NCLEX Study Pre-Uworld

A client w moderate alzheimers disease is started on memantine. In evaluating the effectiveness of this medication, the RN should asses the client for which of the following 1. Improved ability to perform ADLs 2. INdications that disease progression has stopped 3. Rapid improvement in cognitive funtioning 4. Reversal of the disease

1

Puresed lip breathing

Used for clients w COPD. Instruct client to inhale for 2 seconds through my nose, keeping my mouth closed, then exhale for 4 seconds through pursed lips. Goal is to decrease SOB by preventing airway collapse and promoting CO2 elimination and reducing air trapping

Aspirin or tylenol in children?

Tylenol! Aspirin should be avoided due to Reys syndrome

How do you know if acidosis/alkolosis is uncompensated?

Uncomensated if pH is not corrected. Compensated if pH is corrected.

What is the purpose of synchronized cardioversion

"synchronization" is a setting on an AED which delivers a shock on the "R" of the QRS complex. Not appropriate for v fib since there are no identifiable "QRS" complexes. Appropriate rhythms are SVT, Vtach with a pulse, and Afib w rapid ventricular response. If the defibrillator is not synchronized with the R wave in a client with a pulse, the shock may be delivered on a T wave and cause a lethal arrhythmia (Vfib)

A client arrives in the emergency dept on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and pulse ox reading of 78%. The nurse suspects that the clients pulse ox reading is inaccurate. Which factors could be contributing to this reading A. Black fingernal polish B. Cold extremities C. Elevated WBC count D. Hypotension E. Peripheral arterial disease

1, 2, 4, 5 Any factor that affects light transmission or peripheral blood flow can result in a false reading. Common causative factors are Dark fingernail polish or artificial acrylic nails Hypotension and low cardiac output Vasoconstriction (Hypothermia, vasopressor medications) Peripheral arterial disease

A nurse is making a home visit when a fire starts in clients kitchen. What actions should the nurse take with the fire extinguisher: 1. Aim nozzle at the base of the fire 2. Pull out the pin on the handle 3. Shake the canister prior to use 4. Squeeze the handle to spray 5. Sweep the spray from side to side

1, 2, 4, 5 P - Pull the pin A - Aim the spray S - Squeeze the handle S - Sweep the spray

The nurse has provided instructions for a family whose child has been diagnosed with rotavirus. Which statement indicates an understanding of the instructions? 1. Hand washing is extremely important in slowing the spread of rotavirus 2. I will observe my child for decreased urination and dry mucous membranes 3. I will resume breastfeeding as soon as the diarrhea subsides 4. I will use commercial baby wipes that contain alcohol 5. y child can spread the infection with contaminated hands, toys, and food

1, 2, 5 Spread via fecal oral route. Leading cause of diarrhea in children less than 5, also the case of many nosocomial infections each year. Change diaper frequently and wash with mild/soap water. Alcohol is irritating. Absolutely crucial to wash hands, surfaces and combat dehydration.

Which of the following drug administrations should be reported as practice error? Choose all that apply 1. Cephalexin administered; client has a history of anaphylaxis from penicillin 2. Hydromorphone 2 mg administered; client reports pruritis 3. Immunization for 3 month olde administered in ventrogluteal site 4. Oral niacin (nicotinic acid) administered; client has facial flushing 5. Warfarin administered; client at 12 weeks gestation

1, 3, 5 Warfarin contraindicated in pregnancy (teratogen) For children age < 7 months, site for immunizations is anterolateral thigh (Vastus laterals). The gluteus medius muscle is developed through crawling and walking. History of penicillin hypersensitivy should be determined prior to administration. Clients truly allergic to penicillin (anaphylaxis) have increase risk of allergy to other beta lactam antibiotics.

Client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Lab results show an elevated serum lipase level. Which interventions would the nurse anticipate being prescribed. 1. ) Adminster hydromorphone IV PRN for pain 2.) Administer IV fluids 3.) Insert NG tube for NG suction 4.) Maintain client in supine position with head of bed flat 5.) Provide small, frequent, high carb, high calorie meals.

1,2,3 NPO status

Nursing measures required when giving IV mag sulfate to client with pre-eclampsia 1.) Assess deep tendon reflexes hourly 2.) Ensure availability of calcium gluconate 3.) Ensure bright lighting to prevent falls 4.) Have supplemental oxygen at bedside 5.) Limit visitors to minimize stimulation

1,2,4,5 Maintain seizure precautions including bed in low setting ,padding, O2, suction During seizure, nurse should help client turn to L side to promote uterine blood flow and prevent aspiration. After, nurse should suction oral secretions and apply 8-10 L/min o2 via face mask Mag sulf is a CNS depressant. Hyperreflexia or clonus may indicate impending seizure activyt, hyporeflexia may indicate mag toxicity. Calcium gluconate is reversal agent for mag toxicity. Minimize environmental stimuli

The nurse assessing a client notices pearly white plaque like lesions on the mouth mucosa. Which client is at highest risk for oral candidiasis?

1. A client w asthma who uses an albuterol nebulizer once a day 2. A septic client receiving IV broad spectrum antibiotics daily 3. Teenage client w braces who drinks several sugary drinks daily 4. Elderly client w poor oral hygiene and inadequate nutrition 2. Thrush is common in immunosuppressed individuals such as those taking corticosteriod medications, those undergoing chemo or radiation, and those who are immune compromised. Also those receiving prolonged high dose antibiotics because normal flora is reduced and opportunistic infections occur. Also dentures and infants. 1. Inhaled beta 2 agonists (albuterol) do not increase the risk for fungal infections. However, individuals taking an inhaled corticosteriod (budesonide, fluticason) are at increased risk. Treated with antifungals (nystat) and proper oral hygiene

The nurse is managing assigned clients on the evening shift. Which client presentation is priority? 1. Blunt head trauma with projectile vomiting 2. History of alzeimer disease w agitation 3. history of carpal tunnel syndrome w hand numbness 4. history of third cranial nerve pathology with double vision

1. A lient w a traumatic head injury from blunt force can have delayed symptoms if there is bruising on the brain and subdural hematoma/cerebral edema. Subdural hematoma = slower venous bleed, symptoms appear 24-48 hours later. S/s similar to those with increased intracranial pressure and include change in LOC, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. Brain herniation can occur if conditions not recognized and treated.

The nurse receives report on 4 clients. Which client should be seen first 1. Client with amyotrophic lateral sclerosis experiencing increased dysarthria 2. Client with COPD reporting increasing leg edema 3. Client with strep throat and fever of 102 on antibiotics for 12 hours 4. Client with urolithiasis reporting wavelike flank pain and nausea

1. ALS is characterized by progressive loss of motor neurons in brainstem and spinal cord. Clients have spasticity, muscle weakness, atrophy. Neurons involved in swallowing and resp function are eventually impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on maintaining resp function, adequate nutrition, and quality of life. No cure, death usually occurs within 5 years of diagnosis. The client w ALS and worsening ability to speak (dysarthria) may also have dysphagia and resp distress. This client should be seen first. 2. COPD client may have for pulonale (R sided heart failure from vasoconstriction of the pulmonary vessels. Treated w long term low flow oxygen, bronchodilators, diuretics. This client should be seen second. R side heart failure not as dangerous as L sided heart failure. 3. Fever often occurs w strep throat. Client needs antipyretic - but last 4. Wavelike flank pain is characteristic of urolithiasis. This client needs pain meds and possibly lithotrispy - should be seen third.

Nurse receives change of shift report for assigned clients at 7AM. Which client should the nurse assess first? 1. Client w change in LOC who fell in nursing home 2. Client w chronic headaches who is schedule for an MRI at 9Am 3. Client w chronic COPD and pulse ox reading of 90% 4. Client w heart failure and 3+ pitting edema of the lower extremities

1. Change in LOC is priority - Can indicate neurologic defect that can be associated with head injury. Basic neuro assessment at beginning of shift including pupil size and response, LOC, mentation, speech, hand grasps). Done to obtain baseline, compare to subsequent assessments to determine indicators of increased intracranial pressure (change in LOC, cushiness triad, pupillary changes). 2. Prep for MRI not priority 3. Pulse ox 89-92 normal for COPD, hyperemic drive to breathe 4. Heart not pump normally, excess body fluid develops. Pitting edema is expected in lower extremities.

Which clinical finding would the nurse anticipate in a client with chronic venous insufficiency 1. brownish, hardened skin over lower extremities 2. Diminished peripheral pulses 3. Nonhealing ulcer on later surface of great toe 4. Shiny, hairless lower extremities

1. Chronic venous insufficiency occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular apace and into the surrounding tissues, where tissue enzymes breakdown RBC - which releases hemosiderin (a reddish brownish protein that stores iron) which causes a brownish skin discoloration, chronic edema and inflammation causes the tissue to harden and appear leathery. Affected skin is highly prone to ulcers, commonly on the inside of the ankle. 2, 3, 4 all associated with peripheral arterial disease due to hardening of the arterials walls which constricts blood flow and impairs nutrients to tissues

A client w CAD and Afib is being discharged home following Coronary artery stent placement. Discharge medications are shown in the exhibit. The nurse identifies which educational topic as the highest priority for this client. 1. bleeding risk 2. bronchospasm 3. muscle injury 4. tinnitus

1. Client is on 3 meds that affect bleeding risk (aspirin, clopidogrel, rivaroxaban). Nurse should instruct client to monitor for black/tarry school, bleeding gums, nd excessive bruising. Client should use soft toothbrush, shave w electric razor, and refrain from playing contact sports. 2. Bronchospasm rarely occurs with high doses of aspirin and metoprolol, and this patient is on low dose of both 3. Muscle cramps can ovvur with statin. However, muscle injriy is rare and not priority compared to bleeding 4. Tinnitis may occur with aspirin toxicity. Client is on baby aspirin, however.

The nurse assesses a client during the dwell time of a peritoneal dialysis cycle. Which assessment would require immediate intervention? 1. BP 168/88 and pulse 72 2. Client experiencing intermittent nausea 3. Crackles present in L and R lung bases 4. Presence of 1+ pitting edema in ankles and feet bilaterally

1. Clients receiving peritoneal dialysis should be monitored carefully for S/s of respiratory compromise, including difficulty breathing, rapid respirations, and crackles. During peritoneal dialysis, dialysate is infused into the abdominal cavity and the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and fluid drains out via gravity. During the instillation and dwell portions oft he cycle, clients are monitored closely for indications of resp distress (difficulty breathing, rapid respirations, cradles) that can result from instilling the dialysate too rapidly, overfilling the abdomen, or fluid entering the thoracic cavity. Can also occur overtime if there is more dialysate infused than removed. 1. REceives dialysis due to chronic kidney failure. BP likely elevated secondary to renal failure. Important but not most important. 2. Renal failure clients typically have electrolyte abnormalities (acidosis) that can lead to nausea. Not a priority. 3. Edema in the extremities can also indicate volume overload. This could also be due to many other factures (GP meds such as amlodipine).

Before examining the infant of a Mexican American mother, the nurse compliments the childs outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take 1. Ask the mothers permission to touch the childs hand 2. Interview the mother about the reason for bringing the child to the clinic 3. Reassure the mother that there is not reason for distress 4. Suggest postponing the examination until the mother calms down

1. In latin American culture an illness called "mal de ojo" is believed to be caused when a stranger or someone powerful admires or compliments a child. The "illness" or "curse" is usually manifested by vomiting, fever, and crying. Curse can be broken if admire touches the child while speaking to the child or immediately after. Mothers worry when strangers compliment their babies without touching them.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? 1.) 7 day old fussy infant w rectal temp 100.6 and 6 wet diapers today 2.) Client receiving radiation therapy who has 6 inch arm laceration, not actively bleeding 3.) Client w purulent drainage and crusting of eyelid w vision unaffected 4.) New parent who is crying and overwhelmed, denies SI

1. Infants <30 days old have blunted response to infection. High risk for bacteremia. Manifestations often subtle at this age (maybe only fever - although some may have hypothermia, lethargy, poor feeding, decreased urine output) Rectal temp >100.4 or <96.8 is red flag in neonate. 2. Client stable, wound can be closed in 6 to 8 hours. Not high risk. 3.) Bacterial conjunctivitis (pink eye) presents with conjunctival erythema, thick purulent drainage, crusted lid. Client will receive eye drops, warm compress, infection control. 4.) Parent has post-partum blues/depression, not emergent. Client can be counseled or provided resources after infant is seen.

Which infant is most likely to require oral iron supplementation at this time? 1. 2 month old born at 34 weeks gestation who is bottle fed with breastmilk 2. 4 month old born at term who is breast fed exclusively 3. 6 month old born at term who is formula fed 4. 7 month old who is breast fed and was recently started on solid foods

1. Iron necessary for hemoglobin production. Although iron stores typically last 5-6 months in term infants, preterm infants exhaust their iron stores by 2-3 months. Iron must then be acquired through dietary sources (iron fortified formula) or oral supplements.

The nurse is caring for a client with chronic, stable angina. The client takes the long-acting nitrate isosorbide mononitrate. Which client outcome indicates that the drug is effective? 1.) Client is able to shower, dress, and fix hair without any chest pain 2. Client reports reducation in stress level and anxiety 3. Client reports being able to sleep through the night 4. Clients BP is 128/78 mm Hg and heart rate is 82/min

1. Long acting nitrates are used to reduce the incidence of anginal attacks. Nigrates are effective if the client is able to do activities without the incidence of pain. Client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. 2 and 3. positive outcome for client with cardiovascular disease, but not directly related to long acting nitrate use 4. nitrates are vasodilators and may decrease the clients BP, which is a positive outcome but not the primary reason for taking the medication. The client is taking this med for angina.

A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realized that there is a DNR prescription posted in the clients chart. Which action is correct? 1. Stop all resuscitation activity immediately 2. Continue resuscitation until DNR status is verified with health care provider 3. If client shows any signs of life, follow advanced cardiovascular support protocol until stable 4. Once resuscitation has behan, complete it regardless of client code status

1. Many health care professionals react to an emergency situation automatically. However, some states and provinces will further penalize health care workers with loss of their license if they fail to render CPR in emergency situation. Health care professionals will not be penalized for an honest mistake, however, resuscitation must end immediately after they are notified of the error

Which of the following should be removed first to prevent infection 1.)Femoral line inserted in ED post cardiac arrest 48 hours ago 2.) Internal jugular line inserted 6 days ago in OR 3.) Peripherally inserted central catheter line with one lumen occluded that was placed 2 weeks ago 4.) Subclavian line with slight redness at anchor suture sites inserted in ICU 72 hours ago.

1.) Central venous access sites in upper body (subclavian, jugular)are preferred to minimize risk of infection. Lower body sites are easily contaminated with urine and feces and difficult to keep a sterile dressing over them. For 4, the redness is at the suture site! not the insertion site!

How can lithium toxicity occur

1.) Dehydration 2.) Decreased renal function (elderly) 3.) Diet low in sodium 4.) Drug-drug interactions (NSAIDs and thiazide diuretics) Even a mild change in kidney function can cause serious lithium toxicity

A client with terminal cancer arrives in the emergency dept unresponsive and in respiratory distress. The clients sister is the legal medical POA. Bothe the clients spouse and sister are present. Which action by the nurse is appropriate? 1. Ask the spouse about the clients wishes 2. Get directions about care from the clients sister 3. Prepare for emergency intubation 4. Request that the sister provide a living will

2 Advance directives are legal documents that allow clients to make decisions about their future medical treatment in the case that the client later becomes medically incompetent. The most common forms are living will and medical POA.

While preparing to insert a peripheral IV line, the nurse notices scarring near the clients axilla. Client confirms a history of L breast cancer and modified radical mastectomy. Which actions should the nurse take? 1. Advance the entire stylet into the vein upon venipuncture. 2. insert the IV line in the most distal site of the R arm 3. Place an appropriate precaution sign above the bed 4. Review the med record for history of mastectomy 5. Teach the client to keep the L arm in a dependent position

2, 3, 4 A modified radical mastectomy includes removal of axillary lymph nodes that are involved lympathic drainage of the arm. Any trauma (such as IV extraversion) to the arm on the operative side can result in lymphedema, characterized by painful and lengthy swelling, as normal lymphatic circulation is impaired by scarring. Therefor, starting an IV line in this arm is contraindicated

Client is scheduled for cardio cath. Which findings will cause the nurse to question the safety of the test proceeding 1. Elevated c reactive protein 2. history of previous reaction to IV contrast 3. Prolonged PR interval on ECG 4. Serum creatinine of 2.5 5. Took metformin today for type 2 diabetes

2, 4, 5 Includes the injection of idone contrast using a catheter to examine for obstructed coronary arteries Complications: Allergic rxn - Clients w a previous allergic rxn to IV contrast may require premedication or another contrast medium. Contrast nephropathy - iodine can cause kidney damage, result reduced through adequate hydration. Clients w renal impairment (creat >1.3) should not receive IV contrast unless absolutely necessary. Lactic acidosis - Metformin with IV iodine contrast increases the risk for lactic acidosis. Metformin is usually dc'd 24-48 hrs before exposure and restarted after 48 hours, when stable renal function is confirmed. 1 - C reactive protein, produced during acute inflammation may reflect elevated risk for CAD, however it is an acute event and is not a safety concern for this procedure. 3. First degree AV block may precede more serious conditions. However clients are usually asymptomatic and do not require treatment except for stopping the causative meds

The nurse care for a client w type 2 diabetes mellitus and hemoglobin A1C results of 8 percent at an outpatient health clinic. Which statement by the nurse will best address these results 1. It is important for us to review the s/s of a hypoglycemic reaction 2. Lets review your diet, exercise, and medication regime over the past 2-3 months 3. Please describe what you have eaten in the last 24-48 hours 4. You should fast food at least 8 hours prior to your morning blood work

2, Diagnostic tool to test percentage of glycosylated hemoglobin in blood> Norma is 4-6 percent = client without diabetes. Measures glucose control over a 2-3 month period

An elderly client is prescribed codeine for a severe cough. The home health nurse teaches the client how to prevent the common adverse effects associated with codeine. Which statements indicate an understanding: 1. Ill be sure to apply sunscreen if I go outside 2. Ill drink 8 glasses of water a day 3. Ill drink decaffeinated coffee so i can sleep at night 4. Ill sit on the side of my bed for a few minutes before getting up 5. Ill take my medicine with food.

2,4, 5 Opiod prescribed as analgesic to treat mild to moderate pain and as an antitussive to suppress the cough reflex. Although the antitussive dose (10-20 mg) is lower than the analgesic dose, clients can still experience the common adverse effects (constipation, nausea (5), vomiting, orthostatic hypotension (4), dizziness). Also causes gastric motility. 2. Prevent constipation.

CVP normal range and significance

2-8 mmHg Measure of R Ventricular preload (pressure in the ventricle after filling) Indicates fluid volume status

A child is scheduled to have an electroencephalogram EEG. Which statement by the parent indicates understanding of the teaching? 1. I will let my child drink cocoa as usual the morning of the procedure 2. I will wash my childs hair using shampoo the morning of the procedure 3. My child may have scalp tenderness where the electrodes were applied 4. My child will not remember the procedure

2. EEG is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges of the brain, which may result in a seizure disorder. Can be done w child asleep or awake with or without stimulation. Teaching: 1. Hair should be washed w shampoo to remove oaks. No accessories. Hair may need to be washed again after to remove electrode gel. 2. Avoid caffeine, stimulants and CNS depressants prior to 3. Test is not painful, no analgesia required

Cardiac Index normal range and significance

2.2-4 L/min/m^2 CO adjusted for body surface area More precise measure of cardiac function

The nurse is interviewing a non-English speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? 1. Address the interpreter directly 2. Ask the clients adult child to translate 3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences.

3, 4, 5

Drawing a blood specimen from a central line. Steps to prevent transmission of infection. 1. Discard first 6-10 mL of blood drawn 2. Flush the line with sterile normal saline before and after collection 3.) Hand hygiene 4. Place specimen in biohazard bag 5.) Scrub the catheter hub with antiseptic prior to use

3, 4, 5 1.) true to prevent inaccurate lab results, but doesn't affect infection transmission 2.) Prevents infusion and assist with latency but has nothing to do with infection.

The ED nurse receives report on 4 clients. Which client should nurse assess first 1. Client w acute cholecystitics who reports right shoulder pain 2. client with gastroparesis who reports persistent nausea and vomiting 3. client w intractable lower back pain who reports new urinary incontinence 4. client with meniere disease who reports increasing tinnitus

3. Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve to L4-L5 causing motor and sensory deficits. Main symptoms are lower back pain, inability to walk, saddle anesthesia and bladder bowel incontinence (late sign). Treatment requires urgent reduction in pressure on the spinal nerves to prevent permanent damage. 1 May experience referred pain to right shoulder due to irritation of diaphragm from inflamed gallbladder. Pain should be addressed, not priority 2. Delayed gastric emptying causing - requires antiemetics, not priority 3. Inner ear disorder. Expected symptoms are vertigo, tinnitus, muffled hearing. Treatment = antihistamines, anticholinergics, benzodiazepines. If safe from falling, not priority

RN is precepting new grad. Patient is sedated with proposal, on a mechanical ventilator, and is receiving enteral feeding via nasogastric tube. New nurse performs interventions to prevent aspiration. The preceptor should intervene if the new nurse performs which of the following: 1. Assessses gasric residual volumes every 4 hours 2. measures number of cm the feeding tube is secured at the nare every 4 hours 3. Requests that the physician change the client from continual to bolus feedings 4. Uses a sedation scale to titrate down the sedation (if possible)

3. Critically ill clients are at increased risk for aspiration of oropharyngeal secretions. Bolus feedings increase risk and should be avoided. 1. Assess according to policy. Q 4 hrs is standard for many institutions 2. Can determine if it has moved. 3. Ramsay sedation scale asseses LOC (want to keep them asleep but a rousable). This helps reduce aspiration risk.

A nurse is preparing to flush a clients central venous catheter. Which size syringe is best for the nurse to choose? 1. 1 ml 2. 3 ml 3. 10 ml 4. 30 ml

3. Flushing the lumen w normal saline to ensure patency is recommended prior to med infusion, precent med incompatibilities after infusion, and prevent occlusion after blood sampling. A 10 mL syring is recommended: The smaller the syringe, the greater the amount of pressure per square inch exerted during the injection, increasing the risk for damage to the CVC. The "push-pause" method involves slowly injecting NS into the CVC and stopping for any resistance. Injecting against any resistance can damage the CVC, which may result in complications, including embolism and malfunction.

The post partum nurse is assessing a client who gave birth by C section 5 hours ago and is requesting pain meds. The client appears restless, has heart rate of 110 and admits to recent onset of anxiety. Priority nursing action? 1. Assess for lower extremity warmth and redness 2. Instruct client on relaxation breathing techniques 3. Obtain O2 sat reading by pulse ox 4. Offer the client prescribed PRN pain meds

3. Pregnancy is a hypercoag state that protects from post partum hemorrhage. C section increases risk of DVT. Additional risk factors include obesity, smoking, genetic predisposition. DVT (if unrecognized) may progress to PE, often characterized by anxiety/restlessness, pleuritic chest pain/tightness, SOB, tachycardia, hypoxemia and hemoptysis. Nurses priory is to asses resp status, administer oxygen, and notify HCP. 1. Redness, tenderness, warmth would indicate DVT which should be reported, but the priority is to address clients current symptoms indicative of acute PE by assessing oxygenation 2. Although this would be helpful, clients symptoms may be stemming from impaired oxygenation secondary to PE 4. Unmanaged pain can cause tachycardia, however, the additional findings of restlessness/anxiety may indicate PE. Nurse should assess first the clients oxygenation status before administering requested pain medication.

The clinical coordinator RN on a surgical unit makes an assignment for the staff of RN, LPN, and graduate nurse. Which assignment is most appropriate for the new graduate nurse? 1.) Postop, venous thromboembolus who is to be started on IV hep therapy 2.) Newly dx cancer, scheduled for total laryngectomy, now refusing surgery 3.) MS, 2 days post-op cholecystectomy w recurrent mucous plugs, scheduled for bronchoscopy 4.) 3 days Post op colectomy w peritonitis, mentally alert before and develops new onset confusion this morning

3. Prep for bronchoscopy requires basic skills assessment (vitals, lung sounds, swallow ability, gag reflux, NPO, checklist before procedure, monitor for resp difficulty after the procedure). These are all new grad skills. 1.) Complicated - Involves collecting baseline serum specimens (aPTT, INR, prothrombin time, platelets, Hb, Hc), calculating weight base dosages, IV infusion pump hourly rate. Every 6 hours. Change in rate may be necessary to maintain therapeutic level. Too complicated for new grad if other options are available. 2.) Client is having anxiety as procedure will prevent verbal communication. Needs teaching about procedure, what to expect immediately after, methods for speech restoration, general prep teaching, etc. Emotional support, education, and advanced therapeutic communication skills

Prioritization? 1. Client in Afib with INR 4.0 and warfarin due 2. Client w CABG 2 days ago, temp of 99, and has a dose of vancomycin due 3. A client who is 48 hours post MI, is experiencing ventricular bigeminy, and has a dose of amiodarone due 4. A client whose NPO status has just been DCd after 8 hours and who is anxious to drink fluids

3. Ventricular Bigeminy is a rhythm in which every other heartbeat is a premature PVC. PVC's in the presence of MI indicate ventricular irritability and increase risk for a more serious dysrhythmia (vtach or vfib). Causes are electrolyte imbalances and ischemia. Nurse assess VS, assess potassium and mag levels, and apical radial pulse, administer amiodarone, notify HCP. 4. Although VS are stable, INR should be lower 2-3 for AF. Nurse should assess for signs of bleeding and notify HCP, scheduled dose of warfarin should likely be held. 2. Temp of 99 not uncommon after surgery. Nurse should assess incision, resp status, and give schedule antibiotic. Educational objective: Ventricular bigeminy in a client following a MI indicated risk for developing V tach or V fib, both potentially life threatening dysrhythmias. Nurse should assess VS, electrolytes, Apical pulse and notify HCP.

While turning a client, the nurse notices that the radiation implant has dislodged and is now lying on the linens. Which action is most appropriate? 1. Get the client out of bed and away from the radiation source 2. Manually reinsert the implant and notify the provider 3. Use long handled forceps to secure the implant in a lead container. 4. Wrap the implant in the linens and place in biohazard bag

3. Should be kept bedside and nurse should monitor for signs of dislodgment. Priority to contain it since its actively radiating and could pose a danger to staff.

The nurse is caring for a client with severe COPD. The nurse anticipates which lab results for this client? 1. Anemia 2. Neutropenia 3. Polycythemia 4. Thrombocytopenia

3. The client w severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more RBS to carry the needed oxygen cells. A high RBC count is called polycythemia. 1. Not expected 2. Not expected. Neutropenia ( Low WBC count) is not expected in COPD. Chemo and many medications (clozapine (antipsychotic), methimazole (antithyroid) can cause neutropenia which increases the risk of infection. 4. Not anticipated in COPD. Alcohol use, HIV infection, and many medications (heparin).

A client w diabetes and an infected heel ulcer is transferred to the ICU because of deteriorating condition. Based on the admission assessment, what does the nurse identify as the most likely condition? 1. Multiple organ dysfunction syndrome MODS 2. Sepsis 3. Septic shock 4. Systemic inflammatory response syndrome SIRS

3. The presence of infection with a gram positive wound culture increases the risk for developing sepsis and septic shock. Sepsis indued hypotension despite adequate fluid resuscitation is defined as "septic shock". Hypotension and inadequate tissue perfusion (elevated serum lactate level) despite fluid resuscitation and decreased central venous pressure (decreased circulating volume) and pulmonary artery wedge pressure (decreased preload) indicate the presence of septic shock in this client. Based on the alterations in hemodynamic parameters, septic shock is the most likely condition. 1. MODS - failure of 2 or more organs. Nothing indicating this. 2. Sepsis is a systemic inflammatory response (increased heart rate, resp, temp, decreased SBP) to a documented or suspected infection and is present in this client. However, it is not the most likely condition because the assessment data support progression along the sepsis continuum to septic shock. 4. SIRS is a generalized inflammatory response to an infectious or noninfectious insult to the body. It is often difficult to distinguish from early sepsis. When SIRS is suspected, a source for sepsis should be sought.

The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours! How should 1.) I know that you are upset, but I will have to call security if you continue to scream 2.) I see that you are frustrated, but the delay cannot be avoided 3.) It is upsetting to wait so long, How can I best help you 4.) The wait is long today, but you will receive quality unhurried care when it is your turn

3. Therapeutic communication is used to establish trust, encourage communication,and display respect for the client. Validating clients feelings and offering self accomplish this. 1. Unnecessary (client is not danger to self or others) and will escalade situation 2 and 4. Clients feelings are validated but defensive statements follow. When nurse detents, clients are made to feel as if their opinions and feelings do not matter. Also do not indicate nurse is willing to seek a solution.

Nurse is caring for a patient who reports positive home pregnancy test, last period 8 weeks ago, severe abdominal pain and spotting. Which is most concerning? 1.) Abdominal pain 8/10 2.) History of pelvic inflammatory disease 3.) Intermittent nausea and vomiting for the past 7 days 4.) Right should pain and dizzinness

4 - Referred shoulder pain and dizziness are indicative of a rupture, which is more concerning than an enraptured ectopic pregnancy (as suggested by 1)

There has been a large scale community disaster and clients myst be roomed together. Who are appropriate roommates in light of infection risk principles: 1. Client dx with varicella and client w pertussis 2. Client placed in an airborne infection room and client w heart failure 3. Client receiving chemo and client w chronic COPD coughing yellow sputum 4. Client w pelvic inflammatory disease PID and a client w coffee ground emesis 5. 2 clients dx w tuberculosis

4 and 5 For infection control, clients w the same organisms can be placed together. Infectious clients cannot be placed with immunosuppressed clients or at risk clients.

CO normal range and significance

4-8 L/min Volume of blood ejected by the heart, Indicates cardiac functioning

DC teaching for client with herpes lesions, new rx for oral acyclovir and topical lidocaine. What information will the nurse include in the teaching plan . 1.) Adhesive bandage should remain on the lesions to prevent virus shedding 2.) Blood tests will be drawn to ensure virus is eradicated 3.) Condoms should be used during intercourse until the lesions are healed. 4.) Gloves should be used to apply medication to the lesiosn

4.

A client with a C3 spinal cord injury has a headache and nausea. The clients BP is 170/100 mm Hg. How should the nurse respond initially? 1. Administer PRN analgesic medication 2. Administer PRN antihypertesnice medication 3. Lower head of the bed 4. Palpate the clients bladder

4. Autonomic dysreflexia is an acute, life threatening response to noxious stimuli, which clients w spinal cord injuries above T6 are unable to feel. Signs include hypertension, bradycardia, a pounding headache, diaphoresis and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke. Noxious stimuli may include bladder distention (neurogenic bladder, obstructed urinary cath, fecal impaction, tight clothing). 1 and 2 due to uncontrolled sympathetic activity will resolve once the cause is identified and removed 3 Lowering the head of the bed would increase BP. Head of bed should be raised to lower BP.

A charge nurse suspects that the UAP is falsifying the documentation of clients cap glucose results rather than performing the test. Best action by nurse? 1. Ask a client if the UAP has performed the test 2. Discuss the importance of task completion and accurate documentation in a staff meeting. 3. Give the UAP a verbal warning not to falsify data 4. Take the clients capillary glucose personally and compare it to the recorded result

4. Best initial result is to assess and validate the charge nurses perception. Doing the test and comparing results randomly/intermittently will give data to prove/disprove this concern. Educational objective: When deliberate inaccurate documentation is suspected, gather evidence before confronting the staff member. One way of doing this is by checking the data personally and comparing it to what has been documented.

HCP is preparing to place a fetal scalp electrode to monitor fetus of laboring client. Which of the following assessment findings should the nurse communicate immediately 1. Cervix dilated to 3 cm 2. Fetal presenting part is engaged 3. Fetus is in breech position 4. Hep B surgace antigen test is positive

4. Bloodborn infection increases the risk of fetal infection due to the small scalp puncture. 1. 2-3 cm dilation is required to confirm it is not placed on fontanelles, face, genitals, or cervix. 2. Helpful if presenting part is engaged, but not required 3. Breech is not contraindicated, but HCP should take care to avoid genital region.

Client w advanced MS has been in nursing home for 2 years and says to nurse "I want to get out of here and try living in my own home". Best response by nurse? 1. Do yo have family or friends who could take care of you 2. Ill make a referral to the local home care agency in your area 3. It will be very difficult to manage your care at home 4. Tell me how you think your life will be different if you moved from here.

4. Client will need max assistance with all ADLs and household tasks. Will require extensive planning and present many challenges related to safety, finances, support, medical equipment, layout of home etc. Nurse should figure out if something happened and try to see why pt wants to leave - however asking "why" or "yes/no" questions is non therapeutic and does not facilitate interaction. Use therapeutic communication to encourage thoughts, feelings, reasons for wanting to leave the current residence.

A major disaster involving hundred of victims has occurred, and an emergency nurse is sent to assist with field triage. Which client should the nurse prioritize for transport to the hospital 1. Client at 8 weeks gestation with spotting and pulse of 90 2. Client with a compound femoral fracture and and oozing laceration 3. Client w fixed and dilated pupils and no spontaneous respirations 4. Client w paradoxical chest movement throughout respirations

4. Client with "Flail chest" (paradoxical chest movement during respiration) from multiple fractured ribs is at risk for respiratory failure from impaired ventilation. Also, mobile fractured ribs may puncture the pleura or vessels, causing hemothorax and/or pneumothroax. Considered emergent, requires immediate treatment

The clinic nurse receives multiple phone calls regarding client status. Which call should the nurse return first? 1. 3 yr old diagnosed with Kawasaki disease 2 weeks ago with skin peeling 2. 7 year old high fever, cough, sore throat 3. 14 year old asthma corticosteriod inhaler developed oral white patches 4. 16 year old mononucleosis 10 days ago reports abdominal pain

4. Infectious mononucleosis is caused by epstein barr virus. Spleen rupture is a serious complication of infectious mononucleosis that can occur spontaneously and present with sudden onset left upper quadrant abdominal pain. Should be taken to ER for close monitoring of hemoglobin levels, supportive care to prevent hemorrhagic shock and possible surgery

The nurse receives report on 4 clients. Which client should the nurse assess first? 1. Day 1 post op receiving morphine, nausea and itching 2. Maintenance IV NS tubing indicating changed 48 hours ago 3. PE receiving IV hep infusion, warfarin w INR 1.9 4. Resistant bact infection receiving IV vancomycin reporting discomfort at peripheral IV site

4. Phlebitis in inflammation of vein w manifestations including pain, swelling, warmth at site, redness extending along vein. Causes are irritating drugs such as vancomycin, catheter movement within vein (inadequate stabilization), or bacteria (poor aseptic technique). For signs of phlebitis, immediate removal of catheter is necessary - can lead to thrombophlebitis or emboli in bloodstream or infection. 1. Itching (pruritis) and nausea are common adverse effects associated with admin of opiods. Benadryl and Zofran can provide relief. 2. Evidence based practice recommends changing no earlier than every 72 hours unless it becomes contaminated. Intermittent infusions and hypertonic solutions (TPN, proposal, blood) require more front changes (every 4-24 hours) due to high risk infection. 3. INR therapeutic range is 2-3, at which time heparin DCd, warfarin contd

Priority assessment for RN? 1.) Client taking metoprolol with pulse 54/min and BP 154/82 2.) Client w COPD and O2 sat 92 3.) Client w 345 mL gastric residual volume aspirated from a PEG tube before an enteral feed 4.) Client w pneumonia who is receiving IV fluids and has a new S3 heart sound

4. S3 sound is made when blood from atrium is pumped into noncompliant ventricle. May be normal in young adult. However, new sound in older adult is a significant finding as it may indicate devolvement of volume overload or heart failure. May quickly progress to life threatening events (resp compromise, cardiogenic shock). Client may be receiving excess fluids that are causing volume overload

Pulmonary artery wedge pressure normal range and significance

6-12 mmHg Measure of Left ventricular preload Indicates left sided heart function

MAP normal range and significance

70-105 mmHg Avg arterial pressure Indicates perfusion of organs and tissues MAP = SBP+2(DBP)/3

Systemic vascular resistance normal range and significance

800-1200 dynes/sec/cm-5 Measure of vascular resistance

The nurse has received report on 4 patients. Which should she see first? 1. Client admitted this morning with acute pyelonephritis whose IV line is infiltrated 2. Client scheduled for surgery in 2 hours who has questions about the procedure 3. CLitnt who had a colostomy yesterday and now has a leaking colostomy bag 4. Client w total hip replacemetn 3 days ago who reports not BM in 2 days

Acute pyelonephritis is a severe bacterial infection of the kidney that causes it to swell. It can lead to permanent scarring of the kidney and can be life threatening. Initial treatment includes vigorous parenteral IV fluids and IV antibiotics. Patent IC is priority.This clients needs are the priority as treatment is dependent on patent IV access 2. Needs to speak to HCP. Nurse should arrange this asap. Second priority.

Diseases requiring airborne precautions? What will you use when caring for these parents?

Airborne: My Chicken Hez TB -My: measles -Chicken: chickenpox -Hez: herpes zoster -TB: tuberculosis What will we use when treating this patient? -private room, negative pressure room, N95 mask

If an African American comes in on enalopril and reports that "tongue feels thicker than usual", what should you be concerned about?

Andioedema - a side effect of ace inhibitors. Huge concern since it can block airway if untreated.

Acronym to remember malignant skin neoplasm (skin cancer)

Asymmetry Border irregularity Color changes and variation Diameter of 6mm or larger (size of pencil eraser) Evolving (appearance changing overtime0

Family reports that they are unable to wake client. Steps for BLS

Attempt to shake client awake Call for help Check for breathing and a pulse for 10 seconds Begin chest compressions Notify health care provider

Spine segments Injuries above T6 put patients at risk for

Autonomic dysreflexia (aka overactive autonomic system), which is a life threatening response to noxious stimuli. Noxious stimuli should be removed to prevent stroke

The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication? 1. I have gained a few pounds since I started this medication 2. I have had a sore throat for 3 days and feel feverish today 3. I have noticed increased salivation and drooling 4. I often feel sleepy when I take this medication

Clozapine (clozaril) is an atypical antipsychtic med used to manage schizophrenia in clients who have not improved w other antipsychotic meds. Clozapine is highly affective at controlling schizophrenia, however it has many severe, life threatening adverse effects, including agranulocytosis, cardiac disease (myocarditis) and seizures. Agranulocytosis (Decreased neutrophils) increases the risk for infection. Clients require monitoring of WBC and frequent assessment for signs of infection (sore throat, flu like symptoms) which should immediately be reported to the health care provider. 3. possible concerning side effect but not the most concern. Usually requires lowering of dose.

What is pheochromocytoma? What do you need to remember about it and what is the treatment for one of the more dangerous symptoms?

Condition caused by a tumor on the adrenal medulla. results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Remember when providing care: 1. Hypertension is difficult to treat and is often resistant to multiple drugs 2. Client should avoid activities that could precipitate a hypertensive crisis (bending, lifting, valsalva maneuver). 3. Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis Hypertensive crisis puts the client at risk for stroke. Nitroprusside is a vasodilator that could be used for treatment by titrating to keep BP within recommended parameters.

Disease requiring contact precautions? What will you use when caring for these patients?

Contact: MRS. WEE m - multidrug resistant organism (MRSA) r - respiratory infection - rsv s - skin infections w - wound infections e - enteric infections - clostridium defficile e - eye infections skin infections: v - varicella zoster c - cutaneous diptheria h - herpes simplex i - impetigo p - pediculosis s - scabies, staphylococcus What will we use when treating this patient? -Private room, Gloves, Gown

Normal side effects of varicella immunization

Day after injection: Discomfort, slight redness, small vesicles near site. Instruct to cover vesicles with clothing or small bandage to minimize risk of exudate transmission

What types of things would you be thinking about if a client had 7 times the normal values for ALT/AST

Do you use IV drugs How much alcohol What OTC meds do you take ALT and AST are enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in cardiac, renal, skeletal tissues, but ALT/AST are used to diagnose hepatic disorders.

Disease requiring droplet precautions? What will you use when caring for these patients?

Droplet: SSSPPPIDERMMMAN s - sepsis s - scarlet fever s - streptococcal pharyngitis p - parvovirus b19 p - pertussis p - pneumonia i - influenza d - diptheria (pharyngeal) e - epiglottitis r - rubella m - mumps m - meningitis m - mycoplasma or meningeal pneumonia an - adenovirus What will we use when treating this patient? -Private room, Mask

What is SVT. What is they treatment.

Dysrhythmia that originates from an ectopic focus above the bifurcation of the bundle of his. HR can be 150-220. Reg rhythm, P waves often hidden or abnormally shaped, narrow QRS complex Can be caused by stimulants (nicotine, caffeine, cocaine) and heart disease. Prolonged episode of SVT w heart rate >180 can cause decreased cardiac output and hypotension - palpitations, dyspena, angina. Treatment = Vagal stimulation and meds. IV adenosine is drug of choice to convert SVT to SR>

Priority action for PTSD

Encourage client to talk about the trauma without experiencing high levels of anxiety

Steps for trach care

Gather supplies and position client, don mask goggles and clean gloves, remove solid dressing, don sterile gloves and remove disposable cannula and replace with a new one, clean around stoma with sterile water or saline and replace sterile gauze pad

The nurse is triaging victims at the site of a mass casualty incident. Which victims should be seen first? 1. Client w head injury and fixed, dilated pupils 2. Client w open R femur fracture and palpable pedal pulses 3. Client w full thickness burns covering 85% total body surface area 4. Client w shallow lacerations over arms and legs

Goal during mass casualty event is to rapidly triage based on greatest good for greatest number of ppl. Emergent needs first, then urgent (ex = open fracture, palpable pulses), then non urgent needs. Clients who are expectant due to severity of their injuries (severe neurological trauma, full thickness burns (greater than 60% body area) are lowest priority for treatment - but nurse should provide palliative care, if possible. while addressing needs of others.

Pyloric stenosis may be accompanied by which abnormal lab value?

Hematocrit of 57, which is high and indicates hemoconcentration caused by dehydration

List the order for NG tube (used for decompression) after the nurse identifies the client, performs hand hygiene, applies clean gloves assesses nares, and selects a naris. 1. Advance tube to the marked point 2. Ask client to flex head forward and swallow 3. Gently insert tube just past nasopharynx 4. Instruct client to extend neck back slightly 5. Measure, mark, and lubricate tube 6. Verify tube placement and anchor

In order: 5, 4, 3, 2, 1, 6

Something to keep in mind when taking "Linezolid" for a vancomycin-resistant enterococcus infection

Its an oxazolidinone antibiotic use for vanco and MR bacteria, pneumonia, skin infections. It has MAOI type properties (Monoamine oxidasde inhibitor) so it should not be used with SSRIs (selective serotonin reuptake inhibitors (Paroxetine, fluoxetine, sertraline) because that could increase the risk of serotonin syndrome, accumulation of serotonin

Outcome for Trisomy 18 (Edwards syndrome)

Life expectancy of a few weeks. Request meeting with palliative care team and parents to discuss end of life choices

Histrionic personality disorder

Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration

"Phlebostatic axis" relevance and location

Located at atria (4th intercostal space, midaxillary line = medial part of body). Used as a reference point for correct placement of the zeroing point of the transducer when measuring continual arterial BP - direct bp, CVP, and/or cardiopulmonary pressures invasively.

assessment finding for newborn with patent ductus arteriosis

Loud machine like murmur

When a pregnant client arrives and birth is imminent, which critical focused, brief history questions should be asked relevant to potential neonatal resuscitation?

Multiple gestation Color of fluid (Meconium?) Narcotic/drug use, especially in the last 4 hours Preterm labor? To anticipate respiratory immaturity and neonatal ventilation

Marfan syndrome teaching topic

Not engaging in contact sports due to risk of cardiac injury

A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted? 1. Improvement in short term memory 2. Improvement in spontaneous activity 3. Reduction in number of visual hallucinations 4. Reduction in dizziness with standing

Parkinsons disease is caused by low levels of dopamine in the brain. Levodopa is converted to dopamine, but much of this drug is metabolized before reaching the brain. Carbidopa helps stabilize. Effective in treating bradykinesia (generalized slow movement). Tremor and rigidity may also improve to some extent. Once started, should never be stopped suddenly. Prolonged use can also result in dyskinesias.

Highest nursing priority after laparscopic cholecystectomy

Place client in Sims position. Focus on prevention of respiratory complications - helps facilitate movement of CO2 utilized during surgery to fill the abdominal cavity. CO2 can irritate the phrenic nerve and diaphragm, potentially causing breathing difficulty.

What is thoracentesis commonly used to treat? What is a possible complication? What are the initial post procedure monitoring plan

Pleural effusion Could cause pneumothorax Signs = Increased resp rate or effort, resp distress, low O2 sat, absent breath sounds, altered LOC due to decreased oxygenation Tension pneumothorax could also develop, presents w tracheal shift, severe respiratory distress, and cardiovascular compromise, altered LOC due to decreed oxygenation

At what point in the neonatal resuscitation algorithm would you start PPV and chest compressions

Positive pressure ventilation w SP02, consider cardiac monitor (HR<100, gasping or apneic) Intubate, Chest compressions, PPV w 100% O2, cardiac monitor (HR<60)

What are the signs of a transfusion reaction nd what are the appropriate interventiosn

Signs = Chills, fever, low back pain, flushing, itching 1. Immediately stop transfusion and disconnect tubing at catheter hub 2. Maintain IC access with NS, using new tube to prevent hypotension and vascular collapse 3. Notify HCP and blood bank 4. Monitor VS 5. Recheck labels, numbers, and the clients blood type 6. Treat clients symptoms according to HCPs prescription 7. Collect blood and urine for hemolysis 8. Return blood and tubing set to the blood bank for additional testing 9. Complete necessary facility paperwork to document reaction

The clinic nurse prepares to administer a newly prescribed dose of sumatriptan to a client with migraine headache. Which of the following in the clients history would cause the nurse to question the prescription. 1. Blood urea nitrogen of 12 mg/dL 2. BMI of 34 kg/m2 recorded during todays examination 3. Past medical history of uncontrolled hypertension 4. Takes alprazolam as prescribed for anxiety.

Sumatriptan is a selective serotonin agonist prescribed to treat migraine headaches, which are thought to be caused by dilated cranial blood vessels. Triptan drugs work by constricting cranial blood vessels. Clients instructed to take first dose at the sign of a migraine to help prevent and relieve symptoms. Contraindicated w clients who have CAD or uncontrolled hTN because its vasoconstrictive properties increase the risk of angina, hypertensive urgency, decreased cardiac perfusion, and acute MI. 1. Normal value 6-20 2. Not relevant 4. Not contraindicated. However, should be monitored for serotonin syndrome if clients already taking selective serotonin reuptake inhibitors or selective norepinephrine reuptake inhibitors.

Tetracycline for acne

Take on empty stomach, avoid antacids or dairy products, take with full glass of water, promotes photosensitivity, not at nighttime

Which of the following equipment warnings or readings indicated a potential clinical issue with the client and require further assessment by the nurse 1. Blood glucometer displays "HI" after a blood specimen is inserted 2. Finger pulse ox does not register a clients heart rate or o2 reading 3. IV infusion pump display lights up and sounds an alarm for a few seconds when turned on 4. Patient-controlled analgesis pump is unable to read the bar code on the medication vial 5. Ventilators high pressure alarm sounds for a client who is intubated

The following reflect a clients physiologic state and not equipment malfunctions: 1, 2, 5 1. "HI" glucose is too high (greater than 500) 2. Inadequate circulation/perfusion at sensor = pulse ox cannot locate an adequate pulsation and give a reading 5. Ventilators sound high pressure alarm when machine sense resistance (mucous suctioning might be needed, tubing might be kinked, possible tension pneumothorax present). 3 and 4 are both mechanical. IV pump normally self checks when activated. Built in safety mechanism alerts nurse when bar code on med isn't lined up properly. Neither indicates potential client issue.

What do you need to know about allergy immunotherapy injections?

They trigger an increase in the bodes production of specific immunoglobulins to reduce clients allergic reaction when exposed to the irritant. Can cause a major allergic reaction and clients should be monitored for 30 minutes after each dose. \ For the first few weeks, shot is given every week with a dose increase every injection until target dose is reached. Maintenance dose is then given every 3-5 weeks for a few years.

Primary open angle glaucoma - effects for patient

eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (tunnel vision) Signs are painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, halos observed around bright lights. Can lead to blindness if untreated.

What is pediculosis Capitis

head lice

Appropriate chest compression rate and depth for adult

rate = 100-120/min 2-2.4 in (5-6cm)