nclex

Can insulin glargine be mixed with other insulins?

NO - glargine is long acting insulin w/ no peak effect

Epiglottitis is usually caused by?

being unvaccinated

prior to renal biopsy, RN should check what?

bleeding time and coagulation studies for risk for bleed

estrogen therapy has an increased risk for

blood clots

houses built before what year have increased risk of lead paint toxicity?

built before 1978 poses risk for children and lead

Peaked "T" waves on EKG is due to

hyperkalemia

tumor lysis syndrome will have what abnormal lab values?

hyperkalemia and hyperuricemia

When would a valsalva maneuver be contraindicated?

increased ICP, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.

client has acute pancreatitis, what is this client at risk for?

-ARDS

normal urine specific gravity elevated results in? low results in?

1.010-1.030 increased=dehydrated decreased= too diluted, diabetes insipidus

normal umbilical cords contain

2 arteries 1 vein

limit client chair sitting to how many hours?

2 hours

how long can pRBC be hung for?

4 hours MAX

can a nurse splint an incision if client needs to cough?

YES

can clients remain sexually active w/ pessary device?

YES

Addison's disease?

a condition that occurs when the adrenal glands do not produce enough cortisol or aldosterone - crisis s/s include: hypotension, tachycardia, hyperkalemia, hyponatremia, hypoglycemia, fever, change in mental status

if you put all 4 bed rails up, what is that considered?

a restraint

ac, pc, c/o mean?

ac= before meal pc=after meal c/o= complains of

active vs passive ROM?

active= you doing it passive=somebody doing it for you

when should parents take child to first dentist apt?

after first tooth appears

shingles PPE?

airborne precautions n95 private room negative pressure

seizure clients at risk for?

airway obstruction

any patient with altered LOC is at risk for

airway obstruction -for priority q's

acute asthma exacerbation client; give albuterol or methylprednisolone first?

albuterol! albuterol= bronchodilator= acts ASAP methlyprednisolone= takes hours/days to show effect

good sources of potassium for loop diuretic pt's

apricot, avocado, banana, cantaloupe

proper cane walking for clients?

cane first on stronger side weak leg next strong leg last

what is a complication of pericarditis?

cardiac tamponade

pregnant client reports signs related to Pica Syndrome. What should RN check for?

checks Hgb and Hct r/t iron deficiency anemia

w/ medication errors, what is the RN priority

client safety

closest to nurses station usually includes

clients who are at risk for cognitive impairment

meningococcal meningitis pt should be in what isolation?

droplet isolation

Premature Rupture of Membrans (PROM) If labor does not begin after PROM, what should be initiated?

- induction of labor to reduce risk of infection

A home heath nurse is educating a client about home care considerations for *clean intermittent catheterization*. Which statement by the client would best reflect understanding of the nurse's teaching?

"I will wash the re-usable catheter thoroughly with soap and water after use." - I guess they can re-use an intermittent cath??

Hepatitis B is transmitted via

* think Hep B, (*B*ODILY FLUIDS)* -blood -vaginal secretions -semen -NOT THRU FECES

skin cancer ABCDE rule

*A*symmetry (eg, one half unlike the other) *B*order irregularity (eg, edges are notched or irregular) *C*olor changes and variation (eg, different brown or black pigmentation) *D*iameter of 6 mm or larger (about the size of a pencil eraser) *E*volving (eg, appearance is changing in shape, size, color)

management of acute diverticulitis includes

*BOWEL REST* NPO bed rest NG suction antibiotics IV fluids

how long can blood product be out until it needs to be returned?

*Blood products should not be left at room temperature for >30 minutes before a transfusion is started.*

T/F: pregnant clients can receive live vaccines?

FALSE avoid all live vaccinations due to risk of infection

edema present or abdominal girth shows 3rd spacing... what at risk for?

FVD R/t 3rd spacing... s/s cool ext/hypotension `

commonly see PVC's with what condition?

HF pt's

hyperventilation vs hypoventilation acid base imbalance

HYPER- resp ALKALOSIS HYPO- resp ACIDOSIS

priority for sickle cell clients?

IV REHYDRATION

The nurse is caring for a client following a total thyroidectomy. What findings would alert the nurse to potential complications?

Increased blood pressure and pulse High-pitched, harsh respirations Left-sided cheek twitching--> *Hypocalcemia*

The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find?

Increased specific gravity

antiretroviral drugs are to be taken for how long?

LIFETIME

incident/occurrence report involves what

- failure to treat patients, as well as not fulfilling doctor orders (Ex: labs) - falls, with or without injury, including refusal of care as well -assault

Hep A is transmitted via

-fecal/oral route -poor hand hygiene/food handling - vaccine

occupational therapy vs PT?

OT= skills necessary for ADL's (dressing, bathing, cognitive/perception issues) *general rule: OT is for above the waist* PT= focus *below the waist* (mobility, ambulation, ability to transfer, and use of related equipment)

beta block med avoid what

OTC nasal decongestants--> has Alpha adrenergic stims which will increase HR

tip for near drowning accident?

if in DECEREBRATE posture, severe brain damage has occurred

what ED clients are not allowed to AMA?

if you are decreased LOC, suicidal/manic, or intoxicated

Bucks traction is used for

immobilizing patients w/ hip fractures until they are able to have surgery

when is positive pressure rooms needed?

immunocompromised clients require protection from potential infectious agents outside of the room.

what time should you take -statin drugs?

in the evening with a meal or before bed

DASH diet

increase fruit, vegetables, and low fat dairy; k, mg, ca

PEG tube begins to mature to body...

1-2 weeks but not fully until 4-6 weeks. Risk of dislodgment in < 7 days of procedure

The nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The *high-pressure alarm* begins sounding. What actions should the nurse initiate?

1. Check to see if client is biting ET tube. 2. Examine tubing for presence of water. 3. Assess client's need for suctioning. *The client could be fighting against the ventilator and thus biting down on the endotracheal tube. Another possible issue may be the water that accumulates in the vent tubing from condensation. Or the client may have excessive mucus in the airways that requires the nurse to suction lungs frequently. Any of these problems could initiate the high pressure alarm.*

Cirrhosis results in which lab values?

increased- ammonia, bilirubin, PT decreased- albumin, sodium,

solitary play is what age?

infancy

Neutropenia increases susceptibility to

infection part of WBC count; low neutrophil

trachea cuff inflated during? trachea cuff partially or full deflated during?

inflated= if pt intubated on MV partially or fully deflated= conscious/ reduce aspiration pneumonia

meat, fish, and poultry are good source of

iron -good for children with iron deficiency anemia

GI fun fact

laying on LEFT side= *L* eaves food in stomach laying on RIGHT side= *R* eleases food in stomach

chronic pancreatitis diet

low fat , avoid spicy gas forming foods

Rhonchi? What conditions have this?

low pitched adventitious breath sounds bronchitis, cystic fibrosis, pneumonia

PAP smears should be done between what ages?

21+ Done every 3 years

normal PTT range?

25-35 seconds if on heparin= 2-3 x's normal range *>100 seconds is critical*

refeeding syndrome s/s

low: Potassium Phosphorus Magnesium

neurogenic shock causes

massive vasodilation of SNS center ( bradycardia, hypoTN,)

measuring oropharyngeal airway

measure corner of mouth to earlobe

good sources of iron include

meats (beef, lamb, chicken, pork) shellfish eggs green vegetables, broccoli, dried fruits, dried beans, brown rice

Meniere disease good way to remember is

meniere = " my ear"!!!! risk for impaired hearing/tinnitus

vomiting results in what acid base imbalance?

metabolic ALKALOSIS

vancomyicin and gentamicin pose risks of what?

nephrotoxicity--> check creatinine level

when recording I/O, is output just urine?

no its everything

If excess stocking, can RN fold remaining?

no, never fold, roll or clump remaining part of stockings

if patients have a DVT are they on bed rest?

no, not anymore. PE risk if staying immobile.

when performing catheter, would you use dominant hand or non-dominant hand to hold penis?

non-dominant hand

Borborygmi

normal sound = gurgling/rumbling= peristalsis

Stridor is a high-pitched, inspiratory crowing sound commonly associated with:

obstruction or constriction of airway (anaphylaxis, epiglottitis, aspiration of foreign object)

Enteral vs parenteral nutrition

Enteral: Going into the GI system (orally or thru feeding tube) Parenteral: Going into the venous system (ie: central line)

what is cystic fibrosis?

Excess mucus in the lungs, digestive track and liver - need aerobic exercise -chest physiotherapy -financial needs for families as this condition can be expensive

palliative care vs hospice care?

Palliative Care occurs *throughout the course of the illness* and in any setting. It allows for curative therapies, and managing symptoms Hospice care occurs during the *last six months of life*. It can occur in the home, inpatient hospice units, and long-term care settings. The patient decides against life-sustaining therapy.

The nurse, caring for a client post motor vehicle accident who sustained multiple crushing injuries, suspects that the client may be developing disseminated intravascular coagulation (DIC). Which assessment findings by the nurse suggest that the client is developing this complication?

Petechiae Blood oozing from chest tube insertion site Petechiae are red dots on the surface of the skin seen because of minute hemorrhages within the dermal or submucosal layers of the skin. Oozing blood from invasive catheter sites is one sign of DIC. The client can have minor oozing of blood to bleeding from every orifice and into the tissues.

pregnancy after 20 weeks with painless bleeding may be a result of?

placenta previa

associative play is at what age?

preschoolers 3-6

if medication error has occurred, what does RN do?

priority= client safety then contact HCP

why would client w/ glomerulonephritis need bed rest?

promotes diuresis

A woman, diagnosed with an *ectopic pregnancy*, asks the nurse the purpose of receiving methotrexate. What is the best reply for the nurse to make?

This medication will stop the growth of the embryo to save your fallopian tube." *The medical management of an ectopic pregnancy is to prescribe methotrexate. The action of methotrexate is to stop the growth of the embryo in the fallopian tube. The embryo is reabsorbed and the fallopian tube can be saved.*

what would cause phenytoin (Dilantin) to not be absorbed properly?

Tube feedings... they decrease absorption rate

bells palsy s/s

Unilateral facial paralysis: -Inability close eye -Wrinkle the forehead -Mouth drawn the non affected side -Loss of taste 2/3 anterior of the tongue -hyperacusis (hearing sensitivity) -alteration in tear production

What is leukocytosis?

WBC count over 11,000/mm3 Normal response to infection

client admitted with dysarthria ; what is client at risk for?

dysarthria= weakened muscles used for speech this could also increase risk for aspiration, respiratory failure, and death

autonomic dysreflexia s/s? what SCI involves this?

s/s: HTN, diaphoresis, headache, bradycardia, flushing SCI *T6 or higher*

Vtach pulseless and unresponsive initial action

1.defib @120joules 2. cpr

client has bladder spasms after catheter inserted post prostatectomy... what should RN do?

this is a normal finding, RN should just monitor

parallel play is what age?

toddlers age 1-3

CKD puts patients at risk for

uncontrolled HTN

can UAP's empty, measure and record surgical drains?

yes!

can two clients w/ the same organism infection be roomed together if need be?

yes, for example, 2 clients w TB can room together

neonate client has crackles in lungs 1 hour post birth? Is this a normal finding?

yes, normal finding

after extubation, are patients still NPO?

yes, to prevent aspiration until evaluation has been done by physician

will vision be blurry post cataract w lens surgery?

yes-- 2 weeks

what can UAP do for client needing blood transfusion?

- get blood from blood bank -V/S before transfusion -V/S *ANYTIME AFTER FIRST 15 MINUTES OF TRANSFUSION*

post cataract surgery, what do we want to ensure for teaching?

- AVOID ACTIVITIES THAT INCREASE INTRAOCULAR PRESSURE EX: avoid straining for bowel movements, lifting weights, bending over, etc.

Hyperthyroidism diet includes?

- Hyperthyroidism = *increased metabolic rate* 1. high calorie diet 2. meals and snacks high in protein 3. avoid caffeine 4. avoid spicy 5. avoid high fiber foods

Torsade de pointes treatment EKG shows From:

- IV Mg EKG- QRS complex variation "twisting of the points) Hypomagnesemia or Hypokalemia *Chronic alcoholism or malnourished*

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site?

1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform

ANC RANGE

1500-8k <1000 warrants NEUTROPENIC PRECAUTIONS r/t risk of infection for client

blood tranfusions should use what size IV?

18-20 gauge

mitral valve regurgitation pt's usually are *asymptomatic*; what should pt's report to HCP stat?

s/s of heart failure dypsnea fatigue weight gain

common causes of PAC--> premature atrial contractions

stress increased caffeine intake OTC meds that contain caffeine

client states they are having the " worst headache of their life", what could this be?

subarachnoid bleed *high mortality rate*

when giving hemophilia clients vaccinations what is important?

they have deficiency so risk for bleed -*SUBQ* instead of IM

if patient is taking lithium, what medication class should they avoid?

thiazides

client received Nitroglycerin and now has headache. What does RN do?

this is a common side effect - administer acetaminophen or aspirin for pain relief

should you take more than 500mg calcium?

NO take it in divided doses as >500mg of calcium absorption is impaired

is it okay to give bottle of milk at bedtime for babies?

NO, can increase chance of tooth decay -just use normal pacifier

can an LPN administer continuous heparin?

NO, continuous IV drug solutions are managed by RN

should clients w/ constipation use OTC enemas or laxatives?

NO, only if prescribed from their HCP

early decelerations

NOT BAD caused by physiological hypoxia R/T fetal head compression

Mixing Insulins and Insulin Mixes

NPH can be mixed with *regular and rapid acting insulins.* This is done by first drawing up the clear insulin to a syringe (regular or rapid-acting insulin) and then drawing up the cloudy insulin (NPH). long acting insulin CANNOT be mixed (glargine, detemir)

what medications should be avoided in clients with kidney disease?

NSAIDs, as they pose risk to nephrotoxicity

neutropenia

Neutropenia is an abnormally low white blood cell count no live plants, fresh food veggies or fruits no IM injections

in clients with Sickle Cell Disease, do they have normal HCT/Hgb?

No, they will have decreased Hct/Hgb due to their condition.

gluten free diet includes? "BROW"

avoid -barley -rye -oats -wheat

defibrillate is used for

ventricular dysrhythmias -Vfib -Pulseless VTACH

iron injections use what location on pt

ventrogluteal site-- preferred vastus lateralis option 2

is a patient is being delusional, how should the RN reply with conversation?

we want to encourage reality based conversation, not bring the patient back into a delusional realm

Can UAP's peform suction (oral care) to patients?

yes

can UAP's perform active and passive ROM w/ clients?

yes

can family be present in room w/ family member client is resuscitation is needed?

yes!

anti platelet meds include: check for risk of

aspirin, clopidogrel, prasugrel, ticagrelor bleed, bruising, tarry stools, monitor platelets

what are the ONLY exceptions for LPN assessing?

assess lung sounds, bowel sounds, neurovascular checks

liver biopsy post procedure

assist client to a *right-side lying position* for several hours assess for respiratory complaints assess for abdominal pain/ abdominal bleeding fun fact: the liver is very vascular so risk for bleed is higher

Sjogren syndrome is

autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia).

best place to check for petechiae in dark skinned clients?

conjuncitvae of eyes and buccal mucosae

post tonsillectomy; what should be reported as a priority?

constant swallowing

ALT/AST labs are for?

- used to diagnosis hepatic disorders -when hepatic cells are injured, these labs are increased

chest tube... bubbling is appropriate in which chamber?

- want bubbling in suction chamber - bubbling in water seal chamber is BAD and shouldnt bubble unless patient coughs etc

in a near drowning experience, patient is unconscious. After CPR, no sign of pulse. WHEN would declare patient dead?

- when patient is WARM and dead

client has a DVT, can RN elevate leg?

- yes! helps promote venous return and reduces leg edema

amlodi*PINE* drug class common S/E?

-CCB -vasodilator -decreases SVR/ BP S/E: DIZZINESS, peripheral edema

NSAIDs avoid in what patients?

-CVD - recent MI - they increase risk for thrombotic events

acute care for diverticulitis involves

-NPO -IV fluids to prevent dehydration -pain control -avoiding anything that makes you strain -avoid laxatives and straining

to prevent DDH in newborns, what are some good teaching for the family?

-Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement -Choosing infant carriers or car seats with wide bases -infant seats should allow for proper hip positioning in an abducted manner -Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together

continuous bubbling *NORMAL* in suction chamber or water seal chamber?

-SUCTION CONTROL

Aortic Abdominal Aneurysm (AAA) s/s

-abdomen pain radiating to back -pulsatile abdominal mass

what assessment findings in a MV patient would warrant suctioning?

-adventitious breath sounds - increased peak airway pressure -coughing/respiratory distress

what is nystatin?

-antifungal -used to treat oral candidiasis and other fungal infections

RN assessing client post PCI and notes active bleeding, FIRST thing RN should do?

-apply manual pressure to insertion site

Botulism can occur from

-canned foods -raw honey -children <1 at risk

a decrease in mediastinal chest tube should suspect?

-cardiac tamponade ( hypoTN, muffled heart sounds, JVD)

PAD priority assesment

-check for pedal pulses

s/s of pancreatitis?

-cullens sign ( bruising around umbilicus) -fever w tachycardia -pain radiating to back

colorectal cancer risks include

-family history - IBD, Ulcerative Colitis, Crohns Disease -obesity, red meat diet, cigarette smoking, and alcohol consumption

SIADH treatment?

-fluid restriction -strict I/O -seizure precaution -oral salt tabs

*metformin* medication helps with what in regards to insulin production?

-helps increase sensitivity of insulin receptors and reduces glucose production of the liver

why would an RN ask client to void prior to pRBC order?

-if reaction occurs, we need sample of urine to see if RBC hemolyzed

if client has seizure should RN prep and have anything related to mouth?

NO. RN should never place anything inside clients mouth during a seizure

Allens Test for ABG?

- to show if radial artery compliant for ABG -squeeze fist -palpate radial and ulnar artery and allow palm to turn pallor -release and watch hand turn back to pink color *if it does not, use a different site for ABG*

peristalsis AKA

"paralytic ileus" - happens 24-48 post op

pregnant RN should avoid what? TORCH= Can pregnant RN care for client with staph infection?

*T*oxoplasmosis *O*ther = parvovirus B19/varicella-zoster virus *R*ubella *C*ytomegalovirus *H*erpes simplex virus or radiation therapy clients yes, she can care for staph pt

in psych clients you want to...

*develop a trusting relationship* if delusional, do not challenge their delusions as this will make them more upset and angry

common causes of metabolic acidosis includes?

*diarrhea* *ketoacidosis (diabetes, alcoholism, starvation)* sepsis/hypoperfusion renal failure R/T hemodialysis

COPD pt's typically have what lab result?

*polycythemia* - this is due to low oxygen and your bodies compensatory way of producing more RBC to increase oxygen levels

NSAIDs should be avoided in which term of pregnancy?

- 3rd trimester R/T closure of ductus arteriosus

CAD patients should avoid what medication?

- NSAID as this poses risk for thrombotic event

COPD patient currently have exacerbation. What would the BiPAP do to help this client?

- allow for CO2 to decrease effectively

DVT is due to? s/s of DVT?

- blood clot due to decreased mobility or bed rest S/S: unilateral edema calf pain lower leg warmth and redness

What signs/symptoms would the nurse expect to find in a client diagnosed with osteoarthritis (OA) in the knee?

- clicking sounds when bend knee -pain that increases after exercise

if a client is declared brain dead; what should the RN do first?

- contact organ procurement services BEFORE D/C LIFE SUPPORT

The nurse is caring for a client following *gastric bypass surgery*. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms?

- first lets talk about risk; DUMPING SYNDROME - to reduce risk of dumping syndrome Reduce intake of carbohydrates Eat small, frequent meals daily Sit semi-recumbent for meals--> *slows down absorption of GI tract*

Hepatitis C proper PPE include?

- first off, hep c is transmitted via bodily fluids and blood PPE: - glove -mask -goggles -gown

Peak Flow Meter (PFM) green? yellow? red?

- for asthmatic patients green >80% yellow <80% red = medical attention STAT

New Grad RN assignments should be given what kind of clients?

- give them the patients that are most stable out of them

LDL <100 is considered ???

- good, we want your LDL to be under 100

nasopharyngeal airway should never be used when?

- in clients who have head trauma ( seizure, accident, etc)

*most common associated injury with cardiac arrest patients?* 2. *What preventative measure do we follow post cardiac arrest resuscitation?*

- neurologic injury We keep pt in a hypothermic state for 24 hour b/t temp of 89.6-93.2. Interventions include cooling blankets, ice packs near grown etc, cool IV fluids.

if CVC looks infected, first thing to do?

- obtain blood cultures and D/C CVC

in order for patient with rheumatoid arthritis to be able to complete ADL's, what must be accomplished?

- pain control via medication. If the patient can not tolerate pain, then the patient wont be able to do anything -pain control is the priority assessment

acute pericarditis pain is increased with pain is decreased with? and Treatment?

- pain increases with coughing , pain happens on inspiration - take NSAIDs / sit up and lean forward to d/c pain

total knee replacement post op never do what?

- place a pillow etc under the knee! RISK FOR CONTRACTURE

Hypomagnesemia causes what abnormal rhythm?

- prolonged QT intervals= RISK OF VTACH= TORSADES DE POINTES

arterial lines biggest risk?

- risk for hemorrhage - check for bleeding @ site if alarms ever sound

is it okay for patients with PAD to elevate their legs ?

- they should never elevate legs above heart bc of limited blood flow to feet/lower ext.

for *burn pt's* what indicator is most accurate for successful fluid resuscitation?

- urine output > anything

A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction?

-immigrants w induration > 10 mm - HIV w induration >5mm -child less than 4 years having induration > 10

post op eye surgery pt complications/risk

-increased intraocular pressure watch for questions that patient has certain s/s that can increase it etc

amniotomy (artificial rupture of membranes) does what? what actions should RN expect?

-induce labor -assess FHT before and after procedure -check temp Q2H -note characteristics of amniotic fluid -sit client upright after procedure

when preparing for extubation; how would the nurse teach the client to breathe?

-inhale deep and hold it, and bear down - we don't want air to accumulate and possibly cause a pneumothorax

a patient is prescribed vancomycin. What organ is of concern?

-kidney - the kidney should be normal value, raise concern if labs abnormal before administration of medication

CVC displacement, what position should nurse put client in?

-left lateral trendelenburg--> promotes venous air pooling

before -statin drugs should be started, what should the RN check?

-liver function tests - these drugs are metabolized thru the liver and can cause hepatotoxicity

hypothyroidism has high or low T3/T4/TSH levels? S/S?

-low T3/T4 -high TSH S/S: *bradycardia* *heat intolerance* *constipation* *weight loss* *hair loss*

patient has dehiscence and evisceration, best positioning?

-low fowlers w/ knees bent

change in length of a PICC could indicate? what would the RN do?

-misplacement of tip of catheter and possible migration deeper - RN holds all IV fluids/meds, call HCP and get x-ray for evaluation of placement

eye injury first thing to do?

-patch BOTH eyes to prevent further eye movement

complications with peritoneal dialysis?

-peritonitis s/s: cloudy outflow, tachycardia, low grade fever

ET tube suctioning?

-preoxygenate 100% - *only suction while withdrawing out from ET tube - sterile gloves - suction for < 10 seconds

Post Cholecystectomy

-preventing complications = early ambulation

IBS clients should follow which diet?

-proteins, breads, bland foods -veggies -slowly increase fiber intake ( whole grains, legumes, nuts, fruits, vegetables)

pt is coding and CPR is applied. Patient has a DNR for code status, what does the nurse do following?

-stop all RESUSCITATION stat

if pt need arterial line? what anatomical position? And what is appropriate position for arterial line?

-supine -4th intercostal space

what position is NOT allowed when clients are in restraints?

-supine position

SIDS protective factors

-supine sleeping position -breast feeding -pacifier use during sleep -up to date vaccinations -appropriate clothing -firm sleep surface -removal of loose items from bed

how should float nurses be assigned?

-they should be assigned to patients who most reflect the population they care for ex: float icu nurse should be with patients in that nature

vitamin B12 deficiency is likely due to

-vegetarians - b12 is found most in animals (meats)

Duchenne Muscular Dystrophy (DMD)

-x linked (mother carries, male child affected) - lacking dystrophin -S/S: Gower sign/maneuver *(placing hands on the thighs to push up to stand)*, enlarged calves, walking on tiptoes, and frequent tripping/falling.

does hyperventilating before suction help?

-yes, it reduces CO2, and reduces ICP by inducing vasoconstriction

Normal creatinine and use?

0.6-1.3 - good indicator of GFR and indicator of kidney function

A client with a history of *peptic ulcer disease* arrives at the emergency department reporting weakness, and vomiting "a lot of dark coffee-looking stomach contents." The client's skin is cool and moist to the touch. BP 90/50, HR 110, RR 26, T 98, O2 sat 88%. Which primary healthcare provider prescription should the nurse perform first? 1. Initiate oxygen at 2 liters/nasal cannula. 2. Start an IV of NS at 150 ml/hr. 3. Insert nasogastric (NG) tube to low suction. 4. Attach client to the electrocardiography (ECG) monitor.

1. Initiate oxygen at 2 liters/nasal cannula. *The client is showing signs of shock and needs all of the above interventions. However, go back to the ABC's. Oxygen needs to be initiated first because the O2 sat and the increased respiratory rate.* idk about that man i like fluids as the answer lol

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis? 1. Monitor urine for dark, cloudy, foul smelling urine. 2. Place client on intake and output monitoring. 3. Decrease fluid intake to 1 liter/day. 4. Advise client that urine may change color with administration of nitrofurantoin. 5. Monitor for hypotension, tachycardia, fever.

1. Monitor urine for dark, cloudy, foul smelling urine. 2. Place client on intake and output monitoring. 4. Advise client that urine may change color with administration of nitrofurantoin. 5. Monitor for hypotension, tachycardia, fever. With pyelonephritis urine will be dark, cloudy and foul smelling due to the bacteria. *Anytime a client has a renal problem, that client should be placed on I&O.* Nitrofurantoin, an antibiotic, will turn the urine brown. *Monitor for septic shock, a complication of pyelonephritis. S/S include hypotension, tachycardia, and fever.*

What risk factors should the nurse include when teaching a group of clients about osteoarthritis?

1. Sports injury to joint 2. Genetic predisposition 3. Obesity 4. Repetitive joint stress

PAGETS disease what s/s

1. chronic skeletal bone disorder in which there is excessive bone resorption followed by the marrow being replaced by fibrous connective tissue. The new bone is larger, disorganized, and weak. 2. s/s : severe pain, may walk with a limp, and may become bow legged

blood transfusion reaction--> nursing intervention steps?

1.Stop transfusion immediately and disconnect tubing at the catheter hub. 2.Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse 3.Notify health care provider (HCP) and blood bank. 4.Monitor vital signs. 5.Recheck labels, numbers, and the client's blood type. 6.Treat client's symptoms according to the HCP's prescription. 7.Collect blood and urine specimens to evaluate for hemolysis. 8.Return blood and tubing set to the blood bank for additional testing. 9.Complete necessary facility paperwork to document the reaction.

cooperative play is what age?

6-12 school age

common s/s AAA vs. thoracic aortic aneurysm

AAA= lower back pain Thoracic AA= trouble swallowing

what can cause respiratory acidosis?

ARDS, chest trauma, COPD, sleep apnea

What is Sjogren's syndrome?

An autoimmune disease that dries up all lubricating fluids in the body (eyes, saliva, bodily secretions, etc) -schedule dental visits

anorexia nervosa vs bulimia nervosa?

Anorexia = extreme low weight and body image distortion (purging may exist), client may wear oversized clothes. Client also will try to restrict weight gain by fasting, or dieting Bulimia = normal weight with binge eating followed by actions trying to prevent weight gain *client may have scars or calluses on hand from inducing vomiting* EX: laxatives, extreme exercise, self induced vomiting

After a *cholecystectomy*, a client experiences palpitations, weakness and diarrhea following meals. Which teachings would be appropriate for the nurse to provide the client?

Avoid drinking liquids with meals Take adequate vitamins, iron and calcium Eat at least six small meals per day

variable decelerations

BAD caused by umbilical cord compression

Late Deceleration

BAD caused by uteroplacental insufficiency prepare for delivery

WHEN should trough levels be checked for vancomycin infusion on a patient?

BEFORE the *4th* infusion

spinal cord levels include

C 1-8 T 1-12 L 1-5 S 1-4

long term PPI use increases risk of what

CDiff

what vaccines should children get by the age of 2?

DTaP, IPV, MMR, Hib, varicella, pneumococcal, and rotovirus

C section increases risk for?

DVT and PE

What is respiratory acidosis?

Elevation of pCO2 due to ventilation depression. Caused by damaged respiratory drive, obstruction of conducting system, and inadequate minute ventilation. low pH, high PaC02, hypoventilation

nurse floats from med surg unit to your unit , if she has a burn victim what other patients would the charge RN assign to the float?

NONE W INFECTION OR RISK OF INFECTION - no infection pts w burn pt

clients with depression should not interchange which medications?

MAOI's (phenelzine) and TCA's (imipramine, amitriptyline, nortriptyline) - should taper off drug for 2 weeks before switching to different medication. - if you do not taper, risk for hypertensive crisis

During pregnancy, are laxatives or caffeine encouraged?

NO

A client with a history of *myasthenia gravis* (MG) has been discharged from the hospital following a thymectomy. When teaching the client how to prevent complications, the home care nurse emphasizes what daily actions are most important?

Practice stress reduction techniques. Complete chores early in the day. Take medications on time and prior to meals. clients become weakened and tired throughout the day

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse teach the client about how to take these medications?

Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate. taking sucralfate first could would not allow absorption of lansoprazole completely

cholecystitis s/s?

RUQ pain radiating to Right shoulder low grade fever with chills *occurs when fatty foods are consumed, irritation occurs*

restraint clients; general guidelines?

Remove restraints for ROM Q2H fluid, nutrition, toileting Q2H neurovascular checks Q1H

Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response? 1. Remove the dressing and elevate the head of bed. 2. Call a code, open the trach set, and position the client supine. 3. Obtain vital signs. 4. Immediately go to the nurse's station and call the primary healthcare provider.

Remove the dressing and elevate the head of bed. The nurse should identify that the client is in respiratory distress. So get the dressing off the neck, elevate the HOB and see if they can breathe any better. *Stay with the client.*

(CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend *college* in the fall

Seasonal influenza Human papilloma virus Meningococcal

how should suicide assessment start?

Suicide assessment should begin with direct questions about the presence of suicidal thinking

A client with *chronic alcoholism* has been admitted to the intensive care unit after overdosing on alcohol. Which medication should the nurse prepare to administer?

Thiamine 100 mg IV twice a day *Prescribing of thiamine action is to alleviate dehydration, prevent delirium and precaution treatment for vitamin B complex deficiency. Thiamine 50-100 mg IV or IM is indicated twice a day for clients with chronic alcoholism. It is usually given for several days, followed by 10-20 mg once a day until a therapeutic response is obtained.*

risk factors associated w/ DVT include?

Trauma (endothelial injury and venous stasis from immobility) Major surgery (endothelial injury and venous stasis from immobility) Prolonged immobilization (eg, stroke, long travel) causing venous stasis Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) Oral contraceptives (estrogen is thrombotic) Underlying malignancy (cancer cells release procoagulants) Smoking (produces endothelial damage by inflammation) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase blood viscosity) DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.

peritoneal dialysis steps

Warm dialysate Infuse dialysate through peritoneal catheter. Provide 30 minute dwell time. Drain fluid for 30 minutes. Turn client from side to side. *to ensure all drainage out of peritoneum*

A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has *priority* ?

contact PCP STAT Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider.

risk factor for otitis media?

day care tobacco smoke filled houses contact w/ siblings season of year

schizoprenia pts, the RN should address communication how?

direct, clear and concise in communicating with the client schiz pt's have concrete thinking but have *difficulty making decisions*

cardiac tamponde s/s

distended neck veins muffled heart sounds hypotension/narrow pulse pressure AKA--> becks triad

acute diverticulitis patient has pain in ULQ. Why?

diverticulitis develops in the LLQ, if diverticula develop they will cause pain in the ULQ (descending sigmoid colon)

patients w DVT:

do not use anything that may break clot or cause it to embolize - use warm soaks intermittently ONLY

when donning sterile gloves, which hand do you don first?

dominant hand donned first non-dominant hand donned second

pre-eclampsia vs eclampsia main issue

eclampsia = seizure pre-eclampsia= no seizure

goal of case manager?

facilitate provision of quality care across a continuum, decrease fragmentation of care across various settings, and contain costs. -communication b/t HCP -obtaining health information from clients nursing home -referral for home health after discharge

kidneys regulate

fluid volume and blood pressure

polycemia vera can reduce risk of blood clots by?

frequent phlebotomy to decrease amount of RBC in body

when aspirating residual from NG, what does RN do after?

gastric residual should be returned to the stomach

long acting insulin vs short acting insulin

glargine(lantus)- long acting- no peak, good for 24 hours lispro(humalog)- short acting, peak 30 minutes-3 hours

common early symptom of HTN crisis?

headache

unilateral/linear rash resembles what?

herpes zoster virus (shingles)... can lead to chicken pox

bowel obstruction auscultation would be?

high pitched= early hypoactive pitched= late signs

TPN has increased risk for

hyperglycemia

epidural can cause

hypotension R/T vasodilation

When is informed consent not necessary?

non emergency situations

Marfan syndrome patients should avoid

pregnancy -use birth control at all times

client has suspected Reye Syndrome, why would this client get this? What to avoid?

recent exposure to infection... *varicella or influenza* Aspirin can irritate

A client asks the nurse, "What causes hypermagnesemia?" The nurse should explain to the client that hypermagnesemia can occur secondary to what health problem?

renal insufficiency Magnesium is excreted primarily through the kidneys. When the client experiences renal insufficiency, magnesium is held. The incidence of hypermagnesemia is rare in comparison with hypomagnesemia, and it occurs secondary to renal insufficiency.