Readiness exam #2

The nurse in the outpatient clinic is assessing a client with systemic lupus erythematosus (SLE). Which laboratory data is essential for the nurse to monitor to determine if the client is experiencing a complication?

urine analysis A common complication associated with SLE is the development of lupus nephritis. Glomerular injury is seen in lupus nephritis because of the significant inflammation caused by this condition. The client with SLE should have routine urine analysis because evidence of lupus nephritis would consist of proteinuria and microscopic hematuria. Other laboratory testing pointing to lupus nephritis would be an elevated creatinine and decreased glomerular filtration rate. Lupus nephritis may be so aggressive that it may cause an individual to need a kidney transplant.

Interventions for a client experiencing variable decelerations. The nurse observes the umbilical cord protruding through the vagina. 5

(first and priority) apply pressure to lift the presenting fetal part stay with the client and call for help place the client in the Trendelenburg position administer oxygen via face mask at 8-10 L/min prepare the client for immediate cesarean delivery

EtCO2, or End-Tidal Carbon Dioxide is a measurement of? Helps assess?

, is a measurement of the partial pressure of carbon dioxide (CO2) at the end of an exhaled breath. provide valuable information about a patient's ventilation and overall respiratory status. It can help in assessing the effectiveness of ventilation and gas exchange.

Young pregnant women should be taught that most women (carrying one fetus) with a healthy pre-pregnancy weight require an additional ______ extra calories per day beginning in the ________ _________ of pregnancy (i.e., weeks 13 to 26). Similarly, an increase of approximately _____ calories per day is indicated during the _______ ________ (i.e., after 26 weeks)

350 cals per day beginning in the second trimester of pregnancy (i.e., weeks 13 to 26). 450 calories per day is indicated during the third trimester (i.e., after 26 weeks)

What is Coombs test?

A Coombs test, also known as an antiglobulin test, is a laboratory test used to detect the presence of antibodies or complement proteins on the surface of red blood cells. Here are some key points that a nurse should know about the Coombs test: Purpose: The Coombs test is used to diagnose and investigate conditions related to the destruction of red blood cells (hemolysis). It is often used in cases of hemolytic anemia, autoimmune disorders, and in the evaluation of hemolytic disease of the newborn.

Crackles auscultated to the midline of the lung fields post-MI normal or abnormal?

Abnormal Following a myocardial infarction (MI), the client is at risk for developing pulmonary edema due to the heart's inability to eject blood, resulting from myocardial insult. When caring for an MI client, nurses should monitor for life-threatening ventricular arrhythmias and pulmonary edema, characterized by lung crackles, tachypnea, and hypoxia.

Is blurred vision normal or abnormal in a patient taking lithium?

Abnormal; indicates lithium toxicity (medical emergency)

Name 4 risk factors for colorectal cancer

African American, Excessive alcohol consumption, low-fiber diet, ulcerative colitis.

The patient recovering from cardiac surgery is wondering when he can resume sexual activity. The nurse would be most correct in stating that sexual intercourse may be returned at which point in time? Incorrect

After exercise tolerance is assessed Many physicians agree that a patient may return to sexual activity if they can climb two flights of stairs without symptoms.

What is agoraphobia

Agoraphobia is a type of anxiety disorder characterized by a fear of being in situations or places where escape or help might be difficult in the event of a panic attack or another anxiety-related issue. Individuals with agoraphobia often avoid situations that they perceive as potentially distressing or where they might feel trapped or helpless. Common situations that people with agoraphobia may avoid include: Crowded places such as shopping malls or public transportation. Open spaces like parking lots or plazas. Being alone outside the home. Traveling far from home.

What medication is good to treat V tach and a fib

Amiodarone

________ is the preferred drug for A fib and V tach

Amiodarone

Sickle cell anemia is what type of inheritance

Autosomal recessive (need DD to get it)

What is lithium given for?

Bipolar and depression

What is bowel prep and why would it lead to increased risk for falls in older adults?

Bowel preps typically involve the consumption of specific fluids, laxatives, or medications, which result in frequent bowel movements to empty the colon. It is important for the patient to drink plenty of clear liquids during the prep to stay hydrated. This is because the frequent need to use the bathroom during the prep can lead to increased trips to the toilet, which may pose a fall risk for various reasons, including:

What is utilized to protect the myocardium from the irritability caused by hyperkalemia

Calcium gluconate

How does calcium gluconate treat hyperkalemia?

Calcium gluconate is used to quickly stabilize the heart in cases of severe hyperkalemia (high blood potassium levels) to prevent dangerous heart rhythm disturbances. It doesn't lower potassium levels but counteracts some harmful effects.

In septic shock, what is priority? Neuro or circulation?

Circulation In septic shock, the primary concern is hypotension and inadequate tissue perfusion due to vasodilation and reduced vascular tone. While neurological changes can occur due to impaired perfusion, the immediate focus is on stabilizing the client's blood pressure and hemodynamics through vasopressor therapy.

why is this wrong: "If a client should develop crackles in their lung fields after a blood transfusion, it is a sign of a hemolytic reaction."

Crackles in the lung fields are typically associated with a different transfusion reaction known as a transfusion-associated circulatory overload (TACO) rather than a hemolytic reaction.

Which part of the laryngeal cartilage is a full circular ring and is the narrowest part of the airway in young children?

Cricoid

What is a common co-morbidity of Cystic fibrosis? And what should be monitored?

Diabetes; glucose

Two types of coomb tests

Direct Coombs Test (DAT): This test is used to detect antibodies or complement proteins attached to the patient's own red blood cells. It is used to diagnose autoimmune hemolytic anemia. Indirect Coombs Test (IAT or IATC): This test is used to identify antibodies in a patient's serum or plasma that may react with donor red blood cells, as seen in blood compatibility testing before transfusion or in cases of hemolytic disease of the newborn.

Plague precaution

Droplet

What precaution is ebola?

Droplet and contact

What may be administered to stimulate red blood cell production and manage anemia in clients with CKD.

Erythropoietin (EPO)

The nurse is caring for a client who is mechanically ventilated and receiving multiple intravenous medications. The client's family member is upset and overwhelmed by the client's clinical condition. Which therapeutic action would be appropriate for the nurse to take?

Explain the different types of medications and therapies the client is receiving Explaining to the family member the therapies the client is receiving can provide reassurance. It is the unknown that is likely causing the family member emotional distress and explaining the current treatments would provide valuable information, thereby lessening anxiety.

placental abruption affect on heartrate: Fetal and maternal

Fetal bradycardia with decels Maternal tachycardia due to to hypovolemia from blood loss

Why is Fresh frozen plasma given to a bleeding pt related to warfarin instead of PRBCs?

Fresh Frozen Plasma (FFP) is given to a patient bleeding related to warfarin because it contains clotting factors, including factors II, VII, IX, and X, which can help reverse the anticoagulant effects of warfarin and promote blood clotting. Packed Red Blood Cells (PRBCs) are primarily used to replace lost red blood cells but do not address the coagulation factor deficiencies associated with warfarin.

What would be prescribed to this client who is experiencing bleeding related to the prescribed warfarin.

Fresh frozen plasma (FFP)

What is an approved treatment for calcium channel and beta-blocker toxicity.

Glucagon

Is confusion part of hyper or hypothy?

Hypothyroidism

What involves applying pressure against a stable object, like pressing the hands together or pushing an extremity against a wall?

Isometric exercises

Bulls-eye rash is hallmark of

Lyme disease

What med is the treatment for torsades de pointes, a fatal ventricular dysrhythmia.

Magnesium sulfate; This should be combined with defibrillation if the client is hemodynamically unstable with torsades de pointes.

When the nurse is interpreting results from a direct Coombs test, they know that a positive result indicates which of the following?

Maternal antibodies are present on the infant's red blood cells. AND The infant is at risk for erythroblastosis fetalis. When maternal antibodies are present on the infant's red blood cells, it suggests that the baby has been exposed to antibodies from the mother's blood, which can occur in cases of blood group incompatibility between the mother and the baby. This can be a concern in situations like erythroblastosis fetalis (hemolytic disease of the newborn), especially if the antibodies are causing the baby's red blood cells to be destroyed. The Coombs tests, both direct Coombs test (DAT) and indirect Coombs test (IAT), are used to detect and confirm the presence of these antibodies on the baby's red blood cells.

____________ refers to right lower quadrant pain, suggesting appendicitis

McBurney's point tenderness

The nurse is caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider? And what drug class is it

Modafinil Modafinil is a central nervous stimulant dosed during daylight hours to keep the client alert.

The critical care nurse is caring for a client who is experiencing septic shock. The healthcare team has initiated vasopressor therapy to support the client's blood pressure. Which of the following nursing actions is a priority when administering vasopressors to this client?

Monitor the client's cardiac rhythm and electrocardiogram (ECG) for any abnormalities.

Ketorolac; indicated for 2?

NSAID; pain and pyrexia (fevers)

what is narcolepsy

Narcolepsy is a disorder characterized when a client unexpectedly falls asleep in the middle of normal daily activities. Narcolepsy is a chronic neurological disorder characterized by excessive daytime sleepiness and sudden, uncontrollable episodes of falling asleep (known as "sleep attacks") that can occur at any time.

Is continuous pulse oximetry needed for Chest Physiotherapy?

No

Is re-medication with diphenhydramine and acetaminophen always needed before a blood transfusion? Why?

No; Physicians may prescribe pre-medication with diphenhydramine and acetaminophen only if the client has a history of febrile or allergic reactions to prior blood transfusions. Pre-medications are, therefore, not always required.

Can a UAP remind the client how to care for their long-term colostomy?

No; Reminding, reinforcing, and validating teaching is not within the scope of a UAP.

Can UAPs obtain a urine culture from an indwelling urinary catheter?

No; UAPs may not perform any tasks involving sterility.

Is Leukocytosis (elevated WBC count) abnormal or normal post-MI.

Normal; reflects myocardial inflammation

What are 5 risk factors of ovarian cancer

Nulliparity, Advancing age, Family hx, early menarche

If post op 2 days and bp and HR are increasing what is suspected?

Pain

What are prescribed to prevent the absorption of dietary phosphate, thus controlling serum phosphate levels in CKD pts

Phosphate binders

Two appropriate nursing interventions to prevent aspiration after a child has vomited?

Position child on their side and suction the mouth to remove vomitus DONT offer child sip of water to clear mouth

Hyperthy Name two antithyroid meds, what drug class is given to address the heart? What therapy can be given? Surgical treatment?

Propylthiouracil and methimazole Beta blockers: atenolol or propanolol Radioactive Iodine Therapy Thyroidectomy

If a patient is mailed a package what should a nurse do?

Provide the client with the package; if suspected dangerous package, request client to open it in front of them

Abdominal symptoms for placental abruption

Rigid, board-like abdomen

When a dementia patient talks about something that can easily lead to grief, anxiety, or agitation what are nursing considerations.

Show compassion, foster therapeutic communication, and avoid statements that could cause those three things even if it means changing the subject

5 intervention for pt experiencing MI

Start peripheral vascular access device, obtain a prescription for chewable aspirin and nitroglycerin, obtain an order for a CXR, and establish continuous cardiac monitoring

What is the hyoid bone

The hyoid bone serves as an anchor for the muscles of the tongue, which play a crucial role in speech and swallowing.

What do beta blockers do regarding beta receptors? Beta blockers decrease bp by?

They block catecholamines from the beta receptor sites found in the heart and lungs. Vasodilating the vessels Beta-blockers decrease the heart's workload through vasodilation and lowering the heart rate. This relaxation of the vasculature and reduction in heart rate will reduce the myocardial oxygen demand. This is why beta blockers (low doses) may be prescribed during an acute myocardial infarction and afterward.

Mag sulfate is indicated in which ventricular dysrhythmia?

Torsades de pointes

In desentization therapy, why wouldnt a nurse speak frequently of what causes the fear to start for him?

When treating clients with phobias, focusing solely on discussing what frequently triggers the phobia is not recommended. This approach can increase anxiety and keep clients fixated on their fears, potentially triggering panic attacks.

Can a UAP perform ROM activities?

Yes

What med is indicated for HIV? Herpes? Bacterial vaginosis?

Zidovudine Valacyclovir Metronidazole

The nurse is preparing a child with cystic fibrosis for chest physiotherapy (CPT). Prior to performing the prescribed CPT, the nurse should? Why?

administer the prescribed bronchodilator. The nurse should administer the prescribed bronchodilator prior to CPT being performed. The bronchodilator should be administered 15-30 minutes before CPT. Administering the bronchodilator first will facilitate the passage of the mucous.

Smallpox precaution

airborne

CKD can lead to __________ due to decreased erythropoietin production

anemia

Magnesium sulfate, when administered intravenously, can be helpful in the management of acute __________, primarily due to its bronchodilator and anti-inflammatory effects.

asthma attacks

unstageable pressure ulcer

base of the wound is covered by slough or eschar, the nurse can not assess how deep the pressure injury goes. Therefore, such a pressure ulcer is considered unstageable

How is Lyme disease transmitted?

bite of infected tick

Stage IV pressure ulcers expose?

bone and muscle.

If a pressure ulcer develops, tx.? in order To?

cleaned with saline solution and dressed appropriately to promote healing and prevent infection.

CKD can lead to anemia due to?

decreased erythropoietin production

How does brushing teeth immediately after a meal treat nausea in pregnant pt?

decreases the aftertaste of food.

In clients with COPD, there is a loss of ______________ in the lungs leading to __________ of the lungs, as seen on chest x-ray. Prolonged hyperinflation of the lungs causes barrel chest in COPD clients.

elastic recoil; hyperinflation

Stage III pressure ulcers expose? but not?

expose subcutaneous fat but do not extend deep enough to expose the bone and muscle

Consideration if child consumes corrosive poison on the way to hospital

give child milk or water to dilute the corrosive. btw, kids that ingest gasoline should NOT induce vomiting due to risk of aspiration

What PPE for Varicella (chicken pox)

gloves, gown, and respirator/N95 mask.

what is Erythroblastosis fetalis

hemolytic disease of the newborn

The classic manifestations of KD include 6

high fever (unresponsive to antibiotics and antipyretics), red, cracked/chapped lips, strawberry tongue, bilateral conjunctivitis, polymorphous rash (in groin and perineum), and cervical lymphadenopathy.

It is unique in that it is not directly attached to any other bone in the body. Instead, it is suspended by ligaments and muscles, including the muscles of the tongue and the muscles that control the larynx (voice box).

hyoid

Calcium gluconate is utilized to protect the myocardium from the irritability caused by what

hyperkalemia

What BP condition is common in CKD

hypertension

Diaphoresis part of hyper or hypothy

hyperthyroidism

Transfusion-related graft versus host disease most commonly occurs in

immuno-suppressed individuals. In this condition, the donor's T lymphocytes cause an immune response in the recipient by engrafting in the recipient's marrow and attacking the recipient's tissues/ blood cells. Under normal circumstances, donor T-cells are killed by the recipient's immune system, but in severe immunodeficiency, donor T-cells remain, causing GVHD. Transfusion-related GVHD presents with fever, rash all over, including feet and hands, diarrhea, nausea, and elevated Liver function tests.

Buccal route

in the pt's mouth toward the cheek

Impaired kidney function leads to _________ serum phosphate levels.

increased

Beta blockers, anticonvulsants, and levothyroxine are indicated or contraindicated to administer pre-op

indicated with a sip of water Endocrine medications (steroids, thyroid hormone), anticonvulsants, and beta-blockers are okay to give with a sip of water. Beta-blockers are given to clients with a sip of water before surgery to prevent intra- and post-procedure cardiac dysrhythmias. These medications do not prompt the nurse to contact the PHCP as they are typically given (with a sip of water) prior to surgery.

Early treatment with prescribed ciprofloxacin is essential in

inhalation anthrax

Hyperthyroidism eye symptoms other than exophthalmos

injected (red) conjunctiva

Hyperthyroidism: drowsiness or insomnia

insomnia

Stage I pressure ulcers do not involve any _________. The epidermis _____________, but it is _______ and ________

loss of tissue; remains intact; reddened; does not blanch

A common complication associated with systemic lupus erythematosus (SLE) is? what is it?

lupus nephritis It's a kidney problem that happens as a complication of lupus, an autoimmune disease. Lupus nephritis occurs when the immune system, which is supposed to protect the body, mistakenly attacks and damages the kidneys. This can lead to kidney inflammation and problems with filtering waste and excess fluids from the blood. Symptoms may include swelling, high blood pressure, blood or protein in the urine, and decreased kidney function.

Fetal tachycardia should be reported to PCP if it

persists for longer than 10 minutes

What do phosphate binders do in ckd patients?

prevent the absorption of dietary phosphate, thus controlling serum phosphate levels

Treatment for SVT; what does the med do?

rapid administration of adenosine followed by a rapid flush of 0.9% saline. Adenosine slows the electrical conduction time through the AV node.

What is beta blockers' effect on cardiac output?

reduced cardiac output

Transfusion-associated circulatory overload (TACO) is more common in clients with ___________ failure. Cardiac too

renal Volume Overload: Clients with renal failure may have impaired kidney function, which can lead to difficulty in regulating fluid balance in the body. Their ability to excrete excess fluids is compromised, increasing the risk of fluid overload. When a blood transfusion is administered, it adds a volume of fluid to the circulatory system, potentially exacerbating the existing fluid imbalance. Hypertension: Clients with renal failure are more likely to have hypertension (high blood pressure) as a comorbidity. Hypertension can lead to increased stress on the cardiovascular system, making these clients more susceptible to circulatory overload when additional fluid is introduced through a blood transfusion.

Impaired kidney function leads to increased _____ _____ levels (electrolyte)

serum phosphate In impaired kidney function, phosphate levels increase due to decreased phosphate excretion by the kidneys, hormonal imbalances, and reduced activation of vitamin D. This can lead to calcium imbalance and various health complications. Management includes dietary restrictions and medications.

When a client ambulates with a cane, the cane should be placed on which side?

stronger/unaffected side

When obtaining orthostatic blood pressure, the correct sequence is

supine, sitting, and standing.

Stage II pressure ulcers occur when

the epidermis and a part of the dermis are lost

what are symptoms of hemolytic reaction to blood transfusion?

the symptoms are more likely to include fever, chills, chest or back pain, dark urine, or even shock.

Mittens are not restraints if? 2

untethered and the client is physically able to remove the mitt.