Med Surge
a nurse is reviewing the lab findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect?
decreased albumin
Respiratory alkalosis is caused by?
decreased carbon dioxide in the blood
stage 2 ICP
decreased compensation and risk for increased ICP
Heberden's nodes
hard bony lumps in the joints of your fingers. They are typically a symptom of osteoarthritis. The lumps grow on the joint closest to the tip of your finger
toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for?
iron deficiency anemia
A urine protein more than 2+ indicates the pre-eclampsia is?
not controlled
a transfusion of packed RBCs causes a reaction of causes acute kidney injury resulting in?
sudden oliguria and hemoglobinuria, this reaction results from the client's antibodies reacting to the transfused RBCs
tPA's are thrombolytics and contraindicated in?
active bleeding
a nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery?
buck's traction
The nurse should identify that triglycerides 130 mg/dL is within the expected reference range for a male adult client, which decreases the risk for peripheral arterial disease from?
atherosclerosis
which ECG abnormality should the nurse recognize as atrial flutter?
atrial rate 300/min with QRS complex of 80/min
a nurse is assessing a client who had coronary artery bypass grafts for cardiac tamponade. Which of the following actions should the nurse take?
auscultate BP for pulsus paradoxus
which precaution should the nurse include in the plan of care to prevent a pseudomonas aeruginosa infection?
avoid placing plants or flowers in the clients room
Newborns recovering from NEC are left undiapered and in a supine or side-lying position to?
avoid pressure on the distended abdomen and facilitate continuous observation
during a bone-marrow biopsy, the client will receive local anesthesia and mild sedation and will be?
awake during the procedure
pulmonary congestion is a manifestation of mitral valve stenosis. Because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilates. The increased pressure results in a?
backflow of blood from the left atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion.
Conjunctivitis causes:
bacteria, virus or allergies
The performance evaluation provides a ?
balanced and global view of how the nurse views personal contributions, including strengths and areas for improvement
the clients manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a?
chest tube and connect it to a water-seal drainage system
a client comes to the ED in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. Which procedure should the nurse prepare for the client?
chest tube insertion
Dyspnea signifies fluid volume excess (overload). Fluid overload can occur quickly in a?
child as fluid shifts rapidly between the intracellular and extracellular compartments
Meniere's disease affects which structure of the ear?
chochlea
eggs and cheese are high in ?
cholesterol
liver and other organ meats are high in ?
cholesterol
shrimp are high in?
cholesterol and should be eaten in moderation
HDL removes?
cholesterol from the tissues and blood stream for transport to the liver
the nurse should identify that chicken breast is low in cholesterol, and all veggies, including corn, are ?
cholesterol-free
The right person is?
choosing the correct personnel to complete the task
Finger clubbing is not a specific sign of cor pulmonale. This finding may be seen in COPD, indicating?
chronic hypoxemia
Crohn's disease
chronic inflammation of the intestinal tract
the nurse should not restrict fluids in a client who has thrombocytopenia. Most clients require 2,000-2,400 mL of fluids per day to decrease the risk of?
dehydration and promote regular bowel function
a nurse is assessing a client who has DVT in her left calf. Which manifestations should the nurse expect to find?
hardening along the blood vessel, tenderness in the calf, and increased leg circumference
a nurse is assessing a client who has deep-vein thrombosis in her left calf. Which of the following manifestations should the nurse expect to find?
hardening along the blood vessel, tenderness in the calf, increased leg circumference
a client is about to start taking somatropin (Genotropin). You plan to evaluate the effectiveness of this drug therapy with which of the following assessments?
height and weight
PICCs can remain in place for months or years. When not actively in use, the nurse should perform?
heparin flushes at least daily to prevent clotting w/n the line
Hemodialysis treatments actually increase the risk of?
hepatitis and other blood-borne pathogen infections
The development of cirrhosis in a client who consumes alcohol is related to liver inflammation and cell destruction. Over time, nonfunctional scar tissue and fibrosis replace the?
necrotic liver cells
body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant
neonatal withdrawal from prenatal exposure to drugs while in utero. Since these drugs crossed the placenta, the infant suffers from withdrawal symptoms after birth and may experience long-term developmental and neurological deficits. Also, this newborn is at risk for abuse from the mother, as these infants are very difficult to console. A multidisciplinary conference including a social worker, a home health nurse, a nutritionist, and a mental health counselor could greatly benefit both the mother and newborn.
A client who has an elevated serum creatinine level should not receive gentamicin because the medication is ?
nephrotoxic
filgrastim is used to stimulate the production of ?
neutrophils
Granulocytes
neutrophils, eosinophils, basophils
Granulaion tissue
new connective tissue and microscopic blood vessels that form on surfaces of a healing would
Hiccups are normal and frequent in?
newborns
Is cholesterol a triglyceride?
no
Pulse Oximetry
noninvasive method that can be used in any setting to obtain the oxygen saturation of hemoglobin (SpO2) in the blood
Bronchial breath sounds are considered?
normal over the trachea
P waves occurring at 0.16 seconds before each QRS complex should be interpreted as?
normal sinus rhythm
The urethral opening located at the tip of penis is?
normal. An opening underneath (hypospadias) or on top of penis (epispadias) must be reported to the HCP
Clients who are diagnosed with two different infectious organisms should?
not be placed in the same room AND a client who is neutropenic should be in a private room
A front passenger airbag increases the risk of injury. Placing an infant or child there is?
not desired, with or without passenger airbag
In false labor, a bloody show is usually ?
not present
It is inappropriate and unnecessary to have client feedback for a self-evaluation. Self-evaluation information is ?
not solicited
A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis?
prednisone
heparin is acceptable for?
pregnancy
warfarin is not acceptable for?
pregnancy
A nurse is providing teaching to a client who has a family hx of hypertension. The nurse should inform that his BP of 124/84 mmHg places him in which of the following categories?
prehypertension
A QRS duration greater than 0.12 seconds may signify?
premature ventricular contractions
a nurse is assessing a client who is recovering from a thyroidectomy and has a harsh, high-pitched respiratory sound. Which of the following actions should the nurse take?
prepare for a tracheostomy
a nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take?
prepare for replacement of the missing clotting factor
the nurse should administer antihypertensive meds for elevated BP because HTN can cause a sudden rupture of the aneurysm due to?
pressure on the arterial wall
Endotracheal extubation
refers to the removal of an endotracheal tube from the trachea. This procedure is commonly performed in operating rooms, postanesthesia care units, and intensive care units
Oxygen Consumption (VO2)
reflects the amount of oxygen extracted from the blood at the tissue level
a nurse is monitoring a client who had a MI. For which of the following complications should the nurse monitor in the first 24 hrs?
ventricular dysrhythmias
ventricular rate of 82/min with an atrial rate of 80/min should be interpreted as?
ventricular ectopy, such as premature ventricular contractions
spider angioma
-red center with radiating red legs -up to 2 cm -can be raised
Reading EKG Graph: 1 small square within the 5 small squares of 0.20 seconds equal?
0.04 seconds
ECG criteria of PVCs: the QRS width is?
0.12 second or wider
oranges are not a good source of iron. A cup of orange slices contains only?
0.18 mg of iron
Reading EKG Graph: 5 small squares should equal?
0.20 seconds
turnips are not a good source of iron. a cup of cubed turnips contains only?
0.39 mg of iron
a nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical hx. Which IV fluids is contraindicated for this client?
0.45% NaCl - the nurse should identify that 0.45% NaCl is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L, which is less than the expected reference range of the osmolarity value for plasma and body fluid of 285-295 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid.
a nurse planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical hx. Which of the following IV fluids is contraindicated for this client?
0.45% sodium chloride
digoxin level w/n the therapeutic range?
0.5-0.8 ng/mL
therapeutic blood levels of digoxin
0.5-2 ng/ml (push rate over at least 5 mins)
Normal creatinine levels
0.6-1.35 mg/dL
a nurse is admitting a client who has acute HF following MI. The nurse recognizes that which of the following prescriptions by the provider requires clarification?
0.9% normal saline IV at 50 mL/hr continuous
a nurse is caring for a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should administer which IV solution?
0.9% sodium chloride
Oliguria
- decreased amount of urine output, 100-400mL in 24hrs - Shock - End-stage renal disease - Acute kidney injury - Severe dehydration - Blood transfusion reaction
Polyuria
- excess quantities of urine output greater than 2,000 mL in 24 hrs - Excessive fluid intake - Diabetes insipidus - DM - Diuretic meds - diuresis phase of chronic renal failure
Incontinence
- inability to voluntarily control micturition - Bladder infections - trauma to external sphincter - Neurogenic bladder - trauma to nerve innervating urinary tract structures
metabolic acidosis associated w/ hypoxia can occur if a client is rewarmed too quickly. Acidosis develops after the client starts to shiver and increases myocardial oxygen consumption. Rewarming of the client after CABG should occur at a rate no faster than?
1 degree celsius (1.8 degrees F) per hour
Degludec/Tresiba onset:
1 hr
Reading EKG Graph: Width of small square within the 5 small squares of 0.20 seconds is?
1 millimeter (mm)
for a client taking regular insulin, remind them to refrigerate unopened vials until their expiration date and opened vials can be left out at room temp up to how long?
1 month
The nurse delegates care of a client diagnosed with osteoporosis to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include?
"Clean up clutter in the room." Safety is a priority in clients with osteoporosis. Falls can lead to fractures. Weight-bearing exercises also prevent osteoporosis.
a nurse is completing dietary teaching w/ a client who has HF and is prescribed a 2 g sodium diet. Which statement by the client indicates understanding of the teaching?
"I can have yogurt as a dessert"
A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching?
"I may eat 10 ounces of lean protein each day."
The nurse is teaching a client diagnosed with end stage renal disease about hemodialysis. Which statement indicates that teaching has been effective?
"I might have muscle cramps after a treatment." Muscle cramping can occur because of the rapid removal of fluid, electrolytes, and body wastes
A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which statement by the client indicates an understanding of the teaching?
"I need to lie still in bed during my brachytherapy treatment" -> this prevents dislodgment
a nurse is providing discharge instructions for a client who has congestive HF. Which of the following client statements indicates indicates to the nurse that the teaching was effective?
"I plan to slow down if I am tired the day after exercising"
a nurse is providing discharge teaching to a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?
"I should check my HR at the same time each day"
A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?
"I will eat more high-fiber foods." The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.
A nurse is providing teaching about the Mediterranean diet to a client newly who has a new diagnosis of HTN. Which of the following statements by the client indicates a need for further teaching?
"I will limit my intake of red meat to twice weekly"
a nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which statement by the client indicates understanding of the teaching?
"I will no longer floss my teeth after brushing my teeth" The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which could create the opportunity for infection.
a nurse is providing discharge teaching to an adult female client who has infective endocarditis about how to prevent recurrence. Which statement by the client indicates an understanding of the teaching?
"I will notify my doctor before I have dental procedures"
The nurse provides care for a hospitalized client receiving ethambutol, isoniazid, pyrazinamide, and rifampin for active tuberculosis (TB). The client states, "I want to go home! I refuse to stay here another day!" Which statement by the nurse is most appropriate?
"I will notify the health care provider of your request." The client is a candidate for discharge since antibiotic therapy has been initiated.
The nurse teaches a client who had a radical retropubic prostatectomy about potential complications of the surgery. Which client statement indicates the teaching was successful?
"I will perform Kegel exercises." Pelvic floor exercises (Kegel) prevent or reduce the severity of urinary incontinence after a radical retropubic prostatectomy. A client is advised to also increase fluid intake and Opioids are not ideal for post-prostatectomy clients as they might cause constipation
A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching?
"I will take my temperature once a day." A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.
a nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. which of the following statements should the nurse identify as an indication that the client understands the teaching?
"I will use my hands rather than a washcloth to clean the radiation area." - The client should gently wash with their hands using warm water and mild soap to protect the skin from further irritation.
a nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which statement indicates the client understands the precautions he must take at home?
"I'll stick to soft foods for now"
A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
"Ibuprofen can cause gastrointestinal bleeding in older adult clients." A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.
a nurse is providing teaching to a client who is scheduled for a sigmoid colon resection w/ colostomy. Which statement by the client indicates a need for further teaching?
"Ill have to consume a soft diet after surgery"
A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching?
"Increase fiber intake to avoid constipation." The nurse should instruct the client that constipation is an adverse effect of verapamil. The client should increase fiber intake to promote regular bowel function.
a nurse is teaching a client who has AIDS about the transmission of pneumocystis jiroveci pneumonia (PCP). which pieces of info should the nurse include in the teaching?
"PCP results from an impaired immune system"
The nurse is teaching the client about the warning signs and symptoms of lung cancer. Which statement is appropriate for the nurse to include in the teaching?
"Symptoms of lung cancer are vague and often present late in the disease."
a nurse is caring for a client who has type 1 DM and has had acute bronchitis for the past 3 days. Which statement should the nurse include when instructing the client?
"Take insulin even if you are unable to eat your regular diet"
Only the nurse can do assessments such as timing the duration of a seizure activity.
"Take this medication with at least 8 ounces of water." (Bisphosphonate alendronate sodium is given as treatment for osteoporosis. The medication should be taken with at least 8 ounces of water.), "Sit upright for at least 30 minutes after taking the medication." (Alendronate sodium can cause esophageal irritation and erosion. Because of this, the client should be instructed to sit upright for at least 30 minutes after taking), "Take this medication 30 minutes before food or other medications."
The parents bring their 4-month-old infant to the clinic for a wellness visit. They report trying to give the infant prepackaged baby food a couple of weeks ago, but the infant stuck out the tongue and would not take the food. Which response by the nurse is appropriate?
"That's a natural reflex; it will soon disappear and then your baby will be ready for solid foods."
The nurse provides care for a client diagnosed with cervical cancer and spinal metastasis. The client is prescribed dexamethasone three times daily. Which client statement would indicate to the nurse that treatment has been effective?
"The pain in my pelvic area is less." Palliative reduction of pain is the goal of steroid therapy in metastatic cancer.
The nurse provides care for a client diagnosed with a stage 2 sacral pressure injury. The nurse educates the client's family members about proper positioning. Which statement by the family members indicates a need for further teaching?
"We will put our parent on a rubber ring cushion when he is sitting up." Any type of ring cushion should not be used because it can lead to additional or worsening pressure injuries.
The nurse provides care for a client who is status post for a cardiac catheterization. The client is also diagnosed with type 2 diabetes mellitus (DM) and renal insufficiency. Which statement is most important for the nurse to include in discharge teaching?
"You should not take your metformin for the next 48 hours to prevent lactic acidosis." Metformin is excreted via the kidney. A client diagnosed with renal insufficiency has an increased risk for lactic acidosis.
a nurse is providing teaching about lifestyle changes to a client who experienced a MI an has a new prescription for a beta blocker. Which client statement indicates an understanding of the teaching?
"before my medication, I will count my radial pulse rate"
a nurse is teaching a client who has polycythemia vera about self-care measures. Which of the following interventions should the nurse include?
"elevate your legs when sitting"
a nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which statement should the nurse make?
"i will refer you to a community resource that can give support" The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes.
a nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. Which instruction should the nurse include in the teaching?
"keep your cell phone 6in away from your pacemaker when making a call"
a nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions?
"physical activity is good for me, but i need to avoid overextension"
a nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions/statements should the nurse provide to foster a rapport and encourage conversation?
"tell me about you favorite video game" -> use a therapeutic communication technique
a nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, what response should the nurse make?
"the lower tube will drain blood and the higher tube will remove air"
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, what response should the nurse make?
"the lower tube will drain blood, and the higher tube will remove air"
a nurse is teaching a client who had a vaginal hysterectomy w/ a bilateral oopherectomy. Which piece of info should the nurse include?
"use a water-based lubricant when having sexual intercourse"
What statement indicates that the client understands the mechanics of pursed-lip breathing?
"when i breathe out through pursed lips, my airways don't collapse between breaths"
a nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of info should the nurse include in the teaching?
"you might experience manifestations of menopause"
Nurse is providing teaching to a client who has MS and a new prescription for baclofen PO. Which piece of info should the nurse include?
"you should change positions slowly while taking this med" dizziness and hypotension are adverse effects, move slowly to minimize orthostatic hypotension. Take with milk/food to minimize gastric irritation. Urinary frequency is an adverse effect too, notify HCP.
a nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which statement should the nurse include in the teaching?
"you should cut the opening of the skin barrier one-eighth inch wider than the stoma"
a nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which statements should the nurse include?
"you will have a chest tube in place after surgery", "we'll frequently help you turn, cough, and breathe deeply after surgery", "we'll give you oxygen to support your breathing if you need it"
a nurse is caring for a client who requests sildenafil to treat erectile dysfunction. Which statement should the nurse make?
"you will not be able to use sildenafil if you are taking nitroglycerin"
a nurse is preparing a client for a bone marrow biopsy. Which piece of info should the nurse include in preoperative teaching?
"you'll feel a painful, pulling sensation when the doctor withdraws the marrow"
Hematuria
- Blood in urine - Cystitis or other inflammation in urinary tract - Calculi - Cancers of urinary tract - Renal disease - Bleeding disorders - Anticoagulants
antitubercular drug nursing considerations:
- Check LFT - Pyridoxine given for peripheral neuritis - Orange urine/tears/saliva - Can give with food - Eye exams - Risk for ototoxicity
HESITANCY
- DIFFICULTY STARTING THE FLOW OF URINE DESPITE THE SENSATION TO VOID - INDICATIVE OF AGE-RELATED CHANGES IN MALE PROSTATE GLAND (benign or malignant) - Urethral obstruction
Anuria
- total urine output less than 100 mL in 24hrs - End-stage renal disease - Acute renal failure - Urinary tract obstruction
Frequency
- Increase in incidence of voiding, usually small amounts - Bladder inflammation - Excessive fluid intake - Urinary retention
Enuresis
- Involuntary urination at night - Lower urinary tract disorder
DYSURIA
- PAIN/DISCOMFORT WITH URINATION - MAY INDICATE OBSTRUCTION/INFECTION - UTI - Cystitis
Renal colic
- Pain radiating to perineal/groin area - Ureter spasm during passage of calculi - Ureter obstruction
URGENCY
- SUDDEN ONSET OF THE URGE TO VOID ASAP - MEDS - PELVIC ORGAN PROLAPSE - CYSTITIS - UTI
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider?
The client reports back pain. This can indicate that the nephrostomy tube is dislodged or clogged.
The nurse provides care for clients in a headache clinic. Which client should the nurse assess first?
The client with difficulty speaking to the receptionist
The nurse provides care for a client who has mild pre-eclampsia. Which evaluation data indicate that the nursing interventions to help control mild pre-eclampsia have been effective?
The client's patella reflexes are 2+
The nurse provides care for a client taking warfarin for a mechanical prosthetic heart valve. The client has an international normalized ratio (INR) of 3.1. Which is the correct interpretation by the nurse of this finding?
The client's treatment goal has been achieved.
A client in her third trimester of pregnancy asks the nurse how to differentiate between true labor and false labor. Which is the best explanation by the nurse to describe false labor to the client?
The intensity, frequency, and duration of contractions do not change OR contractions are irregular
The nurse performs a follow-up assessment of a newborn. Which finding will the nurse report to the health care provider (HCP)?
The newborn has a pulse rate of 95 beats per minute. Report a pulse outside of the normal range of 110 to 160 beats per minute
The nurse delegates a task to an LPN/LVN. Which action will the nurse make that indicates delegation was appropriate?
The nurse follows up with the LPN/LVN to make sure the task was completed.
The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which findingrequires immediate action? a. The bicarbonate level (HCO3?2-) is 31 mEq/L. b. The arterial oxygen saturation (SaO2) is 92% c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg d. The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg.
The partial pressure of oxygen in arterial blood (PaO2) is 62 mm Hg. - All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should interveneimmediately to improve the patient's oxygenation.
PaO2
The partial pressure of oxygen, it is a measurement of oxygen pressure in arterial blood. It reflects how well oxygen is able to move from the lungs to the blood, and it is often altered by severe illnesses.
The nurse performs a pelvic exam on a client admitted in labor to determine the station of the presenting part. The client asks the nurse, "What does the term station mean?" Which explanation does the nurse give to the client?
The relationship of the presenting fetal parts to the ischial spines
antiinflammatory agents
Therapy for asthma/COPD Leukotriene Modifiers
a nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which info about the function of cochlear implants?
They provide direct stimulation of the auditory nerve fiber
pacing spikes
Thin spike on ECG tracing indicates stimulation of electrical current from pacemaker generator. After spike, either a P wave or wide QRS complex or both will appear, depending on which chamber is being paced.
Reassigned nurse
Think of the least fatal outcome of all the choices, should individual patients problem go downhill
Legumes, grains, fish
This menu selection is appropriate for a client with thiamine (B1) deficiency
Tomatoes, potatoes, fruit juice
This menu selection is appropriate for a client with vitamin C deficiency
Leafy vegetables, eggs, cheese
This menu selection is appropriate for a client with vitamin K deficiency
Complications to prevent during knee replacement:
Thromboembolism Nerve palsy Infection PT for exercises/ambulation
Lyme disease
Tick-borne disease caused by the spirochete Borrelia burgdorferi.
What is the role of erythropoietin in the regulation of red blood cells?
To stimulate RBC production
A client with injuries from a motor vehicle accident is unconscious from a severe head injury. The client's identity is unknown, but the client needs emergency surgery to stabilize fractures. Which action is the best for the nurse to take when obtaining informed consent for the operative procedure?
Transport the client to the operating room for surgery. Informed consent of an adult is generally not needed when an emergency is present, and delaying treatment for the purpose of obtaining consent could result in injury or death of the client. Emergency services personnel do not have the authority to provide consent for the client and asking the police to identify the client and locate the family is not the best option because it may take time and would delay the surgical procedures that the client urgently needs.
Levothyroxine
Treat hypothyroidism, enlarged thyroid and thyroid cancer Brands: synthroid, levoxyl, levo-t Prescription needed
An informed consent would not be required for a chest X-ray. T or F?
True
Diabetes and HTN are the primary causes of chronic kidney disease. T or F?
True
Lead Placement S
Upper sternum (just below sternal angle)
The nurse provides care for a school-age child who has a peanut allergy. Which early manifestation of the allergy should the nurse expect the child to exhibit? (Select all that apply.)
Urticaria, wheezing and dyspnea
A nurse is planning to irrigate and dress a clean, granulating wound for a client with a pressure injury. What action should the nurse take?
Use a 30 mL syringe
Nursing management of pt's wearing a cast:
Use palm of hand Place on pillows Pad edges
enoxaparin
Used to prevent and treat severe blood clots Helps reduce risk of stroke or heart attack
Video Capsule Endoscopy
VCE
The nurse understands that what increases as the delivery of oxygen to the tissues falls below the tissues requirements?
VO2 and oxygen debt
QRS Complex
Ventricular depolarization, atrial repolarization
The nurse provides care to a client who experienced prolonged cold exposure. For which complication does the nurse closely monitor this client?
Ventricular fibrillation. Cold-induced myocardial irritability may cause cardiac arrhythmias, especially ventricular fibrillation
T wave
Ventricular repolarization (resting phase)
The nurse receives a prescription to place a client on 40% oxygen. Which oxygen delivery method does the nurse use?
Venturi mask. A venturi mask provides a precise amount of high flow oxygen.
The client's health care provider advises the client to undergo chemotherapy. The client, who has not yet signed the consent form, requests more information about the chemotherapy medications and the side effects. The nurse answers all the client's questions honestly, even though the client may decide not to proceed with the chemotherapy. Which ethical principle is guiding the nurse's practice?
Veracity. Veracity is the duty to tell the truth.
cobalamin
Vitamin B12
ascorbic acid
Vitamin C Dietary supplement Used to prevent and treat scurvy Repairs tissue and enzymatic production of certin neurotransmitters Trade names: Ascor
antidote for Coumadin toxicity
Vitamin K
pre-load
Volume and stretch of the ventricular myocardium at the end of diastole
A nurse is caring for a client who has celiac disease. Which foods should the nurse remove from the client's meal tray?
Wheat toast - This autoimmune disorder is characterized by a permanent intolerance to wheat, barley, and rye. Wheat toast has gluten and should be removed.
intravascular
Within the blood vessel
Bilirubin
Yellow compound that breaks down heme in vertebrates Catabolism is necessary process in bodys clearance of waste products that arise from the destruction of aged/abnormal RBCs
in mitral stenosis, as the mitral valve opening narrows, blood flow from the atria to the ventricle falls, causing?
a backup and increased pressure in the left atria
Metabolic alkalosis is caused by?
a decrease in acid in the blood
the nurse should identify that a client who has cirrhosis requires what kind of diet?
a diet that includes protein to compensate for disease-related weight loss. Increasing protein intake from animal or plant sources will also provide the client with more energy
turners syndrome
a growth hormone deficiency
the nurse understands that type 1 DM is caused by what conditions?
a hx of mumps/rubella and autoimmune destruction of the beta cells of the pancreas
a client who has hypocalcemia can have a prolonged S-T interval and?
a prolonged Q-T interval
sclerosis of the ossicles, called otosclerosis, is an overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss. A stapedectomy is a surgical procedure that corrects otosclerosis by removing a portion of the stapes and inserting what?
a prosthesis
Recombinant tissue plasminogen activator (tPA)
a protein involved in the breakdown of blood clots. As an enzyme, it catalyzes the conversion of plasminogen to plasmin, the major enzyme responsible for clot breakdown.
Which pt is at risk of developing hypovolemic shock?
a pt with severe diarrhea
pernicious anemia
a rare blood disorder characterized by the inability of the body to properly utilize vitamin B12, which is essential for the development of RBCs
A WBC count of 2,000/mm3 is below the expected reference range and indicates?
a risk for severe immunosuppression
hematoma
a solid swelling of clotted blood within the tissues.
Triple cardiac bypass surgery
a type of coronary artery bypass grafting (CABG). It is an open-heart procedure that is done to treat three blocked or partially blocked coronary arteries in the heart. Each of the operative vessels is individually bypassed so it can deliver blood to the heart muscle
Salicylates are?
a type of drug found in many over-the-counter and prescription medicines. Aspirin is the most common type of salicylate.
regular insulin
a type of short-acting insulin. It is used to treat type 1 diabetes, type 2 diabetes, gestational diabetes, and complications of diabetes such as diabetic ketoacidosis and hyperosmolar hyperglycemic states
neurogenic bladder
a urinary problem caused by interference with the normal nerve pathways associated with urination
blood thinner and clot busters are best absorbed where?
abdomen
the nurse should assess for mid or lower abdominal pain to the left of the midline because of the enlarged artery mass during an?
abdominal aortic aneurysm
the nurse should auscultate for a bruit heard over the location of the mass during an?
abdominal aortic aneurysm
hemophilia is a hereditary bleeding disorder in which blood clots slowly and ?
abnormal bleeding occurs
diverticulosis
abnormal outpouchings in the intestinal wall of the colon
manifestations of a tension pneumothorax can include tracheal deviation, distended neck veins, and?
absent breath sounds on one side
the nurse should tape all connections to ensure that the system is airtight and prevent the chest tube from?
accidentally disconnecting
Chest pain and sometimes jaw, back, and shoulder pain are manifestations of an?
acute MI
albuterol contraindicated in?
allergy to adrenergic amines
Oxygen Delivery (DO2)
amount of oxygen delivered to the tissues
paresthesias
an abnormal sensation, typically tingling or pricking ("pins and needles")
hemoconcentration
an abnormally high concentration of blood
Metabolic acidosis is caused by?
an increase in acid in the blood
epidural
an injection in your back to stop you from feeling pain in a part of your body
Carotid duplex is
an ultrasound test that shows how well blood is flowing through the carotid arteries. The carotid arteries are located in the neck. They supply blood directly to the brain.
During the procedure, the client's bladder is removed and the ureters are brought to the skin surface of the abdomen to form a stoma, from which urine will flow into an external ostomy bag. Therefore, the client will not have?
an urge to void
Chloramphenicol
antibiotic for serious infections
desmopressin is what kind of hormone?
antidiuretic
the 'INE's
antihistamines
A client who has ESKD often is hypertensive, which can further damage renal function. The nurse should plan to administer an?
antihypertensive medication, such as captopril, to a client who is hypertensive.
Lead Placement Green
anywhere
A nurse is providing care to a child who has a nosebleed. What action should the nurse perform?
apply pressure to nose using thumb and forefinger, keep the child calm
for a client following a stroke, the first action the nurse should take when using airway, breathing, and circulation (ABC) approach to client care is to keep the client NPO due to the risk of?
aspiration as a result of the stroke
a nurse is planning care for a client who has acute myelogenous leukemia and a platelet count of 48,000/mm^3. Which of the following interventions should the nurse include?
avoid IM injections
clients who have celiac disease should eliminate as much gluten as possible from their diets. Wheat, rye and?
barley contain gluten and should be eliminated
albuterol binds to?
beta 2 adrenergic receptors
metoprolol
beta blocker, treats HTN, angina and HF
PaO2 (Partial pressure of oxygen) normal limits
between 75 and 100 mmHg
tachycardia is a manifestation of
biliary colic, which can lead to shock
A post-term neonate has dry, cracked (desquamating) skin at?
birth
H. Pilori treatment?
bismuth, metronidazole, tetracycline/amoxicillin
a nurse is triaging clients during a mass casualty event. Which label should the nurse assign to a client who has a head injury with fixed, dilated pupils?
black tag
Bladder training does not increase?
bladder capacity
Cystitis
bladder infection
intrinsic rate
body's natural SA node activation
exenatide
byetta
pruritus is an adverse effect of methotrexate, which is used to treat ?
cancer and rheumatoid arthritis
Obstructive shock
caused by a mechanical barrier to ventricular filling or ventricular emptying (increased afterload), causing decreased CO
Clients who have renal, hepatic, or cardiovascular disease should use sildenafil ?
cautiously
If a peripheral IV catheter dressing becomes loosened, it should be?
changed immediately, not secured with tape. The site should be cleaned with an antiseptic solution, the solution allowed to dry, and a new sterile occlusive dressing applied. An antibiotic ointment should not be applied to the IV insertion site. It is not necessary to remove the IV catheter and insert a new one at another location, unless in the future the site becomes infected as a result of the loose dressing.
a nurse is planning care for a client who has cushings syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care?
check the client's urine specific gravity
a catalyst increases the?
chemical reaction of a substance
The nurse should identify that which group is most at risk fro developing hepatitis A?
children
erythropoietin stimulates the production of RBCs and is used to treat anemia associated with?
chronic renal failure
Which finding should the nurse identify as an indication of a basilar skull fracture?
clear fluid coming from the nares
DIC is a complex malfunction involving the body's ability to?
clot
do not use regular insulin that loos what?
cloudy or discolored
It is not clear whether painful stimuli are perceived in a?
comatose client
CT scan
combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues inside your body. CT scan images provide more-detailed information than plain X-rays do.
dilated pupil can mean a compressed what?
compressed cranial nerve III
osteodystrophies
condition in which there is a disturbance in the growth of bone
Insulin is unlikely to cause what?
constipation
Irritable bowel syndrome is a gastrointestinal disorder characterized by abdominal pain, bloating, and either?
constipation or diarrhea or a mixture of both. Consuming a diet high in dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.
epinephrine acts on the blood vessels by?
constricting them and decreasing blood flow
Angiogenesis
creation of a blood supply. The human body does this for many reasons; it is not unique to tumors
low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include a H/A, chest pain, tachypnea, tachycardia, and?
dark urine
in systolic HF, the heart cannot pump enough oxygenated blood into the circulation, causing CO to?
decrease
A client who is taking sildenafil does not need to limit caffeine intake. However, high-fat meals can ?
decrease absorption of the medication
In primary hyperthyroidism, both TRH and TSH are?
decreased due to elevated thyroid hormones
DVT Virchow's Triad
decreased flow rate of blood (stasis), damage to blood vessel wall (endothelial injury), and increased tendency to clot (hypercoagulability)
Hypercalcemia causes?
decreased neuromuscular excitability. Signs of this imbalance include fatigue, hypoactive deep tendon reflexes, decreased muscle tone and strength, bone pain, and decreased gastrointestinal motility
An elevated temp may indicate fluid volume?
deficit
a nurse is caring for a client who is receiving total parenteral nutrition (TPN) therapy and has just returned to the room following PT. The nurse notes that the infusion pump for the client's TPN is turned off. After restarting the infusion pump, the nurse should monitor the client for what finding?
diaphoresis
Droplet precautions are used for clients with?
diphtheria, rubella, streptococcal pharyngitis, pertussis, and mumps, among other conditions
A client who is taking enalapril can experience?
dizziness
Bacterial meningitis requires ?
droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy
Barbiturates
drugs that depress the activity of the central nervous system, reducing anxiety but impairing memory and judgment
Cardiac Glycosides
drugs used to improve heart output by increasing the muscular contraction
tricyclic antidepressants
drugs used to treat severe depression; three-ringed fused structure. Block reuptake of serotonin and norepinephrine
the client should anticipate insulin dosage adjustments when?
during stress, illness, infection or pregnancy
Drops should be directed along the side of the?
ear canal
Frequent neurovascular assessment is essential for clients with an epidural catheter, as it allows for?
early detection of sensory-motor impairment
a nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which strategy should the nurse include?
eat crackers and yogurt regularly
Which lab finding should the nurse identify as an increased risk for atherosclerosis?
elevated LDL levels
the nurse should monitor the client for findings such as vertigo, headache, facial flushing, and fainting. These manifestations are consistent with a new diagnosis of?
essential hypertension
levothyroxine, a thyroid hormone replacement drug, can cause hyperthyroidism if the prescribed dose exceeds what the client requires to remain what?
euthyroid
Creatinine kinase is a test used to?
evaluate muscle function
polyphagia
excessive hunger
Not only does the client require bedrest in a private room while the radiation implant is in place, but the nurse must also discourage the client from any ?
excessive movements while in bed to prevent dislodging the implant
polydipsia
excessive thirst
an outward protrusion of the eyes is?
exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.
The purpose of repeating cardiac enzymes reading is to verify the original admission result
false
opioid tolerant
fentanyl patch
crackers, toast and yogurt can help reduce what?
flatus
diaphragmatic breathing is the act of inhaling deeply by?
flexing the diaphragm
IV infiltrations and extravasations occur when
fluid leaks out of the vein into surrounding soft tissue. Common signs include inflammation, tightness of the skin, and pain around the IV site.
a nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which action should the nurse take when handling this central venous access device?
flush the line w/ sterile 0.9% sodium chloride before and after med administration, access the PICC for blood sampling, and perform a heparin flush of the line at least daily when not in use
Contractility
force of the mechanical contraction
gout
form of arthritis characterized by severe pain, redness, and tenderness in joints from too much uric acid crystallizing and depositing in the joints
canned fruit has less fiber than?
fresh fruit
manifestations of pulmonary edema can include tachycardia, crackles in the lungs and?
frothy pink sputum
There is little vernix on the body of a ?
full-term neonate except small amounts in the skin creases. No vernix is on the body of a post-term newborn. A preterm neonate has a thick covering of vernix
nephron
functional unit of the kidney
The biliary tract includes the?
gallbladder and bile ducts inside and outside the liver
hydrocortisone can cause peptic ulcer disease and ?
gastric distress
The client should expect stools to appear chalky white until the barium is completely eliminated, which typically takes between 24 and 72 hr. Black, tarry stools are an indication of?
gastrointestinal bleeding
somatropin
genotropin
A glucose tolerance test is used to diagnose?
gestational diabetes
When TB bacteria gather in the lungs, immune cells surround them to fight the infection. The infected tissue dies, leaving white spots called ?
ghon foci. Sometimes an infected area spreads to a nearby lymph node and becomes a ghon complex.
while participating in a community health fair, a nurse is providing info to a client who has a BP of 150/90 mmHh during screening. Which action should the nurse take?
give the client a written record of his BP to bring to his provider
Right direction is ?
giving a clear, concise description of the delegated task
The client should not mix which insulins with any other insulins?
glargine or detemir
the pt should wear a medical alert bracelet in case of hypoglycemia that causes a loss of consciousness, so that health care professionals will know to administer what?
glucose or glucagon parenterally
cornflakes do not contain?
gluten
Beneficence means the nurse's actions do ?
good
a client who has aplastic anemia will have manifestations of petechiae and ecchymosis. Dyspnea on exertion also can be present. In aplastic anemia, all 3 major blood components (RBCs, WBCs, and platelets) are reduced/absent, which is known as pancytopenia. Manifestations usually develop?
gradually
HMG-CoA Reductase Inhibitors (Statins) interact with?
grapefruit juice
The nurse should expect a client who has compartment syndrome to have capillary refill ?
greater than 2 seconds in the affected extremity due to a lack of distal perfusion and venous congestion caused by a decrease in the muscle compartment size.
Anticipatory grieving is?
grieving the loss of someone or something before it occurs
a nurse is teaching dietary modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend?
grilled chicken
a nurse is teaching a client about dietary modifications to control BP. Which food choice should the nurse identify as an indication that the client understands the instructions?
grilled chicken salad with fresh tomatoes
somatropin
growth hormone
fenestrated
having perforations, apertures, or transparent areas
low back pain is a manifestation of a hemolytic transfusion reaction. Other manifestations include what?
headache, chest pain, tachypnea, tachycardia and dark urine
Pain and stiffness are common symptoms of tension?
headaches
Do not wash the penis with soap until the circumcision is?
healed (5 to 6 days)
A PR interval greater than 0.20 seconds indicates a?
heart block
HFpEF
heart failure with preserved ejection fraction
HFrEF
heart failure with reduced ejection fraction
Orthopnea is a manifestation of?
heart failure, which can develop from an MI but is not a common manifestation of an acute MI
An S3 heart sound, a significant finding in older adult clients, suggests ?
heart failure. It is heard in early diastole during the period of rapid ventricular filling as blood flows from the atrium into a noncompliant ventricle
CO is the product of?
heart rate (HR) and stroke volume (SV)
tachycardia is a manifestation of a?
hemolytic reaction
hypotension is a manifestation of a?
hemolytic transfusion reaction
hemolytic blood loss is a result of ?
hemorrhage
tachycardia and pallor are manifestations of?
hemorrhaging
for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) w/ stent placement, the client should remain on bed rest until?
hemostasis is assured
aPTT is used to monitor?
heparin therapy
antitubercular drug side effects
hepatotoxicity, peripheral neuritis, optic neuritis and GI distress
A blood glucose level of 118 mg/dL (6.55 mmol/L) is considered ?
high-normal, although within normal limits
The prothrombin time (PT) test measures
how quickly blood clots
regular insulin
humulin R
Which of the following findings should the nurse identify as a risk factor for osteoporosis?
hx of anorexia nervosa
Fiber helps prevent constipation associated with?
hypercalcemia
Immobility contributes to and exacerbates?
hypercalcemia
somatropin can cause hyperglycemia and ?
hypercalciuria
Type II
hypercapnic respiratory failure
increased tendency to clot
hypercoagulability
hallmark of DM
hyperglycemia
levothyroxine is unlikely to cause what?
hyperglycemia
a nurse is reviewing the lab findings of a client who has chronic kidney disease. The client reports significant persistent nausea and muscle weakness. Which of the following findings should the nurse expect?
hyperkalemia
hydrocortisone can cause fluid and electrolyte imbalances, such as?
hypernatremia
due to the kidneys' role in fluid and blood pressure regulation, a client who is experiencing rejection can have what?
hypertension
Serotonin syndrome
hypertensive crisis, hyperpyrexia, extreme agitation, progressing to delirium and coma
You are caring for a client who is taking levothyroxine (Synthroid) to treat hypothyroidism. The client reports palpitations, weight loss and diarrhea. You suspect which of the following adverse effects of this drug?
hyperthyroidism
50% dextrose solution is?
hypertonic
A sodium level higher than the expected reference range, or greater than 145 mEq/L, can be an indication of excessive free water loss resulting in?
hypertonic dehydration
A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of ?
hypertonic dehydration
0.45% dextrose in normal saline is a ?
hypertonic solution
10% dextrose is a?
hypertonic solution
calciferol is used to prevent ?
hypocalcemia in clients who have chronic kidney disease
exenatide is more likely to cause what?
hypoglycemia
glucagon (GlucaGen) is a therapeutic use for
hypoglycemia
the drug combo acarbose and sulfonylurea can cause what?
hypoglycemia
Insulin can cause hypokalemia or hyperkalemia?
hypokalemia
a nurse is assessing a client who has HF and is taking daily furosemide. The clients apical pulse is weak and irregular. The nurse should identify these findings as manifestations of which electrolyte imbalance?
hypokalemia
a nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. the client is experiencing excessive stools. which of the following findings is an adverse effect of this medication?
hypokalemia
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and ?
hypotension
In pancreatitis, the client may develop hypotension or hypertension?
hypotension
a nurse is caring for a client who has a cerebral lesion and develops hyperthermia. Which area of the brain is affected?
hypothalamus
Hypotension, and not hypertension, is an adverse effect of?
hypothermia
Shivering, the body's self-warming mechanism, may be suppressed with ?
hypothermia
levothyroxine is a therapeutic use for?
hypothyroidism
radioactive iodine-131, an antithyroid drug, can cause what?
hypothyroidism
half-strength NS solution is?
hypotonic and is used to replace cellular fluid. Excessive infusion of a hypotonic solution can cause intravascular fluid depletion/hypotension
Type I
hypoxemic respiratory failure
Thoracentesis, the removal of pleural fluid, can temporarily relieve?
hypoxia and thus ease the client's breathing and improve comfort
Performance improvement typically involves clinical projects conceived in response to?
identified clinical problems and designed to use research findings to improve clinical practice
The client should monitor blood glucose levels at least every 4 hr when?
ill
A nurse names 3 objects for the client to remember, asks the client to repeat them and tells the client he will have to repeat them again. After 5 minutes, the nurse asks the client to name the objects. The nurse is using this strategy to test which type of memory?
immediate
A low pulse oximeter indicates?
impaired gas exchange
Cardiogenic shock
inadequate pumping ability of the heart muscle, typically the result of an acute MI (AMI)
the nurse should use chlorhexidine for cleansing the insertion site of a PICC line. Chlorhexidine is effective in reducing the?
incidence of bloodstream infections
a nurse is teaching a client who has hyperthyroidism about managing this disorder. Which recommendation should the nurse include?
increase caloric intake w/ meals
a nurse is providing discharge instructions to a client following an upper GI series w/ barium contrast. Which info should the nurse provide?
increase fluid intake
Placing the newborn under a radiant warmer can?
increase heat loss from evaporation
a client is about to start taking hydrocortisone (Cortef) to treat adrenocortical insufficiency. You should instruct the client to do which of the following to help reduce the risk for adverse effects of this drug?
increase her calcium and vitamin D intake, take the drug with food, record weight regularly, and report increased stress
Both decerebrate and decorticate posturing indicate?
increased ICP
Hyperosmolality
increased concentration of solutes within the fluid
a nurse is monitoring the lab results of a client who has end-stage liver failure. Which result should the nurse expect?
increased prothrombin time
a nurse is monitoring a client who has HF related to mitral stenosis. The client reports SOB on exertion. Which condition should the nurse expect?
increased pulmonary congestion
Pursed lip breathing prolongs exhalation AND ?
increases airway pressure
loop diuretics hypo everything and thiazides hypo everything BUT?
increases calcium
Not all tumors, benign or malignant, grow aggressively; some are?
indolent, or slow growing
Glomerulonephritis
inflammation of the glomeruli of the kidney that filters blood (called glomeruli)
Bacteriostatic
inhibits bacterial growth
intubation
insertion of a tube
exenatide is unlikely to cause hyperkalemia, an effect much more likely with?
insulin
negligence results in harm from carelessness rather than?
intent
although iron-fortified cereal is a component of a healthy diet, it is a specific recommendation for clients who have?
iron-deficiency anemia, not aplastic anemia
The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize?
irritation of the skin
dialysis disequilibrium syndrome (DDS)
is characterized by a range of neurologic symptoms that affect patients on hemodialysis, particularly when they are first started on dialysis. It is also seen among patients who have missed multiple consecutive dialysis treatments.
Hyperkalemia
is the most immediate life threatening of the fluid and electrolyte imbalances that occur in pts with kidney disorders
ST segment depression of 2 mm or more indicates?
ischemia. Ischemia is a decrease in blood supply to the heart tissue, whereas myocardial infarction or cardiac tissue injury is the end point of this ischemia, resulting in death of heart tissue.
dextrose 5% in water is?
isotonic but can cause hyperglycemia
the client should avoid taking naproxen with any other NSAID because of why?
it can increase the risk of bleeding and GI ulceration
Administration of dopamine is ineffective in the treatment of Parkinson's because?
it does not cross the blood-brain barrier
Urticaria
itchy, red, raised rash
a nurse is preparing a plan of care for a client who is postoperative following a modified radical mastectomy. Which of the following invasive devices should the nurse expect the client to have?
jackson-pratt drain
for a client who has hemophilia, the affected joint should be elevated to allow the blood to drain away from the?
joint
The nurse learns that a client was not prescribed a treatment for a disease process because of age. For which principle violation will the nurse bring this issue to the organization's ethics committee?
justice
a nurse is caring for a client following a stroke. Which action should the nurse take first?
keep the client NPO
a nurse is caring for a client following a stroke. Which of the following actions should the nurse take first?
keep the client NPO
epoetin alfa is used to treat anemia associated w/ ?
kidney disease or medication therapy, it increases and maintains the RBC level
Fondaparinux is excreted by the?
kidneys
lamotrigine aka
lamictal
Degludec/Tresiba has a very long half-life that helps glycemic control if dosage is late. Also available in U-200 for people who require?
large dosages
Glargine as Toujeo is U-300, 3 times the concentration for patients on?
large doses
Droplet precautions should be used for clients known or suspected to have illnesses transmitted through?
large droplets, such as influenza
Humalog/Lispro is also available in U-200 concentrated form for people requiring?
larger doses
manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged QT intervals and?
laryngospasm
intercostal retractions and a high-pitched inspiratory noise (stridor) are manifestations of an airway obstruction caused by?
laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine
Taking an over-the-counter antidiarrheal following an upper gastrointestinal series would slow the elimination of the barium used during the test. The nurse should instruct the client to take a?
laxative
Client with fistula should not bear any weight on that arm, and should ?
lay independently
chest discomfort associated w/ pericarditis will decrease when the client sits upright or ?
leans forward, as this relieves pressure in the pericardial sac
CO is decreased in a client who has HF related to mitral stenosis because the?
left ventricle is receiving insufficient blood volume to pump into the systemic circulation
a client who has experienced a CVA is at risk for dysphagia, which increases the chance of ?
life-threatening aspiration
Simple skull fracture
linear or depressed skull fracture without fragmentation or communicating lacerations - low to moderate impact
injecting room temp insulin and rotating injection sites helps minimize what adverse effect?
lipohypertropjy
In preterm neonates of less than 34 weeks gestation, the ear has ?
little cartilage to keep it stiff. It will remain folded over or return slowly when folded longitudinally and horizontally. In a full- or post-term neonate, the ear springs back to the original position immediately
a client who has sickle cell anemia will have manifestations of jaundice with an enlarged?
liver/spleen
Salmeterol is a?
long acting bronchodilator. It relaxes smooth muscles in the airway, but is not used for sudden symptoms of asthma.
conductive heat loss
loss of body heat to a cooler object that is touching the body
Right homonymous hemianopia
loss of vision in the right temporal field of vision and left nasal field of vision. Pt scan area to see vision on right side
solutions of 0.9% sodium chloride, as well as LR solution, are used for fluid volume replacement. Sodium chloride (a crystalloid) is a physiologically isotonic solution that replaces?
lost volume in the blood stream and is the only solution to use when infusing blood products
which finding should the nurse identify as a manifestation of a hemolytic transfusion reaction?
low back pain
a nurse is assessing a client who has an abdominal aortic aneurysm. Which manifestation should the nurse expect?
lower back discomfort
Lead Placement E
lower sternum (5th intercostal space)
Constant coughing and bloody sputum are late, not warning, symptoms of??
lung cancer. Lung cancer is often diagnosed in late stages because the symptoms are vague and often attributed to other causes. Wheezing can be due to a number of conditions and is not a positive sign for lung cancer.
An amniocentesis is used to determine?
lung maturity
dorsal recumbent
lying on back with legs bent and feet flat
Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and ?
manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia
Initial stage
marked by hypoxia due to decreased DO2 to the cells
Airborne precautions should be used for clients known or suspected to have serious illnesses transmitted by airborne droplet nuclei, such as?
measles, varicella, and tuberculosis
The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to ?
measure radiation exposure
a nurse planning care for a client who has thrombocytopenia. Which intervention should the nurse include in the plan of care?
measure the clients abdominal girth daily
Reading EKG Graph: Time (rate)
measured on horizontal line
Reading EKG Graph: Amplitude (voltage)
measured on the vertical line
Elevated BUN and creatinine levels indicate possible renal failure. Renal failure leads to accumulation of hydrogen ions leading to ?
metabolic acidosis
Salicylate toxicity, type 1 DM, ARF (Acute Renal Failure), and severe diarrhea can cause?
metabolic acidosis, increasing potassium
hypermetabolic
metabolizing at an increased rate
Benign tumors are not able to ?
metastasize
fresh fruit, fresh veggies, eggs, meat and fish can harbor what?
microorganisms, increasing risk of infection
What age group has the highest incidents of amputation
middle and older age groups
Difficulty speaking could be a sign of a cerebral vascular accident (CVA), a ?
migraine complication
Abdominal pain, nausea, and vomiting are common symptoms for those clients who experience ?
migraine headaches
Any grandparent can give consent for a?
minor grandchild in an emergency, if the parents are not present
The fifth intercostal space at the left midclavicular line is the?
mitral area
Following the Mediterranean diet, drinking wine is acceptable in?
moderation
a nurse is planning care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) w/ stent placement. Which of the following actions should the nurse anticipate in the post-procedure plan of care?
monitor for bleeding
demand pacemaker
monitors your heart rhythm. It only sends electrical pulses to your heart if your heart is beating too slowly or if it misses a beat.
Malignant tumors are poorly differentiated. Benign tumors are ?
more differentiated, meaning they more closely resemble the cells of the tissue from which they arose
Dysarthria is a?
motor speech disorder. It results from impaired movement of the muscles used for speech production, including the lips, tongue, vocal folds, and/or diaphragm. It is not a hearing/sensory problem.
thrombocytopenia is common after a bone marrow transplant. To prevent bleeding until the clients platelet count improves, the client should avoid hard foods that could cause?
mouth trauma
a nurse is examining the ECG of a client who has frequent premature ventricular contractions (PVCs). which QRS changes should the nurse expect to see on the clients ECG?
much greater amplitude than the usual QRS complexes
Contact precautions are used for clients diagnosed with?
multidrug resistant infections and Clostridium difficile
ECG criteria of PVCs: they may be unifocal (all look the same) or?
multifocal
manifestations of hypercalcemia can include tachycardia, HTN, and?
muscle weakness
If a pt is on insulin, you should monitor potassium levels and instruct the client to watch for and report what?
muscle weakness, nausea, palpitations or paresthesias
Addisons disease is due to adrenal insufficiency, and levothyroxine treats?
myxedema coma
levothyroxine does not cause what?
myxedema or Addisons disease
keeping the legs of the left device in the closed position will result in a?
narrow base of support for transfer
a client who has peripheral arterial disease can display dry, scaly, pale, or mottled skin w/ minimal body hair because of?
narrowing of the arteries in the legs and and feet
Tracheal stenosis
narrowing of your trachea, or windpipe, due to the formation of scar tissue or malformation of the cartilage in the trachea
peripheral arterial disease
narrowing or blockage of the vessels that carry blood from the heart to the legs
Which finding should the nurse identify as a manifestation of an MI?
nausea
Will a history of gout and hypertension affect the results of allergy skin testing?
no
Lantus, Toujeo, and Basaglar/glargine peak:
no peaks or valleys
Levemir/Detemir peak:
no peaks or valleys
Flushed skin is not an emergency and could be due to a?
non-emergency reason
The medical director is not the ?
nurse's direct supervisor
During the second, or entry phase, of the home visit, the nurse determines?
nursing diagnoses and in collaboration with the client and family, establishes desired outcomes
A nurse is preparing to give a change-of-shift report to the oncoming nurse. Which of the following pieces of info should the nurse include?
objective measurements about the client's condition
for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) w/ stent placement, manual pressure or a closure device is used to?
obtain hemostasis to the site
paroxysmal atrial tachycardia (PAT)
occurs when electrical signals starting in the heart's atria fire irregularly. This affects the electrical signals transmitted from the sinoatrial node, which is your heart's natural pacemaker. Your heart rate will speed up.
Endocarditis
occurs when germs, usually bacteria, enter your bloodstream, travel to your heart, and attach to abnormal heart valves or damaged heart tissue. Fungi or other germs also may cause this.
sickle cell crisis
occurs when sickle-shaped red blood cells clump together and block small blood vessels that carry blood to certain organs, muscles, and bones. This causes mild to severe pain.
TB medication management is given in 2 phases. The initial phase is aggressive, using 3 or 4 antibiotics for at least 2 months and?
often much longer
bilateral dilated, fixed pupils means an
ominous sign
A plasma transfusion is not indicated unless the client's INR is ?
over the therapeutic range and bleeding occurs
systemic circulation
oxygenated - left side of the heart
for clients taking insulin, monitor potassium monitor potassium levels and instruct them to report muscle weakness or?
palpitations
you instruct the client to watch for and report which of the following indications of an adverse reaction to insulin?
palpitations
a client who has chronic kidney disease can have hyperkalemia, which is a potassium level greater than 5.0 mEq/L. The expected reference range for potassium is 3.5 to 5 mEq/L. Other manifestations of hyperkalemia can include what?
palpitations, dysrhythmias, nausea and muscle weakness
the narrow tips of the renal pyramids are the?
papillae
a nurse is caring for an older adult client who had an acute MI. When assessing this client, the nurse should identify that older adults are prone to complications of MI from poor tissue perfusion because of which of the following age-related factors?
peripheral vascular resistance increases
tachycardia is an expected finding of?
pernicious anemia
Conjunctivitis
pinkeye
osteodystrophy
poor bone development
interpretation of 2-hr Postprandial between 140-199 mg/dL
prediabetes
a nurse is caring for a client who has an impairment of cranial nerve II. Which action should the nurse perform to promote the client's safety?
provide an obstacle free path for ambulation
The nurse might need to administer propofol to ?
provide sedation and increase the client's tolerance of mechanical ventilation
Capitation means that?
providers receive a fixed amount per patient or enrollee in a health care plan
To help reduce the risk for colorectal cancer, the client should avoid ?
red meat because it is high in fat. The client's diet should contain lower-fat proteins, such as shellfish and poultry with the skin removed.
Palmer erythema
red palms
Palmer edema/Liver palms
reddened palms
a nurse is assessing a client who has kaposi's sarcoma. Which finding should the nurse expect?
reddish-purple skin lesions
Erythematous
redness
Sedatives are generally administered to clients prior to cardioversion to?
reduce anxiety and minimize the discomfort associated with the procedure. This medication should not be withheld.
sodium bicarbonate
reduces stomach acid
tactile fremitus
refers to the vibration of the chest wall that results from sound vibrations created by speech or other vocal sounds
To help reduce the risk for colorectal cancer, the client should consume a diet that is low in fat and refined carbohydrates. Full-fat yogurt contains fat, and many yogurt products also contain?
refined sugar
a nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which complication?
respiratory obstruction
somatropin is unlikely to affect HR or rhythm, LOC, or?
respiratory status
A general recommendation is that women gain up to 4.4 lb. (2 kg) during the first trimester and approximately 1 lb. (0.44 kg) per week during the?
rest of the pregnancy
Hypovolemic shock
results when there is a rapid fluid loss causing inadequate circulating volume
which piece of info in the clients medical record should the nurse identify as a risk factor for tinnitus?
sclerosis of the ossicles
Glasgow Coma Scale
scores level of consciousness
Photosensitivity
sensitivity to light
Slow capillary refill is common finding with ?
sickle cell crisis due to poor capillary profusion
Cyanosis of the tongue is a common finding with ?
sickle cell crisis due to poor profusion
Jaundiced skin is a common finding with?
sickle cell crisis due to the rapid breakdown of red blood cells
joint pain is a manifestation of ?
sickle cell disease
when the iliac crest is the extraction site of a bone marrow biopsy, the client should be?
side lying or prone
After receiving ear drops the client should remain in _____________ position for ____ minutes.
side-lying; 5
The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to ?
significant hypotension
Angioedema
similar to urticaria swelling but deeper and displays on subcutaneous/submucosal tissues - usually around the eyes and mouth
Sty cause:
staphylococcal organism
Skin turgor can be an unreliable indication of dehydration in older adult clients because of age-related changes to skin elasticity. The nurse should check an older adult client's skin turgor on the?
sternum, rather than on the limbs, for a more reliable indicator
Increased appetite, decreased nausea and improved energy level is a positive side effect of ?
steroids but not the goal of therapy
the nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then ?
suction the client's airway secretions
Acute Kidney Injury
sudden loss of kidney function due to loss of the renal system circulation or glomerular/tubular damage
a nurse is assessing a client who has acute cholecystitis. Which finding is the nurse's priority?
tachycardia
hypoglycemia
tachycardia, hunger, nausea and sweating
insulin can cause hypoglycemia, which causes what?
tachycardia, palpitations, and diaphoresis
Cast
temporary circumferential immobilization
dextrose 10% in water is a hypertonic solution and should not be used for fluid replacement. When the fluid surrounding the cells is hypertonic or has more solutes than the cells, osmotic pressure pulls the fluid from?
the cells
the nurse should ensure that the chest tube drainage system is below the level of?
the chest at all times to facilitate proper drainage by gravity
Many factors can cause a high-pressure alarm to sound. The nurse might have to disconnect the machine and manually ventilate the client if the ventilator fails or?
the client experiences respiratory distress
radioactive iodine-131 is unlikely to affect what?
the client's eyes
the nurse should administer opioids, including morphine and hydromorphone, on a routine schedule during a sickle cell crisis to manage?
the clients pain
evidence based practice indicates that palpitations, epigastric distress, and disorientation is a common manifestation of acute MI, but it is not?
the most common
An elevated AFP level may indicate a neural tube defect, which is ?
the most common birth defect in the United States. A low AFP level may indicate Trisomy 21 (Down syndrome).
hemophilia is caused by a deficiency in?
the most common clotting factor, factor VII (hemophilia A)
third spacing
the movement of bodily fluid from the blood, into the spaces between the cells. Also describes the accumulation of fluid from the blood within body cavities, intestinal areas, or areas of the body that normally contain little fluid.
vasculature
the vascular system of a part of the body and its arrangement.
A nurse is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? - A client who is postmenopausal - A vegetarian - A middle adult male client - A client who is pregnant - A toddler who is overweight
the vegetarian, the pregnant client, and the toddler who is overweight. -> RDA of iron for clients who are pregnant is increased to 27 mg/day. Toddlers who are overweight may get most of their calories from milk/foods not considered healthy, which increases their risk for iron-deficiency anemia
he mid-thigh circumference is used for ?
thigh-high antiembolism stockings
the nurse should identify that 0.45% sodium chloride is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L, which is less than the expected reference range of the osmolarity value for plasma and body fluid of 285-295 mOsm/L. Administering a hypotonic solution to this client can cause what?
third-spacing of fluid
Cushing's triad
three classic signs—bradycardia, hypertension (widened pulse pressure), and irregular respirations
Concurrent use of anticoagulants such as warfarin is a relative contraindication for?
thrombolytic therapy
radioactive iodine-131 (iodotope) is a therapeutic use for
thyroid cancer
Radioactive iodine-131 can cause bone marrow suppression, so make sure the client expects periodic blood sampling to detect bone marrow suppression, such as CBCs, as well as what?
thyroid hormone levels
postictal
time after a seizure
a nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this med?
tinnitus or ototoxicity.
peripheral arterial disease causes a decrease in blood flow to the distal extremities, which can lead to?
tissue damage
a nurse is preparing an in service presentation about the basics of hematology. Which factor provides a stimulus for the production of RBCs?
tissue hypoxia
a nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are a poor prognostic sign and indicate severely increased ICP. In a mass casualty situation, the overall goal is what?
to provide lifesaving treatment to the greatest number of people possible
a nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH) with mild manifestations. The nurse should expect the provider to prescribe which med?
tolvaptan
Stage 1 ICP
total compensation
The nurse should use a PICC to deliver fluids, meds, and?
total parenteral nutrition to the client
atrioventricular block, ventricular fibrillation, and ventricular tachycardia are a few dysrhythmias occurring with?
toxic digoxin levels
Clients with hepatitis B do not require any?
transmission-based precautions
the nurse should use ice to preserve the ABG specimen during?
transportation to the lab. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice on the withdrawal site.
A suprapubic catheter is often used after?
trauma or surgery
you are caring for a client who takes acarbose (Precose) and a sulfonylurea to treat type 2 DM. Which of the following is an indication of an adverse reaction to this drug combo?
tremors
The fifth right and left intercostal spaces make up the?
tricuspid area
Imipramine
tricyclic antidepressant. The therapeutic effect may not be seen for 2 to 4 weeks. The drug should not be withdrawn abruptly. Nausea, headache, and malaise may occur with abrupt withdrawal.
lipase is an enzyme secreted by the pancreas that breaks down?
triglycerides into monoglycerides
steapsin is an enzyme secreted by the gastric mucosa that breaks down?
triglycerides into monoglycerides
Particularly for psych patients (like bulimia), sitting with them in silence establishes a ?
trust relationship, which takes priority over asking what is their emotional distress they are experiencing
Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as ?
tuberculosis, measles, varicella, and disseminated varicella zoster
lispro insulin has a duration of 3-6 hrs, so the client should continue to check her blood glucose and watch for indications of hypoglycemia such as?
tumors, headache, and weakness
A nurse is caring for a client who is having a seizure. Which intervention is the priority?
turn client to the side - The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.
sulfonylurea
type of oral antidiabetic agent that stimulates insulin release
The client should not add an aspirin tablet to the ostomy pouch, because it can?
ulcerate the stoma
clients who have peptic ulcer disease can develop bleeding ulcers in the GI lining. However, alcohol consumption does not cause?
ulceration of the liver tissue
echocardiogram
ultrasound of the heart
Opioids are used very cautiously in an?
unconscious client. If the client gives a behavioral indication that pain is perceived, then an analgesic should be consisted for administration.
characteristic of developmental dysplasia of the hip
unequal leg length, limited abduction of the left hip, and asymmetry of the gluteal folds
Astigmatism
uneven curvature of cornea causing blurring of vision
pulmonary circulation
unoxygenated - right side of the heart
Alendronate sodium is to be taken before any food is eaten. The best time to take this medication is ?
upon awaking in the morning and 30 minutes before eating breakfast
Azotemia
urea in the blood
A client who has malignant hypertension might manifest?
uremia
a nurse is assessing a client who has urolithiasis and reports pain in his thigh. This finding indicates the stone is in which of the following structures?
ureter
Bethenechol
urinary retention and saliva production
Micturition
urination
regular insulin is unlikely to affect what?
urine output
Which finding contributes to delayed wound healing?
urine output 25 mL/hr
Which assessment finding should cause the nurse to suspect that the client has hypertonic dehydration?
urine specific gravity 1.045
The last time the client had a bowel movement does not impact the decision to?
use thrombolytic therapy
Wet to dry gauze/dressing
used to remove dead tissue from a wound
nifedipine
used to treat high blood pressure and to control angina. In a class of medications called calcium-channel blockers. It lowers blood pressure by relaxing the blood vessels so the heart does not have to pump as hard
Right circumstance is?
using the appropriate client and the setting to determine if the delegated task is appropriate
Filling Pressures
values obtained to measure preload
A client who is attempting to quit smoking can take?
varenincline, which acts as a deterrent for using nicotine. Concurrent use with nicotine results in nausea, headache, vomiting, dizziness, and fatigue
An allergy to gelatin is a contraindication for what vaccine?
varicella
Epi is a?
vasoconstrictor, reducing blood flow to organs. It is used mainly for anaphylactic shocks.
the client who has cardiac tamponade will have pulses paradoxus when the systolic BP is at least 10 mmHg higher on expiration than on inspiration. This occurs because of the sudden decrease in CO from the fluid compressing the atria and ?
ventricles
a nurse is monitoring a client for reperfusion following thrombolytic to treat acute MI. Which indication should the nurse identify to confirm reperfusion?
ventricular dysrhythmias
a nurse is caring for a client who has pernicious anemia. Which factor should the nurse identify with this condition?
vitamin b12 deficiency
Potential causes of metabolic alkalosis includes ?
vomiting and nasogastric suctioning
characteristic of intussusception
vomiting, has colicky abdominal pain, and is having jelly-like stools
A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?
warfarin. Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery
a client who has peripheral arterial disease has common manifestations of intermittent claudication (leg pain w/ exercise), cold or numb feet at rest, loss of hair on the lower legs and?
weakened pulses
indications of hypoglycemia include tachycardia, diaphoresis, shakiness and?
weakness
Instruct the client to watch for and report indications of hyperthyroidism such as anxiety, insomnia, tachycardia, palpitations, diarrhea and?
weight loss
diabetic ketoacidosis (DKA)
when your body produces high levels of blood acids called ketones. The condition develops when your body can't produce enough insulin
Smegma is a?
white, cheesy substance under the foreskin, and may be bacteriostatic
white bread has less fiber than?
wholegrain bread
diffuse axonal injury
widespread axonal damage
when do the semilunar valves (aortic and pulmonic) open?
with ventricular diastole and systole
when do the atrioventricular valves (mitral and tricuspid) close?
with ventricular systole
In hepatitis, the sclera and buccal mucosa will be?
yellow in color
Lantus, Toujeo, and Basaglar/glargine onset:
1-1.5 hrs
NPH onset:
1-2 hr
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit, which is indicated by a urine specific gravity greater than ?
1.030
A 5 mL syringe generates too much pressure and could rupture the PICC line. The nurse should use a ?
10 mL syringe instead
The fetal heartbeat may be detected as early as?
10 weeks using a Doppler device
Lidoderm patch administration:
12 on 12 off *may cause skin irritation
a bone marrow biopsy typically takes 5 to?
15 minutes
Quickening, a fetal movement felt by mother, is first perceived at ?
16 to 20 weeks as a faint fluttering in the lower abdomen
NPH duration:
18-24 hrs
it may take how long to see full effects of radioactive iodine-131?
2-3 months
Regular Humulin/Novolin peak:
2-5 hrs
The breathing rate for a small child is ?
20 breaths per minute
Lantus, Toujeo, and Basaglar/glargine duration:
20-24 hrs
A client is scheduled to receive an intravenous antibiotic at 1300 and 2100 hours. The client is prescribed peak and trough blood levels. At which time does the nurse schedule the trough level to be drawn?
2030. A trough level is drawn approximately 30 minutes before the next dose, when the concentration of the medication in the body is at the lowest.
If a pt went through a transurethral resection of the prostate and has an indwelling urinary catheter, blood-tinged urine in the drainage bag is an expected finding for the first how many hours following surgery?
24 hours
Levemir/Detemir duration:
24 hrs
The client should notify the provider if their blood glucose level is greater than?
250 mg/dL
Humalog/Lispro duration:
3-5 hr
Novolog/Aspart duration:
3-5 hrs
CKMB normal value
3-5%
Normal cardiac output is
4 - 8 L/min
ideally, blood samples come from a ?
4 French lumen catheter or larger
NPH peak:
4-12 hrs
normal HbgA1c level
4-5.6%
Novolog/Aspart peak:
40-50 mins
How long should a pt not bear weight on their extremity with a cast?
48 hrs
INR reading for Coumadin toxicity
5 or 6
Normal WBC count
5,000-10,000
albuterol inhalen onset
5-15 minutes
normal ICP
5-15 mmHg
Regular Humulin/Novolin duration:
5-8 hrs
The nurse assigns rooms to clients admitted to the unit. The nurse wants to place clients as far away from the nurses' station as possible to promote rest and relaxation. Which client would be most appropriate for the nurse to place away from the nurses' station?
58-year-old client who had a total abdominal hysterectomy
Establishing the exact time of onset of chest pain is essential in thrombolytic therapy screening because the medicine is ideally given within?
6 hours of a coronary event
After vasectomy, some sperm remains in the vas deferens, wear a condom for?
6 more weeks
Normal stroke volume is
60 - 130 mL
Composition of NovoLog 70/30
70% intermediate-acting insulin and 30% rapid-acting (aspart) insulin
Composition of Humulin 70/30
70% intermediate-acting insulin and 30% regular insulin
Composition of Novolin 70/30
70% intermediate-acting insulin and 30% regular insulin
normal blood glucose
70-110 mg/dL
autoregulation of CBF only effective if MAP (Mean arterial Pressure) is between?
70-150 mmHg
composition of Humalog 75/25
75% intermediate-acting insulin and 25% rapid-acting (lispro)
The expected reference range for blood pressure is a systolic pressure less than 120 mm Hg and a diastolic pressure less than?
80 mm Hg
fasting blood glucose normal range
99 mg/dL or lower
Stage 1 hypertension presents with a systolic pressure between 140 and 159 mm Hg and a diastolic pressure between 90 and ?
99 mm Hg
elevated ICP
>20 mmHg
concussion
A brain injury caused by a blow to the head or a violent shaking of the head and body. This occurs from a mild blow to the head, either with or without loss of consciousness and can lead to temporary cognitive symptoms. Symptoms may include headache, confusion, lack of coordination, memory loss, nausea, vomiting, dizziness, ringing in the ears, sleepiness, and excessive fatigue. There's no specific cure for concussion. Rest and restricting activities allow the brain to recover. This means one should temporarily reduce sports, video games, TV, or too much socializing. Medications for headache pain, or odansetron or other anti-nausea medications can be used for symptoms.
a nurse is teaching a class about client rights. Which instruction should the nurse include?
A client should sign an informed consent before receiving a placebo during a research trial
The nurse assess a pregnant client at 10 weeks gestation. Which finding is consistent with the gestational age of the fetus?
A fetal heartbeat can be heard with a Doppler. Also, the mother's systolic pressure would not expect to increase at this point in the pregnancy.
presbyopia
A gradual, age-related loss of the eyes' ability to focus actively on nearby objects. Farsightedness usually becomes noticeable in the early to mid-40s and worsens until around age 65. Symptoms include a need to hold reading material at arm's length to make letters clearer, blurred vision at normal reading distance, and eyestrain after reading. In rare cases, it may cause headaches. The condition can be corrected with nonprescription or prescription eyeglasses, contact lenses, and rarely surgery.
A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother?
A neural tube defect
A nurse from a pediatric unit works a shift on an adult surgical unit. The charge nurse makes client assignments. Which client is most appropriate for the charge nurse to assign to the pediatric nurse?
A preschool-age client who had a tonsillectomy, A young adult client who had a pilonidal cyst removed, and an adolescent client who had an appendectomy
Linear skull fracture
A simple crack in the skull
myasthenia gravis
A weakness and rapid fatigue of muscles under voluntary control. The condition is caused by a breakdown in communication between nerves and muscles. Symptoms include weakness in the arm and leg muscles, double vision, unsteady walk, and difficulties with speech and chewing. Can't be cured, can last for years or lifelong.
Drug therapy for chronic pain:
Acetaminophen (Tylenol), NSAIDS and Lidocain (Lidoderm) patch
The nurse uses a tape measure to ensure that a client receives the correct size of knee-high antiembolism stockings. Which measurement does the nurse use for these stockings?
Achilles tendon to the popliteal fold
A nurse on a telemetry unit is caring for a pt who has unstable angina and is reporting chest pain with a severity of 6 on a 0 to 10 scale. The nurse administers 1 sublingual nitroglycerin tablet. After 5 min, the pt states that his chest pain is now a severity of 2. Which of the following actions should the nurse take?
Administer another nitroglycerin tablet
The nurse observes a student nurse provide a client with a subcutaneous injection of heparin. For which student action will the nurse intervene?
Administers the injection 1/2 inch from the umbilicus (should be at least 2 inches away from umbilicus), Aspirates after inserting the needle, Massages the site
CCB works best for?
African Americans and elderly
The nurse teaches a health promotion class to help clients better manage modifiable risk factors for diabetes. Which factor does the nurse include as a risk for the development of diabetes mellitus? (Select all that apply.)
Age of 45 years or older, Sedentary lifestyle, Overweight with a waist/hip ratio greater than 1, Triglyceride level consistently greater than 250 mg/dL
benign prostatic hyperplasia
Age-associated prostate gland enlargement that can cause urination difficulty.
ACR
Albumin-to-creatinine ratio
xanthine oxidase inhibitor
Allopurinol
Glucosamine
Amino sugar and a prominent precursor in the biochemical synthesis of glycosylated proteins and lipids
Cardiac Output
Amount of blood pumped by the left ventricle in one minute
after-load
Amount of pressure against which the left ventricle must work during systole to open the aortic valve. Clinically measure by systolic blood pressure
hypertension
An increase in blood pressure such that the systolic pressure is greater than 140 mm Hg and the diastolic pressure is greater than 90 mm Hg
Metformin
Anti-diabetic Class: biguanide Treat type 2 diabetes Brands: Glucophage, Glumetza Prescription needed No known risk to pregnancy Interacts with alcohol Works by reducing the amount of sugar your liver releases into the blood Makes body respond better to insulin Best to take with meal to reduce side effects
adenosine
Antiarrhythmic
Clarithromycin (Biaxin)
Antibiotics, macrolide. It can treat and prevent infections. It can also treat duodenal ulcers caused by H pylori.
Bronchodilators
Anticholinergics ipratropium (Atrovent) ipratropium and albuterol
Metformin (Glucophage)
Antidiabetic
chlorpromazine
Antipsychotic Can treat mental illness, behavioral disorders, tetanus, blood disorders such as porphyria, and severe nausea and vomiting. It can also reduce anxiety before surgery. Prescription needed Consult doctor if pregnant Very serious interactions with alcohol
Ambulatory care
Any health care you can get without staying in a hospital. That includes diagnostic tests, treatments, or rehab visits.
A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a hx of night sweats, anorexia, and weight loss. Which action should the nurse take?
Assign the client to a private room w/ negative-pressure airflow, and wear an N95 respirator when entering the clients room
dobutamine
BP support, treat HF and help pump blood
A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?
BUN 34 mg/dL. Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.
upper GI series
Barium swallow
Diagnostic studies of GI
Barium swallow & barium enema
A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?
Bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body
epidural hematoma
Bleeding between dura and inner surface of skull Neurologic emergency
The nurse performs a nitrazine test on a client at 38 weeks' gestation. Which color change indicates that membranes have likely ruptured?
Blue-green. A blue-green color indicates a pH of 6.5. The membranes have likely ruptured. Dark blue color change is also indicative of membranes that are likely ruptured. A change to yellow indicates a pH of 5.0. An olive-yellow color indicates a pH of 5.5. The membranes are likely intact. The membranes are likely intact. An olive-green color indicates a pH of 6.0. The membranes are likely intact.
A client who has stage II breast cancer asks the nurse about sites of metastasis for this cancer. Which response should the nurse provide?
Breast cancer tends to metastasize to the bones - Common sites are the bones, lungs, brain and liver
exophthalmos
Bulging eyes Eye moves out of socket Does not have to be caused by an underlying disease Finding of GRAVE'S DISEASE An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.
Zetia is pregnancy category?
C
Cholesterol is a lipid whose levels reflect the risk for?
CAD
A client who is taking enoxaparin does not require a daily INR. The nurse should periodically compare the client's?
CBC with a baseline CBC
Administering ipratropium and albuterol (commonly known as Duonebs) is a warranted and expected action for the client with?
COPD
albuterol treats?
COPD
A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.)
Calf pain Numbness in the arms Intense headache
During administration of IV digoxin to a client, the unit secretary informs the nurse that an assigned client with extensive head/facial injuries has arrived on the unit. Which action does the nurse take?
Call and ask the charge nurse to visualize the client and assist the client to the bed. The nurse calls the charge nurse to ensure the new client is settled and then the nurse can admit the new client after med administration is complete. IV digoxin infuses over a minimum of 5 minutes and has the potential to cause extravasation as well as heart rhythm disturbances, requiring careful observation. Any prescribed dose is given at one time. This action ensures that the new client is seen asap to be assessed for airway problems until the assigned nurse can get to the room to do the admission assessment
The visiting nurse notes that a client diagnosed with asthma is in the "red zone" of the peak flow meter system. Which action does the nurse take first?
Call the health care provider. The red zone (50% or below peak flow) of the peak flow meter system signals an emergent situation.
High ammonia levels
Can lead to brain damage, coma, or death Most often caused by liver disease
digoxin
Cardiac glycoside, usually prescribed to clients diagnosed with HF/a-fib. It increases the velocity and force of myocardial systolic contraction, thus increasing contractility. It also decreases conduction velocity through the AV node and slows the HR. Antiarrhythmic and Blood pressure support. Monitor client for arrhythmias/heart block
a nurse is providing discharge teaching to a client who has venous thrombosis and a prescription for warfarin. Which instruction should the nurse include in the teaching?
Carry a med alert ID card
While preparing medications, the nurse documents that a client is allergic to penicillin. Which medication will the nurse question before administering to this client?
Cefazolin
A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?
Change position every hour. Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should also instruct the client to limit the angle of the hips when in a lateral position to no more than 30°. This positioning prevents direct pressure on the trochanter.
The nurse reviews care needs for assigned clients. Which client will the nurse assess first?
Client who had a vaginal hysterectomy 2 days ago and is reporting that the right calf is warm to touch. A warm calf might indicate a deep vein thrombosis. Having a hysterectomy is a risk factor for this health problem, which is a priority since it can be life-threatening if it becomes an embolus
The nurse reviews the daily lab results of four clients. Which client does the nurse delegate to the LPN/LVN to provide care?
Client with an erythrocyte sedimentation rate of 10 mm/h
The nurse provides care for four clients. The nurse recognizes that stress-relieving interventions are the highest priority for which client?
Client with peptic ulcer disease. Intense, prolonged stress contributes directly to the development and treatment of peptic ulcer disease.
The nurse assesses a newly admitted client who reports being a vegan. Which nutritional complication does the nurse recognize that the client is at the highest risk for developing?
Cobalamin deficiency. Red meats, fish, dairy products, and eggs are primary dietary sources of cobalamin (vitamin B12). Therefore, a vegan may be at risk for colbalamin deficiency. However, fortified cereals and soy products are also good sources of colbalamin and should be recommended
hydrocortisone
Cortef
interpretation of 2-hr Postprandial greater than or equal to 200 mg/dL
DM
interpretation of Fasting Blood Glucose greater than or equal to 126 mg/dL
DM
interpretation of Hemoglobin A1c greater than or equal to 6.5%
DM
interpretation of Random Blood Glucose Level greater than or equal to 200 mg/dL
DM if accompanied by classic s/s of hyperglycemia
The nurse should identify obesity as a risk factor for a?
DVT
The nurse teaches the parents of a preschool-age client about age-appropriate home safety. Which safety intervention does the nurse include?
Demonstrate safe street-crossing. A preschool-age child is likely to impetuously cross the street to recover a lost ball or pet. Teaching the child how to safely cross the street while emphasizing that an adult is necessary for crossing the street is appropriate.
Compound skull fracture
Depressed skull fracture and scalp lacerations with communication to intracranial cavity
What conditions does ECT treat?
Depression primarily
The nurse notes that a client with hepatic encephalopathy is increasingly confused and drowsy. Which action will the nurse take first?
Determine the client's current ammonia level
The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. Which sounds would the nurse most likely hear on auscultation?
Discontinuous high-pitched sounds of short duration during inspiration - Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high-pitched sounds of short duration heard on inspiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.
For a client taking glipizide, be sure to monitor for signs of hypoglycemia, HR, and?
ECG
Endoscopic Retrograde Cholangiopancreatography
ERCP
S/S of DDS
Early signs include nausea, headache, vomiting, and restlessness. More serious symptoms can result in seizures and coma. When considering dialysis, review the patient's serum urea and sodium.
What should you not do when a pt has a cast and compartment syndrome?
Elevate the extremity
a nurse is caring for an adult male client who is undergoing screening tests for atherosclerosis. Which lab finding should the nurse identify as an increased risk for this disorder?
Elevated LDL levels
a nurse is demonstrating colostomy care to a client who has a new colostomy. Which actions should the nurse teach the client to perform?
Empty the bag when is is one-third to one-half full, cut the skin barrier opening a little larger than the ostomy and wash the peristomal skin with mild soap/water
The health care provider prescribes a unit of packed red blood cells for a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product?
Ensure adequate infusion access is present before obtaining the blood from the blood bank (An adequate intravenous catheter should be inserted prior to obtaining the blood from the blood bank), Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood, Monitor the client closely during the first 15 to 30 minutes of administration, The infusion should be started within 30 minutes of removing the blood from the blood bank refrigerator,The blood administration time should not exceed 3 to 4 hours to reduce the risk for bacterial growth
a nurse is caring for a client who is receiving cefotetan 1 g via intermittent IV bolus every 12 hrs to treat a postoperative infection. Which of the following manifestations should the nurse monitor for as an adverse effect of the med?
Epistaxis. Notify provider so it can be discontinued.
The nurse provides care to a client with severe hypothermia. Which assessment will the nurse perform first?
Examine cardiac monitor for dysrhythmias. Hypothermia may cause shivering. However, the most important concern is the risk for ventricular dysrhythmia due to hypothermia
Causes of DECREASED fremitus
Excess air in lungs Increased thickness of chest wall
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain?
Exertion and anxiety can trigger the pain.
What is another name for vitamin B12?
Extrinsic factor.
The nurse applies the prescribed medication to an adult client diagnosed with scabies. Which body area should the nurse avoid when applying the scabicide?
Face and scalp
Supraventricular tachycardia
Faster than normal heart rate beginning above the hearts two lower chambers Rapid heartbeat that develops when normal electrical impulses are disrupted
The nurse prepares to auscultate a client's apical pulse. Where will the nurse place the stethoscope?
Fifth intercostal space, midclavicular line
A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include?
Flex the foot every hour when awake. The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.
Alendronate
Fosamax, Osteoporosis
Edema of feet and legs is common during pregnancy. However, edema above the waist does suggest?
GH
Cast syndrome:
GI disturbance in ileus Increased anxiety Depression
The nurse provides preoperative teaching for a client having surgery. Which type of anesthesia does the nurse explain as altering the level of consciousness? (Select all that apply.)
General anesthesia and conscious sedation
Colchicine
Give with meals -- anti gout, remember if diarrhea develops, stop the drug
metformin
Glucophage; Anti-diabetic
Integrative therapies for chronic pain:
Glucosamine and chondroitin
BNP is used to measure and diagnosis ?
HF
Which finding should indicate to the nurse that the client is experiencing fluid volume deficit?
HR 110/min
A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?
HR 52/min. A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing.
a nurse is providing teaching to a client who has anemia and a new prescription for epoetin alfa. Which piece of info should the nurse include in the teaching?
HTN is a common adverse effect of this med
hypothermia promotes vasoconstriction, which puts the client at risk of ?
HTN. Rewarming the client reduces this risk
The nurse provides care for an alcohol-dependent client diagnosed with pancreatitis. Which sign leads the nurse to determine that the client is experiencing alcohol withdrawal? (Select all that apply.)
Hallucinations, Seizures and gross tremors. Visual and auditory hallucinations are a major characteristic of alcohol withdrawal.
The nurse screens a client for sleep apnea. Which question is most important for the nurse to ask the client?
Has anyone told you that you snore loudly? Snoring is associated with obstructive sleep apnea
The nurse assesses an older client for depression. Which risk factor will the nurse associate with depression in an older client?
Has chronic pain. Independent living may reduce the risk for depression.
a nurse is assessing a client who is receiving hemodialysis for the first time. Which finding indicates the client is developing DDS?
Headache
The nurse provides care for a client who is prescribed a transfusion of packed red blood cells. Which information is required to be checked by two registered nurses before beginning the transfusion?
Health care provider's prescription, Client's identity, Hospital ID band name and number, Blood component tag name and number
sensorineural hearing loss
Hearing loss caused by damage to the inner ear or the nerve from the ear to the brain. Permanent. In adults, causes include aging and prolonged exposure to loud noise. In children and infants, causes include congenital abnormalities or infections. In this type of hearing loss, higher pitched tones may sound muffled. It may become difficult to pick out words against background noise. Treatment includes hearing aids and assistive devices. Can last for years or lifelong.
A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?
Hemodialysis is sometimes required following surgery. When a kidney comes from a deceased donor, it might not function immediately, requiring the recipient to continue hemodialysis postoperatively.
The nurse evaluates laboratory values for a client experiencing diaphoresis and weight loss. Which value will the nurse immediately report to the health care professional?
Hemoglobin A1C 8% (0.08). A hemoglobin A1C value of 8% (0.08) indicates hyperglycemia. This blood level evaluates the levels of blood glucose over the previous months
The prevalence of hypertension is highest among African American clients, followed by Caucasian clients, and then ?
Hispanic clients
A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching?
Holding breath for 10 seconds after inhaling so the medication can move deep into the airways
rapid insulin
Humalog/Lispro Novolog/Aspart Apidra/Glulisine Onset: 15 minutes
SQ regular insulin peaks in 1-5 hrs and can cause what?
Hypoglycemia
Which is a prerenal cause of AKI?
Hypovolemia and myocardial infarction
A nurse is providing instruction to a patient with type 2 DM and a new prescription for metformin. which statement by the client indicates an understanding of the teaching.
I should take this with food. The client should take this med with or immediately following meals to improve absorption and to minimize gastrointestinal distress.
Types of antitubercular drugs
INH (isoniazid) Rifampin Ethambutol Streptomycin PAS (pyrazinamide)
after O2 has been administered, the next priority intervention the nurse would initiate for a pt with a PE is the administration of which of these therapies?
IV heparin
LPN/LVN do not administer small volume what?
IV medication
The nurse creates a care plan for a client who has a stage 3 pressure injury. Which nursing diagnosis should the nurse assign as the highest priority for this client?
Impaired skin integrity. The interventions surrounding care for the wound will be the highest priority. Risk for infection would not be the highest priority because it is a risk diagnosis. The client does not show any signs or symptoms of infection.
Hypercapnia/hypercarbia
Increased PaCO2 levels in the blood
A nurse is assessing a client who has manifestations of acromegaly. Which finding should the nurse expect?
Increased head size - a pt who has acromegaly will present with an enlarged head size due to excessive production of growth hormones after closing of the epiphyses (the "growth plate" at the ends of the long bones) by the pituitary gland. This results in gradual enlargement of the body tissues like the bones of the face, jaw, hands, feet and skull
COPD exacerbation
Increased sputum with purulence Increased dyspnea Changes in mental status D's in ABG's
flat jugular veins
Indicates hypovolemia/hemothorax Look for swelling that would indicate bleeding into the tissues
acute cholecystitis
Inflammation of the gallbladder that develops over hrs Symptoms include RUQ pain/tenderness, chills and vomiting
The nurse provides care for a client experiencing supraventricular tachycardia (SVT). Which action by the nurse is appropriate when giving adenosine?
Inject over 1 to 3 seconds, followed by a normal 20 mL saline flush
The home health care nurse teaches a client diagnosed with early dementia and the client's spouse ways to promote physical safety. Which teaching does the nurse include? (Select all that apply.)
Install handrails in hallways and on stairs, where clients are most prone to falling, are needed, Candles are used with supervision, Ensure adequate lighting on stairs. Alcohol does not increase danger to the client in a meaningful way, especially if it is in moderation. Drinking can continue if monitored. The client does not have to stop smoking, but must only smoke with supervision because the client may forget it, leave it, or drop it and start a fire.
A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?
Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.
a nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high pressure alarm is sounding. What actin should the nurse take first?
Instruct the client to allow the machine to breathe for them - When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."
A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the early stage of the disease?
Intermittent claudication
Depressed skull fracture
Inward indentation of the skull with possible pressure on brain
A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the clients indwelling urinary catheter and a decrease in urinary output. Which action should the nurse take?
Irrigate the indwelling urinary catheter per facility protocol to remove clots obstructing the urine flow. Do not remove the client's indwelling urinary catheter as it ensures adequate urine flow. Clamping the urinary catheter can increase pressure inside the client's bladder and cause internal bleeding.
a nurse is assessing a client who has fluid volume overload. Which manifestations should the nurse expect?
JVD, moist crackles, and increased HR
The nurse provides care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which finding indicates to the nurse that the client is experiencing cor pulmonale?
Jugular vein distension
A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?
Keep a lead-lined container in the client's room and forceps in the client's room in case of accidental dislodgement of the implant
A nurse is reviewing the laboratory result of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk?
LDL 172 mg/dL
Eating a low-fat diet decreases ?
LDL cholesterol and can prevent atherosclerosis
Long acting insulin
Lantus (glargine) Levemir (detemir) Onset: 30 min-3 hr
bisacodyl
Laxative It can treat constipation
The nurse assesses a newborn's penis 2 days after a circumcision. The nurse notes a yellow exudate around the head of the penis. Which is the appropriate nursing intervention?
Leave the area alone, as this is a normal finding
Lead Placement A
Left mid-axillary line (5th intercostal space)
Lidocaine patch name:
Lidoderm
The nurse provides care for a client diagnosed with vitamin A deficiency. Which menu selection is most appropriate for the nurse to recommend to the client?
Liver, sweet potato, carrots.
A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (Select all that apply.)
Loosen restrictive clothing on the client and prepare to suction the client's airway
convective heat loss
Loss of heat by air movement - open door, air conditioning vent
A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?
Low back pain and apprehension. Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.
Causes of INCREASED fremitus
Lung consolidation -> air in healthy lung replaced with something else (inflammatory exudate, blood, pus, cells)
What positions are to be avoided after cataract surgery?
Lying face down. Also, do not lie on operative side for a month.
avoid tyramine foods with?
MAOIs
CPP =
MAP - ICP
The client's pain did decrease with nitroglycerin administration, which would not happen if the client were having a ?
MI
chest pain radiating to the left arm is a manifestation of a?
MI
Minor calyces in the kidney widen moving toward the hilum and merge to form?
Major calyces
normal hematocrit level
Male = 41-53% Female = 36-46%
edema is a manifestation of ?
Malnutrition. Decreased serum protein levels cause fluid to move into interstitial spaces.
The nurse provides care for a client who reports fatigue, has dry skin, and a poorly healing wound. Which health problem will the nurse consider the client to be experiencing?
Malnutrition. Manifestations of malnutrition include fatigue from a lack of adequate caloric intake, dry skin from a deficiency in protein and vitamins, and poor wound healing from a lack of adequate protein and vitamins needed for skin repair
dialysis
May need to be considered in the short term to allow recovery of the renal tissue while preventing possible life threatening disorders
Thalassemia is not related to dietary deficiencies. It is a hereditary anemia that occurs in people of?
Mediterranean or Southeast Asian descent
Efferent arterioles
Merges the capillaries within the glomeruli to transport blood away from the glomeruli and into the peritubular capillaries
External fixation device
Metallic device made of metal pins Inserted into bone Attached to external rods Stabilize fracture while it heals
Bronchodilators
Methylxanthines aminophylline (IV) Theo-Dur, Slo-Bid (PO)
A nurse is planning care for a client who is receiving chemotherapy and has a protein deficiency. Which of the following interventions should the nurse include?
Mix powdered skim milk into liquid milk, add a slice of cheese to hot veggies or mix yogurt into fresh fruit - Dairy products are good sources of protein
a nurse is caring for a client who has encephalitis due to west nile virus. Which actions should the nurse take?
Monitor VS q 2 hrs, assess neurological status q 4 hrs, and keep client's room darkened
Post-op management for knee replacement:
Monitor dressing Ice to decrease edema Neuro-vascular check Foot exercise Check wound drain/suction device
closed head injury
Most common type of traumatic brain injury Aka blunt/nonpenetrating head trauma Caused by an external impact from sudden/violent motion that does not include a break in the skull
Comminuted skull fracture
Multiple linear fracture with fragmentation of the bone
Recovering from major abdominal surgery and receiving blood are not characteristics of a stable client and should not be assigned to?
NAP
The nurse delegates several client care tasks to nursing assistive personnel (NAP). Which action will the nurse need to follow up?
NAP discontinues an indwelling urinary catheter. The nurse should complete the task of removing an indwelling catheter. The nurse needs to assess the client's response to the removal of the catheter and document the discontinuation of the catheter and any findings.
The client being discharged in a day is stable enough for ?
NAP to provide care
Standard, not droplet, precautions are used for the newborn recovering from?
NEC
Intermediate acting insulin
NPH Onset: 1-2 hr
clients who have an exacerbation of crohn's disease usually require ?
NPO status to ensure bowel rest and promote healing/recovery
for a client taking hydrocortisone, suggest taking the drug with food and to avoid what?
NSAIDs, especially aspirin
TRIAMCINOLONE: Nursing Considerations
Nasal spray: onset few days, peak 3-4 days PO/IM: peak 1-2 hours Use regular peak flow monitoring to determine respiratory status Rx; Preg Cat C
a nurse is examining the ECG of a client who is having an acute MI. The nurse should identify that the elevated ST segments on the ECG indicate which of the following alterations?
Necrosis
elective cardioversion
Nonemergent A controlled electrical current sent to the heart muscle by special electrodes attached to skin on chest/back Goal is to bring back normal rhythm
The nurse measures a client's vital signs to be: temperature 101°F (38.3°C), heart rate 110 beats/min, blood pressure 82/46 mm Hg, and respiratory rate 32 breaths/min. The most recent white blood cell count is 18,000 cells/mm3. Which intravenous fluid will the nurse anticipate being prescribed for this client?
Normal saline solution, this will increase extracellular fluid volume. They have signs of sepsis/shock. Aggressive fluid resuscitation should be started using an isotonic solution.
The nurse provides care to a client in hypovolemic shock. Which intravenous solution will the nurse recognize as being an isotonic crystalloid solution?
Normal saline, Lactated ringer
A client with a newly casted lower leg reports to the nurse that the foot feels numb. Which action will the nurse take first?
Notify the health care provider
the charge nurse is reviewing orders for a newly admitted pt w/ type 1 DM. It is a priority for the charge nurse to follow up w/ the provider about which order?
NovoLog insulin SQ at bedtime
A nurse is administering a prescription for nifedipine to a client who is pregnant. Which info related to nifedipine should the nurse monitor/document?
Number of uterine contractions -> can be given during preterm. Blocks calcium channels which inhibit the entry of calcium into myometrial cells, delaying labor
widening pulse pressure
Occurs with heart valve conditions, reduced blood viscosity, less compliant arteries, and increased systolic pressure
How many nitroglycerin tabs can you take before you call the doctor?
One. The patient could take three tablets, but call the doctor after one.
How long does the woman have to be off oral contraceptives before hysterectomy?
Oral contraceptives should be discontinued 3 to 4 weeks preoperatively
a nurse is caring for a client who has a prescription for enalapril. the nurse should identify which of the following findings as an adverse effect of the medication?
Orthostatic hypotension
Dependent rubor is a manifestation of ?
PAD
the QRS complexes unusually have greater amplitude in height and depth in clients with?
PVCs
adequate oxygenation with ICP
PaO2 less than or equal to 100 mmHg
Tympany
Percussion over the intestinal area should elicit a drumlike sound known as
A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?
Place a tracheostomy tray at the bedside in case of airway obstruction.
e nurse prepares a client for a contraction stress test using nipple stimulation. Which measure does the nurse include in the plan of care?
Place client in reclining chair with a slight lateral tilt to optimize uterine perfusion and avoid supine hypotension. An internal fetal monitor is not used.
The nurse must position an immobile, 450-pound client up in bed. Mechanical lift equipment is not available. Which technique must the nurse include in this intervention?
Position staff to distribute client weight equally. Lift by flexing knees and hips, then shifting weight from front to back leg while moving drawsheet and client to desired position. The drawsheet should be extended from the client's shoulders to thighs, otherwise the immobile client is at risk of injury and the staff will not be performing an efficient lift
acarbose
Precose
Pre-op management for knee replacement:
Prepare for post-op Prevent infection
The nurse notes that at 2200, a client is scheduled to receive 10 units of insulin glargine. The client also has a "now" prescription of 7 units of regular insulin. Which approach will the nurse use to administer these medications?
Prepare two separate injections
The nurse notes that a 4-hour-old newborn has blue hands and feet. Which action does the nurse implement next?
Proceed with the assessment. The newborn has acrocyanosis, which is a normal finding for 2 to 6 hours of age. This results from diminished peripheral circulation. The newborn should be monitored and the nurse can continue with the assessment.
Albumin
Protein made by the liver Helps keep fluid in bloodstream so it doesn't leak into other tissues Carries substances throughout body Low albumin indicate problems with liver/kidneys
Granules
Proteins that are essential for leukocytes to carry out their functions that appear in the cytoplasm and helps distinguish one WBC from another
An ER nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which action is the nurse's priority?
Provide supplemental oxygen
The nurse provides care for a newborn in the delivery room. Which nursing intervention will the nurse use to prevent the newborn from experiencing conductive heat loss?
Putting the unclothed newborn against the mother's skin
ECG criteria of PVCs: T wave is of opposite polarity to?
QRS complex
hyperkalemia widens?
QRS complexes
The nurse observes a student nurse perform closed urinary catheter irrigation on a client with decreased urinary output. Which observation indicates that the student requires additional teaching to perform the procedure correctly?
Quickly instills sterile saline. The solution should be instilled slowly to help loosen clots and sediment and to prevent trauma to the bladder wall.
What is the common finding with pediculosis pubis?
Reddish-brown dust in the underwear.
The nurse provides care for a hospitalized client. The client's room is located close to the nurses station. The client tells the nurse, "I don't know how anyone can get any rest around here, it is so noisy." The nurse reports these concerns to the nursing supervisor. Which change to the nursing unit should the nursing supervisor implement? (Select all that apply.)
Reduce the volume of phones and pagers, Keep conversations quiet and Close the client's room door if possible, wear rubber soled shoes
Short acting insulin
Regular, Humulin, Actaprid, Novolin Onset: 30-60 min
The nurse provides care for a client who has a peripheral intravenous (IV) catheter. The nurse observes that the client's IV site dressing is loose. Which action does the nurse take next?
Remove the dressing, cleanse the skin with antiseptic, and apply a new dressing
A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?
Report of sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.
cardiac cycle
Represents the actual time sequence between ventricular contraction and ventricular relaxation
Nonsurgical management of chronic pain:
Rest and exercise Positioning Thermal modalities Weight control Integrative therapies
The nurse caring for a client with an acute myocardial infarction and chest pain delegates 5-minute vital sign assessments to nursing assistive personnel (NAP). The charge nurse intervenes and changes the assignment. Which right of delegation does the charge nurse following in this situation?
Right circumstance
An S4 heart sound occurs immediately before the?
S1 heart sound. It is considered a normal finding in older adult clients.
The nurse auscultates the heart of a client experiencing increasing shortness of breath. Which finding causes the nurse the most concern?
S3 heart sound
lovenox is what route only?
SQ
Cardiac Output =
SV x HR
The nurse auscultates heart sounds in a school-age client. Where does the nurse place the stethoscope to listen to the aortic area of the heart?
Second right intercostal space
systole
Simultaneous contraction of the ventricles
The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider?
Slurred speech. Slurred speech indicates a possible stroke and should be reported immediately.
Which lab values should the nurse plan to obtain to assess for DI (Diabetes Insipidus)?
Specific gravity
a nurse is providing discharge instructions to a client who has active TB. Which info should the nurse include in the instructions?
Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. After three negative sputum cultures, the client is no longer considered infectious.
Dexamethasone
Steroid It can treat inflammation
glycogen
Storage form of glucose
the nurse should recognize that which of the following complications is associated w/ long-term mechanical ventilation?
Stress ulcers. Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.
basilar artery syndrome
Strokes due to occlusion or bleeding of the basilar artery can cause a variety of symptoms which include paralysis, difficulty breathing, swallowing, double vision, coma, and even death. Some of the common symptoms of a basilar artery stroke include the following: Balance difficulty and vertigo
diastole
Synonymous with ventricular relaxation. When ventricles fill passively from the atria to 70% of blood capacity
levothyroxine
Synthroid
hypokalemia causes flattened?
T waves and cardiac dysrhythmias
ethusuxamide blocks?
T-type calcium channels
Monitor thyroid function via what?
T4 and TSH levels
A nurse is assessing a client who has acute cholecystitis. Which finding is nurse's priority?
Tachycardia - When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider.
a nurse is providing teaching to a client who has frequent UTI's. What should nurse include in teaching?
Take daily cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.
a nurse is performing a GI assessment of a client who has liver cirrhosis w/ abdominal distention. Which of the following actions should the nurse take to assess for changes in the client's abdominal distention?
Take serial measurements of the abdomen with a tape measure
The nurse working in a community hospital's emergency department provides care to a client with chest pain. Which level of care is the nurse providing?
Tertiary care
a nurse is caring for a client who is dehydrated and is receiving continuous tube feeding through a pump at 75 mL/hr. When the nurse assesses the client at 0800, which finding requires intervention?
The HOB is elevated to 20 degrees
thorax
The area of the body between the neck and the abdomen. Contains vital organs, including the heart, major blood vessels, and lungs. It is supported by the ribs, breastbone, and spine.
The nurse provides care for an unconscious client. The nurse finds a stage 2 pressure injury on the client's elbow. Which statement indicates the best understanding of the client's perception of pain?
The area will be treated as a painful lesion, using gentle cleaning and dressing. Since it is not clearly understood where in the brain pain is perceived, pain may be perceived even in a comatose client. Any noxious stimuli should be treated as potentially painful.
Afferent arterioles
The branches formed off the cortical radiate arteries
The nurse receives report for a group of adult clients. Which client will the nurse see first?
The client diagnosed with failure to thrive lying supine with a nasogastric tube feeding infusing
afterload
the resistance w/n the vasculature
Bruit
abnormal sounds heard upon auscultation of blood vessels
The nurse should elevate the clients DVT extremity to?
decrease swelling and relieve pain
hydrocortisone is a therapeutic use for?
Addisons disease
manifestations of flail chest can include paradoxical chest movement, dyspnea and?
cyanosis
the client may mix NPH insulin and regular insulin in the same syringe to reduce what?
the number of injections
albuterol
bronchodilators/adrenergics
Humalog/Lispro onset:
15-30 mins
CFU
Colony Forming Unit
Hepatomegaly occurs with hemolytic?
anemia
Immobility leads to stasis of blood, thus increasing the risk for ?
clot formation
Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can?
delay wound healing
visual fields
measurement of range of vision (perimetry)
paralytic ileus
paralysis of intestinal peristalsis
insulin is unlikely to cause what?
weight gain
clients who have ulcerative colitis are restricted to what kind of diet?
a low fiber diet, which omits whole grains and raw fruits and veggies
detrimental potentiative interactions worsen ?
adverse effects. An example of this is warfarin and aspirin, which increase the risk of bleeding when used together
Continuing care includes?
assisted living and psychiatric care and older-adult day care
HTN is often?
asymptomatic. Even w/o symptoms like severe headaches or neurological deficits, HTN can cause fatal strokes and MIs
lispro is a rapid acting insulin that has an onset of 15-30 minutes and peaks when?
at 30 minutes to 2.5 hrs
Because glipizide peaks in 1-2 hr, it is inappropriate to take it when?
at bedtime
alcohol consumption does not cause a release of stored glycogen that increases the workload of the liver. However, alcohol consumption can cause a?
decrease in liver function
the nurse should avoid flexion of the clients knees and hips during a sickle cell crisis to promote adequate perfusion to all areas of the clients body, which can?
decrease pain
The nurse understands that which of the following are clinical manifestations of neurogenic shock?
decreased CVP and bradycardia
manifestations of hypermagnesemia can include bradycardia, hypotension, and?
decreased deep tendon reflexes
Continuing active respiratory exercises will aid in?
decreasing congestion and managing secretions
A client who has a mental illness has the right to consent or refuse treatment, unless?
deemed incompetent by a court of law
insulin resistance
defects in the effective action of insulin at the cell membrane
osteomyelitis
inflammation of bone and bone marrow
Keratitis
inflammation of cornea caused by virus or spread of systemic diseases
Uveitis
inflammation of iris, ciliary body, and choroid caused by local/systemic infection
Cholangitis
inflammation of the common bile duct
Lupus nephritis
inflammation of the kidney that is caused by SLE
acute pancreatitis
inflammation of the pancreas
An elevated CRP indicates ?
inflammation, tissue injury, infection, or atherosclerosis and follow up by the nurse. The normal CRP level is less than 1 mg/L
Chalazion
inflammatory cyst caused by duct obstruction
Thalassemia
inherited defect in ability to produce hemoglobin, leading to hypochromia
antitubercular drug action
inhibit cell/protein synthesis of mycobacterium tuberculosis
fludrocortisone is an example of an endocrine-system drug that can cause cataracts and glaucoma with what kind of use?
long-term use
Myopia
nearsightedness, light rays refract at a point in front of the retina
The nurse is discussing infection control guidelines with a group of student nurses. Which information is most important for the nurse to include in the discussion?
"A gown should be worn when measuring the blood pressure of a client with a methicillin-resistant Staphylococcus aureus (MRSA) wound infection." Contact precautions are used to minimize the spread of pathogens that are acquired from direct or indirect contact, especially multidrug-resistant organisms such as MRSA
When treating an adult client diagnosed with scabies, the scabicide is applied from the?
neck down. The drug should not be applied to the face or the scalp of an adult client.
a nurse is assessing a client who has pernicious anemia. Which finding should the nurse expect?
paresthesias in the hands and feet
interpretation of Fasting Blood Glucose between 100-125 mg/dL
prediabetes
interpretation of Hemoglobin A1c between 5.7%-6.4%
prediabetes
Cholesterol Absorption Inhibitor must be combined with what for optimum effect?
statins
Degludec/Tresiba peak:
steady state achieved at 8 days
Apathy/depression is characteristic of withdrawal from?
stimulants
What does betamethasone, a glucocorticoid, stimulate and prevent in a fetus?
stimulates fetal lung maturity and prevents respiratory depression during preterm labor
Lactulose works by
stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration.
Alendronate is to be taken on an empty?
stomach and can be taken at anytime during the day
Statins do not affect?
stool consistency, height and weight. Monitoring cholesterol evaluates the effectiveness of the medication
An S1 heart sound, a normal finding, occurs when?
the mitral and tricuspid valves of the heart close. It corresponds with the onset of ventricular contraction
evidence based practice indicates that dyspnea, diaphoresis, and nausea is a common manifestation of acute MI, but it is not?
the most common
evidence based practice indicates that pain in the shoulder and left arm, dizziness and anxiety is a common manifestation of acute MI, but it is not?
the most common
The nurse assesses a client being considered for thrombolytic therapy. Which question is most appropriate for the nurse to ask?
"Can you tell me the exact time your chest pain began?" and "Are you taking any medications to thin your blood?"
The graduate nurse attends an orientation to the oncology unit. Which statement indicates that the graduate nurse understands the teaching?
"Cancers metastasize through lymphatic spread to organs."
Before delegating tasks to nursing assistive personnel (NAP), a new nurse asks the manager to explain "the right circumstance" of delegation. Which response will the manager make to the nurse?
"Delegating the right circumstance is ensuring the client is stable."
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make?
"Discontinuing with the treatments is your choice if it is your wish to do so." The nurse should recognize the client's right to refuse the treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client.
a nurse is teaching a middle-age client about hypertension. Which of the following information should the nurse include in the teaching?
"Diuretics are the first type of medication to control hypertension."
The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act?
"Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated."
The nurse plans to assess a client with acquired immune deficiency syndrome (AIDS). Which question provides the least amount of information to plan this client's care?
"How old were you when you became sexually active?" Asking about the age when sexual activity started is not relevant because it does not provide any information related to the presence of risk factors for AIDS.
a nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which statement by the client indicates an understanding of the teaching?
"I am dieting to lose weight"
The nurse follows up with a client diagnosed with insomnia. The nurse seeks to determine if treatment was successful. Which response by the client best indicates treatment was successful?
"I am not napping in the day anymore." Insomniacs typically nap in the daytime. Not napping indicates the client is getting through the day now. This is a positive response to treatment.
a nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which statement by the client indicates understanding of the teaching?
"I am taking this med to increase my energy level"
a nurse is teaching a client w/ a recent diagnosis of rheumatoid arthritis who has a new prescription for naproxen tablets. Which of the following statements by the client indicates the need for further teaching?
"I can take this med with aspirin"
A nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions?
"I should eliminate uncooked foods from my diet for now"
a nurse is providing discharge teaching to a client who has aplastic anemia. Which of the following statements indicates that the client understands the instructions?
"I should eliminate uncooked foods from my diet for now"
The nurse instructs a client receiving intramuscular cyanocobalamin injections. Which client statement indicates that teaching is effective?
"I should not drink any alcohol while receiving these injections."
The nurse provides care for a client that reports difficulty falling asleep several nights a week. The nurse reviews the client's bedtime pattern. Which client statement requires an intervention by the nurse?
"I will go to bed when I am wide awake and relax in bed." It is important to not go to bed when wide awake. The client should practice going to bed when sleepy to promote the bed for sleeping. If a client does nap, it is recommended the nap be 20 minutes or less
a nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which client statement indicates an understanding of the teaching?
"I will monitor my BP while taking this med" The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy.
The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication?
"Take the medication with a full glass of water to prevent acid reflux."
A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
"These tests help determine the degree of damage to the heart tissues."
The client says to the nurse, "I'm so upset! I've tried my hardest to give my children everything, but they still hate me." Which response by the nurse is appropriate?
"You think your children hate you?" Restating the client's statement is a therapeutic communication technique. This question repeats the main idea expressed by the client and gives the client an idea of what has been communicated. If the message has been misunderstood, the client can clarify it
A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?
Adjust the thermostat so that the environment is warm.
A 16-year-old client visits the community health clinic. The client tells the nurse, "I think I got an infection from having sex with my boyfriend. I can't tell my parents. They will kill me!" Which is the best response by the nurse?
"Your parents do not need to know, but will you give me consent for treatment?" Unemancipated minors with specific medical conditions, such as a sexually transmitted infection (STI), may consent to medical treatment. Information and treatment can be provided without notification of, or consent from, the parent(s)
a nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of info should the nurse share with the client?
"you'll begin by lying still with your eyes closed"
Retention
- INABILITY TO COMPLETELY EMPTY THE BLADDER OF URINE - NORMAL FINDING BRIEFLY AFTER CHILDBIRTH - PELVIC SURGERY - REMOVAL OF INDWELLING CATHETER - PROLONGED/ABNORMAL RELATED TO NEUROGENIC BLADDER - OBSTRUCTION OR STRICTURE OF URETHRA
NOCTURIA
- INCREASED NEED TO URINATE AT NIGHT - HF - Renal disease - Bladder obstruction - Consumption of excessive fluids late at night
a nurse is checking paradoxical BP of a client who has a possible cardiac tamponade. In what order should the nurse complete the steps?
1) Palpate the BP and inflate the cuff above the systolic pressure 2) Deflate the cuff slowly and listen for the first audible sounds 3) Identify the first BP sounds audible on expiration and then on inspiration 4) Subtract the inspiratory pressure from the expiratory pressure 5) Inspect for jugular venous distention and notify the provider
Levemir/Detemir onset:
1-2 hrs
How long can the client store premixed insulin syringes?
1-2 weeks refrigerated and vertical with the needles pointing upwards
Apidra/Glulisine duration:
1-2.5 hrs
Novolog/Aspart onset:
10-20 mins
Stage 2 hypertension presents with a systolic pressure greater than 160 mm Hg and a diastolic pressure greater than?
100 mm Hg
implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing". It is performed to prevent the formation of blood clots in the catheter, which would disrupt the proper functioning of the catheter. The solution of 5 mL heparin should be?
100 units/mL
Position the car seat in a rear seat with the infant facing the rear of the car until infant is?
12 months old or weighs 20 lbs. (9 kg)
The nurse teaches a community education class about preventing lead poisoning for parents of young children. At which age will the nurse instruct that screening for lead poisoning begins?
12 months. The nurse will start screening a child for lead poisoning at age 12 months for low-risk clients and perform a repeat screening at 24 months of age. High-risk infant clients should have initial lead poisoning screening at 6 months of age.
The nurse is assisting in the care of a client with ventricular fibrillation. The "code" leader called to shock the client uses a biphasic defibrillator. The nurse sets the defibrillator at which energy level?
120 to 200 Joules for biphasic machines
The nurse should identify that an LDL of 172 mg/dL places the client at risk for peripheral arterial disease from atherosclerosis. The expected reference range for an adult is less than ?
130 mg/dL
normal platelet count
150,000-400,000/mm3
after a pneumonectomy, some clients have a clamped chest tube briefly to help reduce mediastinal shift. They do not usually have closed-chest drainage. Helping the client turn, cough, and breathe deeply is standard preventative postoperative care after thoracic surgery. After thoracic surgery, clients typically receive oxygen by nasal cannula or mask for the first how many days?
2 days and then as needed
a client who has an elevated BP reading from a HTN screening, the nurse should encourage him to see his provider for further evaluation within?
2 months. To help with this process, the nurse should give him a written record of the BP at the screening to share with his provider
The glans penis is dark red after circumcision and then becomes covered with yellow exudate within 24 hours. This occurrence is normal and persists for?
2 to 3 days. It is not removed.
The nurse should transfuse the packed RBCs within?
2 to 4 hr based upon the client's age and cardiovascular status. Longer infusion times increase the risk for bacterial contamination of the blood product
How long should the client discontinue prednisone before an allergy skin testing?
2 weeks
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and a BUN greater than?
20 mg/dL
Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for not more than how long?
20 minutes at a time
Apidra/Glulisine onset:
20-30 mins
insulin glargine has an onset of 70 minutes, does not have a peak and lasts up to how long?
24 hrs
The clients feeding bag should be changed every?
24 hrs.
Degludec/Tresiba duration:
24-42 hrs
blood thinner and clot buster needles should be what gauge ?
25 and up
during pregnancy, maternal blood volume increases and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to ?
27 mg per day
The nurse prepares to instruct a client diagnosed with diabetes mellitus on self-injection of insulin. Which gauge and needle length does the nurse teach the client to choose?
28-gauge syringe with a 0.5 inch needle. Subcutaneous injections should be given with a higher gauge needle.
good oral hygiene reduces the risk of recurrence of infective endocarditis. The client should use an antiseptic mouthwash for?
30 seconds twice daily as part of personal oral care
Apidra/Glulisine peak:
30-60 mins
Regular Humulin/Novolin onset:
30-60 mins
Humalog/Lispro peak:
30-90 mins
a client is to receive a 1000 mL bag of 5% dextrose in lactated ringers over 8 hrs. Using tubing with a drop factor of 15 gtt/mL, the nurse should regulate the fluid to infuse at how many drops per minute?
31 gtt/min
TB mandates the provision of a well-ventilated room with?
6-12 exchanges of fresh air per minute
NORMAL CPP =
60-100 mmHg
How long does the oliguric phase last?
7-10 days
A blood pressure of 124/84 mm Hg places this client in the prehypertension category. Prehypertension is indicated by a systolic pressure between 120 and 130 mm Hg and a diastolic pressure between 80 and ?
89 mmHg
pleural effusion
A buildup of fluid between the tissues that line the lungs and the chest
Instruct the client to draw the regular insulin into the syringe first to prevent mixing NPH insulin into the vial of regular insulin, which could cause what?
A change in the onset of action of the regular insulin
leukotriene
A substance produced by mast cells and basophils that causes increased permeability of blood vessels and helps phagocytes attach to pathogens
cochlear implants
A surgically implanted electronic device that partially restores hearing. It can be an option for people who have severe hearing loss from inner-ear damage who are no longer helped by using hearing aids.
MRI
a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in your body. Most MRI machines are large, tube-shaped magnets.
The client will self-inject 8 units of NPH insulin and four units of regular insulin each day before breakfast. As you show the client how to self-administer insulin, you should include which instructions?
Draw the regular insulin into the syringe first then the NPH insulin and use one syringe to reduce the number of injections
radiant heat loss
a method of heat transfer where heat is lost to the atmosphere
STRICTURE
a narrowing of a passage in the body
The tongue extrusion reflex is ?
a natural reflex for an infant who is not developmentally ready for solid foods. This reflex disappears at about 4 to 6 months when solid food can be safely introduced into the diet.
Undersecretion of adrenal cortex
Addison's disease
Decerebrate posturing
Abnormal body posture that involves the arms and legs being held straight out, toes pointed downward, and head/neck arched backward Muscles tightened and held rigidly Usually means severe brain damage
The nurse provides care for a client with a peripherally inserted intravenous (IV) catheter. The client reports pain at the access site and the nurse observes erythema with formation of a streak along the vein path. After removal of the IV catheter, which action does the nurse take next?
Administer an analgesic, as prescribed. The client exhibits signs and symptoms of phlebitis. Therefore, the nurse should apply a warm (not cold) compress to the site and elevate the extremity (not place it in a dependent position)
A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take
Administer o2 Initiate IV therapy Insert an NG tube Administer famotidine The first action the nurse should take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the nurse can administer famotidine when the client is no longer bleeding.
A nurse in an emergency department is preparing to administer alteplase accelerated therapy to a client who is having a myocardial infarction. Which of the following actions should the nurse plan to take?
Administer the medication within 30 min of the client's arrival to the department, Reconstitute the medication with sterile water, Administer a 15 mg IV bolus, and Assess the client for back pain
The nurse works with an LPN/LVN on a team nursing unit. Which task is most appropriate for the nurse to delegate to the LPN/LVN? (Select all that apply.)
Administering an intramuscular injection, Administering oral medications, and Obtaining a capillary blood glucose. The nurse will need to administer an intravenous blood pressure medication because these drugs require close monitoring after administration
the nurse is aware the following is true regarding the administration of methylprednisolone post spinal cord injury?
Administration is controversial
although jaundice can indicate a hematologic disorder such as hyperbilirubinemia, yellowing of the skin is common with?
Aging. Jaundice is an unreliable indicator of hyperbilirubinemia for an older adult
although pallor can indicate a hematologic disorder such as anemia, pigment loss is common with?
Aging. Pallor is an unreliable indicator of anemia for an older adult.
The nurse is providing care to a client diagnosed with measles. Which transmission-based precaution does the nurse implement when caring for this client?
Airborne. Airborne precautions are implemented when providing care for clients with measles for up to 4 days after the onset of rash.
A client with a history of intravenous drug abuse experiences a low-grade fever, cough, night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum. Which transmission-based precaution will the nurse use for this client?
Airborne. The client's history and signs suggest pulmonary tuberculosis, which is spread by airborne pathogens (M. tuberculosis)
HIRSCHSPRUNG'S DISEASE
Aka congenital aganglionic megacolon A structural anomaly of the GI tract caused by lack of ganglionic cells in segments of the colon resulting in decreased motility and mechanical obstruction
Scurvy
Aka scorbutus Condition caused by vitamin C deficiency Symptoms may not appear for months Bruising, bleeding gums, weakness, fatigue ans rash
The partial thromboplastin time (PTT) is mainly used to monitor
a person's response to anticoagulant therapies
ruptured aneurysm
An aneurysm is a balloon-like bulge of an artery wall. As an aneurysm grows it puts pressure on nearby structures and may eventually rupture. A ruptured aneurysm releases blood into the subarachnoid space around the brain. A subarachnoid hemorrhage (SAH) is a life-threatening type of stroke.
The nurse provides care for several clients in Buck traction. Which client is at greatest risk for skin breakdown?
An elderly client with severe Alzheimer disease. A client with Alzheimer disease is an actual risk. Client may be unable to perceive or report pain accurately, and the client may be unable to change position unaided.
Raynaud's phenomenon
a problem that causes decreased blood flow to the fingers. In some cases, it also causes less blood flow to the ears, toes, nipples, knees, or nose
a nurse is caring for a client 1 hour following a cardiac catheterization, the nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity, which of the following interventions is the nurse's priority?
Apply firm pressure to the insertion site. The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.
The nurse plans to teach an adolescent female, newly diagnosed with systemic lupus erythematosus (SLE), about measures to prevent complications. Which information does the nurse include in the teaching session?
Apply sunscreen daily and encourage calcium-rich foods, particularly in adolescent females receiving corticosteroid therapy.
The nurse notes the client on crutches is resting the axilla on the crutch pads while standing. Which action does the nurse take first?
Ask the client if a rest period is needed. Ensuring the client is not over-exerted is the first priority. Improper ambulation device use, such as leaning on the equipment, is often a sign of fatigue. Determining the cause of the improper stance is required.
A nurse is planning dietary teaching for a client who has DM. Which action should the nurse plan to take first?
Ask the client to identify the types of foods she prefers
A client diagnosed with a terminal disease questions the nurse about the purpose of diagnostic tests. Which action should the nurse take next?
Ask the health care provider to discuss the diagnostic tests with the client. When advocating for the client, the nurse should contact the health care provider to have the client's questions and concerns about diagnostic tests addressed.
P wave
Atrial depolarization (contraction)
A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?
Avocados. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.
thoracentesis
a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier
percutaneous transluminal coronary angioplasty
a procedure in which a small balloon on the end of a catheter is used to open a partially blocked coronary artery by flattening the plaque deposit and stretching the lumen
brachytherapy
a procedure that involves placing a sealed radiation source inside/next to the area of treatment in your body. Used to treat cancer. Sometimes called internal radiation
hemodialysis
a process of purifying the blood of a person whose kidneys are not working normally
polycythemia vera
a rare, chronic disorder involving the overproduction of blood cells in the bone marrow
An older client is discharged from the hospital to home following treatment for a fall. The nurse makes a home safety survey. Which findings does the nurse report as fall safety risks? (Select all that apply.)
Bathroom is located on the second floor, Throw rugs are in the pathway to the kitchen, Mailbox is located at the end of the driveway - the older client needs to walk outdoors daily to retrieve mail regardless of the weather. This may pose a risk for falling. Recommend the use of a cane or walker for stability when walking outside.
a charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. Which action by the newly licensed nurse should the charge nurse intervene?
Borrowing a dosimeter film badge from another nurse before entering the client's room
While administering a cleansing enema to a client, the nurse notes the client is restless with a rigid and distended abdomen. The nurse recognizes this client is experiencing which type of complication?
Bowel perforation. Compartment syndrome begins with edema and increased pain. It progresses with decreased perfusion, causing a change in skin color and weak pulses. Numbness is a later sign that could indicate tissue necrosis. This is an emergency that should be reported to the health care provider.
A nurse is reviewing the lab reports of a client and notes an elevated thyroid-stimulating hormone (TSH) level. Which of the following findings should the nurse expect?
Bradycardia - an elevated TSH level indicates hypothyroidism, which is characterized by weight gain, bradycardia, cold intolerance, paresthesia, hearing loss, depression and other manifestations
allopurinal
Brand names: Zyloprim, Aloprim Prescription needed Consult HCP if pregnant Avoid interaction with alcohol Uric acid reducer Treat gout/kidney stones
Atorvastatin
Brand: Lipitor Class: Statin Treat high cholesterol and triglyceride levels May reduce risk of angina, stroke, heart attack, or heart/blood vessel problems Prescription needed Consult HCP if pregnant Interactions can occur with alcohol
Diazepam
Brands: Diastat, Diastat AcuDial Anxiolytic/Sedative Treats anxiety. muscle spasms, seizures Controlled substance Can cause paranoid/suicidal ideation, impair judgment Should not be used with alcohol
Digoxin
Brands: Digox, Lanoxin Antiarrhythmic and BP support Treats HF and heart rhythm problems Prescription needed No known interactions with light drinking Class: Cardiac glycoside
Theophylline
Bronchodilator It can treat asthma and other lung problems, such as emphysema and chronic bronchitis. Prescription needed Consult doctor is pregnant Very serious interactions with alcohol
A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?
Bubbling in the water seal chamber has ceased
Ambulation is inappropriate for a client with an epidural catheter because of ?
a risk for catheter displacement
basal insulin
a slow-acting type of insulin. People take it between mealtimes and before bedtime to control blood sugar outside of eating. Three types currently available: Glargine, detemir, and degludec
A nurse is assessing a client who has fluid volume overload from a cardiovascular disorder. Which manifestations should the nurse expect?
Jugular vein distension, moist crackles and increased heart rate - hypervolemia is an expansion of fluid volume in the extracellular fluid compartment, which results in an increased HR and bounding pulses
A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client?
Keep the client occupied with a manual activity. The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.
The door does not need to be kept closed to the room of a client with a?
C. diff infection
measuring the abdomen is the most effective way to assess for what in abdominal distention?
Changes, because it provides concrete, objective data that can be compared at various points in time
A nurse is caring for a client who has congestive heart failure and is taking Digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Check VS
A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?
Check for the type and number of units of blood to administer
The nurse notes the client's electrocardiogram (ECG) tracing shows a prolonged PR interval, a wide QRS complex, and tall peaked T waves. Which action does the nurse take next?
Check the serum potassium
The nurse receives a prescription to start an IV dopamine infusion for a client with hypotension. Which action does the nurse take next?
Check to see if the client received volume replacement. Adequate fluid volume must be achieved before vasopressors are given because this vasoconstrictor results in further reduction in tissue perfusion without volume. Dopamine is best administered via a central line since infiltration leads to tissue sloughing.
cirrhosis
Chronic liver damage from a variety of causes leading to scarring and liver failure Diseased liver Pain/edema in leg Hepatitis/chronic alcohol abuse are frequent Can't be undone, but further damage can be limited
The nurse provides care for a client at risk for urinary incontinence. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.)
Clean the client after an episode of incontinence and Assist the client in using the bathroom or commode
The nurse reviews care needs for a shift assignment. Which client task will the nurse delegate to newly hired nursing assistive personnel (NAP)?
Client diagnosed with a fractured hip being discharged tomorrow, Client diagnosed with a fractured tibia who had surgery 2 days ago, and Client diagnosed with cellulitis to the lower leg
Union
Complex multistage healing process of a fracture 1. Fracture hematoma 2. Granulation tissue 3. Callus formation 4. Ossification 5. Consolidation 6. Remodeling
The nurse provides care to a client experiencing severe diarrhea after taking antibiotics. Which isolation precaution does the nurse implement for this client?
Contact precautions
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?
Contact the provider to clarify the prescription. Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification.
A client's vital signs pre-blood transfusion were: temperature 98.40 F (36.80 C); pulse 68 beats per minute; respiratory rate 16 breaths per minute; and blood pressure 118/74 mm Hg. Thirty minutes later, the nurse documents the client's temperature is now 98.90 F (37.20 C); pulse 72 beats per minute; respiratory rate 18 breaths per minute; and blood pressure 126/68 mm Hg. Which action will the nurse take next?
Continue to monitor the client. The client's temperature increase is less than 10 F (0.50C). This is not a febrile reaction.
coronary ostia
Coronary Openings that the right and left coronary arteries arise through
antiinflammatory agents
Corticosteroids *must be tapered off slowly* Hydrocortisone beclomethasone
The nurse provides care for a client with severe urinary retention caused by an enlarged prostate. Which type of catheter does the nurse use to relieve the urinary retention?
Coude. The curved tip on the Coude catheter allows the catheter to pass by the prostate more easily.
The nurse is assessing a neonate born at 44 weeks' gestation. Which finding does the nurse document as consistent with the newborn's gestational age?
Cracked, peeling skin
A nurse is caring for a client who has increased ICP and is receiving mannitol. The nurse should report which of the following adverse effects of this medication
Crackles heard on auscultation.
Crepitus
Crackling or grating sound caused by bones rubbing against each other
A nurse is teaching a family about the care of a patient who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching?
Create complete outfits and allow the client to select one each day
The nurse prepares to administer fondaparinux to a client. Which laboratory test result will the nurse monitor in the client receiving this medication?
Creatinine level
fast acting insulin
ONSET: 15-30 MINS PEAK: 2-4 HRS DURATION: 5-7 HRS TYPES: Lispro (Humulog) Aspart (Novolog) Glulisine (Apidra)
A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of he following should the nurse include as a risk factor for the development of hypertension?
Obstructive sleep apnea (OSA)
A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which instruction should the nurse include in the teaching?
Darken the lights
Cardiac catherization
Diagnostic test Used to diagnose/treat caridiovascular conditions A long thin tube is inserted in an artery/vein in the groin, neck or arm and threaded through the blood vessels to the heart
bismuth subsalicylate
Diarrhea medication It can treat diarrhea, heartburn, nausea, and upset stomach
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which prescribed meds should nurse instruct client to withhold for 48 hours before cardioversion?
Digoxin
insulin deficiency
Disruption in the production of insulin.
A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?
Document that depolarization has occurred. When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization
The nurse uses a paper-based documentation system to write a client care note. The previous nurse's documentation appears incomplete. Which action should the nurse take next?
Draw a line through any empty space and continue documenting. Empty spaces should not be left because it allows others to document in that space in an incorrect manner. The nurse who did the documenting should come in to complete it as soon as possible, but calling the nurse to ask if the documentation is complete does not solve the issue.
a nurse is teaching a client who has type 1 DM about a new SQ insulin infusion pump. Which piece of info should the nurse include in the teaching?
Plan to use a type of short duration insulin in the infusion pump
Mucolytics
Drug therapy fro asthma/COPD Acetylcysteine (Mucomyst) - nebulizer or PO
The nurse prepares discharge instructions for an overweight client with gastroesophageal reflux disease (GERD). Which instruction does the nurse include in the teaching plan?
Elevate the head of the bed (elevating the head of the bed about 6 inches will decrease abdominal pressure and decrease symptoms), Decrease caffeine intake (caffeine causes the lower esophageal sphincter (LES) to be looser, thus increasing symptoms of GERD) and Evaluate weight loss strategies (weight loss will decrease abdominal pressure and GERD symptoms)
a nurse is examining the ECG of a client who has hyperkalemia. Which ECG change should the nurse expect?
Elevated ST segments
a nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect?
Elevated bilirubin level - Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.
A nurse is demonstrating colostomy care to a client who has a new colostomy. Which action should the nurse teach the client to perform?
Empty the bag when it is one-third to one-half full, cut the skin barrier opening a little larger than the ostomy and wash the peristomal skin w/ mild soap and water - the client should cut an opening that is about 1/16 to 1/8 larger than the stoma to avoid applying any constricting pressure to the stoma. The client should avoid moisturizing soaps because lubricants can affect adhesion of the appliance
The nurse provides care for a client diagnosed with emphysema. The client becomes anxious and confused. What is the first action the nurse should take?
Encourage the client to do pursed-lip breathing. This prevents the collapse of the alveoli and helps the client control the depth and rate of breathing. The client should receive low-flow oxygen (less than 3 liters per minute) to prevent carbon dioxide narcosis
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?
Encourage the client to take deep breaths after the procedure. After a thoracentesis, the client should deep breathe to re-expand the lung.
A nurse is planning care for a client who has deep vein thrombosis (DVT) and is receiving anticoagulation therapy. Which of the following interventions should the nurse include in the plan of care?
Encourage the client to walk
Clients receiving chemotherapy must NPO. (T/F)
False
in chronic glomerulonephritis, the kidneys are reduced to as ittle as 50% of their normal size. T or F?
False
a nurse is providing education to a client who has TB and their fam. Which info should the nurse include in the teaching?
Family members in the household should undergo TB testing. Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.
A nurse is providing discharge instructions to a client who developed DVT postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include.
Flexing her knees and feet frequently
A client receives treatment with internal radiation for cervical cancer. Which observation by the charge nurse poses the greatest risk to the person involved?
Food service worker who is pregnant delivers a breakfast tray into the room. The pregnant worker needs follow-up to monitor the unborn child for teratogenic-related abnormalities. Education is needed to prevent the dietary staff from entering the room. Reentry into the room may occur if the worker is not educated immediately. Environmental service staff should not enter the room nor bring trash out of the room. The trash may be too radioactive to be serviced like other trash. Education and follow up are needed to reinforce proper waste disposal and exposure concerns. The client's spouse should stay in the room for only 30 minutes, but the risk is fairly low. The nurse should not enter the room without the dosimeter badge to monitor radiation exposure, but the time it took to receive the report represents a small risk
A nurse is checking lab values to determine if a client w/ DM is adhering to the treatment plan. Which test should the nurse use to make this determination?
Glycosylated hemoglobin levels - Checking glycosylated hemoglobin levels (HbA1c) is an accurate method of determining if the client is routinely compliant. Glycosylated hemoglobin refers to hemoglobin that is connected to glucose. Since the lifespan of an RBC is 4 months, this value will not be affected by recent changes in the clients diet or meds.
a nurse is reviewing the progress notes for a client who has HF. The provider noted some improvement in the client's CO. The nurse should understand that CO reflects which of the following physiologic parameters?
HR times the stroke volume
Increased appetite is not an adverse effect of epoetin alfa. Adverse effects of epoetin alfa include seizures, heart failure, myocardial infarction, stroke, thrombolytic event, and ?
HTN
Therapy with erythropoietin increases RBC production, which can result in?
HTN
A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy?
INR 2.5. Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.
levonorgestrel-releasing intrauterine device aka
IUD
On auscultation of a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third bilaterally. How should the nurse document this finding?
Inspiratory crackles at the bases - Crackles are low-pitched, bubbling sounds usually heard on inspiration. Wheezes are high-pitched sounds. They can be heard during the expiratory or inspiratory phase of the respiratory cycle. The lower third of both lungs are the bases, not apices. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.
The nurse provides care for a client who takes digoxin for heart failure. Which finding is a priority for the nurse to communicate to the health care provider (HCP)?
Intermittent nausea and loss of appetite. Nausea, anorexia, and vomiting are early signs of digitalis toxicity.
How do you promote mobility in pt's with a cast to promote atrophy?
Isometrics Muscle stimulators Encourage use of all muscles
Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a ?
MI
Troponin is released by the myocardial muscle when injury occurs. Troponin is not present in the body at any other time, making it very specific to cardiac injury. Troponin levels in the blood can rise within 2 to 3 hr of the onset of an MI. This allows for a quick diagnosis and is the gold standard when treating client's who have suspected?
MI
evidence based practice indicates that HF is a complication of?
MI
evidence based practice indicates that cariogenic shock is a complication of?
MI
evidence based practice indicates that pulmonary edema is a complication of?
MI
a client who has a BP of 150/90 mmHg does not require emergency services unless manifestations of a stroke or?
MI are present
according to evidence based practice, dysrhythmias (specifically ventricular fibrillation) are the most common cause of death following a?
MI, therefore nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat asap
Hands of personnel continue to be the principal mode of transmission for?
MRSA
The nurse should identify that HDL 84 mg/dL is within the expected reference range for a male adult client, which decreases the risk of peripheral arterial disease from?
atherosclerosis
intraventricular catheter
Most accurate monitoring method Inserted through the brain and into the lateral ventricle where CSF is contained
The nurse provides care for a client who has undergone detoxification of long-term opioid use. The nurse plans discharge teaching for the client. Which medication does the nurse include in the discharge teaching?
Naltrexone, an opioid antagonist, can take during detoxification and continue to take this medication as maintenance therapy to eliminate craving
The intensive care unit charge nurse notes an increase in clients coming from the emergency department without identification bracelets. Which action does the charge nurse take?
Notify the emergency department nurse manager about the problem. The ICU charge nurse needs to meet with the ED nurse manager to discuss how the problem began and how it can be corrected.
Mannitol (Osmitrol)
Osmotic diuretics. Pull fluid back into the vascular and extravascular space by increasing serum osmolality to promote osmotic changes. Decrease intracranial pressure related to cerebral edema.
Live plants can harbor?
P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.
Hair loss is a manifestation of ?
PAD
Thick, deformed toenails are a manifestation of ?
PAD
Rabeprazole is a?
PPI
The nurse provides care for a client after an above the knee amputation (AKA) 2 days ago. The nurse places the client in which position?
PRONE. The client is placed in the prone position for a short time on the first postoperative day and then for 30 minutes three times a day to stretch the flexor muscles and prevent hip contracture
Warfarin therapy is evaluated by?
PT and INR. Drawn daily for first 5 days and then twice weekly for next 1-2 weeks
Partial Thromboplastin Time
PTT Or aPTT/APTT (activated ptt) Diagnostic test Blood test that characterizes coagulation of the blood
A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?
PaCO2 56 mm Hg. A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range.
6 P's of caring for a fracture
Pain Pallor Pulselessness Parasthesia Paralysis Poikilothermia
The six P's of nursing care for a fracture:
Pain Pallor Pulselessness Paresthesia Paralysis Poikilothermia (coolness)
Nursing care of a fracture:
Pain management Narcotics PO Elevate extremity Neurovascular check Ice/edema Pain modification techniques
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
Perform a 12-lead ECG
The nurse provides care to a client with an epidural catheter for pain control with fentanyl after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client?
Perform peripheral neurovascular checks every 2 hours, assess for bowel and bladder distention, and monitor client for nausea and vomiting
The nurse uses research findings to improve client care. Which technique of care is the nurse using?
Performance improvement
The nurse prepares a client for surgery. Which task is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)?
Performing a clean catch urinalysis, Collecting vital signs, Applying compression stockings
The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.)
Place respiratory equipment at the bedside, Remove harmful objects from the client's reach, and Apply foam padding around the bed rails. Only the nurse can do assessments such as timing the duration of a seizure activity.
A client receiving a blood transfusion experiences a febrile reaction. Once the transfusion is discontinued, which action will the nurse take next?
Place the bag and tubing in a biohazard container to send back to the blood bank (not discarded) for analysis. Flushing the tubing will cause the blood that is in the tubing to be infused into the client, making the reaction worse
A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the clients VS, which action should the nurse perform next?
Place the client in high-fowlers position
The nurse understands that CKD is characterized by which of the following?
Progressive, irreversible destruction to the kidneys
Cardiac cirrhosis
Pts with severe long term right sided HF develop this which causes decreased oxygenation of the liver cells, leading to liver cell death
Traction
Pulling force to an injured body part/extremity
The nurse is teaching the parent of a 2-year-old client on how to correctly administer ear drops. Which action by the parent indicates to the nurse a need for further education?
Pulls the pinna up and back. The pinna should be pulled down, not up and back. The child should also be lying down for 5 to 10 minutes before administering drops in the other ear.
hypercalcemia shortens?
QT intervals
A nurse is caring for a client who has dementia and is experiencing anxiety. Which action should the nurse take?
Redirect the client to a different activity w/ a small group of people
Nonsurgical management goal of chronic pain:
Reduce pain, stiffness and improve joint mobility
myometrial
Refers to myometrium which is is the middle layer of the uterine wall, consisting mainly of uterine smooth muscle cells (also called uterine myocytes) but also of supporting stromal and vascular tissue. Its main function is to induce uterine contractions.
a charge nurse is observing a newly licensed nurse administer an IV med to a client who has an implanted venous access port. Which observation requires intervention by the charge nurse?
a solution of 5 mL heparin 1,000 units/mL has been prepared
A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?
Regular insulin 20 units IV bolus. DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously.
The nurse provides care for a client experiencing status epilepticus. Which action is most appropriate for the nurse to take?
Remove all pillows and raise the bed rails. Removing pillows and raising bed rails will help prevent the client from falling out of the bed, smothering, or sustaining additional injuries. Padding should be in place at the head of the bed and on the side rails to prevent further injury. The client's head should be positioned so that the tongue and secretions can fall forward during seizure activity
A nurse is transfusing a unit of B-positive fresh frozen plasma to a client whose blood type is O-neg. Which action should the nurse take?
Remove the unit of plasma immediately and start an IV infusion of NS - a client who receives FFP that is not compatible can experience hemolytic transfusion reaction
The nurse provides care for a client with acute pancreatitis. Which finding by the nurse requires immediate action?
Respiratory rate of 34 breaths per minute. Pleural effusion, atelectasis, pneumonia, and acute respiratory distress syndrome (ARDS) are potential complications of pancreatitis.
A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?
Restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.
Lead Placement I
Right mis-axillary line (5th intercostal space)
Uncontrolled COPD can lead to cardiac disease because
Right-sided heart failure results from uncontrolled COPD and more males than females are affected by COPD
The nurse provides care for a client in the final stage of chronic kidney disease. The client's serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client?
Risk for injury. The client in the final stage of chronic kidney disease is at risk for osteodystrophy due to bone mineral loss leading to an increased risk for fractures or osteoporosis
prednisone is a med used for lifelong glucocorticoid replacement therapy for?
adrenal insufficiency
Methylphenidate
Should be given after breakfast. Is a commonly prescribed psychostimulant and works by increasing the activity of the CNS.
The nurse provides care to a client who is unconscious. In which position will the nurse place the client to provide oral care?
Side-lying. When performing oral care to an unconscious client, the nurse should place the client in a side-lying or lateral position to facilitate the flow of secretions by gravity to prevent aspiration during the procedure. The nurse can also keep the head of the bed lowered.
The nurse prepares a patient who has a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
Sitting upright with the arms supported on an over bed table - The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier
A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?
Slow the infusion rate. Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.
After being told the diagnosis of terminal cancer, a client says "Why is God doing this to me?" Which nursing diagnosis does the nurse include in the plan of care for this client?
Spiritual distress
A patient admitted to the emergency department with a sudden onset of shortness of breath is diagnosed with a possible pulmonary embolus. How should the nurse prepare the patient for diagnostic testing to confirm the diagnosis?
Start an IV so contrast media may be given. - Spiral computed tomography scans are the most commonly used test to diagnose pulmonary emboli and contrast media may be given IV. Bronchoscopy is used to detect changes in the bronchial tree, not to assess for vascular changes, and the patient should be NPO 6 to 12 hours before the procedure. Positron emission tomography scans are most useful in determining the presence of cancer and a radioactive glucose preparation is used.
The nurse reviews prescriptions from a health care provider for a client's care. Which prescription will the nurse question before implementing?
Start heparin infusion by 0800 hours. The heparin infusion is missing a dose or amount of heparin to be infused. This prescription should be questioned before implementing
hydrocortisone, a glucocorticoid, treats acute and chronic what?
adrenocortical insufficiency
The nurse teaches a client about taking imipramine. Which information does the nurse include in the teaching?
Take the medication at bedtime to aid sleep and decrease daytime drowsiness
a nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which intervention should the nurse include in the plan?
Tell the client that it is possible to return to similar previous levels of activity
The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child?
The client demonstrates signs of a varicella infection. Airborne and contact precautions are needed and should be maintained for at least 5 days after the onset of the rash and until the vesicular lesions are gone
cardiac tamponade
a serious medical condition in which blood or fluids fill the space between the sac that encases the heart and the heart muscle. This places extreme pressure on your heart. The pressure prevents the heart's ventricles from expanding fully and keeps your heart from functioning properly
Rhabdomyolysis
a serious medical condition that can be fatal or result in permanent disability. Occurs when damaged muscle tissue releases its proteins and electrolytes into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death.
isotonic dehydration
a condition in which both water and sodium are lost proportionally and the serum sodium concentration maintains normal serum osmolality.
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction?
Troponin I Troponin T СРК Myoglobin
a nurse is reviewing the lab findings of a client who developed chest pain 6hrs ago. The nurse should identify which finding as an indication of an MI?
Troponin I 8ng/mL
a nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a MI. While waiting for the troponin levels report, the client asks what this blood test will show. Which explanation should the nurse provide the client?
Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart
Thrombocytopenia
a condition in which you have a low blood platelet count
conscious sedation
a decreased level of consciousness in which the patient is not completely asleep
Chondroitin
a dietary supplement and a vital part of cartilage. Can prevent cartilage breaking down and can also stimulate its repair mechanisms
A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?
Use crutches with rubber tips. Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.
The nurse teaches the client about skin care during radiation therapy. The nurse includes which teaching point?
Use lukewarm water and gentle soap to bathe, Wear loose-fitting clothing made from natural fibers, Shave the area using non-alcohol-based products (teach the client to avoid shaving the irradiated area), and Wear sunblock when engaging in outdoor activities
The nurse provides care for a client who reports difficulty breathing. Which assessment finding requires immediate action by the nurse?
Use of accessory muscles, Oxygen saturation of 78%, and A heart rate of 145/minute
A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take when performing cardiopulmonary resuscitation (CPR)?
Use the heel of one hand for sternal compressions and compress the sternum 2 inches
stroke volume (SV)
Volume of blood being pumped out of ventricles in a single beat or contraction
inflammation and infection trigger the production of ?
WBCs
A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?
Walk for 30 min four times per week. Weight-bearing exercises promote bone mass.
The nurse receives a report from the lab that a client's sputum culture grew acid-fast bacillus. Which transmission-based measure is appropriate for the nurse to implement?
Wearing a fitted N95 respirator/powered air purifying respirator, placing the client in an airborne infection isolation room (AIIR), and adjusting the mask edge to fit under eyeglasses if needed
A nurse is receiving report on a client who is postoperative following an open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations?
Zenker's diverticulum, or pharyngeal pouch, is a herniation of the esophagus occurring through the cricopharyngeal muscle in the midline of the neck. Repair of the diverticulum is accomplished through an open incision in the client's neck
A client who has stress incontinence should avoid intake of caffeine because it is?
a bladder irritant. Many tea and coffee beverages contain caffeine
Valsalva maneuver
a breathing method that may slow your heart when it's beating too fast. To do it, you breathe out strongly through your mouth while holding your nose tightly closed. This creates a forceful strain that can trigger your heart to react and go back into normal rhythm.
An emergency court order for surgery occurs when?
a client waives the right to give informed consent
which clients are at risk for iron deficiency?
a client who is a vegetarian, a client who is pregnant, and a toddler who is overweight
a nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which client should the nurse assess first?
a client who is difficult to arouse and is unable to respond to questions
cellulitis
a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin
although staying active is always a good strategy, clients who have aplastic anemia are not at particular risk for DVT because?
a common manifestation of this disorder is a low platelet count
pulsus paradoxus
a fall of systolic blood pressure of >10 mmHg during the inspiratory phase
a charge nurse is observing a newly licensed nurse administer an IV med to a client who has an implanted venous access port. Which observation requires intervention by charge nurse?
a solution of 5 mL heparin 1,000 units/mL has been prepared. The solution of 5 mL heparin should be 100 units/mL
Methylphenidate is
a stimulant. Concerta, Ritalin
levothyroxine is what kind of hormone?
a thyroid replacement hormone
continuous glucose monitoring (CGM)
a tiny sensor inserted under the skin to check glucose levels in the interstitial fluid
stent
a tubular support placed temporarily inside a blood vessel, canal, or duct to aid healing or relieve an obstruction
Which clients is at risk for iron deficiency?
a vegetarian, a client who is pregnant, and a toddler who is overweight
In false labor, discomfort is usually felt in the?
abdomen. Often it feels like menstrual cramps
Dawn phenomenon
abnormal early-morning increase in blood sugar
Spasticity is
abnormal muscle tightness due to prolonged muscle contraction. It is a symptom associated with damage to the brain, spinal cord or motor nerves, and is seen in individuals with neurological conditions, such as: Cerebral palsy (CP)
Wilson's disease
abnormality of a protein that causes excessive accumulation of copper in the liver leading to chronic inflammation
a nurse is assessing the hematologic system of an older adult client. The nurse should report which finding to the provider as a possible indication of a hematologic disorder?
absence of hair on the legs
Ascites
accumulation of fluid in the abdomen
a nurse is rewarming a client following coronary artery bypass graft (CABG) surgery. Which of the following complications of the rewarming process should the nurse monitor the client?
acidosis
Zoledronate, a bisphosphonate drug, inhibits the?
action of osteoclasts and therefore reduces serum calcium levels
A nurse should ensure a client has provided informed consent before administering a placebo. The nurse should not administer a placebo to a client who thinks it is an ?
active medication, because this action is a violation of client rights.
ethambutol, isoniazid, pyrazinamide, and rifampin for ?
active tuberculosis (TB). The client can be discharged after antibiotics are initiated. The client remains on antibiotics for 6 to 9 months. Hospital discharge is also not contingent on negative sputum cultures. However, the hospitalized client remains in isolation for 2 to 4 weeks, or until the client has had three negative sputum cultures
Nausea and vomiting are manifestations of an?
acute MI
Profuse sweating and anxiety are manifestations of an ?
acute MI
Tachycardia and dysrhythmias are manifestations of an?
acute MI. Tachycardia can also occur as a result of the client's anxiety.
Abdominal pain radiating to the right shoulder is nonurgent because it is an expected finding for a client who has?
acute cholecystitis
Anorexia is nonurgent because it is an expected finding for a client who has?
acute cholecystitis
Rebound abdominal tenderness is nonurgent because it is an expected finding for a client who has?
acute cholecystitis
the nurse should review the clients prothrombin time after the administration of FFP, which is plasma-rich in clotting factors. FFP is administered to treat ?
acute clotting disorders. The desired effect is a decrease in prothrombin time
The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing?
acute compartment syndrome
hallucinations are an adverse effect of asparaginase, which is an antineoplastic med used to treat ?
acute lymphocytic leukemia
exenatide, an incretin mimetic agent, can cause what?
acute pancreatitis
a nurse is teaching a client who has a family history of colorectal cancer. to help mitigate this risk, which of the following dietary alterations should he nurse recommend?
add cabbage to diet
iron requirements are increased for women who have excessive blood loss due to menstruation. Generally, postmenopausal women do not require ?
additional iron
A client who has chronic kidney disease should have?
adequate iron stores for erythropoietin therapy to be effective. Clients are encouraged to consume foods high in iron such as beef, liver, pork, and veal
oil-based ointments on the skin disrupt?
adhesion and antimicrobials are not necessary unless prescribed by the provider to treat an infection
The unit secretary is not qualified to reassign?
admissions
the charge nurse is responsible for managing, supervising and assisting the nursing staff, as well as providing administrative support and client care. The charge nurse also helps with ?
admissions and discharges
The nurse should expect a client who has compartment syndrome to have a diminished pulse or pulselessness in the?
affected extremity due to lack of distal perfusion caused by a decrease in the muscle compartment size
the nurse should flush the line w/ 10 mL of sterile 0.9% sodium chloride solution before and?
after administering meds through the PICC
during a sickle cell crisis, the nurse should encourage increased fluid intake to promote hydration because dehydration increases the viscosity of the blood, which can?
aggravate sickling and client discomfort
Although poor nailbed capillary refill can indicate a hematologic disorder such as arterial insufficiency, thickening and discoloration of the nails are common with ?
aging and are not a reliable indicator of arterial insufficiency for an older adult client
The client needs to be allowed to rest in the postictal state of seizure activity. Continuous arousal will ?
agitate the client and may cause complications
Use of accessory muscles for breathing signifies?
air hunger and immediate attention
Alcoholic cirrhosis
aka Laënnec's Cirrhosis. Second most common form of cirrhosis in US and results from chronic alcoholism/malnutrition
Anaphylactic Shock
aka anaphylaxis, it is a severe/life threatening systemic hypersensitivity reaction
Hypercapnia
aka hypercarbia, increased PaCO2
postural hypotension
aka orthostatic hypotension— when your blood pressure drops when you go from lying down to sitting up, or from sitting to standing
a detrimental inhibitory interaction can occur with the concurrent use of propranolol and albuterol. When a client takes propranolol and albuterol together, propranolol can interfere with?
albuterol's therapeutic effects
A client who has undergone alcohol withdrawal can use disulfiram as an?
alcohol deterrent. Concurrent use with alcohol can result in facial flushing, nausea, vomiting, confusion, blurred vision, and possible severe hypotension
ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, alter?
allergy skin test results, they diminish the client's reaction to the allergen
Leukotriene modifiers
also called leukotriene receptor antagonists, are a group of medications. They can help prevent breathing problems associated with allergies, asthma and chronic obstructive pulmonary disease. Examples include montelukast, zafirlukast and zileuton.
arcuate artery
also known as arciform arteries, are vessels of the renal circulation. They are located at the border of the renal cortex and renal medulla. They are named after the fact that they are shaped in arcs due to the nature of the shape of the renal medulla
mycobacterium tuberculosis bacilli enter lungs where they are ingested by?
alveolar macrophages and multiply
Cyanocobalamin (vitamin B12) interacts with?
aminosalicylic acid, neomycin, colchicine, and chloramphenicol
Lactulose is part of ?
ammonia-lowering therapy and the frequency may be increased based upon the client's ammonia level. The medication may be administered rectally if the client cannot take the medication orally.
Cardiac output
amount of blood ejected by the heart EVERY MINUTE
cerebral blood flow
amount of blood in mL passing through 100 g of brain tissue in 1 min. About 50 mL /min per 100 g of brain tissue
Preload
amount of blood in the ventricles at the end of diastole
a nurse is admitting a client who is in sickle cell crisis. Besides pain management, which of the following interventions should the nurse include in the client's plan of care?
ample hydration
ECG criteria of PVCs: the QRS complex is wide and often premature with increased?
amplitude and of bizarre shape
pilonidal cyst
an abnormal pocket in the skin that usually contains hair and skin debris. Its almost always located near the tailbone at the top of the cleft of the buttocks. They usually occur when hair punctures the skin and then becomes embedded. A relatively uncomplicated procedure, often seen in teenagers and young adults
Stopping baclofen abruptly can cause?
an acute withdrawal reaction, including manifestations of hallucinations and increased spasticity. This med should be discontinued gradually over at least 2 weeks
The client should follow each dose of psyllium with?
an additional 240 mL (8 oz) of liquid
mycobacterium tuberculosis is?
an airborne, gram-positive, acid-fast bacillus. Infection occurs mainly in the lungs but can be transported via lymph system to other organs.
Cefazolin is a cephalosporin that is contraindicated in clients who have ?
an allergic reaction to penicillin
cefotetan is?
an antibiotic that affects vitamin K levels, which can result in bleeding and epistaxis.
ampicillin
an antibiotic used to prevent and treat a number of bacterial infections, such as respiratory tract infections, urinary tract infections, meningitis, salmonellosis, and endocarditis
radioactive iodine-131 is what kind of drug?
an antithyroid drug treating hyperthyroidism from Graves' disease and also thyroid cancer
Alendronate sodium is to be taken on?
an empty stomach
The station is the relationship of the presenting fetal part to ?
an imaginary line drawn between the maternal ischial spines. It is a measure of the degree of descent of the presenting part of the fetus through the birth canal. The station of the presenting part is determined when labor begins so the rate of descent of the fetus during labor can be determined accurately.
A low-fiber diet, used to treat diarrhea, does not facilitate the elimination of the barium used during the test. The nurse should recommend ?
an increase in fiber intake instead
thrombophlebitis
an inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs. The affected vein might be near the surface of your skin (superficial thrombophlebitis) or deep within a muscle (deep vein thrombosis, or DVT)
An elevated sedimentation rate indicates ?
an inflammatory process. The normal value for males under 50 years is less than 15 mm/h. For males over 50 years, it is less than 20 mm/h. For females under 50 years, it is less than 25 mm/h. For females over 50 years, it is less than 30 mm/h. This client can be delegated to the LPN/LVN.
Factor VII- Hemophilia A deficiency
an inherited bleeding disorder caused when a person's body does not produce enough of a protein in the blood (factor VII or FVII) that helps blood clot or the factor VII doesn't work properly.
The client should re-suspend the insulin the insulin gently prior to injection and must always use what?
an insulin syringe to prevent errors
NPH insulin
an intermediate-acting insulin given to help control blood sugar levels in people with diabetes. Onset of effects is typically in 90 minutes and they last for 24 hours
naloxone reverses the effects of?
an opioid overdose
The client does not need to complete an advance directive and identify a health care proxy to become ?
an organ donor
mammogram is what kind of diagnostic procedure?
an x-ray
pregnancy category C
animal studies show adverse effects
a nurse is assessing a client who has peripheral vascular disease and a venous ulcer on the right ankle. Which finding should the nurse expect in the clients affected extremity?
ankle swelling
treatment for flu illness is directed primarily toward prevention by?
annual vaccination
Anaphylaxis
another cause of distributive shock, caused by release of histamine, which results in vasodilation
No nurse should administer anything drawn up by?
another person
avoid sun exposure with?
antipsychotic agents
For a client taking glipizide, be sure to monitor for signs of hypoglycemia such as diaphoresis, tachycardia, sweating, hunger, weakness, dizziness, tremor and?
anxiety
When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit?
anxiety and restlessness when trying to "fight the ventilator."
gestational diabetes
any degree of glucose intolerance w/ onset during pregnancy
a nurse in the ED is preparing to discharge a client following a grade II (moderate) ankle sprain. Which of the following instructions should the nurse plan to give to the client?
apply cold compresses to the extremity intermittently
the nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which intervention is the nurse's priority?
apply firm pressure to the insertion site, The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.
the client should cut an opening that is 1/16 to 1/8 larger than the stoma to avoid?
applying constriction pressure to the stoma. The client should also avoid moisturizing soaps because lubricants can affect adhesion of the appliance
a nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority?
applying oxygen via face mask. The nurse should use a high-flow nonrebreather mask to deliver oxygen at 90% to 100%, place the client in Fowler's position to promote lung expansion after the nurse determines the client is not hypotensive, administer epinephrine quickly to prevent circulatory shock and initiate an IV infusion of 0.9% sodium chloride to maintain IV access and prevent circulatory collapse
the calf usually has warm skin; however, the skin might be cool if the client has an?
arterial problem
a nurse is assisting a provider w/ performing a paracentesis on a client. Which action should the nurse take?
ask the client to empty his bladder before the procedure
Asking a "what" question is another variation of?
asking why
Heparin injections are not ?
aspirated
a nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which complication?
aspiration of water. The client should use a shower shield over the stoma when bathing/showering to keep water out of the airway
Antacid will reduce absorption of?
aspirin
A sudden tap on the cervix during vaginal examination may cause a fetus to rise in amniotic fluid and then rebound to original position. This is referred to as a ?
ballottment and occurs near mid-pregnancy, not at 10 weeks
Lower GI series
barium enema
long-acting insulin
basal insulin; used in combination w/ rapid -acting or short-acting insulin
The client with COPD usually does not receive more than 3L per nasal cannula. Otherwise, the primary drive to breathe, which is hypoxia, can be altered, causing the client to?
become stuporous. If more oxygen is needed, a different device should be used. Also, the client with COPD has an expected oxygen saturation of only 88% to 90%
a nurse is teaching a client who has iron-deficiency anemia. The nurse should encourage the client to increase consumption of which food?
beef liver
atenolol
beta blocker, treats HTN and chest pain
a nurse is assessing for disseminated intravascular coagulation (DIC) in a client who has septic shock secondary to an untreated foot wound. Which finding should the nurse expect?
bleeding at the venipuncture site, petechiae on the chest and arms, and abdominal distention
subdural hematoma
bleeding between dura mater and arachnoid
a nurse should measure the clients abdominal girth daily to monitor for manifestations of internal bleeding. A client who has a reduced platelet count is at risk of?
bleeding due to delayed clotting
the nurse should plant to check the clients IV sites every 2 hrs for bleeding because a reduced platelet count increases the risk of?
bleeding due to delayed clotting
the nurse should not plan to administer an enema to a client who has thrombocytopenia due to the increased risk of?
bleeding from delayed clotting
clients w/ aplastic anemia should not take aspirin b/c it can increase?
bleeding tendencies
The nurse should apply traction to the indwelling urinary catheter to reduce the risk for?
bleeding, but this action will not clear the tubing of an obstruction.
Cardiac tamponade results from bleeding inside the pericardium or ?
blood backing up in the mediastinal tubes and compressing the heart. Rewarming does not contribute to cardiac tamponade
implanted ports should be flushed after each use and at least once a month when not in use. This practice is sometimes referred to as "locking" or "de-accessing". It is performed to prevent the formation of?
blood clots in the catheter, which would disrupt the proper functioning of the catheter
Anticoagulants can be beneficial during cardioversion due to their ability to prevent ?
blood clots that can be released into the client's circulatory system after cardioversion
venous stasis activates platelets and stimulates?
blood clotting
Metabolic acidosis, and not metabolic alkalosis, occurs with hypothermia as ?
blood flow to the extremities becomes compromised
fasting blood glucose
blood glucose level after fasting for at least 8 hrs
hemothorax
blood in the pleural cavity
Which finding indicates the client is experiencing acute kidney rejection?
blood pressure 160/90 mmHg
random blood glucose
blood sugar sample taken at a random time
Prothrombin Time (PT)
blood test that measures how long it takes blood to clot
hemarthrosis
blood within a joint
levodopa, the metabolic precursor of dopamine, does cross the?
blood-brain barrier and is presumably converted to dopamine in the brain. This is thought to be the mechanism of levodopa relieving symptoms of Parkinson's
Symptoms of TB include?
blood-tinged sputum cough, fever and weight loss
a nurse is assessing a client who is 4 hr postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which finding should the nurse expect?
blood-tinged urine in the drainage bag
A client who has malignant hypertension might manifest ?
blurred vision and dyspnea
hydrocortisone can cause what?
bone loss
myelogenous leukemia
bone marrow makes too many white blood cells
acarbose, with or without sulfonylurea therapy is unlikely to cause?
bradycardia
manifestations of hypophasphatemia can include muscle weakness and?
bradycardia
cushings triad
bradycardia, irregular respirations, widened pulse pressure is bodys response to increased ICP, happens from severe lack of oxygen in brain tissue
a beta blocker will induce?
bradycardia, the client should take the pulse rate for 1 min before self-administration
If pregnant woman water breaks, tell husband to?
check to see if anything is presenting or crowning to determine the stage of labor before asking to time contractions
a nurse is completing an assessment for a client who has a hx of unstable angina. Which finding should the nurse expect?
chest pain lasts for longer than 15 mins
stroke aka
brain attack
coup injury
brain injury at the site of impact, Primary impact
counter coup injury
brain trauma to the opposite side of the initial force due to bouncing of the brain inside the cranium, secondary impact
hand and foot syndrome is an adverse effect of capecitabine, an antineoplastic med used to treat ?
breast and colorectal cancer
Pt is fighting the ventilator, look for?
breathing pattern in relation to the ventilator and for symptoms of respiratory distress. Check CURRENT ABGs.
The nurse should avoid massaging the client's injection site after administration to minimize ?
bruising
contusion
bruising of brain tissue
To help reduce the risk for colorectal cancer, the client should consume a diet that is low in fat. Coconut oil, containing 100 g of fat per 100 g, is higher in total fat than?
butter, which contains 81 g of fat per 100 g
a client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. The client should supplement dietary what?
calcium
a nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet?
calcium
a nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which med should the nurse plan to administer?
calcium carbonate
vitamin C deficiency produces symptoms of scurvy such as delayed wound healing and?
capillary fragility
Myoglobin is a heme protein, not to be confused with hemoglobin, found in the blood after damage to both skeletal and cardiac muscle, thus it is not specific to?
cardiac muscle
a client who has pericarditis will experience dyspnea, hiccups, and a nonproductive cough. These manifestations can indicate HF from pericardial compression due to constrictive pericarditis or ?
cardiac tamponade
An ST segment elevation of 2 mm or more indicates ?
cardiac tissue injury, otherwise known as a myocardial infarction
The stress test cannot continue without a ?
cardiologist present in case the client experiences an emergency from the exertion of the test and it must be fully performed from start to finish to give accurate results
An HDL level consistently less than 50 mg/dL is a risk factor for?
cardiovascular disease. An HDL level consistently less than 35 mg/dL is a risk factor for diabetes
The nurse enters a client's room and finds an adult visitor unconscious on the floor. Which pulse will the nurse palpate when performing a rapid assessment of the victim?
carotid. The brachial artery is the appropriate method for palpating a pulse in an infant.
as you continue to talk with the client about managing her diabetes with regular insulin (Humulin R), you should include which of the following instructions?
carry a carb snack, rotate injection sites, wear a medical alert bracelet, and expect to adjust the dosage during illness
hypochromia
cells have reduced color (less hemoglobin)
for a client who has peripheral vascular disease, manifestations can include brown pigmentations and?
cellulitis
Secure the car seat tightly in the?
center of the back seat to reduce the risk of injury
Ammonia is toxic to brain cells. This causes?
central nervous system depression ranging from sleep disturbance to lethargy and deep coma
Cefazolin (Ancef)
cephalosporin antibiotic
cefotetan is a second generation?
cephalosporin. A class of antibiotic that does not manifest disorientation as an adverse effect
Hyponatremia results in fluid shifts into the?
cerebral space causing cerebral edema. Seizures, coma, and respiratory arrest may occur.
cervical os
cervical os is the opening in the cervix at each end of the endocervical canal. The external os is near the vagina, and the internal os is near the uterus. During your menstrual cycle, the cervical os opens more readily during ovulation to allow sperm to enter.
Compensatory stage
characterized by the initiation of compensatory mechanisms in an effort to maintain adequate volume, CO, and blood flow to the tissues
Hypocalcemia can result from blood transfusions containing ?
citrate. Citrate causes increased cell membrane permeability, leading to increased neuromuscular excitability, which may result in numbness or tingling of the ears, nose, fingers, and toes. If severe, laryngospasm, seizures, and cardiac arrest may occur.
malpractice occurs when a nurse fails to act as a competent nurse normally would act in the same situation and this results in?
client injury. It results in harm from being careless, not from intentionally harming a client (which is assault and battery)
Nurse-sensitive indicators are?
client outcomes and nursing workforce characteristics that are directly related to nursing care, such as changes in clients' symptom experiences, functional status, safety, total nursing hours per client day, and costs
Neutropenic precautions are used specifically for?
clients with very low white blood cell counts
The nurse should identify trauma as a risk factor for?
clot formation
The anticoagulants within the dialysate prevent?
clotting and the risk for bleeding
for disseminated intravascular coagulation (DIC), the formation of large amounts of microemboli in the circulation depletes the body's platelets and?
clotting factors
a nurse is assessing a client who is receiving peritoneal dialysis. Which finding should the nurse report to the provider immediately?
cloudy effluent
a nurse is caring for a client who has diverticulitis and a new prescription for a low-fiber diet. Which food items should the nurse remove from the client's meal tray?
coleslaw. Raw cabbage is high in fiber. They should avoid most raw veggies
For a client who has encephalitis due to west nile virus, the nurse should monitor the clients VS to assess for changes consistent w/ increased ICP. In addition, the nurse should monitor the client's neurological status at least q 4 hrs or more frequently if the client's status indicates. The course of encephalitis is unpredictable, so the client should be monitored closely for any indications of deteriorating neurological functioning. The nurse should provide the client w/ a low stimulation environment to promote what?
comfort and decrease agitation
Atrial flutter indicates a lack of ?
conduction b/w the atria and ventricles. The additional atrial beats are not conducting
a nurse is preparing a client for discharge following a bronchoscopy. Which assessment is the nurse's monitoring priority?
confirming the gag reflex
An elevated BNP level indicates ?
congestive heart failure and requires observation by the nurse
A unemancipated minor has the right to ?
consent to treatment for substance use disorder
The nurse provides care to a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation will the nurse implement for this client?
contact
P. aeruginosa spreads by?
contact, either on health care workers' hands or contaminated equipment. It is not airborne, so respirator masks are unnecessary.
In true labor, walking often intensifies the?
contractions and brings about cervical effacement and dilation
A blood pressure less than 140/90 mm Hg indicates that the pre-eclampsia is?
controlled
Edema around the client's eyes is not present if the mild pre-eclampsia is?
controlled
Fluticasone propionate is a ?
corticosteroid. It reduces airway inflammation and bronchial hyperresponsiveness. It is not used for sudden symptoms of asthma
Which med should the nurse anticipate the provider using to determine the presence of adrenal insufficiency?
cosyntropin. The client is monitored after the provider injects cosyntropin to see if the cortisol level rises above 20 mcg/dL. If the adrenal response causes the cortisol level to elevate, the response is considered to be within the expected reference range. If the cortisol level does not elevate, the provider should determine that the client has adrenal insufficiency
the nurse should assess the clients airway after coughing and only suction the clients secretions if the client is not able to?
cough and expectorate secretions
a nurse is caring for a client who is 3 days postoperative following abdominal surgery. The client states "something just popped when I coughed". Which action should the nurse take first?
cover the clients wound with a sterile moist dressing because the greatest risk to this client is injury from infection due to wound exposure.
intermediate acting insulin
covers insulin needs for approximately half the day or overnight; used in combination w/ rapid-acting or short acting insulin
caffeinated beverages and alcohol can worsen an exacerbation of ?
crohn's disease
carbonated beverages can worsen an exacerbation of?
crohn's disease
a nurse should never borrow a dosimeter film badge from another staff member. Nurses who are caring for the client should each have a personal badge and wear it while in the clients room. The badge measures the radiation exposure that the nurse is receiving, and each film badge will indicate the nurse's what radiation exposure?
cumulative
dexamethasone is a synthetic steroid that is used to determine if a client has?
cushings syndrome, as indicated by minimal or no suppression of cortisol production
a nurse is assisting with a clients laceration repair in which the provider will use both lidocaine and epinephrine. The nurse should inform the client that the epinephrine will perform which of the following actions?
delay systemic absorption of the anesthetic properties of lidocaine
a nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which action should the nurse take?
demonstrate ways to deep breathe and cough, The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications
a nurse is assessing a client who has right-sided HF. Which finding should the nurse expect?
dependent edema
the elderly have a ?
depressed immune system
the nurse should explain that alcohol can cause liver cirrhosis through which of the following actions?
destroying liver cells that are later replaced w/ scar tissue
Serum osmolality
determines the movement of fluids and electrolytes across membranes
a nurse is monitoring a client who has asthma, takes albuterol, and recently started taking propranolol to treat a cardiovascular disorder. The client reports that the albuterol has been less effective. Which of the following factors should the nurse identify as a possible explanation for this change?
detrimental inhibitory interaction
A triglyceride level consistently greater than 250 mg/dL is a risk factor for?
diabetes
Being overweight with a waist/hip ratio greater than 1 is a risk factor for?
diabetes
desmopressin (DDAVP) is a therapeutic use for
diabetes insipidus
Hypocalcemia is a manifestation of ESKD and an adverse effect of?
dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement.
Name one carbonic anhydrase inhibitor
diamox
indications of a hypoglycemic reaction include hunger, tachycardia, shakiness, tremors and?
diaphoresis
Cefotetan does not manifest constipation as an adverse effect. The nurse should monitor this client for?
diarrhea
Lactulose rids the body of excess ammonia and can result in hyponatremia if the client experiences ?
diarrhea
Sildenafil can cause?
diarrhea
causes of hypocalcemia include hypoparathyroidism, chronic kidney disease and?
diarrhea
repaglinide is a meglitinide that can cause what?
diarrhea
end-diastolic volume is the amount of blood in the left ventricle at the end of?
diastole (filling)
Oxygen Debt
difference between normal VO2 and VO2 during low-DO2 states
dysphasia
difficulty speaking
A nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?
digoxin
a gown is required to prevent infection spread through ?
direct contact or if spraying with blood/body fluids is likely
the nurse should monitor the client for shortening of the affected leg as an indication of what?
dislocation of the prosthesis. Other findings include increased hip pain, an inability to move the extremity, and rotation of the hip internally or externally
Fractures
disruption/break in continuity of the structure of bone
With increased ICP, the jugular veins are typically?
distended
early lyme disease is characterized by a fever, influenze-like manifestations, and erythema migrans, which is what?
distinct, progressive, circular or bullseye rash that often develops at the bite site but can also develop at other sites such as the thighs and knees
for a client who has a new permanent pacemaker, the nurse should instruct the client to check the HR at the same time each day and to?
document the rate in a log for reporting to the provider
correctional insulin
dose provides a final insulin adjustment based on the preprandial glucose value. This correctional dose resembles a sliding scale, but is only a small fine-tuning of therapy.
an implanted access port is surgically placed in the SQ tissue, usually in the upper chest or an upper extremity. These sites do not require a?
dressing to cover the port site
a nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of info should the nurse include in the teaching?
driving can be dangerous due to the loss of peripheral vision, and laser surgery can help reestablish the flow of a aqueous humor
St. John's wort should be avoided while taking imipramine. Serotonin syndrome (hypertensive crisis, hyperpyrexia, extreme agitation, progressing to delirium and coma) may result if they are used together. Sugarless hard candy or gum, or saliva substitutes, may relieve?
dry mouth associated with imipramine use
a nurse in a clinic is assessing the lower extremities and ankles of a client who has a hx of peripheral arterial disease. Which of the following findings should the nurse expect?
dry, pale skin w/ minimal body hair
The first action the nurse should take when using the ABC approach to client care is to keep the client NPO due to the risk of aspiration as a result of the stroke. The client should be screened for the ability to swallow and should not receive anything by mouth until this has been completed. A client who has experienced a CVA is at risk for what ?
dysphagia, increasing the chance of life-threatening aspiration
A client experiencing an MI typically manifests ?
dyspnea
a nurse is administering adenosine via IV bolus for a client who has developed paroxysmal atrial tachycardia. Which finding should the nurse assess the client during the administration of adenosine?
dyspnea due to bronchoconstriction. Since this med has a short half-life, this effect should be short lived
a nurse is assessing a client who has pericarditis. Which manifestation should the nurse expect?
dyspnea with hiccups
death following MI is often a result of which complication?
dysrhythmias
stroke volume is the amount of blood the left ventricle pumps during?
each heartbeat
furosemide can cause the loss of potassium, sodium, calcium and magnesium. Manifestations of hypokalemia include shallow respirations, muscle weakness, lethargy and?
ectopic heartbeats
An increase in venous hydrostatic pressure, which develops when fluid accumulates in the veins, causes fluid to leak out into the tissues resulting in ?
edema
a nurse is assessing a client who has chronic venous insufficiency. Which finding should the nurse expect?
edema
instruct the client to report any indications of hypothyroidism such as drowsiness, depression, weight gain, or?
edema
radioactive iodine-131 is a teratogenic drug, confirm a negative pregnancy test prior to therapy and tell the client to use what?
effective contraceptive throughout treatment
The INR level monitors the ?
effectiveness of warfarin. The therapeutic range is 2 to 3.5, based on the diagnosis and the reasons for taking warfarin. An elevated INR indicates that the warfarin dose is not therapeutic. The client is at high risk for bleeding and should be monitored by the nurse
a nurse is teaching a client who has pernicious anemia. The nurse should encourage the client to increase consumption of which food?
eggs
Adenosine blocks
electrical signals in the heart that cause irregular heart rhythms, anti arrhythmic
a nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which action should the nurse take?
elevate the affected leg
primary hyperthyroidism is an excess secretion of thyroid hormones, both T3 and T4 levels are?
elevated
a nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect?
elevated Hct
a nurse is caring for a client who has major burn injury and is experiencing third spacing. Which of the following fluid/electrolyte imbalances should the nurse expect?
elevated Hct
Which thyroid hormone value does the nurse correlate with primary hyperthyroidism?
elevated T3
a client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an?
elevated heart rate
A nurse is planning care for a client who is postoperative following a gastrectomy. Which strategy should the nurse include to help prevent dumping syndrome?
eliminate simple sugars and sugar alcohols from the client's diet
The nurse should begin health and lifestyle teaching in the first weeks after starting the dialysis treatment once the client feels better physically and?
emotionally
The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of ?
enalapril
insomnia as an adverse effect of ?
enalapril
tachycardia, not bradycardia, is an adverse effect of?
enalapril
a nurse is planning care for a client during a sickle cell crisis. Which intervention should the nurse include in the client's plan of care?
encourage increased fluid intake
damage to blood vessel wall
endothelial injury
cardiomegaly
enlargement of the heart
a nurse is caring for a client who has an acute exacerbation of crohn's disease. Which action should the nurse take?
ensure bowel rest
The international normalized ratio (INR) calculation helps
ensure that PT test results are standardized and accurate
which finding should the nurse identify as a manifestation of hypertension?
epistaxis
A client who has ESKD is at risk for anemia manifested by malaise, fatigue, and activity intolerance. The nurse should plan to administer an?
erythrocyte-stimulating agent, such as epoetin alfa, to a client who has anemia
a common adverse effect of epoetin alfa is HTN b/c of the rise in the production of?
erythrocytes and other blood cell types
a nurse is reviewing the lab results of a client who has end-stage renal disease and reports fatigue. The clients hemoglobin level is 8 g/dL. The nurse should expect a prescription for which med?
erythropoietin
The client must remain upright 30 minutes after taking alendronate to prevent?
esophagitis
A client who is at risk for developing UTI's should void how often?
every 2-4 hrs
Hemodialysis treatments are typically scheduled?
every other day or three times a week
The client with active tuberculosis must wear a mask around?
everyone, not just around sick people
ptosis, which occurs when?
excess skin of the upper eyelid drops down over the eye. Ptosis can occur due to aging or at any age due to diabetes, myasthenia gravis, or stroke
compliance of pressure in the brain is
expandability of the brain
premature ventricular contractions
extra heartbeats that begin in one of your heart's two lower pumping chambers (ventricles)
stage 3 ICP
failing compensation and clinical manifestations of increased ICP (cushing's triad)
Hyperopia
farsightedness, light rays refract behind the retina
the nurse correlates which lab value w/ the diagnosis of DM?
fasting blood glucose greater than 140 mg/dL
a nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching?
feeling of fullness in the ear
deflate the cuff before capping a?
fenestrated tracheostomy tube
Nausea and vomiting are common side effects of opioids such as?
fentanyl
Full- and post-term neonates have deep plantar creases. A preterm newborn has?
few creases on the foot
hypotonic 0.45% sodium chloride should not be used for fluid replacement. This solution can cause lysis of RBC because it has?
fewer solutes than the cell, causing osmotic pressure to pull the fluid into the few cells remaining
Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in?
fiber
broiled hamburger, fish and poultry are all low in?
fiber
When a client is on somatropin, be sure to monitor serum glucose and urine calcium and instruct the client to watch for and report polyphagia, polyuria, or?
flank pain
asterixis
flapping tremor of the hands
desmopressin, whose brand name is DDAVP, is an endocrine system drug that can cause what?
fluid retention and weight gain
The nurse should identify distended neck and hand veins as indicators of?
fluid volume overload
which action should a nurse take when converting an IV infusion to a saline lock?
flush the Iv catheter to confirm patency
Open Skull Fracture
fracture of the skull with an associated open wound to the scalp. Allows for bacteria and infection to enter the skull and infect the brain.
hydrocortisone is unlikely to cause urinary retention, although it can cause urinary urgency and?
frequency
a thick white coating on the tongue is a manifestation of oral candidiasis rather than pernicious anemia. Instead, the nurse should expect the client to have ?
glossitis, a beefy red discoloration of the tongue
The nurse provides cares for a client with a wound. The client's wound culture is positive for vancomycin-resistant Staphylococcus aureus (VRSA). Which personal protective equipment (PPE) does the nurse don before entering the client's room? (Select all that apply.)
gown and gloves
The nurse provides care for a client diagnosed with cutaneous Kaposi sarcoma lesions. The nurse notes that the lesions are open and draining small amounts of serous fluid. Which personal protective equipment (PPE) does the nurse use when bathing and changing the linens for this client?
gown and gloves. A gown is worn when providing all care to this client, not only when changing the linens.
a nurse is assessing a client who is at risk for DVT. Which finding is a manifestation of DVT?
groin tenderness
somatropin is what kind of hormone?
growth hormone
Somogyi effect
happens when blood sugar levels fall overnight, triggering a rebound effect that causes them to rise high in the morning
polyuria and thirst are indications of?
hyperglycemia
a nurse is caring for a client who has emphysema and chronic respiratory acidosis. The nurse should monitor the client for which of the following electrolyte imbalances?
hyperkalemia
a nurse is assessing a client who is receiving a transfusion of packed RBCs. Which findings should the nurse identify as an indication of an acute intravascular hemolytic reaction?
hypotension/tachypnea due to circulatory shock, fever, and sudden oliguria, this reaction causes acute kidney injury resulting in sudden oliguria/hemoglobinuria. This reaction results from the clients antibodies reacting to the transfused RBCs
Reverse isolation is used to protect an?
immune-compromised client
Preventive care includes?
immunizations, screenings, counseling, crisis prevention, and community safety legislation
WBCs fight infection and respond to foreign bodies. Increased amounts are seen in clients who have an infectious process, and decreased amounts are seen in clients who are ?
immunocompromised
protective environment precautions are for?
immunocompromised clients who are at high risk for infection
Hepatic encephalopathy
impaired ammonia metabolism causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis.
a client who has received several blood transfusions is at risk of hemosiderosis, which is the excess storage or iron in the body. Excessive iron can come from overuse of supplements or from receiving frequent blood transfusions as ?
in sickle cell anemia
CK-MB is found ?
in the heart, skeletal muscle, and brain tissue, and is elevated within 6 hr after an injury occurs. An elevated result indicates a significant injury has already occurred
The goal of erythropoietin therapy is to?
increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.
A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of?
increased ICP
in mitral stenosis, pulmonary artery pressure is ?
increased as a result of backup pressure from the narrowing (stenosis) of the mitral valve that affects the flow of blood from the left atrium to the left ventricle
A nurse is assessing a client who recently transferred from the ICU following endotracheal extubation. Which finding should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?
increased coughing -> other manifestations are coughing up secretions and difficulty talking/breathing
a nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?
increased coughing. Other manifestations include an inability to cough up secretions and difficulty talking/breathing.
a nurse is assessing a client who has isotonic dehydration. Which of the following findings should the nurse expect?
increased hematocrit level
potentiative interactions can be helpful in?
increasing or prolonging a meds therapeutic effects
Using two fingers for chest compressions is recommended for an?
infant
Gastric distention may indicate excessive oral intake or ?
infection
The client should increase the amount of protein in their diet while receiving chemotherapy to decrease the risk for ?
infection
dont put a pt with infection, with a pt at risk for?
infection
A client who has a short leg cast can exhibit areas of warmth on the cast, which can indicate an ?
infection of the underlying tissue
The nurse is hearing a pericardial friction rub, which is a scratchy, high-pitched sound associated with?
infection, inflammation, or infiltration and can be a manifestation of pericarditis. A pericardial friction rub is best heard with the diaphragm of the stethoscope.
intrauterine devices increase the risk of an?
infection, which can lead to recurrence of infective endocarditis
erythromycin is used to treat?
infections
for a client who has femoral thrombophlebitis and a prescription for enoxaparin, the nurse should elevate the clients affected leg when the client is in bed to reduce?
inflammation
a nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin SQ. Which action should the nurse take?
inject the med into the anterolateral abdominal wall. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.
the nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is?
injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.
closed skull fracture
injury in which the skull is fractured but there is no open wound to the overlying scalp.
for a paracentesis, the client should empty their bladder before the procedure to prevent what?
injury to the bladder
The nurse plans a presentation to discuss the concept of malpractice. The nurse covers which element required to be present in a malpractice case?
injury, causation (nurse conduct causes injury), breach of duty and duty (a professional duty owed to the pt/legal relationship between nurse and client)
Suction between 80-120 mmHg, otherwise it will cause trauma to tracheobronchial mucosa. Pt should breathe normal during?
insertion and suction
a nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching?
instill a diluted alcohol solution into the ear after swimming
The client tells the nurse "I don't want any more morphine because I don't want to get addicted" Which of the following actions should the nurse take?
instruct the client on alternative therapies for pain reduction
a client should plan to use short duration insulin such as regular, lispro, aspart or glulisine to deliver a baseline infusion of insulin. The client should also administer bolus doses of ?
insulin before each meal
the client should replace the insulin SQ infusion pump every 1-3 days to maintain asepsis and to reduce the formation of?
insulin microdeposits within the tubing which can decrease the amount of insulin infused
for disseminated intravascular coagulation (DIC), uncontrollable bleeding can occur, as manifested by bleeding at the venipuncture site, petechiae on the chest and arms, and bleeding in the abdominal cavity resulting in abdominal distention due to?
internal bleeding
hypernatremia, water shifts out of the?
intracellular fluid resulting in cellular dehydration. Cerebral vessels shrink and tear, resulting in cerebral hemorrhage. Manifestations of this imbalance include lethargy, irritability on stimulation, and a high-pitched cry.
a client who has pernicious anemia is deficient in vitamin b12 due to a deficiency in an?
intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12
entropion, which occurs when the skin of the eyelids turns?
inward, causing the eyelids to rub the eye. Entropion is caused by spasms of the eyelid muscle or trauma and occurs most often in older adult clients due to the loss of supportive tissue
radioactive iodine-132
iodotope
a 3 oz serving of beef liver contains 4.17 mg of?
iron
whole grains, legumes, and green leafy vegetables also provide ?
iron
whole milk does not contain?
iron
Hemochromatosis
iron overload
Venofer
iron supplement
a nurse is reviewing lab values for an adult client who has sickle cell anemia and a hx of receiving blood transfusions. for which of the following complications should the nurse monitor?
iron toxicity
a client who is a vegetarian might require additional iron because the availability of iron in vegetable food sources is limited. During pregnancy, maternal blood volume increases, and the fetus requires additional iron. Therefore, the RDA of iron for clients who are pregnant is increased to 27 mg per day. Toddlers who are overweight may get most of their calories from milk and foods that are not considered healthy, which increases their risk for?
iron-deficiency anemia
iron deficiency can be a result of blood loss, poor absorption, or poor nutrition in the diet. This condition is called ?
iron-deficiency anemia and is not related to pernicious anemia
a nurse is caring for a client who is NPO and has an NG tube to suction. When the client reports nausea, which of the following actions should the nurse take?
irrigate the tube w/ NS
Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a?
left-hemispheric stroke
A whitish frothy sputum may indicate?
left-sided, not right-sided, heart failure
When measuring for thigh-high antiembolism stockings, the nurse measures the?
leg from the bottom of the heel to the fold of the buttocks
claudication
leg pain w/ exercise
Montelukast is a?
leukotriene receptor antagonist. It modifies the inflammatory response in asthma; however, it is not used for sudden symptoms of asthma
glargine
long acting insulin
Chronic Kidney Failure
long-term chronic damage to kidneys - years and years of destruction resulting in permanent damage
A client who has ESKD can develop pulmonary edema manifested by restlessness, shortness of breath, crackles, and blood-tinged sputum. The nurse should plan to administer a?
loop diuretic, such as furosemide, to a client who has pulmonary edema
A client's blood pressure can be elevated if excessive blood volume is present, occurring, for example, with excessive IV fluid administration. Likewise, a client's blood pressure can be decreased if there is a?
loss of blood volume through bleeding or dehydration
Regional anesthesia involves the?
loss of sensation in a specific area of the body
Left homonymous hemianopia
loss of vision in the left temporal field of vision and right nasal field of vision. Pt scan area to see vision on left side
a nurse is assessing a client who is receiving a unit of whole blood. Which finding should the nurse identify as a manifestation of a hemolytic transfusion reaction?
low back pain
a flattened T wave or the development of U waves is indicated of a ?
low potassium level
Carbidopa levodopa should be taken with a?
low protein duet to decrease GI upset
a nurse is assessing a client who has diabetes insipidus. Which finding should the nurse expect?
low urine specific gravity. An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.
For a pt who is postoperative following a radical mastectomy, the nurse should plan to begin exercises that do not stress the incision on the first postop day to promote what?
lymphatic return and mobility
Agranulocytes
lymphocytes and monoctyes
bucks traction is used prior to hip arthroplasty to maintain what and prevent what?
maintain alignment and prevent muscle spasms
the greatest risk to the clients safety is aspiration resulting from a depressed gag reflex. The nurse's priority is to make sure the client's gag reflex has returned before discharge so that the client can?
maintain hydration and nutrition without risk
multiple myeloma
malignant tumor of bone marrow cells
distraction is used for ?
manics and small children, not schizophrenics (talk to schizophrenics in a nonthreatening way)
calf tenderness
manifestation of blood clot in the leg, which can lead to a pulmonary embolism
C-reactive protein is used to ?
measure inflammation in the body
Pulmonary spirometry test
measures how much air you can breathe in and out of your lungs, as well as how easily and fast you can blow the air out of your lungs.
Tonometry
measures intraocular pressure
Venous Oxygen Saturation
measures the amount of oxygen extracted from the blood at the tissue level through a blood sample
hemoglobin A1c (glycosylated hemoglobin) value
measures the average blood glucose concentration over time by measuring the amount of glucose that binds to RBCs
acute MI
medical name for a heart attack. A heart attack is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage. This is usually the result of a blockage in one or more of the coronary arteries.
a panhysterectomy includes the removal of the uterus and ovaries, which might cause manifestations of what?
menopause
a thoracentesis is indicated for a client who has an increase of pleural fluid due to cancer, pleurisy, TB, or for a client who requires?
microscopic examination of the pleural fluid
Following the Mediterranean diet, red meat should be limited to two times?
monthly
a client who has polycythemia vera will have a plethoric (dark/flushed) manifestation of the facial skin and?
mucous membranes
Which manifestations should the nurse expect to find for a client experiencing an acute MI?
nausea, tachycardia and diaphoresis
theophylline toxicity
nausea, vomiting, abdominal pain, tachycardia, and muscle tremor
a nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which instruction should the nurse include?
numbness can occur along the inside of the affected arm. The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.
Performing a bladder scan is the role of the?
nurse
Clients with pulmonary tuberculosis require high-efficiency particulate air masks to be worn whenever a?
nurse enters the room
Allergy skin testing results can be affected by age; infants and ?
older adult clients can have decreased reactivity to allergens. However, family history is not a factor in consideration for postponing allergy skin testing.
Teaching safe use of the internet, including guidelines, is appropriate for?
older children who can read, understand, and might be trusted to use internet resources without direct supervision
Ipsilateral
on the same side of the body
OREF
open reduction external fixation
ORIF
open reduction internal fixation
peripheral vascular resistance
opposition to blood flow through the vessels
The nurse teaches the client about s/s of ethambutol toxicity. Which symptoms should the nurse include in teaching?
optic neuritis
a nurse is giving a presentation about preventing deep-vein thrombosis (DVT). Which of the following should the nurse include as a risk factor for this disorder?
oral contraceptive use and immobility
Thromboembolic events are an adverse effect of ?
oral contraceptives
Dangling the legs before getting out of bed helps prevent ?
orthostatic blood pressure changes
lactulose
osmotic laxative
CK levels will be elevated as a result of an MI; however, CK levels are no longer used to diagnosis an MI because it is not specific to cardiac muscle. CK levels can be elevated due to neurological or ?
other skeletal muscle injury
ectropion, which occurs when the skin of the eyelids turns?
outward, causing sagging of the lower lids due to muscle weakness. Ectropion occurs with aging and can cause drying of the cornea and ulceration.
reading for a hypertensive crisis
over 180 systolic and over 120 diastolic
to help prevent a recurrence of sickle cell crisis, the client should avoid ?
overextension from especially strenuous activities
Case management encompasses the ?
oversight and education activities conducted by health care professionals to help clients with chronic diseases and health conditions learn to understand their condition and live successfully with it
A utilization review identifies and eliminates the?
overuse of diagnostic and treatment services prescribed by health care providers caring for clients on Medicare
pericarditis is usually seen on an ECG as an ST-T spiking. This elevation represents ischemic changes caused by inflammation around the heart. A client who has pericarditis will have tachycardia because of decreased CO and ?
oxygen perfusion
The nurse should expect the client's respiratory rate to increase if dehydration occurs because the decreased vascular fluid volume seen with dehydration decreases ?
oxygenation and organ perfusion, requiring a compensatory increase in the respiratory rate
the nurse should review the clients hematocrit following the administration of ?
packed RBCs
Administration guidelines for sublingual nitroglycerin indicate that it is appropriate to administer another tablet 5 min after the first one if the client is still reporting?
pain
a nurse is assessing for compartment syndrome in a client who has a short leg cast. Which finding should the nurse identify as a manifestation of this condition?
pain that increases with passive movement. It results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.
costovertebral angle tenderness
pain that results from touching the region inside of the CVA angle. Is formed by the 12th rib and the spine. Assessing for CVA tenderness is part of the abdominal exam, and CVA tenderness indicates kidney pathology
The hooking technique is used to?
palpate the edges of the liver
The nurse should auscultate the BP to detect paradoxical BP for a client w/ possible cardiac tamponade by first ?
palpating the BP and inflating the cuff above the systolic pressure
For a client taking glipizide, instruct the client to watch for and report what?
palpitations
you are caring for a client who is taking exenatide (byetta) to treat type 2 DM. The client reports abdominal pain. You suspect which adverse reaction to this drug?
pancreatitis
certain meds such as clonidine can cause?
paresthesia
a client who has unstable angina will have chest pain lasting longer than 15 mins. This is due to reduced blood flow in a coronary artery from atherosclerotic plaque and thrombus formation causing ?
partial arterial obstruction or from an artery spasm
it is ill-advised to ask other nurses for their input about a self-evaluation. Self-evaluation is not a ?
peer evaluation
Which enzyme plays a role in the digestion of proteins?
pepsin
a nurse is preparing to assist a providr w/ an arterial blood withdrawal from a client's radial artery for ABG measurement. Which action should the nurse plan to take?
perform an allen's test prior to obtaining the specimen
chest pain associated w/ pericarditis will increase w/ deep inspiration due to greater pressure on the?
pericardial sac
Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with ?
peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.
arterial problems, not venous problems affect?
peripheral pulsation
a cloudy or opaque effluent indicates the client is at high risk for what?
peritonitis, a bacterial infection of the peritoneum. Therefore, this is the priority finding for the nurse to report to the provider.
glossitis can indicate?
pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.
a nurse should identify that paresthesias (tingling sensations) in the hands and feet is an expected finding of ?
pernicious anemia. Other manifestations include weight loss and fatigue
a nurse is assessing a client for manifestations of aplastic anemia. Which finding should the nurse expect?
petechiae/ecchymosis
a nurse is caring for a client who has an arterial line. Which action should the nurse take?
place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.
The nurse should instruct the client's family that they should secure extension cords to the client's baseboards using electrical tape, rather than?
placing them under carpeting. This practice can help to reduce the risk for falls
The nurse should cover the nitroglycerin topical ointment with?
plastic wrap. This allows the med to absorb into clients skin fully
the nurse should review the clients platelet count following the administration of?
platelets
pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into?
polypeptides. Other enzymes such as trypsin/aminopeptidase further break down the polypeptides into amino acids, which can be used by the body
insulin is unlikely to cause reduced urine output, although hyperglycemia can cause what?
polyuria
the nurse monitors for which clinical manifestations in the pt newly diagnosed with type 1 DM?
polyuria, fatigue, weight loss and polyphagia
pinpoint pupils means
pons damage or drugs
a progressive loss of hair is common with aging. However, thinning or absence of hair on the extremities indicates ?
poor arterial circulation to that area. The nurse should look for further indications of arterial insufficiency and report these findings to the provider.
A continuous headache, drowsiness, or mental confusion would indicate worsening of GH. These signs indicate?
poor cerebral perfusion and may be precursors of generalized seizures. It is a priority to report this finding to the health care provider.
folic acid deficiency is caused by ?
poor nutrition related to a lack of green leafy veggies, citrus fruits, and nuts in diet. Folic acid is essential for the absorption of vitamin B12
for a client who has peripheral vascular disease, the nurse should identify that swelling of the ankle is a manifestation of venous insufficiency due to?
poor venous return
a nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which action should the nurse take?
position the client supine w/ his legs elevated when in bed
Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should?
position the head of the client's bed flat and report this finding immediately to the provider
a nurse is caring for a client w/ HF whose telemetry reading displays a flattening of the T wave. Which lab results should the nurse anticipate as the cause of this ECG change?
potassium 2.8 mEq/L
furosemide can cause hypokalemia and is often paired w/ a?
potassium replacement medication
Short acting insulin
prandial insulin used for meals eaten w/n 30-60 mins after administration; used in combination w/ long-acting insulin
Rapid Acting Insulin
prandial insulin used w/n 0-15 minutes prior to eating or used as correction insulin for blood glucose elevations; used in combination w/ long-acting insulin
Metformin might be withheld for a client scheduled for cardiac catheterization or other procedures involving contrast dye in order to?
prevent damage to the kidneys. However, metformin should not be withheld prior to cardioversion
Diazepam, a benzodiazepine, is used during acute alcohol withdrawal to?
prevent seizures
Cyanocobalamin interacts with alcohol and ?
prevents the absorption of vitamin B12
Mannitol is an osmotic diuretic that ?
prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.
glycosylated proteins
process by which a carbohydrate is covalently attached to a target macromolecule, typically proteins and lipids
platelets are essential for blood clotting. A platelet deficiency does not affect the?
production of RBCs
in response to tissue hypoxia, the kidneys release erythropoietin, which stimulates the?
production of erythrocytes (RBCs) in the bone marrow
Which of the following early manifestations of lyme disease should the nurse assess the client?
progressive circular rash
a nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect?
prolonged QT intervals
what should the nurse be most concerned about regarding a patient with a fracture?
proper methods to control edema and pain Teach exercises to maintain the health of the unaffected muscles and to increase the strength of muscles needed for transferring Using assistive devices
the nurse should inform the client of ways to decrease the risk of recurrence of infective endocarditis. The client should notify the provider prior to invasive or dental procedures due to the need for?
prophylactic antibiotic therapy to reduce the risk of streptococcal infection
Heparin overdose antidote
protamine sulfate
elevated HDL has what effect against the development of atherosclerosis?
protective
Erythropoietin does not affect the client's ?
protein requirements
Clients who have end-stage liver failure have an inadequate supply of clotting factors and increased what time?
prothrombin
a nurse is reviewing a clients repeat lab results 4 hrs after administering fresh frozen plasma (FFP) which of the following lab results should the nurse review?
prothrombin time
Right supervision is ?
providing appropriate monitoring, intervention if needed, and follow-up
Acid-fast bacillus indicates the client may have?
pulmonary tuberculosis. Client is put in an AIIR appropriate room for airborne-transmission based precautions with 6-12 air exchanges/hour
The second left intercostal space is the location of the?
pulmonic area of the heart
subtract the inspiratory pressure from the expiratory pressure to determine ?
pulsus paradoxus. A difference of >10 mmHg can indicate cardiac tamponade
The medulla of the kidney is the innermost layer of tissue and is composed of multiple?
pyramids
How often are vital sign measurements taken in Acute Glomerular Nephritis?
q 4 hours with blood pressure
Levalbuterol is a?
quick acting bronchodilator and is used to treat sudden symptoms of asthma
Ciprofloxacin (Cipro)
quinolone antibiotic
cortical radiate arteries
radiate out from the arcuate arteries. They branch into numerous afferent arterioles, and then enter the capillaries supplying the nephrons.
Definition of velocity
rapidity of motion or operation; swiftness; speed
Lyme disease =
rash, intermittent fever, H/A, fatigue, muscle pain and stiff neck
The nurse should identify that P. aeruginosa can be found in?
raw fruits and vegetables
The nurse should inform the client of the difficulty of incorporating dialysis into daily life to allow the client to develop?
realistic expectations
Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. Because ammonia is a toxin that contributes to hepatic encephalopathy, effective treatment with lactulose should ?
reduce confusion
Decreasing intake of simple sugars and sweetened foods and increasing complex carbohydrates, such as fiber, can?
reduce the risk of heart disease
The head of the bed needs to be elevated 30 to 45 degrees during the tube feeding to?
reduce the risk of reflux and pulmonary aspiration. The position should be maintained for at least 1 hour post intermittent tube feeding and at all times for continuous tube feedings.
a client who has isotonic dehydration has an increased hematocrit level due to hemoconcentration caused by?
reduced plasma fluid volume
the HOB should be elevated to at least 30 degrees (semi-fowlers position) while a tube feeding is administered. This position uses gravity to help the feeding move through the digestive system and lessens the possibility of?
regurgitation
Restorative care includes?
rehabilitation, sports medicine, spinal cord injury programs, and home care
during a neurological assessment a nurse asks the client to name all of his children, their ages, and their birth dates. Which type of memory is the nurse testing?
remote
The health care provider who signs the client's death certificate is not the person who ?
removes the client's donated organs
Major calyces in the kidney empty into the?
renal pelvis
The plasma glucose concentration above which significant glucosuria occurs is called the
renal threshold for serum glucose.
for a client who has hemophilia, aggressive factor replacement is initiated to prevent hemarthrosis, which can result in a long-term loss of ROM in?
repeatedly affected joints
the appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of?
reperfusion of the coronary artery
Which of the following findings indicates that an abdominal aortic aneurysm is expanding?
report of sudden, severe back pain
Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms. The nurse should ?
report the finding immediately and implement an intervention
When talking with a 30-year-old woman who will receive radioactive iodine-132 (iodotope) to treat Graves' disease, you should include which of the following instructions?
report weight gain and edema, use effective contraceptive, allow up to 2-3 months for full effects and expect periodic blood sampling
most adult males consume adequate iron in their diet and do not?
require supplementation
Afterload
resistance to flow that the ventricle must overcome to eject its contents
The nurse provides care for a pediatric client experiencing an acute episode of croup. It is most important for the nurse to assess the client for which acid-base imbalance?
respiratory acidosis. A pediatric client experiencing an acute episode of croup causes carbon dioxide retention. They have narrowed airways, making it difficult to breathe; thereby, this makes it difficult to eliminate carbon dioxide.
Tachycardia indicates hypoxia and ?
respiratory distress status, and must be addressed immediately
a nurse is caring for a client who has a brainstem injury. Which of the following physiological functions should the nurse monitor?
respiratory effort
evidence based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with?
rest or nitroglycerin. Therefore, nurses should make pain management w/ morphine a priority to reduce myocardial oxygen demand and increase oxygenation
Distributive shock
result of disease states such as, sepsis, anaphylaxis, or neurogenic shock that cause poor vascular tone and vasodilation, resulting in increased vascular capacity and venous pooling
If the client is experiencing hypoglycemia and has already tested their blood glucose, what should they do next?
retest in 15-20 minutes and repeat the carb snack if they are still hypoglycemic
ST-segment elevation during an acute MI indicates necrosis. This ECG change reflects a clot at the site of injury. Therefore, the client requires immediate?
revascularization of the artery
cor pulmonale
right-sided HF
hold metformin for 48 hrs prior to surgery, with due, can cause renal damage and?
risk for lactic acidosis
a nurse is providing dietary teaching to a client who has ulcerative colitis. Which food selection by the client indicates an understanding of the teaching?
roast chicken and white rice
Ear drops should be at?
room temperature
when self administering regular insulin, tell the client to not shake the vial vigorously but to what?
rotate it gently to disperse the particles
Fondaparinux, an anticoagulant that inhibits factor Xa, has no effect on?
routine coagulation tests, such as international normalized ratio, prothrombin time and partial thromboplastin time
Biliary cirrhosis
scarring of the liver tissue around the bile ducts/lobes of the liver because of chronic biliary obstruction and infection
Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide?
secondary and tertiary levels of care
vasospasm
the narrowing of the arteries caused by a persistent contraction of the blood vessels, which is known as vasoconstriction. This narrowing can reduce blood flow
A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?
sedimentation rate. An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.
Readiness for enhanced spiritual well-being is indicated by a?
sense of peace or contentment and comfort with one's spirituality
sensorium
sensory environment
HMG-CoA Reductase Inhibitors (Statins) contraindicated in?
serious liver disease
thyrocalcitonin secretion is based upon?
serum calcium levels
A widely accepted criterion for acute kidney injury is a 50% or greater increase in?
serum creatinine above baseline
A nurse is providing teaching to a client who has a new diagnosis of myasthenia gravis (MG). Which of the following pieces of info should the nurse include?
set an alarm to ensure med dosages are taken on time -> maintains a therapeutic blood level. Missed/postponed because this can cause exacerbation
for a client who has a demand pacemaker, the nurse should not expect pacer spikes when the client's pulse is greater than the set rate of 72/min because the client's intrinsic rate overrides the?
set rate of the pacemaker
Vaginal dryness is a manifestation of menopause after the ovaries are removed. The client may require a water-based lubricant when having what?
sexual intercourse
Using a draw sheet prevents ?
shearing
if the client develops a rupturing AAA, the nurse should expect indications of?
shock (decreased BP and increased HR)
Albuterol
short acting bronchodilator
The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis?
shortening of the right leg
orthopneic position
sitting up and leaning over a table to breathe
Benign tumors can cause tissue destruction by the?
size and location in the body
Troponins are proteins present in ?
skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury.
Baclofen is in a class of medications called
skeletal muscle relaxants. Acts on the spinal cord nerves and decreases the number and severity of muscle spasms caused by multiple sclerosis or spinal cord conditions. It also relieves pain and improves muscle movement.
Creatine kinase is an enzyme that indicates damage to brain, heart, and?
skeletal muscle tissue
Which findings indicates the client is experiencing increased ICP?
sleepiness exhibited by the client, widening pulse pressure, decerebrate posturing
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which findings indicate an increase in ICP?
sleepiness, widening pulse pressure, decerebrate posturing
Cholesterol Absorption Inhibitor inhibits absorption of cholesterol in?
small intestine
spices or vinegar are low in?
sodium and can be used instead of salt for seasoning
yogurt is low in fat and?
sodium and is a god source of calcium and protein
Dehydration contributes to and exacerbates hypercalcemia. Fluids containing sodium should be administered, unless contraindicated, because?
sodium assists with calcium excretion. About 3L of fluids per day or more are encouraged
What type of diet should the patient with MG be on?
soft
Ipratropium Bromide
sold under the trade name Atrovent among others, is a type of anticholinergic, medication which opens up the medium and large airways in the lungs. It is used to treat the symptoms of chronic obstructive pulmonary disease and asthma. It is used by inhaler or nebulizer.
the nurse should prepare the client to expect a painful, pulling sensation when the provider aspirates the marrow as well as ?
some discomfort from the rotation of the needle into the bone
a client who has a tracheostomy with an inflated cuff in place is unable to?
speak
A face shield or goggles is required when ?
splashing with blood or body fluids is likely; it is not required for contact precautions
A nurse is caring for a client who has had a levonorgestrel-releasing intrauterine device (IUD) in place for 1 year. Which finding should indicate that the client is experiencing an adverse effect?
spotting b/w menses cycles -> Alters menses, light spotting and amenorrhea are common adverse effects
Asterixis, or involuntary flapping of the hands, may be seen in?
stage II encephalopathy
amylase is an enzyme secreted by the pancreas and intestine that breaks down ?
starches into glucose
decreased flow rate of blood
stasis
For a client taking exenatide, you instructed the client to watch for and report severe/persistent abdominal pain, sometimes radiating to the back (may or may not be accompanied by vomiting) at the start of therapy and with dose increases, so you should now inform the HCPand tell the client what?
stop taking the drug
the client does not need to wear a mask when going out in public since infective endocarditis does not result in immunosuppression. However, they should avoid contact w/ individuals who have?
streptococcal infection
Excess weight creates increased abdominal pressure that can result in?
stress incontinence
For a client taking hydrocortisone, tell the client to report increased what?
stress, as dosage might require adjustment during stressful times
injectable insulin can cause lipohypertrophy, an accumulation of what?
subcutaneous fat
Massaging is not indicated after a ?
subcutaneous injection
The skin should be pinched and needle inserted at a 90 degree angle when giving a?
subcutaneous injection
the client should inject insulin where?
subcutaneously
What is the most common assessment finding w/ an acute MI?
substernal chest pain
What is the most common assessment finding with an acute MI?
substernal chest pain
a manifestation of pulmonary embolism is?
sudden chest pain that is sharp/stabbing. Other manifestations include dyspnea, coughing, hemoptysis, tachypnea, tachycardia, diaphoresis, and a feeling of impending doom
a nurse is assessing a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication of acute intravascular hemolytic reaction?
sudden oliguria
Acute Kidney Failure
sudden short term loss of kidney function. If not stopped and reversed, can lead to Chronic Renal Failure (CRD)
glipizide is what kind of oral antidiabetic drug?
sulfonylurea
a nurse is showing a client who has right sided HF an illustration of the heart. Which of the following blood vessels carry deoxygenated blood to the right atrium?
superior vena cava
The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to?
suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium
the client could develop an infection following CABG surgery, but this is not the result of rewarming. Infection can be a result of?
surgical incisions or invasive tubes/procedures
cholecystectomy
surgical removal of the gallbladder
coronary artery bypass graft
surgical technique to bring a new blood supply to heart muscle by detouring around blocked arteries
true pelvis
surrounded by bone and lies inferior to flaring parts of the ilia; passage for infant at birth in women
DVT can cause hardening along the affected blood vessel and prominence of superficial veins, pain/tenderness in the calf, and an increase in the circumference of the leg due to?
swelling
pericarditis
swelling and irritation of the thin, saclike tissue surrounding your heart (pericardium)
Arthritis is the
swelling and tenderness of one or more of your joints
laryngeal stridor is a high pitched , harsh breathing sound that indicates respiratory distress due to what?
swelling, tetany or laryngeal spasms
varicose veins
swollen, twisted veins that lie just under the skin and usually occur in the legs. A common condition caused by weak or damaged vein walls and valves
In early TB, infected person is usually free of?
symptoms
Most people infected with TB do not have?
symptoms
epoetin alfa is a?
synthetic version of human erythropoietin
a nurse is providing teaching to a client who has gout urolithiases. The client asks how to prevent future uric acid stones
take allopurinol as prescribed, exercise several times a week, and limit intake of food with high protein
Which of the following instructions should you include when talking with the client about taking glipizide?
take it once a day, 30 min before breakfast
Prandial Insulin or Nutritional Insulin
taken at mealtime and act rapidly in the body, serving to manage the elevation of glucose levels following meals. Can also be used as correction doses - between meals or during the night - if glucose levels are high and out of range on the high side.
Lowering the bed from 90 degrees to 45 degrees allows for adequate lung and diaphragm expansion while?
taking pressure off the coccyx
a nurse is planning care for a client following placement of a chest tube 1 hr ago. Which actions should the nurse include in the plan of care?
tape all connections b/w the chest tube and drainage system
a nurse is caring for a client who has a demand pacemaker inserted w/ a set rate of 72/min. Which of the following findings should the nurse expect?
telemetry monitoring showing QRS complexes occurring at a rate of 74/min with no pacing spikes
a nurse is assessing a client who is postoperative following a thyroidectomy. Which finding is the nurse's priority?
temp 38.9 C (102 F). An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.
Although 3 weeks is a long time to have a headache, this is not unusual for a ?
tension headache
a nurse is caring for a client who is unconscious. Which action should the nurse take when providing oral care for the client?
test for the presence of a client's gag reflex
snellen test
test of visual acuity
Doxycycline (Vibramycin)
tetracycline antibiotic. It can also treat rosacea and severe acne, and prevent malaria
dextrose 5% in 0.9% sodium chloride is a hypertonic solution and should not be used for fluid replacement. The solution will diffuse into the cells of the tissue and have no effect on circulating volume. When fluid surrounding the cells is hypertonic or has more solutes ?
than the cells osmotic pressure pulls the fluid from the cells
for a client following a stroke, the client should be screened for?
the ability to swallow and should not receive anything by mouth until this has been completed
End-diastolic volume is
the amount of blood in the LV at the end of diastole (filling)
Stroke volume is
the amount of blood the LV pumps during each heartbeat
Preload
the amount of stretch in the heart at the end of diastole and is affected by the amount snd pressure of blood returning to the heart
Scanning the bladder with a portable ultrasound device will determine ?
the amount of urine in the bladder
an abdominal aortic aneurysm involves a widening, stretching or ballooning of the aorta. Back pain and abdominal pain indicate that ?
the aneurysm is extending downward and pressing on lumbar spinal nerve roots, causing pain
an aortic aneurysm is a weak spot in the wall of the aorta (the primary artery that carries blood from the heart to the head and extremities) that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that?
the aneurysm is extending downward and pressing on the lumbar sacral nerve roots
An S2 heart sound, a normal finding, occurs when?
the aortic and pulmonic valves close. It occurs at the end of ventricular contraction and the onset of ventricular diastole
damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen what?
the canal of Schlemm
a client's platelet count of 48,000/mm^3 indicates thrombocytopenia; therefore the nurse should avoid invasive procedures such as IM injection which can increase?
the client's risk of bleeding
A synergistic effect is when?
the combination of two medications causes a response that is greater than when the medications are given separately
a client who has low hemoglobin will manifest tachycardia on the ECG rhythm because of?
the compensatory mechanism that provides oxygen to vital organs
A client who has hepatic encephalopathy is at risk for gastrointestinal bleeding due to ?
the decreased ability of the liver to produce clotting factors and the potential presence of esophageal varices
Lyme disease is a vector-borne illness transmitted by ?
the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue
Portal HTN is caused by?
the development of nodules that constrict blood flow through the liver veins. Alcohol consumption does not cause dilated portal circulation.
the nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. Additionally, the nurse should avoid clamping the chest tube unless?
the drainage unit needs to be replaced or an air leak must be located
bleeding is a post-procedure complication of PTCA b/c of the administration of heparin during the procedure and the removal of?
the femoral sheath
Dialysate
the fluid that passes through a semipermeable membrane during dialysis
the nurse should instruct the client to keep a cell phone 6 in away from the pacemaker when making a call to avoid interfering w/ the function of?
the generator inside the clients pacemaker
Snug bedding is needed for?
the infant who might self-asphyxiate, but the preschool age child can have looser bedding such as comforters
Recommended Dietary Allowances (RDAs)
the levels of intake of essential nutrients that, on the basis of scientific knowledge, are judged by the Food and Nutrition Board to be adequate to meet the known nutrient needs of practically all healthy persons.
peritoneal dialysis
the lining of the peritoneal cavity acts as the filter to remove waste from the blood
ALT is an enzyme that is found primarily in?
the liver, although it can also be detected in the kidneys, heart, and skeletal muscle. Increases in this enzyme are associated with injury or disease.
Demineralization
the loss of calcium and other minerals from bone extracellular matrix
glycemic control
the maintenance of blood glucose levels within normal ranges
a nurse is caring for a client who has a tracheostomy w/ an inflated cuff in place. Which finding indicates that the nurse should suction the clients airway secretions?
the nurse auscultates coarse crackles in the lung fields
Health Promotion and Maintenance
the nurse provides and directs nursing care of the client that incorporates knowledge of expected growth and development; prevention and early detection of health problems, and strategies to achieve optimal health.
Ejection fraction is
the percentage of blood the ventricles eject during the systolic phase of each heartbeat
Topical estrogen, not progesterone, can improve the circulation of blood to?
the perineal area and improve the tone of the periurethral muscles for a client who has experienced menopause
The use of spironolactone should be cautioned in pts w/ renal insufficiency because of ?
the potential complication of hyperkalemia
hematocrit
the proportion of red blood cells in your blood
2 hour postprandial (after meals) or the Oral Glucose Tolerance Test
the pt consumes a beverage containing a glucose load (75g of carbohydrate) after fasting for 8-12 hrs. Blood samples taken prior to consuming the drink to get a fasting level, then again at 1 hr and 2 hrs after consumption. The diagnostic value is based on the blood glucose level 2 hrs after consumption.
ejection fraction is the percentage of blood the ventricles eject during?
the systolic phase of each heartbeat
When TB bacteria continue to spread, larger areas of lung tissue may die, leaving cavities near?
the top of the lung
Extravasation:
the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue
propylthiouracil is a therapeutic use for?
thyrotoxic crisis
propylthiouracil, an antithyroid drug, treats hyperthyroidism or graves diseases and?
thyrotoxic crisis
a nurse in the emergency department is caring for a client who is experiencing manifestations of a myocardial infarction. which of the following laboratory tests should the nurse expect the provider to prescribe?
troponin
the glomerular filtration rate and the creatinine clearance decrease with end-stage kidney disease
true
Progressive effacement and dilation of the cervix occur in?
true labor, not in false labor
somatropin is a therapeutic use for?
turners syndrome
Additive effect occurs when?
two medications with similar actions are given together
Acetaminophen aka
tylenol
glipizide (Glucotrol) is a therapeutic use for
type 2 DM
sustained release glipizide is used to treat what?
type 2 diabetes
glyburide (Glynase)
used to treat type 2 diabetes, particularly in people whose diabetes cannot be controlled by diet alone. It lowers blood sugar by stimulating the pancreas to secrete insulin and helping the body use insulin efficiently. The pancreas must produce insulin for this medication to work. It is not used to treat type 1 diabetes.
a nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by what?
vascular dehydration
the nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood volume is reduced by?
vascular dehydration
the nurse should keep the room warm during a sickle cell crisis and apply warm, moist compresses to painful joints. Cold compresses causes?
vasoconstriction, which increases sickling
Meds such as lidocaine are often administered in combination with a ?
vasoconstrictor such as epinephrine. Epinephrine decreases blood flow and delays systemic absorption of the anesthetic property of lidocaine
compression stockings promote?
venous return
elevating the clients legs above their heart promotes ?
venous return by gravity
feet elevated above the heart prevents?
venous stasis
Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for?
ventricular fibrillation after the synchronized countershock of cardioversion
irregular ventricular rate rate of 125/min w/ a wide QRS pattern should be interpreted as?
ventricular tachycardia
a nurse is caring for a client who has a new diagnosis of essential HTN. The nurse should monitor the client for which finding that is consistent with this diagnosis?
vertigo
meniere's disease is a condition of the inner ear in which excess fluid distorts the inner ear canal system. This distortion decreases hearing via dilation of the cochlear duct, leading to what from damage to the vestibular system?
vertigo
self-monitoring of blood glucose
via finger stick (or alternate site) provides a snapshot of blood glucose at a specific instant in time
A home health nurse is assigned to a client who was recently discharged from a rehab center after experiencing a right-hemispheric stroke. Which neurologic deficit should the nurse expect to find when assessing the client?
visual spatial deficits, left hemianopsia, and one-sided neglect
Egg yolks, organ meat, shellfish, and red meat are good sources of ?
vitamin B12
a nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease?
vitamin C
a nurse is providing nutrition education to a client who has osteomalacia. The nurse should identify that this condition is caused by a deficiency in what nutrient?
vitamin D
SIADH is a disorder of water intoxication due to the inappropriate continuous secretion of antidiuretic hormone by the posterior pituitary gland, causing hypervolemia and hyponatremia. Treatment of SIADH includes fluid restriction, sodium replacement with small amounts of 0.9% sodium chloride, and vasopressin antagonist such as tolvaptan. Tolvaptan promotes the excretion of what that helps correct fluid imbalance in clients who have SIADH?
water
a nurse is assessing a client who has guillain-barre syndrome. Which finding should the nurse expect?
weakness of the lower extremities
a nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which action should the nurse include in the client's plan of care?
wear a lead apron while providing care to the client
a nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which instruction?
wear a mask
Following the Mediterranean diet, the intake of fish and seafood is at least two times per ?
week
Following the Mediterranean diet, the client should have dairy in moderate portions daily to ?
weekly
a nurse is assessing a client who has late-stage HF and is experiencing fluid volume overload. Which finding should the nurse expect?
weight gain of 1 kg (2.2 lb) in 1 day
for a client taking hydrocortisone, advise the client to weigh regularly and report what?
weight gain or edema
a client who has pernicious anemia will have glossitis (smooth, beefy red tongue) and?
weight loss
For a client taking hydrocortisone, instruct the client to increase intake of calcium and vitamin D and increase what?
weight-bearing activity
a nurse is providing teaching to the guardian of a child who has celiac disease. Which food should the nurse instruct the guardian to omit from the childs diet?
wheat bread
signs that are characteristic of RSV
wheezing and has moderate subcostal retractions and copious nasal discharge
Monroe-Kellie Doctrine
when one content in the skull increases, another must decrease to compensate and maintain normal ICP
Acute Respiratory Failure
when one or both of the gas exchange functions of the lungs are compromised
when do the atrioventricular valves (mitral and tricuspid) open?
with ventricular diastole
a client with an exacerbation of crohn's disease is already having many stools per day. A stool softener might?
worsen the situation
a weight gain of 1 kg (2.2 lb) in 1 day indicates that the client is retaining fluid and is at risk of fluid volume overload. This suggests the client's HF is?
worsening
A feeling of something popping or loosening with coughing might indicate a?
wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs.
Albumin reflects nutritional status. A low level can indicate malnutrition, which would impair?
wound healing
Unstable angina is when
you get angina symptoms while doing very little or resting
lymphoma
malignant tumor of lymph nodes and lymph tissue
The nurse learns that a client with a seizure disorder has a serum phenytoin level of 35 mcg/ml. Which action does the nurse take first?
Inform the health care provider and expect a change in the phenytoin order. A serum phenytoin level above 25 mcg/ml is toxic.
The nurse prepares discharge instructions for a client with active tuberculosis who has been on a medication regimen for 14 days. Which statement by the client does the nurse recognize as the need for additional education?
"I am so glad that I only have to take that one combination pill now." The client will be on four medications: INH, rifampin, ethambutol, and pyrazinamide. There are some combination drugs that include two of the four medications. However, they cost more and are used most often only when medication adherence is a concern. Family members living with the client with active TB will be treated prophylactically with isoniazid (INH). The client is considered infectious for 2 to 3 weeks after treatment is initiated. Sputum containment and handwashing should continue.
The nurse instructs a client being discharged about home oxygen therapy. Which client statement indicates that further teaching is needed? (Select all that apply.)
"I know I can turn up the rate of oxygen flow if I get short of breath" The client should not adjust the flow rate on the oxygen concentrator. Oxygen is a medication and only the health care provider can adjust the rate, "My family members who smoke promise not to smoke in my room." Smoking is not allowed anywhere in the home of a client receiving home oxygen, "We have a gas fireplace so I won't be breathing smoke from burning logs." Gas stoves or heaters are a fire hazard in the home of a client receiving oxygen
The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for further instructions?
"I should insert the suppository about a half inch into my vagina." The suppository should be inserted a minimum of 2 inches for the medication to be effective. The client should recline for 5 to 10 minutes with the hips elevated after inserting the suppository. The client should wear a perineal pad to protect the clothing from drainage or staining. The applicator for the suppository should be cleansed with soap and water prior to reuse.
Which statement is appropriate for the professional development educator to include in a discussion of medical asepsis with a group of new clinical employees? (Select all that apply.)
"It is necessary to keep the door closed when caring for a client on airborne precautions.", "I need to wear gloves when taking the blood pressure of a client on contact precautions." , "A surgical mask is required when working within 3 feet of client on droplet precautions." , A mask is not needed when taking the temperature of a client on contact precautions and disposable dishes and utensils are not needed for a client on droplet precautions
The nurse provides care for a client diagnosed with a duodenal ulcer. The client asks how a stomach infection can cause a duodenal ulcer. Which response by the nurse is best?
"The bacteria enters the lining of the intestines and changes the protective layer." With Helicobacter pylori (H. pylori), the bacteria penetrate the intestinal mucosa, altering the function and consistency leading to ulcerations. An H. pylori infection causes different manifestations, such as chronic atrophic gastritis, stomach cancer, acute gastritis, or duodenal ulcers. A duodenal ulcer is not caused by antibiotic therapy to treat H. pylori or bacteria that is found in the duodenum. It is caused by gastric bacteria.
The nurse provides care for a client diagnosed with idiopathic thrombocytopenic purpura (ITP). The client asks the nurse why the health care provider (HCP) is not performing a splenectomy since the spleen is causing the thrombocytopenia. Which response by the nurse is best?
"The spleen is important in immune function, and without it the chance of overwhelming infection becomes high." The spleen is a protective organ, and the overall chance of getting infections, especially pneumococcal, meningococcal, and Haemophilus influenza, become very high if the spleen is removed. A splenectomy increases the risk for morbidity and mortality substantially.
Void at least every?
2 to 3 hours during the day
tumor lysis syndrome
Chemotherapy can cause massive destruction of cells leading the creation of uric acid which can be toxic to the kidneys leading to Acute Tubular Necrosis. You can try to prevent this with hydration and allopurinol.
The nurse assesses a yellow-brown coating on a client's tongue. Which assessment data will the nurse consider as the reason for this finding?
Client smokes cigarettes
A client experiencing insomnia asks if there are any dietary modifications that can help improve sleep. Which response by the nurse is best?
Limit alcohol in the late afternoon and evenings. The diuretic effect of alcohol can cause the client to awaken from sleep to void. Salt and sugar reduction is part of general wellness. They are not associated with improved sleep.
A non-rebreather mask delivers a?
60% and 90% oxygen concentration
A partial rebreather mask delivers between a?
60% and 90% oxygen concentration
fetal macrosomia
A situation in which a fetus is large, usually defined as weighing more than 4,500 grams or almost 9 pounds; also known as "large for gestational age." fetus The developing, unborn infant inside the uterus.
Miglitol, an alpha-glucosidase inhibitor, controls blood glucose levels in?
type 2 diabetes by delaying absorption of complex carbohydrates in the intestine. This delays carbohydrate digestion after meals slowing glucose entry into the systemic circulation.
The nurse provides care for a client diagnosed with lymphoma. The client has a large tumor. Which intervention by the nurse is most important in preventing tumor lysis syndrome?
Administer a high rate of intravenous fluid
The nurse develops a brochure on informed consent. Which information is appropriate for the nurse to include in the brochure? (Select all that apply.)
An informed consent should not be obtained until the client has discussed the exact details of the surgery or procedure, Witnessing an informed consent means that the nurse verifies that the client is mentally competent and that the signature is that of the client, Acting as a client advocate, the nurse is responsible for ensuring that the client has received adequate information regarding the proposed procedure
The nurse provides care for a client diagnosed with advanced-stage dementia. The client walks to the nursing station and states, "I don't want to be here. I am going to leave." Which action by the nurse is best?
Assign a sitter to remain with the client. The client is confused and cannot make health care decisions. The next of kin should be notified. A sitter should be assigned or the nurse should remain with the client to ensure the client's safety. Directed activity may be helpful (for example, "pack" and "unpack" a bag full of familiar items or fold towels). The nurse knows the client is confused and has advanced-stage dementia. To minimize client frustration, nurse avoids quizzing the client about orientation or posing questions that require decision making or abstract thinking. Hospital security should be notified of clients at risk for elopement. There is no indication the client requires a psychiatric consult. Confusion could be the client's baseline or the result of infection (such as a urinary tract infection).
The nurse provides care for a client who reports mid-back discomfort. Which technique does the nurse use to determine if the pain is coming from the kidneys?
Blunt percussion is used over the costovertebral angle to assess for kidney tenderness
The nurse observes a student assess an older client with dehydration. Which assessment requires the nurse to intervene?
Checks skin turgor on the hand. In the older client, skin turgor is best assessed by pinching the skin over the sternum and not the hand. A loss of skin elasticity on the hands provides an inaccurate assessment.
The nurse provides care to a client whose insurance coverage is Medicare. Which understanding will the nurse have about Medicare before planning care for this client?
Diagnosis-related groups provide a fixed reimbursement of cost. Medicare uses a fixed reimbursement amount based on assigned diagnosis-related group, regardless of a patient's length of stay or use of services. Diagnosis-related group reimbursement is based on case severity, rural/ urban/ regional costs, and teaching costs, not national averages. The hospital is paid based on a diagnosis-related group system, so a specific amount is paid based on the case severity and the rural/urban/regional standard rates. The reimbursement is based on case severity, rural/urban/regional costs, and teaching costs, not national averages.
The nurse provides care to a client with an internal radiation implant. Which intervention will the nurse include in the plan of care? (Select all that apply.)
Donning gloves when emptying the client's bedpan, Wearing a lead apron when providing direct care to the client, Keeping all linens in the room until the implant is removed, A private room with a private bathroom is essential to prevent the exposure of others to radiation and visitors are limited, not restricted
The nurse provides discharge instructions for an older adult client with osteoporosis. Which point about exercise is most important for the nurse to include in the teaching?
Exercise must include weight bearing activities because the bone adapts by building and becoming stronger. The nurse may counsel the client to avoid activities that include jumping, but must be specific about exercises to avoid or the client may avoid all activity.
The nurse teaches a group of nursing students about informed consent for medical treatment. The nurse includes teaching about informed consent involving minors. Which statement is correct for the nurse to include in the teaching?
Minors in active military service may consent without a parent. Minors who are in active military service are considered to be emancipated minors. Cognitively impaired persons of any age cannot sign their own consent forms. In an emergency, consent is not necessary and may not be obtainable quickly enough. Being an orphan does not prevent an emancipated minor from consenting to medical treatment.
The nurse provides care for a client with a platelet count of 38,000/µL (38 × 109/L). Which actions are appropriate for the nurse to take? (Select all that apply.)
Monitor neurologic changes every 4 hours due to risk of cerebral bleeding, Apply firm pressure to venipuncture sites for 10 mins, Keep pathways and bedside uncluttered
The nurse teaches nursing students about the Institute of Medicine (IOM) competencies for nursing knowledge, skills, and attitudes. Which example, identified by a student, indicates correct understanding of the topic? (Select all that apply.)
Nurses work in interdisciplinary teams, Nurses use evidence-based practice, Nurses apply quality improvement
The nurse provides care for a postoperative client. The nurse notes that the client's wound is red around the margins. Which additional assessment data indicates the need to update the nursing plan of care to address a client infection? (Select all that apply.)
Pain. An infected wound is painful. The tissues are engorged with blood, white blood cells, and body fluids in an attempt to fight the infection, Swelling, Foul odor and drainage. Drainage, particularly if purulent, occurs from the influx of white blood cells to the area to help fight the infection.
staphylococcal pneumonia
Pneumonia caused by infection with Staphylococcus that localizes in and/or around the bronchi
streptococcal pneumonia
Pneumonia caused by infection with Streptococcus that localizes in and/or around the bronchi
The nurse examines the medical record of a client with type 1 diabetes mellitus (DM). Which health problem causes the nurse the most concern?
Pneumonia. The most common precipitating factor in the development of diabetic ketoacidosis is infection.
The nurse notes the presence of purulent drainage at the insertion site of a client's intravenous catheter. Which action will the nurse take after discontinuing the catheter?
Save the catheter to send to the laboratory
A client relieves severe abdominal pain that radiates to the back by sitting forward with the knees bent. Which laboratory test will the nurse expect to be prescribed for this client?
Serum amylase. Amylase is a digestive enzyme secreted by the pancreas. Since the client is demonstrating signs of acute pancreatitis, the nurse should expect a serum amylase level to be prescribed.
The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). Which intervention does the nurse expect the health care provider to prescribe? (Select all that apply.)
Short acting intravenous (IV) insulin to lower blood glucose, Isotonic intravenous (IV) fluids to replace fluid and electrolytes losses that often occur with DKA and Hourly intake and output/Hourly blood glucose check is indicated
The nurse administers an enema to a client with an impaction. As the nurse begins the procedure, the client's heart rate goes from 70 to 40 beats per minute, and the client reports nausea. Which action does the nurse take first?
Stop the enema. The first action is to stop the cause of the vagal response; therefore, the nurse stops the enema.
The nurse reviews a client's prenatal record. Which factor is associated with risk for fetal macrosomia? (Select all that apply.)
Gestational diabetes, and Maternal obesity. The risk for fetal macrosomia is twice as great in an obese mother.
An elderly client with diverticulosis
This client is an actual risk for peritonitis
General consent forms giving permission for treatment in a hospital are signed by?
a client before being admitted
Hydronephrosis
abnormal condition of water in the kidney
Purposely giving medications to cause death is?
active euthanasia
supraventricular tachycardia (SVT)
an abnormal heart rhythm arising from aberrant electrical activity in the heart; originates at or above the AV node. Cardiac compressions are not indicated.
Drying the newborn's skin immediately after birth helps prevent ?
convective heat loss
idiopathic thrombocytopenic purpura (ITP)
disorder marked by platelet destruction by macrophages resulting in bruising and bleeding from mucous membranes
a nurse has initiated a new peripheral IV infusion with 5% dextrose in water for continuous infusion. How often should the nurse plan to replace the primary infusion tubing?
every 96 hours
buck traction
immobilizes hip and femur fractures . the weight pulls the limb into traction. the foot of the bed is elevated
Rectal temperatures are avoided for all newborn clients because of the?
increased danger of perforation
The use of fresh breast milk is the preference for the newborn who is recovering from NEC. It is the preferred enteral nutrient because?
it confers some passive immunity (IgA), macrophages, and lysozymes. Also, breast milk is more easily digested than formula
Increased intracranial pressure and bradycardia is likely to occur with a ?
large brain concussion. Mannitol is an osmotic diuretic that is used to treat intracranial pressure from a large brain concussion. Morphine may cause oversedation, masking early signs of increased intracranial pressure.
Formoterol is a?
long-acting bronchodilator
The nurse provides care for a client admitted with fever, headache, chills, cough, and malaise. Which personal protective equipment (PPE) does the nurse wear to provide care to the client?
mask. The client shows signs of influenza. In addition to standard precautions, the nurse should institute droplet precautions, which require the use of a mask when in close proximity to the client.
A urinalysis helps detect tumor lysis syndrome early in its course, but will not?
prevent it
Keeping the incubator away from windows helps prevent?
radiant heat loss
In the client with a large tumor burden, the nurse should anticipate, or advocate, for the client to have?
sodium bicarbonate, a xanthine oxidase inhibitor, and a high rate of fluid. The fluid administration will help prevent effects of tumor lysis syndrome, such as hyperkalemia, hyperuricemia, cardiac failure, and renal failure.
Urosepsis
spread of infection from the urinary tract to the bloodstream that results in a systemic infection
A three-way catheter is used after a?
transurethral resection of the prostate. It is not used for an enlarged prostate.
