NCLEX INCORRECT-DIFFICULT
Low fetal heart rate
- under 110 *bad* - use LION - stop pitocin oxytocin
Benzodiazepines
-pam -lam Can be used as o Seizures medications o Preop induction of anesthesia o Muscle relaxants o EtOH withdrawal medications
Erikson ages and stages
0-1 = trust vs miss trust 1-3 = autonomy vs shame and doubt 3-6 = initiative vs guilt 6-12 = Industry vs inferiority 12-20 = identity vs role confusion
Steatorrhea
(ie, greasy, bulky stools) is caused by malabsorption of fat in the gastrointestinal tract and indicates nonadherence with pancreatic enzyme replacement therapy; although it is important to address, this is not a priority.
when would you... FIRST feel quickening MOST LIKELY feel quickening SHOULD you feel quickening
"BABY QUICKS' = first kicks felt FIRST = 16 weeks MOST LIKELY = 18 weeks SHOULD = 20 weeks
Dilation of the cervix
0-10 cms
Can you mix insulin in same syringe and how? • Yes, insulin can be mixed in the same syringe • How do you mix insulin?
(1) Pressurize vial and (2) Draw up insulin (1) To pressurize the vial ... Inject air into N, the into R, Draw up R (2) To draw up insulin ... Think of RN air into N first than air into R than draw up R Draw up N
Positive contraction stress test
(Abnormal) A positive result is represented by late decelerations of FHR, with 50% or more of the contractions in the absence of hyperstimulation of the uterus. contractions stimulated by nipple stimulation or oxytocin admin
Negative Contraction Stress Test
(Normal) A negative result is represented by no late decelerations of fetal heart rate (FHR).
Quickening
(baby Qicks) may be first felt between 16 to 20 weeks
intermittent bubbling in the water-seal chamber consistent with respirations
(due to air escaping from the pleural space) is expected until the lung has fully expanded.
Bacterial gastroenteritis
(eg, Shigella, Escherichia coli infection) can cause bloody diarrhea, fever, and abdominal pain. But usually, symptoms last a few days to a week.
Bisphosphonates
(eg, alendronate, risedronate), which inhibit osteoclasts (ie, cells that cause bone resorption) to allow bone mineralization to occur more quickly. Bisphosphonates can decrease the risk for osteoporosis-related fractures. Appropriate teaching about bisphosphonate administration includes: Administering bisphosphonates with a full glass of water (8 oz [240 mL]) and remaining upright for 30 to 60 minutes to promote the complete passage of medication into the stomach and reduce the risk for reflux into the esophagus. Bisphosphonates can cause esophageal irritation and lead to esophagitis and esophageal ulcers. Not administering alendronate with a calcium supplement because calcium reduces absorption of bisphosphonates alendronate should be taken on an empty stomach, ideally 30 minutes before or 2 hours after eating, to ensure optimal absorption
Meniere disease
(endolymphatic hydrops) results from excess fluid accumulation inside the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and associated with nausea and vomiting. Clients report feelings of being pulled to the ground (drop attacks). During an attack, the client is treated with vestibular suppressants, including sedatives (eg, benzodiazepines such as diazepam), antihistamines (eg, diphenhydramine, meclizine), anticholinergics (eg, scopolamine), and antiemetics. The nurse's priority is to plan for client safety with fall precautions given the severe vertigo and use of sedating medications. Fall precautions include adjusting the bed to a low position with side rails up and instructing the client to call for help before getting up. Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television or looking at flickering lights. The client's diet should be salt restricted to prevent fluid buildup in the ear.
Acute nephrolithiasis
(ie, kidney stones) is the presence of solid deposits composed of salts and minerals that form in the kidney and travel through the genitourinary system. Stones can obstruct the ureters and disrupt the ureteral epithelium, leading to hematuria (ie, RBCs in the urine). Additional manifestations include tachycardia, pain radiating to the groin, and nausea and vomiting due to severe pain.
Ultrafiltration
(removal of excess fluid) is a complex task that requires additional training. It is performed for clients who do not respond to IV diuretics. Clients receiving ultrafiltration are more likely to be hemodynamically unstable due to advanced heart failure; therefore, these clients require care from an experienced nurse.
Levetiracetam (Keppra)
*class*: anticonvulsants *Indication* Seizures *Action*: Decreases severity and incidence of seizures *Nursing Considerations*: -May cause suicidal thoughts, dizziness, weakness - May alter RBC, WBC, and liver function - May cause somnolence - Should be infused over 15 minutes
Metoclopramide (Reglan)
*class*: antiemetic is a commonly used antiemetic medication that treats nausea, vomiting, and gastroparesis by increasing gastrointestinal motility and promoting stomach emptying. With extended use and/or high doses, metoclopramide may lead to the development of tardive dyskinesia (TD), a movement disorder that is characterized by uncontrollable motions (eg, sucking/smacking lip motions) and is often irreversible
Metoclopramide (Reglan)
*class*: antiemetic *Indication*: prevention of nausea, vomiting, hiccups, migraines, gastric stasis *Action*: accelerates gastric emptying by stimulating motility *Nursing Considerations*: - don't use with GI obstruction - may cause extrapyramidal reaction, neurolyptic malignant syndrome, tardive dyskinesia, arrhythmias, blood pressure alterations, hematologic alterations, facial movements, sedation - can decrease effects of levodopa - assess nausea/vomiting - monitor liver function tests
Acyclovir (Zovirax)
*class*: antiviral, purine analogues *Indication*:genital herpes, herpes zoster, chicken pox *Action*: interferes with viral DNA synthesis *Nursing Considerations*: - may cause seizures, renal failure, Stevens-Johnson syndrome, thrombotic thrombocytopenic purpura syndrome, diarrhea, dizziness, nausea - monitor renal function - assess lesions - instruct patient to use proper protection during sexual intercourse
Dobutamine (Dobutrex)
*class*: beta-adrenergic agonist, inotropic *Indication*: short term management of heart failure *Action*: Dobutamine has a positive inotropic effect (increases cardiac output) with very little effect on heart rate. Stimulates Beta1 receptors in the heart. *Nursing Considerations*: - Monitor hemodynamics: hypertension, ↑HR, PVCs - Skin reactions may occur with hypersensitivity - Beta blockers may negate therapeutic effects of dobutamine - Monitor cardiac output - Monitor peripheral pulses before, during, and after therapy - DO NOT confuse dobutamine with dopamine
How do you treat morning sickness
*first trimester* dry carbohydrates before getting out of bed
when would you FIRST - heart fetal heart rate - experience quikening
- 8 weeks : first - 16 weeks : first
NSAIDS and heart failure
- contraindicated for pain due to sodium retention, which causes fluid retention and worsens heart failure Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. These drugs also decrease the effectiveness of diuretics and other blood pressure medications. The risks can be even higher in the client who already has cardiovascular disease or takes NSAIDs routinely or for a long time. In addition, long-term use of NSAIDs is associated with peptic ulcers and chronic kidney disease. These clients should use NSAIDs cautiously, at the lowest dose necessary and for a short time. The nurse should notify the health care provider that this client is routinely taking ibuprofen.
Working phase (therapeutic phase)
- Correct answer: should be focused, directive, "tough"; in some ways, these answers will seem stern and slightly unfriendly; set limits, enforce proper communication
ECT post-procedure
- Individual responds slowly after treatment; may not remember the event - In PACU for 1 to 3 hours - Reorient, some short-term memory may be affected, but will return - Monitor virtual signs/secretions
cranial nerves involved with eyes
- Optic (2) nerve - Oculomotor (III) nerve - Trochlear (IV) nerve - Abducen (VI) nerve
Cisplatin (Platinol)
- Treatment for cancer. Check renal functioning
low baseline variability
- bad - fetal hr stays the same, doesn't change - LION
Decorticate posturing
-"flexor posturing" or "mummy baby" (think Egyptian mummy preservation) -adduction of arms (arms fold to chest); flexion of elbows and wrists worsening cerebral impairment possible IICP
Liver biopsy prep
-NPO at midnight -Informed consent -Give meds as prescribed - Labs (PTT-INR-PT) CBC - assess for rising respirations after - splint incision lay on right side
Barium contrast
-PO admin -coats lining of the GI tract in fluoroscopy and CT exams - Pale stool for up to 3 days
primigravida at 5 cm wants IV pain med rn. could u give it?
-YES bc IV meds peak at 15-30 min and she's most likely not gonna deliver that soon.
tumor lysis syndrome
-destruction of tumor cells releases uric acid K decreased Ca Increased phosphorus Complications: - Acute kidney injury - Cardiac arrhythmias - Seizures Prophylaxis - Intravenous fluids - Xanthine oxidase inhibitor* or rasburicase Treatment - Intravenous fluids + rasburicase - Continuous telemetry - Aggressive electrolyte monitoring & treatment Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (eg, >5.0 mEq/L [5.0 mmol/L]) may progress to lethal dysrhythmias (eg, ventricular fibrillation) Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) overwhelm the kidneys, leading to hyperuricemia and acute kidney injury from uric acid crystal formation (Option 3) Hyperphosphatemia (eg, >4.5 mg/dL [>1.45 mmol/L]) can cause acute kidney injury and dysrhythmias TLS is best prevented by aggressive hydration and prophylactic allopurinol for hyperuricemia.
benzodiazepines
-pam and -lam antianxiety valium alc withdrawal , induction of anesthetic, muscle relaxant, seizures (STATUS EPILEPTICUS) WORK fast take no more than 6 weeks - 3 months keep on valium until TCA (elavir takes effect) Anticholinergic Blurred vision Constipation Drowsiness
estrogen therapy increases the risk for
-stroke and VTE -endometrial cancer
The ICU nurse is caring for a sedated patient on a pressure-cycled ventilator. The ventilator alarm is beeping persistently despite the patient's civil status and stable vitals. What is the most appropriate action for the RN to take first?
. If the patient's presentation and vitals are stable, the nurse should check for any apparent equipment malfunction. If no air leaks or kinks are immediately identifiable, the nurse should call respiratory therapy or the rapid response team (RRT). Persistent alarms despite stable vitals may indicate the patient is trying to talk, or is developing a pneumothorax from increased intrathoracic pressure, or is biting/gagging on the endotracheal tube, or is experiencing bronchospasms. These alarms should never be ignored or turned off, as they may indicate early signs of a change in the patient's condition.
engagement
0 station presenting part is at the ischial spines
stage 1
0-10 dilation 0-100% effacement phase latent 0-4 cm contractions every 5-30 minutes frequency 15-30 seconds phase active 5-7cm contractions every 3-5mins frequency 30-60 seconds Phase transition 8-10 cm contractions: 2-3 mins frequency: 60-90
dilation
0-10cm 3 phases 1st stage labor
sensorimotor stage
0-2 present oriented only think about right now as it happens you are doing now tell them what you're doing as you're doing it
Lithium
0.6-1.2 its an electrolyte manic depression 3 p's peeing pooping paresthesia toxic - metallic taste - severe diarrhea - neuro sign toxic #1 intrervention - FLUIDS - if sweating give fluids with electrolytes - Na needs to stay consistent
therapeutic level of lithium
0.6-1.2 toxic > 2
lithium normal range
0.6-1.2 mEq/L
5 stages of grief
1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance
Milia, normal or abnormal?
NORMAL (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks
effacement
100%= thinning 3 phases 1st stage labor
tracheal suction and pressure range
100-120mmhg 10-15 seconds adults children <10
distended sebaceous glands tiny white spots on infants face
NOT concerning milia
The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding? 1.A tongue blade is used to touch the client's pharynx; gag reflex is absent 2.Only one side of the mouth moves when the client is asked to smile and frown 3.The absence of light touch and pain sensation on the left side of the client's face 4.When the client shrugs against resistance, the left shoulder is weaker than the right
1 Cranial nerves IX (glossopharyngeal) and X (vagus) are related to the movement of the pharynx and tongue. To evaluate cranial nerves IX and X, the nurse assesses for the presence of a gag reflex and symmetrical movements of the uvula and soft palate, and listens to voice quality. A tongue blade can be used to touch the posterior pharyngeal wall to assess for a gag reflex. Asking the client to say "ah" will allow assessment of the uvula and soft palate. Harsh or brassy voice quality indicates dysfunction with the vagus nerve (X) (Option 1). (Option 2) The facial nerve (VII) is assessed by observing for symmetrical movements during facial expressions (eg, smile, frown, close eyes). (Option 3) The trigeminal nerve (V) has both sensory and motor functions. The nurse assesses for equal jaw strength by palpating the masseter muscle while the client clenches the jaw. To assess sensory function, the nurse touches the client's face with the client's eyes closed to determine if sensations are equal. (Option 4) The spinal accessory nerve innervates the sternocleidomastoid and part of the trapezius muscles. The nurse applies resistance during shrugging and head turning and assesses for equal strength.
1st trimester weight gain?
1 lb a month x 3 months
2nd trimester weight gain
1 pound per week but varies based on BMI
small for gestation age is defined as
10th percentile
normal prothrombin time
11-16 seconds
Normal fetal heart rate
110-160 bpm
1st trimester
12 weeks
The nurse is teaching a group of clients with type 1 diabetes mellitus about hypoglycemia. Which of the following should the nurse include as signs or symptoms of hypoglycemia? Select all that apply. 1.Diaphoresis 2.Flushing 3.Pallor 4.Polyuria 5.Trembling
1,3,5 Hypoglycemia (low blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially serious complication of diabetes mellitus that occurs when levels of insulin exceed the proportion of glucose in the body. During hypoglycemia, epinephrine is released, activating the autonomic nervous system. When the brain is deprived of glucose, neuroglycopenic symptoms such as confusion and seizures can develop and may progress to a coma. It is important to teach clients to recognize the signs and symptoms of hypoglycemia to avoid complications. Common signs and symptoms of hypoglycemia include: Skin manifestations (eg, diaphoresis, pallor) (Options 1 and 3) Gastrointestinal response (eg, hunger) Neurological manifestations (eg, trembling, palpitations, anxiety/arousal, and restlessness) (Option 5) (Option 2) Flushing (red skin) is commonly seen with fever, hyperthermia, steroid use, and polycythemia vera. Flushing is not commonly seen with changes in blood glucose levels. (Option 4) Polyuria and weight loss are usually associated with hyperglycemia, not hypoglycemia.
In the intensive care unit, the nurse cares for a client admitted with a head injury who develops syndrome of inappropriate antidiuretic hormone. Which data should the nurse expect with the onset of this condition? Select all that apply. 1.Decreased serum osmolality 2.High serum osmolality 3.High urine specific gravity 4.Increased urine output 5.Low serum sodium
1,3,5 Syndrome of inappropriate antidiuretic hormone (SIADH) is potential complication of head injury. In SIADH, the extra ADH leads to excessive water absorption by the kidneys. Low serum osmolality and low serum sodium are the result of increased total body water (dilution). As ADH is secreted and water is retained, urine output is decreased and concentrated, resulting in a high specific gravity. (Options 2 and 4) Increased urine output is associated with diabetes insipidus (DI). In DI, ADH is suppressed, causing polyuria, severe dehydration, and high serum osmolality if the client is unable to drink enough to maintain a fluid balance
A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate order. All options must be used. Unordered Options 1. Assess for presence of adequate pulse 2. Complete an incident report 3. Get help and move the client to the bed 4. Inspect the client for injuries 5. Notify the client's health care provider (HCP)
1. 4. 3. 5. 2.
Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply. 1.Before liver biopsy, pulse is 80/min and blood pressure (BP) is 120/80 mm Hg; 1 hour afterward, pulse is 112/min and BP is 90/60 mm Hg 2.Before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is 80/min and BP is 126/82 mm Hg 3.Client with coronary artery disease on metoprolol; pulse is 62/min 4.Elderly client with black stools; pulse is 112/min 5.Neonate crying inconsolably at feeding time; pulse is 160/min
1,4 The liver is very vascular, which places it at risk for internal bleeding after a tissue sample is removed for biopsy. Liver dysfunction typically results in coagulopathy as many coagulation factors are synthesized in the liver, thereby increasing the risk for bleeding. Early signs of blood loss/shock are tachypnea, tachycardia, and agitation. A later sign is hypotension. Black stools (melena) indicates slow upper gastrointestinal bleeding; tachycardia may indicate significant blood loss. Therefore, this client needs immediate assessment. (Option 2) This change in vital signs from preprocedure to postprocedure most likely reflects decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not produce bleeding serious enough to make a client hypotensive. If this client was bleeding, it would compress the spinal cord, causing paralysis in the lower extremities. (Option 3) This client has a pulse of 62/min (normal 60-100/min), which indicates a therapeutic effect of metoprolol. The nurse should monitor for bradycardia, which is a common and expected finding following administration of a beta-adrenergic blocker. Bradycardia would require nursing intervention only if the client became symptomatic (eg, hypotension, dizziness, nausea). (Option 5) A neonate's resting pulse is 110-160/min. Crying or vigorous kicking can cause a temporary rise. Vital signs are concerning if they rise when a client is at rest.
therapeutic and toxic levels of digoxin
1-2 >2 toxic
Regular inulin - onset - peak - duration
1-2-4 onset 1 hour peak 2 hour duration 4 hours only insulin given IV
The nurse is preparing to perform ear irrigation for a client with impacted cerumen. Place in the correct order the following steps for performing ear irrigation. All options must be used. Unordered Options 1. Assess the client for fever or ear infection 2. Gently irrigate the ear canal with a slow, steady flow of solution 3. Place a towel and an emesis basin under the affected ear 4. Place the client in a sitting position with the head tilted slightly toward the affected ear 5. Straighten the ear canal by pulling the pinna up and back
1. 4. 3. 5. 2.
Fundus palpable reaches umbilical (navel) level at week
12 weeks 20-22
Calcium channel blockers are classified into two categories: 1. dihydropyridine 2. non-dihydropyridine
1. (amlodipine, felodipine, nimodipine, and nifedipine) 2. (diltiazem, verapamil).
The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply. 1.Ecchymosis of the scrotum 2.Increased abdominal girth 3.Increased urinary output 4.Report of groin pain 5.Report of increased thirst and appetite loss
1,2,4 Repair of abdominal aortic aneurysms can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output
The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's electronic health record, the nurse anticipates which assessment findings? Select all that apply. Click on the exhibit button for additional information. Laboratory results Albumin1.5 g/dL (15 g/L) Ammonia 112 mcg/dL (80 µmol/L) INR 1.9 Bilirubin 22 mg/dL (376 µmol/L) Platelets 55,000/mm3 (55 × 109/L) 1.Ascites 2.Bruising 3.Constipation 4.Itching 5.Lethargy
1,2,4,5 Cirrhosis of the liver occurs when chronic liver disease (eg, hepatitis C infection) causes scar tissue and nodules, which can decrease liver function and lead to liver failure. Clients with end-stage liver disease may experience exacerbations requiring hospitalization and acute intervention. Numerous laboratory abnormalities occur in the setting of liver failure and correlate with assessment findings (eg, high serum ammonia resulting in hepatic encephalopathy) (Options 1, 2, 4, and 5). (Option 3) Lactulose, an osmotic laxative, decreases serum ammonia levels by causing ammonia to be excreted through stool. The desired therapeutic effect is the production of 2 or 3 soft bowel movements each day; therefore, clients receiving lactulose should not exhibit constipation.
When SHOULD you - auscultate fetal HR - experience quickening
12 weeks 20 weeks
The nurse is caring for a client with severe anorexia nervosa. Which of the following findings are consistent with this diagnosis? Select all that apply. 1.BMI of 16 kg/m2 2.Fine, downy hair on the face and back 3.Has not menstruated in 3 months 4.Potassium of 3.1 mEq/L (3.1 mmol/L) 5.Refuses to engage in exercise 6.Unable to tolerate heat
1-3-4-2 Anorexia nervosa is an eating disorder common among adolescents and young adults (age 18-24). Subtypes of the disorder include the restricting type, in which there are no bulimic features, and the binging/purging type, in which restriction is still the primary cause of weight loss, but bulimic features such as self-induced vomiting are present. Clinical manifestations of anorexia nervosa include: Fear of weight gain: clients may engage in extensive dieting, intense exercise, and/or purging behaviors (eg, self-induced vomiting, misuse of laxatives or diuretics) resulting in excessive weight loss (BMI <18.5 kg/m2) (Option 1) Lanugo: fine terminal hair can be seen in extreme cases (Option 2) Amenorrhea: clients may stop menstruating due to decreased body fat and the resulting low estrogen levels (Option 3) Fluid and electrolyte imbalance: malnutrition, dehydration, and excessive vomiting can cause hypokalemia and metabolic alkalosis, leading to complications such as cardiac dysrhythmias (Option 4) Decreased metabolic rate: severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance
The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? Select all that apply. 1.Administers coagulation factor replacement IV push 2.Administers ibuprofen PO PRN for pain 3.Applies ice packs to the affected joint hourly for 15 minutes 4.Elevates the affected leg in the extended position 5.Performs neurologic assessment every 30 minutes for 6 hours
1-3-4-5 Hemophilia is a group of disorders characterized by deficiencies in production or use of coagulation proteins (eg, factor VIII, factor IX), resulting in impaired clot formation and increased risk for uncontrolled bleeding. Hemophilia is typically identified by prolonged or excessive bleeding, severe bruising, or joint bleeding (ie, hemarthrosis) after injuries or procedures. Administration of supplemental IV clotting factors (eg, factor VIII, factor IX) is the primary treatment for acute bleeding in clients with hemophilia (Option 1). Clients with hemophilia have increased risk of hemarthrosis (ie, bleeding in joint). In addition to administration of IV clotting factors, hemarthrosis is managed with rest, ice, compression, and elevation (RICE). Application of ice or cold packs promotes local vasoconstriction and clot formation (Option 3). The affected joint should be maintained in the extended position to prevent flexion contracture (Option 4). Frequent neurologic assessments are required for clients with hemophilia who have suspected (facial laceration in this client) or confirmed head trauma, as neurologic alteration may indicate intracranial bleeding (Option 5). (Option 2) When caring for clients with hemophilia, the nurse should eliminate factors that increase bleeding risk or promote complications from bleeding. NSAIDs (eg, aspirin, ibuprofen) are avoided as they inhibit platelet aggregation, which increases bleeding risk
The nurse is suctioning the artificial airway of a conscious client. Which actions demonstrate correct technique? Select all that apply. 1.Apply suction for no longer than 5-10 seconds 2.Insert catheter with low, intermittent suction applied 3.Set suction higher than 130 mm Hg for thick, copious secretions 4.Wait at least 1 minute between suction passes 5.Withdraw catheter immediately if client begins coughing
1-4 The process of suctioning a client's airway removes oxygen in addition to the secretions; therefore, the client should be preoxygenated with 100% O2, and suction should be applied for no more than 10 seconds during each pass to prevent hypoxia (Option 1). The nurse must wait 1-2 minutes between passes for the client to ventilate to prevent hypoxia (Option 4). In addition, deep rebreathing should be encouraged. (Option 2) The suction catheter should be no more than half the width of the artificial airway and inserted without suction. (Option 3) The nurse should don sterile gloves if the client does not have a closed suction system in place. Suction should be set at medium pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as excess pressure will traumatize the mucosa and can cause hypoxia. (Option 5) Clients usually cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, retracted 1 cm before applying suction.
The nursery nurse is performing assessments of several newborns. Which of the following findings are abnormal and need to be reported to the health care provider? Select all that apply. 1.Chest wall retractions 2.Desquamation of the feet 3.Head circumference of 13.5 in (34 cm) 4.Jaundiced appearance 5.No voiding in 24 hours
1-4-5 When caring for newborns, the nurse should recognize abnormal findings and report them to the health care provider. Some abnormal newborn findings include: Abnormal respiratory effort (eg, nasal flaring, chest wall retractions, grunting, tachypnea [>60/min]): Signs of respiratory distress should be evaluated promptly to determine necessary treatment (Option 1). Jaundice, especially in the first 24 hours of life (pathologic): Yellowish hues may be initially noted on the face or eyes and progress to the trunk and extremities (Option 4). Although newborn jaundice after 24 hours of life is usually physiologic and resolves spontaneously, it should still be reported and monitored closely to ensure resolution. No voiding in 24 hours: A newborn should void and pass meconium within 24 hours after birth. Not voiding on the first day of life or in the past 24 hours is concerning for a structural anomaly or dehydration (Option 5). (Option 2) Desquamation (peeling skin) is a normal finding in some newborns, especially those born at late- or post-term gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days. (Option 3) Average newborn head circumference is approximately 13-14 in (33-35 cm). A smaller or larger head circumference may indicate an abnormal condition (eg, microcephaly, hydrocephalus).
formal operations
12-14 think absractly think cuase and effect think like adult teach like an adult
The anterior fontanel typically closes anywhere between
12-18 months
The nurse is teaching a client who had surgery how to use a volume-oriented incentive spirometer. Select, in the correct order, the steps the client should take. All options must be used. Unordered Options 1. Exhale normally and place the mouthpiece in the mouth 2. Exhale slowly around the mouthpiece 3. Hold the breath for at least 2-3 seconds 4. Inhale deeply, until the piston is elevated to the predetermined level 5. Seal the lips tightly on the mouthpiece
1. Exhale normally and place the mouthpiece in the mouth 5. Seal the lips tightly on the mouthpiece 4. Inhale deeply, until the piston is elevated to the predetermined level 3. Hold the breath for at least 2-3 seconds 2. Exhale slowly around the mouthpiece
Positive Signs of Pregnancy
1. Fetal skeleton on x-ray 2. Presence of fetus on ultrasound 3. Auscultation of fetal heart (Doppler) 4.Examiner palpates fetal movement (outline) • Not the mother but the examiner
Maybe signs of pregnancy
1. Positive urine/blood hCG tests • A positive pregnancy test may result from other conditions • For instance, cancer 2. Chadwick sign—cervical color change to cyanosis (Cs) • Bluish discoloration of the vulva, vagina and cervix Goodell sign—good and soft • Softening of the cervix Hegar sign—uterine softening • Softening of lower uterine segment Chadwich ! Goodells ! Hegar • All 3 signs are in alphabetical order and • Move up from the vulva, vagina, cervix to the uterus
what makes a pt stable
1. stable in word 2. chronic 3. post op > 12 hours 4. local/regional anesthesia 5. unchanged assessment 6. "to be discharged" 7. Labs A/B receive typical s/sx of the disease that they are diagnosed and receiving tx
what makes pt unstable
1. unstable 2. acute 3. post op <12 hours 4. general anesthesia 5. changing assessment 6. newly admitted newly diagnosed 7. labs C/D 8. unstable pts are experiencing atypical signs and symptoms/complications
4 things to do 4 times an hour in the 4th stage
1. vital signs (signs of shock) 2. fundus (boggy = massage) deviated or displaced (catheterize) 3. check perineal pads (IF excessive bleeding the pad will saturate in 15 minutes or less (needs to be 100% saturated for new pad) 4. Roll pt check for bleeding underneath
A client is hospitalized with worsening chronic heart failure. Which clinical manifestations does the admitting nurse most likely assess in this client? Select all that apply. 1.Crackles on auscultation 2.Dry mucous membranes 3.Increased jugular venous distention 4.Rhonchi on auscultation 5.Skin "tenting" 6.3+ pitting edema of the lower extremities
1., 3, 6 Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure. Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) in this client. Although dependent pitting edema of the extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is related to sodium and fluid retention (right-sided failure) in this client. (Option 2) Dry mucous membranes are associated with dehydration (increased serum sodium level), not fluid overload (heart failure). (Option 4) Rhonchi are continuous lung sounds usually heard on expiration that indicate the presence of secretions in the larger airways. They are not a classic manifestation of chronic heart failure. (Option 5) Poor skin turgor or "tenting" is associated with skin moisture and elasticity. It is usually associated with dehydration, not fluid overload.
When would you MOST LIKELY - auscultate fetal HR - experience quickening
10 weeks 18 weeks
therapeutic and toxic levels of bilirubin
10-20 >20 kernicterus = bilirubin in CSF opisthotonos = extension
therapeutic and toxic level of aminophylline?
10-20 >20 toxic
anterior fontanel closes
12-18 months
2nd trimester of pregnancy
13-26 weeks
High fetal HR
NOT vital >160 take temp
Ketorolac (Toradol)
NSAID
When taking lithium avoid
NSAIDs
IV peak
15-30 after drug is finished
IV meds peak
15-30 minutes after given
Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) Rapid Acting Insulin - onset - peak - duration
15-30-3 15 minutes = onset 30 minutes = peak 3 hour = duration GIVE WITH MEALS
When do Braxton Hicks contractions occur?
16-28 weeks NOT sign of impending labor inconsistent and irregular
IM injection length
1:15 1 inch 15 gauge 90 degree angle
The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? 1.Check the health care provider's prescription in the medical record 2.Explain that the health care provider has prescribed the medication 3.Look up the medication in the pharmacology reference 4.Teach the client about the purpose of the medication
1Safe medication administration is conducted according to 6 rights: Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option 1). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching.
1st trimester weight gain
1lb per month 3 lbs
2nd/3rd trimester weight gain
1lb/week
oz to ml cup to ml
1oz = 30 mL 1 cup = 240 mL
purpose of contractions in first stage? Second Stage? 3rd stage? 4th stage?
1st = dilation and effacement 2nd = delivery of the baby 3rd = delivery of the placenta 4th = control of postpartum hemorrhage
morning sickness what trimester what treatment
1st trimester dry carb crackers right in morning before out of bed
urinary incontinence with pregnancy when and tx?
1st/3rd void Q2hr
chest circumference exceeds abdominal circumference by age
2
chest circumference exceeds abdominal circumference by age?
2
S/E of Benzodiazepines
ABCD Anticholinergic (dry mouth) blurred vision constipation drowsiness
PaO2 normal range
80-100 mm Hg SaO2 = 96%>
CONTRACTIONS SHOULD NOT BE LONGER THAN? CLOSER THAN?
90 seconds 2 mins
A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse discuss with this client? 1.Diet high in iron 2.Good oral care and dental follow-up 3.Shaving with an electric razor 4.Use of sunglasses for eye protection
2 The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily), especially in high doses. Folic acid supplementation can also reduce this side effect. The other major side effects of phenytoin use are an increase in body hair, rash, folic acid depletion, and decreased bone density (osteoporosis). (Option 1) Long-term use of phenytoin can cause folic acid deficiency and decreased bone density. Therefore, a diet high in folic acid and calcium should be recommended. (Option 3) Clients who use anticoagulants (eg, warfarin, rivaroxaban, apixaban) should avoid cuts and preferably use an electric razor for shaving. (Option 4) Exposure of the eyes to ultraviolet light and use of corticosteroids are risk factors for cataract development.
delivery of placentae what is important
2 A's and V arteries 2 vein 1
When does postpartum technically begin?
2 hours after delivery of placenta
posterior fontanel closes
2 months
Uterine contraction should be no longer than ____ and no closer than _______
90 seconds 2 minutes
Uterine contraction should be no longer than
90 seconds and no closer than 2 minutes
Low fetal heart rate
<110 BAD DO LION + IV STOP - STOP Pitocin - Left side - IV - oxygen - notify HCP
digoxin toxicity
>2 alteration in color perception
Theophylline toxicity
>20 CNS stimulation seizures and headache cardiac toxicity
18month old expected milestones
>3 words feeds with fingers imitates
Chest tube output concerning
>3mL/kg/hr for 3 hours >5-10mL/kg
A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply. 1.Apical pulse 2.Capillary refill time 3.Lung sounds 4.Pupillary response 5.Skin color and temperature
2, 5 Shock is a life-threatening syndrome characterized by decreased perfusion and impaired cellular metabolism. A lack of perfusion at both the tissue and cellular level (anaerobic metabolism) occurs due to decreased cardiac output, ineffective blood flow, and inability to meet the body's demand for increased oxygen. Sustained hypoperfusion activates compensatory mechanisms (eg, neural, hormonal, biochemical) to maintain homeostasis and reverse the consequences of anaerobic metabolism. Shock will progress through 4 stages. Early identification and intervention help to prevent progression. Adequacy of tissue perfusion in a client with shock syndrome and possible organ dysfunction is assessed by the level of consciousness, urine output, capillary refill time, peripheral sensation, skin color, extremity temperature, and peripheral pulses. Capillary refill indicates adequacy of blood flow to the peripheral tissues. It is measured by the time taken for color (pink) to return to an external capillary bed (nail bed) after pressure is applied to cause blanching (Option 2). Normal skin color and temperature are indicators of the adequacy of peripheral blood flow; these are usually within normal limits during the initial and compensatory stages of shock (Option 5). (Option 1) Apical pulse is a central pulse and does not indicate adequacy of peripheral tissue perfusion. (Option 3) Lung sounds indicate the adequacy of ventilation and gas exchange, not peripheral tissue perfusion. (Option 4) Pupillary response is an indicator of cerebral function, not peripheral tissue perfusion.
A client allergic to bee stings was stung about 20 minutes ago at a picnic. Based on the assessment data, the nurse anticipates which immediate actions? Blood pressure 92/40 mm Hg Apical pulse140/min and regular Respirations 36/min and labored Oxygen saturation89% 1.Inhaled albuterol 2.Intramuscular epinephrine 3.Intravenous methylprednisolone 4.Intravenous metoprolol 5.Intravenous nitroglycerine
2,3,1 Anaphylactic shock has an acute onset, and manifestations usually develop quickly (20-30 minutes). It is caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs, foods, and venom. Anaphylactic shock results in hypotension and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine); these can lead to cardiac and respiratory arrest. The management of anaphylactic shock includes: ---Call for help (activate emergency management systems) - first action ---Maintain airway and breathing - administer high-flow O2 via non-rebreather mask ---Epinephrine, intramuscular - the drug of choice and should be given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM route is better than the subcutaneous route. The dose should be repeated every 5-15 minutes if there is no response. ---Elevate the legs ---Volume resuscitation with IV fluids ---Bronchodilator such as albuterol is administered to dilate the small airways and reverse bronchoconstriction ---Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus ---Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction
The nurse in the emergency department is caring for a client with hyperosmolar hyperglycemic state. The nurse should recognize that which of the following findings are commonly associated with the condition? Select all that apply. 1.Abdominal pain 2.Blood glucose level >600 mg/dL (33.3 mmol/L) 3.History of type 2 diabetes mellitus 4.Kussmaul respirations 5.Neurological manifestations
2,3,5 Hyperosmolar hyperglycemic state (HHS) (ie, hyperosmolar hyperglycemic nonketotic state [HHNK]) is a life-threatening complication of type 2 diabetes mellitus (DM). In HHS, the pancreas produces enough insulin to prevent the breakdown of fats that results in diabetic ketoacidosis (DKA) but not enough insulin to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Therefore, DKA is usually associated with type 1 DM, whereas HHS is usually associated with type 2 DM. In HHS, hyperglycemia develops more gradually than in DKA as the pancreas of clients with type 2 DM still produces some insulin. Hyperglycemic symptoms associated with HHS may not be recognized until the serum glucose level reaches >600 mg/dL (33.3 mmol/L) (Options 2 and 3). As the serum glucose level rises, neurological manifestations such as blurry vision, lethargy, altered level of consciousness, and progression to coma occur (Option 5).
The nurse is assessing a client with a brain tumor who has developed diabetes insipidus. Which of the following findings would the nurse expect? Select all that apply. 1.Dark amber urine with sediment 2.High serum osmolality 3.Low urine specific gravity 4.Recent weight gain 5.Reports of excessive thirst
2,3,5 Tumors of the central nervous system can disrupt normal physiological processes throughout the body and cause multi-system dysfunction. One complication associated with brain tumors is diabetes insipidus (DI). In DI there is an interference in the synthesis, release, or transport of antidiuretic hormone (ADH). The decreased presence of circulating ADH signals the body to diurese, leading to: High serum osmolality (>295 mOsm/kg [>295 mmol/kg]) and hypernatremia (sodium >145 mEq/L [>145 mmol/L]) (Option 2) Low urine specific gravity (<1.005) (ie, dilute urine) (Option 3) Dehydration due to polyuria (increased urine output) Polydipsia (increased thirst) (Option 5)
moderate amount of lochia
>4-6 inches in one hour
SVT treatments
ABCD adenosine betablocker (-lol) CCB digoxin/digitalis
The nurse cares for a client admitted to the hospital due to confusion. The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s) should the nurse expect to implement? Select all that apply. 1.Fluid bolus (normal saline) 2.Fluid restriction 3.Salt restriction in the diet 4.Seizure precautions 5.Strict record of fluid intake and output
2,4,5 SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: Fluid restriction to <1000 mL/day Oral salt tablets to increase serum sodium (Option 3) Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations Vasopressin receptor antagonists (eg, conivaptan) The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration.
Therapeutic INR
2-3
therapeutic INR while on coumadin
2-3
crutches measurement
2-3 finger widths OUT of axillary elbow flexion at 30 degrees
posterior fontanel closes
2-3 months
A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? Select all that apply. 1.Administer an analgesic as needed 2.Determine if there is bladder distention 3.Measure the client's blood pressure 4.Place the client in the Sims' position 5.Remove constrictive clothing
2-3-5 Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia (autonomic hyperreflexia). It is an uncompensated sympathetic nervous system stimulation. Classic signs include hypertension (up to 300 mm Hg systolic), throbbing headache, diaphoresis above the level of injury, bradycardia (30-40/min), piloerection ("goose bumps"), flushing, and nausea. This is a life-threatening condition that requires immediate intervention to prevent complications (eg, hypertensive stroke, seizures). Clients with a spinal cord injury should have their blood pressure checked when they report a headache (Option 3). The most common cause of autonomic dysreflexia is bladder irritation due to distention. The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed (Option 2). Bowel impaction can also be a cause; a digital rectal examination should be performed. Constrictive clothing should be removed to decrease skin stimulation (Option 5). The primary health care provider should be notified. An alpha-adrenergic blocker or an arteriolar vasodilator (eg, nifedipine) may be prescribed. (Option 1) Headaches associated with autonomic dysreflexia are typically due to severe hypertension and often resolve after blood pressure has been treated. (Option 4) The client should have the head of the bed elevated 45 degrees or high Fowler's to lower blood pressure. The Sims' position is flat and side-lying.
blood administration should take
2-4 hours
The nurse is assisting with a colorectal cancer screening using the guaiac fecal occult blood test. Place the steps for completing this test in the correct sequence. All options must be used. Unordered Options 1. Document the results in the electronic medical record. 2. Obtain supplies, wash hands, and apply nonsterile gloves. 3. Open the back of the slide and apply 2 drops of developing solution to each box. 4. Open the slide's flap and apply 2 separate stool samples to the boxes on the slide. 5. Wait 30-60 seconds.
2-4-3-5-1 The guaiac fecal occult blood test is used to assess for microscopic blood in the stool as a screening tool for colorectal cancer. The steps for collecting a sample include: Assess for recent ingestion (within last 3 days) of red meat or medications (eg, vitamin C, aspirin, anticoagulants, iron, ibuprofen, corticosteroids) that may interfere and produce false test results. Obtain supplies (Hemoccult test paper, wooden applicator, Hemoccult developer), wash hands, and apply nonsterile gloves (Option 2). Open the slide's flap and use the wooden applicator to apply 2 separate stool samples to the boxes on the slide. Collect from 2 different areas of the specimen as some portions of the stool may not contain microscopic blood (Option 4). Close the slide cover and allow the stool specimen to dry for 3-5 minutes. Open the back of the slide and apply 2 drops of developing solution to the boxes on the slide (Option 3). Assess the color of the Hemoccult slide paper within 30-60 seconds. A positive guaiac result will turn the test paper blue, indicating presence of microscopic blood in the stool (Option 5). Dispose of used gloves and the wooden applicator and perform hand hygiene. Document the results (Option 1).
A client with an asthma exacerbation has been using an albuterol rescue inhaler 10-12 times a day. Which of the following potential adverse effects of albuterol does the nurse anticipate the client will report? Select all that apply. 1.Difficulty hearing 2.Difficulty sleeping 3.Hives with pruritus 4.Palpitations 5.Tremor
2-4-5 Asthma is a lung disease characterized by airway hyperreactivity, bronchospasm, and inflammation, resulting in airway narrowing. During an acute asthma exacerbation, a short-acting bronchodilator (eg, albuterol [salbutamol], levalbuterol) is used as a rescue medication to treat reversible airway obstruction. Albuterol (salbutamol) is a selective beta-2 adrenergic agonist that acts on the beta-2 receptors of the lungs to relax bronchial smooth muscle and promote bronchodilation. When used in large amounts, albuterol (salbutamol) loses selectivity and activates beta-1 receptors, promoting cardiac stimulation. Adverse effects mimic those caused by the stimulation of the sympathetic nervous system and commonly include tachycardia, palpitations, insomnia, mild tremor, nausea, and vomiting (Options 2, 4, and 5).
Normal Central Venous Pressure (CVP)
2-8 mm Hg
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply. 1.Dim lights to prevent overstimulation 2.Directly face the client when speaking 3.Ensure hearing aids are properly applied 4.Provide written information to supplement conversation 5.Raise voice to speak loudly to the client
2. 3. 4.
The nurse is performing a central line tubing change when the client suddenly begins gasping for air and writhing. Order the interventions by priority. All options must be used. Unordered Options 1. Administer oxygen as needed 2. Clamp the catheter tubing 3. Notify the health care provider (HCP) 4. Place the client in Trendelenburg position on the left side 5. Stay with the client and provide reassurance
2. 4. 1. 3. 5. Leakage of more than 500 mL of air into a central venous catheter is potentially fatal. An air embolism in the small pulmonary capillaries obstructs blood circulation. A central venous catheter leaks air rapidly at 100 mL/sec. This client requires immediate intervention to prevent further complications (eg, cardiac arrest, death). The nurse should not delay emergency treatment, not even to stop and contact the HCP or the rapid response team (RRT). Priority interventions for active or suspected air embolism are as follows: --Clamp the catheter to prevent more air from embolizing into the venous circulation. --Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. --Administer oxygen if necessary to relieve dyspnea. --the HCP or call an RRT to provide further resuscitation measures. --Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.
The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain. 3. Place the unaffected leg onto the stair 2. Assume the tripod position, then bear body weight on the crutches 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair
2. Assume the tripod position, then bear body weight on the crutches 3. Place the unaffected leg onto the stair 4. Transfer body weight to the unaffected leg and raise the body onto the stair 1. Advance the affected leg and crutches up the stair
The nurse is preparing to don sterile gloves before suctioning a client's tracheostomy. Place the steps of donning sterile gloves in the correct order. All options must be used. Unordered Options 1. Open the inner glove package by folding back the edges 2. Perform hand hygiene and remove the outer glove package 3. Pull the glove over the dominant hand 4. Pull the glove over the nondominant hand 5. Use the dominant fingers to grasp the cuff of the nondominant glove 6. Use the nondominant fingers to grasp the edge of the cuff of the dominant glove
2. Perform hand hygiene and remove the outer glove package 1. Open the inner glove package by folding back the edges 6. Use the nondominant fingers to grasp the edge of the cuff of the dominant glove 3. Pull the glove over the dominant hand 5. Use the dominant fingers to grasp the cuff of the nondominant glove 4. Pull the glove over the nondominant hand
A pregnant woman at 31 weeks gestation gained 15 lbs. what is your impression? • Using the short method, this pt ideal weight should be
22lb = what should be the ideal weight = she is under weight However, 22 - 15 = 7 lbs less than the ideal o Therefore, the nurse needs to assess the biophysical profile (BPP) on the fetus
total weight in pregnancy
23-31
alcohol withdrawal peak
24-72 hours after last drink begins 6-8 MONITOR hypoglycemia
Insulin should be discarded ___ days after being opened
28
Ideal body weight gain during pregnancy?
28 plus or minus 3
Rh Globulin is given to Rh negative mother when?
28 weeks gestation 72 hours postpartum indirect Comb's detects Rh
3rd trimester of pregnancy
28 weeks until delivery
back pain most common in which trimesters?
2nd 3rd pelvic tilt exercises
Where will you auscultate aortic stenosis
2nd ICS to the right of the sternal border
Aortic heart sound location pulmonic heart sound location Mitral heart sound location
2nd ICS right sternal border 2nd ICS Left sternal border Mitral/apex: 5th intercostal space mid clavicular line If heart sounds are difficult to auscultate, the nurse can ask the client to either sit up and lean forward (best for aortic and pulmonic areas) or lie down on the left side (best for the mitral area).
The nurse is teaching a group of clients with diabetes mellitus about foot care. Which of the following information should the nurse include? Select all that apply. 1.Dry the feet vigorously with a towel after bathing 2.Use an over-the-counter kit to treat corns and calluses 3.Use cotton or lamb's wool to separate overlapping toes 4.Wash the feet with lukewarm water 5.Wear hard-sole shoes and do not go barefoot
3,4,5 Clients with diabetes mellitus are at increased risk for developing peripheral neuropathy, a chronic complication that results from nerve damage in the extremities. Clients with peripheral neuropathy experience alteration or loss of sensation in the extremities and can develop infections or ulcers on the feet. It is important to teach clients proper foot care to avoid these complications. Instructions for foot care include: Preventing injury by using cotton or lamb's wool to separate overlapping toes and wearing protective shoes (Options 3 and 5). Washing the feet daily with lukewarm water and mild soap (Option 4) and testing the water temperature with a thermometer beforehand. Reporting problems such as skin infections immediately.
The nurse practicing in an out-patient clinic cares for a client recently diagnosed with hyperthyroidism. Which diet-related teaching should the nurse add to the client's plan of care? Select all that apply. 1.Emphasize the importance of a low-carbohydrate diet 2.Encourage the client to increase high-fiber foods in the diet 3.Include meals and snacks high in protein content 4.Teach avoidance of caffeine-containing liquids 5.Teach the client about consumption of a high-calorie diet of 4000-5000 calories/day
3,4,5 Adherence to a high calorie diet (4000-5000 calories per day). Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals (Option 1). Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea) (Option 2). However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). Avoidance of spicy foods as these can also increase GI stimulation.
When does the Moro reflex disappear?
3-4 months
Aplastic anemia
characterized by an absence of all formed blood elements caused by the failure of blood cell production in the bone marrow
The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene? 1.Assists the client to use the bedside commode 2.Dims the lights in the client's room 3.Places the bed in the lowest position with all side rails raised 4.Turns off the television in the client's room
3. Ménière disease (ie, endolymphatic hydrops) results from excess fluid accumulation in the inner ear. As a result, the semicircular canals cannot function effectively, leading to acute episodes of vertigo, tinnitus, hearing loss, and aural fullness. Vertigo can be incapacitating and is generally accompanied by nausea and vomiting. Clients experiencing an acute episode of Ménière disease may report a sensation of being pulled to the ground (ie, drop attack) and are at high risk for falls. The bed should be placed in the lowest position with two of the side rails raised for safety. Raising all side rails is considered a restraint and requires intervention by the nurse (Option 3).
You give morphine to a patient when should you assess for effectiveness and safety?
30 mins
give hydromorphone IV at 12:30 when do you reassess pain? respiratory status?
30 mins at the peak
When do you always get a trough?
30 minutes BEFORE NEXT DOSE
IM peak
30-60
typical urine output adult
30mL/hr 0.5mL/kg/hr
head circumference of newborn
32-38
A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply. 1."For the past few years, I get a productive cough in the winter that goes away in spring. 2."I occasionally have heartburn an hour after I eat fried foods and sausage." 3."Last month when I was doing my breast self-examination, I noticed a marble-sized lump." 4."My mole is itchy, and the borders have become uneven with a blackish to bluish color." 5."Recently I have noticed that my bowel movements appear black."
3-4-5 Cancer is a growth of abnormal cells that can cause organ dysfunction and spread throughout the body (ie, metastasize). It is often difficult to identify early because some clients are asymptomatic or have only vague symptoms. However, nurses have an important role in early detection screening and should assess clients for, and immediately report, general warning signs of cancer using the mnemonic - CAUTION: C - Change in bowel or bladder habits (Option 5) A - A sore that does not heal U - Unusual bleeding or discharge from a body orifice T - Thickening or a lump in the breast or elsewhere (Option 3) I - Indigestion or difficulty swallowing that does not go away O - Obvious change in a wart or mole (Option 4) N - Nagging cough or hoarseness
you give 30 units of NPH insulin to a pt at 7 a.m. When do you check for hypoglycemia?
3-5pm 1500-1700 Onset intermittent (NPH) = 6 hours Peak = 8-10 duration = 12
Pre-operational
3-6 preshoolers fantasy oriented illogical no rules slightly ahead of time teach you will do play toys stories
OB answer that always wins
check fetal heart rate no matter what happens what is the fetal heart always comes up
Low pressure alarm on the art line
check for active bleeding
The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used. Unordered Options 1. Gloves 2. Goggles or face shield 3. Gown 4. Hand hygiene 5. Mask or respirator
4. Hand hygiene 3. Gown 5. Mask or respirator 2. Goggles or face shield 1. Gloves
WBC range absolute neutrophil count
5000-11000 500 want above 200>
Pulmonary Wedge Pressure (PWP)
6-12 mmHg
concrete operations
7-11 rule oriented teach days ahead, youre gonna do and skills, age appropriate reading and role play
concrete operational stage
7-11 years school age
Humulin 70/30 is what?
70% N insulin (intermediate) 30% R insulin (short rapid)
Peripheral IV sites should be changed no more frequently than every
72-96 hours unless complications develop.
NPH insulin highest risk of hypoglycemia
8-10 hrs
A nurse preparing to insert a peripheral IV catheter dons clean gloves, applies a tourniquet to the client's arm, and immediately identifies a site for venipuncture. Place in order the remaining steps that the nurse should take. All options must be used. Unordered Options 1. Advance catheter hub while retracting stylet 2. Anchor vein by holding skin taut 3. Apply a transparent dressing 4. Cleanse selected site using an antiseptic swab 5. Insert needle bevel-side up until blood return is observed 6. Remove stylet and attach extension or infusion set
4-2-5-1-6-3 Steps to promote safety and reduce infection risk when initiating IV therapy include the following: Perform hand hygiene using Centers for Disease Control and Prevention guidelines Prepare equipment: Open IV tray, prime tubing with prescribed IV solution for infusion, set IV pump if indicated, prepare tape, and open the over-the-needle catheter (ONC) with safety device Don clean (non-sterile) gloves Identify a possible venipuncture site Apply a tourniquet, ensuring it is tight enough to impede venous return but not tight enough to occlude the artery Select a venipuncture site after palpating the vein. Ask the client to open and close the hand several times to promote vein distension. The tourniquet may need to be released temporarily to restore blood flow and prevent trauma from extended application. Clean the site with chlorhexidine, alcohol, or povidone iodine. Use friction and clean per facility protocol, either back and forth or in a circular motion from insertion site to outward area (clean to dirty direction). Stretch the skin taut using the nondominant hand to stabilize the vein Insert the IV ONC bevel up at a 10- to 30-degree angle and watch for blood backflow as the catheter enters the vein lumen, advancing ¼ inch into the vein to release the stylet. On visualization of blood return, lower the ONC almost parallel with the skin and thread the plastic cannula completely into the vein to the insertion site. Never reinsert the stylet after it is loosened. Use the push-tab safety device to advance the catheter. Apply firm but gentle pressure about 1¼ inch above the catheter tip, release the tourniquet, and retract the stylet from the ONC On removal, guide the protective guard over the stylet for safety and feel for a click as the device is locked. Never try to recap a stylet. Attach a sterile connection of primed IV tubing to the hub of the catheter and stabilize the catheter with tape and dressing using sterile technique. Dispose of the stylet in the sharps container.
A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply. 1.Identify the number "8" traced on the palm 2.Shrug the shoulders against resistance 3.Swallow water 4.Touch each finger of one hand to the hand's thumb 5.Walk heel-to-toe
4-5 The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance and posture. Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe (tandem), on toes, and on heels (Option 5). Coordination testing involves the following: Finger tapping - ability to touch each finger of one hand to the hand's thumb (Option 4). Rapid alternating movements - rapid supination and pronation Finger-to-nose testing - clients touch the clinician's finger and then their own nose as the clinician's finger varies in location Heel-to-shin testing - client runs each heel down each shin while in a supine position
How often do you check gastric residuals with enteral feedings? What gastric residual would cause nurse to implement interventions?
4-6 hours flush before and after feedings gastric residual pH should be less than 5 HOLD feeding if > 500 mL GRV 30-45 degree HOB
Weight gain in toddlers
4-6 lbs/year
SSRIS considerations
4-6 weeks for maximum effect weight gain is common do not abruptly stop decreased labido
normal ranges Cardiac output Cardiac index CVP MAP (SBP + (2x DBP)) / 3 Pulmonary arterial wedge pressure (preload and left sided heart function) Systemic vascular resistance
4-8L 2.2-4 2-8mmhg 70-105mmhg 6-12mmhg 800-1200
The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used. Unordered Options 1. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad 2. Don mask, goggles, and clean gloves 3. Don sterile gloves; remove old disposable cannula and replace with a new one 4. Gather supplies and position client 5. Remove soiled dressing
4. Gather supplies and position client 2. Don mask, goggles, and clean gloves 5. Remove soiled dressing 3. Don sterile gloves; remove old disposable cannula and replace with a new one 1. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad
the fetal HR can be heard first between
8-12 weeks gestation
How much folic acid/day
400mcg
SQ injection angle
45-90 degrees 25 G 5/8 in
Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between
46-70 seconds (1.5-2.0 times the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin). protamine sulfate
A Mantoux test is also referred to as a purified protein derivative (PPD) test. The PPD is injected intradermally and is read at
48-72 hours
Recovery stage 2 hours after delivery what do nurses do?
4th,4,4 vital signs Q4 hours Check fundus (boggy=massage/displaced=cath) check pads (excessive lochia = pad sat in 15 mins) roll on side check bleeding under pt
Sublingual peak level
5-10 mins after disovled
Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued____ before surgery
5-7 days!!! gingival Bilboa should be discontinued 2 WEEKs prior Nonsteroidal anti-inflammatory drugs (NSAIDS) such as naproxen (Naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding. Acetaminophen can be taken to control pain up until surgery.
The nurse is preparing to suction secretions from the airway of an unconscious client whose lungs are mechanically ventilated with an endotracheal tube. Place the steps for suctioning the endotracheal tube in the correct order. All options must be used. Your Response / Incorrect Response 5. Perform hand hygiene and don clean gloves 4. Hyperoxygenate the lungs (100% FiO2) 1. Advance catheter into the trachea 3. Gently rotate the catheter while suctioning 6. Suction the oropharynx and perform oral care 2. Evaluate client tolerance and document
5. Perform hand hygiene and don clean gloves 6. Suction the oropharynx and perform oral care 4. Hyperoxygenate the lungs (100% FiO2) 1. Advance catheter into the trachea 3. Gently rotate the catheter while suctioning 2. Evaluate client tolerance and document Clients with endotracheal tubes (ETTs) have impaired cough and gag reflexes and require suction to clear retained bronchial secretions and promote ventilatory efficacy. Ventilator circuits for ETTs typically have a reusable in-line endotracheal suction device, which remains sterile, in a flexible plastic sleeve. Oral secretions may pool near the base of the ETT and drip into the trachea; therefore, oropharyngeal suctioning and oral care are performed before ETT suctioning to prevent introduction of oral bacteria into the lungs. The steps for suctioning an ETT include: Perform hand hygiene and don clean gloves (Option 5). Suction the oropharynx and perform oral care (Option 6). Ensure that the system is connected to appropriate wall suction (<120 mm Hg). Hyperoxygenate the lungs (100% FiO2) (Option 4). Advance the catheter into the trachea just until resistance is met (level of the carina) (Option 1). Do not suction while advancing the catheter. Gently remove the catheter while suctioning and rotating it. Do not suction for more than 10 seconds (Option 3). Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. Document the procedure when complete (Option 2). Resume oxygenation and ventilation settings as prescribed.
The nurse is assessing the abdomen of a client experiencing gastrointestinal distress. Place the answer choices in the correct order of assessment. All options must be used.
5. Placement of client in supine position 2. Inspection 1. Auscultation 4. Percussion 3. Palpation
insulin need to
check the date refrigerate but once open don't refrigerate
Which interventions should the nurse perform when assisting the health care provider with removal of a client's chest tube? Select all that apply. 1.Ensure the client is given an analgesic 30-60 minutes before tube removal 2.Instruct the client to breathe in, hold it, and bear down while the tube is being removed 3.Place the client in the Trendelenburg position 4.Prepare a sterile airtight petroleum jelly gauze dressing 5.Provide the health care provider with sterile suture removal equipment
A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded. The general steps for chest tube removal include: Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal (Option 1). Provide the health care provider (HCP) with sterile suture removal equipment (Option 5). Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2). Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space (Option 4). Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame.
An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply. 1.Angle bottle up and toward cleft 2.Burping the infant often 3.Feeding in an upright position 4.Feeding slowly over 45 minutes or more 5.Using a specialty bottle or nipple
A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula.
A school-age child is brought to the emergency department due to nausea, vomiting, and severe right lower quadrant pain. The child's white blood cell count is 17,000/mm3 (17.0 x 109/L). Which statement by the child is of most concern to the nurse? 1."I am hungry and they will not let me eat." 2."I don't like hospitals and I want to go home." 3."I'm so tired." 4."My belly doesn't hurt anymore."
A child with acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood cell count likely has acute appendicitis. Appendicitis is a serious condition that usually requires emergency surgery due to the risk of appendix rupture. The pain results from swelling and inflammation of the appendix. However, once the appendix ruptures, pain is relieved only temporarily and will return with full-blown peritonitis and sepsis.
Bisphosphonate medication alendronate [Fosamax] risedronate [Actonel] zoledronic [Reclast]
A class of drugs used to strengthen bone - antiresorptive medicines, which slows or stops the natural process that dissolves bone tissue - this may prevent the development of osteoporosis or slow the rate of bone thinning reduces the risk of broken bones - used to treat osteoporosis and the bone pain from diseases such as metastatic breast cancer, multiple myeloma, and Paget's disease
The nurse in the cardiac intensive care unit receives report on 4 clients. Which client should the nurse assess first? 1.Client who is receiving IV antibiotics for infective endocarditis with a temperature of 101.5 F (38.6 C) 2.Client who underwent coronary artery stent placement via femoral approach 3 hours ago and is reporting severe back pain 3.Client who underwent coronary bypass graft surgery 3 days ago and has swelling in the leg used for the donor graft 4.Client who underwent heart transplantation 2 months ago with sustained sinus tachycardia of 110/min at rest
A client who undergoes percutaneous coronary intervention (PCI) and intracoronary stent placement using the femoral approach is at increased risk for retroperitoneal hemorrhage. Administration of antithrombotic drugs before, during, and after PCI can exacerbate potentially life-threatening bleeding from the femoral artery. Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma formation, and diminished distal pulses can be early signs of bleeding into the retroperitoneal space and require immediate intervention (eg, notify health care provider, serial complete blood count, CT scan of the abdomen) (Option 2). (Option 1) Infective endocarditis is often associated with cardiac valve disease and requires long-term antibiotic therapy (4-6 weeks). Characteristic manifestations include fever, myalgia, chills, joint pain, anorexia, and petechiae. (Option 3) Some clients notice swelling in the leg used for donor venous graft (interruption of blood flow). Elevating the leg and wearing compression stockings can help decrease symptoms. (Option 4) During heart transplantation, the donor heart is cut off from the autonomic nervous system (denervated), altering the heart rate during rest and exercise after the procedure. The heart rate of the transplanted heart is expected to be at the high end of normal or tachycardic (eg, 90-110/min).
The nurse receives report for 4 clients in the emergency department. Which client should be seen first? 1.30-year-old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating 2.33-year-old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait 3.65-year-old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL 4.70-year-old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL
A client with a neurological injury (eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately. (Option 1) Autonomic dysreflexia (eg, throbbing headache, flushing, hypertension) is a life-threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher. This is not the priority assessment as this client's injury is at L3. This client likely has acute urinary retention and needs catheterization. (Option 2) Phenytoin toxicity commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus. These are expected symptoms and therefore are not a priority. (Option 3) A brain tumor can also cause increased intracranial pressure; clients report morning headache, nausea, and vomiting. Dexamethasone (Decadron) can be prescribed short-term to decrease the surrounding edema. A tumor usually grows more slowly than a possible hematoma and is therefore not the priority assessment.
The nurse assesses a client who is 2 days postoperative breast reconstruction surgery. The client has 2 closed-suction Jackson Pratt bulb drains in place. There is approximately 10 mL of serosanguineous fluid in each one. One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL. What is the nurse's priority action? 1.Notify the health care provider (HCP) 2.Open the collection bulb to release excessive negative pressure 3.Record the amount in the output record as wound drainage 4.Reposition the client on the right side
A closed-wound drainage system device (eg, Jackson-Pratt, Hemovac) consists of fenestrated drainage tubing connected to a flexible, vacuum (self-suction) reservoir unit. The distal end lies within the wound and can be sutured to the skin. It is usually inserted near the surgical site through a small puncture wound rather than in the surgical incision. The purpose of the drain is to prevent fluid buildup (eg, blood, serous fluid) in a closed space. Although it depends on the client and type of surgical procedure, about 80-120 mL of serosanguineous or sanguineous drainage per hour during the first 24 hours after surgery can be expected. The priority action is to notify the HCP due to the change in type and amount of drainage after the first 24 hours following surgery. Excessive bleeding and fluid collection into the closed space following breast reconstruction can greatly affect the integrity of the surgical incision, the tissue reconstruction, and wound healing (Option 1). (Option 2) Opening the bulb does not release excessive negative pressure. It would release all negative pressure, drainage would cease, and even more fluid would collect in the closed space, compromising the integrity of the incision even further. (Option 3) Recording the amount of wound drainage on the output record is an appropriate intervention. However, it is not the priority action. (Option 4) Although repositioning the client could affect the amount of drainage, it is not likely as drainage is maintained by negative pressure, not gravity.
Gastro-jejunostomy tube
A combination device that includes access to both the stomach and the jejunum (the middle part of the small intestine). It is also known as a GJ-tube.
A client with acute ST-elevation myocardial infarction intends to leave the hospital now against medical advice (AMA) regardless of what is recommended. The client is determined to be competent to make personal decisions. Which of the following is the most important for the nurse to do before the client leaves the building? 1.Insist the client sign the AMA form 2.Provide the client with a copy of hospital results 3.Reassure that the client can return later 4.Remove the intravenous catheter
A competent client can refuse medical treatment and leave against medical advice (AMA). The nurse should inform the health care provider (HCP) immediately. If the client decides to leave the facility, even after the HCP and nurse explain the consequences (including death), or cannot wait until the HCP speaks with the client, the client should be allowed to do so. It is most important that the client's IV catheter be removed to prevent complications (eg, infections) and misuse (eg, access for illicit drug injections). The nurse should document the fluid infused, the site's appearance, and the integrity of the IV catheter.
The nurse is caring for a client after a motor vehicle collision. The client's injuries include two fractured ribs and a concussion. Which of the following are expected neurological changes for clients with a concussion? Select all that apply. 1.Asymmetrical pupillary constriction 2.Brief period of confusion 3.Headache 4.Loss of vision 5.Retrograde amnesia
A concussion is considered a minor traumatic brain injury that can result from blunt force trauma or acceleration/deceleration damage. Typical clinical manifestations of concussion include: A brief period of confusion with or without loss of consciousness (Option 2) Headache (Option 3) Amnesia regarding events immediately preceding the head trauma (ie, retrograde amnesia) (Option 5) Clients with a concussion should be observed closely by family members and should not participate in strenuous or athletic activities for at least 1-2 days as long as symptoms have resolved. Rest and a light diet are encouraged during this time. (Options 1 and 4) Asymmetrical pupillary constriction and vision loss would indicate a more serious brain injury. These manifestations are not expected with a concussion.
autonomic dysreflexia
A dangerous spike in blood pressure (systolic readings often over 200 mm Hg) Pounding headache (choice B) Flushing of the skin above the level of spinal cord injury (choice C) Nasal congestion (choice D) Profuse sweating above the level of injury, particularly over the forehead (choice E) Dizziness, lightheadedness Dilated pupils Bradycardia Constriction of peripheral blood vessels Anxiety and apprehension Other changes in the body's autonomic functions
The telemetry nurse reports the cardiac monitor rhythms of 4 clients to the medical unit nurse assigned to care for them. The nurse should assess the client with which rhythm first? 1.Atrial fibrillation with a pulse of 76/min in a client prescribed rivaroxaban 2.Bradycardia in a client with a demand pacemaker set at 70/min 3.First-degree atrioventricular block in a client prescribed atenolol 4.Sinus tachycardia in a client with gastroenteritis and dehydration
A demand ventricular electronic pacemaker set at 70/min delivers an impulse (fires) when it senses an intrinsic rate below the predetermined rate of 70/min. Failure to capture occurs when the pacemaker sends an impulse to the ventricle, but the myocardium does not depolarize (pacer spike with no QRS complex; no palpable pulse beat); this is usually associated with pacer lead (wire) displacement or battery failure. The malfunction can result in bradycardia (pulse <60/min) or asystole and decreased cardiac output; the nurse should perform an assessment and notify the health care provider immediately. (Option 1) Clients with atrial fibrillation are usually prescribed an anticoagulant, such as rivaroxaban (Xarelto), due to increased risk for blood clots that can lead to stroke. This client's ventricular rate is controlled, so there is no urgency. (Option 3) First-degree atrioventricular (AV) block can be associated with beta-adrenergic blocker drugs, such as atenolol (Tenormin), as they delay conduction at the AV node. This is reflected as prolonged PR interval on ECG. Although first-degree AV block should be monitored for progression, it is an expected adverse drug effect. Only second- or third-degree heart block should be the priority. (Option 4) Dehydration can cause hypotension. Tachycardia is a normal compensatory mechanism to increase the cardiac output associated with hypotension.
A client comes to the emergency department after being assaulted. Imaging studies show a simple fracture of the mandible. The nurse assesses edema of the face and jaw, drooling, and bleeding in the mouth; the client rates pain as a 9 out of 10. What is the priority nursing intervention? 1.Administer nasal oxygen at 3 L/min 2.Administer opioids for pain 3.Apply ice pack to face for 20 minutes each hour 4.Suction the mouth and oropharynx
A direct blow to the face or a motor vehicle collision is usually the cause of mandibular fracture. The client drools due to inability to close the mouth from edema and misalignment of the jaw. Structural damage, excessive saliva, and bleeding with pooled blood in the mouth can compromise the airway. Therefore, the priority nursing intervention is to suction the mouth and oropharynx to maintain airway patency.
The health care provider (HCP) prepares to place a fetal scalp electrode (FSE) to monitor the fetus of a laboring client. Which information is most important for the nurse to communicate to the HCP before FSE placement? 1.Amniotic fluid is meconium stained 2.Client is HIV positive 3.External fetal monitor shows late decelerations 4.Fetal presenting part is at +1 station
A fetal scalp electrode (FSE) is a common, internally applied, electronic monitoring device used to closely evaluate fetal heart rate (FHR). Indications for FSE placement may include high-risk maternal conditions (eg, obesity, diabetes, hypertension) and/or nonreassuring FHR patterns (eg, late decelerations, minimal variability). FSE placement involves inserting a small, sharp electrode directly into the fetal scalp or presenting part (ie, buttocks if breech). The nurse should notify the health care provider about the client's cervical dilation and membrane status because the cervix should be dilated ≥2-3 cm and the membranes ruptured before placing the FSE. FSE placement should be avoided, if possible, in the presence of bloodborne infections (eg, hepatitis B, HIV) because the risk of fetal infection is increased by the small puncture (Option 2). (Option 1) Meconium-stained amniotic fluid may indicate fetal distress but is not a contraindication to FSE placement. (Option 3) Late decelerations suggest impaired fetal oxygenation and are an indication for FSE placement. (Option 4) It is helpful if the fetal presenting part is engaged (ie, 0, +1, or +2 station) to facilitate proper placement, but it is not required.
The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response? 1.Consumes 600 mL liquid over 4 hours 2.Insertion site dressing saturated with clear fluid 3.Observed lying in the right-sided Sim's position 4.Reports a headache rated 6/10
A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae. Elevated intracranial pressure is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicates that the site did not seal off and a blood patch (autologous blood into the epidural space) is required.
The nurse receives morning report on 4 clients who were admitted 24 hours earlier for injuries incurred in motor vehicle collisions. Which client should the nurse assess first? 1.Client with a fractured pelvis who has a large area of ecchymosis and bruising over the pelvic region 2.Client with a fractured tibia and leg cast who has pink skin under the cast edge and swollen toes 3.Client with a lung contusion who has an oxygen saturation of 90% and severe inspiratory chest pain 4.Client with a pneumothorax and a chest tube who has intermittent bubbling in the water-seal chamber
A lung contusion (bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. Therefore, the nurse should assess this client with lung contusion first and then notify the health care provider as immediate interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary. (Option 1) Ecchymosis and bruising due to trauma would be expected. (Option 2) Skin irritation under rough cast edges is common; oval strips of adhesive or moleskin tape applied to the cast edge (petals) can provide padding. Neurovascular assessment and elevation are necessary as swelling can indicate venous compression. This is not a life-threatening priority. (Option 4) In a client with a pneumothorax, intermittent bubbling in the water-seal chamber consistent with respirations (due to air escaping from the pleural space) is expected until the lung has fully expanded.
The emergency nurse admits a semiconscious client with periorbital bruising and severe tongue edema after a laceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate? 1.Contact the health care provider and clarify the prescription 2.Ensure correct placement after insertion by auscultating the lungs 3.Select an appropriate size by measuring from nose tip to earlobe 4.Verify that the client has no history of bleeding disorders or aspirin use
A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs are frequently used in alert or semiconscious clients, as they are less likely to cause gagging, and in clients with oral trauma or maxillofacial surgery. NPAs should never be inserted in clients who may have head trauma (eg, facial or basilar skull fractures), such as might occur during an unwitnessed seizure. NPAs inserted in clients with skull fractures may be malpositioned into underlying tissues/structures (eg, brain). Therefore, the nurse should immediately clarify prescriptions for NPAs in clients with head trauma (Option 1). An NPA may be inserted after imaging (eg, CT scan) rules out fracture. (Option 2) Once skull fracture is ruled out and an NPA is inserted, the nurse verifies appropriate airway placement by auscultating the lungs. (Option 3) Inappropriate NPA size increases the risk for airway obstruction, sinus blockage, and infection. To select an appropriate size, the nurse measures from the tip of the client's nose to the earlobe and selects a diameter smaller than the naris. (Option 4) Bleeding disorders and use of anticoagulant or antiplatelet medication (eg, aspirin) are relative contraindications to NPA insertion, as these increase the risk of bleeding. However, skull fracture must be excluded prior to placement.
The nurse is assessing a client who had a thyroidectomy 12 hours ago. The client appears anxious and reports tingling around the mouth and muscle twitching in the right hand. Which of the following actions would be a priority for the nurse to take? 1.Change the surgical dressing to assess for bleeding 2.Check the client's most recent arterial blood gas results 3.Evaluate the client's vocal quality and strength 4.Obtain a blood specimen to check the serum calcium level
A normal serum calcium level is 9.0-10.5 mg /dL (2.25-2.62 mmol/L). Hypocalcemia (serum calcium <9.0 mg/dL [2.25 mmol/L]) is a potentially life-threatening complication of a thyroidectomy which can occur when the parathyroids (which regulate calcium levels in the blood) are accidentally removed or damaged during the procedure. The nurse should monitor the client closely for signs of hypocalcemia, which include tetany (ie, overactive neurological responses such as tingling around the mouth or muscle spasms in the hands, feet, or larynx; positive Trousseau or Chvostek sign. A serum calcium level should be obtained, and the nurse should ensure that calcium gluconate is readily available (Option 4).
A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? 1.Epidural anesthesia 2.Hydrotherapy 3.IV narcotics 4.Pudendal nerve block
A pudendal nerve block infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the health care provider. It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor (Option 4). In clients without an epidural, pudendal blocks may be used in preparation for forceps-assisted birth or laceration repair. (Option 1) An epidural can be administered in the first or early second stage of labor but may not be a feasible option in late second stage when birth is imminent. A multiparous client may give birth before the epidural can be administered or before the epidural takes adequate effect (20-30 minutes). (Option 2) Some clients forgo pharmacological pain relief during labor and instead utilize nonpharmacological techniques (eg, hydrotherapy, relaxation breathing). However, this client specifically requests pain relief, and nonpharmacological techniques would likely be ineffective considering birth is imminent. (Option 3) IV narcotics cross the placenta and can cause neonatal respiratory depression when administered close to birth. Therefore, these are not generally administered in the second stage of labor.
A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that the client's pulse oximeter reading is inaccurate. Which factors could be contributing to this reading? Select all that apply. 1.Black fingernail polish 2.Cold extremities 3.Elevated WBC count 4.Hypotension 5.Peripheral arterial disease
A pulse oximeter is a noninvasive device that estimates arterial blood oxygen saturation by using a sensor attached to the client's finger, toe, earlobe, nose, or forehead. The sensor (reusable clip or disposable adhesive) contains light-emitting and light-sensing components that measure the amount of light absorbed by oxygenated hemoglobin. Because the sensor estimates the value at a peripheral site, the pulse oximeter measurement is reported as blood oxygen saturation (SpO2). Normal SpO2 for a healthy client is 95%-100%. Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors of falsely low SpO2 include: Dark fingernail polish or artificial acrylic nails (Option 1) Hypotension and low cardiac output (eg, heart failure) (Option 4) Vasoconstriction (eg, hypothermia, vasopressor medications) (Option 2) Peripheral arterial disease (Option 5)
"the worst headache of my life"
A ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival.
Trousseau's sign
A sign of hypocalcemia . Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.
The nurse reviews the analgesia prescriptions for assigned clients. The nurse should question the health care provider about which prescription? 1.Lidocaine 5% patch over intact skin for a client with chronic postherpetic neuralgia who reports intolerable, persistent, burning pain 2.Hydromorphone IV for a client who has a fractured femur, is a known IV heroin abuser, and rates pain as 9 on a 0-10 scale 3.Tramadol for a client who is being prepared for discharge following a laparoscopic cholecystectomy and rates abdominal pain as 6 on a 0-10 scale 4.Transdermal fentanyl patch for a client who is 1 day postoperative above-the-knee amputation and reports intermittent, throbbing stump pain (26%)
A transdermal fentanyl patch is prescribed for clients suffering from moderate to severe chronic pain. The patch provides continuous analgesia for up to 72 hours. However, the drug is absorbed slowly through the skin into the systemic circulation and can take up to 17 hours to reach its full analgesic effect. Therefore, it is not recommended for treating acute postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied.
Oral fecal hepatitis?
A, E. (2 ends A, anus, and E mouth. (eat).
Chorionic Villous Sampling (CVS)
chromosomal fetal abnormalities
acute beats
chronic
The nurse is teaching a client recently diagnosed with heart failure who is being discharged with a prescription for lisinopril. Which of the following information should the nurse include? 1.Instruct the client to have blood specimens obtained monthly to monitor serum medication levels 2.Review foods that are high in potassium that the client should regularly include in the diet 3.Teach the client to count the pulse for 1 minute and hold the medication if the pulse <60/min 4.Teach the client to rise slowly and sit on the side of the bed for several minutes before standing up
ACE inhibitors (eg, lisinopril) are antihypertensive medications that are also commonly prescribed to decrease ventricular remodeling in chronic heart failure. ACE inhibitors alter the renin-angiotensin-aldosterone system by inhibiting conversion of angiotensin I to angiotensin II, thereby preventing the release of aldosterone. By reducing circulating aldosterone, ACE inhibitors promote vasodilation and urine production, resulting in lower blood pressure. Clients are prone to experience orthostatic hypotension and should be instructed to rise slowly and sit for several minutes before standing (Option 4). Cough and angioedema are other side effects of ACE inhibitors that are thought to be caused by an accumulation of bradykinin. Additionally, ACE inhibitors are contraindicated in pregnancy due to their teratogenic effects on the fetus. (Option 1) Renal function (eg, blood urea nitrogen, creatinine) is commonly checked during the first week of therapy. Regular measurements to ensure therapeutic medication levels are not required. (Option 2) A common side effect of ACE inhibitors is mild hyperkalemia, which may require a lower intake of foods high in potassium. Clients taking loop diuretics (eg, furosemide) will need to increase their intake of foods high in potassium. (Option 3) ACE inhibitors do not directly affect the heart rate. Clients prescribed digoxin are taught to take their pulse and hold their medication if the heart rate is <60/min.
Chronic kidney disease impairs the excretion of excess potassium and can potentiate hyperkalemia, which can lead to life-threatening arrhythmias (eg, ventricular fibrillation).
ACE inhibitors (eg, lisinopril, ramipril) or angiotensin II receptor blockers (eg, valsartan, losartan, irbesartan) can be used to manage hypertension secondary to renal disease; however, these drugs can worsen hyperkalemia. (Option 5) Clients with chronic kidney disease and elevated creatinine are unable to excrete the iodinated contrast administered for CT scans. Toxic effects from the contrast can occur; therefore, this prescription should be clarified before the scan.
A pregnant woman comes in to L&D (labor and delivery). She is 5 cm dilated contraction 5 minutes apart lasting 45 seconds. What phase of labor is the pt in?
ACTIVE contractions 3-5 mins apart lasts 30-60 seconds 5 cm dilated (4-7)
UAP
ADL's hygiene linens routine stable VS document I and O positioning sometimes glucose checks
An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply. 1.Abdominal pain 2.Blood in the stools 3.Change in bowel habits 4.Low hemoglobin level 5.Unexplained weight loss
ALL Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease (eg, Crohn disease, ulcerative colitis); and history of other cancers (eg, gastric, ovarian). Symptoms of colorectal cancer may include: Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps or tumors (Option 2) Abdominal discomfort and/or mass (not common) (Option 1) Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion (Option 4) Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or tumors (Option 3) Unexplained weight loss due to impaired nutrition from altered intestinal absorption (Option 5)
Sulfonamide antibiotics (bactrim) allopurinol anticonvulsants (phenytoin)
ALL have risk factor for Steven Johnson Syndrome Stevens-Johnson syndrome is an immune-mediated reaction most commonly triggered by certain classes of medications (eg, sulfonamide antibiotics, allopurinol, anticonvulsants [eg, phenytoin]). Initial symptoms are nonspecific and flu-like (eg, fever, fatigue) and are followed by blistered lesions and skin detachment on the face, trunk, and palms (Option 4). Stevens-Johnson syndrome can cause fatal complications (eg, sepsis, multiple organ dysfunction) and requires immediate hospitalization and follow-up by the health care provider. Treatment includes prompt discontinuation of the causative medication and initiation of supportive care (eg, fluids, nutrition, wound care).
neutropenia is defined as
ANC < 500 cells/mm3
Systemic lupus erythematosus (SLE)
chronic and progressive inflammatory autoimmune disorder that affects multiple body systems. Manifestations result mainly from the deposition of immunocomplexes (eg, antigen-antibody complexes) in various organs. Complications of SLE include: Pleural effusion: Inflammation of pleural tissue (eg, tissue covering the lungs) can cause buildup of fluid between the visceral and parietal pleura. Clinical manifestations include dyspnea and diminished breath sounds in the affected lung. Inflammation of the pericardium (ie, tissue covering the heart) and pericardial effusion are also common. Lupus nephritis: Inflammation of the kidneys occurs in approximately half of clients with SLE due to vascular inflammation. Severity can range from asymptomatic hematuria to glomerulonephritis and end-stage renal disease. Venous thromboembolism: Vasculitis (eg, inflammation of the blood vessels) and the presence of procoagulant antibodies in the blood (ie, antiphospholipid syndrome) can lead to deep venous thrombosis (DVT). Clients with SLE should be encouraged to monitor for signs of DVT (eg, unilateral erythema, warmth, swelling, tenderness). Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by alternating periods of exacerbation (ie, flare) and remission. Excessive autoimmune activity is often triggered by ultraviolet light (eg, sunlight), medications (eg, oral contraceptives, hydralazine, sulfa-containing medications), infections, and emotional/physical stress (eg, surgery, pregnancy). SLE affects multibody systems, commonly causing fatigue and joint pain. The skin is one of the systems commonly affected, resulting in photosensitivity, a butterfly-shaped rash (ie, malar rash), and painless oral ulcerations. Management of systemic lupus erythematosus (SLE) depends on the degree of organ involvement, which ranges in severity from mild (ie, affecting skin, muscles, and joints) to severe (ie, affecting kidneys, heart, lung, blood vessels, and central nervous system). Medication regimens range from periodic symptom control to immunosuppressants (eg, cyclophosphamide) for severe disease to help prevent significant organ damage. Appropriate interventions include: Administering analgesic medication (eg, NSAIDs) to reduce inflammation for joint pain relief. NSAIDs should be administered before bedtime for adequate pain control during the night, which is particularly important for good sleep and reduction of daytime fatigue (Option 1). Administering prednisone to improve the client's short-term symptoms by suppressing the immune system during flares until hydroxychloroquine takes full effect (Option 2). Administering hydroxychloroquine, an antimalarial agent that reduces immune activity without inducing immunosuppression to improve fatigue and arthralgia. Symptom improvement typically occurs 3-6 months after initiating hydroxychloroquine (Option 3). Encouraging the client to perform gentle range-of-motion exercises after awakening, prolonged rest, or a warm shower (to take the advantage of the heat-induced relaxation) (Option 5). Informing the client about specialty makeup products that can cover skin rashes if desired because these areas can cause body image issues (Option 6).
Meneire's Disease
chronic inner ear disease; too much fluid in the Labyrinth FALL RISK
NEVER ___ THE CHEST TUBE!!!!!!!!!
clamp
Metformin is contraindicated before
BEFORE IODINE DIE PROCEDURE Stop med 24 hours before Start back 48 hours after
What do hypoglycemic symptoms have the most in common with?
BEING DRUNK staggering gait slurred speech cerebral impairment slowed reaction time shock - vasomotor collapse Unconscious - dextrose (D50 - D10) - glucagon
creatine importance
BEST indicator of kidneys 0.6-1.2
BRONCOSCOPY
BRIGHT RED SPUTUM = hemorrhage REPORT general anesthesia is used (midazolam and lidocaine to numb) gag reflux absent for couple hours NPO until return
4 point gait
everything very weak
postpartum assessment
BUBBLE Breasts Uterus Bowels Bladder Lochia Episiotomy/Laceration/C-section incision uterus (firm/midline) lochia (BAD if pad saturated 15 mins) extremities (pulses edema DVT clot risk)
Acamprosate
Acamprosate is a prescribed treatment for alcohol use disorder. This medication decreases an individual's craving for alcohol. It is typically dosed three times a day, with the most common side effect being diarrhea. The client should be encouraged to seek counseling to help enhance their chances of abstinence.
The nurse is assessing a client during a routine physical examination. Which finding would be most important to report to the health care provider? 1.BMI of 30 kg/m2 2.Brownish skin thickening on the neck 3.Fasting total cholesterol of 220 mg/dL (5.7 mmol/L) 4.Round 3x3 mm pale pink mole
Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly seen in regions affected by acanthosis nigricans. Recognition of these skin disorders is important due to their association with insulin resistance. The client should be referred to the health care provider to be evaluated for diabetes mellitus and/or metabolic syndrome
Isotretinoin (Accutane)
Acne medication NEED TWO negative pregnancy test before starting medication Educate: use two forms of brith control Can NOT donate blood for at least one month to ensure preggos do not receive donation Pregnancy X category
The nurse in the outpatient clinic is assessing a 40-year-old client with acromegaly. Which finding would be most important to report to the health care provider? 1.Dark, leathery skin 2.Fasting blood glucose level of 126 mg/dL (7.0 mmol/L) 3.Presence of S3 and S4 heart sounds 4.Reports of knee pain when walking
Acromegaly is an uncommon condition caused by an overproduction of growth hormone (GH). It is usually due to a pituitary adenoma that releases excessive amounts of the hormone. Disease onset in adult clients generally occurs at age 40-45. In an adult, increased GH results in overgrowth of soft tissues of the face, hands, feet, and organs. The high level of GH stimulates an increase secretion of fatty acids into the bloodstream. These higher concentrations of fat in the bloodstream can lead to atherosclerosis and coronary artery disease. Other complications such as arrhythmias and left ventricular hypertrophy are possible. Additional heart sounds (ie, S3, S4) require further assessment by the health care provider for potential cardiac complications (eg, heart failure, cardiomyopathy)
activated charcoal time frame
Activated charcoal is a highly-absorbent powder that binds ingested drugs and toxins in the stomach and can decrease absorption of excess medication after an overdose. However, activated charcoal must be administered shortly after drug ingestion (usually within 1-2 hr); this client's family reported ingestion over 3 hours ago. In addition, a client with a severely depressed mental status is likely unable to protect the airway or take oral medications.
A client in labor has reached 8 cm dilation, feels an urge to push, and reports a pain level of 7 on a scale of 0-10. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action? 1.Administer prescribed IV meperidine for pain relief 2.Encourage client to bear down with spontaneous urges to push 3.Place client in the lithotomy position in preparation for birth 4.Provide encouragement and coaching in breathing techniques
Active labor is often the most emotionally challenging phase of labor, marked by increased maternal anxiety. A mixture of mucus and pink/dark brown blood ("bloody show") is commonly observed. Nursing priorities include providing emotional support and encouragement and coaching the client in breathing techniques (Option 4).
angle closure glaucoma
Acute angle-closure glaucoma causes ocular pain, blurred vision, and a fixed mid-dilated pupil. characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness. In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations: Sudden onset of severe eye pain Reduced central vision Blurred vision Ocular redness Report of seeing halos around lights
Key signs of EPS the nurse should identify are:
Acute dystonia: involuntary muscle contraction Akathisia: motor restlessness and repetitive movements Pseudoparkinsonism: shuffling gait and muscle rigidity (Option 1) Tardive dyskinesia: uncontrollable rhythmic movements (eg, lip smacking, facial grimacing)
The nurse is caring for a 7-year-old client with acute glomerulonephritis. Which of the following is a priority for the nurse to monitor? 1.Blood pressure 2.Hematuria 3.Peripheral edema 4.Serum lipid levels
Acute glomerulonephritis (AGN) is a condition of the kidneys usually following a recent streptococcal infection of the skin or throat. Antibody complexes lodge in the base of the glomeruli leading to an inflammatory reaction of the kidneys that causes protein to leak out of the blood vessels into the urine. Hypoalbuminemia (ie, low protein in the blood) leads to low oncotic pressure, causing vascular fluid to leak into the interstitial spaces, thus causing periorbital, abdominal, and lower extremity edema. Severe hypertension from fluid volume excess may develop suddenly and must be identified early. Monitoring and control of hypertension are a priority to prevent further progression of kidney injury, development of hypertensive encephalopathy, and pulmonary edema (Option 1). (Option 2) Hematuria from the many red blood cells and leukocytes that have leaked into the urine is common, minimal, and resolves spontaneously with AGN. (Option 3) Peripheral edema caused by fluid retention is common with AGN and is managed by reducing dietary intake of sodium. (Option 4) Serum lipid levels may be elevated with nephrotic syndrome as the liver produces increased lipids and proteins to compensate for protein loss. Serum lipid levels remain normal with AGN.
The nurse receives handoff of care report on four clients. Which client should the nurse see first? 1.Client with atrial fibrillation who reports feeling palpitations and has an irregular pulse of 122/min 2.Client with liver cirrhosis who reports bleeding from an IV insertion site and has a platelet count of 48,000 mm3 (48 x 109/L) 3.Client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 98/68 mm Hg over the past hour 4.Client with pneumonia whose white blood cell count has increased from 14,000 mm3 (14 x 109/L) 8 hours ago to 30,000 mm3 (30 x 109/L)
Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). If pericardial effusions accumulate rapidly or are very large, they may compress the heart, altering the mechanics of the cardiac cycle (ie, cardiac tamponade). Cardiac tamponade decreases atrioventricular filling and impairs the heart's ability to contract and eject blood; it is life-threatening without prompt recognition and treatment. Clinical features of cardiac tamponade include hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) (Option 3). In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, and tachycardia may be present. (Option 1) Palpitations, tachycardia, and irregular pulse are expected findings in atrial fibrillation. Atrial fibrillation is usually a chronic arrhythmia. The heart rate must be controlled, but this is not a priority over tamponade. (Option 2) Liver cirrhosis causes portal hypertension and splenomegaly. An enlarged spleen sequestrates platelets, causing thrombocytopenia. Spontaneous bleeding requires further investigation after addressing a client with possible cardiac tamponade. (Option 4) Increased white blood cell count in a client with infection may indicate ineffective treatment and/or progression to sepsis, both of which require follow-up. However, this finding is not immediately life-threatening.
Acute perciardits with NEW signs of JVD and muffled heart sounds
Acute pericarditis is inflammation of the membranous sac (pericardium) surrounding the exterior of the heart, which can cause an increase in the amount of fluid in the pericardium (ie, pericardial effusion). Increased pericardial fluid places pressure on the heart, which impairs the heart's ability to contract and eject blood. This complication (ie, cardiac tamponade) is life-threatening without immediate intervention. When assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade (eg, muffled or distant heart tones, hypotension, jugular venous distension) (Option 2). Development of cardiac tamponade requires emergency pericardiocentesis (ie, needle insertion into the pericardium to remove fluid) to prevent cardiac arrest.
How can you tell if acute pericarditis has led to cardiac tamponade
Acute pericarditis is inflammation of the pericardium, the double-walled sac that surrounds the heart. Pericardial inflammation can progress to pericardial effusion (fluid buildup between the pericardial layers) followed by cardiac tamponade. In cardiac tamponade, a potentially fatal complication, the heart is compressed by fluid buildup and prevented from pumping effectively (decreased atrioventricular filling and contractility). Manifestations of cardiac tamponade (eg, muffled heart tones, narrowed pulse pressure) are a priority to report to the health care provider because the client requires further evaluation (eg, echocardiography) to determine the need for treatment (eg, pericardiocentesis) Pericarditis is characterized by chest and neck pain that increases with inspiration and coughing. It is also expected that supine positioning can aggravate pain but sitting upright and leaning forward relieves it. An expected finding in clients with pericarditis is pericardial friction rub (ie, creaky, grating sound) on cardiac auscultation caused by friction between inflamed pericardial layers. ST-segment elevation across almost all ECG leads (rather than in specific leads, as seen with myocardial infarction) is common in pericarditis due to pericardial sac inflammation. Drug therapy for pericarditis generally includes NSAIDs and colchicine to reduce inflammation.
Acute poststreptococcal glomerulonephritis
Acute postinfectious glomerulonephritis (APGN) is an immune reaction that occurs approximately 2-3 weeks following a skin or upper respiratory infection, most commonly a streptococcal infection. Antibodies respond to the infectious antigens, forming an immune complex that becomes trapped in the capillary loop of the glomeruli. Cellular proliferation leads to swelling and infiltration of leukocytes, which then reduces renal blood flow and causes a decrease in the glomerular filtration rate. Decreased renal filtration causes excessive sodium retention and water accumulation, leading to hypertension and periorbital and lower extremity edema. The client's headache, periorbital/ankle edema, and abdominal distension should alert the nurse to possible APGN given the client's recent streptococcal impetigo infection. When APGN is suspected, the nurse should assess for additional findings such as changes in urine amount and color because APGN can cause decreased urine production and hematuria (ie, dark, cola- or tea-colored urine) (Option 2). A client with signs of APGN should be examined by a health care provider immediately because APGN often requires hospitalization to monitor for potential complications (eg, acute kidney injury, pulmonary edema, hypertensive encephalopathy).
Addisons disease leads to hyper or hyponatremia?
Addison's disease can lead to hyponatremia. In Addison's disease, there is decreased aldosterone secretion. Aldosterone functions to facilitate sodium reabsorption in the collecting ducts of the kidney. So, with less aldosterone, there is less sodium reabsorption, leading to less sodium (hyponatremia)
psych tx of depression
explore suicidal ideation inquire about safety contract activities with others that doesn't require interactions
The nurse in the intensive care unit cares for a client with primary adrenocortical insufficiency (Addison's disease). The client reports nausea and abdominal pain. The blood pressure suddenly drops from 120/74 mm Hg to 88/48 mm Hg, heart rate increases from 80 to 100/min, and the client appears confused. Which action should the nurse take first? 1.Administer as-needed dose of hydrocortisone intravenous (IV) push 2.Complete a head-to-toe assessment to identify any sources of infection 3.Document the findings in the client's electronic medical record 4.Take blood pressure sitting and standing to assess for orthostatic hypotension
Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push.
Addison's crisis treatment
Adhering to lifelong corticosteroid replacement therapy Understanding that periods of stress, illness, and exertion require higher dosing of steroids (Option 1) Avoiding illness and infection (eg, receiving vaccinations, avoiding sick contacts) (Option 2) Wearing a medical alert bracelet to notify others if addisonian crisis occurs (Option 5) Carrying and learning to administer an emergency steroid injection (eg, dexamethasone, hydrocortisone) hyponatremia hyperkalemia
Wound irrigation is performed to flush out debris and bacteria to ensure proper wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) because contamination with soil or dirt greatly increases the risk for infection. To perform wound irrigation, the nurse should:
Administer analgesia 30-60 minutes before the procedure to decrease client discomfort during the procedure (Option 1). Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle to the syringe and hold it 1 inch (2.5 cm) above the wound. Use continuous pressure to flush the wound, repeating until the drainage is clear (Option 5). Dry the surrounding wound area to prevent skin breakdown and irritation.
The nurse should anticipate the following interventions for a client who is experiencing late decelerations and minimal variability of the fetal heart rate (FHR):
Administering an IV fluid bolus to promote uteroplacental perfusion by increasing maternal blood volume Repositioning the client laterally (ie, side-lying) to promote uteroplacental perfusion by decreasing pressure on the maternal inferior vena cava, a large vein that is occluded by the weight of the gravid uterus when the client is supine Discontinuing IV oxytocin infusion to reduce uterine stimulation and decrease the frequency of uterine contractions; relaxation of the uterus increases uteroplacental blood flow and fetal oxygenation Placing an internal fetal scalp electrode, which is attaching a small electrode to the fetal scalp to monitor the FHR more accurately Preparing for a potential cesarean birth if interventions do not successfully resolve the abnormal FHR
The nurse is providing medication teaching to a client who has been prescribed oral hydrocortisone for newly diagnosed Addison disease. Which of the following statements by the nurse are appropriate to include in the teaching? Select all that apply. 1."Discontinue hydrocortisone if you have mood changes or disruptions in behavior." 2."Report even a low-grade fever to the health care provider immediately." 3."Report signs of hyperglycemia, including increased urine, hunger, and thirst." 4."The dose of hydrocortisone may need to be increased during times of stress." 5."This medication should be taken on an empty stomach to enhance absorption."
Adrenal glands are responsible for producing hormones that regulate the body's stress response, metabolism, fluid and electrolyte balance, and immune system. Damage or destruction to the adrenal glands leads to chronic adrenal insufficiency (ie, Addison disease) and the hypofunction of hormones, including mineralocorticoids (eg, aldosterone) and glucocorticoids (eg, cortisol). Clinical manifestations include low blood pressure, hypoglycemia, weight loss, and muscle weakness. Management of Addison disease includes long-term oral glucocorticoid replacement (eg, prednisone, hydrocortisone). Medication teaching reinforcement by the nurse should include the following: Reporting signs and symptoms of infection (eg, fever) immediately (Option 2). Oral corticosteroids can cause immunosuppression, placing the client at risk for infection. Contacting the health care provider if increased thirst, hunger, and urination occur that would indicate rising blood glucose because corticosteroids may cause glucose intolerance (Option 3). Increasing the dose of hydrocortisone as prescribed during times of stress, infection, and before major surgeries (Option 4). (Option 1) Abrupt discontinuation is not recommended due to the risk of adrenal crisis; therefore, the discontinuation of long-term corticosteroids should be tapered over time. (Option 5) Oral corticosteroids should be taken with food to lessen the likelihood of gastric irritation.
The nurse is assessing a client with Addison disease who was involved in a motor vehicle collision and sustained a fracture of the right femur. Which of the following findings would be a priority to follow up? 1.Blood pressure changed from 128/80 mm Hg to 90/50 mm Hg 2.Development of first-degree atrioventricular block on ECG 3.Reports of pain in the affected extremity rated as 7 on a scale of 0-10 4.Vesicular breath sounds auscultated over the upper lobes of the lungs
Adrenocortical insufficiency (ie, Addison disease) is a condition characterized by hypofunction of the adrenal cortex that results in low levels of adrenal hormones (eg, glucocorticoids, mineralocorticoids, androgens). During stress (eg, infection, injury, psychological distress), the body typically increases production of adrenal hormones to maintain fluid and electrolyte balance, blood glucose levels, and blood pressure. However, in clients with Addison disease, this hormonal response is often insufficient to meet physiologic demands, leading to addisonian crisis. Addisonian crisis is a life-threatening complication characterized by fluid and electrolyte disturbances (eg, dehydration, hyponatremia, hyperkalemia, hypoglycemia) and severe hypotension. Additional symptoms include abdominal pain, vomiting, weakness, and fever. The nurse should immediately report new-onset hypotension in a client with Addison disease because the client requires immediate glucocorticoid supplementation (eg, hydrocortisone) to prevent cardiovascular collapse
A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply. 1.Administer oxygen via non-rebreather mask 2.Apply an occlusive dressing over the insertion site 3.Assist the client to high Fowler position 4.Monitor vital signs and respiratory effort 5.Notify the health care provider
Air embolism is a rare but life-threatening complication of central venous catheter (CVC) placement in which air enters the bloodstream. This air displaces blood in the pulmonary vessels, which prevents oxygenation of blood by the lungs. Air embolism may occur after CVC removal, as air can enter the bloodstream via the open, large-bore insertion site. Clients with air embolism can rapidly develop respiratory distress leading to cardiopulmonary collapse. Nurses caring for clients with symptoms of air embolism (eg, hypoxemia, dyspnea, sense of impending doom) after CVC removal or dislodgement should perform these actions: Apply an occlusive dressing to the insertion site to prevent entry of additional air into the bloodstream (Option 2) Administer 100% oxygen via non-rebreather mask to improve oxygenation (Option 1) Position the client in left lateral Trendelenburg position to promote venous air pooling in the heart apex rather than the lung capillary beds Continuously monitor vital signs and client respiratory effort to identify changes in client status (Option 4) Notify the health care provider immediately
The nurse is admitting a client from the emergency department at 2100. The client has acute alcohol intoxication, confusion, and a diabetic toe ulcer and last consumed alcohol at approximately 1830. Which of the following actions would be a priority for the nurse to take? 1.Allow the client to rest undisturbed in a private room 2.Assess the client for signs of alcohol withdrawal syndrome 3.Monitor the client's capillary blood glucose levels during the night 4.Obtain a referral for treatment of alcohol use disorder
Alcohol is a toxin that causes central nervous system depression. Acute alcohol intoxication can cause confusion, coordination impairment, drowsiness, slurred speech, mood swings, and uninhibited actions. Alcohol can also cause hypoglycemia, especially in clients with diabetes mellitus. Although the client is intoxicated, determining whether the confusion is caused by alcohol or hypoglycemia or both is difficult. Monitoring blood glucose levels during the night is a priority to assess for hypoglycemia, which would require immediate intervention (Option 3). (Option 1) The client should be allowed to sleep off the alcohol intoxication, but the nurse must still monitor blood glucose levels during this time. (Option 2) Alcohol withdrawal syndrome generally begins within 6-8 hours after the last drink and peaks at 24-72 hours. The client last consumed alcohol <3 hours ago, so monitoring for alcohol withdrawal syndrome is not yet a priority. (Option 4) A referral for alcohol use disorder treatment can be obtained when the client is no longer intoxicated.
The charge nurse responds to a cardiac arrest with resuscitation in progress of an adult client. Which of the following actions by a resuscitation team member would cause the charge nurse to intervene? Select all that apply. 1.Chest compressions are performed at a rate of 70-80/min 2.Chest compressions are stopped for a 10-second pulse check every 2 minutes 3.Defibrillator pads are applied at the left and right sternal borders 4.Manual breaths are delivered at a rate of 2 breaths per 30 chest compressions 5.Resuscitation team is alerted to remain clear of client before defibrillation
All members of the health care team must follow basic life support guidelines to perform cardiopulmonary resuscitation (CPR) for clients experiencing cardiac arrest. Essential components of adult CPR include: Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions (Option 1). Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line (Option 3).
Variations in the newborn
All of the following skin conditions are normal • Milia—White, pinhead-size, distended sebaceous glands on the nose, cheek, chin, and occasionally on the trunk. Usually disappear after a few week of bathing • Epstein pearls—Palatal cysts of the newborn, which are small white or yellow cystic vesicles • Mongolian spot—Bluish discoloration in the sacral region of newborn usually seen in African Americans ... Carefully document its presence as such action may prevent child abuse charges against parents or caregiver • Erythema toxicum neoratorum—Described as flee-bitten lesion ... pink rash with firm, yellow-white papules or pustule on the face, chest, abdomen, back and buttocks of some newborns. Usually appears 24 to 48 hours after birth and disappear in a few days • Hemangioma—An abnormal accumulation of blood vessels in the skin of the newborn. It is one of the most common birthmarks associated with childhood and affect 10% of all children
The nurse is teaching about cervical cancer prevention at a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply. 1.Human immunodeficiency virus 2.Human papillomavirus 3.Multiple sexual partners 4.Nulliparity 5.Sexual activity before age 18
Almost all cases of cervical cancer result from human papillomavirus (HPV) infection (Option 2). HPV is the most common sexually transmitted infection but is usually transient and resolves spontaneously. However, persistent HPV infection can cause abnormal changes in epithelial tissue that can progress to cancer. Other risk factors for cervical cancer are related to behaviors that increase risk of exposure to HPV. For example, clients who have multiple sexual partners and/or initiate sexual activity (eg, oral, vaginal, or anal sex) at an early age (<18) have an increased risk of contracting HPV (Options 3 and 5). Clients with weakened immunity (eg, HIV infection, immunosuppressive therapy) may have an impaired ability to clear HPV, which increases the risk for cervical cancer due to persistent infection (Option 1). (Option 4) Nulliparity (ie, no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast cancer.
Four clients come to the emergency department (ED). Which client should the triage registered nurse (RN) assign as highest priority for definitive diagnosis and treatment? 1.Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an oxygen saturation of 91% ( 2.Healthy child with new-onset fiery-red rash on cheeks and the "flu" 3.Middle-aged client with vaginal itching and white, curdlike discharge 4.Unconscious elderly client who smells of alcohol and has fresh vomit on the face
Although this elderly client may be unconscious due to intoxication, vomit and decreased level of consciousness place this client at risk for airway obstruction. Treatment of this client is a priority, and measures must be taken to protect the airway (eg, rescue position, head of bed elevation, intubation). (Option 1) Bacterial infection is the most common cause of COPD exacerbation. Although clients with COPD usually have cough and sputum, it becomes a concern when the sputum changes in color, consistency, or volume. This client needs antibiotics. The goal pulse oximetry reading for COPD is typically 90%-93% as many clients with COPD rely on their hypoxemic drive to breathe. Therefore, this client is stable and can wait until the unconscious elderly client is treated. (Option 2) This child has fifth disease ("slapped-cheek," erythema infectiosum), which is caused by parvovirus B19. Symptoms, in addition to a bright-red facial rash, include fever and general flulike symptoms. It is harmless unless the client has a hemolytic/immunodeficient condition. Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia. Prioritization is determined by acuity, and therefore children do not automatically receive higher priority. However, due to the potential exposure of this child to a pregnant client in the ED, the triage RN should prioritize this client ahead of the one with vaginal infection. (Option 3) This client is exhibiting a classic sign of the common Candida vaginitis (yeast) infection. Classic signs and symptoms include itching and irritation in the vulva or vagina, white cheesy vaginal discharge, and low vaginal pH. Although uncomfortable, this client is stable and can safely wait up to 2 hours for treatment.
psychosis of dementia
Alzheimer's Wernicke's and dementia 1. acknowledge feeling 2. redirect get them to express fixation
amiodarone pt has dry cough and chest pain and dyspnea
Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias that cannot be controlled with other medications. Amiodarone therapy is used only if other treatments have failed, as it has many toxic, adverse effects that may be severe. Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible lung damage
The clinic nurse is reviewing telephone messages from four clients. Which client's call should the nurse return first? 1.Client who has just taken albuterol and reports a heart rate of 108/min and a coarse tremor in both arms 2.Client who is prescribed azithromycin and reports frequent, foul-smelling, liquid stools and abdominal cramping 3.Client who is prescribed metformin and reports a blood glucose of 284 mg/dL (15.76 mmol/L) and frequent urination 4.Client who takes amiodarone and reports a dry cough and increased dyspnea when walking around the house
Amiodarone is an antiarrhythmic medication used to treat life-threatening arrhythmias that cannot be controlled with other medications. Amiodarone therapy is used only if other treatments have failed, as it has many toxic, adverse effects that may be severe. Pulmonary toxicity is a life-threatening adverse effect of amiodarone, which is believed to cause direct cellular damage and activation of an immune response in the lungs. Clients who develop pulmonary toxicity may report respiratory symptoms such as dry cough, pleuritic chest pain, and dyspnea. Clients with clinical manifestations of pulmonary toxicity require immediate intervention to prevent fatal, irreversible lung damage (Option 4). (Option 1) Albuterol is a beta-2 agonist used to treat bronchospasm that commonly causes tachycardia and tremor. Clients reporting these symptoms may require a dose adjustment or change in medication regimen. (Option 2) Frequent liquid stools in a client receiving antibiotics (eg, azithromycin) may indicate development of Clostridium difficile infection, a serious gastrointestinal complication. However, possible pulmonary toxicity is the priority. (Option 3) Clients taking metformin, an oral antidiabetic, who report hyperglycemia and polyuria require follow-up to evaluate medication efficacy and glycemic control. Signs of pulmonary toxicity are more urgent, however.
A client is receiving packed RBCs intravenously through a double-lumen peripherally inserted central catheter (PICC) line. During the transfusion, the nurse receives a new prescription to begin intravenous piggyback (IVPB) amphotericin B. What is the nurse's best action? 1.Administer amphotericin B through an open lumen of the PICC line 2.Insert a peripheral IV line to begin infusion of amphotericin B 3.Interrupt the blood transfusion to infuse amphotericin B, then resume after infusion 4.Wait 1 hour after blood transfusion finishes before administering amphotericin B
Amphotericin B is an antifungal medication used to treat systemic fungal infections. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of amphotericin B and the symptoms of a blood transfusion reaction (eg, chills, fever, hypotension, kidney injury), the nurse's best action is to complete the blood transfusion and allow one hour of observation before initiating amphotericin B (Option 4). This enables the nurse to distinguish between transfusion-related reactions and adverse effects from amphotericin B. (Options 1 and 2) Although starting a peripheral IV line or using an open lumen of the peripherally inserted central catheter line would prevent mixing amphotericin B with the blood products, it would not allow the nurse to distinguish the onset of a potentially fatal reaction from either component. (Option 3) The nurse should not interrupt a blood transfusion after initiation except in cases of transfusion-related reactions or fluid overload. In addition, pausing and restarting blood transfusions increases the risk for contamination of blood products. The nurse should complete transfusion of blood products within 4 hours of removal from refrigeration.
The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply. 1.diarrhea 2.Difficulty breathing 3.Difficulty swallowing 4.Muscle weakness 5.Resting tremor
Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include: Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) Feeding tube for enteral nutrition Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) Mobility assistive devices (eg, walker, wheelchair) Communication assistive devices (eg, alphabet boards, specialized computers) (Option 1) Constipation due to decreased mobility is more common in ALS. Diarrhea is not seen. (Option 5) Resting tremor is characteristic of parkinsonism.
The nurse in the emergency department is caring for assigned clients. Which of the following clients should the nurse assess first? Click the exhibit button for additional information. 1.Client who feels cool and clammy to the touch and has a serum glucose level of 60 mg/dL (3.3 mmol/L) 2.Client who has an open fracture of the tibia and the pulses in the affected extremity are 1+ and thready 3.Client who is receiving chemotherapy and has a temperature of 102.7 F (39.3 C) 4.Client who is reporting sharp, tearing back pain and has a blood pressure of 90/60 mm Hg
An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Symptoms of a ruptured AAA include hypotension, a pulsatile abdominal mass, and intense, tearing back pain. Vessel rupture requires immediate follow-up because hemorrhagic shock and death rapidly follow (Option 4).
Electroencephalogram (EEG)
An amplified recording of the waves of electrical activity that sweep across the brain's surface. These waves are measured by electrodes placed on the scalp.
A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? 1."I will let my child drink cocoa as usual the morning of the procedure." 2."I will wash my child's hair using shampoo the morning of the procedure." 3."My child may have scalp tenderness where the electrodes were applied." 4."My child will not remember the procedure."
An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. The test is not painful, and no analgesia is required. (Option 1) Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. (Option 3) This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. (Option 4) A routine EEG is not performed under sedation, and so the child should remember the procedure.
The nurse is assessing a client who had an esophagogastroduodenoscopy 3 hours ago. The client is reporting increasing abdominal pain. Which clinical finding requires an immediate report to the health care provider? Click the exhibit button for additional information. 1.Blood pressure 108/72 mm Hg 2.Gag reflex has not returned 3.Sore throat when swallowing 4.Temperature 100.6 F (38.1 C)
An esophagogastroduodenoscopy (EGD) involves passing an endoscope down the esophagus to visualize the upper gastrointestinal structures (eg, esophagus, stomach, duodenum). Perforation of the gastrointestinal tract is a life-threatening complication of EGD that can lead to peritonitis and sepsis. Signs of perforation include a sudden temperature spike, increasing pain/tenderness, restlessness, tachycardia, and tachypnea. The nurse should notify the health care provider immediately if the client develops a fever (Option 1) Post-procedure changes in blood pressure can be caused by sedation, blood loss, or sepsis. Although the client had a slight decrease in blood pressure, it has remained relatively consistent with the other blood pressure readings and does not require immediate notification of the health care provider. (Option 2) An EGD involves applying a topical anesthetic to the throat to pass the endoscope. It may take a few hours for the gag reflex to return. Absent gag reflex after a prolonged period (eg, 6 hours) should be reported to the health care provider. (Option 3) A sore throat is expected after certain procedures (eg, EGD, intubation) due to local irritation. Warm saline gargles can provide some relief.
The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse? 1."I know you are frightened, but I do not see a man in your room." . 2"Don't you worry, I'll make the bad man go away." 3."Let's go into the dayroom and play a game. I know you like to play checkers." 4."Your illness is making you experience visual hallucinations."
An important step toward self-management of hallucinations is for the client to recognize that the hallucinations are not real. When a client is experiencing hallucinations, the nurse needs to reinforce reality and acknowledge how the client may be feeling (Option 1). The nurse can point out their own perceptions without denying the client's experience. It is nontherapeutic to argue with or challenge the client about the hallucination, saying, for example, "How could a man get into your room? This is a locked hospital unit." Examples of additional therapeutic responses to a client who is experiencing hallucinations include: "I don't see anything, but I understand that what you are seeing may be very upsetting to you." "I understand that you are worried about the voices you are hearing. They are a part of your disease and not real." "I know the voices seem real to you and may be scary. I do not hear the voices."
The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment? 1.Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications 2.Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain 3.Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage 4.Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting
An inguinal hernia is a protrusion of intraperitoneal contents (eg, bowel, tissue) through a weakened area in the abdominal wall (eg, groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge; and incarcerated, if they cannot. Manifestations of a mechanical bowel obstruction (eg, pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical. (Option 1) Elevated creatinine is expected in a client scheduled for hemodialysis. The nurse should review the prescribed medications as many are removed by dialysis. The nurse should follow institution guidelines on holding medications before and after dialysis and seek direction from the health care provider if necessary. (Option 2) Medications with anticholinergic properties (eg, antihistamines [diphenhydramine]; tricyclic antidepressants [amitriptyline]) can precipitate urinary retention, especially in susceptible clients (eg, those with benign prostatic hyperplasia). Urinary catheterization is needed as soon as possible but is not a priority over strangulated bowel. (Option 3) The client with excessive yellow, foul-smelling drainage will need a dressing change; however, these findings are expected in a client with an infected venous leg ulcer.
The nurse is reviewing laboratory results for several clients. Which finding is most important to report to the health care provider? 1.Client at 24 weeks gestation with hemoglobin of 9 g/dL (90 g/L) and hematocrit of 29% (0.29) 2.Client at 26 weeks gestation whose 1-hour (50 g) oral glucose challenge test result is 120 mg/dL (6.7 mmol/L) 3.Client at 36 weeks gestation with blood pressure of 125/85 mm Hg and trace protein detected on urine dipstick 4.Client at 37 weeks gestation with a WBC count of 13,000/mm3 (13 x 109/L)
Anemia is a common complication of pregnancy, sometimes due to iron deficiency. During the second half of pregnancy, the fetus begins to store iron in preparation for extrauterine life and depletes maternal iron stores. Hemoglobin <11 g/dL (110 g/L) in the first or third trimester or <10.5 g/dL (105 g/L) in the second trimester is considered low. The nurse should evaluate a client with a hemoglobin of 9 g/dL (90 g/L) for symptoms of anemia (eg, fatigue, shortness of breath) and notify the health care provider because the client may require additional testing (eg, complete blood count, serum ferritin) and iron supplementation (Option 1). (Option 2) A 1-hour (50 g) oral glucose challenge test screens clients for gestational diabetes and is considered abnormal if blood glucose is ≥130-140 mg/dL (7.2-7.8 mmol/L). (Option 3) Protein is not normally detected in the urine, but large amounts of protein in the urine (eg, ≥300 mg/24 hours, ≥1+ on urine dipstick) along with elevated blood pressure (eg, ≥140/90 mm Hg) may indicate preeclampsia. Trace protein is likely due to specimen contamination or recent illness. (Option 4) During pregnancy, it is normal for the WBC count to increase, even in the absence of infection.
To prevent immobility hazards for a client in skeletal traction, the RN can delegate the following tasks to the UAP
Assist with active and passive ROM exercises Notify the RN of client reports of pain, tingling, or decreased sensation in the affected extremity Remind the client to use the incentive spirometer Maintain proper use of pneumatic compression devices
Timolol contraindication
Asthma
• Know what needle to use for insulin injection? • Giving a SubQ injection
o 5 looks like an "S" in "SubQ" o Pick the answer that has "5s" in it o Use a 25-gauge, 0.5 inch needle
Torades de pointes can be cuased by a prolonged QT interval. What medications have this effect?
Antiarrhythmics (eg, sotalol, amiodarone, ibutilide, dofetilide) Macrolide antibiotics (eg, erythromycin, azithromycin) Electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) NORMAL MAG (1.3-2.1)
Tolterodine (Detrol)
Anticholinergic
Trycyclic antidepressants
Anticholinergic Blurred vision Constipation Drowsiness Euphoria MUST take 2-4 weeks for maximum effect
Typical Antipsychotics side effects expected
Anticholinergic (dry mouth) Blurred vision Constipation Drowsiness Extrapyramidal side effects F (photosensitivity) agranulocytosis weight changes
Rivaroxaban (Xarelto)
Anticoagulant
Levetiracetam (Keppra)
Anticonvulsant
Citalopram (Celexa)
Antidepressant, SSRI
Diphenoxylate/Atropine
Antidiarrheal
Odansteron (Zofran)
Antiemetic
Promethazine (Phenergan)
Antiemetic. Side effects: drowsiness, anticholinergic effects, EPSs, potentiates effects when given with narcotics. Nursing interventions: monitor VS, safety precautions, IM (large muscle)
Terbinafine
Antifungal Even after prolonged treatment, failure and recurrence rate is high (20 to 50% failure). The cure rate with terbinafine is close to 50% (Choice A is incorrect). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails (1 month). Educate the client regarding the prolonged duration of treatment and instruct them to be compliant (Choice B is correct). Educate the client regarding essential side effects and when to contact the healthcare provider. Common side effects include headache, gastrointestinal side effects (abdominal pain, nausea, dyspepsia, diarrhea), rash, and taste changes. To minimize gastrointestinal side effects, terbinafine should be taken with food. Taking it on an empty stomach may exacerbate gastrointestinal side effects (Choice D is incorrect). Vision changes may also occur. These may represent changes in the retina and must be reported immediately to the provider (Choice E is correct). Rarely, terbinafine can cause severe liver toxicity. This can happen in even those without pre-existing liver disease. Yellow-colored urine, pale stools, jaundice, and persistent nausea may indicate acute liver damage (Choice F is correct). Baseline liver function tests (LFTs) must be checked before the initiation of terbinafine (Choice C is correct). In the past, LFTs have been monitored every 4 to 6 weeks while on terbinafine, but new guidelines do not require routine monitoring of LFTs.
Plaquinil (hydroxychloroquine)
Antimalarials are immunomodulators that act on the innate immune system by blocking TLR signaling on plasmacytoid dendritic cells, reducing production of IFN-α and downstream proinflammatory cytokines. · hydroxychloroquine can cause pigment changes in the macula of the retina that can cause vision loss if unrecognized. Risk factors for hydroxychloroquine associated vision loss include daily dose > 400 mg/d or cumulative dose > 1,000 g, underlying retinal or macular disease, age older than 60 years, and underlying kidney or liver disease (drug is eliminated by both routes). A dose of 5 mg/kg per day (maximum, 400 mg/d) is recommended for patients with SLE. ·
The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply. 1.Assess for bruising 2.Assess for tarry stools 3.Monitor intake and output 4.Monitor liver function tests 5.Monitor platelets
Antiplatelet therapy (eg, aspirin, clopidogrel, prasugrel, ticagrelor) is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding (eg, hematuria, bleeding gums, epistaxis) (Options 1 and 2). Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenic purpura, so platelets should be monitored periodically (Option 5). (Option 3) Monitoring intake and output is indicated while a client is on diuretic medications (eg, furosemide, torsemide, bumetanide) but not for antiplatelet agents. (Option 4) Baseline liver enzymes are obtained for clients taking statins (eg, rosuvastatin, atorvastatin) and isoniazid (for tuberculosis). Elevated liver enzymes are an infrequent side effect of clopidogrel, and regular monitoring is usually not required in clients without hepatic impairment.
The nurse is providing discharge instructions on the proper use of prescribed short-acting beta agonist and inhaled corticosteroid metered-dose inhalers to a client with newly diagnosed asthma. Which instructions should the nurse include? Select all that apply. 1."Omit the beclomethasone if the albuterol is effective." 2."Rinse your mouth well after using the beclomethasone inhaler and do not swallow the water." 3."Take the albuterol inhaler apart and wash it after every use." 4."Use the albuterol inhaler first if needed, then the beclomethasone inhaler." 5."Use the beclomethasone inhaler first, then the albuterol, if needed."
Asthma is a disorder of the lungs characterized by reversible airway hyper-reactivity and chronic inflammation of the airways. Albuterol (Proventil) is a short-acting beta agonist (SABA) administered as a quick-relief, rescue drug to relieve symptoms (eg, wheezing, breathlessness, chest tightness) associated with intermittent or persistent asthma. Beclomethasone (Beconase) is an inhaled corticosteroid (ICS) normally used as a long-term, first-line drug to control chronic airway inflammation. When using an ICS metered-dose inhaler (MDI), small particles of the medication are deposited and can impact the tongue and mouth. Rinsing the mouth and throat well after using the MDI and not swallowing the water are recommended to help prevent a Candida infection (thrush) (white spots on tongue, buccal mucosa, and throat), a common side effect of ICSs. The use of a spacer with the inhaler can also decrease the risk of developing thrush (Option 2). When both MDIs are to be taken at the same time, clients are instructed to take the SABA first to open the airways and then the ICS to provide better delivery of the medication. It is important for the nurse to clarify indications and sequencing as the SABA is a rescue drug taken on an as-needed basis and is not always taken with the ICS (Options 4 and 5). (Option 1) Inhaled corticosteroids (eg, fluticasone, beclomethasone) are not rescue drugs. They are prescribed to be taken on a regular schedule (eg, morning, bedtime) on a long-term basis to prevent exacerbations and should not be omitted even if the SABA is effective. (Option 3) Taking the albuterol (Proventil) inhaler apart, washing the mouthpiece (not canister) under warm running water, and letting it air dry at least 1-2 times a week is recommended. Medication particles can deposit in the mouthpiece and prevent a full dose of medication from being dispensed. Taking the ICS inhaler apart and cleaning it every day is recommended.
What is the #1 nursing intervention in a pt on lithium presenting with metallic taste and severe diarrhea?
o Give pt fluids • Notify the HCP—this is a toxic effect
The nurse reinforces teaching to a client with HIV during a follow-up clinic visit after being on antiretroviral drugs for the past 2 months. Which statement by the client indicates a need for further instruction? 1."I can stop taking these HIV drugs once my viral levels are undetectable." 2."I need to get tested regularly for sexually transmitted infections because I'm sexually active." 3."I should use latex condoms and barriers when having anal, vaginal, or oral sex." 4."I won't stop injecting drugs, but I will use a needle exchange program."
Antiretroviral therapy (ART) is a medication regimen consisting of multiple drugs for managing and preventing progression of HIV infections. ART impairs viral replication at multiple points, which leads to decreased viral loads and increased CD4+ (ie, helper T) cell counts. When educating clients about ART, it is critical to explain that treatment is lifelong and requires strict adherence (Option 1). Even clients with undetectable viral loads remain infected with HIV. The discontinuation of, or poor adherence to, ART results in the progression of HIV (which may lead to AIDS) and promotes viral drug resistance.
Sucralfate
Antiulcer Agent
Sucralfate
Antiulcer Agent coats stomach
acyclovir or valacyclovir
Antiviral medications such as acyclovir or valacyclovir are commonly used to treat varicella infections. While these medications are not routinely prescribed for all infections, immunocompromised individuals are at risk for varicella complications, including meningitis. Thus, antiviral medications would be appropriate in this circumstance.Varicella is a highly contagious viral infection spread by aerosolized droplets, contaminated surfaces, and direct contact with the lesions. Treatment is symptomatic with prescribed acetaminophen and therapeutic baths with cool water and uncooked oatmeal or baking soda. If a client is admitted with varicella, they should be isolated using airborne and contact precautions until the lesions have crusted.Sevelamer
Zidovudine (AZT)
Antiviral: prototype nucleoside inhibitor of HIV reverse transcriptase (NRTI). Tox: severe myelosuppression. Others: lamivudine, stavudine, didanosine, zalcitabine.
For donning personal protective equipment, the nurse should instruct the student to
Apply the gown that should be securely fastened behind the neck and waist. Secure the mask that should extend below and under the chin. Fit the goggles/face shield. Don gloves that are a snug fit. reverse alphabet
Aripiprazole (Abilify)
Aripiprazole, an atypical antipsychotic medication, is used in the treatment of irritability associated with autism spectrum disorder (ASD), schizophrenia, bipolar disorder, and other mental health disorders. Aripiprazole works as a partial agonist at the serotonin and dopamine receptor sites. As a result, the medication has a more favorable safety profile (eg, less metabolic effects, lower potential for prolactin release) than other antipsychotics; however, it may be less effective in symptom relief. Clients taking aripiprazole should be instructed to not abruptly stop taking the medication because it can cause withdrawal symptoms (anxiety, dizziness, tachycardia, diaphoresis, insomnia, vomiting) and risk exacerbating previous symptoms. These medications should be weaned over time and substituted with an alternate medication under the supervision of a health care provider (Option 1).
The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1.Avoid suctioning the client 2.Pre-oxygenate the client 3.Raise the head of the bed 4.Reduce the amount of sedation medication
Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results.
The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed, and the standing prescription is to draw arterial blood gases 30 minutes after a ventilator change. In anticipation of this blood draw, what intervention should the nurse implement? 1.Avoid suctioning the client 2.Pre-oxygenate the client 3.Raise the head of the bed 4.Reduce the amount of sedation medication
Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results. (Option 2) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results. (Option 3) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow for adequate chest expansion. This position will not affect ABG results. (Option 4) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become anxious and have an increased activity level; these could affect the ABG results.
Ankle Brachial Index
Arterial occlusive disease of Lower Extremities
What is the #1 nursing intervention in a pt on lithium presenting with peeing/pooping all the time?
o Give pt fluids • The above S/Sx are S/Es—expected • Monitor sodium • Low sodium makes lithium toxic • High makes lithium ineffective • Sodium needs to be normal
A pediatric client is diagnosed with an acute asthma attack. Which immediate-acting medications should the nurse prepare to administer to this client? Select all that apply. 1.Albuterol 2.Ibuprofen 3.Ipratropium 4.Montelukast 5.Tobramycin
Asthma is an inflammatory condition in which the smaller airways constrict and become filled with mucus. Breathing, especially on expiration, becomes more difficult. Pharmacologic treatment for acute asthma includes the following: Oxygen to maintain saturation >90% High-dose inhaled short-acting beta agonist (albuterol or levalbuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes Systemic corticosteroids (Solu-Medrol) to control the underlying inflammation. These will take some time to show an effect. (Option 2) Nonsteroidal anti-inflammatory agents (eg, ibuprofen, naproxen, indomethacin) and aspirin can worsen asthma symptoms in some clients and are not indicated unless necessary. (Option 4) Montelukast (Singulair) is a leukotriene (chemical mediator of inflammation) inhibitor and is not used to treat acute episodes. It is given orally in combination with beta agonists and corticosteroid inhalers (eg, fluticasone, budesonide) to provide long-term asthma control. (Option 5) Tobramycin is an aminoglycoside antibiotic. It is used in aerosolized form to treat cystic fibrosis exacerbation when Pseudomonas is the predominant organism causing lung infection.
The nurse is caring for a client at 12 weeks gestation who has a rubella titer status of nonimmune. Which of the following actions should the nurse anticipate implementing? 1.Administering measles-mumps-rubella (MMR) vaccine now 2.Administering MMR vaccine immediately postpartum 3.Administering MMR vaccine in the third trimester 4.Informing the client that an MMR vaccine is not indicated
At the client's first prenatal visit, a serum sample is collected to determine immunity to the rubella virus. A positive immune response indicates immunity to the rubella virus, attributed to either past infection or vaccination. A negative, or nonimmune, response indicates that the client is susceptible to rubella and requires vaccination. An equivocal response indicates partial immunity and is clinically treated the same as nonimmune status. Measles-mumps-rubella (MMR) is a live attenuated vaccine. Live vaccines are contraindicated in pregnancy due to the theoretical risk of contracting the disease from the vaccine. Maternal rubella infection can be teratogenic for the fetus. The fetal effects of congenital rubella syndrome include cataracts, deafness, heart defects (patent ductus arteriosus), and cerebral palsy. The best time to administer the MMR vaccine to a nonimmune client is in the postpartum period just prior to discharge (Option 2). The MMR vaccine can be safely administered to breastfeeding clients. (Options 1 and 3) The MMR vaccine is contraindicated in pregnancy. Pregnancy should be avoided for at least 4 weeks after the immunization is given. (Option 4) This client is nonimmune to rubella and susceptible to rubella if exposed to it. The vaccine should be offered in the postpartum period.
Acyanotic heart defects
Atrial septal defect Ventricular septal defect Patent ductus arteriosus Coarctation of aorta
The night nurse receives the hand-off report on assigned clients. Which client should the nurse assess first? 1.Client with acute kidney injury scheduled for hemodialysis in the morning has a urine output of 200 mL for the past 8 hours 2.Client with an indwelling urinary catheter who is 1-day postoperative prostatectomy reports severe bladder spasms 3.Client with an ureteral stent placed this morning after laser lithotripsy reports burning on urination and hematuria 4.Client with spinal cord injury (above T6) requiring intermittent catheterization reports a throbbing headache and nausea
Autonomic dysreflexia (hyperreflexia) can occur in any individual with a spinal cord injury at or above T6. The condition causes an exaggerated sympathetic nervous system response resulting in uncontrolled hypertension. Common triggers include bladder or rectum distention and pressure ulcers. Characteristic manifestations include acute onset of throbbing headache, nausea, and blurred vision; hypertension and bradycardia; and diaphoresis and skin flushing above the level of the injury. It is a medical emergency that requires immediate intervention (eg, bladder catheterization) to remove the precipitating trigger. (Option 1) Oliguria (<0.5 mL/kg/hr or <280 mL in 8 hours for an adult of average weight [154 lb or 70 kg]) is an expected finding in a client with kidney injury scheduled for hemodialysis; this client assessment is not the priority. (Option 2) Bladder spasms are an expected finding in a client with an indwelling urinary catheter following a prostatectomy. The nurse can administer prescribed analgesic and antispasmodic drugs (eg, Belladonna-opium suppositories, oxybutynin) to alleviate discomfort. However, this client assessment is not the priority. (Option 3) Laser lithotripsy breaks down a large stone into small fragments to ease stone elimination. The ureteral stent maintains ureter patency by preventing obstruction caused by edema or stone fragments. Burning on urination and hematuria are common expected side effects associated with this procedure. This client assessment is not the priority.
Phenylketonuria
Autosomal recessive mutation in gene for phenylalanine hydroxylase Impaired metabolism of phenylalanine to tyrosine → ↑ phenylalanine causes neurologic injury Neurologic: microcephaly, developmental delay, seizures, severe intellectual disability Nonneurologic: musty body odor, hypopigmentation (eg, skin, hair, eyes), eczema Phenylalanine-restricted diet (ie, avoidance of protein-rich foods) Dietary/supplemental tyrosine Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2) Feeding infants specially prepared formulas that are low in phenylalanine (Option 4) Encouraging consumption of natural foods low in phenylalanine (ie, most fruits and vegetables)
Tetracycline considerations
Avoid sun exposure Do not take with milk Do not give to children until permanent teeth are in place Do not give to pregnant women Take on empty stomach
• Know what needle to use for insulin injection? • Giving an IM injection
o Pick answer in which both answers have a "1" in them o "I" in IM looks like the "#1" o Use a 21-gauge, 1-inch long needle
Blood borne hepatitis pathogens include:
B, C, D
• 4 things to do every 15 minutes in the 4th stage of labor
o V/S ! Fundus ! Peri pads ! Roll
restraints
observe every 15 mins Dr order needed
1.Low Fetal HR (heart rate)—HR <110
BAD Left side IV Oxygen Notify • Stop Pitocin (pit) if it was running o Implement before "LION"
For fetal heart rate tracings starts with an "L" it is ___
BAD late decelerations low baseline variability Low fetal HR • Look at the first letter of a fetal heart rate tracing, it is a bad heart tracing if it starts with an "L" o Therefore, do "LION" which also starts with the letter "L" • Variable deceleration is very bad o PUSH and POSITION) • Ace of spades means that this answer works every time o Check the FHR
Low baseline variability
BAD fetal HR stays the same implement LION STOP PITOCIN FIRST
late decels
BAD placental insufficiency LION stop Pitocin/oxytocin
variable decelerations
BAD! noted as V-shaped on strip. Caused by cord compresion. Intervention is to change mother's position; if pitocin is infusing, stop infusion, apply oxygen, and increase rate of IV fluids. Contact MD is problem persists.
Postpartum assessment
BUBBLE-LEB—fever +100.4 *B= breast* *U= uterus*(firm or boggy) location (deviated=go to bathroom) descends 1cm a day until day 10, At umbilicus after birth, 1 finger above day 1, nonpalpable day 10 *B= bladder* (palpable?) *B= bowels* (last BM) *L= lochia*: rubra (1-3 days) serosa (3-7 days) alba (day 10) - Rubra—red o Serosa (if your cheeks are rosy)—pink o Alba (albino)—white o Moderate amount: 4 to 6 inches on pad in an hour o Excessive: saturate a pad in 15 minutes *E= episiotomy* or incision: REEDA (redness-edema-ecchymosis-discharge-approximation) *L= legs* (Homans) pain/pulses/sensation/movement - BEST WAY to determine thrombophlebitis = measure bilateral calves *E= emotions* *B= bonding* "taking in" gazing, holding, calling baby by name
A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent assessment of which of the following is most important in the plan of care? 1.Babinski reflex 2.Fontanel assessment 3.Pulse pressure 4.Pupillary light response
Bacterial meningitis is inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include fever, restlessness, and a high-pitched cry. One common acute complication of bacterial meningitis is hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow. Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis.
A client with suspected active pulmonary tuberculosis has a positive tuberculin skin test. The nurse anticipates which prescription from the health care provider to confirm the diagnosis in this client? 1.Collect a total of three sterile sputum specimens for culture at 8- to 24-hour intervals 2.Collect two blood cultures from different IV sites after cleansing with a chlorhexidine swab 3.Collect two early morning nose specimens (swabs) from each naris using sterile culturettes 4.Obtain blood for an interferon-gamma release assay after cleansing with a chlorhexidine swab
Bacteriologic testing is performed in clients with suspected tuberculosis (TB) disease to confirm the diagnosis. An acid-fast bacilli (AFB) sputum smear is examined microscopically for the presence of Mycobacterium tuberculosis (tubercle bacillus), and a culture identifies the growth of the microorganisms. For clients with TB symptoms, a nucleic acid amplification test can be used to rapidly determine the presence of TB. However, to accurately diagnose an active TB infection, three sputum cultures should be collected at 8- to 24-hour intervals, with at least one of the sputum cultures collected in the early morning. Although many tests can determine the presence of TB, AFB sputum culture is the standard for diagnosing active TB infection (Option 1).
Late decelerations
Bad (placental insufficiency) LION
Reactive non-stress test
Baseline of 110-160/min Moderate variability (6-25/min) ≥2 accelerations in 20 minutes, each peaking ≥15/min above baseline & lasting ≥15 seconds
The nurse is preparing to administer medications scheduled at 0900 to a client. Which of the following values should the nurse check prior to administering the medications? Select all that apply. Click the exhibit button for additional inform Medication administration recordAllergies: NoneMedicationsTimeAspirin: 81 mg orally, once daily0900Metoprolol: 50 mg orally, twice daily0900, 1700Quinapril: 10 mg orally, once daily0900ation. 1.Blood pressure 2.Blood glucose level 3.Heart rate 4.INR 5.Potassium level
Before administering medications, the nurse should assess relevant vital signs and laboratory test results. Beta blockers (eg, metoprolol, carvedilol) and angiotensin-converting enzyme (ACE) inhibitors (eg, quinapril, lisinopril, enalapril) are antihypertensive medications. Therefore, the nurse should assess the client's blood pressure prior to administering these medications (Option 1). Beta blockers lower the heart rate by blocking the action of beta receptors that increase heart rate and contractility. Therefore, the nurse should assess the client's heart rate prior to administering beta blockers (Option 3). ACE inhibitors increase serum potassium levels by decreasing urinary potassium excretion. Therefore, the nurse should assess the client's serum potassium level prior to administering ACE inhibitors (Option 5).
A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. 1.Apply a patch to the right eye at night 2.Avoid driving 3.Chew on the left side 4.Maintain meticulous oral hygiene 5.Use a cane on the left side
Bell's palsy is an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. Client teaching should include the following: Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea (Option 1). Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries)
Milia
Benign, keratin-filled cysts that can appear just under the epidermis and have no visible opening. NORMAL NOT ALARMING PREGANCY SIGN
Valium (diazepam)
Benzodiazepine
The nurse has provided education for a client newly prescribed alprazolam for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1."Eliminating aged cheeses and processed meats from my diet is essential." 2."I can skip doses on days that I am not feeling anxious." 3."I will take my daily dose at bedtime." 4."Using sunscreen is important as this drug will make me sensitive to sunlight."
Benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan], clonazepam, diazepam) are commonly used antianxiety drugs. They work by potentiating endogenous GABA, a neurotransmitter that decreases excitability of nerve cells, particularly in the limbic system of the brain, which controls emotions. Benzodiazepines may cause sedation, which can interfere with daytime activities. Giving the dose at bedtime will help the client sleep. (Option 1) Eliminating aged cheeses and processed meats, which contain tyramine, is necessary with monoamine oxidase inhibitors (eg, tranylcypromine, phenelzine), which are used for depressive disorders. It is not necessary with benzodiazepines. (Option 2) A benzodiazepine should never be stopped abruptly. Instead, it should be tapered gradually to prevent rebound anxiety and a withdrawal reaction characterized by increased anxiety, confusion, and more. (Option 4) Photosensitivity is a problem with most antipsychotics and many antidepressants, but not with benzodiazepines.
benzodiazepines and antipsychotics taken together
Benzodiazepines (minor tranquilizers) don't take long to take effect - start working right away Antipsychotics (major tranquilizers) take a while to work well can stop taking benzo once they take effect
The nurse reviews a client's medical record and notes the following PRN medication prescriptions: acetaminophen, haloperidol, and benztropine. The nurse would administer a dose of benztropine on assessing which client behavior? 1.Muscle rigidity and shuffling gait 2.Nihilistic delusions 3.Tangential speech 4.Waxy flexibility
Benztropine is an anticholinergic/antiparkinson medication used to treat extrapyramidal symptoms (EPS), which are serious adverse effects of some antipsychotic medications (eg, haloperidol). EPS can often be managed with a medication or dose change, with some adverse effects decreasing on their own over time. It is important that the nurse recognize manifestations of EPS and quickly intervene when these signs are observed. Key signs of EPS the nurse should identify are: Acute dystonia: involuntary muscle contraction Akathisia: motor restlessness and repetitive movements Pseudoparkinsonism: shuffling gait and muscle rigidity (Option 1) Tardive dyskinesia: uncontrollable rhythmic movements (eg, lip smacking, facial grimacing)
Two medication classes that can potentiate asthma?
Beta blockers NSAIDs (ibuprofen-ketoralac)
A nurse in the cardiac intermediate care unit is caring for a client with acute decompensated heart failure (ADHF). The client also has a history of coronary artery disease and peripheral vascular disease. The nurse is preparing to administer medications. Based on the assessment data, the nurse should question which medication? Click on the exhibit button for additional information. Vital signsBlood pressure110/60 mm HgPulse80/minRespirations22/minOxygen saturation90% on room air 1.Aspirin 2.Atorvastatin 3.Furosemide 4.Metoprolol
Beta blockers, or "lols" (metoprolol, carvedilol, bisoprolol, atenolol), are the mainstay of therapy for clients with chronic heart failure as these improve survival rates for both systolic and diastolic heart failure. However, in certain situations beta blockers can worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility. In this client with acute decompensated heart failure (ADHF), marginally low blood pressure (BP), crackles in the lungs, low oxygen saturation, jugular venous distension (JVD), and peripheral edema, the administration of beta blockers can cause the client to further deteriorate. Beta blockers at low doses may be able to be restarted after this client has stabilized and exacerbation of ADHF has resolved with diuresis.
The nurse in the emergency department is caring for a newborn client who has been vomiting. Which finding may indicate a bowel obstruction? 1.Frequent vomiting since birth 2.Green vomit 3.Tiny streaks of blood in the vomit 4.Vomit coming through the nose
Bile produced by the liver is green and is released into the duodenum when a person is eating to aid digestion. When there is an obstruction in the intestines and stool cannot pass, bile may come back up as green vomit (Option 2). A bowel obstruction is an emergency that can lead to bowel rupture, peritonitis, and sepsis. (Option 1) Newborn clients vomit or spit up frequently as they adjust to eating and digesting food. The lower esophageal sphincter in newborns is loose and allows food to come up from the stomach easily. Hydration status and weight gain should be monitored. (Option 3) Tiny blood streaks may be noted due to rupture of pressured esophageal veins from frequent vomiting. This is not a cause for concern unless the vomit contains a large amount of blood or if blood-streaked vomiting persists. Scant amounts seen in vomit can be normal. Interventions include smaller, more frequent feedings and upright positioning after feedings. (Option 4) In newborns, it is common for vomit to come through the nose because the esophagus is connected to the nose and mouth. Vomit comes up through the esophagus and, if forceful enough, can come out of both the mouth and nose.
High pressure alarms are triggered by?
obstruction kinked tubing pt coughing or fighting the vent mucus in airway water in tube
Newborns of mothers with gestational diabetes mellitus (GDM) are at increased risk for complications during birth and the newborn period, including:
Birth injury (eg, brachial plexus injury, cephalohematoma: Fetal macrosomia (fetal weight >8 lb 13 oz [4000 g]), which is common if maternal GDM was poorly controlled, can result in a difficult birth (eg, shoulder dystocia, forceps- or vacuum-assisted birth) that leads to birth injury (Options 1 and 2). Hypoglycemia: If the fetus experienced hyperglycemia and hyperinsulinemia in utero, then the newborn's pancreas will continue to produce high levels of insulin following birth, potentially resulting in low blood glucose levels (Option 3). Polycythemia (ie, increased RBC production leading to hematocrit >65%): GDM can cause poor placental perfusion leading to chronically impaired fetal oxygenation. As a result, fetal erythropoietin production increases to make more RBCs to improve oxygen delivery. Polycythemia in the newborn causes increased blood viscosity and increases the risk of hyperbilirubinemia when RBCs begin to break down (Option 5).
Infant weight gain
Birth weight doubles by 6 months Birth weight triples by 1 year
The nurse receives laboratory reports on 4 clients. Which report is most concerning and should be reported to the health care provider? 1.The client admitted with asthma exacerbation who has a PaCO2 of 32 mm Hg (4.26 kPa) 2.The client diagnosed with chronic obstructive pulmonary disease whose latest arterial blood gas shows a PaO2 of 85 mm Hg (11.33 kPa) 3.The client receiving warfarin for atrial fibrillation whose morning laboratory report includes an INR of 2.5 4.The client who had a total knee replacement 2 hours ago and whose hemoglobin is 7 g/dL (70 g/L)
Blood loss is a common complication of a total knee replacement, and a hemoglobin level of 7 g/dL (70 g/L) is very low (normal adult male: 13.2-17.3 g/dL [132-173 g/L]; normal adult female: 11.7-15.5 g/dL [117-155 g/L]). This client needs to be assessed for any active bleeding as well as for respiratory and cardiac complications (eg, rapid pulse, shortness of breath) resulting from the low hemoglobin level. The health care provider must be notified. Normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). Clients with asthma exacerbations, as well as those with panic attacks, pulmonary embolism, and pneumonia, will have rapid breathing. In all of these conditions, this rapid breathing pushes more CO2 out of lungs, with a mild decrease in PaCO2 as the body's expected compensatory response. In these clients, retention of CO2 (or even normal PaCO2) is more dangerous as it indicates respiratory muscle fatigue (failure) resulting in retention of PaCO2. (Option 2) PaO2 >80 mm Hg (10.66 kPa) is considered a normal finding. In clients with chronic obstructive pulmonary disease (COPD), airflow out of the lungs is impeded, trapping CO2 in the lungs. The body adjusts to the higher CO2 level (which would cause an increase in respirations in a non-COPD client) and then uses the PaO2 as the drive for breathing. (Option 3) Warfarin is prescribed to prevent blood clotting in clients with atrial fibrillation. To be therapeutic and prevent clotting, the dosage of warfarin is adjusted to maintain an INR of 2-3. This client's INR is therapeutic for the diagnosis of atrial fibrillation.
Acrocyanosis
Blue discoloration of the hands and feet in the newborns during the first few days after birth • Normal finding and not indicative of poor oxygenation, respiratory distress, or cold stress
Chadwick's sign Goodell signs Hegar sign
Bluish purple discoloration of the cervix, vagina, and labia during pregnancy as a result of increased vascular congestion. FIRST Goodell = good and soft - softening of cervix Hegar - uterine softening - softening of lower uterine segment
Tamoxifen (Nolvadex)
Breast cancer medication Hormonal agent Stops growth of estrogen-dependent breast cancer cells Can cause endometrial cancer, hypercalcemia, N/V, PE, hot flushes, vaginal discharge or bleeding Increase Ca and vit D intake
The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply. 1. Client coughs and gasps when swallowing food and liquids 2.Client is easily frustrated while attempting to speak 3.Client is unable to understand speech and is completely nonverbal 4.Client misunderstands and inappropriately responds to verbal instruction 5.Client's speech is limited to short phrases that require effort
Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the") Clients with Broca aphasia are aware of their deficits and can become frustrated easily (Option 2). In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment.
presentation baby
part of baby that enters birth canal first
The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply. 1.Client coughs and gasps when swallowing food and liquids 2.Client is easily frustrated while attempting to speak 3.Client is unable to understand speech and is completely nonverbal 4.Client misunderstands and inappropriately responds to verbal instruction 5.Client's speech is limited to short phrases that require effort
Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the") (Option 5). Clients with Broca aphasia are aware of their deficits and can become frustrated easily (Option 2). In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment. (Option 1) Trouble swallowing, often identified by coughing and gasping when eating and drinking, is dysphagia, which is not related to Broca aphasia. (Option 3) Clients with damage to multiple language areas of the brain may develop global aphasia, resulting in the inability to read, write, or understand speech. This is the most severe form of aphasia. (Option 4) Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern.
Key interventions for a client experiencing a delusion include -
Build trust by being open, honest, genuine, and reliable. Respond to suspicion in a matter-of-fact, empathic, supportive, and calm manner. Ask the client to describe their beliefs. Do not use avoidance. Inquire about the delusion and its content. Never debate the delusional content. Validate if part of the delusion is real. Example - "Yes, there was a package at the nurses' station, but it did not contain a recording device."
CO2 in 50's
pursed lip breathing
Prolapsed cord interventions
push head back and off cord position knee to chest oxygen trendelenburg PREP C section
best toys 1-3 toddler
push pull toy wagon gross motor skills parallel play (alongside but not with) no toys with finger dexterity requirement
DYSPHAGIA what cranial nerve affected?
CN IX Glossopharyngeal CN X vagus tuck chin when eating Modification of food consistency (pureed, mechanically altered, soft) Thickened liquids Having the client sit upright at a 90-degree angle (Option 3) Placing food on the stronger side of the mouth to aid in bolus formation (Option 4) Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis
A CST is indicated for high-risk clients who are in the third trimester
CST requires the client to have contractions either through oxytocin administration or nipple stimulation. Choices A, C, and D are incorrect. The client consuming a liquid with concentrated glucose is not indicated for a CST. This is appropriate for a glucose tolerance test. The results for a CST are interpreted as follows - Positive (abnormal) indicates that late decelerations were present in the FHR in more than 50% of the contractions. Negative (normal) indicates that no late or variable decelerations were evident during the contractions.
The nurse is preparing to administer IV calcium to the client. Which action by the nurse requires follow-up? 1.Administering IV calcium over 15 seconds via IV push 2.Checking the client's blood pressure after administration 3.Flushing the IV site with normal saline after administration 4.Initiating continuous telemetry monitoring prior to administration
Calcium (eg, calcium gluconate, calcium chloride) is administered intravenously to correct severe hypocalcemia in clients who are symptomatic (eg, tetany). Calcium should be administered as a slow IV push over 10-15 minutes. If IV calcium is administered too fast (eg, over 15 seconds), there is an increased risk for cardiac dysrhythmias (eg, bradycardia) and cardiac arrest (Option 1). (Option 2) The nurse should monitor the client's blood pressure after IV calcium administration due to the risk for hypotension. (Option 3) IV calcium is a vesicant (ie, tissue damaging) medication. The nurse should flush the IV with normal saline before and after administration to verify IV patency and to clear the vein of calcium to prevent phlebitis and extravasation (eg, infiltration with a vesicant). (Option 4) The nurse should initiate continuous telemetry monitoring prior to administering IV calcium to monitor the client for potential cardiac arrhythmias from increased calcium levels.
A nurse in the emergency department assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment? 1.Client with abdominal pain, respirations 28/min, and blood alcohol level 80 mg/dL (0.08 mg% [17.4 mmol/L]) 2.Client with chronic obstructive pulmonary disease, pH 7.34, pO2 86 mm Hg (11.5 kPa), pCO2 48 mm Hg (6.4 kPa), and HCO3 30 mEq/L (30 mmol/L) 3.Client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% 4.Client with emesis of 100 mL coffee-ground gastric contents and serum hemoglobin 15 g/dL (150 g/L)
Carbon monoxide (CO) is a toxic inhalant that enters the blood and binds more readily to hemoglobin than oxygen does. When hemoglobin is saturated with CO, the pulse oximeter reading is falsely normal as conventional devices detect saturated hemoglobin only and cannot differentiate between CO and oxygen. The diagnosis of CO poisoning is often missed in the emergency department because symptoms are nonspecific (eg, headache, dizziness, fatigue, nausea, dyspnea) and the pulse oximeter reading often appears within normal limits. A serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%) in smokers. This client with CO poisoning is the highest priority for treatment and requires immediate administration of 100% oxygen to increase the rate at which CO dissipates from the blood to prevent tissue hypoxia and severe hypoxemia (Option 3).
Balcofen (lioresal)
Category: Centrally Acting Muscle Relaxants Indication: Relieves skeletal muscle spasm in spinal cord injury, MS, cerebral palsy MOA: Enhance Inhibitory effect of GABA; CNS relax Side/Adverse Effects: - Drowsiness, Dizziness - Nausea/Constipation causes -fatigue - paresis (muscle weakness) - do not drink alc - no driving - do not supervise kids
The nurse attempts to flush a client's subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion. What should the nurse do next? 1.Flush and lock with heparinized saline flush 2.Flush with normal saline using a 5-mL syringe 3.Notify the health care provider 4.Reposition the client
Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first assess for mechanical, nonthrombotic problems by: Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (Option 4) Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath.
Clinical features of tricyclic antidepressant overdose
Central nervous system Mental status changes (eg, drowsiness, delirium, coma) Seizures, respiratory depression Cardiovascular Sinus tachycardia, hypotension Prolonged PR/QRS/QT intervals Arrhythmias (eg, ventricular tachycardia, fibrillation) Anticholinergic Dry mouth, blurred vision, dilated pupils Urinary retention, flushing, hyperthermia Tricyclic antidepressants (TCAs) (eg, amitriptyline, nortriptyline) are used for treatment-resistant depression and chronic pain (eg, peripheral neuropathy, migraines). Its effects are due to inhibition of norepinephrine and serotonin reuptake. The extensive adverse and toxic effects are due to antagonism of multiple other receptor sites such as histamine and acetylcholine and include: Cardiovascular effects - tachycardia, orthostatic hypotension, and QT prolongation. Central nervous system effects - sedation and, in an overdose, may lead to altered mental status or seizures. Anticholinergic effects - hyperthermia, hypoactive bowel sounds, pupillary dilation, facial flushing, urinary retention, and dry skin and mucous membranes. Decrease in anticholinergic vagal stimulation further contributes to tachycardia. The priority intervention for tricyclic antidepressant (TCA) overdose management is administration of IV fluids and sodium bicarbonate IV. Sodium bicarbonate raises the blood pH, which neutralizes toxic levels of TCAs by reducing the drug's receptor-binding ability. Sodium bicarbonate also increases the extracellular sodium concentration, which helps overcome the sodium channel blockade induced by TCAs. These effects narrow the widened QRS TCAs inhibit gamma-aminobutyric acid (GABA) receptors, lowering the seizure threshold and increasing the risk for seizures, especially in overdose. Benzodiazepines (eg, diazepam, lorazepam) increase the seizure threshold by stimulating GABA receptors. Although administering diazepam is important in TCA overdose, there is currently no seizure activity that would indicate urgent administration.complex and reduce the risk of life-threatening arrhythmias.
Cephalohematoma vs. Caput succedaneum
Cephalohematoma—A collection of blood between the periosteum of a skull bone and the bone itself o Occurs in one or both sides of the head o Occasionally forms over the occipital bone o Develops within the first 24 to 48 hours after birth Caput succedaneum—An edema of the scalp of the neonate during birth from mechanical trauma of the initial portion of scalp pushing through a narrowed cervix o The edema crosses the suture lines o May involve wide areas of the head or it may just be a size of a large egg o Caput Succedaneum (CS)—Crosses Suture line, and Caput Symmetrical
Tamsulosin dutasteride considerations
Change positions slowly Given at bedtime to decrease incidence of hypotension Ask about concurrent use of Saw Palmetto (herb has similar action to tamsulosin) Treats benign prostatic hyperplasia
A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering? 1.Haloperidol for a client with a fall history who keeps getting out of bed without assistance 2.Lorazepam for a client who is in alcohol withdrawal and is extremely agitated 3.Olanzapine for a client with schizophrenia who is exhibiting violent behavior 4.Propofol for a client who is intubated and receiving mechanical ventilation
Chemical restraints are medications (eg, benzodiazepines, psychotropics) used to restrict freedom of movement or to control socially disruptive behavior in clients who have no medical indications for them. Although this client is at risk of injury from falling, the use of a psychotropic drug is not considered the standard treatment for a client with a history of falls who keeps getting out of bed without assistance. The least restrictive method to ensure client safety (eg, bed alarm, sitter, assistive devices) should be tried first before administering a chemical restraint. Therefore, the nurse should question the prescription for haloperidol (Haldol) in this client (Option 1). (Option 2) Benzodiazepines (eg, lorazepam [Ativan], diazepam, chlordiazepoxide) are considered standard treatment to control agitation in the client in alcohol withdrawal. (Option 3) Antipsychotics (eg, olanzapine [Zyprexa], ziprasidone [Geodon], haloperidol) are considered standard treatment to control violent behavior in the client with schizophrenia. (Option 4) Propofol (Diprivan) is considered standard treatment to sedate the client receiving mechanical ventilation to provide ventilator control, prevent accidental extubation, and promote comfort.
differance between gonorrhea - chlamydia - trichomoniasis
Chlamydia is a sexually transmitted infection (STI) caused by the bacteria Chlamydia trachomatis. Infection with chlamydia is frequently asymptomatic; however, clients can develop urethritis (ie, urethral inflammation) or pelvic inflammatory disease (PID) (ie, infection of the cervix, uterus, and fallopian tubes). Urethritis can present with urinary pain and frequency and urethral discharge. PID can present with abdominal pain, mucopurulent cervical discharge, bleeding after intercourse, and a friable/inflamed cervix. Vulvovaginitis is not common. Gonorrhea is an STI caused by Neisseria gonorrhoeae, a bacterial pathogen that most commonly infects the cervix and urethra. Manifestations of cervicitis include profuse, purulent cervical discharge (eg, yellow-green color, odorous) and cervical bleeding with contact (eg, bleeding after intercourse). Urethritis can cause urinary pain and frequency. Vulvovaginitis is not common. Trichomoniasis is an STI caused by Trichomonas vaginalis, a protozoan that most commonly infects the vagina and urethra; however, the cervix can also be infected. Manifestations of vaginitis include thin, frothy, yellow-green vaginal discharge; vulvovaginal erythema, inflammation, and pruritus; dyspareunia (ie, painful intercourse); and bleeding after intercourse. Urethritis can cause urinary pain and frequency.
The nurse is caring for a client receiving chemotherapy. The client is prescribed filgrastim to improve the function of the immune system. Which finding does the nurse anticipate in response to the medication? 1.Decrease in serum uric acid 2.Increase in hemoglobin level 3.Increase in neutrophil count 4.Increase in platelet count
Chemotherapy can cause suppression of rapidly reproducing cells, including bone marrow suppression. This can result in decreased RBCs, WBCs, and platelets, all manufactured in the bone marrow. It is most likely to be seen with chemotherapy (versus radiation), with the lowest counts (ie, the nadir) usually at 7-10 days after therapy initiation. Leukopenia is a decrease in total circulating WBC count (<2,000/mm3 [<2 × 109/L]) and neutropenia is a decrease in circulating neutrophils (<1000/mm3 [<1 × 109/L]). Filgrastim stimulates neutrophil production and is given prophylactically or if the client has an infection and more neutrophils are needed to fight it (Option 3). Option 1) Chemotherapy causes cell lysis, which can result in tumor lysis syndrome due to massive release of nucleic acid and its metabolic product, uric acid. Uric acid deposition leads to acute kidney injury. Medications such as allopurinol or rasburicase and aggressive IV hydration are used to prevent this complication. (Option 2) Anemia (low hemoglobin) is also common with chemotherapy. Epoetin, a form of erythropoietin, stimulates the body to make additional red blood cells. (Option 4) Low platelet count (ie, thrombocytopenia) is not considered critical until it is <20,000/mm3 (<20 × 109/L). Platelet transfusions are given to increase the body's ability to clot blood.
The nurse is caring for a client who just had aortic valve replacement surgery. Which assessment information is most important to report to the health care provider (HCP)? 1.Chest tube output of 175 mL in past hour 2.International Normalized Ratio (INR) of 1.5 3.Temperature of 100.3 F (37.9 C) 4.Total urine output of 85 mL over past 3 hours
Chest drainage >100 mL/hr should be reported to the HCP. Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products. (Option 2) Clients who receive a mechanical valve replacement will be started on anticoagulants. A therapeutic INR is 2.5-3.5. This client just had surgery and so has not received enough anticoagulation to get the INR to a therapeutic level. (Option 3) Although this is an abnormal temperature, it is not as high a priority as the blood loss. The nurse should continue to monitor and administer prescribed postoperative antibiotics. (Option 4) Normal urine output is 30 mL/hr. This urine level is just 5 mL below normal. The nurse should continue to monitor.
A new chest tube collection device is attached and set to water seal suction. Which of the following observations are expected? Select all that apply. 1.Chest tube collection device positioned below the chest tube insertion site 2.Continuous bubbling in the water seal chamber 3.Drainage tube coiled on the floor next to the chest tube collection device 4.Occlusive sterile gauze dressing present over the tubing insertion site 5.Tidaling in the water seal chamber with inspiration and expiration
Chest tube drainage collection containers must always remain upright and be dependent to (lower than) the client's chest to prevent gravitational reflux of any secretions back into the pleural cavity (Option 1). An occlusive sterile gauze dressing should cover the chest tube insertion site. An occlusive dressing (eg, petroleum gauze) protects against infection and prevents atmospheric air from entering the pleural space if a leak is present (Option 4). The water level in the water seal chamber rises with inspiration and falls with expiration due to changes in intrapleural pressure, a process known as tidaling. This movement indicates negative pressure is being maintained. Tidaling is not expected when the device is connected to suction; therefore, the nurse should disconnect suction to assess tidaling (Option 5).
The nurse is admitting an 8-year-old client with suspected Reye syndrome. Which of the following information obtained during admission would be most consistent with the condition? 1.No history of varicella vaccination 2.Previous exposure to lead-based paint 3.Recent exposure to bats 4.Recent influenza infection
Children who develop Reye syndrome often have had a recent viral infection, especially influenza or varicella (ie, chickenpox) (Option 4). Clinical manifestations include fever, lethargy, acute encephalopathy, and altered hepatic function. Elevated serum ammonia levels are an expected laboratory finding. Acute encephalopathy causes vomiting and a severely altered level of consciousness, which can rapidly progress to seizures and/or coma. The risk for Reye syndrome may increase even further if aspirin is used to treat fever associated with varicella or influenza infection. As a result, the use of acetaminophen or ibuprofen for fever management in children has increased significantly.
A client is admitted to the behavioral health unit and diagnosed with acute mania. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe which medication? Correct A. Valproic acid [32%] B. Haloperidol [49%] C. Bupropion [9%] D. Fluoxetine
Choice A is correct. The gold standard for treating bipolar mania is mood stabilizers. Valproic acid (VPA) is a mood stabilizer and is efficacious in treating mania because it has a fast onset. Choices B, C, and D are incorrect. Haloperidol is a first-generation (typical) antipsychotic. The goal for acute mania (or bipolar depression) is mood stabilization. First-generation antipsychotics are not the mainstay of treatment for bipolar disorder. Antidepressants such as fluoxetine and bupropion would be detrimental for a client who is manic. This could exacerbate the mania.
The nurse reviews prescriptions for assigned clients. Which prescription should the nurse question? A. Albuterol via nebulizer for a client with hypokalemia. B. Clozapine for a client with severe schizophrenia. C. Lisinopril for a client with congestive heart failure. D. Verapamil for a client with migraine headaches.
Choice A is correct. Albuterol is a bronchodilator that is used for asthma exacerbations. Adversely, this medication may lower serum potassium levels. The nurse should question this order as this medication may decrease the potassium further. Choices B, C, and D are incorrect. Clozapine is an atypical antipsychotic used in the treatment of severe schizophrenia. Lisinopril is an ACE inhibitor indicated for heart failure and hypertension. Verapamil is commonly used as prophylaxis for migraine headaches; this medication may also be used for individuals with hypertension. Learning Objective Recognize that albuterol can drive potassium into the cells and cause hypokalemia. Additional Info Albuterol is a short-acting bronchodilator. Common side effects of albuterol include tremors, tachycardia, palpitations, and metabolic disturbances such as hypokalemia and hyperglycemia. This medication is emergently indicated for asthma exacerbations. Sometimes, it is used as an adjunctive agent for treating hyperkalemia because it can drive potassium into the cells and lower serum potassium.
The nurse is caring for a client who ingested a lethal dose of aspirin (ASA). Which assessment finding is most concerning? A. Pulmonary edema B. Tinnitus C. Nausea and vomiting D. Tachycardia
Choice A is correct. All of these manifestations are associated with an aspirin overdose. Pulmonary edema is the most concerning and is caused by a lung injury induced by aspirin. A treatment for aspirin overdose is an infusion of sodium bicarbonate to correct metabolic acidosis. During the infusion, the nurse must be sensitive to the potential lung injury caused by aspirin; thus, auscultating lung sounds and assessing for pulmonary edema will be essential. Manifestations of pulmonary edema include tachypnea, tachycardia, and crackles in the lung fields. Choices B, C, and D are incorrect. All of these clinical manifestations are associated with an aspirin overdose. Tinnitus (humming, buzzing, or ringing in the ear) may be transient and is not life-threatening. Nause and vomiting are expected and are concerning because they may lead to hypovolemia. Treatment is parenteral fluids and prescribed anti-emetics. Tachycardia is likely with ASA poisoning because of the electrolyte shift and fluid volume depletion. Cardiac monitoring is the standard of care for this diagnosis.
The client admitted to the gynecology ward for premature labor is given terbutaline to arrest labor. The nurse should monitor which of the following parameters when administering this medication? A. Breath sounds B. Urine output C. Pain D. Level of consciousness
Choice A is correct. Although rare, one of terbutaline's most serious adverse effects is pulmonary edema. The nurse should monitor the client's breath sounds and assess for respiratory crackles and difficulty breathing to detect if pulmonary edema is present. Choice B is incorrect. Terbutaline does not affect a client's urine output. Choice C is incorrect. Terbutaline is a tocolytic agent. It arrests labor and uterine contractions, likely decreasing the client's pain levels. Although the medication may decrease or alleviate the client's labor pain, this is not the nurse's priority assessment. Choice D is incorrect. Terbutaline does not have any effect on a client's level of consciousness. Learning Objective When caring for a client receiving terbutaline to arrest premature labor, recognize the need to assess the client's breath sounds to monitor signs and symptoms of pulmonary edema, an adverse side effect of terbutaline administration. Additional Info If terbutaline-related pulmonary edema develops, the condition will generally develop within 72 hours of the initiation of the drug therapy. Pulmonary edema typically resolves within 24 hours of the discontinuation of the medication.
The nurse is caring for a client who was prescribed prednisone. The nurse should instruct the client to take this medication at what time? Correct A. In the morning [68%] B. Around noon [1%] C. Before bed [6%] D. Anytime, but at the same time every day
Choice A is correct. Corticosteroids should be taken in the morning, preferably before 9 AM. This mimics the natural release of glucocorticoids from the adrenal glands in the morning. Further, corticosteroids have an activating effect that, if taken late afternoon or at night, would cause insomnia. Choices B, C, and D are incorrect. Prednisone is a corticosteroid and has an activating effect. The client should take this medication at the same time every day, preferably in the morning, to avoid a disturbed sleep pattern. Additional Info ✓ Corticosteroids are the mainstay treatment in an array of disease exacerbations such as multiple sclerosis, rheumatoid arthritis, asthma, and lupus. ✓ The nurse should instruct the client to take the medication in the morning with food ✓ Take the steroid as prescribed, do not self-discontinue, and anticipate weight gain. ✓ To prevent the development of ulcers, the nurse should instruct the client not to take any NSAIDs, such as ibuprofen or naproxen, while on the steroid.
The nurse is educating a new nurse working on the pediatric unit about the causes of bacterial tonsillitis in children. Which of the following is the most common cause of bacterial tonsillitis? Correct A. Group A beta hemolytic streptococcus B. Streptococcus pneumoniae C. Group B Streptococcus D. Neisseria meningitidis
Choice A is correct. Group A beta hemolytic streptococcus is the most common cause of bacterial tonsillitis. Choice B is incorrect. Streptococcus pneumoniae is a gram-positive bacterium that causes pneumonia; this bacterium does not cause tonsillitis. Choice C is incorrect. Group B Streptococcus is a type of bacteria sometimes found in a pregnant woman's vagina or rectum; this bacterium does not cause tonsillitis. Choice D is incorrect. Neisseria meningitidis is a gram-negative bacterium that causes meningococcal diseases such as meningitis; this bacterium does not cause tonsillitis.
The nurse is performing medication reconciliation for a client with Parkinson's disease. Which medication should the nurse question with the primary healthcare provider (PHCP)? Correct A. Haloperidol [63%] B. Levodopa-carbidopa [12%] C. Pramipexole [13%] D. Ropinirole
Choice A is correct. Haloperidol is a typical antipsychotic indicated in treating schizophrenia and other psychotic disorders. This medication antagonizes dopamine which is lacking in a client with Parkinson's disease. Thus, this medication would be questioned. Antipsychotics may be used in a client with Parkinson's disease because the progression of the disease often brings about hallucinations and delusions. However, an atypical antipsychotic such as pimavanserin or quetiapine is often utilized because it does not block as much dopamine. Choices B, C, and D are incorrect. All of these medications are indicated for Parkinson's disease. Levodopa is a typical medication used to treat Parkinson's disease and is commonly combined with carbidopa. Ropinirole and Pramipexole are dopamine agonists used to treat Parkinson's disease.
The nurse is caring for a client who has sickle cell disease (SCD). Which prescription from the primary healthcare provider (PHCP) should the nurse anticipate? Correct A. Hydroxyurea [43%] B. Methotrexate [31%] C. Nortriptyline [13%] D. Verapamil
Choice A is correct. Hydroxyurea is an effective treatment for SCD. This medication increases fetal hemoglobin and decreases hemoglobin S. By increasing fetal hemoglobin, the sickling effect can be reduced, and oxygen carrying capacity can be improved. Choices B, C, and D are incorrect. Methotrexate is a medication indicated to treat autoimmune conditions such as rheumatoid arthritis. Nortriptyline is a tricyclic antidepressant (TCA) with significant anticholinergic properties and would be detrimental to the management of SCD. Verapamil is a calcium channel blocker and is utilized in the management of hypertension and other vascular disorders. Additional Info Hydroxyurea is an efficacious medication used in the management of sickle cell disease (SCD). This medication has been shown to decrease vaso-occlusive events and therefore reduce hospitalization. Adversely, this medication increases the risk of leukemia, myelosuppression, alopecia, and other malignancies.
The nurse is caring for a client with a potassium of 3.1 mEq/L(3.5-5 mEq/L). The primary healthcare provider (PHCP) prescribed 40 mEq of intravenous (IV) potassium over four hours. Which assessment finding would indicate a therapeutic effect? A. Normoactive bowel sounds B. Flattered T-waves C. Reduced deep tendon reflexes D. Muscle cramping
Choice A is correct. Hypokalemia (potassium less than 3.5 mEq/l) produces manifestations such as hypoactive bowel sounds, muscle cramping, weakness, and electrocardiogram changes such as flattened T-waves. Bowel sounds that are normoactive indicate a therapeutic finding because of the restoration peristalsis. Choices B, C, and D are incorrect. These manifestations following the potassium infusion would not be therapeutic because they are consistent with hypokalemia. A therapeutic finding would indicate that the manifestations of hypokalemia have abated. Additional Info When replacing potassium intravenously: ✓ Ensure that the client is connected to continuous cardiac monitoring. ✓ IV potassium should be administered via a controlled device such as a pump. ✓ The IV site must be patent and assessed for patency before administration. ✓ Potassium should be administered at a maximum of 10 mEq/L/hr peripherally; 40 mEq/L/hr in a central line.
The nurse is caring for a client experiencing labor dystocia. Which medication does the nurse anticipate from the primary healthcare provider (PHCP)? A. Oxytocin B. Terbutaline C. Magnesium sulfate D. Betamethasone
Choice A is correct. Labor dystocia is a broad term indicating difficult labor that is not progressing. One of the medications that may be used to assist in labor progression is oxytocin. This medication stimulates uterine contractions. Choices B, C, and D are incorrect. Terbutaline is a tocolytic and is used to suppress uterine contractions. This medication would further decrease the progress of labor. Magnesium sulfate is a medication used in preterm labor to help stop contractions. It would be contraindicated in the client experiencing labor dystocia. Betamethasone is a steroid administered to mothers in preterm labor to help the development of the fetus's lungs in anticipation of preterm delivery. This medication is not indicated for labor dystocia. Additional Info Labor dystocia describes difficult labor that does not progress as expected. During labor dystocia, uterine contractions are not effective or infrequent. Management of labor dystocia includes Administration of intravenous (IV) or oral fluids to correct any electrolyte imbalances. Frequent maternal position changes. Standing or sitting in a warm shower can be therapeutic. Pain management is important; however, epidural blocks decrease labor progress. Prescriptive treatments such as oxytocin may be used.
A 56-year-old female client presents to the emergency department (ED) who reports dyspnea, fatigue, and indigestion. The nurse should take which priority action? A. Obtain a 12-lead electrocardiogram B. Provide supplemental nasal cannula oxygen C. Established intravenous (IV) access D. Auscultate lung sounds
Choice A is correct. Obtaining a 12-lead electrocardiogram is the priority as the client is exhibiting classic symptoms of acute coronary syndrome (ACS). Women over the age of 50 are at a higher risk of developing this potentially fatal syndrome. Women may exhibit manifestations other than substernal chest pain. The ECG will help determine if the client has a STEMI or an NSTEMI.
The nurse is caring for a client with hypokalemia scheduled to receive the prescribed 20 mEq of intravenous (IV) potassium. Which client assessment requires notification of the primary healthcare provider (PHCP)? A. Oliguria B. Abdominal distention C. Muscle weakness D. Weak peripheral pulses
Choice A is correct. Oliguria is a contraindication to the administration of IV potassium. Parenteral potassium is highly concentrated, and this may cause life-threatening hyperkalemia. Choices B, C, and D are incorrect. The manifestations of hypokalemia include abdominal distention, hypoactive bowel sounds, muscle weakness, weak peripheral pulses, and confusion. ECG changes associated with hypokalemia include ST-segment depression and an increase in the amplitude of the U wave.
A 38-week pregnant woman comes into the emergency department complaining of vaginal bleeding. The client is not in obvious distress or pain. Which statement by the client would lead the nurse to suspect placenta previa? A. "I don't feel any pain at all. It's just the bleeding that concerns me. B. "I feel like I'm about to go into labor. My tummy is starting to contract." C. "I started bleeding when I picked up my 3-year-old son, who weighs 32 pounds." D. "I feel like I'm about to vomit."
Choice A is correct. Placenta previa typically manifests as painless vaginal bleeding after 20 weeks gestation. Choice B is incorrect. The client's statement's regarding contractions (including the implied pain associated with contractions) do not correlate with the symptoms of placenta previa. This client's comments would likely lead the nurse to assume this client is in early labor. Choice C is incorrect. With placenta previa clients, bleeding is not necessarily correlated with lifting heavy objects. Choice D is incorrect. Nausea is not typically associated with placenta previa. Typically, nausea is more common in early pregnancy than in late pregnancy. Learning Objective Associate a client's painless vaginal bleeding in the 38th week of pregnancy with a suspected diagnosis of placenta previa. Additional Info Placenta previa occurs when the placenta implants over or near the internal os of the cervix. In clients with placenta previa, the source of bleeding is maternal. Diagnosis is performed by ultrasonography. Treatment is modified activity if minor vaginal bleeding occurs before 36 weeks gestation, with cesarean delivery at 36 to 37 weeks, 6 days. Immediate cesarean delivery is indicated if the bleeding is severe or refractory or if the fetal status is nonreassuring.
The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following? A. Prepares to administer intravenous valproate. B. Places the client in a lateral position. C. Activates the rapid response team (RRT). D. Loosens any restrictive clothing.
Choice A is correct. This action requires follow-up because, during an acute seizure or status epilepticus, intravenous benzodiazepines such as lorazepam, diazepam, or midazolam should be promptly administered to this client. These medications help terminate the seizure. IV antiepileptics such as valproate, topiramate, and phenytoin should be used secondary only after the acute seizure has terminated. Thus, a medication used to prevent seizure reoccurrence rather than medication used to terminate a seizure is not the priority. lorazepam, diazepam, or midazolam TERMINATE SEIZURE RIGHT AWAY
The nurse is discussing ocular disorders with a group of nursing students. Which of the following statements would be correct for the nurse to make? Select all that apply. 1/2 Your Score/Max +/- Scoring Rule Cataracts are caused by increased ocular pressure (IOP). Graves' disease may cause exophthalmos. Macular degeneration is manifested by loss of peripheral vision. Angle-closure glaucoma is manifested by headache and eye pain. Hyphema results in increased aqueous humor in the anterior chamber.
Choice B and D are correct. Graves' disease may cause a client to develop exophthalmos. Angle-closure glaucoma is a medical emergency where the IOP is greater than 30 mmHg, and the client has manifestations such as eye pain, headache, blurred vision, and reddened eye appearance. Choices A, C, and E are incorrect. Increased IOP is a central feature of glaucoma. Cataracts is a disorder of the lens as it causes the client to have difficulty discriminating colors and seeing in low light. Opacities can commonly be seen in the affected eye. Macular degeneration causes central vision loss, not vision loss in the peripheral fields. A hyphema is caused by blood in the eye's anterior chamber. NCLEX Category: Physiological Adaptation Activity Statement: Illness management Question type: Analysis Additional Info In managing a hyphema and angle-closure glaucoma, the nurse should be aware of the following: A hyphema is an ocular emergency that has been caused by blood in the anterior chamber. This injury results from trauma and should be addressed promptly with interventions such as elevating the head of the bed to 30 degrees and shielding the affected eye. Angle-closure glaucoma is an ocular emergency that requires the client to receive prescribed agents such as timolol to lower intraocular pressure. The client should be placed supine, which will assist in the lens falling away from the iris, decreasing the pupillary block.
The nurse identifies that one of her clients will need education on caring for their stoma and instruction on self-catheterization by three weeks post-op. Based on this information, what urinary diversion methods does this client have? A. Vesicostomy B. Kock Pouch C. Ileal Conduit D. Condom Catheter
Choice B is correct. A Kock pouch is an internal urinary reservoir made from the terminal ileum. This is created during the continent urinary diversion (continent urostomy) procedure. The urine diverts to and gets stored in the pouch. Postoperatively, the client will have an indwelling urinary catheter to drain urine continuously until the pouch has healed. This catheter will require irrigation. Clients will then perform self-catheterization every 4 to 6 hours to empty this internal pouch and for urinary diversion. Choices A, C, and D are incorrect. Clients do not perform self-catheterization with a vesicostomy, ileal conduit, or condom catheter. In a vesicostomy, urine empties through a stoma into an externally placed collection pouch (Choice A). In an ileal conduit, the urine flows into the conduit and is continually propelled out through the stoma by peristalsis. An ileal conduit is, therefore, an incontinent urinary diversion procedure. An external collection pouch will have to be worn at all times (Choice C). A condom catheter is a non-invasive device placed externally on the male penis. When the man urinates, gravity propels the urine through a tube to a collection bag (Choice D). Learning Objective Utilize the objective information provided to determine which urinary diversion method the client has in place. Additional Info The urinary diversion methods mentioned below may be utilized due to bladder removal (usually from cancer), interstitial cystitis, painful bladder syndrome, incontinence after trauma or surgery, neurogenic bladder, congenital anomalies, strictures, bladder trauma, chronic bladder inflammation, etc. Vesicostomy: the bladder is sutured to the abdomen, and a stoma is created in the bladder wall. The bladder then empties through the stoma. This procedure is primarily performed on children who void into a diaper. Kock pouch: is a continent internal ileal reservoir created from a segment of the ileum and ascending colon. The ureters are implanted into the side of the reservoir, and a valve is constructed to prevent the backflow of urine. Postoperatively, the client will have an indwelling catheter to drain until the pouch heals continuously. After it heals, the client can intermitt
The new registered nurse (RN) is caring for a preschool-aged pediatric client in the pediatric ward under the supervision of a nurse educator. Which statement by the new RN indicates to the nurse educator that the new RN understands how to provide age-appropriate care to the preschooler? A. "We can convince the preschooler to cooperate with us by providing a thorough explanation of the procedure." B. "We need to ensure that the preschooler doesn't feel threatened about being hurt during nursing care by explaining what we are doing and assessing understanding." C. "We can make the preschooler more cooperative by involving them in competitive games." D. "The preschooler should not wait to have their needs met."
Choice B is correct. A preschool-age client has many fears at this stage. One concern at this age is the fear of pain or, more specifically, mutilation. For children who possess this specific fear, it is essential that the nurse repeatedly stress the reason for a procedure and evaluate the pediatric client's understanding. For example, explaining cast removal to a preschooler client may seem simple enough, but the child's comprehension of the details may vary considerably from the explanation. Choice A is incorrect. Preschoolers increasingly use language without comprehending the meaning of words. Therefore, the nurse should provide a simple explanation to the child, not a thorough explanation, as preschool children are only capable of simple reasoning. Choice C is incorrect. Various types of play are typical of the preschool period, but children in this age group especially enjoy associative play (i.e., group play in similar or identical activities but without rigid organization or rules). Therefore, involvement in competitive games or sports is not typical at this age. Choice D is incorrect. The ability to tolerate delayed gratification typically begins during toddlerhood. During the preschool years, the child should be able to handle increased periods of delayed gratification. There is no specific need to provide instant gratification during the preschool years. Learning Objective When caring for a preschool-aged pediatric client in the pediatric ward under the supervision of a nurse educator, correctly identify, "[w]e need to ensure that the preschooler doesn't feel threatened about being hurt during nursing care by explaining what we are doing and assessing understanding" as the statement by the new RN to the nurse educator that indicates the new RN understands how to provide age-appropriate care to the preschooler. Additional Info Preschoolers assume that everyone thinks as they do and that a brief explanation of their thinking makes the entire thought understood by others. For children in this age group, the most enlightening and effective method is play, which becomes the child's way of understanding, adjusting to, and working out life's experiences.
The nurse is performing an initial assessment on a patient being admitted for acute pancreatitis. Which assessment data would support this diagnosis? A. Homan's sign B. Cullen's sign C. Hyperactive bowel sounds D. Kernig's sign
Choice B is correct. Cullen's sign refers to the bluish periumbilical discoloration/ecchymosis that is common in acute pancreatitis. The discoloration occurs due to blood-stained exudates seeping from the pancreas. Pancreatitis = Cullen's sign Choice A is incorrect. A positive Homan's sign (pain in the calf with foot dorsiflexion) would indicate the presence of a DVT, not pancreatitis. Choice C is incorrect. A patient with acute pancreatitis would present with hypoactive (decreased) bowel sounds, not hyperactive. Choice D is incorrect. A positive Kernig's sign indicates possible subarachnoid hemorrhage or meningitis. It would not support the patient's acute pancreatitis diagnosis
The nurse is assessing clients for the risk of developing Cushing's syndrome. The nurse should identify which client is at greatest risk for this syndrome? A client A. recently diagnosed with hyperpituitarism and high blood pressure. B. who has been taking prednisone for 2 years to treat rheumatoid arthritis (RA). C. who has a goiter, and is receiving propranolol and propylthiouracil (PTU). D. experiencing eczema and is prescribed a seven-day course of topical hydrocortisone.
Choice B is correct. Cushing's syndrome is characterized by chronic exposure to a glucocorticoid. This is oftentimes referred to as secondary Cushing's syndrome. This client has been on a steroid for two years, and considering the long duration, this client is at the highest risk of developing this syndrome. thinning hair moon face increased facial hair red cheeks acne increased weight stretch marks thin skin easy bruising fat around neck buffalo hump CNS irritability osteoporosis thin extremities slow healing fluid retention hyperglycemia
chest tube falls damages system and tube falls off system what do you need to do?
put the distal end of the tube into sterile water water seal - tidaling and sometimes intermittent bubbling suction control chamber - continuous bubbling
The nurse is caring for a client who is receiving prescribed doxorubicin. Which of the following findings would warrant immediate follow-up? A. Anorexia B. Fever C. Alopecia D. Malaise
Choice B is correct. Doxorubicin is an antineoplastic that may cause pancytopenia. Pancytopenia is when the client has low WBCs, RBCs, and platelets. The significant leukopenia caused by this medication makes the client quite susceptible to infection. A fever for a client receiving an antineoplastic is highly concerning because it could indicate infection. Choices A, C, and D are incorrect. Common effects of antineoplastics, including doxorubicin, are anorexia, alopecia, and malaise. These are expected findings and are not life-threatening compared to a fever which may be a warning sign of a systemic bacterial, viral, or fungal infection.
Which of the following medications may be prescribed to control hypertension associated with a nephroblastoma? Incorrect Correct Answer(s): B A. Propranolol [36%] B. Enalapril [38%] C. Nitroprusside [22%] D. Digoxin
Choice B is correct. Enalapril is an ACE inhibitor used to lower blood pressure. Since clients with nephroblastoma are hypertensive due to increased renin levels, this medication is commonly prescribed to decrease their blood pressure. Any ACE inhibitor reduces blood pressure by inhibiting the formation of angiotensin II in the renin-angiotensin-aldosterone system (RAAS), so they are an excellent choice for treating hypertension caused by nephroblastoma. While ACE-I's may be nephrotoxic, this is still the recommended treatment and is therapeutic as long as the creatinine levels are monitored closely. Choices A, C, and D are incorrect. Propranolol is a beta-blocker used to slow the heart rate. While it can decrease blood pressure in specific client populations, it is not prescribed to clients with nephroblastoma to reduce their hypertension. Nitroprusside is a direct-acting vasodilator. This means it acts on the muscles of your blood vessels to dilate them, lowering the blood pressure. While this drug also lowers blood pressure, it is not the right choice for hypertension associated with nephroblastoma. It does not address the RAAS, which causes hypertension in clients with nephroblastoma. Digoxin is a cardiac glycoside. It increases the force of contraction of the muscle of the heart and is commonly prescribed to clients with heart failure. It would not be administered to clients with a nephroblastoma to lower their blood pressure.
The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication? Incorrect Correct Answer(s): B A. Diabetes insipidus [25%] B. Cushing's syndrome [27%] C. Hemophilia [40%] D. Inflammatory bowel disease
Choice B is correct. Excessive corticosteroids characterize Cushing's syndrome. Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence. Choices A, C, and D are incorrect. Diabetes insipidus would not increase the risk of wound disruption, whereas diabetes mellitus would increase the risk of poor wound healing, especially if the diabetes is uncontrolled. Hemophilia is a genetic blood clotting disorder and does not directly cause poor wound healing. Inflammatory bowel disorder is a broad term for Crohn's or Ulcerative Colitis. These conditions do not directly lead to poor wound healing like Cushing's syndrome.
The nurse is caring for a newborn with erythroblastosis fetalis. The nurse understands that this disease is characterized by A. excessive red blood cell production that requires therapeutic blood donation. B. incompatibility between maternal and fetal blood. C. an excessive amount of circulating white blood cells (WBC). D. erythrocytes become shaped like a sickle and sensitive to hypoxia.
Choice B is correct. Infants with erythroblastosis fetalis are anemic from the destruction of RBCs. Severely affected infants may develop hydrops fetalis, a severe anemia resulting in heart failure and generalized edema. This hemolysis stems from maternal-fetal blood incompatibility. Choices A, C, and D are incorrect. Polycythemia vera is characterized by excessive red blood cell production that requires therapeutic blood donation. Excessive WBCs would be leukocytosis which is a non-specific indicator of possible infection or inflammation. Sickle cell anemia fits the description of erythrocytes becoming shaped like a sickle and sensitive to hypoxia.
The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first? A. Administer prescribed ibuprofen. B. Place the client on droplet precautions. C. Notify the public health department. D. Obtain prescribed blood cultures.
Choice B is correct. Initiating droplet precautions is a high priority for this client. The classic bacterial meningitis triad is fever, neck stiffness, and altered mental status. The nurse must protect the other clients and staff from disease transmission. Thus, the nurse should initiate droplet precautions by placing the client in a room with all visitors and staff wearing surgical mask in the client's presence. Choices A, C, and D are incorrect. Medications to lower fever, such as acetaminophen or ibuprofen, would be helpful for a client with bacterial meningitis. If bacterial meningitis is confirmed, the public health department must be notified to initiate contact tracing. However, these actions are not a higher priority than the safety and infection control of the clients and staff within the ED. Learning Objective Recognize that placing a bacterial meningitis patient on droplet isolation precautions is a priority to protect the staff and other visitors in the ED. Additional Info Neisseria meningitidis is a common cause of bacterial meningitis in children and adolescents. Symptoms classically have an abrupt onset and include headache, fever, nuchal rigidity, photophobia, and myalgias. The nurse's immediate concern is to protect the safety of the staff and the other clients by placing the client in isolation with droplet precautions. Treatment for N. meningitidis includes prompt initiation of antibiotics such as ceftriaxone.
A nurse is caring for a client taking sildenafil. While reviewing the client's other medications, which medication requires follow-up? A. Furosemide B. Isosorbide C. Atorvastatin D. Losartan
Choice B is correct. Isosorbide is a nitrate medication and should not be taken concurrently with phosphodiesterase inhibitors such as sildenafil. The combination of the two may result in profound hypotension. Phosphodiesterase inhibitors such as sildenafil, tadalafil, and vardenafil are indicated to treat erectile dysfunction and pulmonary hypertension. The client should not take these medications concurrently with isosorbide, a nitrate, because of the serious hypotension that may develop.
Projectile vomiting hungry after feeding palpable olive shaped mass
pyloric stenosis
olive shaped epigastric mass
pyloric stenosis
The nurse is preparing to administer the prescribed mannitol. The nurse plans to administer the infusion using Incorrect Correct Answer(s): B A. microdrip intravenous tubing. [36%] B. filtered intravenous tubing. [40%] C. vented intravenous tubing. [14%] D. non-vented intravenous tubing.
Choice B is correct. Mannitol is an osmotic diuretic indicated for cerebral edema. Mannitol may crystallize when exposed to low temperatures. Because of this, mannitol is always administered intravenously through intravenous tubing with a filter. Choices A, C, and D are incorrect. These tubing choices are incorrect and should not be used for mannitol administration. Micro drip tubing is utilized when precise amounts of fluid need to be administered. For this tubing, 60/gtts = 1 mL of fluid. Vented tubing is helpful to progress the infusion of fluids (or medication). The vent allows air to enter the container and displace the medication or solution as it's infused. Non-vented tubing creates a vacuum that allows the container to shrink or collapse as the fluid drains from the container. Additional Info ✓ Mannitol is used in treating patients in the early oliguric phase of acute renal failure. ✓ For it to be effective in this setting, however, enough renal blood flow and glomerular filtration must remain to enable the drug to reach the renal tubules. ✓ Mannitol can also promote the excretion of toxic substances, reduce intracranial pressure, and treat cerebral edema. ✓ The normal intracranial pressure is 10-15 mm Hg.
An emergency department nurse receives a 10-year-old pediatric client with nuchal rigidity, fever, and a positive Kernig sign. Which of the following should be the nurse's priority? Incorrect Correct Answer(s): B A. Give a client a tepid sponge bath [3%] B. Arrange for the client to be placed in respiratory isolation using droplet precautions [75%] C. Prepare the client for a lumbar puncture [18%] D. Refer the case to infection control
Choice B is correct. Meningitis should be suspected based on this client's fever symptoms and signs of meningitis with nuchal rigidity (as indicated by a positive Kernig sign). Until the etiology is clear, the pediatric client must be placed in respiratory isolation using droplet precautions to prevent the spread of the disease to other individuals. Suspected bacterial meningitis cases warrant placing the client on droplet isolation. All transmission-based precautions must be implemented based on clinical suspicion and immediately on presentation of the client to a health care facility. Diagnosis often requires laboratory confirmation with culture data techniques that require an extended period before the result; therefore, droplet precautions should be implemented while these tests are still pending. Choice C is incorrect. A lumbar puncture is performed to obtain cerebrospinal fluid (CSF) for analysis, the mainstay of diagnosis. However, the priority nursing action is to place the client in respiratory isolation using droplet precautions upon suspicion of meningitis and arrange for diagnostic procedures once the client has been placed in isolation.
The nurse is caring for a client who is receiving newly prescribed prednisone. Which of the following medications should the client avoid while receiving this medication? A. Valsartan B. Naproxen C. Omeprazole D. Acetaminophen
Choice B is correct. Naproxen should not be administered concomitantly with corticosteroids. These two medications taken together will increase the risk of gastrointestinal bleeding. Choices A, C, and D are incorrect. Valsartan, omeprazole, and acetaminophen should be administered concomitantly with corticosteroids. Acetaminophen is highly preferred over non-steroidal anti-inflammatory drugs (NSAIDs) because it does not raise the risk of gastrointestinal bleeding. Additional Info Corticosteroids may cause an array of adverse effects while they mitigate inflammation. This includes peptic ulcer disease, edema, hypokalemia, hyperglycemia, and hypernatremia. The client should be educated to maintain a low sodium and high potassium diet while taking prednisone, if not contraindicated.
The nurse is caring for a client who has influenza. Which of the following prescriptions may be prescribed by the primary healthcare provider (PHCP)? Incorrect Correct Answer(s): B A. Valacyclovir B. Oseltamivir C. Azithromycin D. Omeprazole
Choice B is correct. Oseltamivir is an antiviral agent approved for the treatment of influenza. This medication should be initiated within 48 hours of symptom onset. Choices A, C, and D are incorrect. Valacyclovir is an antiviral indicated in the treatment of the herpes virus. This medication does not have efficacy in influenza. Azithromycin is an antibiotic quite effective for respiratory infections; this medication is not used in influenza infections. Omeprazole is a proton pump inhibitor (PPI) indicated for treating peptic ulcer disease and gastric reflux. Additional Info ✓ Influenza is a highly contagious respiratory infection primarily spread by infected respiratory droplets ✓ Appropriate infection control includes isolating the client using droplet precautions. This includes staff and visitors wearing a surgical mask within three feet of the client. Meticulous hand hygiene should be reinforced, including alcohol-based hand sanitizers before and after client care. ✓ Medical management aims to provide symptomatic care by using prescribed antipyretics and encouraging PO (by mouth) fluids. Antivirals may be used to shorten the duration of the illness; the guideline is to initiate oseltamivir 48 hours within influenza symptom onset.
The nurse is caring for a client who sustained an ischemic cerebrovascular accident (CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg. The nurse should take which action? A. Place the client supine B. Continue to monitor Obtain orthostatic blood pressure D. Request a prescription for an antihypertensive
Choice B is correct. Permissive hypertension during an ischemic stroke allows the blood pressure to go up to 185/110 mm Hg. This enables perfusion around the stroke to distal tissue. Thus, the nurse will continue to monitor because the blood pressure of 168/101 mmHg does not meet the threshold to notify the PCP. A blood pressure of 150/100 mm Hg is needed to maintain cerebral perfusion after an acute ischemic stroke. Choice A, C, and D are incorrect. Placing the client supine during a stroke is contraindicated because of its increase in intracranial pressure. Orthostatic blood pressure is not indicated and is usually performed if hypovolemia could cause hypotension, not hypertension. An antihypertensive is not necessary based on this blood pressure. Additional Info Labetalol is a common antihypertensive used when a client has an ischemic stroke and has a blood pressure greater than 185/110 mm Hg.
This nurse is caring for a client who is receiving prescribed sitagliptin. The nurse understands that this medication is intended to treat which condition? Incorrect A. Hyperlipidemia B. Diabetes mellitus C. Hypothyroidism D. Hypertension
Choice B is correct. Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood. Choices A, C, and D are incorrect. Sitagliptin is not indicated for hyperlipidemia, hypothyroidism, or hypertension. ✓ Medications used to treat hyperlipidemia would be statin medications. ✓ Medications used to treat hypothyroidism would be levothyroxine. ✓ Medications used to treat hypertension would be lisinopril, diltiazem, propranolol, or candesartan. Additional Info Sitagliptin is a treatment that may be prescribed for type II diabetes mellitus ✓ Persistent abdominal pain should be reported because pancreatitis is the major adverse effect of this medication. ✓ Other medications in this class include linagliptin, saxagliptin, and alogliptin.
The nurse is assessing a client taking prescribed lamotrigine. Which client finding requires immediate follow-up? A. Abnormal dreams B. Skin blistering C. Dyspepsia D. Xerostomia
Choice B is correct. Skin blistering associated with lamotrigine therapy is a critical finding to report. This is a feature of Steven-Johnson syndrome (SJS). Lamotrigine has been implicated as causing this adverse finding. Choices A, C, and D are incorrect. Lamotrigine may cause alteration in the mood either intentionally or unintentionally. The indication for this medication is epilepsy or bipolar disorder. Abnormal dreams are a common effect associated with this medication but are not highly concerning compared to skin blistering, which is consistent with SJS. Dyspepsia (painful digestion) and xerostomia (dry mouth) are not priority effects that should be reported as they are not life-threatening. ADDITIONAL INFO ✓ Lamotrigine is a mood stabilizer and antiepileptic. ✓ This medication is indicated for bipolar disorder and epilepsy. ✓ This medication may adversely cause SJS, manifested by tender skin lesions that appear as blisters. ✓ These skin eruptions may also involve the eyes and mouth. ✓ Prompt treatment is necessary because of the risk of sepsis that may result from skin erosion. ✓ These lesions often spread fast, underlining the necessity of prompt treatment. If this should occur, the offending agent should be withdrawn.
The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe? A. Isoniazid B. Colchicine C. Allopurinol D. Warfarin
Choice B is correct. The initial treatment for acute pericarditis includes NSAIDs or colchicine. Pericarditis is an inflammatory condition of the pericardium that causes a client to experience chest pain, pericardial friction rub heard on auscultation and leukocytosis. Colchicine reduces the inflammation in the pericardium and may be prescribed for several weeks to achieve efficacy. Corticosteroids may be used as an adjunctive treatment. Choices A, C, and D are incorrect. Isoniazid is indicated for pulmonary tuberculosis, allopurinol is indicated for gout, and warfarin is an anticoagulant used to prevent thrombosis. Additional Info ✓ Acute pericarditis can be managed with NSAIDs, colchicine, or glucocorticoids ✓ Major side effects of colchicine include gastrointestinal upset, which may be mitigated by taking this medication with food ✓ Colchicine may be added to NSAID therapy adjunctively to maximize treatment response ✓ Colchicine is commonly used in acute gouty episodes to treat the significant inflammation
A client with episodes of vertigo who has a fractured leg has been ordered crutches and not to bear weight on the affected extremity. The most appropriate crutch-walking gait the nurse should teach the client is the A. Two-point gait B. Three-point gait C. Four-point gait D. Swing-through gait
Choice B is correct. The three-point gait is most appropriate because the client is of non-weight bearing status on the affected leg. In a three-point gait, the client bears weight on both crutches and then the unaffected leg. This gait is also appropriate because it is slower than the swing-through gait, which requires more balance and is faster. The two-point gait requires at least partial weight bearing on each foot. This gait would be inappropriate because the client is instructed to have non-weight bearing status on the affected leg. The four-point, gait gives stability to the client but requires weight-bearing on both legs. This gait would be inappropriate because the client has non-weight bearing status ordered to the affected extremity. If the client has complete paralysis of the hips and legs, the swing-to gait or swing-through gait is utilized. While a swing-to gait may be utilized if the client has a non-weight bearing status of an extremity, this would not be recommended because the client has a history of vertigo. The swing-through gait requires the client to swing forward as a pendulum, which may increase their risk of falling.
While performing a cardiovascular assessment on an infant at 2 hours of life, you note the following: Normal sinus rhythm HR = 178 Systolic murmur +1 pedal pulses +3 radial pulses 5 second capillary refill No edema What is the priority nursing action after this assessment? A. Continue to monitor B. Notify the health care provider C. Administer PRN acetaminophen D. Re-evaluate the patient in one hour
Choice B is correct. This patient is displaying signs and symptoms of congenital heart disease; specifically coarctation of the aorta. Even if you did not know which congenital heart disease they may have, you would be expected to know that the healthcare provider needs to be notified of these symptoms. Your patient is in normal sinus rhythm and has a normal heart rate for the newborn age group. The systolic murmur, the gradient in peripheral pulses, and 5 second capillary refill are all abnormal. The murmur indicates that there is an opening somewhere in the heart where there should not be. This could be an ASD, VSD, or one of the bypasses in fetal circulation (the ductus arteriosus or foramen ovale) may not have closed on their own. The gradient in pulses indicates that there is more blood flow in the top half of the body than in the lower half - this is what points to coarctation of the aorta. A capillary refill time of 5 seconds is the last abnormal sign for this patient. Capillary refill should be less than 3 seconds in a newborn - delayed capillary refill indicates poor perfusion and must be addressed quickly. It is important to recognize that these are abnormal signs and symptoms and need to be reported to the health care provider for prompt intervention. pulses differant can mean COARCTION OF AORTA
The nurse is caring for a client in labor who is positive for the human immunodeficiency virus (HIV). The nurse should obtain a prescription for which medication? A. valacyclovir B. zidovudine C. amphotericin b D. metronidazole
Choice B is correct. Zidovudine (ZDV) is an antiretroviral medication that may be administered intrapartum to further reduce vertical transmission of HIV. This medication is commonly indicated for women who have a scheduled cesarean delivery or, in the rare instance of a vaginal delivery. This medication is preferred because it may be administered intravenously and can provide pre-exposure prophylaxis to the fetus. Whether this medication is prescribed and administered intrapartum depends on the mother's viral load. The lower the viral load, the less likely of transmission to the fetus. Choices A, C, and D are incorrect. Valacyclovir is an antiviral indicated in the treatment of herpes simplex. This medication may be used during pregnancy, despite the limited safety profile. Amphotericin b is an antifungal drug indicated in treating systemic fungal infections. Metronidazole is an effective antibiotic indicated for bacterial and parasitic infections such as vaginosis and trichomonas. ✓ Women should continue taking their antiretroviral therapy (ART) regimen as much as possible during labor and delivery or scheduled cesarean delivery ✓ Zidovudine is an intravenous antiretroviral that is administered intrapartum to reduce vertical transmission further ✓ To further reduce HIV transmission during labor and delivery, avoid fetal scalp electrode monitoring when possible ✓ To identify HIV infection in infants and young children (less than 18 months), HIV viral load (VL) testing must be performed using assays that detect HIV deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) ✓ Antibody tests are not accurate because the infant acquires maternal antibodies, which may cause a false positive ✓ Cord blood should not be used for testing because of the possibility of contamination of the sample with maternal blood
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure? A. Nasogastric tube (NGT) B. Bottle of sterile water C. Suction equipment D. Tracheostomy
Choice C is correct. A cheiloplasty is a procedure to repair a cleft lip (CL). This procedure is typically done by age three to six months. A concern after this procedure is that the child may have excessive secretions that may trigger aspiration. The nurse should have a bulb syringe or some other suction equipment available if the infant begins to choke. While routine suctioning is not done to minimize pain or trauma, this is necessary to have it available to prevent respiratory distress.
The nurse is assessing a client who is two days postpartum and is breastfeeding her infant and reports uterine contractions while breastfeeding. The nurse should take which action? A. Perform a vaginal examination B. Prepare the client for a pelvic ultrasound C. Reassure the client that this is a normal finding D. Instruct the client to bottle feed the infant until the sensation subsides
Choice C is correct. Breastfeeding causes the release of oxytocin which stimulates uterine contractions. The client may describe a cramping type of sensation which is expected. The cramping sensation is generally strongest two to three days postpartum
The nurse is caring for a client with acute myocardial infarction (AMI). Which diagnostic intervention should the nurse anticipate? A. Exercise electrocardiography B. Computed tomography (CT) of the chest with contrast C. Cardiac catheterization D. Echocardiogram
Choice C is correct. Cardiac catheterization involves the insertion of a large catheter into the femoral or radial artery to access the coronary arteries. A stent may be placed to keep the lumen of the artery open. This test can diagnose narrowing in the coronary arteries and intervene with angioplasty and stenting, if necessary. Choice A, B, D is incorrect. Exercise electrocardiography is commonly known as a stress test. This is a planned procedure that examines exercise tolerance and its cardiovascular effects. The client is having an acute infarction, and this test would be inappropriate. A chest CT may assist in diagnosing an occlusion in the coronary artery, but this test does not allow for intervention. An echocardiogram is performed to examine the heart's structures and its output. This is not appropriate during an acute myocardial infarction. Additional Info When interventions needed, percutaneous coronary intervention is performed in the cardiac catheterization laboratory and combines clot retrieval, coronary angioplasty, and stent placement. Under fluoroscopic guidance, the cardiologist performs initial coronary angiography, inserting an arterial sheath and advancing a catheter retrograde through the aorta. Here the physician may determine which arteries are narrowed and require intervention. Intervention may come in the form of angioplasty with or without stenting.
The nurse administers dobutamine to a patient with heart failure following a cardiac procedure. Which of the following should the nurse recognize as an intended effect of this medication? A. Increased heart rate B. Increased vasoconstriction C. Increased cardiac output D. Increased blood pressure
Choice C is correct. Dobutamine is a positive inotropic and chronotropic drug that helps increase myocardial contractility by selectively acting on the beta-1 receptors in the myocardium. By increasing the heart rate and contractility, dobutamine helps increase cardiac output in acute heart failure settings. Dobutamine is indicated in the short-term management of decompensated congestive heart failure. Choice A, B, and D are incorrect. Stimulation of beta-1 adrenergic receptors in the myocardial tissue results in increased heart rate ( positive chronotropic) and myocardial contractility ( positive inotropic). Dobutamine selectively stimulates these receptors and, therefore, can increase the heart rate. However, the intended therapeutic effect of dobutamine is increased cardiac output, not an increased heart rate ( Choice A). In addition to beta-1 stimulation, dobutamine also has mild beta-2 agonistic action, resulting in peripheral vasodilation. Additionally, increased cardiac contractility causes reflex systemic vasodilation, not vasoconstriction (Choice B). Systemic vasodilation decreases resistance (afterload) and reduces the demand on the heart. Blood pressure is a product of cardiac output and systemic vascular resistance. Therefore, increased cardiac output increases blood pressure. Because of its sympathomimetic activity, dobutamine can substantially increase systolic blood pressure. Increased blood pressure above the normal range would be an adverse effect, not intended ( Choice D). Patients with pre-existing hypertension are even more prone to dobutamine's adverse impacts of increased systolic blood pressure.
The nurse is preparing a client for a scheduled colonoscopy. Which prescription should the nurse anticipate from the primary healthcare provider (PHCP) while the client is preparing for this procedure? A. docusate B. loperamide C. polyethylene glycol 3350 D. famotidine
Choice C is correct. Polyethylene glycol 3350 is an osmotic laxative commonly used before a colonoscopy. This powder is typically dissolved in a sports drink and can be consumed by the client. Efficacy is usually within one hour. Fluid and electrolyte disturbance is unlikely as the powdered solution contains electrolytes. Choices A, B, and D are incorrect. Docusate is a stool softener and is not used to prepare for a colonoscopy. This medication would help prevent constipation. Loperamide is a medication to slow peristalsis and is indicated in the treatment of diarrhea. Famotidine is a histamine blocker and is used to manage peptic ulcer disease.
The nurse is caring for a client scheduled for electroconvulsive therapy (ECT). Which medication should the nurse question? A. Venlafaxine B. Esomeprazole C. Topiramate D. Lurasidone
Choice C is correct. ECT is a safe therapy that induces seizures theorized to release monoamines, which may assist in treating psychiatric illnesses such as major depressive disorder. If a client is taking the anticonvulsant topiramate, this will increase the seizure threshold and may attenuate the efficacy of ECT. Choices A, B, and D are incorrect. Antidepressant medications (such as venlafaxine) and antipsychotics (such as lurasidone) may be given concurrently with ECT. These medications may enhance the efficacy of the treatment. Proton pump inhibitors (such as esomeprazole) are typically given the day of treatment to prevent gastric reflux and aspiration. Electroconvulsive therapy (ECT) is an effective treatment for an array of conditions, including major depressive disorder, psychosis, and post-partum disorders. A stigma is attached to ECT that it is somehow cruel. This stigma is false as ECT is a highly effective treatment when medications are ineffective. Nursing care for ECT includes witnessing informed consent, ensuring that the client is NPO prior to the procedure, and preprocedural laboratory work including a 12-lead electrocardiogram (ECG) has been completed. Certain medications should be withheld prior to ECT, including anticonvulsants and benzodiazepines.
The nurse is preparing to admit a client following lumbar spinal fusion surgery. The nurse should instruct the unlicensed assistive personnel (UAP) to have which equipment at the bedside? Incorrect Correct Answer(s): C A. Overhead trapeze [12%] B. Abduction pillow [12%] C. Transfer board [68%] D. Continuous passive motion (CPM)
Choice C is correct. Following a lumbar spinal fusion, the client will need to be log rolled. A transfer board/sheet, along with an ample amount of staff (at least three), will be necessary to facilitate the log roll. Choices A, B, and D are incorrect. None of this equipment is necessary following a lumbar spinal fusion. A trapeze is helpful if a client were to have a lower extremity amputation. Further, an abduction pillow may be warranted after hip arthroplasty. Finally, a CPM may be indicated following a joint replacement. Additional Info Log rolling after a lumbar spinal fusion is likely ordered to protect the client from injury. Log rolling aims to keep the spinal column in straight alignment to prevent further injury. A minimum of three individuals is necessary to perform log rolling safely. A transfer sheet or board assists with the client being rolled as one unit.
While working in the nursery, a nurse assesses a newborn born less than two hours ago. Which of the following findings by the nurse would necessitate further investigation? A. A diamond-shaped soft area present at the top of the newborn's head B. Greasy, white substance that resembles cheese on the newborn's neck, back, and thighs C. A single crease on the palm D. Acrocyanosis
Choice C is correct. It is widely accepted that a finding of a single transverse palmar crease on the palm - often referred to as a simian line or simian crease - is often observed in a wide range of chromosomal defects, including, but not limited to, Down syndrome, congenital limb deficiency, trisomy 13/18/21, 4p, 18q, etc. Although this finding does not in and of itself render a diagnosis of a chromosomal disorder, this finding by the nurse would necessitate the need to alert the newborn's primary health care provider (HCP), as genetic and chromosomal testing will likely need to be performed. Choice A is incorrect. Fontanels are one of a newborn's skull's most prominent anatomical features, helping to facilitate the movement and molding of the newborn's cranium through the birth canal during labor. The diamond-shaped soft area present at the top of the newborn's head is the anterior fontanel (also commonly referred to as a fontanelle), the largest of the six fontanels present at birth. The anterior fontanel typically fuses between 12 and 18 months of age. Choice B is incorrect. This finding is indicative of vernix caseosa. At birth, a newborn's skin may be covered with vernix caseosa, a grayish-white, cheese-like substance composed of a mixture of sebum and desquamating cells. If it is not entirely removed during the post-birth bath, the newborn's skin will absorb any remaining vernix caseosa within 24 to 48 hours. Choice D is incorrect. Acrocyanosis is often seen in healthy newborns and refers to the peripheral cyanosis around the mouth and the extremities (hands and feet). Unlike other causes of peripheral cyanosis with significant pathology (e.g., septic shock), acrocyanosis is a harmless condition caused by benign vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction. Additionally, acrocyanosis is further differentiated from peripheral cyanosis as acrocyanosis occurs immediately after birth in healthy infants and is a common finding, at times persisting for 24 to 48 hours. Learning Objective While working as a nurse in a nursery, recognize that a single crease on the palm of a newborn would be the nursing assessment finding that would necessitate further investigation. Additional Info Using simian creases to screen for certain known congenital chromosomal disorders and syndromes could be useful in conjunction with other diagnostic practices. Simian creases can be examined quickly without causing physical pain or incurring expensive medical bills. However, the detection of simian creases should not be used independently for diagnosing known associated chromosomal disorders and/or other disorders, but rather in combination with other diagnostic tests. A consensus statement based on the results of a study conducted by the National Association of Neonatal Nursing (NANN) and the Association of Women's Health Obstetrical and Neonatal Nursing (AWHONN) directed "removal of all vernix is not necessary for hygienic reasons" and "vernix may provide antibacterial promotion and wound healing."
A client with peptic ulcer disease from chronic nonsteroidal anti-inflammatory drug (NSAID) use is prescribed misoprostol. In educating the client regarding this drug's mechanism of action, the nurse would be most accurate in informing the client that this medication: Correct A. Decreases gas formation B. Increases the speed of gastric emptying C. Lines the stomach for protection D. Increases the lower esophageal sphincter pressure
Choice C is correct. Misoprostol is a synthetic prostaglandin that protects the gastric mucosa by decreasing gastric acid secretion and lining the stomach for protection by increasing mucus and bicarbonate secretion. Misoprostol reduces the risk of NSAID-induced gastric ulcers, as NSAIDs decrease prostaglandin production and predispose the client to peptic ulceration. Misoprostol is a synthetic prostaglandin E1 analog that stimulates prostaglandin E1 receptors on parietal cells. Mucus and bicarbonate secretion are also increased along with thickening of the mucosal bilayer so the mucosa can generate new cells. Women of childbearing age should not use misoprostol. Avoid taking magnesium-containing antacids while using misoprostol.
The nurse is caring for a client who has osteoarthritis. Which of the following medications should the nurse expect to be prescribed for the client? A. Allopurinol B. Etanercept C. Oxaprozin D. Methotrexate
Choice C is correct. Oxaprozin is a non-steroidal anti-inflammatory drug (NSAID). This drug is effective in osteoarthritis because this disease causes significant pain, especially when the affected joint is used. Long-term NSAID use may cause renal insufficiency and increase the risk of a gastrointestinal ulcer. Choices A, B, and D are incorrect. Allopurinol is a medication indicated to lower uric acid levels. This medication is used to treat gout. Methotrexate and etanercept are biologic agents indicated in the treatment of rheumatoid arthritis. Additional Info ✓ NSAIDs include ibuprofen, naproxen, oxaprozin, and ketorolac ✓ NSAIDs are efficacious for pain or pyrexia ✓ NSAIDs are nephrotoxic; therefore, monitoring renal function (BUN and creatinine) is essential ✓ NSAIDs may adversely cause gastrointestinal bleeding, renal insufficiency, myocardial infarction (MI), or stroke ✓ Clients with peptic ulcer disease, congestive heart failure, renal injury, or a previous MI should not use NSAIDs
Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease, which has developed contractures? A. The patient will monitor for signs of skin breakdown as a result of the contractures. B. The patient will learn to reposition himself in bed and in his chair without assistance. C. The patient will participate in range of motion exercises to reduce the effects of contractures. D. The patient will verbalize the effects of contractures on activities of daily living.
Choice C is correct. Performing range of motion exercises will help decrease the risk of further atrophy and should be encouraged. Huntington's disease is a progressive condition that can lead to muscle atrophy and potential contractures. The patient in this situation should be given a program of range of motion exercises in which he may need assistance. The nurse can help the patient to increase his range of motion and to prevent worsening of contractures by improving flexibility and reducing rigidity. Choice A is incorrect. Contractures and lack of mobility put a client at risk of compromised skin integrity. However, the nurse is responsible for monitoring for any signs of breakdown. Choice B is incorrect. The client has developed contractures and muscle atrophy. He may be unable to reposition himself without assistance. Choice D is incorrect. The client may not verbalize the effects on ADLs.
The nurse cares for a client with a potassium of 3.2 mEq/L (3.5-5 mEq/L). Which of the following medications may cause this abnormality? Incorrect Correct Answer(s): C A. spironolactone [32%] B. triamterene [13%] C. prednisone [34%] D. lisinopril
Choice C is correct. Prednisone is a corticosteroid that increases aldosterone and is responsible for sodium retention and the elimination of potassium. Therefore, a client's potassium level will decrease while taking this medication. If a client is taking prednisone, the recommendation is that they reduce dietary sodium and increase dietary potassium. Choices A, B, and D are incorrect. Spironolactone, Triamterene, and Lisinopril are all medications that increase potassium. Therefore, the nurse must monitor the client for potential hyperkalemia (potassium greater than 5.0 mEq/L).
The nurse cares for a client immediately following a percutaneous coronary intervention (PCI). Upon sheath removal, the client develops bradycardia and hypotension. Which intervention would be the nurse's priority? Incorrect Correct Answer(s): C A. Assess bilateral pedal pulses [14%] B. Apply sandbag to the puncture site [14%] C. Administer prescribed bolus of intravenous (IV) fluids [53%] D. Elevate the head of the bed
Choice C is correct. The client presents with signs of vasovagal response. A vasovagal response may occur due to pain and baroreceptor stimulation from manual pressure during femoral sheath removal. Decreased heart rate (bradycardia) and reduced blood pressure (hypotension) are typical of a vasovagal (para-sympathetic) response. The nurse's priority would be to address the hypotension by administering a bolus of intravenous isotonic fluids and lowering the head end of the bed (elevating lower extremities > 30 degrees). If bradycardia persists, atropine is used. With timely and accurate treatment, vasovagal reactions typically resolve without clinical complication
The nurse has attended a continuing education conference regarding medication administration and meal times. Which statement, if made by the nurse, would indicate correct understanding? Correct A. Proton pump inhibitors (PPIs) should be given as the client eats their breakfast. [7%] B. Glucocorticoids should be given on an empty stomach to prevent gastrointestinal irritation. [6%] C. Rapid-acting insulins should be administered approximately 10-15 minutes before meals [74%] D. Levodopa-Carbidopa should be administered with a high-protein snack to enhance its absorption.
Choice C is correct. This is correct because rapid-acting insulin (lispro, aspart, glulisine) should be given within 10-15 minutes before a meal or while the client is actively eating. Choices A, B, and D are incorrect. PPIs (omeprazole, pantoprazole) should not be given with a meal. The medication is intended to ameliorate esophageal reflux symptoms, and medications in this class are intended to be given 30 minutes before the main meal of the day. Glucocorticoids (prednisone) may cause GI irritation and cause ulcers. To minimize GI irritation, the client should take the medication with food and avoid concurrent use of NSAIDs. Finally, when a client is taking levodopa-carbidopa for Parkinson's disease, the client is instructed to take the medication one-half hour before eating a protein-containing meal or one hour after. Protein-dense meals given with the medication interfere with the medication's efficacy. The recommendation is for the client to eat higher protein-containing foods later in the day or small amounts over the course of the day. Additional Info ✓ The three rapid-acting insulins are lispro, aspart, and glulisine. ✓ The client needs to take this insulin 10-15 minutes before a meal or while actively eating. ✓ A rapid-acting insulin is utilized as correctional insulin before meals to prevent post-prandial hyperglycemia. ✓ This type of insulin is commonly loaded into an insulin pump
The nurse is reviewing newly prescribed medications for assigned clients. Which of the following prescribed medications should the nurse question? A. Furosemide for a client with hyperparathyroidism B. Methimazole for a client with hyperthyroidism C. Hydrocortisone for a client with diabetes insipidus D. Prazosin for a client with pheochromocytoma
Choice C is correct. Treatment for diabetes insipidus includes medications such as desmopressin, thiazide diuretics, and anti-inflammatories. Hydrocortisone is a short-acting corticosteroid and is indicated in the treatment of adrenal insufficiency. This requires follow-up because DI is not treated with hydrocortisone. Choices A, B, and D are incorrect. Hyperparathyroidism causes hypercalcemia, and the treatment for hyperparathyroidism is a combination of 0.9% saline infusion followed by furosemide. Hyperthyroidism requires antithyroid medications such as methimazole or propylthiouracil. The classic manifestation of pheochromocytoma is hypertension, and treatment of this condition involves antihypertensive such as prazosin, an alpha-adrenergic blocker. Additional Info Diabetes insipidus may be central (problem with the pituitary gland secreting antidiuretic hormone) or nephrogenic (resistance at the ADH site of action in the collecting tubules). The major symptoms of central diabetes insipidus (DI) are polyuria, nocturia, and polydipsia due to the concentrating defect. In treating central DI, desmopressin is utilized and can be administered either intranasally or by tablet.
The nurse observes the fetal heart monitor (FHR) tracing showing variable decelerations. Which of the following could cause this FHR pattern? A. Fetal movement B. Fetal head compression C. Compression of the maternal vena cava D. Prolapsed umbilical cord
Choice D is correct. A prolapsed umbilical cord is a serious finding that may lead to fetal hypoxia. The nurse must act quickly if this is suspected. Common fetal heart rate patterns observed during a prolapsed umbilical cord include variable decelerations, sustained bradycardia, or prolonged decelerations. All of these patterns are non-reassuring. Choices A, B, and C are incorrect. Fetal movement would cause an acceleration which is a reassuring FHR pattern. This would not be a cause of variable decelerations. Fetal head compression would cause early decelerations, which are benign. Compression of the maternal vena cava would cause a client to develop late decelerations because this causes uteroplacental insufficiency. ✓ A prolapsed umbilical cord is a medical emergency ✓ The prolapse may be hidden or complete ✓ This condition should be suspected if the fetal heart monitor should show sustained bradycardia, variable decelerations or prolonged deceleration ✓ The nurse should reposition the client with the intent to position the woman's hips higher than her head to shift the fetal presenting part ✓ Acceptable positions include knee-chest, Trendelenburg, or hips elevated with pillows, with side-lying position maintained ✓ The nurse should shout for help, pause oxytocin infusion, and provide oxygen via face mask at 8-10 liters/minute ✓ Provide and maintain vaginal elevation of the presenting part using a gloved hand ✓ An emergency cesarean section is likely
The nurse is caring for a client who developed a thyroid storm. The nurse should obtain a prescription for A. enalapril B. regular insulin C. levothyroxine D. dexamethasone
Choice D is correct. A thyroid storm is a medical emergency and is a complication of hyperthyroidism. Manifestations of a thyroid storm include fever, tachycardia, hypertension, and cardiac dysrhythmias. Emergent treatments for a thyroid storm include prescribed dexamethasone (corticosteroids inhibit the peripheral conversion of T4 into T3), propranolol (reduce heart rate and blood pressure), and an antithyroid medication such as propylthiouracil. Choices A, B, and D are incorrect. Enalapril is an ACE inhibitor and has no role in treating a thyroid storm. While this medication may ameliorate hypertension found with a thyroid storm, this is not the preferred drug because it is both tachycardia and hypertension present in this endocrine emergency. Thus, the prescribed propranolol should target. ACE inhibitors are preferred drugs for heart failure and hypertension. Regular insulin is not used in the management of a thyroid storm. Regular insulin is one of the two treatments for diabetic ketoacidosis. Levothyroxine is the treatment for hypothyroidism. Giving this medication would be catastrophic because it would further increase circulating thyroid levels. ADDITIONAL INFO ✓ A thyroid storm is a medical emergency and is manifested by tachycardia, fever, hypertension, and restlessness ✓ Treatment is administering an array of medications including - IV corticosteroids to decrease the conversion from T3 to T4 IV antithyroid medications such as methimazole or propylthiouracil IV propranolol to treat the adrenergic symptoms ✓ Nursing care includes maintaining the client's patent airway, providing cooling blankets, and initiating continuous cardiac monitoring to detect any dysrhythmias ✓ Salicylates should not be given because they would increase circulating thyroid hormones
A nurse is taking care of a client with acute peritonitis. The current focus of care is the client's nutritional needs. To meet this, the nurse should do which of the following? A. Administer feedings via nasogastric (NG) tube B. Administer gastric enteral feedings C. Feed the client orally D. Administer parenteral nutrition
Choice D is correct. All clients with acute peritonitis should be NPO until the cause of the peritonitis has been identified and fully addressed. By making the client NPO, the gastrointestinal tract time is provided time to rest and recover, as food is no longer being administered through the gastrointestinal tract. Additionally, the NPO status allows flexibility regarding any surgical needs the client may require. Depending on the duration and severity of the peritonitis, clients may require parenteral nutrition. Choice A is incorrect. Although the client likely has a nasogastric (NG) tube, the NG tube is in place to decompress the client's bowel, not to be used for feedings. Choice B is incorrect. An enteral feeding (or gastric enteral feeding) is a feeding delivered to the traditional gastrointestinal tract. Here, the client would be NPO, as the client is currently suffering from acute peritonitis and should, therefore, not receive an enteral feeding. Choice C is incorrect. Any client currently experiencing acute peritonitis would be NPO and would, therefore, not be eligible to be fed orally. Doing so would likely harm the client. Learning Objective Recognize administering parenteral nutrition as the appropriate intervention when caring for an acute peritonitis client. Additional Info Parenteral nutrition provides nutrients to the client by bypassing the digestive system. The two forms of parenteral nutrition are peripheral parenteral nutrition (PPN) and total parenteral nutrition (TPN).
The nurse is caring for a client who is nothing by mouth status (NPO) for scheduled surgery. Which prescribed medication requires clarification with the physician prior to administration? Incorrect Correct Answer(s): D A. Metoprolol [15%] B. Phenytoin [16%] C. Levothyroxine [21%] D. Glipizide
Choice D is correct. Glipizide is a sulfonylurea and is given to the client with meals to manage blood glucose. This medication will lower blood glucose and could potentially cause hypoglycemia. The client is NPO and will not receive any food. Thus, the nurse should question the administration of this medication to prevent the client from developing hypoglycemia. Choices A, B, and C are incorrect. Endocrine medications (steroids, thyroid hormone), anticonvulsants, and beta-blockers are okay to give with a sip of water. Beta-blockers are given to clients with a sip of water before surgery to prevent intra- and post-procedure cardiac dysrhythmias. Additional Info Drugs for cardiac disease, respiratory disease, seizures, and hypertension are commonly allowed with a sip of water before surgery. Clients at risk for intra- and post-procedure cardiac dysrhythmias and hypertension are typically prescribed a presurgical beta-blocker to prevent this complication. Before administering a beta-blocker, the nurse should obtain the client's pulse and blood pressure.
The nurse is caring for a client diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which medication? Incorrect Correct Answer(s): D A. Topiramate [19%] B. Risperidone [17%] C. Prazosin [9%] D. Baclofen
Choice D is correct. Multiple Sclerosis (MS) may produce symptoms such as muscle spasticity, optic neuritis, fatigue, heat intolerance, and symptoms that seem to intensify on occasion (relapses). Muscle spasticity is best controlled with muscle relaxers such as baclofen. Choices A, B, and C are incorrect. Topiramate is an anticonvulsant drug indicated in the treatment of epilepsy as well as psychiatric conditions such as bipolar disorder. Risperidone is indicated for psychotic disorders such as schizophrenia. Prazosin is an antihypertensive that may be used for high blood pressure. This medication also may be indicated for psychiatric illnesses such as PTSD.
You are caring for a patient with Raynaud's disease who has intractable pain. The patient is scheduled to undergo surgical interruption of pain conduction pathways to improve vascular blood supply as well as eliminate vasospasm and pain. Which type of surgery is the patient most likely to undergo? A. Cordotomy B. Rhizotomy C. Neurectomy D. Sympathectomy
Choice D is correct. Sympathectomy severs the paths to the sympathetic division of the autonomic nervous system. The outcomes of this procedure include improvement in vascular blood supply and the elimination of vasospasm. It is used to treat the pain from vascular disorders, such as Raynaud's disease. Raynaud's phenomenon is a problem that causes decreased blood flow to the fingers. In some cases, it also causes less blood flow to the ears, toes, nipples, knees, or nose. This happens due to spasms of blood vessels in those areas. The seizures occur in response to cold, stress, or emotional upset. Raynaud's can occur on its own, known as the primary form or it may happen along with other diseases, known as the secondary form. The conditions most often linked with Raynaud's are autoimmune or connective tissue diseases. Choice A is incorrect. Cordotomy interrupts pain and temperature sensation below the tract that is severed. This is most frequently done for leg and trunk pain. Choice B is incorrect. Rhizotomy interrupts the anterior or posterior nerve route that is located between the ganglion and the cord. Anterior interruption is generally used to stop spastic movements that accompany paraplegia, whereas posterior interruption eliminates pain in the area innervated. This procedure may be safely performed at any level along the spine but is most often used for head and neck pain produced by cancer. Choice C is incorrect. Neurectomy is used to eliminate intractable localized pain. The pathways of peripheral or cranial nerves are interrupted to block pain transmission.
Shortly after checking into the obstetrics unit, a client currently at 39 weeks gestation spontaneously ruptured her membranes when ambulating to the bathroom. After the client returns to bed, which of the following should be the nurse's initial action? A. Assess the color and quantity of the fluid. B. Perform a vaginal examination to assess the cervix for dilation. C. Inform the client she is now on strict bed rest until further notice. D. Assess the fetal heart tones.
Choice D is correct. The priority is for the nurse to assess the fetal status following the spontaneous rupture of the client's membranes. Although numerous methods may be utilized to evaluate fetal status, the assessment of fetal heart tones provides reliable information in a relatively prompt manner. Following the assessment of fetal heart tones, the nurse should then assess the color and quality of the amniotic fluid. Choice A is incorrect. Following a spontaneous rupture of the client's membranes, the priority is for the nurse to assess the fetal status via fetal heart tones. Assessment of the color and quantity of the amniotic fluid does not provide any indication regarding the current status of the fetus. Choice B is incorrect. While certain circumstances may justify performing a vaginal examination to assess for cervical dilatation, nothing in this scenario suggests such intervention. As such, in this scenario, the nurse's priority following a spontaneous rupture of the client's membranes remains to assess the fetal status via fetal heart tones. Choice C is incorrect. Fetal head engagement and descent are not dependent on the client's movement during labor. Keeping the client on bed rest is not necessary. Often, the client will be encouraged to ambulate. Learning Objective Following the spontaneous rupture of a 39-week gestation pregnant client's membranes, prioritize assessing the fetal status via assessment of the fetal heart tones. Additional Info To confirm the rupture of a client's membranes, the pH of the fluid may be tested. Vaginal fluid may be tested with Nitrazine paper, which turns deep blue at a pH >6.5 (pH of amniotic fluid is 7.0 to 7.6). Amniotic fluid should be assessed for meconium-stained fluid, other discoloration, etc.
The nurse is caring for a client with the below tracing on the electrocardiogram (ECG). The nurse should anticipate which prescription from the primary healthcare provider (PHCP)? See the exhibit. "atrial fibrilation" A. captopril B. atropine C. adenosine D. diltiazem
Choice D is correct. The tracing in the exhibit shows irregularly irregular rhythm with no identifiable p-waves. This rhythm can be clearly identified as "atrial fibrillation. Diltiazem is a calcium channel blocker (CCB) and provides rate control in atrial fibrillation.Atrial fibrillation results in increased ventricular rate and reduced ventricular diastolic filling. If the ventricular rate is not controlled, cardiac output is reduced, resulting in hypotension and congestive heart failure. Initial treatment in atrial fibrillation is aimed at ventricular rate control with calcium channel blockers (diltiazem, verapamil), a beta-blocker (atenolol, metoprolol), or digoxin. If the atrial fibrillation remains persistent, cardioversion is considered. Choices A, B, and C are incorrect. Captopril is an ACE inhibitor used to treat heart failure and hypertension. Atropine increases the heart rate and is efficacious for symptomatic sinus bradycardia, not atrial fibrillation. Adenosine is approved for supraventricular tachycardia when vagal maneuvers are not efficacious. Note that the term " supraventricular tachycardia ( SVT)" refers to a wide variety of atrial arrhythmias ( atrial flutter, atrial fibrillation, atrial tachycardia) when the rhythm can not be clearly identified. During an SVT, the heart rate is very high at 150 to 220 beats per minute. The rate needs to be slowed so the rhythm can be appropriately identified and treated precisely. Vagal maneuvers ( carotid sinus massage, Valsalva maneuver) are applied first. IV adenosine is used to slow down or terminate if the SVT is refractory to vagal maneuvers. Adenosine's principal purpose in an SVT is to slow the rate to allow for appropriate rhythm identification. Because the rhythm strip in the exhibit can clearly be identified as atrial fibrillation, adenosine is unnecessary and must be treated with more specific rate-controlling medications (CCBs, beta-blockers).
A preeclamptic client, currently in the 38th week of pregnancy, was admitted and given magnesium sulfate to prevent seizures. The nurse understands that this client should be monitored for: A. Blurring of vision B. Tachypnea C. Pain in the epigastric region D. Respiratory depression
Choice D is correct. When administering magnesium sulfate, the nurse should monitor the client for respiratory depression. Magnesium toxicity can lead to respiratory paralysis, central nervous system depression, and cardiac arrest. If respiratory depression or another sign of magnesium toxicity is noted, the antidote is calcium gluconate, one gram, infused intravenously over two minutes.
The nurse is caring for a client who has been diagnosed with generalized anxiety disorder. The nurse should anticipate a prescription for which medication? Select all that apply. 2/2 Your Score/Max +/- Scoring Rule Citalopram Methylphenidate Alprazolam Haloperidol Zolpidem
Choices A and C are correct. Generalized anxiety disorder is treated with selective serotonin reuptake inhibitors (citalopram) and/or short-term use of a benzodiazepine (alprazolam). Although benzodiazepines are not the gold standard in treating GAD, they are commonly used until the SSRI can gain efficacy which may take about 4 to 6 weeks. Choices B, D, and E are incorrect. Methylphenidate is a psychostimulant indicated in managing attention deficit hyperactivity disorder (ADHD). Haloperidol is a typical antipsychotic used to treat schizophrenia and other psychotic disorders. Zolpidem is a non-benzodiazepine hypnotic indicated in the treatment of insomnia. These medications are not used in the treatment of GAD. Additional Info ✓ GAD is a disorder where the client may have an excessive worry that causes impairment in functioning and interpersonal relationships ✓ Treatment is best achieved through a combination of psychotherapy and SSRIs (fluoxetine, citalopram). Occasionally, buspirone may be used as well ✓ Benzodiazepines (alprazolam, diazepam, clonazepam) may be used short-term for significant anxiety until the SSRI gains optimal efficacy
The nurse is caring for a client receiving lorazepam. Which of the following reported herbal supplements would require follow-up? Select all that apply. 1/2 Your Score/Max +/- Scoring Rule Kava Glucosamine Valerian Garlic Saw palmetto
Choices A and C are correct. Lorazepam is a CNS depressant, and the client should avoid potentiating the effects of this medication. Herbal products such as kava and valerian are CNS depressant medications that should not be given concurrently while a client is receiving lorazepam. Lorazepam and one of these medications may cause profound sedation. Choices B, D, and E are incorrect. Glucosamine is an herbal product that may benefit clients with osteoarthritis in the knees, waist, and hips. This medication does not cause CNS depression. Garlic may be taken to assist a client in reducing their cholesterol and should be avoided if the client is taking anticoagulants. This medication does not alter the CNS. Saw palmetto may be taken for men who have prostate hyperplasia. This herbal supplement does not alter the CNS.
The nurse is reviewing a client's list of medications who has cystic fibrosis. The nurse anticipates a prescription for which medication? Select all that apply. Pancrelipase Aspirin Lactulose Multivitamin Clopidogrel
Choices A and D are correct. Pancrelipase is a digestive enzyme that is given to the client with meals. This allows the client to digest the food and absorb the vitamins and minerals. This is the exact reason that a multivitamin is necessary for the treatment of cystic fibrosis. Choices B, C, and E are incorrect. These medications are not indicated in the direct management of cystic fibrosis. Additional Info Cystic fibrosis is a multisystem disorder that has no cure. A well-balanced diet rich in calories, protein, and fat is recommended to help prevent (or treat) the malabsorption associated with CF. Foods rich in sodium are also recommended because of the salt loss through the skin. A multivitamin is commonly prescribed to help mitigate the vitamin deficiencies that may develop. Finally, pancrelipase is prescribed before snacks and meals to enable the digestion of the dietary items.
The new graduate nurse knows that malignant hyperthermia is a serious adverse reaction that can occur after the administration of which of the following medications? Select all that apply. 2/2 Your Score/Max +/- Scoring Rule halothane vancomycin succinylcholine omeprazole penicillin hydrocodone
Choices A and C are correct. Malignant hyperthermia is a severe adverse medication reaction. The nurse should know to monitor for this adverse reaction when administering induction agents such as halothane and succinylcholine. These medications can cause excess calcium to build up in the cells, resulting in the client experiencing sustained skeletal muscle contractions. These contractions cause a hypermetabolic state and fever and can lead to death. Choices B, D, E, and F are incorrect. Vancomycin does not carry the risk of malignant hyperthermia. It is an antibiotic that has many other adverse reactions. Omeprazole is a proton-pump inhibitor (PPI) used to treat reflux. It does not cause malignant hyperthermia. Penicillin is an antibiotic that does not cause malignant hyperthermia. Hydrocodone is a pain medication with other adverse reactions but not malignant hyperthermia. Additional Info ✓ Malignant hyperthermia (MH) is an autosomal dominant disorder ✓ Succinylcholine is a neuromuscular blocker indicated in a client being intubated or electroconvulsive therapy (ECT) and has been implicated in causing MH ✓ MH may be life-threatening ✓ The manifestations of MH include muscular rigidity, high fever, mixed metabolic and respiratory acidosis, and hyperkalemia
The nurse has provided medication instructions to a client who has been prescribed venlafaxine. Which of the following statements, if made by the client, would indicate a correct understanding of the teaching? Select all that apply. "I may not notice an improvement in my mood right away." "This medication may lower my blood pressure." "If I have thoughts of harming myself, I should call 911." "I will need to have weekly laboratory tests." "I may continue taking St. John's Wort."
Choices A and C are correct. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI). This medication is used to treat depression and anxiety. Like most serotonergic drugs, the client may not experience an effect for two to four weeks. If no effect is achieved by six weeks, the prescriber may change the medication. Venlafaxine may increase thoughts of suicidal ideation, and the client should be educated to seek help if these thoughts should occur. Choices B, D, and E are incorrect. Venlafaxine is a medication that modulates serotonin and norepinephrine. The norepinephrine may cause a client to have an increase in their blood pressure, not a decrease. Weekly laboratory testing is not indicated for this medication as weekly laboratory testing is required for clients prescribed clozapine. St. John's Wort should not be combined with a serotonergic because of this risk of serotonin toxicity. Venlafaxine is a common SNRI. This medication may be used for depressive and anxiety disorders. The benefit of venlafaxine is that it may be activating and assist a client who may have decreased energy. Like all antidepressant medications, it will take two to four weeks for a client to experience a response. Antidepressant medications may produce an array of adverse reactions, including suicidal ideations. Thus, education must be provided to seek help if this should occur.
The nurse is caring for a client with an acute exacerbation of Bell's palsy. Which of the following prescriptions would the nurse anticipate? Select all that apply. 0/2 Your Score/Max +/- Scoring Rule Prednisone Donepezil Pyridostigmine Valacyclovir Topiramate
Choices A and D are correct. Bell's palsy classically causes facial nerve paralysis. It is usually idiopathic. However, etiologies such as herpes simplex virus may be present. Exacerbations of Bell's palsy are treated with corticosteroids (prednisone, choice A) and antivirals (valacyclovir, choice D). Corticosteroids decrease facial nerve inflammation, and antivirals address the possible underlying viral etiology. Choices B, C, and E are incorrect. Donepezil is an acetylcholinesterase inhibitor utilized to manage dementia in Alzheimer's disease (choice B). Although Donepezil does not decrease the progression of Alzheimer's disease, it does help symptoms by improving cognition and behavior. Pyridostigmine is an acetylcholinesterase inhibitor indicated for improving muscle strength in myasthenia gravis (choice C). Topiramate is an anticonvulsant indicated for epilepsy and migraine headache prevention (choice E).
The nurse is teaching a client about congestive heart failure (CHF). Which of the following information should the nurse include? Select all that apply. "Foods such as canned vegetables and luncheon meat should be avoided." "Weigh yourself daily and notify the physician when weight gain is more than ten pounds in a week." "You may continue to take ibuprofen for your aches and pains." "Annual immunizations such as the influenza vaccine are recommended." "If you feel sick, you will need to check your urine for ketones."
Choices A and D are correct. Congestive heart failure (CHF) is a chronic condition that causes a decrease in cardiac output. The client will need to maintain a low sodium diet, so processed foods such as luncheon meat should be avoided. Annual immunizations are recommended because of the increased risk of complications from influenza. Complications from influenza are higher in those with co-morbidities such as CHF. Choice B is incorrect. The client should be taught to weigh themselves daily and to report a weight gain of five pounds or more within one week. The client must not wait until he/she gains 10lbs/week. Choice C is incorrect. NSAIDs such as ibuprofen may contribute toward fluid retention and should not be used in clients with CHF. Choice E is incorrect. Assessing the urinary ketones is only done for those with hyperglycemia secondary to diabetes mellitus. This is done to check for the potential development of ketoacidosis. Additional Info For a client with heart failure, self-management strategies include following the MAWDS approach. Medications ✓ Take medications as prescribed and do not run out. ✓ Know the purpose and side effects of each drug. ✓ Avoid NSAIDs to prevent sodium and fluid retention. Activity ✓ Stay as active as possible but don't overdo it. ✓ Know your limits. ✓ Be able to carry on a conversation while exercising. Weight ✓ Weigh each day simultaneously on the same scale to monitor for fluid retention. Diet ✓ Limit daily sodium intake to 2 to 3 g as prescribed. ✓ Limit daily fluid intake to 2 L. Symptoms ✓ Note any new or worsening symptoms and immediately notify the health care provider.
The nurse is performing a physical assessment on a child with suspected Kawasaki disease (KD). Which of the following assessment findings would support this diagnosis? Select all that apply. strawberry tongue fruity breath drooling fever bright red rash on the cheeks
Choices A and D are correct. KD is an autoimmune disorder that occurs primarily in individuals younger than five. This condition may cause systemic vasculitis and cardiac abnormalities, including an aneurysm. The classic manifestations of KD include a high fever (unresponsive to antibiotics and antipyretics), red, cracked lips, strawberry tongue, and cervical lymphadenopathy. Choices B, C, and E are incorrect. Fruity breath is not a sign of Kawasaki's disease. Fruity breath is characteristic of diabetic ketoacidosis (DKA). Drooling is not a sign of Kawasaki's disease. Drooling is characteristic of a child presenting with epiglottitis. A bright red rash on the cheeks is a characteristic sign of Fifth's disease (parvovirus B19). The rash in KD is in the groin and perineum. Additional Info ✓ Kawasaki disease is an inflammatory syndrome commonly found in individuals younger than five, affecting males more than females. ✓ Classic symptoms include fever, chapped lips, bilateral conjunctivitis, and polymorphous rash. ✓ Prompt treatment with aspirin or intravenous immunoglobin is needed to prevent injury to the coronary arteries. ✓ It is important to note that Kawasaki disease is the one time that aspirin is administered in the pediatric population. ✓ Usually, it is avoided due to the risk of Reye's syndrome. However, Kawasaki disease is the exception to this rule, and aspirin is routinely used in this case.
A nurse is educating a student nurse about blood transfusions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply. "If a client should develop crackles in their lung fields, it is a sign of a hemolytic reaction." "Transfusion-related graft versus host disease most commonly occurs in immuno-suppressed individuals." "Transfusion-associated circulatory overload (TACO) is more common in clients with renal failure." "It is important to ask the client about history of previous blood transfusions." "Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion."
Choices A and E are correct. These two statements indicate that the student nurse needs further teaching on blood transfusions. Crackles in the lung fields suggest a transfusion-associated circulatory overload (TACO). Physicians may prescribe pre-medication with diphenhydramine and acetaminophen only if the client has a history of febrile or allergic reactions to prior blood transfusions. Pre-medications are, therefore, not always required. Choices B, C, and D are incorrect. Graft-versus-host-disease (GVHD) is a rare transfusion reaction that occurs mostly in severely immunocompromised clients (post-bone-marrow transplant, Hodgkin disease, non-Hodgkin lymphoma, and acute myeloid and acute lymphoid leukemias). In this condition, the donor's T lymphocytes cause an immune response in the recipient by engrafting in the recipient's marrow and attacking the recipient's tissues/ blood cells. Under normal circumstances, donor T-cells are killed by the recipient's immune system, but in severe immunodeficiency, donor T-cells remain, causing GVHD. Transfusion-related GVHD presents with fever, rash all over, including feet and hands, diarrhea, nausea, and elevated Liver function tests. Such reactions can be limited by a process called "Cytoreduction" where the T-cells are removed from the donor blood products. Transfusion Associated Circulatory Overload (TACO) is more common in patients with baseline cardiac and renal disorders. Fluid overload can happen during transfusion if the client already has underlying congestive heart failure. If the client is felt to be at risk for circulatory overload, a loop diuretic such as furosemide may be ordered before, after, or in between PRBC units. It is important to get a history of previous blood transfusions as the nurse can take action before the transfusion to pre-medicate the client, as prescribed. ➢ A hemolytic blood transfusion may be fatal if not caught promptly. The primary cause of this reaction is the misidentification of the client and the blood product. ➢ Manifestations of a hemolytic reaction include low-back pain, chest pain, tachycardia, hypotension, and a feeling of impending doom. ➢ If a hemolytic reaction is assessed, the nurse should immediately discontinue the transfusion and save the tubing and unit of blood for further analysis. ➢ Immediate client care involves spiking a new bag of isotonic saline (with new tubing) and keeping the intravenous catheter patent.
The nurse is caring for a client diagnosed with a myxedema coma. The nurse should anticipate a prescription for which of the following medications? Select all that apply. Levothyroxine Methimazole Tolvaptan Hydrochlorothiazide Hydrocortisone
Choices A and E are correct. When a client experiences a myxedema coma, it is because of severe hypothyroidism. These dangerously low levels of thyroid hormone produce symptoms such as altered level of consciousness, hyponatremia, hypothermia, hypoventilation, and hypoglycemia. Treatment is essential and is geared towards the prompt administration of intravenous levothyroxine and liothyronine. Glucocorticoids are usually added to the treatment to help mitigate the hypotension and potential overlook of adrenal dysfunction. Choices B, C, and D are incorrect. Methimazole would be contraindicated in myxedema since this is a type of antithyroid medication. Furthermore, tolvaptan is not indicated because this medication is used to treat SIADH. HCTZ is a treatment for essential hypertension and nephrogenic diabetes inspidus. It has no role in a myxedema coma. Additional Info ✓ Myxedema coma is a rare but extremely serious complication associated with severe hypothyroidism. ✓ Manifestations of a myxedema coma include hyponatremia, hypothermia, hypoventilation, and hypoglycemia. ✓ The nurse must initiate medical and symptomatic treatment, such as intravenous levothyroxine and hydrocortisone. ✓ The nurse may also treat the client's symptoms with passive rewarming.
While reviewing congenital heart defects with a senior nurse in the PICU, she asks you which defects have increased pulmonary blood flow. You respond by listing which of the following? Atrial septal defect (ASD) Atrioventricular canal defect Ventricular septal defect (VSD) Aortic stenosis Transposition of the Great Arteries
Choices A, B, and C are correct. An ASD is an abnormal opening between the atria. It causes an increased flow of oxygenated blood into the right side of the heart, which therefore increases pulmonary blood flow. An atrioventricular canal defect (AV canal) is the incomplete fusion of the endocardial cushions leading to an open 'canal' between both atriums and ventricles. Oxygenated and deoxygenated blood mix in the open canal and cause increased pulmonary blood flow. A VSD is an opening between the two ventricles. Blood shunts from the left ventricle where there is higher pressure and then to the right ventricle where there is lower pressure, causing the increased pulmonary blood flow. Choice D and E are incorrect. Aortic stenosis is the narrowing of the aortic valve. This causes resistance to systemic blood flow and is characterized as an obstructive congenital heart defect. Transposition of the Great Arteries is where the aorta and pulmonary artery are switched. These do not create increased pulmonary blood flow. ✓ Congenital heart defects that lead to increased pulmonary blood flow are often also acyanotic, since there is oxygenated blood going to the lungs ✓ Increased pulmonary bloodflow can lead to pulmonary hypertension ✓ Blood wants to travel the path of least resistance, which is from left to right through septal defects
The nurse has provided medication instruction to a client prescribed sucralfate. Which of the following statements, if made by the client, would require further teaching? Select all that apply. 2/3 Your Score/Max +/- Scoring Rule "I should take this medication one hour after meals." "I will remain upright for 30 minutes after taking this medicine." "This medication will help with my peptic ulcer disease." "I know this medication works when my nausea and vomiting are gone." "I may dissolve this medication in warm water."
Choices A, B, and D are correct. These statements are false and require further teaching. Sucralfate is a medication indicated in peptic ulcer disease. This medication should be taken one hour before meals as the medication will coat the ulcer allowing a client to eat meals without pain. The client is not required to be upright 30 minutes after taking this medication. This would be applicable instruction for a patient prescribed a bisphosphonate. This medication has no indication for nausea and vomiting treatment. Appropriate treatment for nausea and vomiting would be ondansetron or metoclopramide. Choices C and E are incorrect. Sucralfate is a gastric fortifier intended to help with peptic ulcer disease. The pills are rather large and may be dissolved in water to improve the client's ability to swallow. Additional Info ✓ Sucralfate is a gastric fortifier intended to help with peptic ulcer disease. ✓ This medication should be taken one hour before meals and at bedtime. ✓ This medication allows the client to eat their meal without the pain of the ulcer. ✓ Constipation is the most common side-effect associated with this medication.
The nurse is assigned to care for a client with a sodium level of 122 mEq/L(135-145 mEq/L). Which assessment findings does the nurse anticipate based on this lab result? Confusion Abdominal cramps Tall, peaked t-waves Hypoactive bowel sounds Nausea and vomiting
Choices A, B, and E are correct. This client's sodium level is critically low. When sodium falls below 125 mEq/L, it is considered severe hyponatremia. Sodium plays a key role in the brain, so low levels of this electrolyte can be devastating and produce symptoms ranging from confusion, lethargy, and stupor as well as seizures and cerebral edema. Abdominal cramps are another symptom of hyponatremia. Since water follows sodium, there are decreased levels of sodium in the blood and decreased fluid. This creates a fluid volume deficit, decreased urine output, muscle spasms, and abdominal cramping. Nausea and vomiting are common signs of hyponatremia. Choices C and D are incorrect. Arrhythmias such as tall, peaked t-waves are not indicative of hyponatremia. Rather, tall, peaked t-waves are characteristic of hyperkalemia. Hypoactive bowel sounds are not a sign of hyponatremia. Hyperactive bowel sounds rather would be a symptom the nurse might observe if there are decreased levels of sodium in the blood. Sodium also plays an important role in muscle cells; when levels are too low, this results in cramping, spasms, and hyperactive bowel sounds.
The nurse is caring for a client who presents with a blood glucose level of 45 mg/dL(70-110 mg/dL). Which of the following findings are expected? Select all that apply. Blurred vision Increased urinary output Cool and clammy skin Palpitations Orthostatic hypotension Paresthesias
Choices A, C, D, and F are correct. Blurred vision (Choice A), cool and clammy skin (Choice C), palpitations (Choice D), and paresthesias (Choice F) are expected findings with hypoglycemia. Hypoglycemia is a blood sugar less than 70 mg/dL. Symptoms of hypoglycemia can be divided into two broad categories: Neurogenic (autonomic): Adrenergic vs cholinergic symptoms: include those from the release of catecholamines such as tremors, palpitations (Choice D), anxiety (catecholamine-mediated, adrenergic), sweating, hunger, and paresthesias (Choice F) (acetylcholine-mediated, cholinergic). Neuroglycopenic: Neuroglycopenia refers to a deficiency of glucose in the brain and neurons secondary to hypoglycemia. Symptoms of moderate neuroglycopenia include blurred vision (Choice A), slurred speech, drowsiness, dizziness, and extreme fatigue. Severe neuroglycopenia can cause delirium, confusion, and eventually, seizure and coma.
A nurse is reviewing prescriptions for assigned clients. Which prescriptions require follow-up with the primary healthcare provider? A client with Select all that apply. congestive heart failure prescribed diltiazem. hypertension prescribed clonidine. diabetes insipidus prescribed hydrocortisone. pulmonary emboli prescribed clopidogrel. atrial fibrillation prescribed amiodarone. bacterial cystitis prescribed valacyclovir.
Choices A, C, D, and F are correct. These prescriptions are inappropriate and require follow-up with the PHCP. The client with congestive heart failure should not be prescribed calcium channel blockers because of their negative inotropic effects, worsening heart failure. Further, hydrocortisone would be indicated to treat adrenal insufficiency, whereas vasopressin would be used for diabetes insipidus. Additionally, clopidogrel is an antiplatelet medication used to prevent stroke where a client with a pulmonary embolism requires anticoagulants or thrombolytics. Finally, antibiotics such as ceftriaxone are indicated for bacterial cystitis, not antivirals such as valacyclovir.
The nurse is caring for a child experiencing an adrenal crisis. The nurse has established a peripheral vascular access device and should be prepared to administer intravenous Select all that apply. 2/2 Your Score/Max +/- Scoring Rule potassium chloride. 5% dextrose with 0.9% saline. hydrocortisone. levothyroxine. desmopressin. propranolol.
Choices B and C are correct. An adrenal crisis is a medical emergency for both an adult and a child. Remember, you need to add the treatment in an adrenal crisis (Addisonian crisis). The immediate treatment for a client in an adrenal crisis is replacing the corticosteroid via intravenous (IV) hydrocortisone. The treatment goal of administering IV hydrocortisone is to increase the low glucose levels and retain some of the fluid and sodium. The second essential treatment is administering IV fluids of 5% dextrose with 0.9% saline. The 5% dextrose with 0.9% saline will raise the glucose (D5) and circulating volume (0.9% saline). Giving D5W alone would be detrimental as the water will lower serum sodium levels. Choices A, D, E, and F are incorrect. In an adrenal crisis, the client's sodium is low, and their potassium is high. Giving potassium chloride would be detrimental as the expected hyperkalemia must be treated with medications such as regular insulin and dextrose and/or sodium polystyrene. Intravenous levothyroxine is not indicated in an adrenal crisis; rather, IV levothyroxine is an essential treatment in a myxedema coma. Desmopressin IV is the treatment for central diabetes inspidus, not an adrenal crisis. Propranolol would be detrimental because when a client arrives with an adrenal crisis, they are significantly dehydrated, thus, having low blood pressure. Giving propranolol, a beta-blocker, would lower the blood pressure further. IV propranolol, along with methimazole or propylthiouracil, is the treatment for a thyroid storm.
The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse anticipate from the primary healthcare provider (PHCP)? Select all that apply. Furosemide Neomycin Naproxen Lactulose Diazepam
Choices B and D are correct. Neomycin is an antibiotic and is indicated for hepatic encephalopathy. This oral medication is taken to decrease ammonia's gastrointestinal production, which is contributing to encephalopathy. Lactulose is central in treating hepatic encephalopathy because it traps ammonia in the colon and increases its transit. Thereby decreasing serum ammonia levels. Treatment options for hepatic encephalopathy would include prescribed potassium-sparing diuretics, lactulose, and antibiotics such as neomycin or rifaximin. Nursing care aims to assist the client in achieving and maintaining treatment adherence and the avoidance of medication such as NSAIDs and benzodiazepines that could worsen the encephalopathy.
A nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client stating that they took their prescribed carbamazepine with a sip of water. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL. reporting that they shaved their abdomen for their scheduled appendectomy. reporting difficulty with their last surgery, stating they got 'a really high fever'. reporting burning upon urination and increased urinary frequency.
Choices B, C, D, and E are correct. These clients require follow-up. Preoperative (and postoperative) hyperglycemia is detrimental to optimal outcomes. This client has a glucose of 266 mg/dL, which is hyperglycemia. This client should also have the prescribed infusion of D5W questioned, as this solution would further increase the glucose. Clipping hair at the operative site is the best practice because it reduces the risk of surgical site infection. If shaving has to be done, it is completed immediately before the incision to reduce the chance of postoperative infection. The client stated that they got a high fever after their previous surgery and requires follow-up. This could be a concern for malignant hyperthermia. Although rare, this genetic disorder can be life-threatening when the client is exposed to certain anesthesia. The client reported burning upon urination preoperative and requires follow-up as preoperative infections may cause surgery cancelation as they complicate healing. Choice A is incorrect. This client does not require follow-up. Carbamazepine is an anticonvulsant and is commonly permitted to be taken with a sip of water to prevent seizure activity.
The nurse is developing a plan of care for a client diagnosed with Addison's disease. Which of the following should the nurse include in the client's plan of care? Select all that apply. 3/3 Your Score/Max +/- Scoring Rule Diet high in potassium Continuous telemetry monitoring Intravenous hydrocortisone Fluid restriction Fall precautions Indwelling urinary catheter
Choices B, C, and E are correct. Addison's disease is a problem dealing with deficient aldosterone and cortisol. Aldosterone is responsible for sodium retention and potassium elimination. A clinical feature of this disorder is insufficient aldosterone, causing the client to experience elevated potassium; thus, continuous cardiac monitoring is warranted. The priority treatment for a client with Addison's is to replace the missing steroid. Thus, hydrocortisone is essential. The nurse should implement fall precautions because, with a low amount of cortisol and aldosterone, the client is at risk for dehydration, leading to orthostatic hypotension. Choices A, D, and F are incorrect. A high potassium diet is contraindicated for a client with Addison's as their potassium will already be elevated. The client should consume low-potassium foods and be encouraged to increase their fluids as dehydration is a common manifestation of this disease. Finally, the nurse must monitor the client's fluid volume status, but an indwelling catheter is invasive and raises the risk of infection. Additional Info Addison's disease (adrenal insufficiency) is characterized by an insufficient amount of glucocorticoid and mineralocorticoid. Lifelong steroid replacement is often necessary to manage this condition. Teaching points for a client with adrenal insufficiency include - Medication adherence to the prescribed corticosteroid Dietary management involves adequate sodium and reducing potassium Self-monitoring of weight and blood pressure Notifying the primary healthcare provider of any stressful events or illnesses which may trigger a crisis Wear a medical alert ID bracelet or tag Keep a dose of emergency hydrocortisone at all times, and know when and how to administer the injection Understand and be alert for the signs of an Addisonian crisis (profound fatigue, dizziness, abdominal cramping, confusion)
intussusception
vomiting changes in stool consistency and color sausage shaped palpable mass right lower abd quadrant empty
The nurse is preparing to provide care for a client with disseminated herpes zoster. The nurse plans to don which personal protective equipment (PPE)? Select all that apply. == goggles gown gloves shoe covers n95 respirator Surgical face mask
Choices B, C, and E are correct. When varicella zoster is disseminated, it can be transmitted through airborne means and by direct contact with the lesions. The isolation required is contact + airborne. This means the nurse should wear an N95 respirator, high-efficiency particulate air filter respirator, gown, and gloves. Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia. VZV can be reactive later in a person's life and create a painful, maculopapular rash called herpes zoster. When herpes zoster (varicella-zoster) (shingles) is localized and can be covered, standard precautions are implemented until all of the lesions have crusted over. When herpes zoster (varicella-zoster) (shingles) is disseminated, airborne + contact precautions are implemented for the duration of the illness.
The nurse is caring for a client who is receiving prescribed olanzapine. Which findings would indicate that the client has an adverse effect from this medication? Weight loss Hyperglycemia Weight gain Hyperlipidemia Nystagmus
Choices B, C, are D are correct. Olanzapine is a second-generation antipsychotic (SGA). SGAs such as olanzapine and clozapine have a high risk of causing a client to develop metabolic syndrome. Metabolic syndrome includes hyperglycemia, overweight or obesity, abdominal obesity, hyperlipidemia, and hypertension. Olanzapine and clozapine are implicated in causing some of the worse metabolic effects. Choices A and E are incorrect. Weight loss is not a feature associated with olanzapine. By far, the most common effect associated with olanzapine is weight gain. Nystagmus is not an adverse effect associated with olanzapine. Additional Info Second-generation antipsychotics (risperidone, olanzapine, quetiapine, clozapine, lurasidone, ziprasidone, aripiprazole, brexpiprazole, cariprazine) are commonly utilized in the management of psychotic and some mood disorders. The two pines of olanzapine and clozapine are quite efficacious in psychotic disorders but also have the highest risk of a client developing metabolic syndrome.
The nurse is preparing a staff in-service regarding conductive hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. 0/2 Your Score/Max +/- Scoring Rule Presbycusis Prolonged exposure to noise Foreign body Ototoxic substance Cerumen
Choices C and E are correct. Conductive hearing loss is typically reversible and caused by cerumen, foreign body, tumor, edema, and acute infection. Choices A, B, and D are incorrect. Presbycusis, prolonged exposure to noise, and ototoxic substances cause sensorineural hearing loss. Sensorineural hearing loss is often irreversible.
The nurse is caring for a client with the following clinical data. Based on the clinical data, which prescription would the nurse request from the primary healthcare provider (PHCP)? Select all that apply. See the image below. medical history congestive heart failure - HTN - DM 2 crackles - bounding pulses - tachypnea - JVD - abd distention dx: pulmonary edema - acute decompensated HF albuterol hydrocortisone diltiazem nitroglycerin furosemide
Choices D and E are correct. Pulmonary edema secondary to acute decompensated heart failure (ADHF) is a medical emergency and requires rapid treatment. Vasodilators such as nitroglycerin help decrease preload and afterload, reducing the heart's workload. This medication is often combined with a loop diuretic such as furosemide or bumetanide to decrease volume. If vasodilators or loop diuretics are prescribed, close blood pressure monitoring is essential. Choices A, B, and C are incorrect. Albuterol would be unnecessary and harmful for a client with pulmonary edema and ADHF. This would be useful for a client experiencing bronchoconstriction, such as an asthma exacerbation. The assessment for this client revealed crackles in the lung fields - not wheezes. Hydrocortisone is a steroid and would be unhelpful in the management of ADHF. This medication may be detrimental as this medication leads to fluid retention. Diltiazem is a calcium channel blocker and is grossly contraindicated in ADHF because of its negative inotropic effects. Additional Info Priority nursing care for a client with pulmonary edema includes: ✓ Airway assessment and pulse oximetry monitoring ✓ High-flow oxygen therapy via nonrebreather or intubation if clinically indicated ✓ Cardiac and vital sign monitoring with critical care placement ✓ High-fowler's positioning ✓ Emergent intravenous diuresis and vasodilators, as prescribed Once the client has been stabilized, the urinary output should be monitored along with daily weights to evaluate their response to the therapy ✓ VTE prophylaxis should be maintained coupled with prescriptions such as ACE inhibitors (lisinopril)
hypoparathyroidism
Chvostek's cheek - facial spasm Trousseau's BP thumb abduction and flexion of wrist
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up? 1.Black, tarry stool 2.Bright red-streaked stool 3.Light gray clay-colored stool 4.Small, dry, rocky stool
Cirrhosis is a progressive, degenerative condition caused by destruction and subsequent disordered regeneration of the liver parenchyma. Clients with cirrhosis may experience progressive complications (eg, esophageal varices, ascites, encephalopathy) without intervention. Black, tarry stools (melena) are caused by digested blood and indicate active upper gastrointestinal (GI) bleeding or bleeding esophageal varices, a potentially life-threatening complication of cirrhosis (Option 2) Bright red, blood-streaked stool indicates hemorrhoids or rectal bleeding. Further evaluation of hemorrhoids can be safely delayed. (Option 3) Decreased bile flow into the intestine due to biliary tract obstruction (eg, cholelithiasis) produces a light gray "clay-colored" stool. This finding requires further evaluation but is not life-threatening. (Option 4) Small, dry, hard stool indicates constipation. Inactivity, decreased peristalsis, inadequate fiber intake, decreased fluid intake, and some medications (eg, anticholinergics, opioid analgesics) may contribute to constipation.
Flagyl (metronidazole)
Classification: Antiinfective, antiulcer, Antiprotozoal Therapeutic Effects: Treatment of anaerobic and parasitic infections Adverse Reactions & side effects: SEIZURES, dizziness, HA, anorexia, nausea, GI effects Nursing Implications & teaching:Monitor WBC, neurological status, and I/Os, TAKE WITH FOOD
What is the #1 priority of second stage?
Clearing baby's airway
A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. 1.Assess abdominal distension every 4 hours 2.Check gastric residual every 12 hours 3.Keep head of the bed at ≥30 degrees 4.Maintain endotracheal cuff pressure 5.Use caution when administering sedatives
Clients who are critically ill are at increased risk for aspiration of oropharyngeal secretions and gastric contents, particularly when they are receiving enteral feedings. Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include: Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus (Option 1) Assess feeding tube placement at regular intervals Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated (Option 3) Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents (Option 4) Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex (Option 5) Avoid bolus tube feedings for clients at high risk for aspiration
The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? 1.Blood glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L) 2.Client is lying with knees drawn up to the abdomen to alleviate pain 3.Five large, liquid stools that are yellow and foul-smelling 4.Temperature of 102.2 F (39 C) with increasing abdominal pain
Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain may indicate abscess formation (Option 4). The abscess must be treated promptly to prevent sepsis. The health care provider should be notified immediately as antibiotic therapy and immediate surgical management may be required. (Option 1) Elevated blood glucose is an expected finding in clients with pancreatitis. Elevated blood glucose is associated with pancreatic dysfunction and may necessitate insulin administration, but this is not the most concerning finding. (Option 2) Clients with acute pancreatitis often report severe, burning midepigastric abdominal pain that radiates to the back. Clients may seek relief from pain by positioning themselves in the knee-chest position, which decreases intra-abdominal pressure. Pain relief interventions should be attempted, but this is not the priority. (Option 3) The client with pancreatitis may develop steatorrhea (eg, fatty, yellow, foul-smelling stools) due to a decrease in lipase production. Although fluid and nutritional status are important, this does not take precedence over a possible surgical emergency.
Based on the lung assessment information included in the hand-off report, which client should the nurse assess first? 1.Client 1-day postoperative abdominal surgery who has fine inspiratory crackles at the lung bases 2.Client with chronic bronchitis who has rhonchi in the anterior and posterior chest 3.Client with right-sided pleural effusion who has decreased breath sounds at the right lung base 4.Client with severe acute pancreatitis who has inspiratory crackles at the lung bases (45%)
Clients with acute pancreatitis can develop respiratory complications including pleural effusions, atelectasis, and acute respiratory distress syndrome (ARDS). These complications are often due to activated pancreatic enzymes and cytokines that are released from the pancreas into the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these complications and can rapidly progress to respiratory failure within a few hours. Therefore, the presence of inspiratory crackles in this client could indicate early ARDS and needs to be assessed further for progression. (Option 1) Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in clients who have undergone abdominal surgery due to shallow breathing related to pain. Although the presence of fine crackles requires treatment (eg, ambulation, deep breathing), this is not the priority assessment. (Option 2) Rhonchi are continuous, low-pitched wheezes usually heard on expiration that sound like moaning or snoring. The sound originates from air moving through large airways (bronchi) filled with mucus secretions and are expected in clients with chronic bronchitis. Although they require treatment (eg, medication, mobilization of secretions), this is not the priority assessment. (Option 3) The lung under the pleural effusion is compressed, and the breath sounds are decreased/absent if auscultated over the area; this is an expected finding. Until the pleural effusion is treated with diuretics or thoracentesis, these findings will remain unchanged.
The home-health nurse is assessing a client who reports severe anxiety associated with riding in a train for a new job. The nurse recognizes that the client most likely has what disorder? 1.Agoraphobia 2.Generalized anxiety disorder 3.Social anxiety disorder 4.Zoophobia
Clients with agoraphobia have intense fear and anxiety about being in certain situations or spaces. These clients are highly concerned about having trouble escaping or getting help in the event of a panic attack. This fear is out of proportion to any actual danger (Option 1). In severe agoraphobia, the client often prefers not to leave the home and avoids public places for fear of recurring panic attacks or embarrassment. Clients with agoraphobia actively avoid these situations and often feel the need to be accompanied by a relative or friend if avoidance is impossible. Such clients experience fear and anxiety while in the following situations: Public transportation (eg, bus, train) Open spaces (eg, stores, bridges, parking lots) Enclosed places (eg, movie theaters, stores) Crowds or standing in line Outside the home alone
The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose? 1.To lower the blood alcohol level 2.To prevent gross tremors 3.To prevent Wernicke encephalopathy 4.To treat seizures related to acute alcohol withdrawal
Clients with chronic alcohol abuse suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition. (Option 1) Thiamine is not used to reduce the blood alcohol level; there is no antidote for elevated blood alcohol levels. Supportive measures are used until levels fall and the client is no longer experiencing acute withdrawal symptoms. (Option 2) Gross tremors related to acute alcohol withdrawal are treated with benzodiazepines (eg, lorazepam, diazepam). (Option 4) Seizures related to acute alcohol withdrawal are treated with benzodiazepines (eg, lorazepam, diazepam, chlordiazepoxide). Thiamine is used to prevent encephalopathy. Encephalopathy may lead to seizures, but thiamine is not used to treat seizures.
The nurse is performing discharge teaching on nutritional therapy for a client with chronic kidney disease. Which statement indicates that further teaching is needed? 1."Because I have chronic kidney disease, I should avoid canned soups and cold-cut sandwiches." 2."I can use a salt substitute because I am required to restrict both sodium and potassium in my daily diet." 3."I must avoid eating raw carrots and tomatoes on my salads because I take hemodialysis treatments." 4."The popsicles I eat should be counted in my daily fluid intake because they become liquid at room temperature."
Clients with chronic kidney disease (CKD) are at risk for fluid overload and hyperkalemia. Clients should avoid salt substitutes, which typically contain potassium chloride and may contribute to hyperkalemia (Option 2). To avoid further complications and prevent progressive kidney damage, clients with CKD are advised to follow certain dietary restrictions, including: Sodium restriction - Avoid high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings (Option 1). Potassium restriction - Avoid high-potassium foods such as raw carrots, tomatoes, and orange juice (Option 3). Fluid intake monitoring - Monitor fluid intake closely and accurately, being careful to include foods that are liquid-based (eg, popsicles, gelatin), because fluid is often restricted (Option 4). Low-protein diet - Eat 0.6-0.8 g/kg/day of protein to help prevent progression of kidney disease. If the client is already on hemodialysis, increased protein intake is recommended to prevent malnutrition. Low-phosphorus diet - Avoid foods high in phosphorus (eg, chicken, turkey, dairy).
The nurse has received report on four clients at the start of the shift. Which client should the nurse assess first? 1.Client in a body cast who reports abdominal pain and bloating 2.Client receiving antibiotics who reports new-onset vaginal itching 3.Client who reports numbness of the surgical site following mastectomy 4.Client who reports shoulder pain following robotic laparoscopic cholecystectomy
Clients with large body casts are at risk for bowel obstruction due to cast syndrome (ie, superior mesenteric artery [SMA] syndrome), which causes decreased peristalsis. Cast syndrome is a rare complication of an overly tight cast and involves compression of the duodenum by the SMA. Immobilization of clients in body casts decreases peristalsis and may cause a paralytic ileus (ie, bowel obstruction). If severe, bowel obstruction can result in bowel ischemia. The nurse should immediately report symptoms of bowel obstruction (eg, abdominal pain, distension, nausea, vomiting) to the health care provider. If cast syndrome is suspected, a window may be cut out of the cast over the abdomen to relieve pressure (Option 1). (Option 2) Antibiotics disrupt normal vaginal flora and may precipitate the development of a yeast infection, which presents with vaginal discharge and itching. A client reporting new-onset vaginal itching should be assessed, but this is a lower priority. (Option 3) Following a mastectomy, tingling, numbness, and itching are common at the incision site. A client experiencing these symptoms likely requires reassurance, but this is a lower priority. (Option 4) Following a laparoscopic cholecystectomy, the client may have referred shoulder pain caused by carbon dioxide gas used during surgery to inflate the abdomen. Managing postoperative pain is important but is not the priority.
The nurse is caring for a client with a history of heroin use. Which clinical finding may indicate withdrawal? 1.Constipation 2.Constricted pupils 3.Drowsiness 4.Tachycardia
Clients with opioid dependence (eg, oxycodone, hydrocodone, heroin) may develop acute withdrawal if opioids are abruptly stopped, dosage is reduced, or a reversal agent (ie, naloxone) is administered. Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes (Option 4). Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions. (Options 1, 2, and 3) Opioid use typically causes constipation, constricted pupils, and drowsiness due to its central nervous system depressant effects.
Which of the following client findings are consistent with a cystic fibrosis exacerbation? Select all that apply. 1.Blood-tinged sputum 2.Greasy, bulky stools\ 3.Paroxysmal coughing 4.SpO2 of 87% on room air 5.Temperature of 101.6 F (38.7 C)
Clinical manifestations of a cystic fibrosis (CF) exacerbation include: Blood-tinged sputum (ie, hemoptysis): Pulmonary capillaries can be chronically damaged from repeated infections, resulting in hemoptysis with acute exacerbations (Option 1). Greasy, bulky stools (ie, steatorrhea): Viscous secretions block pancreatic ducts, preventing the release of the pancreatic enzymes necessary for fat absorption by the intestines. Clients with CF should take replacement pancreatic enzymes with food to promote fat absorption and normal stool formation. Steatorrhea occurs when unabsorbed fat is released in the stool (Option 2). Paroxysmal cough: Violent coughing may occur to attempt to clear thick mucoid secretions (Option 3). Hypoxia (ie, capillary oxygen saturation [SpO2] of 87% on room air): Viscous airway sections block the respiratory tract and impair mucociliary clearance, leading to obstruction, bacterial colonization, and chronic sinopulmonary infections. Frequent infections damage lung tissue, which can cause chronic hypoxia. However, a sudden drop in the client's oxygen saturation indicates possible mucus plug in the airway (Option 4). Fever (ie, temperature of 101.6 F [38.7 C]): A fever is caused by an acute inflammatory response to underlying infection (Option 5
The health care provider prescribes clomiphene for 5 days, beginning on the fifth day of menses, for treatment of infertility. After the nurse provides medication teaching, which client statement would indicate a need for further teaching? 1."Clomiphene increases my risk of having more than one baby, such as twins or triplets." 2."Hot flashes, mood swings, nausea, and headache are possible side effects of this medication." 3."My partner and I should have sexual intercourse on the days that I am taking the medication." 4."This medication will help my body release eggs and increase my chance of becoming pregnant."
Clomiphene (Clomid, Serophene) is a selective estrogen receptor modulator that is used as a first-line treatment for infertility for women and works by stimulating ovulation. This medication blocks estrogen receptors in the hypothalamus and pituitary, which causes the release of hormones (ie, gonadotropin-releasing hormone, follicle-stimulating hormone, luteinizing hormone) that stimulate the ovaries to release an egg. The medication is taken orally for 5 days early in the menstrual cycle (eg, beginning on days 3-5 of menses). Ovulation typically occurs 5-9 days after completing the medication. Therefore, it is necessary for the client to understand the importance of engaging in frequent sexual intercourse (eg, every other day for 1 week) 5 days after completing the medication for the best chance of successful conception
A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? 1.Complete blood count and absolute neutrophil count 2.ECG and blood pressure 3.Fasting blood glucose and fasting lipid panel 4.Height, weight, and waist circumference
Clozapine (Clozaril) is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia. A client must have a WBC count of ≥3500/mm3 (3.5 × 109/L) and an absolute neutrophil count (ANC) of ≥2000/mm3 (2 × 109/L) before starting clozapine, so it is critical to obtain a baseline complete blood count and ANC. Because agranulocytosis is reversible if caught early, the client's WBC count and ANC must also be monitored regularly throughout the course of clozapine therapy (initially once a week) (Option 1). Clients should also contact the health care provider immediately if they develop fever or sore throat, which can indicate infection due to neutropenia.
obstructive heart defects
Coarctation of the aorta Aortic stenosis Pulmonic stenosis
The nurse is reviewing the medication administration record for a 70-year-old client. Which of the following prescriptions have the potential for injury in older adult clients? Select all that apply. 1.Amitriptyline 2.Chlorpheniramine 3.Diazepam 4.Famotidine 5.Sertraline
Common medications to avoid in older adults (Beers criteria) Anticholinergic --First-generation antihistamines --Gastrointestinal antispasmodics Cardiovascular --Alpha-1 blockers (as antihypertensives) --Centrally acting alpha-2 agonists --Many antiarrhythmics CNS --Tricyclic antidepressants --Antipsychotics --Barbiturates, benzodiazepines & other hypnotics Endocrine --Long-acting sulfonylureas --Sliding-scale insulin Pain --Nonselective NSAIDs --Skeletal muscle relaxants Older adults are at increased risk for medication adverse effects due to polypharmacy and age-related physiologic changes (eg, decreased renal and hepatic function, orthostatic hypotension, decreased visual acuity). The Beers criteria list recognizes medications associated with adverse effects (eg, drug-induced toxicity, cognitive dysfunction, falls) in older adults and provides evidence-based alternate recommendations. Examples of medications to avoid include: Tricyclic antidepressants (eg, amitriptyline) and first-generation antihistamines (eg, chlorpheniramine), which cause anticholinergic effects (eg, constipation, blurred vision, urinary retention, orthostatic hypotension) (Options 1 and 2) Benzodiazepines (eg, diazepam), which cause sedation, cognitive dysfunction, and increase the risk for falls (Option 3) (Option 4) Famotidine is an H2-receptor antagonist that is approved for treating gastroesophageal reflux disease and is safe for use in older adults. (Option 5) Selective serotonin reuptake inhibitors with shorter half-lives (eg, sertraline, escitalopram) are used to treat major depressive disorder and are generally safe for use in older adults.
The nurse on the orthopedic unit receives information during evening report. Which client should the nurse assess first? 1.Client 3 hours postoperative tibial fracture repair who reports severe pain and pressure under the cast and is requesting opioids every hour 2.Client 6 hours postoperative rotator cuff repair with a sling immobilizer who has moderate swelling and tingling of the hand and fingers 3.Client 8 hours postoperative total knee arthroplasty who has 2 closed-wound suction drains and a total output of 200 mL sanguineous drainage 4.Male client 1 day postoperative total hip replacement prescribed enoxaparin who has a hematocrit of 37% (0.37) and hemoglobin of 12.5 g/dL (125 g/L)
Compartment syndrome results from swelling and increased pressure within a confined space (a compartment). It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset (eg, surgical fasciotomy, cast removal), irreversible nerve and muscle injury can occur. (Option 2) Immobilization of the extremity in a sling can lead to venous pooling and edema of the hands and fingers if the sling is not applied properly. The nurse should evaluate the elbow and hand positions and perform a neurovascular assessment, but this is not the priority. (Option 3) Sanguineous (red) wound drainage at 25 mL/hr is expected 1 day postoperative knee replacement. Drains are usually removed in 24 hours unless drainage is excessive (eg, >1500 mL/24 hr). (Option 4) Anticoagulant therapy (eg, unfractionated heparin, enoxaparin, fondaparinux) is standard following total hip replacement. Slightly decreased hematocrit and hemoglobin levels (normal male: 39%-50% [0.39-.50], 13.2-17.3 g/dL [132-173 g/L], respectively) are expected due to intra- and postoperative blood loss.
What parameters would make you STOP an IV infusion of oxytocin/Pitocin?
Contractions lasting longer than 90 seconds Contractions less than every 2 minutes
variable decels
Cord Compression - have mom reposition - sometimes emergency c-section
Variable Early Acceleration Late deceleration
Cord compression Head compression Okay Placental insufficiency
The nurse prepares to exit the room of a client on airborne and contact isolation precautions. Place the following nursing actions in the correct order. 3. Place the call light within the client's reach 2. Exit the negative-pressure room and close the door 4. Remove the gown and gloves without contaminating hands 1. Discard the gown and gloves and perform hand hygiene 5. Remove the N95 respirator mask and perform hand hygiene
Correct Response 3. Place the call light within the client's reach 4. Remove the gown and gloves without contaminating hands 1. Discard the gown and gloves and perform hand hygiene 2. Exit the negative-pressure room and close the door 5. Remove the N95 respirator mask and perform hand hygiene
IM corticosteroids (eg, betamethasone
Corticosteroids accelerate fetal lung maturity by stimulating surfactant production, which reduces the risk of respiratory distress syndrome following birth. Interventions to delay preterm birth (eg, tocolytics) are simultaneously indicated so corticosteroids can have greater efficacy
The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? 1."I will ask the health care provider to explain the consequences of your procedure." 2."This is a common complication that will require you to have a hearing test every year." 3."This is a common complication; your health care provider will order a consult for the speech pathologist." 4."This is the reason you are using a special swallowing technique when you eat and drink."
Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. Clients are instructed to: Inhale deeply Hold breath tightly to close the vocal cords Place food in mouth and swallow while continuing to hold breath Cough to dispel remaining food from vocal cords Swallow a second time before breathing (Option 1) This would be considered "passing the buck." The nurse should try to address the client's concerns before calling the health care provider. (Option 2) Cranial nerve VIII (vestibulocochlear) affects hearing and equilibrium, not swallowing. (Option 3) The speech pathologist conducts a swallowing assessment early on to evaluate a client's ability to swallow safely. This consult is not done at discharge
Boston brace and Milwaukee brace
wear cotton shirt under helps to correct spinal deformities
when can you palpate the fundal height
week 12
Wilms tumor
DO NOT PALPATE
TPN nursing instructions
DO NOT stop abruptly - if stopped need dextrose 10% in water to prevent hypoglycemia check BG every 4-6hrs NO loading dose/ bolus record daily weight and I and O Central venous access device preferred Always have dextrose 10% available
isoniazid watch for
DRUG induced hepatitis
Fundal height =
Day post partum
dehydration signs review
Decreased blood pressure due to intravascular fluid loss and a compensatory increase in heart rate (ie, tachycardia) Increased hematocrit due to hemoconcentration from fluid loss Increased urine specific gravity, which indicates a high concentration of urine due to fluid loss Increased BUN due to low urine output and renal accumulation of waste products that would normally be excreted in urine
Myxedema coma is a severe form of hypothyroidism that causes an array of clinical manifestations, including -
Decreased mental status Bradycardia Hyponatremia Hypoglycemia Hypotension Hypothermia Treatment is aimed at giving the client intravenous levothyroxine, corticosteroids, intravenous fluids with dextrose, rewarming, and mechanical ventilation, if necessary.
Anticipated findings for a newborn at 31 weeks gestation may include:
Decreased muscle tone: The resting posture of a newborn at term gestation is flexion of arms and legs. A newborn at 31 weeks gestation may exhibit only mild flexion of the extremities due to poor muscle tone. In addition, magnesium sulfate may cause muscle hypotonia due to its neuromuscular effects (Option 3). Lanugo: At 31 weeks gestation, the nurse should anticipate thick lanugo (ie, fine, downy hair) over several parts of the newborn's body (eg, back, shoulders). Lanugo is abundant around midpregnancy and mostly disappeared by term gestation (Option 4). Difficulty with thermoregulation: Newborns at preterm gestation are at high risk for cold stress due to immaturity of the thermoregulatory center in the brain, inadequate subcutaneous fat, and inability to initiate shivering. The nurse should initially anticipate the newborn requiring assistance to maintain a normal body temperature (eg, radiant warmer, skin-to-skin contact with mother) (Option 5). (Option 1) Newborns develop a coordinated suck and swallow reflex around 32-34 weeks gestation. Therefore, the nurse should not anticipate a newborn at 31 weeks gestation to have effective breastfeeding. (Option 2) Newborns, especially at preterm gestation, may have brief episodes of apnea lasting a few seconds. However, apneic episodes >20 seconds or if accompanied by symptoms of poor oxygenation (eg, central cyanosis) are not expected.
Newborn characteristics associated with postterm gestation include:
Deep plantar creases over the entire sole of the foot (Option 1) Dry, cracked, and peeling skin, especially on the hands and feet (Option 2) Abundant scalp hair and long fingernails (Option 4) Minimal to absent vernix caseosa (ie, protective, white, waxy substance on the skin) (Option 5) Signs of meconium passage in utero (eg, meconium-stained [yellowish-green] skin or nails)
Succinylcholine (Anectine)
Depolarizing neuromuscular blocker agent used with intubation
The nurse is assessing a 6-month-old infant. Which of the following developmental findings would the nurse expect to observe? Select all that apply. 1.Holds and manipulates objects with a fine pincer grasp 2.Maintains head control when held in a sitting position 3.Recognizes and smiles at familiar faces 4.Rolls from a prone to a supine position 5.Uses the forearms to push up from a prone position
Developmental milestones are patterns of motor, language, social, and cognitive skills that are seen in most children by a specific age and serve as helpful guides for developmental surveillance. By 6 months of age, most infants reach the following milestones: Maintaining head control when pulled from a supine to a sitting position, the lack of which may indicate developmental and neurological delay (eg, cerebral palsy) (Option 2) Recognizing and smiling at familiar faces (Option 3) Rolling from a prone to a supine position (Option 4) Using the elbows and forearms to push up from a prone position (Option 5) (Option 1) By 6 months of age, the infant is expected to use a palmar grasp and a raking or sweeping motion of the hand to grab and manipulate objects. A fine pincer grasp (ie, use of the thumb and forefingers to pick up objects) is typically accomplished by age 10-12 months.
The nurse is assessing an 18-month-old client during a well-child visit. Which of the following would be expected age-related findings? Select all that apply. 1.Balances and hops on one foot 2.Copies a circle 3.Follows one-step commands' 4.Stacks two blocks 5.Walks independently
Developmental surveillance is the continuous process of monitoring a client's growth and development, using screening tools and physical assessments, to quickly identify potential delays. Early identification promotes timely referral and intervention so the client is more likely to reach full growth potential. Developmental milestones are patterns of motor, language, and social/cognitive skills seen in most children by a specific age and are helpful guides for developmental surveillance. Developmental milestones that an 18-month-old client should meet include: Cognitive/social: follows one-step commands without gestures (Option 3) Motor: stacks two blocks and walks independently (Options 4 and 5) Language: has a vocabulary of more than three words (in addition to caregiver titles [eg, "mama," "dada"])
The nurse in the intensive care unit is caring for a client who had a hypophysectomy 2 days ago and has developed diabetes insipidus. Which action should the nurse take? 1.Administer desmopressin 2.Check the client's fasting blood glucose level 3.Institute a fluid restriction 4.Place the client in the Trendelenburg position
Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH). DI is characterized by polydipsia (increased thirst) and polyuria (increased urine output) with low urine specific gravity (dilute urine). Neurogenic DI is caused by impaired ADH secretion, transport, or synthesis. It can result from manipulation of the pituitary gland or other parts of the brain during surgery, brain tumors, or head injury. Because ADH release is impaired in neurogenic DI, ADH replacement with vasopressin can be used to treat DI. However, vasopressin has vasoconstrictive properties. Therefore, desmopressin, an analog without vasopressor activity, is the preferred therapy (Option 1). Clients' urine output, urine specific gravity, and serum sodium levels should be monitored (to avoid hyponatremia due to excess desmopressin).
The nurse evaluates the effectiveness of desmopressin use for diabetes insipidus in a client with a pituitary tumor. Which client assessment finding indicates that the medication is having the desired effect? 1.Appetite has improved 2.Blood glucose is 110 mg/dL (6.1 mmol/L) 3.Urine output has decreased 4.Urine specific gravity is lower
Diabetes insipidus (DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia). Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute (Option 3).
The nurse in the emergency department is caring for a client with diabetic ketoacidosis. After obtaining the client's blood glucose level, which prescription should the nurse implement first? 1.Administer 0.9% sodium chloride 1000 mL IV bolus 2.Administer long-acting insulin subcutaneously 3.Initiate continuous regular insulin IV infusion 4.Obtain serum potassium level
Diabetic ketoacidosis (DKA) is a complication of diabetes mellitus that results from lack of insulin. Insulin is required to transport glucose into cells for energy; therefore, lack of insulin leads to intracellular starvation despite a high level of glucose circulating in the blood (hyperglycemia). Physiologic responses to hyperglycemia include osmotic diuresis (polyuria) for reduction of blood glucose levels, and breakdown of fat into acidic ketone bodies for energy (ketosis). DKA results in dehydration, electrolyte imbalances, and metabolic acidosis that can lead to life-threatening complications (eg, hypovolemic shock, cardiac arrhythmias) without prompt intervention. The nurse should prioritize fluid resuscitation with isotonic IV fluid (eg, 0.9% sodium chloride) to stabilize fluid volume prior to intervention that shifts blood glucose. Insulin administration will cause a shift of water, potassium, and glucose into cells, which worsens dehydration and electrolyte imbalances and can increase the risk of hypovolemic shock if fluid is not initiated first
Levofloxacin (Levaquin)
quinolone antibiotic. For this class of antibiotics, 2 hours should pass between drug ingestion and consumption of aluminum/magnesium antacids, iron supplements, multivitamins with zinc, or sucralfate. These substances can bind up to 98% of the drug and make it ineffective.
A client with type I diabetes mellitus comes to the emergency department with deep respirations of 36/min, abdominal pain, and fruity breath; the client also appears lethargic. The nurse should anticipate which of the following prescriptions? Select all that apply. 1.Administer a 1 L 0.9% sodium chloride IV bolus 2.Initiate an IV infusion of regular insulin 3.Instruct client to breathe into a paper bag 4.Obtain blood specimens for a serum glucose test 5.Place the client on continuous cardiac monitoring
Diabetic ketoacidosis (DKA) is an acute, life-threatening complication of diabetes mellitus that results from a lack of insulin. Insulin is required to transport glucose into cells for energy; therefore, lack of insulin leads to intracellular starvation despite a high level of glucose circulating in the blood (ie, hyperglycemia). Physiologic responses to hyperglycemia include polyuria, electrolyte imbalances, and metabolic acidosis that can lead to life-threatening complications (eg, hypovolemic shock, cardiac arrhythmias) without prompt intervention. The priority intervention for DKA is fluid resuscitation to restore intravascular volume and organ perfusion. The nurse should anticipate a prescription to infuse a bolus of 0.9% sodium chloride, followed by a continuous infusion (Option 1). Next, the nurse should anticipate: Initiating a continuous regular insulin infusion. Blood glucose should be monitored hourly to prevent hypoglycemia (Option 2). Obtaining serum blood glucose levels to confirm hyperglycemia (Option 4). Initiating continuous cardiac monitoring due to the increased risk for cardiac dysrhythmias secondary to electrolyte imbalances resulting from osmotic diuresis (Option 3) Kussmaul respirations are deep, rapid breaths that have a fruity smell as CO2 is exhaled. The respirations are a compensatory mechanism to lower PaCO2 and combat metabolic acidosis that should not be inhibited by breathing into a paper bag.
In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse expect to implement? 1.Check serum BUN and creatinine levels every hour 2.Discontinue insulin infusion when blood glucose is <350 mg/dL (19.4 mmol/L) 3.Increase insulin infusion rate when blood glucose level decreases 4.Initiate potassium IV when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmol/L)
Diabetic ketoacidosis (DKA) is an acute, serious complication generally due to lack of insulin in clients with type 1 diabetes. DKA is characterized by hyperglycemia, ketosis, and acidosis. Hyperglycemia causes osmotic diuresis, resulting in profound dehydration. Clients with DKA may initially develop hyperkalemia as a compensatory response to acidosis despite having a total body potassium deficit from urinary loss. Management of DKA includes fluid resuscitation, IV insulin, and hourly blood glucose monitoring. When serum glucose is <250 mg/dL (13.9 mmol/L), D5W is administered to prevent hypoglycemia until ketoacidosis is resolved. Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic (3.5-5.0 mEq/L [3.5-5.0 mmol/L]) to prevent hypokalemia and subsequent life-threatening arrhythmias (Option 4).
The nurse is caring for an elderly client who has type 2 diabetes mellitus and has just been diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? 1."Half of my vision looks like it's being blocked by a curtain." 2."I have to use reading glasses to see small print." 3."My vision seems cloudy, and I notice a lot of glare." 4."The colors don't seem as bright as they used to."
Diabetic retinopathy occurs due to microvascular damage to the retina resulting from chronic hyperglycemia (eg, diabetes mellitus). Diabetic retinopathy can lead to retinal detachment, which is a separation of the retina from the underlying epithelium. Symptoms of retinal detachment include flashes of light, floaters, or black spots across the field of vision, the sense of a curtain being drawn over the eye, and loss of a portion of the visual field. Retinal detachment requires emergency surgery to reattach the retina in an attempt to restore vision. Without rapid intervention, it can lead to permanent blindness (Option 1). (Option 2) Presbyopia is a normal age-related process that occurs from loss of accommodation, making it harder to see objects that are near. This can be treated with reading glasses. (Option 3) A cataract is an opacity in the lens of the eye causing cloudy vision with a glare. It is a nonemergency, age-related visual disorder. (Option 4) Decreased vibrancy of colors is a sign of diabetic retinopathy but does not indicate retinal detachment; therefore, it is not an emergency.
urine specific gravity of 1.003
Dilute over hydration diabetes insipidus **Think opposite of Lower->higher->higher vol**
Big risk of radioactive iodine
radiation risk in urine double flush need private bathroom
The mental health nurse is planning care for a client newly admitted with dissociative identity disorder. Which interventions will the nurse include? Select all that apply. 1.Develop a trusting relationship with each of the alternate identities 2.Encourage the client to journal about feelings and dissociation triggers 3.Explain to the client in detail the events of missing memories and lost time 4.Listen for expressions of self-harm from the alternate identities 5.Teach grounding techniques such as deep breathing to hinder dissociation
Dissociative identity disorder is a condition in which 2 or more identities alternately control the client's behavior. The alternate identities likely develop as a response to abuse or traumatic events and serve to protect the client from stressful memories. The client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory. Switching between identities occurs as a reaction to stress and individual triggers. The goal of treatment is to integrate the identities into one personality while maintaining safety. The client should journal about feelings and dissociation triggers and use a grounding technique (eg, deep breathing, rubbing a stone, counting coins) to counter dissociative episodes (Options 2 and 5). Identities may be volatile and should be monitored for indications of harm to self or others (Option 4). The nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate identity integration (Option 1). (Option 3) Dissociation and memory gaps are protective mechanisms. Forcing the client to hear or attempt to recall memories may result in distress and regression. Allow clients to recall memories at their own pace.
The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include? 1.Disulfiram is not a cure for alcoholism 2.Importance of continuing to see a therapist 3.List of everyday items containing hidden alcohol 4.Medical alert bracelet should identify disulfiram therapy
Disulfiram (Antabuse) is a form of aversion therapy that promotes abstinence from alcohol. If the client consumes alcohol while taking disulfiram, unpleasant side effects (eg, headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur. If large amounts are consumed, the reaction can be fatal. Disulfiram therapy does not cure alcoholism; the client should continue seeing a therapist (Options 1 and 2). Due to the hazards of treatment, clients are carefully selected for disulfiram therapy, and informed consent is often required. It is a priority for the nurse to educate the client about the hazards of drinking alcohol and about sources of hidden alcohol (Option 3). Teaching includes: Avoid hidden alcohol in:liquid cold and cough medicationsaftershave lotions, colognes, and mouthwashesfoods such as sauces, vinegars, and flavor extracts Abstain from alcohol for 2 weeks after the last dose as the disulfiram reaction could still occur Wear a bracelet alerting others of being on disulfiram therapy (Option 4
A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply. 1.Drink plenty of fluids 2.Exercise regularly 3.Follow a low-residue diet 4.Include whole grains, fruits, and vegetables in the diet 5.Increase intake of red meat
Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula). Diverticulosis is characterized by the presence of these protrusions; the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce the risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past, clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that avoidance of these foods will prevent an episode of diverticulitis. (Option 3) A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. (Option 5) Increased consumption of red meat and other high-fat foods can increase the risk of diverticulitis.
You have a multigravida at 8-cm wants her IM pain med. What is the nursing intervention?
Do not administer the pain medication multigravida at 8-cm can deliver in the next 15-30 mins
Neisseria meningitidis Haemophilus influenzae type B Diphtheria Mumps Rubella Pertussis Group A Streptococcus (strep throat) Influenza are all? SO PPE?
Droplet (surgical mask - gloves - gown - goggles (face shield) DON (reverse spelling) - gown - mask - goggles - gloves DOFF (alphabetical) - gloves - goggles - mask - gown
Haemophilus influenzae, type b Meningi requires
Droplet precautions require the nurse to don a surgical mask upon entry to the client's room. Cohorting with droplet precautions is permitted as long as the other individual has the same pathogen. Clients who require transport or want to ambulate outside their room should don a surgical mask.
The nurse is inserting a peripheral IV catheter. During the procedure, the infant starts crying and becomes dyspneic and cyanotic. Which action should the nurse take first? 1.Administer prescribed PRN morphine 2.Administer prescribed PRN oxygen via high-flow nasal cannula 3.Place the infant in knee-chest position 4.Soothe the infant to stop crying
During a hypercyanotic episode (ie, tet spell), the nurse should first place the infant in the knee-chest position. This position increases systemic vascular resistance to reduce right-to-left shunting and promote movement of blood into pulmonary circulation (ie, reduce the amount of unoxygenated blood delivered to systemic circulation) (Option 3). Older children who experience hypercyanotic episodes will often assume a squatting position to relieve the cyanosis, which has the same hemodynamic effect as the knee-chest position in an infant.
A nurse is caring for a client at 27 weeks gestation after a motor vehicle collision with side airbag deployment. The client's blood type is O negative. Which laboratory test should the nurse anticipate? 1.Group B streptococcal culture 2.Indirect Coombs test 3.Rubella immunity titer 4.Serum alpha-fetoprotein
During pregnancy, maternal and fetal blood supply mechanisms are separated. Disruption of this separation (eg, delivery, trauma) results in fetomaternal hemorrhage (eg, placental abruption after a motor vehicle collision). If a client who is Rh-negative (eg, O negative blood type) is exposed to Rh-positive fetal blood, the client develops antibodies to the Rh antigen (ie, Rh sensitization), placing the current fetus and all future pregnancies at risk for serious complications (eg, hemolytic anemia). An indirect Coombs test is performed to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected (eg, maternal trauma) (Option 2). To prevent the development of Rh antibodies, Rh immune globulin is administered at 28 weeks gestation and within 72 hours postpartum to all clients who are Rh-negative, as well as after any maternal trauma. Rh immune globulin is not effective once sensitization has occurred. (Option 1) Group B streptococcal cultures are obtained at 35-37 weeks gestation to determine the need for antibiotics during labor to prevent neonatal infection. (Option 3) Testing for rubella immunity is performed in the first trimester; clients who are nonimmune should receive the measles-mumps-rubella vaccine in the postpartum period. (Option 4) Serum alpha-fetoprotein is a blood test to screen for fetal neural tube defects.
IV antibiotics for group B Streptococcus (GBS) prophylaxis (eg, penicillin):
During pregnancy, the client is screened for GBS colonization around 36 weeks gestation. If labor occurs before that time, antibiotic prophylaxis is indicated until results of a GBS test are known because the newborn at preterm gestation is at high risk for neonatal sepsis if infected. Antibiotics are most effective if administered at least 4 hours prior to a vaginal birth (Option 5).
The nurse is assessing a 4-day-old, full-term newborn who is being breastfed exclusively. Which of the following findings should the nurse recognize as a possible indication for breastfeeding supplementation? 1.12% weight loss since birth 2.Cracked, peeling skin 3.Feeds every 2-3 hours 4.Runny, seedy, yellow stools
During the first 3-5 days of life, a weight loss of approximately 5%-10% of birth weight is expected due to fluid excretion (eg, urine, stool, respirations). Weight loss usually ceases around day 5 of life in healthy newborns, who return to their birth weight after 7-14 days of life. Weight loss >10% of birth weight warrants further evaluation. The nurse should assess the newborn, review intake and output, observe breastfeeding technique (eg, positioning, effective latching), and notify the health care provider. To prevent further weight loss, breastfeeding support and supplementation with expressed breast milk or formula may be indicated until exclusive breastfeeding is adequate (Option 1). (Option 2) Peeling of the term newborn's skin is a sign of physical maturity and is an expected finding around the third day of life. Cracked, peeling skin may also be present in postterm (ie, >42 weeks gestation) newborns at birth. (Option 3) Feeding every 2-3 hours is normal for breastfed newborns; breast milk is easily digested and more frequent feeding is noted than in formula-fed newborns. (Option 4) After passing meconium, newborns produce transitional stools that are thin and yellowish-brown or yellowish-green. Stools of breastfed newborns progress to a seedy, yellow paste. Formula-fed newborns have firmer, light-brown stools.
Intussusception
EXPECTED currant jelly stool suasage shape NOT abdominal guarding rebound tenderness = peritonitis NEEDS to be addressed
The nurse is assessing a 70-year-old client with a long history of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the emergency department. Which hospital protocol would be the most appropriate to follow initially? 1.Food poisoning 2.Influenza 3.Myocardial infarction 4.Stroke
Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. (Option 1) Taking a careful history and evaluating for any sick contacts would be helpful in identifying food poisoning, but a more important initial step is to assess for a heart attack. (Option 2) A viral infection is a possibility, but fever and myalgia are usually present during an episode of influenza. (Option 4) Early intervention in stroke is also critical, and a neurologic assessment would take place after the acute coronary syndrome algorithm, especially with negative electrocardiography and serum heart enzyme levels.
Acute HIV infection
HIV is a virus transmitted through contact with infected body fluids (eg, semen, vaginal secretions, blood, breast milk) that proliferates within and destroys immune cells. During the acute (initial) phase of infection, clients can be asymptomatic or have flu-like symptoms, lymphadenopathy, and a generalized maculopapular rash. Manifestations are typically vague and may be mistaken for other disease processes. Genital sores are not typical.
contraindicated vaccines in pregnancy
HPV MMR Live attenuated influenza Varicella
A client with Ebola was just admitted to the unit. Which actions by the nurse would represent appropriate care of this client? Select all that apply. 1.Ensuring the client wears an N95 respirator at all times 2.Keeping the door of the client's room closed at all times 3.Maintaining a log of everyone in and out of the client's room 4.Removing both pairs of gloves before removing gown and mask 5.Restricting visitors from entering the client's room
Ebola (viral hemorrhagic fever) is an extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions (eg, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apron). The client is placed in a single-client airborne isolation room with the door closed (Option 2). Visitors are prohibited unless absolutely necessary for the client's well-being (eg, parent visiting an infected child) (Option 5). For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals are monitored for symptoms (Option 3). Procedures and use of sharps/needles are limited whenever possible. There are currently no medications or vaccines approved by the Food and Drug Administration to treat Ebola. Prevention is crucial. (Option 1) In a private airborne isolation room, the client does not require a respirator mask. However, all other individuals entering the room must don appropriate personal protective equipment (PPE). (Option 4) The PPE removal process after caring for a client with Ebola requires strict monitoring by a trained observer. The outer gloves are first cleaned with disinfectant and removed. The inner gloves are wiped between removal of every subsequent piece of PPE (eg, respirator, gown) and removed last.
The most common clinical manifestations of hip fractures include:
Ecchymosis and tenderness over the thigh and hip - occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL) (Option 1) Groin and hip pain with weight bearing (Option 2) Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area (Option 4) Shortening of the affected extremity - occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward (Option 5) Abduction or adduction of the affected extremity depending on location and mechanism of injury.
pneumectomy position post procedure
Either low fowlers or on operative site to prevent pulmonary edema
When caring for a client with a suspected retinal detachment they should do the following
Encourage the client to have bed rest Apply an eye patch to both eyes Instruct the client to avoid sudden movements Prepare the client for surgery, as directed A retinal detachment is a medical emergency as it may become progressive and give the client blindness in the affected eye. The client may experience a loss of vision that appears as if a curtain is closing, or they may experience bright flashes of light.
Hypocalcemia can be caused by
End stage renal disease (inability of body to recycle vitamin D) additonally high phosphorus levels drive calcium levels down Crohns disease malabsorption of vitamins and minerals hypoparathyroidism
End stage glaucoma
End-stage glaucoma will show a very constricted visual field with the loss of peripheral vision by causing damage to the optic nerve.
The client's last menstrual period was March 10-17. Unprotected intercourse occurred on March 24. The client's menstrual cycles are regular and occur every 28 days. Based on the Naegele rule, what is the estimated date of birth for the client? 1.December 3 2.December 17 3.December 24 4.December 31
Establishing an estimated date of birth (EDB) is important because many decisions and interventions during pregnancy (eg, labor induction, diagnosis of preterm labor) are based on this information. Methods for determining EDB include the Naegele rule, ultrasound, fundal height measurement, and fetal heart rate auscultation via handheld Doppler monitor (at ~10 weeks gestation). The Naegele rule uses a standard formula based on the last (normal) menstrual period (LMP) to determine EDB based on a 28-day menstrual cycle: EDB = (LMP − 3 months) + 7 days. First day of LMP: March 10 Subtract 3 months: December 10 Add 7 days: December 17
A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? 1.Blurred vision 2.Dark-colored urine 3.Difficulty hearing 4.Yellow skin
Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination
The nurse is caring for several clients at a clinic. Based on the data collected, which client's history is most concerning for an increased risk of endometrial cancer? 1.40-year-old client who has been taking hormonal birth control pills for the past 10 years 2.45-year-old client who reports a history of an ectopic pregnancy with a ruptured ovary and two preterm births 3.47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments 4.60-year-old client who recently had a colposcopy after testing positive for a high-risk type of human papillomavirus
Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, breast cancer 1 [BRCA1] gene carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) (Option 3) Obesity Tamoxifen (a medication given for breast cancer) (Option 1) Progestin-containing contraceptives (eg, birth control pills) are associated with a decreased endometrial cancer risk because progestins thin the uterine lining, therefore preventing endometrial hyperplasia. (Option 2) Ectopic pregnancy with a ruptured ovary or preterm birth is not associated with endometrial cancer, although never giving birth at term gestation may increase ovarian cancer risk. (Option 4) Infection with a high-risk type of human papillomavirus increases cervical (not endometrial) cancer risk.
The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply. 1."Avoid drinking alcoholic beverages." 2."Do not abruptly stop taking your phenytoin." 3."Go to the emergency department every time a seizure occurs." 4."Wear an epilepsy medical identification bracelet." 5."You may need to start using a nonhormonal birth control method."
Epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication. The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake, sleep deprivation, and stress (Option 1). Practicing relaxation techniques (eg, biofeedback) may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency (Option 4). Phenytoin (Dilantin), a hydantoin anticonvulsant, may decrease the effectiveness of some medications (eg, oral contraceptives, warfarin) due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral contraceptives (Option 5). Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal abnormalities (eg, cleft palate, heart malformations, bleeding disorders). Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure (Option 2). (Option 3) For a client with epilepsy, it is not necessary to go to an emergency department after a seizure, unless status epilepticus (ie, prolonged, repeated seizures) occurs or the client is injured.
__________ is an effective treatment for anemia secondary to chronic kidney disease.
Epoetin Alfa
Small, white epithelial cysts on baby's gums
Epstein pearls NOT concerning
Autonomic neuropathy causes: form of diabetic neuropathy caused by long term hyperglycemia irreversible damage
Erectile dysfunction, which is often the first perceived symptom because normal male erectile function depends on stimulation, as well as vascular, neurologic, and hormonal systems (Option 2). Gastroparesis (delayed gastric emptying), which occurs from damage to enteric neurons that results in uncoordinated smooth muscle contractions and ineffective peristalsis in the gastrointestinal tract (Option 3). Hypoglycemia unawareness, which results from a blunted autonomic response to low blood glucose with less prominent neurogenic symptoms (eg, tremor, sweating) (Option 4). Orthostatic hypotension, which occurs from damaged autonomic ganglia that disrupt the release of norepinephrine from sympathetic neurons. The expected peripheral vasoconstriction and increased heart rate are impaired, resulting in orthostatic hypotension. Painless myocardial infarction, which is due to impaired pain perception. Clients with DM are more likely to have an atypical presentation (ie, silent) myocardial infarction with no chest pain. Urinary retention, which results from decreased perception of fullness.
epoetin alfa (Epogen, Procrit)
Erythropoiesis-stimulating agents (ESAs) (eg, epoetin alfa [Epogen, Procrit], darbepoetin alfa [Aranesp]) are used to treat chronic anemia related to chronic kidney disease (CKD) or bone marrow suppression (chemotherapy). ESAs are synthetic forms of the naturally occurring hormone erythropoietin, which stimulates the production of red blood cells (ie, erythropoiesis) by the bone marrow. Erythropoietin is normally produced by the kidneys, so clients with CKD may develop anemia due to decreased erythropoietin production. STOP when hemoglobin exceeds 11 which leads to UNCONTROLLED HTN
Disulfuram (Antabuse)
Ethanol Aversion Agent
A home health nurse is assessing for complications in a client who has been using crutches for 2 weeks. Assessing for which finding is most important? 1.Biceps muscle spasm 2.Forearm swelling 3.Hand and wrist weakness 4.Shoulder range of motion
Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axilla. This leads to a reversible condition known as crutch paralysis, or palsy, which manifests as muscle weakness and/or sensory symptoms (tingling, numbness) of the arm, wrist, and hand. It is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Therefore, clients are taught to support body weight on the hands and arms, not the axillae, when ambulating to ensure that there is a 1-2 in (2.5-5 cm) space between the axilla and the axilla crutch pad. Crutches should be checked for proper length. (Option 1) Triceps muscle spasm can occur due to increased muscle use, especially in clients with decreased upper body strength. Triceps and biceps muscle spasms are not complications associated with crutch walking. (Option 2) Forearm swelling is not a common complication associated with crutch walking. In rare cases, arterial obstruction can cause ischemic symptoms. (Option 4) Restricted shoulder range of motion is not a major complication of crutch use.
broca aphasia
Expressive aphasia. The person can understand language but cannot express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech. The speech is mostly nouns and verbs (high-content words) with few grammatic fillers, termed agrammatic or telegraphic speech. Repetition and reading aloud are severely impaired. Auditory and reading comprehensions are surprisingly intact. Lesion is in anterior language area called the motor speech cortex or Broca area.
A pt is being treated with an antipsychotic medication. Pt becomes anxious and presents with tremors. What is the nurse intervention to differentiate NMS (neuroleptic malignant syndrome) from EPS (extrapyramidal syndrome)?
FEVER o If temperature is WNL, this is EPS o If temperature is 102 and rising, call the emergency response team and notify HCP ... NMS is lifethreatening • NMS presents with anxiety and tremors, and so does EPS
Chadwick sign
FIRST bluish discoloration of cervix that occurs normally in pregnancy at 6 to 8 weeks' gestation
when would you... FIRST hear a fetal HR MOST LIKELY hear a fetal HR SHOULD you hear a fetal HR
FIRST: 8 weeks MOST LIKELY: 10 weeks SHOULD: 12 weeks
The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply. 1.Combine all medications and administer together 2.Crush each medication separately before administration 3.Determine if the medications are available in liquid form 4.Flush the tube before and after medication administration 5.Mix medications with enteral feeding formula before administration
Failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy, and medication toxicity. Before administering medications through a feeding tube, the nurse should determine if any of the medications are available in a liquid form because liquid medications are less likely to clog the tube (Option 3). Medications should be crushed, dissolved, and administered separately to prevent interactions (eg, chemical reactions) between medications or interference with absorption (Option 2). In addition, a feeding tube should be flushed before and after each medication is given to avoid potential drug interactions and ensure tube patency (Option 4).
The nurse is caring for a client with a fractured femur. Which nursing intervention is most effective in helping reduce the risk for fat emboli? 1.Administering prophylactic enoxaparin as prescribed 2.Frequent use of incentive spirometry 3.Minimizing movement of the fractured extremity 4.Use of an intermittent pneumatic compression device
Fat embolism syndrome (FES) is a life-threatening condition that has no specific treatment. Therefore, prevention, early diagnosis, and immediate management of symptoms are critical. When a long bone is fractured, pressure within the bone marrow leads to release of fat globules into the bloodstream. These combine with platelets (fat embolus) and can travel to the brain, lungs, and kidneys, leading to small-vessel occlusion and tissue ischemia. Therefore, early stabilization of the injury and surgery as soon as possible to repair long bone (eg, humerus, radius, ulna, femur, tibia, fibula) fractures is recommended to reduce further injury to soft tissue. The nurse should minimize movement of the injured extremity to reduce the risk for fat emboli.
Vernix caseosa
Fatty, whitish secretion of the fetal sebaceous gland to protect the skin from amniotic fluid exposure
High baseline variability?
HR changing a lot. This is ok.
Variable decelerations
HR up or down, cord compression = VERY BAD Prolapsed cord= push head up, change mom position
CO =
HR x SV
A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching? 1."Give acetaminophen or ibuprofen every 6 hours to control the fever." 2."Give the infant frequent tepid sponge baths to control the fever." 3."If the infant develops another seizure, wait 15 minutes to see if it subsides." 4."Place ice bags under the arms and around the neck to reduce the fever."
Febrile seizures are an alarming experience for parents. They most commonly occur in children between ages 6 months to 6 years, with the peak of incidence occurring at age 18 months. The etiology is unknown. Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use antipyretics such as acetaminophen or ibuprofen (in children age >6 months) to control fever and make the child more comfortable (Option 1). However, there is no evidence that antipyretics reduce the risk of future febrile seizures. After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing. (Options 2 and 4) Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort for the child. (Option 3) Parents should be instructed to call 911 and seek medical assistance for a seizure lasting more than 5 minutes. Neurologic damage can occur with frequent and prolonged seizures.
The nurse receives hand-off report on assigned clients. Which client should the nurse assess first? 1.Client 1 day post femoral-popliteal bypass surgery who now has a nonpalpable pedal pulse present only with Doppler 2.Client with chronic venous insufficiency who has edema and brown discoloration of the lower extremities 3.Client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless extremity 4.Client with peripheral arterial disease who reports severe cramping pain in the calf with activity such as walking
Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately. (Option 2) Chronic venous insufficiency is the inability of the leg veins to efficiently pump blood back to the heart. It can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected manifestations, so this is not the priority assessment. (Option 3) Gangrene of the foot is a complication of peripheral arterial disease (PAD) associated with decreased blood flow to the extremity. Coolness of the skin and shiny, hairless legs, feet, and toes are expected manifestations of PAD, so the nurse would not assess this client first. (Option 4) Intermittent claudication is leg pain caused by decreased blood flow to the muscles that reoccurs during activity such as walking and dissipates with rest. It is an expected manifestation of PAD of the lower extremities, so the nurse would not assess this client first.
The nurse is admitting an infant who has severe growth deficiency and facial characteristics of indistinct philtrum, a thin upper lip, and short palpebral fissures. Which question should the nurse ask to assess the cause of these clinical findings? 1."Is the mother of advanced age?" 2."Is there a history of cigarette use during pregnancy?" 3."Is there a history of exposure to alcohol in utero?" 4."Is there a maternal history of valproate use?"
Fetal alcohol syndrome (FAS) is a leading cause of intellectual disability and developmental delay in the United States. Diagnosis includes history of prenatal exposure to any amount of alcohol, growth deficiency, neurological symptoms (eg, microcephaly), or specific facial characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat midface, and short palpebral fissures). Asking about alcohol use during pregnancy can identify newborns and infants who are at risk for FAS. Family support, early intervention, and prevention for subsequent pregnancies are important for families with an infant with this diagnosis. (Option 1) Advanced maternal age has been associated with a higher incidence of trisomy 21 (Down syndrome). Characteristic features include a single palmar crease and a short neck with excess skin (nuchal fold). (Option 2) Cigarette smoking is linked to perinatal loss, sudden infant death syndrome, low birth weight, and prematurity. Specific facial characteristics or syndromes are not typically caused by tobacco exposure in utero. (Option 4) Valproate (Depakote), a medication used to control seizures, is an FDA pregnancy category D drug that can cause neural tube defects such as spina bifida, but not the distinct facial features of FAS.
normal labor
Fetal heart rate (FHR) baseline of 110-160/min FHR accelerations (ie, ≥15 beats above baseline for at least 15 seconds) Moderate FHR variability (ie, fluctuations in baseline of 6-25/min) Uterine contractions every 2-5 minutes, lasting 40-90 seconds Progressive cervical dilation, effacement, and fetal descent Clear amniotic fluid Bloody show and increased cervical mucus
3.Low Baseline Variability
Fetal heart rate stays the same doesn't change • Fetal HR stays the same—it doesn't change • You do "LION" o Left side o IV o Oxygen o Notify HCP • Stop pit if it is running (first)
Mononucleosis (Mono) is an acute infectious disease common for individuals younger than 25. Mono may produce symptoms such as -
Fever Significant fatigue Pharyngitis that has exudate and petechiae Enlarged tonsils Lymphadenopathy Splenomegaly This condition is usually self-limiting and treated with supportive measures such as cool fluids and acetaminophen. This condition is caused Epstein-Barr virus spread by oral secretions. Antibiotics are not effective for this condition. The splenomegaly is concerning because if the individual plays contact sports, they are at high risk of splenic injury, which could lead to life-threatening hemorrhage. Thus, contact sports should be restricted until the spleen returns to its normal size, which may take several weeks.
The nurse is providing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching? 1."Our child should be feeling much better in 7-10 days." 2."Our child's condition is communicable until the rash disappears." 3."We will ensure our child covers the mouth and nose when coughing or sneezing." 4."We will give our child ibuprofen to treat the joint pain."
Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition.
Fluphenazine (Prolixin)
First generation antipsychotic
SSRI's
Fluoxetine, paroxetine, sertraline, citalopram. fluvoxamine
HIV splashed into eyes
Following accidental eye exposure to body fluids (eg, blood, urine) or chemicals, health care workers should immediately flush the affected eye with water or saline for at least 10 minutes to reduce exposure to potentially infected material and prevent/reduce injury (eg, burn). The risk of HIV transmission through urine is low unless there is visible blood in the fluid; however, flushing the eye is the priority action with any accidental exposure
The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply. 1."I can mix the medication in a bowl of my child's favorite cereal." 2."I should give another dose if my child vomits after taking the medication." 3."I should measure liquid medications using an oral syringe." 4."I will encourage my child to help me as I prepare the medication." 5."I will place my child in time-out if the medication is refused."
For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses (Option 3). Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control (Option 4). (Option 1) The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. (Option 2) Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. (Option 5) Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior.
The clinic nurse is caring for several clients who are pregnant. The nurse should alert the health care provider to see which client first? 1.Client in the first trimester who reports frequent nausea and vomiting 2.Client in the first trimester with malaise, myalgia, and temperature of 100.8 F (38.2 C) 3.Client in the second trimester who reports dysuria and urinary frequency 4.Client in the third trimester with right upper quadrant pain and nausea
HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome is a form of preeclampsia that most often develops during the third trimester of pregnancy. HELLP is associated with hemolysis (ie, microangiopathic hemolytic anemia) due to vascular damage, end-organ damage due to vasospasm, and thrombocytopenia due to increased platelet aggregation. Treatment includes delivery of the fetus/placenta and management of complications (eg, hypertension, bleeding). The nurse should prioritize a client with HELLP because the condition may rapidly worsen and lead to severe complications (eg, placental abruption, liver bleeding, stroke) and/or maternal/fetal death. However, HELLP is often not recognized because presenting symptoms, such as nausea, vomiting, malaise, and right upper quadrant pain or epigastric pain, are usually nonspecific
A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply. 1.Apply occlusive dressings after rewarming 2.Elevate affected extremities after rewarming 3.Massage the areas to increase circulation 4.Provide adequate analgesia 5.Provide continuous warm water soaks
Frostbite involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow, vascular stasis, and cell damage. Superficial frostbite can manifest as mottled, blue, or waxy yellow skin. Deeper frostbite may cause skin to appear white and hard and unable to sense touch. This can eventually progress to gangrene. Treatment of frostbite should include the following: Remove clothing and jewelry to prevent constriction. Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged (Option 3). Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain (Option 5). Avoid heavy blankets or clothing to prevent tissue sloughing. Provide analgesia as the rewarming procedure is extremely painful (Option 4). As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema (Option 2). Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings (Option 1). Monitor for signs of compartment syndrome.
stage 3 pressure ulcer
Full-thickness pressure ulcer extending into the subcutaneous tissue and resembling a crater. May see subcutaneous fat but not muscle, bone, or tendon.
Common causes of metabolic acidosis include:
GI bicarbonate losses (eg, diarrhea) (Option 2) Ketoacidosis (eg, diabetes, alcoholism, starvation) Lactic acidosis (eg, sepsis, hypoperfusion) (Option 4) Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option 5) Salicylate toxicity
Enteral feeding is done through
GI tract feeding tube
High baseline variability
GOOD document
4.High Baseline Variability
GOOD • Fetal heart rate is always changing—This is GOOD • Document finding
The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? 1.Lavage through a small-bore nasogastric tube 2.Place client in Trendelenburg position during lavage 3.Prepare intubation and suction supplies at the bedside 4.Wait an hour after gastric decompression to initiate lavage
Gastric lavage (GL) is performed through an orogastric tube to remove ingested toxins and irrigate the stomach. GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress (Option 3). (Option 1) GL is usually performed through a large-bore (36 to 42 French) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube. (Option 2) During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. (Option 4) GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards.
You are working in the emergency department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), all of the tasks listed below should be done for this patient. What is the correct sequence for these tasks? Neurologic assessment by the stroke team Obtain a non-contrast CT scan Administer rtPA General assessment and stabilization
General assessment and stabilization Neurologic assessment by the stroke team Obtain a non-contrast CT scan Administer rtPA Correct ordered sequence: According to the AHA's suspected stroke algorithm, the correct course for the treatment of the stroke patient is: General assessment and stabilization within 10 minutes of arrival at the ED. Neurologic evaluation by the stroke team within 25 minutes of entry to the ED. Obtain a CT scan of the head without contrast within 45 minutes of entry to the ED. The purpose of a non-contrast CT scan is to determine if there is intracranial hemorrhage (hemorrhagic stroke). If an ischemic stroke is suspected, determine if the patient is a candidate for fibrinolytic (thrombolytic, tPA) therapy using the fibrinolytic checklist. Administer rtPA within 60 minutes of entry to the ED (within 4.5 hours of symptom onset). Admit to the stroke unit within 3 hours of entry to the ED.
hunningtons disease
Genetic disorder that doesnt appear until person is in late 30s early 40s. Clients with Huntington disease or other degenerative neurologic conditions advance through several phases over the course of their illness. Each stage represents further progression of the disease and decline of the client's physical, emotional, and cognitive abilities.
Reportable Infectious diseases
HIV Hep A Syphilis chlamydia pulmonary tuberculosis rabies chickenpox (varicella) influenza gonorrhea
The client has been diagnosed with gestational diabetes mellitus. Which of the following potential complications could occur as a result of the diagnosis? Select all that apply. 1.Fetal heart defects 2.Fetal macrosomia 3.Fetal shoulder dystocia 4.Placenta previa 5.Polyhydramnios6.Preeclampsia
Gestational diabetes mellitus (GDM) is associated with several pregnancy-related complications, including: Fetal macrosomia (ie, fetal weight ≥8 lb 13 oz-9 lb 14 oz [4000-4500 g]): Glucose freely crosses the placenta, resulting in extra glucose for the fetus that causes an increase in fat storage (Option 2). Fetal shoulder dystocia: This is a complication of fetal macrosomia that occurs when the anterior fetal shoulder becomes lodged behind the maternal pelvis, delaying expulsion and increasing the risk for fetal asphyxia or death (Option 3). Polyhydramnios (ie, abnormally increased amniotic fluid levels): This can cause uterine distension, unstable fetal lie, and other complications. Fetal hyperglycemia may lead to fetal polyuria, which increases amniotic fluid levels (Option 5). Preeclampsia: This is a multisystem disorder that occurs after the 20th week of pregnancy. Preeclampsia is defined as new-onset hypertension (≥140/90 mm Hg) after 20 weeks gestation plus proteinuria or signs of end-organ damage (Option 6). Hypoglycemia: After delivery, the fetus is no longer exposed to high glucose levels; however, the neonate continues to secrete high levels of insulin, resulting in symptomatic low glucose levels (eg, jitteriness, irritability).
The nurse is providing teaching to a prenatal client about the 1-hour glucose challenge test that will be performed at the next visit. Which client statement indicates a need for further teaching? 1."Fasting is required before the 1-hour glucose challenge test." 2."One blood sample is obtained at the end of the test." 3."The test includes drinking a 50-g glucose solution." 4."The test's purpose is to screen for gestational diabetes, not diagnose it."
Gestational diabetes mellitus (GDM) is diagnosed in clients who have impaired blood glucose (BG) regulation due to physiologic pregnancy changes (eg, rising BG levels, insulin resistance). GDM screening occurs at 24-28 weeks gestation. If GDM is diagnosed, management includes nutritional counseling and, if needed, pharmacologic therapy. Two-step GDM testing begins with a screening test: the 1-hour glucose challenge test (GCT). The 1-hour GCT can be performed any time of day and does not require fasting (Option 1). If the client's serum BG is <140 mg/dL (7.8 mmol/L), GDM is unlikely, and the client requires no further testing. If serum BG is ≥140 mg/dL (7.8 mmol/L), the client requires a 2- or 3-hour glucose tolerance test (GTT) to diagnose GDM. (Options 2 and 3) For the 1-hour GCT, the nurse draws one blood sample an hour after ingestion of a 50-g glucose solution (eg, glucola). In contrast, a 2- or 3-hour GTT requires the nurse to obtain fasting and hourly blood samples. (Option 4) The 1-hour GCT is a screening test only.
Which of the following herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1.Black cohosh 2.Garlic 3.Ginger 4.Ginkgo biloba 5.Hawthorn
Ginkgo biloba Memory enhancement Increased bleeding risk Ginseng Improved mental performance Increased bleeding risk Saw palmetto Benign prostatic hyperplasia Mild stomach discomfort Black cohosh Menopausal symptoms (hot flashes & vaginal dryness) Hepatic injury St. John's wort Depression Insomnia Drug interactions: Antidepressants (serotonin syndrome), OCs, anticoagulants (↓ INR), digoxin Hypertensive crisis Kava Anxiety Insomnia Severe liver damage Licorice Stomach ulcers Bronchitis/viral infections Hypertension Hypokalemia Echinacea Treatment & prevention ofcold & flu Allergic reactions Dyspepsia Ephedra Treatment of cold & flu Weight loss & improved athletic performance Hypertension Arrhythmia/MI/sudden death Stroke Seizure
For doffing personal protective equipment, the nurse should instruct the student to
Gloves Goggles/face shield Gown Mask alphabet
The nurse is assessing a client with Graves disease. Which finding would require immediate follow-up? 1.Agitation and confusion 2.Heat intolerance 3.Irregular pulse of 110/min 4.Red and bulging eyes
Graves disease is an autoimmune disorder characterized by thyroid enlargement and excessive production of thyroid hormones (T3 and T4), leading to hyperthyroidism. Thyroid storm (ie, thyrotoxic crisis) is a serious and potentially life-threatening emergency for clients with hyperthyroidism. This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection), acutely increasing the metabolic rate. Characteristic features include altered mentation (eg, agitation, confusion), extreme tachycardia, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-41.1 C). Other findings include severe nausea, vomiting, anxiety, and seizures (Option 1). (Option 2) Heat intolerance is an expected finding for hyperthyroidism, including Graves disease. (Option 3) Tachycardia and arrhythmias (eg, atrial fibrillation) are common findings in hyperthyroidism of any cause, including Graves disease. Extreme tachycardia (eg, ˃130/min) is indicative of thyroid storm. (Option 4) Exophthalmos (ie, protruding eyeball) is a common finding in Graves disease. The eyelids do not close over the eyeballs properly, leading to excessive dryness and resultant corneal damage (ie, exposure keratitis). Although it is important to treat exophthalmos, it can be safely delayed.
Upper respiratory infections correlate with the diagnosis and onset of?
Guillain Barre
Common applications of droplet precautions
Neisseria meningitidis Haemophilus influenzae type B Diphtheria Mumps Rubella Pertussis Group A Streptococcus (strep throat) Influenza Surgical mask when providing care Place client in private room if possible As needed for procedures with risk for splash or body fluid contact: gloves, gown, goggles/face shield
Herpes Simplex Virus
HSV is a sexually transmitted viral infection that causes genital herpes. Genital sores initially appear as a group of painful vesicles on an erythematous base and evolve into a group of shallow ulcers that eventually crust over. Clients with HSV typically have primary and recurrent infections; those with primary infection often have systemic symptoms (eg, fever, malaise, lymphadenopathy), in addition to genital lesions.
Only antipsychotic that can be given to pregnant women
Haldol
another name for hypothyroidism
Hashimoto's disease myxedema
Early decelerations
Head pressed on. This is ok.
Induration of 10 mm or more is positive in:
Healthcare workers and residents in high-risk areas (nursing homes, hospitals, prisons) Injection drug users Children aged less than four years Clients who immigrated from countries with high TB prevalence in the last five years.
BNP?
Heart failure >100
After morning report, the nurse must perform which action first when caring for assigned clients? 1.Administer IV bumetanide to a client with heart failure who has bilateral crackles and dyspnea 2.Hang the second unit of packed red blood cells for a client with a hemoglobin of 6 g/dL (60 g/L) 3.Replace the empty IV opioid medication syringe in a patient-controlled analgesia pump 4.Replace the heparin infusion bag that has 100 mL remaining and is infusing at 50 mL/hr
Heart failure involves the inability of the heart to pump blood effectively to meet the body's oxygen needs. The nurse should first administer the IV bumetanide (Bumex) or furosemide (Lasix) to promote diuresis and mobilize excess fluid in the systemic circulation and lungs. This is the priority action as it improves oxygenation and gas exchange in the lungs and helps relieve dyspnea. (Option 2) The second unit of packed red blood cells is required to raise the hemoglobin to increase the blood's oxygen-carrying capacity, but this is not as urgent as improving gas exchange in the lungs. (Option 3) The patient-controlled analgesia tubing is connected to a running IV that is attached to an IV pump, so the IV line should remain patent even if the opioid syringe is empty. A short delay in receiving analgesia does not pose a threat to the client's survival, so this is not the priority action. (Option 4) An electronic IV pump is used to administer a heparin infusion. A new IV container is replaced when 50 mL is remaining to ensure the bag does not run dry. At the current rate of 50 mL/hr with 100 mL remaining, the new bag should be hung in about 1 hour, so this is not the priority action.
hepatitis with vaccine
Hep A and Hep B
what types of hepatitis have vaccines
Hep A and Hep B
Early treatment is critical to prevent progression to septic shock and death. Initial management includes:
IV fluid resuscitation to restore intravascular volume and improve blood pressure. Fluids should be initiated within 1 hour of presentation. Blood cultures to identify the pathogen. Blood cultures should be collected before initiating antibiotics to ensure that the pathogen is detected. Broad-spectrum antibiotics, which are effective against multiple common pathogens. Once the pathogen is identified, antibiotic therapy is targeted to the specific pathogen. The goal is to administer antibiotics as soon as possible (within 1 hr) if sepsis is suspected
The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? Select all that apply. 1.Ask if the client knows what day it is 2.Ask the client to extend the arms 3.Assess for telangiectasia (spider nevi) 4.Determine if the conjunctiva is jaundiced 5.Note amylase and lipase serum levels
Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option 3) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. (Option 5) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis.
A graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement about newborn care made by the graduate nurse should cause the precepting nurse to intervene? 1."IM injections will be given after the newborn's bath to reduce exposure to bodily fluids during needle sticks." 2."The newborn will receive both the hepatitis B vaccination and hepatitis B immune globulin injection after birth." 3."You may safely initiate skin-to-skin contact after birth, which promotes bonding and keeps the newborn warm." 4."You will need to formula feed your newborn to reduce the risk of transmitting the virus via breast milk."
Hepatitis B virus infection is a bloodborne disease that poses a significant infection risk to the newborn because of exposure to maternal blood and bodily fluids during birth. The most important interventions to prevent maternal-to-newborn transmission after birth include initiation of the hepatitis B vaccine series and administration of hepatitis B immune globulin (HBIG) within 12 hours of birth. Clients who desire to breastfeed should be encouraged to do so if possible because very few absolute contraindications to breastfeeding exist. Breastfeeding has not been shown to affect newborn infection rates and is not contraindicated as long as the client's nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately administered (Option 4). (Option 1) To protect the newborn from further exposure to maternal blood and bodily fluids, the nurse should wash the newborn's skin prior to any procedures that puncture the skin (eg, vaccination). (Option 2) All newborns of mothers with a positive hepatitis B surface antigen (HBsAg) test should receive the HBIG injection and hepatitis B vaccination to prevent infection and ensure long-term immunity. (Option 3) Skin-to-skin contact promotes maternal-newborn bonding, breastfeeding initiation, and temperature regulation and is not contraindicated for clients with hepatitis B.
If a woman comes in for her 12th week prenatal checkup, when is her next prenatal
Her next visit is at 16 weeks
A nurse is preparing an educational presentation on herbal supplements for the local community center. The nurse anticipates discussion of saw palmetto with what type of clients? 1.Clients diagnosed with dyslipidemia 2.Clients experiencing major depression 3.Clients with benign prostatic hyperplasia 4.Perimenopausal clients experiencing hot flashes
Herbal preparations are commonly used by clients for the treatment or prevention of illness and are generally classified as food or dietary supplements. Herbal preparations often interact with conventional medication and should be used with caution under the supervision of a health care provider. These products are not regulated by governmental agencies, making it difficult to ascertain efficacy through standardized systemic studies. Saw palmetto is an herbal preparation often used by clients to treat symptoms of benign prostatic hyperplasia. Although studies are not conclusive on its mechanism or effectiveness, it is still publicly promoted and used. Saw palmetto should be taken cautiously with anticoagulants and antiplatelets because it may increase the risk for bleeding (Option 3). (Option 1) Garlic is indicated to promote cardiovascular health and may reduce triglyceride levels and increase HDL cholesterol. (Option 2) St. John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with other antidepressants. (Option 4) Black cohosh is an herbal supplement often used by perimenopausal clients experiencing hot flashes
The health care provider (HCP) has prescribed 50,000 units of heparin via subcutaneous injection for a client with a pulmonary embolism (PE). The vial on hand contains 20,000 units per mL. The nurse calculates that the drug volume to be administered will be 2.5 mL. The nurse verifies that the client understands the action of the medication when the client states: "This medication will help prevent blood clots." After double-checking the dosage to be administered, the nurse decides to do which of the following? A. Hold administration and contact the health care provider (HCP) to clarify the medication order B. Administer 0.2 mL of the medication instead of the calculated volume of 2.5 mL C. Administer the prescribed dose while monitoring the client for signs of bleeding D. Administer the medication as prescribed, initiate bleeding precautions, and instruct the client to remain in bed to prevent injury
Here, the nurse should hold the medication and contact the HCP to clarify the medication order, as multiple red flags have been presented in the scenario. First, subcutaneous heparin is typically used as prophylaxis against deep vein thrombosis (DVT) and pulmonary embolism (PE), with intravenous heparin used in the event of a PE developing. Here, the client has a PE, raising questions about the route of administration ordered. Second, an order for 50,000 units of heparin should raise questions, as this dose is significantly higher than any dose appropriate for a PE client. The prescribed dosage of 50,000 units is unsafe and would put the client at an increased risk for bleeding. Therefore, the nurse should hold the medication and contact the HCP to clarify the medication order. [As a footnote, following order clarification (i.e., when the medication is ultimately administered), the client should be informed that in this instance, the medication is being administered not to prevent blood clots, but to treat blood clots, as this client currently has a pulmonary embolism.] Choice B is incorrect. The nurse must never alter the prescribed dosage of any medication. If a dosage adjustment is needed, the nurse should contact the HCP, discuss the concern(s), and obtain the appropriate order from the HCP. Here, administering an amount different than that ordered would be a medication error. Moreover, knowingly administering less than the dose ordered without clarifying with the HCP places the nurse at an increased liability risk if harm to the client does subsequently occur. Choice C is incorrect. Prior to administering this dose of heparin, the nurse should verify the order. Monitoring the client for signs and symptoms of bleeding is an appropriate nursing intervention. Choice D is incorrect. Before administering this dose of heparin, the nurse should verify the order. Bleeding precautions and instructing the client to remain in bed are appropriate nursing interventions. Learning Objective When caring for a pulmonary embolism client with a 50,000 unit subcutaneous heparin order, identify the need to hold the medication and contact the health care provider (HCP) to clarify the order. Additional Info Heparin is a "high-alert" medication. Heparin is commonly used for deep vein thrombosis (DVT) prophylaxis in a dose of 5,000 units two to three times per day given subcutaneously. When used for prophylaxis, heparin does not need to be monitored. Heparin is given by continuous intravenous infusion when used therapeutically.
Heparin
IV or SQ works immediately cannot be given for longer than 3 weeks --EXCEPT FOR LOVENOX antidote protamine sulfate PTT monitored for lab can be given to pregnant women
ribbon like stool is? current red jelly stool? Greasy foul smelling?
Hirschsprung's Intussusception cystic fibrosis
A newborn that has not passed a meconium stool for 24 hours should be evaluated for
Hirschsprung's diease
Mechonium has not based day 2
Hirschsprung's disease? meconium plug syndrome meconium illeus
The home health nurse is visiting a client who is prescribed home oxygen for treatment of chronic obstructive pulmonary disease. The nurse observes narrow hallways due to wall-to-wall stacks of old newspapers and large piles of magazines in every room. What is the priority nursing action? 1.Call the mobile community mental health crisis unit 2.Contact a service to remove the newspapers and magazines 3.Reconcile the client's discharge medications 4.Teach the safe use of oxygen
Hoarding disorder is an anxiety disorder characterized by persistent difficulty with discarding or parting with possessions, even those of little value. Clients with hoarding disorder will typically accumulate items such as clothing, food, boxes, bags, newspapers, and magazines. These items commonly fill up and clutter their living areas and can create environmental and fire hazards. The client will most likely experience severe anxiety if the items are removed. The treatment for the client with severe chronic obstructive pulmonary disorder will include home oxygen therapy. The priority nursing action is to ensure the safety of the client when using oxygen in an environment that is already at high risk for fire due to the accumulation of newspapers and magazines
Sevelamer
Hyperphosphatemia is a common problem associated with chronic kidney disease and end-stage renal disease, and medications such as sevelamer are used in its management. ➢ Management is with restricting dietary phosphorus combined with oral phosphate binders. ➢ Food sources with high levels of phosphorus include beans, fish, and nuts. ➢ These phosphate binders may be calcium-containing (calcium carbonate) and noncalcium-containing (sevelamer). ➢ These medications are only effective when taken with meals. ➢ Major side effects of these medications include constipation which may lead to paralytic ileus. ➢ Other side effects include vitamin deficiencies which is why a renal vitamin may be prescribed. ➢ Calcium and phosphorus levels should be monitored closely during the treatment.
The nurse in the outpatient clinic is caring for assigned clients with type 1 diabetes mellitus. Which client should the nurse recognize as having the highest risk of developing hypoglycemia? 1.29-year-old client with new-onset influenza 2.40-year-old client who is a cyclist and is training for an upcoming race 3.65-year-old client with cellulitis of the right leg 4.72-year-old client with emphysema who is receiving prednisone
Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) is an acute and potentially life-threatening complication of diabetes mellitus. It occurs when the proportion of insulin exceeds glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released, and the autonomic nervous system is activated, causing symptoms of hypoglycemia such as sweating, tremor, and hunger to occur. Aerobic exercise typically lowers blood glucose levels. As muscles use up glucose, the liver is unable to produce enough glucose to keep up with the demand. An experienced exerciser should always check blood glucose levels before, during, and after exercise, and carry a carbohydrate drink or snack in case of a hypoglycemic episode
U waves on the ECG
Hypokalaemia
A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. 1. Bruising easily, especially on the arms (38%) 2.Fatigue (3%) 3.Feeling depressed (5%) 4.Muscle cramps in the legs (51%)
Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia (Option 4). Additional causes of hypokalemia include gastrointestinal losses (eg, vomiting, diarrhea, nasogastric suctioning) and medications (eg, insulin). To combat hypokalemia in clients receiving potassium-wasting diuretics, supplemental potassium and/or a high-potassium diet may be required. (Option 1) Bruising is common with the use of antiplatelet agents (eg, aspirin, clopidogrel). However, the nurse should monitor for and report signs of uncontrolled bleeding, such as bloody stools and signs of stroke (eg, headache, slurred speech).
The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1.Constipation and polyuria 2.Increased thirst and dry mucous membranes 3.Leg weakness and soft, flabby muscles 4.Tremors and brisk deep-tendon reflexes
Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures.
The nurse is providing education to a pregnant client diagnosed with symptomatic hypothyroidism regarding levothyroxine therapy during pregnancy. Which is appropriate teaching for the nurse to include? 1.After symptoms resolve, levothyroxine may be discontinued 2.Levothyroxine should be taken in the evening with a prenatal vitamin 3.Medication dose will remain the same throughout pregnancy 4.Symptoms should begin improving within 4 weeks of starting levothyroxine
Hypothyroidism during pregnancy places clients at increased risk for other complications of pregnancy (eg, preeclampsia, placental abruption, preterm labor). Symptoms of hypothyroidism may include fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails. Levothyroxine (Synthroid) is the first-line medication for treatment of hypothyroidism during pregnancy. The client may experience some relief of symptoms beginning approximately 3-4 weeks after initiating levothyroxine therapy (Option 4). Hormone levels are usually rechecked every 4-6 weeks until normal thyroid hormone levels are achieved. It may take up to 8 weeks after initiation to see the full therapeutic effect. (Option 1) Adequate levels of maternal thyroid hormones are important for fetal brain development, particularly during the first trimester. Levothyroxine should not be stopped during pregnancy, even if symptoms resolve. (Option 2) Prenatal vitamins containing iron can affect the absorption of levothyroxine and decrease its effectiveness. The nurse should instruct the client to take levothyroxine in the morning on an empty stomach, at least 4 hours before or after taking a prenatal vitamin. (Option 3) As the pregnancy advances, the client's dose of levothyroxine may need to be increased. Thyroid stimulating hormone (TSH) levels are closely monitored during pregnancy, and the client's dose is modified as needed to maintain normal levels.
A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? 1.Jugular venous distension 2.Mean arterial blood pressure 65 mm Hg 3.Urine output <0.5 mL/kg/hr 4.Warm, flushed skin
Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, hemorrhage, surgery, gastrointestinal bleeding, vomiting, diarrhea) or a relative (eg, pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: Change in mental status Tachycardia with thready pulse Cool, clammy skin Oliguria Tachypnea Decreased urine output (<0.5 mL/kg/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function
The charge nurse is evaluating the skills of graduate nurses (GNs) who are caring for clients with shock. Which action taken by a GN indicates a need for further education? 1.Administers furosemide to a client with elevated pulmonary artery wedge pressure and cardiogenic shock 2.Applies an SpO2 sensor to the forehead of a client with septic shock rather than using a finger 3.Raises the head of the bed to high Fowler position for a client with hypovolemic shock 4.Titrates norepinephrine infusion to maintain mean arterial pressure ≥65 mm Hg in a client with anaphylactic shock
Hypovolemic shock occurs when there is inadequate circulating volume to maintain perfusion due to hemorrhage, decreased fluid intake, or fluid loss (eg, vomiting, diarrhea, diuresis). Care of the client with shock includes restoring circulation (eg, IV fluids). Positioning for a client with hypovolemic shock involves elevating the legs and maintaining the head of bed (HOB) ≤30 degrees; this allows gravity to assist with venous return, cardiac output, and perfusion of vital organs (eg, brain, kidney). Raising the HOB >30 degrees (eg, high Fowler position [seated upright]) is inappropriate in a client with hypovolemic shock and inadequate circulating vascular volume (Option 3
(eg, etanercept, infliximab, adalimumab) block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These medications reduce the manifestations of rheumatoid arthritis (RA) and slow the progression of joint damage by inhibiting the inflammatory response. TNF inhibitors also cause
IMMUNOSUPPRESSION
hypokalemia
INCREASE urine output and HR bradypnea hypotension hyporeflexia paresthesia
Calcitonin and bisphosphonates
these medications prevent bone resorption, which increases calcium storage in bone and decreases serum calcium levels. These medications are used in the treatment of hypercalcemia associated with hyperparathyroidism.
Induration of 5 mm and more is positive in:
Immunosuppressed clients (those using long-term steroids, those on immunosuppressive medications) Clients who have had recent contact with active TB patients. HIV infected patients
The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time? 1.Immunosuppressive therapy as a lifelong commitment 2.Importance of accurate daily weight monitoring 3.Importance of periodic endomyocardial biopsies 4.Maintenance of meticulous surgical incision care
Immunosuppressive therapy (eg, mycophenolate, tacrolimus, corticosteroids) is required after organ transplantation to prevent acute and chronic rejection of the organ. This is a lifelong drug regimen for the transplant client, and it has adverse side effects (eg, nephrotoxicity, hepatotoxicity, infection susceptibility). Prior to surgery, the client needs to fully understand the physical, psychological, and financial commitment required. It is important for the nurse at every opportunity to emphasize strict immunosuppressive therapy compliance to prevent acute transplanted organ rejection. (Option 2) Daily weight monitoring is important for identifying signs of heart failure; however, immunosuppressive therapy compliance is the priority. (Option 3) Endomyocardial biopsies are performed regularly, in addition to routine blood tests, to check for signs of rejection. This is important for the client to know; however, it is not the priority over strict immunosuppressive therapy compliance. (Option 4) Surgical incision care and signs of infection are important teaching topics; however, prior to transplantation, it is most important to ensure that the client understands and will comply with lifelong immunosuppressive therapy.
A client presents to the emergency department with a stab wound to the chest. The nurse assesses tachycardia, tachypnea, and a sucking sound coming from the wound. Which of the following actions is priority? 1.Administer prescribed IV fluids 2.Apply supplemental oxygen via nonrebreather mask 3.Assist the health care provider to prepare for chest tube insertion 4.Cover the wound with petroleum gauze taped on three sides
In a traumatic, or "open," pneumothorax, air rushes in through the wound with each inspiration, creating a sucking sound, and fills the pleural space. The lungs cannot expand, so the client develops respiratory distress and air hunger. Tachycardia and hypotension result from impaired venous return, as the heart and great vessels shift with each breath. A tension pneumothorax may also develop if air cannot escape the pleural space. The priority action in this medical emergency is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides, preventing inward air flow while allowing air to escape the pleural space. (Option 1) This client's tachycardia and hypotension are likely related to pneumothorax and should improve once the pneumothorax is resolved; administering fluids alone would not help if the pneumothorax continues to worsen. Fluids are given to treat blood loss hypotension, but this should not be the first step in this case. (Option 2) Supplemental oxygen should be applied as needed after covering the wound. If possible, correcting the underlying cause is always a priority over treating manifestations. (Option 3) After covering the wound, chest tube placement is usually performed to evacuate air and blood from the pleural cavity. The client may need more than one chest tube to evacuate both air (placed higher) and fluid or blood (placed lower).
The nurse is providing postoperative care to a client who had a laparoscopic cholecystectomy 4 hours ago. Which intervention is the priority? 1.Apply antiembolism stockings 2.Assist with early ambulation 3.Encourage a low-fat diet 4.Offer stool softeners
In laparoscopic cholecystectomy, carbon dioxide (CO2) is used to inflate and expand the abdominal cavity to allow insertion of surgical instruments and better visualization of organs. CO2 can irritate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the shoulder. The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 (Option 2). Early ambulation improves breathing, decreases the risk for thromboembolism, and stimulates bowel motility (ie, peristalsis). Clients who have laparoscopic procedures are often discharged the same or next day, so initiating mobility is a priority.
The parent of a 21-day-old male infant reports that the infant is "throwing up a lot." Which assessments should the nurse make to help determine if pyloric stenosis is an issue? Select all that apply. 1.Assess the parent's feeding technique 2.Check for family history of gluten enteropathy 3.Check for history of physiological hyperbilirubinemia 4.Check if the vomiting is projectile 5.Compare current weight to birth weight
In pyloric stenosis, there is gradual hypertrophy of the pylorus until symptom onset at age 3-5 weeks. It is common in first-born boys and the etiology is unclear. Pyloric stenosis presents with postprandial projectile vomiting (ejected up to 3 feet) followed by hunger (eg, "hungry vomiter"). This is clearly distinguished from the "wet burps" infants have due to a weak lower esophageal sphincter. The emesis is nonbilious as the obstruction is proximal to the bile duct. Infants have poor weight gain and are often dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill). The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology. (Option 2) At times, formula intolerance or allergy is suspected initially when the infant first starts vomiting. However, celiac disease or gluten enteropathy is related to intolerance to gluten, a protein in barley, rye, oats, and wheat (BROW). Clients with celiac disease cannot eat these foods. A 3-week-old infant would only consume milk; this history would not be a factor at this time. (Option 3) Physiological hyperbilirubinemia occurs due to the newborn's immature liver that is unable to metabolize hemoglobin byproducts. This is a "normal" finding that is unrelated to pyloric stenosis.
Two techniques are acceptable for performing chest compressions on a newborn or infant.
In the first, two thumbs are placed on the middle third of the sternum, with the fingers encircling the chest and supporting the back. The thumbs should be positioned side by side, just below the nipple line.
Nausea and vomiting in which client is of greatest concern to the nurse? 1.Client postoperative ophthalmic surgery 2.Client receiving chemotherapy 3.Client with Ménière disease 4.Client with severe gastroenteritis
Increased intraocular pressure can cause damage to the blood vessels and retina and cause potential permanent vision loss. Coughing, vomiting, straining to lift objects (>5 lb), and bending at the waist temporarily increase intraocular pressure and must be avoided after eye surgery. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting. (Options 2 and 4) Nausea and vomiting are expected side effects of chemotherapy and severe gastroenteritis. (Option 3) Ménière disease affects the inner ear. Vertigo, nausea, and vomiting are expected manifestations of this disease.
A nurse evaluates a client's understanding of infant formula preparation. Which of the following client statements indicate a correct understanding? Select all that apply. 1."I can add extra water to powdered formula if it seems that my baby wants to feed longer." 2."I can heat formula in the microwave for less than 1 minute." 3."I must wash the top of concentrated formula cans before opening." 4."Leftover formula in the bottle may be refrigerated and used at a later feeding." 5."Unused, prepared formula should be kept in the refrigerator and discarded after 24 hours."
Infant formula is readily available as ready-to-feed, concentrate, or powder. Parents should exactly follow the manufacturer's recommendations for preparation. Basic guidelines for preparation, safe storage, and handling of formula include: Keep bottles, nipples, caps, and other parts as clean as possible (ie, boil or wash in the dishwasher). Wash the tops of formula cans (eg, concentrated formula) with hot water and soap prior to opening to prevent contamination (Option 3). Refrigerate any unused, prepared formula or unused, opened formula (eg, ready-to-feed, concentrated), but use within 24 hours or discard to reduce the risk of bacterial growth (Option 5). Warm bottles in a pan of hot water or under warm tap water for several minutes. Test formula temperature on the inner wrist before serving to the infant (should feel lukewarm, not hot).
Moro reflex
Infant reflex where a baby will startle in response to a loud sound or sudden movement.
Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting? 1.A 2-month-old who rolled off the changing table and is now lethargic 2.A 3-month-old with flat bluish discoloration on the buttock that the mother says has been present since birth 3.A 3-year-old with forehead bruises that the mother says come from running into a table 4.A 4-year-old who pulled boiling water off the stove and has splattered burns on the arms
Infants do not start rolling until age 4 months and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. Because lethargy is present, head injury must be ruled out.
The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1.A 3-year-old diagnosed with Kawasaki disease 2 weeks ago developed skin peeling 2.A 7-year-old has had a high fever, cough, and sore throat for the past 2 days 3.A 14-year-old with asthma controlled with a corticosteroid inhaler developed oral white patches 4.A 16-year-old diagnosed with mononucleosis 10 days ago reports abdominal pain
Infectious mononucleosis is caused by the Epstein-Barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset of left upper quadrant abdominal pain. The 16-year-old client should be taken to the emergency department for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock, and possible surgery. (Option 1) Skin peeling is expected in the subacute stage of Kawasaki disease; the new skin might be tender. This client is not the priority. (Option 2) Fever, cough, and a sore throat in a 7-year-old must be evaluated. However, the client's condition is not immediately life-threatening; this client should be treated after the client with infectious mononucleosis. (Option 3) Corticosteroid inhalers can cause oral thrush. Clients must perform proper oral care (rinsing after use) and may use a nystatin oral suspension (swish throughout the mouth as long as possible before swallowing). This client is not the priority.
The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation? 1."I am taking an antibiotic for a urinary tract infection." 2."I had a negative tuberculosis skin test 2 weeks ago." 3."I just received my yearly flu shot a week ago." 4."I will continue taking naproxen at night to help with pain."
Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking these drugs are at increased risk for infection. A client with current, recent, or chronic infection should not take a TNF inhibitor (Option 1). (Option 2) The immunosuppressive action of TNF inhibitors can activate latent tuberculosis (TB). Therefore, a tuberculin skin test (TST) should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo treatment for TB before starting therapy. Clients should have a TST every year while receiving the drug. (Option 3) Clients taking immunosuppressive TNF inhibitors (eg, adalimumab) should receive an annual inactivated (injectable) influenza vaccine to reduce the risk of contracting the flu virus. Clients taking TNF inhibitors or other immunosuppressants are at risk for infection and therefore should not receive live attenuated vaccines. (Option 4) Many clients with rheumatoid arthritis use nonsteroidal anti-inflammatory medications (eg, celecoxib, naproxen) in conjunction with antirheumatic and/or targeted therapies (eg, methotrexate, adalimumab, etanercept) to effectively treat pain and minimize inflammation.
Non live okay to give to immunocompromised vaccines
Influenza (intramuscular) Pneumococcus Diphtheria-tetanus-pertussis Typhoid Hepatitis A Hepatitis B Haemophilus influenzae type b Human papillomavirus Meningococcus Polio (inactivated
Vancomycin is an antibiotic used to treat infections with gram-positive bacteria (eg, Staphylococcus aureus). Clients receiving vancomycin require close monitoring due to its narrow therapeutic window. Appropriate interventions for IV vancomycin administration include:
Infusing vancomycin over at least 60 minutes to decrease the risk for vancomycin infusion reaction (VIR), also known as vancomycin flushing syndrome. VIR occurs when vancomycin is infused rapidly and causes mast cells to release histamine (Option 2). Monitoring for signs of VIR, including upper body pruritus (ie, itchiness) and erythema. Muscle pain, spasms, dyspnea, and hypotension may also develop (Option 3). Observing the peripheral venous access device (VAD) site frequently for pain, erythema, and swelling because vancomycin is a vesicant and may cause thrombophlebitis or extravasation (Option 4). Obtaining a vancomycin trough level prior to administration because vancomycin has a narrow therapeutic index and adverse effects (eg, nephrotoxicity, ototoxicity) occur if serum drug levels are too high
Which of the following laboratory tests should the nurse anticipate during the first prenatal visit? Select all that apply. 1.1-hour glucose tolerance test 2.Group B Streptococcus rectovaginal culture 3.Maternal blood type and screen 4.Sexually transmitted infection screening 5.Urinalysis
Initial prenatal visit Rh(D) type & antibody screen Hemoglobin/hematocrit, MCV, ferritin HIV, VDRL/RPR, HBsAg, anti-HCV Ab Rubella & varicella immunity Urine culture Urine dipstick for protein Chlamydia PCR (if risk factors are present) Pap test (if screening indicated) 24-28 weeks Hemoglobin/hematocrit Antibody screen if Rh(D)-negative 1-hr 50-g GCT 36-38 weeks Group B Streptococcus rectovaginal culture
The nurse is preparing to administer insulin at 1700 to a client with type 1 diabetes mellitus whose blood glucose level was 245 mg/dL (13.6 mmol/L) at 1645. During what time frame is the client at highest risk for hypoglycemia? Click the exhibit button for additional information. Insulin glargine: 6 units subcutaneously Sliding-Scale Blood Glucose Levels Insulin Lispro <150 mg/dL (<8.3 mmol/L) 0 units 150-199 mg/dL (8.3-11.0 mmol/L)2 units 200-249 mg/dL (11.1-13.8 mmol/L)4 units 250-299 mg/dL (13.9-16.6 mmol/L)6 units 300-350 mg/dL (16.7-19.4 mmol/L)8 units ≥351 mg/dL (≥19.5 mmol/L) 10 units and notify the health care provider 1.1730-2000 2.1900-2200 3.2000-0700 4.2100-0500
Insulin is a medication commonly administered subcutaneously to control and lower blood glucose levels in clients with diabetes mellitus. The nurse should be familiar with the various insulin types and their times of peak effect, which are the periods of highest risk for hypoglycemic events. Rapid-acting insulins (eg, aspart, lispro) peak quickly, often within 30 minutes to 3 hours of administration. Therefore, the client who receives insulin lispro at 1700 is at highest risk for hypoglycemia from 1730-2000 (Option 1). Insulin glargine is a long-acting insulin that does not have a peak effect. (Option 2) The peak effect of regular insulin, which is short acting, is 2-5 hours. Clients who receive regular insulin at 1700 would be most at risk for hypoglycemia from 1900-2200. (Option 3) Insulin detemir, a long-acting insulin, takes peak effect in 3-14 hours. Clients who receive insulin detemir at 1700 would be most at risk for hypoglycemia from 2000-0700. (Option 4) Insulin NPH, an intermediate-acting insulin, takes peak effect in 4-12 hours. Clients who receive insulin NPH at 1700 are most at risk for hypoglycemia from 2100-0500.
The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?\ 1.0830 2.1100 3.1330 4.1500
Insulin is produced and excreted by the pancreas into the bloodstream to move glucose into cells. Clients with diabetes mellitus are unable to produce sufficient insulin (ie, type 1) and/or are unable to properly use insulin due to insulin resistance of the cells (ie, type 2). Clients are often prescribed combination therapy of long-acting insulin (eg, detemir, glargine, degludec) to help maintain consistent blood glucose levels and supplemental rapid- or short-acting insulin to regulate blood glucose levels with food intake. Peak effect indicates the time when a medication will reach maximum effectiveness. Understanding peak effect for each type of insulin helps to predict when the client will have the lowest blood glucose level and highest risk for insulin-related hypoglycemia. Rapid-acting insulins (eg, lispro) reach peak effect 1-3 hours after subcutaneous administration. A client who received lispro at 0730 has highest risk for hypoglycemia from 0830-1030
currant jelly stools
Intussusception
The nurse is assessing an infant with intussusception. Which of the following clinical findings should the nurse expect? Select all that apply. 1.Palpable olive-shaped mass in epigastrium 2.Palpable sausage-shaped abdominal mass 3.Projectile vomiting without visualized blood 4.Screaming and drawing of the knees up to the chest 5.Stool mixed with blood and mucus
Intussusception is an obstructive gastrointestinal disorder caused when a segment of the bowel slides, or telescopes, into another section. This typically occurs in infants and children age <6. Once the bowel telescopes in, pressure increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen of the bowel. Classic clinical manifestations of intussusception include episodes of sudden, crampy abdominal pain; a palpable sausage-shaped abdominal mass; and red, "currant jelly" stools (Options 2 and 5). Other manifestations include inconsolable crying with the knees drawn up to the chest and vomiting (Option 4). The child may appear normal and calm between painful episodes. (Options 1 and 3) A palpable, epigastric, olive-shaped mass and nonbloody projectile vomiting (ie, up to 3-4 feet [~1 meter]) are clinical manifestations often seen with pyloric stenosis. Projectile vomiting may also be a symptom of elevated intracranial pressure. However, intussusception typically causes bilious, nonprojectile vomiting and involves a sausage-shaped mass.
An overweight toddler is diagnosed with iron deficiency anemia. Which is the most likely explanation for the anemia? 1.excessive intake of meat products 2.Excessive intake of milk 3.Gastrointestinal blood loss 4.Impaired iron transfer from the mother
Iron deficiency anemia is the most common chronic nutritional disorder in children. There are many risk factors for iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1 year. One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight, toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of milk, a poor source of available iron. Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake (16-24 oz/day) in toddlers to ensure a balanced diet. (Option 1) Red meat and other meat products are considered good sources of dietary iron. However, clients may be at risk for obesity if meat consumption exceeds protein and caloric needs. (Option 3) Gastrointestinal blood loss, which can occur if infants under age 1 year are fed cow's milk, is a potential cause of iron deficiency anemia. However, excessive milk intake is a more common cause, particularly in clients over age 1 year. (Option 4) Impaired or decreased iron transfer is a potential cause of iron deficiency anemia, particularly in preterm infants or infants born in multiples. However, iron stores received from the mother are typically depleted by age 5-6 months (2-3 months for preterm infants); after this point, iron must be acquired through dietary sources. Because this client is a toddler (age 1-3 years), impaired iron transfer is not a likely cause of the current anemia.
Monoamine Oxidase Inhibitors (MAOIs)
Isocarboxazid (Marplan) Phenelzine (Nardil) Tranylcypromine (Parnate) antidepressant increases serotonin norepinephrine and dopamine in the brain Anticholinergic Blurred vision Constipation D drowsiness teaching - NO tyramine - NO bar = bananas avocados, raisins (dried fruit) meats no ORGANS NO preserved meats- smoked - dried - cured - pickled dairy no cheese (except mozzarella and cottage) NO alc - elexirs - caffeine - chocolate - soy sauce - licorice
A client with latent tuberculosis has been taking oral isoniazid (INH) daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of what would most likely have prevented this? 1.Folic acid 2.Vitamin B6 3.Vitamin B12 4.Vitamin D3
Isoniazid (INH) is an antitubercular medication used in combination with other medications to treat tuberculosis. INH can deplete the body of pyridoxine (ie, vitamin B6) and lead to peripheral neuropathy. Clinical manifestations include ataxia and paresthesia. Factors that increase the risk for becoming neurotoxic from taking INH include advanced age, malnourishment, diabetes, pregnancy or breastfeeding, alcohol use disorder, liver or renal disease, and HIV. To prevent these complications, a vitamin B6 supplement is recommended for those at high risk
The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? 1."I should not donate blood while taking this medication." 2."I will stop taking my tetracycline prior to taking this medication." 3."I will take vitamin A supplements." 4."I will use condoms and birth control pills."
Isotretinoin is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception (Option 4). Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication (Option 3). (Option 1) Blood donation is also prohibited during the duration of treatment and up to a month after treatment ends due to the possibility of inadvertent transfusion to a pregnant woman. (Option 2) Isotretinoin should not be taken with tetracycline because the latter also increases the risk for intracranial hypertension.
genital herpes simplex virus (HSV)
It is a lifelong condition with periods of dormancy between outbreaks of active lesions. Treatment is aimed at relieving symptoms and preventing transmission. Appropriate home care teaching for the client with HSV includes: Avoiding sexual activity when lesions are present: The virus is transmitted via contact with infected mucosa. Therefore, clients with genital HSV should avoid sexual activity when active lesions are present or if the client has prodromal symptoms (eg, genital itching). After the outbreak has resolved, the client should use condoms during sexual encounters because transmission is possible even in the absence of active lesions (Option 1). Anticipating antiviral prophylaxis: Clients who become pregnant and have a history of genital HSV should receive antiviral medications (eg, acyclovir, valacyclovir) beginning at 36 weeks gestation until delivery regardless of symptoms to prevent vertical transmission to the newborn (Option 2). Performing frequent hand hygiene: Wash hands frequently to help prevent transmission of viral particles shed from active lesions (Option 3). Wearing a mask: Postnatal HSV infection can be transmitted through respiratory droplets or close contact (eg, kissing, routine skin-to-skin contact) from a person with active oral lesions (ie, cold sores). To reduce the risk of transmission to the newborn, the client with a cold sore should practice strict hand hygiene and wear a mask (Option 4).
unconcious client with neck injury
JAW THRUST
Cardiac Tamponade s/s
JVD, narrow pulse pressure, hypotension ( Becks Triad) pulse pressure = difference between systolic and diastolic
THE most critical lab values
K > 6 Co2 > 60 pH < 6 O2 < 60 Platelets < 40,000
5 D's of lab values
K >6 PaO2 <60 Co2>60 pH <6 platelets <40,000 (150,000-400,000)
Hypercyanotic episode of teratology of Fallot what position will make the most comfortable?
KNEE TO CHEST
Bad fetal heart rate tracings start with?
L and V late declarations low variability low fetal HR L = LION Variable declarations - VERY BAD push (cord off presenting part) - position (knee to chest off cord)
ALL maternal complications except prolapsed cord and back pain what nursing interventions are implemented?
L-I-O-N STOP PITOCIN (OXYTOCIN) if it is running = FIRST Left side IV Oxygen Notify HCP STOP PITOCIN (OXYTOCIN) if it is running = FIRST
Thiazide diuretics do what to calcium?
LEAD to hypercalcemia
why anemia in ESRD
LESS erythropoietin
BESIDES BACK PAIN AND prolapsed cord due causing variable declerations What is the "typical" nursing interventions
LION left side oxygen notify stop Pitocin (oxytocin) if running)
Spinal best way to turn patient
LOG ROLL
Filgrastim (Neupogen)
Leukopoietic growth factor Used for neutropenia (cancer) Can cause bone pain, leukocytosis (WBC > 100,000)
Patient has hypercalcemia what medication should be avoided?
thiazide diuretics Addison's disease can also cause
What medication should you clarify when you have a pt taking lithium?
Lithium is a mood stabilizer most often used to treat bipolar affective disorders. Lithium has a very narrow therapeutic index (0.8-1.2 mEq/L [0.8-1.2 mmol/L]) that should be closely monitored; it also has the potential for many drug interactions. Several medications can cause increased lithium levels, including thiazide diuretics (eg, hydrochlorothiazide), nonsteroidal anti-inflammatory drugs, and antidepressants. Thiazide diuretics have demonstrated the greatest potential to increase lithium concentrations, with a possible 25%-40% increase in concentrations (Option 2). The nurse should assess the client for signs and symptoms of lithium toxicity and report the findings to the health care provider. The client should bring all prescription and over-the-counter medications to each office visit to perform a medication reconciliation and reduce the risks associated with polypharmacy. (Options 1 and 4) Acetaminophen and sulfa antibiotics (eg, sulfadiazine) do not interact with lithium and are safe for the client to take. (Option 3) Lithium levels are not affected by antidiabetic medications such as metformin; however, lithium has been known to increase serum glucose levels. This may necessitate a dose adjustment of the antidiabetic medications. The client's blood glucose should be monitored, but this effect is not the most concerning at this time.
Lithium levels should be maintained between 0.6 - 1.2 mEq/L. The client should be educated on the following points -
Lithium requires the client to maintain adequate fluid and salt. Failing for the client to do so may result in lithium toxicity. Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use). The client should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity. Lithium levels should be drawn twelve hours following the client's last dose. If not, this may falsely elevate the lithium level. Lithium toxicity signs and symptoms include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension.
#1 post op answer for spinal problems is
Log roll the patient
logrolling patient
Logrolling a client is utilized to keep the spinal column in straight alignment to prevent further injury. This turning technique is commonly used for clients with spinal cord injuries or who are recovering from neck, back, or spinal surgery. A minimum of three individuals is necessary to perform log rolling safely. The procedure of logrolling a client: Place a small pillow between the client's knees. Cross the client's arm on their chest. Position two nurses on the side where the client is to be turned and one nurse on the side where pillows are to be placed behind the patient's back. Fanfold drawsheet along the backside of the client. One nurse should grasp the drawsheet at the lower hips and thighs, and the other nurse grasping the drawsheet at the client's shoulders and lower back and roll the client as one unit in a smooth, continuous motion. The nurse on the opposite side of the bed places pillows along length of client for support. Gently lean the client as a unit back toward pillows for support.
Esomeprazole = PPI
Long-term therapy with a proton pump inhibitor (PPI) (eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis. A bone density test can assess if the client already has osteoporosis. Hospitalized clients also have an increased risk of diarrhea caused by Clostridium difficile. PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper gastrointestinal tract. This leads to increased risk of pneumonias.
The nurse is admitting a client who has a urinary tract infection. The client has a history of gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for which complication related to omeprazole therapy? 1.Clostridioides (formerly Clostridium) difficile infection 2.Gait disturbance 3.Jaw necrosis 4.Vision changes
Long-term use of proton pump inhibitors (PPIs) ("prazoles" - omeprazole, lansoprazole, pantoprazole, rabeprazole) is common because these medications are available over the counter. PPIs are used to suppress gastric acid secretion in common conditions such as peptic ulcer disease and gastroesophageal reflux disease (GERD). PPIs are associated with an increased risk of Clostridioides (formerly Clostridium) difficile-associated diarrhea (CDAD). Although the exact mechanism is unknown, CDAD should be considered in clients who use PPIs and have unresolved diarrhea. In addition, urinary tract infections are treated with antibiotics which would further increase the risk for C difficile infection (Option 1). Additional common adverse effects associated with PPIs include: Fractures of the spine, hip, and wrist due to decreased bone density from decreased calcium absorption Pneumonia due to alteration of upper gastrointestinal flora Hypomagnesemia due to decreased intestinal magnesium absorption, which can lead to tremors, muscle cramps, seizures, and dysrhythmias (Options 2 and 4) Gait disturbance (ataxia) and visual changes (eg, diplopia, nystagmus) are commonly seen with phenytoin toxicity. (Option 3) Jaw necrosis is associated with long-term bisphosphonate (eg, alendronate, risedronate) therapy and is not associated with PPI use.
Acute pancreatitis is inflammation and autodigestion of pancreatic tissue that occurs from activation of pancreatic enzymes within the pancreas. Severe abdominal pain, especially after eating, is the primary clinical manifestation and is typically accompanied by nausea, vomiting, tachycardia, and jaundice. Management of acute pancreatitis includes:
Maintaining NPO status to inhibit stimulation of the pancreas and the excretion of pancreatic enzymes Administering IV fluids to prevent hypovolemic shock; inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (ie, fluid entering empty spaces) (Option 1) Administering IV opioid analgesics (eg, hydromorphone, fentanyl) to manage pain (Option 2) Inserting a nasogastric tube to suction gastric secretions; this reduces nausea and lessens stimulation of the pancreas (Option 3) (Option 4) To relieve pain, the client should maintain a position that flexes the trunk and draw the knees up to the abdomen, decreasing tension on the abdomen. A side-lying position with the head elevated to 45 degrees will also help relieve pain. (Option 5) Clients should be kept NPO to prevent pain, nausea, and/or vomiting due to stimulation of pancreatic enzymes.
A client with chronic heart failure is being discharged home on furosemide and sustained-release potassium chloride tablets. Which instructions related to the potassium supplement should the nurse give to the client? 1."A diet rich in protein and vitamin D will help with absorption." 2."If the tablet is too large to swallow, crush and mix it with applesauce or pudding." 3."Potassium tablets should be taken on an empty stomach." 4."Take it with a full glass of water and stay sitting upright afterward."
Loop diuretics (eg, furosemide [Lasix], bumetanide [Bumex]) are "potassium-wasting" diuretics, meaning that clients may experience potassium loss and hypokalemia. Hypokalemia in a client with heart failure creates a risk for life-threatening cardiac dysrhythmias. Therefore, clients taking loop diuretics usually require potassium supplementation. Potassium is an erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the client should take potassium tablets with plenty of water (at least 4 oz [120 mL]) and remain sitting upright for ≥30 minutes after ingestion. This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach (Option 4). Pill-induced esophagitis is also common with tetracyclines (eg, doxycycline) and bisphosphonates ("dronates": alendronate, ibandronate, pamidronate, risedronate), so clients taking these medications should be given similar instructions.
Which medication should the nurse clarify with the health care provider due to client complaints of ototoxicity? 1.Furosemide 2.Hydrochlorothiazide 3.Lisinopril 4.Metoprolol
Loop diuretics (eg, furosemide, torsemide, bumetanide) significantly increase urine output and are commonly used to treat heart failure and fluid volume overload. Adverse effects include electrolyte abnormalities (eg, hypokalemia, hypomagnesemia) due to increased fluid loss and ototoxicity. Loop diuretics can damage the inner ear (eg, cochlea), leading to sensorineural hearing loss that may be irreversible. Risk is increased with high doses of loop diuretics, concurrent use with other ototoxic medications (eg, aminoglycoside antibiotics), and in clients with comorbid renal failure. Hearing loss typically begins with high-frequency sounds. A new onset of muffled hearing and difficulty understanding speech in a client recently prescribed furosemide requires follow-up with the health care provider (Option 1). (Option 2) Thiazide diuretics (eg, hydrochlorothiazide) are most often used to treat hypertension by increasing urine output but are less potent than loop diuretics. Adverse effects include electrolyte abnormalities; however, ototoxicity is not associated with thiazide diuretics. (Option 3) ACE inhibitors (eg, lisinopril) promote vasodilation and are commonly used in clients with hypertension and heart failure. Adverse effects include dry cough and hyperkalemia, not ototoxicity. (Option 4) Beta blockers (eg, metoprolol) reduce cardiac workload and are commonly used in clients with hypertension and heart failure. Adverse effects include bradycardia, bronchospasm, and rebound hypertension (with sudden treatment discontinuation). Ototoxicity is not associated with beta blockers.
what can be used for alcohol withdrawal?
Lorazepam is a benzodiazepine used in the management of alcohol withdrawal symptoms. The client is exhibiting these symptoms as evidenced by perspiration on the forehead, nystagmus, coarse tremors, and visual hallucinations. Alcohol withdrawal symptoms may manifest six hours after the last alcohol consumption. ✓ The withdrawal symptoms may worsen and cause the client to potentially develop delirium tremens. ✓ Mild withdrawal signs and symptoms include irritability, anorexia, nausea, palpitations, and tachycardia. ✓ Moderate to severe signs and symptoms include clouded sensorium, tremors, hallucinations, unpredictable behavior, and agitation. The client may be at risk of having a seizure. Medications used for alcohol withdrawal include ✓ Benzodiazepines are intended to suppress seizure activity and mitigate unpleasant withdrawal symptoms. ✓ Clonidine to mitigate the adrenergic signs (hypertension) ✓ Intravenous fluid repletion that may be supplemented with B-complex vitamins. ✓ Antipsychotics such as risperidone may be utilized to assist with residual delirium.
HYPERkalemia
Low urine output low HR everything else is high
Serious adverse effects of metformin
MALAISE, MYALGIA, RESPIRATORY DISTRESS, HYPOTENSION lactic acidosis weight loss - common
Aminoglycosides
MEAN OLD MYCINS used for SERIOUS infections cleomycin vancomycin neomycin streptomycin tobramycin gentamycin clindamycin Ototoxicity (hearing balance tinnitus) Nephrotoxicity (creatinine) monitor cranial nerve 8 ONLY GIVEN PO FOR - hepatic encephalopathy - pre-op bowel surgery
A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting. The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse? 1."I am sorry you have so much pain. I'll go get your pain medication right now." 2."Let me call the health care provider (HCP) to see if we can increase the dose of your pain medicine." 3."Take deep breaths while splinting your chest with a pillow, and use your incentive spirometer every 2 hours. This will help your recovery." 4."The overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incisions are made between the ribs."
MIDCAB does not involve a sternotomy incision or placement on cardiopulmonary bypass. Several small incisions are made between the ribs. A thoracotomy scope or robot is used to dissect the internal mammary artery (IMA) that is used as a bypass graft. Radial artery or saphenous veins may be used if the IMA is not available. Recovery time is typically shorter with these procedures and clients are able to resume activities sooner than with traditional open chest coronary artery bypass graft surgery. However, clients may report higher levels of pain with MIDCAB due to the thoracotomy incisions made between the ribs.
CONTACT PERCAUTIONS
MRSA rotavirus RSV (transmitted droplet but kids mouths on everything) gloves handwashing gown private room disposable supplies stethoscope sterilized
tinnitus and hearing loss what medications
MYCINS
effacement of cervix
thinning of cervix goes to 100% effaced
Effacement
thinning of the cervix during labor
A client undergoing endotracheal intubation received IV sedation and succinylcholine. Shortly after respiratory status has been stabilized, the client becomes flushed and profusely diaphoretic and has a rigid jaw. Which medication should the nurse prepare to administer? Click the exhibit button for more information. Vital signs Temperature 105 F (40.6 C) Blood pressure 140/90 mm Hg Heart rate1 50/min Respirations 28/min O2 saturation 98% 1.IM epinephrine 2.IV atropine 3.IV dantrolene 4.IV glucagon
Malignant hyperthermia (MH) is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia). Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels. (Option 1) IM epinephrine is administered for cardiac arrest, anaphylactic reactions, or severe asthma attacks; it is not appropriate for MH. (Option 2) IV atropine, an anticholinergic agent, is used to treat bradycardia. It would worsen tachycardia in this client. (Option 4) Naturally produced by the pancreas, glucagon is given intramuscularly, subcutaneously, or intravenously for severe hypoglycemia. IV glucose is preferred due to its immediate effect; however, if it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver, thereby raising blood glucose.
Upon arrival in the post-anesthesia care unit, the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider immediately? 1.Difficult to arouse 2.Muscle stiffness 3.Pinpoint pupils 4.Temperature 94 F (34.4 C) (28%)
Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the operating room or in the post-anesthesia care unit (PACU). The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C). The nurse would notify the health care provider, indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation) (Option 2).
An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment? 1.Client consuming 90% of each meal 2.Serum albumin of 3.6 g/dL (36 g/L) 3.Weight gain of 2 lb (0.9 kg) in 2 weeks 4.White blood cell count of 15,000/mm 3 (15.0 × 109/L)
Malnutrition occurs due to inadequate intake of major nutrients (eg, calories, carbohydrates, fat, protein) or micronutrients (eg, minerals, vitamins). As malnutrition worsens and protein intake is reduced, muscles become fatigued and weak. Clinical manifestations depend on the severity of the malnutrition, ranging from mild to extreme (eg, emaciation). Weight gain is the best indicator that the client is responding to medical nutritional therapy. (Option 1) Consuming 90% of meals indicates that the client's appetite is good or improving but does not provide conclusive evidence of an improved nutritional status. (Option 2) Although a serum albumin level of 3.6 g/dL (36 g/L) is within the normal range of 3.5-5.0 g/dL (35-50 g/L), visceral protein stores are poor indicators of nutritional status in acute and chronic disease. During an inflammatory response (eg, pneumonia), protein synthesis by the liver is decreased. Serum albumin has a long half-life, so laboratory levels may not reflect the change in nutritional status for over 2 weeks. Prealbumin has a half-life of only 2 days and is quicker and more reliable than serum albumin as an indicator of acute change in nutritional status. (Option 4) A white blood cell count of 15,000/mm3 (15.0 × 109/L) is elevated (normal: 4,000-11,000/mm3 [4.0-10.0 × 119/L]), which indicates that the infection has not resolved.
Administration of an osmotic diuretic (eg, mannitol) to reduce intraocular pressure (IOP).
Mannitol increases plasma oncotic pressure, pulling water from the extravascular space into the intravascular space. This fluid, along with the diuretic, is excreted through the kidneys, thereby reducing IOP. This is similar to the management of cerebral (brain) edema
The nurse has just completed discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective? 1."I'm glad that I can continue taking my Ginkgo biloba." 2."I will increase my intake of leafy green vegetables." 3."I will start applying vitamin E to my chest incision after showering." 4."I will shave with an electric razor from now on."
Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding. Teaching topics for clients on anticoagulants: --Take medication at the same time daily --Depending on medication, report for periodic blood tests to assess therapeutic effect --Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a razor blade) (Option 4) --Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) --Limit alcohol consumption --Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale, spinach, broccoli, greens) (Option 2) and do not take vitamin K supplements --Consult with health care provider before beginning or discontinuing any medication or dietary/herbal supplement (eg, Ginkgo biloba and ginseng affect blood clotting and may increase bleeding risk) (Option 1) --Wear a medical alert bracelet indicating what anticoagulant is being taken -------(Option 3) Early in the recovery period, care of the incision site typically includes washing with soap and water and patting it dry. Ointments (eg, vitamin E) may be applied after the incision has healed.
The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? Select all that apply. 1.Biting endotracheal tube 2.Disconnected ventilator tubing 3.Endotracheal tube cuff leak 4.Excessive airway secretions 5.Kinked ventilator tubing
Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a problem with the ventilator. Peak airway pressure is the amount of pressure required to deliver a tidal volume. Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung compliance, such as: Excessive secretions: Obstruct the airway, increasing resistance Biting the endotracheal tube and kinked ventilator tubing: Air flow is obstructed, increasing resistance Any condition that decreases airway resistance (eg, tubing disconnect, extubating, endotracheal or tracheostomy tube cuff leak) can trigger the low-pressure limit alarm.
Neomycin enema
Medicated enema that reduces the number of bacteria in the intestines in preparation for colon surgery
Menopause
Menopause is a normal physiological decline in estrogen that commonly occurs in clients age >45 and is retrospectively diagnosed once menses has been absent for 12 months. Findings that require follow-up include: Last menstrual period 3 months ago (ie, secondary amenorrhea), which can be related to perimenopause but requires follow-up to rule out other etiologies (eg, pregnancy, polycystic ovary syndrome, thyroid dysfunction). A copper intrauterine device (IUD) does not affect ovulation; therefore, clients will continue to have a regular menses. Vasomotor symptoms (eg, excessive perspiration at night, hot flashes), which can be caused by hormonal changes (eg, hyperthyroidism, perimenopause) Pain during sexual intercourse, which can be caused by vaginal atrophy associated with perimenopause, pelvic inflammatory disease, sexually transmitted infections, or endometriosis. Vaginal dryness makes vulvovaginal atrophy more likely. Persistent loss of interest in normal activities and difficulty concentrating, which is concerning for depression and thoughts of self-harm.
MACkussmal
Metabolic Acidosis Kussmal respirations
The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client's risk for metabolic syndrome? 1.27-year-old woman with triglycerides of 210 mg/dL (2.4 mmol/L), blood pressure of 128/82 mm Hg, and fasting blood glucose of 98 mg/dL (5.4 mmol/L) 2.45-year-old man with waist circumference of 38 in (96.5 cm), HDL of 49 mg/dL (1.3 mmol/L), and fasting blood glucose of 118 mg/dL (6.6 mmol/L) (11%) 3.55-year-old woman with waist circumference of 37 in (94 cm), triglycerides of 190 mg/dL (2.2 mmol/L), and fasting blood glucose of 120 mg/dL (6.7 mmol/L) 4.82-year-old man with HDL of 45 mg/dL (1.2 mmol/L), blood pressure of 148/88 mm Hg, and fasting blood glucose of 104 mg/dL (5.8 mmol/L)
Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client's risk for stroke, diabetes mellitus, and cardiovascular disease. A mnemonic for metabolic syndrome is "We Better Think High Glucose" (Waist circumference, Blood pressure, Triglycerides, HDL, Glucose). Criteria includes: Abdominal obesity: Waist circumference ≥40 in (102 cm) in men, ≥35 in (89 cm) in women High serum triglycerides: >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment Low HDL cholesterol: <40 mg/dL (1.04 mmol/L) in men, <50 mg/dL (1.3 mmol) in women or hyperlipidemia drug treatment High blood pressure: ≥130/85 mm Hg or hypertension drug treatment Increased fasting blood glucose: ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment The 55-year-old woman (waist circumference 37 in [94 cm], triglycerides 190 mg/dL [2.2 mmol/L], fasting blood glucose 120 mg/dL [6.7 mmol/L]) is at highest risk for metabolic syndrome with 3 of 5 criteria (obesity, hypertriglyceridemia, hyperglycemia)
A diabetic client is prescribed metoclopramide. Which of the following side effects must the nurse teach the client to report immediately to the health care provider? Select all that apply . 1.Excess blinking of eyes 2.Dry mouth 3.Dull headache 4.Lip smacking 5.Puffing of cheeks
Metoclopramide (Reglan) is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). This is especially common in older adults with long-term use. The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: Protruding and twisting of the tongue Lip smacking Puffing of cheeks Chewing movements Frowning or blinking of eyes Twisting fingers Twisted or rotated neck (torticollis)
The nurse is talking with a client who has a new prescription for metronidazole. Which of the following statements by the client would require follow-up? 1."I can continue to drink a glass of wine with dinner while I am taking this medication." 2."I might experience a metallic taste in my mouth while I am taking this medication." 3."I should not be concerned if my urine turns a dark color while taking this medication." 4."I will immediately contact my health care provider if I experience a rash or skin peeling."
Metronidazole is an antibiotic used to treat bacterial, parasitic, and protozoal infections. Clients who are prescribed metronidazole should be made aware of medication interactions and adverse reactions to report. The client should be instructed to abstain completely from consuming food, drinks, or products containing alcohol during therapy and for three days after. The combination of alcohol and metronidazole may cause a disulfiram-like reaction (eg, facial flushing, headaches, nausea, vomiting, abdominal cramping) (Option 1). (Options 2 and 3) Metronidazole commonly causes an unpleasant metallic taste in the mouth and harmless darkening of the urine (eg, brown, rust-colored). (Option 4) Although rare, metronidazole may cause Stevens-Johnson syndrome, a life-threatening adverse reaction characterized by necrosis and sloughing of the skin and mucous membranes. Clients should immediately notify the health care provider if signs or symptoms (eg, rash, skin peeling, fever) develop.
The nurse is educating the parent of an adolescent client who is newly diagnosed with infectious mononucleosis. Which statement by the parent indicates the need for additional instruction? 1."I need to go to the pharmacy to pick up an antibiotic prescription." 2."It is acceptable for my child to have ibuprofen for discomfort." 3."My child will be on bed rest with few activities for several days." 4."Participation in soccer practice will not be allowed for the next month."
Mononucleosis is caused by Epstein-Barr virus. It is typically seen in adolescents, resulting from the sharing of drinks, kissing, or other direct exposure to the saliva of infected individuals. Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Treatment for mononucleosis includes hydration, rest, pain control, and reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches (eg, cough drops). Antibiotic treatment is inappropriate for a viral infection and antibiotic use (eg, amoxicillin, azithromycin) can cause a rash (Option 1). Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph nodes around the neck, and severe abdominal pain (eg, splenic rupture).
The nurse reinforces teaching to a female client about taking misoprostol to prevent stomach ulcers. Which statement by the client would prompt further instruction? 1."I can take this medication with food if it hurts my stomach." 2."I must use a reliable form of birth control while taking this medication." 3."I should continue to take my ibuprofen as prescribed." 4."I will take this medicine with an antacid to decrease stomach upset."
Misoprostol (Cytotec) is a synthetic prostaglandin that protects against gastric ulcers by reducing stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving long-term nonsteroidal anti-inflammatory drug (NSAID) therapy. Antacids, especially those that contain magnesium (eg, Gaviscon), can increase the adverse effects of misoprostol (eg, diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (eg, calcium carbonate [Tums]) and contact the health care provider if adverse effects occur (Option 4). (Option 1) Taking misoprostol with food can help decrease gastrointestinal side effects (eg, abdominal pain, cramping, diarrhea). (Option 2) Misoprostol is also used for labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping while taking misoprostol. Clients who suspect they are pregnant must stop taking the medication and contact their health care provider immediately. (Option 3) The client can continue taking ibuprofen (an NSAID) with misoprostol because misoprostol is designed to reduce side effects of ibuprofen.
The nurse receives handoff report on 4 clients. Which client should the nurse assess first? 1.Client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth 2.Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up 3.Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache 4.Client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea
Monoamine oxidase inhibitors (MAOIs) (eg, isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]) are often prescribed for depression. MAOIs deactivate an enzyme that breaks down norepinephrine, dopamine, and serotonin. Increased levels of norepinephrine can increase blood pressure. This increased norepinephrine level combined with certain medications that also increase blood pressure (eg, nasal decongestants [eg, pseudoephedrine, oxymetazoline]) may lead to hypertensive crisis, a complication that can result in hemorrhagic stroke and death. Headache is a common, early symptom of hypertensive crisis that should be evaluated immediately in clients taking MAOIs (Option 3).
LONG TERM asthma medications
Montelukast is a leukotriene receptor blocker with bronchodilator and anti-inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma exacerbation. Long-acting beta-2 agonists (LABAs) (eg, salmeterol) are used in combination with an inhaled corticosteroid as maintenance therapy to promote bronchodilation. LABAs are not indicated for treatment of an acute asthma exacerbation.
ototoxic medications
More common with CKD or heart failure Usually dose-dependent Common medications: Aminoglycoside antibiotics Chemotherapy agents (eg, cisplatin) Loop diuretics (eg, furosemide) High-dose salicylates
You palpate a ___ and auscltate a ____
thrill (vibration over fistula) bruit (swooshing sounds over fistula)
The nurse is assessing a client who had surgery 12 hours ago and is receiving IV morphine for incisional pain. It would require immediate follow-up if the client 1.Has a blood pressure of 108/68 mm Hg 2.Falls asleep while speaking with the nurse 3.Reports burning at the IV site during administration of the medication 4.Reports dizziness when getting out of bed to use the bathroom
Morphine is an opioid analgesic often used to manage postoperative pain. A client's level of consciousness should be monitored closely following administration because sedation precedes respiratory depression, the most serious adverse effect of morphine. A common tool used for this purpose is the Pasero Opioid-induced Sedation Scale. The health care provider should be notified if the client becomes sedated (Option 2). The nurse should prepare to administer naloxone, an opioid antagonist, if the client is minimally responsive to verbal and physical stimuli. Additional doses of morphine should not be administered until the health care provider has decreased the dosage or frequency of the medication and the client's level of consciousness returns to an acceptable level.
(acetaminiophen) Tylenol overdose antidote
Mucomyst (acetylcysteine)
Postpartum hemorrhage (PPH) is serious and a significant contributor to maternal death in morbidity worldwide Risk factors and causes of PPH include
Multiple gestation Uterine atony Macrosomia birth (increased risk of lacerations) Hydramnios (large amniotic fluid volume making uterine contraction difficult) Retained placenta (it will now allow the uterus to fully contract) Manual removal of the placenta Clotting disorders Lacerations Any delivery that was assisted with a tool or instrument (increased risk of lacerations) Manifestations of a client experiencing PPH include excessive lochia, uterine tenderness, and unstable vital signs (tachycardia, hypotension) Treatment includes prompt recognition and activation of a PPH protocol (each facility is required to have a protocol that streamlines treatment). If uterine atony is the cause, a fundal massage is necessary. Blood product replacement, intravenous oxytocin, and/or intramuscular (IM) methylergonovine.
Risk factors for pelvic inflammatory disease
Multiple sexual partners History of chlamydia or gonorrhea History of pelvic inflammatory disease Partner with a sexually transmitted infection Lack of consistent barrier contraception use Age 15-25
The nurse is assessing a client with newly diagnosed myasthenia gravis. Which of the following findings would be consistent with the condition? Select all that apply. 1.Cogwheel rigidity 2.Difficulty chewing 3.Drooping eyelids 4.Progressive fatigue 5.Resting tremor
Myasthenia gravis (MG) is an autoimmune neuromuscular disease that involves the attack of acetylcholine receptors by autoantibodies at the neuromuscular junction. The resulting deficit in available acetylcholine receptors causes fluctuating skeletal muscle weakness, leading to decreased/delayed muscle contraction. Common clinical manifestations of MG include: Difficulty speaking, swallowing, and chewing (Option 2) New-onset ocular symptoms, including fluctuating ptosis (ie, eyelid drooping in which the eyelid can close but cannot lift or open) and/or diplopia (ie, double vision) (Option 3) Fatigue that worsens over the course of the day, because skeletal muscles tend to be stronger in the morning and weaken throughout the day, requiring more energy expenditure (Option 4) Breathing difficulty and diminished breath sounds (Options 1 and 5) Muscle rigidity (ie, cogwheel rigidity) and resting tremors are symptoms commonly associated with Parkinson disease, not MG.
The nurse is caring for a 72-year-old client with hypothyroidism admitted to the emergency department for altered mental status. The client lives alone but has not taken medications or seen a health care provider for several months. Which action is the priority? Click on the exhibit button for additional information. Temperature 95 F (35 C) Blood pressure 90/50 mm Hg Heart rate50/min Respirations10/min SaO283% 1.Administer IV levothyroxine 2.Check serum TSH, triiodothyronine, and thyroxine 3.Place a warming blanket on the client 4.Prepare for endotracheal intubation
Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state. Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation. Hypoventilation may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue. Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency endotracheal intubation and mechanical ventilation. The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation (Option 4). (Option 1) Clients with myxedema coma require thyroid hormone replacement with IV levothyroxine to correct the hypothyroid state but only after respiratory status is secured. Improvement in clinical status may not occur for up to a week after initiation of hormone replacement. (Option 2) A serum thyroid panel (eg, TSH, triiodothyronine, thyroxine) is required to confirm hypothyroidism, and these measurements should be monitored during treatment; however, the nurse should ensure that the client is stable before reviewing laboratory values. (Option 3) A warming blanket should be placed on the client to treat hypothermia; however, respiratory support is the priority.
NPH insulin (intermittent insulin) - onset - peak - duration
N = NOT so clear (cloudy) cannot be given IV 6-8-10-12 onset 6 hours peak 8-10 hours duration 12 hours EVEN Numbers
Can you give potassium chloride as an IV bolus?
NO
can a nurse administer Varicella and MMR to an immunocompromised pt?
NO they are live attenuated
Does levothyroxine (synthroid) relieve syptoms right away?
NO 3-4 weeks complete effect CAN be given with pregnant pt
Long acting insulin glargine (Lantus) detemir (Levemir) onset peak duration
NO PEAK Duration 12-24 hours ONLY ONE SAFE TO GIVE AT BEDTIME
should a patient hold thyroid pills before anesthesia?
NOOO take even if NPO
The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. 1.0.3 mg of nitroglycerin sublingual PRN 2.10 mg of ezetimibe PO once daily 3.20 mg of lisinopril PO once daily 4.200 mg of celecoxib PO once daily
NSAIDs (eg, naproxen, ibuprofen, celecoxib) are used for their analgesic, antipyretic, and anti-inflammatory properties. However, they increase the risk of thrombotic events (eg, myocardial infarction [MI], stroke), especially in clients with cardiovascular disease (eg, coronary artery disease). The nurse should investigate why a client with a history of cardiovascular disease is taking an NSAID and alert the health care provider of its use (Option 4). (Option 1) Sublingual nitroglycerin may be prescribed to alleviate an exacerbation of acute angina in a client with a history of chronic stable angina. Nitrates promote coronary vasodilation, thereby improving blood flow and relieving ischemic chest pain. (Option 2) Ezetimibe inhibits cholesterol absorption from the small intestine, which reduces the risk of atherosclerosis and helps to treat coronary artery disease. (Option 3) ACE inhibitors (eg, lisinopril, enalapril, captopril) are prescribed to treat hypertension. These medications interfere with the conversion of angiotensin I to angiotensin II, which lowers blood pressure by reducing vasoconstriction and promoting sodium excretion. ACE inhibitors also inhibit ventricular remodeling after an MI, which reduces the risk of recurrent MI.
The health care provider (HCP) prescribes naproxen for a client who has degenerative joint disease. What instructions regarding this drug does the nurse include in the client's discharge plan? Select all that apply. 1.Avoid driving while taking this medicine 2.Change positions slowly 3.Discontinue immediately if suicidal thoughts occur 4.Notify the HCP of tarry stools 5.Take the medicine with food
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) commonly prescribed to decrease joint pain and inflammation. All NSAIDs (eg, indomethacin, ibuprofen) are associated with the following: --Gastrointestinal (GI) toxicity - symptoms of GI bleeding such as black tarry stools should be reported. Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. --Kidney injury - long-term use is associated with kidney injury --Hypertension and heart failure - NSAIDs can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension --Bleeding risk - clients should notify the HCP if taking concurrently with aspirin, other NSAIDs, or anticoagulant or antiplatelet drugs as they can increase the risk of GI bleeding. (Option 1) Clients should not drive when taking sedating medications (eg, antihistamines, benzodiazepines). However, sedation is not associated with NSAID use. (Option 2) Orthostatic hypotension is common with blood pressure medications (eg, ACE inhibitors, alpha blockers) but not with NSAIDs. (Option 3) Suicidal thoughts are commonly associated with selective serotonin reuptake inhibitors (antidepressants) and varenicline (Chantix), a smoking cessation medication.
The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first? 1. Client 1 week postoperative appendectomy who has not had a bowel movement in 4 days 2.Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating 3.Client postoperative right below-the-knee amputation who is concerned about a new tingling sensation in the right foot 4.Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the next morning
Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner. (Option 1) Constipation is common after abdominal surgery due to opioid usage and decreased peristalsis from bowel manipulation. Increasing food or fluids might help the client have a bowel movement.
RISK with SUBTOTAL thyroidectomy
thyroid storm extreamly high VS delirious oxygen and lower body temp
serotonin syndrome vs NMS
Neuroleptic malignant syndrome (NMS) is immediately excluded because the trigger for NMS is an antipsychotic. This client is not taking an antipsychotic, as paroxetine is an SSRI. While certain clinical features of NMS and serotonin syndrome overlap (psychomotor agitation, fever, delirium), clients with serotonin syndrome have hyperreflexia and myoclonus. Clients with NMS feel like a lead pipe because of the muscle rigidity they develop, along with hyporeflexia.
Nevi (Telangiectatic nevi)
Nevi or telangiectatic nevi, a.k.a. "stork bites," are pink and easily blanched skin lesion that appear on upper eyelid, nose, upper lip, lower occipital area, and nape of the neck • No clinical significance • Disappears by 2 years of age
The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention? 1.The client cannot remember what was done yesterday 2.The client has a painful red area on the buttocks 3.The client has new dependent edema of the feet 4.The client has strong, foul smelling urine
New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs (eg, weight gain, lung crackles) and treatment. (Option 1) Loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening. (Option 2) A painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly. (Option 4) Strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly.
Oxybutynin (Ditropan) is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include:
New-onset constipation Dry mouth Flushing Heat intolerance Blurred vision Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity
The nurse is evaluating a client's understanding of post-circumcision care for a 24-hour-old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching? 1."Bleeding that doesn't stop with gentle pressure should be reported." 2."I should cleanse the glans with warm water during diaper changes." 3."I should expect at least 2 wet diapers in the next 24 hours." 4."Yellow exudate on the glans penis indicates infection."
Newborn circumcision is a procedure that removes the foreskin from the glans penis using a clamp or plastic ring method. Circumcision is typically performed near discharge to ensure that the newborn is stable. Circumcision care education includes: Washing hands before providing care Applying petroleum jelly during diaper changes (unless the plastic ring method was used) to prevent the exposed glans from adhering to the diaper until the site heals, which is typically within 7-10 days Teaching parents that yellow exudate on the penis after the first day is a normal part of the healing process that disappears in 2-3 days and should not be removed forcefully (Option 4). Swelling, increasing redness, odor, or abnormal discharge may indicate infection and should be reported.
What is a sign of uterine tetany?
No longer than 90 seconds and no closer than 2 minutes
The nurse is assessing a diabetic client for pain following right total knee replacement surgery. The client reports "numbness and tingling" in the bilateral lower extremities. Pedal pulses are strong bilaterally, and capillary refill is <3 seconds in the right great toe. Which action should the nurse take? 1.Ask if the client wants pain medication for the "numbness and tingling" 2.Ask the client if the "numbness and tingling" were present before surgery 3.Continue assessment by observing the surgical dressing 4.Notify the health care provider (HCP) immediately
Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of bilateral peripheral neuropathy include the following: Diabetic neuropathy - most common; distribution is usually sock-and-glove pattern Autoimmune neuropathy - Guillain-Barré syndrome Toxic neuropathy - alcohol use Establishing that the sensations the client is experiencing were present before surgery indicates whether this is a complication of surgery. Because the sensation is bilateral and the surgery was on the right knee, the "numbness and tingling" are probably baseline diabetic neuropathy. This should be confirmed by gathering more information from the client (Option 2). (Option 1) Diabetic neuropathy is not usually treated with traditional post-surgical medications such as opioids. Medications for diabetic neuropathy are usually given on a fixed, timed schedule and include duloxetine, pregabalin, amitriptyline, and gabapentin. If the client uses an as-needed medication, it is important to ask for more information before administering it. The client should be asked whether the pain is baseline and what medication is taken. (Option 3) The nurse should question any abnormal finding, whether expected or unexpected. Questioning the client further would allow the nurse to gather more information and confirm that the client's "numbness and tingling" do not indicate a more serious situation. (Option 4) It is not necessary to notify the HCP immediately. Bilateral pedal pulses and normal capillary refill indicate sufficient blood flow to the extremities.
There has been an explosion at a local chemical plant. A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid. The victims are wheezing. The nurse should implement which intervention first? 1.Assessing the clients' respiratory systems 2.Decontaminating the clients 3.Donning personal protective equipment 4.Providing oxygen by nasal cannula
Nursing priorities when implementing a chemical contamination emergency response plan include the following: Restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant Donning personal protective equipment to protect the nurse when providing care (Option 3) Decontaminating the clients outside the facility before initiating treatment. If the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients (Option 2). Assessing and providing treatment of symptoms. Initial treatment is for the symptoms (eg, wheezing), regardless of the specific cause (Options 1 and 4).
What action inactivates the manufactures expiration date?
OPENING THE MEDICATION
Cranial Nerve Pneumonic
Oh Olfactory (I) Smell test Oh Optic (II) Visual acuity & visual fields Oh Oculomotor (III) Pupil constriction & extraocular movements To Trochlear (IV) Extraocular movements - inferior adduction Touch Trigeminal (V) Clench teeth -close eyes, light touch face And Abducens (VI) Extraocular movements - lateral abduction Feel Facial (VII) Facial movement - close eyes, smile A Acoustic (VIII) Hearing & Romberg test (balance) Girls Glossopharyngeal (IX) Gag reflex Vagina Vagus (X) Uvular and palate movement - say "ah" Ah Spinal accessory (XI) Turn head & lift shoulders Heaven Hypoglossal (XII)Stick out tongue
atypical antipsychotics
Olanzapine Clozapine Respiradone
The nurse is administering IV hydromorphone to a client every 3-4 hours as needed for postoperative pain. Which interventions should the nurse implement? Select all that apply. 1.Administer IV hydromorphone over 5-10 seconds 2.Administer PRN stool softener with daily medications 3.Hold hydromorphone if client is not practicing deep breathing exercises 4.Perform reassessment an hour after administration 5.Tell the client to call for assistance before getting out of bed
Opioid analgesics (eg, hydromorphone, morphine) are effective for controlling moderate to severe pain. Major side effects include sedation, respiratory depression, hypotension, and constipation. The client is at risk for falls from sedation or hypotension and should not get out of bed unassisted (Option 5). Slowed bowel motility persists throughout opioid use, and measures to prevent constipation (eg, administration of daily stool softeners) should be implemented (Option 2). (Option 1) IV hydromorphone should be administered slowly over 2-3 minutes. Rapid IV administration of opioid analgesics can cause severe hypotension and respiratory or cardiac arrest. (Option 3) Postoperative clients may experience pain with breathing exercises (eg, turning, coughing, deep breathing, incentive spirometry). Uncontrolled postoperative pain may cause clients to avoid deep breathing and lead to atelectasis and pneumonia. The nurse should administer opioids to achieve adequate pain control as needed to encourage participation in postoperative exercises and prevent complications. (Option 4) The nurse should reassess pain and sedation level during the opioid's peak effect, which is 15-30 minutes after administration of IV hydromorphone.
osteoarthritis vs osteoporosis
Osteoarthritis is a noninflammatory degradation of cartilage in synovial joints (eg, knee, hip, fingers) that gradually worsens over time. - Risk for osteoarthritis increases with age, overuse of joints, excess weight bearing on joints, or trauma. Manifestations include - joint pain that worsens as the day progresses, - deformity, and/or instability. - Regular muscle strengthening exercise (eg, quadriceps strengthening) - healthy weight loss can reduce pain by decreasing strain on the joints. Osteoporosis is a musculoskeletal disorder that occurs when the rate of bone resorption (ie, bone breakdown) exceeds bone formation, resulting in porous, fragile bone. Loss of bone mass is present on bone density scans. Bones of the spine, hips, and wrist are most affected. Clients often develop compression fractures (ie, vertebral fractures) that can lead to musculoskeletal deformities (eg, kyphosis) and loss of height. Pain is not typical unless a fracture is present.
A client with cancer pain is prescribed oxycodone. Which teaching is most essential to help prevent long-term complications? 1.Teach the client how to assess blood pressure daily 2.Teach the client how to prevent constipation 3.Teach the client how to prevent itching 4.Teach the client how to prevent nausea
Oxycodone is a morphine-like opioid medication. Opioid medications bind to opioid receptors in the intestine, which slows peristalsis and increases water absorption, leading to constipation. Constipation is an almost universally expected side effect from opioid medications. Clients will not develop tolerance to this side effect. Although clients with idiopathic chronic constipation are not commonly advised to take laxatives, opioid-induced constipation is treated with simultaneous use of senna (stimulant) and docusate (stool softener). (Options 1 and 3) Opioids cause the release of histamine, a vasodilator, which is responsible for pruritus and flushing. Opioids can also cause peripheral vasodilation and nervous system depression; both can lead to hypotension. These develop in some clients when the treatment is initiated but usually resolve over time. Antihistamines (eg, diphenhydramine) can prevent the pruritus. Lifestyle changes (eg, rising slowly from a seated position) and adequate hydration can prevent hypotension. (Option 4) Opioids stimulate the opioid receptors in the gastrointestinal tract and the chemoreceptor trigger zone in the brain, producing nausea. This is also not seen with long-term use. Antiemetics (eg, ondansetron) can be helpful.
Pelvic inflammatory disease
PID is commonly associated with an untreated sexually transmitted infection such as gonorrhea or chlamydia. Untreated BV infections may also lead to PID. What is ruling out the possibility of PID is that the client has a negative screening for gonorrhea and chlamydia. Additionally, the client has no fever, another manifestation of PID.
Coumadin (warfarin)
PO takes a few days to a week can be given for the rest of your life antidote vitamin K PT-INR CANNOT be given to pregnant women
A client with Parkinson disease is prescribed carbidopa-levodopa. Which of the following instructions should the nurse include with the client's discharge teaching? Select all that apply. 1."Change positions slowly, and sit on the side of the bed before standing." 2."This medication takes several weeks to reach maximum benefit." 3."You may experience some facial and eye twitching, but this is not harmful." 4."Your tremors should disappear completely while on this medication." 5."Your urine and saliva may turn reddish-brown, but this is not harmful."
Parkinson disease (PD) is characterized by decreased dopamine levels, uncontrolled acetylcholine, and formation of abnormal protein clusters (Lewy bodies) in the brain. PD causes both physical and neurological (eg, mood alterations, dementia) symptoms. Carbidopa-levodopa is a combination antiparkinsonian medication used to reduce physical symptoms of PD by increasing dopamine levels in the brain. Levodopa is converted to dopamine in the brain but is largely metabolized before reaching the brain. Carbidopa does not have a therapeutic effect on PD but prevents breakdown of levodopa before reaching the brain, which makes levodopa more effective. Client teaching for carbidopa-levodopa includes: Implementing fall precautions (eg, changing positions slowly, removing rugs), as orthostatic hypotension is a common side effect (Option 1) Knowing that carbidopa-levodopa takes several weeks to reach its maximum effectiveness (Option 2) Understanding that harmless discoloration (eg, red, brown, black) of secretions (eg, urine, perspiration, saliva) may occur while taking carbidopa-levodopa (Option 5) Avoiding high-protein meals, which interfere with the absorption of carbidopa-levodopa (Option 3) Dyskinesia (eg, facial or eyelid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity of carbidopa-levodopa and should be reported immediately to the health care provider. (Option 4) Carbidopa-levodopa often decreases, but does not eliminate, tremor and rigidity.
The charge nurse is making assignments for the oncoming shift. Which client assignments should be avoided by the nurse who is pregnant? 1.2-year-old client who is combative on postoperative day 2 for tonsillectomy and adenoidectomy 2.5-year-old client admitted for dehydration secondary to severe throat pain associated with group A Streptococcus 3.9-year-old client with parvovirus B-19 infection admitted for observation after a febrile seizure 4.14-year-old client with acute lymphocytic leukemia who received intrathecal chemotherapy 4 days ago and was admitted for a blood transfusion
Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg, hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other [parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. (Option 1) A combative toddler should not be a hazard to the pregnant nurse. Appropriate precautions should be taken to ensure safety around combative clients. (Option 2) Group A Streptococcus infection requires droplet precautions; however, it does not pose a perinatal infection risk. Group A Streptococcus may manifest as sore throat. (Option 4) Extreme caution should be taken while handling cytotoxic medications; however, intrathecal administration days prior to contact should not pose a risk to the pregnant nurse. The nurse should use standard precautions if contact with the client's blood or bodily fluids is anticipated.
scleroedema
tightening and hardening of connective tissue renal crisis and malignant hypertension are complications
A nurse in the cardiac intensive care unit assesses a client with diabetes mellitus who underwent a percutaneous coronary intervention with stent placement via the left femoral artery 3 hours ago. Which assessment finding requires priority notification of the health care provider? 1.1+ palpable pedal pulses bilaterally 2.2-cm area of ecchymosis in the left groin 3.Angina rated as 4 on a pain scale of 0-10 4.Blood glucose of 220 mg/dL (12.2 mmol/L)
Percutaneous coronary intervention (PCI) with stent placement is performed to improve coronary artery patency and increase cardiac perfusion. A balloon and stent are inserted via a catheter through a large artery (eg, femoral artery) and threaded toward the blocked coronary artery. The balloon expands the stent against the arterial wall, compressing plaque and improving patency. The stent remains in the client after the balloon and catheter are removed. Potential complications of PCI include thrombosis, stent occlusion, bleeding/hematoma, and limb ischemia. The nurse should immediately notify the health care provider of postprocedure angina, which indicates possible thrombosis or stent occlusion; necessary prescriptions (eg, nitroglycerin, second PCI) should be obtained and promptly initiated (Option 3). (Option 1) Neurovascular assessments of the affected extremity should be compared with the unaffected extremity and the client's baseline; this client's 1+ pulses are not a concern because they are bilateral, not unilateral. Most clients with diabetes mellitus and coronary artery disease may also have baseline peripheral artery disease. (Option 2) A small amount of bleeding/ecchymosis is expected at the access site due to anticoagulation therapy, which is initiated prior to PCI. The nurse should assess for signs of hematoma formation and retroperitoneal hemorrhage. (Option 4) Increased blood glucose must be treated but is not a priority over stent occlusion.
Clients with latent tuberculosis (TB) who do not adhere to treatment regimens have an increased risk for active infection. Clinical manifestations of active TB include low-grade fevers, chills, night sweats, malaise, weight loss, and coughing up sputum or blood.\ Indicated interventions for a client with active TB include:
Performing another chest x-ray: X-ray confirms the presence of active TB if a client has had a positive tuberculin skin test and is now symptomatic. Initiating long-term combination antibiotics (eg, isoniazid, rifampin, pyrazinamide, ethambutol): Antibiotics are used to treat the active TB infection. Collecting three separate sputum cultures at timed intervals: This confirms the presence of active TB and tests drug sensitivities: Cultures are also obtained later during treatment to assess the effectiveness of antibiotic therapy. Obtaining a blood specimen to measure baseline liver function, which is essential due to the hepatotoxicity of the antibiotic regimen: Liver function must also be monitored throughout treatment and the nurse should provide teaching for signs of liver toxicity (eg, jaundice, dark urine).
The nurse suspects the client is experiencing cardiac tamponade and measures the client's blood pressure. Which finding does the nurse expect? 1.Decrease in diastolic blood pressure when standing 2.Decrease in systolic blood pressure during inspiration 3.Difference in blood pressure between the upper and lower extremities 4.Widened pulse pressure
Pericarditis causes fluid accumulation (ie, pericardial effusion) within the membrane that surrounds the exterior of the heart. A large pericardial effusion from the pericarditis or blood from the ventricular free wall rupture (from recent necrosed myocardium) can cause cardiac tamponade. Cardiac function becomes impaired as the volume of pericardial fluid increases and compresses the heart, resulting in decreased cardiac output. Signs of cardiac tamponade include tachycardia, muffled heart tones, jugular vein distension, and an abnormal decrease in systolic blood pressure (>10 mm Hg) with inspiration (ie, pulsus paradoxus) (Option 2). (Option 1) A decrease in diastolic blood pressure when standing is orthostatic hypotension, which can cause dizziness when changing positions. A client with jugular venous distension and muffled heart tones is most likely experiencing cardiac tamponade, not orthostatic hypotension. (Option 3) A significant difference in blood pressure between the upper and lower extremities is caused by coarctation of the aorta. Coarctation of the aorta is an abnormal narrowing of the aorta that typically presents in childhood and does not cause muffled heart tones. (Option 4) A widened pulse pressure (ie, significant difference between systolic and diastolic blood pressure) is seen when there is a large volume of blood to pump from the ventricles (eg, aortic regurgitation, hyperthyroidism). In cardiac tamponade, the ventricles have a small volume to pump out; therefore, the systolic pressure (ie, pressure in the arterial system during the heartbeat) would be low. If the systolic pressure is low, pulse pressure would be low. Educational objective:Cardiac tamponade is a life-threatening complication of pericarditis that can occur as the volume of pericardial fluid increases and compresses the heart. Signs of cardiac tamponade include muffled heart tones, jugular vein distension, and an abnormal decrease in systolic blood pressure with inspiration (ie, pulsus paradoxus).
Stage 1 of labor: onset of labor
Phase 1: latent (cervical dilation (0-3) o Phase 1 o Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds o Mild intensity Phase 2: Active (cervical dilation 4-7) o Phase 2 o Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds o Moderate intensity Phase 3: Transition (cervical dilation 8-10) o Phase 3 o Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds o Strong intensity
Phenazopyridine
Phenazopyridine is a urinary tract analgesic used to relieve pain and burning during urination. The medication can cause the client's urine to turn a reddish-orange color. This coloration is an expected effect of this medication (although it can stain clothing) and does not need to be reported to the provider.
The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take? 1.Check the results of the client's most recent renal function tests 2.Obtain the client's blood pressure 3.Stop the continuous feeding for 1-2 hours 4.Verify placement of the nasogastric tube after administering the medication
Phenytoin is an anticonvulsant medication commonly used to treat focal and tonic-clonic seizures. Phenytoin has a narrow therapeutic range, is absorbed slowly, and requires steady absorption to maintain therapeutic serum levels and control seizure activity. The nurse should pause tube feedings for 1-2 hours before and after phenytoin administration, as tube feedings can decrease phenytoin absorption and serum levels (Option 3). (Option 1) Phenytoin is metabolized in the liver and requires liver function monitoring as it can cause liver damage. Unless clients have renal insufficiency, renal function tests are not routinely monitored. (Option 2) Blood pressure is not usually affected in clients receiving oral phenytoin therapy for seizure disorders. However, IV phenytoin may cause hypotension and cardiac arrhythmias. (Option 4) The nurse should verify nasogastric tube placement before medication administration to prevent aspiration/delivery into the lung.
Calcium of 13.2 current meds include phosphorus calcitonin Vitamin D IV calcium gluconate IV Bisphosphonates What should the nurse GIVE
Phosphorus inverse relationship with calcium Calcitonin: thyroid hormone that decreases plasma Ca levels inhibits bone reabsorption and lowers serum Ca Bisphosphonates: IV osteoporosis drug that can quickly lower Ca levels
A client who is pregnant arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client has not received prenatal care and reports being "about 7-8 months." Which of the following interventions should the nurse anticipate? Select all that apply. 1.Collecting a blood specimen for type and screen 2.Electronic fetal monitoring 3.Initiation of 2 large-bore IV catheters 4.Pad counts to assess bleeding 5.Vaginal examination for cervical dilation
Placenta previa is an abnormal implantation of the placenta resulting in partial or complete covering of the cervical os (opening). The condition is diagnosed by ultrasound. In clients reporting painless vaginal bleeding after 20 weeks gestation, placenta previa should be suspected. Placenta previa found early in pregnancy may resolve by the third trimester, but clients with persistent placenta previa or hemorrhage require cesarean birth. A type and screen to determine blood type and Rh status is appropriate due to the potential for excessive blood loss and need for blood transfusion (Option 1). Fetal well-being is assessed via continuous electronic fetal monitoring to help determine appropriate timing for birth (Option 2). Large-bore IV access is established in anticipation of fluid resuscitation and administration of blood products (Option 3). The client should also be monitored frequently for any changes in bleeding via pad counts (Option 4). (Option 5) Digital vaginal examinations are contraindicated in the presence of vaginal bleeding of unknown origin. When placenta previa is present, manual manipulation of the cervix can damage placental blood vessels, causing subsequent bleeding that can progress to hemorrhage. Clients with placenta previa are on pelvic rest (ie, no intercourse, nothing per vagina).
A client at 32 gestational weeks reports the sudden onset of painless, bright red vaginal bleeding. The assessment showed a normal fetal heart rate and a non-tender uterus. The nurse understands that this client is at the highest risk of developing
Placenta previa may occur as early as 20 gestational weeks. The manifestations of painless, bright red vaginal bleeding coincide with this condition. Commonly, the presentation of placenta previa is a finding on routine ultrasound examination at approximately 16 to 20 weeks.
A pregnant client at 38 weeks gestation is admitted to the labor and delivery unit reporting contractions, severe abdominal pain, and dark vaginal bleeding. What is the nurse's priority action? 1.Initiate a large-bore (18-gauge) peripheral IV line 2.Notify the operating room staff of emergency cesarean birth 3.Palpate the abdomen and apply a fetal heart rate monitor 4.Perform a vaginal examination to assess cervical dilation
Placental abruption (abruptio placentae) occurs when the placenta prematurely detaches from the uterine wall. This life-threatening complication can interrupt fetal oxygen supply and cause maternal hemorrhage. Associated symptoms may include frequent contractions, abdominal pain, dark red vaginal bleeding, uterine tenderness, and elevated uterine resting tone. Priorities include assessment of maternal vital signs, palpation of the abdomen/uterus, and continuous fetal heart rate monitoring (Option 3). If monitoring indicates fetal distress and/or maternal hemodynamic compromise, the health care team will prepare for emergency cesarean birth. (Option 1) Clients with placental abruption require large-bore (eg, 18-gauge) IV access to allow for fluid resuscitation and possible administration of blood products. However, assessing maternal/fetal status is the first step before initiating these interventions. (Option 2) Although emergency cesarean birth may become necessary, vaginal birth may be possible with a mild or partial abruption. Assessing maternal/fetal status and relaying that information to the health care provider is the priority. (Option 4) Vaginal examination is not performed in the presence of active bleeding until the possibility of placenta previa is ruled out; placenta previa typically presents with painless vaginal bleeding. Information about bleeding should be relayed to the health care provider, who can then determine if a vaginal examination would be appropriate.
A client at 38 weeks gestation is brought to the emergency department after a motor vehicle collision. The client reports severe, continuous abdominal pain. The nurse notes frequent uterine contractions and mild, dark vaginal bleeding. Which of the following actions should the nurse take? Select all that apply. 1.Anticipate emergency cesarean birth 2.Apply continuous external fetal monitoring 3.Assess routine vital signs every 4 hours 4.Initiate IV access with a 22-gauge catheter 5.Obtain blood specimen for type and crossmatch
Placental abruption occurs when the placenta separates prematurely from the uterine wall, causing hemorrhage beneath the placenta. Abruptions are classified as partial, complete, or marginal and may be overt (visible vaginal bleeding) or concealed (bleeding behind placenta). Risk factors include abdominal trauma, hypertension, cocaine use, history of previous abruption, and preterm premature rupture of membranes. Symptoms and their severity depend on the extent of abruption and include abdominal and/or back pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. In severe cases, emergency cesarean birth is indicated (Option 1). Tachysystole (ie, excessive uterine contractions), with or without fetal distress, is often present, and continuous fetal monitoring is necessary (Option 2). A blood specimen should be obtained for type and crossmatch because blood transfusion may be indicated (Option 5). Although blood loss is maternal, the loss of functional placental surface area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death. (Option 3) Maternal vital signs should be assessed frequently for signs of shock (eg, tachycardia, hypotension) because client condition can decline rapidly. In this scenario, assessment of vital signs every 4 hours is insufficient. (Option 4) Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated.
What play behavior would the nurse be most likely to observe in a group of 4-year-old children? 1.Children playing and borrowing blocks from each other without directing others 2.Children playing and working together to build a castle out of blocks 3.Children playing next to each other with blocks, but not interacting 4.Children playing with blocks by themselves in separate areas of the room
Play is an important developmental task of childhood and is an indication of physical, social, and emotional health. Preschoolers (age 3-6) enjoy associative play, in which they engage in similar activities or play with the same or similar items, but the play is unorganized without specific goals or rules. They often borrow items from each other without directing each other's play. Preschoolers also enjoy play involving motor activities and imaginative, pretend play. (Option 2) Cooperative play is common in school-age children (age 6-12). These children play with one another with a specific goal (eg, building a castle from blocks), often within a rigid set of rules. Cooperative play is likely too advanced for preschool-age children, as it involves more organizational skills. (Option 3) Parallel play is more common in toddlers (age 1-3). During parallel play, these children play next to each other and are happy to be in the presence of peers, but they do not play directly with one another. (Option 4) Solitary play is common in infants (birth to 1 year). Children at this stage are focused on their own activity and will play alone in the presence of others.
Live attenuated vaccines
Polio oral measles mumps rubella rotavirus yellow fever varicella - zoster
Port wine stain
Port-wine stain or nevus flammeus is seen at birth and is composed of a plexus of newly formed capillaries in the papillary layer of the corium • Commonly found on the face and neck • Red to purple, varies in size, shape and location • Does not blanch on pressure
Pregnant patient complains of severe back pain? What nursing interventions?
Position-push Position knee to chest Push counter pressure on sarcum
A client with acute respiratory distress syndrome is receiving positive pressure mechanical ventilation with 15 cm H2O (11 mm Hg) positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP? 1.Barotrauma 2.Decreased oxygen saturation 3.Hypertension 4.Oxygen toxicity
Positive end-expiratory pressure (PEEP) applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema. (Option 2) PEEP opens up collapsed alveoli and improves gas exchange at a lower fraction of inspired oxygen (FiO2), resulting in increased, not decreased, oxygen saturation. (Option 3) Hemodynamic effects of PEEP include increased intrathoracic pressure, which leads to reduced venous return, decreased preload and cardiac output, and hypotension, not hypertension. (Option 4) Keeping the alveoli open between breaths with PEEP improves gas exchange across the alveolar-capillary membrane, reduces hypoxemia, and allows for the use of a lower FiO2, which can reduce the risk for oxygen toxicity.
The nurse has just received report. Which client should the nurse assess first? 1.Client admitted from coronary angiography in the past hour with back pain 2.Client with a deep vein thrombosis (DVT) on heparin drip at 1250 units/hr with an activated partial thromboplastin time (aPTT) of 60 seconds 3.Client with a head injury and a Glasgow Coma Scale of 14 4.Postoperative day 2 coronary artery bypass graft client with incisional pain rated 6 on pain scale
Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. (Option 2) A heparin infusion is used for a client with DVT. An aPTT of 60 indicates a therapeutic value. The therapeutic range for a client on anticoagulation is usually 46-70 seconds (1½ -2 times the normal value). (Option 3) This client should be evaluated hourly for any change in neurological status. However, because the highest possible score on the Glasgow Coma Scale is 15 for a fully alert person, a client with a score of 14 is not in need of urgent reassessment. (Option 4) The report of incisional pain on postoperative day 2 would take second priority for further assessment, but evaluating a client with possible internal bleeding takes priority.
The client is diagnosed with acute primary angle-closure glaucoma. The nurse anticipates a prescription of ophthalmic drops to
timolol lower intraocular pressure
The nurse is assessing a client who delivered a full-term newborn vaginally 12 hours ago after prolonged labor. Which of the following findings would be essential to follow up? Click the exhibit button for additional information. 1.Discomfort during fundal massage 2.Foul-smelling lochia 3.Temperature of 100 F (37.8 C) 4.WBC count of 17,000/mm3 (17 × 109/L)
Postpartum endometritis is an infection of the endometrium (uterine lining) that often begins at the placental site, where pathogenic bacteria from the genital tract ascend and infect the endometrium; the infection may extend into the uterine smooth muscle or myometrium (endomyometritis). It is characterized by fever >100.4 F (38 C), chills, pelvic pain, uterine tenderness, and foul-smelling or purulent lochia. Prolonged labor is a risk factor for postpartum endometritis. Lochia is normally described as having a fleshy or musty smell. Foul-smelling lochia is likely indicative of infection and should be reported to the health care provider immediately
The nurse is caring for a client born at 42 weeks gestation. Which of the following potential clinical findings should the nurse anticipate for a postterm newborn? Select all that apply. 1.Deep plantar creases 2.Dry, cracked, peeling skin 3.Lanugo on the extremities 4.Long fingernails and scalp hair 5.Minimal or absent vernix
Postterm (ie, postmature) newborns have a longer-than-average gestation and are born at ≥42 weeks. Pregnancies that extend into the postterm period have increased risk of complications for the fetus/newborn (eg, postmaturity [ie, dysmaturity] syndrome, meconium aspiration syndrome, macrosomia) as the placenta begins to decompensate, resulting in placental insufficiency and fetal hypoxia. Newborn characteristics associated with postterm gestation include: Deep plantar creases over the entire sole of the foot (Option 1) Dry, cracked, and peeling skin, especially on the hands and feet (Option 2) Abundant scalp hair and long fingernails (Option 4) Minimal to absent vernix caseosa (ie, protective, white, waxy substance on the skin) (Option 5) Signs of meconium passage in utero (eg, meconium-stained [yellowish-green] skin or nails) (Option 3) Lanugo is a fine, downy hair that covers the fetus early in gestation and begins to disappear around 32 weeks gestation; it is normally not present in a term or postterm newborn.
Exercise and its relationship with glucose and insulin
Potentiates HYPOGLYCEMIA need to lower the insulin dosage BEFORE exericse IN ADDITION have rapid metabolized carbs before exercise
Which client is at the greatest risk for development of hospital-acquired pressure injuries? 1.25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm3 (18.0 x 109/L) (46%) 2.50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg (26%) 3.80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) (23%) 4.87-year-old client 2 days post open cholecystectomy (3%)
Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells.
Which client is at the greatest risk for development of hospital-acquired pressure injuries? 1.25-year-old client with quadriplegia, urosepsis, temperature of 101 F (38.3 C), and white blood cell count of 18,000/mm3 (18.0 x 109/L) 2.50-year-old client with AIDS who is receiving norepinephrine infusion and has a weight loss of 20 lb (9.1 kg) in a month, prealbumin level <10 mg/dL (100 mg/L), and mean arterial pressure of 50 mm Hg 3.80-year-old client 2 days post hip replacement with dementia, 2 Jackson-Pratt drains, and hemoglobin level of 14 g/dL (140 g/L) 4.87-year-old client 2 days post open cholecystectomy
Pressure injuries are areas of localized skin injury and underlying tissue caused by external pressure with or without friction and/or shearing. These result from ischemia and hypoxia of tissue following periods of prolonged pressure. Clients at greatest risk include older adults with limited movement and long bone (femur) or hip fractures, those with quadriplegia, and the critically ill. Clients with deficits in mobility and activity, incontinence, inadequate nutrition, chronic illness, renal failure, anemia, problems with oxygenation, edema, or infection are also at increased risk. This client (Option 2) has 5 risk factors: chronic illness and immune deficiency disease; significant weight loss; prealbumin <16 mg/dL (<160 mg/L), indicating inadequate nutrition and protein deficiency; hypotension (decreases perfusion pressure); and receiving norepinephrine (Levophed), a vasoconstrictor. These risks affect circulation, capillary perfusion pressure, and the ability to provide adequate nutrition to the cells. (Option 1) This client has 4 risk factors: a deficit in independent mobility and activity, spinal cord injury with quadriplegia, decreased sensation, and fever and infection. (Option 3) This client has 3 risk factors: advanced age, surgery, and dementia. Hemoglobin is within the normal range. (Option 4) This client has 2 risk factors: advanced age and surgery. Surgery can be associated with deep-tissue injuries. Positioning and immobility during the surgical procedures (>2½ hours) and receiving anesthetic and vasoactive drugs (to treat hypotension) present a special risk for the development of deep-tissue injury in postoperative clients.
Based on the nursing assessment progress notes, what is the correct staging of the client's pressure injury? Click on the exhibit button for additional information. Shallow, open area with clean, dark pink wound bed about 1 cm in diameter noted on coccyx. Surrounding area is slightly hard and warm to touch with erythema. Foam dressing clean, dry, and intact. No drainage noted. Enterostomal consult made.________________, RN 1.Stage 1 2.Stage 2 3.Stage 3 4.Stage 4
Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most appropriate and effective wound treatments. Stage 1: Intact skin with nonblanchable redness Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis; the wound bed is red or pink and may be shiny or dry Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon, muscle, or bone; tunneling may be present Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or eschar (scabbing, dead tissue) may be present; undermining and tunneling may be present Pressure injuries are described as "unstageable" if the base is covered by necrotic tissue or eschar
A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply. 1.Administering IM betamethasone 2.Administering penicillin via IV piggyback 3.Assisting with artificial rupture of membranes 4.Initiating IV magnesium sulfate 5.Obtaining fetal heart tones once per shift
Preterm labor (PTL) is defined as progressive cervical dilation and/or effacement resulting from uterine contractions before term gestation. The nurse should anticipate the following interventions for clients in PTL before 34 weeks gestation: Administering IM antenatal glucocorticoids (eg, betamethasone, dexamethasone) to stimulate fetal lung maturation and promote surfactant development (Option 1) Administering antibiotics (eg, penicillin) to prevent group B Streptococcus infection in the newborn if preterm birth occurs (Option 2) Initiating an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation (Option 4) Giving tocolytic medications (eg, nifedipine, indomethacin) to suppress uterine activity, which allows antenatal glucocorticoids time to have a therapeutic effect Monitoring pertinent laboratory results, including cultures for vaginal or urinary tract infection and group B Streptococcus, if obtained
The nurse is assessing a client who has primary adrenal insufficiency (Addison disease). Which of the following findings is consistent with the condition? 1.Bronze pigmentation of the skin 2.Increased body and facial hair 3.Purple or red striae on the abdomen 4.Supraclavicular fat pad
Primary adrenal insufficiency (Addison disease) is also described as hypofunction of the adrenal cortex. The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids. Bronze hyperpigmentation of the skin in sun-exposed areas is caused by an increase in adrenocorticotropic hormone by the pituitary gland in response to low cortisol (ie, glucocorticoid) levels (Option 1). Clients with Addison disease may also have vitiligo, or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin (or brown pigment), resulting in a patchy appearance. Other common manifestations of Addison disease include: Slow, progressive onset of weakness and fatigue Anorexia and weight loss Hyponatremia and hyperkalemia Nausea and vomiting (Options 2, 3, and 4) Hirsutism (increased facial and body hair), purple or red striae on the abdomen, and a supraclavicular fat pad are characteristics of Cushing syndrome, a condition associated with excess corticosteroid production. In contrast, Addison disease is a condition associated with hyposecretion of glucocorticoid
The nurse is assessing a client with primary adrenal insufficiency (ie, Addison disease). Which of the following findings would be consistent with the condition? Select all that apply. 1.Acanthosis nigricans 2.Hirsutism 3.Hyperpigmented skin 4.Truncal obesity 5.Weight loss
Primary adrenal insufficiency (ie, Addison disease) occurs when the adrenal glands do not produce adequate amounts of steroid hormones (eg, mineralocorticoids, glucocorticoids, androgens). Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (eg, skin folds, buccal area, palmar crease) (Options 3 and 5). Hyperpigmented skin is a characteristic universal finding that results from increased adrenocorticotropic hormone due to a decrease in cortisol negative feedback. Treatment of Addison disease consists of replacement therapy with oral mineralocorticoids and corticosteroids. (Option 1) Acanthosis nigricans, a skin condition that occurs with obesity and diabetes mellitus, appears as velvet-like patches of darkened, thick skin. These areas typically manifest around the back of the neck and in the groin and armpits. (Option 2) Hirsutism consists of male-pattern hair growth on a female's face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing syndrome. Loss of libido and decreased axillary and pubic hair are common in Addison disease due to lower levels of androgens. (Option 4) Clients with Cushing syndrome, an overproduction of steroid hormones, have truncal obesity, or large deposits of abdominal fat.
The nurse reinforces teaching for a client newly diagnosed with primary open-angle glaucoma. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1."After a few months of using the eye drops, my vision will be near normal." 2."I need to keep all follow-up appointments with my health care provider." 3."I will check with my health care provider before using allergy or cold medications." 4."I will need to use prescribed eye drops for the rest of my life." 5."If I see colored halos around lights, I should notify my health care provider."
Primary open-angle glaucoma is a chronic condition in which aqueous humor does not drain properly, leading to elevated intraocular pressure (IOP) that causes optic nerve damage and progressive peripheral vision loss (eventually "tunnel vision"). Treatment focuses on minimizing vision loss and monitoring the IOP (eg, several times per year). Client teaching includes: ----Keeping all appointments with the health care provider (HCP) for continual monitoring of IOP (Option 2) ----Consulting the HCP before taking over-the-counter medications with anticholinergic properties (eg, allergy, cough, or cold medications) to avoid increasing the IOP (Option 3) ----Taking prescribed eye drops (eg, prostaglandin analogs, beta-adrenergic blockers, alpha-adrenergic agonists, cholinergic agonists, carbonic anhydrase inhibitors) for life and on time (eg, every 12 hours) to control IOP (Option 4) ----Reporting sudden eye pain, halos around lights, and abrupt onset of blurry vision because these may indicate acute angle-closure glaucoma, a medical emergency that requires immediate surgical intervention (Option 5)
haldol (haloperidol)
typical antipsychotic Anticholinergic (bladder/eyes) Blurred vision Consitpation Drowsy E EPS (Parkinson's tremor) F photosensitive G agranulocytosis Neuroleptic Malignant Syndrome!!! fatal fever with temp > 104
The nurse is teaching the parents of a newborn about newborn safety. What information should the nurse include? 1."Dress your baby in a coat during cold weather before securing the car seat harness." 2."Dress your baby in a wearable blanket, such as a sleep sack, for sleep." 3."Place your baby in the prone position in the crib for sleep." 4."Place your baby's car seat facing forward in the back seat of your car."
Principles of newborn safety should be reinforced during postpartum discharge teaching. Safe sleep practices to help prevent sudden infant death syndrome (SIDS) include: Dressing newborns in no more than one additional layer of clothing than an adult requires. A wearable blanket (ie, sleep sack) can provide warmth and prevents the head from becoming covered (Option 2). Ensuring that no loose bedding or other objects are in the crib (eg, blankets, stuffed toys, pillows). Principles of proper car seat safety include: Securing the car seat harness to fit snuggly against the newborn's body, with the retaining clip secured near the level of the armpits. Positioning the newborn at a 45-degree angle to prevent airway obstruction. Rolled blankets/car seat inserts on both sides or under the crotch strap may be used to prevent slouching.
Assessed patient in labor and see cord protruding from vagina ? What is this? What nursing interventions?
Prolapsed cord Push: head off of cord Position: knee to chest OFF cord Prep for C section THINK PUSH-POSITION - Push head off cord - position knee to chest - prep C section - oxygen nonrebreather 8-10 liters - variable decelerations
Omperazole (Prilosec)
Proton Pump Inhibitors (PPI) Clients who experience diarrhea while taking omeprazole or other proton pump inhibitors (PPIs) should report this finding to the provider immediately. Omeprazole and other PPIs are associated with a dose-related increase in the risk of infection with Clostridium difficile, which is a bacterium that can cause severe diarrhea.
gold standard therapy for eating disorders
Psychotherapy is the gold standard treatment for a client with an eating disorder. While therapeutic approaches may differ, the most common psychotherapeutic approach is cognitive-behavioral therapy (CBT). CBT is helpful because it examines the client's distorted thoughts to remedy the harmful behavior. Changing the client's negative thoughts regarding food and their self-image is essential in the management of most eating disorders.
Important considerations for administration of ophthalmic drops include:
Pulling the lower eyelid down by gently pressing on the lower orbital bone to expose the conjunctival sac (Option 1) Applying pressure over the inner corner of the eye (eg, lacrimal duct) to avoid systemic absorption (Option 2) Waiting at least 5 minutes before instilling a different medication into the same eye to allow absorption of the first medication and to avoid overflow with multiple drops (Option 4) Holding the dropper ½-¾ in (1-2 cm) above the conjunctival sac to prevent infection and contamination of the dropper (Option 5)
The following nursing actions are appropriate for maximizing fetal oxygenation during pushing efforts:
Pushing while lying down in a lateral position: Lateral positioning helps to relieve pressure on the maternal inferior vena cava and optimizes uteroplacental blood flow (Option 1). Using an open-glottis pushing technique (ie, slow exhalation during pushing): Open-glottis pushing promotes maternal cardiac output and uteroplacental perfusion, unlike closed-glottis pushing (eg, pushing while holding breath, using the Valsalva maneuver) (Option 2). Pushing with every other contraction to allow more time between maternal pushing efforts: This can increase uteroplacental blood flow and fetal oxygenation (Option 3). (Option 4) Ensuring each pushing effort lasts at least 10 seconds may reduce fetal oxygenation during the second stage of labor. Shorter pushes lasting 6-8 seconds promote fetal oxygenation. (Option 5) Administering IV meperidine (ie, an opioid) for pain relief is not appropriate because it can cause newborn respiratory depression if the birth occurs within 1-4 hours.
TCA overdose
QT prolongation Cardiovascular effects - tachycardia, orthostatic hypotension, and QT prolongation. Central nervous system effects - sedation and, in an overdose, may lead to altered mental status or seizures. Anticholinergic effects - hyperthermia, hypoactive bowel sounds, pupillary dilation, facial flushing, urinary retention, and dry skin and mucous membranes. Decrease in anticholinergic vagal stimulation further contributes to tachycardia.
19 week gestation woman who has not felt any fetal movement
QUICKENING can begin any where from 18-20 weeks gestation
Insulin steps
R before N air up NPH (intermittent insulin) air Rapid (lispro) draw up dose rapid draw up dose intermittent
Radioactive iodine (RAI) is the primary treatment for nonpregnant adults with hyperthyroidism
RAI destroys the thyroid gland, which prevents thyroid hormone secretion. Following RAI therapy, the client will emit radiation through bodily fluids (eg, saliva, urine). The length of time varies depending on the dose received. Appropriate home precautions to reduce radiation exposure to others include: Avoiding sharing utensils Washing clothes separately Sleeping in a separate bedroom Delaying pregnancy attempts for 4-6 months Using a separate bathroom and flushing at least 3 times with every use The client is the most radioactive during the first week following RAI. During that time, the client should limit contact with others, especially pregnant women and children, to minimize radiation exposure. It is not appropriate to hold a child 2 hours after receiving RAI.
Sodium Polstyrene Sulfonate (Kayexalate)
REMOVES K in bowel
nurse stealing pills (illegally) what action?
REPORT tell supervisor
Most common fetal lie
ROA LOA
Most common presentation is
ROA or LOA—that's the guess—don't bother memorizing • ROA (right occiput anterior) • LOA (left occiput anterior) • Pick ROA before LOA
The graduate nurse (GN) is providing education to a 30-year-old female client who is being evaluated for hyperthyroidism with a radioactive iodine uptake (RAIU) test. Which statement by the GN requires the nurse preceptor to intervene? 1."A pregnancy test must be obtained prior to RAIU test administration." 2."After the test, you will need to remain away from family for 48 hours." 3."All jewelry around the neck should be removed before the RAIU test." 4."You should be sure to drink plenty of fluids after the RAIU test."
Radioactive iodine uptake (RAIU) test involves administering a low dose of oral RAI to measure via imaging the amount of iodine that the client's thyroid absorbs. The thyroid gland is the only body tissue that absorbs iodine; therefore, measuring iodine absorption helps diagnose hyperfunctioning thyroid disorders (eg, Graves disease, nodular thyroid disease). For hyperthyroidism, RAIU is increased compared to RAIU in a normal functioning thyroid, which indicates a positive test. Only a trace amount of RAI is used in the test; therefore, isolation after the scan is unnecessary (Option 2). In contrast, RAI treatment for thyroid cancer uses a high dose and does require some isolation. (Option 1) RAI exposure can cause congenital defects, so all female clients of childbearing potential should take a pregnancy test before the test. (Option 3) The client should remove objects (eg, jewelry, metal) around the neck to allow clear visualization during the scan. (Option 4) The client should drink plenty of fluids after the test to clear the radioactive iodine from the system.
The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?
The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess for the presence or absence of an air leak and to determine whether it originates from the client or the chest tube system. (Option 1) Section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is present.
erythema toxicum neonatorum
Red papular rash on babys torso which is benign and disappears after a few days. NORMAL NOT ALARMING
Lie (pregnancy)
Relationship between the spine of the Mom and spine of the baby • You want a vertical lie—compatible with vaginal birth o If the mother's spine and the baby's spine is parallel—we got a baby • If lie is perpendicular—tranverse lie = Trouble ... C-section o If we got them perpendicular, we've got trouble—T
station
Relationship of the presenting fetal part to an imaginary line drawn between the pelvic ischial spines.
The nurse reviews discharge teaching about residual limb care for a client who had a lower limb amputation. Which of the following instructions should the nurse include? Select all that apply. 1.Assess the residual limb daily for redness or irritation 2.Keep limb socks and elastic wraps clean and dry 3.Lie on your stomach three times a day for 30 minutes 4.Massage the residual limb with lotion each day 5.Wash the residual limb daily with soap and water
Residual limb care following an above-knee amputation (AKA) or a below-knee amputation (BKA) is an important component of rehabilitation and focuses on maintaining skin integrity, controlling pain, preventing infection, and restoring mobility. It is also important for the nurse to consider that the client may experience grief due to disturbed body image. The nurse should include the following residual limb care instructions when discharging a client after an AKA or BKA: Clean the limb by washing it daily with soap and warm water. Thoroughly dry after washing to prevent skin maceration (Option 5). Thoroughly inspect the limb for signs of infection (eg, redness) and areas that may be at risk for infection (eg, irritation, skin breakdown) (Option 1). Keep limb socks, wraps, and appliances/prostheses clean and dry (Option 2). Perform daily range-of-motion exercises to improve muscle strength and mobility. Hip flexion contractures are a common complication during the recovery process. Nurses should teach clients to lie prone several times each day and to avoid sitting in a chair for ≥1 hour (Option 3).
The nurse is teaching a client who had coronary angioplasty with stent placement following a myocardial infarction. The client is scheduled to participate in outpatient cardiac rehabilitation and asks the nurse about resuming sexual activity. Which statement would be appropriate for the nurse to make? 1.it is generally considered safe to resume sexual activity when you can climb two flights of stairs without symptoms." 2."It may take up to three months before your heart muscle is fully healed and you can safely resume sexual activity." 3."You may resume sexual activity after you have completed your outpatient cardiac rehabilitation program." 4."You may resume sexual activity as soon as you and your partner feel emotionally ready."
Resumption of sexual activity after myocardial infarction (MI) can be a source of concern and embarrassment for clients, making it difficult for clients and health care providers (HCPs) to discuss. The nurse should provide information and encourage clients to discuss any concerns with their HCP. In general, when a client can engage in moderate-intensity physical activity (eg, walking one block, climbing two flights of stairs) without symptoms (eg, angina, dyspnea), the client can safely resume sexual activity (Option 1).
A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1.ECG 2.IV morphine 2 mg 3.Normal saline bolus 4.Urine sample
Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability. The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body. Common signs of rhabdomyolysis are dark, oftentimes bloody urine, oliguria, and fatigue. (Option 1) With muscle injury, intracellular potassium is released into the circulation, potentially causing dangerous arrythmias. Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium levels decrease rapidly. In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the injured muscles. Therefore, aggressive fluid resucitation is a high priority. The general rule is that treatment/prevention of an underlying expected problem is a priority over testing to identify the problem.
Which statement made by the client indicates correct understanding of the teaching? 1."I can never get tuberculosis again once I finish treatment." 2."I should take the medications with antacids." 3."I will notify my health care provider if my urine becomes orange." 4."I will use additional contraception while taking rifampin."
Rifampin is often used in the management of both latent and active tuberculosis (TB) but reduces the effectiveness of oral contraceptive pills. Therefore, the client should be instructed to use additional methods of contraception during treatment and for 1 month following the completion of treatment (Option 4). (Option 1) Clients exposed to tuberculosis after treatment can develop reinfection. There is no lifelong immunity. In addition, reactivation of infection can occur if clients do not complete the prescribed medication regimen. (Option 2) Antacids typically reduce the absorption of other medications, including antitubercular medications. If needed for gastrointestinal discomfort, antacids should be taken 1 hour before or 2 hours after antitubercular medications are administered. (Option 3) Orange urine is an expected finding in clients taking rifampin. In addition to urine, clients also may experience red-orange tears, sweat, and saliva. Clients should also know that this medication may permanently stain contact lenses.
A nurse is administering a rituximab infusion to a client with lymphoma in an oncology clinic. Which client symptom would be a priority to report to the health care provider? 1.Dizziness and sudden diarrhea 2.Nausea and onset of vomiting 3.New-onset tachypnea and dyspnea 4.Temperature of 101 F (38.3 C)
Rituximab (Rituxan) is a monoclonal antibody (end in -mab) that affects the lymphocytes. It is commonly prescribed to treat certain forms of cancer (eg, lymphoma) and autoimmune diseases (eg, lupus). Like many monoclonal antibodies, rituximab can produce a powerful immune response (eg, bronchospasm, dyspnea, tachypnea, hypotension, angioedema) (Option 3). The nurse should closely monitor the client during and after the infusion. If life-threatening symptoms develop, the nurse should stop the infusion and immediately notify the health care provider. The symptoms will be treated (eg, corticosteroids) and, when resolved, the infusion is usually restarted at a slower rate. (Options 1, 2, and 4) In many clients, monoclonal antibody therapies, like many oncology pharmaceuticals, invoke flu-like responses (eg, fever, chills, diarrhea, nausea, vomiting). Clients are often pretreated with acetaminophen and diphenhydramine in anticipation of these reactions. Clients' symptoms are treated as needed (eg, antiemetics, antidiarrheals).
Rota virus
Rotavirus is a contagious infection that is easily spread via the fecal-oral route by touching contaminated objects (eg, toys, diapers), food, and hands; therefore, handwashing is essential to prevent spreading the virus. Parents should be taught the symptoms of dehydration because children with rotavirus are at risk for dehydration.
The nurse has provided instructions about home care management to the parents of a child diagnosed with rotavirus infection. Which of the following statements by the parents indicate that the teaching has been effective? Select all that apply. 1."Handwashing is extremely important in preventing the spread of rotavirus." 2."I will observe my child for decreased urination and dry mucous membranes." 3."I will resume breastfeeding as soon as my child's diarrhea subsides." 4."I will use commercial baby wipes containing alcohol during diaper changing." 5."My child can spread the infection via contaminated toys, food, and hands."
Rotavirus is a contagious virus and the leading cause of diarrhea in children age <5; it is also the cause of many nosocomial infections each year. Rotavirus is spread via the fecal-oral route. Because the virus is stable in the environment, transmission to a human host can occur via contact with objects (eg, toys, diapers), food, and hands. Meticulous handwashing and proper diaper disposal prevent spreading the virus (Options 1 and 5). Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting. Vaccination is available and must be given before the child is age 8 months. Because the virus can easily lead to dehydration, parents should be taught the symptoms of dehydration (eg, lack of tears, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration (Option 2). (Option 3) Breastfeeding and a normal diet should be maintained, not stopped, when the child is sick. (Option 4) Parents should change the child's diapers more frequently and wash the perianal area with mild soap and water. Commercial baby wipes containing alcohol can irritate the skin and should not be used.
Droplet precautions Spiderman
S-SEPSIS-SCARLET FEVER-STREPTOCCAL PHARGITIS P-PARAVIRUS-PNEUNOMIA-PERTUSISS I-INFLUENZA D-DIPTHERIA (PHARYNGEAL) E-EPIGLOTISIS RUBELLA Rhinovirus M-MUMPS-MENINGITISIS (bacterial)-MYCOPLASM OR MENGIEAL PNEUMONIA A-ADENO VIRUS **PRIVATE ROOM OR COHOR OR MASK
Selective Serotonin Reuptake Inhibitors (SSRIs)
S/E: ABCDE A: anticholinergic B: blurred vision C: constipation D: drowsiness E: euphoric CAUSES insomnia: NEED to give early in day not after noon What for suicidal risks in adolescents
Serotonin syndrome
SAD HEAD -sweating -apprehension -dizziness -Headache
small bowel obstruction vs ileus
SBO - prior surgery - distention increased bowel sounds - dilation of small bowel Ileus - recent surgery hours to days - metabolic (hypokalemia) - medication indused - reduced absent bowel sounds - abdominal pain - vomiting - distention
Goodwell's sign
SECOND softening of the cervix that occurs at the beginning of pregnancy -a probable sign of pregnancy
ACE inhibitors quick facts
SERIOUS concern angioedema also dry cough Raise potassium levels
Lower urine output Higher urine osmolality Higher urine-specific gravity (concentrated urine) Low serum osmolality Low serum sodium (hyponatremia)
SIADH
stage 1 pressure ulcer
SKIN intact nonblanching erythema
Citalopram
SSRI
Prozac (fluoxetine)
SSRI antidepressant Anticholinergic Blurred vision Constipation Drowsiness insomnia Before noon take watch for increase risk in suicide
Sertaline (Zoloft)
SSRI antidepressant insomnia INTERACTS WITH ST JOHNS WORT Warfarin = increased risk of bleeding
Zoloft (sertraline)
SSRI watch suicide ideation insomnia apprehensive sweating dizzy headache NO ST JOHNS WORT NO WARFARIN
Before implementing LION what should the nurse do?
STOP IV infusion of Pitocin or oxytocin
Continuous bubbling in?
SUCTION CONTROL is okay WATER seal = PROBLEM AIR LEAK
Valsalva maneuver
SVT contra - glaucoma - recent MI - closed head injury - portal HTN due to cirrhosis
The clinic nurse assesses an 8-year-old client who reports a sore throat and has a bright red, pruritic rash on the chest that feels like fine bumps and looks like a sunburn. Which diagnostic tool does the nurse anticipate the health care provider will prescribe? 1.Allergy skin testing 2.Complete blood count 3.Rapid streptococcal antigen test 4.Skin biopsy
Scarlet fever (ie, scarlatina), a complication of group A streptococcal infection (eg, streptococcal pharyngitis), is common in early childhood and is characterized by a distinctive red rash. The rash begins on the neck and chest and spreads to the extremities, resembles a bad sunburn, blanches with pressure, and has fine bumps like sandpaper. Additional manifestations of streptococcal pharyngitis (eg, exudative pharyngitis, fever, swollen anterior cervical lymph nodes) are typically present. Because the clinical presentation (ie, rash plus sore throat) is characteristic, but not diagnostic, of scarlet fever, the health care provider will prescribe a rapid streptococcal antigen test to confirm symptom etiology (Option 3). Swabbing the posterior pharynx and tonsils provides test results within minutes. Throat culture may be necessary to verify results.
The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside?
Scissors must be kept at the bedside of any client with a Sengstaken-Blakemore tube. The nurse should check for this essential item at the beginning of the shift to ensure the safety of the client. A Sengstaken-Blakemore tube has esophageal and gastric balloons. If the gastric balloon ruptures or moves substantially, the entire tube might migrate proximally, resulting in airway obstruction. This is an emergency, and the nurse must act immediately to deflate the balloons. Scissors are always kept at the bedside to cut across all the tube lumens and rapidly deflate the balloons. Following this, the tube can be extracted.
A behavioral health clinic nurse assesses a 23-year-old client who started taking paroxetine 3 weeks ago. Which statement made by the client is most important for the nurse to investigate? 1."I don't have much of an appetite since starting this medication." 2."I have a lot more energy, but I'm feeling just as depressed." 3."I have been feeling dizzy when I walk around at home." 4."I have experienced frequent headaches lately."
Selective serotonin reuptake inhibitors (SSRIs) (eg, fluoxetine, paroxetine, sertraline, citalopram) are used to treat a number of psychiatric conditions (eg, major depressive disorder, generalized anxiety disorder). Clients usually see therapeutic effects in 1-4 weeks. SSRIs may increase the risk of suicide, especially in young adults (age 18-24) during initial therapy or after a dosage increase. A client who reports increased energy without a change in depressive feelings needs to be assessed and monitored for suicidal ideation or actions as the client may now have the energy to execute the suicide plan (Option 2). Common, expected side effects of SSRIs include: Loss of appetite; weight loss or weight gain (Option 1) Gastrointestinal disturbances (nausea, vomiting, diarrhea) Headaches, dizziness, drowsiness, insomnia (Options 3 and 4) Sexual dysfunction
serotonin syndrome neuroleptic malignant syndrome extrapyramidal syndrome
Serotonin = SAD HEAD - sweating - apprehensive - dizziness - headache ST Johns wort neuroleptic - happens with antipsychotic medications - halidol risperdone etc - DIFFUSE muscle rigidity EPS - no FEVER
The client has new-onset tremors, extreme restlessness, nausea, and anxiety. The client recently had a back injury and was prescribed tramadol. The client also takes sertraline for major depression. On examination, the client is flushed and diaphoretic. The client's voice is tremulous. Mild rigidity and tremors are noted in the lower extremities. Deep tendon reflexes are 3+. Pupillary dilation and ocular clonus are present. T 100.9 F (38.3 C) P 125 RR 20 BP 160/100 SpO2 99% on room air TSH 0.3-5 μU/mL(0.3-5 mU/L) 2 μU/mL(2 mU/L) WBC 5,000-10,000/mm3(5.0-10.0 × 109/L) 7,800/mm3(7.8 × 109/L)
Serotonin syndrome (ie, serotonin toxicity) is a life-threatening condition caused by excess serotonin in the central nervous system. Tramadol is an analgesic medication with serotonergic activity that can lead to serotonin syndrome when taken with a selective serotonin reuptake inhibitor (eg, sertraline). Clinical manifestations include mental status changes (eg, anxiety, restlessness, agitation), autonomic dysregulation (eg, diaphoresis, tachycardia, hypertension, hyperthermia), and neuromuscular hyperactivity. Treatment involves discontinuing all serotonergic agents (eg, sertraline, tramadol) and administering a benzodiazepine to improve agitation and decrease muscle contraction (eg, clonus), which reduces temperature. (Incorrect) Although seizures are a severe complication of serotonin syndrome, antiseizure medications (eg, phenytoin) are not indicated in a client who is not seizing. (Incorrect) In clients with serotonin syndrome, hyperthermia is caused by sustained muscle contraction, not infection. Therefore, monitoring WBC count is not indicated. (Incorrect) Panic attacks are brief episodes characterized by sudden, intense anxiety that may occur in response to a stressor. Symptoms include feelings of impending doom, tachycardia, shortness of breath, trembling hands, and diaphoresis. Severe hypertension, hyperthermia, brisk reflexes, and clonus are not characteristic.
A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN), are being administered to a client with sepsis and respiratory failure. Which is the best response by the registered nurse? 1."Enteral feedings have no complications." 2."Enteral feedings maintain gut integrity and help prevent stress ulcers." 3."Enteral feedings provide higher calorie content." 4."Risk of hyperglycemia is lower with enteral feedings than with TPN."
Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes.
A client with advanced kidney disease has serum potassium of 7.1 mEq/L (7.1 mmol/L) and creatinine of 4.5 mg/dL (398 µmol/L). What is the priority prescribed intervention? 1.Administer IV 50% dextrose and regular insulin 2.Administer IV furosemide 3.Administer oral sodium polystyrene sulfonate 4.Prepare the client for hemodialysis catheter placement
Severe hyperkalemia (potassium >7.0 mEq/L [7.0 mmol/L]) requires urgent treatment because cardiac muscle cannot tolerate very high potassium levels. Severe hyperkalemia increases the risk for life-threatening ventricular dysrhythmias (eg, ventricular tachycardia and fibrillation, asystole). IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the extracellular fluid back into the intracellular fluid. The dextrose prevents hypoglycemia associated with the increase of insulin in the body and can be eliminated if the client has hyperglycemia (Option 1). If the client has ECG changes (eg, tall peaked T waves), calcium gluconate should be given before insulin/dextrose. This will stabilize the cardiac muscle until the potassium level can be reduced with insulin/dextrose. (Option 2) Furosemide (Lasix) increases the renal excretion of potassium and is usually prescribed for clients with fluid overload. However, administration of furosemide would take time to be effective and is not the priority. (Option 3) Sodium polystyrene sulfonate (Kayexalate) is administered by mouth or enema to remove potassium from the body by exchanging sodium for potassium ions in the intestines; these are then excreted in feces. This is not the priority due to the delayed onset of potassium removal. (Option 4) Hemodialysis is an invasive procedure that can be initiated if more conservative, noninvasive therapies are ineffective in reducing the potassium level. Placement of the catheter will delay treatment.
A clinic nurse examines a client with a tentative diagnosis of primary Sjögren's syndrome. Which finding observed by the nurse would most likely be associated with this syndrome? 1.Dry eyes and mouth 2.Low back stiffness 3.Multiple tender points 4.Thickening of the skin
Sjögren's syndrome is an 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). Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help (Option 1). (Option 2) Early-morning low back stiffness is seen with ankylosing spondylitis. (Option 3) Multiple tender points are characteristic of fibromyalgia. (Option 4) Thickening of the skin is seen with scleroderma.
Breast feeding the newborn
Sore nipples and painful breastfeeding are common reasons clients discontinue breastfeeding. Teaching proper technique helps clients continue breastfeeding, promotes comfort for the mother, and ensures adequate newborn nutrition. Key principles of proper breastfeeding and latch technique include: Breastfeed every 2-3 hours on average (8-12 times/day) Breastfeed "on demand" whenever the newborn exhibits hunger cues (eg, sucking, rooting reflex) Position the newborn "tummy to tummy" with mouth in front of nipple and head in alignment with body Ensure a proper latch (ie, grasps both nipple and part of areola) Feed for at least 15-20 minutes per breast or until the newborn appears satisfied Insert a clean finger beside the newborn's gums to break suction before unlatching (Option 3) Alternate which breast is offered first at each feeding
A client diagnosed with septic shock has an upward-trending glucose level (180-225 mg/dL [10.0-12.5 mmol/L]) requiring control with insulin. The client's spouse asks why insulin is needed as the client is not a diabetic. What is the most appropriate response by the nurse? 1."It is common for critically ill clients to develop type II diabetes. We give insulin to keep the glucose level under control (<140 mg/dL [7.8 mmol/L])." 2."The client was diabetic before, but you just didn't know it. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])." 3."The increase in glucose is a normal response to stress by the body. We give insulin to keep the level at 140-180 mg/dL (7.8-10.0 mmol/L)." 4."This increase is common in critically ill clients and affects their ability to fight off infection. We give insulin to keep the glucose level in the normal range (70-110 mg/dL [3.9-6.1 mmol/L])."
Stress-induced hyperglycemia (gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection. Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill. Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission. Hyperglycemia is associated with increased risk of complications (eg, health care-associated infection, increased length of stay, acute kidney injury). To minimize complications and avoid hypoglycemia, the recommended glucose target range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL [7.8 mmol/L] fasting and <180 mg/dL [10.0 mmol/L] random blood glucose are recommended.
The nurse is at a community swimming event and rescues a child who is submerged in the water. The child is unconscious, and emergency services are activated. Next, the nurse should immediately
Submersion injuries (eg, drowning) can cause life-threatening organ damage to multiple body systems. After initial holding of the breath, air hunger eventually causes reflex inspiration and aspiration. Even if a client is submerged for a brief period, any amount of aspirated liquid can be life-threatening. Immediate resuscitation of clients with submersion injuries prioritizes ventilation. The nurse should first administer rescue breaths (eg, mouth to mouth) to promote oxygen delivery to tissues. The nurse should witness the rise and fall of the chest with the administration of rescue breaths. The most feared complication of drowning is delayed development of acute respiratory distress syndrome, so clients are often observed if they are asymptomatic. (Incorrect) If the client does not respond to two rescue breaths (eg, chest does not rise and fall, client remains unconscious) and does not have a pulse, the nurse should initiate high-quality chest compressions and apply pads for an automated external defibrillator. The nurse should defibrillate the client (ie, pass an electric shock through the heart) as indicated to restore an organized heart rhythm.
Symptoms of hypoglycemia
Sweating & pallor Irritability Tremors & weakness Tachycardia Drowsiness Hunger Clients experiencing hypoglycemia may develop shakiness, palpitations, sweating, pallor, and altered mental status. If manifestations of hypoglycemia are present, the nurse should check the client's capillary blood glucose (BG) level immediately. A BG level of <70 mg/dL (3.9 mmol/L) requires treatment; however, if glucose testing is not readily available, the client should be treated based on symptoms. Management of hypoglycemia for a conscious client includes administration of 15 g of a quick-acting carbohydrate (Option 3). After treatment, the nurse should recheck the client's BG level every 15 minutes, repeating treatment if it remains low. Quick-acting carbohydrate options include: 4 oz (120 mL) of a regular soft drink or fruit juice 8 oz (240 mL) of low-fat milk 1 tablespoon (15 mL) of honey or syrup Commercial dextrose products
Cephalohematoma
Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines. occurs on one or both sides of head occasionally forms over occipital bone develops within first 24-48 hours
Necrotizing enterocolitis
typically occurs in preterm newborns after the introduction of cow's milk and is characterized by inflammation of the bowel, resulting in ischemia and necrosis.
A full bladder is help when doing an
ultrasound of the uterus
The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? 1.Abdominal pain rated as 8 out of 10 2.History of pelvic inflammatory disease 3.Intermittent nausea and vomiting for the past 7 days 4.Right shoulder pain and dizziness
Symptoms of ectopic pregnancy may include lower abdominal and pelvic pain; amenorrhea, possibly followed by vaginal spotting or bleeding; and a palpable adnexal mass on pelvic examination. An ectopic pregnancy may implant in one of many locations outside the uterine cavity, including the fallopian tubes, ovaries, or abdominal cavity. As the ectopic pregnancy outgrows its environment, it may rupture, causing life-threatening maternal hemorrhage. Symptoms indicative of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain (Option 4). Shoulder pain results from irritation of the diaphragm by intraabdominal blood. A ruptured ectopic pregnancy is a surgical emergency and requires immediate intervention.
The nurse is caring for assigned clients. The nurse should recognize that the client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone? 1.Carpal tunnel syndrome 2.Diabetes mellitus 3.Sciatica 4.Small cell lung cancer
Syndrome of inappropriate antidiuretic hormone (SIADH) is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (serum sodium <136 mEq/L [136 mmol/L]). Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH (Option 4). Other causes of SIADH include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some medications (eg, desmopressin, carbamazepine). Treatment of SIADH focuses on reducing fluid volume, correcting hyponatremia, and preventing complications (eg, seizures). (Options 1 and 3) Carpal tunnel syndrome is a result of aggravated tendons in the wrists causing narrow, pinched nerves. Sciatica is numbness, tingling, or pain caused by irritation of the sciatic nerve. Both are examples of peripheral nerve disorders. SIADH can occur in clients with central nerve disorders (eg, stroke, neurosurgery). (Option 2) Diabetes mellitus is an endocrine disorder characterized by hyperglycemia and is not commonly associated with SIADH.
The graduate nurse (GN) is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precepting nurse, which statement by the GN indicates an appropriate understanding? 1."Doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy." 2."The client will require penicillin desensitization to receive appropriate treatment." 3."The newborn can be treated after birth if antepartum treatment is contraindicated." 4."Treatment is only effective if provided during the primary stage of syphilis."
Syphilis in pregnancy Screening Universal at first prenatal visit Third trimester & delivery (if high risk) Serologic tests Nontreponemal (RPR, VDRL) Treponemal (FTA-ABS) Treatment Intramuscular penicillin G benzathine Pregnancy effects Intrauterine fetal demise Preterm labor Fetal effects Hepatic (hepatomegaly, jaundice) Hematologic (hemolytic anemia, ↓ platelets) Musculoskeletal (long bone abnormalities) Failure to thrive Syphilis is a sexually transmitted infection that crosses the placenta and may have teratogenic effects on fetal development. All pregnant clients are screened for syphilis at the initial prenatal visit, and high-risk clients are screened again during the third trimester and labor. Maternal manifestations of syphilis may vary depending on the time of diagnosis. The only adequate prenatal treatment is IM penicillin injection (ie, benzathine penicillin G). Expected outcomes include resolution of maternal infection and prevention or treatment of fetal infection. If a pregnant client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that adequate treatment can be provided (Option 2). (Option 1) Doxycycline, a tetracycline antibiotic, is a potential treatment alternative for nonpregnant clients with syphilis but is contraindicated in pregnancy because it can impair fetal bone mineralization and discolor permanent teeth.
Syphilis
Syphilis is a sexually transmitted bacterial infection. Initially, clients develop painless genital sores (ie, chancres) that resolve spontaneously (primary syphilis). Without treatment, clients can develop systemic symptoms (eg, fever, malaise, sore throat, headache), widespread lymphadenopathy, and a diffuse maculopapular rash that begins on the trunk, extends to the extremities, and involves the palms and soles (secondary syphilis). Syphilis is a sexually transmitted bacterial infection caused by Treponema pallidum. Although syphilis is highly treatable, it can be difficult to recognize, leading to delayed treatment and progression of the disease. Syphilis is categorized into 4 stages based on clinical manifestations. Untreated primary syphilis leads to secondary syphilis infection, which typically occurs a few weeks after the painless genital ulcer (ie, chancre) heals. Secondary syphilis is characterized by systemic symptoms (eg, fever, malaise, sore throat), widespread lymphadenopathy, gray genital papules (ie, condylomata lata), and a diffuse maculopapular rash that begins on the trunk and extends to the extremities, followed by the palms and soles. Secondary syphilis is highly contagious. If left untreated, secondary syphilis can lead to latent syphilis, which is asymptomatic and can be lifelong. Interventions that are indicated for clients with syphilis include: --Performing a pregnancy test because Treponema pallidum readily crosses the placenta and is associated with many adverse fetal outcomes, including intrauterine growth restriction, fetal death, and congenital infection. --Penicillin is the only adequate prenatal treatment for syphilis. If a pregnant client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that treatment can be provided. --Assessing for a penicillin allergy because the most effective treatment for syphilis is an IM penicillin injection. Alternate antibiotics (eg, ceftriaxone, doxycycline) are available for nonpregnant clients with a penicillin allergy. --Notifying the public health department to identify and treat other exposed individuals.
Anticipated interventions for clients with an acute asthma exacerbation include:
Systemic corticosteroids (eg, prednisone) to reduce underlying inflammation and mucus production (Option 1). These medications are crucial to prevent immediate relapse. Nebulized beta-2 agonists (eg, albuterol [salbutamol]) to produce bronchodilation and anticholinergics (eg, ipratropium bromide) to prevent bronchoconstriction and reduce mucus production. These medications are often administered together to achieve a synergistic effect (Option 2). High-flow oxygen to improve hypoxia. Humidification can be added to prevent the nasal passage and airway from drying out when high levels of oxygen flow are required (Option 4). Continuous pulse oximetry to allow close monitoring of the client's oxygenation status and become immediately aware if the client's condition worsens. Oxygen saturation levels are also used to evaluate the effectiveness of treatment
TRouBLe congenital heart defects
T - All begin with letter T R- right to left blood shunting o u B- blue skin/cyanotic L - life expectancy is shorter e - exercise intolerance/apnea Trunkus arteriosus Transpositions of great vessels Tetrology of Fallot Tricuspic stenosis left ventricular hyperplasmic syndrome
TORCH infections
T - toxoplasmosis O - other (syphilis) R - rubella C - cytomegalovirus H - herpes
pre interaction phase correct answer purpose to prevent judgemental intolerant reactions length: when you learn you will be giving care to someone to when you meet them
THE NURSE WILL EXPORE HIS/HER FEELINGS ABOUT
Hegar's sign
THIRD softening and compressibility of lower uterus
pt has tumor lysis syndrome and is perscribed spironolactone normal saline sevelamer alopurinol what do you question?
TLS may result in the following life-threatening conditions: Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias SPIRONOLACTONE IS NOT GOOD
calcemias do the opposite of the prefix? true or false?
TRUE
The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? 1.12 hours 2.24 hours 3.36 hours 4.72 hours
TST (Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: Injection of purified protein derivative solution under the first layer of skin of the forearm Evaluation of the injection site 48-72 hours later The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB.
Ferrous sulfate can be taken with ___ to enhance absorption
Taking an iron supplement with vitamin C (eg, orange juice) further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption
Tamulosin
Tamsulosin is an alpha-1 antagonist medication indicated in the treatment of benign prostatic hypertrophy. This medication causes vasodilation, and the biggest side effect is orthostatic hypotension. The nurse should educate the client to change positions slowly while taking this medication to reduce the risk of orthostasis. ✓ Tamsulosin is an alpha-1 antagonist which induces vasodilation. ✓ Tamsulosin enables smooth muscle to relax, therefore improving urine flow and decreasing the symptoms of BPH. ✓ Orthostatic hypotension is the most common effect associated with this medication. ✓ This medication may contribute to a client falling because of the orthostasis.
tracheal deviation
Tension pneumothorax - need chest tube
Cyanotic congenital heart defects
Tetralogy of Fallot Transposition of the Great Vessels
The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed? 1."I will always check my blood glucose prior to using the sliding scale." 2."I will eat breakfast 30 minutes after taking my morning NPH and regular insulin." 3."I will use a new insulin syringe each time I give myself an injection." 4."I will use the sliding scale to determine my NPH dose 4 times a day."
The Institute for Safe Medication Practices has labeled insulin a high-alert medication. These types of medication can be safe and effective when administered or taken according to recommendations. However, errors in administration may cause death or serious illness. NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glulisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime.
The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? Select all that apply. 1.No sexual activity for at least 6 weeks postoperatively 2.Notify health care provider (HCP) of redness, swelling, or drainage at the incision site 3.Refrain from lifting objects weighing >5 lb (2.26 kg) until approved by the HCP 4.Take a shower daily without soaking chest and leg incisions 5.Use lotion on incision sites with dressing changes if the area is dry
The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. Clarify no driving for 4-6 weeks or until the HCP approves. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). Notify the HCP if the following symptoms occur:Chest pain or shortness of breath that does not subside with restFever >101 F (38.3 C)Redness, drainage, or swelling at the incision sites (Option 2).
A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1.Nasal cannula 2.Non-rebreathing mask 3.Oxymizer 4.Venturi mask
The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD. (Option 1) The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen concentration is not guaranteed. (Option 2) The non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client in this situation. (Option 3) An oxymizer is a nasal reservoir cannula-type device that conserves on oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen (eg, 3 L/min nasal cannula is equivalent to 1 L/min oxymizer device) to reach the same saturation. It is not the best choice in an unstable COPD client with varying TVs as the inspired oxygen concentration is not guaranteed.
Expected findings for older adults
The age-related cardiovascular and renal function changes that can occur in the elderly, such as a mild increase in the size and thickness of the heart, prolonged filling time, and declined glomerular filtration rate, may put the client at risk for rapid development of hypervolemia. Use of an infusion pump is recommended, even in clients with dementia, as they are at increased risk for fluid imbalance Older adults with fragile veins are at increased risk for IV infiltration; therefore, the site should be monitored carefully by the nurse every 1-2 hours. Fragile skin may tear easily; use nonporous tape, skin protectant solutions, and minimal tourniquet pressure. Because hearing and visual impairments may pose a problem for client education, the nurse should speak clearly and face the client when speaking. Use the smallest gauge catheter (24-26 gauge) indicated for the client's therapy as veins are more fragile. Consider vein sites to promote client independence (non-dominant arm, avoiding back of the hand). Use a 5-15-degree angle on insertion as veins of the elderly are usually more superficial (Option 5).
The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1.Room 1 - Client with diabetes mellitus and chronic kidney disease who is on hemodialysis and has a serum glucose level of 265 mg/dL (14.7 mmol/L) 2.Room 2 - Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 (0.2 x 109/L) 3.Room 3 - Client with cellulitis of the leg due to a spider bite who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) 4.Room 4 - Client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 (85 x 109/L)
The best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3 [150-400 x 109/L]) as this does not place the immediate post-operative client at increased risk for infection. (Options 1, 2, and 3) The clients in these rooms place the postoperative client at increased risk for infection: Room 1: A client with diabetes mellitus and advanced chronic kidney disease may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia. In addition, hemodialysis increases the risk for infection due to invasive lines and catheters. Room 2: A low CD4+ cell count (<500/mm3 [0.5 x 109/L], normal is 500-1,200/mm3 [0.5-1.2 x 109/L]) in a client with chronic HIV infection indicates disease progression. It can also indicate progression of asymptomatic early infections to more advanced symptomatic infections. Room 3: The client with cellulitis and an increased white blood cell count (>11,000/mm3 [11.0 x 109/L]) has an infection.
The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? 1.Room 1 - Client with diabetes mellitus and chronic kidney disease who is on hemodialysis and has a serum glucose level of 265 mg/dL (14.7 mmol/L) 2.Room 2 - Client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 (0.2 x 109/L) 3.Room 3 - Client with cellulitis of the leg due to a spider bite who has a white blood cell count of 13,000/mm3 (13.0 x 109/L) 4.Room 4 - Client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3 (85 x 109/L) (35%)
The best option is room 4 with the client who has severe epistaxis and decreased platelet count (normal 150,000-400,000/mm3 [150-400 x 109/L]) as this does not place the immediate post-operative client at increased risk for infection. (Options 1, 2, and 3) The clients in these rooms place the postoperative client at increased risk for infection: Room 1: A client with diabetes mellitus and advanced chronic kidney disease may have infectious complications due to increased susceptibility to infection resulting from an altered immune response and decreased leukocyte function due to hyperglycemia. In addition, hemodialysis increases the risk for infection due to invasive lines and catheters. Room 2: A low CD4+ cell count (<500/mm3 [0.5 x 109/L], normal is 500-1,200/mm3 [0.5-1.2 x 109/L]) in a client with chronic HIV infection indicates disease progression. It can also indicate progression of asymptomatic early infections to more advanced symptomatic infections. Room 3: The client with cellulitis and an increased white blood cell count (>11,000/mm3 [11.0 x 109/L]) has an infection.
The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first? 1.2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear 2.4-year-old post adenotonsillectomy who is now reporting ear pain (53%) 3.6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics 4.7-year-old 5 days post tonsillectomy who wants to return to soccer practice today
The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery. During the healing process, white scabs will form at the surgical sites. Sloughing then occurs approximately 7 days after the procedure, increasing the risk for bleeding. Caregivers should be taught to observe for signs of bleeding (eg, frequent swallowing or throat clearing). The child may also experience increased pain. The nurse should instruct this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery. (Option 1) Tympanostomy tubes or grommets are pressure-equalizing tubes placed in the tympanic membrane to facilitate drainage of middle ear fluid (eg, for eustachian tube dysfunction or recurrent otitis media with effusion). One of this child's tubes has most likely fallen out of the eardrum. No immediate intervention is required; however, the health care provider should be notified. (Option 2) Clients often report ear pain (otalgia) following adenotonsillectomy due to irritation of the 9th cranial nerve (glossopharyngeal) in the throat, causing referred pain to the ears. This is a normal, expected finding. (Option 3) The contagious period for strep throat starts at the onset of symptoms and lasts through the first 24 hours of beginning antibiotic treatment. This client is able to return to activities and does not require an immediate call back.
The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client? 1.2-point gait 2.3-point gait 3.4-point gait 4.5-point gait
The client who is rehabilitating from an injury of the lower extremity usually progresses from no touch down, non-weight bearing status, using the 3-point gait (Option 2) to touch down with partial weight bearing status, using the 2 point-gait (Option 1), to full weight bearing status, using the 4-point gait. The nurse teaches the client how to use the most advanced gait, the 4-point crutch gait. It requires weight bearing on both legs and is the most stable as there are 3 points of support on the ground at all times (eg, 2 crutches and 1 foot; 2 feet and 1 crutch). It is the easiest to use as it resembles normal walking: advance right crutch, then left foot, and advance left crutch, then right foot. (Option 3) (Option 4) There are 5 crutch gaits: 2-point, 3-point, 4-point, swing-to, and swing-through. There is no 5-point crutch gait. Educational objective:The 4-point crutch gait is appropriate for a client with leg weakness, who can bear partial or full weight with both legs. It is the easiest gait to use as it resembles normal walking and provides the most stability with 3 points of support on the ground at all times.
Addison's disease
under secretion of adrenal cortex hyperpigmented darker - doesn't respond well to stress NEED steroids - medical alert bracelet addisons = add a son hyperkalemia
Which client is most appropriate for the charge nurse in the postpartum unit to assign to the float nurse from the intensive care unit? 1.Client experiencing fever and pain with mastitis 2.Client preparing for discharge after cesarean birth 3.Client showing disinterest in caring for the newborn 4.Client with hysterectomy after postpartum hemorrhage
The client with blood loss leading to a hysterectomy would require close observation of hemodynamic status. Signs could be subtle, and the nurse floating from the intensive care unit would have the assessment skills needed to recognize any changes. (Option 1) Mastitis is a very painful infection. A postpartum nurse would be most familiar with the comfort measures associated with mastitis. (Option 2) A client preparing for discharge after cesarean birth would require an experienced postpartum nurse as discharge instructions would involve teaching related to both the newborn and the client. (Option 3) Psychosocial adjustment after giving birth can be complex. An experienced postpartum nurse would be trained to assess for signs of adjustment issues.
The nurse is assisting a client who has a bedside needle liver biopsy scheduled. Which are the essential actions? Select all that apply. 1.Assess for rising pulse and respirations afterward 2.Check PT/INR and PTT values before the procedure 3.Ensure that the client's blood is typed and cross matched 4.Have the client void to ensure an empty bladder 5.Position the client flat or on the left side after the procedure
The client's coagulation status is checked before the liver biopsy using PT/INR and PTT. The liver ordinarily produces many coagulation factors and is a highly vascular organ. Therefore, bleeding risk should be assessed and corrected prior to the biopsy (Option 2). Blood should be typed and crossmatched in case hemorrhage occurs (Option 3).After the procedure, frequent vital sign monitoring is indicated as the early signs of hemorrhage are rising pulse and respirations, with hypotension occurring later (Option 1). (Option 4) The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. (Option 5) The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.
Streptococcus pyogenes impetigo
The client's erythematous rash with honey-colored crusting on and around the nose and mouth is consistent with a diagnosis of impetigo. Impetigo is caused by either Streptococcal pyogenes or Staphylococcal aureus bacteria. Preferred treatment for localized infection is topical antibiotics (eg, mupirocin); however, for severe or systemic manifestations, oral antibiotics (eg, cephalexin) may be indicated. Adherence to antibiotic therapy is important to prevent transmission and avoid complications (eg, poststreptococcal glomerulonephritis, rheumatic fever). Teaching about impetigo should focus on treating the infection and preventing transmission. Important teaching includes: Avoid sharing linens or personal items that could spread the infection. All linens, towels, and clothes should be washed and dried on high heat (Option 2). Contact precautions and home isolation are recommended. Keep the client's fingernails short to control scratching. Bacteria can accumulate under longer nails, be transferred to, and infect other areas of the body and/or other individuals. In addition, itching should be controlled to prevent a secondary infection (Option 4). Soak the lesions and then remove crusts with antiseptic soap and water. A clean washcloth should be used to wash the affected lesions each time to avoid transferring bacteria back to the skin. Prescribed antibiotic ointment should be applied after crusts are removed to improve the absorption. A cotton applicator should be used, and hands must be washed before and after the application (Option 5).
The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse? 1."Bring the child to the health care provider's (HCP) office immediately." 2."Give your child something warm to drink." 3."Massage the child's feet gently until they warm up." 4."Place the child's feet in warm water immediately."
The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths (Option 4). Once re-warming has been effective, the child should be seen by an HCP as soon as possible (Option 1).
15 chest compressions and 2 ventilations.
The cycle of chest compressions and ventilations in two-rescuer CPR for an infant is... Additional Info ✓ For an infant, deliver repeated cycles of 5 back blows (slaps) followed by 5 chest compressions until the object is expelled or the victim becomes unresponsive ✓ Abdominal thrusts are not recommended for infants because they may damage the infant's relatively large and unprotected liver ✓ If the victim becomes unresponsive, start CPR with chest compressions (do not perform a pulse check) ✓ After 30 chest compressions, open the airway. If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects farther into the pharynx and may damage the oropharynx ✓ Attempt to give 2 breaths and continue with cycles of chest compressions and ventilations until the object is expelled ✓ After 2 minutes, if no one has already done so, activate the emergency response system.
Cataracts
uniformly blurred image
ear drops when >4
up and back
A client is brought to the emergency department after sustaining third-degree burns over 50% of the body. Which solution is the best choice for fluid resuscitation in this client? 1.0.45% normal saline 2.5% dextrose in 0.9% normal saline (D5NS) 3.5% dextrose in water (D5W) 4.Lactated Ringer's solution
The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes. Lactated Ringer's (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma (Option 4). LR remains in the intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock. (Option 1) Hypotonic solutions (eg, 0.45% normal saline) quickly leave the intravascular space and are not useful in replacing intravascular volume. They may also contribute to peripheral and interstitial edema, which can lead to pulmonary complications. (Option 2) Hypertonic solutions (eg, 5% dextrose in 0.9% normal saline [D5NS], 3% saline) can cause further electrolyte imbalances in a client with severe burns, resulting in hypernatremia, hyperchloremia, and arrhythmias. (Option 3) Although technically an isotonic solution, 5% dextrose in water (D5W) behaves as a hypotonic solution when dextrose is metabolized by the body and free water is released to the tissues rather than remaining in the intravascular space.
Kava supplement melatonin usage and Clonazepam
The herbal supplements kava and valerian root—both used for anxiety, insomnia, and depression—may increase central nervous system (CNS) depression when used with benzodiazepines (eg, clonazepam). Kava should not be combined with benzodiazepines because this increases the risk of hepatotoxicity. (Option 2) Melatonin is a hormone supplement used at bedtime to promote sleep and may increase drowsiness and CNS depression when taken with clonazepam. Combining melatonin with benzodiazepine medications can exaggerate side effects of the benzodiazepine (eg, dizziness, impaired concentration, daytime sleepiness).
The nurse is admitting a client with cholelithiasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority? 1.Administer promethazine 25 mg suppository 2.Infuse normal saline 100 mL/hour 3.Insert nasogastric tube to low suction 4.Maintain nothing-by-mouth (NPO) status
The highest priority intervention for an actively vomiting client with cholelithiasis is maintenance of strict NPO status to avoid additional gallbladder stimulation. Additional collaborative interventions (see table) for cholecystitis should also be taken into account. (Option 1) Promethazine 25 mg suppository is the second priority. Promethazine promotes the relief of nausea and vomiting and minimizes further fluid loss. (Option 2) Obtaining fluid and electrolyte replacement with sodium chloride 100 mL/hr is the third priority and assists in the maintenance of fluid balance. (Option 3) Insertion of a nasogastric (NG) tube to low suction is the fourth priority. NG suction provides gastric decompression, alleviates nausea and vomiting, and promotes bowel rest. Educational objective:The highest priority intervention for an actively vomiting client with acute cholecystitis is maintenance of strict NPO status to avoid additional stimulation of the gallbladder. Additional priorities include management of nausea and vomiting, pain, fluid balance, and gastric decompression.
The nurse in the emergency department is admitting a client who sustained a submersion injury and has moderate hypothermia. Which of the following interventions should the nurse anticipate for this client? Select all that apply. 1.Administration of warmed blood products 2.Administration of warmed IV fluids 3.Application of warm blankets 4.Frequent repositioning from side to side 5.Intubation and mechanical ventilation
The initial management of a client with a submersion injury focuses on airway management due to potential aspiration (leading to acute respiratory distress syndrome), pulmonary edema, or bronchospasm (leading to airway obstruction). Hypoxia is managed and prevented by ensuring a patent airway via intubation and mechanical ventilation as necessary (Option 5). Management of hypothermia includes rewarming methods. Passive, active external, and active internal rewarming methods exist. Passive rewarming methods include removing the client's wet clothing, providing dry clothing, and applying warm blankets (Option 2). Active external rewarming involves using heating devices or a warm-water immersion. Active internal rewarming is used for moderate to severe hypothermia and involves administering warmed IV fluids and warm humidified oxygen (Option 3). (Option 1) Unless blood loss has occurred from trauma during the incident, the administration of blood products is not indicated. (Option 4) Careful handling of the client with hypothermia is important because as the core temperature decreases, the cold myocardium becomes extremely irritable. Frequent repositioning could cause spontaneous ventricular fibrillation and should not be performed during the acute stage of hypothermia. Continuous cardiac monitoring should be initiated.
The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess? 1.28-year-old with infective endocarditis and heart rate of 105/min 2.45-year-old with acute pancreatitis and sinus tachycardia of 120/min 3.65-year-old with tachycardia of 110/min after liver biopsy 4.74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min
The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage. The 65-year-old client should be assessed first. (Option 1) Tachycardia can be caused by underlying infection and can resolve with treatment of the infection. Valve infections can require several weeks of antibiotics. This client is not the priority. (Option 2) Pancreatitis is a very painful condition and sinus tachycardia is expected. These clients are also at risk of developing complications such as third spacing of volume and require large quantities of IV fluids. This client is the second priority. (Option 4) Atrial fibrillation is commonly treated with calcium channel blockers such as diltiazem. The dosage needs to be adjusted to achieve a goal heart rate of <100/min. Atrial fibrillation is usually not immediately life-threatening.
It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1.Administer pain medication 2.Call the health care provider to meet with the family to obtain informed consent 3.Complete the preoperative checklist 4.Perform the morning assessment
The morning shift assessment should be completed first to collect baseline assessment data (eg, vital signs, lung sounds, level of consciousness), assess pain, and collect necessary information for the preoperative checklist. (Option 1) Pain medicine is not due until 0730 and can be administered after the initial assessment if necessary. (Option 2) The nurse should call the health care provider after the initial assessment (by 0730) and arrange for a meeting with family members at 0900 to obtain informed consent as the client is not capable of giving it. (Option 3) The preoperative checklist can be completed after consent is obtained.
The nurse cares for a client with type 1 diabetes mellitus. Which laboratory result is most important to report to the primary health care provider? 1.Fasting blood glucose 99 mg/dL (5.5 mmol/L) 2.Serum creatinine 2.0 mg/dL (177 µmol/L) 3.Serum potassium 3.9 mEq/L (3.9 mmol/L) 4.Serum sodium 140 mEq/L (140 mmol/L)
The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L). It provides an estimation of the glomerular filtration rate and is an indicator of kidney function. A level of 2 mg/dL (177 µmol/L) is clearly abnormal. The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney. Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy.
The nurse receives report on 4 assigned clients. Which client should the nurse assess first? 1.Client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain 2.Client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheotomy dressing 3.Client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg 4.Client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site
The nurse should first assess the client showing symptoms of a deep venous thrombosis (DVT) (eg, unilateral edema, warmth, redness, tenderness on palpation). DVT is a postoperative complication related to venous stasis and subsequent thrombosis. If a DVT is suspected, early diagnostic testing (eg, venous ultrasound) and treatment with anticoagulant therapy (eg, heparin, enoxaparin) are critical to prevent clots from traveling to the pulmonary circulation and causing pulmonary embolism. (Option 1) The client is experiencing a common post laparoscopic cholecystectomy problem of referred pain to the right shoulder. Carbon dioxide, used to inflate the abdominal cavity during surgery, causes irritation to the phrenic nerve and diaphragm, which may cause difficulty breathing. Interventions for alleviation include the Sims position, deep breathing, ambulation, and analgesics. (Option 2) A small amount of pink serosanguineous drainage at the new tracheostomy site is expected postoperatively. The nurse should notify the health care provider if bleeding becomes excessive. (Option 4) Conditions that increase the likelihood of surgical site infection include obesity, immunosuppression, malnutrition, diabetes, and advanced age. The nurse should notify the health care provider of signs and symptoms of infection (eg, fever, purulent drainage), but the client with a DVT is priority due to the risk of pulmonary embolism.
A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? 1 .0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours 2.IV bolus of 1000 mL 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy 3.IV bolus of 1000 mL 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dL (36.1 mmol/L) 4.IV mannitol 25% solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure
The nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. (Option 2) Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. (Option 3) Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. (Option 4) A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature.
A parent calls the after-hours triage nurse about a 3-year-old who is sick with the flu. Which report by the parent would necessitate intervention by the nurse? 1.Acetaminophen being given every 4 hours for fever 2.Bismuth subsalicylate being used for nausea 3.Ibuprofen being given every 6 hours for body aches 4.Popsicles and gelatin desserts being used for hydration
The nurse should tell the parent to discontinue the use of bismuth subsalicylate (Pepto-Bismol) as it contains a salicylate (same class as aspirin) and could possibly cause Reye syndrome. Reye syndrome can develop in children with a recent viral illness such as varicella or influenza. It can cause acute encephalopathy and hepatic dysfunction. Children with viral infections should not be given aspirin or products containing salicylates.
Buspirone is a non-controlled medication indicated in the treatment of anxiety. This medication does not cause dependence or withdrawal symptoms. Essential patient teaching points include -
The onset time may be delayed up to two weeks to four weeks. This medication should be taken consistently with or without food. The medication is not a benzodiazepine and should not be taken during acute anxiety. Instead, this medication helps attenuate the response to triggers of anxiety. Sexual dysfunction is unlikely with this medication.
The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client? 1.Ask the client to place the backs of the hands against each other to provide hyperflexion of the wrist while the elbows remain flexed 2.Instruct the client to lie down and run the heel of one foot down the shin of the other leg 3.Perform the Romberg test by asking the client to stand with the eyes closed and the feet together 4.Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
The parathyroid glands are responsible for the production of parathyroid hormone (PTH), which acts to increase serum calcium levels through the breakdown of bone tissue (ie, bone resorption). With the surgical removal of one or more of the parathyroid glands (ie, parathyroidectomy), PTH levels can decrease significantly. A significant reduction in PTH levels will decrease serum calcium levels and can cause hypocalcemia (ie, serum calcium <9.0 mg/dL [2.25 mmol/L]). Trousseau sign may indicate hypocalcemia before other manifestations of hypocalcemia (eg, tetany, laryngeal stridor) occur. For clients with suspected hypocalcemia, Trousseau sign can be elicited by temporarily occluding the brachial artery, which will induce muscle spasms of the hand and forearm (ie, carpal spasm). The nurse may accomplish this by placing a blood pressure (BP) cuff on either arm, inflating to a pressure greater than systolic BP, and monitoring for carpal spasm (Option 4).
A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? 1.Document a description of the injury 2.Question the parent about where the infant sleeps 3.Report the injury per facility protocol 4.Separate the parent from the infant
The parent's account of this injury is inconsistent with the developmental milestones of a 3-month-old, because the muscles required for rolling over do not develop until age 6 months. Additionally, spiral femur fractures indicate that pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a nonambulatory child. Fractures in young children, especially nonambulatory, are always concerning and suspicious of child abuse. The nurse's priority is to report suspected child maltreatment to the appropriate authorities following facility protocol as required by law in the United States and Canada (Option 3). However, the nurse should also be aware of cultural health practices (eg, cupping, coining) and physiologic conditions (eg, hemophilia, congenital dermal melanocytosis) mimicking maltreatment. After reporting suspected maltreatment, the nurse should facilitate a complete physical evaluation (eg, skeletal survey, growth/development comparisons, radiographic studies, neurologic examination) (Option 1) The nurse should document facts and observations objectively. The history provided by the parent or caregiver and the time from injury occurrence to evaluation should be included. (Option 2) The nurse should perform a review of child-care practices with the caregiver but this is not the priority. (Option 4) A child and caregiver should be separated only when the child is in immediate physical danger or if authorities interview a verbal child without the parent present.
Managing acute asthma in the hospital
albuterol (SABA) ipratropium (anticholinergic bronchodilation) methylprednisolone (steroid inflammation)
The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling? 1.Air leak monitor 2.Collection chamber 3.Suction control chamber 4.Water seal chamber
The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle bubbling indicates that the suction level is appropriate. The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is drawn out through the vent of the suction control chamber. Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level. (Option 1) The air leak monitor (Section C) is part of the water seal chamber. Continuous or intermittent bubbling seen here indicates the presence of an air leak. (Option 2) The collection chamber (Section D) is where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record as output. (Option 4) The water seal chamber contains water, which prevents air from flowing into the client. Up and down movement of fluid (tidaling) in Section B would be seen with inspiration and expiration and indicates normal functioning of the system. This will gradually reduce in intensity as the lung reexpands.
The women's health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse? 1.Client reports heavy menstrual cycles 2.History of breast cancer in maternal aunt 3.History of deep venous thrombosis 4.Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m2
The transdermal contraceptive patch (ethinyl estradiol and norelgestromin) is a combined hormonal contraceptive (CHC) that is absorbed through the skin. The client applies a patch weekly for 3 weeks, then removes it for 1 hormone-free week. The patch has similar contraindications as other CHCs, and some research shows that the patch may have an increased risk of thromboembolism (compared with oral contraception) due to higher serum concentrations of estrogen. A history of deep venous thrombosis (DVT) is the most concerning finding because of the additional risk of thromboembolic events when using CHCs (Option 3). (Option 1) CHCs help regulate menstrual cycles, typically reducing the amount of bleeding during menses; therefore, heavy menses is not as concerning as the client's history of DVT. (Option 2) A personal history of breast cancer or the breast cancer susceptibility gene (BRCA) is concerning because contraceptives may stimulate hormone-dependent tumor growth. The nurse should report the family history to the health care provider, but it is not more concerning than a personal history of DVT or breast cancer. (Option 4) The patch may have a higher failure rate in obese clients who are approximately >200 lb (90.7 kg) and should be avoided. The nurse should counsel the client about diet and exercise, but this is not more important than the client's history of DVT.
What is the truest most valid sign that she is in labor?
The truest most valid sign of labor is the onset of regular/progressive contractions
stairs and crutched
up with the good - good leads down with the bad - bad leads
Trichomonas vaginalis.
Thin, malodorous vaginal discharge that is yellow/green is a classic presentation of this flagellated protozoan. This infection is commonly transmitted sexually. However, another unlikely source of transmission is fomites such as towels. This protozoan may be asymptomatic in males but commonly causes symptoms in females. Diagnosis of Trichomonas vaginalis is confirmed through wet-mount microscopy, where the trichomonads are often seen in locomotion. Syphilis and HIV infection should be ruled out for this client because of her reported sexual activity. Her symptoms are not suggestive of an acute HIV infection or syphilis. HIV and syphilis do not produce any vaginal discharge and cause a client to have constitutional symptoms such as fatigue, fever, and malaise. Syphilis may cause a chancre to develop at the site of inoculation. The client's VS show no fever, and the client denies any constitutional symptoms. Despite the lack of symptoms, this client should be tested for additional coinfections such as syphilis and HIV. However, her presentation is classically consistent with Trichomonas vaginalis. Additional Info ✓ Trichomonas vaginalis causes Trichomoniasis. ✓ Trichomonas vaginalis is a protozoan parasite primarily spread via sexual contact. ✓ This infection is only found in humans and may cause symptoms in females such as thin, malodorous vaginal discharge that is yellow/green. ✓ Other manifestations include pelvic pain and dyspareunia ✓ Males are commonly asymptomatic. However, they may have symptoms such as urethritis with purulent discharge. ✓ Treatment of this infection is a prescription of metronidazole which may be given in a single dose.
The nurse receives report on 4 clients. Which client should the nurse assess first? 1.Client with end-stage renal disease receiving hemodialysis who reports fever with chills and nausea 2.Client taking ibuprofen for ankylosing spondylitis who reports black-colored stools 3.Client with altered mental status who is not following commands starts vomiting 4.Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain
This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected. (Option 1) Clients receiving hemodialysis are at risk for bloodstream infections. Blood cultures need to be obtained from a client with a bloodstream infection, and antibiotics would then be administered. This is not a priority over airway compromise. (Option 2) Clients with ankylosing spondylitis often take nonsteroidal anti-inflammatory drugs to control back pain and are at risk of developing gastric ulcers. They can cause melena (black stools). The client needs further assessment of orthostatic vital signs and hemoglobin level. This is not a priority over airway compromise. (Option 4) Clients with acute diverticulitis (inflammation of the diverticula) are at risk for perforation, which can be manifested by increasing abdominal pain, rigidity, guarding, and rebound tenderness (peritoneal signs). This client needs further assessment, but this is not a priority over airway compromise.
active phase of labor.
This client's uterine contractions were every 2-3 minutes, lasting 40-60 seconds, consistent with the active phase of labor. The active phase is between the latent and the transition phase and is characterized by cervical dilation between 4 to 7 cm. The phases of the first stage include - latent, active, and transition. Uterine contractions are 30 to 60 seconds in duration and are of moderate intensity. Additional Info ✓ The first labor stage comprises three phases (latent, active, and transition). ✓ The first stage of labor starts with cervical dilation of 1 cm and ends with 10 cm (fully dilated). ✓ During the active phase, the client is quite talkative and is experiencing increased pain with the contractions. ✓ During the active phase, nursing care is implementing pain management strategies such as preparing the client for an epidural, ambulating the client to the bathroom, offering ice chips, and promoting nonpharmacological pain management options such as back rubs and frequent position changes.
Asthma attack immediate medications and long term medications
albuterol - salbutamol anticholinergics (tiotropium and ipratropium) MORE LONG TERM corticosteroids leukotriene modifiers
Radioactive iodine therapy
This therapy is used to destroy the hyperthyroid gland. Radioactive iodine (RAI) is the primary treatment for nonpregnant adults with hyperthyroidism who do not respond to antithyroid medication. RAI destroys the thyroid gland, which prevents thyroid hormone secretion. Following RAI therapy, the client will emit radiation through bodily fluids (eg, saliva, urine). The length of time varies depending on the dose received. Appropriate home precautions to reduce radiation exposure to others include: Avoiding sharing utensils Washing clothes separately Sleeping in a separate bedroom Delaying pregnancy attempts for 4-6 months Using a separate bathroom and flushing at least 3 times with every use
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial postprocedure monitoring plan should include what? Select all that apply. 1.Level of alertness 2.Lung sounds 3.Oxygen saturation 4.Respiratory pattern 5.Temperature 6.Urine output
Thoracentesis is commonly used to treat pleural effusion. The health care provider (HCP) will prepare the skin, inject a local anesthetic, and then insert a needle between the ribs into the pleural space where the fluid is located. A complication of thoracentesis is pneumothorax, which occurs when the needle goes into the lung and causes the lung to slowly deflate, like a balloon with a small hole in it. Bleeding is another, yet less common, complication of the procedure. Signs of pneumothorax include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed) (Options 2, 3, and 4). Tension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. Altered level of consciousness may occur due to decreased oxygenation and blood flow to the brain (Option 1). A tension pneumothorax may be prevented by early detection of pneumothorax through appropriate monitoring. (Option 5) Infection would be a later complication (occurring a few days after the procedure), so monitoring temperature is not required during the initial postprocedure period. (Option 6) Urine output should not be affected by thoracentesis or the drugs administered for this procedure.
Methimazole (Tapazole)
Thyroid hormone antagonist. Inhibits synthesis of thyroid hormone. Used for hyperthyroidism, preoperative thyroidectomy, thyrotoxic crisis, and thyroid storm.
A client with primary hypothyroidism has been taking levothyroxine for a year. Laboratory results today show high levels of TSH. Which statement by the nurse to the client is appropriate? 1."A new prescription will likely be issued for a decreased dose of levothyroxine." 2."Dosages of levothyroxine may need to be increased to improve TSH levels." 3."Levothyroxine should be held, and the TSH levels will be reassessed in 3 months." 4."Start taking your levothyroxine with dietary fiber or calcium to increase its effectiveness."
Thyroid-stimulating hormone (TSH) is released from the pituitary gland to stimulate the thyroid to secrete hormones (T3, T4). When sufficient thyroid hormone is circulating, negative feedback causes a normally functioning pituitary to slow or stop the release of TSH. In primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4, slowing the metabolic rate. In response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high TSH levels. Levothyroxine (Synthroid), a thyroid hormone replacement drug, is commonly used to treat hypothyroidism. Levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH levels are decreased (Option 2).
The clinic nurse is assessing the client's understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD). Which statement indicates that the client has a correct understanding of this medication? 1."A capsule holds the powdered medication that I have to put in a special inhaler." 2."I do not need to rinse my mouth with water after taking tiotropium." 3."I have been taking tiotropium every time I have difficulty breathing." 4."Tiotropium helps control my COPD by reducing inflammation in my airway."
Tiotropium (Spiriva) is a long-acting, 24-hour, anticholinergic, inhaled medication used to control chronic obstructive pulmonary disease (COPD). It is administered most commonly using a capsule-inhaler system called the HandiHaler. The powdered medication dose is contained in a capsule. The client places the capsule in the inhaler device and pushes a button on the side of the device, which pokes a hole in the capsule. As the client inhales, the powder is dispersed through the hole. Unlike most inhaled medications, tiotropium looks like an oral medication because it comes in a capsule. Therefore, it is important to teach the client proper administration prior to the first dose, emphasizing that the capsule should not be swallowed and that the button on the inhaler must be pushed to allow for medication dispersion. During future appointments, the nurse should assess/reassess the client's ability to use this medication correctly. (Option 2) Clients should rinse the mouth after using tiotropium and inhaled steroids (eg, beclomethasone, budesonide, fluticasone) to remove any medication remaining in the mouth, which decreases the risk of developing thrush. (Option 3) Tiotropium is a controller medication for COPD with a peak effect of approximately 1 week; therefore, it should not be used as a rescue medication. Instead, short-acting bronchodilators (eg, albuterol and/or ipratropium) should be used for symptom rescue. Clients must discontinue ipratropium before taking tiotropium as both are anticholinergic. (Option 4) Anticholinergic inhaled medications (eg, ipratropium, tiotropium, umeclidinium) do not reduce inflammation in the airway. Instead, they relax the airway by blocking parasympathetic bronchoconstriction. They also help dry up airway secretions.
A client having an ischemic stroke arrives at the emergency department. The health care provider prescribes tissue plasminogen activator (tPA). Which client statement would be most important to clarify before administering tPA? 1."I can't believe this is happening right after my stomach surgery." 2."I had a concussion after a car accident a year ago." 3."I started noticing my right arm becoming weak approximately an hour ago." 4."I stopped taking my warfarin 4 weeks ago."
Tissue plasminogen activator (tPA) dissolves clots and restores perfusion in clients with ischemic stroke. It must be administered within a 3- to 4½-hour window from onset of symptoms for full effectiveness. The nurse assesses for contraindications to tPA due to the risk of hemorrhage. The client should not have a history of intracranial hemorrhage or be actively bleeding. Surgery within the last 2 weeks is a contraindication as tPA dissolves all clots in the body and may disrupt the surgical site. This client indicates a recent stomach surgery, which would need further clarification to determine eligibility to receive tPA (Option 1). (Option 2) A client's history of stroke or head trauma in the last 3 months could exclude tPA use. (Option 3) The nurse should determine when the client first developed stroke symptoms. tPA can be administered if symptoms started within the last 3 to 4½ hours or based on facility guidelines. (Option 4) Current anticoagulant use may exclude a client from receiving tPA. The duration of action for warfarin is 2-5 days; this client can safely receive tPA as warfarin was discontinued 4 weeks ago. However, if pending coagulation studies drawn prior to tPA administration are elevated, the infusion may be discontinued.
The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. 1.Applying an air-occlusive dressing 2.Instructing the client to bear down 3.Instructing the client to lie in a supine position 4.Pulling the line harder if there is resistance 5.Pulling the line out when the client is inhaling
To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of air getting into the vessel (Option 3). Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure (Options 2 and 5). Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line (Option 1). Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel (Option 4).
Methylergonovine (Methergine)
To promote uterine involution, uterotonics (eg, PO methylergonovine) may be prescribed. Although uterine involution can promote drainage of purulent lochia, methylergonovine does not take priority over antibiotics, which are needed to treat the cause of infection.
Responding to a choking RESPONSIVE infant
To relieve choking in a responsive infant, the rescuer should: Hold the infant face down on the forearm with the infant's head slightly lower than the body. The rescuer's forearm is supported on the thigh to avoid compressing the infant's soft throat tissue and fontanelles. Forcefully perform 5 back slaps between the infant's shoulder blades with the heel of the hand. Using both forearms, turn the infant face up on the forearm with the head slightly lower than the body. Forcefully provide 5 chest thrusts in a downward motion over the lower half of the breastbone using 2-3 fingers (Option 2).
Complications of ulcerative colitis (UC) include:
Toxic megacolon (ie, severe inflammatory colonic distension and paralysis). Without prompt diagnosis (eg, imaging) and intervention, toxic megacolon can result in life-threatening bowel perforation and peritonitis. Colorectal cancer due to dysplastic lesions. Over time, chronic inflammation from UC can cause abnormal cellular activity resulting in malignancy. Regular colorectal screening with colonoscopy is recommended for clients with UC. Clostridioides difficile infection. Clients with UC have altered intestinal microbiome, which facilities the overgrowth of C difficile within the intestines. Clients are most susceptible to C difficile infection during an exacerbation of UC.
Accelerations in FHR
Transient increase in FHR (15x15) GOOD
probable/presumptive signs of pregnancy
all urine blood tests Chadwick's sign (color change cervix) Goodell's sign (cervical softening) Hegar's sign (uterine softening)
The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? Select all that apply. 1.Decreased serum sodium 2.Excess oral water intake 3.High urine output 4.Increased serum osmolality 5.Increased urine specific gravity
Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone). Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include: Decreased urine specific gravity (<1.003) (Option 5) Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg]) (Option 4) Hypernatremia (>145 mEq/L [145 mmol/L]) (Option 1) Hypovolemia and potential hypotension Polydipsia (Option 2) Polyuria (2-20 L/day) (Option 3)
The nurse is providing education to a client diagnosed with a trichomoniasis vaginal infection who has been prescribed a onetime dose of oral metronidazole. Which of the following statements by the nurse are appropriate? Select all that apply. 1."Abstain from sexual intercourse until the symptoms are cleared." 2."Avoid drinking alcohol for at least 3 days after taking the last dose." 3."Inform your sexual partners that they need to be treated." 4."Metronidazole may temporarily turn your urine a dark, brownish color." 5."Vaginal douching after intercourse may prevent recurrence of infection."
Trichomoniasis is a sexually transmitted infection caused by Trichomonas vaginalis. Infected clients may be asymptomatic but usually seek care when a profuse, frothy, yellow-green, malodorous vaginal discharge is noted. Pruritus, dysuria, and dyspareunia (ie, pain during sex) may also occur. Oral metronidazole (Flagyl) is the most common drug used to treat trichomoniasis. Client education includes: Abstain from sexual intercourse until the infection is cleared (ie, about 1 week after treatment) (Option 1). Avoid drinking alcohol while taking metronidazole and for 3 days after completion of therapy because the combination can cause flushing, nausea/vomiting, and severe abdominal pain (Option 2). Have partner(s) treated simultaneously to avoid reinfection. Use condoms to prevent the infection in the future (Option 3). Know that potential side effects of metronidazole may include a metallic taste, gastrointestinal upset, or dark-colored urine (Option 4).
A client in the emergency department is being discharged with a prescription for trimethoprim-sulfamethoxazole. Which statement by the client would indicate a need for further evaluation? 1."I developed a whole-body rash while on glyburide." 2."I drink at least 5 large bottles of water daily." 3."I had to stop using lisinopril due to a bad cough." 4."I have a birth control implant in place."
Trimethoprim-sulfamethoxazole (Bactrim) is a sulfonamide antibiotic, commonly referred to as a sulfa drug. These antibiotics are prescribed to treat bacterial infections (eg, urinary tract infections). Contraindications include hypersensitivity to sulfa drugs, and pregnancy or breastfeeding. Glyburide is a sulfonylurea and has the potential to cause a sulfa cross-sensitivity reaction. Commonly used diuretics (eg, thiazides, furosemide) are also sulfa derivatives and can cause cross-sensitivity reaction. Although this reaction is uncommon, an alternate antibiotic, if possible, can be prescribed by the health care provider. (Option 2) Crystalluria is a potential adverse effect of sulfa medications. Clients should drink at least 2-3 L of water daily to prevent crystalluria. (Option 3) Angiotensin-converting enzyme inhibitors (eg, lisinopril) can produce an intractable cough. The only way to relieve this adverse effect is to discontinue the medication. There is no cross-reactivity with sulfa medications. (Option 4) Birth control implants (eg, IMPLANON, NEXPLANON) are progestin rods placed subdermally in the upper arm that provide contraception for up to 3 years. They are not contraindicated with concurrent trimethoprim-sulfamethoxazole use.
Confirming placement of NG tube
Tube placement is confirmed prior to any use of suction, irrigation, medication administration or feedings. Initially, an x-ray should be ordered to confirm placement of ALL feeding tubes. In addition, the nurse may verify NG or Salem Sump tubes by aspirating stomach contents and checking pH. <4 Measurement of tube length and visual inspection of aspirate is also recommended.
Airborne percautions
Tuberculosis Varicella* (chickenpox): WHEN UNCRUSTED LESIONS Herpes zoster** (shingles): WHEN DISESSMINATED Rubeola (measles) N95 respirator or powered air-purifying respirator Negative-pressure isolation room withhigh-efficiency particulate air filter As needed if contact with body fluid is anticipated:clean gloves, disposable gown, goggles/face shield Herpes zoster (ie, shingles) is caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox. After initial VZV infection earlier in life, the virus remains dormant in the sensory nerves. Reactivation of VZV can occur when the immune system is compromised (eg, aging, immunosuppression), resulting in the formation of pruritic, painful, fluid-filled blisters. These blisters can manifest along the distribution of one or more nerves, causing a characteristic unilateral linear pattern, or the lesions can be disseminated (ie, spreading beyond adjacent dermatomes). The fluid in the blisters carries a high viral load and is contagious to those who have not had chickenpox or received the varicella vaccine. For clients with disseminated shingles, airborne and contact precautions should be followed. Nurses should use an eye shield if there is a chance of virus-containing fluid splashing into the eyes (eg, bathing) (Option 1). Once the lesions have crusted over, the likelihood of transmitting the virus is greatly reduced, and only standard precautions (eg, hand hygiene) would be required.
Doffing PPE
alphabetical gloves goggles gown mask
The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD). The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated. Which prescription is of concern and prompts the nurse to notify the health care provider (HCP)? 1.lansoprazole 2.Metronidazole 3.Prednisone 4.Sulfasalazine
Tuberculosis is an infection caused by the Mycobacterium tuberculosis microorganism. A client with active, primary TB disease has a positive tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications. A client with a latent TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, cannot transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease. Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), can convert LTBI to active disease. A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should notify the HCP. (Option 1) Lansoprazole (Prevacid) is a proton pump inhibitor used to treat ulcer disease, erosive esophagitis, and gastroesophageal reflux disease. It does not convert LTBI to active disease. (Option 2) Metronidazole (Flagyl) is an antimicrobial medication used to treat IBD and does not convert LTBI to active disease. (Option 4) Sulfasalazine (Azulfidine) is a gastrointestinal anti-inflammatory medication used to treat IBD and does not convert LTBI to active disease.
Tolvaptan (Samsca)
Tx SIADH Promotes excretion of water which helps correct the flute in balance and patient to have SIADH
cane and stairs
UP WITH GOOD DOWN WITH BAD down stairs - Lead with the cane - Bring the weaker leg down next (in this client, it is the left leg) - Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: - Step up with the stronger leg first - Move the cane next, while bearing weight on the stronger leg - Finally, move the weaker leg length of cane is equal to the distance from the floor to the greater trochanter of hip
A client with unstable angina and chronic kidney disease is receiving a continuous infusion of unfractionated heparin. Which value for activated partial thromboplastin time (aPTT) would indicate to the nurse that the heparin therapy is at an optimal therapeutic level? 1.30 seconds 2.35 seconds 3.60 seconds 4.85 seconds
Unfractionated heparin is used as an anticoagulant in unstable angina. It prevents the conversion of fibrinogen to fibrin and prothrombin to thrombin, both components of clot formation. The aPTT is a laboratory test that characterizes blood coagulation. It is used to monitor treatment effects of clients receiving heparin. The normal aPTT is 25-35 seconds. Heparin infusions are titrated to obtain a therapeutic value of aPTT, typically 1.5-2 times the normal value. Therapeutic value for aPTT is 46-70 seconds. The nurse would evaluate the aPTT for a therapeutic value and make adjustments in the rate of infusion of the heparin as needed.
Lithium
Used with bipolar disorder to manage mania acts like an electrolyte S/E's 3 P's - peeing (polyuria) -pooing (diarrhea) -paresthesia (numbness and tingling) ----- FIRST SIGN ELECTROLYTE IMBALANCE toxic effects - metallic taste - severe diarrhea - tremors
6. Variable (VERY) Decelerations
VERY BAD • This is very BAD • This indicates prolapsed cord • What is the nursing intervention? o PUSH and POSITION
Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination? 1.Haemophilus influenzae type b vaccine for client allergic to penicillin 2.Hepatitis A vaccine for a client with a "cold" and temperature of 99.0 F (37.2 C) 3.Pneumococcal vaccine for client with local swelling after last immunization 4.Varicella-zoster vaccine for client recently diagnosed with leukemia
Vaccines should be administered at specific ages and intervals as passive placental immunity decreases and the child's immune system develops enough to produce antibodies in response to the vaccine. The nurse should always assess for allergies to vaccine components (eg, neomycin, gelatin, yeast) and screen for an allergy to latex (eg, lips swelling from contact with bananas, kiwis, or latex balloons). Severely immunocompromised children (eg, corticosteroid therapy, chemotherapy, AIDS) generally should not receive live vaccines (eg, varicella-zoster vaccine, measles-mumps-rubella, rotavirus, yellow fever) (Option 4). Passive immunization may be the only option for children with severe immunosuppression or those unable to mount an antibody immune response. Common misperceptions of contraindications to immunization: Penicillin allergy (Option 1) Mild illness (with or without an elevated temperature) (Option 2) Mild site reactions (eg, swelling, erythema, soreness) (Option 3) Recent infection exposure Current course of antibiotics
The valproic acid administered intravenously will assist in breaking the mania.
Valproic acid may cause hepatotoxicity and blood dyscrasias such as thrombocytopenia. These are essential monitoring parameters for the nurse.
red man syndrome
Vancomycin should be infused over at least 60 minutes (100 minutes if infusing ≥1 gram). When the infusion is given too fast, the client may develop red man syndrome, which is characterized by facial and upper body flushing. If this occurs, the infusion should be slowed or stopped and restarted at a slower rate after 30 minutes. Facial flushing in isolation is not indicative of an allergic or anaphylactic reaction, and the nurse can independently manage this side effect.
The nurse caring for multiple clients who underwent renal system diagnostic testing should report which post-procedure finding to the health care provider? 1.150 mL residual urine on bladder scan 2.Burning sensation when voiding after cystoscopy 3.Increased urinary output after arteriogram 4.Less than 10,000 organisms/mL on urine culture
Various diagnostic tests, including bladder scans, urine cultures, cystoscopy, renal arteriograms, and renal scans, assess the renal system. It is necessary to understand the purpose and procedures for each examination when evaluating complications arising from these assessments. Portable ultrasonic bladder scanners are used at the bedside to determine the amount of residual urine in the bladder. Amounts >100 mL should be reported as the client may be experiencing urinary retention (Option 1). (Option 2) A cystoscope is inserted through the urethra to directly visualize the bladder wall and urethra. Irritation of the urethral and bladder lining from the insertion and manipulation of the cystoscope may cause a slight burning sensation with voiding for a day or two. (Option 3) Renal arteriogram is a radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding. (Option 4) Urine is sterile, but the urethra contains bacteria and a few white blood cells. Less than 10,000 organisms/mL is a normal value for urine culture. Values >10,000 organisms/mL indicate urinary tract infection (UTI).
The nurse is caring for a client diagnosed with a deep venous thrombosis 1 day ago. Which action by the client would require an immediate intervention by the nurse? 1.Ambulates through the hallway several times per day 2.Applies a warm compress to the site of inflammation 3.Elevates the limb above the level of the heart while in bed 4.Massages the affected leg to reduce pain and swelling
Venous thromboembolism (VTE) (eg, deep venous thrombosis [DVT]) occurs when a clot becomes lodged in a vein, most often in the deep veins of the lower extremities due to venous stasis, endothelial damage, and hypercoagulability of blood (ie, Virchow triad). Treatment of a VTE includes anticoagulants (eg, enoxaparin, rivaroxaban, heparin, warfarin) to prevent further clotting as the body's fibrinolytic system naturally dissolves the clot by breaking down fibrin deposits. Clients with DVT are at risk for developing a life-threatening pulmonary embolism (PE). The clot may become dislodged by massage or use of sequential compression devices on the affected extremity. The nurse would intervene immediately if a client was observed massaging the site because this may trigger an embolism (Option 4).
The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first? 1.Adolescent client with coarctation of the aorta and diminished femoral pulses 2.Infant client with ventricular septal defect with reported grunting during feeding 3.Newborn client with patent ductus arteriosus and a loud machinery-like systolic murmur 4.Preschool client with tetralogy of Fallot who has finger clubbing and irritability
Ventricular septal defect (VSD) is a congenital abnormality in which a septal opening between ventricles causes left-to-right shunting, leading to excess blood flow to the lungs. This places the client at risk for congestive heart failure (CHF) and pulmonary hypertension. Clinical manifestations of VSD include a systolic murmur auscultated near the sternal border at the third or fourth intercostal spaces, and hallmark CHF signs (eg, diaphoresis, tachypnea, dyspnea). The client is currently showing signs of increased respiratory exertion (eg, grunting) and requires further assessment for CHF (Option 2). (Option 1) Coarctation of the aorta (COA) is an abnormal aortic narrowing that results in decreased cardiac output. The client will exhibit elevated pulse pressure in the upper extremities and diminished pressures in the lower extremities. Further assessment is needed, but this client is not the current priority. (Option 3) A systolic murmur with a machine sound and poor feeding are expected, nonurgent findings in clients with patent ductus arteriosus (PDA). PDA commonly resolves within 48 hours and requires no intervention in full-term newborns. (Option 4) Tetralogy of Fallot (TOF) is a cyanotic congenital heart defect commonly manifested by signs of irritability and clubbing of fingers due to oxygen saturation chronically remaining between 65-85% until the client can undergo surgical repair. Further evaluation of the client's oxygenation is necessary but not urgently required.
Extravasation occurs when a tissue-damaging medication (ie, vesicant) leaks outside the vessel and into surrounding tissues (ie, infiltration).
Vesicants (eg, potassium chloride) may lead to skin breakdown and tissue necrosis if extravasation occurs. Depending on the severity of tissue damage, surgery or limb amputation may be required. Clinical manifestations of extravasation include pain, swelling, pallor, coolness, and fluid-filled blisters around the IV site. If extravasation is suspected, appropriate interventions include: Elevating the affected extremity above the heart to reduce swelling Immediately discontinuing the infusion to minimize tissue damage Leaving the IV catheter in place to aspirate the medication and potentially administer an antidote Notifying the health care provider Initiating new IV access in the unaffected extremity Administering pain medication
cranial nerve VIII
Vestibulocochlear (hearing and balance)
The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply. 1.Blood 2.Feces 3.Semen 4.Urine 5.Vaginal secretions
Viral hepatitis is a disease of the liver characterized by inflammation, necrosis, and cirrhosis. One of the most common viral strains that causes hepatitis is hepatitis B. The transmission of hepatitis B is primarily through contact with blood, semen, and vaginal secretions (mnemonic: B for body fluids), commonly through unprotected sexual intercourse and intravenous illicit drug use (Options 1, 3, and 5). Infants born to infected mothers are also at risk for vertical transmission of hepatitis B. Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite. Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are often nonspecific (eg, malaise, nausea, vomiting, abdominal pain). Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An effective vaccine is widely available for hepatitis B. (Option 2) The transmission of hepatitis A occurs through the fecal-oral route via poor hand hygiene and improper food handling. Therefore, this infection is seen primarily in developing countries. Hepatitis B is not transmitted through feces. (Option 4) Urine is not known to be a mode of transmission for any form of hepatitis.
Iron supplement considerations
Vitamin C enhances absorption black tarry stools can occur
Aortic root repair with mechanical heart valve replacement is a procedure often performed for clients with Marfan syndrome
a connective tissue disorder that increases the risk for aortic rupture. Clients with mechanical valve replacement via sternotomy require education on lifestyle changes and prevention of complications, including: Avoiding heavy lifting (ie, objects over 10 lb [4.5 kg]) for 3-6 months after surgery to prevent disruption of the sternotomy sutures/wires and allow the breastbone to heal (Option 2). Maintaining lifelong anticoagulant therapy (eg, warfarin, apixaban) after a mechanical valve replacement to prevent thromboembolic events (eg, stroke) and valve thrombosis (Option 3). Reporting signs and symptoms of heart failure (eg, weight gain >5 lb [2.3 kg] in 1 week) immediately which may indicate valve failure (Option 4). Initiating bleeding precautions (eg, using an electric shaver) because anticoagulant therapy increases the risk of uncontrolled bleeding (Option 5).
Which client does the nurse assess first after receiving the morning report? 1.Client has cellulitis from injecting heroin; threatening to leave against medical advice if more morphine is not given right now 2.Client is 1 day postoperative colectomy; night nurse medicated client with morphine 15 minutes ago 3.Client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving 4.Client is 3 days postoperative total knee replacement; waiting to be discharged
Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and administer an antiemetic medication (Option 3). (Option 1) This client trying to leave against medical advice is the second priority. The nurse needs to assess this client for pain and determine when pain medication was administered last. If this situation cannot be resolved quickly, the nurse should notify the client's health care provider immediately to determine level of competency and inform the client of the risks of refusing treatment. (Option 2) The nurse must follow-up 30 minutes after the morphine is administered, not immediately, to assess the effectiveness of the pain medication. (Option 4) Providing discharge instructions to this client can wait without consequence.
tiddling in the?
WATER SEAL
Nagelle's Rule
Way to determine the EED (estimated date of delivery); subtract 3 months from first day of last period and add 7 days.
The nurse develops a teaching care plan for the client with a prescription to change antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching? 1.Continue avoiding foods high in tyramine until the imipramine withdrawal period is over 2.Skip the nighttime dose of imipramine and start the phenelzine the next morning 3.Taper down the imipramine, then discontinue for 2 weeks before starting phenelzine 4.Taper down the imipramine while gradually increasing the phenelzine
When a client switches from a tricyclic antidepressant (TCA) (eg, imipramine, amitriptyline, nortriptyline) to a monoamine oxidase inhibitor (MAOI) (eg, phenelzine, isocarboxazid, tranylcypromine), a drug-free period of at least 2 weeks should elapse between the tapered discontinuation of the TCA and the initiation of the MAOI. This timing is based on the half-life value and allows for the first medication to leave the system. Without a washout period, the client could experience hypertensive crisis (eg, blurred vision, dizziness, severe headache, shortness of breath). If the TCA is withdrawn abruptly, the client may experience a discontinuation syndrome. (Option 1) A tyramine-restricted diet is indicated for clients on an antidepressant regimen containing an MAOI to decrease the risk of hypertensive crisis. Because this client is starting an MAOI, the diet should be initiated 2 weeks prior to starting the medication. If the switch was from an MAOI inhibitor to another antidepressant, the client would need to continue to follow the dietary restrictions for 2 weeks after discontinuing the MAOI. (Option 2) An overnight washout period is inadequate to clear the imipramine from the client's system before starting the phenelzine. (Option 4) TCAs and MAOIs cannot be taken at the same time due to the risk of a hypertensive crisis.
When are hypertonic solutions used?
When hypertonic solutions are used (very cautiously....most likely to be given in the ICU due to quickly arising side effects of pulmonary edema/fluid over load). In addition, it is prefered to give hypertonic solutions via a central line due to the hypertonic solution being vesicant on the veins and the risk of infiltration.
The client is brought to the emergency department in handcuffs by the police. Witnesses said that the client became violent and confused after consuming large amounts of alcohol at a party. The client is placed in 4-point restraints, and ziprasidone hydrochloride is administered. The client is sleeping 30 minutes later. What is a priority action for the nurse at this time? 1.Check for a history of bipolar disease 2.Determine if restraints can now be removed 3.Monitor for widened QT intervals and hypotension 4.Obtain blood for the current blood alcohol level
Ziprasidone hydrochloride is an atypical antipsychotic that is used for acute bipolar mania, acute psychosis, and agitation. Its use carries a risk for QT prolongation leading to torsade de pointes. A baseline electrocardiogram and potassium are usually checked. At a minimum, the client should be placed on a cardiac monitor. The client should also be monitored for hypotension and seizures, especially if the previous medical history is not known or obtainable. The risk for adverse effects is increased with the interaction of alcohol (Option 3). (Option 1) Although knowing past psychiatric history will assist in determining the cause of this episode, this knowledge is not essential when caring for this client's current needs. Any physical reasons for the behavior should be ruled out before focusing on psychiatric history. Risk for suicide also needs to be assessed after the client is alert and sober. (Option 2) This should be reassessed after the drug is wearing off, not before the medication is peaking. The client could suddenly wake up and become violent again. Also, it is a priority to perform restraint monitoring per protocol, including checks on circulation and hydration/elimination needs. The client's physiological response is priority. (Option 4) It would be beneficial to know the current alcohol (ethanol) level in order to estimate the client's level of intoxication and when the client will be sober. The body normally clears alcohol at a rate of 25-50 mg/dL per hour. However, there is a reliable history that the client had been drinking, and the presence of alcohol in the blood carries a risk for drug interaction. Therefore, it is more important to monitor the client for any negative effects (adverse physiological responses) from the drug than to quantify the current alcohol level.
Neonatal Abstinence Syndrome (NAS)
a condition in which a child, at birth, goes through withdrawal as a consequence of maternal drug use hyperreflexia seizures rapid HR high BP tachypnea CNS irritability
tetralogy of Fallot (TOF)
a cyanotic congenital heart disease (CHD) defect characterized by the presence of four defects (Option 4): Ventricular septal defect (VSD): An opening between the right and left ventricles, which allows mixing of oxygenated and unoxygenated blood. Pulmonary stenosis: Narrowing of the pulmonary valve, which increases pulmonary vascular resistance and decreases the amount of blood going to the lungs for oxygenation. Pulmonary stenosis can cause a systolic ejection murmur. Overriding aorta: This occurs when the aorta is positioned over the VSD (between the right and left ventricles) instead of over the left ventricle, which allows unoxygenated blood to enter systemic circulation. Right ventricular hypertrophy: Enlargement (ie, thickening) of the wall of the right ventricle, which is caused by increased pulmonary vascular resistance (ie, pulmonary stenosis) due to the right ventricle working harder to pump blood into the lungs.
Electroencephalography,
a diagnostic procedure used to diagnose seizures, evaluates the presence of abnormal electrical discharges in the brain.
delirium tremens
a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol
delirium tremens
a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol 48-96 hours after last drink
chaotic p wave
a fib
Raynaud's phenomenon
a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress
Retinoblastoma
a unilateral or bilateral retinal tumor, is the most common childhood intraocular malignancy. It is typically diagnosed in children under age 2 and is usually first recognized when parents report a white "glow" of the pupil (leukocoria). Light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex (Option 1). Parents may even accidentally visualize leukocoria when taking a photograph of the child using a flash. Strabismus (misalignment of the eyes) is the second most common sign; visual impairment is a late sign indicative of advanced disease.
rapid p wave depolarizations (sawtooth)
a-flutter
Tenofovir and emtricitabine are
are antiretrovirals indicated in the prevention and treatment of HIV infection. This combination of medication aims to decrease the viral load (VL) and increase the CD4/CD8 count.
cervical laminectomy MOST important assessment
upper extremities and breathing watch pneumonia
when auscultating abdomen you hear swooshing noise what could be causing this?
abdominal aortic aneurysm Upon auscultation, the nurse should suspect this client is presenting with an abdominal aortic aneurysm (AAA) due to the bruit or swooshing sound. The nurse should immediately notify the patient's healthcare provider of this urgent situation. An AAA Rupture can occur spontaneously or with trauma. If the aneurysm bursts, it may cause life-threatening bleeding. The aneurysm should be assessed immediately to determine the need for surgical intervention.
thoracic laminectomy MOST important assessment
abdominal muscles (cough) bowels post op complication pneumonia paralytic illeus
streptococcal pharyngitis
abrupt onset. These manifestations include fever, headache, malaise, throat pain, cervical lymphadenopathy, reddened tonsils, and exudate covered on the tonsils. This illness is caused by group A β-hemolytic streptococci and is treated with prescribed antibiotics (azithromycin, penicillin) and over-the-counter pain medication such as ibuprofen. Antibiotic therapy needs to be completed because it may consequently lead to glomerulonephritis. This condition does not feature inspiratory stridor, restlessness, muffled voice, or stridor because it does not extend beyond the throat or feature significant edema causing airway compromise.
pH down
acidosis bradycardia bradypnea hypotension hyporeflexia hypoactive bowel sounds flaccid constipation
mid dilated and fixed pupil
acute angle closure glaucoma
Patent ductus arteriosus
acyanotic CHD defect that occurs when the ductus arteriosus remains open, causing blood to shunt from the aorta to the pulmonary artery (ie, left-to-right shunt). Manifestations include a loud, machine-like systolic and diastolic murmur and bounding pulses.
IV push is typically slow EXCEPT for?
adenosine push fast short half life
Thiamine
administered before or along with glucose to help prevent Wernicke encephalopathy, which is characterized by confusion, visual disturbances, and gait abnormalities and can progress to coma and Korsakoff syndrome (ie, permanent cognitive dysfunction). Folic acid and multivitamins are also given simultaneously.
in a standard pregnancy membranes rupture ___
after the mom has had dilation effacement and contactions
measles, tuberculosis, varicella
airborne diseases
Measles rubeola
airbrone KOPLIK SPOTS\ Measles (ie, rubeola) is a highly contagious viral illness that affects people of all ages. Measles spreads when infected individuals cough or sneeze, sending the virus through the air, where it remains suspended for up to 2 hours. Widespread vaccination with the measles, mumps, and rubella (MMR) vaccine, such as in the United States, has reduced measles incidence by 99%. However, an increase in international travel and unvaccinated children have caused a resurgence of the disease. For hospitalized clients with measles, the plan of care should include the following: Recommendation of postexposure prophylaxis (ie, MMR vaccine) for eligible, susceptible (eg, unvaccinated) family members within 72 hours of exposure to decrease the severity and duration of symptoms in case they contract the disease (Option 1) Implementation of airborne precautions, including a negative-pressure isolation room and use of an N95 respirator mask, during contact with the client by health care staff (Options 4 and 5) Administration of vitamin A supplements to prevent severe, measles-induced vitamin A deficiency, which can cause blindness, particularly in clients in low-resource areas
What can be given for PVC's and v tach
amiodarone lidocaine
chronic kidney disease with metallic taste in mouth?
ammonia
hydroxychloroquine
an antimalarial agent that reduces immune activity without inducing immunosuppression to improve fatigue and arthralgia. Symptom improvement typically occurs 3-6 months after initiating hydroxychloroquine
Postpartum hemorrhage (PPH)
an obstetric emergency characterized by profuse bleeding (eg, saturating ≥1 pad/hr, passage of large clots) after childbirth. Risk factors include uterine overdistension (often associated with fetal macrosomia (ie, weight ≥ 8 lb 13 oz- [4000 g]), uterine fatigue (eg, prolonged induction of labor), and operative vaginal delivery (eg, forceps assisted). Uterine atony (ie, soft, "boggy" uterus) is a common cause of PPH that occurs due to insufficient uterine contractility, resulting in the inability of the uterus to clamp down on bleeding vessels at the previous placenta site. Bladder distension caused by urinary retention may contribute to uterine atony by elevating and displacing the uterus to the right, further impeding uterine contractility. Expected interventions for a client with suspected PPH due to uterine atony include: --Assisting the client to void to relieve bladder distension. --Massaging the uterine fundus to expel blood clots and stimulate uterine contraction. --Obtaining vital signs frequently to monitor for hypovolemia. --Ensuring perineal laceration repair is intact because this is another potential source of PPH, especially after an operative vaginal delivery. --Tocolytic medications (eg, terbutaline) are used to relax the uterus during labor. Terbutaline is not expected for a client with PPH due to uterine atony. --Oxytocin is a medication that stimulates uterine contractions and can be used to treat PPH. Therefore, discontinuing the IV oxytocin infusion is not expected.
Monoamine oxidase inhibitors (MAOIs)
antidepressant S/E: ABCD anticholinergic (dry mouth) blurred vision constipation drowsiness
Sertraline
antidepressant medication used to treat generalized anxiety disorder and major depressive disorder. This medication is a selective serotonin reuptake inhibitor (SSRI).
Serotonin syndrome
anxiety mental status change clonus hyperreflexia tremor hyperactive bowel diarrhea autonomic instability HTN agitation diaphoresis tachycardia discontinue seratogenics (sertraline - tramadol) give benzodiazepine Neuroleptic malignant syndrome (NMS) is a life-threatening adverse reaction to antipsychotic medications (eg, haloperidol, risperidone) that can also cause mental status changes, hyperthermia, and sympathetic hyperactivity. However, NMS typically causes diffuse muscle rigidity, as opposed to neuromuscular hyperactivity (eg, clonus, hyperreflexia). This client is taking no antipsychotic medications, so NMS should not be suspected.
What medication to avoid before electroconvulsive therapy
anything that increases seizure threshold benzodiazepines and anticonvulsants
2nd ICS of right sternal border 2ns ICS of left sternal border Erb point (3rd ICS to left of SB) 5th ICS MCL
aortic pulmonic Erb point mitral apex point of maximal impulse
assessing mechanical capture of pacemaker
apical pulse
The nurse is caring for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina. Place the priority actions in the correct order. Incorrect administer oxygen via face mask place the client in the Trendelenburg position apply pressure to lift the presenting fetal part stay with the client and call for help prepare the client for immediate cesarean delivery
apply pressure to lift the presenting fetal part stay with the client and call for help place the client in the Trendelenburg position administer oxygen via face mask prepare the client for immediate cesarean delivery
Four teretolgy of fallot defects varied pictures of ranch
ventricular septal defect pulmonary stenosis overriding aorta right hypertrophy
Clients who consume alcohol regularly
are at risk for multiple vitamin (thiamine, folic acid) and electrolyte (potassium, magnesium, phosphorus) deficiencies. Hypoglycemia is also common. Vitamin B1 (thiamine) deficiency results from malnutrition or malabsorption and can lead to Wernicke-Korsakoff syndrome. Thiamine is administered before or along with glucose to help prevent Wernicke encephalopathy, which is characterized by confusion, visual disturbances, and gait abnormalities and can progress to coma and Korsakoff syndrome (ie, permanent cognitive dysfunction). Folic acid and multivitamins are also given simultaneously.
Benzodiazepines (eg, diazepam, lorazepam, chlordiazepoxide)
are central nervous system depressants that work by potentiating the effect of gamma-aminobutyric acid (GABA). GABA is a powerful inhibitory neurotransmitter in the brain that decreases the excitability of neurons, producing a sedative effect. Benzodiazepines manage symptoms of alcohol withdrawal by mimicking alcohol's effect on the brain, thereby preventing withdrawal symptoms and complications. These drugs are then slowly tapered.
hemoglobin less than 8
assess bleeding possible transfusion call Dr 12-18 about normal
Bishop's Scoring System
assesses cervical readiness for labor via five factors: cervical dilation, effacement, consistency, position, and fetal station.
NOT delegated to LPN
assessment teaching starting IV hanging mixing IV meds IV push giving blood transfusion plan of care take verbal orders from MD THEY CAN REINFORCE TEACHING
NOT delegate to a UAP
assessments - EXCEPT VS and BS check meds and IV's CAN apply topical lotions and creams can delegate baths - beds - ADL's
peak expiratory flow rate
asthma severity exhale as quickly as possible
when should you take a statin
at bedtime
post term infant
at risk for hypoglycemia hypothermia meconium aspiration
Risperidone
atypicImportant antipsychotic side effects Extrapyramidal side effects Acute dystonic reaction: sudden-onset, sustained muscle contractions Akathisia: subjective restlessness with inability to sit still Drug-induced parkinsonism: tremor, rigidity, bradykinesia, masked facies Tardive dyskinesia Involuntary movements after chronic use (eg, lip smacking, choreoathetoid movements) Neuroleptic malignant syndrome Fever, rigidity, mental status changes, autonomic instability Second-generation (atypical) antipsychotic medications (eg, risperidone, quetiapine, olanzapine) are used to treat schizophrenia, bipolar disorder, and other mental health disorders. The nurse should educate clients and caregivers on the potential adverse effects of atypical antipsychotic medications. Symptoms are evaluated on an individual basis; most minor symptoms can be managed with a decrease in dosage or change in medication. One of the main adverse effects the nurse should recognize with second-generation antipsychotic medications is extrapyramidal symptoms (EPSs). EPSs include manifestations of akathisia (ie, restlessness, fidgeting), parkinsonism (eg, tremors, shuffling gait), and tardive dyskinesia (eg, lip smacking, facial grimacing). These symptoms are important to monitor because they may be easily mistaken for agitation or negative schizophrenic symptoms (eg, pacing, rocking) (Option 4). The health care provider may prescribe anticholinergics (eg, benztropine, diphenhydramine) or benzodiazepines to treat EPSs. (Option 1) The client should report fever and muscle rigidity, which may indicate a potentially fatal adverse effect of antipsychotic medications, neuroleptic malignant syndrome, which requires emergency intervention. (Option 2) The nurse should teach that the sedating effects of second-generation antipsychotic medications (eg, drowsiness, hypersomnia [ie, excessive daytime sleepiness]) are common. (Option 3) The caregiver should identify that the client needs to change positions slowly to prevent orthostatic hypotension, another potential adverse effect of antipsychotic medications.al antipsychotic
Aripirazole (Abilify)
atypical antipsychotic Aripiprazole, an atypical antipsychotic medication, is used in the treatment of irritability associated with autism spectrum disorder (ASD), schizophrenia, bipolar disorder, and other mental health disorders. Aripiprazole works as a partial agonist at the serotonin and dopamine receptor sites. As a result, the medication has a more favorable safety profile (eg, less metabolic effects, lower potential for prolactin release) than other antipsychotics; however, it may be less effective in symptom relief. Clients taking aripiprazole should be instructed to not abruptly stop taking the medication because it can cause withdrawal symptoms (anxiety, dizziness, tachycardia, diaphoresis, insomnia, vomiting) and risk exacerbating previous symptoms. These medications should be weaned over time and substituted with an alternate medication under the supervision of a health care provider
Clozapine (Clozaril)
atypical antipsychotic • S/Es of clozapine o aGranulocytosis! It is worse than cancer drugs and can trash the pt's bone marrow
Clozaril (clozapine)
atypical antipsychotic agranulocytosis
Clozapine (Clozaril)
atypical antipsychotic medication used to manage schizophrenia in clients who have not improved with other antipsychotic medications. Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis), and seizures. Agranulocytosis (decreased neutrophils) increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection (eg, sore throat, fever, flulike symptoms), which should be reported immediately to the health care provider (Option 2). (Option 1) Weight gain is a common side effect. Clients should be educated about weight management. (Option 3) Hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. The side effect can be reduced by lowering the dose. The client should chew sugarless gum to promote swallowing and reduce drooling. (Option 4) Many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve.
Guillain-Barre syndrome
autoimmune condition that causes acute inflammation of the peripheral nerves in which myelin sheaths on the axons are destroyed, resulting in decreased nerve impulses, loss of reflex response, and sudden muscle weakness radiating back pain difficultly swallowing recent viral infection ascending muscle weakness
Myasthesia Gravis
autoimmune disease of the neuromuscular junction resulting in fluctuating muscle weakness. Autoantibodies are formed against the acetylcholine receptors, so fewer receptors are available for acetylcholine to bind. It is treated with pyridostigmine (Mestinon), which increases the amount of acetylcholine at the synaptic junction, augmenting neuromuscular signals and improving muscle strength. Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's infection and increasing difficulty swallowing indicate the need for immediate intervention.
Sickle cell disease is
autosomal recessive so both parents need to have the gene for there to be a chance
antabuse/revia (disulfiram)
aversion therapy 2 weeks to work need to avoid all forms of alc mouth wash, cologne, perfume, aftershave, elixir, most OTC liquid medicines, insect repellant, vanilla extract, vinagerettes, hand sanitizer
Teaching points for MAOI's
avoid tyramine - HTN crisis BAR - bananas - avocados - raisins (all dried fruit) Meats - no organ meat- no preserved meat (smoked-dried pickled hot dog - dairy NO cheeses except (mozzarella - cottage cheese - no chocolate - caffeine
Hydrochlorothiazide causes retention of ____ therefore it should NOT be given to patient with ______
calcium HYPERparathyroidism
Verapamil
calcium channel blocker
Verapamil, Diltiazem
calcium channel blockers
best toy 9-12
verbal toy talking elmo purposeful activity with objects
Lyme disease
bacterial infection that can develop after a bite from an infected deer tick. Manifestations include flu-like symptoms (eg, fatigue, headache, fever, joint pain) and an erythematous rash with a bull's eye appearance (ie, erythema migrans). Late complications include cardiac involvement (eg, heart block, muscle inflammation) and central nervous system involvement (eg, Bell palsy). Chorea and strawberry tongue are not characteristic of Lyme disease.
In utero, low variability of V/S is a __ sign but highly variable V/S is a __sign
bad good don't like to see stable vital signs = low baseline variability
introductory phase in nursing oriatation phase explore and assess
be tolerant accepting explorative probing
Betamethasone
before baby is born given IM to mom can repeat as long as baby is in utero
how to measure frequency intensity duration
beginning of one contraction to beginning of another strength of contraction beginning to end of one contraction
. Agitation without delirium is better treated with
benzodiazepines (lorazepam) rather than dopamine antagonists (haloperidol). Note that while agitation can be a common symptom of delirium, it can occur without delirium, i.e. patients can be agitated without having acute changes in consciousness.
heparin s to warfarin as
benzodiazepines are to major tranquilizers
Pregnancy extremity check
best way to determine thrombophlebitis - bilateral calf measurement BEST - Homan sign no best answer not as reliable
fetal lung meds
betamethasone (given mother IM) surfactant (survanta) - give to baby after baby is born (trasntracheal)
lab values elevated with cirrhosis
bilirubin PT/INR ammonia LOW albumin
lumbar spinal injury
bladder legs assess urinary retention or last time voided and assess leg mobility
lumbar laminectomy MOST important assessment post op complication
bladder legs urine retention
Mongolian spot
bluish discoloration of the sacral region carefully assess as child abuse could go undocumented NORMAL NOT ALARMING
DO Not give systemic pain medications when?
born pain peaking (respiratory depression)
swelling caused by bleeding between the ostium and periosteum of skull NOT Cross suture lines
cephalohematoma
HPV can lead to
cervical cancer
HPV cancer risk
cervix
cheese like substance appears intermittently
vernix caseosa normal finding
The nurse is reviewing the laboratory results of a client who reports fatigue for the last month. Based on the laboratory results, which additional clinical manifestations would the nurse expect? Select all that apply. Laboratory test TSH 12.4 µU/mL (12.4 mU/L) 2-10 µU/mL (2-10 mU/L) Free T4 0.2 ng/dL (2.57 pmol/L) 0.8-2.8 ng/dL (10-36 pmol/L) 1.Bradycardia 2.Cold intolerance 3.Constipation 4.Hair loss 5.Warm, moist skin 6.Weight loss
bradycardia cold intolerance constipation hair loss Primary hypothyroidism is an endocrine disorder identified by low thyroid hormone (ie, triiodothyronine [T3], thyroxine [T4]) and high thyroid-stimulating hormone (TSH) levels. Primary hypothyroidism occurs when TSH is unable to stimulate the thyroid to produce thyroid hormones, often after trauma or autoimmune-related tissue damage (eg, Hashimoto thyroiditis). Therefore, TSH levels remain elevated as primary counterregulatory hormone (ie, T3, T4) levels remain low. Thyroid hormones act in multiple body sites to stimulate and increase metabolic functions (eg, body temperature, cellular energy, oxygen consumption, neuron conduction). Therefore, clients with hypothyroidism exhibit clinical manifestations of low metabolic state, including: Bradycardia and hypotension (Option 1) Hypothermia and cold intolerance (Option 2) Constipation (Option 3) Fragile, dry skin and hair loss (Option 4) Forgetfulness, slurred speech, and confusion
hypermagnesemia
bradycardia hypotension respiratory arrest hyporeflexia absent bowel
"BUBBLE HEAD" stands for
breasts uterine fundus (NEED TO KNOW) bowel bladder lochia (NEED TO KNOW) episiotomy hemoglobin-hematocrit extremities (need to know) affect discomforts
avoid these answers if child less than 9 months
build sort stack make construct
Lyme disease
bulls eye rash deer tick ✓ Lyme disease is a tick-borne illness causing the client to have B. burgdorferi. ✓ Symptoms may begin one month after a client was exposed to the bacteria via the tick. ✓ The symptoms start with the classic bullseye rash progressing to lymph node enlargement, arthralgias, malaise, fatigue, and encephalopathy. ✓ The mainstay treatment is antibiotics such as doxycycline. ✓ The client can reduce exposure risk by wearing long sleeve clothing, tick repellent, and avoiding high grass and wooded areas without the recommended attire.
hyperkalemia causing tall peaked T waves in pt with CKD. What med can be given not to LOWER K but to protect myocardium?
calcium gluconate Intravenous calcium gluconate is administered to hyperkalemic clients with ECG changes (eg, peaked T waves). Calcium gluconate itself does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. Once the nurse stabilizes the client by administering calcium gluconate, other prescriptions may then be implemented to decrease serum potassium level (eg, intravenous regular insulin with dextrose, sodium polystyrene sulfonate, hemodialysis) to lower K itself give: dextrose and insulin kayexalate (sodium polystyrene sulfonate)
The Parkland formula
calculate the fluid requirements following a major thermal burn. The formula of 4 mL x the client's weight in kilograms x the body surface area burned will determine the 24-hour fluid requirement. Once the total amount of fluid is calculated, divide it by two because of the two phases of fluid resuscitation (8 hours, then the remaining 16 hours).
Hemophilia
can be factor VIII or IX DONT NEED platelet transfusion that isn't the problem
Corticosteroids considerations
can cause insomnia give in morning can cause GI distress take with food immunosuppression mood changes FLUID retention HYPOkalemia Corticosteroids are the mainstay treatment in an array of disease exacerbations such as multiple sclerosis, rheumatoid arthritis, asthma, and lupus. ➢ The nurse should instruct the client to take the medication in the morning with food ➢ Take the steroid as prescribed, do not self-discontinue, and anticipate weight gain. ➢ To prevent the development of ulcers, the nurse should instruct the client not to take any NSAIDs, such as ibuprofen or naproxen, while on the steroid.
Pitocin (oxytocin)
can cuase uterine hyperstimulation - >long than 90 seconds <closer than 2minutes
Amniocenteses
can determine neuro tube defects can also determine fetal lung maturity
Crosses suture lines and heals in about 1 week
caput succedaneum
hypokalemia
cardiac dysrhythmia muscle cramping Hypokalemia (ie, serum potassium <3.5 mEq/L [2.5 mmol/L]) is caused by gastrointestinal fluid loss (eg, diarrhea, nasogastric suctioning), renal potassium loss (eg, hyperaldosteronism, diuretics), or excess insulin (eg, increases intracellular potassium). Manifestations include muscle cramping due to impaired muscle contractility and cardiac dysrhythmias due to altered myocardial conduction.
hyponatremia
cardiac dysrhythmia muscle cramping seizure activity Hyponatremia (ie, serum sodium <136 mEq/L [136 mmol/L]) is most often associated with alterations in fluid balance. Water loss (eg, dehydration, diuretics) can lead to hyponatremia because sodium follows water. Water retention (eg, syndrome of inappropriate antidiuretic hormone) can also cause dilutional hyponatremia. Manifestations of hyponatremia include neurologic changes (eg, seizure activity) due to cerebral edema, muscle cramping, and cardiac dysrhythmias due to impaired myocardial conduction.
Wernickle-Korsakoff Syndrome
caused by deficiency in thiamine B1 occurs often in alcoholics Wernicke encephalopathy, which is characterized by confusion, visual disturbances, and gait abnormalities and can progress to coma and Korsakoff syndrome (ie, permanent cognitive dysfunction). Folic acid and multivitamins are also given simultaneously
Perinatal asphyxia
caused by inadequate fetal oxygenation can lead to a range of poor cognitive outcomes in the newborn (eg, learning disabilities, hypoxic-ischemic encephalopathy, cerebral palsy). The nurse should identify signs of asphyxia early during newborn care so that interventions to reduce the risk of severe neurodevelopmental disability can be considered (eg, therapeutic hypothermia). Newborn assessment findings associated with perinatal asphyxia include: Low Apgar scores: An Apgar (ie, Appearance/color, Pulse, Grimace/reaction, Activity/tone, Respiratory effort) score of <7 out of 10 at 5 minutes may indicate a poor transition to extrauterine life due to perinatal asphyxia (Option 1). Neonatal seizures: Jerking movements that do not go away and ocular manifestations (eg, rapid eye movement, excessive blinking) are findings that require further evaluation to determine if seizure activity is present because hypoxia-induced brain damage may be the underlying cause (Option 3). Acidemia: Umbilical cord arterial blood can be analyzed to evaluate fetal oxygenation status in utero. A low arterial blood pH is caused by a lack of oxygen and lactic acid accumulation (Option 5).
Methergine
causes high blood pressure contracts blood vessels
Positive station numbers
centimeters below pelvis positive sign
Haloperidol (a first-generation antipsychotic) and lorazepam (a benzodiazepine) are commonly administered together to depress the
central nervous system and decrease aggressive behaviors
A client with Cushing's disease has too many steroids and will have manifestations such as
central obesity, weight gain, hypokalemia, hypernatremia, and hypertension. The client will not need more steroids during periods of stress as this is necessary for a patient with Addison's disease to prevent a crisis. High levels of cortisol and aldosterone characterize Cushing's disease. The client will have clinical features such as truncal obesity, hyperglycemia, hypernatremia, hypokalemia, and hyperlipidemia.
Cyclobenzaprine (Flexeril)
centrally acting skeletal muscle relaxant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Centrally acting muscle relaxants interfere with reflexes within the central nervous system (CNS) to decrease muscle spasm and rigidity. Like many medications, muscle relaxants are metabolized by the liver. The presence of liver disease (eg, hepatitis) decreases hepatic metabolism and can cause a buildup of medication, leading to medication toxicity and increased CNS depression (eg, weakness, confusion, drowsiness, lethargy). The prescription for a muscle relaxant would need to be clarified in a client with liver disease
JP drain
closed wound surgical drain prevents fluid build up in closed space pull plug on hub - and poor drainage into calibrated container empty device every 4-12 hrs unless it is 1/2 to 1/3 full compress empty bulb and replace plug on spout
Sucralfate
coat and protect the mucosal lining from ulceration medication absorption while taking can be altered need to take AFTER medication 2 hours after digoxin Sucralfate forms a better protective layer at a low pH level. Therefore, antacids or other acid-reducing medications (eg, proton pump inhibitors, H2 blockers) should be avoided within 30 minutes of taking sucralfate to prevent altered absorption Sucralfate binds with many medications (eg, digoxin, warfarin, phenytoin), reducing their bioavailability and effectiveness. Therefore, all other medications are generally taken ≥1-2 hours before or after taking sucralfate.
Barium enema used before
colonoscopy
Misoprostol
combats uterine atony by contracting the uterine muscle, rather than through vasoconstriction, making it a safe option for clients with hypertension. The drug is often given per rectum for PPH to increase absorption.
hemangioma
common accumulation of blood vessels in the skin of a newborn normal and not alarming
open angle gluacoma
common form of gluacoma, the normal spatial relation between iris and cornea is preserves and the iris is fully lit Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle glaucoma. Although further evaluation and treatment are necessary, this condition develops slowly and is not considered an emergency situation.
colchicine
commonly used to reduce inflammation in clients with gout and has been effective in reducing symptoms associated with pericarditis. In addition, colchicine use may decrease the risk of recurrent pericarditis.
inotropic chronotropic dromotropic
contractility HR conductivity in heart
Prolapsed Cord
cord is the presenting part • Push head in off cord and position knee-chest or Trendelenburg • Prep for C-section • Think PUSH/POSTION o Push head off the cord of fetus and position mother to knee-chest delaying pushing to position increases risk of fetal death
adrenal crisis can occur when
corticosteroids are suddenly abruptly stopped ✓ An adrenal crisis is a medical emergency manifested by hypovolemia which causes hypotension and tachycardia. ✓ Hypoglycemia is also a clinical feature along with hyponatremia. ✓ The client will have elevated potassium levels that may cause cardiac dysrhythmias. ✓ The priority treatment for a client with an adrenal crisis is prompt administration of intravenous hydrocortisone! ✓ Additional treatment includes intravenous fluids, glucose, and regular insulin to lower the potassium.
INR
coumadin (warfarin) 2-3 if >4 STOP coumadin assess bleeding VITAMIN K call Dr
nurse not wearing correct PPE and uses gloves in hallway NOT illegal NOT harmful
counsel later when appropriate
6-9 month toys
cover uncover toy jack in the box firm but large wood hard plastic
chest tube comes out
cover with gloved hand put on dry sterile dressing tape on THREE sides
School age (7-11 yr.) is characterized by the 3 C's, what are they?
created creative competitive collective
LOW pressure alarm on ventilator
cuff leak disconnected tubing pt pulled tube out
detached retina
curtain coming down over the field of vision
categories of congenital heart defects
cyanotic and acyanotic
Hypernatremia
dEhydration (dry skin, thready pulse, rapid HR)
most accurate indication of fluid loss or gain
daily weights
PO2 <60
dangerous sign of resp failure assess respirations give oxygen prepare to intubate and ventilate call R therapy call Dr
emergency management of malignant hyperthermia
dantrolene
cytoscopy
visial bladder can expect pink tinged urine 48 hrs following HEMORHAGE NOT GOOD bright red blood when urinating is not normal
Hypoparathyroidism
decreased function of the parathyroid glands, resulting in low levels of parathyroid hormone (PTH). PTH is released from the parathyroid glands in response to low serum calcium levels. PTH increases (restores) serum calcium levels by releasing stored calcium from bone, increasing renal reabsorption of calcium, and increasing dietary absorption of calcium in the small intestine. Because PTH and calcium have a reciprocal relationship, when PTH levels decrease, calcium levels also decrease (ie, hypocalcemia). Inadvertent removal or injury to the parathyroid glands during cervical spine or neck surgery (eg, thyroidectomy) is a common cause. Manifestations of hypocalcemia include tetany (eg, presence of Chvostek or Trousseau sign), cardiac dysrhythmias, and neuromuscular irritability (eg, paresthesia, muscle cramps, hyperreflexia, seizures). Anticipated interventions for clients with hypoparathyroidism and severe hypocalcemia include: Administering calcium gluconate to increase serum calcium levels Administering vitamin D (eg, calcitriol) to increase calcium absorption in the intestine Monitoring serum magnesium levels because hypomagnesemia can worsen hypocalcemia. Clients may also need magnesium supplementation.
What is the purpose in 2nd stage?
delivery of baby
Diagnosis of fetal alcohol spectrum disorder (FASD)
depends on maternal alcohol intake during pregnancy, which there is no indication of in this client. FASD can lead to dysmorphic facial features (eg, thin upper lip), hypotonia, cognitive impairment, and growth restriction.
unstagable/unclassified pressure ulcer
depth unknown full thickness (full skin loss) base of ulcer covered by slough or eschar in wound bed
unequal thigh and gluteal folds
developmental dysplasia of the hip
3 main reasons for accuchecks
diabetes TPN Steroids
cervical back injury
diaphragm arms assess breathing and arm movement
mitral valve stenosis murmur hear?
diastolic murmur 5th intercostal space MCL
What is purpose of uterine contraction in first stage?
dilation and effacement (thinning)
what to avoid before allergy testing
diphenhydramine [Benadryl], loratadine [Claritin], promethazine [Phenergan]) for up to 2 weeks prior to the test
Key clinical features of myasthenia gravis (MG)
diplopia, ptosis, facial muscle weakness, and may progress to respiratory failure. Some of the earlier manifestations associated with MG are ocular. Myasthenia gravis is a rare and serious autoimmune disorder that impairs the acetylcholine receptors. Commonly occurring more in women, this disorder impacts motor nerves which impair facial and eye muscles. In its severe form, myasthenia gravis may impact respiratory muscles causing respiratory failure.
Reye syndrome (RS)
disorder characterized by fever, profoundly impaired consciousness, and disordered hepatic function. A liver biopsy is used to confirm the diagnosis of RS and the client may experience dangerously high ammonia levels. By avoiding the child's exposure to salicylates, the client may avert this syndrome.
Pain medications in labor
do NOT admin pain meds to woman in labor IF: -baby is likely to be born when the MED PEAKS (d/t resp depression). ex: primigravida at 5 cm wants IV pain med rn. could u give it? -YES bc IV meds peak at 15-30 min and she's most likely not gonna deliver that soon.
Pulmonary function tests (PFTs)
do not require any sedation or invasive machinery and may be done at the bedside. The purpose is to assess lung function and breathing problems. These tests measure lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and ventilation distribution. The results are interpreted by comparing the patient's data with expected findings for age, gender, race, height, weight, and smoking status. Before the testing, the client is instructed to withhold any bronchodilators four to six hours prior, abstain from smoking, and refrain from wearing tight or restrictive clothing.
birth weight should __ at 6 months and __ and 12 monts
double 6 months triple one year
ear drops when less than <3
down and back
infant single transverse crease across palm
down syndrome
meds to avoid in pregnancy
doxycycline isotretinoin lisinopril lithium valporate methotrexate ace warfarin phenytoin
pertusis (whooping cough) precautions
droplet mask gloves This means that the client needs a private room, or a room shared only with another client with pertussis. Staff should and visitors must wear a mask when entering the room. A mask must be placed on the client if they need to leave the room.
Age-related macular degeneration (AMD)
is a progressive, incurable disease of the eye characterized by deterioration of the macula, the central portion of the retina. This deterioration causes visual disturbances (wavy or blurred vision), blind spots, or loss of the central field of vision; peripheral vision remains intact. AMD has a vascular pathogenesis that is unrelated to increased IOP. Clients with AMD have a normal cornea, lens, and optic nerve; therefore, halos are not seen.
neonatal absitence syndrome (NAS)
drug dependency acquired in utero manifested by neurologic and physical behaviors In utero exposure to maternal substances (primarily opioids) Clinical manifestations CNS: irritability, hypertonia, tremor, shortened sleep-wake cycles, uncoordinated swallowing Autonomic nervous system: diaphoresis, sneezing, yawning Gastrointestinal: feeding difficulty, vomiting, diarrhea Diagnosis Primarily clinical Confirm: umbilical cord blood, urine, or meconium drug testing Treatment Mild withdrawal: nonpharmacologic Minimize environmental stimuli, swaddling, frequent small feeds Moderate to severe withdrawal: pharmacologic Morphine, methadone Neonatal abstinence syndrome (NAS) is a potentially life-threatening withdrawal syndrome affecting newborns exposed in utero to physiologically addictive substances (eg, opioids, benzodiazepines, nicotine). NAS usually presents hours to days after birth as the newborn's blood level of the substance decreases after being separated from maternal circulation. Newborns with NAS can be identified by irritability and inconsolability, a high-pitched/shrill cry, and neuromuscular irritability (eg, tremors, hypertonia). It is critical that the nurse recognizes and reports these potential symptoms of NAS because central nervous system irritability places the client at risk for life-threatening seizures. During this weaning period, the nurse must be aware of the client's respiratory status while administering opioid medications. Opioids may cause life-threatening respiratory depression, for which naloxone, an opioid antagonist that reverses the effects of opioid drugs, is usually administered. However, naloxone administration would also drastically increase CNS irritability by causing acute withdrawal in a client with NAS and may cause life-threatening seizures, making it an inappropriate prescription that requires clarification (Option 3) Methadone and morphine are opioid agonists and first-line treatments for newborns with NAS..
ACE Inhibitor quick facts
dry cough hyperkalemia increased creatinine and BUN hypotension
Buspirone, an anxiolytic medication, and diphenhydramine, an antihistamine and anticholinergic, commonly cause
dry mouth
Waiting to administer feedings postsurgical procedure until bowel sounds return helps to eliminate what complication
dumping syndrome Abdominal pain, diarrhea, nausea Hypotension/tachycardia Dizziness/confusion, fatigue, diaphoresis Timing 15-30 minutes after meals Pathogenesis Rapid emptying of hypertonic gastric contents Initial management Small/frequent meals Replace simple sugars with complex carbohydrates Incorporate high-fiber & protein-rich foods
The nurse should suspect a possible ectopic pregnancy. Abdominal pain, vaginal bleeding, and an adnexal mass are the classic triad for
ectopic pregnancy. The developing chorion produces progesterone. A normal progesterone level is > 15 ng/mL. A lower than normal progesterone level is uncommon in normal pregnancies but is very common in an ectopic pregnancy. Further testing will usually be done to confirm the diagnosis.
caput succedaneum
edema of neonate during birth from mechanical trauma Crosses suture line""" Symmetrical
What is the nursing action when someone presents with a S/E? • What is the nursing action when someone presents with a Toxic effect? o
educate the patient hold - notify provider
tricyclic antidepressants
elavil (Amitriptyline), nortriptyline, trofanil (imipramine), desipramine, clomipramine, doxepin, amoxapine. MOOD elevators A = anticholinergic (dry mouth) B = blurry vision C = constipation D = drowsiness E = euphoria 2-4 weeks to reach MAX effect
levothyroxine needs to be taken
empty stomach in morning opposite of statin
confirming placement of an endotracheal tube
end tidal Co2 (20-40mmhg) chest x-ray
Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche)
endometrial cancer
infertility risk factors
endometriosis maternal age > 35 polycystic ovarian syndrome recurrent Chlamydial infections
first sign of puberty in men
enlargement of the testes
Haemohpilus influenzae type B (HiB) vaccine is extreamly important becuase it can cuase?
epiglottitis
papular rash on babies torso which is benign and disappears within a few days
erythema toxicum neonatorum NOT concerning
Alendronate is a bisphosphonate that may cause a side effect of
esophagitis when the tablet is not completely swallowed. The client should take the drug early in the morning, 30 minutes before eating, and should remain upright during the 30 minutes before eating.
The phlebostatic axis
external anatomical point on the chest at the level of the atria of the heart (fourth intercostal space at the midaxillary line or midway point of the anterior posterior diameter of the chest). It is used as a reference point for correct placement of the zeroing point of the transducer when measuring continual arterial blood pressure (BP), central venous pressure (CVP) using a central line, and/or cardiopulmonary pressures via a pulmonary artery (Swan-Ganz) catheter. The nurse places the transducer and marks the chest at the phlebostatic axis, which helps to assure accuracy of measurement. After it is placed, the zero reference stopcock of the transducer is "leveled," or aligned with the level of the atrium, using a ruler or carpenter's level. If the zeroing stopcock is placed below this level, falsely high readings occur; if it is too high, falsely low readings are obtained. The phlebostatic axis is also used as a reference point for the upper arm when measuring BP indirectly using a noninvasive BP device or the auscultatory method with sphygmomanometer and stethoscope. If the upper arm is above or below this level, the BP reading will be inaccurate.
Myxedema coma
extreme hypothyroidism Clinical features of myxedema coma Hypothermia Hypoventilation Bradycardia Hypertension or hypotension with narrow pulse pressure Decreased mental status, psychosis, seizure & coma Nonpitting edema of hands, face & tongue Pericardial effusion Hyponatremia & hypoglycemia Possible concurrent adrenal insufficiency or hypothalamic/pituitary dysfunction
hemophilia coagulation
factor 8 Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins (ie, clotting factors). Clients with classic hemophilia (ie, hemophilia A) lack factor VIII. Clients with hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. NSAIDs (eg, ibuprofen, aspirin) should not be taken by clients with hemophilia as they inhibit platelet aggregation. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood as the child becomes active and ambulatory. The most frequent sites of internal bleeding are the joint cavities, especially the ankles, elbows, and knees. Over time, chronic swelling and deformity can occur (Option 3). Rest, ice, and elevation should be used to treat occurrences of hemarthrosis. Regular exercise and prescribed physical therapy may reduce episodes long-term.
Delusion Hallucination Illusion
false fixed belief or thought (no sensory) false fixed sensory experience misinterpretation of reality
Muscle relaxant: o Brand Generic o Lioresal Baclofen o Flexeril Cyclobenzaprine
fatigue and muscle weakness TEACH dont drink dont drive dont operate heavy machinery
4 positive signs of pregnancy
fetal HR fetal skeleton fetal presence on ultrasound examiner palpates fetal movement
thin upper lip hypotonia cognitive impairment growth restriction
fetal alcohol spectrum disorder
fetal station
fetal presenting part in relation to the ischial spines (tightest part of pevlis) POSITVE - GOOD below ischial spines tightest part
The apical pulse is best assessed by placing the diaphragm of the stethoscope at the apex of the heart/mitral area. This is located at the
fifth intercostal space on the midclavicular line. For a client who is receiving digoxin, the apical heart rate should be assessed for 1 full minute. If the heart rate is <60/min, the nurse should consider holding the dose of digoxin based on the health care provider's instructions. In addition to the apical heart rate, digoxin and potassium levels should be monitored. Digoxin has a very narrow therapeutic range (0.8-2.0 ng/mL [1.02-2.56 nmol/L]), and hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L] can potentiate digoxin toxicity (>2.0 ng/mL [>2.56 nmol/L]).
preschool 3-6 toys
fine motor skills balance cooperative play pretend play
psych tx bipolar
finger foods high calorie 8 hours sleep encourage naps
Uterus description right after birth (healthy)
firm midlines at level of umbilicus size of grape fruit by day 10 not palpable
A woman is in her 28th week gestation. She gained 22 lbs, what is your impression? • Using the long method
first 12 weeks = 3 13-28 = 16 19lbs SHE had extra 3 lbs therefore = assess patient
Nagele's rule
first day last mensural period add 7 days subtract 3 months
Hydroxyzine
first-generation antihistamine similar to diphenhydramine and chlorpheniramine. Anticholinergic adverse effects (eg, urinary retention, dry mouth, constipation, blurred vision) are common.
Methotrexate (Rheumatrex)
folate antimetabolite, antineoplastic, immunosuppressant drug to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) to treat rheumatoid arthritis and psoriasis. (Option 1) Methotrexate is an immunosuppressant and can cause bone marrow suppression. Clients are at risk for infection. They should avoid crowded places and individuals with known infection and should receive appropriate killed (inactivated) vaccines (eg, influenza, pneumococcal). Live vaccines (eg, herpes zoster) are contraindicated. (Option 2) Clients should not become pregnant while taking methotrexate or for at least 3 months after it is discontinued as the drug is teratogenic and can cause congenital abnormalities and fetal death. (Option 4) Clients taking methotrexate should avoid alcohol as the prescription drug is hepatotoxic and drinking alcohol increases the risk for hepatotoxicity.
When is the McRoberts maneuver used?
for shoulder dystocia to straighten the sacrum suprapubic pressure
swing through
for two braced extremities (amputees)
Broca aphasia
frontal lobe
types of psychosis
functional dementia delirium
3 MOST important parts of the fetal assessment include?
fundus lochia thrombophlebitis
3 big postpartum questions
fundus lochia thrombophlebitis
Cryptococcosis pneumonia
fungal infection not transmitted from human to human. Rather, this infection is opportunistic for individuals who are significantly immunocompromised. Standard precautions are necessary, which involve appropriate hand hygiene. Cryptococcus neoformans is a fungal infection that is pathogenic for immunocompromised individuals. This pathogen is not transmitted from person to person and may trigger either pneumonia or meningitis. Individuals with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) are at significant risk for this infection if their CD4 count is significantly depressed. Treatment includes antifungals such as fluconazole.
4 month old expected milestones
gains head control when held holds objects placed in hand makes cooing sounds turns head to caregivers voice tracks caregiver with eyes
lyphoma
general term applied to malignancies that develop in the lymphatic system
phenytoin toxicity
gingival hyperplasia
Phenytoin (Dilantin) adverse effects
gingival hyperplasia; CNS depression; skin rash; cardiac dysrhythmias; hypotension; narrow therapeutic index
surfactant
given after baby is born given transtracheal
sterile gloving
glove dominant hand first grasp outside of cuff touch only the inside surface of glove space do not roll cuff fingers inside second glove cuff keep thumb abducted only touch outside surface of glove
Thoracic spinal injury
gut abdominal muscles assess cough and bowels complications = pneumonia (cant cough) Paralytic ileus (no bowel movement)
Typical Antipsychotics include
haloperidol loxapine pimozide thiothixene Side effects A (anticholinergic dry mouth) B (blurred vision- bladder rentetion) C (constipation) D (drowsiness) E (extrapyramidal tremors parkinsonian) F (photosensitivity skin burns) G (agranulocytosis immunocompromised) SORE THROAT BAD
4 questions to ask your self when you see inappropriate behavior
harm to pt or staff? illegal? legal/not harmful BUT not Correct?
Herpes zoster, or shingles
has a characteristic unilateral, linear pattern of fluid-filled blisters. Affected clients commonly report pain and itching. Herpes zoster infection is due to the varicella-zoster virus (VZV), which also causes chickenpox. After initial VZV infection (chickenpox) in early childhood, the virus remains dormant in the sensory nerves. Reactivation of VZV when the immune system is compromised (eg, aging, immunosuppression) results in the formation of lesions along the distribution of one or more such nerves (dermatomal distribution). Vaccination can prevent shingles.
Methylergonovine
is an alkaloid medication used to manage postpartum hemorrhage (PPH). This medication causes vasoconstriction, therefore, decreasing postpartum bleeding.
Carbamazepine
is an anticonvulsant indicated for bipolar disorders as it has a mood-stabilizing effect.
Epiglottitis
has manifestations that have an abrupt onset that may progress rapidly. Various pathogens may cause epiglottitis, but the most common one is Haemophilus influenzae. The manifestations associated with epiglottitis include dysphagia, inspiratory stridor that is worse when the child is supine, restlessness, high fever, tachycardia, and tachypnea. The voice is thick and muffled, with a froglike croaking sound on inspiration. This condition may be life-threatening if not treated with antibiotics, humidified oxygen, corticosteroids, and parenteral fluids. Airway protection is essential because it may become so progressive that it causes airway obstruction. Epiglottitis does not feature a cough which is a crucial distinguishment between laryngotracheobronchitis .✓ Epiglottis is a cartilaginous flap present at the back of the throat ✓ Its primary function is to close over the airway during swallowing so that the food does not enter the airway ✓ Acute epiglottitis is a medical emergency that has an abrupt onset ✓ In epiglottitis, the epiglottis becomes inflamed and swollen and constructs the airway ✓ Classic epiglottis symptoms include sore throat and, pain in swallowing, fever. The child insists on sitting upright and leaning forward (tripod position), with the chin thrust out, mouth open, and tongue protruding. Drooling of saliva, red and inflamed mucous membranes, large, cherry red, edematous epiglottis ✓ Prevention: Key prevention for epiglottitis is immunization with H. influenzae type B conjugate beginning at two months of age
toddler physical
have parent stay and comfort go from most to least invasive
Asterixis is a hand flapping tremor that may be elicited by
having the client close their eyes, extend their arms, dorsiflex their wrist, and spread their fingers. End-stage renal disease causes azotemia and may trigger this unilateral or bilateral tremor in end-stage renal disease. While this tremor is poorly understood, it is likely the accumulation of nitrogenous waste that contributes to the development of this action. This tremor has also been associated with moderate to severe hepatic encephalopathy.
advanced care planning includes
health care proxy (durable power of attorney for health) Living will (life sustaining treatments)
Kalemias do the same as the prefix except for
heart rate and urine output
Hemophilia common long term complication?
hemarthrosis chronic swelling in joints can lead to deformity
4 pt's always unstable
hemorrhage hypoglycemia fever > 104 pulselessness or breathlessness
Central line facts
heparin flush used to maintain patency at 10-100units NO 1000-10000 this for DVT TPN should be administered through a CVC only different from PICC due to where it is inserted (neck or chest) occlusive dressing changed every 7 days distal port best used for monitor Central venous pressure
omphalocele
herniation at the umbilicus (a part of the intestine protrudes through the abdominal wall at birth)
resp alkalosis means ventilator is set to
high
Methylergonovine [Methergine] is contraindicated for clients with
high blood pressure (eg, preeclampsia, preexisting hypertension) because the primary mechanism of action is vasoconstriction. If administered to a hypertensive client, it can lead to further blood pressure elevation, seizure, or stroke
What labs to expect with liver cirhosis
high serum ammonia low serum albumin elevated INR - PT elevated AST ALT
Ketorolac (Toradol)
highly potent nonsteroidal anti-inflammatory drug (NSAID) often used for pain and available in intravenous form. However, NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given 2 types of NSAIDs simultaneously (eg, naproxen plus ibuprofen) as they can be toxic to the stomach and kidneys.
2 month old expected milestones
holds head up when prone open and close hands startles to loud noise smiles in response to smiling and talking
Infants with myelomeningocele are at increased risk for
hydrocephalus
Hydroxychloroquine (Plaquenil)
is an antimalarial drug, but it is more commonly prescribed to reduce fatigue and treat the skin and arthritic (eg, joint inflammation, pain) manifestations of systemic lupus erythematosus (SLE). Hydroxychloroquine can also help to reduce lupus exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent. Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. take with food
Fundal height cannot be palpated until
week 12 o That when the fundus is midway between the umbilicus and the pubic symphysis • The fundus can be palpated at the umbilicus between 20 and 22 weeks
The nurse assesses a client with Cushing syndrome. Which of the following clinical manifestations should the nurse expect? Select all that apply. 1.Hyperglycemia 2.Hypertension 3.Hyponatremia 4.Truncal obesity 5.Weight loss
hyperglycemia truncal obesity hypertension Cushing syndrome is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids. The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other conditions. However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the adrenal glands to produce too much cortisol. Clinical manifestations of Cushing syndrome include: Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg, oligomenorrhea). Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension, and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis). Fat accumulation in the face (ie, moon face) and the back of neck (ie, dorsocervical fat pad) is common (Options 1, 2, and 4). Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen. Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in untreated clients.
Total parenteral nutrition (TPN) is an IV nutrition feeding that may be prescribed to clients with dysfunction of the gastrointestinal tract (eg, short bowel). Glucose (dextrose) is a primary component of TPN solutions; therefore, the nurse should monitor blood glucose and assess for symptoms of
hyperglycemia (eg, polydipsia, polyuria, headaches, blurred vision). A urine output of 4800 mL over the past 12 hours (ie, 400 mL/hr) may indicate hyperglycemia (Option 3). Symptomatic clients should be assessed and treated immediately because hyperglycemia can lead to seizures, coma, or death.
ARB's and ACE's potentiate
hyperkalemia
Magnesium sulfate
hypermagnesemia - high mag makes everything go down - so will everything lessen - low HR low BP reflexes 0-1 - LOC down - RR down Respiratory and reflexes most important to know lowers both of them
Calcium acetate can be used for
hyperphosphatemia > 4.5 (3.0-4.5)
contraindication to kidney biopsy
hypertension highly vascular organ blood flow can cause bleed EXPECTED creatinine >1.2 (renal failure) low hemoglobin and hematocrit NO erythropoieten (renal failure)
Two signs of neuromuscular irritability associated with?
hypocalcemia Chvostek's sign - cheek tap - facial spasm trousseau's sign - BP cuff - carpal spasm
symptoms often manifest as numbness and tingling of the lips and hands, tetany, carpopedal spasms (Trousseau's sign), Chvostek's sign, and/or muscle/abdominal cramps. ECG analysis often reveals changes in the T waves and prolonged QT intervals
hypocalcemia hypoparathyroid
pH up
hypokalemia tachycardia tachypnea HTN borborygmic seizures irritability hyperreflexia PH UP SO GOES MY PT EXCEPT FOR HYPOKALEMIA
✓ Hypertonic solutions are utilized for severe
hyponatremia and cerebral edema. They should always be given via an intravenous pump ✓ Hypertonic solutions include 5% Dextrose and Lactated Ringer's (D5LR), 3% saline, 5% Dextrose and 0.45% Sodium Chloride Injection, and total parenteral nutrition (TPN)
positive end-expiratory pressure (PEEP) side effect
hypotension ✓ PEEP is a setting that may be added to a mechanical ventilator, CPAP, or BiPAP ✓ PEEP is commonly prescribed for clients with acute respiratory distress syndrome (ARDS) because PEEP prevents alveolar collapse, allowing for better gas exchange, thus, improving oxygenation ✓ By improving gas exchange, therapeutically, the client will enjoy increased oxygen and less lactic acid from the stress of breathing (clients with low pulmonary compliance will have an increase in their breathing, thus, creating lactate and sending the client into acidosis ✓ PEEP can cause decreased venous return and lower the mean arterial pressure ✓ The blood pressure should be monitored closely for a client receiving PEEP because of the risk of hypotension ✓ PEEP also raises the client's risk for a stress ulcer ✓ 5-15 cm H2O is the range for PEEP that may be adjusted
ALL psych drugs cause
hypotension weight changes primary weight gain
D5W
hypotonic solution (although it goes in isotonic, it then becomes hypotonic) and raises blood glucose while restoring intracellular volume. D5W provides an individual with water and some calories. Prolonged use of this fluid may cause hyperglycemia and hyponatremia.
0.45% sodium chloride
hypotonic solution (ie, osmolality less than extracellular fluid) that promotes movement of fluid from the extracellular intravascular space to the intracellular space. Hypotonic solutions can worsen edema in clients with APGN and lead to life-threatening pulmonary or cerebral edema
Infants with underlying infection and increased intracranial pressure (ICP)
ill be very irritable and have fever and a high-pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanelles. The 3-month-old needs to be seen first due to the potential for bacterial meningitis. If bacterial meningitis is suspected, droplet precautions should be initiated and the infant should be treated
Baclofen
is an antispasmodic drug commonly prescribed to clients with multiple sclerosis to relieve uncomfortable spasms and muscular pain. Dizziness when attempting to stand or changing positions (ie, orthostatic hypotension) is a common adverse effect but is not a contraindication
Cushing's triad
is related to increased intracranial pressure (ICP). Early signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure (difference between systolic and diastolic), and slowed irregular (Cheyne-Stokes) respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression.
Acute rheumatic fever (ARF)
immune-mediated inflammatory condition that occurs several weeks following untreated group A Streptococcus infection (ie, strep throat). Manifestations include fever, joint pain, erythematous rash (ie, erythema marginatum), cardiac involvement (eg, carditis), and involuntary jerking movements of the arms and legs (ie, chorea). Strawberry tongue is not characteristic of ARF. Anticipated interventions for a client with acute rheumatic fever (ARF) include: Assessing the client for penicillin allergies: Penicillin is the first-line treatment for group A Streptococcus (GAS) infection and ARF. Providing activities for the client to perform while resting in bed: Fatigue, joint pain, and involuntary jerking movements (ie, chorea) make physical activity difficult and increase the risk for injury. The nurse should encourage bed rest and provide the client with quiet, age-appropriate activities until symptoms subside.
Methotrexate (Rheumatrex)
immunosuppressant tx: RA and psoriasis s/sx: bone marrow suppression, increased risk for infection, education: avoid large groups, people with infections, receive inactivated vaccines (flue and pneumococcal) NO live (herpes voter) NO preggos, and NO ETOH r/t hepatotoxic side effects
cyclosporine
immunosuppressant prescribed to manage rheumatoid arthritis (RA) and psoriasis, and to prevent transplant rejection. This medication inhibits the normal immune response by interfering with T cell response, which slows the progression of certain autoimmune diseases. Clients taking cyclosporine have an increased risk for infection and are instructed to avoid large crowds (eg, concerts, movie theaters) and known sick contacts (Option 1). It can take 1-2 months for the full effect of therapy and relief of symptoms from autoimmune disease (eg, joint stiffness in RA, psoriasis symptoms) to occur. considerations - NO grape fruit juice - Nephrotoxicity and HTN - gingival hyperplasia (proper oral care)
uterine atony
inability of the uterine muscle to contract adequately following birth leads to vaginal bleeding and postpartum hemorrhage = fundal massage will stimulate the uterus to contract
Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L
include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria. B. Manifestations of lithium toxicity with levels above 2.5 mEq/L include seizures and oliguria. For levels above 3.5 mg/dL, delirium, cardiovascular collapse, coma, and death can occur. C. Nausea, vomiting, diarrhea, and lethargy are early manifestations of lithium toxicity. These manifestations are common with lithium levels between 1.0 and 1.5 mEq/L.
Albuterol is a beta-adrenergic agonist; thus, this medication would cause an
increase in blood pressure and heart rate
albuterol considerations
increases HR dry mouth can occur palpitations tremors hyperglycemia HYPOKALEMIA
norepinephrine and glucose
increases blood glucose
oxytocics
induce labor oxytocin-pitocin - uterine stimulation STOP if >90 or <2 minutes cervidil (prostaglandin) dilates cervix - s/e uterine hyperstimulation
Hepatitis B virus
infection is a bloodborne disease that poses a significant risk to the newborn because of exposure to maternal blood and bodily fluids during birth. Interventions to prevent maternal-to-newborn transmission after birth include administration of the hepatitis B vaccine and administration of hepatitis B immune globulin (HBIG) within 12 hours of birth. Clients who desire to breast-feed should be encouraged to do so if possible because very few absolute contraindications to breastfeeding exist. Breastfeeding has not been shown to affect newborn hepatitis B infection rates and is not contraindicated if the client's nipples are intact (eg, not bleeding) and immunoprophylaxis (ie, HBIG, hepatitis B vaccine) is appropriately administered. Therefore, the nurse's statement regarding formula feeding would require follow-up
Carbidopa-levodopa
is prescribed to decrease symptoms of Parkinson disease (eg, bradykinesia, tremor, rigidity). Orthostatic hypotension is an adverse effect of the drug and may also occur from disease-related autonomic nervous system dysfunction. This client should be taught to slowly change positions; this is not the priority action. """"Change in urine color
position after liver biopsy
lie on R side for 2 hrs and then supine
Preeclampsia occurs with HBP after
week 20 gestation
Extraversion vs infiltration
infiltration: ✓ Infiltration occurs when the intravenous catheter migrates out of the vein. ✓ The intravenous catheter migration is often caused by the catheter not being secured to the client's skin. ✓ When infiltration occurs, the medication leaks into the tissues around the vein. ✓ Manifestations of infiltration include swelling, coolness, tingling, or redness at the IV site. ✓ Treatment for infiltration includes pausing the infusion, discontinuing the IV catheter, and elevating the extremity above the heart. Extraversion ✓ Extravasation is significantly worse than infiltration because the medication leaks into the surrounding tissue, and the medication is a vesicant. ✓ A vesicant is a medication with a low pH or may cause significant irritation to the surrounding tissue. ✓ If extravasation occurs, the nurse should pause the infusion and aspirate any medication in the IV catheter. ✓ The nurse should not flush the IV catheter, which will further cause more damage. The catheter should be discontinued, and the physician should be notified.
Gastroenteritis
inflammation of the gastric and intestinal mucosa, most often caused by a virus (eg, norovirus, adenovirus, rotavirus). Clinical manifestations include fever, vomiting, and changes in stool consistency and color (ie, loose, watery stools). Gastroenteritis increases the child's risk for dehydration; therefore, the nurse should monitor fluid and electrolyte balances and administer IV fluids if dehydration is suspected.
droplet percaution
influenza meningitis diphtheria pertussis Mumps private room mask gloves handwashing disposable supplies wear mask when leaving room
abdominal assessment sequence
inspection, auscultation, percussion, palpation
quick and NOT permanent way to decrease K
insulin and d5W
Stage 1 pressure ulcer
intact skin with nonblanchable redness epidermis stays intact Stage I: no tissue loss; the epidermis is intact but reddened and does not blanch. Stage II: partial-thickness skin loss; the dermis is exposed, but the adipose tissue is not. The ulcer bed is pink or red without eschar. Stage III: full-thickness skin loss; the adipose tissue (subcutaneous fat) is visible. Muscle, tendon, and/ or bone are not visible. Stage IV: full-thickness skin and tissue loss; muscle, tendon, and/ or bone are visible. Unstageable: there is full-thickness tissue loss. However, the actual depth of the pressure ulcer is obscured by slough or eschar. The actual depth cannot be assessed until the slough or eschar is removed. Once the slough and/ or eschar is removed, a Stage 3 or 4 pressure ulcer can be revealed. Suspected deep tissue injury (sDTI): purple or maroon localized area of discolored intact skin or blood-filled blister. This results from damage to underlying soft tissue from prolonged pressure and/or shear.
occiput posterior (OP) position
intense lower back pain during contractions, sometimes called "back labor." This is because the fetal occiput exerts added pressure on the client's sacrum during contractions. Therefore, the nurse should suspect that the fetus is in an OP position such as the right occiput posterior (ROP) position (Option 1). The hands and knees position or sacral counterpressure helps to decrease back pain and facilitate fetal rotation into an occiput anterior position.
Corticosteroids (eg, prednisone) and bone formation
interfere with the absorption of calcium and vitamin D and are not anticipated for the treatment of osteoporosis. Long-term corticosteroid use increases the risk for osteoporosis..
see a nurse causing harm to pt what do you do?
intervene IMMEDIATELY
Hypotonic solutions are utilized for
intracellular dehydration and hypernatremia ✓ Hypotonic solutions include: 0.45% Sodium Chloride (0.45% NaCl) 5% Dextrose in Water (D5W) - D5W may be referred to as both isotonic and hypotonic based on the context. Please note that D5W enters the body as isotonic and quickly becomes hypotonic as the liver rapidly metabolizes glucose. Thus, D5W is a hypotonic solution inside the body
Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate
intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be brought to the emergency department for further evaluation.
✓ Hydralazine
is primarily an arteriolar vasodilation. ✓ The nurse should take the client's blood pressure before administering this medication. ✓ The client is at risk for falls with this medication related to orthostatic hypotension. ✓ Hydralazine toxicity or overdose produces hypotension, tachycardia, headache, and generalized skin flushing. ✓ Reflex tachycardia may occur with this medication because as the blood pressure declines, the heart rate will increase to maintain cardiac output.
Hemophilia
is a bleeding disorder caused by a deficiency in coagulation proteins that increases the risk for bleeding. Generally, the nurse should avoid procedures that can cause bleeding (eg, IM injections, rectal temperatures, heel sticks). However, clients with hemophilia should receive all recommended vaccinations via the subcutaneous and/or IM route, as indicated. Interventions to reduce the risk for bleeding with the administration of vaccines include: Applying firm, continuous pressure and/or ice at the site for 5 minutes (Option 3) Using the smallest gauge and needle length indicated when administering the vaccine (Option 5) Limiting the number of injections per extremity Scheduling vaccine administration soon after factor VIII administration (Option 1) Clients with hemophilia should avoid aspirin and NSAIDs (eg, ibuprofen) due to the risk for bleeding. Acetaminophen is recommended for pain relief. (Options 2 and 4) Applying a warm compress causes vasodilation and can prolong bleeding. Superficial bleeding can be controlled using ice packs, which promote vasoconstriction. Firm pressure should be held on the site without rubbing or massaging, which can cause bleeding and hematoma formation.
Theophylline
is a bronchodilator that works as a long-term medication for asthma. This medication must be taken regularly to be effective and does not work immediately so would not be useful if only taken prior to exercising.
A central venous access device (CVAD) (eg, peripherally inserted central catheter, central venous catheter)
is a catheter inserted into a large vein (eg, internal jugular, femoral) to administer medications, collect blood samples, or monitor central venous pressure. Sterile technique during insertion reduces the risk of central line-associated bloodstream infections. When assisting with CVAD placement, the nurse: Completes a safety checklist (eg, verifies consent and client identifiers) prior to the procedure (Option 5) Limits traffic in and out of the room (Option 2) Assists the health care provider (HCP) in establishing a sterile field with maximal barrier precautions (eg, head-to-toe sterile drape, sterile gowns). All individuals in the room, including the nurse and HCP, must wear face masks (Option 4). Places a sterile, occlusive dressing as soon as the CVAD is in place (Option 1) Maintains a sterile environment, monitors the client, and assists the HCP as needed
Polycystic Kidney Disease
is a genetic disorder manifested by fluid-filled cysts that grow on the kidneys. Additional findings in PKD include: • Abdominal or flank pain • Hypertension • Nocturia • Frequent urinary tract infections • Increased abdominal girth • Constipation • Hematuria (bloody urine) • Sodium wasting and inability to concentrate urine in the early stage • Progression to kidney failure with anuria
Impetigo
is a highly contagious bacterial infection of the skin that initially manifests as erythematous fluid-filled lesions (ie, vesicles [<1 cm] or bullae [>1 cm]) on exposed areas (eg, face, limbs). As the vesicles or bullae rupture, the characteristic honey-colored crust forms. Primary impetigo can develop in previously healthy skin; however, secondary impetigo (the most common form) usually occurs in areas where the skin barrier is already impaired (eg, eczema, abrasions). HONEY CRUSTED LESIONS crusted lesions erythema contagious blisters or vesicles
✓ Syphilis
is a highly contagious sexually transmitted infection. ✓ Different stages are found in this infection and are classically marked by a chancre in the primary stage, a diffuse rash in the secondary stage, and systemic cardiovascular abnormalities in the tertiary stage. ✓ Treatment is through prescribed antibiotics such as doxycycline, or penicillin G. ✓ Nursing care aims to educate the client on preventative measures such as using condoms. ✓ This sexually transmitted infection is required to be reported to the public health department. An RPR is a common screening test for syphilis infections. This test is often confirmed with a fluorescent treponemal antibody absorption (FTA-ABS) test.
Herpes simplex virus type 1
is a life-long viral infection with periods of dormancy and flares (often triggered by stress or illness). Initial infection may cause gingivostomatitis (ie, painful oral lesions), pharyngitis, lymphadenopathy, fever, and malaise. HSV-1 is most contagious during flares and clients may experience a recurrence of painful, erythematous, vesicular lesions around the mouth (ie, cold sores). Lesions frequently begin with an itching or tingling sensation (due to being dormant in dorsal nerve ganglia) and then rupture to form a crust. crusted lesions erythema contagious tingling sensation blisters or vesicles
Valproic acid
is a mood stabilizer, and when administered IV, it can resolve manic episodes quite quickly. Valproic acid is prescribed to ameliorate mania symptoms (psychomotor agitation, affect, speech, etc.). ✓ VPA is indicated in preventing seizures, treatment for bipolar disorder, and migraine headache prevention ✓ The most common adverse effects of VPA include nausea, vomiting, blood dyscrasias, hair loss, and metabolic syndrome ✓ The liver enzymes should be monitored while a client takes VPA, as hepatic injury may occur ✓ The therapeutic level of VPA is 50-125 mcg/mL
Acute Kawasaki disease (AKD)
is a noncontagious disease that primarily occurs during childhood and causes systemic inflammation of arterial walls (ie, vasculitis). Manifestations include persistent fever, joint pain, strawberry tongue (ie, mucositis), erythematous polymorphous rash, peeling skin on the hands, bilateral reddened conjunctivae, and cardiac involvement (eg, coronary aneurysm). Involuntary movements of the arms and legs is not characteristic of AKD.
Poststreptococcal glomerulonephritis (PSGN)
is a noninfectious kidney disease that occurs when immune complexes are deposited in the glomeruli following infection with certain strains of group A beta-hemolytic Streptococcus, resulting in decreased glomerular filtration. Clinical manifestations of PSGN can occur up to 6 weeks after the initial infection and include hematuria, proteinuria, tachycardia, nausea, and vomiting.
Cilostazol
is a phosphodiesterase inhibitor approved to treat peripheral arterial disease. Its action mechanism decreases platelet aggregation and promotes vasodilation, allowing a client to ambulate distances without pain.
Induration of 15 mm or more:
is a positive test in any person. This includes even healthy clients with no TB risk factors
Electroconvulsive therapy (ECT)
is a procedure in which the client receives an electrical current via electrodes placed on the temples to induce a brief seizure. It can be used to treat clients with mood disorders (eg, major depression, bipolar disorder) or schizophrenia.
Tidaling in the water seal chamber is a
normal finding when a client has a chest tube
Myasthenia gravis (MG)
is an autoimmune neuromuscular disease that involves the attack of acetylcholine receptors by autoantibodies at the neuromuscular junction. The deficit acetylcholine receptors cause fluctuating skeletal muscle weakness and fatigue. Myasthenic crisis is an exacerbation of MG due to disease progression, deficiency in anticholinesterase, illness, or stress. Interventions to manage MG and prevent myasthenic crisis at home include: Eating semisolid (easily-chewed) foods instead of solids or liquids to conserve energy and prevent choking/aspiration (Option 1) Receiving an annual flu vaccine to prevent infection and undue stress on the respiratory system and muscles (Option 2) Treatment Acetylcholinesterase inhibitors (eg, pyridostigmine) Thymectomy Taking acetylcholinesterase inhibitors (eg, pyridostigmine, neostigmine) before meals so that peak effects of the medication help the client to eat and swallow food (Option 5)
Azathioprine
is an immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as inflammatory bowel diseases (eg, Crohn disease) and to prevent organ transplant rejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. However, leukopenia (white blood cell count <4,000/mm3 [4 × 109/L]) can be a severe adverse effect of the drug and should be reported to the health care provider before administering the medication due to high risk for infection
Hepatitis A
is an infection contracted through the consumption of raw or undercooked food, fecal-oral route, or contaminated water. Most cases are self-limiting with complete clinical recovery within three to six months. Vaccination for hepatitis A is a two-dose series beginning as early as six months for international travel; 12 months for routine vaccination.
Neuroleptic Malignant Syndrome
is an insidious autonomic reaction that adversely causes muscle rigidity, tachycardia, and pyrexia. NMS is commonly triggered by antipsychotics and causes hyporeflexia;
Meperidine (eg, Demerol)
is an opioid analgesic that may cause newborn respiratory depression if administered close to the time of birth. The nurse should follow up with the health care provider to determine if this medication is still appropriate because the client may have advanced too far in labor to safely administer it.
Systemic lupus erythematosus (SLE)
is associated with an elevated risk of lupus nephritis, a severe complication in which the immune system attacks the kidneys. In addition to signs and symptoms associated with SLE, clients with lupus nephritis will often exhibit or report foamy urine (due to the amount of protein in the urine) and possibly hematuria. Once these findings are reported to the nurse, the nurse should perform an additional assessment, assessing the client for possible renal involvement or dysfunction. The nurse should then alert the health care provider (HCP) of these findings and initiate further diagnostic testing as ordered.
Herpes simplex virus (HSV)
is both sexually and non-sexually transmitted. The client often experiences the worst symptoms during the initial outbreak, which include headache, malaise, fever, and localized lymphadenopathy. Following these prodromal symptoms, painful skin eruptions occur, putting the client at higher risk of transmitting the infection. The client should be educated that even when an outbreak is not present, they risk infecting others with the virus. Medications to manage outbreaks are best taken early and include valacyclovir.
The petit mal (or absence) seizure
is characterized by blank staring and an impaired level of consciousness. This type of seizure usually begins between the ages of 3 and 15 years.
Trigeminal neuralgia
is characterized by intermittent severe, unilateral facial pain precipitated by light touch, hot or cold foods, chewing, and swallowing. This client may require a change in treatment regimen (eg, carbamazepine, gabapentin, baclofen) for improved pain relief.
Laryngotracheobronchitis (croup)
is commonly caused by a viral infection (influenza types A and B, adenovirus, RSV, and measles) that is slowly progressive. It typically features a brassy (barking) cough, hoarseness, restlessness because of the frequent coughing, low-grade fever, and inspiratory stridor. Treatment is with corticosteroids, fluids, and nebulized epinephrine in severe cases. Laryngotracheobronchitis does not feature a primary complaint of throat pain or dysphagia. The common feature of this condition is that the client sounds worse than they feel. This condition does not feature drooling or difficulty while in the supine position.
✓ The appropriate sequence for doffing PPE
is gloves, face shield or goggles, gown, and mask or respirator.
Appendicitis
is inflammation of the appendix that is commonly caused by obstruction of the appendiceal lumen (eg, hard fecal matter). Obstruction causes luminal distension, mucus collection, and vascular compression/thrombosis within the appendix, which then leads to tissue ischemia, necrosis, and infection. Characteristic abdominal pain begins in the umbilical area and migrates to the right lower quadrant (ie, McBurney point). The body's inflammatory response to appendicitis causes leukocytosis, tachycardia, and fever. Distension and pressure within the intestine induce nausea, vomiting, and anorexia.
Pericarditis
is inflammation of the membrane surrounding the heart (ie, pericardium) commonly caused by viral infections but can occur following recent MI and surgery. Pericarditis is characterized by pleuritic chest pain (sharp, worsens with deep breathing) that is typically relieved by sitting up and leaning forward. This position relieves pressure on the inflamed pericardium, especially during lung inflation. Manifestations include pericardial friction rub (ie, grating, squeaky sound auscultated over the chest wall) and ST-segment elevation on ECG due to inflammation of the pericardium.
Coarctation of the aorta
is narrowing of the descending aorta, which results in increased blood flow to the upper extremities and decreased blood flow to the lower extremities. Because the client's blood pressure and pulses are equal in all four extremities, TOF is more likely.
Sumatriptan
is prescribed for moderate to severe, acute migraine headaches that are characterized by severe pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting. The client with uncontrolled migraine headaches requires a change in treatment regimen (eg, ergotamine)
central venous pressure
normal: 2-8 mm Hg
succinylcholine
is sometimes preceded by muscle spasms, which may damage muscles. These muscle spasms cause the release of potassium which may lead to hyperkalemia. Prolonged exposure to this medication may lead to hyperkalemia, and this medication should not be used if the client already has hyperkalemia. Finally, this medication may cause malignant hyperthermia. If a client develops a significant fever, muscle rigidity, and tachycardia, immediate treatment must be implemented
Radioactive iodine (RAI)
is the primary treatment for nonpregnant adults with hyperthyroidism who do not respond to antithyroid medication. RAI destroys the thyroid gland, which prevents thyroid hormone secretion. Following RAI therapy, the client will emit radiation through bodily fluids (eg, saliva, urine). The length of time varies depending on the dose received. Appropriate home precautions to reduce radiation exposure to others include: Avoiding sharing utensils Washing clothes separately Sleeping in a separate bedroom Delaying pregnancy attempts for 4-6 months Using a separate bathroom and flushing at least 3 times with every use The client is the most radioactive during the first week following RAI. During that time, the client should limit contact with others, especially pregnant women and children, to minimize radiation exposure. It is not appropriate to hold a child 2 hours after receiving RAI.
Acute angle-closure glaucoma (ACG)
is the sudden onset of increased intraocular pressure (IOP) due to impaired aqueous humor drainage through the angle of the anterior chamber. Acute ACG typically occurs spontaneously but may be triggered by impaired aqueous outflow from pupillary dilatation (eg, emotional excitement, medications [decongestants, anticholinergics, antihistamines], darkness). As IOP increases, clients develop blurry vision, unilateral headache, conjunctival redness, nausea and vomiting, and/or report seeing halos around lights. Increased IOP damages the optic nerve, and the cornea becomes edematous; therefore, light cannot travel effectively from the cornea to the optic nerve, causing halos to be seen.
Perimenopause
is the transitional phase preceding menopause when ovarian function declines and estrogen levels decrease, suppressing ovulation and resulting in amenorrhea. Because estrogen is responsible for supporting secondary sex characteristics (eg, hair growth, breast development, vaginal tissue), decreased estrogen leads to characteristic menopausal changes, including hair loss, vaginal dryness, and breast tenderness. Weight gain (particularly around the abdomen) may also occur due to decreased metabolism.
MAOI's
isocarboxazid [Marplan], phenelzine [Nardil], tranylcypromine [Parnate]
TB drugs with liver damage possibility
isoniazid pyrazinamide rifampin (ORANGE) NO LIKELY ethambutol BUT OPTIC effects
Liver failure effects
jaundice, ascites, coagulopathy, hepatic ecephalopathy
Seizure pharmacologic interventions
keppra - carbamazepine - valporic acid - phenytoin (10-20) -----PREVENTION TO immediately stop status epilepticus administer and benzodiazepine
what activities would you expect a 2 year old to perform?
kick large ball walk without help use two word phrases parallel play
extracorporeal shock wave lithotripsy (ESWL)
kidney stone break down After an ESWL procedure, the client should be instructed to: Increase fluid intake to help flush out the kidney stone fragments (Option 3). Expect some bruising and pain of the back and/or flank of the affected side. Analgesics may be required (Option 5). Expect to see blood in the urine (hematuria). Urine color should progress from bright red to pink-tinged during the first several hours. Hematuria is concerning if the urine remains bright red for a prolonged period (eg, >24 hours) (Option 4). Report any symptoms of infection (eg, fever, chills) to the health care provider (Option 1).
What happens to calcium in chronic kidney disease?
kidneys not able to convert vitamin D into its active form that allows for calcium absorption Parathyroid in response tries to adapt by secreting calcium
HIGH pressure alarm on ventilator
kinked condensation in tubing obstruction biting increased airway resistance decreased lung compliance (pneumothorax, atelectasis, pulmonary edema, acute respiratory distress syndrome) ventilator dyssynchrony
labor complication with severe back pain interventions
knee to chest can apply counter pressure to sacrum
Phases of stage 1 of labor dilation frequency of contractions duration of contractions
latent - 0-4cms - contraction frequency: 5-30 minutes apart - contraction duration: 15 30 seconds active - 5-7cms - contraction frequency: 3-5 minutes apart - contraction duration: 30-60 seconds transition - 8-10cms - contraction frequency: 2-3 minutes apart - contraction duration: 60-90 seconds
AIDS Cd4 count
less than 200
when to hold digoxin in infant
less than 90
Names for low WBC
leukopenia neutropenia immunosuppression agranulocytosis bone marrow suppression
Disseminated intravascular coagulation (DIC)
life-threatening disorder characterized by widespread activation of the coagulation cascade, causing abnormal clot formation and hemorrhage due to consumption of clotting factors and platelets. Clients are in a hypercoagulable state during pregnancy, which increases the risk for DIC. Obstetric complications (eg, placental abruption) are often the underlying cause of DIC. Manifestations include external bleeding (eg, gums, nose, IV sites), internal bleeding (eg, petechiae, ecchymosis), and organ damage from clot formation (ie, respiratory distress, renal insufficiency). Care is supportive and focuses on treating the underlying cause. Indicated interventions include: Performing frequent fundal massage to stimulate uterine contractions and decrease bleeding. Inserting a urinary catheter to monitor renal function (ie, urine output) and prevent bladder distension that may contribute to hemorrhage. Preparing for rapid transfusion of blood products (ie, fresh frozen plasma, platelets) to replace clotting factors and reduce blood loss. Administering high-flow oxygen (ie, via nonrebreather face mask) to increase oxygen delivery.
resp acidosis means vent is set to
low
Wernicke-Korsakoff syndrome
low vitamin B1(thiamine) psychosis confabulations and amnesia (memory loss) 1. preventable take vitamin B1 thiamine 2. arrestable take vitamin 3. irreversible (kills brain cells)
Calcium gluconate is the antidote for
magnesium toxicity but is not currently indicated by this client's condition.
The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions? Select all that apply. Major Depressive Disorder Attention Deficit Hyperactivity Disorder Obsessive-Compulsive Disorder Generalized Anxiety Disorder Bipolar Disorder
major depressive disorder obsessive compulsive disorder generalized anxiety disorder
inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia) can lead to?
malignant hyperthermia
Retinoblastoma
malignant neoplasm of primitive retinal cells absent red reflex strabismus (misalignment of eyes) white pupil
June 10 -15 last menstrual period when is the estimated date of delivery
march 17
5-Aminosalicylic acid (5-ASA)
may be prescribed via enema to reduce inflammation in the large intestine.
Preoperational Stage (Piaget) 2-7
may blame themselves
sevelamer, lanthanum carbonate, calcium acetate
meal time phosphate binders that can be prescribed when TLS is present and there is an abundance of phosphate with low CA
airborne
measles TB chicken pox (vasricella) private room mask when outside room pt specialty respirator mask wear mask when leaving room disposable supplies negative airflow
fresh post op beats _ or __
medical other surgical
pregnancy exposure to cytomegalovirus - alcohol - valproic acid?
microcephaly and cleft palate can occur
give emergency epi injection at
mid out thigh close can be on
earliest sign of electrolyte imbalance
numbness tingling paresthesia
Infiltration occurs when the intravenous (IV) catheter has
migrated out of the vein, and the fluid spills into the surrounding tissue. Manifestations of infiltration include swelling, coolness, tingling, or redness at the IV site. The nurse should stop the infusion, discontinue the IV catheter, elevate the affected extremity above the client's heart, apply a warm compress to the affected area, and restart the IV in the opposite extremity. ✓ Infiltration occurs when the intravenous catheter migrates out of the vein. ✓ The intravenous catheter migration is often caused by the catheter not being secured to the client's skin. ✓ When infiltration occurs, the medication leaks into the tissues around the vein. ✓ Manifestations of infiltration include swelling, coolness, tingling, or redness at the IV site. ✓ Treatment for infiltration includes pausing the infusion, discontinuing the IV catheter, and elevating the extremity above the heart. ✓ Extravasation is significantly worse than infiltration because the medication leaks into the surrounding tissue, and the medication is a vesicant. ✓ A vesicant is a medication with a low pH or may cause significant irritation to the surrounding tissue. ✓ If extravasation occurs, the nurse should pause the infusion and aspirate any medication in the IV catheter. ✓ The nurse should not flush the IV catheter, which will further cause more damage. The catheter should be discontinued, and the physician should be notified.
2 point gait
minor weakness BOTH legs move crutch and OPOSITE foot move other crutch and opposite foot
bluish black macules appearing over buttox and or thighs of darker skinned neonates
mongolian spot NOT concerning
LPN
monitor RN reinforce edu routine most meds (NOT IV or FIRST TIME) ostomy tube patency enteral feeding NOT FIRST ASSESSMENTS
What is the #1 nursing intervention in a pt taking Clozaril (clozapine)
monitor WBC count
Concerned about PVC's when
more than 6 > minute 6 in a row PVC falls on T-wave of previous beat
when is it best collect sputum specimens
morning
3 point gait
move two crutches and bad leg TOGETHER move good foot 3 points touch the ground at once Unilateral weakness or injury
9 month old expected milestones
moves to sitting position moves objects between hands babbles and imitates sounds stranger anxiety
12 month old expected milestones
moves to standing position may walk with help or independent steps 2 finger pincer grasp identifies caregivers by name searches for hidden objects uses nonverbal gestures
cardiac tamponade
muffled heart sounds pulsus paradox dyspnea tachypnea narrowed pulse pressure hypotension tachycardia JVD complication of pericardial effusion as it compresses the heart
Epstein pearls
multiple small, white-yellowish, epithelial inclusion cysts found in the midline of the palate in newborn infants NORMAL NOT ALARMING
ALL cogenital heart defects have 2 things
murmurs echocardiogram
universal sign of electrolyte imbalances
muscle weakness (paresis)
best toy for 0-6 months
musical and mobile large and soft
COPD pt has decreased breath sounds and nasal flaring what is more indicative of respiratory distress or EXCACERBATION
nasal flaring retractions change in positioning and grunting
Kawasaki disease
need IV immunoglobulin to prevent coronary aneurysms fever>5 days cervical lymph large rash bilateral conjunctivitis
total thyroidectomy
need long term levothyroid risk for hypocalcemia
CCB indications
negative inotropic - chronotropic - and dromotropic HTN Anti-angina Anti atrial arrhythmic (A-flut, A-fib) Nifedipine, Verapamil, Diltiazem, Amlodipine
CNS: irritability, hypertonia, tremor, shortened sleep-wake cycles, uncoordinated swallowing Autonomic nervous system: diaphoresis, sneezing, yawning Gastrointestinal: feeding difficulty, vomiting, diarrhea
neonatal abstinence syndrome NO naloxone = drastic increase irritability = seizures
amniocenteses can determine
neural tube defects lung maturity gender chromosomal abnormalities
Olanzapine is an atypical antipsychotic drug. Adverse reactions of olanzapine include
neuroleptic malignant syndrome, which is manifested by tachycardia, delirium, fever, and muscle rigidity. Thus, muscle rigidity should be reported to the provider immediately.
autism spectrum disorder
no direct eye contact or therapeutic touch
3rd trimester weight gain
no more than a pound a week
ACE ARBS
no salt substitute K already at risk for hyperkalemia
UTI can cause
nocturnal enuresis urinary frequency
COPD why is a venturi mask better than a nonrebreather mask
nonrebreather delivers HIGH FiO2 and is contraindicated as it can over oxygenate in COPD over correcting the hypoxia can suppress the drive to breath A Venturi mask is the best choice for clients with COPD because the adapter allows precise control of the FiO2 that the client will receive.
Acute postinfectious glomerulonephritis (APGN)
occurs when immune complexes are deposited in the glomeruli following infection with certain strains of bacteria (eg, Streptococcus). Clients with APGN have decreased renal blood flow and glomerular filtration, which causes excessive sodium and water retention, leading to hypertension and edema.
Esophageal atresia
occurs when the proximal (upper) esophagus ends in a pouch (ie, atresia) and the distal (lower) esophagus connects to the primary bronchus or trachea through a fistula. Clinical manifestations include abrupt vomiting after feeding, poor weight gain, abdominal distension, frothy saliva, drooling, and apnea and cyanosis from aspiration. Although this client has cyanosis with exertion (ie, feeding), the client is tolerating feeds well and there are no signs of respiratory difficulties, therefore, TOF is more likely.
Antiemetrics
ondansterone promethazine
truest most valid sign of labor
onset regular contractions with cervical dilation and effacement advancing station
dilation of cervix
opening of cervix to 10 cm's
pin point pupils
opioid overdose
magneesemias do the __ of the prefix
opposite
rifampin
orange red secretion OKAY
the more vital the ___ the higher the priority
organ brain lungs heart liver kidney pancreas
Gentamycin adverse effects
ototoxicity and nephrotoxicity
Cushing's syndrome
over secretion moon face buffalo hump striae water retention gynecomastia hirsutism increased glucose hypokalemia skinny arms wide waist central obesity IMMUNOSUPPRESSION easily bruise irritable decreased bone density tx - adrenalectomy - replacement therapy - steroids
hyponatremia
overload (crackles distended neck veins)
What is the #1 priority of second phase?
pain management
Kerning's sign
pain occurs upon extension of the knee inflamed meninges
Cystic fibrosis and salt
parents should increase child's salt intake in summer/hot weather
Contraindication to TPA
past 3-4.5 hour window SBP < 185 DBP < 110 hemorrhagic stroke and stroke or head trauma within the past 3 months. Recent major surgery (ie, within the past 14 days) is a contraindication because t-PA dissolves all clots in the body and may therefore disrupt the surgical site. Gallbladder surgery 2 months prior is outside the window of contraindication.
The nurse should recognize Guillain Barré quickly and ensure a
patent airway, as the ascending paralysis may impact the diaphragm. The cause of Guillain Barré can be certain pathogens, such as Campylobacter jejuni, which may induce massive peripheral nerve demyelination. Other causes include certain immunizations and bone marrow transplantation. . Guillain Barré is a polyneuropathy manifested by paralysis, paresthesia, autonomic disturbances, and depressed or absent reflexes. The paresthesia is typically found in the peripheral extremities and may persist for quite some time, even after the return of motor function.
NO trouble heart defects
patent foreman ovale ventricular septal defect pulmonary stenosis
Regular insulin when most risk of hypogylcemia?
peak 2 hr
Rapid insulin hypoglycemia risk
peak 30 mins
adolescents 12-18 play
peer group association
macular degeneration
peripheral vision remains intact, while the central area becomes darker and darker until there is a spot in the center of their visual field through which they cannot see.
arterial line transducer should be placed even with the
phlebostatic axis of 4th intercostal space
psych tx anxiety disorder
phobia desensitization gradually expose talk about it show pics be around interact
Sevelamer
phosphate binder indicated for individuals with chronic kidney disease (CKD). This medication inhibits phosphorus absorption, thereby increasing the calcium level. ✓ Hyperphosphatemia and hypocalcemia are common laboratory abnormalities found in CKD ✓ Phosphorus and calcium have a reciprocal relationship; therefore, lowering phosphorus levels through phosphate binders is a standard treatment for CKD ✓ The nurse should ensure these medications are given with meals and advise the client to mitigate the common effect of constipation through stool softeners and laxatives
Painless vaginal bleeding is a possible sign of what?
placenta previa
Dark red vaginal bleeding
placental abruption
dark red vaginal bleeding
placental abruption
dextran and albumin
plasma volume expanders for hypovolemia
Dumping syndrome
post-op complication gastric contents dump to quickly into the duodenum in the right direction AT the WRONG rate abdominal distress (cramping n/v, hyperactive borborygmic) cerebral impairment "drunk" shock (vasomotor collapse, rapid thready HR) HOB during/after meals LOW amount of fluids LOW carb content LOW Goal: FUll stomach
Addisons disease requires a diet low in?
potassium
Refeeding syndrome
potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually
what can potentiate DKA
recent viral upper respiratory infection dehydration ketones kussmal breathing high potassium acidosis ketone breath anorexia
4th stage of labor 4 things to do 4 times an hour
vital signs fundus (boggy = massage displaced = urinate) Check perineal pads if saturate in less than 15 minutes if EXCESSIVE bleeding roll patient and check for bleeding underneath
Neuroleptic malignant syndrome (NMS)
potentially life-threatening adverse reaction to antipsychotics (eg, olanzapine) that typically occurs 1-3 days after initiation or dose escalation. It is thought to be caused by dysfunction in areas of the central nervous system involved in the thermoregulation and regulation of muscle tone and movement. NMS is characterized by mental status changes, severe hyperthermia, muscle rigidity, and autonomic dysfunction (eg, tachycardia, fluctuating blood pressure, diaphoresis). Sustained muscle contraction results in muscle breakdown that can lead to electrolyte imbalances (eg, hyperkalemia, metabolic acidosis) and acute kidney injury due to rhabdomyolysis (eg, elevated BUN and creatinine). Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication. Benzodiazepines and dantrolene, a muscle relaxant, may be used in severe cases. (Incorrect) Acute lithium toxicity typically begins with nausea, vomiting, and diarrhea, with neuromuscular signs developing later. Diffuse rigidity and severe hyperthermia would not be expected. Lithium treatment can cause diabetes insipidus (DI) due to a dysfunction in the kidneys' ability to respond to antidiuretic hormone, but this client does not have symptoms of DI (eg, polyuria). (Incorrect) Although serotonin syndrome (due to overdose or combinations of serotonergic drugs [eg, fluoxetine]) can also cause mental status changes, hyperthermia, and sympathetic hyperactivity, it typically leads to neuromuscular hyperactivity (eg, clonus, hyperreflexia) as opposed to the diffuse rigidity seen in NMS.
exercise ___ insulin
potentiates need less insulin before exercise
✓ Second-generation antipsychotics (risperidone, olanzapine, quetiapine, clozapine, lurasidone, ziprasidone, aripiprazole, brexpiprazole)
preferred because of the decreased risk of movement disorders. ✓ The concern with SGAs is that they may adversely impact the client metabolically by raising glucose and weight (especially clozapine and olanzapine). ✓ For a client receiving any generation antipsychotic, the nurse must always monitor for neuroleptic malignant syndrome (NMS) manifested by fever, muscle rigidity, delirium, and tachycardia Risperidone is an atypical (second-generation) antipsychotic indicated in treating disorders such as schizophrenia, autism with behavioral disturbances, delusional disorder, and bipolar disorder. Risperidone is notorious for causing increased prolactin levels. This increase in prolactin levels may cause a client to develop gynecomastia and/or galactorrhea.
ARBs and ACE inhibitors have black box warnings that indicate contraindication in
pregnancy
periodic wide bizarre QRS's
premature ventricular contractions
Sucralfate (Carafate, Sulcrate)
prescribed to treat gastric ulcers, should be administered before meals to coat the mucosa and prevent irritation of the ulcer during meals. It should also be given at least 2 hours before or after other medications to prevent interactions that reduce drug efficacy.
Why Trendelenburg position
prevent air embolism
Delirium tremens usually have
private room close to nursing station in restraints NPO or liquid diet restricted bed rest
. If the 20% dextrose solution is temporarily replaced with an infusion lacking dextrose (eg, normal saline, lactated Ringer's [LR]), the pancreas will continue to If TPN stops abruptly and new bag is not available what solution can be used ?
produce insulin leading to HYPOglycemia 10% dextrose 75mL/hr
risk factors for uterine atony include
prolonged labor precipitous labor fibroid uterus prolonged use of oxytocin retained placental tissue placental disorders (placeta previa - abruptio placentae) BMI > 40
metabolic alkalosis
prolonged vomiting continuous suction IF METBOLIC AND NOT THOSE CHOOSE ACIDOSIS
Loop diuretics (eg, furosemide) and CALCIUM SERUM LEVEL
promote renal excretion of calcium (ie, decrease serum calcium levels) and are not anticipated for clients with hypocalcemia.
Enteral tube feeding complications
pulmonary aspiration diarrhea constipation tube occlusion tube displacement abdominal cramping n&v fluid overload delayed gastric emptying serum electrolyte imbalance fluid overload pyerosmolar dehydration electrolyte imbalance, hyercapnia, hypo/hyperglycemia, hyperglycemic hyperosmolar nonketotic dehydration/coma (HHNC)
stage 4 pressure ulcer
red-white muscle bone
lactulose (Cephulac)
reduce blood ammonia by excreation of ammonia by stools 2 -3 soft stools per day Lactulose promotes fecal excretion of ammonia in clients with severe liver disease (eg, cirrhosis) because the damaged liver is unable to effectively convert serum ammonia into urea. In clients with normal liver function and CKD, ammonia is converted into urea, but urea cannot be eliminated by the kidneys.
psych tx schizophrenia
reduce stimulation (clear room) make observation offer presence need reality based activities BUT NOT competative - should be with others
amnioinfusion used to
reduce variable decelerations and dilute meconium stained amniotic fluid
Legionnaire's disease
refers to a type of pneumonia caused by the Legionella bacteria, typically found in water or soil. An appropriate nursing diagnosis would be ineffective airway clearance, as this disease impairs the airway and lung function.
Amniotomy
refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure (Option 1). Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2). The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection (Option 5).
Hiatal hernia
regurgitation of acid to esophagus upper stomach herniates upward through diaphragm right rate WRONG direction GERD-like symptoms after meal HOB raised during and after meals high amount of fluids with foods high carb content goal: get an empty stomach
Station
relationship of the fetal presenting part to the ischial spines - ischial spines=narrowest part of pelvis positive numbers = past narrowest part negative numbers = negative news
Lie pregnancy
relationship to spine of baby to spine of mom
Pregnancy
results in amenorrhea because ovulation ceases once an embryo is implanted. Manifestations of pregnancy include gradual weight gain from an increase in adipose tissue stores, increased circulating blood volume, and expanding uterine contents (eg, developing fetus, placenta, amniotic fluid). Breast tenderness occurs due to an increase in estrogen during pregnancy. Hair loss can occur during the postpartum period due to a decrease in estrogen after delivery. Hormonal changes during pregnancy can cause increased vaginal mucus production, not dryness.
donning PPE
reverse alphabet gown mask goggles gloves
Alternative method to determine ideal weight gain
weeks pregnant minus 9
An untreated streptococcal infection, specifically Group A streptococcus, may lead to
rheumatic fever, a severe condition with cardiac implications. Rheumatic fever (RF) has a strong relationship with group A streptococci (GAS) infection, usually pharyngitis. Manifestations of this illness include carditis, murmur, cardiomegaly, polyarthritis, and chorea. Severe cases may cause heart failure. Treatment for RF includes antibiotics, anti-inflammatory agents (aspirin), and supportive care.
6 month old expected milestones
roles from prone to supine position later progresses to rolling from supine to prone sits up with support puts objects in mouth begins to laugh makes some sounds becomes calmed by caregivers voice
first couple days of lochia PP after week PP lochia
rubra serosa
lochia
rubra, serosa, alba IN THAT ORDER VAGINAL DRAINAGE rubra (rub and rub turns red) - red Serosa (rosa - rose) - pink Alba (albino = white) - white Amount - moderate 4-6 inch on pad in hour - EXCESSIVE saturate pad in 15 mins
2 years month old expected milestones
run kick ball walks upstairs spoon
Chorionic villus sampling
sampling of placental tissue for microscopic and chemical examination to detect fetal abnormalities
excessive lochia
saturated pad in 15 mins
functional psychosis nursing interventions
schizophrenia - schizoaffective - mania 1. acknowledge 2. present reality 3. set limit 4. enforce limit
Head circumference (HC) growth
second year = 1 inch growth growth slows until age 5 grows 0.5 cm/year
retinal detachment
serious ocular condition that occurs suddenly and is painless. The client often describes bright flashes of light or floating dark spots in the eye. Aging and ocular injury are common causes of retinal detachment. The client should seek emergent medical treatment as surgery is the remedy. A retinal detachment is an ocular emergency. The client moving may hasten the detachment. It is important to inform the client to restrict their activity, and the nurse should apply an eye patch to the affected eye.
Mental status changes (eg, restlessness, agitation, confusion) (Option 2) Shivering and tremors (Option 4) Autonomic dysregulation (eg, diaphoresis, hypertension, tachycardia) (Optio
serotonin syndrome Drugs that may trigger this reaction include selective serotonin reuptake inhibitors (eg, citalopram, sertraline), serotonin norepinephrine reuptake inhibitors (eg, venlafaxine, duloxetine), monoamine oxidase inhibitors (eg, isocarboxazid, phenelzine), dextromethorphan, St. John's wort, and tramadol. In severe cases, serotonin syndrome can progress to cardiovascular shock, seizures, or even death. Serotonin syndrome typically resolves within one day after discontinuation of the causative drug and starting supportive treatment. Treatment involves administration of serotonin receptor antagonist (ie, cyproheptadine) and supportive care (eg, benzodiazepines, cooling blankets).
Sick days and its relation ship to insulin and glucose
serum glucose levels increase = at risk for HYPERGLYCEMIA need insulin even if NOT EATING Need sips of water TWO MAIN PROBLEMS WITH A SICK DIABETIC PT - HYPERGLYCEMIA - dehydration
what kind of pain is expected with pancreatitis?
severe pain in the mid epigastric area radiating to the back
Uterine fundus should be
should be firm ... Important o Massage if fundus is boggy and midline o Catheterize pt if fundus is boggy and not midline
Braxton Hicks contraction do not
signify labor no cervical dilation or effacement
newborn resuscitation airway placement
slightly extended place blanket or towel roll under shoulders "sniffing position"
Cranial nerve XI
spinal accessory
Small tuft of hair at the base of the spine
spinal bifida neural tube defect NORMAL (Option 1) Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to prolonged pressure of the presenting part against the cervix during labor, resolves in a few days. (Option 2) Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal melanocytosis (ie, Mongolian spots). (Option 4) Vernix caseosa, a protective substance covering the fetus, is secreted by the sebaceous glands. This white, cheesy/waxy substance is most likely seen in the axillary and genital areas of term newborns.
anthrax
spread by inflammation looks like flu dies from respiratory failure treat with supro - PCN - streptomycin
unstable beats
stable
15 month old expected milestones
stacks 2 blocks says 2 words
4 stages of labor
stage 1 = dilation of cervix to 10cm and effacement to 100% stage 2 = delivery of baby stage 3 = delivery of placenta stage 4 = recovery 2 hours until bleeding has stopped
ulcerated superficial pink dermis
stage 2 pressure ulcer
Iron considerations
stains teeth empty stomach vitamin C enhances absorption dark stools normal Calcium absorption EFFECTS iron absorption
engagement
station 0 - babys head is in ischial spines
Terbutaline (Brethine)
stops labor and speeds up the heart side effect tachycardia = don't give cardiac pt
Pantoprazole can be used to prevent?
stress ulcer proton pump inhibitor
fight of ideas word salad neologisms
stringing together phrases throw words together making up new words
cane is held
strong side
A Jarisch-Herxheimer reaction
systemic inflammatory response that occurs within hours of initiating antibiotic therapy for certain infections (eg, syphilis, Lyme disease). Rapid lysis of large amounts of bacteria causes the releases of intracellular components into the bloodstream, which triggers a strong immunological response. Symptoms include fever, myalgia, rigors, sweating, hypotension, and aggravation of preexisting rashes (ie, worsened maculopapular rash). Manifestations are usually self-limited and resolve spontaneously within 48 hours.
Butterfly rash
systemic lupus erythematosus
S3 is seen in what type pf HF S4 is seen in what type of HF
systolic diastolic
Parkland formula
tBSA x Wt (Kg) x 4ml LR = 24hr dosage 1/2 = @ 1st 8 hrs 1/2 = @ 2nd 16 hrs
Hypomagnesemia
tachycardia HTN seizure hyperreflexia tachypnea
heroine withdrawal in infant
tachypnea tachycardia diaphoretic hyperactive reflexes
sick day and insulin
take insulin sip water stay active
What is uterine hyperstimulation?
• No longer than 90 seconds and no closer than 2 minutes
Coumadin
takes days for full effect can take for entire life antidote Vitamin K Labs PT INR (2-3 on coumadin) NOT in pregnancy
prescription change from imipramine to phenelzine what instructors should be done
taper imipramine (TCA) than discontinue 2 weeks prior to taking phenelzine (MOA) DRUG free period of 2 weeks after taper DO NOT stop abruptly
A PTT of > 100 seconds while on heraprin
target is 1.5-2x normal range of 25-35 this is critical need to stop the pump
4 options of intervening with inappropriate staff
tell supervisor intervene immediately counsel them later ignore (NEVER RIGHT0
fetal tachycardia assessment
temperature >160BPM Hypotension Drug sideeffects
psychotic delirium
temporary - UTI thyroid electrolyte 1. acknowledge feeling 2. reassure them safety and temporarynesss
Toxycolytics that STOP contractions
terbutaline (brethine) - tachycardia - dont give cardiac disease Nifedipine - s/e headache/hypotension
Misoprostol (Cytotec), a prostaglandin E1, is a cervical ripening agent. Cervical ripening is a process that normally occurs before the onset of labor in which the cervix softens and becomes more pliable so that dilation and effacement can occur more easily during contractions. Mechanical or pharmacologic cervical ripening methods simulate this process and increase the client's probability of achieving a vaginal birth. In addition to ripening the cervix, prostaglandins (eg, misoprostol, dinoprostone) can stimulate frequent contractions. Therefore, administration of misoprostol is contraindicated if:
the client is receiving another uterotonic simultaneously (eg, oxytocin) (Option 1). the client has a history of uterine surgery (eg, cesarean birth) due to an increased risk of uterine rupture at the surgical scar site (Option 2). the client has an abnormal fetal heart rate pattern or uterine tachysystole (ie, >5 contractions in 10 min) (Option 4).
The HFCWO vest's rapid vibrations may induce nausea and vomiting in some clients. Therefore,
the client should avoid meals and snacks 1 hour before, during, or 2 hours following CPT to prevent gastrointestinal upset (Option 1). The nurse may suggest other more appropriate ways to ensure compliance with CPT, such as allowing the child to watch a favorite television show or reading the child a story while wearing the HFCWO vest.
✓ The appropriate donning sequence of PPE is
the gown, mask or respirator, goggles or face shield, and gloves.
Hypocalcemia
tingling lips bronchospasm seizure activity muscle cramping cardiac dysrhythmia Hypocalcemia (ie, serum calcium <9.0 mg/dL [2.25 mmol/L]) is most often associated with decreased parathyroid hormone levels. Manifestations of hypocalcemia include tingling lips and seizure activity due to impaired nerve impulse transmission, laryngospasm/bronchospasm and muscle cramping due to impaired muscle contractility, and cardiac dysrhythmias due to impaired myocardial contraction.
Dantrolene (Dantrium)
to treat malignant hyperthermia by slowing down metabolism and reducing muscle contractions
tone height location uterus postpartum
tone = firm (NOT BOGGY) height = pubis 24hr2cm every PP day location = midline (displaced cath)
What should the postpartum uterine tone, height, and location normally be?
tone = firm (not boggy not deviated) height = at umbilicus involutes 2 cm/day location = midline NOT DEVIATED =CATH IT
total and subtotal thyroidectomy
total tetany = hypocalcemia subtotal storm = thyroid storm post op airway breathing risks
parietal frontal occipital temporal
touch executive functioning and personality vision auditory input
life threatening complication of IBS
toxic megacolon Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to colonic smooth muscle paralysis. Rapid colonic distension ensues, thinning the intestinal wall and making it prone to perforation. Imaging confirms the diagnosis.
throughout stage 1 of labor what is the greatest frequency and longest duration of contractions you SHOULD expect
transition phase - 60-90 seconds duration - EVERY 2-3 minutes
ethambutol
treats TB OCULAR TOXICITY red green vision effects color discrimination loss
Phoechromocytoma
tumor on the adrenal gland Pheochromocytoma is a neuroendocrine tumor that arises in the adrenal medulla and secretes an excess of catecholamines (eg, dopamine, epinephrine, norepinephrine) into the bloodstream. This results in characteristic clinical manifestations such as persistent hypertension, headache, sweating, and tachycardia. The most severe complication of pheochromocytoma is hypertensive crisis, which can lead to encephalopathy, organ failure, and death. Anticipated interventions for a client with suspected pheochromocytoma who is experiencing a hypertensive crisis include: Administering antihypertensive medications ("alpha and beta blockers") to stabilize blood pressure, decrease tachycardia, and reduce the risk for dysrhythmias (Option 1) Initiating a 24-hour urine collection to assess for metanephrines and catecholamines to diagnose pheochromocytoma (Option 3) Obtaining a CT scan or MRI of the adrenals to localize the site of the tumor Preparing the client for surgical removal of the tumor (Option 5)
Gonorrhea and Chlamydia
two STD's are the leading causes of pelvic inflammatory disease (PID) and infertility
Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos])
type 2 diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin, leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or volume overload is a contraindication to thiazolidinedione use. These medications also increase the risk of cardiovascular events such as myocardial infarction.
Haldol (haloperidol)
typical antipsychotic ABCDEFG - anticholinergic - blurred vision - Constipation - drowsiness - EPS (tremors - Parkinson's) - F = "photosensitivty" - aGanulocytosis NEED TO REPORT FEVER OR SX INFECTIONS RISK OF Neuroleptic Malignant Sydrome - HIGH fever -
What parameters regarding uterine contraction would make you stop Pitocin?
• No longer than 90 seconds and no closer than 2 minutes
Phenazopyridine hydrochloride (Pyridium)
urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics.
urine specific gravity of 1.032
urine is low in water high in solutes SIADH dehydration
The rule of nines
used to estimate quickly the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. Superficial burns (first-degree burns) are not included in the calculation of affected TBSA. For a client who has sustained partial-thickness burns to all anterior body surfaces below the neck, TBSA is calculated as follows: TBSA = [anterior torso] + [anterior arms] + [anterior legs] + [perineum]TBSA = [18] + [4.5 + 4.5] + [9 + 9] + [1]TBSA = 18 + 9 + 18 + 1 = 46%
Antipsychotics (haloperidol)
usually the preferred treatment for management of agitated delirium in most situations. However, they reduce the seizure threshold and, therefore, are not used in alcohol withdrawal-induced delirium. In addition, the client's psychotic symptoms (eg, hallucinations) are likely occurring due to the alcohol withdrawal and should subside with administration of benzodiazepines.
> than 5 contractions in 10 minutes
uterine tachysystole STOP oxytocin
late decels
uteroplacental insufficiency
A pharmacologic nuclear stress test
utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected so that a special camera can produce images of the heart. Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion. Pre-procedure client instructions include the following: Avoid caffeine and decaffeinated products 24 hours before the test (Option 2). Do not smoke or drink alcohol on the day of the test (Option 3). Do not take beta blockers on the day of the test (unless otherwise instructed by the HCP) because certain cardiac medications can interfere with the test results by masking angina (Option 4). Wear comfortable clothing and supportive shoes (Option 5).
wide bizarre QRS's
v-tach
SVT first steps
vagal maneuvers ✓ During SVT, P waves may not be visible because the P waves are embedded in the preceding T wave ✓ A client with SVT may be asymptomatic. If the client is symptomatic, they may exhibit manifestations such as palpitations, dizziness, dyspnea, and nervousness ✓ Treatment includes vagal maneuvers. Vagal maneuvers include having the beardown, blowing through a straw, having the primary healthcare provider (PHCP) perform a carotid massage, and, if the client is an infant, applying a bag filled with ice and water to the face above the nose and mouth for 15 to 30 seconds. If that is ineffective, another vagal maneuver would be pressing the infant's knees to the chest for 15-30 seconds. ✓ If these measures are ineffective, the nurse should prepare to administer the prescribed adenosine by rapid intravenous push (IVP) that is followed by a flush of 0.9% saline. ✓ When adenosine is administered, the emergency (code) cart should be nearby, and the nurse should always have additional personnel in the room.
Superventricular tachycardia
vagal maneuvers (valsalva) adenosine IVP (FAST 1-2 seconds)
contraindicated vaccines in pregnancy
varicella Nasal infleunza MMR HPV
shingles (herpes zoster) is reactivation?
varicella virus Incidence increases after age 50. Active chickenpox requires airborne and contact precautions, but not the shingles with crusted lesions, especially if the lesions are covered with clothes. It can be contagious to individuals who have not had varicella or who are immunocompromised. However, this is the second priority as this is a localized issue; the nurse can place this client in a private area.
Low pressure alarms are triggered when?
vent tubing not connected pt pulls out vent IF vent tube on floor - Bag mask this and get respiratory
A ventriculoperitoneal (VP) shunt drains excess cerebrospinal fluid (CSF) from the
ventricles of the brain into the peritoneum, where the CSF is reabsorbed into the bloodstream. Indicated interventions when preparing an infant for placement of a VP shunt include: Initiating seizure precautions because the infant is at increased risk for seizures due to progressing hydrocephalus and increased intracranial pressure Shaving the hair on the infant's head to help the neurosurgeon visualize the area in which the VP shunt will be placed Marking the location where the head circumference was measured to consistently compare consecutive measurements during the postoperative period Verifying informed consent (ie, the parents' understanding of the indication, risks, alternatives, and right to refuse the procedure) Check drainage site for glucose - WHY? Cerebrospinal fluid has glucose The shunt requires revision surgeries as the child grows, or if the shunt malfunctions. Certain sports (ie, contact sports [eg, boxing, wrestling]) should be avoided when the child is older due to the risk for shunt displacement or disconnection. Early childhood development programs can be used to monitor the infant's development and provide early detection of areas in which the infant needs additional supportive services. Monitoring for signs of increased intracranial pressure (eg, persistent irritability, poor feeding, vomiting), which may indicate that the tubing has become obstructed.
A holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a
ventricular septal defect
Engagement in pregnancy
when fetal presenting part gets to 0 station at ischial spines tightest part of pelvis
hypotonic solutions are used
when the cell is dehydrated and fluids need to be put back intracellularly. This happens when patients develop diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemia.
Pt gets a TURP - has urine output equal to the continuous bladder irrigation what could be happening?
when urine output = irrigation mean kidneys not making urine and obstruction could be happening normal findings - blood and small clots up to 36 hours - painful bladder spasms (give oxybutrin)
The client is experiencing pheochromocytoma
which causes the classic triad of symptoms (headache, hyperglycemia, hypertension). Other clinical features supporting the diagnosis include how the symptoms are induced during stressful periods (episodic), tremors, weight loss, and thirst, which is explained by elevated blood glucose and heat intolerance, seen in pheochromocytoma.
NPH insulin is intermediate-acting onset peak duration
with an onset of 1-2 hours, peak of 4-12 hours, and duration of 12-18 hours. Due to its long peak, hypoglycemia (blood glucose <70 mg/dL [<3.9 mmol/L]) can result from use of NPH, especially because the overnight hours (during sleep) typically represent the longest interval between meals. To prevent hypoglycemia related to an evening dose of NPH, the client should eat a bedtime snack consisting of protein and complex carbohydrates (eg, cereal with milk, crackers with peanut butter) (Option 2). Complex carbohydrates paired with protein provide sustained, slow release of glucose, thereby preventing hypoglycemia.
neonatal abstinence syndrome
withdrawal from opiates NO NALOXONE Neurologic: irritability, hypertonia, jittery movements, seizures (rare) Gastrointestinal: diarrhea, vomiting, feeding intolerance Autonomic: sweating, sneezing, pupillary dilation
Every acholic goes through
withdrawals BUT not all have delirum tremens
heparin
works immediately can only take 21 days antidote = protamine sulfate labs PTT and platelets can use in pregnancy class C
Treating ileus
x ray of the bowel and abdomen to rule SBO Monitoring and measuring abdominal girth (ie, distension) frequently Using nonopioid pain medications (eg, nonsteroidal anti-inflammatory drugs) and nonpharmacological pain-management strategies (eg, cold packs) because opioids decrease bowel motility Administering IV fluids to prevent hypovolemia Correcting electrolyte abnormalities (especially hypokalemia) Encouraging frequent ambulation to increase blood flow and stimulation of the gastrointestinal (GI) tract Balancing bowel rest with limited oral intake to promote slow stimulation of peristalsis
Wash the injury with soap and water Screen the client for hepatitis C virus Squeeze tissue to let the wound bleed Anticipate initiating antiretrovirals for the nurse Anticipate initiating oral antibiotics for the nurse Replace the cap on the needle prior to disposal what does the nurse anticipate following needle stick injury?
yes yes no yes no no
when choosing from a vairiety of ages always go ____
younger when sick children regress in hospital need as much time to grow as possible
Interventions for all other complications • Tetany • Maternal hypertension • Vena cava syndrome • Toxemia • Uterine rupture
• All treated the same—with "LION" o Left side (place mother on the left side) o IV o Oxygen o Notify HCP • Stop Pitocin (pit) if it was running—the first thing to do Implement before "LION" • In an OB crisis, if pitocin is running, stop it first. Then, implement "LION"
What is the #1 priority of third stage?
• Assess the placenta for smoothness and intactness, and for 3-vessel (not 2) umbilical cord present 2 A's 1V
A pregnant pt complains of back pain. What should you advise her to do?
• Back Pain is seen during the 2nd and 3rd trimester • Advise pelvic tilt exercises to pt
3.Fetal/Neonatal Lung Meds
• Betamethasone (steroid) o Given to mother IM o Can repeat as long baby is in utero o S/E: increase glucose (steroid) • Surfactant (Survanta) o Given to baby via transtracheal route o Given After birth Both given to mature longs
What is the #1 priority of third phase?
• Checking cervical dilation, Helping pregnant mother with breathing and pain management
What is the purpose 3rd stage?
• Delivery of placenta
Second stage of L&D (labor and delivery)
• Delivery of the fetus ... This is about order. 1. Deliver head ... The mother needs to stop pushing 2. Suction the mouth then the nose ... ABC order 3.Check for nuchal (around the neck) cord 4. Deliver the shoulders, next, the body 5. Make sure baby has ID band on before it leaves the delivery area
Third stage of L&D
• Delivery of the placenta • What do you check for with the delivery of the placenta? o Make sure the placenta is complete and intact o Check for 3-vessel cord—2 arteries and 1 vein, AVA
A pregnant pt complains of difficulty breathing. What should you advise her to do?
• Difficulty breathing is a problem during the 2nd and 3rd trimesters • Advise pt to assume to tripod position o Tripod position is a physical stance often assumed by people experiencing respiratory distress o The pt will be leaning forward with hands on knees or the surface of a desk or table
2.High Fetal HR—HR >160
• Document acceleration of fetal HR • Take the mother's temp • Not a high priority ... Baby is WNL
So, what is the nursing intervention for hypermagnesemia due to mag sulfate treatment?
• Monitor respiration o If RR <12, decrease dose of Mag sulfate • Assess for reflexes o Normal reflex is 2+ o If reflexes are 0 or 1+ ... Decrease dose of mag sulfate o If reflexes are 3+ or 4+ ... Increase dose of mag sulfate
During pregnancy, pt is advised to go for prenatal visits as follows
• Once a Month until week 28 • Every other week between 28 and 36 • Once a week after week 36 until delivery or week 42, whichever comes first o At week 42, delivery can be induced or by C-section
One good studying strategy to use for memorizing the 3 phases of Stage 1 labor is to know everything about the Active (or Phase 2) of Stage 1
• Once you know the upper and lower limit values, you can deduce the values of Phase 1 and Phase 3 o Phase 2 — Contractions: 3 to 5 minutes and last 30 to 60 seconds active -contractions every 3-5 minutes - duration 30-60 seconds - 4-7 dilation
Hyperbilirubinemia in the Newborn
• Physiologic jaundice is normal and appears after 24 hours after birth ... Disappears in about one week • Pathologic jaundice is seen in the 1st 24 hours after birth
2.Oxytocics (Stimulate and strengthen labor)
• Pitocin (Oxytocin) o S/Es: Uterine hyperstimulation (defined as longer than 90 seconds, closer than 2 minutes) The nursing intervention is to lower the dose of Pitocin in case of uterine hyperstimulation (>90seconds duration <2 minutes frequency) • Methergine o Causes HTN—if it contracts blood vessels it makes sense that this increases BP
Painful Back pain—"OP" = Oh Pain. What do you do?
• Position—Push • What position? o KNEE-CHEST position then o PUSH with fist into sacrum to use counter pressure
• Geodon (ziprasidone) has a black box warning
• Prolong the QT interval, which can cause sudden cardiac arrest • Do not use in pts with cardiac condition
Fourth Stage of L&D
• Recovery • There are 4 things you do in the 4th stage, 4 times an hour (every 15 minutes) 1. Vital signs: Assessing for shock ... Blood pressure goes down, HR goes up ... Pt looks pale, cold, and clammy 2. Fundus: If it is boggy, massage it ... If displaced, catheterize it 3.Check perineal pads ... If there is excessive bleeding, the pad will saturate in 15 minutes or less 4.Roll pt over and check for bleeding underneath her
Stages and Phases of Labor
• Stage 1—Onset of Labor o Phase 1—Latent ... Dilation from 0 to 4 cm Contractions are 5 to 30 minutes apart, lasting 15 to 30 seconds Mild intensity o Phase 2—Active ... dilation from 5 to 7 cm Contractions are 3 to 5 minutes apart, lasting 30 to 60 seconds Moderate intensity o Phase 3—Transition ... dilation from 8 to 10 cm Contractions are 2 to 3 minutes apart, lasting 60 to 90 seconds Strong intensity • Stage 2—Delivery of Baby • Stage 3—Delivery of Placenta • Stage 4—Recovery: 2 hours until bleeding stops
Stages and Phases of Labor
• Stage 1—Onset of Labor ! Cervical Dilation and Effacement o Phase 1—Latent (15-30duration//5-30 mins apart//0-4/) o Phase 2—Active(30-60 duration/4-7 dilation/contractions 3-5mins) o Phase 3—Transition (60-90 duration/7-10/2-3 minutes apart) • Stage 2—Delivery of Baby • Stage 3—Delivery of Placenta • Stage 4—Recovery: 2 hours until bleeding stops
What is the purpose of 4th stage?
• Stop bleeding
A 19-month-old infant is about to have a lumbar puncture (LP) for csf analysis and culture. Howwould the nurse teach the child?
• Tell the child how the LP is done while it is being done. • There is no such thing as preop teaching for this age group • Preop teaching are only for the parents—mom and dad—or guardian
What is the significance of being able to palpable fundal height?
• The examiner should be able to determine in what trimester the pregnancy is o In case pt is unconscious, for instance o It has diagnostic significance as well ... A much bigger than normal fundus may indicate molar pregnancy
What should the postpartum uterine tone, height, and location normally be?
• The tone of the fundus should be firm, not boggy • The height of the fundus after delivery should be at the umbilicus (or navel) o Fundus involutes about 2 cm every day PP (postpartum) • The location of the uterus should be midline o If not midline, the bladder is distended
2.Preoperational (Preschooler)—3 to 6 years
• They are fantasy-oriented, imaginative, and illogical, there thinking obeys no rules • However, they understand the future and they understand the past
1. Sensorimotor—0 to 2 years
• They only think about what they are sensing right now • You can teach only in the present (while you are doing it) o Think Present Tense o Just tell them o Children at this age don't understand play o Tell them as it is happening
7.Late Decelerations
• This is BAD • You do "LION" o Left side o IV o Oxygen o Notify HCP • Stop pit if it is running
5.Early Deceleration
• This is normal ... No big deal • Document finding head compression no alarming
1.Tocolytics(Stop contractions, stop labor)
• Tocolytics are given to women in premature labor that must be stopped • Terbutaline (Brethine) o S/E: maternal tachycardia (don't give with cardiac disease) • Mag sulfate o Treatment with Mag sulfate will induce hypermagnesemia, which will cause everything to go down o HR will go down, BP go down, Reflexes go down, RR go down, LOC go down
When will pregnant pt experience urinary incontinence
• Urinary incontinence is seen in the 1st and 3rd trimesters • Pt needs to void every 2 hours from the day she gets pregnant until 6 weeks postpartum
determining the estimated date delivery
• Use the Naegele rul first day of last menstural period subtract 3 months add 7 days
variable decels
✓ A prolapsed umbilical cord is a medical emergency ✓ The prolapse may be hidden or complete ✓ This condition should be suspected if the fetal heart monitor should show sustained bradycardia, variable decelerations or prolonged deceleration ✓ The nurse should reposition the client with the intent to position the woman's hips higher than her head to shift the fetal presenting part ✓ Acceptable positions include knee-chest, Trendelenburg, or hips elevated with pillows, with side-lying position maintained ✓ The nurse should shout for help, pause oxytocin infusion, and provide oxygen via face mask at 8-10 liters/minute ✓ Provide and maintain vaginal elevation of the presenting part using a gloved hand ✓ An emergency cesarean section is likely
Normal postpartum findings include -
✓ A urinary output of up to 3000 mL/day may occur, especially on days 2 through 5 postpartum. ✓ Diaphoresis is a common postpartum finding ✓ White blood cell (WBC) count increases to as high as 30,000/mm3 during labor and the immediate postpartum period ✓ The hematocrit returns to normal limits 4 to 6 weeks postpartum ✓ The first stool usually occurs within 2 to 3 days postpartum. Constipation is common during the first bowel movement. ✓ Approximately 4.5 to 5.8 kg (10 to 13 lb) is lost during childbirth. This includes the weight of the fetus, placenta, and amniotic fluid and blood lost during the birth ✓ An additional 2.3 to 3.6 kilograms (kg) (5 to 8 lb) are lost as a result of diuresis and 0.9 kg to 1.4 kg (2 to 3 lb) from involution and lochia by the end of the first week
Acute Glomerularnephritis
✓ AGN is a severe condition secondary to many infectious processes, such as streptococcal infections, mononucleosis, and hepatitis. ✓ Clinical features of AGN include oliguria, fatigue (from the uremia), fluid retention, proteinuria, hematuria, and elevation in blood pressure. ✓ Nursing care aims to prevent the most common complication, fluid volume overload. ✓ The client may have dietary restrictions for fluid, sodium, and potassium. ✓ The nurse should monitor the client's intake, output, weight, and blood pressure.
APAP (acetaminophen)
✓ APAP is commonly used for mild to moderate pain ✓ APAP is also indicated for pyrexia ✓ 4000 mg every 24 hours is the dosing ceiling ✓ Toxicity may cause a client to develop symptoms such as nausea and vomiting, or they may be asymptomatic ✓ Liver function tests may rise as early as eight hours following ingestion ✓ Peak injury is within 72-96 hours following ingestion ✓ Acetylcysteine is a treatment for APAP toxicity
Anthrax
✓ Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate. ✓ Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium. ✓ Standard precautions are used for a client with inhalation anthrax. ✓ Nursing care is aimed at stabilizing the client's breathing and promptly initiating treatment: antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.
Amphotericin B is a potent antifungal medication
✓ Anticipating that the client will be premedicated with isotonic saline, diphenhydramine, ondansetron, and acetaminophen. A corticosteroid may be used in lieu of diphenhydramine. ✓ During the therapy, the client may experience fever, chills, rash, rigors, and nausea. Thus, this is why premedication may be necessary. ✓ This medication is known to decrease serum potassium. Potassium supplementation is likely for repeated infusions. ✓ Amphotericin b is nephrotoxic, and the creatinine should be closely monitored.
The nurse reviews the function of a prescribed beta-blocker in the cardiovascular system. It would be appropriate for the nurse to state that beta-blockers Select all that apply. block catecholamines from binding to the beta receptors. reduce myocardial oxygen demand. increase cardiac contractility. increase cardiac output. prevent sodium and water resorption by inhibiting aldosterone secretion.
✓ Beta-adrenergic blockers, more commonly referred to as beta blockers ✓ Beta-blockers block catecholamines from binding to the receptors found in the heart and lungs ✓ These medications block the beta receptors, the rate at which the pacemaker (sinoatrial [SA] node) fires decreases, and the time it takes for the node to recover increases ✓ Some beta-blockers are more cardioselective (metoprolol and atenolol) compared to nonselective beta-blockers (propranolol) ✓ Underlying restrictive and obstructive respiratory illness may worsen when beta-blockers are given because the medication causes bronchoconstriction ✓ The nurse needs to assess the client's pulse (P) and blood pressure (BP) before administration ✓ These medications may raise the client's risk for falls because they may cause orthostatic hypotension ✓ Beta-blockers should not be administered if the client is experiencing any atrioventricular (AV) block or bradyarrhythmia ✓ Examples of beta-blockers include propranolol, metoprolol, and carvedilol Beta-blockers decrease blood pressure by causing vasodilation of the vessels. They block catecholamines from the beta receptor sites found in the heart and lungs. Beta-blockers decrease the heart's workload through vasodilation and lowering the heart rate. This relaxation of the vasculature and reduction in heart rate will reduce the myocardial oxygen demand. This is why beta blockers (low doses) may be prescribed during an acute myocardial infarction and afterward.
endometriosis
✓ Endometrial glands and stroma outside the uterine cavity characterize endometriosis. The lesions are typically located in the pelvis but may occur at multiple sites, including the bowel, diaphragm, and pleural cavity ✓ Endometriosis commonly occurs in individuals between the age of 25 and 35 ✓ Clinical manifestations include pelvic pain/pressure, dyspareunia, heavy menstrual bleeding, and fertility problems ✓ Other manifestations include bowel and bladder dysfunction, including dysuria, constipation, and diarrhea ✓ Diagnosis is through a transvaginal ultrasound and vaginal examination ✓ Treatment is with NSAIDs to mitigate pain and estrogen and progestin contraceptives because they suppress ovarian function and thereby reduce endometriosis disease activity and pain
The nurse reviews newly prescribed medications from the primary healthcare provider (PHCP). The nurse understands that the prescribed etanercept is intended to treat which condition? A. Osteoarthritis B. Diabetes mellitus C. Infective endocarditis (IE) D. Rheumatoid arthritis
✓ Etanercept is a tumor necrosis factor-blocking medication used to treat autoimmune conditions such as psoriasis or rheumatoid arthritis ✓ This medication is given by subcutaneous injection ✓ This medication increases the risk of infection, which requires baseline testing for tuberculosis ✓ Blood dyscrasias such as pancytopenia may occur, and a baseline complete blood count is required ✓ Injection site reaction is the most common reaction, which includes redness at the site, itching, and discomfort ✓ The client should be instructed to prevent infection through hand hygiene and avoiding individuals who may be ill Etanercept is a biologic intended to treat specific autoimmune conditions such as plaque psoriasis, psoriatic arthritis, and rheumatoid arthritis (RA). This medication decreases the inflammatory process by blocking tumor necrosis factor. This medication is administered subcutaneously on a specified dosing schedule depending on the condition it is intended to treat.
therapeutic INR while on warfarin
✓ Heparin to warfarin bridge is prescribed so the client may be discharged on an anticoagulant within a therapeutic range (INR ✓ It typically requires 3-5 days for a client's INR to become therapeutic between 2.0 and 3.0.2.0 - 3.0).
Common complications following thyroidectomy surgery are as follows:
✓ Hypocalcemia: accidental injury or removal of the parathyroid gland can reduce the circulating blood calcium levels. Acute hypocalcemia may present with the Chvostek Sign (tapping on the cheek causes facial twitching), Trousseau's Sign (applying pressure on the arm causes carpopedal spasms), muscle cramps, paresthesia, peri-oral numbness, tetany, seizures, and cardiac arrhythmias. If untreated, it can be life-threatening. To prevent this complication, every thyroidectomy patient is started on 3 grams of elemental calcium per day as soon as they can begin an oral diet. ✓ Recurrent laryngeal nerve (RLN) injury: hoarseness of voice from RLN injury is common due to the damage of RLN intra-operatively. ✓ Following a thyroidectomy, the nurse should have readily available airway equipment and calcium gluconate.
Impetigo
✓ Impetigo is a contagious skin condition that is caused by Staphylococcus aureus or Streptococcus pyogenes ✓ This condition is commonly found in young children and typically presents around the face, mouth, and then on the hands, neck, and extremities ✓ The lesions have drainage and then begin to crust ✓ Medical treatment is antibacterial ointments that should be applied via a sterile cotton tip applicator ✓ Nursing care focuses on educating the client on hand hygiene, pain control with warm compresses to the affected area, preventing transmission by not sharing linens, etc. ✓ The individual with impetigo should not go into any pools, hot tubs, or saunas to prevent further transmission ✓ The child may return to school if the vesicles are covered and antibiotic treatment has been started for 24 hours
Vaccines either not recommended or contraindicated during pregnancy include:
✓ MMR ✓ Varicella ✓ Zoster ✓ HPV ✓ Polio ✓ Any live vaccine
muscle relaxants tizanidine, baclofen, carisoprodol, cyclobenzaprine, and methocarbamol
✓ Muscle relaxers are central nervous system depressants ✓ Key teaching points for this medication (and others in this class) include avoiding driving while taking the medication and not combining the medication with alcohol Tizanidine is a muscle relaxant and is utilized in the treatment of multiple sclerosis. Other indications for a muscle relaxant include an injury such as a motor vehicle crash that may cause muscle spasms.
Esomeprazole
✓ PPIs are the gold standard in the treatment of GERD. ✓ Medications in this class include esomeprazole, pantoprazole, and lansoprazole. ✓ The client should be instructed to take the medication first thing in the morning without food or other medications. ✓ The long-term use of a PPI has been linked to osteoporosis and hypomagnesemia. Therefore, it is reasonable to recommend weight-bearing exercises and magnesium and calcium supplements approved by the primary healthcare provider (PHCP).
Syphillis
✓ Syphilis is a highly contagious sexually transmitted infection. ✓ Different stages are found in this infection and are classically marked by a painless chancre lesion in the primary stage, a diffuse rash in the secondary stage, and systemic cardiovascular abnormalities in the tertiary stage. ✓ Treatment is through prescribed antibiotics such as doxycycline or penicillin G. ✓ Nursing care aims to educate the client on preventative measures such as using condoms. ✓ This sexually transmitted infection is required to be reported to the public health department. Syphilis does not cause penile or vaginal discharge. Discharge that is foul smelling may be associated with other infections such as trichomoniasis, gonorrhea, or chlamydia. Dyspareunia is pain during intercourse commonly associated with pelvic inflammatory disease. Syphilis is a sexually transmitted infection caused by T. pallidum. This insidious infection causes a client to experience a painless chancre in the area where the infection was contracted. That could be the penis, vagina, or rectum. This chancre lesion will eventually disappear and cause constitutional symptoms such as a generalized macular rash and malaise.
The three rapid-acting insulins are lispro, aspart, and glulisine
✓ The client must take this insulin 10-15 minutes before a meal or while actively eating ✓ A rapid-acting insulin is utilized as correctional insulin before meals to prevent post-prandial hyperglycemia ✓ This type of insulin is commonly loaded into an insulin pump ✓ Short-acting insulin may also be used in an insulin pump
Therapeutic PTT for Heparin
✓ The goal is to prolong the aPTT from 1.5 to 2.5 times the control value. The normal aPTT is 30-40 seconds.
The nurse is caring for a client diagnosed with atrial fibrillation. The nurse should anticipate a prescription for which of the following medications? Select all that apply. Diltiazem Nitroglycerin Clonidine Atorvastatin Warfarin
✓ The primary goal for a client with atrial fibrillation is to maintain rate control (60-100) and to prevent stroke ✓ Medications such as diltiazem, digoxin, amiodarone, and dronedarone may be used to control heart rate ✓ Anticoagulants are also indicated as ischemic strokes are commonly associated with atrial fibrillation ✓ Anticoagulants commonly used include rivaroxaban, apixaban, and warfarin
Abdominal paracentesis is performed for clients with gross ascitic fluid due to liver cirrhosis. Nursing care for an abdominal paracentesis includes -
➢ Witnessing informed consent that the primary healthcare provider obtains ➢ Assisting the client to void before the procedure ➢ Obtaining baseline vital signs ➢ Measure the abdominal girth ➢ Gather appropriate supplies (suction, tubing, paracentesis kit) ➢ Position the client per the physician's prescription. The positioning is likely upright to allow the fluid to settle in the lower abdominal quadrants. ➢ Monitor the client and the drainage ➢ Send the initial ascitic fluid to the lab for culture and sensitivity, as prescribed ➢ Reposition the client, as needed to facilitate better drainage ➢ Monitor the client's vital signs throughout and after the procedure ➢ Administer an infusion of albumin, as prescribed for large volume (> 5 liters) paracentesis
