EXIT EXAM CRAM
what do you do if a PICC catheter piece breaks off during removal?
apply tourniquet close to the axilla, check radial pulse, keep in place until xray and surgry attempt
what solution is used for fluid replacement in burn victims?
lactated ringers, 50% replaced in first 8 hours and 50 % replaced in the next 16 hours totaling 24 hours
what position for air embolism?
lateral trendelenburg
typical antipsychotic for schizo?
thorazine/chlorpromazine
how is mono transmitted?
through oral secretions, blood, or genital contact
isoniazid can cause peripheral neuropathy.... what are these signs?
tingling in the hands and feet
thrombolytic therapy is used to .....
tissue plasminogen activator or streptokinase is used to break down clots
when to begin excercises in post hip sx?
ASAP even on day of surgery if possible
What does joint pain in hemophilia indicate?
bleeding; priority over abdominal pain
3 year old, sore throat, fever 102.2, and has began drooling. what statement to the mother is appropriate?
bring your child to the ER immediately. signs of epiglotitis -can be life threatning, drooling from difficulty swallowing, transport in parents lap to decrease stress *** DO NOT INSPECT THROAT unless intubation can be performed if needed
Abdominal aortic anurism
bruit heard over aorta, BP may be lower in legs than in arms monitor BP and renal fx avoid bending lifting constipation
what is a thermal injury
burn from hot substance (solid, liquid, or gas)
therapeutic positioning for any paralysis
upper extremity should be elevated to prevent subluxation of the shoulder, each extremity should be elevated so the joint is higher than the one proximal to it,
what to monitor in burn victim?
urine output (30ml/hr) CVP (3-12) vital signs and pulmonary artery pressures, maintain warm humid environment
what is a good indicator of improved status with a dehydrated patient
urine output at least 30 ml/hr 1500 in 24hrs
what to assess before IV potassium supplement?
urine output, to make sure clearance will be adequate thus preventing cardiac dysrhythmias
what food to avoid in goiter?
cabbage turnips seafood spinach, it promotes goiter growth
what PPE worn for burn vitim care?
cap gown gloves and mask ALL OF IT!
bipolar disorder: manic phase, which activities do we avoid?
competative; increase agitation decrease stimuli
what is tactile fremitus?
vibration created when pt says 99 to assess vocal transmission and lung fields
what is redness and pain in the left great toe symptom of?
acute gout subsides spontaneously in 3-4 days admin NSAIDS and cholchicine
what are main risks for stroke?
age race HTN and obesity
right sided heart failure not only causes peripheral edema but....
congestion in gastric veins resulting in anorexia and eventually ascites
pre lumbar puncture?
consent, explain procedure, assure patient that paralysis will not occur, have pt void, position in lateral recumbant fetal
The client in an alcohol treatment program asks the nurse, "Why do we need to talk about relapse? I know I'll never drink again." Which of the following responses by the nurse is best?
"Anyone can slip. Relapse commonly occurs during the first few months after a treatment program."
when is shock observed in a burn patient? (TIME FRAME)
24-48hours CVP and urine output decrease
A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. Which of the following is the most appropriate response by the nurse?
"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis
what kind of statement indicates patient asthma trigger?
"i slept on a new pillow last night"
A postpartum client decides to bottle-feed her neonate. Which client statement indicates the need for further teaching about preventing engorgement?
"i will take a hot shower" this releases milk and promotes production
airborne precautions
"my chicken has TB" measels chicken pox herpes zoster TB private, negative pressure room (6-12 air exchanges/hr) mask (N95 respirator for TB) UV
patient dx with terminal cancer becomes combative and physical abuse is carried out. what statement is correct?
"this behavior will not be accepted, the healthcare team has the right to work in a safe envirnment"
when does alcohol withdrawal peak?
24-48hrs
difference in colitis and chrons?
-crohns can affect any part of the GI tract -colitis affects only the colon -blood stools in colitis -blood stools uncommon in crohns -crohns=persistent/recurrent diarrhea -colitis=urgency to move bowels
where does the drainage bag go after cholecystectomy? how much drainage a day from Ttube? What position after Ttube is removed? what do we assess during followup visit?
-on bed the same level as gall bladder -500-1000ml -semi fowlers -stool and urine for claycolor and concentration indicating bile is draining into liver
elderly client with increased drowsiness and muscle weakness, decreased DTR, hypotension. what statement is appropriate for the nurse to make?
....ask the client if they have been taking antacids. -Antacids and laxatives that contain magnesium can cause hypermagnesium (too sedated) - discont. the med, support ventilation, Admin IV calcium, loop diuretics,
normal esr
0-20
maintanence dose of digoxin is?
0.125-0.5
what is a normal lithium range?
0.5-1.5
acetaminophen overdose hepatic toxicity occurs when?
1-3 days after ingestion increased enzymes ALT AST
what is 1 liter equal to in Kg?
1L=Ikg in fluid
In general, new mothers who are breast-feeding should consume
2-3L fluids 2300-2700 cal or 500 more cal than normal intake
normal CVP?
5-12 (according to kaplan)
what ph should the aspirated stomach content be?
5.0 or less
where is PMI?
5th intercostal space midclavicuar ( i remember this by it being closest to the left armpit, on diagrams that ask to pick the location)
how many hours NPO before contrast dye?
8hrs
what interventions to perform on emergency care for burns?
ABC, wrap in warm blanket to prevent temp drop
TB treatment regimen
AIRBORNE PRECAUTION chemo, 9 months of isoniazid, combined with streptomycin, rifampin, ethambutol, pyrazinamide
What is lactovegan?
ALL VEGAN WITH ADDED MILK YOGURT AND CHEESE
A nurse is teaching new staff members about groups considered at highest risk for suicide. Which group should the nurse emphasize
Adolescents, men older than age 45, and persons who are unemployed
Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which of the following?
Allow the 5-year-old undivided attention several times a day.
which intervention is appropriate for a patient with increased ICP.... This intervention would make you think that its contraindicated???
Assess the cough and gag reflex before oral fluids! Inc. ICP can interfere with these reflexes increasing risk for aspiration
obesity is defined as ? and morbid obesity?
BMI greater than 30 and BMI greater than 40
what do you check after giving nitro?
BP
what is priority at the bedside of a patient receiving paracentesis?
BP CUFF
While assisting a primiparous client with her first breastfeeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
Brush the neonate's lips lightly with the nipple. Explanation: Lightly brushing the neonate's lips with the nipple causes the neonate to open the mouth and begin sucking
The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?
Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.
if the pt is in vfib whats the priority?
DEFIB THE VFIB!! not chest cmpressions
hearing impairment communication....
DO NOT SHOUT! talk in front of patient in a well lit quiet room, use appropriate hand notions, ask client to repeat what was heard
FVD/dehydrated
Elevated hemoglobin hematacrit and elevated blood urea nitrogen (BUN) suggest fluid deficit. Urine-specific gravity is likewise increased.
A client whose blood type is A− gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important?
Ensuring that the client understands the procedure and signs a consent for the vaccination Explanation: Before Rho(D) immune globulin administration, the nurse must educate the client about the medication, and the client must sign consent.
What virus causes infectious mono?
Eppstein barr
A clinic nurse is assigned to care for a suicidal client. During the preinteraction phase, what should the nurse's priority be?
Exploring the nurse's own feelings about suicide. The nurse's values, beliefs, and attitudes toward self-destructive behavior influence her responses to a suicidal client; such responses set the overall mood for the nurse-client relationship. Therefore, the nurse must initially explore her personal feelings about suicide to avoid conveying negative feelings to the client.
what systems do CF effect?
GI (mostly pancreas) respiratory, ans sweat glands
A client is receiving ergonovine to treat postpartum hemorrhage. Which client complaint indicates the drug should be stopped?
Headache Explanation: Ergonovine may cause severe hypertension, which may be indicated by a headache. If hypertension occurs, the drug should be discontinued.
azotemia?
High levels of BUN and creatinine
pregnant woman received epidural and BP drops from 120/84 to 94/50 what do you do?
I chose elevate the bed; WRONG!! left side with legs flexed to increase venous return and cardiac output
chrons and colitis are both forms of
IBD not irritable bowel syndrome
what is the treatment for MI?
INITIAL thrombolytic therapy(WItHIN 3 HRS ONSET) *all meds end in ASE ^ Percutaneous transluminal coronary angioplasty (PTCA) OTHER oxygen nitro morphine aspirin iv heparin
left sided or right sided heart failure takes priority?
LEFT SIDED HF TAKES PRIORITY
what symptoms are seen in diabetes insipidus
LOW ADH; dry mucous membranes, tachy, low BP, weight loss, low specific gravity, hypona and ka, confusion dizzy
what is dieting teaching for carbido-levodopa?
LOW PROTEIN DIET to prevent gi upset
A client who is experiencing alcohol withdrawal exhibits tremors, diaphoresis, and hyperactivity. Blood pressure is 190/87 mm Hg and pulse is 92 bpm. Which of the following medications should the nurse expect to administer?
Lorazepam, Benzo, The benzodiazepine substitutes for the alcohol to suppress withdrawal symptoms. The client experiences symptoms of withdrawal because of the "rebound phenomenon" when sedation of the central nervous system (CNS) from alcohol begins to decrease.
is there pain with full thickness burns?
NO!! the pain receptors are burnt off
A nurse is evaluating a client for probable amphetamine overdose. Which assessment finding supports this diagnosis?
Tachycardia
what must first be collected to design a behavior modification program?
OBSERVE THE CLIENT AT REGULAR INTERVALS-frequency, time, amount , and precipitating factors
what to expect after ECT therapy and interventions
POSTOP: take vitals, orient patient, observe reaction to tx, watch for sudden improvement and suicide stay with client **shoert term memory loss is expected even up to several hours
what are the five Ps for neurovascular status?
Pallor Paralysis Pulselessness Pain Paresthesia
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Explanation: The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client.
A client is beginning to participate in the alcohol treatment program. Which nursing approach would be most effective in decreasing his denial about his alcoholism?
Point out concrete problems that are a direct consequence of his alcoholism.
A nurse is assigned to care for a client with anorexia nervosa. During the first 48 hours of treatment, which nursing intervention is most appropriate for this client?
Providing one-on-one supervision during meals and for 1 hour afterward Explanation: Because a client with anorexia nervosa may discard food or induce vomiting in the bathroom, the nurse should provide one-on-one supervision during meals and for 1 to 2 hours afterward
Lochia normally progresses in which pattern?
RSA! rubra serosa alba (really silly andrea)
multiple myeloma is better detected studied using?
a plain radiograph NO BONE IMAGE STUDY
what breath sounds are heard during acute asthma attack?
high pitched musical like squeaky sounds, usually on expiration
A hospitalized client craves a drink after withdrawing from alcohol. Which of the following measures is the best way to help the client resist the urge to drink?
Support from other alcoholic clients. Explanation: Group support has proved more successful than individual attention from the staff in influencing positive behavior in alcoholics.
what happens 48 hrs after a burn episode?
THE REMOBILIZATION PHASE!!! the capillary permeability stabilizes and the patient experiences hypervolemia -decreases hct and BUN
T/F: nurse can clarify questions for a patient in preop AFTER the physician has informed them?
TRUE, address concerns
Which statement summarizes the underlying principle for the development of a parent-child relationship?
The relationship is based on the need for early and frequent parent-infant contact.
A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant's plan of care?
Urine toxicology screening. Explanation: A urine toxicology screening will be collected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant.
patient develops allergic reaction after taking aspirin and penicillin.... doctor orders ceflocor and naproxen as alternate medications..... should the nurse intervene??
YES!! do not administer. notify hcp -cephalosporins (ceflacor) have cross allergies with penicillins -use nsaids cautiosly with aspirin allergy
BUN and creatinine levels
a BUN has 7-18 seseme seeds and "create" 0.7-1.4 burgers
what to report immediately in bulemia nervosa?
a hoarse voice barely inaudible laryngitis^^^ danger sign risk for trachesophageal fistual related to esophageal tear
what is a situation of air embolism?
a patient receiving TPN suddenly becomes dyspenic restless chest pain diaphoretic
what are insulin doses based on in type 1?
activity, emotions, puberty, nutritional intake, illness
what do you do 30 mins before wound care?
admin analgesics
what are risks for Pneumonia?
advanced age immunosuppresed (cancer) underlying lung condition, bedridden, postop
when is a good time to schedule upper GI?
after xrays, any tests requiring iodine, photoscopy, colonoscopy, ultrasound BECAUSE barium interferes with these kinds of tests
A client is being treated for alcoholism. After a family meeting, the client's spouse asks a nurse about ways to help the family deal with the effects of her husband's alcoholism. The nurse should suggest that the family join which organization?
al-anon Al-Anon is an organization that assists family members in sharing common experiences and increasing their understanding of alcoholism.
assess food allergies before flu vaccine
allergy to eggs contraindicated
first actions in a phobic disorder?
allow client to avoid phobia FIRST then encourage discussion of feelings do not attempt to remove defense mechanism
when do the newborn fontanels close?
anterior- 12-18 mos posterior- 2 mos
Meds for IBD?
anticholinergics, analgesics, sulfonamides, corticosteroids, antidiarrheals, antiperistalics,
PHENYTOIN
anticonvulsant side effects: gingival hypertrophy *never mix with other IV meds or dextrose *sweat or urine may become red or pink *take with 1/2 glass water or food
A client is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. His history suggests maladaptive coping, which is associated with:
antisocial personality disorder. Correct Explanation: This client's history of delinquency, running away from home, vandalism, and dropping out of school is characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is characterized by a pattern of self-involvement, grandiosity, and demand for constant attention.
what to report postop catarac surgery?
any drainage on the eye pad
what part of assessment is done last on children?
any invasive ears nose ears mouth as not to upset cardiopulonary
when does hypoglycemia occur?
anytime, but mostly as insulin is peaking
schizophrenia negative symptoms....
apathy (no feeling) a motivation (no motivation) flat affect (empty expression) social withdrawal, poverty of speech, anhedonia (inability to feel pleasure)
what to avoid in infectious mononucleosis?
aspirin, streneous activity to prevent rupturing the spleen
what to do immediately after normal vag delivery?
assess lochia flow
stomatitis care
assess q4h, offer mouth care before and after meals, no commercially prepared mouth products, rinse with water or saline
what is priority when planning care for pt with chest tube?
assess resp. status frequently
acute hyponatremia can cause ......
cerebral edema and seizures
enteral tube feeding procedure
check placement check residual and return unles greater that 100ml flush 30ml feed flush 30ml change tube and bag q24h
what are things a patient can do with bells palsy?
chew on unaffected side of mouth, use imermable eye shield or eye ointment, use frequent artificial tears, tape eyes shut at night
Four hours after cesarean birth of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which of the following?
classic (vertical incision) is contraindicated Transverse incision is not contraindicated
When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the
clients safety needs TP over physical
what are some atypical antipsychotics used for schizo?
clonzapine, olanzapine, and risperidone
The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm?
close all the doors to prevent smoke spreading to the unit
pregnant woman exposed to rubella 2 days what do you tell her?
come in this afternoon for your reg. appt. incubatio is 14-21 days not contagious at this point
what do you tell a pregnant woman experiencing unilater abdominal pain?
come in to the ER possible ectopic pregnancy
when and what does colustrum do
comes first for 3-4 days and delivers mothers antibodies to infant
what are three serum markers for acute MI?
creatinine kinase, myoglobin, troponin
what two conditions are involved with inflammatory bowel disease?
crohns and ulcerative coloitis
what is circumoral cyanosis?
cyanosis of membrane late indication
a patient with bells palsy makes the statement, I LIKE TO SLEEP WITH THE WINDOW OPEN! whats wrong with this?
due to trigeminal hyperstethsia- protect face from cold and drafts
what is neurogenic bladder?
damage to upper motor neurons causing urine retention
epinephrine is given in an acute asthma attack what shows this is effective?
decrease in pt respiratory difficulty
manic bipolar interventions
decrease stimuli distract and redirect behaviors promote rest and nourishment
the emergent phase of burns what are we looking for? (first 24hours)
decreased urinary output, increased Hct from large fluid shift
what does digoxin do?
decreases HR, increases force of contraction
the clients skin is red moist very painful to touch, fluid filled vesicles are present. What type of burn?
deep partial thickness burn
second degree burn classified as...
deep partial thickness; painful red exudes fluid edema and blisters
what do you do before plugging a fenestrated trach tube?
deflate the cuff
what does increased Na and BUN indicate?
dehydration, NaBUN needs water
what are anticholinegics useful for?
drying secretions controlling tremors and rigidity
most important position in shock?
elevate the lower extremeties to increase blood flow to heart and vital organs
what is goiter?
enlanged thyroid seen in hypothyroidism or hyper
what should you avoid with an ileostomy
enteric coated meds capsule meds osmotic laxatives
nursing actions during crisis...
explore own and client perception, help client to become aware of feelings and validate them, assess for suicide, develop coping, refer to crisis service
During a home visit 4 days after delivery, the breast-feeding primiparous client tells the nurse that her breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to:
express a small amount before feeding
trach becomes dislodged what do you do?
extend the neck, call for help, place supine, check breath sounds, use hemostats to open airway
the elation phase of bipolar consists of
extreme excitability, stimulated by the environment easily, distracted easily
syncope
fainting
acetaminophen can cause a ........
false decrease in home blood glucose monitoring
coercive power uses....
fear and punish to achieve goals
to prevent sensory overload what is a simple method to use...
finish care in one visit rather than repetitive interruptions
what is prodromal phase
first sign of disease
weight loss of 10lbs in 4 weeks or similar scenario what to do ?
focus on here and now.... normal daily intake is important but not as important as assessing favorite foods to provide adequate nutrition
what is a kosher diet?
follows jewish law no meat or poultry in the same meal as dairy or using the same utensils no pork no scavenger fish, must have scales
Wernickes syndrome
form of dementia expect diplopia nystagmus
third degree burn classified as....
full thickness burn and NO PAIN!!!!! destroyed epidermis dermis and in some cases subcu muscle and bone, can be red brown white black in color, dry leathery, edema, signs of shock probable hematuria and hemolysis
how to treat hypoglycemia...
give 15 gram load of carb (candy sugar juice) or 1mg glucagon subcu or IM, if unconcious admin 50% dextrose; follow with additional carb or dextrose in 15 min if level is still unstable; follow with a starch snack after resolved
Corticosteroids are classified as either:
glucocorticoids (anti-inflammatory) which suppress inflammation and immunity and assist in the breakdown of fats, carbohydrates, and proteins, or as. mineralocorticoids (salt retaining) that regulate the balance of salt and water in the body.
schizophrenia positive symptoms....
hallucinations, delusions
post lumbar puncture?
have pt lie prone for first 2-3 hours, then supine or prone for 6 hours, assess q15-30, encourage fluids to reduce post headache, assess drainage on dressing
what is the immediate systemic event after a sever burn?
hemodynamic issues, fluid shift of fluids sodium and protein
a patient receiving blood tranfusion, which is the most dangerous reaction?
hemolytic. nausea vomiting pain in lower back hematuria TX: stop inf, obtain urine specimen, maintain blood vlume and renal perfusion
what are some complications w hip surgery?
hemorrhage, fat emboli, dislocation, venous thrombo
what assess diabetes long term control?
hgb A1C
what diet for hypothyroidism?
high bulk low cal and encourage activity
what diet for IBD?
high cal high pro low fat low fiber
what are acid reducing meds?
histmine 2 blockers and proton pump inhibitors
what do we assess prior to nicotene gum?
history of chest pain
A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to:
hold the baby after the mother gives permission
what is the client with CF appetite like?
huge in the beginning then lost in the end
what does fasting do to urine activity?
hyperuricemia can develop, increasing ketones and inhibiting normal excretion of uric acid
side effects from atypical and typival antipsych meds....
hypotension, EPS, neuroleptic malignant syndrome, anticholinergic effects,
what can cause diabetes insipidus?
hypothalmus or pituitary damage, lithium therapy
what symptoms do you watch for in a hyperthyroid pt being tx with radioactive iodine I-130?
hypothyroidism. lethary cold sensitivity dry skin weight gain depression
dehydration needs what kind of iv soltion?
hypotonic, 0.45 NACL
minimize breast engorgement by....
ice/cool compress, supportive bra, take warm shower before feeding, use good latch technique
A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen 200 mg orally. The nurse instructs the client to take the medication:
immediately after a feeding
child best indication from abdominal pain relief after morphine inj 1 hr ago?
improved spirometer outcome. child may state pain is gone in fear of another inj
how should the "CHEIF COMPLAINT" be recorded?
in the clients own words
what is ovovegan?
includes all vegan (fruit veggies nuts seeds beans) AND EGGS (OVO)
what is the vegan diet?
includes no animal proteins; FRUITS VEGGIES NUTS SEEDS BEANS
iron deficiency anemia look for....
increased bp and pulse
signs of nephrotoxicity include...
increased bun decreased creatinine clearance thirst hematuria proteinuria
what imbalances are seen in burn victims
increased potassium (from cell trauma), decreased sodium, decreased bicarb
what is an electrical burn?
injury from electrical current, internal damage can be worse than external
repression/reaction conversion
instinctive drives and accompanyed stress are repressed and converted into a physical symptom
sputum specimen steps....
instruct pt to clear nose and throat, rinse mouth, take deep breath and cough into a sterile specimen cup, deliver to lab within two hours
what to do for a pt with neurogenic bladder incontinence and frequent UTI?
intermittent cath for residual urine, condition causes urine to not fully empty=urinary stasis=UTI
how do we treat chickenpox?
isolation until lesions are crusted over, tylenol for discomfort, NO ASPIRIN (reyes syndrome) decrease itching live vaccine given
why is alka seltzer contraindicated in chemo?
it contains aspirin, increase bleeding risk
signs of DKA...
kussamaul respiration, dehydration, fruity breath
whats a normal cuff pressure?
less than 20
when does urnie output require further evaluation?
less than 30ml/hr
A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the level in the abdomen where the nurse should expect to feel the fundus?
level of umbilicus for first 24hrs postpartum
what is the bulge test?
lie down with knees flat to test for fluid in the knee
what is important to remember when giving enteral tube medication?
liquid meds often contain sorbitol, causes diarrhea
what do we monitor in cirrhosis?
liver disease!! increased bleeding tendencies(check skin stool vomit and gums on the REG), assess fluid retention, avoid soap for skin breakdown, observe for behavioral/personality changes *ESOPHOGEAL VARICES are risk for bleed
school age fears....
loss of control; explain procedures and allow choices when able
adolescence fears....
loss of independence, involve in procedures
GERD diet
low fat non acidic ** NO lemonade, mint, cola, tomato, chocolate
just to remember about COPD patients....
low pa02 is normal for this client
A nurse works with a client diagnosed with bulimia. What is an appropriate long-term client goal for this client?
managing stress without bingeing or purging
what do you avoid taking ferrous sulfate with?
milk, eggs, coffee, tea; use straw to prevent teeth staining *takes about 4 days for effect
what are some nursing interventions with diabetes insipidus
monitor I&O, fluid intake, specific gravity, provide meticulous skin and mouth care, SAFETY fall risk side rails andassist with walking, admin vasopressin, ** MIX MEDS AND IRRIGATE W NORMAL SALINE IF FLUIDS ARE NECESSARY!!
chemo considerations
monitor bleeding avoid injections or rectal temp, preserve energy, avoid hot spicy foods, monitor for infection
LITHIUM
mood stabilizer ANTIMANIC; used in manic episodes of bipolar disorder; get adequate salt intake; check levels 2-3 times/wk initially then moves to monthly; 2500-3000 fluid intake daily
latex allergy cross foods to avoid....
mostly fruits, potato and tomato avacado
sypmtoms of myasthenia gravis include....
muscular weakness produced by repeated movements that soon disappear following rest
preschoolers fear....
mutilation; allow to play with equipment encourage expression of feelings
homonymous hemianopsia
neglect of one side of the body, instruct client to turn head in direction of visual loss. tuen the clients plate if only eating one side
IV heparin is used to prevent .....
new thrombus formation
to avoid abdominal distention postop and promote nutrition and elimination...
no oral fluids until bowel sounds are present, assess perstalisis
is lupus contagious?
no, autoimmune, stable to transfer to another unit if necessary
what is the best indication of pain relief?
nonverbal cues
best indication of fluid retention in infant?
not wet diapers, DAILY WEIGHTS!!!
Where does the sheild go for radium implant patient?
on the hallway side of the bed
introjection
one symbolically takes the characteristics of another
school age accident prevention....
only helmet required for bike riding, ammo and ammunition should be kept separate, teach correct way to use recreational equipment such as monkey bars
what classifies a burn as being severe or major?
over 25% TBSA
when is it appropriate to let a clients feet hang off the bed in the prone position?
paralysis, if tolerated, and to prevent footdrop
first sign of parent acceptance of "imperfect" infant?
participating in care
what is it most important to assess in IMPETIGO that has not been cared for properly?
periorbital edema -impetigo is caused by strept and staph bacteria - untreated can cause acute glomerulonephritis -periobital edema indicates poststrptococcal nephritis
type 1 diabetes common cause of hypoglycemia
physical activity without food
oxytocin in labor is always administered via.... & monitor what?
piggyback in case of need to stop primary infusion can continue - monitor FHR and uterine contraction -before increase assess contraction, maternal vitals, FHR&rhythm
how do we reposition a patient post lumbar laminectomy
pillow between legs and turn client, log rolling
what do substitute salts and licorice contain?
potassium
The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which of the following?
praise and encouragement
priority prior to femoral angiogram
presence of peripheral pulses, shaving may not be reccomended consult facility policy
client reports diffuse pain over the right abdomen 1 week after transplant what does the indicate?
rejection along with oliguria edema weight gain
droplet precautions "S..S..S..P..P..PIDER..M..M..MAN"
private room mask S - Sepsis S - Scarlet fever S - Streptococcal pharyngitis P - Parvovirus B19 P - Pertussis P - Pneumonia I - Influenza D - Diptheria (Pharyngeal) E - Epiglottitis R - Rubella M - Mumps M - Meningitis M - Mycoplasma or meningeal pneumonia An - Adenovirus
aids drug therapy....
protease inhibitors
Korsakoff syndrome expect
psychosis form of dementia alzheimer; confabulation, memory deficit
what is classical of left sided HR?
pulm edema manifested by dyspnea.... "I have trouble catching by breath after I take the gar bage out"
The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be:
red and moderate During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.
displacement
redirecting feeling or emotions to subject more acceptable
what is the nurses THERAPEUTIC goal in treating pain?
reducing the clients perception of pain
who is at risk for metabolic acidosis?
renal failure, salicytate toxicity, diarrhea, type 1 diabetes,
common causes of acure renal injury
renal ischemia by hypovolemia or hf
a client with diabetes insipidus taking vasopressin, what do we do to fluid intake?
restrict, patient is severely hydrated and increased urine output. more fluids will contribute to the issue
A woman who has given birth to a healthy baby is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?
saturating pad in one hr A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum
what needs to be at the bedside of a patient with sengstaken blankenmore tube?
scissors
what stage of labor is observed when increased comfort and increased bloody show is noted?
second
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective in the client does not develop:
seizures
Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect?
seizures
where should incident reports be kept
separate from pt chart, only chart care given in regards to incident
toddlers fear....
separation
hypothyroidism with myxedema is....
slowed metabolism, social isolation is a concern because of weight gain and lethargy. goiter can develop(mass in the neck)
if presented with a lithium diet question choose.....
sodium containing item, something for adequate hydration or lemonade
signs of infective endocarditis
splinter hemmrhages in nails, petechia in conjunctiva, heart murmur, IV antibiotic 4-6 wks followed w oral antibiotic
what is administered in burn victims to help with infection barrier? what kind of dressing?
standard dressing (layers of guaze) tetanus prophylactic, silver sulfadiazine, silvadene,
A client recently gave birth to a boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug?
stimulate lactation
oral oxytocin?
stimulates lactation
PTT (heparin) greater than 39
stop infusion notify provider for dosage of protamine sulfate normal ranges 20-25 32-39
first degree burn classified as...
superficial partial thickness burn; painful dry red little or no edema
position for acute stroke phase?
supine elevated 15-30
what to do before admin digoxin?
take apical 1 full minute, with hold med if less than 60 and notify HCP
best to prevent spread of TB?
take meds as prescribed, cover mouth and nose , do not go to work or school until 3 negative sputum specimens
Thirty hours after a client has given birth, the nurse plans discharge teaching for the client about infant care, because at this time the client is in which of the following phase of postpartal psychological adaptation?
taking hold Beginning after completion of the taking-in phase, the taking-hold phase lasts about 4 to 5 weeks. At this time, she is ready to learn self-care and infant care skills. The taking-in phase occurs 1 to 2 days postpartum. The letting-go phase is the final phase of postpartal psychological adaptation. This phase is characterized by readjustment, viewing the infant as a separate being, refocusing on her relationship with her partner, and maternal role attainment. Resolution is not considered an accepted phase of postpartal psychological adjustmen
a client is receiving IV heparin via infusion pump, which medication should the nurse expect the doctor to order?
the antidote- calcium gluconate Warafarin-oral anticoagulant therapy should be instituted 4-5 days before discontinuing IV heparin
referent power is...
the follower desiring to be like the leader; student to instructor or staff nurse
What NOT to use to prevent footdrop (plantar flexion)
the footboard, this stimulates plantar flexion rather than preventing it
what causes edema in malnutrition?
the lack of protein causes fluid to shift into interstitial/extracellualar space
what is the cause of hypothyroidism after radiation in conditions like hodgkins?
the radiation destroys the thyroid gland
what does fluorescin angiography determine?
theamount of pressure in the eye
post stroke what is important to remember about their lungs?
they need to be assess q4h, decrease oxygen will increase ICP, risk for aspiration
what is the purpose of a low sodium diet?
to decrease the total body water and promote excretion
what is the overall goal in IBD?
to rest the bowel which may require TPN
whats iportant to teach your patient with a permanent pace make?
to take pulse same time each day for 1 min and record report any significant changes can indicate pacemake malfx, avoid tight clothing over it
What is a lumbar puncture used for?
to withdraw fluid specimen, relieve pressure, admin meds, inject dye
where are lymphatic tissues located?
tonsils, GI tract, spleen, and thymus
what procedure id a full bladder necessary?
transabdominal pelvic ultrsound
what condition requires oral hypoglycemics? and what do they do?
type 2 diabetes; stimulates insulin production
identification
unconsciously assumes characteristics of authority figure or parent
ADH is also referred to as......
vassopressin/ddavp
most important to remember during CPR?
vertical pressure of chest compression through the heel of the hand
when is 2 units of packed rbc given?
when hgb is down to 8
when do you notify PCP regarding I&O?
when the totals change significantly over 24hrs
signs of successful latch and feeding (3)
wide-open mouth position, aubible sucking noise, tongue and jaw movements indicating swallowing
type 1 diabetes interventions...
will have rapid changes (muscle waste and subcu tissue loss), requires insulin daily (2 or more doses) MONITOR DKA
when should b-feeding begin?
within 1 hour after birth of healthy infant
when can a child return to school after hep A?
within a week or so after clinical symptoms appear. contagious 2-3 weeks before onset of jaundice and ab 1 week after
The nurse is caring for a client hospitalized for anorexia nervosa. Which of the following interventions should the nurse include for the plan of care? Select all that apply.
• Encourage the client to talk about non-food-related topics during mealtimes. • Collaborate with nutritional counselors and dieticians at the hospital. • Have highly structured mealtimes. • Provide regular meals of sufficient caloric intake to promote weight gain. Explanation: Structured mealtimes should be encouraged. During mealtimes, non-food-related social conversation is the encouraged treatment. Nutritional counseling is also encouraged. Sneaking food, laxatives, and diuretics is a much greater concern in clients with bulimia nervosa than in those with anorexia nervosa