Nclex and Hesi Study Guide

Atypical Antipsychotics SE

- Side Effects are similar to the Typical Antipsychotics by much lower. - ELEVATED: weight, cholesterol, triglycerides, blood sigar

Teaching plan for Type 1 DM

-client exercise -stress -meds that influence BG -diet -glucose monitoring -insulin use -Evaluate pt use of blood glucose meter -Evaluate other meds: asthma meds (albuterol and corticosteroids) increase BG -determine work/home life **evaluate current glucose monitor (before replacing it) **reusing needles should be investigated

Spec Gravity

1.005-1.030

MG+

1.5-2.5

BUN

10-20

DilantinTR

10-20

Tachycardia in adults is greater than

100bpm

PT (Coumadin/Warfin)

11-12.5 sec (INR and PT TR =1.5-2 times normal)

Normal Platelet Level

150-400 k

Ventilators ... Make sure alarms are on ... Check every __________ minimum

4 hours

Normal White Blood Cell Level (WBC)

4.5-11 k

Stay in bed for 3 hrs after first

ACE inhibitor dose

A male client has been taking proprenolol (Inderal) for 18 months tells the nurse that the HCP discontinued the med. Which instruction nurse provide?

Ask the HCP about tapering the drug dose over the next week

Nursing Process (AD-PIE)

Assessment Diagnosis (analysis) Planning Implementation Evaluation

124. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. D. Constipation for 2 days

B. Apical pulse 58/min. **HOLD Under 60

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

B. Furosemide Majority of symptoms come from fluid overload.

125. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply) A. Lentils. B. Teas. C. Potato soup. D. Whole grain breads. E. Cheese.

B. Teas. C. Potato soup.

Mastectomy pt : do not do what?

BP or IV on surgery side

A client receives a prescription for nystatin (Mycostatin) oral suspension for the treatment of oral thrush. Which information should the practical nurse (PN) provide? A. Take on an empty stomach. B. Mix the suspension with water. C. Swish then swallow the medication. D. Keep in the refrigerator.

C. Swish then swallow the medication.

Thromboangiitis obliterans (Buerger disease) usually prescribed:

CCBs : Nifedipine

rapid sequence intubation

CPAP not doing its job

Antidotes to Magnesium Sulfate

Calcium Gluconate

Antidotes to Digoxin

Digiband

#1 nursing intervention for lithium SE peeing/pooping

Give pt fluids (normal S/Sx SEs), then monitor sodium Low sodium = lithium toxic High sodium = lithium ineffective

In case of Fire

Race and Pass

Phenothiazines end in?

Zine! Thorazine, Compazine "We use Zines for Zany" : Major antipsychotics

R sided HF s/s

affects periphery; dependent edema, hepatomegaly, cool extremities, anxiety, depression, weight gain -peripheral edema -distended neck veins

Magnesium sulfate antidote

calcium gluconate

pancytopenia definition and interventions

deficiency of all types of blood cells -Infection risk -bleeding risk **Avoid injury/exposure to infection**

Ptosis

drooping

Acute HIV infection symptoms

flu like symptoms: Malaise, swollen lymph nodes. fever, sore throat, HA, Nausea, diarrhea, muscle/joint pain, rash **confusion, candidiasis are later stages**

bowel obstruction can lead to

peritonitis Watch for : rebound tenderness in upper quadrants

Singulair (montelukast) feel better how soon

w/in 24 hours of first dose

Opiate (Heroin Morphine etc) Withdrawal S/Sx

water eyes, runny nose, dilated pupils, NVD, cramps

liver disease

withhold med/contact HCP

Glycosylated Hemoglobin

(Hgb A1c): 46% ideal, <7.5% =ok (120days)

Magnesium Sulfate in labor monitor:

- decreased urine output (UOP < 30ml/hr) = increase in mag levels -Respiratory depression: RR < 12pm = HOLD

Pt. receiving IV fluids by gravity/nurse should monitor?

-Observe the drip chamber to determine flow rate and slow if indicated

renal failure interventions

-Strict I/O -Address underlying cause -Fluid restriction -Adequate protein intake -Dietary restrictions in phosphate, potassium and sodium. -Parenteral/enteral nutrition -Calcium supplement or phosphate binding agent (Calcium acetate, Calcium carbonate and phoslow) -Dialysis

Balance

-bringing object close to body before lifting -widening stance

Hypoventilation can develop in situations of

-fever -pain -anxiety ***Leads to Resp. Alkalosis**

Resp Alkalosis results from ___________________ by depleting the amt of ____________ exhaled through the lungs which reduces the ________________ in plasma and increases pH.

-hypoventilation -Carbon Dioxide (CO2) -Carbonic Acid (HCO2)

STI nurse teaches pt to:

-understand the disease/correct misinformation -explain mode of transmission -potential complications if untreated -importance of follow-up care

Creatinine

0.5-1.2

Lithium TR

0.5-1.5

Lithium Therapeutic Range

0.5-1.5

Digoxin therapeutic level

0.5-2 ng/mL

Bilirubin Newborn

1-12

Phosphorus

3-4.5

Beta blocker ok to give if apical pulse is over

60

APTT (Heparin)

60-70 sec (APTT and PTT TR=1.5-2.5 times normal

Nasal cannula can deliver up to

6L/min O2. Higher doses=different device

Glucose

70-110

02

80-100

Ca++

9-10.5

02 Sat

95-100%

Hypoventilation leads to

Acidosis (too much CO2)

ABCs

Airway Breathing Circulation

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early Decelerations in the FHR D. Temperature 37.4 C (99.3 F)

B. FHR baseline 170/min

8. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) Lethargy B) Irritability C) Negative Moro D) Depressed fontanel

B: Irritability

Benzodiazepines are prescribed for

Bipolar, Alcohol withdrawal , seizures/status epilepticus, acute anxiety

The primary nursing diagnosis for a client with congestive HF with pulmonary edema is

Cardiac output altered: decreased

diabetes insipidus (DI)

DI "Dry Inside" -Not enough ADH -Loses H2O

Alcohol withdrawal can result in

Delerium Tremens

second or third-degree heart block and BBs

Hold the dose and contact HCP = BBs lower HR

Pulmonary air embolism prevention

Trendelenburg (HOB down) + on left side (to trap air in right side of heart)

Drug that causes urinary retention in geriatric pt?

Tricyclic antidepressants

Contact Precautions

Universal + Goggles Mask and Grown

Bronchodilator/Steroids order for asthma

Use bronchodilators before steroids for asthma ... Exhale completely, Inhale deeply, Hold breath for 10 seconds

Antidotes to Coumadin

Vitamin K (keep PT and INR @ 1-1.5 x normal)

Characteristic of addiction?

Wanting the drug is all that matters to an addict

Bacterial Meningitis S/Sx

agitation, vomiting, fever, high-pitched cry

risk factors for ischemia

because of family history

Lithium is used to treat what?

bipolar disorder

Chronic Bronchitis =

blue bloater; hypoxia and cyanosis; edema from right side heart failure = bloating/edema

New mother with uncomplicated birth/day 3 will

exhibit interest in learning more about infant care

chest tube

lower than insertion site

early strep sign

rash on the chest

nosocomial pneumonia

report watery diarrhea

A 4-year-old-child is brought to the emergency department by a parent after being bitten by a non-venomous snake. The child is anxious and fearful, with a heart rate of 120 bpm and respirations of 42 bpm. The nurse anticipates the child developing which acid base imbalance?

respiratory alkalosis

The nurse should monitor what in child with meningitis to see if infection has resolved?

temperature and CBC

cardiac enzymes

test to measure the levels of enzymes that are released into the blood when myocardial cells die during a myocardial infarction. Troponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4 hr), LDH1 (12-24 hr)

second stage of labor

the stage during which the baby moves out through the vagina and is delivered **HELP with pushing**

Renal failure would likely lead to A. volume depletion. B. hypotonicity. C. volume excess. D. hypertonic ascites.

volume excess

Atypical Antipsychotics (CHECK NAMES)

work on positive and negative symptoms, less EPS

SIADH s/s

**TOO MUCH ADH** **Retains H2O** -Low UO of concentrated urine = Increased urine specific gravity -fluid overload -weight gain w/out edema -HTN -Tachycardia -N/V -Hyponatremia: report muscle cramping

SIADH treatment

**demeclocycline, a tetracycline derivate that blocks the action of ADH= report muscle cramping** -Implement seizure precautions -Elevate HOB to promote venous return -restrict fluids -Admin loop diuretics -Adm. vasopressor antagonists

Shoulder dystocia management

*nurse stay calm and call for immediate help*, assist provider, Mc Roberts maneuver (bring legs as far up as possible to ear, opens up pelvis and allows baby to move), suprapubic pressure (must be on top of pt on stool and apply suprapubic pressure), avoid fundal pressure (neurological complications), position changes (hands & knees, squatting, left lateral recumbent)

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

-Inform the family that death is imminent.

O2 Administration do/don'ts

-Never more than 6L/min by cannula -Must humidify with more than 4L/hr -No more than 2L/min with COPD ... (CO2 Narcosis) -In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask -Restlessness and Irritability = Early signs of cerebral hypoxia

Aspirin therapy for CAD teaching

-Take aspirin with food -Report ringing in ears (toxicity) -Monitor/report excessive bleeding/bruising -Avoid OTC meds containing aspirin

Nurse applying supplemental oxygen should assess:

-respiratory function -skin around the face before applying 02. -Hand hygiene/don gloves -5 rights = 2 identifiers

Panic attack: Nurse should

-use therapeutic communication -teach coping skills -monitor for suicidal ideation -monitor VSs

Tachypnea is a RR greater than

24bpm

Lithium SE

3 P's: Peeing (Polyuria), Pooping (diarrhea), Paresthesia (elec. imbalance)

Albumin

3.5-5

K+

3.5-5

CI

96-106

The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?

A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20. BP down-HR UP

Addison's disease

A rare, chronic endocrine disorder in which the adrenal glands do not produce sufficient steroid hormones.

Hyperventilation leads to

Alkalosis (low CO2)

Pericarditis treatment

Analgesics, antibiotics if bacterial, steroids, monitor for signs of cardiac tamponade. Position: high fowler's leaning forward to relieve pain

An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse?

Antacids will neutralize the acid in your stomach

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

Ask the client about gastrointestinal pain

Antidotes to Cholonergic

Atropine

Blanching of neonate's feet (or buttocks, genitalia, legs)

Contact HCP

Early sign of minimal change nephrotic syndrome (MCNS)?

Glomerular leak of protein **Nurse should recognize presence of albumin in urine as early sign of relapse**

Antidotes to Tylenol

Mucomist (17 doses + loading dose)

Addison's crisis immediate action by nurse

a. headache and tremors b. irregular HR e. Pallor and diaphoresis

Self injection of insulin is commonly administered in the

anterior thigh

A nurse is caring for a client who has arteriovenous fistula which of the following findings should the nurse report? a. Thrill upon palpation. b. Absence of a bruit. c. Distended blood vessels d. Swishing sound upon auscultation

b. Absence of a bruit.

mom scolding kiddos

calmly assist, offer wet pants

A pt. exhibiting symptoms of an acute exacerbation of a chronic obstructive lung disease such as emphysema what intervention to do.

client's baseline oxygen level should be compared to the current level to determine if respiratory decompensation is occurring.

Premature infants feeding tube practice to avoid over-distending the stomach...

deduct the amount of the residual gastric volume from the total prescribed bolus feeding. -Before instilling the bolus feeding: -aspirate the stomach contents -measure it/return it -and deduct that amount from the next feeding

hemodialysis nurse

first observe incision

Acid- Base Balance

if it comes out of you ass is Acidosis Vomiting = Alkalosis

Bladder Irrigation solution

isotonic sterile saline

decreased pH and HCO3 with decreased PaCO

metabolic acidosis

Full liquid diet includes

milk, yogurt, custard, ice cream, pureed vegetables, vegetable juice, cooked refined cereals, pudding, protein drinks/shakes. **includes all liquids that are not clear as well as clear liquids**

discusses domestic violence with pt level of prevention

secondary

Anorexia Nursing Interventions

**Monitor: Cardiorespiratory monitor (for rhythm, and elec imbalance) and client's weight -monitor daily caloric intake -monitor electrolytes -encourage appropriate exercise level -weight after voiding -weight after same time each day -examine body for weights before weighing -use matter of fact approaah -be aware of refeeding syndrome -discourage food rituals -monitor for cardiac issues and arrhythmias -group therapy -encourage realizing problematic behavior -promote positive body self confidence image

acute severe diverticulitis highest priority?

- should be made NPO to reduce risk of intestinal rupture - pt is at risk for peritonitis and intestinal obstruction

chronic venous insufficiency caused by DVT teaching

-Avoid prolonged standing/sitting -Use recliner for long period of sitting -Continue wearing elastic stocking

epidural anesthesia common complications:

-Hypotension = peripheral vasodilation. **Administer bolus of IV fluids** -uterine atony = bladder overfills because unable to feel sensation to void -difficulty breathing if extensive spread of local anesthetic

Suctioning Do/don'ts

-Pre and Post oxygenate with 100% O2 ... -No more than 3 passes ... -No longer than 15 seconds ... -Suction on withdrawal with rotation

The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). What is the most significant desired outcome for this client? -Free from injury of drug side effects. -Return to pre-illness weight. -Adequate oxygenation. -Maintenance of intact perineal skin.

-Return to pre-illness weight.

muscular dystrophy (MD) s/sx

-waddling gait -toe walking -lordosis -frequent falls

Thyroidectomy( post op)

1. Semi Fowlers, neck neutral 2. Monitor for respiratory distress-appparatus at bedside (trach set, 02 tank and suction machine) 3. Check for edema and bleeding by noting dressing 4. limit talking 5. monitor for laryneal nerve damage 6. monitor for hypocalcemia and tentancy 7. prepare CALCIUM GLUCONATE 8. Monitor for thyroid storm

Phenylalanine Adult

<6

Multiple Myeloma Treatment

Blood transfusion Radiation Chemotherapy Bone Marrow Transplant Repair of fractures Treatment of infections

Skin Tastes Salty with

Cystic Fibrosis

A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. Administer the medication.

D. Administer the medication.

The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? A. Assess warmth of extremities B. Keep head of bed raised 45 degrees C. Monitor blood glucose level D. Maintain strict intake and output

D. Maintain strict intake and output

A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Destruction of joint cartilage.

Fruity Breath found in

Diabetic Ketoacidosis

Stroke symptoms

F - Face drooping A- Arm weakness S- Speech difficulties T- Time (is of the essence)

Normal HemoglobinLevels For Female

Female:12-16

Normal Hematocrit Levels for Female

Female:37-47

Normal Red Blood Cell Level (RBC) Female

Female:4.2-5.4 million

Renal failure electrolytes

First: Hyperkalemia (dizzy, wk, nausea, cramps, arrhythmias) Elevated Electrolytes: potassium, phosphate, and magnesium Decreased Electrolytes: sodium, calcium Other Increases: urea, creatinine, uric acid, sulfate, phosphorus, lipids, cholesterol Other Decreases: albumin Acid/Base: anion gap metabolic acidosis

GI Bleed Concern

HR high (compensation) for hypovolemia

Anthrax

Multi vector biohazard

S/S-Hypocalcemia

Musle spasms, convulsions, cramps/tetany, + Trousseau's + Chvostek's, prolonged ST interval, prolonged QT segment.

MAOIs medication names

NARdil MARplan PARnate

Hyper K+

Tall T waves, Prolonged PR interval, wide QRS

Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first?

Transfuse packed red blood cells Rational: The client is exhibiting signs of multiple organ dysfunction syndrome. Transfusion is the first intervention which provide hemoglobin to carry the oxygen to the tissues, is critical.

Diabetes Insipidus treatment/Monitor

Treat the underlying cause if possible; -fluid intake: IV hypotonic -ADH hormone replacement therapy, -vasopressin/desopressin medications MONITOR: -I&Os -weight

furosemide therapeutic effects

Treatment of HTN: Inhibits sodium and water reabsorption from the loop of Henle and distal tubules Treatment of fluid overload: HTN, CHF, cirrhosis, renal dysfunction, acute pulmonary edema -Increased UO -Decreased BP -Decreased adventitious sounds in lungs

A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Urine output 20 ml/hour Rational: urinary output of less than 30 ml/hour indicates that the kidneys are being affected by the high level of magnesium, which is excreted through kidneys.

A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity?

Vomiting

The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next

Wait 1 minute and palpate the systolic pressure before auscultating again

Delegation to Universal (Standard) Precautions...HIV Initiated

Wash Hands Wear gloves Gowns for splashes Mask and Eye Protection for splashes and droplets Don't recap needles Mouthpiece or Amu-bag for resuscitation refrain from giving care if you have skin lesion

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Watery diarrhea

Gullain Barre Syndrome

Weakness progresses from legs upward/resp arrest

Cholinergic Crisis

Weakness with no change in vitals (reduce meds)

Amitriptyline (Elavil) tricyclic antidepressant avoid

alcohol

OSA (sleep apnea)

apply positive airway device/ airway open

The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate? a- Initiation of the impulses from a location outside the SA node b- Inability of the SA node to initiate an impulse at the normal rate c- Increased conduction time from the SA node to the AV junctionInterference with the conduction through one or both ventricles

b- Inability of the SA node to initiate an impulse at the normal rate Rationale: A prolonged PR reflects an increased amount of time for an impulse to travel from the SA node through the AV node and is characteristic of a first-degree heart block.

Child with history of hydrocephalus and ventriculoperitoneal shunt is at risk for

bacterial meningitis

Fetal s/s when mother is hypotensive

bradycardia, lessened variability or decelerations from contractions

A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? a- Prepare the client for an emergency cesarean birth b- Encourage the client to move to a hands-and-knees position. c- Assist the client to sharply flex her thighs up again the abdomen. d- Lower the head of the bed an apply suprapubic pressure.

c- Assist the client to sharply flex her thighs up again the abdomen. **Suprapubic pressure after leg flex, NOT HOB lower*** The hands-and-knees position may be used if the McRoberts maneuver and suprapubic pressure are not successful.

A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma? a. Pindolol (Visken) b. carteolol (Ocupress) c. Metoprolol tartrate (Lopressor) d. Proprenolol hydrochloride (Inderal)

c. Metoprolol tartrate (Lopressor)

nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium d. Platelet count

c. Serum potassium- diuretic that retains potassium= hyperkalemic risk

L sided HF s/s

crackles in lungs, pulmonary edema on xray, coughing (pink frothy sputum), pale, clammy, low o2, SOB -confusion -crackles in lungs -Dyspnea If it keeps going it can lead to right sided heart failure

aplastic anemia

failure of blood cell production in the bone marrow

Peptic Ulcers and food

feed a duodenal ulcer (pain relieved by food)

TB treatment

multidrug regimen for 9 months ... -Rifampin reduces effectiveness of OTCs and turns pee orange -Isoniazide (INH) increases Dilantin blood levels

Milwaukee brace worn

over T shirt 23 hrs day

low fiber foods

roast turkey with canned veggies

delirium tremens (DTs) S/Sx

tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia (DTs start 12-36 hrs after last drink)

Thromboangiitis obliterans (Buerger disease) associated with:

tobacco use **Teach tobacco cessation**

Delegation of No infection patients with immunosuppressed patients

weird miscellaneous stuff

Nurse can help pt. with pneumonia improve ventilation and oxygenation by

-ambulating safely -elevating HOB -teaching client to cough/deep breathe

Indications for induction related to post-term pregnancy explained to client:

-decreased amniotic fluid -decreased placental functioning after 41 wks -provide info about unexpected complications related to post-term pregnancy

Urine Output for minimal competency of heart and kidney function

30 mL/hr

A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include?

Children who have varicella are contagious until vesicles are crusted.

Thyroidectomy expected outcome

Client restricted from eating seafood

What med is used in clients with congestive HF to relieve pulmonary congestion? And SEs?

Furosemide SE: hypokalemia

Addisonian crisis

N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP

Addison's crisis causes

Surgical removal or infection of adrenal glands, TB, CMV, bacterial infections

Sex after MI okay when

able to climb 2 flights of stairs without exertion (Take nitro prophylactically before sex)

antisocial teen

at risk d/t getting yelled at

A nurse is caring for a client who is 12 hr. postpartum and has a third- degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? a. Bisacodyl 10 mg rectal suppository. b. Magnesium hydroxide 30 ml PO. c. Famotidine 20 mg PO. d. Loperamide 4 mg PO

b. Magnesium hydroxide 30 ml PO.

Zidovudine can cause

bone marrow suppression resulting in pancytopenia.

pregnancy depp tendon reflexes

check 1st trimester pregnancy

Acute Pancreatitis S/Sx

fetal position, bluish discoloration of flanks (turner's sign) bluish discoloration of pericumbelical region (Cullen's Sign) Board like abdomen with guarding self digestion of pancreas by trypsin

prolonged PR is characteristic of a

first-degree heart block.

Primary prevention examples

immunizations, nutrition, exercise

TB induration and neg chest xray, latent TB give

isoniazid (INH) for 6-9 months

Head Trauma and Seizures priority

maintain airway = primary concern

multiple myeloma

malignant tumor of bone marrow cells

Crede method or manual compression of bladder

placing hands over bladder (suprapubic region) and compressing (downward) to help emptying; not used until consultation w provider

alc-based hand rub

sufficient/dry

Carboprost tromethamine (Hemabate) is a prescription medicine used

to treat the symptoms of severe bleeding after childbirth (refractory postpartum uterine bleeding) and abortion.

mechanical lift assess

tolerance of exertion

MAOIs - hypertensive crisis with

tyramine foods

Antabuse onset and duration is?

2 weeks *pt must be off med for 2wks before being able to drink

Trough draw taken

< 30 min before scheduled administration

Phenylalanine Newborn

<2

Cholesterol

<200

Hold Digoxin if HR

<60

Glasgow Coma Scale

<8 = coma

Hold tube feeding if residual is :

>100 mL

A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A . Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr

A . Prime IV tubing with 0.9% sodium chloride.

Delegation to RN only

Blood Products (2 RNs must check) Clotting Factors sterile dressing changes and procedures assessments that require clinical judgement Ultimately responsible for all delegated duties

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?

Chest pain and dysrhythmia

Intra-renal Problem=

Damage to renal parenchyma

Lesions of the midbrain cause

Decerebrate posturing (extended elbows, head arched back)

Lipitor (statins) in PMs only and

No grapefruit jiuce

Tyramine foods include:

Salad BAR: Bananas, Avocados, Raisins Yeast Meats: organs, liver, preserved meat (smoked, dried, cured, pickled, hot dogs) Dairy: no cheese except mozzarella, cottage cheese (no aged cheese) No ETOH, elixirs, tinctures, iodine/betadine, caffeine, chocolate, licorice, soy sauce

Ulcer into subQ stage?

Stage 3

A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon

b. Whole grain bread

eye drops instilled then..

close eyes

What do you need bedside for use of adenosine for SVT

crash cart expect: bradycardia, short episode of asystole w/hypotension

Antabuse is used for

for alcohol deterrence: makes you sick with ETOH intake

minimal change nephrotic syndrome

kidney disease in which large amounts of protein are lost in urine **Kids get this**

Heart failure interventions

oxygen High fowler's weigh daily caloric and fluid intake monitoring

opioid OD signs and symptoms

pinpoint pupils, depressed respiration, coma

blown AV fistula peritoneal dialysis

small feedings/complete protein

Cholelithiasis pain in flank =

stone in kidney or upper ureter

If bacterial meningitis is suspected implement which precautions:

-seizure precautions (for child = observation and padding side rails/crib) -Droplet precautions: private room and PPE for nurse including gown

Microvascular angina teaching

-use of daily aspirin -tobacco cessation -management of usual daily activities to avoid symptoms -use of nitroglycerin to prevent and treat anginal symptoms

To treat metabolic acidosis

1. hydration (elevate BP) 2. K+ replacement 3. Dopamine if needed for BP 4. Promethazine to decrease vomiting, but only after hydration is improved.

Check Restraints every 30 minutes

2 fingers room underneath

A home health nurse is conducting home visits for several patients who are diagnosed with acquired immunodeficiency syndrome (AIDS). Which patient would the nurse see first? 1. A patient who is receiving antiviral therapy because of a diagnosis of a low CD4cell count 2. A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath 3. A patient with weight loss who needs modifications and education regarding dietary changes 4. A patient who is receiving IV antibiotics daily for toxoplasmosis

2. A patient with Pneumocystis carinii pneumonia (PCP) who called the office this morning to report a new onset of fever, cough, and shortness of breath **The nurse should monitor for signs of shock. PCP can result in life threatening septic shock as result of the infection and body's inability to fight it due to a severely compromised immune system.**

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record? A. Excessive concave curvature of the lumbar spine. B. Posterior curvature that is convex in the thoracic cavity. C. Rounded spine from head to hips without concave curves. D. Lateral curvature that creates asymmetry of the shoulders.

A. Excessive concave curvature of the lumbar spine.

The nurse is caring for a one-week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? (Select all that apply) A. Poor feeding and vomiting B. Leakage of CSF from the incisional site C. Hyperactive bowel sound D. Abdominal distention E. White Blood Count of 10000/mm3

A. Poor feeding and vomiting B. Leakage of CSF from the incisional site D. Abdominal distention

A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C. Colchicin D. Codeine.

A.Pregabalin

103. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function

A: Assess for abdominal distention

Phenothiazines SE

ABCDEFG Anticholinergic (dry mouth, urinary retention): Safety Blurred Vision: Safety Constipation: Safety Drowsiness: Safety EPS (tremors, Parkinson): Safety Foto Sensitivity: Safety aGranulocytosis (low WBC count = immunosuppressed): **Teach pt how to recognize/report sore throat or infection**

Post Strep URI diseases and conditions:

Acute glomerulonephritis (triggered by immunologic mechanism), rheumatic fever (valve disease), Scarlet fever

A 3rd day post-operative patient has developed abdominal distention and reports nausea and severe abdominal pain on assessment. The nurse will contact the provider to clarify which prescriptions? Select all that apply A. Administer phenergan 12.5 mg IVP every 4 hours PRN for N/V B. Give fentanyl 0.75mg IVP every 2 hours PRN for pain C. Increase IV fluid rate from 150mL to 175 mL/hr D. Place an NG tube and apply low intermittent suction E. Advance current diet to full liquids as tolerated

B. Give fentanyl 0.75mg IVP every 2 hours PRN for pain E. Advance current diet to full liquids as tolerated (you need to think hey this patient has a paralytic ileus. We absolutely do. not want to add food. Or administer an opioid, bc this will slow the bowel even more. DO NOT ADD to the question. it doesn't say anything about this being a "GI surgery" so an NG tube is fine. Pt should maintain NPO status until bowel sounds return, and there is confirmation of no other issues such as perforation.)

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

Bone marrow transplantation

A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. "Taking furosemide can cause your potassium levels to be high" B. "Eat foods that are high in sodium" C. "Rise slowly when getting out of bed" D. "Taking furosemide can cause you to be overhydrated"

C. "Rise slowly when getting out of bed"

The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? (Select all that apply)

C. Gently palpate the client's bladder for distention D. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip E. Secure the urinary drainage bag to the bed frame

Lesions of Cortex cause

Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position) "CORE"

HF is characterized by ____________ which causes compensatory ________________ resulting in excess ______________ _______________. The ineffectiveness of the the heart's pumping action in those with HF results in altered ___________ ______________ ________________ and _______________.

Decreased cardiac output excess fluid retention fluid volume peripheral tissue perfusion fatigue

Peak Draw taken

Depends on Route: Peak Sub L: 5-10min Peak IV: 15-30 min after bag finished Peak IM: 30-60 min after drug administration Peak SubQ: Depends on insulin Peal PO: not necessary

Stimulants Withdrawal S/Sx

Depression, fatigue, anxiety, disturbed sleep

Pt. receiving IV fluids by gravity risk for ?

Fluid volume overload. Can't regulate volume of infusing fluids.

Antidotes to Benzodiazapines

Flumazenil (tomazicon)

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first?

Furosemide

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse?

Give IV dose of adenosine rapidly over 1-2 seconds.

The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement?

Give the prescribed antiemetic.

tumor lysis syndrome treatment

HYDRATION first With this, monitor urine pH to prevent ARF. You want a pH below 6.57. - Also, hydration is important. Have patients drink the day before, of, and 3 days after treatment at scheduled times. - do an EKG - Medication - Alopurinol to decrease uric acid.

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)

Headache and tremors Postural hypotension Pallor and diaphoresis Irregular heart beat

Enema obtain prior?

History of bowel disorders

What to monitor with Spironolactone (Aldactone)

Hyperkalemia

Bruit over thyroid

Hyperthyroidism (bruit may be localized systolic or continuous)

Addisonian crisis expect to see?

Hypotension, rapid weak pulse, rapid RR (think shock)

antipsychotic med discharge teaching?

Increase daily intake of raw fruits/veggies for fiber due to constipation

DI caution for parent for?

Increased thirst

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first?pH 7.50; PaCo2 42; HCO3 33; pO2 92

Infuse 0.9 % sodium chloride 500 ml bolus

Pre-renal Problem =

Interference with renal perfusion

Cholelithiasis

Kidney Stone

Antidotes to Methotrexate

Leucovorin

Post thyroidectomy care

Low or semi-fowler's position Support head, neck, and shoulders to prevent flexion or hyperextension of suture line. Tracheostomy set at beside: O2, suction, calcium gluconate Give fluids as tolerated

Mycobacterium avium complex (MAC)

MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed.

MI Tx

MONA - morphine, oxygen, nitroglycerin and aspirin

Normal Hemoglobin Levels for Male

Male:14-18

Normal Hematocrit Levels for Male

Male:42-52

Normal Red Blood Cell Level (RBC) Male:

Males:4.7-6.1 million

Addison's crisis

Medical emergency-vascular collapse, hypoglycemia, hyperkalemia, tachycardia, FATIGUE, dehydration = shock Administer: IV glucose, IV fluids, corticosteroids; **no PO corticosteroids on an empty stomach

A 4-year-old child developed proteinuria, hypoalbuminemia and edema (i.e. nephrotic syndrome). The urinary sediment contained no inflammatory or red blood cells, but did contain lipid casts. What is the most likely diagnosis?

Minimal change nephrotic syndrome

Steroid Effects =

Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain - Spindle shape, osteoporosis, adrenal suppression. in kids: (delayed growth). . . (Cushing's Syndrome symptoms)

Coughing after bronchoscopy

NPO until gag reflex returns

Pancreatitis Nursing Interventions

NPO=rest pancreas -IV fluids -NSG w suction (relieves n/v, distention & paralytic ileus) -provide oral care -monitor/maintain fluid electrolyte balance, infection, shock & hyperglycemia -position pt on semi-fowler's (knees flexed & pillow on abdomen relieves pain) or fetal position -Labs: serum amylase/lipase increased

Antidotes to Opiates Narcotic analgesics heroin morphine

Narcan (Naloxone)

Peritonitis s/s:

Nausea, vomiting and severe abdominal pain/cramping (guarding) and distention. Low urine output. Loss of appetite. No motility sounds, abdomen rigid. Fever, chills, tachycardia, pallor possible shock.

How much of a time gap from SSRIs and TCAs to admin MAOIs

Need 2 wk gap

Delegation to Unlicensed Assistive Personal

Non Sterile procedures Precautions & Room Assignments

acute asthma treatment

O2, bronchodilator, glucocorticoid, inhaled ipratropium

3 phases of renal failure

OLIGURIC - less than 400ml a day last serval days to 4 weeks DIURETIC - increased urine 1000-2000ml last 1-3 weeks RECOVERY - GFR rises can take up to 1 year

Post-renal Problem =

Obstruction in UT anywhere from tubules to urethral meatus.

16 year old surgery to immobilize fracture. Which action to obtain valid consent form?

Obtain permission of the custodial parent for the surgery

PACU care: Abdominal surgery/post op bleeding S/Sx

Oliguria RR: rapid/shallow Peri pulse: rapid/thready Blood glucose: increase (stress)

Pyridium(for bladder infection) makes urine

Orange/red/pink urine

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus?

Oxygen saturation

Arterial Blood Gases Used for Acidosis vs. Alkalosis

PH 7.35-7.45 CO2: 35-45 (respitory driver) HIGH= Acidosis HC03:21-28 (Metabolic driver) HIGH=Alkalosis

Maslows Hierarchy of Needs

Physiologic Safety Love and Belonging Esteem Self-actualazation

Magnesium Sulfate is used in labor as:

Preeclampsia: Prevent seizures -Magnesium = depressant

Hypo K+

Prominent U waves, Depresed ST segment, Flat T waves

Antidotes to Heparin

Protamine Sulfate ( Keep APTT and PTT @ 1.5-2.5 x normal

SIADH causes/risk factors

Pulmonary disease: -Small cell carcinoma of lung** -TB/COPD CNS Disorders: -Head injury or injury of hypothalamus or pituitary -Malignancy near or of Hypothalamus or pituitary -Brain surgery CANCERS: -Cancer of prostate, pancreas, or duodenum Hodgkin's disease -HIV

MI interventions

RAPID RESPONSE 1. Call MD stat 2.Get IV access AND Place on EKG 3. Admin morphine, nitro, aspirin, oxygen 4. Assess VSs: ( Assess level of pain) heart/lung sounds. BP, pulse, rest, temp, o2 sat 4. Draw cardiac enzymes 5. Encourgae bedrest/Quiet room 6. Get chest X-ray, Echocardiogram, CBC, electrolytes, myoglobin,ABG, CK-MB, troponin LEVELS MONITORED 7.Transfer to higher level of care

basilar skull fracture

Raccoon eyes (periorbital ecchymosis) and Battle's sign (mastoid ecchymosis), rhinnorrhoea or otorrhoea with Halo sign

What action should the nurse take when a client who is psychotic proposes goals that are both unrealistic and undesirable?

Reflect the client's behavior and its consequences.

Normal assessment sounds

Regular pulsation at the epigastric area when the client is supine

Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis?a. Begin a weight-bearing exercise plan b. Increase intake of foods rich in calcium c. Schedule a bone density tests every year. d. Remain upright after taking the medication.

Remain upright after taking the medication Rationale: Risendronate, causes reflux and esophageal erosion.

A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take?

Report the incident to the immediate supervisor

Rifampin (for TP) makes urine

Rust/orange/ed urine and body fluids

Delegation of Droplet (Respiratory) Precaution (Wear mask)

Sepsis, scarlet fever, strep, fifth disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola, Meningitis, mycoplasma, adenovirus, rhinovirus RSV(needs contract precautions too) TB Respiratory Isolation

Renal failure and osteodystrophy labs

Serum K+ and total calcium

Potassium sparing diuretics

Spironolactone (Aldactone)

Fibrinolytics/Thrombolytics

Streptokinase, Tenecteplase (TNKase): suffix: -teplase, -ase Clot buster used in emergencies **Watch for bleeding**

Pt with severe postpartum depression Plan of care?

Supervised and guided visits with infant

BPH tx

TURP (Transurethral Resection of Prostate) ... some blood for 4 days, and burning for 7 days post-TURP.

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan?

Take on an empty stomach with a full glass of water

Myasthenia gravis takes pyridostigmine (Mestinon), a cholinergic agent...what instructions for meds?

Take the med 30 min before eating on empty stomach. Helps improve swallowing/chewing

Myesthenic crisis

Weakness with change in vitals (give more meds)

Why should pacreatic enzyme supplement capsule contents be kept away from all mucus membranes?

With the loss of exocrine function for a client with chronic pancreatitis, replacement of pancreatic enzymes using pancrelipase (Pancrease) becomes necessary. Diarrhea and steatorrhea (fatty stools) indicate insufficient pancreatic enzymes are present to digest dietary fats and other of nutrients, so pancrelipase, a fat-digesting enzyme, should be consumed with any type of food.

Benzodiazepines have what in their name?

ZEP, What do you find at a Zeppelin concert? "minors on tranquilizers" (minor antipsychotic) zePAM/zoLAM: Alprazolam (xanax), larazepam (Ativan), diazepam (Valium), clonazepam (Klonopin)

megaloblastic anemia

a blood disorder characterized by anemia in which the red blood cells are larger than normal Lab values to watch for treatment: -folate and vitamin b12

Peripheral vascular disease (PVD)

a condition in which the legs, feet, arms, or hands do not have enough blood circulation Interventions: Help the client dangle legs

muscular dystrophy (MD)

a hereditary condition causing progressive degeneration of skeletal muscles (wasting) by degeneration of muscle fibers without neurologic or vascular movement

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) a- Monitor heart, lung, and kidney function. b- Notify healthcare provider of serum amylase and lipase levels. c- Position client on abdomen to provide organ stability d- Encourage an increased intake of clear oral fluids e- Review client's abdominal ultrasound findings.

a- Monitor heart, lung, and kidney function. b- Notify healthcare provider of serum amylase and lipase levels. e- Review client's abdominal ultrasound findings.

A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below-the knee amputation b. Fractured tibia c. 95% full-thickness body burn d. 10cm (4in) laceration to the forearm

a. Below-the knee amputation

An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150mL of dark brown emesis. In what order should the nurse implement these interventions? a. Elevate the head of the bed b. Send emesis sample to the lab c. Complete focused assessment d. Offer PRN pain medication

a. Elevate the head of the bed c. Complete focused assessment d. Offer PRN pain medication b. Send emesis sample to the lab

A nurse is caring for a client who has returned to the med surg unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment? a. LOC b. skin turgor c. deep tendon reflexes d. bowel sounds

a. LOC c. deep tendon reflexes

Fetal well-being during labor is assessed by: a. The response of the fetal heart rate (FHR) to uterine contractions (UCs). b. Maternal pain control. c. Accelerations in the FHR. d. An FHR above 110 beats/min.

a. Monitoring the response of the fetal heart rate (FHR) to uterine contractions (UCs). In general, reassuring FHR patterns are characterized by an FHR baseline in the range of 110 to 160 beats/min and demonstrates moderate variability, and accelerations.

What is the expected outcome of esomeprazole (Nexium) when prescribed for a client with gastroesophageal reflux disease (GERD)? a Promotion of rapid tissue healing. b. Increased gastric emptying. c. Improved esophageal peristalsis. d. Neutralization of gastric secretions.

a.Promotion of rapid tissue healing. Proton pump inhibitors, such as esomeprazole (Nexium), act to inhibit gastric acid secretion and promote rapid healing of esophageal tissue.

lordosis

abnormal anterior curvature of the lumbar spine that is concave in nature (sway-back condition)

mental health - most suicides occur when

after beginning of improvement with increase in energy levels

A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider? a- Insomnia b- Muscle cramping c- Increase appetite d- Anxiety.

b- Muscle cramping Rationale: SIADH causes dilution hyponatremia because of the increased release of ADH, which is treated with water restriction and demeclocycline, a tetracycline derivate that blocks the action of ADH. Signs of hyponatremia (normal 136-145), which indicate the need for increasing the dosage of demeclocycline, should be reported to the healthcare provider. The signs include: plasma sodium level less than 120, anorexia, nausea, weight changes related to fluid disturbance, headache, weakness, fatigue, and muscle cramping. AC& D are not related to hyponatremia.

A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child's cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom

b. Monitor the child's cardiac status

The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? a. Hypoactive bowel sounds in the lower quadrant. b. Rebound tenderness in the upper quadrants. c. Tympani with percussion of the abdomen. d. Light colors gastric aspirate via the nasogastric tube.

b. Rebound tenderness in the upper quadrants. Rationale: Rebound tenderness in the upper quadrant may be indicative of peritonitis. A is a clinical finding associated with bowel obstruction and does not need to be reported D may be something characteristic of the client's condition.

The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide? a- Stroke the inner thigh below the perineum to initiate urinary flow b- Contract, hold, and then relax the pubococcygeal muscle c- Pour warm water over the external sphincter at the distal glans d- Apply downward manual pressure at the suprapubic regions.

d- Apply downward manual pressure at the suprapubic regions. Rationale: The Crede Method is used for those clients with atonic bladders, which is a concomitant of demyelinating disorders like multiple sclerosis. The client is applying pressure in the wrong region (umbilical Are) and should be instructed to apply pressure at the suprapubic area.

Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? a- Maintain adequate cardiac output b- Promote adequate tissue perfusion c- Promote rest and sleep d- Reduce the risk for injury

d- Reduce the risk for injury Rationale: Paget's is a metabolic bone disorder which place the client at high risk for injury. Once the client is symptom free the next goal is reducing risk for injury

The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? a- Administer the Tropol immediately and monitor the client until the heart rate increases. b- Provide the dose of Tropol as scheduled and assign a UAP to monitor the client's BP q30 minutes. c- Give the Tropol as scheduled if the client's systolic blood pressure reading is greater than 180. d- Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.

d. Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern. Rationale: Beta blockers such as metoprolol (Tropol SR) are contraindicated in clients with second or third-degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.

A client with chronic pancreatitis receives a new prescription for pancrelipase (Pancrease). Which instruction is most important for the nurse to include in this client's teaching? a. Avoid prolonged exposure to direct sunlight. b. Stay away from products containing alcohol. c. Ingest 8 oz of grapefruit juice with the medication. d. Take the medication when consuming food.

d. Take the medication when consuming food.

Care team can differentiate between panic attack and life-threatening condition by:

diagnostic tests

1st sign of infection in a postpartum mom

foul smelling lochia

Diabetic Coma vs Insulin Shock

give glucose first - if no help, give insulin

Suctioning PPE

gloves, goggles, mask

CA++ channel blockers avoid

grapefruit juice

pyloric stenosis

hydration first

Diabetes Insipidus immediate intervention when see:

hypernatremia

Pt with decreased O2 saturation and radiological evidence of pneumonia has:

hypoxia related to decreased diffusion of O2 for the alveoli to the blood

#1 intervention for lithium toxicity

increase fluids then contact HCP

Bacterial Meningitis

inflammation of the protective membranes covering the brain and spinal cord caused by various types of bacteria

Hepatic encephalopathy treatment and monitor what?

lactulose Monitor: mental status **Should see improvement as serum ammonia decreases**

Anorexia S/S

lanugo, osteoporosis, BMI <18.5, peripheral edema, heart problems. -bradycardia -hypotension -fatigue -orthrostatic BP changes -suicidal ideation

sedative precautions

measure BP before standing

A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client's ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect

metabolic acidosis

Acute Kidney Injury (AKI)

metabolic acidosis

Dopamine therapy levels

monitor I&Os

droplet - airborne, contact resp mask

montoux test

Digitalis toxicity

nausea and vomiting, yellow-green vision, extrasystole, AV conduction block related to coadministration with chlorothiazide

Hypoglycemia S/S

nausea, nervousness, & irritability, sweatinesss w/ pale skin diaphoresis, pale cool skin, irritability, normal/shallow respirations, tachycardia and palpitations, strange or unusual respirations. slurred speech, headache and blurred vision, decreasing loc, seizures leading to coma, change in emotional behavior, difficulty thinking.

What should not be mixed with meds for ED

nitrates = LOW BP

child inconsolable look for:

pain (infiltrated IV), fever, neruo changes

Fibromyalgia pt wants to go to hospice

pain specialist

panic attack symptoms

palpitations, chest pain, dizziness, sweating, shakiness, stomach distress, feelings of suffocation, numbing or tingling, sense of unreality or being detached from oneself, fear of dying or losing control

When pt taking zidovudine nurse should recognize what?

pinpoint, red, round spots as petechiae and report results of CBC to HCP

CVA symptoms

prepare for IV fibronalytic therapy

Renal Failure = restrict what

protein intake

primary intervention for alcohol withdrawal

quiet, non-stimulating environment

Sepsis protocol is centered around

rapid initiation of hemodynamic resuscitation including: -administration of fluids, vasopressors, and transfusions Priority= maintain strict I&Os (hourly)

Short term goal should be

realistic/attainable in timeline of 7-10 days before discharge

Peritonitis s/s:

rebound tenderness, muscular rigidity, laying still w/fast shallow breaths, distended abd, ascites, fever

STI reporting

remain confidential

Diabetes insipidus (decreased ADH) S/Sx,

s/s: Excessive urine output, thirst, dehydration, & weakness. -Polydipsia (thirst) -Polyuria (increased urine output) Decreased skin turgor -Postural hypotension -Tachycardia -Low urine specific gravity

Post op SBAR:

significant data related to the the post op condition of pt after transfer ***abdominal and wound assessment**

Hand contamination happens when

sliding gloved fingers inside the other glove while removing exam gloves

Gastric Ulcers and food

starve

Theophylline toxicity

stomachache, tachycardia, sweating profusely Early signs: Nausea/irritability Not: 110bpm in 4 year old

Cholelithiasis pain in ab/scrotal area =

stone in mid/lower ureter or bladder

Stroke

tongue points toward side of lesion(paralysis), uvula deviates away from the side of lesion (paralysis)

toxic effects of lithium

tremors, metallic taste, severe diarrhea

Phenothiazines

typical antipsychotics and they are major tranquilizers so think safety: positive symptoms of schizo

Pt. with prostasis

urinary cath to be avoided ; infection

Post thyroidectomy complications

• Hypothyroidism • Parathyroid gland damage= hypocalcemia (tetany) - Hemorrhage - Laryngeal stridor - Nerve damage (vocal cord paralysis) - Tracheal compression

The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication?

• Poor feeding and vomiting

methotrexate caution

•Bone marrow depression • Watch for sun sensitivity** • Avoid foods high in purine