounds.

Pinching of the tubing used to deliver oxygen causes a

high-pitched whistling sound. .

Mitral insufficiency has a

high-pitched, blowing murmur at the apex.

A nurse who suspects an air embolism should place the client on

his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system.

warm shock Vasodilation from the effects of

histamine, bradykinins, serotonin, and endorphins dramatically decrease total peripheral vascular resistance

Spontaneously occurring wheals occur in.

hives.

Beau's line is a

horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth.

multiple sclerosis who has an impaired peripheral sensation should avoid

hot because they cant feel well and cold because of it constrictive behavior

ABO compatibility is not a necessary requirement for plasma , but

human leukocyte antigen (HLA) matching of lymphocytes may be completed to avoid development of anti-HLA antibodies when multiple platelet transfusions are necessary.

Ranitidine blocks secretion of

hydrochloric acid.

. Forcing large quantities of fluid may cause

hydronephrosis if urine is prevented from flowing past calculi.

Weakness, tingling, and cardiac arrhythmias suggest

hyperkalemia, which is associated with renal failure.

di has

hypernatremia and siadah has hyponatremia

Over secretion of Prolactin

hyperprolactinoma--> abnormal milk production

Bending, lifting, and the Valsalva maneuver can precipitate

hypertensive crises They increase transabdominal pressure and may cause cardiac-stimulating effects

The client with pheochromocytoma should be instructed to avoid activities that precipitate

hypertensive crises or paroxysms, such as The Valsalva maneuver.

The TPN solution is usually

hypertonic dextrose solution.

Pyloric stenosis involves

hypertrophy of the pylorus muscle distal to the stomach and obstruction of the gastric outlet resulting in vomiting, metabolic acidosis, and dehydration.

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. In assessing the client before his scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate?

hypocalcemia

Fat necrosis occurring with acute pancreatitis can cause

hypocalcemia requiring calcium replacement

Fat necrosis occurring with acute pancreatitis can cause \

hypocalcemia requiring calcium replacement.

nephrotic syndrome has what type of calcium

hypocalcemia.

Cool, clammy skin occurs in the .

hypodynamic or cold phase (later phase). of septic shock

When taken in combination with aspirin, glipizide commonly causes

hypoglycemia

With a client in metabolic alkalosis, the nurse should monitor for

hypokalemia

Muscle spasms are not seen in

hypokalemia.

With a client in metabolic alkalosis, the nurse should monitor for

hypokalemia.

Thyroidectomy may lead to

hypoparathyroidism if the parathyroid is also removed during surgery.

The chordee is corrected when the

hypospadias is repaired. Circumcision is performed at the same time.

The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as

hypospadias.

The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe

hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued.

The chief complications of diltiazem are

hypotension, atrioventricular blocks, heart failure, and elevated liver enzyme levels. Other reported reactions include flushing, nocturia, and polyuria, but not renal failure.

A typical physical examination finding for a patient with pneumonia is

increased vocal fremitus on palpation. Other signs of pulmonary consolidation include dullness to percussion, bronchial breath sounds, and crackles in the affected area.

When calcium levels are too low, the body responds by

increasing production of parathyroid hormone

Q-waves may become evident when the injury progresses to

infarction.

Second intention healing occurs in

infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings

A boggy, tender prostate is found with

infection (e.g., acute or chronic prostatitis).

legionnaires' disease

infection caused by gram neg BACTERIA

Abdominal distention is an early sign of

infection hirshsprung and therefore the parents need to report it to the physician.

A fungus that enters the skin surface and causes

infection is a dermatophyte.

Leads II, III, and aVF record electrical events on the

inferior surface of the left ventricle

Buerger's disease is characterized by

inflammation and fibrosis of arteries, veins, and nerves. White blood cells infiltrate the area and become fibrotic, which results in occlusion of the vessels.

Chorioamnionitis is an

inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection.

Paronychia refers to an

inflammation of the skinfold at the nail margin

What is Trousseau's sign?

inflate BP cuff 10-20 mm Hg above systolic pressure, capral spasms w/in 2-5 min indicate tetany

The Sengstaken-Blakemore tube has a gastric and an esophageal balloon that are

inflated to compress bleeding esophageal varices. An inflated esophageal balloon prevents swallowing. Therefore, the nurse should provide the client with tissues and encourage him to spit into the tissues or an emesis basin.

The nurse would keep the client's head flat after

infratentorial, not supratentorial, surgery.

The most common complication after an

inguinal hernia repair is the inability to void, especially in men.

Exhalation should be longer than

inhalation to prevent collapse of the bronchioles.

In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with

inhaled bronchodilators, I.V. corticosteroids and, possibly, I.V. theophylline (Theo-Dur).

Drugs administered intradermally

injected between the skin layers just below the surface stratum corneum) diffuse slowly into the local microcapillary system.

Vitamin B12 needs to b

injected every month because the ileum has been surgically removed.

Considering that there is usually 1 L of

insensible fluid loss, this client's output exceeds his intake (intake, 2,000 ml; output, 2,200 ml), indicating deficient fluid volume.

The obturator is inserted into the replacement tracheostomy tube to guide

insertion and is then removed to allow passage of air through the tube.

Goiter attacks and severe laryngotracheitis are associated with

inspiratory stridor only.

Tuberculosis can be controlled but never completely eradicated from the body. Periods of

intense physical or emotional stress increase the likelihood of recurrence.

conductive loss

interrupted sound from external ear to junction of staples and oval window due to wax

Lymphedema after breast cancer It is caused by the

interruption or removal of lymph channels and nodes after axillary node dissection. Removal results in less efficient filtration of lymph fluid and a pooling of lymph fluid in the tissues on the affected side.

Heparin is administered subcutaneously, never

intramuscularly. A 25- or 26-gauge, ½- to 5/8-inch needle is most appropriate for heparin administration.

Clients taking metoclopramide should be instructed to report any

involuntary movements of the face, eyes, or extremities because adverse effects of the drug include extrapyramidal reactions and parkinsonism-like reactions.

An incarcerated hernia refers to a hernia that is

irreducible but has not necessarily resulted in an obstruction.

Clinical manifestations of hypokalemia include an

irregular pulse, fatigue, muscle weakness, flabby muscles, decreased reflexes, nausea, vomiting, and ileus.

Intestinal cantour tubes are not

irrigated.

Although all the options are associated with hepatitis B, the onset of

irritability and drowsiness suggests a decrease in hepatic function.

A client with metabolic alkalosis may exhibit

irritability or nervousness.

There are two kinds of contact dermatitis:

irritant or allergic.

Intertrigo refers to

irritation of opposing skin surfaces caused by friction.

CEA is tested in blood. The normal range

is <2.5 ng/ml in an adult non-smoker and <5.0 ng/ml in a smoker

DEXAMETHASONE

is a steroid for cushings

if hip is dislocated wiggling toes

is not good indicator if it occured

How does HTN manifest in the peripheral vasculature?

ischemia (PVD)

To prevent the spread of scabies

isolate the client's bed linens until the client is no longer infectious — usually 24 hours after treatment begins, wearing gloves when applying the pediculicide and during all contact with the client.

air born precaution The preferred placement is in an

isolation single-patient room that is equipped with special air handling and ventilation.

diarrhea has what type of potassium

it has low potassium because they are losing electrolytes i know you thought since diarrhea has metabolic acidosis it has low potassium the acidosis is from loss of bicarbonate acid loss and potassium loss

If a neck or spine injury is suspected, the

jaw-thrust maneuver should be used to open the client's airway.

Spinal fusion, also known as spondylodesis or spondylosyndesis, is a surgical technique used to

join two or more vertebrae. Supplementary bone tissue, either from the patient (autograft) or a donor (allograft), is used in conjunction with the body's natural bone growth (osteoblastic) processes to fuse the vertebrae.

Clinical findings for osteoarthritis include

joint pain, crepitus, Heberden's nodes (bony growths at the distal interphalangeal joints), Bouchard's nodes (growths involving the proximal interphalangeal joints), and enlarged joints.

A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?

just prior to tube feeding

autograft donar site Occlusive dressings are not used because they do not

keep the donor site dry and open to the air.

ketonuria is a sign of diabetic

ketoacidosis.

Diabetic nephropathy is

kidney disease or damage that occurs in people with diabetes.

Unilateral hydronephrosis is swelling of one

kidney due to a backup of urine

Anesthesia and analgesia can slow the process o

labor

The normal uterus is only able to distend to a certain point and when that point is reached,

labor may be initiated.

The client will probably not be able to tolerate a full meal comfortably the day after

laparoscopic cholecystectomy surgery.

Hirschsprung's disease is a blockage of the

large intestine due to improper muscle movement in the bowel.

Oral hygiene is an important aspect of self-care for the

laryngectomy client, who is less able to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth care reduces the risk of infection.

Leads I, aVL, V5, and V6 record electrical events on the

lateral surface of the left ventricle

Leads I, aVL, V5, and V6 record electrical events on the

lateral surface of the left ventricle.

Stomal stenosis may be present when there is

suprasternal and intercostal retractions and difficult breathing.

pacemaker care The client should be instructed to avoid

lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to heal and full range of motion to return.

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: a) a recent driving accident while changing lanes. b) headaches, nausea, and redness of the eyes. c) light flashes and floaters in front of the eye. d) frequent episodes of double vision.

light flashes and floaters in front of the eye. Correct Explanation: The sudden appearance of light flashes and floaters in front of the affected eye is characteristic of retinal detachment. Difficulty seeing cars in another driving lane suggests gradual loss of peripheral vision, which may indicate glaucoma. Headache, nausea, and redness of the eyes are signs of acute (angle-closure) glaucoma. Double vision is common in clients with cataracts.

A splinter hemorrhage is

linear red or brown streak in the nail bed.

Humidified air helps to

liquefy respiratory secretions, making them easier to raise and expectorate

encephalopathy is when

liver can not detoxify blood so ammonia builds up and go to the brain

Because of its location near the xiphoid process, th

liver is the organ most easily damaged from pressure exerted over the xiphoid process during CPR.

Atopic dermatitis is a

long-term (chronic) skin disorder that involves scaly and itchy rashes

How does an MI contribute to systolic HF?

loss of contractility

An aortic murmur i

loud and rough and is heard over the aortic area.

Bronchial breath sounds are

loud, high-pitched sounds normally heard next to the trachea; discontinuous, they're loudest during expiration.

herniated disc Common symptoms include

low back pain, numbness or tingling starting in the rear and radiating down one leg, or numbness or weakness in the chest, neck or arm.

di urine osmolarity is

low because there is high water less solutes

Typical signs of cardiogenic shock include

low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness.

The kidneys are concentrating urine in response to

low circulating volume, as evidenced by a urine output of less than 30 ml/hour. This indicates that increased fluid replacement is needed.

calculi can form with

low fluid intake.

thyrotoxicosis

low thyroid

Mitral stenosis has a

low-pitched rumbling murmur heard at the apex.

Hydralazine acts to

lower blood pressure by peripheral dilation without interfering with placental circulation.

morphine works by

lowers resistance, reduces cardiac workload, and decreases myocardial oxygen demand

symptoms of esophageal cancer include

lump in throat dysphagia, substernal pain, regurgitation of undigested food, foul breath, and hiccups.

CT scanning is the standard noninvasive method used in a workup for

lung cancer because it can distinguish small differences in tissue density and can detect nodal involvement.

. Diaphragmatic breathing — not chest breathing — increases

lung expansion.

burns Adherence to standard precautions requires the nurse to wear a

mask, eye goggles, gown, and gloves to prevent contamination from the irrigation.

During the emergent phase of burn management, there is a

massive shift of fluid from the blood vessels (intravascular compartment) into the tissues (interstitial compartment).

herniated disc occurs when the inner

material of a disc protrudes through the outer layer.

dont use Plain tap water for gavage because

may be contaminated. If introduced inadvertently into the lungs, it could result in damage or pneumonia.

C. trachomatis infection in women is commonly asymptomatic, but symptoms

may include a yellowish discharge and painful urination.

Urethral meatal stenosis, which can occur in circumcised infants, results from

meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision.

Good sources of vitamin B12 include

meats and dairy products.

Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged

mechanical ventilation because of the development of stress ulcers.

The dorsalis pedis pulse is found on the

medial aspect of the dorsal surface of the foot in line with the big toe.

Bronchovesicular breath sounds are

medium-pitched, continuous sounds that occur during inhalation or exhalation.

Hypertonic dextrose solutions are used t

meet the body's calorie demands in a volume of fluid that will not overload the cardiovascular system.

Fair skin with a history of sunburn and the location of the lesion on the leg (the most common site in women) suggest

melanoma.

Elderly clients should not be given

meperidine because of the risk of acute confusion and seizures in this population.

someone with diarrhea has

metabolic acidosis which is associated with loss of bicarbonate which means there is loss of base so then there is more acid

intermediate phase of burn care Loss of serum sodium leads to

metabolic acidosis, not metabolic alkalosis.

What is pain related to myocardial ischemia associated with abnormalities of the coronary microcirculation?

microvascular angina - more prevalent in women

ivh signs are

neurologic signs such as hypotonia ( low muscle tone, often involving reduced muscle strength. ), lethargy,

: Clindamycin may enhance the action o

neuromuscular blocking agents by blocking neuromuscular transmission.

Clindamycin may enhance the action of

neuromuscular blocking agents by blocking neuromuscular transmission.

abundant wbc is

neutrophil

Green, leafy vegetables are good sources of

niacin, folate, and carotenoids (precursors of vitamin A)

Breast milk has been found to heal nipples when placed on the

nipple at the completion of a feeding.

if one parent dose not have sickle sell hba and other has hbs then

no chance of sickle cell

emergent Little fluctuation in weight suggests that there is

no fluid retention and the intake is equal to output.

What type of angina only occurs at night, but not necessarily while reclined or asleep?

nocturnal angina *angina decubitus is anging experienced while lying down

The client should receiv

normal saline solution through the second I.V. site until his blood glucose level reaches 250 mg/dl.

White pulmonary secretions are

normal with deep partial-thickness and full-thickness burns on the face, arms, and chest

Cirrhosis Clients are encouraged to eat

normal, well-balanced diets and to restrict sodium to prevent fluid retention. Protein is not restricted until the liver actually fails, which is usually late in the disease.

Bradycardia for the first 7 days in the postpartum period is

normal.

Bile green or cloudy white drainage is

not expected during the first 12 to 24 hours after a subtotal gastrectomy.

In cholinergic crisis, I.V. edrophonium chloride (Tensilon), a cholinergic agent, does

not improve muscle weakness; in myasthenic crisis, it does.

illeostomy Eating six small meals a day is

not necessary.

burns The irrigation is

not painful and sedatives or pain medications are not usually necessary.

note question with pt with spinal anesthesia and 4000 ml of isotonic bladder irrigation

note it says patient is getting irrigation it dosent say that the bag is full

Stridor occurs as a result of a partially

obstructed larynx or trachea; stridor can be heard without auscultation.

Hypertension, not hypotension, is a sign

of hypoxia

Orthostatic hypotension occurs most frequently in which patients?

older adults with ISH (isolated systolic HTN)

The donor twin may become growth restricted and can have

oligohydramnios while the recipient twin may become polycythemic with polyhydramnios and develop heart failure

Pulmonary edema can develop during the

oliguric phase of acute renal failure because of decreased urine output and fluid retention.

I.V. dressing be changed

once or twice per week or when it becomes soiled, loose, or wet.

Two-point gait:

one crutch and opposite extremity move together followed by the opposite crutch and extremity; requires use of two assistive devices (canes or crutches)

Neonates born before 36 weeks' gestation will hav

only an anterior transverse crease on the soles of the feet.

squamous cell carcinoma Early lesions appear are

opaque, firm nodules with indistinct borders, scaling, and ulceration.

Hypothermia may occur as a result of

open body wounds

Secondary or second intention healing occurs in

open wounds. When the wound edges are not approximated and it heals with formation of granulation tissue, contraction and eventual spontaneous migration of epithelial cells.

Imperforate anus is a defect that is present from birth (congenital) in which the

opening to the anus is missing or blocked.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies showed a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?

oral temp 102 F

Sulfasalazine gives alkaline urine an

orange-yellow color, but it is not necessary to stop the drug when this occurs.

Raynaud's disease An adverse effect of reserpine is

orthostatic hypotension. The client should report dizziness and low blood pressure as it may be necessary to consider stopping the drug

Raloxifene hydrochloride (Evista) is useful in preventing

osteoporosis in postmenopausal women

note that steroid use mimics cushing disease and cushings cause

ostoprorosis because takes calcium from the bone so high calcium

Intermittent self-catheterization is appropriate for

overflow or reflux incontinence, but not urge incontinence, because it does not treat the underlying cause.

Therefore, an SaO2 of 90% indicates inadequate

oxygenation, an adverse effect of moderate sedation. The nurse should respond by attempting to arouse the client, assisting the client with deep breathing, and administering a higher dose of oxygen.

The nurse recognizes that the patient diagnosed with a duodenal ulcer will likely experience

pain 2 to 3 hours after a meal

pad They should be advised to rest if

pain develops and resume activity when pain subsides

claudication is

pain with walking as seen with peripheral arterial disease

Genital herpes simplex lesions typically ar

painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks

The chancre of syphilis is characteristically a

painless, moist ulcer.

An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by

palpating the pulse.

The use of histamine2 (H2) blockers such as cimetidine can cause

paradoxic central nervous system (CNS) stimulation, resulting in ataxia in the elderly. Impaired vision, gait, and thinking may also occur.

Propantheline is contraindicated in

paralytic ileus, therefore the nurse should be concerned with the absent bowel sounds.

oxytocin is used to treat eclampsia, reduce postpartum bleeding, or treat erythroblastosis fetalis, the drug is administered

parenterally

Interferons (IFNs) are proteins made and released by host cells in response to the presence of

pathogens such as viruses, bacteria, parasites or tumor cells

Who is at risk for HTN crisis?

patients with hx of HTN who have been undermedicated or who have failed to comply with medications

The Seldinger maneuver is a method of

percutaneous introduction of a catheter into a vessel.

A potent topical corticosteroid may increase the client's risk for injury because it may be absorbed

percutaneously, causing the same adverse effects as systemic corticosteroids

A notched T-wave may indicate

pericarditis in an adult client.

Tailor sitting and squatting help stretch the

perineal muscles in preparation for labor.

A basilar skull fracture commonly causes only

periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function.

There is no need for the client to remain on nothing-by-mouth status after laparoscopic cholecystectomy surgery because

peristaltic bowel activity should not be affected.

Prothrombin synthesis in the liver requires vitamin K. In cirrhosis, vitamin K is lacking, precluding prothrombin synthesis and, in turn, increasing the client's PT. An increased PT, which indicates clotting time, increases the risk of bleeding. Therefore, the nurse should expect to administer

phytonadione (vitamin K1) to promote prothrombin synthesis.

Nose drops are not instilled with packing in

place.

SARS, a highly contagious viral respiratory illness, is spread by

placed on airborne and contact precautions

Placenta accreta, a rare phenomenon, refers to a condition in which the

placenta abnormally adheres to the uterine lining

Administering serum albumin increases the

plasma colloid osmotic pressure, which causes fluid to flow from the tissue space into the plasma.

Legionellosis is a

pneumonia caused by the bacterium Legionella pneumophilia that thrives in water that is 95° to 115° F (35° to 46° C).

After a bronchoscopy with a lung biopsy, the nurse should monitor the client for signs of

pneumothorax as well as hemorrhage

Which type of fat should primarily be consumed?

polyunsaturated fats (vegetable oils, shellfish, walnuts, seeds, margarine)

jaw thrust

position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward.

A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:

possible hematologic problem.

emphysema If the client has copious secretions and has difficulty mobilizing secretions, the nurse should teach him and his family members how to perform

postural drainage and chest physiotherapy.

Owing to the massive cellular destruction that occurs in burns,

potassium is released into the extracellular fluid, which leads to hyperkalemia.

emergent phase of burn

potassium is released into the extracellular fluid, which leads to hyperkalemia.

Although loop diuretics block

potassium reabsorption, this isn't a therapeutic action.

The nurse should expect to hold the insulin infusion for 30 minutes until the ]

potassium replacement has been initiated.

Insulin administration causes

potassium to enter the cells, which further lowers the serum potassium level.

A group of students are studying for an examination on the gastrointestinal (GI) system and are reviewing the structures of the esophagus and stomach. The students demonstrate understanding of the material when they identify which of the following as the opening between the stomach and duodenum?

ppyloric sphincter

Insulin is a required hormone for any client with diabetes mellitus, including the

pregnant client.

Actinic keratosis is a

premalignant skin lesion.

Castor oil can initiate

premature uterine contractions and other adverse effects in pregnant women.

A Foley catheter provides accurate output assessment to monitor for

prerenal acute renal failure that can occur from hypovolemia.

The multiple gestation client is at risk for

preterm labor because uterine distention, a major factor initiating preterm labor, is more likely with a twin gestation

Pneumovax 23, a polyvalent pneumococcal vaccine, is administered prophylactically to

prevent the pneumococcal sepsis that sometimes occurs after splenectomy.

A major focus of nursing care after transsphenoidal hypophysectomy is

prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted.

Letting go is the

process beginning about 6 weeks postpartum when the mother may be preparing to go back to work.

bronchopulmonary dysplasia BPD is a chronic illness that may require

prolonged hospitalization and permanent assisted ventilation.

: All clients exposed to persons with tuberculosis should receive

prophylactic isoniazid in daily doses of 300 mg for 6 months to 1 year to avoid the deleterious effects of the latent mycobacterium

renal failure Carbohydrates provide energy and decrease the need for

protein breakdown.

The main goal of nutritional therapy in acute renal failure is to decrease

protein catabolism.

Carcinoembryonic antigen (CEA) is a

protein found in many types of cells but associated with tumors and the developing fetus.

Testosterone is an androgen hormone that is responsible for

protein metabolism as well as maintenance of secondary sexual characteristics; therefore, it is needed by both males and females.

The mother is commonly unable to consume enough

protein, calcium, and iron to supply her needs and those of the fetuses.

pku neonate must have ingested sufficient

protein, such as breast milk or formula, for at least 24 hours.

An inguinal hernia ( /ˈɪŋɡwɨnəl ˈhɜrniə/) is a

protrusion of abdominal-cavity contents through the inguinal canal.

allergic reaction to the dye used during the arteriogram

pruritus and urticaria, which may indicate a mild anaphylactic reaction Decreased alertness may and dyspnea (not hypoventilation).

Chancres often disappear even without

treatment.

What is a type of HTN that occurs with atherosclerotic patients?

pseudohypertension - the veins can't collapse and give a falsely high reading

In a low anorectal anomaly, the rectum has descended normally through the

puborectalis muscle.

A reduction in pulmonary artery pressures should improve the

pulmonary congestion and lung sounds.

Hypotension, not hypertension, would suggest a possible

pulmonary embolism.

A progressive activity regimen may be prescribed to increase

pulmonary function after surgical lung resection

The most accurate method for determining the presence of hypoxia is to evaluate the

pulse oximeter value or arterial blood gas values

Hypotension, hypothermia, and vasoconstriction may alter

pulse oximetry values by reducing arterial blood flow

The client with chronic bronchitis should exhale through

pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping

Exhaling slowly as if trying to blow out a candle is a technique used in

pursed-lip breathing to facilitate exhalation in clients with chronic obstructive pulmonary disease.

Because terbutaline can cause tachycardia, the woman should be taught to monitor her

radial pulse and call the physician for a heart rate greater than 120 beats/minute.

A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if

recirculation is unavoidable.

hiatal hernia to minimize intra-abdominal pressure, the client shouldn't

recline after meals, lift heavy objects, or bend.

Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to

reconstruct the urethra.

Water-soluble lubricants used during sexual intercourse can augment

reduced natural vaginal lubrication caused by ovarian dysfunction and decreased circulating estrogen related to chemotherapy.

Mexiletine, an antiarrhythmic, is used to treat

refractory ventricular arrhythmias; it doesn't cause hypoglycemia.

illeostomy The client is usually placed on a

regular diet but is encouraged to eat high-fiber, high-cellulose foods (e.g., nuts, popcorn, corn, peas, tomatoes) with caution; these foods may swell in the intestine and cause an obstruction.

After a fracture, during which stage or phase of bone healing is devitalized tissue removed and new bone reorganized into its former arrangement

remodeling

radiation Lotion should be

removed from the skin before any treatment and then reapplied after the treatment.

Moist heat to the flank area is helpful when

renal colic occurs, but it is less necessary as pain is lessened.

If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as

renal colic.

intermediate phase of burn care Urinary output increases during this phase as

renal perfusion increases.

calculi can form with

repeated urinary tract infections, high doses of vitamin C or D, immobility, and large doses of calcium.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. What action should the nurse take first?

reposition the patient on her side

Hyperventilation is a clinical manifestation of

respiratory alkalosis.

Benzonatate is used for cough associated with

respiratory conditions and chronic pulmonary diseases.

Laryngeal stridor is characteristic of

respiratory distress from inflammation and swelling after bronchoscopy. It must be reported immediately.

The client with acute pancreatitis is prone to complications associated with the

respiratory system. Pneumonia, atelectasis, and pleural effusion are examples of respiratory complications that can develop as a result of pancreatic enzyme exudate.

.Intermittent claudication subsides with

rest.

oa The joint pain occurs with movement and is relieved by

rest. As the disease progresses, pain may also occur at rest.

pseudoephedrine (Sudafed) The most common CNS adverse effects include

restlessness, dizziness, tension, anxiety, insomnia, and weakness.

A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client?

restrict salts and fluid intakes

The adolescent is most likely experiencing heat exhaustion or heat collapse, Symptoms

result from loss of fluids and include nausea, vomiting, dizziness, headache, and thirst.

Vitamin A is a vitamin that is needed by the

retina of the eye

The nurse receives the client's next scheduled bag of total parental nutrition (TPN) labeled with the additive NPH insulin. What action should the nurse implement?

return solution to pharmacy

The client should review the adcance directive with the physician at every admission because some conditions may be

reversible and temporary, making portions of the advance directive inappropriate.

Other symptoms associated with cholelithiasis are

right upper quadrant tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal

Group B Streptococcus is a

risk factor for all pregnant women and is not limited to those carrying twins.

Obesity, stress, high intake of sodium or saturated fat, and family history are all

risk factors for primary hypertension.

he nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis?

risk for infection

Passive ROM exercises and isometric exercises do not provide the bone stress necessary to reduce the

risk of osteoporosis.

The bag containing platelets needs to be gently

rotated to prevent clumping.

osteoarthritis Intra-articular corticosteroid injections are not used

routinely; rather, they are cautiously used during periods of acute joint pain.

A salivary fistula is suspected when there i

saliva collecting beneath skin flaps or leaking through the suture line or drain site.

herpes virus 2 Other signs and symptoms during the primary episode may include a

second crop of sores, and flu-like symptoms, including fever and swollen glands.

Cutaneous lesions on the palms and soles and alopecia are signs of

secondary syphilis. Chancres do not bleed sufficiently to alter tissue perfusion.

Propantheline bromide is used to reduce

secretions and spasms of the GI tract in clients with diverticulitis, a condition characterized by bowel inflammation and colonic irritability and spasticity.

drinking water with copd can cause

secretions to be liquidified so it is to mobilize and get rid of secretions

The parietal lobe interprets and integrate

sensations, including pain, temperature, and touch; it also interprets size, shape, distance, and texture.

Aging and ototoxicity are two causes of

sensorineural hearing loss.

Leads V3 and V4 record electrical events in the

septal region of the left ventricle.

What blood levels need to be monitored on a patient taking digoxin and a thiazide or a loop diuretic?

serum Digoxin levels serum potassium Digoxin and potassium have an inverse relationship. If potassium is too high, Digoxin will be suptherapeutic. If potassium is too low, Digoxin levels rise and toxicity can occur leading to fatal dysrhythmias.

Metabolic alkalosis can cause potassium to shift into the cells, resulting in a decrease of

serum potassium

siadh has high urine osmolarity

siadh body retains water so there is less water being released meaning more solutes just thing they are inversely related

Lethargy puts the posttonsillectomy client at risk for aspirating blood from the surgical wound. Therefore, placing the client in the \

side-lying position until he's fully awake is best.

empirical formula

simplest formula

postion for buck traction The client can

sit up in bed, remaining in the supine position so that an even, sustained amount of traction is maintained under the bandage used in the Buck's traction and bandage doesnt slip

Hypothyroidism has a metabolic effect on

skeletal muscle. Muscle injury results, causing the CPK-MM to spill out of the damaged cells and into the bloodstream.

Adequate protein intake is necessary for improving

skin integrity.

The stoma does not need to be kept clean and dry; rather the

skin surrounding the stoma needs to be kept clean and dry.

cushings Loss of collagen makes the

skin weaker and thinner; therefore, the client bruises more easily. The nurse should instruct the client to report any of these signs to the physician.

avoid shoes to stop falls

slippers and shoes with deep treads

Raloxifene hydrochloride (Evista) is contraindicated for women who

smoke cigarettes or who have a history of venous thrombosis.

Raynaud's disease The nurse should instruct the client to stop

smoking because nicotine is a vasoconstrictor. \

Benign conditions that can increase CEA include

smoking, infection, inflammatory bowel disease, pancreatitis, cirrhosis of the liver, and some benign tumors

A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. Which of the following are risk factors for cardiovascular problems in clients with hypertension? Choose all that apply

smoking, physical inactivity, diabetes mellitus

alpha-adrenergic blockers. These drugs relax the

smooth muscle of the bladder neck and prostate, so the urinary symptoms of BPH are reduced in many clients.

in chronic renal failure the kidney cant make vitamin d i

so then it cant make calcium so then then the parathyroid gland begins to increase production negative feed back loop

Lactated Ringer's solution replaces lost

sodium and corrects metabolic acidosis, both of which commonly occur following a burn.

In the intermediate phase of burn care, the client will experience serum

sodium deficits.

Loop diuretics block

sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also dilate renal vessels

Which of the following interventions will be most effective in reducing a client's fluid volume excess?

sodium restriction may be necessary to promote fluid loss. Restricting fluid intake will not reduce retained fluids

Thiazide diuretics, not loop diuretics, promote

sodium secretion into the distal tubule.

An abdominal CT scan is used to

stage the presence of colorectal cancer.

A male client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? The client

states that changes in the pulse and feelings of dizziness are significant changes.

Mitral stenosis, or severe narrowing of the mitral valve, impedes blood flow through the

stenotic valve, increasing pressure in the left atrium and pulmonary circulation. These problems may lead to low cardiac output, pulmonary hypertension, edema, and right-sided (not left-sided) heart failure.

suctioning a tracheostomy tube The recommended technique is to use a

sterile catheter each time the client is suctioned.

If a clamp isn't available, the nurse may place a

sterile syringe or catheter plug in the catheter hub.

The catheter used for gavage feeding a neonate should be lubricated with

sterile water before introduction so that if the catheter is inadvertently introduced into the lungs, serious damage would not occur.

Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it

stimulates the development of collateral circulation.

A soft toothbrush, Toothette, or gauze pad should be used to provide oral hygiene at least every 2 hours to promote client comfort and prevent

stomatitis

Daunorubicin The nurse should immediately

stop the medication, apply ice to the site, and notify the physician.

What is the most important nursing priority for a client who has been admitted for a possible kidney stone?

straining all urine

Surgery is required to release the

strangulation.

Isometric, not isotonic, exercises are used to

strengthen muscles

hemorrhoidectomy Positioning in the early postoperative phase should avoid

stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective.

Loss of urine when coughing occurs with

stress incontinence

Emotional stressors do not cause

stress incontinence. It is most commonly caused by relaxed pelvic musculature.

Obesity is a risk factor for osteoarthritis because it places increased

stress on the joints.

. The loss of color vision, or achromatopsia, is a rare symptom that occurs when a

stroke damages the fusiform gyrus. It most often affects only half of the visual field.

In addition, some spermicides alter the vaginal pH to a

strong acidic environment, which is not conducive to survival of spermatozoa.

Pneumothorax signs and symptoms include

sudden, sharp chest pain; tachypnea; and tachycardia, absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side.

Adequate fluid intake of at least 8 glasses a day prevents crystalluria and stone formation during

sulfasalazine therapy.

The client with a Sengstaken-Blakemore tube cannot

swallow.

Tube feedings do not prevent

swallowing or pain upon swallowing.

When the client advances both crutches together and follows by lifting both lower extremities PAST the level of the crutches, the gait is called a

swing through" gait.

Clonidine (Catapres) reduces of this drug

sympathetic outflow from the central nervous system.

history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen

symptoms mean infection so you need to call doctor not elevate on pillows because the symptoms not from lymph edema or lymph swellng but from infection

The ABI test is a noninvasive test that compares the

systolic blood pressure in the arm with that of the ankle.

Adenosine treats

tachyarrhythmias

complication of deep vein thrombosis is pulmonary embolism

tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub.

pseudoephedrine (Sudafed) Common cardiovascular adverse effects include

tachycardia, hypertension, palpitations, and arrhythmias. Tachycardia,

The blood pressure is very labile with these activities, and paroxysms may be accompanied by

tachycardia, palpitations, angina, or electrocardiographic changes.

: One of the most common adverse effects of the drug hydralazine (Apresoline) is

tachycardia.

Eating and sleep are high priorities during this

taking in phase

A wound (regardless of its size) that contains

tan, leathery tissue requires evaluation by the wound care nurse. This wound most likely requires debridement before wound healing can take place.

What is Chovstek's sign?

tap facial nerve 2 cm anterior to the earlobe just below the zygomatic arch, twitching indicates tetany

ivh signs are

temperature instability, nystagmus, apnea, bradycardia

transsphenoidal hypophysectomy The nurse should monitor for signs of infection, including elevated

temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical insufficiency may occur.

question asked if someone with hep b which is worse fatigue when walking or iritability and drowsniness

the answer was irritablity because that implies hepatic encephalthypy from liver having to much ammonia

Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in

the detection of two-thirds of all colorectal cancers

when breast feeding As much of the mother's nipple and areola need to be in

the infant's mouth in order to establish a latch that does not cause nipple cracks or fissures which decreasing pain, cracking and fissures.

in di the low levels of potassium or high calcium cause

the kidneys to not respond to the adh

An automated drug delivery system most effectively reduces

the likelihood of medication errors by automatically dispensing the drug.

If you don't hear anything, check to make sure that all

the other unused openings of the feeding tube are closed.

Bleeding is related to the degree of

thrombocytopenia, and infection is related to the degree of neutropenia.

Because of the inflammation, a common complication of Buerger's disease is

thrombus formation and potential occlusion of the vessel. Inflammation of the immediate and small arteries and veins is involved in the disease process.

The parathyroid glands are located in the neck, near or attached to the back side of the

thyroid gland.

Primary or first intention healing occurs when

tissue is cleanly incised and re-approximated and healing occurs without complications. The incisional defect re-epithelizes rapidly and matrix deposition seals the defect

Metabolic alkalosis can cause potassium

to shift into the cells, resulting in a decrease of serum potassium.

normally liver transforms ammoina

to urea which the kidney excrete

Diet therapy for peptic ulcer disease Most clients are instructed to follow a diet that they can

tolerate.

The greater the concentration of dextrose in solution, the greater the

tonicity.

Opioid antitussives, such as codeine and hydrocodone, are reserved for

treating unruly coughs usually associated with lung cancer

cytoscopy is

tube into bladder

Rifampin is used to treat

tuberculosis

The main use of CEA is as a

tumor marker, especially with intestinal cancer

bucks traction the client should not

turn his body to another position because the bandage may slip.

By 4 months, the neonate should

turn his eyes and head toward a sound coming from behind

Twin-to-twin transfusion drains blood from one

twin to the second and is a problem that may occur with multiple gestation.

When taking isoniazid, the client should limit

tyramine-rich foods in his diet because these foods and the drug could interact to cause hypertensio

When a client has one-sided weakness, the nurse should place the wheelchair on the client's

unaffected side. strong side

Herpetic keratoconjunctivitis usually is

unilateral and causes localized symptoms, such as conjunctivitis ( pink eye swelling of conjuctivi) with herpes simplex virus

Hemoglobin and HCT are typically performed first in clients with \

upper GI bleeding to evaluate the extent of blood loss.

In producing urine, the kidneys excrete wastes such as

urea and ammonia

if the kidney is not working in glomnerphritis then it cannot excrete

urea and ammonia so then there is buildup of ammonia which cause encephalthpy

Protein catabolism causes increased levels of

urea, phosphate, and potassium.

Epidural anesthesia is associated with a decreased

urge to void; therefore, catheterization of a full bladder may be necessary.

Propantheline Side effects are

urinary retention, constipation, and tachycardia.

However, it is not as direct an indicator as increase

urine output.

Coffee and tea are considered neutral because they don't alter the

urine pH.

Lomotil, a combination drug containing atropine, has anticholinergic properties. Common side effects include

urine retention, blurred vision, constipation, palpitations, nervousness, and decreased sweating.

Aspirin, magnesium hydroxide, and oral antidiabetic agents aren't recommended for

use during pregnancy because these agents may cause fetal harm.

formula weight

used instead of molas mass for ionic compounds (same as molar mass)

After intracavity radiation, some

vaginal bleeding occurs for 1 to 3 months.

The passage of feces through the vagina, not

vaginal bleeding, is a sign of rectovaginal fistula.

a routine ultrasound is

valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle.

Most HTN meds work to influence what?

vascular resistance - determined by the size of the vessel

Alpha 1 receptors are responsible for what?

vasoconstriction

potent topical corticosteroid cause

vasoconstriction, not vasodilation.

Rapid filling of the ventricle causes

vasodilation that a nurse auscultates as an S3.

acid ash diet Other foods to avoid on this diet include all

vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium

Chordee refers to a

ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue.

Angiotensin-converting enzyme-inhibitor drugs,may help to prevent

ventricular remodeling

Epistaxis, or nosebleed significant blood loss, systemic symptoms, such as

vertigo, increased pulse, shortness of breath, decreased blood pressure, and pallor, will occur.

Scabies is an easily spread skin disease caused by a

very small species of mite

Daunorubicin is a

vesicant chemotherapeutic agent and can be very damaging to tissue if it infiltrates.

Sensorineural hearing loss (SNHL) is a type of hearing loss in which the root cause lies in the

vestibulocochlear nerve (Cranial nerve VIII), the inner ear, or central processing centers of the brain.

When arsenic overexposure occurs, the symptoms include

violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis.

• When arsenic overexposure occurs, the signs and symptoms include

violent nausea, vomiting, abdominal pain, skin irritation, severe diarrhea, laryngitis, and bronchitis. o Dehydration can lead to shock and death. o After the acute phase, bone marrow depression, encephalopathy, and sensory neuropathy occur.

Endoscopy is then performed to directly

visualize the upper GI tract and locate the source of bleeding.

Signs of hypocortisolism include

vomiting, increased weakness, dehydration, and hypotension.

laryngectomy client should be encouraged to participate in activities such as

walking, golfing, and other moderate recreational sports.

Septic shock can be broken down into two different types of shock:

warm (or hyperdynamic) shock and cold (or hypodynamic) shock.

Other signs and symptoms of early septic shock include

warm and flushed skin fever with restlessness and confusion; decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea.

Raynaud's disease The nurse can teach the client to rewarm exposed extremities by using

warm water or placing them next to the body, such as under the axilla. It is not realistic to ask this client to change jobs at this time.

To maintain enteric precautions, the nurse must

wash her hands after touching the client or potentially contaminated articles and before caring for another client.

Because external radiation commonly causes skin irritation, the nurse should wash the irradiated area with

water only and leave the area open to air. No soaps, deodorants, lotions, or powders should be applied.

After removal of nasal packing, the client should be instructed to apply

water-soluble jelly to the nares to lubricate the nares and promote comfort.

Oxygen therapy is drying to the oral and nasal mucosa; therefore, the client should be encouraged to apply a

water-soluble lubricant, such as K-Y jelly, to prevent drying.

Although an upper GI series might confirm the presence of a lesion, it wouldn't necessarily reveal

whether the lesion is bleeding.

Thrush is characterized by

whitish yellow patches in the mouth

if calcium levels are high then parathyroid gland

will not cause production of calcium because its already high

Skeletal traction is not used to pull weight

with a boot.

During a spinal tap, a sample of cerebrospinal fluid i

withdrawn from your spinal canal.

In chronic bronchitis the diaphragm is flat and

weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation.

The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when

weaning the client from tracheal support.

For enteric precautions, the nurse need not

wear a mask and must wear a gown only if soiling from fecal matter is likely.

question about imobilized patient and osteoporosis what should you do

weight bearing excersises remember it does not necessarily mean just walking

The "swing through" gait is often used by paraplegic clients because it allows them to place

weight on their legs while the crutches are moved one stride ahead.

Water does not harm the stoma, so the client does not have to worry about getting it

wet.

Expressive aphasia is a condition in which the client understands what is heard or written but cannot say

what he or she wants to say

Acute asthmatic attacks are characterized by

wheezing.

When is a heart transplant indicated?

when NOTHING else has worked *Treatment of choice for patients with refractory end-stage HF, inoperable CAD, and cardiomyopathy

Vitamins A, C, and K; pyridoxine; riboflavin; and thiamin are necessary for

wound healing.

Third intention healing (delayed primary) occurs when a

wound is allowed to heal open for a few days and then closed as if primarily. Such wounds are left open initially because of gross contamination.

The bacteria may enter the body through

wounds, or they may live in improperly canned or preserved food

hemophila

x linked genetics

People who are lactose-intolerant usually are able to tolerate dairy products in which lactose has been fermented, such as

yogurt, cheese, and buttermilk

The following measures are required for Droplet Precaution

· If the patient must leave their room, notify the receiving area and have the patient wear a surgical mask when possible to minimize the dispersal of droplets.

discharge plan for a client with multiple sclerosis

• Carefully test the temperature of bath water. • Avoid hot water bottles and heating pads. • Inspect the skin daily for injury or pressure points. • Wear warm clothing when outside in cold temperatures.

Choice Multiple question - Select all answer choices that apply. A client is postoperative for a partial laryngectomy following a diagnosed malignancy. The client is to start oral feedings. The nurse does the following interventions: (Select all that apply.) a) Encourages the client to ingest sweet foods b) Provides thick liquids c) Orders a regular diet tray d) Obtains results of a swallow study e) Facilitates privacy while eating

• Obtains results of a swallow study • Provides thick liquids Explanation: When a client is allowed to eat following a partial laryngectomy, a swallow study may be obtained first to determine the client's risk of aspiration. The client is started with thick liquids because they are easy to swallow. The nurse stays with the client during initial feedings to ensure safe ingestion. Solid foods are introduced as tolerated. The nurse encourages the client to avoid sweet foods, which increase salivation and suppress appetite.

tpa on ulcer

• Prevent direct trauma to the ulcer. • Prevent infection. • Reduce pain. • Increase oxygen to the tissues.

inferior wall myocardial infarction (MI). ECG changes associated with an evolving MI?

• T-wave inversion • ST-segment elevation • Pathologic Q-wave

A client with jaundice has pruritis What can the nurse discuss to prevent skin breakdown?

• Take baking soda baths. • Keep nails short and clean. • Rub with knuckles instead of nails.

arsenic symptoms

• Violent vomiting. • Severe diarrhea. • Abdominal pain.