NCLEX REVIEW
Metformin (Glucophage)
"Use: Type 2 diabetes mellitus Class: Antidiabetic, biguanide AEs: Lactic acidosis" Controls glucose Helps endogenous insulin work better
WHAT IS THE MEANING OF PHYSIOLOGICAL SIGN IN PSYCH PATIENT
.Anxiety (also called angst or worry) is a psychological and physiological sign and also including vital signs of the patient...
Adolescent to adult pain scale
0-10 numeric scale
Normal PR interval
0.12-0.20 seconds
Creatinine
0.6-1.3mg/dl nitrogenous waste excreted in the urine
4. Which symptom should the nurse expect to assess in the client diagnosed with hemophilia A? 1. Epistaxis. 2. Petechiae. 3. Subcutaneous emphysema. 4. Intermittent claudication.
1
A nurse is developing an informational session about hepatitis B infection. Which information should the nurse include? Select all that apply. 1. A vaccination against hepatitis B is available. 2. Hepatitis B is rarely seen in middle-aged adults. 3. Hepatitis B can be considered a sexually transmitted infection. 4. Hepatitis B is spread by contaminated food or water. 5. Hepatitis B is endemic in the United States.
1 3
What is the ideal situation that is present on the NCLEX?
1 nurse, 1 patient, and all the time in the world. Assume all orders are written.
Pediatric output
1-2 ml/ kg / hour
RULE: ASSIGN OB FLOAT NURSE (telemetery)
1. Closed abdominal surgeries 2. Hypertension 3. Diabetes Mellitus 4. Epidurals 5. IV drips
RULE: MED SURGE ASSIGN MED SURGE FLOAT NURSE
1. Diabetes mellitus 2. DVT( deep vein thrombosis) 3. Hypertension 4.Surgeries 5.Chronic condition 6. seizures
he nurse identifies the client problem "risk for imbalanced body temperature" fort he client diagnosed with hypothyroidism. Which intervention should be included in the plan of care? 1. Discourage the use of an electric blanket. 2. Assess the client's temperature every two (2) hours. 3. Keep the room temperature cool. 4. Space activities to promote rest.
1. Not good, hypothyroidism already has a low bp, electric blanket will vasodilate lowering bp even more
The client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? 1. Complaints of extreme fatigue and hair loss. 2. Exophthalmos and complaints of nervousness. 3. Complaints of profuse sweating and flushed skin. 4. Tetany and complaints of stiffness of the hands.
1. low and slow
Pediatric specific gravity
1.005-1.015
Magnesium
1.5-2.5 mEq/L
Fluid replacement 0-10 kg
100ml/kg
adolescent respiratory rate
12-18 breaths per min
Hemoglobin
12-18 g/dL
Sodium
135-145 meq/L
The medication order reads: heparin (HIGH ALERT) IV at 1400 units/hr. The pharmacy sends a bag of heparin containing 25,000 units in 250 ml D5W. What infusion rate should the RN set the IV pump? Answer with a number only. _____ ml/hr
14 ml/hr
School age respiratory rate
14-22 breaths / min
What should be done 1st and 2nd if the event of a med error, pt injury, or attempted suicide?
1st provide care, and 2nd notify MD.
How are patients on the psych ward prioritized?
1st: Physiological, 2nd: Change in psych behavior, 3rd: Safety
5. The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24 to 48 hours to the affected area. 3. Perform active range-of-motion exercise on the extremity. 4. Put the affected extremity in the dependent position.
2
A client with bacterial pneumonia is to start IV antibiotics. The nurse should verify which diagnostic test before administration? 1.urinalysis 2.sputum cultures 3.chest radiograph 4.RBC count
2
For the client who is experiencing expressive aphasia, which nursing iNtervention in promoting communication is most effective: 1, speaking loudly and slew 2. using a "picture board" fs the client to point to pictures 2. writing directions so the client can read them 4. speaking in short sentences
2
Which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? 1. Obstipation and hypoactive bowel sounds. 2. Hyperpyrexia and extreme tachycardia. 3. Hypotension and bradycardia. 4. Decreased respirations and hypoxia.
2. HOT STORM, FAtal
The client is admitted to the intensive care department diagnosed with myxedemacoma. Which assessment data warrant immediate intervention by the nurse? 1. Serum blood glucose level of 74 mg/dL. 2. Pulse oximeter reading of 90%. 3. Telemetry reading showing sinus bradycardia. 4. The client is lethargic and sleeps all the time.
2. O2, circulation rest are expected
48. A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital sign? 1. pulse 2. respirations 3. blood pressure 4. temperature
3
the nurse is caring for a client with bacterial pneumonia. The effectiveness of the clients oxygen therapy is best determined by? 1.absence of cyanosis 2.clients RR 3.ABG value 4.clients LOC
3
A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which of the following diets would likely be prescribed for this client? 1. Low-protein diet 2. Low-sodium diet 3. High-sodium diet 4. Low-carbohydrate diet
3. HIGH SODIUM TO HELP PREVENT EXCESS NA AND H2O LOSS
47. A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activa- tor (t-PA)? 1. Ask what medications the client is taking. 2. Complete a history and health assessment. 3. Identify the time of onset of the stroke. 4. Determine if the client is scheduled for any surgical procedures.
3. Tpa 4.5 hours
RBC
3.5-5 mill/mm3
Potassium
3.5-5.0 mEq/L
A cllient with chronic renal failure has been prescribed calcium carbonate. What is the rationale for this particular medication? 1) Diminishes incidence of gastric ulcer formation 2) Alleviates constipation 3) Binds with phosphorus to lower concentration 4) Increase tubular reabsorption of sodium
3: Clients with ARF have hyperphosphatemia. Clients are prescribed calcium-based phosphate binders to improve excretion of phosphorus.
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identity as the primary safety precaution to use? - 1. Wear a patch over one eye. - 2. Place personal items on the sighted side. -3. Lie in bed with the unaffected side toward the door. - 4. Turn the head from side to side when walking.
4
WBC
5,000-10,000/mm3
Fluid replacement 11-20 kg
50ml/kg
Adolescent heart rate
55-90
What should pregnant nurses avoid?
5th disease (slapface/Parovirus), measles, varicella, internal radiation, isotopes, and chemo drug handing.
BUN
6-20 mg/dL blood urea nitrogen
REGULAR Rate on EKG
60-100
Neonate Blood Pressure
60-90/20-60
school age heart rate
60-95 bpm
fasting blood sugar
60-99 ml/dl
Preschool heart rate
65-110
Toddler heart rate
70-110bpm
Infant heart rate
80-160 bpm
Calcium
9-11 mg/dL
metabolic syndrome
A syndrome marked by the presence of usually three or more of a group of factors (as high blood pressure, abdominal obesity, high triglyceride levels, low HDL levels, and high fasting levels of blood sugar) that are linked to increased risk of cardiovascular disease and Type 2 diabetes. I
The healthcare provider is teaching a patient diagnosed with hepatitis C about the disease. Which of these statements made by the patient indicate that the patient has an understanding of the teaching? Choose all answers that apply: A "I should get vaccinated for hepatitis A and hepatitis B." B "It's important for me to use barrier protection when I have sex." C "I should not drink any wine, beer or other alcoholic beverages." D "I'll plan to do all my activities in the morning when I'm most rested." E "I should avoid sharing drinking cups and eating utensils with my family." F "Acetaminophen is the best medication for me if I have a headache."
A, B, C Hepatitis C is a parenterally transmitted virus. Inflammation caused by the hepatitis C virus can result in cirrhosis and liver cancer, so the patient will want to take steps to avoid further damage to the liver Patients infected with the hepatitis C virus should avoid alcohol, avoid acetaminophen, and get vaccinated for hepatitis A and B. Barrier protection should be used during sex, but casual household contact is not a risk factor for transmission. Fatigue is best managed by spacing activities throughout the day and taking rest periods as needed.
3. A patient is undergoing diagnostic testing for suspected systemic lupus erythematosus (SLE). Which assessment findings may help confirm the diagnosis? Select all that apply. A. Malar butterfly rash B. Photosensitivity C. Painful sores in the oral cavity D. Decreased white blood cell count E. Multiple swollen and painful joints
A,B,E
Who should manage a patient on a vent after a week (chronic/stable)?
An LPN
Who should take care of an SCI after a week (chronic/stable)?
An LPN
Who should take care of patients with airborne, droplet, or contact precautions?
An LPN
Who should feed a patient with a chronic CVA?
An NA
Who should establish a patient's initial plan of care?
An RN
Who should evaluate an initial post op patient's pain?
An RN
Who should feed a new trach patient?
An RN
Who should complete sterile procedures?
An RN or LPN
A 19-year-old student comes to the student health center at the end of the semester complaining that, My heart is skipping beats. An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next? a. Start supplemental O2 at 2 to 3 L/min via nasal cannula. b. Ask the patient about current stress level and caffeine use. c. Ask the patient about any history of coronary artery disease. d. Have the patient taken to the hospital emergency department (ED).
B
A client with glomerulonephritis is at risk of developing acute renal failure. The nurse monitors the client for which sign of this complication? a) bradycardia b) hypertension c) decreased cardiac output d) decreased central venous pressure
B
the client is diagnosed with an anaphylactic reaction is admitted to the ED. which assessment data indicate the client is not responding to treatment? a the client has a urinary output of 120ml in 2 hours b. the client has an hr of 110 and a BP of 90/60 c. the client has clear breath sounds and an RR of 26 d. the client has hyperactive bowel sounds
B.
The home health nurse is caring for an 81-year-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history, physical assessment, and physical therapy/occupational therapy, which nursing diagnosis is the highest priority for this patient? a. Impaired transfer ability b. Risk for caregiver role strain c. Ineffective health maintenance d. Risk for unstable blood glucose level
B. The spouse's household and patient care responsibilities, in combination with chronic illnesses, indicate a high risk for caregiver role strain. The nurse should further assess the situation and take appropriate actions. The data about the control of the patient's diabetes indicates that ineffective health maintenance and risk for unstable blood glucose are not priority concerns at this time. Because the patient is able to ambulate with a cane, the nursing diagnosis of impaired transfer ability is not supported.
Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider? a. The patient complains of having a stiff neck. b. The patient's blood pressure (BP) is 90/50 mm Hg. c. The patient reports a severe and unrelenting headache. d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).
B. To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.
Your assigned first day post-operative client, who has a new colostomy, seems to worry a lot and has symptoms of sensory overload. Which of the following client goals, if met, would most contribute to reducing sensory overload for this client? [Hint] A. Will not sleep or nap during the day. B. Will report pain at 4 or less on a 10-point scale. C. Will attend classes on colostomy care. D. Will look at colostomy during colostomy care.
B. Will report pain at 4 or less on a 10-point scale. People who have sensory overload may appear fatigued. They cannot internalize new information and experience cognitive overload as a result of everything that is happening to them. Such factors as pain, lack of sleep, and worry can also contribute to sensory overload.
The culturally sensitive nurse will realize which of the following about a client from a large active Latino family who is put into isolation for a communicable disease? [Hint] A. The number of visitors greatly needs to be restricted. B. may be accustomed to, and need, high stimulation level C. is a likely candidate for sensory overload D. will need more personal space than other clients
B. may be accustomed to, and need, high stimulation level
A patient is diagnosed with an infection caused by the hepatitis A virus. Which statement, if made by the patient, would indicate the patient needs further teaching about the infection? A "I will wash raw fruits and vegetables thoroughly before I eat them." B"Before I take any over-the-counter medicines I should call the clinic." C"I might get liver cancer someday because I have this infection." D"It's important for me to remember to wash my hands after I use the bathroom."
C
A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin? a. The patient has dysphasia. b. The patient has atrial fibrillation. c. The patient reports that symptoms began with a severe headache. d. The patient has a history of brief episodes of right-sided hemiplegia.
C. A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
In responding to visceral stimuli, the client would be most likely to experience which of the following? [Hint] A. being aware train is coming because of hearing whistle B. being aware of which foot is forward when walking C. awareness of a full stomach D. being aware of an unpleasant smell
C. awareness of a full stomach
A patient with heart failure is taking Losartan and Spironolactone. The patient is having EKG changes that presents with tall peaked T-waves and flat p-waves. Which of the following lab results confirms these findings? A. Na+ 135 B. BNP 560 C. K+ 8.0 D. K+ 1.5
C. tall t waves = hyperkalemia
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?a. Roast beef, gelatin salad, green beans, and peach pie b. Chicken salad sandwich, coleslaw, French fries, ice cream c. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie d. Pork chop, creamed potatoes, corn, and coconut cake
C. want foods that are high in iron
A patient who has acute glomerulonephritis is hospitalized with acute kidney injury (AKI) and hyperkalemia. Which information will the nurse obtain to evaluate the effectiveness of the prescribed calcium gluconate IV?
Cardiac rhythm
Biguanides and Thiazolidinediones
Cause the liver to produce less glucose and reduce insulin resistance
What should be included in change of shift report?
Changes in condition, new medications, complications, diagnostic procedures, treatments (lasix for crackles, etc.)
What should be done if an Oto thermometer isn't registering?
Check charge or send to biomed engineering and obtain new.
7.A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? a) Imbalanced nutrition: Less than body requirements b) Risk for infection c) Impaired physical mobility d) Decreased cardiac output
D
which is the highest priority nursing intervention for the client who is having an anaphylactic reaction? a. administer parenteral epinephrine, an adrenergic agonist b. prepare for immediate endotracheal intubation c provide a calm assurance when caring for the client d establish and maintain a patent airway
D. AIRWAY TOP PRIORITY (give EPI to protect the airway)
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a. to monitor and record the blood pressure daily. b. that Plavix will dissolve clots in the cerebral arteries. c. that Plavix will reduce cerebral artery plaque formation. d. to call the health care provider if stools are bloody or tarry.
D. Clopidogrel (Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients should be advised to notify the health care provider about any signs of bleeding. The medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A PATIENT WITH GLAUCOMA IS TREATED WITH MANNITOL?
DIAMOX is used for glaucoma patient to decrease aqueous humor. But here mannitol used for PAIN (eye).
What kinds of patients could be assigned to a medical surgical float nurse?
DM, DVT, HTN, SURGERIES, CHRONIC CONDITIONS, AND SEIZURES.
A client has developed HELLP syndrome and the last liver function tests suggest acute liver failure is beginning. The nurse should prepare for which intervention? Insertion of a intrahepatic shunt Administration of penicillin G Delivery by cesarean section Administration of acyclovir
Delivery by cesarean section
What is contraindicated with an allergy to iodine/shellfish?
Diagnostic test with dye/ cleaning solution for foleys/surgery.
A 22 month old child is admitted with second degree burns to his arms and legs due to a kitchen accident involving boiling water. While the RN tries to assess his vital signs he cries, clings to his blanket and continuously points to the door. When the child's grandmother, his primary caregiver at home, finally arrives the child begins crying even louder and tries to physically escape the RN's arms into the arms of the grandma. The nurse assesses this behavior as A. indicative of pain and the need for pharmacologic intervention. B. likely from the abusive situation that led to the burns; contact CPS. C. possibly the result of regression back to the stage of trust vs. mistrust. D. evidence of the need for an early intervention program with the social worker. E. none of the above.
E. normal behavior bonded with grandma
What is contraindicated with an allergy to yeast?
Hepatitis B vaccine
What is Cyclosporine used for?
Immunosuppressive agent. Patients that receive organ transplants will need to take them for the rest of their lives
What kills the immunocompromised patients?
Infection, live viruses (oral polio or varicella), Pneumocystis Carnii Pneumonia (PCP) (danger to immcprd pts only).
What should be your response when a patient will be harmed d/t lack of intervention?
Intervene immediately and do procedure correctly. (Ex: Staff contaminating foley).
What does it mean if a patients pacemaker is set at 75 and the patients rate is 80?
It OK and working fine. The patients heart can do better than the pacemaker just no worse!
What does it mean if the patients pacemaker is set at 75 and the patient's rate is 60?
It is defective and the MD should see the patient.
What is important to remember about prioritizing in the ER?
It won't be the obvious answer and don't be swayed by adjectives.
What does it mean if there is no pulse ox reading?
It's on too fat of a finger or no light is seen through the finger. Put it on another location.
When a patient who has had progressive chronic kidney disease (CKD) for several years is started on hemodialysis, which information about diet will the nurse include in patient teaching?
More protein will be allowed because of the removal of urea and creatinine by dialysis.
What are examples of progressive neurological diseases? What kind of death do they suffer from?
Multiple Sclerosis, Amynotrophic lateral Sclerosis (ALS), Parkinsons, Huntingtons Chorea, Gullian Barre Syndrome, Myasthenia Gravis, and Scleroderma (hardening). THEY DIET A RESPIRATORY DEATH.
Fluid replacement: remaining weight kg
Multiply XXX by 20 ml/kg
can a UAP... change bed linens while log rolling a pt from side to side of a pt in skeletal traction?
NO (bc logrolling a pt in traction will require multiple staff members)
can an LPN... assess the skin around an ostomy?
NO (they can monitor the skin for areas of breakdown though)
What meds/herbs should you make sure to ask patients if they are taking (so can implement bleeding precautions)?
NSAIDS, ASA, Heparin, Coumadin, Garlic, Ginkgo, Ginseng, and Vitamin E.
HbA1c
Normal <5.6 glycosylated hemoglobin
What should be done if there is no drainage from an NG tube?
Reposition patient or tube
What does it mean if an O2 mask with a rebreather bag deflates during inspiration?
The bag should NEVER deflate so get new equipment.
What does it mean if a PCA pump isn't delivering medication to the patient?
The may be asking to often or not enough medication to control the pain.
What does it mean if the vent is beeping with a high pressure alarm?
The patient is causing problems (fighting the vent- holding breath,etc.).
can a UAP... measure vitals just prior to beginning RBC transfusion?
YES
can a UAP... perform ROM exercises?
YES
The healthcare provider is teaching a patient diagnosed with hepatitis C about the disease. Which of these statements made by the patient indicate that the patient has an understanding of the teaching?Choose all answers that apply: A"I should get vaccinated for hepatitis A and hepatitis B." B"It's important for me to use barrier protection when I have sex." C"I should not drink any wine, beer or other alcoholic beverages." D"I'll plan to do all my activities in the morning when I'm most rested." E"I should avoid sharing drinking cups and eating utensils with my family." F"Acetaminophen is the best medication for me if I have a headache."
a,b,c
Which nursing actions are considered tertiary health promotion? Select all that apply. a. A nurse runs an immunization clinic in the inner city. b. A nurse teaches a patient with an amputation how to care for the residual limb. c. A nurse provides range-of-motion exercises for a paralyzed patient. d. A nurse teaches parents of toddlers how to childproof their homes. e. A school nurse provides screening for scoliosis for the students .f. A nurse teaches new parents how to choose and use an infant car seat.
b,c
A patient diagnosed with chronic hepatitis has developed hepatic encephalopathy. When assessing the patient, the healthcare provider looks for which of the following clinical manifestations characteristic of this condition Choose all answers that apply: ARetroperitoneal bleeding BInvoluntary hand tremoe CBloody emesis DShortened attention span EHypersomnia FSlurred speech
b,d,e,f
A patient diagnosed with hepatitis is undergoing a liver biopsy. When caring for the patient, which of these actions would be essential for the healthcare provider to take? Choose all answers that apply: A Review the patient's baseline liver function tests B Ensure the patient's clotting profile is within normal limits C Provide a mechanical soft diet for before the procedure D Ensure the patient has an empty bladder before the procedure E Help the patient assume a left lateral position after the procedure F Monitor the patient's vital signs after the procedure
b,d,f
Which of the following are NOT typical signs and symptoms of right-sided heart failure? Select-all-that-apply: A. Jugular venous distention B. Persistent cough C. Weight gain D. Crackles E. Nocturia F. Orthopnea
b,d,f
A 9 month old infant is hospitalized after a three day history of nausea and vomiting. Which urine specific gravity indicates achievement of an expected outcome related to rehydration? 1.001 1.007 1.018 1.025
b. 1.007
What is a D-Dimer test used for/indicative of?
blood test that can be used to help rule out the presence of a serious blood clot. DVT
A client has acute liver failure. The nurse would assess for which skin changes? Select all that apply. a Poor wound healing b Dark-brownish discolorations on the chest c Pale mucous membranes d Presence of pruritus e Presence of petechiae
c,d,e
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? a. Peaches b. Cottage cheese c. Popsicle d. Lima beans
c. HYDRATION FOR SICKLE CELL
can a UAP... recharge a JP or Hemovac drain?
no (according to u world- they can record output though) JUST KIDDING IDKKKKKK
Hematocrit
percentage of blood volume occupied by red blood cell 35-50%
Prothrombin Time (PT)
test to measure activity of prothrombin in the blood Use to see if warfarin(Coumadin) is effective
How should Peds patients be transferred to the Med Surg floor?
Oldest child 1st, No communicable diseases, Not immunocompromised, and No teaching needed.
What patients are on bleeding precautions?
On coumadin/heparin, hemophilia, problems with bone marrow, chemo, liver disease, HIV, DIC, ASA/NSAIDS, and Cancer.
Wafarin (Coumadin)
Oral anticoagulant
What is the memonic to remember how to use the fire extinguisher?
PASS= Pull Pin, Aim, Squeeze, and Sweep
Bronchodilators Side Effects
Palpitations, tachycardia Hyperglycemia Decreased clotting time
A patient with CKD has a low erythropoietin (EPO) level. The patient is at risk for? A. Hypercalcemia B. Anemia C. Blood clots D. Hyperkalemia
The answer is B. EPO (erythropoietin) helps create red blood cells in the bone marrow. The kidneys produce EPO and when the kidneys are damaged in CKD they can decrease in the production of EPO. Therefore, the patient is at risk for anemia.
A patient with early evidence of obstructive airway disease states, "My smoking has already damaged my lung. Why stop now?" On what information should the RN base the response? a Encouraging patients to stop smoking is rarely effective. b Smoking cessation rates are low, even with drug therapy. c Avoiding environmental irritants can minimize the effect of smoking. d If smoking cessation occurs in time, the changes may be reversible.
d
Considering the developmental tasks of toddlers, which approach would best enhance communication between the RN and the child? A. respect the child's need for privacy; close the door when providing care. B. Prepare the child several days in advance for painful or invasive procedures. C. Use appropriate medical terminology; allow the child to ask questions. D. Integrate dolls, storytelling and picture books into conversations.
d
Erythropoietin sometimes is administered subcutaneously to treat which of the following? (Select all that apply.) a. Clients with marrow suppression b. Clients with chronic liver disease c. Clients with Hodgkin's disease and non-Hodgkin's lymphoma d. Clients with anemia and fatigue related to non-myeloid cancers
d
The pediatric surgery team arrives to perform an unscheduled, potentially painful procedure on a 3 year old child. What is the RN's best action? A. Encourage the mom to hold the child in the bed while the RN sets up supplies. B. Assign the child life specialist to distract the child with a toy. C. Demonstrate the procedure using a teddy bear first. D. Facilitate the set up for the procedure in the treatment room.
d
You're providing diet discharge teaching to a patient with a history of heart failure. Which of the following statements made by the patient represents they understood the diet teaching? A. "I will limit my sodium intake to 5-6 grams a day." B. "I will be sure to incorporate canned vegetables and fish into my diet." C. "I'm glad I can still eat sandwiches because I love bologna and cheese sandwiches." D. "I will limit my consumption of frozen meals."
d
Who should ambulate an acutely ill, chronic condition patient?
An LPN
Who should do an assessment on a stable acute patient?
An LPN
Who should do an assessment on a stable chronic patient?
An LPN
Who should feed a stable trach patient on a vent?
An LPN
Who should ambulate a one day P/O patient?
An LPN or an NA
Who should change sheets, get water for, enemas, stool spec/I&O for stable patients?
An NA
Who should feed a person with chronic parkinson's?
An NA
Who should transport a patient to an area within the hospital?
An NA
Who should ambulate a newly admitted post-op/acutely ill patient?
An RN
Who should ambulate a stable medical & surgical patient?
An RN
Who should do an assessment on a new admit and new P/O patient?
An RN
Who should feed a patient with an acute CVA?
An RN
Who should manage a patient's on a vent for the first week (acute)?
An RN
Who should take care of an SCI patient during their first week (acute)?
An RN
Who should teach self injections, dressing changes, or diets (except DM and CRF)?
An RN
Who should transcribe orders?
An RN
Who should evaluate a patients pain after a narcotic?
An RN or LPN
Who should up date a patient's plan of care?
An RN or LPN
Who should administer medications?
An RN or LPN (no IVs)
RULES TO WATCH THE PATIENT WHEN THE PATIENT HAVE SERIOUS PROBLEMS
Anytime a forgien object inserted into the body the complication may be rupture of the organ. Cold/ Dehydrated baby is the DEAD BABY. Drunks and druggies commit SUICIDE Never discharge a WHEEZER watch for MUSCLE and WEAKNESS.
What should be given to a patient on coumadin before they have surgery? When should it be given?
Aqua Mephyton (Vitamin K) is needed b4 surgery for someone on coumadin so they don't bleed out (it helps coagulation). If it is D/C 24 hours before they may still bleed because it's not long enough prior to surgery so Vit K will help.
B
F
What is the memonic for remembering who to see first (prioritizing patients)?
FIRST= Find hypoxia (oxygenation first-anxiousness and cardiac patient). Immunocompromised (prevent infection). Rectal bleeding (hemorrhaging from major artery otherwise don't care- VS changes) Safety, and Try Infection (Ex: septic and high temperature, need to take blood culture before start the antibiotics).
Toddler to school age pain scale
FLACC
School age to early adolescent pain scale
Faces scale
What should be done if the pyxis doesn't deliver a stat medication?
Filled Q24 hours so call the pharmacy for the med.
What procedures are done non-sterile in the home?
Foley catheter, trach suctioning, insulin, injections, intermittent, and suprapublic catheters.
For whom does the interdisciplinary team meet?
For those with chronic non compliance issues (Ex: sickle cell admitted 3x for crisis, DM admitted for hyperglycemia, celiac not gaining weight, asthma admitted for bronchospasms several times a year).
What is worn for droplet precautions?
Glove, gown, and mask
What patients are immunocompromised?
HIV, cancer, chemo, steroids, organ transplants, cushings, addisons, and radiation.
What interventions are needed to prevent aspiration?
HOB elevated to eat, bed in low position, place on right side after eating, call bell in reach, suction available, and side rails elevated.
What is contraindicated with an allergy to bananas, kiwi, chesnuts, an avocado?
Latex/rubber
Who does an interdisciplinary team consist of?
MD, RN, PT, Social worker, etc.
What is contraindicated with an allergy to egg?
MMR and flu shot
What should be done if staff applies restraints to a patient to keep them from falling or wandering?
MORE EDUCATION
What should be done if staff doesn't recognize false imprisonment such as gerichair c tray, not allowing patient to leave w/o MD orders, or anything preventing freedom to move about?
MORE EDUCATION
What should be done if staff turns of alarms on equipment?
MORE EDUCATION
What should be done if staff uses extension cords for equipment?
MORE EDUCATION
What should be done if staff breaches confidentiality (taking in public areas, giving D/C instructions with others in room, teaching with family in room, calling support groups w/o pt permission?
MORE EDUCATION. NURSE MANAGER OFFICE IS NOT OPEN TO THE GENERAL PUBLIC (=safe place to discuss).
What should you be concerned about first with someone who experienced burns?
Airway and breathing bc if they were close enough to get burned they were close enough to inhale smoke.
What should be done if an IV pump (IVAC) set to run 1 liter of fluid at 150 ml/hr after 6 hours there is 200 ml left in the bag?
Send to biomed engineering and obtain another pump.
Ipratropium Bromide (Atrovent)
Used to reverse airway constriction Facilitates removal of secretions bronchodilator
What should you NEVER Massage?
Veins, Z-track, Pressure ulcers, SQ heparin, Wilm's tumor, and intradural (PPD TB test).
Metabolic syndrome tests
Waist circumference Blood pressure FBG/FBS HDL cholesterol Triglycerides BMI
Which of these is within the RN scope of practice? Starting IVs, Isolation placement, Problem w/NGs, and Room assignments.
All are within the RN scope of practice.
What should be your response if a staff members action is incorrect but will not harm the patient?
Wait until they are finished then teach the correct procedure to them.
What is important to know about evaluating a treatment?
All drugs/tx are used to bring a pt back to normal. A successful tx will always reverse the presenting signs and symptoms (ask why treatment initiated).
infant respiratory rate
25-55 breaths per min
Fluid replacement 71+ kg
2500/24 hours. (Adult fluid requirement)
43. Following a stroke, a client has dysphagia mad left-sided facial paralysis. Which feeding tech- ique will be most helpful at this time? 1. Encourage sipping diluted liquid meal supplements from a straw. 2. Position the client with the bed at a 30-degree angle. 3. Offer solid foods from the unaffected side of the mouth. 4. Feed the client a soft diet from a spoon intothe left side of the mouth.
3
A nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care? Select all that apply. 1. Encouraging fluid intake of at least 3000 mL/day 2. Encouraging an intake of low-protein foods 3. Monitoring for changes in mental status 4. Monitoring intake and output 5. Maintaining a low-sodium diet
1,3,4 INCREASE sodium intake, carbs, protein
Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis? 1. Child's reluctance to move a body part 2. Cool, pale, clammy extremity 3. Eccymosis formation around a joint 4. Instability of a long bone in passive movement
1.
Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply. 1. Instruct the client to use a razor blade to shave. 2. Avoid administering enemas to the client .3. Encourage participation in noncontact sports. 4. Teach the client how to apply direct pressure if bleeding occurs. 5. Explain the importance of not flossing the gums
2,3,4
A patient with newly diagnosed SLE asks the nurse how the disease will affect her life. The best response by the nurse is: A. You can plan to have a near-normal life since SLE rarely causes death B. It is difficult to tell because to disease is so variable in its severity and progression C. Life span is shortened somewhat in people with SLE, but the disease can be controlled with long-term use of corticosteroids D. Most people with SLE have alternating periods of remissions and exacerbations with rapid progression to permanent organ damage
2.
The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24 to 48 hours to the affected area. 3. Perform active range-of-motion exercise on the extremity. 4. Put the affected extremity in the dependent position.
2. Ice is good NO HEAT PACKS
preschool respiratory rate
20-25 breaths/min
toddler respiratory rate
20-30 breaths/min
fluid replacement 21-70 kg
20ml / kg
The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse? 1. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation. 2. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGsof pH 7.35, PaO2 88, PaCO2 44, and HCO3 22. 3. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45,P 124, and R 28. 4. The client diagnosed with hyperthyroidism who has undergone a thyroidectomytwo (2) days ago and has a negative Trousseau's sign.
3. low bp, increased hr could be addison crisis
A client with acute renal failure develops sever hyperkalemia. What would the nurse anticipate to be used to treat this imbalance? 1) Furosemide (Lasix) 2) Amphojel (aluminum hydroxide) 3) 50% glucose and regular insulin 4) Epoetin (Procrit)
3: Hyperkalemia can develop into an emergency situation (Cardia Arrest). It is important to quickly move the potassium back into the cells by administering 50% glucose and regular insulin, usually in conjunction with some type of base to correct the acidosis, such as sodium bicarbonate or calcium gluconate given IV. Insulin assists in the movement of potassium into the cells and helps to reduce the serum potassium level. Amphojel is used for the treatment of hyperphosphatemia that occurs with ARF. Procrit is used for the treatment of anemia caused by a decrease in erythropoietin production by the kidneys. A diuretic, such as Lasix, may lead to a loss of potassium, but the rate is too slow.
A client with chronic renal failure has an internal venous access site for hemodialysis on her left forearm. What action will the nurse take to protect this access site? 1) Irrigate with heparin and NS q8 hrs 2) Apply warm moist packs to the area after hemodialysis 3) Do not use the left arm to take blood pressure readings. 4) Keep the arm elevated above the level of the heart.
3: Protect the arm with the functioning shunt. No blood pressure readings should be taken from that arm, and there should be no needle sticks. The access is not irrigated with Heparin.
Which clinical manifestation should the nurse expect to note when assessing a client with Addison's disease? 1. Edema 2. Obesity 3. Hirsutism 4. Hypotension
4
Which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? 1. Increase the amount of fiber in the diet. 2. Encourage a low-calorie, low-protein diet. 3. Decrease the client's fluid intake to 1,000 mL/day. 4. Provide six (6) small, well-balanced meals a day.
4. small frequent meals to help with the increased appetite
Infant Blood Pressure
87-105/53-66
Toddler Blood Pressure
95-105/53-66
School Age Blood Pressure
97-112/57-71
Normal ORS interval
<0.12 seconds
Adolscent blood pressure
<120 / < 80
Hypoglycemia
<60 mg/dl
Diabetes HbA1C
>/= 6.5%
hyperglycemia
>126
fasting blood sugar diabetes
>126 mg/dL
A patient diagnosed with viral hepatitis is prescribed ribavirin and interferon alfa-2a. The patient calls the clinic to report shortness of breath and increasing fatigue over the past week. Which of the following responses would be most appropriate for the healthcare provider to make? A "Do you have any other symptoms such as a headache or rash?" B "Please come to the clinic so we can send some of your blood to the lab' C "How many hours of sleep do you usually get each night?" D "These symptoms are very common in patients diagnosed with hepatitis.'
A Although it's true these symptoms are associated with hepatitis, the healthcare provider will want to assess for serious problems associated with the prescribed medications. Think about other physiological problems besides hepatitis that can cause these symptoms. Ribavirin toxicity can cause hemolytic anemia, and interferon alpha-2a can cause bone marrow depression. This can lead to decreased oxygen-carrying capacity of the blood resulting in fatigue and shortness of breath.
diabetes type 2
A chronic condition where the body does not use insulin properly and becomes insulin resistant.
1. patient presents with malaise, a fever, and joint pain. If a systemic lupus erythematosus (SLE) diagnosis is being considered, which additional assessments should the nurse perform? Select all that apply.] A. Take patient blood pressure B. Assess for enlarged thyroid gland C. Ensure that urine is collected for a urinalysis D. Palpate the abdomen and listen to bowel sounds E. Ask the patient simple questions and note patient response
A,C,E
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the patient communicate is to a. ask questions that the patient can answer with "yes" or "no." b. develop a list of words that the patient can read and practice reciting. c. have the patient practice her facial and tongue exercises with a mirror. d. prevent embarrassing the patient by answering for her if she does not respond.
A. Communication will be facilitated and less frustrating to the patient when questions that require a "yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be able to read or recite words, which will frustrate the patient without improving communication. Expressive aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor aspects of speech. The nurse should allow time for the patient to respond.
The nurse is admitting a person who has had a sudden loss of eyesight. On assessing this client, the nurse finds that the client is disoriented. The nurse will most suspect which of the following about the disorientation? [Hint] A. Disorientation is a normal reaction to sudden blindness. B. Compensatory behavior to eyesight loss includes disorientation. C. Client will compensate for the eyesight loss within 48 hours. D. Disorientation is a symptom of the cause of sudden eyesight loss.
A. Disorientation is a normal reaction to sudden blindness. Sudden loss of eyesight can result in disorientation. With gradual loss of sensory function, individuals often develop behaviors to compensate for loss, whereas with sudden loss, the compensatory behavior often takes days or weeks to develop.
the client is diagnosed with a bee sting allergy is being discharged from the ED. which priority discharge instruction should be taught to the client? a. demonstrate how to use the EpiPen, an adrenergic agonist b. teach the client to never go outdoors in the spring and summer c. have the client buy diphenhydramine over the counter to use when stung d. discuss wearing a medic alert bracelet when going outside
A. Epi education
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate? a. "The obstructing plaque is surgically removed from an artery in the neck." b. "The diseased portion of the artery in the brain is replaced with a synthetic graft." c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed." d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque."
A. In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The final response beginning, "A wire is threaded through the artery" describes the mechanical embolus removal in cerebral ischemia (MERCI) procedure.
A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? A Normal sinus rhythm B Sinus tachycardia C Sinus bradycardia D Sinus arrhythmia
A. Normal sinus rhythm Atrial and ventricular rates are the same and range from 60 to 100 beats per minute. Rhythm is regular or essentially regular. PR interval is 0.12 to 0.20 seconds. QRS interval is 0.04 to 0.10 seconds. P and QRS waves are consistent in shape.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan? a. Apply intermittent pneumatic compression stockings. b. Assist to dangle on edge of bed and assess for dizziness. c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to prevent airway obstruction.
A. The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of a. risk for injury related to denial of deficits and impulsiveness. b. impaired physical mobility related to right-sided hemiplegia. c. impaired verbal communication related to speech-language deficits. d. ineffective coping related to depression and distress about disability.
A. The patient with right-sided brain damage typically denies any deficits and has poor impulse control, leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair. Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits. Left-sided brain damage is associated with depression and distress about the disability.
When gathering data to assist with assessments of clients, you will find which of the following clients most at risk for sensory overload? [Hint] A. a client in pain B. a homebound client C. a client on bed rest D. a client in isolation
A. a client in pain
A client, who lives alone in the country, was admitted to the hospital two days ago. The client begins to show signs of confusion and disorientation. You would most suspect which of the following problems as most contributing to the confusion and disorientation? [Hint] A.changes in quantity and quality of sensory stimuli B. changes in the amount or type of medication C. excessive worry about a variety of things D. a mental condition that has previously gone undetected
A. changes in quantity and quality of sensory stimuli
After receiving change-of-shift report on the following four patients, which patient should the nurse see first? a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled
A. tPA needs to be infused within the first few hours after stroke symptoms start in order to be effective in minimizing brain injury. The other medications should also be given as quickly as possible, but timing of the medications is not as critical.
In what order should patients be removed in the event of a disaster?
ABC= Ambulatory, bed ridden, and critical care patients.
Patients on/with what should never be sent to surgery?
ANTICOAGULATED PATIENTS: With low platelets, high PT or PTT, or on coumadin/heparin.
What three things should the Dr. be called for?
Acute epiglottitis, back pain (Abdominal Aortic Aneurysm (triple A)), and Eye Pain (glaucoma or cataract surgery). Only call MD for abnormal situations not what is expected.
What are the rules for prioritizing patients?
Acute problems more serious than chronic. <24 hrs post op= more serious than medical conditions/older surgeries. Unstable patient more serious (ACUTE) than stable, when in doubt Select the more vital organ (heart or lungs over toes, fingers and legs).
What adults should be transferred to the Peds ward if necessary?
Adult with condition/tx similar to that which is seen in the pediatric population. (COPD is like cystic fibrosis, pneumonia is pneumonia).
What is Kernig's sign?
After flexing the hip and knee at 90 degree angles, pain and resistance are noted.
If there is a problem that requires immediate attention when should you call the doctor?
After you have initiated an ACTIVE INTERVENTION. If it is serious enough to call the Dr. then need something to keep them alive until Dr. gets there.
FLOATERS (NRSES WHO FLOAT FROM THE OTHER UNITS)
Assign the float nurse a condition they would see their own ward. Give them the most stable patients. Float nurses NEVER get Cardiac pts, Borderline/ Antisocial
What should be done for pain and discomfort?
Avoid drugs, use nursing interventions (positioning, heat, etc.), when in doubt flush the patient out.
10. A patient with Addison's Disease is being discharged home on Prednisone. Which of the following statements by the patient warrants you to re-educate the patient? A. "I will notify the doctor if I become sick or experience extra stress." B. "I will take this medication as needed when symptoms present." C. "I will take this medication at the same time every day." D. "My daughter has bought me a Medic-Alert bracelet."
B
8. Which of the following patients are at risk for developing Cushing's Syndrome? A. A patient with a tumor on the pituitary gland, which is causing too much ACTH to be secreted. B. A patient taking glucocorticoids for several weeks. C. A patient with a tuberculosis infection. D. A patient who is post-opt from an adrenalectomy.
B
A member of the clinic housekeeping staff experiences a needlestick by a contaminated needle. Which of the following should be administered by the healthcare provider to provide the patient with passive immunity against the hepatitis B virus? A. Antiviral medication B Hepatitis B immune globulin (HBIG) C Hepatitis B vaccine D Interferon
B Eliminate the options that interfere with viral replication, since this is not a characteristic of passive immunity. Vaccines stimulate the immune system to make antibodies. HBIG contains IgG antibodies specific to hepatitis B, providing passive immunity (which means that a person is given antibodies to a disease instead of producing them through his or her own immune system). HBIG is used for prophylaxis after exposure to the hepatitis B virus.
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia? a. BP 146/88 b. Respirations 28 shallow c. Weight gain of 10 pounds in 6 months d. Pink complexion
B increased O2 demand
Several weeks after a stroke, a 50-year-old male patient has impaired awareness of bladder fullness, resulting in urinary incontinence. Which nursing intervention will be best to include in the initial plan for an effective bladder training program? a. Limit fluid intake to 1200 mL daily to reduce urine volume. b. Assist the patient onto the bedside commode every 2 hours. c. Perform intermittent catheterization after each voiding to check for residual urine. d. Use an external "condom" catheter to protect the skin and prevent embarrassment.
B. Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and use of a condom catheter are appropriate in the acute phase of stroke, but should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.
The client has some equipment that is noisy, and the roommate also has equipment that makes noise, and the room is close to a noisy nursing station, where they can be watched a little closer. Which of the following interventions by the nurse would be best for the client as well as reduce the risk of sensory overload? [Hint] A. Move the client away from the nurses' station area. B. Explain the sounds in the environment. C. Tell the client to ignore the sounds. D. Play the client's favorite music louder than the sounds.
B. Explain the sounds in the environment.
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours. The nurse will anticipate teaching the patient about a. alteplase (tPA). b. aspirin (Ecotrin). c. warfarin (Coumadin). d. nimodipine (Nimotop).
B. Following a transient ischemic attack (TIA), patients typically are started on medications such as aspirin to inhibit platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
Which of the following interventions would most help reduce olfactory stimuli for a client who is hospitalized with a draining wound and is sensory overloaded? [Hint] A. Use strong disinfectants to clean the wound. B. Place liquid deodorant on a gauze near the clean, covered wound. C. Spray strong floral room deodorizer in room to mask wound odor. D. Use strong disinfectant on everything possible in room.
B. Place liquid deodorant on a gauze near the clean, covered wound.
The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse? a. The pulse rate is 102 beats/min. b. The patient has difficulty speaking. c. The blood pressure is 144/86 mm Hg. d. There are fine crackles at the lung bases.
B. Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.
Diabetes Type 2 Treatment
Begin with weight control for obese, dietary treatment, exercise, early use of oral antidiabetics (metformin)
What should be taught regarding home safety?
Bikes & skateboards should not be ridden in the street, guns should not be in homes with children even if they are locked up, <1 year old=sit in back seat facing backward >1 yr & <12 yrs= sit in back seat facing forward, home oxygen should be kept away from flames (stove, fireplace, no wool blankets, and no smoking- the smoke itself won't cause an explosion).
What does it mean if the bladder scanner doesn't produce a reading?
Bladder is empty
Alpha-glucosidase inhibitors
Block breakdown of carbohydrates and sugars in the intestines so less is absorbed
What information do you need to know prior to starting your shift?
Blood sugars, pre-ops, post-ops, change of condition on last shift, and new admits.
2. The nurse is caring for an adolescent patient with systemic lupus erythematosus (SLE) who is receiving antihypertensive therapy and has been eating a low-salt diet. Which assessment finding should prompt the nurse to alert the health care provider immediately? A. Blood pressure of 98/60 B. Bilateral edema of both wrists C. Mild confusion during conversation D. Bright red rash on the shoulders following sun exposure
C
6. A client sustained a head injury when falling off of a ladder. While in the hospital, the client begins voiding large amounts of clear urine and states he is very thirsty. The client states that he feels weak and has had an 8-lb weight loss since admission. What should the client be tested for? a) Hypothyroidism b) Syndrome of inappropriate antidiuretic hormone secretion (SIADH) c) Diabetes insipidus (DI) d) Pituitary tumor
C
A patient is diagnosed with an infection caused by the hepatitis A virus. Which statement, if made by the patient, would indicate the patient needs further teaching about the infection? A "I will wash raw fruits and vegetables thoroughly before I eat them." B"Before I take any over-the-counter medicines I should call the clinic." C"I might get liver cancer someday because I have this infection." D"It's important for me to remember to wash my hands after I use the bathroom."
C Hepatitis A virus is more common in areas that lack adequate sanitation or have poor hygiene practices. Infection with hepatitis A may be caused by eating contaminated foods such as fruits, vegetables, or shellfish. Many over-the-counter medications contain acetaminophen. Hepatitis A does not lead to chronic liver problems.
When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needlestick with a contaminated needle. Which of the following actions should the healthcare provider do first? A. Make an appointment with the infection control department B. Put the needle in a biohazard bag for testing C Wash the area thoroughly with soap and water D Report to the emergency department
C The healthcare provider will follow the facility-specific protocol for when a needlestick occurs. The initial action is aimed at reducing the possibility of infection. The puncture site and skin should be washed thoroughly with soap and water. Then the healthcare provider will follow the next steps in the facility protocol.
A 63-year-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? a. Obtain computed tomography (CT) scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess patient.
C, D, A, B The initial actions should be those that help with airway, breathing, and circulation. Baseline neurologic assessments should be done next. A CT scan will be needed to rule out hemorrhagic stroke before tPA can be administered.
The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Assess the patient's gag and cough reflexes. b. Determine when the stroke symptoms began. c. Administer the prescribed short-acting insulin. d. Infuse the prescribed IV metoprolol (Lopressor).
C. Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.
C. Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should be included in the plan of care? a. Provide a wide variety of food choices. b. Provide oral care before and after meals. c. Assist the patient to eat with the right hand. d. Teach the patient the "chin-tuck" technique.
C. Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced nutrition.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke, which intervention should the nurse include in the plan of care? a. Apply an eye patch to the right eye. b. Approach the patient from the right side. c. Place objects needed on the patient's left side. d. Teach the patient that the left visual deficit will resolve.
C. During the acute period, the nurse should place objects on the patient's unaffected side. Because there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be approached from the left side. The visual deficit may not resolve, although the patient can learn to compensate for the defect.
You are about to bathe an unconscious client. Which of the following interventions are most important on your part? [Hint] A. Vary the schedule of bathing and care from day to day. B. Tune the radio to client's favorite music during bath time. C. Explain procedures to client, and talk as if client can hear. D. Speak louder to the client than to other clients.
C. Explain procedures to client, and talk as if client can hear.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address? a. The patient is 25 pounds above the ideal weight. b. The patient drinks a glass of red wine with dinner daily. c. The patient's usual blood pressure (BP) is 170/94 mm Hg. d. The patient works at a desk and relaxes by watching television.
C. Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity contribute to stroke risk but not as much as hypertension.
A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting, she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient? a. Interrupted family processes related to effects of illness of a family member b. Situational low self-esteem related to increasing dependence on spouse for care c. Disabled family coping related to inadequate understanding by patient's spouse d. Impaired nutrition: less than body requirements related to hemiplegia and aphasia
C. The information supports the diagnosis of disabled family coping because the wife does not understand the rehabilitation program. There are no data supporting low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first? a. Monitor the blood pressure. b. Send the patient for a computed tomography (CT) scan. c. Check the respiratory rate and effort. d. Assess the Glasgow Coma Scale score.
C. The initial nursing action should be to assess the airway and take any needed actions to ensure a patent airway. The other activities should take place quickly after the ABCs (airway, breathing, and circulation) are completed.
A 47-year-old patient will attempt oral feedings for the first time since having a stroke. The nurse should assess the gag reflex and then a. order a varied pureed diet. b. assess the patient's appetite. c. assist the patient into a chair. d. offer the patient a sip of juice.
C. The patient should be as upright as possible before attempting feeding to make swallowing easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a poor appetite, but the oral feeding should be attempted regardless.
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects, the nurse anticipates teaching the patient about a. cerebral aneurysm clipping. b. heparin intravenous infusion. c. oral low-dose aspirin therapy. d. tissue plasminogen activator (tPA).
C. The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have a. dysphasia. b. confusion. c. visual deficits. d. poor judgment.
C. Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral artery occlusion.
The nurse advises a woman considering pregnancy of the importance of being tested for syphilis and rubella. What is most likely the reason the nurse is offering this advice? [Hint] A. suspicion that a client has high risk of sexual and drug behaviors B. assess factors that mainly cause visual impairments in baby C. assess factors that mainly cause hearing impairments in baby D. the health history assessment findings
C. assess factors that mainly cause hearing impairments in baby. Women who are considering pregnancy should be advised of the importance of testing for syphilis and rubella, which can cause hearing impairments in newborns.
What does it mean if the pulse ox is not alarming when O2 is at 92%?
Check the alarm level settings. May be too low and need readjusted.
During hemodialysis, a patient complains of nausea and dizziness. Which action should the nurse take first?
Check the patient's blood pressure.
What should be done if a pressure ulcer vacuum device has no suction?
Check to see if the tape is loose.
What types of conditions doesn't the interdisciplinary team not meet for?
Chronic stable conditions that are compliant and/or resolved by surgery or medical management (Ex: Pyloric stenosis, cleft lip, nephritis, glomerulonephritis, multiple fx after MVA, and acute leukemia on chemo).
What are the rules to remember when delegating to NAs?
Chronic stable patient only. Assigned tasks defiened in procedures Can take VS on stable patients and 1/2 hour after blood is started. NO delegation of tasks where medical knowledge is necessary or required WATCH KEY WORDS AND STAY AWAY FROM: (show,explain, monitor, teach, check, assess, and demonstrate=NO), Can walk stable patients, reorient/co-conduct . NO TO NA : Sterile procedures Assessments including VS on new admits Feeding choking risk patients Drugs (even OTC topicals), teaching, chest tubes, art lines, trachs, endo tubes, contagious diseases, or vents.
What conditions require seizure precautions?
Cirrhosis encephalopathy, PIH (HTN), DTs, ICP, CVA, Meningitis, Brain surgery, and Head trauma.
What kinds of patients could be assigned to an OB float nurse?
Closed abdominal surgeries, HTN, DM, Epidurals, and IV drips. If cardiac maybe telemetry bc similar.
9. Addison's Disease is: A. Increased secretion of cortisol B. Increased secretion of aldosterone and cortisol C. Decreased secretion of cortisol D. Decreased secretion of aldosterone and cortisol
D
During your morning assessment of a patient with heart failure, the patient complains of sudden vision changes that include seeing yellowish-green halos around the lights. Which of the following medications do you suspect is causing this issue? A. Lisinopril B. Losartan C. Lasix D. Digoxin
D
While assessing a patient who was admitted with heart failure, the nurse notes that the patient has jugular venous distention (JVD) when lying flat in bed. Whichaction should the nurse take next? a. Document this finding in the patients record. b. Obtain vital signs, including oxygen saturation. c. Have the patient perform the Valsalva maneuver. d. Observe for JVD with the patient upright at 45 degrees
D
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question? a. Keep head of bed elevated at least 30 degrees. b. Infuse normal saline intravenously at 75 mL/hr. c. Administer tissue plasminogen activator (tPA) per protocol. d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
D. Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should a. use a calm voice to ask the patient to stop the crying behavior. b. explain to the family that depression is normal following a stroke. c. have the family members leave the patient alone for a few minutes. d. teach the family that emotional outbursts are common after strokes.
D. Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient? a. Impaired physical mobility related to weakness b. Disturbed sensory perception related to brain injury c. Risk for impaired skin integrity related to immobility d. Risk for aspiration related to inability to protect airway
D. Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first? a. Complete blood count (CBC) b. Chest radiograph (Chest x-ray) c. 12-Lead electrocardiogram (ECG) d. Noncontrast computed tomography (CT) scan
D. Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible causes of the stroke and do not need to be completed as urgently as the CT scan.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find? a. Impulsive behavior b. Right-sided neglect c. Hyperactive left-sided tendon reflexes d. Difficulty comprehending instructions
D. Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side stroke.
The nurse is teaching a patient with Addison's disease about corticosteroid therapy. The nurse should prioritize which of these teaching points? Multiple choice question a. "Plan a high-carbohydrate diet." b. "Increase your daily intake of sodium." c. "Decrease your daily intake of calcium." d. "Do not stop taking the medication abruptly."
D. TAPER STEROIDS
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for a. surgical endarterectomy. b. transluminal angioplasty. c. intravenous heparin administration. d. tissue plasminogen activator (tPA) infusion.
D. The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider? a. The patient's speech is difficult to understand. b. The patient's blood pressure is 144/90 mm Hg. c. The patient takes a diuretic because of a history of hypertension. d. The patient has atrial fibrillation and takes warfarin (Coumadin).
D. The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient's care. The BP of 144/90 indicates the need for ongoing monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in therapy is indicated.
What are the rules to remember when delegating to an LPN?
HOSPITAL: An LPN works under direct supervision of an RN. IN a nursing home they might be charge nurses and handle all aspects of care. EX: plan, assess, evaluate, intervene and notify Dr. GET IN HOSPITAL Assign: stable chronic conditions with predictable outcomes .(Pts 24 hours after surgery). NO: discharge planning, admission assessments (including VS). NO IVs, and NO teaching. CAN: give narcotics. HAVE patient 72 hours after MI, CVA, SCI (spinal cord injury), Vents, or low coma scale (after 1 week), and may reinforce teaching.
What causes a non priority patient to become priority if it exits ?
Head trauma with INCREASED ICP, Bleeding FROM MAJOR ARTERY, Increased (blood sugar)BS IN COMA, decreased BS C S&S OF SHOCK, Paperwork FOR PREOP CHECKLIST, Poop FROM AN SCI ABOVE T6 OR APPENDICITIS (STRAIN AND RUPTURE), lab studies- ABGs, chronic conditions C ACUTE LIFE THREATENING PROBLEM. Angina c decreased LOC, decreased cardiac output = decreased urine output, arrhythmia, dizziness/faint PAIN- BACK PAIN : abdominal aortic aneurysm, RLQ: appendicitis, (RLQ with rebound tendernessand rigidity over the right rectus muscle or McBurney's point) ectopic pregnancy, or back pain with blood transfusions, .
A client is about to have a blood transfusion and asks the nurse which type of hepatitis is most frequently transmitted through food. Which type of hepatitis should the nurse teach the client about being most associated with food? Hepatitis.... A B C D
Hepatitis A
RNs should delegate to what level of a person's confidence? Based on?
Highest level of confidence and based on experience, training, and licensure.
What is a patient at risk for after parathyroidectomy?
Hypocalcemia
What should be done for effective infection control?
ID type of precautions required (airborne, droplet, contact, or standard), put infected patients in private rooms or with patient c same organism, airborne in private room with negative pressure (TB), Droplet (mask within 3 feet), contact (gown & gloves), and infected patients can leave room as long as wear same PPE out of room as ppl wear going into the room.
What procedures are done sterile in the home?
IVs, dressings, and peritoneal dialysis.
What is given to anyone with acute exposure to any infection or enlarged lymph nodes?
Immunoglobulins
What types of patients should never be transferred from the OB floor to the med surg floor?
Moms c babies, in labor, or c complications
STRESS RELATED CONDITION PATIENT
Multiple sclerosis (MS), Lupus, psoriasis Addison, Rheumatoid arthritis, Rayanuds Crohn's and asthma These patient need relaxation technoques: Meditation, quite environment, imagery, music, breathing exercise and regular exercise.
Fluid replacement: First 10 kg
Multiply first 10kg X 100ml/kg
Fluid replacement: SECOND 10 kg
Multiply second 10kg X 50ml/kg
What does it mean if the patient with an NG tube complains of N&V?
NG may be occluded so irrigate.
Infant pain scale
NIPS - facial expression, cry, breathing pattern, muscle tone, state of arousal
can an LPN... admit a patient from PACU?
NO
can an LPN... document a stoma's appearance?
NO
can an LPN... initiate a primary IV medication?
NO
can an LPN... teach a patient anything?
NO
can a UAP... instruct a pt admitted with renal calculi to strain all urine?
NO (RN bc it is pt education)
can a UAP... logroll a stable pt with a cervical collar?
NO (a nurse needs to be present for spinal cord stabilization)
can a UAP... collect a urine specimen for culture and sensitivity from a pt with a foley catheter?
NO (bc its a strike procedure) however a clean catch yes
With which conditions are droplet precautions important?
Neisseria meningitis, mycoplasma pneumonia, strep group A, or pertussis.
What are the 2 general rules for vaccines?
No vaccine given if pt temp > 101 or on an antibiotic.
can 2 UAPs pull up a pt that is 300lbs?
No... 3 people are preferred for a pt over 200 lbs
What should be done if someone is brought in with fixed and dilated pupils, not breathing and no heart rate present?
Nothing they are dead so go to the next person.
What type of patient should be discharged during an emergency?
Select patient with stable chronic condition. DO NOT discharge acute surgical patients. Pressure ulcers are considered chronic.
Heparin
Parenteral anticoagulant found in blood and tissue cells Used for DVT with PE
What does it mean if the pulse ox read 100% but patient is restless?
Patient may have been exposed to carbon monoxide.
What does it mean if the doppler isn't reading?
Patient may not have pulses
Which patient information will the nurse plan to obtain in order to determine the effectiveness of the prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)?
Phosphate level
Who should be isolated?
Pt with night sweats/temp/ and cough (TB), Pt with HA and stiff neck (meningitis), adult patient with rash or blisters (shingles), and any patient showing S&S of infection (increased temp, rash, increased WBCs) until verified. Follow CDC guidelines.
What should be done if someone is pulling out their IVs?
Put a mitten on them (least restrictive).
What is the memonic to help you prioritize steps in the event of a fire?
RACE= Remove, Activate, Contain, and Extinguish. Remove the client, Activate the fire alarm, confine the fire and extinguish the fire).
What is important to remember with room assignments?
RISK= Radiation (isolation), Infection/Immunocompromised/Isolation, Safety/Sex, and Know growth and development. If older than 6= must have a same sex roommate and must be both children have the same disease( example: one child has a fractured femur and another child with a fracture or a post-procedure with no infection = best room placement. HOWEVER, there is another 6 years old child but the child has an infection, this would not be an appropriate roomate for the child due to the risk of transmitting the infection.
What should be done if a cooling blanket is on a patient with a temp of 38 C (100.4 F), then after three hours their temp is 102F?
Send to biomed engineering and obtain a new cooling blanket.
What patients are prioritizing-----life threatening
RLQ (appendix) pain, LLQ (diverticulosis) pain, mid epigastric pain (preg-seizure), spinal cord injury above T6, child drooling (epiglotitis), central line with SOB, compartment syndrome (pain not relieved by drugs/cast or crushing injury c swelling), muffled heart sounds (cardiac tamponade), taking nitro within 1 week of MI (may be another MI), Femur/Pelvis fx c S&S of fat emboli, enlarged veins on Abd (portal HTN), DVT/PE, Immunocompromised pt with nonproductive cough (PCP) or temp, restlessness, abnormal electrolytes, progressive neurological diseases, burns c smoke inhalation, withdrawal symptoms of drugs/alcohol, angina c indigestion=MI, neuroleptic malignant syndrome, toxic levels of medication, and Spinal cord injury (SCI) c autonomic dysreflexia (crazy high BP).
What patients are NOT a priority?
RUQ (gallbladder) pain, Pain in the(CVA) costovertebral angle= (kidney stones), head trauma, bleeding, pain butt to ankle (sciatica), straining to urinate with bloody urine, menieres disease (these people always dizzy), chronic conditions, COPD, cystic fibrosis, laprascopy c chest or shoulder pain, Paperwork (document wait end of shift), calling doctor, teaching, bleeding, high or low BS, Poop, FXs, obtaining lab studies, and Pain.
What needs to be done prior to transferring patient to another unit?
Receiving unit must be familiar with the disease/treatment, be alert for gender specific wards (OB), don't transfer (unstable pts, unknown diagnosis pts, or pt whose condition is made worse with stress (addisons, lupus, RA, raynauds, asthma, etc.).
After the insertion of an arteriovenous graft (AVG) in the right forearm, a patient complains of pain and coldness of the right fingers. Which action should the nurse take?
Report the patient's symptoms to the health care provider.
What should be done if a peritoneal dialysis machine (CAPD) shows 2000 ml in and 1500 ml cloudy output?
Reposition patient and call MD.
The delegator delegates tasks but no what?
Responsibility. Still legally responsible for the outcomes.
MISC: FACTS ON PSYCH WARD
SUICIDE: highest in patient with drinkand /or take drugs. ALWAYS bring the patient back to reality --- avoid selecting answers that advise----giving meds or using restrains When choosing nursing intervention for patient problems------STAY AWAY FROM CRY BABIES.
What types of activities should a nurse delegate to NAs?
Standard unchanging procedures and Stable patients only. Always ask, which patient will die 1st.
Sulfonylueras and meglitinides
Stimulate pancreatic beta cells to release more insulin
T
T
With which conditions are airborne precautions important?
TB, varicella, or measles.
What do we need to know about delegating?
TELL= Taught (does the person know the skill), Evaluate (return demonstration), License (is one needed for the skill), and Lists (agency policy).
What things should an RN never delegate?
TIA= Teaching, Interventions, and Assessments
WHAT IS THE MEMONIC TO REMEMBER THE PROPER TRIAGE PRIORITIES? (NEED TO KNOW WHO TO HELP!)
TRIAGE= Trauma-no internal injuries (breathing, bleeding, broken bones, burns), Respiratory (1st)/ Cardiac (2nd), ICP (Head trauma, LOC/seizure-airway or numerous head and facial abrasions and lacerations), AN Infection (septic shock). NOT MPORTANT: meaning not priority GI (bleed, pain, and distention-not impt), Elimination- (pyelonephritis or trouble voiding) these client should be triaged.
What should be your response to Non-patient/non-medical issues that arise?
Tell direct supervisor (Ex: staff eating off of patient's trays).
Who should do the steps of the nursing process (assess, plan, interventions, outcomes)?
The RN
Who should manage IVs for regular infusions, TPN, ABX, and drips?
The RN (LPN or NA should never manage IVs)
Which action by a patient who is using peritoneal dialysis (PD) indicates that the nurse should provide more teaching about PD?
The patient cleans the catheter while taking a bath every day.
The nurse is assessing a patient who is receiving peritoneal dialysis with 2 L inflows. Which information should be reported immediately to the health care provider?
The patient's peritoneal effluent appears cloudy.
Polypharmacy
The use of many different drugs concurrently in treating a patient, who often has several health problems.
What two things should you use to help determine appropriate delegation tasks for a UAP?
Their ability and demonstration of the task.
What does it mean if the vent is beeping with a low pressure alarm?
There is a problem with the machine so get a new one and send the broken one to biomed engineering to have it fixed.
What does it mean if there is continuous bubbling in the H20 seal chamber of a chest tube?
There is an air leak so a new Plurovac should be used.
What does it mean if the glucometer isn't giving a reading?
There isn't enough blood to get a reading.
What should be done if someone presents with dilated pupils and decreased LOC?
They probably have increased ICP so sit them up to help decrease the pressure.
Who is at risk for falling blind/deaf patients or those with canes/walkers/or small animals?
Those with canes/walkers/small animals (geriatrics) are at risk for falling.
For what things should you use massage?
To decrease PAD pain, claudication (pain with walking) and increase circulation= increased O2 and decreased pain, prevent hemorrhage after delivery, decrease neuropathy, after bleeding stop hemophiliac.
Who should floaters be assigned to?
To patients with a condition similar to what they would see on their own floor, and most stable person possible, NEVER cardiac patients or borderline/antisocial patients (will eat them up bc so manipulative).
Who should an NA never position?
Total Hip replacement, total knee replacement, Increased ICP, acute CVA, or Above knee/below knee amputations.
Latanoprost (Xalatan)
Treatment of glaucoma Reduces intraocular pressure in the by increasing fluid drainage
Timolol maleate (Timoptic)
Use for treatment of glaucoma Reduces intraocular pressure by decreasing fluid production
What are interventions for a patient with a progressive neurological disease who may have respiratory problems as a result?
Use peak flow meter, get advanced directive, mechanical soft diet, and thickened liquids.
Pioglitazone (Actos)
Use: Type 2 Diabetes mellitus Helps control glucose Helps endogenous insulin work better
Albueterol (Proventil, Ventolin)
Used to reverse airway constriction Facilitates removal of secretions bronchodilator
can a UAP... reapply wrist restraints after toileting?
YES
can a UAP... take the 4th set of vital signs to a pt getting RBCs?
YES
can an LPN... administer IM medication?
YES
can an LPN... administer PO medication?
YES
can an LPN... administer SQ medication?
YES
can an LPN... administer drugs by an NG?
YES
can an LPN... monitor IV flow rate and administer IV piggyback meds?
YES
can an LPN... monitor pain level and administer pain medication?
YES
can an LPN... participate in narcotics/controlled substances count?
YES
can an LPN... perform wound care and/ or dressing changes?
YES
can an LPN... place a urinary catheter?
YES
can an LPN... program the feeding pump to administer a prescribed bolus feeding?
YES
can an LPN... remove wound sutures or staples?
YES
can an LPN... titrate o2 per unit protocol?
YES
can a UAP... perform oral suctioning? perform oral care, using a tonsil tip suction devise to suction the oropharynx to a pt with a trach?
YES (according to uworld) & YES
can a UAP... reapply a nasal cannula if it accidentally comes off?
YES (but can not ADMINISTER oxygen)
A client has acute liver failure. The nurse would assess for which skin changes? Select all that apply. Poor wound healing Dark-brownish discolorations on the chest Pale mucous membranes Presence of pruritus Presence of petechiae
Your Answers: Pale mucous membranes Presence of petechiae Presence of pruritus Bleeding may result in pale mucous membranes. Problems with coagulation can result in presence of petechiae. Pruritus is a common finding associated with acute or chronic liver failure.
A 6 month old infant is sleeping. The RN notes a heart rate of 140 beats per minute on the hard wired monitor. What is the RN's best action? A. Chart the normal pulse. B. Recheck after arousing the infant. C. Report the abnormal pulse immediately. D. Retake the pulse apically in 15 minutes.
a
You have a patient that is receiving peritoneal dialysis. What should you do when you notice the return fluid is slowly draining? A. Check for kinks in the outflow tubing B. Raise the drainage bag above the level of the abdomen C. Place the patient in a reverse Trendelenburg position D. Ask the patient to cough
a
A patient has a history of heart failure. Which of the following statements by the patient indicates the patient may be experiencing heart failure exacerbation?SATA A. "I've noticed that I've gain 6 lbs in one week." B. "While I sleep I have to prop myself up with a pillow so I can breathe." C. "I haven't noticed any swelling in my feet or hands lately."
a,b
the client is experiencing an anaphylactic reaction to bee venom. which interventions should the nurse implement? list in order of priority a. establish a patent airway b. administer epinephrine IM c. teach the client to carry an EpiPen when outside d. administer diphenhydramine (Benadryl), an antihistamine, IVP
a,b,d,c
The RN is caring for a patient whose cultural background is different from the RN's own. Which actions are appropriate for the RN to take? Select all that apply. A. Consider that nonverbal cues, such as eye contact, may have a different meaning in different cultures. B. Explain the RN's beliefs so that the patient will understand the differences. C. Respect the patient's cultural beliefs. D. Ask the patient about cultural or religious requirements that should be considered for nursing care. E. Understand that most cultures experience and respond to pain the same way.
a,c,d
Which of the following patients are MOST at risk for developing heart failure? Select-all-that-apply: A.A 69 year old male with a history of alcohol abuse and is recovering from a myocardial infarction. B. A 55 year old female with a health history of asthma and hypoparathyroidism. C. A 30 year old male with a history of endocarditis and has severe mitral stenosis. D. A 45 year old female with lung cancer stage 2. E. A 58 year old female with uncontrolled hypertension and is being treated for influenza.
a,c,e
A member of the clinic housekeeping staff experiences a needlestick by a contaminated needle. Which of the following should be administered by the healthcare provider to provide the patient with passive immunity against the hepatitis B virus? A. Antiviral medication B Hepatitis B immune globulin (HBIG) C Hepatitis B vaccine d. Antibiotics
b
An 8-month-old infant is sitting quietly on the mother's lap, chewing on a toy. When preparing to perform a routine assessment of this infant the RN should plan to do which action first? A. Measure head circumference. B. Auscultate heart and lung sounds. C. Perform a neuro check. D. Obtain a body weight.
b
The RN is planning care for a four year old child admitted with viral gastroenteritis. The child who is NPO, has been vomiting and has a urine specific gravity of 1.020 over the last 24 hours. Which client problem is the highest priority? A. Imbalanced nutrition B. Fluid volume deficit C. Risk for infection D. Altered urinary elimination
b
When auscultating the heart, the RN identifies the S1 component as the closing of which valves? A. Mitral and aortic valves B. Mitral and tricuspid valves C. Tricuspid and pulmonic valves D. Tricuspid and aortic valves
b
Which items are part of the neuro check, but are not an assessment of LOC? A. Vision and hearing ability. B. Pupillary size and reaction to light. C. Alertness and verbal response. D. Best motor response.
b
Which is the nurse's PRIORITY action when managing a client experiencing a type I hypersensitivity? A. Management of arthralgia B. Airway management C. Stopping the blood transfusion D. Decreasing a fever
b AIRWAY
During the patient's hospital stay, the patient states, "I told my wife that I was going to start exercising and I think I will join a fitness club." What stage of Prochaska's Transtheoretical model of Health Behavior change is the patient exhibiting? a Action b Preparation c Precontemplation d Maintenance
b preparation
A patient diagnosed with chronic hepatitis has developed hepatic encephalopathy. When assessing the patient, the healthcare provider looks for which of the following clinical manifestations characteristic of this condition Choose all answers that apply: Choose all answers that apply: A Retroperitoneal bleeding B Involuntary hand tremor C Bloody emesis D Shortened attention span E Hypersomnia F Slurred speech
b,d,e,f Hepatic encephalopathy is a result of hepatic dysfunction and portal hypertension. Hepatic encephalopathy is characterized by neuropsychiatric abnormalities secondary to increased serum ammonia levels. Hepatic encephalopathy characterized by progressive cognitive deficits and impaired neuromuscular function, so the healthcare provider would anticipate assessing symptoms such as sleep disturbances, confusion, impaired attention span, slurred speech, and asterixis (flapping tremor). Esophageal varices often result in bloody emesis, and retroperitoneal bleeding is a symptom of pancreatitis.
A patient diagnosed with hepatitis is undergoing a liver biopsy. When caring for the patient, which of these actions would be essential for the healthcare provider to take? Choose all answers that apply: (Choice A) A Review the patient's baseline liver function tests B Ensure the patient's clotting profile is within normal limits C Provide a mechanical soft diet for before the procedure D Ensure the patient has an empty bladder before the procedure E Help the patient assume a left lateral position after the procedure F Monitor the patient's vital signs after the procedure
b,d,f The liver is located in the right upper quadrant of the abdomen Liver function labs will be assessed, but these are not directly related to the procedure. Hemorrhage is a potential complication of the procedure. To manage bleeding, the patient's clotting profile should be within normal limits and the patient should be positioned on the right side after the procedure to provide pressure to the site. Vital signs are checked afterwards to detect changes that could signal hemorrhage. An empty bladder before the procedure will ensure it isn't damaged. The patient is usually advised to have nothing to eat or drink for six hours before the procedure.
The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear? a. Stridor b. Crackles c. Wheezes d. Friction rubs
b. Crackles LHF
A 3.12 kg baby is ordered to have a medication via IV piggyback every six hours. Which type of delivery device should the RN use to administer this medication? a Standard IV tubing since there is nothing in the stem to indicate otherwise. b There is no way to answer this question without more information. c Syringe tubing for such a small child. d Call the primary health care provider or pharmacist for advice. e IV push method would work best.
c
A client has developed HELLP syndrome and the last liver function tests suggest acute liver failure is beginning. The nurse should prepare for which intervention?I a. Insertion of a intrahepatic shunt B Administration of penicillin G c Delivery by cesarean section d Administration of acyclovir
c
A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care? A. Institute seizure precautions .B. Reorient to time and place PRN. C. Monitor intake and output. D. Place on cardiac monitor.
c
During an acute exacerbation, a patient with SLE is treated with corticosteroids. The nurse would expect the steroids to begin to be tapered when serum laboratory results indicate: A. Increased RBCs B. Decreased ESR C. Decreased anti-DNA D. Increased complement
c
The 2.96 kg baby is ordered to have Ampicillin 155 mg. IVPB. every six hours. Which type of delivery device should the RN choose to administer this medication? A.Standard IV tubing; there is nothing in the stem to indicate otherwise. B.The syringe will be enough; for such a small baby and small dose, IV Push would work best. C.Syringe tubing is small bore; given this child's age and weight a 4 ml flush is the best choice .D.Without knowing the underlying morbidity, i.e. cardiac and renal status, there is no way to answer this question. E.Call the doctor or pharmacist for advice.
c
When completing discharge teaching for the mother of a toddler, which activity should the RN recommend to help the child meet the major developmental task for this age group? a Feed the child favorite foods at mealtime. b Read the child bedtime stories. c Allow the child to pull a small wagon. d Have the child watch "Sesame Street".
c
When caring for a patient diagnosed with viral hepatitis, the healthcare provider experiences a needlestick with a contaminated needle. Which of the following actions should the healthcare provider do first? A. Make an appointment with the infection control department B. Put the needle in a biohazard bag for testing C Wash the area thoroughly with soap and water D Report to the emergency department
c wash then notify
