AAOI -Alai Arrest of Info - NCLEX ® Tutor
Beta Blockers
"olol" Decrease HR Reduce workload of Heart Decrease O2 demand of myocardium ( Propranolol/Inderal )
CCB
"pine" Decrease conduction thru AV node Slows HR Decrease O2 demand by myocardium (Nifedipine, verapamil, diltiazem)
ACE Inhibitor
"pril" (lisinopril) Drug that causes dilation of blood vessels and lowers blood pressure, prevents heart attacks, strokes, and congestive heart failure.
Cholesterol Lower Drug
"statin" atorvastatin(Lipitor) simvastatin(Zocor)
45% 55%
% of blood that is components: % of blood that is plasma:
% by wt or grams
% solution as described in composition
what is the correct order of completing a self breast examination
(1) while standing in front of mirror with arms at sides, inspect breast and nipples for asymmetry, changes, drainage (2) with hands firmly into hips and bow slightly, examine breast and nipples (3) with pads of fingers on left hand palpate the right breast using light pressure that feels the tissue just below the skin, medium pressure that feels the deeper tissue, firm that feels the tissue closest to the chest wall and ribs; this method feels all the breast tissue; then use the fingers of the eight hand to palpate the left breast; using a vertical pattern, the preferred method, palpate the entire breast from sternum outward including the Tail of Spence under the arm
Ego Integrity vs. Despair
(Erikson) People in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived
in case of prolapsed cord, which position would be best for pt. to assume?
(with position changes, we are trying to prevent or promote something.) In this case, we want to prevent placing pressure on umbilical cord. in order to do so, we put put the patient on her back, with the foot of the bed elevated (trendelenberg)
a. aspirate for gastric contents on the end of NG tube b. Inject rapidly 30 cc of air into the NG tube while auscultating over the epigastrum c. place the distal end of the NG tube into a glass of water and observe for bubbling with the xperation phase of respiratory cycle. d. test NG aspirate for pH value - gastric aspirate in a fasting client is usually acidic (pH 1-4 where pulmonary fluids will be greater than 6) e. small bore feeding tubes usually have placement verified by x-ray prior to instilling feeding formula
* name the 5 methods of checking tube placement
*Per Hospital Policy* *connect 10mL syringe containing 4-5mL of heparin flush solution (100units/mL) and inject into the port using spasmotic pressure *clamp before removing
**What if the central line will NOT have IV fluids infusing through that port, what do you do?
what are side effects of antineoplastics
**bone marrow suppression **stomatitis (occurs 5-10 days after start of med) alopecia N/V gonadal suppression renal tox ototoxicity
Don clean gloves place ties on pt with helper if needed, remove old ties
*STEP 5 REPLACE TIES
Patient using two identifiers Pt. understanding of procedure
*Step 2 Planning - verify
Adjust suction device to moderate to moderate high level using non dominant hand Validate by placing into sterile water
*Step 3 Implementation
Apply suction intermittently while rotating the catheter between the fingers and withdrawing it gradually from trach. Do NOT stay in more than 10 seconds let pt. recover
*Step 3 Implementation
Hyper-oxygenate pt., turn up 02 to 100% instruct client to take several deep breaths remove oxygen delivery device with non dominant hand
*Step 3 Implementation
insert suction into trach until resistance is met (do NOT apply suction)
*Step 3 Implementation
gloves on remove inner cannula and discard
*Step 4 INNER CANNULA
open inner cannula grasp only by outer portion (stays outside the throat) slide into place 9:00 to 6:00
*Step 4 INNER CANNULA
sodium requirement
, 2,300 mg of NA (approx 1 tsp of salt) per day increase K+ rich foods
symptoms of Acute Hemolytic reaction with blood transfusion:
-could be life threatening anxiety, chills, fever, low back pain, tachycardia, hypotension, chest tightness or pain, flushing, tachypnea, nausea, hemoglobinuria, vomiting A Fat Cholo Faked (Low back pain) Thinking He Could Trick His Nurse's Vagina
what are measures to prevent dumping syndrome
-lie down for 30 min after eating -drinking fluids between meals as opposed to with meals -reducing intake of carbs and fiber -eat smaller, more frequent meals -antispasmotic
what are the correct actions in pursed lip breathing
-take twice as long to exhale as it took to inhale -pretend you are whistling as you breathe out -tighten stomach muscles as you finish breathing out to sqeeze out all the air
assessment findings of pt with developmental dysplasia of the hip
-uneven gluteal folds and thigh creases (deeper on affected side) -limited abduction of the hip with pain -unequal knee height with thigh flexion -Ortolani's sign-placing infant on back with flex legs will yield a clicking sound on abduction of the legs -in older child, shortened limb on affected side -delays in walking, limp, lordosis, waddling gait in older child
what are assessment findings with strabismus
-visual deviation of the eye -diplopia -child tilts head or squints to focus
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LOOK FROM PREVIOUS NOTECARDS BOUT NEPHROTIC SYNDROME
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LOOK UP DELIRIUM VS DEMENTIA
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LOOK UP RIGHT VS LEFT CVA SIGNS
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normal creatnine
.7-1.4 mg/dL
normal INR
.7-1.8
what is the appropriate oral loading dose for digoxin? and how should it be administered?
.75-1.25 mg admin over 24 hours in divided doses
lithium level
.8 to 1.2
The total apgar score can range from
0 to 10
what is the target for synthroid therapy
0.5 to 2 microunits/mL
Chem-7 Creatine normal range
0.8 - 1.4 mg/dL
what is the therapeutic range for lithium ? what is the toxic dose for lithium?
0.8 to 1.4 mEq/L 1.5 mEq/L
Normal INR -on therapy?
0.8-1.2 Therapy = 2.0-3.0 ANTIDOTE: Vit. K
the lipid infusion should be connected to TPN solution tubing below the filter at a rate of for first 1/2 hour
1 ml/minute
how should i intro. food to my baby
1 new food no more freq. q 4 to 7 days to detect allergy give 1 to 2 tsps initally and increase over time
Definitive Dx of TB
1 positive TB screen and Chest X-ray
Nitro admin guidline
1 tab q5min x 3 doses Angina unresolved call 911 (take asprin)
how often is a clients PICC line dressing changed
1 to 2 times a week
The insanity defense is used in approximately how many criminal cases?
1%
Common Preoperative Medications:
1) Benzodiazepines and barbiturates: for sedation and amnesia 2) Anticholinergics: to reduce secretions 3) Opioids: to decrease intraoperative anesthetic requirements and pain 4) Additional drugs include antiemetics, antibiotics, eye drops, and regular prescription drugs
what is normal urinary output
1,200 to 1,500 mL/day or 50 to 63 mL/hr normal voiding patterns are 5 to 6x day
how much calcium do menopausal women need each day?
1,5000 mg of calcium
what is therapeutic level of lithium?
1-1.5 mEq/L
over how long of a period should Lasix be administered
1-2 min
at what age does infant lift head up 45 degrees when in prone position
1-3 months
1. collection chamber 2. water seal 3. suction control chamber
1. Fluids drain directly into chamber, calibrated in mL fluid, write-on surface to note level and time 2. One way valve, U-tube design, can monitor air leaks & changes in intrathoracic pressure 3. U-tube, narrow arm is the atmospheric vent, large arm is the fluid reservoir, system is regulated, easy to control negative pressure
What are some common Nursing Interventions to reduce risk/avoid post-op complications?
1. Turn & reposition the pt to promote circulation and reduce the risk of skin breakdown, especially over boney prominences. Initially position pt in a Lateral recumbant position until arousal from anesthesia, then position pt in Semi or Fowler position to reduce breathing effort. 2. Encourage coughing & deep breathing. This helps clear anestetics from the body, lowers risk of pulmonary/fat emboli, and hypostatic pneumonia associated with secretion buildup in the airways. 3. Encourage use of Incentive Spirometer. 4. Monitor In's and Out's. Hydration and protein rich nutrition promotes healing and provides energy to meet the needs of the pts increased metabolism associated with surgery. 5. Promote early ambulation. Early post-op exercise and ambulation significantly reduce the risk of thromboembolism.
what are the steps for injecting a medications
1. choose a needle based on volume, type of medication, destination site, client size, viscosity of med 2. maintain sterility when assembling the syringe and needle 3. withdraw mediction from the vial/ampule 4. use anatomical landmarks (IM, IV, subq) 5. wash hands and put on gloves 6. cleanse area with alcohol swabs and wait for it to dry 7. inject medication 8. discard the syringe and needle into a sharps container 9. remove gloves 10. wash hands
when the client approaches the RN states his wife wanted to commit suicide you shoud
1. first acknowledge the husbands feelings to establish trust 2. try to help the husband learn how to talk to his wife 3. assure the husband will assess the clients potential 4. acknoledge that the clients condition and improvemtn
what are the 3 phases of clinical manifestations of acute renal failure
1. initiation - little signs 2. maintenance - oliguria, signs of improve UO, 3. recovery -- renal function normal
Cranial nerves Oh! Oh! Oh! To Touch And Feel Virgin Girls Vag And Hymen
1. olfactory 2. optic 3. oculomotor 4.Trochlear 5. trigeminal 6. abducens 7. facial 8. vestibulocochlear 9. glossopharyngeal 10. vagus 11. accessory/spinal 12. hypolglossal
directions for deep breathing and coughing after abdominal surgery includes
1. taking three deep breaths 2. holding the incision 3. and then coughing
Normal specific gravity
1.010-1.030
Normal range for serum [Mg]
1.4 - 1.8 mEq/L
1.Assessment findings for Impetigo 2.what organisms cause impetigo? 3.how to remove impetigo?
1.Reddish macule becomes honey colored crusted vesicle, then crust, pruritis, 2. caused by staph, strep 3. loosen scab with Burrow's solution compress, remove gently.
1.what is the reason for physiological jaundice 2.when does it occur? 3. how long does it last?
1.the liver is unable to clear the billirubin from the blood 2.occurs after 24 hours, peaks at 72 hours 3.lasts 5-7 days
how thick is the film applied to a burn of nitrofurazone?
1/16 inch is applied directly to the burn using a sterile gloved hand
what is pulsas paradoxus and what is it a sign of
10 mm Hg or higher on expiration than inspiration
client receives a mantoux test.. what is considered positive reading for client
10 mm or more
how long should you suction for each pass in an adult
10 sec. per catheter pass to reduce the risk of inadequate oxygenation
pt with HIV asks what he should clean his bathroom with
10% bleach solution
what is the maximum % of dextrose used for a PPN
10% maximum of dextrose to avoid vein irritation
how much fat should someone consume
10% or less of calories from saturated fats <300 mg/day of cholesterol keep trans fatty acid consumption as low as possible
Hypercalcemia
10.5 mg/L (serum [Ca] greater than)
On heart rate or cardiac status, a 2 means that the HR is above _______ BPM.
100
hold sulfonureas for blood sugar under
100 Hurst
For every 1 mEq/L deficit below 3.5 mEq/L of serum [K] there is a corresponding total body [K] deficit of
100 - 400 mEq
Tachycardia HR
100 bpm (greater than 100 bpm)
required daily fluid for pediatric clients between 10-20 kg
1000 ml + 50 ml per each kg
required daily fluid for pediatric clients between 0-10 kg
100ml/kg
Chem-7 Serum [Cl] normal range
101 - 111 mmol/L
What is the hightes that the temp will be in appendicitis?
102 F
normal PT
11-12.5 sec
Bradypnea rate
12 bpm ( less than 12 bpm)
when should the person take disulfiram?
12 hours after alcohol intake long half life so you can't drink after you stop right away
how long does a drug baby go through withdrawals
12 hrs up to 10 days after delivery
normal hemoglobin for females
12-16
How long should the stump be elevated to prevent post op swelling?
12-24 hours
Pre-HTN systolic / diastolic ranges
120 - 139 / 80 - 89 mmHg
Normal Blood pressure BP
120 / 80 mmHg (< 120, < 80)
what is the normal resting rate for an infant
120 to 160 bpm with apneic episodes normal respirations are 30 to 60
HTN Pre-hypertension
120-139 / 80-89
Chem-7 Serum [Na] normal range
136 - 144 mEq/L (2 * [Na])
normal hemoglobin for males
14-18
Stage 1 HTN systolic / diastolic ranges
140 - 159 / 90 - 99 mmHg
HTN Stage 1
140-149 / 90-99
The diagnosis is made when there is a weight loss of _______% or more of body weight.
15 (weigh < 85% of normal body weight), hospitalize if 30% weight loss
bmi of 29 < mom should gain what
15 or less
how long should newborns should try to feed for when breast feeding
15 to 20 min per breast
bmi 25 to 29 mom should gain what
15 to 25
low fowlers
15 to 30
Apendicitis occurs most in what age group?
15 to 35
required daily fluid for pediatric clients between 20-70 kg
1500 ml + 20 ml per each kg
Stage 2 HTN systolic / diastolic ranges
160 / 100 mmHg ( > 160, > 100)
HTN Stage 2
160+ / 100+
If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use?
18 (in preparation to give blood if necessary)
Normal adult BMI range
18.5 - 24.9
what is a healthy range for bmi
18.5 to 24.9
what size and type of catheter is used for acentral line TPN
18G triple lumen
What is the age range for early adulthood?
19 to 35 years of age
If an AIDS patient's blood contaminates a counter top, with what di you clean?
1:10 solution of bleach and water
The maximum score and infant can receive on any one of the criteria is
2
POsm formula?
2 Na + BUN / 2.8 + Glu / 18 (normal 275 - 290 mOsm)
when is the hepatitis B vaccine repeated?
2 and 4 months
FDA approved must have documentaion available
2 criteria to add or infuse med and IV solutions:
how many cups of fruits and vegetables are recommended for a 2,000 cal diet
2 cups of fruit 2 1/2 cups of veggies
when drinking alochol what should be exchanged in the pt with DM1 diet
2 fat exchanges for every beverage containing alcohol
what is a favorable non stress test outcome?
2 or more FHR accels of 15 bmp lasting at least 15 seconds in a 20 min interval
what kind of gait is this called? advance the right crutch and the left foot forward, followed by the right foot and the left crutch forward.
2 point gait
A person can be detained for which amount of time on an emergency basis until a hearing can be conducted to decide commitment?
2 to 3 days -A person can be detained in a psychiatric facility for 48 to 72 hours on an emergency basis until a he rating an be conducted to determins whether he or she should be commiteed to a faciltity for treatment for a specified period
how often do you change the PICC dressing if TPN is running through it
2 to 3 times a week standard
how long does it take for atomoxetine to take effect to relieve depression
2 to 3 weeks
What are the urinaysis findings on AGN?
2 to 3 weeks after initial infection
pt is taking levodopa (Dopar) for Parkinson's Disease, how long does it take effect
2 to 3 weeks some 6 months emphasize compliance with medication therapy
a mom is lactating and she asked when her real milk comes in
2 to 4 days milky white appearance contains more fat and lactose than colostrum
how long does acrocyanosis last after delivery
2 to 6 hours due to poor peripheral circulation
what is a mastecomy indicated for.. how many tumors
2 tumors in the same breast
for woman just diagnosed with Lupus, it is recommended that she wait how long before she gets pregnant?
2 years following diagnosis
At what age are accidental poisonings most common?
2 years old
Moderate hypokalemia serum [K] range
2.5 - 3 mEq/L
how many pounds should pt gain in first trimester of pregnancy
2.5 -5 (1-3 kg)
Severe hypokalemia serum [K]
2.5 mEq/L (less than 2.5 mEq/L)
what is normal serum uric acid in women
2.5-5.5 mg/dL
Chem-7 CO2 normal range
20 - 29 mmol/L
Tachypnea rate
20 bpm (greater than 20 bpm)
Apnea elapsed time
20 sec (greater than 20 secs elapsed between breath)
what should the fat intake be
20 to 35% of calories most fat should be polyunsaturated and monosat. fatty acids fish nuts veggie oils
A CD4 count of under _______ is associated with the onset of opportunistic infections.
200
normal level for HCO3
22 to 26
nasal cannula concentration of Oxygen
24 to 44%
overweight
25 to 29.9
how much should a mom of 19.8 to 24.9 gain
25 to 35 lbs
Normal PTT -on therapy?
25-35 seconds Therapy = 1.5-2 x's normal (50-90) ANTIDOTE: PROTAMINE SULFATE
how much weight should underweight mom gain <19.8
28 to 40 lbs
when is nitrofurazone used
2nd or 3rd degree burns when bacterial resistance to other agents is a potential harm
what is the dosing shcedule for atomoxetine
2x day in the morning and afternoon
pt asks how often he should apply his minoxidil solution (Rogaine)
2xday 1mL dosage applied twice daily
How many nitro tabs can you take before you call the doctor?
3
Mild hypokalemia serum [K] range
3 - 3.5 mEq/L
suction control bottle water seal bottle collection bottle
3 chambers of a chest tube drainage system:
what is the best diet for someone who has chronic pancreatitis
3 meals per day small frequent meals are the most beneficial
in pt with mononucleosis, avoid direct contact with saliva for about
3 months
head injury within ___ (time frame) is an absolute contraindication for ____ therapy
3 months, thrombolytic
when does the colostomy begin to function after surgery
3 to 6 days
to perform the venipuncture, the nurse should start the IV with which of the following (for IV with D5W a) the veins of the clients wrist on the nondominant side b)the veins of the leg so it will not interfere with the clients ability to feed herself c)the dorsal veins of the clients forearm on the nondominant side d) the dorsal surface of the clients hand on the nondominant side
3) the dorsal veins of the client's forearm on the nondominant side is the best area d/t ease of access, availability of elastic veins, and limited use by the client
how many calories are in a pound
3,500 calories
moro reflex should disappear by what age
3-4 months
how long does it take for symptoms of viral conjunctivitis to resolve?
3-7 days
HypoKalemia is defined as
3.5 mEq/L (less than 3.5 - 4 mEq/L is an early sign of hypokalemia)
what is normal albumin levels
3.5 to 5.5 gm/dl
normal serum albumin levels
3.5-5
normal RBC for female
3.5-5.5
Chem-7 Serum [K] normal range
3.7 - 5.2 mEq/L
how much do you flush with before you administer a bolus or medication?
30 mL
what is the stomach capacity of the infant
30 mL
how often do you assess for circumcision care for hemorrhage
30 min for 2 hrs post op
onset of febrile reaction to blood transfusion
30 min- 6 hr after transfusion
after getting the blood from the blood bank, the nurse must begin administering it within which of the following time periods?
30 minutes
obese
30 to 34.9
semi-fowlers
30 to 45 degrees
how should you position the client to eat with dysphagia
30 to 45 degrees head elevated use chin tuck (head and neck slightly flexed) and monitor feedings to decrease risk of aspiration and evaluate the clients attempts at eating
when the pt takes imitrex upon symptoms of migraine, how long does it take to effect
30 to 50 min. for an oral dosing
semi-fowlers
30-45
how much do calories increase during pregnancy
300 cal/day
what is the minimum urine output after renal transplant
30mL /hr
obese 2
35 to 39
What is the age range for middle adulthood?
35 to 64 years of age
Hypothermic temperature in C
35.7 C (96.4 F = (1.8) 35.7 + 32)
normal hematocrit for females
37%-47%
Hyperthermic temperature in C
38 C (100.4 F = (1.8) 38 + 32)
How long will it take for the person to see results when acne is being treated?
4 to 6 weeks
how long should the person with a new colostomy be on a low fiber diet
4 to 6 weeks avoid gas forming and odor producing or excessively laxative / constipating foods
if you get bitten by a tick when should you get tested
4 to 6 weeks after
1L of oxygen is what percentage of o2 concentration
4%
normal RBC for male
4.3-5.9
what is normal serum uric acid in men
4.5-6.5 mg/dL
Mammogram start age
40 = q1-2 years 50 = q Year
obese 3
40 or higher
normal hematocrit for males
42-52%
fowlers
45 - 60
after administering DPaT immunization, fever is expected within
48 hours
How many minutes should lapse between the nitro pills you take?
5 minutes - take one nitro tab every 5 minutes 3 times, if no relief, call MD
client receives a mantoux test. what is considered a positive reading for a client with HIV/ AIDS
5 mm <
a woman who has lupus, it is recommended that she be in remission for how long before she conceives?
5 months
how long should you suction for each pass in a child
5 seconds per catheter pass
what is the therapeutic range of Theophylline?
5-15 mcg/mL
birth weight doubles by how old
5-6 months
how many times a day should a newborn infant void?
5-8 times
Mild hyperkalemia range is
5.5 - 6 mEq/L
Hyperkalemia is defined as
5.5 mEq/L (greater than 5.5 mEq/L)
what is the screening protocol for american cancer society for early detection of cancer in asymptomatic people
50 < men and women should hav fecal occult blood testing every year or flexible sigmoidoscopy every 5 years or colonoscopy every 10 years.
what is the initial rate of infusion of TPN
50 mL/hr and gradually increased to 100 to 125 as the clients fluid and electrolyte tolerance permits
at what rate should TPN solution be started
50 ml/hr
A CD4 count of under __________ is associated with the onset of AIDS-related symptoms.
500
how much do calories increase for lactation
500 cal/day
WBCs, RBCs, plasma, platelets, clotting factors, immunoglobulins
6 components of blood:
when should pt take (DextroStat) for their narcolepsy
6 hrs before bedtime to prevent sleep disturbance
when breast feeding a baby, how many wet diapers should they have
6 to 8 diapers a day minimum of 2
client just had abdominal surgery and asked, when can i go back to work?
6 weeks
what is normal serum protein
6-8 g/dL
Moderate hyperkalemia range is
6.1 - 6.9 mEq/L
high fowlers
60 - 90
beta blockers should NOT be given if pulse is less than
60 bpm Hurst
Bradycardia HR
60 bpm (less than 60 bpm)
how many grams equal 1 grain
60 mg
normal fasting blood glucose is
60-110
Chem-7 Glucose normal range
64 - 128 mg/dL (Glu / 18)
What is the age range for late adulthood?
64 years of age to death
Chem-7 BUN normal range
7 - 20 mg/dL (BUN / 2.8)
Severe hyperkalemia serum [K]
7 mEq/L (greater than 7 mEq/L)
normal BUN
7-18 mg/dL
when is pulmonary embolus most likely to occur between
7th and 10th postop days both are complications of life threatening
Average anion gap for a healthy adult
8 - 12 mEq/L ( AG = (Na + K) - (HCO2 + Cl) )
when a person is on a NTG patch how long is the period they should not have it on for and why
8 to 10 hr period to prevent development of tolerance to NTG
what is a normal biophysical profile score?
8-10
Normal AST
8-20 units/L
normal ALT
8-20 units/L
what is the suggested wall suction pressure for suctioning a tracheastomy?
80-120 mmHg
TB Medication time till done
9-12 months
how much oxygen does a Non-rebreather mask deliver
90%
beta blockers should NOT be given if blood pressure is lower than
90/60 Hurst
what are normal labs for Cl
95 to 105 mEq/L
HTN Normal range
< 120/80
Hypokalemia S/S -level
< 3.5 DYSRHYTHMIAS, Muscle Cramping
Hypocalcemia -level
< 8.5 Trousseau/Chvostek sign Numbness Convulsions Diarrhea
Hyponatremia S/S -level
<135 Muscle Cramping Confusion Check BP Frequently
Hypercalcemia S/S -level
>10.5 Muscle weakness N/V Behavioral changes Constipation
Hypernatremia S/S -level
>145 Pulmonary Edema Seizure Thirst
Hyperkalemia S/S -level
>5 Muscle Weakness Diarrhea
what is a sign of cardiotoxicity?
A QRS widening greater than 50%
hemoglobin
A complex iron containing compound that caries O2 and gives blood its red color:
Rales
A crackling, rattling breath sound that signals fluid in the air spaces of the lungs; also called crackles (Pneumonia/CHF)
What does the physician hope to achieve with NRTI's and PI's for HIV?
A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years)
ARDS definition
A disorder of the lung tissue caused by infection, shock, burns, or other insults in which the capillaries became leaky and the air spaces fill with fluid.
Loop Stoma
A loop stoma can be made in the ileum ("loop ileostomy") or colon ("loop colostomy"). A loop stoma often is made when the stoma will be temporary. However, not all loop stomas are temporary
The telemetry unit nurse is reviewing laboratory results for a patient who is scheduled for an operative procedure later in the day. The nurse notes on the laboratory report that the patient has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia. The nurse informs the physician of this laboratory result because the nurse recognizes hyperkalemia increases the patient's operative risk for: A. Cardiac problems B. Bleeding with anemia C. Fluid imbalances D. Infection
A) Hyper/hypokalemia increases the patient's risk for cardiac problems. A decrease in the hematocrit and hemoglobin level may indicate the presence of anemia or bleeding. An elevated WBC occurs in the presence of infection. Abnormal urine constituents may indicate infection or fluid imbalances.
Upon assessment, a patient reports that he drinks 5-6 bottles of beer every evening after work. Based upon this information, the nurse is aware that the patient may require: A. Larger doses of anesthetic agents and larger doses of postoperative analgesics. B. Larger doses of anesthetic agents and lower doses of postoperative analgesics. C. Lower doses of anesthetic agents and larger doses of postoperative analgesics. D. Lower doses of anesthetics agents and lower doses of postoperative analgesics.
A) Patients with a larger habitual intake of alcohol require larger doses of anesthetic agents and postoperative analgesics, increasing the risk for drug-related complications.
The nurse is providing teaching to a patient regarding pain control after surgery. The nurse informs the patient that the best time to request pain medication is: A. Before the pain becomes severe. B. When the patient experiences a pain rating of 10 on a 1-to-10 pain scale. C. After the pain becomes severe and relaxation techniques have failed. D. When there is no pain, but it is time for the medication to be administered.
A) The question states that the patient is being instructed on when to "request" pain medication. If a pain medication is ordered PRN, the patient should be instructed to ask for the medication before the pain becomes severe.
The nurse is preparing to send a patient to the operating room for an exploratory laparoscopy. The nurse recognizes that there is no informed consent for the procedure on the patient's chart. The nurse informs the physician who is performing the procedure. The physician asks the nurse to obtain the informed consent signature from the patient. The nurse's best action to the physician's request is to: A. Inform the physician that is his responsibility to obtain the signature. B. Obtain the signature and ask another nurse to co-sign the signature. C. Inform the physician that the nurse manager will need to obtain the signature.
A) The responsibility for securing informed consent from the patient lies with the person who will perform the procedure. The nurse's best action is to inform the physician that it is his responsibility to obtain the signature.
A client who is started on metformin and glyburide would have initially present with with symptoms? A. Polydipsia, polyuria, and weight loss B. Weight gain, tiredness, and bradycardia C. irritability, diaphoresis and tachycardia D. Diarrhea, abdominal pain and weight loss
A) symptoms of hyperglycemia included polydispia, polyuria, and weightloss. Metformin and sulfonylureas are commonly ordered medications. Weight gain, tiredness, and bradycardia are symptoms of hypothyroidism. Irritability, diaphoresis, and tachycardia are symptoms of hypoglycemia. Symptoms of Crohn's disease include diarrhea, abdominal pain, and weight loss.
Select all that apply. Advantages of laser surgery include diminished A. bleeding. B. swelling. C. tissue damage. D. postoperative pain. E. postoperative infection.
A, B, C, D, & E (All of the above) Laser surgery offers the benefits of diminished bleeding, swelling, tissue damage, and postoperative pain and infection.
the nurse cares for a client diagnosed with a Right sided CVA with dysphagia. which of the folllowing actions by the nurse reflects appropriate care for the client? SATP a) the nurse assesses the clients ability to swallow b) the nurse offers the client apple juice c) the nurse positions the client at a 45 degree angle d) the nurse offers the client scrambled eggs e) the nurse instructs the client to place food on the left side of the mouth f) the nurse turns off the television
A, B, D, F B) the client has difficulty taking fluid it is important to offer slowly
what areas do adolescents lack in vitamins
A,C,B6, calcium, zinc, mg+
A pt has returned from surgery with a tracheostomy tube in place. After about 10 minutes in postoperative recovery, the pt begins to have noisy, increased respirations and an elevated heart rate. What action should the RN take immediately? A. Suction the tracheostomy. B. Readjust the tracheostomy tube and tighten the ties. C. Preform a complete respiratory assessment.
A. Noisy, increased respiration & increased pulse are signs that the pt needs immediate suctioning to clear the airway of secretions. A complete respiratory assessment may then be completed.
The reason pts are sent to a PACU after surgery is: A. to be monitored while recovering from anesthesia. B. to remain near the surgeon immediately after surgery. C. to allow the medical-surgical unit time to prepare for transfer. D. to provide time for the pt to cope with the effects of surgery.
A. Pts are sent to a PACU to be monitored while they're recovering from anesthesia.
Select all that apply. A nurse is caring for patients on a medical-surgical unit. The nurse plans the patients' care and instructs the nursing assistant to assist in repositioning patients every 2 hours. Which patients are at the greatest risk for complications if not repositioned properly? A. A 20-year-old unconscious patient B. A 90-year-old frail patient C. A 65-year-old patient who is visually impaired D. A 40-year-old patient who has paraplegia
A. A 20-year-old unconscious patient B. A 90-year-old frail patient (&) D. A 40-year-old patient who has paraplegia Patients who are at the greatest risk for complications if not properly repositioned are those who are unconscious, frail, or paralyzed.
In the operating room, a patient tells a circulating nurse that he is going to have the cataract in his left eye removed. If the nurse notes that the consent form indicates that surgery is to be performed on the right eye, what should be the nurse's first action? A. Ask the patient his name. B. Notify the surgeon and anesthesiologist. C. Check to see whether the patient has received any preoperative medications. D. Assume that the patient is a little confused because he is older and has received midazolam intramuscularly.
A. Ask the patient his name. Ensuring proper identification of a patient is a responsibility of all members of the surgical team. In a specialty surgical setting where many patients undergo the same type of surgery each day, such as cataract removal, it is possible that the patient and the record do not match. Nurses do not assume in the care of their patients. The priority is with the nurse identifying the patient and the patient's consent form before the physicians are notified.
Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment? A. Excessive thirst B. Gradual weight gain C. Overwhelming fatigue D. Recurrent blurred vision
A. Excessive thirst. The classic clinical manifestations of diabetes mellitus are increased frequency of urination (polyuria); increased thirst and fluid intake (polydipsia); and as the disease progresses, weight loss despite increased hunger and food intake (polyphagia). Weakness, fatigue, and recurrent blurred vision are associated with diabetes mellitus but are not considered priority manifestations because of the generalization of these complaints being applied to other disease processes. Weight loss is the cardinal sign related to the depletion of water, glycogen, and triglyceride stores.
The nurse is admitting a patient to the same day surgery unit. The patient tells the nurse that he was so nervous he had to take kava last evening to help him sleep. Which of the following nursing actions would be most appropriate? A. Inform the anesthesiologist of the patient's ingestion of kava. B. Tell the patient that using kava to help sleep was a good idea. C. Tell the patient that the kava should continue to help him relax before surgery. D. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.
A. Inform the anesthesiologist of the patient's ingestion of kava. Kava may prolong the effects of certain anesthetics. Thus the anesthesiologist needs to be informed of recent ingestion of this herbal supplement.
Select all that apply. A nurse is caring for a surgical patient in the preoperative area. The nurse obtains the patient's informed consent for the surgical procedure. Which statements are true regarding informed consent? A. Informed consent must be signed while the patient is free from mind-altering medications. B. Informed consent must be witnessed. C. Informed consent may be withdrawn at any time. D. Informed consent must be signed by patients age 16 and older. E. Informed consent must be obtained by the physician. F. Informed consent must be obtained from the family even in a life-threatening emergency.
A. Informed consent must be signed while the patient is free from mind-altering medications. B. Informed consent must be witnessed. An informed consent must be signed while the patient is free from mind-altering medications and must be witnessed after it has been determined that the patient has received all of the necessary information needed to make an informed decision. An informed consent may be withdrawn at any time before the procedure and must be signed by patients age 18 and older. A parent or guardian's signature is required for minors. The informed consent may be obtained by the physician or the nurse and is not required in the event of a life-threatening emergency.
Select all that apply. Which of the following best describes a consent form? A. May be signed by an emancipated minor. B. Protects the health care facility but not the physician C. Signifies that the patient understands all aspects of the procedure. D. Signifies that the patient and family have been told about the procedure E. Must be signed by the patient or responsible party at the health care facility, and that consent may not be obtained by phone or fax
A. May be signed by an emancipated minor. (&) C. Signifies that the patient understands all aspects of the procedure. A consent form may be signed by an emancipated minor, and consent may be obtained by fax or phone with appropriate witnesses. Only in the cases of underage children or unconscious or mentally incompetent people must a family member be aware of the procedure. The document protects the surgeon and the health care facility in that it indicates that the patient knows and understands all aspects of the procedure.
Which of the following nursing interventions should receive highest priority when a patient is admitted to the postanesthesia care unit? A. Positioning the patient B. Observing the operative site C. Checking the postoperative orders D. Receiving report from operating room personnel.
A. Positioning the patient. A patient is received in the postanesthesia care unit on a bed or stretcher. Proper positioning is necessary to ensure airway patency in a sedated, unconscious, or semiconscious patient. Observation of the operative site, receiving report from operating room personnel, and checking postoperative orders are interventions made after proper positioning of the patient.
In caring for a person receiving an opioid analgesic through an epidural catheter, the nursing responsibility of prime importance is A. assessing for respiratory depression. B. establishing a baseline laboratory profile. C. inspecting the catheter insertion site hourly. D. ensuring that the patient remains on strict bed rest.
A. assessing for respiratory depression. Possible side effects of epidural opioids are pruritus, urinary retention, and delayed respiratory depression, occurring 4 to 12 hours after a dose. Establishing a baseline laboratory profile is outside the scope of practice for a nurse. Hourly inspection of the catheter insertion site is an unnecessary nursing intervention. In general, the site is assessed once a shift unless unexpected complications occur. Strict bed rest is not necessary for the patient with an epidural catheter; however, assistance with getting out of bed could be necessary related to effects of the opioid analgesic.
The primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team is A. avoiding any type of injury to the patient. B. maintaining a clean environment for the patient. C. providing for patient comfort and sense of well-being. D. preventing breaks in aseptic technique by the sterile members of the team.
A. avoiding any type of injury to the patient. The protection of the patient from injury in the operating room environment is maintained by the circulating nurse by ensuring functioning equipment, preventing falls and injury during transport and transfer, monitoring asepsis, and being with the patient during anesthesia induction.
When administering low-molecular-weight heparin (LMWH) after an operation, a nurse should A. explain that the drug will help prevent clot formation in the legs. B. check the results of the partial thromboplastin time before administration. C. administer the dose with meals to prevent GI irritation and bleeding. D. inform the patient that blood will be drawn every 6 hours to monitor the prothrombin time.
A. explain that the drug will help prevent clot formation in the legs. Unfractionated heparin or LMWH is given as a prophylactic measure for venous thrombosis and pulmonary embolism. These anticoagulants work by inhibiting thrombin-mediated conversion of fibrinogen to fibrin. LMWH is injected subcutaneously with no relationship to meals. It has a more predictable dose response and less risk of bleeding complications. It does not require anticoagulant monitoring and dosage adjustments.
A patient is scheduled for a hemorrhoidectomy at an ambulatory day-surgery center. An advantage of performing surgery at an ambulatory center is a decreased need for A. laboratory tests and perioperative medications. B. preoperative and postoperative teaching by the nurse. C. psychologic support to alleviate fears of pain and discomfort. D. preoperative nursing assessment related to possible risks and complications.
A. laboratory tests and perioperative medications. Ambulatory surgery is usually less expensive and more convenient, generally involving fewer laboratory tests, fewer preoperative and postoperative medications, less psychological stress, and less susceptibility to hospital-acquired infections. However, the nurse is still responsible for assessing, supporting, and teaching the patient undergoing surgery, regardless of where the surgery is performed.
what 3 things are required for a platelet transufion
ABO compatibility Rh compatibility platelets are admin. using a specialized platelet filter
what is the most definitive test for Addisons disease
ACTH test adrenocorticotropic hormone
How would a nurse differentiate a client diagnosed with obsessive-compulsive disorder (OCD) from a client diagnosed with obsessive-compulsive personality disorder? A. Clients diagnosed with OCD experience both obsessions and compulsions, and clients diagnosed with obsessive-compulsive personality disorder do not. B. Clients diagnosed with obsessive-compulsive personality disorder experience both obsessions and compulsions, and clients diagnosed with OCD do not. C. Clients diagnosed with obsessive-compulsive personality disorder experience only obsessions, and clients diagnosed with OCD experience only compulsions. D. Clients diagnosed with OCD experience only obsessions, and clients diagnosed with obsessive-compulsive personality disorder experience only compulsions.
ANS: A A client diagnosed with OCD experiences both obsessions and compulsions. Clients diagnosed with obsessive-compulsive personality disorder exhibit a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control.
A nurse is providing discharge teaching to a client taking a benzodiazepine. Which client statement would indicate a need for further follow-up instructions? A. "I will need scheduled blood work in order to monitor for toxic levels of this drug." B. "I won't stop taking this medication abruptly because there could be serious complications." C. "I will not drink alcohol while taking this medication." D. "I won't take extra doses of this drug because I can become addicted."
ANS: A The client indicates a need for additional information about taking benzodiazepines when stating the need for blood work to monitor for toxic levels. No blood work is needed when taking a short-acting benzodiazepine. The client should understand that taking extra doses of a benzodiazepine may result in addiction and that the drug should not be taken in conjunction with alcohol.
A client diagnosed with panic disorder states, "When an attack happens, I feel like I am going to die." Which is the most appropriate nursing reply? A. "I know it's frightening, but try to remind yourself that this will only last a short time." B. "Death from a panic attack happens so infrequently that there is no need to worry." C. "Most people who experience panic attacks have feelings of impending doom." D. "Tell me why you think you are going to die every time you have a panic attack."
ANS: A The most appropriate nursing reply to the client's concerns is to empathize with the client and provide encouragement that panic attacks last only a short period. Panic attacks usually last minutes but can, rarely, last hours. Symptoms of depression are also common with this disorder.
A client has a history of excessive fear of water. What is the term that a nurse should use to describe this specific phobia, and under what subtype is this phobia identified? A. Aquaphobia, a natural environment type of phobia B. Aquaphobia, a situational type of phobia C. Acrophobia, a natural environment type of phobia D. Acrophobia, a situational type of phobia
ANS: A The nurse should determine that an excessive fear of water is identified as aquaphobia which is a natural environment type of phobia. Natural environment-type phobias are fears about objects or situations that occur in the natural environment such as a fear of heights or storms.
A client is prescribed alprazolam (Xanax) for acute anxiety. What client history should cause a nurse to question this order? A. History of alcohol dependence B. History of personality disorder C. History of schizophrenia D. History of hypertension
ANS: A The nurse should question a prescription of alprazolam (Xanax) for acute anxiety if the client has a history of alcohol dependence. Alprazolam is a benzodiazepine used in the treatment of anxiety and has an increased risk for physiological dependence and tolerance. A client with a history of substance abuse may be more likely to abuse other addictive substances and/or combine this drug with alcohol.
A nursing instructor is teaching about the medications used to treat panic disorder. Which student statement indicates that learning has occurred? A. "Clonazepam (Klonopin) is particularly effective in the treatment of panic disorder." B. "Clozapine (Clozaril) is used off-label in long-term treatment of panic disorder." C. "Doxepin (Sinequan) can be used in low doses to relieve symptoms of panic attacks." D. "Buspirone (BuSpar) is used for its immediate effect to lower anxiety during panic attacks."
ANS: A The student indicates learning has occurred when he or she states that clonazepam is a particularly effective treatment for panic disorder. Clonazepam is a type of benzodiazepine that can be abused and lead to physical dependence and tolerance. It can be used on an as-needed basis to reduce anxiety and its related symptoms.
A nurse has been caring for a client diagnosed with generalized anxiety disorder (GAD). Which of the following nursing interventions would address this client's symptoms? (Select all that apply.) A. Encourage the client to recognize the signs of escalating anxiety. B. Encourage the client to avoid any situation that causes stress. C. Encourage the client to employ newly learned relaxation techniques. D. Encourage the client to cognitively reframe thoughts about situations that generate anxiety. E. Encourage the client to avoid caffeinated products.
ANS: A, C, D, E Nursing interventions that address GAD symptoms should include encouraging the client to recognize signs of escalating anxiety, to employ relaxation techniques, to cognitively reframe thoughts about anxiety-provoking situations, and to avoid caffeinated products. Avoiding situations that cause stress is not an appropriate intervention because avoidance does not help the client overcome anxiety. Stress is a component of life and is not easily evaded.
A college student has been diagnosed with generalized anxiety disorder (GAD). Which of the following symptoms should a campus nurse expect this client to exhibit? (Select all that apply.) A. Fatigue B. Anorexia C. Hyperventilation D. Insomnia E. Irritability
ANS: A, D, E The nurse should expect that a client diagnosed with GAD would experience fatigue, insomnia, and irritability. GAD is characterized by chronic, unrealistic, and excessive anxiety and worry.
A client diagnosed with obsessive-compulsive disorder is admitted to a psychiatric unit. The client has an elaborate routine for toileting activities. Which would be an appropriate initial client outcome during the first week of hospitalization? A. The client will refrain from ritualistic behaviors during daylight hours. B. The client will wake early enough to complete rituals prior to breakfast. C. The client will participate in three unit activities by day 3. D. The client will substitute a productive activity for rituals by day 1.
ANS: B An appropriate initial client outcome is for the client to wake early enough to complete rituals prior to breakfast. The nurse should also provide a structured schedule of activities and later in treatment begin to gradually limit the time allowed for rituals.
A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose? A. When the client has a knowledge deficit related to the effects of the drug B. When the client combines the drug with alcohol C. When the client takes the drug on an empty stomach D. When the client fails to follow dietary restrictions
ANS: B Both Librium and alcohol are central nervous system depressants. In combination, these drugs have an additive effect and can suppress the respiratory system leading to respiratory arrest and death.
Which nursing diagnosis would best describe the problems evidenced by the following client symptoms: avoidance, poor concentration, nightmares, hypervigilance, exaggerated startle response, detachment, emotional numbing, and flashbacks? A. Ineffective coping B. Post-trauma syndrome C. Complicated grieving D. Panic anxiety
ANS: B Post-trauma syndrome is defined as a sustained maladaptive response to a traumatic, overwhelming event. This nursing diagnosis addresses the problems experienced by clients diagnosed with post-traumatic stress disorder.
A nursing student questions an instructor regarding the order for fluvoxamine (Luvox) 300 mg daily for a client diagnosed with obsessive-compulsive disorder (OCD). Which instructor reply is most accurate? A. "High doses of tricyclic medications will be required for effective treatment of OCD." B. "Selective serotonin reuptake inhibitor (SSRI) doses, in excess of what is effective for treating depression, may be required for OCD." C. "The dose of Luvox is low due to the side effect of daytime drowsiness and nighttime insomnia." D. "The dosage of Luvox is outside the therapeutic range and needs to be questioned."
ANS: B The most accurate instructor response is that SSRI doses, in excess of what is effective for treating depression, may be required in the treatment of OCD. SSRIs have been approved by the U.S. Food and Drug Administration for the treatment of OCD. Common side effects include headache, sleep disturbances, and restlessness.
A family member is seeking advice about an elderly parent who seems to worry unnecessarily about everything. The family member states, "Should I seek psychiatric help for my mother?" Which is an appropriate nursing reply? A. "My mother also worries unnecessarily. I think it is part of the aging process." B. "Anxiety is considered abnormal when it is out of proportion to the stimulus causing it and when it impairs functioning." C. "From what you have told me, you should get her to a psychiatrist as soon as possible." D. "Anxiety is a complex phenomenon and is effectively treated only with psychotropic medications."
ANS: B The most appropriate reply by the nurse is to explain to the family member that anxiety is considered abnormal when it is out of proportion and impairs functioning. Anxiety is a normal reaction to a realistic danger or threat to biological integrity or self-concept.
A client refuses to go on a cruise to the Bahamas with his spouse due to fearing that the cruise ship will sink and all will drown. Using a cognitive theory perspective, how should a nurse explain to the spouse the etiology of this fear? A. "Your spouse may be unable to resolve internal conflicts which result in projected anxiety." B. "Your spouse may be experiencing a distorted and unrealistic appraisal of the situation." C. "Your spouse may have a genetic predisposition to overreacting to potential danger." D. "Your spouse may have high levels of brain chemicals that may distort thinking."
ANS: B The nurse should explain that from a cognitive perspective the client is experiencing a distorted and unrealistic appraisal of the situation. From a cognitive perspective, fear is described as the result of faulty cognitions.
A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred? A. "These clients do not recognize that their fear is excessive and rarely seek treatment." B. "These clients have a panic level of fear that is overwhelming and unreasonable." C. "These clients experience symptoms that mirror a cerebrovascular accident (CVA)." D. "These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis."
ANS: B The nursing instructor should evaluate that learning has occurred when the student knows that clients experiencing phobias have a panic level of fear that is overwhelming and unreasonable. Phobia is fear cued by a specific object or situation in which exposure to the stimuli produces an immediate anxiety response.
A nurse is discussing treatment options with a client whose life has been negatively impacted by claustrophobia. The nurse would expect which of the following behavioral therapies to be most commonly used in the treatment of phobias? (Select all that apply.) A. Benzodiazepine therapy B. Systematic desensitization C. Imploding (flooding) D. Assertiveness training E. Aversion therapy
ANS: B, C The nurse should explain to the client that systematic desensitization and imploding are the most commonly used behavioral therapies in the treatment of phobias. Systematic desensitization involves the gradual exposure of the client to anxiety-provoking stimuli. Imploding is the intervention used in which the client is exposed to extremely frightening stimuli for prolonged periods of time.
A client who is a veteran of the Gulf War is being assessed by a nurse for post-traumatic stress disorder (PTSD). Which of the following client symptoms would support this diagnosis? (Select all that apply.) A. The client has experienced symptoms of the disorder for 2 weeks. B. The client fears a physical integrity threat to self. C. The client feels detached and estranged from others. D. The client experiences fear and helplessness. E. The client is lethargic and somnolent.
ANS: B, C, D Clients diagnosed with PTSD can experience the following symptoms: fear of a physical integrity threat to self, detachment and estrangement from others, and intense fear and helplessness. Characteristic symptoms of PTSD include re-living the traumatic event, a sustained high level of arousal, and a general numbing of responsiveness.
How would a nurse differentiate a client diagnosed with a social phobia from a client diagnosed with a schizoid personality disorder (SPD)? A. Clients diagnosed with social phobia can manage anxiety without medications, whereas clients diagnosed with SPD can manage anxiety only with medications. B. Clients diagnosed with SPD are distressed by the symptoms experienced in social settings, whereas clients diagnosed with social phobia are not. C. Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. D. Clients diagnosed with SPD avoid interactions only in social settings, whereas clients diagnosed with social phobias tend to avoid interactions in all areas of life.
ANS: C Clients diagnosed with social phobia avoid interactions only in social settings, whereas clients diagnosed with SPD avoid interactions in all areas of life. Social phobia is an excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others.
How should a nurse best describe the major maladaptive client response to panic disorder? A. Clients overuse medical care due to physical symptoms. B. Clients use illegal drugs to ease symptoms. C. Clients perceive having no control over life situations. D. Clients develop compulsions to deal with anxiety.
ANS: C The major maladaptive client response to panic disorder is the perception of having no control over life situations which leads to nonparticipation in decision making and doubts regarding role performance.
A client is experiencing a severe panic attack. Which nursing intervention would meet this client's immediate need? A. Teach deep breathing relaxation exercises B. Place the client in a Trendelenburg position C. Stay with the client and offer reassurance of safety D. Administer the ordered prn buspirone (BuSpar)
ANS: C The nurse can meet this client's immediate need by staying with the client and offering reassurance of safety and security. The client may fear for his or her life and the presence of a trusted individual provides assurance of personal safety.
A client living on the beachfront seeks help with an extreme fear of crossing bridges which interferes with daily life. A psychiatric nurse practitioner decides to try systematic desensitization. Which explanation of this therapy should the nurse convey to the client? A. "Using your imagination, we will attempt to achieve a state of relaxation that you can replicate when faced with crossing a bridge." B. "Because anxiety and relaxation are mutually exclusive states, we can attempt to substitute a relaxation response for the anxiety response." C. "Through a series of increasingly anxiety-provoking steps, we will gradually increase your tolerance to anxiety." D. "In one intense session, you will be exposed to a maximum level of anxiety that you will learn to tolerate."
ANS: C The nurse should explain to the client that systematic desensitization exposes the client to a series of increasingly anxiety provoking steps that will gradually increase anxiety tolerance. Systematic desensitization was introduced by Joseph Wolpe in 1958 and is based on behavioral conditioning principles.
A client diagnosed with post-traumatic stress disorder is receiving paliperidone (Invega). Which symptoms should a nurse identify that warrant the need for this medication? A. Flat affect and anhedonia B. Persistent anorexia and 10 lb weight loss in 3 weeks C. Flashbacks of killing the enemy D. Distant and guarded relationships
ANS: C The nurse should identify that a client who has flashbacks of killing the enemy may need paliperidone (Invega). Paliperidone is an antipsychotic medication that can be used to treat the psychotic symptom of flashbacks.
Which treatment should a nurse identify as most appropriate for clients diagnosed with generalized anxiety disorder (GAD)? A. Long-term treatment with diazepam (Valium) B. Acute symptom control with citalopram (Celexa) C. Long-term treatment with buspirone (BuSpar) D. Acute symptom control with ziprasidone (Geodon)
ANS: C The nurse should identify that an appropriate treatment for clients diagnosed with GAD is long-term treatment with buspirone. Buspirone is an anxiolytic medication that is effective in 60% to 80% of clients with GAD. It takes 10 to 14 days for alleviation of symptoms but does not have the dependency concerns of other anxiolytics.
A nurse has been caring for a client diagnosed with post-traumatic stress disorder. What short-term, realistic, correctly written outcome should be included in this client's plan of care? A. The client will have no flashbacks. B. The client will be able to feel a full range of emotions by discharge. C. The client will not require zolpidem (Ambien) to obtain adequate sleep by discharge. D. The client will refrain from discussing the traumatic event.
ANS: C The nurse should include obtaining adequate sleep without zolpidem (Ambien) by discharge as a realistic outcome for this client. Having no flashbacks and experiencing a full range of emotions are long-term not short-term outcomes for this client. Clients are encouraged to discuss the traumatic event.
A college student is unable to take a final examination due to severe test anxiety. Instead of studying, the student relieves stress by attending a movie. Which priority nursing diagnosis should a campus nurse assign for this client? A. Noncompliance R/T test taking B. Ineffective role performance R/T helplessness C. Altered coping R/T anxiety D. Powerlessness R/T fear
ANS: C The priority nursing diagnosis for this client is altered coping R/T anxiety. The nurse should assist in implementing interventions that should improve the client's healthy coping skills and reduce anxiety.
A client diagnosed with generalized anxiety states, "I know the best thing for me to do now is to just forget my worries." How should the nurse evaluate this statement? A. The client is developing insight. B. The client's coping skills are improving. C. The client has a distorted perception of problem resolution. D. The client is meeting outcomes and moving toward discharge.
ANS: C This client has a distorted perception of how to deal with the problem of anxiety. Clients should be encouraged to openly deal with anxiety and recognize the triggers that precipitate anxiety responses.
A client is newly diagnosed with obsessive-compulsive disorder and spends 45 minutes folding clothes and rearranging them in drawers. Which nursing intervention would best address this client's problem? A. Distract the client with other activities whenever ritual behaviors begin. B. Report the behavior to the psychiatrist to obtain an order for medication dosage increase. C. Lock the room to discourage ritualistic behavior. D. Discuss the anxiety-provoking triggers that precipitate the ritualistic behaviors.
ANS: D The nurse should discuss with the client the anxiety-provoking triggers that precipitate the ritualistic behavior. If the client is going to be able to avoid the anxiety, he or she must first learn to recognize precipitating factors. Attempting to distract the client, seeking medication increase, and locking the client's room are not appropriate interventions because they do not help the client recognize anxiety triggers.
A client diagnosed with an obsessive-compulsive disorder spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify? A. Sublimation B. Dissociation C. Rationalization D. Intellectualization
ANS: D The nurse should identify that the client is using the defense mechanism of intellectualization when discussing the rituals of obsessive-compulsive disorder in detail while avoiding discussion of feelings. Intellectualization is an attempt to avoid expressing emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis.
How would a nurse differentiate a client diagnosed with panic disorder from a client diagnosed with generalized anxiety disorder (GAD)? A. GAD is acute in nature, and panic disorder is chronic. B. Chest pain is a common GAD symptom, whereas this symptom is absent in panic disorders. C. Hyperventilation is a common symptom in GAD and rare in panic disorder. D. Depersonalization is commonly seen in panic disorder and absent in GAD.
ANS: D The nurse should recognize that a client diagnosed with panic disorder experiences depersonalization, whereas a client diagnosed with GAD would not. Depersonalization refers to being detached from oneself when experiencing extreme anxiety.
A cab driver, stuck in traffic, suddenly is lightheaded, tremulous, diaphoretic, and experiences tachycardia and dyspnea. An extensive workup in an emergency department reveals no pathology. Which medical diagnosis is suspected, and what nursing diagnosis takes priority? A. Generalized anxiety disorder and a nursing diagnosis of fear B. Altered sensory perception and a nursing diagnosis of panic disorder C. Pain disorder and a nursing diagnosis of altered role performance D. Panic disorder and a nursing diagnosis of anxiety
ANS: D The nurse should suspect that the client has exhibited signs/symptoms of a panic disorder. The priority nursing diagnosis should be anxiety. Panic disorder is characterized by recurrent, sudden onset panic attacks in which the person feels intense fear, apprehension, or terror.
what is a common complication of multiple trauma
ARDS
What is the most common NRTI used?
AZT (zidovudine)
DIC S/S
Abnormal Clotting then lack of clotting due to used up clotting factor. bleeding GI, gums, hematuria
-area of increased lung density -increases or changes transmission -if heard always abnormal
Abnormal voice sound
What does AKA mean?
Above the knee amputation
Any pt who can't feed for >10-14 days
Absolute indications for TPN
What is the most common retinoid given to people with acne?
Accutane
-pain at IV site, up hr, chills, fever, anxiety, N, back pain, dyspnea -vascular collapse, hypotension, renal failure, massive systemic hemorrhage
Acute intravascular hemolytic reaction- early S&S: 8 later S&S: 4
ALL -age
Acute lymphocytic leukemia - before 14years
AML -age
Acute myelogenous leukemia - 60-70 years old
-always abnormal -all during inhalation/exhalation or both -superimposed on normal breath sounds -crackles, wheezes, rubs
Adventitious breath sounds
*Connect a 10mL syringe of NS to the access port *unclamp port *inject using spasmotic pressure *reclamp port and remove syringe Restart any infusions that you clamped off
After blood has been collected, what do you do?
Initial stage of Shock
Agitation Restlessness Increased HR Cool pale skin
pneumothorax hemothorax pleural effusion
Air in the pleural space: blood in the pleura space: Transudate or exudate in the pleural space is:
A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________.
Altered body image
Give 6 symptoms of HIV disease.
Anorexia, fatigue, weakness, night sweats, fever, diarrhea
What body system or hormone should you consider in cancer? in other words, what hormone does cancer secrete more of?
Antidiuretic hormone. Therefore, with cancer, SIADH is considered to be an issue
What class of drugs is the client with an aneurysm most likely to be on?
Antihypertensives
Fat may not have efficacy as energy source in catabolic pts Glucose is less costly
Arguments for use of glucose
1. assess clients need - a. gastric decompression b. enteral feeding 2. assess client's understanding of the procedure 3. assess medical history: nose bleeds, nasal surgery, deviated septum, ANTICOAGULANT therapy 4. assess for GAG REFLEX, PATENCY of NARES (hold each nostril and breath - which is best?), mental status NOTE: have emission basin and tissues within reach, water and straw
Assessment 1-4
Statin admin time
At night when peak production of cholesterol occurs
-collapse of lung tissue
Atelectasis
The clients right to self-determination and independence is guided by which ethical principle?
Autonomy -Autonomy involves the right of the client to make his or her own decisions. -Justice refers to fairness -Nonmaleficence is the requirment to do no harm to others either intentionally or unintentionally. -Benficence refers to one's duty to benefit or promote good for others
A pediatric nurse is preparing a child for cleft palate repair surgery. The nurse recognizes that this type of surgery is categorized as: A. Transplantation surgery B. Constructive surgery C. Palliative surgery D. Reconstructive surgery
B) Cleft palate repair considered constructive surgery because the goal is to restore function in congenital anomalies. Reconstructive surgery serves to restore function to traumatized or malfunctioning tissues and includes plastic surgery or skin grafting. Transplant surgery replaces organs or structures that are diseased or malfunctioning, such as a liver or kidney transplant. Palliative surgery is not a curative and seeks to relieve or reduce the intensity of an illness, such as debridement or necrotic tissue.
The operating room is aware that which of the following patients are at a greater risk related to a surgical procedure? A. 34 yr old female B. 83 yr old female C. 48 yr old male D. 8 yr old male
B)Infants and older adults are at greatest risk from surgery than are children and young or middle-aged adults. Physiologic changes associated with aging increase the surgical risk for older patients.
A patient returning to the floor after orthopedic surgery is complaining of nausea. The nurse is aware that an appropriate intervention is to: A. Hold all medications. B. Avoid strong smelling foods. C. Avoid oral hygiene until the nausea subsides. D. Provide clear liquids with a straw.
B)Nursing care for a patient with nausea includes avoiding strong smelling foods. Providing oral hygiene, administering prescribed medications (especially if medications ordered are anti-nausea/antiemetics), and avoid the use of a straw.
Which of the following may be left in place when a patient is sent to the operating room? A. Wig B. Hearing aid C. Engagement ring D. Well-fitting dentures
B. Hearing aid If a patient is wearing a hearing aid, the perioperative nurse should be notified. Leaving the hearing aid in place enhances communication in the operating room. The nurse should make certain to record that the appliance is in place. Wigs, engagement rings, and dentures are not necessary items to facilitate quality patient care in the operating room.
The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates: A. Hypocapnia B. Muscle rigidity C. Decreased body temperature D. Confusion upon arousal from anesthesia
B. Muscle rigidity Malignant hyperthermia is a metabolic disease characterized by hyperthermia with rigidity of skeletal muscles occurring secondary to exposure to certain anesthetic agents in susceptible patients. Hypoxemia, hypercarbia, and dysrhythmias may also be seen with this disorder.
If a 77-year-old patient who is NPO after surgery has dry oral mucous membranes, which of the following is the most appropriate nursing intervention? A. Increase oral fluid intake. B. Perform oral hygiene frequently. C. Swab the inside of the mouth with petroleum. D. Increase the rate of IV fluid administration.
B. Perform oral hygiene frequently. Frequent oral hygiene will help alleviate discomfort for a patient who is NPO. IV fluid rate is prescribed by the physician. Petroleum is always inappropriate intraorally. Oral fluid intake is contraindicated in a patient who is NPO.
Which of the following preoperative assessment findings should be reported to a surgeon for preoperative treatment? A. Serum sodium level of 140 mEq/L B. Serum potassium level of 3 mEq/L C. Hb concentration of 13.5 mg/dl D. Partial thromboplastin time of 25 seconds
B. Serum potassium level of 3 mEq/L. Electrolyte imbalances increase operative risk. Preoperative laboratory results should be checked to see whether they are within the normal range. The normal potassium level is 3.5 to 5.0 mEq/L. A low serum potassium level puts the patient at risk for cardiac dysrhythmias. A serum sodium level of 140 mEq/L is considered a normal value. An Hb concentration of 13.5 mg/dl is considered a normal value by most laboratory standards and does not interfere with operative decisions. A partial thromboplastin time of 25 seconds is a normal value and conducive to proceeding with a surgical procedure.
Which of the following is most likely to be effective in meeting a patient's teaching/learning needs preoperatively? A. Teaching only the patient B. Teaching the patient and family C. Using brief verbal instructions D. Using only written instructions
B. Teaching the patient and family. A nurse should determine learning needs preoperatively and teach both the patient and the family before surgery. Using only written instructions does not provide the opportunity for evaluation for learning. Brief verbal instructions are often forgotten. Teaching only the patient limits learning preoperatively because the patient can be anxious and not receptive to new information.
A patient has the following preoperative medication order: morphine 10 mg with atropine 0.4 mg IM. The nurse informs the patient that this injection will A. decrease nausea and vomiting during and after surgery. B. decrease oral and respiratory secretions, thereby drying the mouth. C. decrease anxiety and produce amnesia of the preoperative period. D. induce sleep, so the patient will not be aware during transport to the operating room.
B. decrease oral and respiratory secretions, thereby drying the mouth. Atropine, an anticholinergic medication, is frequently used preoperatively to decrease oral and respiratory secretions during surgery, and the addition of morphine will help to relieve discomfort during the preoperative procedures. Antiemetics decrease nausea and vomiting during and after surgery, and scopolamine and some benzodiazepines induce amnesia. An actual sleep state is rarely induced by preoperative medications unless an anesthetic agent is administered before the patient is transported to the operating room.
Conscious sedation is being considered for a patient undergoing a cervical dilation and endometrial biopsy in the health care provider's office. The patient asks the nurse, "What is this conscious sedation?" The nurse's response is based on the knowledge that conscious sedation A. can be administered only by anesthesiologists or nurse anesthetists. B. enables the patient to respond to commands and accept painful procedures. C. is so safe that it can be administered by nurses with direction from health care providers. D. should never be used outside of the OR because of the risk of serious complications.
B. enables the patient to respond to commands and accept painful procedures. Conscious sedation is a moderate sedation that allows the patient to manage his or her own airway and respond to commands, and yet the patient can emotionally and physically accept painful procedures. Drugs are used to provide analgesia, relieve anxiety and/or provide amnesia. It can be administered by personnel other than anesthesiologists, but nurses should be specially trained in the techniques of conscious sedation to carry out this procedure because of the high risk of complications resulting in clinical emergencies.
Touching a client without consent is an example of which of the following?
Battery -Battery involves harmful or unwanted contact with the client. -Assault involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority -False imprisonment is defined as the unjustified detention of a client, such as inappropriate use if restraint or seclusion. -Causation occurs when a breach of duty was the direct cause of loss, damage, or injury.
What is the most important intervention in treating AGN?
Bedrest - they can walk if hematuria, edema and hypertension are gone.
What activity order is the client with an aneurysm supposed to have?
Bedrest. do not get these people up
-belly predominantly using diaphragm -belly is more efficient
Belly VS chest breathing
What does BKA mean?
Below the knee amputation
What are comedones?
Blackheads and white heads
Venous Disorders
Bluish purple skin discoloration Normal peripheral pulses Warm to touch Monitor for hx of DVT Slightly painful ulcers /w marked edema
The pulse rate of anorexics is tachycardic or bradycardic?
Bradycardic
when discussing a clients mental health condition with someone other than the health care team, the nurse must be aware of which of the following? -assault -breach of confidentiality -neglect -battery
Breach of confidentiality -the protection and privacy of personal health information is regulated by the federal government through the HIPPA.
-bradypnea (slow) -tachypnea (fast) -apnea (stop)
Breathing rate abnormalities
-aka tracheal -loud, harsh, high pitched -heard over trachea, large bronchi -turbulent airflow -only place you should hear bronchial sounds are to right and left of sternum -velocity greatest, loudest, harshest
Bronchial
Beta 2
Bronchodilation Vasodilation
-say "99" -clinician auscultates all lung fields -normal = muffled -abnormal = 99 heard clearly -denser medium
Bronchophony
Dehiscence
Bursting open of a wound, especially a surgical abdominal wound
nonbenzo anxiolytic
Buspirone no abuse potential
what are examples of antineoplastic meds?
Busulfan (Myleran) Chlorambucil (Leukran) Cisplatin platinol -AQ cyclophosphamide (cytotoxan)
How can AGN be prevented?
By having all sore throats cultured for strep and treating any strep infections
The PACU has received a semiconscious patient from the operating room and reviews the chart for orders related to positioning of the patient. There are no specific orders on the chart related to specific orders for the patient's position. In this situation, in what position will the nurse place the patient? A. Trendelenburg position B. Prone position C. Side-lying position D. Supine position
C) If the patient is not fully conscious, place the patient in the side-lying position, unless there is an ordered position on the patient's chart.
The nurse is preparing a patient for a colonoscopy. The nurse is familiar with the colonoscopy procedures at the hospital and is aware that which type of anesthesia os commonly used for his procedure? A. Spinal anesthesia B. Nerve block C. Conscious sedation D. Epidural anesthesia
C) Moderate sedation/analgesia is also known as conscious sedation or procedural sedation and is used for short-term and minimally invasive procedures such as a colonoscopy.
Which statement should be stressed while giving instructions after adrenalectomy? A. Stop taking medication when pts physical appearance improves. B. Pt should take steroids on an empty stomach. C. Pt should take the prescribed medication as directed.
C. The pt should take prescribed medication as directed. Sudden withdrawl of steroids can precipitate adrenal crisis.
Which statement about diabetes mellitus is false? A. Type 2 diabetes commonly occurs in adults <40 yr. old. B. Type 1 diabetes usually occurs before age 30. C. Type 1 diabetes is treatable with exercise, meal planning, and antidiabetic drugs. D. An increasing number of adolescents are being diagnosed with type 2 diabetes.
C. Type 1 diabetes is treated with insulin and dietary management.
Patients may experience which problem 24-48 hrs post-op as a result of anesthetics? A. colitis B. Stomatitis C. Paralytic ileus D. Gastrocolic reflux
C. After surgery, pts are clients are at risk for paralytic ileus as a result of anesthesia.
Before admitting a patient to the operating room, the nurse recognizes that which of the following must be attached to the chart of all patients? A. A functional status evaluation B. Renal and liver function tests C. A physical examination report D. An electrocardiogram
C. A physical examination report. It is essential to have a physical examination report attached to the chart of a patient going for surgery. This document explains in detail the overall status of the patient for the surgeon and other members of the surgical team.
What would be the most effective way for a nurse to validate "informed consent"? A. Ask the family whether the patient understands the procedure. B. Check the chart for a completed and signed consent form. C. Ask the patient what he or she understands regarding the procedure. D. Determine from the physician what was discussed with the patient.
C. Ask the patient what he or she understands regarding the procedure. Informed consent in the health care setting is a process whereby a patient is informed of the risks, benefits, and alternatives of a certain procedure, and then gives consent for it to be done. The piece of paper is simply evidence that the informed consent process has been done.
As the nurse is preparing a patient for surgery, the patient refuses to remove a wedding ring. Which of the following is the most appropriate action by the nurse? A. Note the presence of the ring in the nurse's notes of the chart. B. Insist the patient remove the ring. C. Explain that the hospital will not be responsible for the ring. D. Tape the ring securely to the finger.
C. Explain that the hospital will not be responsible for the ring. It is customary policy to tape a patient's wedding band to the finger and make a notation on the preoperative checklist that the ring is taped in place.
Which of the following should be included in the plan of care for a patient who had spinal anesthesia? A. Elevating the head of the bed to decrease nausea B. Elevating the patient's feet to increase blood pressure C. Instructing the patient to remain flat in bed for 6 hours D. Administering oxygen to reduce hypoxia produced by spinal anesthesia
C. Instructing the patient to remain flat in bed for 6 hours. In addition to interventions designed to replace fluids and indirectly replace lost spinal fluid after administration of spinal anesthesia, the patient is instructed to lie flat for 6 to 8 hours. Elevating the head of the bed after spinal anesthesia can precipitate "spinal headache" or nausea related to losses of cerebrospinal fluid or changes in ICP. Elevating the patient's feet or administering oxygen are not necessary interventions unless the patient becomes hypotensive or hypoxic.
Five minutes after receiving a preoperative sedative medication by IV injection, a patient asks the nurse to get up to go to the bathroom to urinate. Which of the following is the most appropriate action for the nurse to take? A.) Assist patient to bathroom and stay next to door to assist patient back to bed when done. B. Allow patient to go to the bathroom since the onset of the medication will be more than 5 minutes. C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. D. Ask patient to hold the urine for a short period of time since a urinary catheter will be placed in the operating room.
C. Offer the patient to use the urinal/bedpan after explaining the need to maintain safety. The prime issue after administration of either sedative or opioid analgesic medications is safety. Because the medications affect the central nervous system, the patient is at risk for falls and should not be allowed out of bed, even with assistance.
Which of the following is most appropriate after administration of preoperative medications? A. Confirming that the patient has voided B. Monitoring vital signs every 15 minutes C. Placing the patient in bed with the rails up D. Transporting the patient immediately to the operating room
C. Placing the patient in bed with the rails up. After administration of preoperative medications, a nurse should instruct a patient not to get up without assistance because medications can cause drowsiness or dizziness. Confirming that the patient has recently voided should be done before preoperative medications are administered. Monitoring vital signs every 15 minutes is not a necessary intervention unless prescribed by the physician. Transporting the patient immediately to the operating room is not necessary unless the patient is called for.
While performing preoperative teaching, the patient asks when she needs to stop drinking water before the surgery. Based on the most recent practice guidelines established by the American Society of Anesthesiologists, the nurse tells the patient that: A. She must be NPO after breakfast. B. She needs to be NPO after midnight. C. She can drink clear liquids up to 2 hours before surgery. D. She can drink clear liquids up until she is taken to the OR.
C. She can drink clear liquids up to 2 hours before surgery. Practice guidelines for preoperative fasting state the minimum fasting period for clear liquids is 2 hours. Evidenced-based practice no longer supports the long-standing practice of requiring patients to be NPO after midnight.
In the absence of postoperative vomiting, GI suctioning, and wound drainage, the physiologic responses to the stress of surgery are most likely to cause A. diuresis. B. hyperkalemia. C. fluid overload. D. impaired blood coagulation.
C. fluid overload. Secretion and release of aldosterone and cortisol from the adrenal gland and ADH from the posterior pituitary as a result of the stress response cause fluid retention during the first 2 to 5 days postoperatively, and fluid overload is possible during this time. Aldosterone causes renal potassium loss with possible hypokalemia, and blood coagulation is enhanced by cortisol.
Which test is the best indicator of the progress of HIV disease?
CD4 count
Fluid Volume Excess causes
CHF, renal failure, cirrhosis, over-hydration
what lab levels do you need to monitor when admin. foscarnet to a person
CR and BUn foscarnet is nephrotoxic also causes decrease in ca++ , mg+ phosphorous
what is the gold standard for visualizing the size of the pancreas and identifying collections of fluids , abscesses, masses, and areas of hemorrhage or necrosis
CT scan
Interactions with Theophylline
Caffeine increases CNS effects of theophylline phenobarbital and phenytoin decrease levels of theophylline Cimetedine, Ciproflaxin, and floroquinolones increase theopylline levels
Thrombophlebitis
Calf pain, Positive Homans sign Edema in calf
What type of oral/esophageal infections do AIDS patients get?
Candida
Troponin
Cardiac enzyme which elevates within 3 hrs and will still be elevated for 7 days (Test for MI)
Name the 5 criteria that are recorded on an apgar scale
Cardiac status, respiratory effort, muscle tone, neuromuscular irritability, and color
Colorectal Cancer S/S
Change in bowel habits Ribbon-like stool
Chvostek sign
Cheek twitching
The post op thoracic aneurysm is most likely to have which type of tube?
Chest tube, because the chest was opened
CLL -age
Chronic lymphocytic leukemia - 50-70 years old
CML -age
Chronic myelogenous leukemia - 20-60 years old
Chronic Bronchitis
Chronic sputum with cough production on a daily basis for a minimum of 3 months/year
Hemovac
Closed wound drainage system connected to a suction often used for mastectomy and total knee/hip replacement.
Jackson-Pratt
Closed wound suction drainage system often used for neurosurgery, neck surgery, abdominal surgery and urologic problems
Secondary Intention
Commonly used in the management of contaminated or infected wounds. The wound is allowed to granulate Surgeon may pack the wound with a gauze or use a drainage system (Stage 3 Pressure Ulcer)
infection, pneumothorax, hemothorax, hematoma, embolism, perforation of the vein, air embolus, nerve inj, hyperglycemia, hypoglycemia, excess energy.
Complications for TPN
-deep inhalation -momentary hold -explosive exhalation
Components of normal cough
All nutrients, 3-15% cyrstalline AAs, <70% dextrose, and 10-20%
Composition of solution
Compensatory stage of Shock
Confusion Decreased urinary output BP systolic < 100
why are Congentin and Thorazine given together?
Congentin is given to treat some of the side effects of Thorazine (such as parkinsonism) Hurst
expense and possible risk of complications
Cons of TPN
ACE Inhibitor SE -1 specific
Cough, renal dysfxn, hyperkalemia, angioedema
-aka rales -sounds like bubbles, hair rolled or velcro -made by secretions moving airways -rapid opening of small airways -pneumonia, CHF, early atelectasis
Crackles
Chronic Bronchitis Auscultation
Crackles Rhonchi Expiratory Wheezes
Upon admission for an appendectomy, the patient provides the nurse with a document that specifies instructions his healthcare team should follow in the event he is unable to communicate these wishes postoperatively. This document is best known as: A. An informed consent B. An insurance card C. A Patient's Bill of Rights D. An advance directive
D) An advance directive, a legal document, allows the patient to specify instructions for his or her healthcare treatment should he or she be unable to communicate these wishes postoperatively. The advance directive allows the patient to discuss his or her wishes with the family members in advance of the surgery. Two common forms of advance directives include living wills and durable powers of attorney for healthcare.
A nurse is assessing a pt with a closed chest tube drainage system connected to suction. Which finding would require additional evaluation in the post-operative period? A. 75ml of bright red drainage in the system. B. A column of water 20cm high in the suction control chamber. C. Constant bubbling in the water seal chamber.
D. Constant bubbling in the water seal chamber is indicative of an air leak. The nurse should assess the entire system to the pt to find the sourse of he leak. The leak may be with in the pts chest or at the insertion site. If it is, notify physician. This could cause the lung to collapse due to a buildup of air pressure within the plural cavity.
An adrenal crisis is characterized by all of the signs and symptoms except: A. weakness and fatigue B. nausea & vomiting C. hypotension D. sodium & fluid retention
D. Sodium and fluid retention are characteristics of Cushing's Syndrome. Adrenal crisis causes decreased sodium levels and hypotension.
While a nurse is caring for a patient who is scheduled to have surgery in 2 hours, the patient states, "My doctor was here and told me a lot of stuff I didn't understand and then I signed a paper for her." To fulfill the role of advocate, what is the best nursing action? A. Reassure the patient that the surgery will go as planned. B. Explain the surgery and possible outcomes to the patient. C. Complete her first priority, the preoperative teaching plan. D. Call the physician to return and clarify information for the patient.
D. Call the physician to return and clarify information for the patient. Examples of nursing advocacy include questioning doctors' orders, promoting patient comfort, and supporting patient decisions regarding health care choices.
A nurse has requested and gotten permission to observe a surgical procedure of interest in the hospital in which the nurse is employed. While the patient is being draped, the nurse notices that a break in sterile technique occurs. Which of the following actions on the nurse's part is most appropriate? A. Tell the surgeon before an incision is made. B. Tell the circulating nurse at the end of the surgery. C. Say nothing because someone else is likely to notice also. D. Point out the observation immediately to the personnel involved.
D. Point out the observation immediately to the personnel involved. Any break in sterile technique in the operating room should be immediately pointed out and remedied.
A physician is performing a sterile procedure at a patient's bedside. Near the end of the procedure, the nurse thinks that the physician has contaminated a sterile glove and the sterile field. The nurse should A. report the physician for violating surgical asepsis and endangering the patient. B. not say anything, because the nurse is not sure that the gloves and field were contaminated. C. ask the physician whether the contaminated glove and the sterile field have been contaminated. D. point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field.
D. point out the possible break in surgical asepsis and provide another set of sterile gloves and fresh sterile field. It is the responsibility of the nurse to point out any possible break in surgical asepsis when others are unaware that they have contaminated the field. Reporting the physician is not indicated, nor does it protect the patient. Asking the physician may lead to infection if the physician is unaware of the break in technique that the nurse believes may have happened. Saying nothing does not protect the patient and is negligence on the part of the nurse.
To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, the nurse A. encourages deep breathing. B. elevates the head of the bed. C. administers oxygen per mask. D. positions the patient in a side-lying position.
D. positions the patient in a side-lying position. An unconscious or semiconscious patient should be placed in a lateral position to protect the airway from obstruction by the tongue. Deep breathing and elevation of the head of the bed are implemented to facilitate gas exchange when the patient is responsive. Oxygen administration is often used, but the patient must first have a patent airway.
pt has had TSS and now exhibits petechiae, oozing from puncture sites, and coolness of digits of the hands and feet.. and prolonged clotting times.. what do you think is going on
DIC
what is a complication of TSS
DIC
ASSESSMENT: check prescribing order assess client for allergies determine pt. understanding
DRESSING CHANGE step 1:
How do you assess fluid excess in the child with AGN?
Daily weight
Niacin effect
Decrease triglyceride, total cholesterol, LDL. Increase HDL cholesterol level
FVE Labs
Decreased BUN, Hgb, Hct
What lab findings are present in AIDS?
Decreased RBC's, WBC's and platelets
What causes angina pectoris?
Decreased blood supply to myocardium, resulting in ischemia and pain
Death and Grief
Denial Anger Bargaining Depression Acceptance
-hypoventilation = shallow -hyperventilation = deep
Depth
Emphysema Auscultation
Distant breath sounds Quiet breath sounds Wheezes
HTN Medications
Diuretics Antihypertensives ACE inhibitors Calcium Cannel Blockers
FVE Tx
Diuretics Fluid restriction Daily weights Monitor K+
Assemble sterile gloves and dressing change box take sterile supplies out of box don mask have pt. turn head away *wash hands and don gloves *remove bandage (do not touch insertion site!) *remove gloves *wash hands
Dressing change step 2?
*don sterile gloves *open supplies completely
Dressing change step 3?
*clean central line site *swabs then chlorahex. site and last the line *LET DRY *apply dressing label with DATE, TIME, Initials
Dressing change step 4?
Drug Use in Pre-Op setting: Benzodiazepines and barbiturates
Drug used in pre-op setting for sedation and amnesia
Drug Use in Pre-Op setting: Opioids
Drug used in pre-op setting to decrease intraoperative anesthetic requirements and pain.
Drug Use in Pre-Op setting: Anticholinergics
Drug used in pre-op setting to reduce secretions.
Vesicants
Drugs capable of causing pain, inflammation and blistering of skin, underlying flesh and structures leading to tissue death & necrosis
-difficulty breathing -excessive effort -SOB
Dyspnea
What is the first test for HIV antibodies?
ELISA
pt who had a tonsillectomy had an episode of coffee-ground emesis. expected or unexpected
EXPECTED
Right-sided Heart Failure effects
Edema JVD (jugular vein distention) Dyspnea on exertion
"If I had to do it over again, I'd life my life just about the same," is an example of ____ ____________
Ego Integrity
What is the developmental task for later adulthood?
Ego Integrity vs. Despair
-say "E" -clinician auscultates all lung fields -normal = 'e' heard as 'e' -abnormal = 'e' sounds like 'a'
Egophony
Septic Shock
Endotoxins released from bacteria Massive vasodilation and pooling
Intimacy vs. Isolation
Erikson's stage in which individuals form deeply personal relationships, marry, begin families
Generativity vs. Stagnation
Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service
1. Monitor client for signs and symptoms of tube displacement or poor tolerance such as coughing or gagging or respiratory distress. 2. Monitor daily weights, serum glucose, serum electrolytes, albumin and intake/output of clients receiving enteral feedings or gastric decompression to assess hydration, electrolytes and or nutritional status. 3. Monitor bowel sounds and abdominal distention to assess integrity of GI function.
Evaluation 1-3
decreased immune fx, hepatic, renal, caridac, pulmonary and neurologic problems
Excessive fat (more than 2g/kg/d) can cause this
T/F is bowel prepration necessary prior to bronchoscopy
FALSE
T/F hematuria is a sign of acute renal failure
FALSE hematuria is not associated with renal failure but it is associated with UTI and TRAUMA
T/F a preservative is used in the container for 24 hr urine sample
FALSE save all the urine in a container with no preservatives refrigerate or keep on ice
Vasogenic Shock
Failure of arteriolar resistance Massive vasodilation and pooling of blood
Everyone with angina needs bypass surgery? t/f
False
T/F answering the phone while giving a bed bath to a client is alright
False considered contamination and you will need to get new ones
T/F it is beneficial to massage lotion on the abdomen of a 3 year old with wilms tumor
False manipulation of the mass may cause dissemination of cancer cells
chills, temp (30 min to 6 hrs post transfusion) stop transfusion, admin antipyretic, follow Dr. (may infuse slower), ck VS q.4 hrs.
Febrile non-hemolytic transfusion reaction S&S: interventions: 4
Endocarditis S/S
Fever, weigh loss, joint pain, changing heart murmur, splenomegaly, petechiae, clubbing, CHF signs
ASSESSMENT: ck prescribing order for labs explain to pt. what you will be doing assess patency of central line
First steps to Blood draws?
What is the #1 contracture problem after BKA?
Flexion of the knee
30 min.
From the time blood is issued from the blood bank, you have ____ to begin the infusion:
Hyperglycemia S/S
Fruity odor, headache, N/V, abd. pain, Rapid Pulse
Toxic signs of Theophylline
GI distress(nausea, vomiting, diarrhea), restless, dysrythmia, seizures, confusion, headache, flushing, tachycardia,
absorption
GI, respiratory, skin
what are 6 conditions for a patient to recieve TPN
GI, trauma, burn, malnutrtion, cancer, AIDS
-many pulm pts either cachetic (skinny) or obese -related to BMI
General body build of pulmonary pt
What is the developmental task for middle adulthood?
Generativity vs. stagnation.
If an aneurysm ruptures what is the #1 priority?
Get them to the operating room ASAP
Parenteral Iron
Given via Z-Track to reduce leak/stain
What organism causes acute glomerular nephritis?
Group A beta hemolytic strep
purpose of Rantidine (zantac) for ulcer
H2 receptor antagonist that decreased gastric acid production
what do you have to give baby and when after being born to mom with hep B?
HBIG and hep B vaccine within 12 hours
What virus causes AIDS?
HIV - Human immunodeficiency virus
Gardasil/Cervarix
HPV vaccine 3 shots over 6 months
pt is taking epoetin alfa (Procrit) and experiences an increase in blood pressure what is this an indicator of
HTN seizures can result from the rapid rise in hematocrit
with meningitis, which organisms are potentially responsible
Haemophilus influenzae type b and Neisseria meningitidis
-hemorrhage -abscess or tumor
Hemoptysis
Statin SE
Hepatotoxicity- Monitor liver function (AST, ALT) Avoid Alcohol Myopathy
What are the 3 causative factors in acne vulgaris?
Heredity, Bacterial, Hormonal
Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa?
Highter
Name the 5 risk groups for AIDS
Homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women
*ck for blood return AND flush it with NS.
How do you assess patency of the central line?
*Single lumen - the port closest to the insertion site *multi-lumen- select the distal port (brown)
How do you choose the Safest Access for a central line blood draw or flush?
24 hours coagulatin factors deteriorate after 24 hours
How much time do you have to infuse whole blood after collection: Why:
*EVERY SHIFT
How often do you assess patency of the central line?
24hrs due to bacteria growth potential
How often do you change TPN tubes and bags?
7 days
How often is a central line dressing change done?
what diagnostic level is used to diagnose testicular cancer
Human chorionic gonadotropin
symptoms of early withdrawal from alcohol
Hyper-alert, startles easily, and anorexia, increased pulse, anxiety, tremors, insomnia, hallucinations
Will the client have hypo or hyper tension with AGN? Why?
Hypertension, because of fluid retention
Types of Shock
Hypovolemic Cardiogenic Vasogenic Septic
besides vitals what other signs should be noted during TPN
I and O
1. Explain procedure to client and explain what pt. needs to do do help. (mouth breath and swallow - have a glass of water and straw) 2. Lubricate the first 2-3 inches of NG tube (we use spray, normally dip into water or water soluble lubricant. **3. Hold hand behind head and have pt. bring chin to chest. Insert the NB tube into the most open nare to the back of the throat. GAG reflex will occur **4. Instruct pt to flex head toward the chest as NG tube passes through the nasopharynx. Slight rotation of the tube between the fingers may facilitate movement as the NG tube turns downward at the nasopharynx. **5. When tip of NG tube is past the flexion of the nasopharynx, instruct the client to swallow repeatedly. Advance tube each time the client swallows. Allow client to sip small amounts of water to facilitate swallowing.
IMPLEMENTATION 1-5
**6. Advance the tube until the marked postion has been reached. If a small bore tube advance a few centimeters more. 7. If client develops respirator distress, coughing, tube is coiled in throat, etc... withdraw tube and reattempt. **8. Check placement of tube through two or more methods 9. Secure NG tube to nose while avoiding pressure on the nares. May loop and secure to gown also. 10. Prior to instillation of any enteral feeding formula, aspirate gastric contents to determine whether gastric empyting is occurring at a reasonable rate.
IMPLEMENTATION 6-10
peripheral neuropathy is a common side effect of
INH: administer pyridoxine
Coumadin Therapy Test
INR PT
Pain Medication Assessments -what changes
IV admin = 15 min Peds = 30 min Oral = 1 hr
Predigested
IV feedings include this form of nutrients
how do you treat peritonitis
IV fluids administer broad-spectrum antibiotics surgical intervenion pain management postop
pt has acute angle glaucoma.. what med is given to decrease intraocular presssure
IV mannitol (Osmitrol) 25%
person is diagnosed with angle closure glaucoma what do you give them to decrease the pressure
IV osmotic diuretics
ELISA
If Positive = Retest If second Positive = Western Blot
-indicates area of consolidation (lung tissue density) more fluid
If bronchial sounds heard in abnormal area?
-blockage, obstruction, hypoventilation -decreased means partial blockage -absent means obstruction
If decreased or absent sound?
When do you need a gown with AIDS?
If you are going to get contaminated with secretions
500 Units 5mL x 100U/1mL = 5x100 = 500 Units
If you have a 10mL syringe with 5mL of Heparin in it, and you have 100units/mL, how many units of Heparin are you infusing?
FVD causes
Inadequate fluid intake Hemorrhage Vomiting Diarrhea Massive edema
FVD Labs
Increased BUN, Creatinine, Hgb, Hct
Hypermetabolism- burns, sepsis, major surgery, trauma, anorexia- cancer, chemotherapy, radiation therapy. Pre or post op if malnourished.
Indications for TPN
Nosocomial
Infections that originate in hospitals
Stages of Shock
Initial Compensatory Progressive Irreversible
Respiratory assessment order
Inspection Palpation Percussion Auscultation
-monitoring -LOC, mental/cognitive status -general body build -skin integrity, coloration, temp -signs of distress
Inspection: components
Left-sided Heart Failure effects
Inspiratory rales beginining at lung bases Expiratory Wheezes (mis-DX as Asthma) Dyspnea Cough
Malpractice must be proven by four elements. All of the following must be proven except? A. Duty B. Causation C.Injury D. Intent
Intent Malpractice must be proven by duty, breach of duty, injury or damage, and causation
-perform a physical assessment (breath sounds, itching, pain, chg in mental status, anxiety, SOB) -notify Dr of chg in status -conitnue to monitor chg in cardiac, resp or uinary status -notify blood bank (may need to send back w/tubing)
Intervention for suspected reaction: 4
early recognition, stop infusion, support bp and renal circulation, Notify Dr, collect urine and blood samples, ck VS q.15 min, observe for - signs of bleeding, hourly urinary output, interventions if shock
Interventions for acute intravascular hemolytic reaction: 9
-obtain blood and urine samples ASAP -Advise pt- always inform heatlhcare providers of your previous reaction
Interventions of hemolytic and allergic reactions:
What is the developmental task for early adulthood?
Intimacy vs. Isolation
Infants and Food
Introduce one food at a time to discover any allergies Progress as Tolerated
All but which of the following states have abolished the insantiy defense? A. Utah B. Montana C. Idaho D. Iowa
Iowa -Iowa has not abolished the insanity defense. Idaho, Montana, and Utah have abolished this defense
What happens to the kidney in AGN?
It becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function.
uterine contractions are not affected by multiple sclerosis
JUST know it!
What is the #1 cancer that AIDS patients get?
Kaposi's sarcoma
what are weak peripheral pulses a sign of in terms of HF
LHF decreased cardiac output resulting from left side heart failure
-may be decreased with hypoxemia or hypercapnia (too much CO2) -confusion can have other non-pulmonary causes as well
LOC and orientation
Dispose of all containers, sharps, syringes Monitor client for adverse reactions Monitor glucose, VS, weight, lung sounds DOCUMENT administration and client reaction
Last step in TPN:
dispose of used supplies DOCUMENT dressing change, site appearance, client responses
Last step of dressing change is?
What is the name for an elevated WBC?
Leukocytosis
reduces
Lipids in solutions have this effect on osmolaltiy
Tuberculosis S/S
Low-Grade fever Nigh Sweats Anorexia Wt. loss
Oral PO4 used for
Lowering Serum Ca++ levels
COPD Warning
Lowest O2 to prevent CO2 retention (Respiratory now based on O2 levels)
#1 Cancer in the US
Lung Cancer
What types of chemicals cause burns to oral mucosa when ingested?
Lye, caustic cleaners
What will prevent hip flexion contracture after AKA?
Lying prone several times a day
tyramine should be avoided with use of __ because it can cause __
MAOI, can cause hypertensive crisis
when taking atomoxetine, what other med class is contrainidicated
MAOIs
3
Max fluids in L/d
4 hrs.
Maximum time for infusion once bag is spiked:
Angina presentation in Females
May radiate to either arm, shoulder, jaw, neck or epigastric area (heartburn)
What is the name of the RLQ abd pain where appendicitis pain finally localizes?
McBirney's point
how do you measure client for use of crutches
Measuring the client from 3-finger widths below the axilla to 6 inches lateral to the client's heel correctly measures a client for crutches Hurst
it is important that if patient is to undergo procedure with iodine containing contrast, which medication is held and why?
Metformin (glucophage) -->can cause renal failure
What is the most common dietary restriction for AGN?
Moderate sodium restriction. Fluid restriction is #2 if edema is severe.
Hypovolemic shock
Most Common r/t internal or external blood/fluid loss (Post-op, OB)
Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________.
Multi, 35 (HTN, trauma, cocaine)
MODS
Multiorgan dysfunction syndrome; functional abnormalities in one or more vital organ system in patients with SIRS; once occurs mortality is greater than 50%
What follows the RUQ abd pain of appendicitis?
N/V
early signs of lithium toxicity LOOK UP ALL SIGNS OF LITHIUM TOXICITY
N/V slurred speech muscle weakness
what are signs of disequilibrium syndrome?
N/V, changes in LOC, seizures, agitation
symptoms of barbiturate withdrawal
N/V, tachycardia, course tremors, seizures
The post op abdominal aneurysm repair client is most likely to have which type of tube?
NG tube for decompression of bowel
Dietary indiscretions and uncleanliness are causes of acne?
NO
are you allowed to wear any jewelry or watches underneath your scrubs in the OR
NO jewelry can harbor bacteria
pt is taking tobramycin sulfate and he wants to take Ibuprofen or another NSAID what do you say
NO, it will cause nephrotoxicity
piggyback a secondary tubing into the TPN administration line, below the filter (NOTE: many docs prescribe combined TPN/fat emulsion in same container)
NOTE if Fat Emulsion is to be administered concurrently from a separate container, do what?
nursing care for pt with pancreatitis
NPO gastric decompression maintain fluid/ electrolyte balance monitor for infection cough and deep breathe semi fowlers monitor for shock and hyperglycemia TPN
With electroconvulsive therapy, general anesthesia is given, so pt should be
NPO after midnight
Which 2 classes of drugs are given in combination for HIV sero-positivity?
NRTI's (nucleoside reverse transcriptease inhibitors) and PI's (protease inhibitors)
Indomethacin (Indocin) is in which class of meds?
NSAID
what are examples of nephrotoxic drugs that will be detrimental to a person in acute renal failure
NSAIDS some antibiotics - gentamycin, vancomycin radiologic contrast to media, heavy metals, consult HCP before OTC drugs
a person with a flare up for SLE is on what meds for what part of the condition
NSAIDs and acetylsalicyclic acid are used to control joint pain hydroxychloroquine (Plaquenil) is used for dermatologic symptoms glucocorticoids suppress disease activity immunosuppressive agent may module immune response
What is the Chem-7?
Na | Cl | BUN | K | HCO2 | Cr |
What drug treates angina pectoris?
Nitroglycerine
pt is not tolerating it well
No bowel sounds and lots of residual means
V-fib
No cardiac output Start CPR
pt who has alcoholic heptatitis and wants to take simvistation to lower cholesterol.. what do you say
No, its contraindicated
Non-Hodgkin Lymphoma
Non-painful enargement MRI/CT
-improper shipping or storage temp or warming in a microwave overn ow w/ hot-water baths -acute intravascular hemolytic reaction
Nonimmune-mediated hemolysis causes: S&S similar to:
Which ethical principle is at risk when the client presents an imminent threat of danger to himself or others?
Nonmaleficence -Nonmaleficence is the requirement to do no harm to others either intentionally or unintentionally. -Beneficence refers to one's duty to benefit or promote good for others. -Autonomy involves the right of the client to make his or her own decisions. -Justice refers to fairness
Hypertention Stages
Normal PreHTN Stage 1 Stage 2
-where they're expected to be heard -symmetrical from side to side -can be diminished in presence of thickened chest wall, large amt of soft tissue, hypoventilation or cheap stethoscope
Normal breath sounds
-location -pitch and intensity -ration of inspiration to expiration -2 types: bronchial and vesicular
Normal breath sounds classified by?
-words soft, muffled incoherent
Normal voice sound
-does not matter -no difference in O2 content -in thru nose, out thru mouth slows rate and increases depth
Nose VS mouth
When do you need a mask with AIDS?
Not usually unless they have an infection caused by an airborne bug
Is dietary protein limited in AGN?
Not usually, however if there is severe azotemia then it may be restricted
-no standard protocol for edema assessment -several ways to assess, describe -clubbing fingers = advanced PVD -mild, mod or severe good descriptors
Note presence of peripheral edema
Potassium
Nutrient lost when muscle is catabolized
unsafe working conditions need to be reported to
OSHA occupational safety health act
0.9% NaCl
Only solution that can be infused w/blood:
Beta Blockers SE -1 specific
Orthostatic Hypotention bronchiospasms, drowsiness
What is the causative organism of acne?
P. acnes (propionibacterium acnes)
Peripheral insertion of a central line into a central vein by threading.
PICC line
peripherally inserted central catheter aka this, used in basilic or cephalic vein when TPN is needed for more than 4 weeks
PICC line
1. select appropriate type and size of nasogastric tube to suit client and intended therapy. (Salem sump, Levine tube, Small bore feeding tube) **2. Measure from tip of clients nose to earlobe to xiphoid process (IN THAT ORDER) to determine minimal tubing length to be introduced and mark the tubing. 3. prepare bedside suction apparatus for use in gastric decompression OR for emergency use during NG intubation. 4. position client in high-Fowler's position, towel over chest/upper abdomen. Pull screen for privacy. 5. Wash hands don gloves NOTE: water and straw
PLANNING 1-5
Peripheral Access
PPN
if TPN is dislodged or pulled out what is to be in replace until another TPN is placed
PPN of less than 10% Dextrose
Heparin Therapy Test
PTT
-Pulmonary vascular disease
PVD
Homan's Sign
Pain in the calf when the foot is passively dorsiflexed, can indicate DVT (not very reliable)
provision of nutrients by any route that does not involve the intestinal tract
Parenteral feeding
-give full breath cycle -must by systematic and thorough -all lung fields -listen to one area than contralateral area -lungs are lower posteriorly
Performing auscultation
Peripheral IV vein line
Peripheral Perenteral Nutrition
What is present when rebound tenderness is present?
Peritoneal inflammation
What is the most common complication of appendicitis?
Peritonitis
FVE S/S
Perpheral edema periorbital edema Elevated BP Dyspnea Altered LOC
Surgically placed into subclavian vein then threaded into the superior vena cava.
Placement of central catheter
The typical pneumonia of AIDS is caused by ___________ ____________.
Pneumocystic carinii
Mastectomy post-op
Position arm on operative side on a pillow
Pre-Op patients should be screened for possible critical allergies?
Pre-Op pts should be screened for critical allergies: Latex, Iodine, and allergies to anesthesia that may result in Malignant Hyperthermia.
Prepared in pharmacy then infuse solution steadily over 24 hr period then increase as needed to reach final rate.
Preperation of TPN solution
Wound Intentions
Primary Secondary Tertiary
Irreversible stage of Shock
Profound hypotension HR slows Multi organ failure Severe hypoxemia
What are the first signs of AGN?
Puffiness of face, dark urine
Abdominal Aoritic Aneurysm Dx
Pulsating Abd. mass Bruit herad over Abd. Confirmed on Xray
Cardiogenic Shock
Pump Failure decreased cardiac output
High blood volume and movement allow it to disperse rapidly
Purpose of TPN being so close to the heart
Emphysema Inspection
Pursed-lip breathing Noncyanotic
How often are vital sign measurements taken in AGN?
Q4 hours with blood pressure
How often should you measure the vital signs, vaginal bleeding, fetal heart rate during Abruptio Placenta>?
Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress
hemoglobin, heatocrit, blood volume
RBCs raise ____________ & ________w/o little increase of _____.
Where does the pain of appendicitis finally end up?
RLQ
50cc/hr first 12 hrs then increase to 83 cc/hr for second 12 hrs.
Rate of infusion of solution
-normal rate (eupnea) 12-16 -normal regularity -normal inspiration:exhalation = 1:2 at rest -decreases with exertion -increases with COPD
Rate/rhythm
lower osmolarity, used for short term needs and when reqs are modest, pt must tolerate large fluid load, and have extended dwell catheter,
Recommendations for PPN
ARDS S/S
Refactory hypoxemia, decrease pulmonary compliance (elasticity); dyspnea, noncardiac-associated bilateral pulmonary edema; dense pulmonary infiltrates on x-ray (ground-glass appearance
The occurance of sever fluid and electrolyte shifts and their assoc. complications in malnourished pts
Refeeding Syndrome
How do you prevent flexion contracture of the knee after BKA?
Remide the patient to straighten their knee constantly while standing
100% goes to the blood without absorption
Requirements for nutrients are lower than enteral for this reason
Common causes/ risk factors: Atelectasis
Respiratory complication that may be the result of a blocked airway, diminished surfactant, or mucus plug. Recent general anesthesia, shallow breathing, respiratory muscle weakness and immobility are common risk factors.
Definition: Atelectasis
Respiratory complication when the alveoli within the lung becomes deflated, resulting in a complete or partial collapse of a lung.
rh compatibility problems occurs in woman who is
Rh negative and conceives with Rh + man
Chronic Bronchitis Inspection
Right-sided heart failure Cyanosis Distended neck veins
-course, grating, leathery sounds -indicative of pleural inflammation
Rubs
What is the BIG danger with aneurysms of any type?
Rupture, leads to shock and death
with meningitis, what can be a possible complication by abnormal stimulation of the hypothalamic area of the brain?
SIADH--> causing excess secretion of ADH
what is atomoxetine
SNRI selective norepinephrine reuptake inhibitor antidepressant (not a stimulant)
dyspnea
SOB; labored or difficult breathing
what is the med class of Prozac? and what is it used for
SSRI for OCD, and depression
Adjust ties snug, but two fingers fit in remove gloves and wash hands
STEP 5 REPLACE TIES
Cardiac Output
SV x HR for 1 min
HIV Tests
Screen = ELISA Confirm = Western blot
PLANNING: STOP INFUSING (1 min) Assemble equipment and blood tubes explain procedure to pt. wash hands don gloves *identify port for safest access for central line blood draw and or flush
Second step to Blood draws?
In Abruptio Placenta, the placenta _______________ from the uterine wall ____________.
Separates, prematurely
Stoma Assessment
Should be Pink -Blue = compromised circulation(notify M.D.) -Red = skin irritation (non stoma skin exposed to gastric contents, ensure tight fit of bag seal)
-not normally
Should you see much mvmt at rest?
subclavian vein sourced down to superior vena cava
Site of TPN
-pale, cynosis -check nail bed or inside of lips (should be pink) -rubor dependency -note capillary refill following 3-5 sec hold
Skin and mucous membrane coloration
-cool, clammy skin suggest cardio dysfxn
Skin temp
-scoliosis -barrel chest -pectus carinatum and excavatum
Spine/chest wall deformities
Without leukopenia the AIDS patient will be on ____________ precautions.
Standard precautions or blood and body fluid precautions
ck for respiratory distress - listen for Ronchi secretion production determine client's understanding of purpose of tracheotomy and care
Step 1 Assessment
ASSESSMENT: ck prescribing order assess client for allergies determine client understanding identify crucial info regarding solutions being given Assess pts nutritional status, caloric intake, lab values, weight, VS, lung sounds
Step 1 TPN:
**Triflo suction **cath. and glove kit disposable inner cannula sterile gloves
Step 2 Planning - gather
Wash hands Elevate bed
Step 2 Planning - prepare
assemble equipment (regular primary tubing with filter) explain procedure wash hands position client for comfort coordinate and communicate with pharmacy regarding pt needs
Step 2 TPN:
BE STERILE grasp suction cath and aseptically insert into connecting tubing NOW the non dom. hand is NOT sterile
Step 3 Implementation
Rinse cath by placing in sterile water
Step 3 Implementation
remove cath and gloves *Wash Hands turn 02 back to prescribed amount note quality of breath sounds and resp. status
Step 3 Implementation
repeat re-suctioning/cleaning/re-oxygenation if needed
Step 3 Implementation
replace 02 device and re-oxygenate
Step 3 Implementation
Open kit remove box and pour saline put on sterile gloves
Step 3 Implementation -
5 Rights of med. adminstration 1. Right patient 2. Right solution 3. Right time 4. Right route 5. Right dose
Step 3 TPN:
gather inner cannula and velcro tie make sure inner cannula is smaller than outer cannula
Step 4 INNER CANNULA
replace oxygen delivery device and adjust 02 flow to prescribed rate remove gloves and wash hands
Step 4 INNER CANNULA
*verify client identity NAME, BIRTHDATE
Step 4 TPN:
Inspect solution for labeling, expiration date, clarity, etc...
Step 5 TPN:
what you did - suctioning, tracheostomy care what you saw - site appearance, sputum characteristics and any client responses
Step 6 DOCUMENTATION
Auscultate clients breath sounds O2 sats breathing laboriously or not
Step 6 EVALUATION
*Spike parenteral nutrition solution container with appropriate administration set, including filter. Purge tube in same manner as for primary IV infusion
Step 6 TPN:
Regulate flow rate to prescribed administration rate monitor patient regularly
Step 7:
1. calculate needs 2. choose formula 3. calculate PRO in formula and compare to needs 4. Determine rate 5. calculate free water 6. calculate NPC:N 7. chart final reccs
Steps in making Tubefeeding recommendations
Thrombosis, erosion of the wall of the vein, and infection
Stiff catheters are not suitable due to these risks
FVD Tx
Strict I&O replace with isotonic fluids Monitor BP Daily Wt.
Stroke Volume
Stroke Volume = amount of blood pumped by the heart each minute
When do you need goggles with AIDS?
Suctioning, central line start, arterial procedures
Primary Intention
Surgical Wound, wound edges are brought together (well-repaired lacerations, well reduced bone fractures, healing after flap) surgery
The AIDS virus invades helper ____________.
T-lymphocytes (or CD4 cells)
Implementation: Have client's face away from port clamp any fluids currently infusing *clamp port *clean port with alcohol swab *connect an empty 10mL syringe to central line port ck for blood return *withdraw 8-10mL blood *Waste blood withdrawn in biohazard bag *clean access port again *attach second 10mL syringe and unclamp *withdraw amount of blood needed *reclamp *place blood in blood tubes GO SLOWLY not to damage RBCs
THIRD step in blood draws and flushes?
in what order do these sensations come back after spinal anesthesia
TOUCH 1 PAIN 2 Warmth 3 cold 4
Total Parentaeral Nutrition
TPN
T/F the nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. fluctuation means the chest tube system is functioning normally
TRUE
What instructions do you give to a client taking tetracycline?
Take it on an empty stomach and avoid the sunlight (photosensitivity)
Acrocyanosis
Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.
What is the antibiotic most commonly given to clients with acne?
Tetracycline
In the surgical setting, where is the center of the sterile field?
The center of the sterile field is the site of the surgical incision.
What is the most challenging aspect of combination of drug therapy for HIV disease?
The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used.
What are some common RN interventions to prevent/ minimize paralytic ileus?
The nurse can prevent/minimize paralytic ileus after surgery with pt positioning and early ambulation. Evidence of bowel function returning to normal includes auscultation of bowel sounds and passing of flatus and stool.
Which vital signs are most important to measure in clients with aneurysm?
The pulse and blood pressure
What structures are involved in acne vulgaris?
The sebaceous glands
What is the best indicator of renal function?
The serum creatinine
Tertiary Intention
The wound is purposely left open due to heavy infection or contamination initially cleaned, debrided and observed (Tissue Graft, Stage 4 Pressure ulcer with necrotic tissue and infection)
What do NRTI's and PI's do?
They prevent viral replication
In what trimester does Abruptio Placenta most commonly occur?
Third
tPA
Thrombolytic agent that is given in the event of a thrombosis or TIA. Increases chance of full recovery by 30%.
Streptokinase
Thrombolytics
fear, chills, shivering, fever, vomiting, chest & back pain, hyperlipidemia
Transient side effects of lipid infusion
T/F it is beneficial for a child with juvenile arthritis to play kickball
True
T/F: AIDS patients get lymphomas?
True
what is the most common urinary problem
UTI
pt has hematuria what is this a usual sign of
UTI or trauma
what are triggers for SLE flare up
UV light infection stressors drugs
-can use palpation or inspection -observe neck, shld, chest mvmts
Use of accessory mm's
How is an infant delivered when Abruptio Placenta is present?
Usually C-section
how should a restraint jacket be on the pt
V opening of the jacket should be in front of the pt to prevent pressure against the neck, particularly against the trachea rounded side of the restraint jacket goes to the back
what are criteria when leaving the PACU
VS stable and spont. respirations gag reflex is present client is easily arousable
Alpha 2
Vasodilation and decreased BP.
-heard everywhere else -soft, rustling sounds -over peripheral lung fields -smallest airways -least turbulent airflow
Vesicular
Accutane is an analog of which vitamin?
Vitamin A
Name 3 drugs given for acne?
Vitamin A, Antibiotics, Retinoids
What blood count is elevated in appendicitis?
WBC
Arterial Disorders
Weak peripheral pulses Cool to touch Painful, nonedematous ulcers
Progressive stage of Shock
Weak thready pulse Excessively low BP Edema Dysrhythmia
What test confirms the ELISA?
Western Blot
-less fit -less active
What does body build suggest about activity tolerance?
EVALUATION: *dispose of used supplies perform hand hygiene AFTER dressing change *document assessment of blood return through central line ans well as flushing and maintenance of the central line Document blood specimens were obtained through central access
What is the fourth step in blood draws and flushes?
Confirm correct placement by chest Xray!
What must be done before infusing saline in a central line?
-musical quality -high/low pitched -made by air moving thru narrowed airway -mucus plug or emphysema
Wheezes
-whisper '99', 'e' or '1,2,3' -normal = not heard or muffled -abnormal = heard clearly thru consolidated area
Whispered pectoriloquy
-neuromuscular disorders -general deconditioning -prolonged immobility -thoracic or abdominal surgery -chronic pulmonary condition
Who is at risk for weak, ineffective cough?
Pt has malfunctioning GI tract, can't feed themselves, use this till a peg tub is put in.
Why do you give TPN?
-closer to 1:1 so it flattens out diaphragm -seen in chronic emphysema
Why is barrel chest a problem?
-airway clearance
Why is cough important?
-to id: abnormal sounds, areas of congestion, secretion, decreased aeration and chest PT indicated -assess efficacy of chest PT
Why lung auscultation?
stored at rm temp.
Why platelets are more likely to be contaminated w/bactera:
Lower Respiratory quotent from fat metabolism requires less CO2 to be driven off therefore lower respiration rate/work in the lungs
Why pts with COPD would benefit from higher fat
FVD S/S
Wt. Loss Oliguria Postural Hypotension
Does AIDS require a single room?
Yes - if WBC counts are low
HIV is present in all body fluids?
Yes, but not transmitted by all, only blood, semen and breast milk
Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room?
Yes, if available you can get them into antishock trousers but not if this causes a delay in getting them to the operating room
Do people recover from AGN?
Yes, the vast majority of all clients recover completely from it
Can AIDS patients leave the floor?
Yes, unless WBC's are very low
Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred?
Yes, when lye or caustic agents have been ingested
pt is taking procainamide (Pronestyl) for MI and premature ventircular beats and experiences cardiotoxcity, what is this a sign of
a QRS widening greater than 50%
what is a danger of procainamide (Pronestyl)
a QRS widening greater than 50% cardiotoxicity
The Tarasoff decision involves an exception to the clients right to confidentiality as being?
a duty to warn
justice
a fair, equitable, and appropriate treatment
Iron deficiency Anemia
a form of anemia caused by inadequate supply of iron for synthesis of hemoglobin (Malnutrition/Bleeding)
what is cerebral palsy
a nonprogressive neuromuscular disorder can be a result of hypoxia event during the pregnancy or the birth process
beneficence
a nurse's duty to do what is in the best interest of the client
what is a manifestation of primary syphillis
a papule like lesion in the vaginal area turns into a painless ulcer
what is the greatest risk of a thoracentesis?
a pneumothorax diminished breath sounds will indicate a pneumothorax
ESWL extracorporeal shock wave lithotripsy
a procedure that uses externally generated waves to pulverize or shatter urinary stones and calculi which are then excreted in urine
autologous transfusion
a process of collectging, storing and re-infusing the pts own blood:
apheresis or plateletpheresis
a process that centrifuges and extracts platelets while returning red cells and plasma to the donor's circulation:
The most common symptom of abdominal aneurysm is:
a pulsating mass above the umbilicus
battery
a purposeful touching of the client without the clients consent
team nursing
a team of nursing personnel provide total care for a group of clients
nurse enters the room to admin. the medication and notices the ID bracelet is gone. what should the nurse do? a) ask the parents at the child's bedside to state their child's name b) ask the child to say his first and last name c) have a coworker ID the child before giving the medication d) hold the medication until an ID bracelet can be obtained
a) ask the parents a the childs bedside to state their childs name
what is most effective in decreasing a clients fluid volume a) low sodium diet b) monitoring serum electrolytes daily c) restrict fluid intake d) elevation of the client feet
a) low sodium diet
what is significant in the health history of a patient who has acute glomerulonephritis associated with beta-hemolytic streptococcus? a) sore throat 3 weeks earlier b) family hx of glomerulonephritis c) renal calculus 2 years earlier d) an accident involving renal trauma several years ago
a) sore throat 3 weeks earlier immunologic disorder that is caused by beta-hemolytic streptococcus. it occurs 21 days after a respiratory or skin infection
an appropriate ND is decreased cardiac output secondary to which of the following? if a client was just diagnosed with an acute myocardial infarcation? a) ventricular dysrhythmias b) CHF c) recurrent MI d) hypertensive crisis
a) ventricular dysrhythmias are common after an MI and reduce the efficiency of the heart
when assessment of the abd for a pt with acute pancreatitis what do you see
abd tenderness rigidity progressive distention decreased bowel sounds
what do you need to monitor for when pt is on exenatide (Byretta) for DM II
abdominal pain greatest risk for taking exenatide is pancreatitis notify HCP immediately
Ovarian Cancer S/S
abdominal pain, dysuria, dysmenorrhia
how are bowel problems diagnosed?
abdominal x-ray, upper GI barium test, barium enema, upper (oral) and lower (rectal) endoscopy
6 mo expected finding
able to hold head when sitting
8 mo expected finding
able to take a small object and put into a container should be accomplished by 12 months
Dysplasia
abnormal development (of organs or cells) or an abnormal structure resulting from such growth
varicocele
abnormal dilation of the veins in the spermatic cord is an associated cause of a low sperm count
waxy flexibility is ___ and associated with __
abnormal posturing, associated with catatonic schizophrenia
exophthalmos
abnormal protrusion of the eye ball
what is SIADH?
abnormal stimulation to the hypothalmic area of the brain, causing excessive secretion of antidiuretic hormone (Vasopressin)
Dawn phenomena
abnormally high levels of glucose upon awakening in the morning
what are 3 objectives of client care for personality disorder
accept that clients change or dont change help client see behavior and how it affects their lives to motivate and develop a more adaptive lifestyle short term goals and focus on small steps to improve functioning and decrease stress ID emotional responses of client and use structured mileau
what is azotemia a sign of
accute renal failure
what happens when a person drinks alcohol on antabuse
acetaldehyde increase significantly producing unpleasant symptoms of flushing, tachycardia, nausea, vomiting, and hypotension
pt is taking fluoxetine (Prozac) what should the pt take for a HA
acetaminophen b/c ibuprofen and other NSAIDS increase the risk of bleeding
what is a sign of tissue hypoxia
aching pain, burning sensation, numbness, tingling
what kind of diet should person with renal calculi be put on
acid ash diet with limitations of food high in CA and oxalates increase hydration and exercise
thick, lethery eschar forms from exposure to ....
acid or heat
what are toxicity signs of NSAIDS
acidosis hyperthermia sweating dehydration
phospholipids effect on body
act as emulsifiers keep fat dispersed in water
act of comission
activities nurse did
what should you educate a pt with cushings syndrome
activity tolerance is limited osteoporosis frequent bruising fluid volume excess from water and sodium retention hyperglycemia increased from increase in cortisol
what are signs of acute pancreatitis
acute epigastric pain steady and severe can occur in umbilical area and radiate to back can be temporarily associated with ingestion of -OH and or fatty meal nausea / vomiting low grad fever, hypotension, tachycardia
what should you monitor for in Impetigo?
acute glomerulonephritis
ARDS
acute respiratory distress syndrome
what is difficult about the deprovera shots
adherence to appointments
what to do to correct dawn phenomona
adjust bedtime snack, evening diet, insulin dose, and exercise to prevent early AM hyperglycemia
how do you treat the somogyi effect?
adjusting the evening diet, changing insulin dose, altering amount of exercise to prevent noctural hypoglycemia
how do you treat exocrine insufficiency when a pt has pancreatitis?
admin meds containing amylase, lipase, trypsin to aid digestion
what happens in Cushing's disease? In other words, what is the pathophysiology of this disease
adrenal hormones such as androgens, mineralcorticoids, and gluccocorticoids are hyper-secreted.--> leads to: increased sodium and water retention increased blood volume --> increased BP decreased potassium--> metabolic alkalosis + shock increased blood sugar-->ketoacidosis
what happens in Addison's disease? In other words, what is the pathophysiology of Addison's?
adrenal hormones such as mineralcorticoids, glucocorticoids, and androgen are hypo-secreted --> leads to: -decreased sodium-->dehydration -decreased blood sugar-->insulin shock -increased potassium-->metabolic acidosis + arrhythmia -decreased blood volume --> shock
nurse has a client with Guillain Barre Syndrome, she knows she will have to admin these meds to this client to reduce symptoms
adrenocorticotropic hormone (ACTH) corticosteroids anit-inflammatory supportive meds like stool softeners and antacids analgesics
what does breast tissue with orange peel appearance indicate
advanced breast cancer due to blockage of lymph channels
when is preterm labor occur
after 20th week and before the 37th
at what time of the day should ritalin be administered?
after breakfast to reduce appetite-suppressant effects
when do you want to irrigate the colostomy
after the colostomy starts to function in 6 days
what 3 factors increase the risk of thrombophlebitis in a pt
age hypertonic fluids poor peripheral venous access
emetic
agent given to producing vomiting
Teratogens
agents, such as chemicals and viruses, that can reach the embryo or fetus during prenatal development and cause harm
serotonin syndrome
agitation sweating confusion fever hyperreflexia tachycardia hypotension muscle rigidity ataxia
what is the major adverse effecct of clozapine
agranulocytosis
what is the most serious side effect of carbazapine?
agranulocytosis (low WBC) need to monitor CBC with WBC
what are possible complications of stopping TPN abruptly?
air embolism infection sepsis hyperglycemia hypoglycemia
bubbling in water seal system means
air leak in system
what is an adverse effect of haloperidol (haldol)
akathisia extrapyramidal symptom
extrapyramidal side effects of haldol
akathisia or restlessness
what lab do you monitor if the person is talking about weight
albumin, prealbumin, transferrin levels total lymphocyte count
in cold/cough preparations, they contain ___ which is contraindicated with the use of Antabuse
alcohol
tx for uric acid calculi
alkaline diet and low purine diet increase hydration
-hives, itching, flushing -Stop infusion, notify Dr., notify blood bank, ck VS q. 15 min, (admin antihistamine), resume transfusion per Dr. instructions -bronchospasm, laryngeal edema, shock
allergic S&S: interventions: more severe allergic reaction S&S:
side lateral
allows drainage of oral secretions
side with bent leg (sims)
allows drainage of oral secretions decreases abdominal tension
what class is prazosin (minipress) in
alpha blocker
what is a maternal blood test used to determine
alpha fetoprotein
when you have altered elimination patterns in a client, what lab will you look at to determine this
alteration in K+ normal K+ (3.5 to 5)
List the most common gynecologic symptom of anorexia nervosa?
amenorrhea
what are two main products of TPN
amino acids and dextrose
what is mesalamine (rowasa) used for
aminosalicylate ( 5-ASA) exerts anti-inflammatory effect for intestinal mucosa
what level increases with clients with cirrhosis
ammonia
what level increases with pancretitis
amylase
malpractice
an act of misconduct of commission or omission performed in professional practice that results in harm to another
The best goal to evaluate the progress of the client with anorexia nervosa?
an adequate weight gain
NRTI (nucleoside reverse transcriptease inhibitors)
an antiviral drug used against HIV (is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs)
cholecystectomy is located where
an incision made for the upper abd near diaphragm and make breathing painful
the appointment of a conservator would be inappropriate in which situation? A. an individual exhibiting bizarre behavior B. an individual who is incompetent C. an individual who is gravely disabled D. an individual whi is unable to provide basic needs for himself
an individual exhibiting bizarre behavior -People who are gravely disabled; are found to be incompetent; cannot provide food, clothing, and shelter for themselves even when resources exsist; and cannot act in their own best interests may require an appointment of a conservator
akathisia
an uncontrollable need to move
what is nalbuphine used for during labor
analgesic for labor pain
what is malignant hyperthermia a reaction to
anesthetic
a bruit heard over the abdominal aorta indicates
aneurysm is present
catatonic schizophrenia causes sudden loss of
animation and a tendency to remain motionless in a stereotyped position
ankle-brachial index (ABI)
ankle systolic blood pressure ratio to the arm systolic blood pressure allows to quantify the arterial stenosis normal result is no drop in ankle systolic pressure after exercise
aluminum hydroxide (Amphojel)
antacid that neutralizes gastric acid
what meds are given to someone with pancreatitis
antacids analgesics antibiotics anticholinergics
CCB uses
antianginal, HTN, dysrhythmias, a-fib, migraines, raynaud's diesease
what class is trihexyphenidryl (artane) in
anticholingergic medication used for Parkinsons
what class is propantheline bromide in
anticholingeric used to decrease biliary spasm
what is imodium
antidiarrheal
what class of meds is Adriamycin in?
antineoplastics
what drugs should you tell the client to avoid for occult testing
antiplatelet properties increase the risk for bleeding NSAIDS aspirin
Ticlopidine is what class
antiplatelet use to prevent thrmobotic stroke
what is foscarnet used for?
antiviral agent used to treat cytomegalovirus (CMV) in clients with AIDS
what do you give and anxiolytic for
anxiety
etiologic agent
any pathogen that can cause an infection bacteria, fungi, protozoa, rickettsiae, helminthes
fulminant
any process that occurs suddenly and quickly and is intense and severe to the point of lethality
when is there an increase in reticulocyte
anytime there is an accelerated production of RBC
point of maximal impulse is AKA
apical pulse or the feeling for the mitral area at the fifth intercostal space at the left midclavicular line... in infants the apical pulse is lateral to the left nipple. this is also the strongest point where you can feel the left ventricle
what is nitrofurazone (furacin)?
applied to burn injuries topical medication that has a broad spectrum of antibiotic activity
post hip surgery what should you educate the AP for care
apply thromboembolic hose to prevent develoment of emboli in lower extremities do not have the client sit forward --should not be more than 90 degree angle should be in an upright wheelchair with the back reclined abductor pillow between legs if client becomes restless
healthcare proxy aka durable power of attorney for healthcare
appoints someone (usually a family or trusted friend) to make healthcare decisions if client is unable to do so
how often do newborns feed
approx every 2 to 3 hrs during the day and every 4 hrs at night
arciform lesions are in what shape
arc shaped
when is cleft lip defect surgically repaired
around 3 months and before 18 months can be corrected through several surgeries
pt has hep B what is a sign of that
arthralgia joint pain is an expected finding of acute hep B
what is the most common symptom pain of SLE
arthritis joint pain
pt is on ventilation, and the low alarm sounds.. what does this mean?
artificial airway cuff leak indicates low pressure and low oxygenation of the client
amniotomy
artificial rupture of the membranes
how should you move a pt after intracranial surgery
as a unit to prevent increased ICP and to prevent disruption of ICP monitoring system
how low is it acceptable for the hematocrit of a postpartum client to be
as low as 20%. below 18 is significant finding Hurst
when is sumatriptan (Imitrex) most effective
as soon as migraine symptoms appear
when can newborns hear
as soon as the amniotic fluid drains from the ear canal reccommend hearing screening
when a client begins to choke, what is the first thing you do
ask are you choking
foods high in oxalates
asparagus beets celery cabbage dark green leafy veggies fruits tomatoes green beans chocolate and cocoa beer cola beverates tes
what must be done before injecting med with z track method what should not be done
aspirate to ensure in muscle and not blood vessel DO NOT massage
do not give Naproxyn to a patient with ___ allergy
aspirin Naproxyn is an NSAID
The nurse is threatening to give the client an injection in order to restrain the clinet for inappropriate behavior. This is an example of...
assault -assault involves any aciton that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority
how do you monitor for a postop ileus
assess bowel sounds first stool amount of gastric output
V-tach
assess for pulse Admin antiarrhythmic drugs
what do you do for a drug baby going through withdrawal
assess muscle tone irritability VS administer phenobarbital as ordered report symptoms of Respiratory distress reduce stimulation provide adequate nutrition/fluids monitor mother/child interactions
what is the greatest risk complication after a bronchoscopy
assessment of safety and assess gag reflex d/t aspiration precautions
koplik spots
associated with measles in children patchy and bright red with a bluish-white speck in the middle
continuous, high pitched musical sounds heard on expiration are common in
asthma-->caused by narrowed bronchioles
what position for acute respiratory failure
at least 45 degrees
When is apgar scoring performed on infants?
at one minute and again at 5 minutes after the birth
third degree heart block
atrial stimuli are blocked at the AV node. p wave and QRS wave are conducted independently of one another.
what are complications of immobility
atrophy joint contracture pressure ulcers orthostatic hypotension deep vein thrombosis pneumonia and pulmonary embolisms decreased peristalsis, constipation kidney stones
patient iv site extravasated, you stopped the infusion, disconnected the tubing, what is your next step
attempt to remove any residual drug using the 1-3 cc syringe
purpose of huff coughing
attempts sequential coughing while saying huff keeps glottis open during coughing beneficial to pt with COPD
ALPP stands for
attitude lie presentation position
borborygmi
audible high pitched loud gurgling sounds that occur frequently hyperactive bowel sounds
what is the best indicator of milk transfer
audible swallowing
tinnitus is an altered function of what nerve
auditory branch of the eigth cranial nerve
when is a splenectomy indicated as a form of therapeutic management of a condition
autoimmune diseases this is not guaranteed and chemo and biological response modifierss are being looked into
which eithical principle involves the right of the client to make his or her own decisions?
autonomy
how is cystic fibrosis inherited?
autosomal recessive trait meaning both parents carry a recessive trait for the disease
pt is on fluoxetine (Prozac) what should you tell the pt.
avoid NSAIDS because Prozac suppresses platelet aggregation and increases the risk for bleeding
what do you edu. about to a pt with chronic pancreatitis
avoid alcohol low fat bland diet small frequent meals monitor for signs of DM
what should you educate the client who is taking disulfiram
avoid all forms of alcohol cold syrups aftershave lotions
what edu do you want to give to mom about nutrition for baby in first year
avoid giving cows milk during first year
therapeutic function of supine
avoid hip flexion, which can compress arterial flow
what meds do you admin. for acute renal failure
avoid nephrotoxic drugs volume expanders to restore renal perfusion in hypotensive clients and dopamine (Intropin) IV to increase renal blood flow diuretic ACE inhibitors to control hypertension antacids Kayexalate to reduce K+ and HCO3 for acidosis
pt is taking prazosin (minipress) what do you educate to the pt.
avoid salt, use substitutes b/c alpha blockers cause sodium retention move slowly from sitting to standing to prevent falls
how does pregnant client avoid heartburn during pregnancy
avoid spicy food eat smaller more frequent meals avoid lying down after eating
what should a person with ear surgery take to decrease the pressure
avoid straining the person should take stool softeners avoid drinking through a straw because air travel and avoid excess coughing avoid getting hair head wet and washing hair for 1 week avoid rapid movements of the head and bouncing or bending over 3 weeks
client comes to the ER complaining of N/V/ severe RUQ pain. temp is 103 F, and an abdominal x-ray reveals an enlarged gallbladder. He is scheduled for surgery. Which of the following actions should the nurse take first? a) assess the clients need for dietary teaching b) evaluate the clients fluid electrolyte status c) examine the health history for allergies to antibiotics d) determine whether the client has signed consent for surgery
b) evaluate the clients fluid and electrolyte status because hypokalemia and hypomagnesemia commonly occur after repeated vomiting
the nurse delivers cardiac compressions to a client while performing CPR, what is the best action by the RN? a) maintain a position close to the client with the nurses knees apart b) maintain a vertical pressure on the clients chest through the heel of the nurse's hand c) re-check the nurses hand position after every 10 chest compressions d) check for a return of the clients pulse after every 8 breaths
b) maintain vertical pressure on the client's chest through the heel of the nurse's hand elbows locked, arms straight, with shoulders directly over the hands. Incorrect pressure or improperly placed hands could cause injury to the client
the nurse understands that hemorrhage is a complication of a liver biopsy due to which of the following? a) several large blood vessels near the liver b) the liver cells are bathed with a mixture of venous and arterial blood c) the test is performed on clients with elevated enzymes d) the procedure requires a large piece of tissue to be removed
b) the liver cells are bathed with a mixture of venous and arterial blood. the liver is a highly vascular organ where the hepatic artery and the portal vein join in the liver and form sinusoids that bathe the cells .
how much weight does a baby gain in the beginning of the first yeat
baby's weight doubles in 6 mo. triples by 1 year
Bacteremia
bacteria in the blood
how often should TPN tube and bag be replaced
bag and tube every 24 hours
amount of dialysate outflow is to
be the same or exceed inflow
why does the cord most likely prolapse during labor
because a presenting part other than the head is engaged
enuresis
bed wetting
if taking zantac once a day, take it at what time
bedtime
eructation
belching
facial droop is associated with what
bells palsy disorder of facial nerve VII
flexion
bending
what is impetigo caused by?
beta-hemolytic streptococci or staphylococci or both
when is dehiscence most likely to occur
between the 5th and 8th postop day not life threatening
choluria
bile in the urine
when conducting an admission history for a psychiatric client, the admission should include what information
biopsychosocial approach including a family system assessment
What is the most common side effect of accutane and Tetracycline?
birth defects
third stage
birth of newborn to delivery of placenta
gangrene
blackened decomposing tissue that is devoid of circulation chronic ischemia and tissue death can lead to gangrene in the affected extremity.
aspirin contraindicated for pt with
bleeding disorders
what are bloody stools and indication of in someone with cirrhosis
bleeding in gi tract d/t impaired coagulation
When the AIDS patient has a low platelet count, what is indicated?
bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions
what is an esophagogastric tube used for
bleeding varices
what is a late sign of karposi's sarcoma
bleeding/ hemorrhage because tumor has interfered with function of the internal organ function
hematemesis
blood in the vomit
what is a sign of lung cancer
blood tinged sputum may be secondary to bleeding tumor
AIDS is trasmissible through what four routs?
blood, sexual contact, breast feeding, across placenta in utero
sanguineous
bloody and may be dark red or bright red depending on freshness of blood
sanguineous
bloody drainage
what is the cullens sign
bluish discoloration around umbilicus
what is grey turner sign
bluish discoloration over flank area and represents accumulation of blood in that area
sign of dig toxicity
blurred vision first action - obtain an order for serum dig level
psychological complications of immobility
body image issues lack of social interaction sensory deprivation depression
After appendectomy, document in the nurses notes the return of __________
bowel sounds (peristalsis)
<60 (adult)
bradycardia
respiratory rate < 8
bradypnea
Which element of malpractice occurs when the nurse does not act as a reasonable, prudent person would have acted in a similar circumstance?
breach of duty
what should you teach the client who has emphysema
breathing exercises such as pursed lip breathing stop smoking avoid hot/cold air/ allergens instructions regarding meds avoid crowds or close contact with sick people adequate rest and nutrition oral hygiene flu vaccines observe for sputum to see if there is an infection
apnea
brief pause in breathing
what are classic symptoms of detached retina?
bright flashes of light and client stating that portion of visual field is dark
what are early signs of cushings disease?
bruising, moonface, buffalo hump, osteoporosis loss of collagen makes the skin weaker and thinner, therefore the client bruises more easily hypertension
why would you give buspirone over a phenobarbital to pt with a hx of addiction
buspirone has no abuse potential
what is the most common physical appearance of sle
butterfly rash (malar rash) across the bridge of the nose and cheeks or erythema of face is most common dermatologic expression palmar erythema also possible
Client is being treated in the burn unit for 2nd / 3rd degree burns over 45% of his body. the MD orders include the application of silver sulfadiazine (silvadene cream). the best way for the nurse to apply this medication is to use which of the following? a) sterile 4x4 dressings soaked in saline b) sterile tongue depressor c) sterile glove hand d) sterile cotton-tipped applicator
c) sterile gloved hand will cause the least amount of trauma to tissues and will decrease the chances of breaking blisters
a client is being treated for CHF with diuretic therapy. Which of the following assessment Best indicates to the nurse that the clients condition is improving? a) the clients weight has remained stable since admission b) the clients systolic blood pressure has decreased c) there are fewer crackles heard when auscultating the clients lungs d) the clients urianry output is 1,500 per day
c) there are fewer crackles heard when auscultating the clients lungs. diuretics are given to promote excretion of sodium and water through the kidneys. decreased crackles would indicate that the pulmonary edema is improving.
A 50 yo male client asks to go to the cafeteria, but it is not included in his privileges, the client becomes verbally abusive. What approach is the most effective? a) tell the client to lower his voice, because he is disturbing the other clients b)ask the client what he wants from the cafeteria and have it delivered to his room c) calmly but firmly escort the client back to his room d) assign a nursing assistant to accompany the client to the cafeteria
c)calmly but firmly escort the client back to his room
If a child swallows a potentially poisonous substance, what should be done first?
call medical help
why is acetaminophen contraindicated in a client with HEP C
can cause additional liver damage and should be avoided
amniocentesis
can evaluate for down syndrome (trisomy 21) women older than 35 are at risk for down syndrome
a decrease in adrenal hormone excretion
can have an elevated calcium level due to dehyration and a decreased sodium level
what do hiccups mean after an insertion of a permanent pacemaker/ diaphragm
can indicate a lead wire perforation
when admin IV immunoglobulins to a client with GBS to reduce symptoms and protect client.. what do you need to watch out for
can result in low grade fever muscle aches HA rare but acute renal failure retinal necrosis
ketoconazole is the drug of choice for
candidiasis
what do you monitor during lithotripsy for urolithiasis
cardiac rhythm is monitored during lithotripsy by ECG. shock waves are delivered in synchronized with R wave on ECG monitor
what are some examples of phytochemicals
carotenoids indoles isflavones phenolic acids terpones phytoestrogens catechins
Trousseau's sign
carpal spasm result when a blood pressure cuff is inflated above the client's systolic pressure, and left in place for three minutes.
what types of equipment are used to deliver fluids IV
catheters needles infusion pumps electronic delivery devices regulators controllers mechanical infusion devices tubing
why is Ditropan contrindicated for someone GERD
cause lower esophageal sphincter pressure and reflux
what is Legionnaires' disease.
caused by Legionella pneumophila which is found in warm, stagnant water, such as hot water tanks, and spread by aerosolized routes from the environmental source to the client
what are 2 things the RN has to educate the pt on about taking phenytoin ?
causes hyperplasia of the gums -- need to visit the dentist more often take folic acid -- can cause folic acid deficiency
what type of line is used for TPN
central line for 4 weeks
lie
cephalocaudal axis of fetal part to pelvis vertex, breech, broww, face footling
what is a pap smear used to screen for
cervical cancer
what are early signs of increased ICP
changes in pupil size, shape, or reactivity icP for pupil. -->size, shape, reactivity
what is the most important nursing intervention to complete when restraining an aggressive client
check correct application of the restraints
what should you check when pt takes ketorolac (toradol)
check for bruising while taking med b/c it increases risk for bleeding with platelet aggregation take with food to reduce gastric upset
renal diet should contain
check on this.
If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours?
check the distal extremity (far from center) for color, temperature, pain and PULSE, also document
Pericarditis S/S
chest pain worse when lying down, cough, fever, anxiety, FRICTION RUB,
Herpes zoster (shingles) is contagious to anyone who has not had
chickenpox
symptoms of febrile reaction to blood transfusion
chills, fever, flushing, headache, anxiety remember: febrile=fever--> fever=chills--> chills, fever and flushing usually come together. anxiety will cause him a headache!!
what test is used to detect chromosomal abnormalities
chorionic villi
chronic bronchitis
chronic airway inflammation iwth a chronic productive cough lasting 3 months to 2 years
what is the most common cause of hypomagnesemia
chronic alcohol use
what is immunosuppressive therapy used for in a person with a kidney transplant
chronic rejection not hyperacute rejection
what signs to you need to check for after thyroidectomy
chvosteks and trousseaus signs to check for tetany d/t decrease in calcium d/t removal of parathyroid by accident
is nutrition or circulation more important during the healing of a decubitis ulcer
circulation
8 mo expected finding
clap hands together by 9 months
when educating a client about their trach cleaning at home, what do they use?
clean the cannula with half-strength peroxide and rinse with saline
transudate
clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure
molar pregnancy
clear vesicles and brown vaginal discharge is a sign of a molar pregnancy
color of dialysate outflow is expected to be
clear, light yellow
signs of overdose on Doxepin (Sinequan) are
client becomes excitable and develops tremors
pt with scabies is taking lindane and is contraindicated for what condition
client has a history of seizure disorder
what is a person with thrombocyotopenia at risk for
client is at risk for occult bleeding
Decerebrate posturing
client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Hurst
nurse care delivery system
client needs are defined by tasks to be allocated to RNs, LPNs and UAP and coordinated by charge nurse
egosyntonic
client personality thinkg patterns are natural and comfortable and dont seek help
Trousseaus sign
client spontaneously flexes his wrist when the blood pressure is obtained carpal spasms indicate hypocalcemia
what position do you place someone after a thryoidectomy?
client supports his head and neck when turning his head to the right (prevents stress on the incision) low semi fowlers position
describe how to use esophageal speech following a total laryngectomy
client swallows air and then eructates it while forming words with the mouth
what should you indicate after vasectomy
clients must be informed that conception is possible in immediate postvastecomy period
who is most at risk for latex allergy
clients with spina bifida and multiple surgeries
anxiolytics are used to treat acute mania and manage psychomotor agitation often seen in mania.
clonzepam (klonopin) lorazepam (ativan)
what is an early sign of infection of peritonitis
cloudy dialysate effleuent
exudate
cloudy fluid with cells and proteins that collects when the pleurae are affected by malignancy or diseases such as tuberculosis and pneumonia
talipes equinovarus is AKA
club foot
what cluster of disorders is antisocial borderline histrionic narcissistic in
cluster B of axis II disorders
"my husband will do well as long as i keep him engaged in activities that he likes" what behavior is this an example of
codependent behavior
when assessing a person with PVD what is a manifestation that would indicate arterial obstruction
coldness of the foot and ankle
best condition for acid-fast bacilli
collect early in morning after a long sleep period for greater concentration can also do gastric specimen if you cant get sputum specimen
lesions associated with acne
comedone (open and closed) pustules papules nodules
paoxysmal
coming in seizures
what is presentation during labor
coming through the cervix and birth canal first
reflective communication
communication to the client that the nurse has heard and understood what the client is trying to communicate
what are the key elements of the ANA code of ethics
compassion, respect, commitment, advocacy, accountability and responsibility to the profession
virtues
compassion, trustworthiness, integrity, veracity (truthfulness)
how do you know when a patient is in a hyperosmolar state from their TPN therpy
complain of headache nausea fever chills malaise
what is obstipation a sign of
complete bowel obstruction
Impairment of diffusion of gas in lungs Impairment of immune fx impairment of blood coagulation
complications from fat emulsions
refeeding syndrome, hyperglycemia, used for lipogenesis, may cause fatty liver or liver dysfx, increased VE
complications of excessive dextrose
metabolic strain and refeeding syndrome
complications of excessive kcal
how should you identify the pt. before starting to do a foley insertion?
confirm the clients identity the nurse should confirm the clients medical record number via the wristband and order the nurse should confirm the clients name via the wristband and order
what is the first sign of fat embolism
confusion
what is neuroleptic malignant syndrome
consists of muscle rigidity, fever, autonomic instability, and cognitive changes such as delirium Hurst
what is impetigo?
contagious bacterial infection of the skin
purulent
containing pus
what does Ma Huang contain, and who can it be dangerous for?
contains ephedrine and can be dangerous for pts with HTN
tonic tremor
continuous shaking
what is the benefit of teaching a client with a cast isometric exercises for affected leg?
contraction of the muscle without moving the joint promotes venous return and circulation prevents thrombi quadricep setting and glueteal setting
what medication will increase Blood Sugar tests and create a false reading of TPN therapy
corticosteroids
soft, high pitched interrupted sounds heard on inspiration are ___ and common in
crackles heard in pneumonia and CHF
by which cranial nerve is Meniere's disease diagnosed?
cranial nerve VIII
what are signs of osteoarthritis
crepitus with joint movement decreased range of motion of the affected joint joint pain the resolves with rest larger joints like hips and knees are primarily effected
Describe the pain of angina pectoris
crushing substernal chest pain that may radiate
what two signs are associated with acute pancreatitis
cullens sign (bluish discoloration around the umbilicus) grey turner sign (bluish discoloration over the flank area and represents accumulation of blood in that area
In babinski reflex for adult and babies, the toes
curl for adults fan for <12 mo
what are late signs of respiratory distress?
cyanosis use of accessory muscles (such as intercostal retractions)
what immunosuppressive meds is a client on for SLE
cyclophosphamide (cytoxan) azathiopine (Imuran)
what is the most important in educating the patient's mother about treatment for talipes equinovarus? a) offer appropriate toys for age b)make frequent clinic visits for cast and adjustment c) provide an analgesic as needed d) do circulatory checks for casted extremity
d) do circulatory checks for casted extremity
the nurse is caring for a client who has severe burns on the head, neck, trunk, and groin areas. which position would be most appropriate for preventing contractures? a) high fowlers b) semi- fowlers c) prone d) supine
d) supine position in extension is the position most likely to prevent contractures. clients who have experienced burns will find flexed positions to be the most comfortable
why is muscle wasting an additional sign of long term corticosteroid use
d/t the depletion of the nitrogen which decreases the muscle mass
How often should a stump be washed?
daily
pt has DI , how often should weights be taken
daily to detect dehydration in early stage
pt is admitted for acute pancreatitis how often do you monitor VS
daily weights hourly Urinary output bowel sounds, stool
when a pt goes into NMS what drugs are used for hyperthermia
dantrolene (dantrium) bromocriptine (parlodel)
who is least at risk for psoriasis
darker skinned ethnic groups
what does a person with HTN have to worry about with decongestants?
decongestants can constrict blood vessels and relieve congestion but increased blood pressure
what labs are associated with SLE systemic lupus erythematosus
decrease RBC leukopenia - infection and fever thrombocytopenia - low platelet count hemolytic anemia - positive coombs test decreased ESR, CRP elevated
what is propantheline bromide used for
decrease biliary spasm
what is propantheline bromide indicated for
decrease biliary spasm to help reduce pain in cholecystitis
why is captopril contraindicated for surgery with anesthetic agent
decrease in BP will cause hypotensive crisis
why can tetany happen after a thyroidectomy
decrease in calcium from removal of parathyroid during thyroidectomy
baclofen (Lioresal) purpose
decrease in flexor and extensor spasticity decrease in the frequency / severity of muscle spasms allows for improved muscle function
what is a side effect of sotalol hydrochloride (BEtapace)
decrease in heart rate d/t inhibitory effects
Define Leukopenia
decrease in wbc, indicated viral infection
If an aneurysm is ruptured how would you know it?
decreased LOC (restlessness), tachycardia, hypotension - all signs of shock
what if you give flumazenil for a BZ OD? what do you consider
decreased LOC d/t alcohol, barbituates, and opioid analgesics
what can urine output <20mL/hr indicate
decreased blood flow to the kidneys can indicate shock
client receives paracentesis for ascites what is the best indicator of treatment being effective
decreased shortness of breath
rantidine (zantac) is taken for what condition
decreases gastric pH and treats GERD
why is diphenoxylate (Lomotil) containdicated for gastroenteritis
decreases motility
what is the action of morphine sulfate?
decreases preload and afterload pressures, and cardiac workload.--> vasodilation and pooling of fluid in extremities-->also provides anxiety relief
upon assessment of breath sounds in a pt with chronic bronchitis, what is heard?
deep, low pitched rumbling sounds heard primarily on expiration-->caused by mucus in airways
Hypoxemia
deficient amount of oxygen in the blood
clients who present with diabetic ketoacidosis, are severely ____ (related to fluid status)
dehydrated Hurst
hypernatremia can indicate
dehydration insufficient water intake 145<
fraud
deliberately deceiving client for purposeful or unlawful gains
dental caries
dental decay of teeth
magnesium toxicity
depressed deep tendon reflexes decreased level of consciousness lethargy decreased BP (everything is decreased)
manifestations of myxedema coma
depressed respirations (hypoxia, hypercapnia) decreased CO lethargy, stupor, coma hypothermia bradycardia, hypotension hyponatremia
pt is taking imipramine (tofranil) for what
depression
when giving a child amphetamine or dextroamphetamine (adderall) what should the nurse be alert for? what adverse drug effect
depression
symptoms of amphetamine withdrawal
depression, disturbed sleep, restless, disoriented
pt is taking tranylcypromine (Parnate) for what
depresssion
structure indicator
describes the characteristics of a setting and support to have an impact on care
"Time is too short to start another life, though I wish I could," is an example of ___________.
despair
Bismuth subsalicylate (pepto-bismol)
destroys the cell wall of H. pylori and does not affect gastric acid secretion
what will the tensilon test do if the person is in myasthenic crisis
determine if it is myasthenic crisis or cholingeric crisis
what does the NPA do
determines the scope of practice for a professional nurse in a specific state establish guidelines requirements, educations, and standards of nursing care
purpose of the digital rectal exam in a client with an elevated PSA level
determines the size and consistency of the prostate help differentiate between BPH and prostate cancer
pt is on vasopressin (pitressin) for what type of diabetes
diabetes insipidus
what disease processes is Dupuytren contracture associated with
diabetes, gout, arthiritis, alcoholism
what is a percutaneous umbilical blood sampling used for?
diagnosis of Rh disease obtain fetal complete blood count karyotyping chromosomes to eval genetic disorders
what are the signs of withrawal of alcohol and CNS depressants
diaphoretic disoriented temp 100<
What should you teach the client with Acute Renal Failure
dietary and fluid restrictins look for complications - fluid excess, CHF, hyperkalemia monitor weight, BP, P, UO avoid nephrotoxic drugs and substances recovery takes up to 1 year so susceptible to nephrotoxins
dyspnea
difficulty breathing
What is the action of nitro?
dilates coronary arteries to increase blood supply (O2 supply) and reduces preload.
second stage
dilation of cervix to delivery of fetus
what should you monitor for in SIADH
dilute blood, concentrated urine, disorientation/confusion, headache, vomiting.
how should NTG be administered
diluted in 5% dextrose or 0.9% NaCl solution mixed in glass bottles and infused on through the manufacturer supplied IV tubing
assessment findings in myasthenia gravis
diplopia+ptosis Impaired speech + dysphagia respiratory distress periods of remission/exacerbation
hydralazine hydrochloride (Apresoline) is a and what does it do?
direct acting vasodilator HYdralazine=HYpotension -->way to remember decreases BP fast fast acting antihypertensive also: relaxes smooth muscle
credes maneuver
direct pressure applied over the bladder can be used to express urine from a flaccid bladder
suppurating
discharging pus
what is the first sign of sepsis in burn clients?
disorientation and fever are the first signs of fever in sepsis in burn clients
antisocial personality disorder
disregard for and violation of rights of others
DIC
disseminated intravascular coagulation -Abnormal Clotting then lack of clotting due to used up clotting factor.
When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________.
distally (far from the center), proximally (neareast to the point)
anxiety and fatigue are pain
distracters
what is used for alcohol abuse ?
disulfiram (antabuse)
what are SE of flumazenil?
dizziness, agitation, confusion, NV, hiccups , parasethesia, rigors, shivering
nonmaleficence
do no harm
if TPN solutions are behind schedule what is to be done
do not catch up set at normal rate
pilocarpine (pilocar) education for pt with glaucoma should know
do not drive until vision clears up after drops are in can cause transient brow pain that disappears 10 to 14 days later have to take the rest of life can cause AR in other areas of body
what do you monitor for a client receiving TPN?
do not use the IV for anything other than TPN monitor the blood glucose level measure daily weights to determine and adjust fluid balance monitor other lab results, such as electrolytes, protein, prealbumin/albumin, creatinine, lymphocytic count, liver function
which of the following is an inappropriate intervention for the client in seclusion? A. documented assessment by the nurse every 30min B. Face-to-face evaluation by a licensed independent practioner w/i 1 hour of seclusion C. close supervision of the client D. A physician's order every 4 hours
documented assessment by the nurse every 30 min -Documented assessment should take place by the nurse every 1-2 hours with close supervision of the client
this med is given to people with oliguric renal failure to enhance blood flow to the kidneys and increase BP
dopamin (Intropin)
with Z track medication administration, what should be the site used?
dorsal gluteal
titrated
dose adjusted according to a predetermined parameter, such as chest pain
mucopurulent
drainage containing mucus and pus
purulent
drainage containing pus
lochia
drainage from the vagina after delivery
serous drainage
drainage of lymphatic fluid
patient with meningitis should be on what kind of precautions?
droplet
patient with pertussis should be placed on ___ precautions with how much separation?
droplet precautions with a spatial separation of 3 feet
what is an adverse effect of phenobarbital
drowsiness and irritability
Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________.
drugs, insecticides
anticholinergic effects are
dry mouth urinary retention constipation mydriasis tachycardia diminished lacrimation
basic guidelines to teach client post-gastrectomy are measures to prevent
dumping syndrome
person states "burning, heavy, sharp, hunger pain" localized in the midepigastric area what does this person have
duodenal ulcer
when is impetigo most common?
during hot, humid summer months in areas of broken skin such as an insect bite or an area of atopic dermatitis
onset of mild allergic rxn to blood transfusion
during or up to 24 hours after transfusion
sign and symptoms of pleural effusion
dysnpea with exertion dry non productive cough pain is sharp and increases with inspiration
progressive systemic sclerosis causes what foods should be avoid
dysphagia and esophageal reflux avoid spicy foods, caffeine, and alcohol bc they stimulate gastric secretions -->thus cause more esophageal reflux
side effects of corticosteroids are
dysphonia and oral cadidiasis
client with donepezil (Aricept) is on it for their AD what is an adverse effect needed to notify the HCP
dyspnea
most common complication following an MI is
dysrhythmia with ventricular types being most serious
what can hypokalemia cause in a pt with HF
dysrhythmias
what chronic abnormal movements can occur with buspirone?
dystonia motor restlessness involuntary movements of facial or cervical muscles prego
when should nurse assess pt. TPN insertion site for infection and patency
each shift
What are the three adult stages of development called
early adulthood, middle adulthood and later adulthood
why is a clear liquid diet given to a client after abd surgery
easier to digest
what factors can lead to false positives in occult testing
eating red meat 1 to 3 days prior meds herbs foods activities iron pills turnips horseradish
what does the CEA level determin in chemotherapy of client with GI cancer
efficacy of chemo treatment by controlling growth of cancer cells
when a person exhibits signs of a dvt, what are you supposed to do
elevate the right extremity to increase venous return
To prevent post-op swelling, the stump should be __________.
elevated
what tests are done for peritonitis
elevated WBC blood culture to ID organism abd x-ray to show free air from perforation US to ID causative problem peritoneal lavage to analyze fluid of WBC count, bacteria, bile CT to ID causative problem
pyrexia
elevated temp
a person who is underweight in appearance, labored breathing is indicative of what disease
emphysema
how should you admin erythromycin
empty stomach with a full glass of water
what do you educate someone who is admitted to the hospital for pyelonephritis?
encourage bed rest during acute phase finish complete course of antibiotics even if symptoms resolve
what are the cardinal movements
engagement descent flexion internal rotation extension resitution external rotation expulsion
in a child with PKU, the child lacks
enzyme necessary to convert phenylalanine to tyrosine
pt is on an opioid epidural anesthesia.. states "crushing headache".. what is the pathophys for this
epidural catheter may be dislodged and in the subarachnoid space rather than the epidural space
pt has diabetes insipidus, how much fluid should the pt be allowed
equal to their output
what can alendronate (fosamax) cause in pts with osteoporosis
esophagitis esophageal ulcers to prevent this = med should be taken before breakfast in an upright position for 30 min. maintained
what does upper GI series include
esophagus stomach duodenum upper portion of jejunum
in a crisis situation, it is important to
establishing coping methods used in the past
what occurs when there is a situation in which ethical principles conflict or when there is not one clear course of action in a given situation?
ethical dilemma
how often should orders for restraints be renewed if a client is already in them?
every 24 hours
how often do women get deprovera shots
every 3 months
assess temperature every __ hours for presence of infection
every 4 hours
how often should a picc line be changed if it has TPN running through it
every 4 weeeks
how often should Blood Sugar levels be monitored for hyperglycemia while on TPN
every 6 hours
how often do you wash the burn site
every day
how often do you examine the IV site for TPN risk for infection
every shift
what is SIADH characterized by (what hormones)
excess antidiuretic hormone ADH, vasopressin
what are causes of high alarm sounds during mechanical ventilation
excess secretions kinks in the tubing biting the endotracheal tube
what are the greatest risk factors for pancreatitis?
excessive alcohol use gallstones hyperlipidemia is a risk factor for recurring pancreatitis
histrionic
excessive emotionality and attention seeking
what is the primary symptom of chronic bronchitis?
excessive mucous production
pt has pink and bloody urine after renal transplant, is this finding expected or unexpected
expected
are crackles an expected finding or an unexpected finding in someone who has emphysema
expected finding
a 43 yo who had a mastectomy 2 days ago with 23 ml of serosanguinous fluid noted in jackson pratt drain... is this expected or unexpected outcome?
expected outcome
what is a sign of anemia
experience SOB and complain of fatigue because of decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands tachycardia
when administering Haldol, monitor for ___ and immediately intervene
extrapyramidal side effects
side effects of Haldol include
extrapyramidal side effects galactorrhea (excessive and spontaneous flow of milk) lactation gynecomastia
what is the greatest risk of chemo therapy
extravasation and infection erythema at the site may indicate extravasation
what are signs of viral conjunctivitis?
extreme tearing, redness, foreign body sensation-HIGHLY CONTAGIOUS
where is impetigo located
extremely contagious and lesions are located around the mouth and nose, as well as hands and extremities
obstipation
failure to pass stools
for a pregnant patient with diabetes, after she gives birth, her blood sugar will
fall because of decrease in insulin requirements
The nurse is detaining the client from leaving the hospital by refusing to allow him to take his personal items. This is an example of?
false imprisonment
the inappropriate use of restraints or seclusion is
false imprisonment
what is a side effect of long term steroid therapy
fat deposition on the trunk and face producing classic cushingoid signs
lipids aka __ may be added to TPN 1-3 x a week
fat emulsion
why ask pt. if they are allergic to eggs if receiving a lipid solution of TPN
fat emulsion may have egg yolk phospholipids
signs and symptoms of cellulitis
fatigue fever chills HA myalgia inflammation of epidermis
in children with type 1 diabetes, what do we expect to see?
fatigue and bed wetting
what are assessment findings in anemia?
fatigue, decreased serum albumin/transferrin/gamma globulin, glossitis, "spoon" fingernails--> koilonychica, pallor, exertional dyspnea, impaired cognition
what are assessment findings in Addison's disease?
fatigue, weakness, dehydration, decreased BP, hyperpigmentation, decrease resistance to stress, alopecia, weight loss, pathological fractures, depression, lethargy, emotional liability
assessment findings in Cushing's syndrome
fatigue, weakness, osteoporosis (remember too much glucocorticoids), muscle wasting, cramps, edema, increased blood pressure, purple skin striations, hirsutism, depression, decreased resistance to infection, moon face, buffalo hump, obesity (trunk), mood swings, masculinzation in females, blood sugar imbalance
what is common sign with crohns disease
fatty diarrheal stools
modified trendelenburg
feet elevated 20 degrees, knees straight, trunk flat, head slightly elevated increase venous return, used for shock
Anorexics are usually __________ under the age of _____.
females, 25
what are the 5 parameters of the biophysical profile?
fetal breathing fetal movement fetal tone amniotic fluid volume fetal heart reactivity
position
fetal presenting part to maternal pelvis angle of the head ROA LOA
amphotericin B (Fungizone) is given int. IV bolus of histoplasmosis ...what is an adverse reaction that needs to be notified
fever and chills are signs of an infusion reaction that requires intervention.
signs of infection in peritoneal dialysis
fever, bloody, cloudy or frothy dialysate return, drainage at access site,
when taking antiepileptic drugs what should the client report immediately
fever, sore throat, mouth ulcers, easy bruising, petechiae, unusual bleeding, abdominal pain, chills, rash, pale stools, urine, jaundice
what are the early signs of mumps?
few days of fever, headache, muscle aches, malaise, anorexia, swelling of salivary glands (possible earache)
what is the older adult deficient in
fiber, protein, total calories, iron, calcium, mg, vitamins D, B12 , B6
when you make a promise to a client and you keep it, what is that considered?
fidelity
mitral area
fifth intercostal space at the left midclavicular line
tympanic
filled with gas
first leopold maneuever
find the fundus with both hands
what does crisis intervention focus on?
finding the client's inner strengths to deal with the problem at hand
how do you use percussion on a person
firmly yet gently strike the chest wall with the hand cupped to make a hollow popping sound
what foods can cause allergies during breastfeeding and should be avoided
fish and peanuts
what is a sign of retinal detachment
flashes of bright light floating dark spots in the eye are symptoms of a detached retina
signs of retinal detachment
flashing lights loss of vision veil orcurtain being drawn across the eye
lithotomy
flat on back thighs flexed legs abducted increases vaginal opening for examination
tredenlenburg position
flat on back with pelvis higher than head, food of bed elevated six inches
attitude
flexion of teh neck arms and legs relationship of pars to one another
what position promotes contractues
flexion positions
The #1 contracture problem in AKA is ____________ of the _____________
flexion, hip
what does stage I lyme disease look like
flu like symptoms bulls eye rash muscle and ache and stiffness in joints
exudate
fluid and cells that accumulate in a wound present on a dressing
nursing care for a client with a basiliar skull fracture
fluid balance is monitored closely by daily weight, intake and output measurement serum osmolarity water retenion excessive dehyrdration child is maintained on NPO and clear liquid until it is known that vomiting wont occur
serosanguineous
fluid composed of serum and blood
bounding peripheral pulses is a sign of what when a person is receiving IV fluids
fluid excess
vesicle
fluid filled blister
patients on lithium should increase their daily
fluid intake to 2500-3000 ml /day
treatment of SIADH includes
fluid restriction, administration of demeclocycline, and treatment of hyponatremia.
person with acute glomeruolonephritis usually has what
fluid retention
if a pt is on a benzo what is the agonist what is it used for?
flumazenil (Romazicon) reverse sedative effects of BZs but not respiratory depression works within 30 to 60 seconds
what should you do if the central venous line does not aspirate blood but you don't meet resistance when infusing NS
flush the catheter with saline using a 10cc syringe and push pull technique 2. instruct the client to cough before reattempting to aspirate 3. initiate a declotting protocol per policy
when reprimanding a child what is appropriate action
focus on the behavior not on the child focus on I statement not You statements
when is laisssez-faire leadership appropriate
for a group of individuals who have inernal locus of control and desire autonomy and independence professionally mature and motivated
pilocarpine (pilocar) is a med for glaucoma, how long will the pt have to take it
for the rest of their life
gavage
forced feeding through a tube passed into the stomach
purpose of sucralfate (Carafate)
form a protective coating over the gastric ulcer
what does sucralfate do for peptic ulcers
forms a protective barrier over ulcer
fetid
foul
To lessen pain place the client in ___________ position.
fowlers (a sitting position) (also use post op)
characteristics of chronic bronchitis
frequent coughing, bronchospasms, copious sputum
harsh, grating sounds heard during inspiration are___ and common in
friction rub common in inflamed pleura or pericarditis
when placing a trochanter roll, position
from lateral aspect of of hip to mid thigh
postop ileaus
functional obstruction of the bowel
parenchyma
functional portion of the kidney
what is an effective medication to relieve limb pain after an AKA
gabapentin (Neurontin)
what immoglobulin would would give to client with SLE
gamma globulin can be given IV for Specific immune function
sausage, sauerkraut are examples of what kind of foods that a person with a new colostomy should not eat
gas forming
person comes in with weight loss and nausea and says my stomach hurts when i eat, what is this a sign of
gastric ulcer
cri du chat syndrome
genetic disorder involving a short arm on chromosome 5
what are HLA human leukocyte antigens
genetic markers found on chromosome 6 and are involved with many diagnosis of many autoimmune diseases and are also used for tissue typing
HMO
geographically organized system that provides enrollees with an agreed-on package of health maintenance and treatment services
what does phenytoin (dilantin) cause
gingival hyperplasia it is important to maintain good oral hyiene you need to use antiseptic mouthwash dental floss and gum massage
the goal of seclusion is
give the client the opportunity to gain self-control
glycosuria
glucose in the urine
unilateral lung disease what position
good lung down position the unaffected lung in a dependent position
what is the greatest risk after an aortic aneurysm resection
graft occlusion or dissection need to assess urine output
narcissistic prsonality disorder
grandiosity need for admiration lack of empathy
what is filgastrim (Neupogen)
granulocyte colony stimulating factor that produces by human DNA administer to clients with agranulocytosis to promote growth of neutrophils and enhance function of mature neutrophils
what drink should you not have with CA++ blockers
grapefruit is contraindicated
what juice do you not take simvastatin with
grapefruit juice
what foods are contraindicated for kids
grapes peanuts popcorn hotdogs avoid using honey to prevent botulism
how much dextrose may be used for a TPN
greater than 10%
On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100
greater, less than
what does the pt have to monitor or look out for when taking (zantac) rantidine for their GERD?
green sputum beccause it decreases the pH and increases the bacterial colonization in stomach and respiratory tract increased risk for pneumonia. need to report this sign to the HCP because it could be PNA
what is the best central access device to reduce heparin induced thrombocytopenia
groshong is a valved catheter that does not require heparin flushing
syndrome
group of symptoms
adverse effect of spironolactone
gynecomastia
what is an optimal site and manner of admin topical ointment of NTG
hair free site that is as close to body as possible rotate sites to avoid skin irritation prolonged effect up to 24 hrs use gloves and an applicator avoid scar tissue and lesions
what is Asterixis? and what organ disease is it a complication of?
hand flapping, associated with liver disease Hurst
once TPN is completed and new bag is not available what should be hung instead to prevent hypoglycemia
hang a 10% dextrose bag
what question do you want to ask someone who is exhibiting signs of GBS
have you had a viral infecction immunization vaccination lately
what position should the infant be in after a pyloromyotomy
head elevated and slightly on the right side to promote gastric emptying
Narcotic analgesic is contraindicated in what kind of injury, because it masks the signs of ____
head injury bc it masks the signs of increased intrancranial pressure.
what position do you put a client who has a break in their central line
head lower than their feet turn client to left side and place head lower than feet notify MD
how does prevention of a prolapsed cord happen
head should be engaged to prevent prolapse
when is NG suctioning a contraindication?
head surgery
what are signs of hyperosmolar state
headache nausea fever chills malaise
what are side effects of hydralazine hydrochloride (Apresoline)
headache (HAT PALS) angina tachycardia palpitations sodium retention anorexia lupus like syndromes (sore throat, fever, muscle aches, rash)
What are the top 2 side effects of nitro?
headache and hypotension
Managed care
health care plan that brings delivery and financing functions into one entity in contrast to a fee for service
Never apply __________ to the area of the appendix.
heat (it causes rupture)
what is the purpose of the spacer for an MDI
help deliver the medicine to the lungs
function of mono sat. fats
help maintain or lower blood cholesterol
for a patient taking epoetin alpha, the likelihood of hypertension and seizures increase if
hematocrit increases by more than 4 points in 2 weeks
what lab values do you want to watch with clozapine
hematological monitoring a weekly blood test is mandatory no exam no med monitors for agranulocytosis
what are you going to find in the urine culture for someone with pyelonephritis
hematuria pyuria bacteriuria leukocyte casts leukocytosis
hemoglobinuira
hemoglobulin in the urine
what is the highest priority of cirrhosis
hemorrhage due to impaired coagulation
carbamazepine (tegretol) is contraindicated with oral contraceptives bc
hepatic medication causes an acceleration inactivation of OC
what do you give someone who has been exposed to hepatitis B
hepatitis B immune globulin
Thalassemias
hereditary hemolytic anemias
An elderly client is a (high/low) risk for accidental poisoning? What about a school age child?
high - due to poor eyesight, high
roseola signs
high fever for 3 days which drops suddenly nonpruritic rash appears typically lasting 1 to 2 days high fever followed by a rash is a characteristic sign associated symptoms are cold symptoms, cough, and lymphadenopathy
what positions can cause hip flexion
high fowlers semi-fowlers
what is the best position for someone to be in with emphysema
high fowlers with hands in front of them on the bedside table this allows for better expansion of chest
what is one of the first signs of increased ICP in infants? other signs?
high pitched cry other signs include irritability, poor feeding, increased occipital circumference
what kind of foods should someone with cushings syndrome eat
high potassium because the pt will have hypokalemia client is instructed to consume food with high potassium
with Addison's disease, what kind of diet should patient consume?
high protein high carb high sodium low potassium
what kind of diet is reccommended for dumping syndrome
high protein eggs are encourage for a client with dumping syndrome
what kind of diet should a person be on if they have osteomyelitis?
high protein and high in calories. ex: milk, eggs, cheese, meat, fish, beans are the best source of nutrients
what diet should the person with a new colostomy be on after 6 weeks
high protein high carbohydrate
what are the symptoms of drug withdrawal in a baby
high-pitched cry hyperreflexia decreased sleep diaphoresis tachypnea excessive mucus vomiting uncoordinated sucking
what should be monitored for foscarnet?
highly toxic to the kidneys --monitor Creatinine normal is 0.5 to 1.2 for Cr will need to measure Cr frequently during therapy
pt develops hair growth on face and chest while taking phenytoin (dilantin) what is this
hirsutism
what is an associated finding of a pt with cushings
hirsutism
what is the most common cause of mitral valve problems?
history of rheumatic fever with a subsequent complication of carditis
urticaria
hives or wheals, eruption on skin or mucous membranes
check per shift
how often to you check placement
pharmacokinetics
how the body absorbs, distributes, metabolizes the med
distribution
how the drug moves through the body from the absorption site to action site
which of the following occurs when staff members physically control the client and move him or her to a seclusion room
human restraint
kyphosis
hump back concavity of spine
what is a sign of hyperparathyroidism
hypercalcemia occurs with hyperparathyroidism and causes osmotic diuresis
what ECG is associated with prolonged PR interval and widened QRS complex
hyperkalemia
what do you have to do prior to ventilation in order to maintain oxygenation
hyperoxygenate the pt
when a person is on an MAOI they should not take foods with tyramine in it because it will lead to what (Nardil) phenyzine
hypertension and other complications
over the counter medications could cause ____ if taken with MAOI's.
hypertensive crisis Hurst
what is the tonicity of fluid instilled in peritoneal dialysis?
hypertonic dialysate solution
with pyrazinamide what could occur?
hyperuricemia resulting in acute gout symptoms such as severe pain in big toe **impt to d/c drug normal uric acid=3.5-7.5
it is important to remember that metformin does not cause
hypoglycemia
slowed rate of infusion can result in what
hypoglycemia d/t delayed pancreatic reaction in insulin requirements
The typical electrolyte abnormaly associated with bulimia is, and which type of acid/base imbalance?
hypokalemia and metabolic alkalosis Hurst
what are metabolic factors that increase the risk for someone to have renal calculi
hypoparathyroidism -- renal tubular acidosis elevated uric acid levels defective oxalate metabolism excessive vitamin D or Ca++ intake
methyldopa (Aldomet) can cause what in clients with chronic renal failure if the dosage is not adjusted properly
hypotension
what are side effects of benzodiazepines
hypotension dry mouth ataxia dizziness drowsiness nausea
when a client is under epidural opioid anesthesia.. what do you look out for?
hypotension - drop in BP crushing headache 1mL < of fluid or blood is aspirated from the catheter before a bolus injection
CCB SE
hypotension, palpations, tachycardia, rash, flushing, peripheral edema, dermatitis, headache, nausea, dizziness, constipation
what part of the brain controls NREM
hypothalamus
what is a complication of radioactive Iodine therapy for hyperthyroidism?
hypothyroidism
<95%
hypoxia
second leopold maneuver
identifies the back of the fetus
fourth maneuver
identifies the cephalic prominence
third leopold maneuver
identifies the presenting part where the fetus is positioned
what kind of diet and nutrition care does someone with Guillan Barre syndrome have
if client can swallow -- assist with small frequent feedings of soft food weigh client weekly check electrolyte status provide mouth care every 2 hours
after a total join replacement of the hip, if the leg is positioned ____, it indicates dislocation of prosthesis
if the leg is outwardly rotated
reticulocyte
immature RBC
onset of anaphylactic reaction to blood transfusion
immediate
when should metformin be taken?
immediate release tablets 2x/day, w. bfast, and dinner. and sustained release tablet 1x/day w dinner
onset of Acute hemolytic reaction
immediately
when is the communicability of mumps the greatest?
immediately before and after swelling begins
what is the leading cause of problem with Buck's traction?
immobility
what is the most important aspect of food preparation for client with AIDS
immunocompromised and food safety is an important concern
what do you give to people with hep A
immunoglobulin A
cyclophosphamide (cytoxan) azathipine (Imuran) are used for what conditions
immunosupressive agents for autoimmune disorders such as SLE flare ups to control immune response pt is at risk for myelosuppression watch out!
why is Asparaginase (Elspar) contraindicated for pancreatitis
impairs pancreatic function
in third trimester of pregnancy, if pt complains of epigastric pain, it is a sign of
impending convulsion
pt has hypocalcemia what do you do
implement seizure precautions
When will phantom limb sensation subside?
in a few months
in C-Section, compared to general surgery, what is the difference in pre-op medication?
in c-section, less narcotic is used to avoid cross of med over placenta to baby
A 10 on the apgar means the baby is
in terrific health
remember that Compazine should be considered _______in a syringe with all other medications
incompatible
pt is on phenytoin, what education would you tell him/her
increase dentist visits b/c phenytoin causes hyperplasia of the gums
what can happen if the hematocrit rises to quickly
increase in BP, HTN, seizures
early sign of hypoxia
increase in HR to improve cardiac output
what is associated with SIADH
increase in water retention, dilution of sodium, hyponatremia
does alcohol increase or decrease triglycerides
increase level of triglycerides
what is the purpose of turning the mom on her left side during labor
increase uteroplacental blood flow
are CEA elevated or decreased in people with colorectal cancer
increased
what are withdrawal symptoms of benzodiazepines
increased anxiety, flulike symptoms, tremors
pt is taking epoetin alfa (Procrit) what should you monitor?
increased blood pressure b/c HTN and seizures can result if the hematocrit rises to quickly
what nursing interventions are appropriate for someone with herniated lumbar disk
increased fluid intake increase dietary fiber decrease pressure
why do you want to report a high blood pressure after a CABG
increased in vascular pressure places pressure on incision site
what are late signs of Increased ICP
increased temperature changes in vital signs "late signs" indicates the pressure has INCREASED severely. "INCREASE" icp= "INCREASE" temp + vital sign changes!
what are symptoms of Diabetes insipidus
increased thirst and urination
Beta 1
increases HR, inotrophy (forced contraction of heart), increased AV, increased renal renin secretion
feet and leg elevated
increases blood return to heart relieves pressure on the lumbosacral area
education about IM route
increases infection rate oral route is the safest absorbed quickly because in muscle it is highly vascular increases risk of reaction d/t rapid absorption rate
elevation of the extremity
increases venous return increases blood volume to extremity
head elevated (fowlers)
increases venous return allows maximal lung expansion
cheyenne-strokes respirations
increasing dyspnea with periods of apnea
remember that in NCLEX lnd, we want to keep patient's, especially the elderly as _____ possible
independent
high alarm sound on ventilator
indicates a need for suctioning or kinking/compression of ET tube
what does disturbed thought processes
indicates a state of increased anxiety in which hallucinations and delusions previal
pt with a collapsed lung due to an accident and has no drainage noted on the previous 8 hours .... what does this mean?
indicates resolution
knee-chest position
inface down position resting on knees and chest
9 months expected finding
infant is able to pull him/herself into a sitting position
solitary play is seen at what age?
infants
patients with lymphedema are at high risk for
infection
An aneurysm can result from an _____________ and from ____________.
infection, syphilis
cystitis
inflammation of the bladder
what is chronic bronchitis?
inflammation of the bronchi and bronchioles due to chronic exposure to irritants
pyelonephritis
inflammation of the pelvis and parenchyma
Peritonitis
inflammation of the peritoneum
prostatitis
inflammation of the prostate
urethritis
inflammation of the urethra
Apendicitis is an _________ of the appendix due to __________.
inflammation, obstruction
clients rights according to the bill of rights
info disclosure choice of providers/ plans access to ER services participation in treatment decisions confidentiality complaints and appeals consumer responsibilities
how is Dupuytren contracture contracted
inherited autosomal dominant trait
myelosuppression
inhibition or destruction of bone marrow
postop pyloric stenosis
initiate small frequent feedings of clear liquids 4 to 6 hr after surgery follow strict diet and gradual advancement of feedings until normal formula is resumed assess incision for redness, swelling, drainage, immediately report signs of infection to HCP monitor VS q 4 hr
like blood products being infused what type of tubing should be used for TPN
inline filter
what should you do prior to hanging the bag of TPN
inspect the bag of solution for particles prior to hanging
borderline personality disorder
instability in interpersonal relationships self image and affect marked impulsivity
when obtaining a urine culture and sensitivity for a client with symptoms of a UTI you do what
instruct the client to initiate the flow of urine before collecting the specimen pass into a sterile container into the urine stream after initiating the flow
what two meds may be added to TPN solution to prevent problems
insulin and or heparin
What is the top priority in the care of the client with anorexia nervosa?
intake of enough food to keep them alive, have them gain weight
what is the action of antineoplastic meds?
interferes with rapidly producing cell DNA
NPH is what kind of insulin, and has a peak action of ___
intermediate-acting and has peak action of 6-12 hours
what is the plan for someone with Guillain-Barre syndrome
intervention is aimed at symptoms use steroids in acute phase plasmapheresis aggressive respiratory care prevent hazards of immbolity maintain adequate nutrition physical therapy pain reducing measure eye care prevention of complications (UTI, respiration) psychosocial support
stop the transfusion infuse normal saline through new tubing at a slow rate
interventions when adverse reaction noted:
Flagyl used to treat what?
intestinal amebiasis, trichomoniasis, inflammatory bowel disease
carbon dioxide can have a vasodilation effect on the body and can increase what
intracranial pressure
pt has grey-blue discoloration in periumbilical region... what does this mean
intraperitoneal bleeding
what is an arteriogram used for?
involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels CT scanning velocity of blood flow is determined by ultrasound
oculogyric crisis
involves painful twisting and turning of the head and neck
Sodium Hypoclorite (Dakin's) solution is used for a purulent wound, how do you administer
irrigate the wound
what are signs of metabolic alkyalosis
irritability or nervousness
End Stoma
is formed when the proximal end of the bowel is brought to the outside abdominal wall. -Permanent
A 0 on the apgar means the baby
is stillborn
what precautions do you put a child with bacterial meningitis in?
isolation near the nurses station until the child can receive 24 hrs of antibiotics
quadricep setting and gluteal setting
isometric exercise used for cast care of an affected leg to reduce skin breakdown
why can't you drink beer while on metronidazole (flagyl)
it can cuase disulfiram like reaction severe vomiting, hypotension, weaknesss
what is the purpose of using an infusion pump for foscarnet admin?
it is toxic to the kidneys and it cannot be infused too quickly
symptoms of mild allergic reaction to blood transfusion
itching, urticaria, flushing
when should you get a trough level for gentamacin?
just before the admin of the next I.V. dose
fidelity
keeping faithful to ethical principles and ANA code of ethics for nurses
what is the objective after a lumbar laminectomy
keeping the back straight
after a craniotomy why do you want to elevate the hob 30 degrees
keeps head in the neutral position and promotes venous drainage
is foscarnet toxic to the liver of the kidneys?
kidneys
woman has a prolapsed cord, what position do you put her in?
knee to chest
judiasm meals
kosher and poultry no pork, shellfish, fishlike mammals do not consume milk or dairy at same meal with meat or poultry (forbidden)
what respirations are associated with DKA
kussmual respirations deep and rapid
what is a main characteristic of Narcisistic personality disorder?
lack of empathy
when a pt has occasional atrial contractions and HR 88/min what is this assoc. with
lack of sleep and caffeine intake
what is an adverse rxns of metformin and what are its manifestations?
lactic acidosis: manifested by drowsy, hyperventilation, muscle pain
What is found over the body of the client with anorexia nervosa?
lanugo
diuresis
large amount of urine voided
laparotomy
large incision through the ABD wall to gain access to abdominal cavity aka celiotomy
what is an Ewald tube?
large, orogastric tube designed for rapid lavage. insertion can cause gagging and vomiting, and suction must be available for reduction of aspiration risk
what are complications of tracheostomy
laryngeal nerve damage bleeding infection
what complications should you look out for after a thyroidectomy
laryngeal nerve injury thyroid storm hemorrhage respiratory obstruction tetany
complication within 24 hrs of total thryroidectomy
laryngeal stridor
stages of birth first stage
latent active transition
pt that was recently intubated is at highest risk for
layrngeal spasm can be caused by irritation of the presence of the intubation tube in the glottis
low pressure sound on ventilator
leak disconnection manually ventilate client if alarms sound without apparent cause
abandonment
leaving an assignment without proper notification and approval
what position is client to be in if air embolism occurs during TPN
left trendlenberg
competency for psych mental health settings
legal determination that a client can make reasonable judgments and decisions about treatment and other significant areas of personal life considered competent unless court rules otherwise
what should the Blood Sugar maintained while on TPN
less than 200 mg/dL
what are some manifestations of hypothyroidism
lethargy sensitivity to cold dry skin weight gain depression "everything slow's down"
what are mild CNS changes d/t mild toxicity of lithium?
lethargy, decreased concentration, slight muscle weakness, coarse hand tremors, mild ataxia
infant with pyloric stenosis is expected to display which findings?
lethargy, dehydration, malnourishment "child is fussy and seems to be hungry all the time"
what are antineoplastic meds used for?
leukemia multiple myeloma
what labs are associated with acute pancreatitis
leukocytosis hyperglycemia 500 to 900 mg/dL elevated amylase for 48 hrs elevated lipase for 5 to 7 days increase in urinary amylase
when you observe a person with a suspected personality disorder what do you want to assess
levels of function in areas of affect, cognition, behavior (impulse control), sociocultural adaptation (interpersonal relationships)
pediculi, pediculosis
lice
which medication is the drug of choice for Premature ventricular contractions occuring in excess of 6-10 a min
lidocaine
What is myxedema coma?
life threatening condition that occurs if hypothyroidism is not treated
if beta blocker is discontinued abruptly, what can occur?
life threatening dysrhythmias, hypertension, or myocardial ischemia.
tension- lets air in, not out mediastinal shift (no venous return to heart)
life threatening pneumothorax: dangerous sign:
hormone replacement for addisons disease may be (time frame)..
lifelong
person on simvastatin (zocor) asks how long they have to be taking the med
lifelong. otherwise the cholesterol levels will go back up
what color clothing should you wear to prevent ticks biting you
light color so ticks can be seen easily
what is an adverse effect of dig and lasix
light headedness
what do you do for someone with graves disease or hyperthyroidism
limit activities to quiet and provide frequent rest periods advise light , cool clothing avoid stimulants use calm and unhurried speech administer anithyroid med irradiation with I131 PO
why id lindane contraindicated for seizure disorder
lindane can penetrate intact skin and cause seizures if absorbed in sufficient quanitities do not use on peds
what is the only solution to be able to piggyback a TPN
lipids
exposure to lye causes what
liquefaction necrosis exposure to fat results in formation of soapy coagulum
when checking NG tube placement, it is not appropriate to
listen as air is introduced into NG tube
lithium carbonate brands
lithane eskalith Lithobid
what are common mood stabalizing drugs
lithium carbonate carbamazepine (tegretol) lamotrigine (lamictal) divalproex (valproic acid, depakote)
how to ID the left dorsogluteal site for IM injection
locate the lower edge of the acromion and the midpoint of the lateral aspect of the arm
glargine is what kind of insulin?
long acting-with no peak
what do clients with chronic pancreatitis need long term
long term pancreatic replacement
what is a non stress test
looks for acceleration in FHR in relationship to fetal activity.
Clients with AIDS (gain/lose) weight?
lose
what is a classic sign of cataracts?
loss of acuity of vision
anorexia
loss of appetite
amnesia
loss of defective memory
what is a classic sign of glaucoma?
loss of peripheral vision
what is a hallmark sign of air embolism of TPN
low BP and churning heart murmur
what is an indicator of ARDS
low arterial oxygen levels that are not responding to the administration of high concentration of oxygen
what kind of diet is appropriate for pt diagnosed with crohns disease
low fat high protein low residue non irritating high in calories minerals
if abdominal wound dehisces, the best position for the patient would be
low fowler's with legs bent up to abdomen to relieve pressure from wound
the rationale for the rooms being maintained at a cool temperature with low humidity is becuse
low humidity reduces the risk of fires in the surgery secondary to volatile anesthetic agents being used
preoperatively for parathyroidectomy, what kind of diet is recommended
low in calcium high in phosphorous the KEY here is "PRE-operatively."
how do you minimize chances of baby having phenylketonuira
low protein diet , restricts the exposure to phenylaline
symptoms of Meniere's disease is usually controlled by adhering to what kind of diet?
low sodium, no caffeine, nicotine, or alcohol
Rhonchi
lower-pitched sounds like snoring or rattling, secretions in larger airways (pneumonia, bronchitis, aspiration)
Wheezes
lungs clamping down (Asthma, Emphysema)
when asking a pt with acute pancreatitis what position makes it better or worse, what does he say
lying down makes it worse sitting up makes it better sitting forward and flexing my knees fetal position
dorsal recumbent
lying on back, knees flexed and apart
these two blood tests, if abnormally high, may indicate problems with glucose or protein metabolism or excess lipids
lymphocyte, liver function
what electrolyte is spinach high in
magnesium
nursing care for pyloric stenosis prior to surgery
maintain NPO status monitor I&O q hr admin IV fluids and electrolytes PRN maintain NG tube patency and monitor NG output keep warm and quiet
postop care for laryngectomy
maintain airway pain mangement appropr nutritional support teach client how to care for trach and feeding tube communicating devices
function of polysaturated fats
maintain blood cholesterol
what are the outcomes for TPN goals
maintain fluid, electrolyte, and weight
confidentiality
maintaining the clients privacy by not disclosing personal information about the client
examples of nurse-sensitive indicators
maintenance of skin integrity pressure ulcer prevalence and incidence fall injury rate medication incident rate restraint utilization rate client satisfaction with pain management client satisfaction with overall nursing care nursing satisfaction
what is important to monitor after a contraction stress test is over
make sure the contractions have ceased
what id dantrolene (dantrium) given for
malignant hyperthermia 2 to 3mg/kg to reverse malignant hyperthermia
edema is a manifestation of
malnutrition--> decreased protein serum protein levels cause fluid to move into interstitial space.
can mammograms detect breast cancer before lumps? yes ..how far in advance
mammograms can detect a lesion the size of a pinhead a lump is about 2cm before it can be detected by a bse
MOA of buspirone
manages anxiety binds to serotonin and dopamine receptors and increases norepinephrine
trigeminal neuralgia
manifested by pain that begins suddenly and lasts anywhere from seconds to minutes "stabbing or similar to an electric shock"
angle of louis
manubrial sternal junction at the second rib
when doing percussion on a person with lung cancer, what are you going to hear?
masses in lung will sound dull or flat on percussion
Russells traction
may reduce fractures of the hip or femur person has a trapeze, a sling for leg and pillows underneath used a system connected to the bed
what meds help control symptoms of menieres disease
mclizine antivertigo and antiemetic
what should you do when caring for a pt with portal systemic shunt
measure abd daily to determine if the ascites has gone down
nurse sensitive indicators
measurements of client care that are impacted by nursing interventions
what is biophysical profile? what is it used to measure?
measures 5 parameters to assess the fetus fetal breathing fetal movement tone amniotic fluid volume fetal heart reactivity test uses a scale of 0 to 2 for each parameter with a maximum socre of 10
process indicator
measures an activity that is carried out for cleints nature and amount of nursing care
Heart Aorta and great vessels Esophagus Trachea Thymus
mediastinum contains:
in what sex, age and cultures does Dupuytren contracture occur in?
men over 50 years old, of scandinavian or Celtic descent
what are side effects of tamoxifen
menstrual irregularities hot flashes* vaginal discharge anything associated with the effects of anti-estrogen
what kinds of diseases puts client at risk for degenerative joint disease?
metabolic diseases (diabetes, Paget's disease) and blood disorders (hemophilia)
normal magnesium levels normal phosphorous levels
mg. 1.5-2.5 phsphrs. 2.5-4.5
where is the loudest area that you can hear the s1 sound?
mitral area
what sign is an indication to suction
moist wet respirations restlessness rhonchi on auscultation visible mucous bubbling increased pulse and respiratory rates and increased peak respiratory rates on the ventilator
what are 2 systems you need to monitor aggressively for Guillan Barre syndrome
monitor Respiratory status rate, depth, breath sounds, vital capacity, note secretions, gag reflex, cough and swallowing monitor cardiac status: HR, BP, dyrhythmias
What actions should the nurse take when caring for a pt after intracranial surgery
monitor VS hourly elevate the hob 15 to 30 degrees to promote venous drainage from brain avoid neck flexion and head rotation by supporting it with a cervical collar and neck rolls reduce environmental stimuli prevent valsalva maneuver teach client to exhale while turning or moving to bed admin stool softeners restrict fluids to 1,200 to 1,500 ml/day
what is the greatest risk that you need to watch out for .. pt with amyotrophic lateral sclerosis
monitor pulse oximetry findings monitor respiratory compromise d/t progressive paralysis of respiratory muscles.
how often should a man perform a testicular self-examination
monthly basis after showering to allow for easier palpation
amoxicillin-clavulanic acid (Augmentin) is given together because
more effective antimicrobial spectrum of penicillin is extended by adding a beta-lactamase inhibitor
report an increased weight of _- per week due to possible fluid overload or retention
more than 3 pounds per week
PI's (Protease inhibitors)
most potent of antiviral meds, inhibit cell protein synthesis that interferes with viral replication, does not cure but slows progression of AIDS and prolongs life, used prophylactically, used in AIDS to decrease viral load and opportunistic infections
fixed
motionless
what should the client be able to do before being dc from the PACU
move all four extremities
rotation
move in a circular pattern
what does the pt taking tranylcypromine (parnate) need to know
move slowly when changing positions because orthostatic hypotension is common side effect avoid things that can cause dizziness or falling
dystonia
muscle rigidity
what is myasthenia gravis
muscular weakness produced by repeated movements, which is relieved by rest
what do you need in order to relieve bladder if the person has an internal ileal reservoir
must insert a catheter through your stoma to drain the urine
what is an adverse effect of simvastatin (zocor)
myopathy
pt is taking simivastatin and has muscle pain... what does this mean
myopathy this is an adverse effect. contact HCP
pt is taking dextroamphetamine (DextroStat) for what condition
narcolepsy
what are side effects of desmopressin nasal spray
nasal congestion headache
what are examples of enteral routes
nasogastric nasointestinal percutaneous
what is an action that is contraindicated in a child with a basilar skull fracture
nasotracheal suctioning
what are common side effects of lithium therapy (you don't need to report these side effects)?
nausea dry mouth diarrhea thirst mild hand tremor weight gain bloating insomnia light-headedness
adverse effects of the acoustic nerve vestibular branch
nausea vomiting ataxia
signs of pancreatitis
nausea vomiting abdominal pain
what are side effects of atomoxetine
nausea and dizziness
symptoms of hyponatremia
nausea, increased ICP, headache, convulsions, lethargy, apprehension, muscle twitching, diarrhea, fingerprinting of the skin
myopia
near sightedness
what is nuchal rigidity?
neck stiffness
pt did not receive med on time, what do you do
need to write an incident report
malpractice
negligence by a professional professional failure to carry out/ perform duties that result in injury to another, acting outside one's scope of practice
what can aminoglycoside antibiotics do ex. gentamicin (garamycin)
nephrotoxic aminoglycoside-induced nephrotoxicity can cause acute tubular necrosis
what is an adverse reaction of taking cyclosporine (Sandimmune)
nephrotoxicity
what labs are associated with GBS
nerve conduction results are diminished elevated protein in CSF
reticular lesions come in what appearance
net appearance
fixed and dilated pupil represents a
neurological emergency
dysthymia
neurotic depression same symptoms of depression but less severe and lasts longer
what position should the head be kept in after intracranial surgery
neutral position
when using pursed lipped breathing, breath should
never be held
refreezing in management
new goal becomes established as an expected outcome
what should you educate to the mom before performing the PKU test on the child
newborn should have intake of formula or breast milk 24 prior to screening so that there is sufficient protein intake
how do you suspect pemphigus vulgaris
nicolskys sign top layers of skin slip away from the lower layers when slightly rubbed with a finger
Define azotemia?
nitrogenous wastes in the blood (increased creatinine, BUN)
do clients contaminated with radiation pose a risk to medical personnel?
no therefore, its okay to treat client before "decontamination process." however, must still wear protective gear while caring for pt
Are all articles used by AIDS patients double-bagged?
no - only those contaminated with secretions
what is not to be added to TPN solutions
no blood or meds
requirements for organ donation
no history of significant disease process in organ/tissue to be donated no untreated sepsis brain death of donor no history of extracranial malignancy relative hemodynamic stability blood group compatibility newborn donors must be full term 200 mg < CANT = HIV infected family members can give consent
with a tracheostomy in place, the inflated cuff pressure should be
no more than 20 mmHg
do you discard the last voided specimen prior to ending the collection
no you collect all the urine voided during the time period
If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing?
no, bedrest until the client is stable!
can you take live vaccines if you are on gluococorticoids
no, wait until you have completed the therapy
which ethical principle focuses on the duty to do no harm?
nonmaleficence
phytochemicals
nonnutrient chemical substances found in plants that may correlate with health benefits in disease tx and prevention
what are signs and symptoms of wilms tumor
nonspecific symptoms abdominal swelling abdominal mass abd pain fever blood in urine
90+ age to age 40/60-85
normal BP for adult female
100+ age to age 40/60-85
normal BP for adult male
80+ 2age/ 2/3 sys.
normal BP for child
60-105
normal P for adolescent
60-80 bpm
normal P for adult at rest
90
normal P for elderly at rest
100-180
normal P for newborn at rest
fluctuation of level of water in water seal chamber means
normal function
97-100%
normal pulse ox
what is the normal range for saliclates and why do you monitor them
normal range for ANA or salicylates is 10 to 20 mg/dL and you monitor it for RA
8-24 bpm (ave 12-20)
normal respiratory range at rest for adult
12-20 bpm
normal respiratory rate at rest for adolescent
30-60 bpm
normal respiratory rate at rest for newborn
20-30
normal respiratory rate at rest for toddler
pt is on exenatide (Byretta) for DM II and experiences abdominal pain? what should you do
notify HCP immediately sign of pancreatitis
what is nicolskys sign
noting skin blistering and sloughing after application of lateral finger on the epidermis
signs of meningeal irritation
nuchal rigidity kernigs sign-when hip flexed to 90 degrees, complete extension of the knee is restricted and painful Brudzinski's sign-attempts to flex the neck will produce flexion at the knee and thigh opisthotonic position-extensor rigidity with legs hyperextended and forming an arc with the trunk
the triad of meningitis
nuchal rigidity, headache, photophobia
liability
nurses are responsible and accountable for incorrect / inappropriate actions or inactions
what is a risk for a toddler since they have food jag
nutritional deficiences b/c they only prefer certain foods. try to give balanced meals
what is an NSI?
nutritional screening initiative
what is the treatment for thrush
nystatin (myocstatin) hand washing
no fluctuation in water seal chamber means
obstruction
what do you monitor during an amniotomy
obtain FHR before and after assess color, odor, consistency of amniotic fluid check maternal temp q 2 hr notify HCP if temp is 100.4 <
gastroschisis
obvious protrusion of abd contents present at time of delivery
periodic accelerations indicate
occur with contractions and can indicate decreased amniotic fluid or mild umbilical cord compression
early deceleration
occurs at the beginning of a contraction
palliative
offering temporary relief
how often do you monitor HR and BP if pt is on IV of NTG
often as q 5 to 10 min.
what is medicare for?
older adults
if a person is in acute renal failure,do you see oliguria or diuresis
oliguria first and then diuresis kidneys cant filter because to many objects, then they fail and then stuff comes through so diuresis with everything is when you will see it all come out
prone
on abdomen face turned to one side
when do you begin to rehabiliate someone
on admission
pt is on thryoid replacement therapy, how should he take his meds
on an empty stomach
when administering ferrous sulfate (Feosol) how should you administer it?
on an empty stomach to enhance absorption
lithotomy position
on back buttocks near edge of table knees flexed and seperated
sims position
on left side left arm behind back leg leg slightly flexed right leg slight flexed
if pregnant pt, after receiving epidural, experiences hypotension, what position should the pt be placed in?
on the side with legs flexed
pt asks, if i have a PICC in can I still be active with it in
only minor activity restrictions apply to this type of catheter
what meds are given to someone with pancreatitis
opioids for severe pain antiemetics for N/V gastric protection h2 blockers to decrease gastric secretions and reduce strain and secretions for pancrease antispaspasmodics electrolyte replenishment d/t alt. electrolyte imbalances d/t pancreas insulin for hyperglycemia antibiotics for infection
what is a major adverse effect of ethambutol? and what would be its initial sign?
optic neuritis with reduced visual activity lessened ability to see green could be an initial sign
what is a predisposing factor for developing candiddiasis
oral contraceptive predispose individuals to candidiasis
a female client asks about forms of birth control, has SLE what do you say to her
oral contraceptives that fluctuate with estrogen levels can increase your risk for flare ups but you can use condoms and diaphragm
KAYEXELATE is contraindic with ___ juice
orange
Rifampin (Rifadin) causes what in pt
orange discoloration of sweat, tears, urine, and feces. people who take Rifampin are obviously giants fans!
Put in order: 1.explain the procedure to the client 2. obtain the clients vitals 3. assess that the client has a blood bank id armband 4. obtain the prbcs from the blood bank according to hospital policy and perform a visual check of the blood 5. perform a beside id and blood product verification by 2 license nurses 6. verify the physicians order 7. prime the transfusion tubing with a 0.9% sodium chloride solution
ordering goes 6,3,1,2,7,4,5
high purine foods increase incidence of gout; what foods have high purine
organ meats, meat soups, gravy, anchovies, sardines, fish, seafood, asparagus, spinach, peas, dried legumes, wild game
case management
organizes client care by major diagnoses and focuses on attaining predetermined client outcomes within specific time frames
what is an expected finding with hypokalemia
orthostatic hypotension
side effects of mAOI
orthostatic hypotension edema weight gain reports of insomnia, anxiety , agitation, hypomania, even mania sexual dysfunction
side effects of demerol include
orthostatic hypotension, decreased BP, bradycardia
what meds will you admin. during post op for intracranial surgery
osmotic diuretics corticosteroid therapy anticonvulsant meds
In a patient who has an ileostomy, ____ are contraindicated
osmotic laxative, and enteric coated capsules-->cannot be absorbed in GI system
common side effects of prednisone
osteoporosis low serum potassium fluid retention hyperglycemia hypernatremia
children in a supine position for bottle feeding are at risk for what condition
otitis media the reflux of milk into the eustachian tubes during feedings
what is NOT a contraindication for an immunization
otitis media mild diarrhea cold
what is gentamyacin toxic for
ototoxic and renal toxicity not visual
living will
outlines medical treatment that the client wishes or refuses if the client is unable to communicate wishes at the time ex: intubation
multiple sexual partners increases risk for
ovarian cancer
with kidney stones, avoid foods that are high in
oxalates such as spinach, asparagus, and cabbage
pulse oximetry monitors
oxygen saturation percentage of O2 bound to hemoglobin compared to the volume of Hgb is capable of binding
what are the main causes of impaired mobility
pain motor/nervous system impairment functional problems generalized weakness psychological problems side effect of medication
How is the bleeding of Abruptio Placenta different from that in placenta previa?
pain and less voluminous in abruptio
what is the most common finding of a duodenal ulcer
pain is relieved with food intake
Before the client with suspected appendicitis sees the physician what should be avoided?
pain meds, enemas, laxatives, food! NPO
quality of pain refers to
pain sensation
dyuria
painful of difficulty urinating
Testicular Cancer S/S
painless firm lump. scrotal swelling, feeling of heaviness. dull ache in lower abdomen. acute pain-10%.
placenta previa is characterized by
painless vaginal bleeding
Hypoglycemia S/S
palpitations, tachy., sweat, fatigue, hunger
what do you have to monitor while pt is on Asparaginase (Elspar)
pancreatic function tests before therapy begins and then when a week or more has elapsed between dose admin.
pt is on Asparaginase (Elspar) and experiences nausea vomiting abd. pain what is this a sign of
pancreatitis
Asparaginase (Elspar) is contrainidicated for what condition
pancreatitis or hypersensitivity history of pancreatitis
what action decreases the need for the client to push during labor
panting
paraplegia
paralysis of legs
monoplegia
paralysis of one limb
what is toxoplasmosis
parasitic disease that is transmitted through feces of cats who have eaten mice and animals.
extrapyramidal side effects are
parkinsonism dystonia akathisia tardive dyskinesia
stuporous
partial unconsciousness
intact blisters is a sign of what
partial-thickness thermal injury
transurethral uroscopy
passage of ureteral catheter via cytoscope to drain urine proximal to a stone and dilate ureter, allowing stone to pass use of a basket catheter passed through cytoscope to remove calculus
a patient who has an oral airway in place can cough due to irritation of the airway and does not reflect
patient responsivness
do not give a cephlosporin to a patient with ___ allergy
penicillin
what are the 4 types of infusion therapy
peripheral central continuous intermittent
what type of line is used for PPN
peripheral line for ten days
what physiological changes effect the increase of heartburn during pregnancy
peristalsis decreases during the latter half of the pregnancy displacement of the stomach by the uterus increased secretion of HCL
Lung Cancer early sign
persistent hacking dry cough
who is hemodialysis contraindicated for
person who cant take anticoagulants the anticoagulants prevent clot formation
what should the pt do if the cast is rubbing on the clients skin
petal the edges with tape
what do you put over the colostomy when there is no pouch
petrolatum gauze over the stoma keep stoma moist cover with dry sterile dressing
If after a right BKA, the client c/o pain in his right tow, he is experiencing _____________.
phantom limb sensation (which is normal)
what kind of sensitivity does carbamazepine cause and how will you educate the client
photosensitivity wear clothing and sunscreen
what action should you take when a client has head and neck burns
pillows should not be used under the head or neck because it promotes neck flexion contractures
flushed
pink or hot
signs of pt with emphysema
pink puffer barrel chest pursed lip breathing accessory muscle use when breathing underweight appearance
what do you do when you notice opaque fluid coming out of the central line when there is TPN being infused
place the client head lower than his feet the trickling of fluid indicates a break in the line which places the client at risk for an air embolism
multiple myeloma is best detected with a ___ rather than __
plain radiograph rather than nuclear scan such as bone imaging study. false negatives could occur otherwise.
when a patient is on methotrexate one of the labs you need to monitor is...
platelet count and WBC with changes in the CBC . so CBC with a differential monitor the client for dyscrasias
what is interleukin 11 used to stimulate
platelet production for clients receiving chemo
crowning
point in time when the perineum is thin and stretching around the fetal head both between and during contractions delivery is imminent when crowning occurs
who do you report homicide, suicide, inflicted injury stab/ gunshot wound, abuse to?
police
in type 1 diabetes, what do we expect to see?
polyphagia polydipsia polyuria weight loss
why do you use the manufacturer tubing for NTG instead of regular tubing
polyvinylcholoride IV tubing can absorb 40% to 80% of NTG
when injecting insulin, failure to rotate sites results in
poor absorption of insulin, which increases blood sugar
how does an infant get exposed to thrush
poor handwashing or infected vagina during birth
what does an elevated ammonia level indicate
portal-systemic encephalopathy
after total joint replacement of the hip, how should the leg be position to avoid dislocation
position of abduction for 2-3 months
what is meperidine (demerol) used for
post op pain
in asians, best place to assess for jaundice is
posterior hard palate
primary concern with antipsychotic meds= in regards to BP
postural hypotension
ACE inhibitors promote retention of
potassium
what is cantaloupe, spinach, and potatoes high in?
potassium
instillation
pouring into a body cavity
what is the best way to find out if TPN is effective
prealbumin levels
what is the cause of Guillain Barre Syndrome
precipitated by a viral infection immunization fever injury and sometimes surgery it is when IgM anitbody targets the peripheral nerve myelin and damages myelin sheath and disrupts nerve conduction nerve remyelinzes in opposite direction of demyelination
food jag
preferring 1 or 2 kinds of food over all of the others
what do you want to educate a female client about SLE?
pregnancy and oral contraceptive increase risk for disease flare ups
associative play in which there are no group goals and there is often a leader is played at what age
preschool children
Hodgkin Lymphoma Dx
presence of Reed-Sternberg cells -Painful
heat indicates
pressure
intrapulmonary pressure
pressure in the lung:
feigned
pretended
what is the purpose of pursed lip breathing for an emphysema pt
prevent collapse of alveoli
what is the first goal of rehabiliation
prevent deformities
why do you support the head and neck and have a client in semi fowlers after post thyroidectomy
prevent flexion or hyperextension of suture line
why would you administer mannitol to a client with hypovolemic shock
prevent renal failure best indicator is to look at urine output and if it is above 30ml/hr
what is the leading cause of preventable mental retardation in pediatric clients
prevention of alcoholism
TPN prevents catabolism of this electrolyte from this tissue
prevents catabolism of protien from muscle or fat
what does alcohol do to the liver
prevents the liver from produce glucose. therefore the pt should consume carbodyrates while drinking alcohol to prevent hypoglycemia
signs and symptoms of pyloric stenosis
previously healthy infant progressive projectile, nonbilious vomiting movabale palpable firm olive shaped mass in RUQ
primary nursing
primary nurse designs, implements, and is acccountable for nursing care for clients with delegation of care to an associate nurse
menorrhagia
profuse menstruation
Diaphoresis
profuse sweating
giving a pt with dementia a bed bath, what do you do
progress through each aspect of the bath direct statements to limit the amount of incoming stimuli at one time promote comprehension and self-care
chronotherapy
progressively delaying bedtime by 1 or more hours each night is most commonly used to treat delayed sleep phase sleep disorder
false imprisonment
prohibiting a client from leaving a health care facility with no legal justification using chemical restraints or physical restraints without satisfactory clinical evidence of need
what is the risk with taking a benzo
prolonged therapy can lead to psychological and physical dependence need to restrict the amount to the client
filgastrim (Neupogen) is for a client with agranulocytosis to do what
promote growth of neutrophils and enhance the function of mature neutrophils
prone
promotes extension of hip joint not well tolerated by persons with respiratory or cardiovascular difficulties
If the patient had an AKA they should lie ____________ several times per day.
prone (to prevent flexion contracture
jacknife position
prone with hips over the break in the table and feet below level of head
what do you teach to someone with renal calculi
proper diet low in ca+, phosphorous, oxalates increase fluid 2500 to 3000mL/day exercise to reduce urinary stasis collect and strain all stones at home if able to and bring to follow up visit report increased pain, blood in urine, inability to void, sig. IO decrease report infection burning cloudy fever
if you are a woman and you have BRCA 1 or BRCA2 genes.. what is reccommended for you
prophylactic bilateral mastectomy for women
pt has asthma and is taking montelukast (singulair) when do they take it
prophylaxis of asthma exacerbation and should be taken on a daily basis in the evening
PSA age
prostate-specific antigen 50 and older
a patient is taking cyclosporine (Sandimmune) after a renal transplant, what for
protect kidneys and needs to be taken every day for the rest of their life.
risk management program
protect the client and the nurse from harm and organization from liability related to harm
If the AIDS patient has leukopenia they will be on _____________ ________________.
protective (reverse) isolation
knee- chest
provides maximal visualization of rectal area
what is a very high priority in clients with sickle cell crisis?
providing adequate hydration
what reflects patient responsiveness in client who has an oral airway in place
pt. responding to normal spoken voice.
who do you report communicable diseases to?
public health department
cylothorax
pulomonary lymph vessels disrupted by surgery or trauma can lead to abnormal accumulation of lymph fluid in plueral space produce fat malabsorption of GI tract
what is a sign of cardiac tamponade
pulsas paradoxus
CNS disorder, narcotics use
pupils constricted
cardiac arrest, drug use (LSD, amphetamines, cocaine)
pupils dilated
stroke, head injury, artificial eye, eye drops
pupils unequal
cardiac arrest, brain injury, drug intox/overdose
pupils unreactive
what kind of diet is used for a pt with dysphagia
pureed foods ground/minced meat soft/easy to chew foods modified general diet commerical thickeners for liquids
pyuria
pus in urine
Name ways to toughen a stump so it will not breakdown due to the wear of the prosthetic leg?
push the stump against the wall, hitting it with a pillow
upper urinary tract issues
pyelonephritis
how often do you change TPN tubing and filters
q 24 hrs
pt asks you, how often am i suppossed to replace the NTG tablets
q 3 to 6 months after opening each tablet should cause a slight stinging or tingling sensation when placed under tongue if fresh
how often should i check my glucose when i am sick, says a pt with DM1
q 4 hrs
What is the apgar scale?
quick objective way to evaluate the vital functions of the newborn
what is done during a MUGA
radioisotope is injected IV the procedure does not use radiopaque dye so you dont have to ask about allergies to iodine and shellfish
what is MUGA
radionuclide study used to detect myocardial infarction, decreased myocardial blood flow, left ventricular function
function of saturated fats on body
raise blood cholesterol
lispro is what kind of insulin? and what is its onset of action
rapid acting 5-15 min
pt is on hemodialysis, what can cause the client to have a seizure
rapid decrease in fluid the decrease causes cerebral edema and increased ICP and is a risk for seizures
elevated BUN can indicate
rapid protien catabolism kidney dysfunction dehydration
which foods can cause false positive readings in a Hemocult test?
rare meats, liver, poultry, turnips, broccoli, cauliflower, melons, salmon, sardines, horseradish Hurst
excoriation
raw surface
somogyi effect
rebound hyperglycemia that occurs in the response to a rapid decrease in blood glucose during the night
what is reccommended for a child who has rheumatic fever
receive prophylaxis antibiotc for the next 5 years to prevent reoccurrence
with ambulatory electrocardiography, if pt feels lightheaded, he should
record the event in the daily log
when should you administer mesalamine (Rowasa) to a client with ulcerative colitis?
rectally at bedtime to reduce the anti-inflammatory effect
lower GI series incudes
rectum sigmoid. descending, transverse, ascending colon this is barium enema!
what are signs of chronic pancreatitis?
recurrent epigastric pain, LUQ pain, anorexia, nausea, vomiting, weight loss, constipation, flatulence, and steatorrhea (fatty stools)
what is a common side effect of doxorubicin (adriamycin)
red colored urine
Niacin SE
red, flushed face, decreased by asprin or long-term use.
what does Metformin do?
reduces the production of glucose in the liver by suppressing glucogenesis --> it increases the muscles glucose uptake and use
what is the purpose of rotating the catheter when suctioning trach tube
reduces the risk of tissue trauma
in malnourished clients watch for this... a drop in potassium, magnesium and phosphate is called
refeeding syndrome
intensity of pain
refers to the strength of the amount of pain experienced rated mild to excruciating
when a pt states they can hear voices but know that they are not real and they are on haloperdol what does this mean
reflects that the medication is effective in decreasing the psychosis
Mydriasis
reflex pupillary dilation as a muscle pulls the iris outward
client has chronic renal failure BUN, K+, NA+ are all elevated what do you give pt.
regular insulin given IV with dextrose 10% in water can be admin for K+ to go back into cell.
what is Theophylline used for? and what is its class?
relax the bronchial smooth muscle-->resulting in bronchodilation class of methylxanthines
what are the therapeutic effects of desmopressin?
relief from polydipsia control of polyuria and nocturia in the client with Diabetes insipidus
lumbar laminectomy
removal of one or more of the vertebrae
mastoidectomy
removal of the mastoid bone or partially for chronic otits media is sometimes tx
what do you do if you have a tick embedded in your skin
remove gently with tweezer or the fingers
how are isolated lesions of karposis sarcoma treated
removed by excision cryotherapy local radiation for comfort
afterload
resistance of blood being ejected by left ventricle
home health nurse teaches the pt about id resources, provides info. makes referrels she acts as
resource for pt
what is the classic triad of symptoms of a barbituate OD? client took -arbital
respiratory depression coma pinpoint pupils hypotension / hypothermia
what do you need to monitor when a client is on a phenobarbital?
respiratory depression so watch the HR and the Respirations and BP
accumulation of CO2 is danger sign of
respiratory failure and cardiac arrest
accountability
responsibility of one's actions
what is a side effect of haloperdol?
restlessness
what is the purpose of acupuntcure
restore energy balance
pt with pheochromocytoma is schedule for vanillylmandelic acid test.. what should you educate the client on?
restrict caffeine intake 2 to 3 days prior pt can take Ibuprofen during collection period but Aspirin and antihypertensive should be avoided the first morning urine is discarded during the 24 hr urine collection. the test begins with the next voiding client is not NPO prior to the test
what happens when aldosterone is suppressed in SIADH
result in increase in renal excretion of Sodium 3rd spacing goes to interstitial spaces
cherry red, firm tissue is exposure to what...
result of thermal injury
azotemia
retention of excess nitrogenous wastes in blood
Impulsive behavior, Disorientation to person, place, and time, are associated with which side of brain?
right side
what is JVD a sign of in terms of HF
right sided HF
what are the 5 rights of delegation
right task right circumstance right person right direction/ communication right supervision
all of the following are civil rights afforded to all people recieving mental health care except which of the following? -right to send and recieve sealed mail -right to refuse treatment -right to have or refuse visitors -right to leave the hospital when involuntarily committed
right to leave the hospital when involuntarily committed
What is the first sign of appendicitis?
right upper quadrant pain
annular lesions are what shaped
ring shaped
a pt asks if there are any risk factors for d/t his occupational chemical exposures.. what do you say
risk for cancer
a client that has had an abdominal-perineal resection 3 days ago and complains of chills what is this a sign of
risk for peritonitis should be assessed for further symptoms of infection
what is the risk when inserting a PICC line
risk of a pneumothorax
how should a person with parkinsons initiate movement with bradykinesia?
rock back and forth to initiate movement
in clients with dementia, schedules should be
routine, reinforced, and repeated. flexibility in schedule can cause confusion
symptoms of heroin withdrawal
runny nose, yawning, fever, muscle and joint pain, diarrhea
what lab do you monitor on a regular basis
salicylates for RA normal range is 10 to 20 mg/dL
lindane is treatment for what condition
scabies
oliguria
scan urination less than 400 mL per 24 hr
cooperative play in which there are organized rules, and leader/follower relationship is played at what age
school age children
abraded
scraped
what is an alpha fetoprotein test for between 15 to 20 weeks
screen for neural tube defects such as spina bifida
pulmonic area
second intercostal space to the left of the sternum
aortic area
second intercostal space to the right of the sternum
when listening to heart sounds, aortic area is located in which intercostal space?
second, right next to sternal border. (i knew this)
what are the effects of nalbuphine
sedative effect and can slow the respiratory rate
treatment for blunt trauma to the eye
semi-fowlers position carbonic anhydrase (Diamox)
photophobia
sensitive to light
what is the most frequent cause of DIC
sepsis
home care definition
services for people who are recovering, disabled, chronically ill, and who need treatment or support the function effectively in the home environ.
symptoms of cocaine withdrawal
severe cravings, depression, fatigue, hypersomnia
what is electroconvulsive therapy used for?
severe depression and catatonic conditions with failed attempts at other treatment
burns on the abdomen, face, neck, and chest result in
severe edema, which could cause airway restriction
what is a contraindication for immunization
severe ferbrile illness
Aplastic Anemia
severe form of anemia that develops as a consquences of loss of functioning red bone marrow.
what are signs of adverse reaction to procanamide?
severe hypotension and bradycardia
<90%
severe hypoxia
clonic tumor
shaking with intervals of rest
defamation of character
sharing client information with a third party that results in damage to clients reputation; can occur in the form of slander (oral) or libel (writing)
glossy
shiny
when you think of adrenal insufficiency + weakness, think ___
shock!! think of what happens in addisons disease Hurst
Regular insulin is what kind of insulin and has an onset of action of_ ___
short acting onset of action 30-60 min
what is used to treat circadian rhythm sleep disorders
short acting sedative hypnotics
gentamycin is ototoxic
should have a vestibular and auditory check every 3 to 4 weeks after dicontiniuing the drug
outcome indicator
show impact of nursing care interventions
Diabetic Angina
sick to stomach/nausea Diaphoresis
hydroxyurea (Droxia) is used for what
sickle cell anemia
what is the assumed position for epidural patch?
side lying
what is abdominal pain a sign of if pt is taking exenatide (byretta) for their DMII
sign of pancreatitis
client taking desmopressin should report
signs of nasal ulceration congestion respiratory infection
contraction stress test
simulates labor and determines the fetal response to the labor process and the mothers contractions
what do you need to monitor with someone with DKA?
size of pupils and reaction to pupils to light response to verbal and painful stimuli skin condition and presence of any rashes, lesions, ulcers blood pressure hourly urine output
omphecele
size of sac varies depending on extent of protrusion rupture of sac results in evisceration of adb contents
Kaposi's sarcoma is a cancer of the ___________.
skin
what dignostic confirms pemphigus vulgaris
skin biopsy
photosensitivity
skin reaction cause by exposure to sunlight
patients who are to under go electroencephalogram must be EEG
sleep deprived
how should a person with a herniated lumbar disk get out of bed
slide near edge of mattress roll on to one side push self up from bed using 1 or both arms keep back straight and swing legs over side
in myxedema coma the body systems
slow down
what is Dupuytren contracture
slow progressive contracture of the palmar fascia causing flexion of the fourth and fifth fingers;
epigastric abdominal distention means what
small bowel obstruction
To determine the heart rate for a regular rhythm, count the number of
small boxes between two R waves; 1,500 divided by the number of boxes between two R waves equals the heart rate.
percutaneous nephrostomy
small incision in flank endoscope to visualize renal pelvis stones removed with forceps or a basket device lithotripsy is used to crush stones
petchia
small rupture of blood vessels
what are predisposing factors for emphysema
smoking chronic infections environmental pollution
stertorous
snoring
goodells sign
softening of the cervix begins at the 2nd month of gestation as a result of increased vascularity and hyperplasia
signs of agranulocytosis
sore throat, fever, malaise,
paroxysm
spasms of convulsive seizure
what is best way to feed client in a spica cast
special table
Western blot
specific confirmatory antibody test for presence of hiv in blood
left hemisphere of brain controls
speech, math skills, analytical thinking
when can a person have sex after a vasectomy
sperm analysis will be performed every 4 to 6 weeks a sperm free analysis is necessary before the man can be considered sterile
baclofen is treatment for what problem
spinal cord injury
hemoptysis
spitting up blood
strabismus
squinting
during client care for cutaneous anthrax, what kind of precaution should be observed?
standard
decreased level of HCO3 can indicate
starvation renal failure diarrhea
definition of psychosis
state in which a persons mental capacity to recognize reality and communicate and relate to others is impaired, thus interfering with the persons capacity to deal with life's demands
what do you do when a client is experiencing a flashaback
stay with the client and offer reassurance, present reality in a nonthreatening manner to minimize the clients anxiety and agitation
what is an expected finding of the chest after CABG
sternal instability
trimethoprim/sulfamethoxazole (Bactrim DS) what do you have to watch out for
steven johnsons syndrome
ankyloses
stiff joints
what is kindling
stimuli from an earlier injury may eventually elicit seizure activity
why tell the client to taper the dose and not abruptly stop taking valproic acid?
stopping the med abruptly can cause seizures
how is TPN solution stored
store in fridge
what do you do for someone who has suspected renal calculi by sudden onset of severe right flank pain
strain all his urine through several layers of gauze
what kinds of incontinence are there
stress reflex urge functional
what are potential causes for psoriasis
stress trauma infection hormonal changes obesity autoimmune reaction climate changes genetic predisposition exacerbated by certain meds
what foods to avoid if the client has dysphagia
stringy, raw, dry, fried foods, those that are small in size or hand held, popcorn, nuts, small candies
By what route do you take nitro?
sublingual
dissociative disorders characterized by
sudden or gradual disruption in the integrative functions of identity, memory, or conciousness,
signs of a pneumothorax
sudden sharp pain with breathing or coughing on the affected side, tachpnea, dyspnea, diminished or absent breath sounds on the affected side tachycardia, anxiety, restlessness, tracheal deviation away from the affected side indicates a tension pneumothorax (medical emergency)
asphyxia
suffocation
a pt is receiving an epidural analagesia and suddenly has a crushing HA, what does this indicate
suggests that the epidural catheter may be dislodged and in the subarachnoid space rather than the epidural space.
who do you report suspected chemical abuse to?
supervisor
when planning to do a liver biopsy, what position is best for patient to be in?
supine with arms elevated over head so that the ribs are elevated to allow access to the liver
what position do you put a patient in after an angiogram?
supine with leg extended b/c you want to promote circulation to the extemity. it should be at the level of the head/ heart. pt should be on bed rest for 8 to 12 hours in a supine position after the angiogram
dorsal recumbent
supine with the knees flexed more comfortable
when a person is in surgery how should you prevent neuromuscular complication during surgical procedures
support bony prominances with foam padding -- this helps prevent pressure on nerves and blood vessels body should be placed in a flexed position to prevent neuromuscular complications
what is treatment aimed at for a pt with pancreatitis
supportive care and prevention of autodigestion and systemic complications
goal of therapy for GBS
supportive care to maintain function of all systems
what is the MOA of phenytoin (dilantin)
suppress the influx of sodium, thereby decreasing the ability of the neurons to fire.
What is the only treatment recommended for appendicitis?
surgery - appendectomy
what is a contraindication for thrombolytic therapy for an MI
surgery 10 days prior to incident
WHAT IS stereotactic pallidotomy
surgery for parkinsons??
myringotomy
surgical procedure that will allow fluid to drain from the middle ear
ureterolithotomy pyelolithotomy nephrolithotomy
surgical removal of calculi from the affected area flank incision and extended recovery time
pt with COPD presents to the hospital with productive cough and green sputum, what does this mean?>
suspected infection
what is an intial sign of hemorrhaging after tonsillectomy
swallowing
pt on beta blocker and insulin.. what is the first sign of hypoglycemia since it can be suppressed
sweating
what happens when a person drinks alcohol while taking antabuse?
sweating, flushing of the face and neck, tachycardia, hypotension, throbing HA, nausea, vomiting, palpitations, dyspnea, tremor, weakness
what is lymphedema
swelling (usually in the legs) caused by lymph accumulating in the tissues in the affected areas.
the best mode to wean client from ventilator is
synchronized intermittent mandatory ventilation (SIMV) which allows for spontaneous breaths at his own rate and tidal volume between ventilator breaths
SIRS
systemic inflammatory response syndrome (sever bacteremia)
>100 (adult)
tachycardia
what are fetal side effects to terbutaline
tachycardia hypoglycemia
what are maternal side effects to terbutaline
tachycardia nervous tremors headache possible pulmonary edema Terbutaline=Tachycardia. (T=T) when your nervous, you have fast HR, and you shake, and you get a headache
respiratory rate > 24
tachypnea
remember a very important factor for infants is
tactile stimulation -->imperative for infant's emotional development
when is it most effective to take simvastatin (zocor)
take at night because cholesterol level tends to increase at night
what should you emphasize when teaching client with chronic pancreatitis
take enzyme replacment to prevent malnutrition and weight loss
what edu should you remember to tell the client when taking amoxicillin (amoxil)
take medication with food can open capsul and mix with liquids if its hard to swallow
pt is taking colesevelam (Welchol) what should they know about the medication
take other meds 1 hr prior or 4 hr after to this med take med with breakfast oral tablet increase fiber intake
what is the best way to handle a stressed infant?
talk to him quietly to soothe the infant
how is TPN to be discontinued
taper down to prevent hypoglycemia
what are side effects of antipsychotics
tardive dyskinesia
gustatory hallucination
tasting something that is not there
veracity
telling the truth, not lying to the patient about a bad prognosis
what 2 meds are commonly used to treat insomnia
temazepam (restoril) zolpidem (ambien)
after kidney transplant, what is a sign of rejection?
tenderness over the kidney oliguria edema and weight gain
when a person had gastric distention and an NG tube in place you think this is what
the NG tube might not be in place
Which aneurysm is most likely to have no symptoms?
the abdominal is most often "silent"
What artery is widened in a thoracic aneurysm?
the aorta
how can you tell if compressions are effective
the carotid will be palpable during each compression at best it only produces 30% of normal cardiace output
A client has been voluntarily admitted to the hospital. The nurse knows that which of the following statements is inconsistent with this type of hospitalization? A. the client retains all of his or her rights B. the client has a right to leave if not a danger to self or others C.the client can sign a written request for discharge D. the client cannot be released without medical advice
the client cannot be released without medical advice -When a client is involuntarily admitted to the hospital, the client cannot be released without medical advice. The clinet does retain all of his rights, can sign a written request for discharge, and has a right to leave if not a danger to self or others
short-term use of restraints is permitted only in which of the following situations?
the client is imminently aggressive and a danger to himself or others
When is it most beneficial for a person with Parkinsons exercise?
the morning when the energy levels are the highest
what is treatment if a pt with a kidney transplant has hyperacute kidney rejection
the organ will have to be removed if hyperacute rejection occurs
How do you tell if a client has angina or an MI?
the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. For angina, nitro and rest relieve the pain, for MI, nitro and rest do not relieve the pain
prodromal period
the period of time between the initial symptoms and the presence of the full-blown disease
what does a Swanz-Ganz catheter measure?
the pulmonary artery wedge pressure, which is an indirect measure of the left ventricle
An aneurysm will most affect which of the following, the blood pressure or the pusle?
the pulse (many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change.
Pelvic exeneration
the removal of the vagina, cervix, uterus, fallopian tubes, ovaries
autonomy
the right of individuals to make decisions for themselves
who's role is it to obtain the informed consent from the pt, if the pt is receiving surgery?
the surgeon the nurse acts only as a witness
Double-barrel Stoma
the surgeon divides the bowel completely. Each opening is brought to the surface as a separate stoma. -Permanent
When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER?
the suspected poison
micturition
the want to pee
proximate cause
there is a reasonably close causual connection between the nurse's conduct and resulting in injury
what does all these drug classes have in common NSAIDS, aminoglycosides, amphotercin B
they are nephrotoxic
emaciated
thin, underweight
what happens to the skin of someone who has cushings disease
thinning of the skin
Erbs point
third intercostal space to the left of the sternum
what is the older adult at risk for
thirst response declines and dehydration and electrolyte imbalances can occur
what do you have to teach to client taking Ticlopidine (ticlid)
this is to prevent a stroke you need to take with meals we need to monitor your blood work to prevent neutropenia do not stop taking medication until Dr. says ok
alendronate (fosamax) is given to people with osteoporosis admin. edu
this medication should be taken before breakfast and in an upright position maintained for 30 min.
Right lung Left lung Mediastinum
thoracic cavity contains:
assault
threat or harm or unwanted contact with client that causes the client fear
what are side effects of nitroglycerin
throbing HA flushing hypotension tachycardia
buergers disease
thromboangitis obliterans rare disease of arteries, veins that become inflamed, swell, and clotted
active peptic ulcer disease is a contraindication for ___ therapy
thrombolytic
surgery within 3 weeks is a potential contraindication for ___ therapy
thrombolytic
during a crisis such as hospitalization, what is important for children to establish a sense of security?
through consistency of the rituals and routines at home
percutaneous
through the skin directly into the stomach
early signs of decreased calcium
tingling of fingers, toes, and lips., tremors.
what is a sign of aspirin toxicity
tinnitus and it needs to be reported
epsteins pearls
tiny hard white nodules found in the mouth of some neonates normal and disappear without treatment
in order to promote rest in an elderly client, it is best
to explain to them what is going on with their care, and show them how to ask for help if needed if pt feels isolated and unable to attain help if needed, patient cannot rest well
what is expected after a pt receives conscious sedation
to feel drowsy for several hours after the procedure
extension
to straighten
pronation
to turn downward
supination
to turn upward
micturate
to urinate or pass urine
parallel play in which kids play side by side is seen at what age?
toddler
what is disequilibrium syndrome?
too rapid of a decrease in BUN and circulating fluid volume-->may result in cerebral edema and increased ICP
what is the objective of nursing care after intracranial surgery
total care is to reduce ICP
what labs are studied due to TPN causing excess amino acid intake, will increase these levels
total protein, prealbumin, albumin, BUN/creatinine will all increase
Gentamicin is nephro-
toxic
tension pneumothorax sign
tracheal deviation to the UNAFFECTED side!!! remember!!!
what should you have at the bedside
tracheostomy set at bedside
HIV and Pregnancy -Transmission
transmission possible during pregnancy time of delivery after birth through breast feeding
purpose of nitroglycerin
treat angina pectoris reduce ischemia, relieve pain dilate arteries and veins
1. Remove fluid & air as promptly as possible 2. Prevent drained air & fluid from returning to the pleural space 3. Restore negative pressure in the pleural space to re-expand the lung
treatment for pleural conditions: 1. remove: 2. prevent: 3. restore
what is a Sengstaken-Blakemore tube used for?
treatment of esophageal varices
signs of hypoglycemia
tremors, nervousness, irritability
nenates exposed to cocaine through pregnancy of mom what will you see
tremors, tachycardia, marked irritability, muscular rigidity, hypertension, exaggerated startle reflex inability to console exhibit inability to response to voices and environmental stimuli poor feeders and have episodes of diarrhea
what class if imipramine (tofranil) in?
tricyclic antidepressant
client states "stabbing or similar to an electric shock" accompanied by spasms of facial muscles which cause closure of the eye and twitching of the face or mouth is associated with what
trigeminal neuralgia
what is a sign of a side effect of steroid therapy
truncal obesity mood swings or altered moods weight gain inhibit growth hormone
pt is receiving enteral tube feeding what do you do if pt reports SOB and cyanosis
turn client to a side lying position to promote gastric emptying
what do you do when a client has an obstruction of a TURP with a CBI
turn off the irrigation system to reduce the amount of fluid going into the bladder
How often should the client with acne wash his face each day?
twice a day
it is important that patient does not ___ after lumbar laminectomy
twist
recurrent UTI's are an early sign of _____ in adolescents
type 2 diabetes
oral hypoglycemic agents are administered to type___ diabetes. why?
type 2 diabetics. bc they are able to produce minimal amts of insulin
what is a sign of RA
ulnar deviation lateral deviation
in droplet precautions, gowns are
uncessary
what is neurasthenia?
unexplained chronic fatigue with nervousness, anxiety, and irritability
negligence
unintentional failure to act as a resonable person in a similar circumstance would act that results in injury to another duty-breech of duty- injury occurred-proximate cause- actual loss
how long does bladder distention last after a spinal anesthesia
up to 24 hrs client should spontaneously void between 6 to 8 hrs unable to void need to cath them
most comfortable chair for pt with rheumatic arthritis is what
upright chair with seat elevated because avoid excessive hip flexion and place less stress on hip joints
what are lower UTIssues
urethritis cystitis prostatitis
what are signs of someone who has suspected pyelonephritis what are you going to find
urinary frequency dysuria flank pain costovertebral tenderness tachypnea muscle tenderness fevers chills malaise
neurogenic bladder results in
urinary retention
after a hemorrhoidectomy, it is important to assess for
urinary retention because of swelling (edema) in the tissues or a spasm of the pelvic muscles.
amitriptyline (Elavil) adverse effect
urinary retention anticholinergic effect
what is an adverse effect of anticholinergic meds like trihexyphenidyl (artane)
urinary retention constipation dry mouth decreased sweating
what is an expected change when on antipsychotics
urine color changes from yellow to pinkish or red-brown expected and not harmful
what does the urine usually look like for someone who has acute glomerulonephritis
urine is dark, reddish-brown color
vesicoureteral reflux
urine moves from bladder back toward the kidney
what is the best indicator of effictiveness for mannitol
urine output
what do you need to educate about this medication phenazopyridine HCL (pyridium)
urine will turn red-orange color
a client with SLE is at risk for myelosuppression d/t what factor
use of immunosuppresive agents to modulate immune response -- need to be monitored accordingly
what are the principles of skin protection
use skin sealant under all tapes use skin barrier to protect skin around the stoma cleanse skin gently and pat dry do not rub skin change appliance immediately when seal breaks
MOA of valproic acid (depakote)
used for absence of seizures suppress the influx of calcium
Peak and Trough
used for drugs with narrow therapeutic index -draw blood 30 min prior to next dose
Bryants traction
used in children younger than 2 yo to reduce femur fractures / stabilize hips hips are elevated off of the bed and the legs are straight up in the air. bryants butt is in the air!
90 degree traction
used on the femur if skin traction isn't suitable knee is at a 90 degree angle and the hip/knee is stabalized with a pully connected to a weight and the calf is in a swing connected to a pully that holds a weight
feet elevated and head lowered (trendelenburg)
used to insert CVP line or for treatment of umbilical cord compression
Cervical traction
used to stabilize a spinal fracture or muscle spasm
Bucks traction
used to temporarily immobilize a fractured leg boot connected to a pully that hooks onto the bed
heliotherapy
using sunlight as therapeutic agent
hydroptherapy
using water for treatment
radiotherapy
using x-ray or radium as a therapeutic agent
late decel is caused by
uteroplacental insufficiency
antiepileptic meds
valproic acid (depakote) carbamazepine (tegretol) lamotrigine (lamictal)
what does the client need to do when a tube or cap is changed on TPN
valsalva maneuver
metrorrhagia
variable amount of uterine bleeding occurring frequently but at irregular intervals
frequent use of nasal sprays to relieve allergic symptoms can result in
vasoconstriction that causes atrophy of nasal membranes cause a decreased integrity of blood vessels
Alpha 1
vasoconstriction, increased PVR, BP, bladder contraction, pupil dilation
what is the action of nicotine?
vasoconstriction-thus increases heart rate and myocardial oxygen consumption
where do you do an IM injection in a child 18 mo
vastus lateralis
The risk factors known as Virchow's triad include
venous stasis, injury to vessel wall, hypercoagulability Hurst
ARDS Tx
ventilation, pressure support, and positive end-expiratory pressure (PEEP)
what is common to occur and you need to watch out for after a patient has an MI?
ventricular dysrhythmias
what is the earliest sign of heart failure
ventricular gallop
the nurse must be truthful and honest when caring for mental health clients. In this instance, the nurse is utilizing which ethical principle?
veracity -Veracity is the duty to be honest or truthful.
what is the rational of checking the gastric contents before the next feeding
verify the effectiveness of gastric emptying
signs of menieres disease
vertigo, tinnitus, hearing loss and sense of fullness in the ear
what is a common risk for many kids who have pylonephritits
vesicoureteral reflux
pt is takig trimethoprim/sulfamethoxazole (Bactrim DS) and pt experiences vesicular, crusty rash.. what is this a sign of
vesicular, crusty rash is a a sign of stevens johnsons syndrome
invasion of privacy
violation of confidentiality
what is the monospot test used to detect
viral infectin mononucleosis
cleft palate
visible gap in uvula, soft palate, hard palate, and or incivsive foramen with exposed nasal cavities and associated nasal distortion
what is strabismus
visual axes are not parallel so the brain receives two images
what can lead to a false negative for an occult test?
vitamin c
ingestion of what can cause false negative readings in hemocult test?
vitamin containing foods (such as orange) Hurst
preload
volume in left ventricle of just prior to concentration
the frontal lobe controls
voluntary activity, concentration, motivation, ability to plan and problem solving (personality)
what are signs of lithium toxicity
vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, muscle weakness, twitching
education for mastectomy
wait 3 to 4 weeks after surgery to exercise hand strengthening exercises should be started day after avoid having blood drawn in arm of mastectomy can shower after drain is removed
what do you tell a pregnant woman about heartburn
wait at least 1 hour before reclining aftr a meal
signs of Rheumatoid Arthritis
warm red joints
what does excess ADH cause
water retention
serous
watery clear
coryza
watery drainage from nose
in flaccid bladder, we want to promote what kind of urine? and why? therefore, what kind of drinks should the patient consume?
we want to promote acidic urine to prevent UTI and stone formation. the drinks: prune juice cranberry juice tomato juice
sign and symptoms of pernicious anemia
weakness mild diarrhea smooth, sore, red tongue parethesias difficulty with balance occasional confusion
raynauds syndrome accompanies SLE therefore what should the pt do as prevention
wear gloves when its cold outside wear sunscreen spf 30
What precaution must the nurse take when administering topical nitro paste?
wear gloves, nurse may get a dose of the med
what do you have to educate to clients who are on antipsychotics
wear protective clothing d/t photosensitivity change slowly avoid hypotension
what intervention do you need to perform for someone who has acute glomerulonephritis
weigh client daily because they have fluid retention
what is important interventions you need to perform for someone with acute renal failure
weigh daily and observe for edema monitor for complications of electrolyte imbalances (acidosis or elevated K+) encourage prescribed diet: moderate protein restriction, high CHO, restrict K+ and Na+ avoid nephrotoxic drugs
what is an adverse effect of valproic acid (depakote)?
weight gain
residual gastric contents of 100ml indicates a need to temporarily withhold feedings
what are guidelines for gastric emptying rate
straw - normal brown - has blood in it green
what color is gastic apirate
shortness of breath, tachycardia, 02 sats, dyspnea, respiratory distress site for redness, patency, swelling
what do we monitor a patient with central line for?
tube, syringe, gloves, tape, nose band, cloth, tongue blade, rubber band and pin
what do you need to gather:
Hang a solution of D10W at same rate of flow as a temporary fix
what if you run out of solution before a new supply can be obtained?
1. yellow - sterile/blood cultures - PT, PTT, fibrinogen, D-Dimer testing 2. light blue - coagulation tube 3. red - non additive - has a clot activator, HIV, Hepatitis, pregnancy, chemisty testing (BMP, CMP, Lipids, Fe, therapeutic drugs, etc....) 4. tiger top - red gel separator tube 5. green - heparin, for STAT chemistry, cardia labs like CK and troponin. 6. green/gray mottled - plasma separator tube with haparin 7. lavendar - CBC, H&H, Hemagram, HCT 8. gray top - potassium oxalate/sodium fluoride tube, blood alcohol testing, lactic acid, or glucose testing 9. any other
what is the order of the draw?
glucose levels (hyperglycemia), VS, weight, labs, bacteria growth ~high concentration of dextrose~
what should you monitor?
symptoms of anaphylactic reaction to blood transfusion
wheezing, dyspnea, chest tightness, cyanosis, hypotension
when is oral feeding resumed for pt with acute pancreatitis
when amylase level returns to normal and abd pain subsides
when is there a decrease in reticulocyte
when bone marrow has slowed production of RBC
when do you use two point gait for a client
when client can bear weight on both legs most similar to walking
renal colic
when flank pain radiates to the groin d/t renal calculi
working phase
when nurse and pt work together to meet mutual goals exhibited by client recognizing an dexpressing feelings
when should you withold clozapine
when pulse is 140 < can cause tachycardia
cause of heartburn
when stomach contents enter the distal end of the esophagus producing a burning sensation
vertex breech
when the head is in the pelvis
when is breech of duty an aspect of a situation?
when there is a nurse-client relationship established (you are employed, therefore you have a duty to your patients) think: if you have a breech of duty, then you have to have a duty. if breech of duty is not applicable if the situation if there is no duty there
pallor
white
what is thrush or oral candiasis
white plaque on oral mucous membranes and gums or tongue
An aneurysim is an abnormal _______________ of the wall of a(n) artery.
widening (it is also weakening)
Medication Parlodel should be taken with, ___ and when how often for how long
with meals to avoid GI upset twice a day for 2-3 weeks
pt with DM1 asks about alcohol, when is the best time to drink it
with meals to decrease the hypoglycemia effect
afebrile
without a fever
how long after taking flurazepam (dalmane) will it take into effect
works within 30 minutes to one hour after administration
Evisceration
wound separation with protrusion of organs
sprain
wrenching of a joint
communicating devices for pt with laryngectomy
writing supplies picture or word board speaking trachestomy valve teach esophageal speech transesophageal puncture use of electrolarynx
how is TPN tube placement verified
xray
Does stress make acne worse?
yes
are assistive personnel allowed to put on condom catheters
yes
are small dark red clots a common finding after chest surgery
yes
after a heart transplant what is important to tell the person about their new heart
you may no longer be able to feel chest pain d/t denervation of the heart
mom asks, when do i give solid foods
you say 4 to 6 months of age to reduc the risk of food allergies and b/c of immaturity of gi tract
pt asks you, can i still swim every day and take showers with my NTG patch on
yup
what med do you give for insomnia
zolpidem (ambien)
