MED SURG FALL 2k19

Fructosamine

-molecular that if formed by a chemical reaction between glucose and plasma protein Reflects glucose control for 1-3 weeks -SHows change in glucose before A1C does

hct overall low and high

36%-54%

Hct Women

36-46%

S3 Gallop

3rd heart sound, early diastolic filling sounds an increased in left ventricle.

Prevention of Diabetes in Prediabetic Patient

1) Increase level of exercise 2) Maintain healthy weight 3)Use diet low in fat content, total calories, and processed foods and high in whole grains, fruits, vegetables 4) If overweight and over age 45, get diabetes screening done.

ANS: A, B, D Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

Primary Arthroplasty

1. 2 components surgically implanted to replace fractured bones; acetabular & femoral. 2. Non-cemented prosthesis most common. 3. NWB allow bone to grow into prosthesis.

Glucose Range

1. 70-130 per cranial before meals. 2. Greater than 180 2 hrs after meals. 3. Range needs to be 6.5% or lower.

DM Nutrition

1. Based on blood glucose, lipids, & A1C levels. 2. Daily blood glucose control. 3. Diet include calories: carbs, fats/cholesterol, & protein. 4. Adjust diet during illness, stress, & pregnancy.

Meds affecting Respiratory Function

1. Benzodiazepine; hypnotics 2. Anti-anxiety 3. Opiods 4. Morphine

Parkinson's disease: Stage II Mild

1. Bilateral limb involvement. 2. Masklike face. 3. Slow; shuffling gait.

DM Foot Care- Assess Foot Deformity

1. Calluses/Corns 2. Prominent metatarsals heads 3. Toe contractures; clawed toes or hammertoes. 4. Hallux valgus/bunions. 5. Charcot foot

Reporting

1. Change of Shift Reports- SBAR Communication Tool. 2. Telephone Reports 3. Telephone Orders 4. Care Plan Conference 5. Nursing Rounds

Angina Stable

1. Chest pain return exertion; familiar pattern. 2. Symptoms remain the same over months. 3. Relieved by Nitro or Rest. 4. Only slightly limits activity.

Angina Unstable

1. Chest pain that occurs @ rest or with exertion. 2. Symptoms increase over time. 3. Poorly relieved by Nitro or rest. 4. Causes severe activity limitations.

Aging Oxygenation Older Adults

1. Chest wall & airways more rigid; less elastic. 2. Amount of exchanged air decreased. 3. Cough reflex & cilia action decreased. 4. Mucous membranes drier; more fragile. 5. Decreased muscle strength. 6. Decreased endurance. 7. Deficiency immune system. 8. Some disease process.

Types of duration of HF

1. Chronic 2. Acute

OA- Physical Assessment

1. Chronic joint pain/stiffness; spine or muscle spasms. 2. May have tenderness palpation or w/ ROM. 3. Crepitus felt or heard. 4. Enlarged/Hard joints; can be red. 5. Deformity/Atrophy 6. Assess pt mobility/ROM.

DAR charting

1. Data 2. Action 3. Response

Client Edu- Respiratory

1. Deep, reg. breathing; 3 deep breaths a day. 2. Incentive Spirometry 3. Immunizations 4. Aspirations 5. Proper/changing positions. 6. Hydration

Cardio Nursing Assessment- Pyschosocial Assessment

1. Depression 2 Anxiety

Common Ethical Dilemmas

1. HIV/AIDS 2. Abortion 3. Organ/Tissue Transplantation 4. End of Life

Risk Factors of Type 1 Diabetes

1. Hereditary 2. Environmental 3. Immunological

Cardiovascular Disease Non-Modifiable

1. Heredity 2. Ethnicity 3. Age 4. Gender

TB

1. Highly communicable 2. Mycobacterium tuberculosis 3. Transmitted via airbourne; coughing, sneezing, laughing, whistling or singing. 4. Airbourne precautions

Hypoglycemia Sluggish Food Intake

1. Honey 2. Icing 3. Syrup

TB Precautions

1. Hospital pt; airbourne precautions. 2. Health care work wear a N95 mask. 3. Pt leaves room must wear mask.

DM Foot Care- Pt Risk for Foot Problems

1. Hx of previous ulcers. 2. Hx of previous amputation.

Asthma Triggers

1. Hypersensitivity 2. URI 3. Exercise 4. Air Pollution 5. Respiratory Infection 6. GERD

Delirium Causes

1. Infection 2. Meds 3. Med. Illness 4. Prolonged Hospt. 5. Stress

Older Adults- Safety

1. Injury Prevention 2. Fires 3. Wandering 4. Meds 5. Suicide 6. Elder Abuse 7. Domestic Violence

Right Side HF Signs- Nursing Assessment

1. JVD; enlarged 2. Lower extremities; enlarged. 3. Enlarged liver or spleen. 4. Increased blood to body. 5. Decreased blood to lungs. 6. Edema

Right Ventricular Failure-Systemic Congestion

1. Jugular distention 2. Enlarged liver/spleen 3. Anorexia/nausea 4. Dependent edema; legs & sacrum. 5. Distended abdomen 6. Swollen hands/fingers. 7. Polyuria @ night 8. Wt gain 8. Hypertension/Hypotension

Right Side HF Causes

1. Left-Side HF 2. MI 3. Pulmonary HTN 4. COPD

Upper Respiratory System- Organs

1. Mouth 2. Nose 3. Pharynx 4. Larynx

Infections Risk Factors

1. Poor Hygiene 2. Indwelling Device 3. Skin Integrity 4. Poor Lifestyle; IV drugs, unprotected sex, smoking, & excess alcohol. 5. Physical/Emotional Stressors. 6. Medical Therapies 7. Disease Process 8. Poor Nutrition 9. Age

Droplet Precautions

1. Private Room 2. Nurse; surgical mask. 3. Pt. surgical mask during transport.

PIE chart documentation

1. Problems-Assessment, objective/subjective data 2. Interventions 3. Evaluations

Parkinson's disease- Dx

1. Pt hx 2. CSF Fluid; decrease dopamine levels & lumbar puncture. 3. MRI

Meds: Bones

1. Pt-Controlled Analgesia (PCA) 2. Opioids- fx pain; Dilaudid, Morphine, & Oxy. 3. Non-opioid; Tylenol. 4. NSAID 5. Muscle Relaxer; Vallium.

Urine Test for Glucose

1. Reflects renal threshold for glucose. 2. Not accurate measure of blood glucose @ time of test.

DM Treatment

1. Requires daily mgt; no know cure. 2. Goal to control disease; eat in moderation. 3. Mgt. blood glucose levels.

osteoporosis characteristics

1. Results in decreased bone mineral density (BMD). 2. BMD peaks ages 25-30. 3. BMD decreases is postmenopausal/estrogen in older females. 4. Causes: spine, hip, & wrist fractures.

Types of HF

1. Right Side 2. Left Side

i. Five rights when delegating a task or activity to a UAP:

1. Right task- task is within UAP's Scope of practice 2. Right circumstance- patient care setting and resources are appropriate for the delegation 3. Right Person- the UAP is competent to perform the delegated task or activity 4. Right Communication- the nurse provides a clear and concise explanation of the task or activity including limits and expectations 5. Right Supervision- the nurse appropriately monitors, evaluates, intervene and provides feedback on the delegation process as needed

Electrical pathway of the heart

1. SA node 2. AV node 3.Bundle of His 4. Purkinje fibers

Preventing Sensory Overload

1. Schedule activities 2. Cluster care 3. Speak clear; use low tone voice. 4. Explain test/procedures. 5. Provide info. in small doses; pt won't be overwhelmed. 6. Take time to discuss pt's concerns. 7. Reduce noxious odor by emptying bedpan immediately, keep wounds clean/covered, & provide good ventilation. 8. Assist pt w/ stress reducing techq.

Types of Drainage

1. Serous 2. Purulent 3. Sanguineous 4. Serosanguinous

Peak Flow Meter Steps

1. Set meter @ 0. 2. Standing position, w/out leaning/supporting yourself on anything. 3. Take deepest breath. 4. Place mouthpiece of the meter in mouth; taking care to wrap your lips tightly around it. 5. Blow breath out through the mouthpiece as hard/fast as able. 6. Reset/perform 2 times. 7. Highest reading of 3 is the flow rate. 8. Keep a record of peak flow rates; examine trends.

Right Hemisphere Stroke- Vision

1. Spatial Deficits 2. Neglect of the left visual field. 3. Loss of depth perception. 4. Cortical blindness.

Care of Pt in Restraints

1. Toileting 2. Offering food/fluids every 2 hrs. 3. Family @ bedside. 4. Position bed @ lowest position. 5. Re-orient pt every hr. 6. Move pt near Nursing Station. 7. Hr rounding.

Metoprolol (lopressor) Dose

100-450 mg/day

Type 2 DM- Insulin

20-30% required.

hgb overall high and low

12-18g/dl

ANS: B If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.

6. A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client? a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends. b. Ensure the balloon does not remain wedged. c. Keep the client on strict NPO status. d. Maintain the client in a semi-Fowlers position.

Glucose normal range

74-106 mg/dL

Furosemide (lasix) Dose

80-20 PO 40-20 IV

Calcium

9-10.5 mg/dL

Calcium normal range

9-10.5mg/dL

ANS: A Concerns about resuming sexual activity are common after cardiac events. The nurse should gently inquire if this is the issue. While it is good that the client is sleeping well, the nurse should investigate the reason for the move. The other two responses are likely to cause the client to be defensive.

9. A client is in the clinic a month after having a myocardial infarction. The client reports sleeping well since moving into the guest bedroom. What response by the nurse is best? a. Do you have any concerns about sexuality? b. Im glad to hear you are sleeping well now. c. Sleep near your spouse in case of emergency. d. Why would you move into the guest room?

ANS: A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

9. The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L

Type 2 Diabetes

90-95% people with DM; occur @ any age; usually adult onset (over 40 yrs old) in obesity. Decreased sensitivity to insulin tissues/production. High risk groups: African-American, Hispanics, Native Americans, & Pacific Islanders.

Asthma

A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing.

Osteoporosis

A condition in which the body's bones become weak and break easily; loss of bone density.

CT (computed tomography)

A cross-sectional image of a specific part of the body, noninvasive, contrast can be used to enhance the images

Nasal Cannula

A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils.

Parkinson's disease

A disorder of the central nervous system that affects movement, often including tremors.

High Folwer's Position

A semi-sitting position; the head of the bed is raised 60 to 90 degrees.

ANS: B A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

20. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met? a. Ambulates with assistance b. Oxygen saturation of 98% c. Pain of 2/10 after medication d. Verbalizing risk factors

ANS: B Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the clients legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

21. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Ambulate the client. b. Apply a warm moist pack. c. Massage the clients leg. d. Provide an ice pack.

ANS: A Dopamine should be infused through a central line to prevent extravasation and necrosis of tissue. If it needs to be run peripherally, the nurse assesses the site hourly for problems. When the client is getting the central line, ensuring informed consent is on the chart is a priority. But at this point, the client has only a peripheral line, so caution must be taken to preserve the integrity of the clients integumentary system. Monitoring pedal pulses and vital signs give indications as to how well the drug is working.

21. A client is on a dopamine infusion via a peripheral line. What action by the nurse takes priority for safety? a. Assess the IV site hourly. b. Monitor the pedal pulses. c. Monitor the clients vital signs. d. Obtain consent for a central line.

ANS: C Poor peripheral pulses and cool skin may be signs of impending cardiogenic shock and should be reported immediately. A blood pressure drop of 20 mm Hg is not worrisome. An oxygen saturation of 94% is just slightly below normal. A urine output of 1.2 mL/kg/hr for 4 hours is normal.

22. A client had an acute myocardial infarction. What assessment finding indicates to the nurse that a significant complication has occurred? a. Blood pressure that is 20 mm Hg below baseline b. Oxygen saturation of 94% on room air c. Poor peripheral pulses and cool skin d. Urine output of 1.2 mL/kg/hr for 4 hours

ANS: C Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

22. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best? a. Ask if the weight loss was intended. b. Encourage a high-protein, high-fiber diet. c. Measure for new compression stockings. d. Review a 3-day food recall diary.

ANS: C The Joint Commissions Core Measures set for MI includes percutaneous coronary intervention within 90 minutes of diagnosis of myocardial infarction. Therefore, the client should have a percutaneous coronary intervention performed no later than 1630 (4:30 PM).

23. A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commissions Core Measures set, by what time should the client have a percutaneous coronary intervention performed? a. 1530 (3:30 PM) b. 1600 (4:00 PM) c. 1630 (4:30 PM) d. 1700 (5:00 PM)

ANS: B An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

23. A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal? a. Teach high school students heart-healthy living. b. Participate in blood pressure screenings at the mall. c. Provide pamphlets on heart disease at the grocery store. d. Set up an Ask the nurse booth at the pet store.

Timed urine specimen is for

24 hour urine collection

Timed- Urine Specimen

24 hr urine collection; place on ice to preserve sample.

ANS: A, B, D, E The pain from an MI is often accompanied by shortness of breath and fear or anxiety. It lasts longer than 15 minutes and is not relieved by nitroglycerin. It occurs without a known cause such as exertion.

3. A nursing student studying acute coronary syndromes learns that the pain of a myocardial infarction (MI) differs from stable angina in what ways? (Select all that apply.) a. Accompanied by shortness of breath b. Feelings of fear or anxiety c. Lasts less than 15 minutes d. No relief from taking nitroglycerin e. Pain occurs without known cause

Type 1 Diabete Mellitus Environmental Factors

55+ More prevalent in: African Americans Asian Americans Hispanics Native Hawaiians Pacific Islanders Native Americans

Albumin levels

3.5-5 g/dL Albumin is a protein made by the liver. A serum albumin test measures the amount of this protein in the clear liquid portion of the blood Measures a 2-3 week time frame

Potassium

3.5-5 mEq/L

Potassium normal range

3.5-5 mEq/L

Ampicillin/Sulbactam (Unasyn)

ANAPHYAXIS BLOODY STOOLS, FEVER, ABD CRAMPING---CDIFF SEIZURES HEPATOTOXICITY

AMOXICILLIN

ANAPHYLAXIS BLOODY STOOLS, FEVER, ABD CRAMPING---CDIFF GI DISTRESS GENERALIZED RASH

PENICILLIN (PCN-G)

ANAPHYLAXIS BLOODY STOOLS, FEVER, ABD CRAMPING---CDIFF GI DISTRESS GENERALIZED RASH

CEFAZOLIN (Ancef)

ANAPHYLAXIS BLOODY STOOLS, FEVER, ABD CRAMPING---CDIFF SEIZURES STEVENS JOHNSON SYNDROME

CIPROFLOXACIN (Cipro)

ANAPHYLAXIS CDIFF SEIZURES STEVENS JOHNSON SYNDROME HEPATOTOXICITY

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: • Fasting blood glucose: 75 mg/dL • Postprandial blood glucose: 200 mg/dL • Hemoglobin A1c level: 5.5% How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

ANS: B The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the client's glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

priority nursing intervention for wound healing

A. Sphenco boots B. High protein diet C. Air mattress D. Out of bed to chair

Atorvastatin (lipitor) Adverse Actions

Abdominal cramps, constipation, diarrhea, flatus, heartburn

Asepsis

Absence of pathogens

Inhalation

Act of breathing O2 into the lungs.

Exhalation

Act of breathing out CO2 in the outside environment.

Factors Influencing Grief Response

Age Significance of the loss Culture Spiritual beliefs Support system Cause of the loss

Postmortem Care Nursing Interventions

All equipment, soiled linen, and supplies removed from bedside All tubes remain in place, but can be cut 1 inch from the skin and taped in place Place body in supine position with arms at sides, palms down, or across abdomen Place one pillow behind head and shoulders Wash visibly soiled areas of body

MRI

An imaging scan that provides cross-sectional images of a specific area. Noninvasive diagnostic test. Uses magnets &/or contrast dye to enhance the image

Chronic Infection

An infection of long duration.

Acute Infection

An infection of short duration.

Pneumonia

An inflammation of lung tissue, where the alveoli in the affected areas fill w/fluid.

Amoxicillin adverse/side effects

Anaphylaxis, bloody stool, fever, abd cramping-cdiff, GI Distress, & generalized rash

Cefazolin (Ancef) adverse/side effects

Anaphylaxis, bloody stool, fever, abd cramping-cdiff, seizures, & stevens johnson syndrome

Parkinson's disease: Meds: Carbidopa-Levodopa (Sinemet)

Anti-cholinergic; dries mucous membranes, take in PM, monitor for hypotension, tripping, drowsiness, facial grimising, & tongue protrusion.

Anti-infectives medication meaning

Anti-infectives means against or capable of defeating infection

Buck's Traction

Applied b4 surgery to decrease pain w/ muscle spasms.

moral principles

Autonomy Nonmaleficence Beneficence Justice Fidelity Veracity Accountability Responsibility

Type 2 DM- Inheritance

Autosomal-dominant; multifactorial.

Nursing interventions/teaching for steroids

Avoid grapefruit juice Monitor I/Os, daily weights, edema Assess lung sounds and RR prior and post May mask signs of infection May increase Blood Sugar

Change of shift reports should

Be concise Use only pertinent up to date info Minimize interruptions Verify, clarify info Interactive if possible Follow same order for all reports

Ulcer Prevension

Beds, heel protectors, & supporting surfaces.

Values

Beliefs about the worth of a person, object, idea, or action.

Values

Beliefs or attitudes about the worth of a person, object, idea, or action

Respiration

Breathing/Ventilation of air in & out of the lungs.

Charismatic

Builds emotional relationships High commitment levels

Charismatic

Builds emotional relationships & high commitment levels.

Transactional

Builds relationships based on exchanges

Ketoacidosis

Buildup of ketone bodies, small acids that are the breakdown product of fatty acids. Insulin deficiency causes lipolysis and release of FFAs which are broken down into ketones.

Dysesthesias

Burning, stinging, or stabbing pains

Paresthesias

Burning/tingling sensations, starting in toes and moving up legs

Left Side HF

Decreased tissue perfusion form poor CO or pulmonary congestion.

Type II DM Insulin Resistance

Decreased tissue sensitivity to insulin; less effective @ stimulating glucose uptake by tissues @ regs. glucose release by liver.

Kussmaul respirations

Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body.

Stool specimen client education

Defecate in a clean bedpan or BSCC, do not contaminate w/urine or menstrual discharge, do not place tissue in sample, notify immediately, omit NSAIDS, horseradish, anticoagulants, fish, red meats, raw fruit and vegi's, vitamin c due to false negative

Virulence

Degree of pathogenicity; how strong the infection.

MRI Indications/Interpretations of findings

Detect abnormalities, monitor response to treatment, discriminates soft tissue from tumor or bone

Chemoreceptors

Detect changes of blood pH, O2 levels, & CO2 levels.

Most common type of diabetic peripheral neuropathy

Diffuse neuropathy, widespread loss of nerve function and sensory perception. Slow, symmetrical onset. Progresses slowly, and is permanent. Includes autonomic nerve dysfunction. Late complications include foot ulcers and deformities.

Advance Directives

Direct caregivers as the pt wishes about treatments & life saving measure if they have lost the ability to communicate their decision. Inform them about DNR.

Stress Implementation-Stress

Encourage: exercise, nutrition, & sleep.

Long-Term Coping Strategies

Can be constructive & practical: talking with others, trying to find out more about the situation, and change in life-style patterns, using problem solving in decision making instead of anger or other nonconstructive responses; effective method.

Perceived Loss

Cannot be verified by others; psychological.

DM Microvascular Complications

Cap. basement membrane thickening: diabetic rethinopathy, nephropathy, & neuropathies.

Hospice Care

Care focused on support/care of the dying person & family; terminal dx only 6 months to live. Focuses on quality of life vs length; supports family through the dying process & bereavement care. Treatment/cure not sought; only providing a comfortable death.

anti-infectives nursing interventions

Check blood work prior to giving medication, check allergies, monitor for superinfection, ADVERSE effects, evaluate renal/liver function, & cultures. Priority nursing intervention HYDRATION!

Angina

Chest pain in the heart region caused by lack of oxygen; heart demands what the coronary arteries can supply. Limited duration & doesn't cause permanent damage.

Neuropathic Pain

Chronic pain experienced by people who have damaged or malfunctioning nerves as a result of illness, injury, or undetermined reasons.

Sources of Data

Client Support people Client records Health care professionals Literature

Termination of life-sustaining treatment

Client advance directives may indicate they do not wish to have life-sustaining treatment such as antibiotics, transplants, or technological interventions (ventilator). Educate family about treatments that are life-sustaining

nursing assessment for the Nursing Process for Death

Client and family awareness Closed awareness Mutual pretense Open awareness

open awareness

Client and others know about the impending death and feel comfortable discussing it.

MRI-Pre-interventions

Client education & nursing interventions

Stress Assessment

Client stress and coping mechanisms Physical examination for indicators of stress Stress-related health problems

Anemia

Condition in blood is deficient in RBCs or hemoglobin.

Anticipatory Loss

Condition in which a person displays loss and grief behaviors for a loss that has yet to take place.

Perception

Conscious organization/translation of stimuli/date; ex. remove hand from hot stove.

WHITE BLOOD CELL (WBC) COUNT definition

Count of the total number of WBCs in a cubic millimeter of blood.

Manifestations of Grief

Crying Sleep disturbance Loss of appetite Difficulty concentrating

Short-Acting

Ex. Regular (Humulin R, Novolin R)-clear Onset:30mins-1hr Peak:2-5hrs Duration:5-8 hours Notes: -Used before meals. -Not very popular- meals are hard to plan out 30-45mins in advanced -Higher risk for hypoglycemia because of longer duration of action. -IV for HHS orDKA

Long -Acting

Ex.-clear Glargine (Lantus) Detemir (Levemir) Onset: 0.8-4hrs Peak: No pronounced peak Duration: 24+hrs Notes: -Release steady supply of insulin -Low risk for hypoglycemia -Must not be diluted -Must not be mixed with any other insulin/solution

Lung Compliance

Expansibility of the lung tissue.

Insulin Deficiency

Failure of pancreatic beta cells for insulin production.

Prediabetes

Fasting BG between 100-125 mg/dl or A1C between 5.5% and 6.0%

Nursing diagnosis for death

Fear Hopelessness Risk for caregiver role strain Interrupted family process

Nursing Dx- Death

Fear, hopelessness, risk for caregiver role strain, & interrupted family process.

Warfarin Sodium (coumadin) Adverse Actions

Fever, diarrhea, rash

Situational Stressors

Finances, job, etc.

Traction

Force to reduce, align, or rest a part of the body. Wt should never touch the floor, prevents deformities, & muscle spasms.

Nursing Code of Ethics

Formal statement of a group's ideals & values.

Nursing Code of Ethics

Formal statement of a group's ideals and values Shared by members of the group Reflects moral judgments Serves as a standard for professional actions

Transformational

Fosters creativity, collaboration & commitment

Transformational

Fosters creativity, collaboration, & commitment.

Pt Teaching- Activity

Frequent; appropriate activity.

Risk Factors

Friction and shearing Immobility Inadequate nutrition Fecal and Urinary incontinence Maceration Wet Excoriation Top layer lost (denuded)

Grading of heart murmurs

GRADE I - very faint GRADE II - faint but recognizable GRADE III - loud but moderate in intesity GRADE IV - loud and ccompanied by a palpable thrill GRADE V - very loud, accompanied by palpable thrill and audible with the stethoscope partially off the chest GRADE VI - extremely loud may be heard with the stethoscope slightly above the patients chest accompanied by a palpable thrill

Algor Mortis

Gradual decrease of body temp after death.

Infection Interventions

Hand hygiene Educate-Immunizations Educate-oral hygiene Encourage adequate fluid intake Pulmonary Hygiene Aseptic Technique Respiratory hygiene Standard precautions vs. Transmission precautions

Nosocomial Infections

Health care associated-infection UTI Surgical Sites Bloodstream Pneumonia

Pt Teaching- Diet/Wt

Heart healthy diet & limit Na+. Daily wt on same scale, time, & clothes.

Internal Stressor

Illness or disease.

Right Hemisphere Stoke- Language

Impaired sense of humor.

Alpha cells

In the endocrine portion of the pancreas, in the islets of Langerhans. Secrete glucagon.

Beta cells

In the endocrine portion of the pancreas, in the islets of Langerhans. Secrete insulin.

Insulin Resistance

Inability of insulin sensitive tissue to respond to insulin stimulated glucose uptake.

Ischemia

Inadequate blood supply to an organ or part of the body; due to obstructed circulation.

Physiological Indicators

Increased HR, BP, RR, & Urinary/fecal output.

Kassmaul respiration

Increased respiratory rate and depth, body's attempt to blow off carbon dioxide. Breath has a rotting fruit odor from exhaled acetone.

anti effectives medications

LINEZOLID (Zyvox) GENTAMICIN (Garamycin) VANCOMYCIN (Vancocin) AMOXICILLIN PENICILLIN (PCN-G) PIPERCILLIN/TAZOBACTAM (Zosyn) CEFAZOLIN (Ancef) AMPICILLIN/SULBACTAM (Unasyn) CIPROFLOXACIN (Cipro) Levofloxacin (Levaquin)

urine specimen post-interventions

Label prior to leaving the room and document

Planning Process

Establish client goals/outcomes SMART Goals Outcomes should be client-focused, not nursing focused Develop care plans Select nursing interventions Delegation 5 Rights of Delegation

Euthanasia and Assisted Suicide

Euthanasia = "mercy killing" Active euthanasia - actions to bring about a client's death directly, with or without client's consent (illegal in most states) Assisted Suicide Passive euthanasia - Withholding or withdrawing life-sustaining therapy (legal)

Shared

Everyone is equal Shared governance

Side effects of bronchodilators

Tachycardia, hypertension, nervousness, shaking, tremors, chest pain, paradoxical bronchospasm(wheezing)

Sick Days

Take insulin as usual -Sugar q3-4 hours If nausea try Soup Broth Gelatin Custard Gatorade

Teaching on Isoniazid (INH)

Take on an empty stomach (1hr prior to food or 2hr post food) Take a MVI w/ B-complex as a co-med NO ALCOHOL- this treatment is hard on the liver Report any s/sx liver damage (dark urine and jaundice) Report an increased tendency to bleed

Care of Pt in Traction

Temp Ropes Hang Freely Alignment Circulation Check (5 P's) Type/Location of Fracture Increase Fluids Overhead Trapeze No wt on bed/floor

Venous Return

The amount of blood returned to the heart by the veins; low pressure. Use of respiratory, muscular, & venous pumps.

rbc definition

The number of RBCs per cubic millimeter (mm3 ).

Teriparatide (Forteo): Bone Med

Therapeutic Effect: Helps increase bone mass/strength. Used in pt dx w/ osteoporosis; who are high fracture risk.

Vit D: Bone Med

Therapeutic Effect: Treat/prevent vit D deficiency, improves Ca+ & P+. Toxicity: N/V, anorexia, weakness, constipation, headache, bone ache, & metallic taste.

Biphosphonates: Bone Meds

Therapeutic class: bone resorption. Therapeutic effects: Reversal of osteoporosis progression w/ decrease fractures.

Care of Patient in Restraints

Toileting Offering the patient food and fluids every 2 hours Family at bedside Position bed in lowest position Re-orient patient every hour Move patient near nursing station Hourly rounding (per facility policy)

Insulin therapy indications

Type 1 DM T2DM patients on 2-3 antidiabetic drugs with uncontrolled BG levels

Which disorder could have similar clinical presentation to multiple sclerosis? a. Amyotrophic lateral sclerosis b. Spinal cord tumor c. Guillan-Barre d. Quadriplegia

a. Amyotrophic lateral sclerosis

Diagnosis

a. Analyze data b. Identify health problems, risks and strengths c. Formulate diagnostic statements

1. Assessment

a. Collect data b. Organize data c. Validate data d. Document data

Reasons for documenting

a. Communication/continuity of care b. Planning c. Research d. Audits e. Reimbursement $$ f. Education g. Legal Stuff

Standard Precautions

Used for all patients when there MAY be contact with: blood, body fluids, secretions, excretions (not sweat), non-intact skin, and mucous membranes

Hypoxemia

Low blood O2; secondarily stimulate breathing.

Opportunistic Pathogen

Weak immune system.

Can Delegation to a UAP

Weighing Simple drsg. changes CPR Attending to safety Vital signs Intake and output Transfers ADLs (feeding, bathing, dressing, and etc.)

Side effects of corticosteroids

Weight gain, rounded face, increased appetite, and Buffalo hump

Passive Euthanasia

Withholding/withdrawing life sustaining therapy.

Legal Restraints

Written order is valid for 24 hrs; assess every 15 min.

Laissez-Faire (Permissive)

Low secure & predictable

Laissez-Faire (Permissive)

Low secure & predictable.

Type 2 DM- Endogenous Insulin & C-Peptide

Low, normal, high.

Aspiration/biopsy procedures

Lumbar Puncture Abdominal Paracentesis Thoracentesis Bone Marrow Biopsy Liver Biopsy

MRS WEE

M-ultidrug resistant organism R-espiratory infection S-kin infections W-ound infections E-nteric (c-diff) E-ye infection (conjunctivitis)

CO2 Levels

Normally stimulate breathing.

CVA- Nursing Management

Maintain adequate BP: 1. Hypotension is avoided to prevent cerebral ischemia & thrombosis. 2. Uncontrolled HTN may precipitate cerebral hemorhage/edema. 3. Monitor neurologic status 4. Assess for new onset of difficulty swallowing, hoarseness, etc.

Nursing planning for death

Maintain physical and psychological comfort Achieve dignified and peaceful death

Planning- Death

Maintain physical/psychological comfort; achieve dignified & peaceful death.

Type 1/2 DM- Medical Therapy

Mandatory

What adults need pneumonia vaccines?

Older adults; 65 yrs and older.

Examples of Nurses' Obligations in Ethical Decision Making BOX 5-4

Maximize the client's well-being. • Balance the client's need for autonomy with family members' responsibilities for the client's well-being. • Support each family member and enhance the family support system. • Carry out hospital policies. • Protect other clients' well-being. • Protect the nurse's own standards of care.

Advocate

One who expresses & defends the cause of another.

Asepsis types

Medical vs surgical ◦Medical asepsis ◦Clean ◦Dirty ◦Surgical asepsis (sterile technique)

Chemical Restraints

Meds used to control socially disruptive behavior; prevent pt from injuring themselves or others.

Respiratory Center

Medulla of the brainstream.

Short Acting: Regular (Humalog R)

Onset 30 min, Peak 2-4 hrs, & Duration 6 hrs.

Nursing Interventions- Improve Gas Exchange

Monitor VS; keep SpO2 levels > 92%.

Airborne Precautions

PRIVATE ROOM ❖Negative air pressure ❖N95 respirator-Nurse ❖Surgical mask-Patient

Non-surgical Options: Bones

Pain mgt w/ natural healing & bedrest.

Depression

Mood disorder w/ cognitive, affective, & physical manifestation. Ex: Early AM insomnia, increase daytime sleeping, poor appetite, decreased energy, decrease social.

Atherosclerosis

Most common cause of impaired blood flow to organs & tissues.

Hip Fracture

Most common in older adults; high mortality rate & osteoporosis is the main factor.

Abdominal Paracentesis Client education

NPO prior to procedure, Empty bladder prior, procedure is not quick because fluid is removed slowly

Asepsis

No pathogens present.

MRI-Post-Interventions

No real interventions unless contrast dye or sedation is used

Bureaucratic

No trust for anyone even self Relies only on organization's rules, policies & procedures

Bureaucratic

No trust for anyone; even themselves. Relies only on organization's rules, policies, & procedures.

Stage I Pressure Ulcer

Non-blanching redness of a localized, area of intact skin.

Indicators of Stress

Physiological indicators Psychological indicators-Anxiety and fear, Anger,Depression,Ego Defense Mechanisms

Sanguineous

Pink to reddish tinge.

Infection Risk Factors

Poor hygiene Indwelling devise Skin integrity Poor lifestyle (IV Drugs/unprotected sex/smoking/excess alcohol) Physical/emotional stressors Medical therapies Medications Disease processes Poor nutrition Age!

Treat Dysrhythmias

Positive inotropic drug; digoxin- squeeze heart. Antidote: Digibind Check apical pulse- 1 min; don't give if HR less than 60 bpm & watch K+ levels. Side Effects: confusion, irregular HR, anorexia, vision change; green halos, bradycardia, & nausea/vomiting.

Left Hemisphere Stoke- Memory

Possible Deficit

Meperidine (Opioid)

Potent pain med; binds w/ pain receptors. Sides Effects: short half-life, toxic metabolite, & may cause tremors/seizures.

Morphine (Opioid)

Potent pain med; no max. dose limit unless combined w/ other meds & binds w/ pain receptors. Side Effects: N&V, constipation, decreased RR, & fall risk.

ethics

Practices or beliefs of a certain group

Ethics

Practices or beliefs of a certain group.

Social Cognition

Processes by which people come to understand others each other.

Alpha Cells

Produce glucagon.

Diabetic peripheral neuropathy

Progressive deterioration of nerve function resulting in loss of sensory perception. Damage may manifest as pain or loss of sensation. Factors: hyperglycemia, long duration of DM, hyperlipidemia, damaged blood vessels leading to reduce neuronal oxygen and nutrients, autoimmune neuronal inflammation, increased generic susceptibility, smoking and alcohol use. Hyperglycemia leads to DPN via reduced tissue perfusion, nerve hypoxia, resulting in blocked nerve transmission.

Complicated Grief

Prolonged grief; after 6 months of the event.

Restraints

Protective devices used to limit the physical activity of the pt or part of the body.

Albumin

Protein made by the liver; test measures the amount of protein in clear liquid portion of blood.

Blood Test

Puncture of the vein for purpose of blood collection. Vein + Puncture= Venipuncture

PERRL

Pupils are equal, round, and reactive to light

COMPLETE BLOOD COUNT labs

RBC HGB HCT WBC PLATELETS

COMPLICATIONS OF CARDIAC CATHETERIZATION

RIGHT SIDE: thrombophlebitis, pulmonary embolism, vagal response LEFT SIDE AND CORONARY ARTERIOGRAPHY : MI, stroke, arterial bleeding or thromboembolism, dysrhythmias RIGHT/LEFT : cardiac tamponade, hypovolemia, pulmonary edema, hematoma or blood loss at insertion site, reaction to contrast medium

Type 2 Diabetes Mellitus

Ranges from insulin resistance with relative insulin deficiency to secretory deficit with insulin resistance

Biot's respirations

Rapid and deep respirations followed by 10 to 30 seconds of apnea

ORIF

Reduces pain & improve mobility.

Clean voided urine specimen is for

Routine urinalysis

Droplet precaution conditions

S-epsis/scarlet fever/streptococcal pharyngitis P-arvovirus B19/bacterial pneumonia/pertussis I-influenza D-iphtheria E-piglottis R-ubella M-umps/meningitis/ mycoplasma/meningeal pneumonia A-deNovirus

CO formula

SV x HR= CO

Furosemide (lasix) Nursing Considerations

Severe dehydration can promote hypotension (orthostatic hypotension), thrombosis and embolism

Venturi- Face Mask

Shape change in carburetor that creates an area of low pressure; increases air velocity; decreases temperature.

Acute Pain

Short-term pain that is felt suddenly from injury, disease, trauma, or surgery.

Risk factors contributing to poor health outcomes for people with DM

Smoking Physical inactivity Obesity Hypertension High blood fat and cholesterol levels

Pt Teaching- Lifestyle

Smoking cessation & diet modification.

Serum Electrolytes labs

Sodium Potassium Chloride Calcium Magnesium Phosphate Glucose

Sputum specimens

Sputum-not saliva is tested for Culture and sensitivity Lung cancer cell type TB Effectiveness of therapy

1. Types of data (table 11-4 p 163)

Subjective, Objective, Constant, Variable

Anticipatory Grief

Syndrome characterized by the presence of grief in anticipation of death or loss; the actual death comes as a confirmation of knowledge of a life-limiting condition

SPUTUM specimen Interpretations of findings

TB, CAncer, Pneumonia, Any lung/bronchi/trachea disorders

DIAGNOSTIC ASSESS

TROPONIN - released into the bloodstream with unjury to myocardial muscle - not found in healthy patients so any rise indicates cardiac necrosis or MI CREATININE KINASE - specific to cells of the brain, myocardium, and skeletal muscle - presence indicates tussue necrosis or injury CK-MB is specific to myocardial muscle - peak is 24 hrs after chest pain MYOGLOBIN - found in cardiac and skeletal muscle - EARLIEST MARKER AS EARLY AS 2 HOURS AFTER MI - limited use due to also found in skeletal muscle SERUM LIPIDS - cholesterol < 200 triglycerides between 40 - 160 for men and 35-135 for women HDL >45 for men >55 for women LDL<130

A patient with COPD has meal-related dyspnea. To address this issue, which drug does the nurse offer the patient 30 mins before the meal? a. albuterol lb. guaifenesin c. fluticasone d. pantoprazole sodium

a. albuterol

The nurse is helping a patient learn about managing her asthma. What does the nurse instruct the patient to do? a. keep a symptom diary to identify what triggers the asthma attack b. make an appointment with an allergist for allergy therapy c. take a low dose of aspirin every day for the anti-inflammatory action d. drink large amounts of clear fluid to keep mucus thin and watery.

a. keep a symptom diary to identify what triggers the asthma attack

Orthopnea

ability to breathe only in an upright position

AKA

above the knee amputation

Hyper

above, more than usual

Apnea

absence of breathing

ADL

activities of daily living

Cardiac Output

amount of blood pumped from the left ventricle EACH MINUTE heart rate X stroke volume (stroke volume is amount of blood ejected with EACH CONTRACTION) ADULTS - 4-7L/min

Peri

around

Ad lib

as desired/freely

PRN

as needed

Killer T cells

attack and destroy infected body cells

Leadership Styles

authoritarian, democratic, laissez-faire, Bureaucratic Charismatic Transactional Transformational Shared

AA&O

awake, alert and oriented

What are key features of a brainstem tumor? Select all that apply. a. Vomiting unrelated to food intake b. Facial pain or weakness c. Nystagmus d. Headache e. Hearing loss f. Hoarseness

b. Facial pain or weakness c. Nystagmus. e. Hearing loss f. Hoarseness

In planning care for a patient with IICP, what does the nurse do to minimize ICP? a. Gives the bath, changes the linens, does passive ROM to hands/fingers, and then allows the pt to rest b. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises c. Gives the bath, defers the linen change and passive ROM exercises until the danger of IICP has passed. d. Contacts the provider for specific orders about activities related to patient care that might cause IICP.

b. Gives the bath, allows rest, changes linens, allows rest, and then performs passive ROM exercises

A patient with respiratory difficulty has completed a pulmonary function test before starting any treatment. The peak expiratory flow (PEF) is 15%-20% below what is expected for the adult's age, gender, and size. the nurse anticipates this patient will need additional information about which topic? a. Further diagnostic tests to confirm pulmonary hypertension. b. How to manage asthma medications and identify triggers. c. Smoking cessation and its relationship to COPD. d. How to manage the acute episode of respiratory infection.

b. How to manage asthma medications and identify triggers.

Which symptoms indicate that a pt with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply. a. Flaccid paralysis b. Hypertension c. Tachypnea d. Severe headache e. Blurred vision f. Loss of reflexes below the injury

b. Hypertension d. Severe headache e. Blurred vision

A patient is diagnosed with cor pulmonale secondary to pumonary hypertension and is receiving an infusion of epoprostenol through a small portable IV pump. What is the critical priority for the patient? a. Strict aseptic technique must be used to prevent sepsis. b. Infusion must not be interrupted, even for a few minutes. c. The patient must have a daily dose of warfarin. d. the patient must be assessed for angina-like chest pain and fatigue.

b. Infusion must not be interrupted, even for a few minutes.

The nurse is caring for several patients who have spinal cord injuries. Which task is best to delegate to UAP? a. Encourage use of incentive spirometry; evaluate the pt's ability to use it correctly b. Log-roll the pt; maintain proper body alignment and place a bedpan for toileting c. Check for skin breakdown under the immobilization devices during bathing d. Insert an indwelling catheter and report the amt and color of the urine

b. Log-roll the pt; maintain proper body alignment and place a bedpan for toileting

The nurse is caring for a pt with recent SCI. Which interventions does the nurse use to target and prevent the potential SCI complication of autonomic dysreflexia? Select all that apply. a. Frequently perform passive ROM exercises b. Loosen or remove any tight clothing c. Monitor stool output and maintain a bowel program d. Keep the pt immobilized with neck or back braces e. Monitor urinary output and check for bladder distention f. Maintain stable environmental temperature

b. Loosen or remove any tight clothing c. Monitor stool output and maintain a bowel program e. Monitor urinary output and check for bladder distention f. Maintain stable environmental temperature

A patient is experiencing an asthma attack and shows an increased respiratory effort. Which ABG value is more associated with the early phase of the attack? a. PaCO2 of 60 mmHg b. PaCO2 of 30 mmHg c. pH of 7.40 d. PaO2 of 98 mmHg

b. PaCO2 of 30 mmHg

A stroke pt is at risk for increased intracranial pressure and is receiving 2 L via nasal cannula. The nurse is reviewing ABG results. Which value is of greatest concern for this patient? a. pH of 7.32 b. PaCO2 of 60 c. PaO2 of 95 d. HCO3 of 28

b. PaCO2 of 60

The nurse is caring for a patient who had a stroke in the right cerebral hemisphere and the pt demonstrates unilateral body neglect syndrome. Based on this information, which behavior would the nurse expect to observe? a. Pt uses a pencil and fingers to eat food from the meal tray b. Pt combs hair on the unaffected side, but not on the affected side c. Pt tells the nurse that bathing and hygiene should be done next month d. Pt generally looks disheveled and disorganized but is always pleasant.

b. Pt combs hair on the unaffected side, but not on the affected side

The nurse is assessing a pt with a spinal cord injury that occurred several months ago. The nurse recognizes that the patient is experiencing autonomic dysreflexia. What is the nurse's first priority action? a. Check for bladder distention b. Raise the head of bed c. Administer an anti-hypertensive med d. Notify the provider

b. Raise the head of bed

A pt has been diagnosed with a large lesion of the parietal lobe and demonstrates loss of sensory function. Which nursing intervention is applicable for this pt? a. Play music for the patient for at least 30 mins a day b. Teach the pt to test the water temperature used for bathing c. Position the patient reclining in bed or in a chair for meals. d. Show a picture of the spouse and ask patient to identify the person.

b. Teach the pt to test the water temperature used for bathing

A patient who has well-controlled asthma has what kind of airway changes? a. Chronic, leading to hyperplasia b. Temporary and reversible c. Acute loss of smooth muscle mass d. Permanent and irreversible

b. Temporary and reversible

actual loss

can be recognized by others

perceived loss

cannot be verified by others

Hospice care

care focused on support and care of the dying person and family Focuses on quality of life vs. length Supports the family through the dying process and bereavement care Treatment or cure not sought after

pallative care

care is an approach that improves the quality of life of clients facing life-threatening illness Prevention and relief of suffering through early identification and treatment of problems

CXR

chest x-ray

CT (computed tomography) pre-interventions

client education

MRI-Intra-interventions

client is supine (may need pillows for support) provide ear plugs if needed

CT (computed tomography) intra-interventions

client must lay supine

Liver Biopsy Intra-interventions

client remains still in a supine position with the right arm up

SPUTUM specimen client education

collect early in am, gather sputum not saliva

SPUTUM specimen pre-interventions

collect supplies and educate client

c/o

complains of / complaints of

CBC

complete blood count

Liver Biopsy Pre-interventions

consent, client education, may need ultrasound to guide (possibly given vitamin K to lower hemorrhage (clot),

Bone Marrow Biopsy pre-interventions

consent, client education, prone position or side lying

Stool specimen Potential complications

contamination or incorrect collection technique

SPUTUM specimen Indications

culture to determine specific microorganisms, cancer in the lungs (3 early am samples) , TB (Acid fast bacillus) 3 am samples

The neurologist tells the nurse that the stroke patient has some deficits associated with cranial nerves, V, VII, IX, X, and XII. Which intervention is the nurse most likely to initiate? a. Prevention of Valsalva maneuver b. Fall precautions c. Prevention of corneal abrasions d. Aspiration precautions

d. Aspiration precautions

A patient with IICP is to receive IV mannitol. Which assessment would the nurse perform to prevent complications in a body system other than the nervous system? a. Assess for cardiac dysrhythmias b. Assess for gastric bleeding c. Assess for respiratory distress d. Assess for acute renal failure

d. Assess for acute renal failure

A patient had an anterior cervical discectomy with fusion and has returned from the recovery room. What is the priority assessment? a. Assess for gag reflex and ability to swallow own secretions. b. Check for bleeding and drainage at the incision site. c. Monitor vital signs and check neuro status. d. Assess for patency of airway and respiratory effort.

d. Assess for patency of airway and respiratory effort.

A neighbor with asthma is experiencing a severe and prolonged asthma attack that is unresponsive to treatment with a SABA drug. What is the nurse's best action? a. Continue to administer the patient's SABA drug at 5 minute intervals. b. Call the patient's HCP. c. Apply the supplemental oxygen that is in the patient's home. d. Call 911 and get the patient to emergency care ASAP

d. Call 911 and get the patient to emergency care ASAP

A pt had an infratentorial craniotomy. Which position does the nurse use for this patient? a. High Fowlers turned to operative side b. HOB at 30 degrees, turned to non-operative side c. Flat in bed, except elevate HOB for meals and meds d. Flat and positioned side-lying, alternating sides every 2 hrs.

d. Flat and positioned side-lying, alternating sides every 2 hrs.

Which Glasgow Coma Scale data set indicates the most severe injury for a patient with traumatic brain injury and loss of consciousness? a. GCS of 13 with loss of consciousness for 5 mins b. GCS of 9 with loss of consciousness for 30 mins c. GCS of 12 with loss of consciousness for 15 mins d. GCS of 8 with loss of consciousness for 60 mins.

d. GCS of 8 with loss of consciousness for 60 mins.

A patient with pulmonary arterial hypertension is prescribed bosentan. For which side effect must the nurse monitor? a. Bradycardia b. Increased risk for blood clotting c. Decreased urine output d. Hypotension

d. Hypotension

A pt presents to the advanced stroke center with signs and symptoms of an ischemic stroke. What is the priority factor when considering fibrinolytic therapy? a. Age less than 80 years b. Hx of stroke c. Recent surgery d. Time of onset of symptoms

d. Time of onset of symptoms

Following a left cerebral hemisphere stroke, the pt has expressive (Broca's) aphasia. Which intervention is best to use when communicating with this patient? a. Repeat the names of objects on a routine basis. b. Face the pt and speak slowly and clearly c. Obtain a whiteboard with an erasable marker d. Use a picture board that displays objects and activities..

d. Use a picture board that displays objects and activities..

A pt with a spinal cord injury has paraplegia and paraparesis. The nurse assesses the calf area of both legs for swelling, tenderness, redness, or pain. This assessment is specific to the patient's increased risk for which condition? a. Contractures of both joints b. Bone fractures c. Pressure ulcers d. Venous thromboembolism

d. Venous thromboembolism

5th Vital Sign

degree of pain

Dx or DX

diagnosis

Dyspnea

difficult or labored breathing

D/C

discontinue

gtt

drop

Stevens-Johnson Syndrome

dry,crusty rash and should be reported to the PCP

ENT

ear, nose, throat

Stool specimen nursing interventions

educate client, document relevant info (color, odor, amount) sterile samples have to be taken by nurse, delegations depends on sterile or not

What does teamwork and collaboration entail?

entails planning, implementing, and evaluating patient care together using an interdisciplinary plan of care

Skin layers

epidermis, dermis, subcutaneous, fat, muscle tissue and bone

anticipatory grief

grief experienced prior to a loss

HOB

head of bed

Cardio

heart

Adaptive Coping

helps the person to deal effectively with stressful events & minimizes distress assoc. w/ them; good strategy.

Hx

history

H&P

history and physical

HS

hour of sleep

normal vital signs

i. Blood pressure: 120/80 ii. Pulse: 80 (60-100) iii. Respiration: 16 (12-20) iv. Temp: 98.6 (36-27.5 C)

what to look for when collecting data by OBSERVATION

i. Clinical signs of patient distress ii. Threats to patient safety (real or anticipated) iii. Presence and functioning of equipment iv. Immediate environment, including people

urine specimen Potential complications

incorrect collection technique (false reading)

Bone Marrow Biopsy complications

infection, bleeding, and hematoma formation

Endo

innermost, within

I&O

intake and output

IM

intramuscular

IV

intravenous

What is the priority medical-surgical concept for patients with noninfectious lower respiratory problems such as emphysema? a. perfusion b. gas exchange c. cellular regulation d. tissue integrity

b. gas exchange

Types of Microorganisms

bacteria, viruses, fungi, parasites

BRAT

bananas, rice, applesauce, toast

BRP

bathroom privileges

Mourning - behavioral process through which grief is eventually resolved

behavioral process through which grief is eventually resolved

Lumbar Puncture Potential complications

bleeding disorders (i.e. client on anticoagulants)

Lumbar Puncture potential complications

bleeding disorders (i.e. client on anticoagulants)

Hemat/o

blood

what should you check

blood sugars

PO

by mouth

The pt reports a sudden, severe headache with nausea and vomiting. He says, "This is the worst headache of my life." What condition does the nurse suspect? a. Brain tumor b. Migraine headache c. Cerebral aneurysm d. Ischemic stroke

c. Cerebral aneurysm

The nurse is caring for a pt with right cerebral hemisphere damage. The pt demonstrates disorientation to time and place and neglect of the left visual field, and he has poor depth perception. Which task is best delegated to the UAP? a. Move the pt's bed so that his affected side faces the door b. Teach the pt to wash both sides of his face c. Ensure a safe environment by removing clutter d. Suggest to the family tat they bring familiar family photos

c. Ensure a safe environment by removing clutter

The nurse is assessing a pt who was struck in the head several times with a baseball bat. There is clear fluid that appears to be leaking from the nose. What action does the nurse take first? a. Ask the pt to gently blow the nose; observe the nasal discharge for blood clots b. Immediately report the finding to the provider and document the observation c. Place a drop of the fluid on a white absorbent background and look fro a yellow halo. d. Assist the pt to wipe his nose, but no other action is needed; he has probably been crying

c. Place a drop of the fluid on a white absorbent background and look fro a yellow halo.

Which finding could help the health care team differentiate a TIA from a stroke? a. Pt has a unilateral facial droop b. Pt has slurred speech c. Symptoms resolve in 30-60 mins d. ECG is normal

c. Symptoms resolve in 30-60 mins

Arthro

joint

Stool specimen pre-interventions

know the reason for sample and how much sample you need and collection equipment for either clean or sterile collection

SPUTUM specimen post-intervention

label sample in room, document sample

Stool specimen post-intervention

label specimen before leaving the room and document

Serous drainage

leaking plasma serum that is clear

Bone Marrow Biopsy client education

local anesthesia or conscious sedation, will be in prone position, will feel pressure & pain during aspiration, bedrest 30-60 minutes after procedure

Pneumo

lung

Bone Marrow Biopsy Indications / Interpretation of findings

malignancy, blood disorders (anemia or thrombocytopenia) Leukemia

euthanasia

mercy killing

MRSA

methicillin-resistant staphylococcus aureus

Resident Flora

microorganisms that normally reside on the skin, & mucous membranes; inside the respiratory & gastrointestinal tracts.

Bone Marrow Biopsy nursing intervention

monitor for s/s of infection (fever, pain, swelling high WBC) apply ice to minimize bleeding or bruising (no heat), send tissue sample to lab for biopsy

Abdominal Paracentesis Nursing Interventions

monitor incision site, hypovolemic shock BP, HR, urine output, send fluids to the lab immediately, monitor for abdominal girth after procedure

side effects

moon face buffalo hump increase weight increase blood sugars fluid and sodium retention, increased appetite

Acetylsalicylic Acid (aspirin) Adverse Actions

nausea, vomiting, rash

Neuro

nerve

CT (computed tomography) post-intervention

no follow-up needed

NKDA

no known drug allergies

ECHOCARDIOGRAPHY

noninvasive performed at bedside use ultrasound waves to assess cardiac structure and mobility-especially valves

Eupnea

normal respiration

NPO

nothing by mouth

advocate

one who expresses and defends the cause of another. Inform client's of their rights and protect their rights Support the client in their decisions Mediate and directly intervene on the client's behalf

Gentamicin (Garamycin) adverse/side effects

ototoxic(ear) , neurotoxic, nephrotoxic (kidney) (peak <10 mcg/mL) (Trough <2mcg/mL)

OOB

out of bed

Dys

painful, difficult, abnormal

PR

per rectum

Stool specimen Interpretation of findings

positive guaiac test (3 test)

urine specimen Client education

prefer AM collection due to higher concentration and more acidic PH, free of fecal contamination, do not place tissue in sample

preload and afterload

preload - the degree that the muscle fibers in the heart stretch due to blood volume in the heart during diastole (the greater the amount of blood in the heart during diastole the more the muscle fibers stretch which increases the force of which the blood will be ejected-improves stroke volume and cardiac output) afterload - the resistance the ventricles have to overcome to eject the blood (from preload) IF THE BLOOD VESSELS ARE CONSTRICTED IT WILL DECREASE THE AMOUNT OF BLOOD BEING EJECTED - MAKING THE HEART WORK HARDER

Sepsis

presence of a pathogen

Liver Biopsy client education

process: exhales & holds breath while provider inserts biopsy needle (puts diaphragm in the highest position) NPO prior to procedure, supine w/ arm above head or on the left side, lye on Right side for 1-2 minutes after and may be on bedrest for another 4-24 hours

Tachypnea

rapid breathing

DIASTOLE

relaxation and filling of the atria and ventricles (the relaxed pressure through the walls with only peripheral resistance)

Lumbar Puncture

removal of csf from the spin, removed from the third or fourth or the fourth and fifth spinal space, syphilis, meningitis, reduce spinal pressure, consent required, sterile procedure, complications include bleeding and infection

Susp

suspension

Tbs

tablespoon

anti-infectives Patient Education

take probiotic, complete the entire amount of medication, inform provider prior to taking other meds, no alcohol

PROCEDURE OF CATHETERIZATION

taken to cath lab placed in SUPINE POSTION ON CRAY TABLE and strapped physician injects local anesthetic at insertion site the patient is instructed to rport an chest pain, pressure, or other symptoms RIGHT SIDE IS CATHED FIRST

Tsp

teaspoon

60ml

the amount of blood the heart pumps with each beat - 5ml/min

mean arterial pressure (map)

the average/mean of systolic and diastolic pressures Needs to be between 60 and 70mmHg to adequately perfuse all of the body's organs ESPECIALLY THE KIDNEYS if it is less than that then the kidneys will not get adequate tissue perfusion

valvular regurgitation

the back flow of blood into the atria

systole

the contraction and emptying of the atria and ventricles (the greatest amount of pressure through the blood vessels due to the force of contractions)

Common Health Problems

❖Decreased Nutrition and Hydration ❖Decreased Mobility ❖Stress, Loss and Coping ❖Accidents ❖Drug Use and Misuse ❖Inadequate Cognition

Contact Precautions

❖Private room ❖Gloves and gown ❖HAND HYGIENE!! ❖C-DIFF: SOAP AND WATER ONLY

Droplet Precautions

❖Private room ❖Nurse: Surgical mask ❖Patient: Surgical mask during transport

CVA Risk Factors- Modifiable

1. HTN 2. Afib 3. High cholesterol 4. Obesity 5. Alcohol abuse 6. Smoking 7. DMII 8. Asymptomatic Carotid Stenosis 9. Oral contraceptives

Left Side HF Causes

1. HTN 2. CAD 3. Valve Disease

TIA Risk Factors

1. HTN- hypertension 2. DM II 3. Cardiac disease 4. Hx of smoking 5. Family hx of stroke 6. Chronic alcoholism

Left Ventricular Failure- Pulmonary Congestion

1. Hacking cough; worse @ night. 2. Dyspnea/breathlessness 3. Crackles/wheezes 4. Frothy; pink-tinged sputum. 5. Tachypnea 6. S3/S4; summation gallop.

Infection- Nursing Interventions

1. Hand Hygiene 2. Pt edu.; oral hygiene & immunizations. 3. Adequate fluid intake. 4. Pulmonary Hygiene 5. Aseptic Technique 6. Respiratory Hygiene 7. Standard precautions vs Transmission

Left Cardiac Blood Flow (Oxygenated)

1. Veins carry oxygenated blood back to heart. 2. Flows to the body. 3. Arteries carry oxygenated blood to body.

TB Treatment

1. Combination therapy is effective with INH & Rigadin. 2. Treatment last 2 yrs. 3. Strict meds therapy 4. Avoid alcohol

Pain- Nursing Interventions

1. Strategies Pain Mgt.-goals. 2. Pharmacologic Pain Mgt.- meds. 3. Non-Pharmocolgic Pain Mgt- no meds.

Documenting with the SOAPIER method

1. Subjective data 2. Objective data 3. Assessment 4. Plan 5. Intervention 6. Evaluation 7. Revision

Heart Blood Flow Order

1. Superior Vena Cava 2. Right Antrium 3. Tricuspid Valve 4. Right Ventricle 5. Pulmonary Valve 6. Lungs 7. Pulmonary Artery 8. Pulmonary Veins 9. Left Ventricle 10. Mitral Valve 11. Left Antrium 12. Aorta

Isoniazid (INH)-TB Treatment

1. Take on empty stomach. 2. Take daily MVI with B-complex. 3. No alcohol 4. Report dark urine, yellow in skin/eyes, & increased tendency to bleed.

Rifadin- TB Treatment

1. Teach pt drug will stain skin & urine. 2. Contact lens will be permanently stained. 3. Females who take oral contraceptives need to use another form of birth control. 4. Report dark urine & yellow skin/eyes. 5. Ask about other meds.

Sensory Health Promations

1. Teach risk of sensory loss; how to prevent/reduce loss. 2. Encourage regular vision/hearing screenings. 3. Teach how to control DM; if dx.

Chronic Bronchitis- Physiologic Changes

1. Thickened bronchial walls. 2. Smoke/irritants cause hypersecretion & inflammation. 3. Mucous plugs 4. Bronchioles fibrosed. 5. Affects airways; not alveoli. 6. Chronic inflammation; cause thick mucous. 7. Mucous is a breeding group for bacteria.

Factors to consider while interviewing

1. Time- should plan when client is physically comfortable and free of pain and when interruptions will be minimal 2. Place- well lit, well ventilated room that is free of distractions and provides privacy 3. Seating arrangement- sit eye level at about 45 degrees from the bed 4. Distance- 2-3 feet 5. Language- failure to communicate in language of client is discrimination

INDICATIONS FOR CATHETERIZATION

1. To confirm suspected heart disorders 2. to determine location and extent of disease process 3. to assess stable severe angina unresponsive to medical management, unstable angina pectoris, uncontrolled heart failure, ventricular dysrhythmias, or cardiogenic shock assoc with acute MI, aneurism or septal perforation 4. to determine best therapeutic option 5. to eval effects of medical or invasive treatment on cardio function etc...

Parkinson's disease- 4 Cardinal Symp

1. Tremor 2. Muscle Rigidity 3. Bradykinesia or akinesia; slow/no movement. 4. Postural Instability

Types of Nosocomial Infections

1. UTI 2. Surgical Sites 3. Bloodstream 4. Pneumonia

Removing PPE Order

1. Undo gown ties 2. Remove gloves 3. Hand Hygiene 4. Remove eyewear 5. Remove gown 6. Remove mask

Order to remove PPE

1. Undo gown ties (if they tie in front) 2. Remove gloves 3. Hand hygiene 4. Remove eyewear 5. Remove gown 6. Remove mask

Parkinson's disease: Stage I Initial

1. Unilateral limb involvement. 2. Min. weakness 3. Hand/arm trembling.

Right Cardiac Blood Flow (Deoxygenated)

1. Veins carry deoxygenated blood to heart. 2. Flows to the lungs 3. Arteries carry deoxygenated blood to lungs.

Reception Senses

1. Visual 2. Auditory 3. Olfactory 4. Tactile-touch 5. Gustatory- taste

Delegation to UAP: Planning

1. Vitals 2. Intake/Output 3. Transfers 4. ADLs- feeding, bathing, dressing, etc. 5. Weighing 6. Simple dressing changes. 7. CPR 8. Attending to safety.

Supplying O2

1. Wall Outlets 2. Compressed O2; portable tanks. 3. Liquid O2; not commonly used. 4. Oxygen Concentrator

TIA- Mobility Deficits

1. Weakness; facial droop, arm/leg drift, & hand grasp. 2. Ataxia-gait disturbances.

ANS: B, C, D The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

1. What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

Nasopharyngeal

pertaining to the nose and pharynx

Endotracheal

pertaining to within the trachea

Peripheral Pain

phantom pain, post-herpetic neuralgia, or carpal tunnel syndrome that follows damage and/or sensitization of peripheral nerves.

purulent drainage

thick green, yellow, or brown drainage

Maceration

softening or dissolution of tissue after lengthy exposure to fluid

Maceration

softening through liquid; over-hydration; wet.

Delegation

the process of transferring to a competent person the authority to perform a selected nursing task or activity

passive euthanasia

the withholding of available treatments, such as life-sustaining devices, allowing the person to die(legal)

Order to apply PPE

1. Gown 2. Face mask 3. Eyewear 4. Clean gloves

Warfarin Sodium (coumadin) Nursing Considerations

*Bleeding *Do not use in pregnancy

Algor Mortis

- Gradual decrease of the body's temperature after death

Livor mortis

- Red blood cells break down causing discoloration of tissues

Manifestations of Hyperglycemia

-Elevated BG -Increase in urination -Increase in appetite followed by lack of appetite -Weakness -Fatigue -Blurred Vision -Headache -Glycosuria -Nausea -Vomiting - Abdominal cramps -Progression to DKA/HSS

Causes of Hyperglycemia

-Illness -Infection -Corticosteroids -Too much food -too little or no diabetic medication -Inactivity -Emotional or physical stress -Poor absorption of insulin

Pathophyisology of Hyperosmolar Hyperglycemic Syndrome

-Occurs in patients with diabetes who is able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion Occurs less common than DKA but occurs in patients over 60 with type 2 diabetes Causes: -UTI -Pneumonia -Sepsis -Any acute illness -Newly diagnosed Type 2 DM -Impaired thirst sensation -Inability to replace fluids

Islet Cell Antibodies

-Ordered to help distinguish between type 1 diabetes and type 2 diabetes.

Parkinson's disease- Pathophysiology

1. Dopamine & Ach imbalance. 2. Decrease dopamine; no control over involuntary movements to refine voluntary movements. 3. Ach remains in the body; increase of excitatory messages.

Sensory Experience

1. Stimulus 2. Receptor 3. Impulse Conduction 4. Perception

specific gravity of urine(concentrated)

1.001-1.025

Warfarin Sodium (coumadin) Dose

2 mg/day

DM Type 2 should monitor glucose levels?

2-3 times per wk.

DM Type 1 should monitor glucose levels?

2-4 times per day.

ANS: A Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

27. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. I can use a heating pad on my legs if its set on low. b. I should not cross my legs when sitting or lying down. c. I will go out and buy some warm, heavy socks to wear. d. Its going to be really hard but I will stop smoking.

WBC

4,500-11,000/mm3

WBC normal count

4,500-11,000/mm3

RBC Men

4.6-6 million/mm3

Hct Men

40-54%

S4

4th heart sound, not a sign of failure; reflection of decreased ventricular compliance.

ANS: A African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

7. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Womens health clinics

Medical Asepsis

Clean technique; clean vs dirty.

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

ANS: B Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The client's diet does not need to be decreased in carbohydrates, fats, or total calories.

Urine specimen

Clean voided- Routine urinalysis Clean-catch or midstream- Urine culture Timed 24 hour urine collection

HCT decreased

Acute blood loss Pregnancy Dietary deficiencies Anemias

WBC increased

Acute infections Tissue necrosis (e.g., myocardial infarction) Collagen diseases

Type I Diabetes

Acute onset; pt often islet cell antibodies & hereditary developing disease. Occur @ any age; usually under age 30. No cure; difficult to control & requires insulin injections.

Nociceptive pain

Acute pain; a pain sensation that results abruptly.

Lumbar Puncture Interpretation of findings

Administer chemotherapy

Administration of corticosteriods

Administer in AM to coincide w/ natural secretion of cortisol If P.O. administer w/ food

Kidney function tests in DM

Albumin in urine Serum creatinine

Example of bronchodilator

Albuterol (Proventil)

Type 1 DM- Insulin

All dependent on insulin.

Type 1 Diabetes Mellitus

Beta cell destruction Absolute insulin deficiency Autoimmune Idiopathic

Developmental Stressor

Birth of baby & puberty.

Hypoglycemia

Blood glucose less than 70mg/dl.

HGB decreased

Blood loss Anemias Kidney diseases Cancers

rbc decreased

Blood loss Anemias Overhydration Leukemias Chronic renal failure Pregnancy

Double Pnuemonia

Both lung infected.

Disenfranchised Grief

Grief that is unnoticed by others.

Nursing Diagnosis for Nursing Management for loss/grief

Grieving Complicated grieving/risk for complicated grieving Interrupted family process Risk-prone health behavior Risk for loneliness

Diabetes Mellitus

Group of metabolic diseases characterized by elevated levels of glucose in the blood.

stool specimens are tested for

Guaiac Test Dietary or digestive problems Ova and parasites Bacteria or viruses

HAP

Hospital Acquired Pneumonia called nosocomial.

Nosocomial Infection

Infections that originate in a hospital.

Types of Planning

Initial Ongoing Discharge

Ranibizumab (Lucentis)

Injections into the vitreous humor can improve vision for some with macular edema.

Side Effects of Insulin Injections

Local -tenderness/ swelling Redness and induration (firm / hard skin) Systemic -Urticaria -rash of the skin -Hypoglycemia -Lipodystrophy - atrophy of subcutaneous tissue- any occur of same injection site is used frequently.- subsides after 6 months -Insulin resistance

Furosemide (lasix) Pharm Class

Loop diuretic

Anesthesia

Loss of sensation

Metabolic syndrome

Metabolic factors known to increase risk of type 2 DM and cardiovascular disease. ▪ Abdominal circumference of 40 inches or more (men) or 35 inches or more (women) ▪ Hyperglycemia ▪ Abnormal A1C ▪ Hypertension ▪ Hyperlipidemia

Example of corticosteroids(systemic)

Methylprednisolone (Solu-Medrol)

Proliferative diabetic retinopathy

Neovascularization: growth of new retinal blood vessels in response to poor blood flow and hypoxemia. New vessels are thin and fragile, leading to eye hemorrhage and vision loss.

Microvascular complications of diabetes mellitus

Nephropathy Neuropathy Retinopathy

Trachesotomy

New opening of the trachea to the outside of the body.

Nurse planning for stress

Nurse and client set goals to change existing client responses to stressors- Decrease or resolve anxiety Increase coping skills Improve role performance

External Stressor

Originates outside the individual from situations and events in the environment; ex. punch in the face.

Bouchard's nodes

Osteoarthritis (PIP swelling 2° to osteophytes); proximal swelling.

Vancomycin (Vancocin) adverse/side effects

Ototoxic (ear) , nephrotoxic (kidney), anaphylaxis, REDMAN syndrome, (Peak 20-40 mcg/mL ) (trough 5-10 mcg/ml) Benadryl to conteract REDMAN syndrome

Simple Face Mask

Oxygen-delivery apparatus used for patients who require a moderate flow rate for a short period of time via a plastic mask that fits snugly over the mouth and nose,

Stage II Pressure Ulcer

Partial thickness, blistering may be present, abrasion, small crater, & mostly epidermis; dermis maybe involved.

Coping Mechanisms

Patterns of behavior used to neutralize, deny, or counteract anxiety.

Thoracentesis Potential complications

Pre-expansion pulmonary edema (too much fluid removed), collapsed lung (pneumothorax) affected side not moving, HR up rapid shallow respirations fell of air hunger, bleeding, and infection

Colonization

Presence of organisms in body secretions or excretions in which strains of bacteria become resident flora but do not cause illness.

Type 1 DM- Antibodies

Present @ dx

Pt teaching for infection medication

Priority finish all medications

Morality

Private, personal standards of what is right and wrong in conduct, character, and attitude.

moralities

Private, personal standards of what is right/wrong in conduct, character, and attitude

Implementation

Reassessing the client Determining the nurse's need for assistance Implementing the nursing interventions Supervising the delegated care Documenting nursing activities

Short-Term Coping Strategies

Reduce stress temporarily but ineffective to deal with reality; may be destructive or detrimental

Function of Bronchodilators

Relax smooth muscle airways which leads to Bronchodilation

Diastole

Relaxation of the heart; ventricles fill w/ blood. Known as S2; 2nd reading monitoring BP.

Thoracentesis Client education

Remain positioned and still during the procedure (lye on unaffected side with HOB elevated 30 degrees for 30 minutes which facilitates lung expansion

Thoracentesis Indications

Remove air (upper anterior) & fluid (lower anterior) r/t blunt trauma, Pneumonia

Thoracentesis

Remove excess fluid or air to ease breathing

Death/Dying

Signs of impending clinical death; loss of muscle tone, slow circulation, changes in respiration, & sensory impairment.

Insulin secretogogues: Sulfonylurea agents

Simulate insulin release from pancreatic beta cells. Used in patients who are still able to produce insulin. Glipizide (Glucotrol) Glimepiride (Amaryl) ⚠Many drug interactions!

Focal neuropathy in DM

Single nerve or group are affected, usually caused by an acute ischemic event. Most commonly affecting the nerves that control eye muscles. Manifestations include double vision from paralyzed eye muscles. Usually resolves in 2-3 months.

Orthopedic Position

Sitting up in bed at 90 degree angle sometimes resting forward supported by pillow on over bed table.

Excoriation

Skin sore or abrasion produced by scratching or scraping

Excoriation

Skin sore or abrasion produced by scratching or scraping; red rash.

Heberden's nodes

Swelling of distal interphalangeal finger joints, characteristic of osteoarthritis.

Asthma ER

Symptoms don't respond normal w/in 30 min. seek medical attention.

Type II DM Impaired Secretion

There us enough insulin to prevent breakdown of fat & accompanying production of ketone bodies.

Purulent- Drainage

Thick pus; yellow, green, or blue tinged.

Abdominal Paracentesis contraindication

Thrombocytopenia (low platelets)

barriers to EBP

Time to read, clinical application, drs v nurses, real world v research world, levels of evidence, most programs require an article is current within last 5 years

Bone Marrow Biopsy

Tissue from the bone marrow is obtained for examination (popular locations sternum & iliac crest

Corticosteroids used for

To decrease inflammation

Grief

Total response to the emotional experience related to loss.

Tib-Fib Fractures

Trauma to lower 3rd of leg; closed reduction w/ casting, & internal/external fixation.

Ascorbic Acid (Vitamin C): Bone Med

Treat/prevent low Vit C.

Bereavement - subjective response experienced by the surviving loved one

subjective response experienced by the surviving loved one

Type 1 DM- Nutritional Status

Usually nonobese

Acetylsalicylic Acid (aspirin) Dose

Varies, 3 g/day, divided doses q4-6hr

Lisinopril (zestril) Adverse Actions

Vertigo, headache, fatigue, dizziness, hypotension, hyperkalemia

1. Principals of Delegation:

a. Assess the patient before delegating b. Patient must be medically stable, not fragile or critical c. Task should be routine—if first time, RN do it d. Must not require a lot of skill e. Must be considered safe for the patient f. Must have predictable outcome g. Always adhere to facilities P&P h. Must adhere to YOUR scope of practice and UAPs scope i. Must know UAPs work abilities j. Observe if unsure k. Clarify expectations l. Use opps to teach

The nurse is teaching a pt with multiple sclerosis and her family about her exercise program. Which points must the nurse include? Select all that apply. a. ROM exercises are an important component b. Stretching should precede rigorous activity c. Increased body temperature can lead to increased fatigue d. Steadily increasing walking distances can lead to jogging e. Stretching and strengthening exercises will be part of your program f. Take your pain medication at least 30 mins prior to exercise

a. ROM exercises are an important component c. Increased body temperature can lead to increased fatigue e. Stretching and strengthening exercises will be part of your program

1. Implementing

a. Reassess the client b. Determine nurses need for assistance c. Implement nursing interventions d. Supervise delegated care e. Document nursing activities

The home health nurse reads in the patient's chart that he has spinal cord injury and has developed heterotopic ossification of the right hip. What would the nurse expect to observe while assessing the hip? a. Redness, warmth, and decreased ROM b. Obvious deformity, with protrusion of the hip joint c. Pronounced muscle atrophy and wasting of the femur d. Poor skin turgor, with fragility and possible skin tears.

a. Redness, warmth, and decreased ROM

If specially trained, can delegate

a. Simple dressing changes b. Suctioning of chronic tracheostomies (NEVER NEW) c. Gastrostomy feeding d. CPR

The nurse is caring for an older adult patient with a history of chronic asthma. Which problem related to aging can influence the care and treatment of this patient? a. Asthma usually resolves with age, so the condition is less severe in older adult patients. b. It is more difficult to teach older adult patients about asthma than to teach younger patients. c. With aging, the beta-adrenergic drugs do not work as effectively. d. Older adult patients have difficulty manipulating handheld inhalers.

c. With aging, the beta-adrenergic drugs do not work as effectively.

Retino

eye

Tachy

fast

QID

four times a day

Lumbar Puncture post-intervention

send CSF for analysis, client remains in lying position for hours (prevent HA r/t CSF leakage)

BID

twice daily

CT (computed tomography) potential complications

unknown allergies to contrast dye shellfish/iodine

Veno

vein

Hgb Women

12-15 g/dL

ANS: A This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the clients lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

25. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the clients lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil

ANS: D The sound the nurse hears is an S3 heart sound, an abnormal sound that may indicate heart failure. The nurse should next assess the clients lung sounds. Assessing for chest pain is not directly related. There is no indication that the Rapid Response Team is needed. Having the client sit up will not change the heart sound.

25. A nurse is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the nurse hears the following sound. What action by the nurse is most appropriate? (Click the media button to hear the audio clip.) a. Assess for further chest pain. b. Call the Rapid Response Team. c. Have the client sit upright. d. Listen to the clients lung sounds.

ANS: A Clients with an inferior wall MI often have bradycardia and blocks that lead to decreased perfusion, as seen in this ECG strip showing sinus bradycardia. The nurse should first assess the clients hemodynamic status, including vital signs and level of consciousness. The client may or may not need the Rapid Response Team, a temporary pacemaker, or medication; there is no indication of this in the question.

26. A client had an inferior wall myocardial infarction (MI). The nurse notes the clients cardiac rhythm as shown below: What action by the nurse is most important? a. Assess the clients blood pressure and level of consciousness. b. Call the health care provider or the Rapid Response Team. c. Obtain a permit for an emergency temporary pacemaker insertion. d. Prepare to administer antidysrhythmic medication.

ANS: A A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

26. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

ANS: B Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures.

28. A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline.

Autocratic

High secure & predictable. Individuals are incapable of independent decision making.

Authoritarian/Autocratic

Highly secure & predictable Individuals are incapable of independent decision making

nurse Evaluation questions for stress

How does the client perceive the problem? Were existing coping strategies sufficient to meet intended outcomes? Did the client implement new coping strategies properly? Did client use available resources?

Abdominal Paracentesis Pre-Interventions

Consent & Client Education

Intermediate Acting: NPH (Humulin N)

Onset 2-4 hrs, Peak 8 hrs, & Duration 12 hrs.

Type 1 Diabetes Mellitus vs Type 2 Diabetes Mellitus: Type 2

Onset: Usually 35 years or older, but can occur at any age. Incidence is increasing in children Type of Onset: Insidious, may go undiagnosed for years Prevalence: 90% Environmental Factors: Obesity, lack of exercise, poor diet Primary Defect: Insulin resistance, decreased insulin production over time, and alterations in production of adipokines (role in glucose and fat metabolism. Thought to cause chronic inflammation , a factor involved in insulin resistance) . When cells need sugar , liver releases glucose furthering hyperglycemia Islet Cell antibodies: Absent Endogenous Insulin: Initially increased in response to insulin resistance. Secretion diminish over time due to beta cell fatigue. Nutritional Statues: Frequently overweight or obese Symptoms: Frequently none, fatigue, recurrent infections, recurrent vaginal yeast or candidal infections, prolonged wound healing, visual changes. MAY experience : Polydipsia(abnormally great thirst as a symptom of disease) Polyuria polyphagia ( is the medical term used to describe excessive hunger or increased appetite) Ketosis: Resistance except during infection or stress Nutritional Therapy : Essential Insulin: Required for some. Disease is progressive, and insulin treatment may need to be added to treatment regimen. Vascular and Neurologic Complications: Frequent

When nurses give insulin?

Requires dose verification from 2 licensed nurses; before giving to pt.

a. General guidelines for documenting

i. DATE AND TIME EVERYHING ii. Document as often as facility requires, at least 1 time per shift but probably more iii. Write legibly iv. Black ink v. Only approved: make copy of DO NOT USE LIST vi. Always sign vii. If error, just put one line through, never write ERROR viii. Document in right order of events ix. Do not document things that do not pertain to patients health or safety x. DO chart psych issues xi. Be timely—don't wait too long to chart xii. Be objective (JUST THE FACTS!) xiii. Document all client teaching xiv. Never chart before you do something xv. Don't be vague (ex: don't use the word "appears") xvi. NEVER chart for somone else xvii. No need to use the word patient unless its unclear that is who you are referring to xviii. CHARTS CAN BE USED IN COURT

what should you document?

i. Initial head to toe assessment ii. Abnormalities iii. Actions taken to help correct abnormalities iv. Care provided, ADLs any nursing interventions v. Follow up assessments (i.e: your evaluations)

mEq

milliequivalent

sanguineous drainage

mixture of serum and red blood cells

Serosanguineous drainage

mixture of serum and red blood cells. light pink to blood tinged

Abdominal Paracentesis post-interventions

monitor for bleeding, infection, hypovolemic shock

Metoprolol (lopressor) Nursing Considerations

*Abrupt withdraw may result in MI, ventricular dysrhythmias, taper dose *I&Os, check weight daily *Monitor BP Pregnancy- use only as needed

ANS: C A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.

1. A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best? a. Assess the clients pupillary responses. b. Request a neurologic consultation. c. Stop the infusion and call the provider. d. Take and document a full set of vital signs.

Types of Assessment

1. Initial 2. Problem 3. ER 4. Time-Lapsed

Types of Planning

1. Initial 2. Ongoing 3. Discharge

SBAR

1. Situation- describe what is happening at the time of the communication 2. Background- explain any relevant background information that relates to the situation 3. Assessment- provide an analysis of the problem or patient need based on assessment data 4. Recommendation- State what is needed or what the desired outcome is

Types of Data

1. Subjective 2. Objective

ANS: B This clients physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

3. A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the clients O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min. b. Allow continued bathroom privileges. c. Obtain a bedside commode. d. Suggest the client use a bedpan.

RBC Women

4-5 million/mm3

Type 1 Diabetes Mellitus vs Type 2 Diabetes Mellitus: Type 1

Age of onset: More common in young people but can occur at any age Type of Onset: Signs and symptoms are usually abrupt but disease process may be present for several years. (Destruction of Beta cells can take years before signs and symptoms are seen) Prevalence: 5-10% of all types of diabetes Environmental Factors: Virus, Toxins Primary Defect: Absent or minimal insulin production Islet Cell Antibodies : Often present at onset Endogenous Insulin: Absent Nutritional Statues: Thin, normal, or obese Symptoms: Polydipsia(abnormally great thirst as a symptom of disease) Polyuria polyphagia ( is the medical term used to describe excessive hunger or increased appetite) fatigue weight loss Ketosis: Prone at onset or during insulin deficiency Nutritional Therapy: Essential Insulin: Required for all Vascular and Neurological Complications: Frequent

Levofloxacin (Levaquin) adverse/side effects

Anaphylaxis, Cdiff, Seizures, & Steven Johnson syndrome

Ciprofloxacin (Cipro) adverse/side effects

Anaphylaxis, Cdiff, Seizures, Steven Johnson syndrome, & Hepatotoxicity

Penicillin (PCN-G) adverse/side effects

Anaphylaxis, bloody stool, fever, abd cramping-cdiff, GI Distress, & generalized rash

a. Ethical Principals for nurses:

Autonomy- self determiniation or self management: the patient is capable of making informed decisions Beneficence- promotes positive actions to help others Nonmalefience- prevent/ do no harm Fidelity- keep obligations and promises Veracity- Tell the truth to the best of his or her knowledge Social justice- equality and fairness, all patients should be treated equally and fairly regardless of gender, age, sexual orientation, religion, race, ethnicity etc

Type 2 Diabetes Mellitus

Characterised : 1) Pancreas -Defective Beta Cell secretions of insulin -Insulin resistance stimulates increased insulin secretions -Eventual exhaustion of Beta Cells in many people 2) Liver -Excess glucose production -Inappropriate regulation of glucose production 3) Adipose Tissue -Decreased adiponectin and Increased leptin -Results in altered glucose and fat metabolism 4) Muscle -Defective insulin receptors -Insulin resistance -Decreased uptake of glucose by cells resulting in hyperglycemia

Type 1 Diabetes Mellitus

Defined as: -Autoimmune destruction of Beta Cells in the islet of Langerhans -Autoantibodies present for months to years before clinical symptoms -No production of insulin -juvenile onset- under 40 -First Symptoms develop when pancreas can no longer maintain normal glucose production. (Symptoms are normally rapid after this) -Need insulin for live after -Honeymoon period- 3-12 months after initial treatment- Little injections are needed because pancreas is still producing some insulin.

Type of Assessments

Initial Problem Emergency Time-lapsed

Metoprolol (lopressor) Adverse Actions

Insomnia, dizziness, hypotension, palpitations, N/V, diarrhea

Normal Pancreatic Function

Islets of langerhan secret insulin through Beta Cells Glucagon- Produced by delta cells in response to low levels of blood glucose. -Increases blood glucose by stimulating glycogenolysis, gluconeogenesis, and ketogenesis. -Works with insulin to maintain normal blood sugar -Catecholamines, cortisol, glucagon break down complex flues to provide glucose . -Insulin- regulator of metabolism and storage of ingested carbohydrates ,fats, and proteins. Facilitates transport of glucose transport across cell membranes. -Inhibits gluconeogenesis in liver.

Metoprolol (lopressor) Therapeutic Use/Mechanism of Action

Mild to moderate hypertension, acute MI to reduce cardiovascular mortality, angina pectoris, NYHA class II, III heart failure, cardiomyopathy Lowers B/P by beta-blocking effects; reduces elevated renin plasma levels, blocks beta2-adrenergic receptors in bronchial, vascular smooth muscle only at high doses, negative chronotropic effect

Quality Safety Education for Nurses. Competencies:

Provide patient centered care Teamwork and collaboration Evidence-based practice Quality Improvement Infomatics

Abdominal Paracentesis

The retrieval of excess fluid in the abdominal cavity

what class is this

glucocorticoids

The nurse is preparing to discharge a pt with transient ischemic attacks. What topics does the nurse include in discharge teaching? Select all that apply. a. Reduction of high blood pressure b. Drug teaching for aspirin or other antiplatelet drug c. Lifestyle changes such as smoking cessation d. Self-care for managing chronic conditions such as diabetes e. Increased risk fro stroke and signs/symptoms f. Benefits of taking vitamin supplements

a. Reduction of high blood pressure b. Drug teaching for aspirin or other antiplatelet drug c. Lifestyle changes such as smoking cessation d. Self-care for managing chronic conditions such as diabetes e. Increased risk fro stroke and signs/symptoms

The nurse is assessing a pt who was brought to the ED for altered mental status. In the absence of family members or witnesses to give a history, what does the nurse do to identify two conditions that could mimic emergent neurologic conditions? a. Check skin turgor and perform a bladder scan b. Check blood glucose and oxygen saturation c. Observe for jugular vein distention and pitting edema d. Observe for jaundice and abdominal distention

b. Check blood glucose and oxygen saturation

what is a side effect

fluid and sodium retention, increased appetite

what does this do

suppresses inflammation

DM Foot Care- Assess foot loss of strength

1. Limited ankle joint range of motion 2. Limited motion of greater toe.

Types of Nociceptive Pain

1. Somatic 2. Visceral

active euthanasia

actions to bring about a client's death directly, with or without client's consent (illegal in most states)

Cardiac Function

1. CO 2. HR 3. Preload; stretch 4. Contractility; snap 5. Afterload; resistance

TIA- Sensory Perceptions Deficits

1. Numbness; face, hand, arm, or leg. 2. Vertigo

DM 3 P's

1. Polydipsia 2. Polyuria 3. Polyhphagia

Lower Respiratory System-Organs

1. Trachea 2. Lungs

Platelets

150,000-400,000/mm3

ALT

4-36 u/L

Duration of TB treatment

6 months to 2 years Strict adherence to med therapy is essential!

Reception

Ability to receive stimuli/data; ex. touch a hot stove.

HCT increased

Dehydration Burns Hypovolemia

VISUALIZATION PROCEDURES

GI URINARY CARDIOPULMONARY CT SCANS MRI NUCLEAR IMAGING

Lumbar Puncture Pre-Interventions

Obtain consent and educate patient

Visceral Pain

Pain that originates from organs or smooth muscles.

Beta Cells

Produce insulin.

Liver Biopsy

Retrieval of liver tissue at the bedside

Surgical Asespis

Sterile technique.

Closed Awareness

Type of awareness in which the client is unaware of impending death

RBC normal lab values women

Women: 4-5 million/mm3

Peritonitis

inflammation of the peritoneum into the stomach; 2nd worst infection.

Wt

weight

Linezolid (Zyvox) adverse/side effects

(use for VRE) bloody stool, fever, abd cramping-cdiff

Acetylsalicylic Acid (aspirin) Nursing Considerations

*Hypersensitivity to aspirin or NSAIDS *Bleeding GI ulcers *Take w/ food *Do not use in 1st trimester of pregnancy *Avoid breastfeeding

Lisinopril (zestril) Nursing Considerations

*Pregnancy *Blood studies at baseline, if neutrophils <1000/mm3 discontinue *Do not discontinue abruptly *Rise slowly to sitting or standing *Avoid increasing K *Report a dry cough

Atorvastatin (lipitor) Nursing Considerations

*Pregnancy/breastfeeding *Decreases LDL *Blood work and eye exam necessary during treatment

Causes of hypoglycemia

-Alcohol intake without food -too little food -to much diabetic medication -too much exercise without proper food intake -Diabetic medication or food taken at wrong time -Loss of weight without change in medication - Use of Beta-Adrenergic blockers interfering with recognition of symptoms!

Other Diagnostic tools

-BUN -Blood Pressure -ECG -Fundoscopic examination (Dilated eye examination) -Dental examination -Neurologic examination (monofilament test for sensation to lower extremities) -Ankle-Brachial Index -Foot (podiatric) examination -Monitoring examination

Manifestations of Hypoglycemia

-Blood glucose <70 -Cold , clammy hands -Numbness of fingers, toes, mouth -Rapid heartbeat -Emotional changes -Headache -Nervousness, tremors -Faintness -Dizziness -Unsteady gait -Slurred speech -HUngar -changes in vision -Seizures -Coma

Exercise Therapy

-Exercise at least 30 mins a day/5 times a week. -Resistance training 3 times a week. Exercise effects: -Decrease insulin resistance -Direct effect on lowering BG -Weight loss= decreases insulin resistance further -Reduces triglyceride and low-density lipoprotein -Increases high-density lipoprotein -Reduce BP -Improve circulation Teaching: -Get approval from doctor before beginning exercise program -Patients on insulin/ sulfonylureas/meglitinides are at increased risk for hypoglycemia when they increase exercise (can last up to 48hrs after working out) -Exercise 1 hour after meal OR HAVE SNACK OF 10-15g and check BP before exercising. -EAT SNACK EVERY 30 minutes during workout

Treatment of Hyperglycemia

-Get medical care -Continue diabetes medication as ordered -Check BG frequently -Check urine for ketones -Drink fluids at least on an hourly basis -Contact health care provider -COntact health care provider regarding ketonuria

What information is pertinent in Change of Shift reports?

-ID information -Reason for admission -Significant changes in condition on your shift or anything from previous shift that is pertinent -Be EXACT with information -Needs for emotional support services -Discuss major health care -provider orders and nursing interventions that should continue -Priorities of care

Hypoglycemia Defined

-Insulin levels are too high -Glucose drops to less than 70mg/dL When glucose drops below 70, counterregulartory hormones take over -Insulin is suppressed and glucagon and epinephrine provide defense against hypoglycemia -S/S of epinephrine release -shakiness, palpitations, nervousness, diaphoresis , anxiety, hunger, pallor , altered mental status from low glucose (difficulty speaking, visual disturbances , stupor, confusion,coma) -Mimic alcohol intoxication Hypoglycemic Unawareness- person does not experience s/s of hypoglycemia until glucose reaches critical levels Reasons: -Autonomic Neuropathy of diabetes- interferes with counterregulatory hormones that produce s/s of hypoglycemia -at risk for Unawareness -repeated episodes of hypoglycemia -older patients -Beta-Adrenergic blockers S/S of hypoglycemia may also occurs when very high levels of BG call to suddenly. (300 quickly falling to 180) Sudden metabolic shift - too vigorous management of hyperglycemia

Treatment of HHS

-Ketoacidosis doesn't occur as insulin is sufficient enough to prevent fatty acid breakdown -Few symptoms early on -Can easily jump to BG of 600+ before symptoms appear -Increased Serum osmolality -More severe Neurologic manifestations (somnolence/coma/ seizures/hemiparesis/aphasia -Symptoms resemble a stoke!!!! GET BLOOD GLUCOSE IMMEDIATELY ------------------------------------------------------------------ 1) Administer 0.9% or 0.45% NaCl (usually more fluid replacement is needed with HHS than DKA) 2) Administer Insulin 3) When BG hit 250- Administer IV fluids containing glucose to prevent hypoglycemia 4) Monitor and replace electrolytes 5)Potassium loss won't be as signifcant as DKA 6) Assess VS/Intake + output/ tissue turgor / lab values/ cardiac monitoring/ mental status / serum osmolality

A1C Defined

-Measures amount of glycosylated hemoglobin as a percentage of total hemoglobin. -increased glucose levels= more glucose is attached to hemoglobin. -Amount of glucose stays on hemoglobin for 120 days -Provides accurate measurement for blood glucose for past 3 months.

Nephropathy

-Microvascular complications with kidney Risk factors -hypertension -genetic predisposition -smoking -chronic hyperglycemia -Increased albuminuria/ creatinine

Basal-Bolus

-Most closely resembles endogenous insulin production Regular or rapid before breakfast, lunch, and dinner + Long-acting once a day OR Regular or rapid before breakfast lunch and dinner + NPH twice a day More flexibility is allowed at mealtimes and for amount of food intake. Good postprandial control Prepandial blood glucose checks are establishing and following individualized algorithms are necessary. Patients with type 1 regular basal insulin to cover 24hrs.

Treatment of DKA in hospital

-Not severe DKA can be handled at home ------------------------------------------------------------------ Initial Therapy/Goal -IV Access and begin fluids and electrolyte therapy ----0.45% or 0.9% NaCl at a rate to promote urine output of 30-60mL/hr + Restore BP -Once glucose levels fall to 250mg/dL- start 5-10% dextrose to prevent glucose levels from falling too fast to prevent cerebral edema (fluids more into cell too fast= cellular swelling) Goal of therapy is to replace extracellular and intracellular water and to correct sodium, chloride , bicarbonate , potassium, phosphate , magnesium, and nitrogen deficiencies !!!! OBTAIN POTASSIUM LEVELS BEFORE INSULIN IS STARTED!!!! -Fluid therapy forces potassium back into cell. -Insulin only makes potassium levels drop more as glucose and water rush back into cell. IV insulin is directed at correcting hyperglycemia and hyperketonemia Start at 0.1U/Kg/HR-continuous infusion Glucose level should only fall 36-45mg/dL/hr to prevent cerebral edema. Continue to monitor vascular volume and potassium as insulin allows water , glucose and potassium to return into cell. SAFETY ALERT! -too rapid administration of IV fluids and rapid lowering of serum glucose can lead to cerebral edema -Incorrect fluid replacement with hypotonic fluids can cause to sudden fall in serum sodium and can cause cerebral edema.

Charting by Exception (CBE)

-Only abnormal or significant findings or exceptions to norms are recorded -Makes great use of flow sheets a. Ex: graphic records of a vital sign sheet, a head and face assessment, Braden assessment (p 227-228) -Documents that a procedure was performed and refer to the agencies policies and proceedures a. Ex: 16 Fr Foley cath inserted per facility policy -Bedside access to forms or COWs

Diabetic Retinopathy

-Process of Microvascular damage to retina as result from chronic hyperglycemia Nonproliferative- most common- partial occlusion of small blood vessels in retina cause microaneurysms- capillary fluid leaks out causing retinal edema + hard exudates or intraretinal Hemorrhages Proliferation- most severe -involves retina and vitreous - new blood vessels are formed around high to make up for occluded blood vessels canned neovasculaziation -new blood vessels are fragile and hemorrhage easily producing vitreous contraction -Light is prevented from reaching retina as blood vessels become torn and bleed into vitreous cavity Patient sees black or red spots or lines Blood vessel pull retina while vitreous contacts= retinal detachment Macular is involved= vision is lost Glaucoma can occur as a result of occlusion of outflow channels secondary to neovasculaziation .

RN vs LPN vs UAP

-RNs need to EAT - Evaluate, Assess, Teach (LPNs/UAPs cannot!) -LPNs get the stable/chronic patients... RNs get the unstable/acute patients -UAPs can assist with ADLs

Treatment of Hypoglycemia

-Rule of 15 1) If BG is <70 ; treat with 15g of carbohydrates (simple, fasting acting) ex 4-6oz of fruit juice or regular soft drink, 8-10 lifesavers, 2-3 tbs syrup or honey, 4tsp jelly, commercial dextrose products 3-4 glucose tablets (severe) and 50 mL D 50% IV push (severe)) 2) Wait 15 mins, then check BG again 3) If BG <70, retreat with 15g carbohydrates 4) No improvement after 2-3 doses of carbohydrates, contact health care provider. 5) Avoid carbohydrates such as candy bars, cookies, whole milk, ice cream or (Fats) Worsening symptoms: -SQ or IM injection of 1 mg glucagon. IV administration of 25-50 mL of 50% glucose if patient is unable to swallow -Nausea man result from glucagon injection (turn patient on side if vomiting starts)

Preventive measures of Hyperglycemia

-Take prescribed dose and medication -Accurately administer insulin, noninsulin, Oa -Maintain diet -Adhere to sick-day rules when ill -Check BG as ordered -Wear diabetic identification

Preventive Measures for Hypoglycemia

-Take prescribed dose at proper time -Accurately administer antidiabetic medications -Ingest all recommended foods at proper time -Provide adequate food intake during exercise periods -Be able to recognize and know symptoms and treat -Carry simple carbohydrates -Educate family and friends about symptoms and treatment -Check BG as ordered -Wear Medic Alert Identification

Storage of Insulin

-freezing and heat destroy insulin -Inuse insulins can be left at room temperature for 4weeks -Unopened insulins should be kept in freezer. -Avoid prolonged sun exposure -Syringes are stable for 1 week (mixed) or 1 month (one insulin) -Store syringes in vertical position with needle pointed up to avoid clumping of suspended insulin in needle. -Before injection: roll prefilled insulin syringes between palms 10-20 times to warm insulin and resuspend insulin -DO not use insulin if bottle is "frosty)

AST

0-35 u/L

AST normal range

0-35 u/L

Creatinine

0.5-1.2 mg/dL

INR

0.8-1.1

INR normal range

0.8-1.1

Diagnostic Studies for Type 1 and Type 2

1) AIC of 6.5% or higher 2) Fasting Plasma Glucose )FPG) level greater than or equal to 125mg/dl (Fasting means 8 hours without eating) 3) Two- hour plasma glucose level greater than or equal to 200mg/dL 4) IN a patient with hyperglycemia (polyuria, polydipsia, polyphagia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose greater than or equal to 200mg/dL. (No repeat test is done, diagnosis is confirmed) Criteria 1-3 should be done again to confirm diagnosis. (same test)

Emergency Management of DKA

1) Ensure patient airway 2) Administer O2 via nasal cannula or non rebreather 3) Establish IV access- large bore 4) Begin fluid resuscitation with 0.9% NaCl solution at 1L/hr until BP stabilizes and urine output is 30-60mL/hr 5)Begin continuous regular insulin drip at 0.1U/Kg/Hr Ongoing Assessments 1) Monitor VS/LOC/Cardiac Rhythm/ O2 saturation/ urine output 2)Assess breath sounds for fluid overload 3)Monitor serum glucose and serum potassium 4)Administer potassium to correct hypokalemia 5) administer bicarbonate if severe acidosis (pH<7.0)

Patient Teaching for Exercising

1) Exercise does not need to be vigorous (brisk walk) 2)Pick exercise that you enjoy to promote regularity 3)Proper fitting footwear 4)Warm-up period and cool down period. Start gradually and increase slowly 5)Exercise after meal when BP is rising 6)Monitor by healthcare provider 7) Self monitoring BG before, during, and after exercise. --Before Exercise- if BG <100 , eat a 15g carbohydrate snack. After 15-30 mins, if BP is still <100 do not exercise --Before exercise if BG is >250 in a person with type 1 and ketones are present, avoid vigorous activity 8)Delayed exercise induced hypoglycemia is common several hours after 9)Taking a glucose lower medication does not mean that planned or spontaneous exercise cannot occur 10) Compensate for extensive planned and spontaneous exercise by monitoring BG levels to make adjustments in insulin.

Foot Care

1) Wash feet daily in mild soap and warm water 2) Pat feet dry, especially between toes 3)Examine foot daily for cuts. Poor eye sight- have someone else inspect 4)Use lanolin on feet to prevent drying and cracking. No not apply between does 5)Use mild foot powder on sweaty feet 6)Do not use commercial remedies to remove calluses or corns 7) Cleanse cuts with warm water and mild soap, covering with clean dressings (no alcohol , iodine, or strong adhesives) 8) Report skin infections or no healing wounds to doctor 9) Cut toenails evenly with rounded contour of toe. DO not cut down corners - cut nails after shower 10) Separate overlapping toes with cotton or lamb's wool 11) Avoid open-toe , open heel, or high heel shoes. Leather shoes are preferred, Wear slippers with soles. Do not go barefoot/ shake out shoes before putting on 12)Wear clean absorbent cotton or wool socks or stockings that have not been mended. 13) Do not wear clothing that leaves impressions (hinders circulation) 14) Do not use hot water bottles or heating pads to warm feet, Wear socks to warm 15) Guard against frostbite 16) exercise feet daily , by walking or flexing and extending feet in suspended position. Avoid prolonged sitting, standing , and crossing of legs.

Mixing Insulins

1) Wash hands 2) Gently rotate NPH Insulin Bottle 3)Wipe off tops of vials with alcohol sponge 4) Drawback amount of air into syringe that equals total dose 5) Inject air equal to NPH dose into NPH vial. Remove syringe from vial 6) Inject air equal to regular dose into regular insulin vial 7) Invert regular insulin bottle and withdraw regular insulin dose 8) Without adding more air to NPH vial, carefully withdraw NPH dose and add to regular insulin already in syringe Remember: -Clear before cloudy

Teaching for Insulin Administration

1) Wash hands thoroughly 2) Always inspect insulin bottle before using it. Make sure that it is proper type and concentration, expiration date has not passed and top of bottle is in perfect condition. The Insulin (except NPH) should look clear and colorless. Discard insulin if it looks discolored or has particles in solution. 3) If insulin is cloudy, gently roll insulin bottle between palms to mix it. 4) Select proper injection site. 5)Cleanse skin with soap and water or alcohol 6)Pinch up the skin, and push needle straight into pinched-up area (90degrees). 7) If patient is very thin or using a 5/16 needle, you may use a 45degree angle. 8) Push plunger all the way down, let go of pinched skin, leave needle in place for 5 seconds to ensure insulin has been injected and remove needle 9) Destroy and dispose of single-use syringes safely . Addition teaching: -Caution patient not to inject insulin in a body part that they are going to be exercising with as it increases absorption rate. Typically the abdomen is best to use. (Injections should be 1/2-1inch away from eachother.) -Use one injection site for atleast a week before moving to a different site. -Never recap a needle used by the patient. Always have patient recap needle. -Using an alcohol swab is no longer recommended prior to injection -Needle sizes come in 1/4 inches. 5/16 inches, 1/2 inch and in 28-31 gauge.

Glucose Monitoring Teaching

1)Wash hands in warm water. Do not clean with alcohol as it might interfere with test . Make sure finger is dry 2)If difficult to obtain drop of blood- Warm hands in warm water or let arms hang dependently for a few minutes 3) Penlet lancing device is usually used. If puncture is used on finger, use side of finger pad (Fewer nerve endings) 4)Make puncture just deep enough to obtain sample. Too deep and pain and bruising may occur 5)Record results and compare with target BG.

Environmental Affects in Respiratory Function

1. Altitude 2. Heat 3. Cold 4. Air Pollution

How much Ca do older adults need daily?

1,000 mg; ages 50-70.

SPUTUM specimen Intra-intervention

1-2 tsp. of sputum, take deep breaths

Dementia Causes

1. Alzheimer's 2. Vascular dementia 3. Frontotemporal dementia 4. Lewy Body dementia 5. Prion 6. Wernicke's Korsakoff Syndrome 7. Huntington chorea 8. Parkinson's

Hypoglycemia Conscious Food Intake

1. 1/2 cup OJ 2. 4 oz Jello 3. 6 oz Soda 4. 3 pieces of hard candy

ANS: B, C, D, E Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.

1. A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Age b. Hypertension c. Obesity d. Smoking e. Stress

ANS: D The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

1. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary refill of 4 seconds as normal d. Palpating both carotid arteries at the same time

Sensory Nursing Assessment- Mental Status

1. AAO 2. Orientation 3. Memory 4. Attention span

TIA- Visual Deficits

1. Blurred Vision 2. Diplopia-double vision. 3. Blindness in 1 eye. 4. Tunnel vision.

Chronic Bronchitis Symptoms

1. Color dusky to cyanotic. 2. Recurrent cough & increased sputum. 3. Hypoxia 4. Hypercapnia 5. Respiratory acidosis. 6. Increased Hgb, RR, & heavy smokers. 7. Exertional dyspnea 8. Clubbing

Meds for Pain Mgt.

1. Acetaminophen 2. NSAID 3. Opiods 4. Injections 5. Muscle Relaxers (Valium) 6. Weak Opiods (Tramadol)

Complication of Bone Fractures & Joint Replacements.

1. Acute Compartment Syndrome (ACS) 2. Hypovolemic Shock 3. Fat Embolism Syndrome (FES) 4. Venous Thromboembolism 5. Infection; osteomyelitis.

Pain- Nursing Dx

1. Acute pain 2. Chronic pain 3. Impaired Mobility 4. Insomnia

Pt Evaluation: Bones

1. Adequate pain control 2. Adequate blood flow maintaining perfection/function. 3. Free of infection 4. No physiologic & impaired mobility. 5. Ambulates/moves independently w/ or w/out assisted devices.

Acetaminophen

1. Admin less than 2-3 grams per day. 2. Doesn't effect platelets. 3. Don't use with alcohol. 4. Side Effects: GI distress, liver/renal damage, & reduce alcohol.

Factors affecting Respiratory Function

1. Age 2. Environment 3. Lifestyle 4. Health Status 5. Meds 6. Stress

CVA Risk Factors: Non-Modifiable

1. Age 2. Race 3. Gender

Factors Influencing Grief

1. Age 2. Sig. of loss 3. Culture 4. Spiritual Beliefs 5. Support System 6. Cause of Loss

Parkinson's disease: Stage IV Severe Disability

1. Akinesia 2. Rigidity

Meds that help with Asthma?

1. Albuterol 2. Methylprednisolone

COPD- Psychosocial Assessment

1. All aspect of pt's life w/ COPD 2. Interest & hobbies. 3. Living conditions & exposure to irritants. 4. Economic impart of disease. 5. Anxiety/fear of dyspnea.

Postmortem Care

1. All equipment, soiled linen, & supplies removed from bedside. 2. All tubes remain in place; can cut 1" from the skin & tape in place. 3. Place body supine w/ arms @ sides, palms down, or across abdomen. 4. Place 1 pillow behind head & shoulders. 5. Wash visibly soiled area of body.

Parkinson's disease- Nursing Interventions

1. Allow pt extra time to answer questions & perform ADLs. 2. Admin med timely. 3. Collaborate with therapists. 4. Provide high protein/calorie foods; supplements for wt gain. 5. Goals: preserve pt's mobility, cognition, & quality of life.

Diabetes Mellitus Cells

1. Alpha 2. Beta 3. Delta

DM Exercise Med Mgt

1. Anti-diabetic meds need to be reduced during exercise. 2. Monitor blood glucose before/after exercise. 3. Monitor HR 4. Wear well-fitted shoes; don't exercise in extreme weather.

NSAID

1. Anti-inflammatory, analgesic, & antipyretic. 2. Side Effects: heartburn, ingestion, ulcers, & GI bleeds. 3. Take w/ food/H2O.

Nursing Dx-Stress

1. Anxiety 2. Caregiver Role Strain 3. Compromised Family Coping 4. Defensive Coping 5. Ineffective Denial 6. Ineffective Denial 7. Post-Trauma Syndrome

Hypoxia Symptoms

1. Anxiousness 2. Restlessness 3. Light-Headedness 4. Rapid Pulse 5. Nasal Flaring 6. Rapid shallow respiration & dyspnea. 7. Substernal/intercostal retractions. 8. Central cyanosis

Left Hemisphere Stoke- Language

1. Aphasia 2. Agraphia 3. Alexia

TIA- Speech Deficits

1. Aphasia 2. Dysarthria- slurred speech.

Cardio Nursing Assessment- Physical Assessment

1. Apical Pulse; 1 min. 2. Respiration; crackles/wheezes. 3. Mental Status 4. S3 gallop 5. Distended Neck Veins 6. Dependent edema

Albuterol- Nursing Assessment/Intervention

1. Assess lungs sounds, HR, & BP. 2. Amount/Color of sputum. 3. Observe for paradoxical bronchospam; wheezing. 4. Teach pt. to take meds. 5. Notify MD of increased dyspnea. 6. Can be given PO/inhalation.

Don't Delegate to UAP: Planning

1. Assessment 2. Interpretation of data. 3. Nursing dx 4. Nursing Care Plan 5. Evaluations 6. Care of invasive lines. 7. Admin. meds 8. Inserting NG Tubes. 9. Client edu. 10. Telephone advice

Respiratory Conditions

1. Asthma 2. Pneumonia 3. TB 4. COPD 5. Emphysema 6. Bronchitis

Nuerocognitive Functions

1. Attention 2. Short-Term Memory 3. Long-Term Memory 4. Social Cognition

Leadership Styles

1. Autocratic 2. Democratic 3. Laissez-Faire 4. Bureaucratic 5. Charismatic 6. Transnational 7. Transformational 8. Shared

Types of Moral Principles

1. Autonomy- self choice. 2. Nonmaleficence- don't harm. 3. Beneficence- Doing good; benefit. 4. Justice- Fairness 5. Fidelity- Loyalty; keeping promises. 6. Veracity 7. Accountability/Responsibility- Be responsible for your actions.

Asthma Mgmt

1. Avoid environ. asthma triggers; smoke, fireplaces, dust, mold, & weather changes. 2. Avoid drug that trigger your asthma; NSAIDs & beta blockers. 3. Avoid food that has been prepared w/ MSG. 4. Exercise-induced asthma, use bronchodilator inhaler 30 min before exercise; reduce bronchospams. 5. Meds admin use metered dose inhalers. 6. Rest/Sleep 7. Reduce stress/anxiety 8. Wash bedding w hot H2O to destroy bed bugs. 9. Monitory flow rates twice daily.

COPD- Client Edu

1. Avoid inhaled irritants. 2. Improve breathing patterns. 3. Maintain pulse ox 88%. 4. Improve gas exchange; 1-2 L O2 5. Airway clearance 6. Prevent infection 7. Nutritional intake 8. Teach pursed lip breathing

Oxygenation- Nursing Assessment Physical Exam

1. BR, rhythm, pattern, & effort. 2. Cough 3. BP 4. Breath Sounds 5. Chest shape/size 6. Use of accessory muscles.

Types of Microorganisms

1. Bacteria; antibiotic treatment. 2. Virus 3. Fungi 4. Parasites

Dementia- Age Related

1. Bad decisions 2. Missed monthly payments 3. Forget the day 4. Forgetting word to use 5. Losing something

Inhaler Steps w/out Spacer

1. Before use, remove cap & shake inhaler. 2. Tilt head back slightly; breath out fully. 3. Open mouth, place the mouthpiece 1-2" away. 4. Breathe deeply through mouth, press down firmly on canister of inhaler to release 1 dose of meds. 5. Cont. breathe out slowly/deeply; over 5-7 secs. 6. Hold breath @ least 10 secs.; allow meds to reach deep in lungs & breathe out slowly. 7. Wait 1 min between each puff. 8. Replace the cap of inhaler. 9. Once a day clean inhaler w/ warm H2O.

Older Adults- Cardio

1. Blood vessels lose elasticity 2. Impaired valve function 3. Decreased muscle tone 4. Decreased barorecptors 5. Decreased conduction 6. Orthostatic; falls & dizziness

Asthma Mgmt. ER Care

1. Blue fingertips/lips 2. Difficulty walking, breathing, & talking. 3. Retractions of neck, chest, or ribs. 4. Nasal flaring 5. Failure meds; worsening symptoms. 6. Flow rate declining steadily after tx; flow rate 50% below usual flow rate.

Cardio Nursing Assessment- Hx

1. Cardiac problems? 2. Activity Level? 3. Lifestyle? 4. Recent Changes?

CVA Hemorrhagic Stoke- Complications

1. Cerebral Hypoxia 2. Decreased cerebral blood flow. 3. Extension of the area of injury.

MI Symptoms- Men

1. Chest Pain 2. Left arm pain 3. Reflux 4. Nausea 5. SOB 6. Diaphoresis

Diagnostics- Respiratory

1. Chest X-Ray; anterior/posterior. 2. EKG 3. Sputum specimen 4. Bronchoscopy 5. Pulmonary Function Test- expand chest. 6. Labs; CBC, WBC, ABG, & cholesterol. 7. Pulse Ox.

Pneumonia C-AP Risk Factors

1. Chronic health problems 2. Immunosuppression 3. Smoking 4. Respirator infection 5. Older adults 6. Never got a pnumococcal vaccination 7. Didn't receive the influenza vaccination

COPD

1. Chronic lung disease; most common. 2. Destructive changes in alveolar wall & enlargement of air spaces. 3. Airflow limits is progessive w/ abnormal inflammatory response. 4. Not fully reversible 5. Chronic bronchitis & emphysema

OA- Psychosocial

1. Chronic pain; interferes w/ quality of life, sex, & energy levels. 2. Cause depression/anxiety. 3. Can lead to role changes, altered body images, & low self-esteem.

Nonverbal Pain Indicators

1. Clenching Teeth 2. Biting Lip 3. Facial Grimacing 4. Moaning 5. Crying 6. Rubbing an area 7. Not moving a certain part. 8. Holding an area. 9. Tossing/turning 10. Reflective jerks 11. Confusion 12. Agitation 13. Anger 14. Increased HR/BP

Sources of Data

1. Client 2. Support People 3. Client Records 4. Health Care Professionals 5. Literature

Nursing Assessment-Stress

1. Client stress & coping mechanisms. 2. Physical exam. for indicators of stress. 3. Stress-related health problems. 4. Vitals are increased HR, RR, BP, sweating, agitated, & moving around.

Hip Replacement THA- Preoperative

1. Collaborate w/ PT ensure pt has appropriate equip. post-op. 2. Admin IV antibiotic (cephalosporin like cefazolin) 1 hr prior to surgery. 3. Assess risk factors for bleeding/clotting.

Evaluating

1. Collect data 2. Comparing data w/ desired outcomes. 3. Relating nursing activities to outcomes. 4. Drawing conclusions about problems status. 5. Continuing, modify, or terminate the nursing care plan.

Sputum Cultures

1. Collect in the AM 2. Don't contaminate with saliva or sinus drainage. 3. Collect before antibiotics. If pt is taking antibiotic inform the lab for accurate test results.

Nursing Dx- Grief

1. Complicated grieving/risk 2. Interrupted family process 3. Risk prone health behavior 4. Risk of loneliness

TB Risk Factors

1. Contact w/ untreated people. 2. Decreased immune system. 3. Crowded living conditions. 4. Older homeless people. 5. Abusers of drugs & alcohol. 6. Lower socioeconomic groups. 7. Immigrants

Med Classification

1. Controlled 2. Partly Controlled 3. Uncontrolled

DM Long-Term Complications

1. Coronary Artery Disease; myocardial infarction & atherosclerosis. 2. Cerebral Vascular Disease; stroke. 3. Peripheral Vascular Disease; arterial occlusive disease.

Pneumonia Symptoms

1. Cough 2. Fever 3. Chills 4. Tachycardia 5. Dyspnea 6. Pleural Pain 7. Malaise 8. Respiratory Distress 9. Decrease Breath Sounds

Asthma Symptoms

1. Cough 2. Increase Mucous 3. Shortness of Breath 4. Wheezing 5. Prolonged Expiration 6. Increased CO2 Retention 7. Chest Tightness 8. Retractions

Pneumonia- Nursing Assessment

1. Cough/sputum production 2. Fever; shaking chills 3. Tachycardia 4. Hemoptysis 5. Chest Pain 6. Decreased lung sounds/PO2 7. Elevated WBC 9. Chest x-ray 10. Common manifestation in Older Adults.

Manifestations of Grief

1. Crying 2. Sleep Disturbance 3. Loss of Appetite 4. Difficulty Concentrating

Factors affecting Pain

1. Cultural Values 2. Developmental Stage 3. Previous Pain experience 4. Meaning of pain

Doc. Guidelines

1. Date/Time 2. Timing 3. Legibility 4. Permanence 5. Accepted Terminology 6. Correct Spelling 7. Signature 8. Accuracy

Decrease Insulin

1. Decreased Calories 2. Wt loss 3. Increased activity 4. Renal insufficiency 5. Liver impairment 6. Hypothyroidism

Factors Affection Sensory

1. Developmental stage 2. Culture 3. Stress 4. Meds/Illness 5. Lifestyle/Personality

DM Symptoms

1. Diabetes casual plasma blood glucose less than 200 mg/dL; anytime w/out meal. 2. Fasting plasma blood glucose 126-130 mg/dL; no calories for @ least 8 hrs.

Hypoglycemia Symptoms

1. Diaphoresis 2. Tachycardia 3. Nervousness 4. Poor Concentration 5. Blurred Vision 6. Confusion 7. Coma 8. Death

Evaluation-Grief

1. Difficult due to long term nature of grieving. 2. Pt behaviors indicate complicated grieving? 3. Expected outcome unrealistic for given time frame? 4. Pt additional stressors previously not considered affecting grief resolution?

Types of Interviews

1. Directive vs Nondirective 2. Closed vs Open Questions 3. Neutral vs Leading Questions

Types of interviews

1. Directive- highly structured and elicits specific information a. Used when time is limited 2. Nondirective- rapport building interview, allow client to control the purpose, subject matter and pacing

Right Hemisphere Stoke- Memory

1. Disorientation of time, place, & person. 2. Inability to recognize faces.

Pt Edu-Bones: Cast Removal

1. Don't scrub; gently remove skin. 2. Move carefully 3. Expect discomfort, weakness, & decreased ROM. 4. Extremity will look smaller than the other one. 5. Support extremity will pillow until strength/movement returns. 6. Wear support stockings/elastic bandages to prevent swelling. 7. Teach to assess NV check @ home. 8. Teach pt check for infection.

Hip Replacement- Pt edu

1. Hip precautions; prevent hip dislocation. 2. Incisional Care 3. Ambulate to prevent DVT 4. Preform postoperative exercises; straight leg raises, gluteal sets, ankle pumps, & ham sets. 5. Report bleeding/excessive bruising, pain, swelling, & redness; avoid straight razor.

DM Foot Care- Nursing Assessment

1. Dry, cracked, & fissured skin. 2. Ulcers 3. Toenails; thick, long, & ingrown nails. 4. Tinea pedis; onychomycosis-mycotic nails. 5. Claudication 6. Presence/absence of dorsalis pedis or posterior tibial pulse. 7. Prolonged cap. filling time; greater than 25 secs. 8. Presence/absence of hair growth on top of foot.

COPD Nursing Assessment

1. Dyspnea 2. Use of acces. muscles 3. Prolonged expiration 4. Thin w/ barrel chest 5. Assess BR/pattern, HR, cyanosis, cap refill, & clubbing.

Cardio Nursing Assessment- Dx Tests

1. Echocardiogram 2. Chest X-Ray 3. ECG

Delirium Risk Factors

1. Electrolyte imbalances 2. Fever 3. Sepsis 4. Hypotension 5. Shock 6. Infection 7. Foley Catheter; long term. 8. Age 9. Anemia 10. Hypertension 11. Resp. disease 12. Dementia 13. Restraints 14. Malnutrition 15. Limited environmental stimuli

Cardio Nursing Assessment- Labs

1. Electrolytes 2. Cardiac; CKMB, Trop, & BNP. 3. Cholesterol & Lipids 4. Creatinine; kidney 5. Hgb A1C; glucose. 6. K+ levels; causes cardiac distythemia

Nursing Intervention- Improve Peripheral Tissue Perfusion

1. Elevate legs 2. Ambulation 3. Leg exercises 4. Meds; ASA, anticoagulants, & SCDs/TED hose.

Preventing Sensory Deprivation

1. Encourage pt to use sensory aids; like glasses/hearing aids. 2. Address pt by name & touch pt which speaking. 3. Comms. frequently w/ pt & maintain meaningful interactions. 4. Provide phone, radio, TV, clock, & calendar. 5. Have family bring fresh flowers. 6. Arrange pet visits. 7. Increase tactile stimulation through physical care measures; hair care, massage, foot soaks. 8. Encourage socialization. 9. Encourage puzzles/other mental stimulating activities.

OA- Labs

1. Erythrocyte sedimentation rate (ESR) 2. High-sensitivity C-reactive protein (hsCRP)

Ca+ Carbonate/Ca+ Citrate- Osteoporosis Meds

1. Essential for bone formation. 2. Replaces Ca+ 3. Observe hypocalcemia; muscle twitching & laryngospams. 4. Toxicity: anorexia, thirst, constipation, & bradycardia.

Planning Process

1. Est. client goals/outcomes- SMART Goals & outcomes should be client-focused; not nursing focused. 2. Develop Care Plans 3. Select Nursing Interventions 4. Delegation- 5 Rights of delegation.

Altered Breathing Patterns

1. Eupnea 2. Tachypnea 3. Bradypnea 4. Apnea 5. Kussmaul's 6. Cheyne-Stokes 7. Biot's 8. Dyspnea 9. Orthopnea

Sensory Deprivation- Examples

1. Excessive yawning, drowsiness, sleeping. 2. Decreased attention span, difficulty concentrating, decreased problem solving. 3. Impaired memory 4.Periodic disorientation, general confusion, or nocturnal confusion 5. Preoccupation with somatic complaints, such as palpitations 6. Hallucinations or delusions 7. Crying, annoyance over small matters, depression 8. Apathy, emotional liability

Type II DM Risk Factors

1. Family hx 2. Obesity 3. Race 4. Over 40 yrs old. 5. Gave birth to a baby weighing over 9 lbs.

COPD Symptoms

1. Fatigue 2. Freq. respiratory infections. 3. Use of assec. muscles when breathing. 4. Orthopneic 5. Wheezing 6. Pursed Lip Breathing 7. Barrel Chest 8. Prolonged Expiatory Time 9. Bronchitis 10. Digital Clubbing

Decreased CO- Left Ventricular Failure

1. Fatigue/Weakness 2. Oliguria @ day; Nocturia @ night. 3. Angina 4. Confusion, restlessness, & dizziness 5. Tachycardia/palpitations 6. Pallor, weak pulses, & cool extremities.

Infections- Assessment

1. Fever 2. Chills 3. Increase HR & RR 4. Fatigue 5. Anorexia 6. Abdominal Cramping/Diarrhea 7. Enlarged Lymph Nodes

Parkinson's disease- Causes

1. Genetic Predisposition 2. Antipsychotic meds 3. Structural damage from neurological disorders. 4. Decreased estrogen levels. 5. Pesticides 6. Carbon Monoxide poisoning

Osteoporosis Causes

1. Genetics 2. Low Ca levels 3. Low estrogen; females. 4. Low testosterone; males.

Hypoglycemia Unconscious Food Intake

1. Glucagon Injections 2. Follow hospt. policy; D5OW IV push.

CVA medical management

1. Goals to allow the brain to recover form the initial insult to prevent the risk of rebleeding. 2. Bed rest w/ sedation to prevent agitation & stress. 3. Analgesics codeine & acetaminophen may be prescribed for head/neck pain. 4. Compression devices

Applying PPE Order

1. Gown 2. Face Mask 3. Eyewear 4. Clean gloves

Type 1 DM- Antigen Patterns

1. HLA-DR 2. HLA-DQ

CO is affect by?

1. HR 2. Preload 3. Contractility 4. Afterload

Evaluation-Stress

1. How does the pt perceive the problem? 2. Were existing coping strategies sufficient to meet intended outcomes? 3. Did pt implement new coping strategies properly? 4. Did pt use available resources?

DM- Nursing Assessment

1. Hyperglycemia 2. Signs/Symptoms- thirst, freq. urination, hunger, fatigue, weakness, vision changes, tingling, numbness hand/feet, dry skin, wounds slow to heal, late signs; wt loss, nausea, & abdominal pain.

Common Causes of Heart Failure

1. Hypertension 2. Coronary artery disease 3. Cardiomyopathy 4. Substance Abuse 5. Valvular disease 6. Congential defects 7. Cardiac infections/inflammations 8. Drsrhythmias 9. DM 10. Tobacco use 11. Family hx 12. Obesitu 13. Severe lung disease 14. Sleep apena 15. Hyperkinetic conditions

Cardiovascular Disease Modifiable

1. Hypertension 2. Increased Liqids 3. Smoking; Nicotine is a vasoconstricter. 4. DMII 5. Obesity 6. Sedentary Lifestyle 7. Metabolic Syndrome

Sensory Nursing Assessment- Pt Environment

1. Id pt risk fro sensory deprivation/overload; should be done preventative measures. 2. Nurse asses pt's environment for quantity, quality, & stimuli. 3. Determine is non-stimulating/overstimulating. 4. Adjust mod. stimuli to pt's needs.

Nursing Dx- Cardio

1. Impaired gas exchange 2. Decreased CO 3. Fatigue/weakness 4. Ineffective peripheral tissue perfusion 5. Activity tolerance

Sensory Deprivation- Risk Factors

1. Impaired vision/hearing 2. Mobility restrictions 3. Inability to process stimuli 4. Emotional disorders 5. Limited social contact.

Sensory- Pt Safety

1. Implement safety precautions in health care for pts. 2. Ensure beds locks in lowest position, side rails up, & call light w/in reach.

Chronic Bronchitis- Nursing Goals

1. Improve O2 & activity intolerance. 2. Preventing wt loss 3. Min. anxiety 4. Prevent respiratory infection.

CVA Goals

1. Improved mobility 2. Avoidance of shoulder pain. 3. Self-care 4. Relief of Sensory 5. Perceptual Deprivation 6. Prevention of aspiration 7. Continence of bowel/bladder. 8. Form of comms. 9. Skin integrity 10. Family functions 11. Sexual function 12. Absence of Complications

Right Hemisphere Stoke- Behavior

1. Impulsiveness 2. Lack of awareness of neurological deficits. 3. Confabulation 4. Euphoria 5. Constant smile, denial of illness, poor judgement, & overestimation of abilities; risk of injury.

Left Hemisphere Stoke- Vision

1. Inability to discriminate words/letters. 2. Reading problems. 3. Deficits in right visual field. 4. Cortical blindness.

Increase Insulin

1. Increase Calories 2. Wt gain 3. Pregnancy 4. Acute infections 5. Decreased activity 6. Hypokalemia 7. Corticosteriod 8. Thiazide diruetics

DM Exercise

1. Increase cellular use of glucose; lowers blood glucose. 2. Promotes wt loss; improves sense of well being.

Emphysema Symptoms

1. Increased CO2 retention; pink. 2. Min. cyanosis 3. Purse lip breathing 4. Dyspnea 5. Hyperresonance on chest percussion 6. Orthopneic 7. Barrel Chest 8. Exertional Dyspnea 9. Prolonged expiatory time 10. Speaking in short jerky sentences. 11. Thin apperance 12. Use of acces. muscles with breathing.

Acute Pain signs

1. Increased HR, RR, BP 2. Diaphoresis 3. Dilated Pupils 4. Restlessness/Anxious 5. Pain Complaints

Nurse Advocate to Pt

1. Inform pt of their rights & protect them. 2. Support pt in their decisions. 3. Mediate/directly intervene on pt behalf.

Hypoglycemia Causes

1. Insulin & oral anti-diabetic meds. 2. Delayed/missed meals 3. Exercise 4. Too few carbs 5. Alcohol

Type 2 DM- Pathology

1. Insulin Resistance 2. Dysfunctional pancreatic beta cells.

Perception Senses

1. Kinesthetic- moving 2. Sterognosis- use of all other sense expect sight. 3. Visceral- when you need to use the bathroom.

Emphysema Physiologic Changes

1. Loss of elastic recoil. 2. Lungs permanently over distended. 3. Air becomes trapped in alveoli. 4. Altered O2/CO2 exchange. 5. Lead to heart failure. 6. Increase respiratory rate.

Diet- Nursing Interventions

1. Low Na, cholesterol; cardiac. 2. High protein; COPD. 3. Daily weight. 4. Intake/Output 5. Postural Drainage 6. O2

CVA Prevention

1. Manage hypertension 2. Reduce alcohol intake 3. Increase public awareness about the assoc. between phenlpropanolamine & hemorrhagic stroke. 4. Nutrition

Pnuemonia in Older Adults

1. May be vage/non-present. 2. Increase infection rate. 3. Difficult to treat. 4. Symptoms may be masked.

Parkinson's disease- Treatment

1. Meds 2. Deep Brain Stimulator (DBS)

Dementia- Chronic Confusion

1. Memory impairment 2. Gradual & irreversible 3. No correlation w/ time of day 4. Sleep wake cycles are disturbed, fragmented, awakens, often during the night. 5. Judgement is impaired & personality changes. 6. Delusions, paranoia, hallucinations, & depression.

Planning Implementation- Death

1. Min. loneliness, fear, & depression. 2. Maintain pt sense of security, dignity, & self-worth. 3. Help pt accept losses. 4. Provide physical comfort.

Activity/Exercise Characteristics

1. Mobility 2. ROM 3. Osteoporosis 4. Nutrition 5. Exercise 6. Immobility

Methylprednisolone Nursing Assessment/Interventions

1. Monitor Input/Output, daily wt, & edema. 2. Assess lung sounds & RR. 3. Should be admin. in the morning to coincide with body's natural secretion of cortisol. 4. Admin. PO; with food.

Hip Replacement- Post-Operative Care

1. Monitor infection; observe elevated temp, confusion, foul odor from drainage. 2. Assess bleeding & managing anemia; assess hip dressing for drainage & if drain placed monitor output. 3. Assess NV checks 4. Admin pain meds 5. Fall Precautions 6. Maintain hip abduction/prevent rotation; increase risk for hip dislocation.

O2 Therapy Equipment

1. Nasal Cannula 2. Face Mask; venturi, simple, partial rebreather, & nonrebreather.

MI Symptoms- Women

1. Neck Pain 2. Chest Pain 3. Cold sweats 4. Shoulder Pain 5. Fatigue

Albuterol Side Effects

1. Nervousness 2. Restlessness 3. Tremor 4. Chest Pain 5. Palpitations 6. Paradoxical Bronchospasm

CVA & TIA- Common Dx Tests

1. Non-Contrast CT of head/neck & initial dx test; no dye used. 2. Doppler ultrasound 3. Arteriogram

CVA Hemorrhagic Stoke- Nursing Assessment/Dx

1. Non-contrast CT determine size/location of the hematoma; presence/absence of ventricular blood & hydrocephalus. 2. Cerebral angiogram can confirm the dx of intracranial aneurysm/AVM.

Chronic Pain signs

1. Normal vitals 2. Dry, warm skin 3. Normal/dilated pupils 4. Depressed 5. May not complain

DM Mgmt- Sick Day Rules

1. Notify MD 2. Monitor glucose every 4 hrs. 3. Test urine for ketones, glucose level greater than 240 mg/dl. 4. Cont. take insulin/other anti-diabetic meds. 5. Prevent dehydration, drink 8-12 oz of sugar free liquids every awake. 6. Unable to tolerate foods/liquids equal to carbs content of your usual meal. 7. Treat symptoms as directed. 8. Get plenty of rest.

DM Foot Care- Assess foot loss of protective sensation

1. Numbness, burning, & tingling. 2. Semmes-Weinstein monofilament testing @ 10 pts on each foot.

CVA- Clinical Manifestations

1. Numbness/weakness of face, arm, or leg; usually on 1 side of the body. 2. Confusion/change in mental status. 3. Trouble speaking or understanding speech 4. Visual disturbances 5. Difficulty walking, dizziness, or loss of balance. 6. Sudden severe headaches

Nursing Assessment- Grief

1. Nursing Hx 2. Assess Coping Mechanism 3. Physical Assess. 4. Mental Status

DM Pt Edu

1. Nutritional Mgt 2. Exercise 3. Meds 4. Edu

O2 Hazards

1. O2 is a drug! 2. O2 toxicity; CO2 narcosis. 3. Combustible 4. Pressure

Pneumonia Nursing Interventions

1. O2 therapy/adequate oxygenation 2. Give antibiotics; if ordered 3. Admin bronchodilators; albuterol. 4. Admin IV steriods: methylpredisolone 5. Maintain gas exchange 6. Promote rest, hydration, & nutrition.

Data Collection Methods

1. Observation 2. Interviewing 3. Examining

Pneumonia characteristics

1. Obstruction of Bronchioles 2. Decreased gas exchange. 3. Increased exudate.

OA- Nursing Assessment

1. Obtain pt hx 2. Nature, location, & severity of joint pain? 3. Joint swelling? 4. Loss of mobility or performing ADLs? 5. Occupation?

Common Locations of Ulcers

1. Occiput 2. Scapula 3. Elbows 4. Sacrum 5. Heels 6. Ear 7. Greater Trochanter 8. Knees

Types of interview questions

1. Open ended- associated with the nondirective interview, invites clients to discover, explore and clarify 2. Close ended- yes, no or short factual answers. Often begin with who what when where who or is 1. Neutral- client can answer without direction or pressure from the nurse a. Ex: how do you feel about that?? 2. Leading- usually closed, used in directive interview and directs clients answer a. Ex: youre stressed about surgery tomorrow aren't you?

Artificial Airways

1. Orpharyngeal 2. Endotracheal 3. Nasopharyngeal 4. Tracheostomy

Respiratory Positions

1. Orthopedic 2. Tripod 3. High Fowler's

Pt Teaching- Meds

1. Orthostatic hypertension 2. Expected side effects 3. Take as prescribed

i. UALR Nursing prioritization Construct

1. Oxygen 2. Safety, Elimination, Fluid and Electrolytes, Nutrition 3. Rest and Activity, Sensory, Comfort 4. Human interaction, Sexuality, Spirituality, Learning

Pain- Nursing Assessment

1. Pain hx 2. Direct Observation

Sensory Overload- Risk Factors

1. Pain/discomfort 2. Hospitalization 3. Equip. Alarms 4. Invasive tubes 5. Decreased cognitive ability.

Left Side Hemispheric Stroke

1. Paralysis/weakness of right side of body. 2. Right visual field deficit 3. Aphasia 4. Altered intellectual ability 5. Slow; cautious behavior.

Right-Side Hemispheric Stoke

1. Paralysis/weakness on left side. 2. Left visual field deficit. 3. Spatial-perceptual deficits. 4. Increased distractibility. 5. Impulsive behavior/poor judgement. 6. Lack of awareness of deficits.

Alteration in Respiratory Function

1. Patency 2. Movement of air in/out of lungs. 3. Diffusion of O2 & CO2. 4. Transport of O2 & CO2; by blood to/from tissue cells.

Types of Neuropathic Pain

1. Peripheral 2. Central

DM- Sick Days: Notify Health Provider

1. Persistent nausea/vomiting. 2. Moderate/large ketones. 3. Glucose elevation after 2 doses on insulin. 4. High temp 101.5F or increasing fever; fever more than 24 hrs.

i. Maslow's Heirarchy of needs

1. Physiological 2. Safety and sercurity 3. Love and belonging 4. Self esteem 5. Self actualization

Setting Priorities: Planning

1. Physiological- breathing, food, water, sex, sleep, homeostasis, excretion, etc. 2. Safety- security of body, employment, resources, family, health. 3. Love/Belonging- friendship, family, sexual intimacy. 4. Esteem: self-esteem, confidence, achievements, respect of/by others. 5. Self-Actualization: morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts.

Manage Acute Sensory Deficits

1. Place dentures/hearing aids in containers. 2. Keep clear pathways. 3. Organize pt's items w/in reach. 4. Reinforce use of call light. 5. Assist ambulation. 6. Teach importance of changing position q2h.

Left Side HF Signs- Nursing Assessment

1. Poor Urine Output 2. S3; 3rd gallop. 3. Crackles in lung sounds. 4. Decreased blood, HR, & dyspnea.

Dementia- Warning Signs

1. Poor judgement/bad decisions 2. Can't budget 3. Misplace items 4. Won't know day/season 5. Difficulty comms

OA Pt Edu

1. Position joints in functional position to avoid contractures; use small pillow. 2. Low impact exercise; decrease joint pressure. 3. Proper posture when standing/sitting to reduce spine pressure. 4. Wear supportive shoes to relieve pressure.

Nursing Interventions

1. Positioning 2. Suction 3. Breathing techniques 4. Liquify secretion; humidification & oral fluids.

Insulin Injection Sites

1. Posterior of Arm 2. Posterior of Thigh 3. Abdomen

Parkinson's disease: Stage III Moderate Disease

1. Postural instability 2. Increased gait disturbances.

Pneumonia HC-A Risk Factors

1. Presence of tracheostomy, endotracheal, or NG tube. 2. Ventilator use 3. Older Adults 4. Recent aspiration 5. Altered LOC 6. Poor nutrition 7. Immunocompromised 8. Chronic Lung Disease 9. Gram-neg colonization

Sensory- Nursing Assessment

1. Present sensory perceptions 2. Usual functioning 3. Sensory deficits/alterations 4. Potential problems 5. Physical Exam- awareness/orientation, speech, pupil response, & strength.

Sensory- Nurse Planning

1. Prevent Injury 2. Prevent sensory deprivation/overload. 3. Maintain function of senses. 4. Perform ADLs independently/safely. 5. Develop comms. 6. Reduce social isolation.

Osteoporosis- Pt edu

1. Prevent falls 2. Include Ca & Vit D in diet; dairy, dark green veggies, & read food labels for Ca amount. 3. Explain importance of sunlight. 4. Limit caffeinated/carbonated drinks. 5. Exercise to prevent wt gain; walking is best. 6. Med regimen

2 Types of Hip Replacements

1. Primary Arthroplasty 2. Revision Arthroplasty

Contact Precaustions

1. Private Room 2. Gloves & gown. 3. Hand Hygiene 4. C-Diff: Soap & Water Only!

Airborne Precautions

1. Private Room 2. Negative air pressure; N95 respirator. 3. Pt has surgical mask.

CVA Hemorrhagic Stoke- Clinical Manifestations

1. Prognosis depends on neurological condition of the pt; age, assoc. diseases, & extent/location of the hemorrhage/intracranial aneurysm. 2. Present neurological deficits; similar to ischemic stroke. 3. Pt w/ intracranial aneurysm or AVM; present w/ unusually severe headache, & loss of consciousness for a period of time; rigidity of back of neck.

Osteoarthritis (OA)

1. Progressive deterioration & loss of bone/cartilage. 2. Chronic pain; audible crepitus due to bone fragments & floating cartridge entering the joint cavity. 3. Bony outgrowths or bony spurs. 4. Decreased function, mobility, & muscle atrophy.

TB Symptoms

1. Progressive fatigue 2. Malaise 3. Anorexia 4. Wt loss 5. Chronic cough 6. Night sweats 7. Hemoptysis 8. Pleuritic Chest pain 9. Low Grade Temp.

Osteoporosis- Planning

1. Promote safety 2. Reduce risk factors 3. Admin meds 4. Monitor adverse effects. 5. Pt teaching.

SHARE (how to ensure successful hand-offs)

1. Standardize critical content- provide details of patients history to the receiver, emphasizing key information 2. Hardwire within your system- develop standardize forms, tools and methods to assist in handoff 3. Allow the opportunity to ask questions 4. Reinforce quality and measurement- old staff accountable to quality handoffs 5. Educate and Coach- teach staff about successful handoffs

Stress affecting Respiratory Function

1. Stimulates sympathetic nervous system. 2. Suppresses immune system. 3. Alters glucose, fat, & protein metabolism. 4. Lead to Cardio. disease; greater risk for respiratory function.

Planning Implementation- Grief

1. Provide physical comfort 2. Promote independence 3. Therapeutic Comms. 4. Provide emotional support

Chronic Respiratory Disorder- Older Adults

1. Provide rest periods between activities: bathing, meals, & ambulation. 2. Place pt in upright position for meals to prevent aspiration. 3. Increase nutritional fluid intake after meal promoting increase calorie intake. 4. Schedule meds around routine activities to increase adherence to drug therapy. 5. Pt notify primary health provider for any symptoms of infections. 6. Pt receive pneumococcal vaccine; annual influenza vac. 7. Pt prescribed home O2; keep tubing coiled when walking reducing tripping.

Pt Edu: Bones

1. Pt can be discharged home w/ cast, splint, external fixator. 2. Teach pt cast care & pin care. 3. Teach pt food high in protein, Ca+, & iron. 4. Wt bearing stimulates RBCs production.

Parkinson's disease- Nursing Assessment

1. Pt hx 2. Pt handwriting, posture, gait, motor, speech, ROM, & ability to relax. 3. Ex: difficulty chewing, swallowing, drooling, excessive perspiration, hypotension, emotional changes, & changes in speech, bowel, & bladder patterns.

Sensory Nursing Assessment- Social Network

1. Pt live alone? 2. Who visits & when? 3. Are there signs that indicate social deprivation?

Cardiac Disease- Reduce Hospitalizations in Older Adults

1. Pt's hospitalized for heart failure, collaborate w/ the case manager for discharge planning; adequate support in the community. 2. Plan of care for pt & their families or other caregivers when pt is discharged from the hospital. 3. Pt discharged to home, call to check pt has no signs/symptoms of heart failure. 4. Teach pt/family or other caregivers about the call the health care provider for health changes so pt can be treated @ home. 5. Ensure interprofessional team provides the pt when follow-up care in the home.

Types of Insulin Pumps?

1. Quick-acting insulin 2. Basal rate 3. Pre-prandial doses

Types of Insulin

1. Rapid Acting 2. Short Acting 3. Intermediate Acting 4. Long Acting 5. Combinations

Sensory - Nurse Planning: Discharge

1. Reassess pt's abilities for self care. 2. Availability/skills of support people. 3. Assess instructional need of pt's family/caregivers. 4. Determine the needs for referrals/home services.

Implementation

1. Reassessing Client 2. Determining nurse's need for assistance. 3. Implementing the nursing interventions. 4. Supervising delegated care. 5. Doc. nursing activities.

Inhaler Steps w Spacer

1. Remove caps from inhaler & spacer. 2. Insert mouthpiece of inhaler into nonmouthpiece end of spacer. 3. Shake 3-4 times. 4. Fully exhale, place mouthpiece in mouth, over tongue, & seal lips around it. 5. Press down firmly on canister of inhaler to release 1 dose of meds in spacer. 6. Breath in slowly/deeply, spacer makes whistling sound; when breathing too rapidly. 7. Remove mouthpiece from mouth; keeping lips closed. Hold breath for 10 secc; breath out slowly. 8. Wait 1 min 9. Replace caps on inhaler/spacer. 10. Once a day, clean inhaler w warm H2O. Clean spacer once a wk.

COPD Complications

1. Respiratory failure/infection 2. Cor pulmonale; right-side heart failure.

Respiratory Risks- Older Adults

1. Respiratory infections; decreased immune system. 2. Increased O2 demand 3. Rising CO2 levels 4. Lower exercise tolerance

Ethical Decision Making

1. Responsible ethical reasoning is rational & systematic. 2. Decisions based on ethical principles & code rather than emotion/intuition. 3. Decisions should've pt best interest & preserve integrity of all involved. 4. Max. pt well being. 5. Balance pt need for autonomy. 6. Support each family member & enhance family support. 7. Carry out hospital polices. 8. Protect other pt well being. 9. Protect nurse's own standards of care.

OA Pain Mgt. Non-Meds

1. Rest 2. Low-impact exercise 3. Joint positioning 4. Heat/Cold app. 5. Wt control 6. Topical Capsaicin 7. Glucosamine 8. Chondroitin

DM Hospitalization

1. Restore fluid & replace electrolytes. 2. Lower blood glucose w/ insulin. 3. Monitor levels of consciousness, vitals, intake/output, & electrolyte levels. 4. Promote emotional support.

Lifestyle Affects in Respiratory Function

1. Sedentary Lifestyle 2. Occupation 3. Diet 4. Diseases of respiratory system

Planning- Grief

1. Setting goal; remember the loss w/out experiencing intense pain. 2. Adapt to loss.

Types of Nursing Code of Ethics

1. Shared by members of a group. 2. Reflects moral judgement. 3. Serves as a standard for professional actions.

Older Adult Care

1. Sleeping 2. Nutrition 3. Continence 4. Confusion 5. Falls 6. Skin Breakdown

Left Hemisphere Stoke- Behavior

1. Slowness/Cautiousness 2. Anxiety on new task. 3. Depression; feeling worthless, worries of future, & quick anger/frustration. 4. Sense of guilt 5. Intellectual impairment.

ANS: C Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the providers prescription and the clients current medications.

10. A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Administer an aspirin. b. Call for an electrocardiogram (ECG). c. Maintain airway patency. d. Notify the provider.

Age related changes

1. valves become calcified and degenerate-assess HR and rythm and heart sounds (listen for murmers), ask about dyspnea 2. amount of pacemaker (cells in SA and AV node) cells decrease, while an increase in fat and fibrous tissue (causes an increased conduction time - in other words it takes the heart longer to fully contract) - assess ECG and HR for dysrhythmias or bradycardia 3. the size of the left ventricle increases and becomes stiff which decreases preload by 50% (decreases cardiac output which decreases amount of blood and oxygen to vital organs -remember MAP needs to be at least 60mmHg!) - assess ECG for wide QRS (ventricular contractions) and long QT intervals, resting heart rate and with activity (will be decreased) and assess for activity intolerance (less oxygen to vital organs) 4. arteries will thicken and stiffen (increases resistance because no elasticity so increases systolic blood pressure) which also cause the left ventricle to enlarge since it has to work harder to get the blood out - assess blood pressure (increased), assess for SOB and activity intolerance, and assess peripheral pulses 5. Baroreceptors become less sensitive (these help regulate blood pressure according to blood volume and resistance) - assess for orthostatic hypotension (blood pressure may drop due to insensitive receptors)

Urine Specific Gravity

1.010-1.025

BUN

10-20 mg/dL

BUN normal range

10-20 mg/dL

Lisinopril (zestril) Dose

10-40 mg/day 80 mg/day max

Atorvastatin (lipitor) Dose

10-80 mg/day

ANS: A As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the clients disease is worsening. The other questions are useful, but not as important.

10. A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. Could you walk further than that a few months ago? b. Do you walk mostly uphill, downhill, or on flat surfaces? c. Have you ever considered swimming instead of walking? d. How much pain medication do you take each day?

PT

11-12.5 sec

PT normal range

11-12.5 sec

ANS: A Older clients may have dysrhythmias due to age-related changes in the cardiac conduction system. They may have no significant hemodynamic effects from these changes. The nurse should first assess for the effects of the dysrhythmia before proceeding further. The alarms on a cardiac monitor should never be shut off. The other two actions may or may not be needed.

11. An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate? a. Assess for any hemodynamic effects of the rhythm. b. Prepare to administer antidysrhythmic medication. c. Notify the provider or call the Rapid Response Team. d. Turn the alarms off on the cardiac monitor.

ANS: D Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

11. An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. I nearly always wear comfy sweatpants and house shoes. b. Im glad I get energy assistance so my house isnt so cold. c. My daughter makes sure I have plenty of lotion for my feet. d. My hands shake when I try to do things requiring coordination

ANS: A Many foods and drugs interfere with warfarin, St. Johns wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.

12. A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What response by the nurse is best? a. No, it may interfere with the warfarin. b. There isnt any information about that. c. Why would you want to take that? d. Yes, it is a good supplement for you.

ANS: D To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.

12. The nurse is preparing to change a clients sternal dressing. What action by the nurse is most important? a. Assess vital signs. b. Don a mask and gown. c. Gather needed supplies. d. Perform hand hygiene.

ANS: C For the nurses safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves.

13. A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the clients sheets. What action should the nurse perform first? a. Assess the insertion site. b. Change the clients sheets. c. Put on a pair of gloves. d. Assess blood pressure.

ANS: A Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A drink is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The womans size does not matter.

13. A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. No, women should only have one beer a day as a general rule. b. No, you should not drink any alcohol with hypertension. c. Yes, since you are larger, you can have more alcohol. d. Yes, two beers per day is an acceptable amount of alcohol

Hgb Men

13.5-18 g/dL

Sodium

135-145 mEq/L

Sodium normal range

135-145 mEq/L

ANS: B Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

14. A nurse is caring for four clients. Which one should the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom c. Hypertensive client with a blood pressure of 188/92 mm Hg d. Client who needs pain medication prior to a dressing change of a surgical wound

ANS: B Hypertension after coronary artery bypass graft surgery can be dangerous because it puts too much pressure on the suture lines and can cause bleeding. The charge nurse should see this client first. The client who became dizzy earlier should be seen next. The client on the nitroglycerin drip is stable. The client going home can wait until the other clients are cared for.

14. A nurse is in charge of the coronary intensive care unit. Which client should the nurse see first? a. Client on a nitroglycerin infusion at 5 mcg/min, not titrated in the last 4 hours b. Client who is 1 day post coronary artery bypass graft, blood pressure 180/100 mm Hg c. Client who is 1 day post percutaneous coronary intervention, going home this morning d. Client who is 2 days post coronary artery bypass graft, became dizzy this a.m. while walking

Pre-albumin normal levels

15-36 mg/dL Gives an idea of protein intake over that last 2-3 days

ANS: B Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

15. A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Pain rated as 2/10 after medication b. Distal pulse on affected extremity 2+/4+ c. Remains on bedrest as directed d. Verbalizes understanding of procedure

ANS: B Omega-3 fatty acids have shown benefit in reducing lipid levels, in reducing the incidence of sudden cardiac death, and for stabilizing atherosclerotic plaque. The best source is fish three times a week or some fish oil supplements. The other options are not accurate.

15. A client with coronary artery disease (CAD) asks the nurse about taking fish oil supplements. What response by the nurse is best? a. Fish oil is contraindicated with most drugs for CAD. b. The best source is fish, but pills have benefits too. c. There is no evidence to support fish oil use with CAD. d. You can reverse CAD totally with diet and supplements.

Platelets normal range

150,000-400,000/mm3

Abdominal Paracentesis complications

1500ml+ fluid drained can result in hypovolemic shock, bleeding, infection, or bowel perforation

ANS: B The Joint Commissions Core Measures set for acute MI require that aspirin is administered when a client with MI presents to the emergency department or when an MI occurs in the hospital. A rapid ECG is vital, but getting another one in the morning is not part of the Core Measures set. The Rapid Response Team is not needed if an emergency department provider is available. Thrombolytics may or may not be needed.

16. A client has presented to the emergency department with an acute myocardial infarction (MI). What action by the nurse is best to meet The Joint Commissions Core Measures outcomes? a. Obtain an electrocardiogram (ECG) now and in the morning. b. Give the client an aspirin. c. Notify the Rapid Response Team. d. Prepare to administer thrombolytics

ANS: B Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the clients perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

16. A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the clients chart. d. Notify the surgeon immediately.

ANS: A Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

17. A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the clients temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the clients daily white blood cell count

ANS: B The post-angioplasty client with tongue swelling and anxiety is exhibiting manifestations of an allergic reaction that could progress to anaphylaxis. The nurse should assess this client first. The client with a heart rate of 102 beats/min may have increased oxygen demands but is just over the normal limit for heart rate. The two post coronary artery bypass clients are stable.

17. A nurse is caring for four clients. Which client should the nurse assess first? a. Client with an acute myocardial infarction, pulse 102 beats/min b. Client who is 1 hour post angioplasty, has tongue swelling and anxiety c. Client who is post coronary artery bypass, chest tube drained 100 mL/hr d. Client who is post coronary artery bypass, potassium 4.2 mEq/L A

ANS: B Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the clients manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

18. A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority? a. Assess the clients neurologic status. b. Notify the Rapid Response Team. c. Prepare to administer vitamin K. d. Turn down the infusion rate.

ANS: A Allowing the family to remain at the bedside can help calm the client with familiar voices (and faces if the client wakes up). A fan might be helpful but may also spread germs through air movement. The TV should not be kept on all the time to allow for rest. Speaking loudly may agitate the client more

18. A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first for comfort? a. Allow family members to remain at the bedside. b. Ask the family if the client would like a fan in the room. c. Keep the television tuned to the clients favorite channel. d. Speak loudly to the client in case of hearing problems.

ANS: D Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

19. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a. Assesses the client for back pain b. Auscultates over abdominal bruit c. Measures the abdominal girth d. Palpates the abdomen in four quadrants

ANS: B If the drainage in the chest tube decreases significantly and dramatically, the tube may be blocked by a clot. This could lead to cardiac tamponade. The nurse should notify the provider immediately. The nurse should not independently increase the suction, re-position the chest tube, or take the tubing apart.

19. The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important? a. Increase the setting on the suction. b. Notify the provider immediately. c. Re-position the chest tube. d. Take the tubing apart to assess for clots.

ANS: B After the original intracoronary clot has dissolved, large amounts of thrombin are released into the bloodstream, increasing the chance of the vessel reoccluding. The other statements are not accurate. Heparin is not a blood thinner, although laypeople may refer to it as such.

2. A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The clients spouse asks why the client needs this medication. What response by the nurse is best? a. The t-PA didnt dissolve the entire coronary clot. b. The heparin keeps that artery from getting blocked again. c. Heparin keeps the blood as thin as possible for a longer time. d. The heparin prevents a stroke from occurring as the t-PA wears off.

ANS: A, C, E The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

2. A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol

ANS: D, E The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

2. A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs

ANS: D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

2. The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL

ANS: B Expired food in the refrigerator demonstrates a safety concern for the client and a possible lack of money to buy food. The nurse can consider a referral to Meals on Wheels or another home-based food program. Dirty carpets may indicate the client has no household help and is waiting for clearance to vacuum. Old medications can be managed by the home health care nurse and the client working collaboratively. Having pets is not a cause for concern.

20. A home health care nurse is visiting an older client who lives alone after being discharged from the hospital after a coronary artery bypass graft. What finding in the home most causes the nurse to consider additional referrals? a. Dirty carpets in need of vacuuming b. Expired food in the refrigerator c. Old medications in the kitchen d. Several cats present in the home

ANS: A The first step is to assess the reason behind the clients fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like drugs are safer today do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

24. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best? a. Assess the reason behind the clients fear. b. Remind the client about laboratory monitoring. c. Tell the client drugs are safer today than before. d. Warn the client about consequences of noncompliance.

ANS: C A positive inotrope is a medication that increases the strength of the hearts contractions. The other options are not correct.

24. The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. It constricts vessels, improving blood flow. b. It dilates vessels, which lessens the work of the heart. c. It increases the force of the hearts contractions. d. It slows the heart rate down for better filling.

ANS: A This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the clients ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

29. The nurse is assessing a client on admission to the hospital. The clients leg appears as shown below: What action by the nurse is best? a. Assess the clients ankle-brachial index. b. Elevate the clients leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

ANS: A, B, D The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

3. A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

ANS: B The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

3. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

ALT normal range

4-36 u/L

rbc overall low and high

4-6 million/mm3

ANS: B, D, E Nonpharmacologic comfort measures can include positioning, complementary therapies, and splinting the chest incision. Medications are not nonpharmacologic. Food choices are not comfort measures.

4. A client is 1 day postoperative after a coronary artery bypass graft. What nonpharmacologic comfort measures does the nurse include when caring for this client? (Select all that apply.) a. Administer pain medication before ambulating. b. Assist the client into a position of comfort in bed. c. Encourage high-protein diet selections. d. Provide complementary therapies such as music. e. Remind the client to splint the incision when coughing.

ANS: A There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

4. A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis.

ANS: A Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

4. A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the faculty member is best? a. Continue to educate the client on possible healthy changes. b. Emphasize complications that can occur with noncompliance. c. Tell the client that denial is normal and will soon go away. d. You need to make sure the client understands this illness.

ANS: B Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. Do you have trouble affording your medications? b. Most people with hypertension do not have symptoms. c. You are lucky; most people get severe morning headaches. d. You need to take your medicine or you will get kidney failure.

ANS: A, C, D, E The Joint Commissions Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.

5. A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

ANS: D Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated.

5. A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate? a. Level the transducer at the phlebostatic axis. b. Lay the client in the supine position. c. Prepare to administer diuretics. d. Prepare to administer a fluid bolus.

ANS: A, B, C, E Age, diabetes, ethnic background, and smoking are all risk factors for developing CAD; medication use is not.

5. A nursing student planning to teach clients about risk factors for coronary artery disease (CAD) would include which topics? (Select all that apply.) a. Advanced age b. Diabetes c. Ethnic background d. Medication use e. Smoking

Creatine normal range

: 0.5-1.2 mg/dL

Urine pH

6

pH of urine

6

Partial Rebreather Face Mask

6-15L, 50-90% O2

ANS: C Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

6. A student nurse asks what essential hypertension is. What response by the registered nurse is best? a. It means it is caused by another disease. b. It means it is essential that it be treated. c. It is hypertension with no specific cause. d. It refers to severe and life-threatening hypertension.

ANS: C, D, E Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and wont offer much protection against injury.

6. Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. A good abrasive pumice stone will keep my feet soft. b. Ill always wear shoes if I can buy cheap flip-flops. c. I will keep my feet dry, especially between the toes. d. Lotion is important to keep my feet smooth and soft. e. Washing my feet in room-temperature water is best.

Glucose

60-100 mg/dL

Normal blood glucose range

60-100 mg/dl

Type 2 DM- Nutritional Status

60-80% obese

ANS: B A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

7. A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the clients heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg. What action by the nurse is most appropriate? a. Allow the client to rest quietly. b. Assess the client for bleeding. c. Document the findings in the chart. d. Medicate the client for pain.

ANS: A, B, C When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the clients feelings.

7. A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the clients leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.

ANS: B All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the clients feelings of control.

8. A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the clients support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the clients obligations.

ANS: D Preoperative fear and anxiety are common prior to cardiac surgery, especially in emergent situations. The client is exhibiting anxiety, and the nurse should reassure the client that fear is common and offer to help. The other actions will not reduce the clients anxiety.

8. A client is in the preoperative holding area prior to an emergency coronary artery bypass graft (CABG). The client is yelling at family members and tells the doctor to just get this over with when asked to sign the consent form. What action by the nurse is best? a. Ask the family members to wait in the waiting area. b. Inform the client that this behavior is unacceptable. c. Stay out of the room to decrease the clients stress levels. d. Tell the client that anxiety is common and that you can help.

ANS: A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

8. The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

ANS: B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the clients blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

parts of the nursing process

ADPIE Assessment Diagnosis Planning Implementing Evaluation

PIPERCILLIN/TAZOBACTAM (Zosyn)

ANAPHYLAXIS BLOODY STOOLS, FEVER, ABD CRAMPING---CDIFF SEIZURES STEVENS JOHNSON SYNDROME, do not give if allergic to penicillin

Levofloxacin (Levaquin)

ANAPHYLAXIS CDIFF SEIZURES STEVENS JOHNSON SYNDROME

TYPES OF CHEST PAIN

ANGINA - sudden usually in response to exertions, emotion, or extremes in temp - squeezing or vice like - located usually in left chest WITHOUT RADIATION or substernal that speads across the chest and back, maybe down the arms - usually lasts less than 15 minutes and is relieved with rest, nitrate, or o2 MYOCARDIAL INFARCTIONS - sudden without precipitating factos usually early in the morning - Intense stabbing, viselike pain or pressure, SEVERE - Located substernal - may spread throughout the anterior chest and to the arms, jaw, back, or neck - continuous or no chest discomfort relieved with morphine, cardiac drugs, and o2 PERICARDITIS - sudden - sharp, stabbing, moderate to severe - located substernal usually spreads to the left side or back - Intermittent relieved with sitting upright, analgesia, or admin of antinflammatory agents PLEUROPULMONARY - Varied anset - Moderate ache, worse on insiration - Located in lung fields - continuous until the underlying condition is treated or the patient has rested ESOPHAGEAL-GASTRIC - varied onset - squeezing, heartburn, variable severity - located substernal may spread to the shoulders or abdomen - may be relieved with antacid admin, food intake, or taking a sitting position ANXIETY - varied onset may be in response to stress or fatigue - dull ache to sharp stabbing, may be associated with numbness in fingers - Not well located and usually does not radiate - usually lasts a few minutes

A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis

ANS: A, B, C Complications of diabetes mellitus are caused by macrovascular and microvascular changes. Macrovascular complications include coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Microvascular complications include nephropathy, retinopathy, and neuropathy. Respiratory failure and cirrhosis are not complications of diabetes mellitus.

Cardiovascular autonomic neuropathy in DM

Affects sympathetic and parasympathetic nerves to the heart and blood vessels. Contributes to left ventricular dysfunction, painless MI, and exercise intolerance. Most often leads to orthostatic hypotension and syncope, both of which increase fall risk.

A nurse prepares to administer prescribed regular and NPH insulin. Place the nurse's actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab.

ANS: 3, 1, 2, 8, 7, 4, 6, 5 After washing hands, it is important to inspect the bottles and then to roll the NPH to mix the insulin. Rubber stoppers should be cleaned with alcohol after rolling the NPH and before sticking a needle into either bottle. It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.

A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The client's blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the client's chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.

ANS: A Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period. The nurse should document the finding and proceed with other operative care. The need for a bolus of insulin, canceling the procedure, or drawing arterial blood gases is not required.

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. "Maintain tight glycemic control and prevent hyperglycemia." b. "Restrict your fluid intake to no more than 2 liters a day." c. "Prevent hypoglycemia by eating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis."

ANS: A Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications. Restricting fluid intake is not part of the treatment plan for clients with diabetes. Preventing hypoglycemia and ketosis, although important, are not as important as maintaining daily glycemic control.

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional education? a. "If I develop an infection, I should stop taking my corticosteroid." b. "If I have pain over the transplant site, I will call the surgeon immediately." c. "I should avoid people who are ill or who have an infection." d. "I should take my cyclosporine exactly the way I was taught."

ANS: A Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti-rejection medications may cause them to not work optimally.

A nurse prepares to administer insulin to a client at 1800. The client's medication administration record contains the following information: • Insulin glargine: 12 units daily at 1800 • Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the client's medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

ANS: A Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine and then the regular insulin right afterward.

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, "Can I ask my niece to prefill my syringes and then store them for later use when I need them?" How should the nurse respond? a. "Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up." b. "Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light." c. "Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes." d. "No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container."

ANS: A Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks. They should be stored in the refrigerator in the vertical position with the needle pointing up to prevent suspended insulin particles from clogging the needle.

An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension

ANS: A Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How should the nurse respond? a. "Your risk of diabetes is higher than the general population, but it may not occur." b. "No genetic risk is associated with the development of type 1 diabetes mellitus." c. "The risk for becoming a diabetic is 50% because of how it is inherited." d. "Female children do not inherit diabetes mellitus, but male children will."

ANS: A Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development. Diabetes (type 1) seems to require interaction between inherited risk and environmental factors, so not everyone with these genes develops diabetes. The other statements are not accurate.

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "The lower abdomen is the best location because it is closest to the pancreas." b. "I can reach my thigh the best, so I will use the different areas of my thighs." c. "By rotating the sites in one area, my chance of having a reaction is decreased." d. "Changing injection sites from the thigh to the arm will change absorption rates."

ANS: A The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas. The other statements are accurate assessments of insulin administration.

A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a. Administer 1 mg of intramuscular glucagon. b. Encourage the client to drink orange juice. c. Insert a new intravenous access line. d. Administer 25 mL dextrose 50% (D50) IV push.

ANS: A The client's blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the client's blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the client's blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

ANS: A This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

Serous- Drainage

Clear; straw, & light yellow.

A nurse collaborates with the interdisciplinary team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members should the nurse include in this interdisciplinary team meeting? (Select all that apply.) a. Registered dietitian b. Clinical pharmacist c. Occupational therapist d. Health care provider e. Speech-language pathologist

ANS: A, B, D When planning care for a client newly diagnosed with diabetes mellitus, the nurse should collaborate with a registered dietitian, clinical pharmacist, and health care provider. The focus of treatment for a newly diagnosed client would be nutrition, medication therapy, and education. The nurse could also consult with a diabetic educator. There is no need for occupational therapy or speech therapy at this time.

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Do not walk around barefoot." b. "Soak your feet in a tub each evening." c. "Trim toenails straight across with a nail clipper." d. "Treat any blisters or sores with Epsom salts." e. "Wash your feet every other day."

ANS: A, C Clients who have diabetes mellitus are at high risk for wounds on the feet secondary to peripheral neuropathy and poor arterial circulation. The client should be instructed to not walk around barefoot or wear sandals with open toes. These actions place the client at higher risk for skin breakdown of the feet. The client should be instructed to trim toenails straight across with a nail clipper. Feet should be washed daily with lukewarm water and soap, but feet should not be soaked in the tub. The client should contact the provider immediately if blisters or sores appear and should not use home remedies to treat these wounds.

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension

ANS: A, C, E DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually clients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

ANS: A, D, E, F Risk factors for type 2 diabetes include certain ethnic/racial groups (African Americans, American Indians, Hispanics), obesity and physical inactivity, and giving birth to large babies. Pancreatic trauma and a 30-pound gestational weight gain are not risk factors.

A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections? a. "Wash your hands after completing each test." b. "Do not share your monitoring equipment." c. "Blot excess blood from the strip with a cotton ball." d. "Use gloves when monitoring your blood glucose."

ANS: B Small particles of blood can adhere to the monitoring device, and infection can be transported from one user to another. Hepatitis B in particular can survive in a dried state for about a week. The client should be taught to avoid sharing any equipment, including the lancet holder. The client should be taught to wash his or her hands before testing. The client would not need to blot excess blood away from the strip or wear gloves.

A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, "I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing." How should the nurse respond? a. "Following the drug regimen more closely would have prevented this." b. "One acute rejection episode does not mean that you will lose the new organs." c. "Dialysis is a viable treatment option for you and may save your life." d. "Since you are on the national registry, you can receive a second transplantation."

ANS: B An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained. The other statements either belittle the client or downplay his or her concerns. The client may not be a candidate for additional organ transplantation.

A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How should the nurse respond? a. "Glucose is the only fuel used by the body to produce the energy that it needs." b. "Your brain needs a constant supply of glucose because it cannot store it." c. "Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

ANS: B Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system. The nurse would want to educate the client to prevent hypoglycemia. The body can use other sources of fuel, including fat and protein, and glucose is not involved in the production of red blood cells. Glucose in the blood will encourage glucose metabolism but is not directly responsible for lactic acid formation.

After teaching a client with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I need to have an annual appointment even if my glucose levels are in good control." b. "Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick." c. "I can still develop complications even though I do not have to take insulin at this time." d. "If I have surgery or get very ill, I may have to receive insulin injections for a short time."

ANS: B Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in the future.

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, "My cousin has depression and is taking this drug. Do you think I'm depressed?" How should the nurse respond? a. "Many people with long-term diabetes become depressed after a while." b. "It's for peripheral neuropathy. Do you have burning pain in your feet or hands?" c. "This antidepressant also has anti-inflammatory properties for diabetic pain." d. "No. Many medications can be used for several different disorders."

ANS: B Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy. The nurse should assess the client for this condition and then should provide an explanation of why this drug is being used. This medication, although it is used for depression, is not being used for that reason in this case. Duloxetine does not have anti-inflammatory properties. Telling the client that many medications are used for different disorders does not provide the client with enough information to be useful.

A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How should the nurse respond? a. "You need to start with multiple injections until you become more proficient at self-injection." b. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."

ANS: B Even when a single injection of insulin contains a combined dose of different-acting insulin types, the timing of the actions and the timing of food intake may not match well enough to prevent wide variations in blood glucose levels. One dose of insulin would not be appropriate even if the client decreased carbohydrate intake. Additional injections are not required to allow the client practice with injections, nor will one dose increase the client's risk of insulin shock.

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

ANS: B Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600.

A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine

ANS: B Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

infection medications

Antipyretics Acetaminophen Aspirin Anti-infectives Amoxicillin (amoxicillin) Ampicillin/sulbactam(Unasyn) Cefazolin (Ancef) Ciprofloacin (Cipro) Gentamycin (Garamycin) Levofloxacin (Levaquin) Linezolid (Zyvox) Penicillin (PCN-G) Piperacillian/tazobactum(Zosyn) Vancomycin (Vancocin)

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? a. Assess for pain or burning with urination. b. Review the client's liver function study results. c. Instruct the client to increase water intake. d. Test a sample of urine for occult blood.

ANS: B Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the client's most recent liver function studies. The nurse does not need to assess for pain or burning with urination and does not need to check the urine for occult blood. The client does not need to be told to increase water intake.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching? a. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." b. "Monitor your blood glucose levels at least every 4 hours while sick." c. "If vomiting, do not use insulin or take your oral antidiabetic agent." d. "Try to continue your prescribed exercise regimen even if you are sick."

ANS: B When ill, the client should monitor his or her blood glucose at least every 4 hours. The client should continue taking the medication regimen while ill. The client should continue to eat and drink as tolerated but should not exercise while sick.

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3- 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3- 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3- 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3- 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

ANS: B When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

Nursing Diagnosis for stress

Anxiety Caregiver Role Strain Compromised Family Coping Defensive Coping Ineffective Denial Post-Trauma Syndrome

Psychological Indicators

Anxiety, fear, anger, depression, & ego defense mechanisms.

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this client's teaching? a. "Change positions slowly when you get out of bed." b. "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." c. "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."

ANS: B NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.

ANS: C A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement. The Glasgow Coma Scale assesses the client's state of consciousness against criteria of a scale including best eye, verbal, and motor responses. An increase in serum potassium, decreased blood osmolality, and urine negative for ketone bodies do not indicate adequacy of treatment.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the client's chart. b. Assess tactile sensation in the client's hands. c. Examine the client's feet for signs of injury. d. Notify the health care provider.

ANS: C Diabetic neuropathy is common when the disease is of long duration. The client is at great risk for injury in any area with decreased sensation because he or she is less able to feel injurious events. Feet are common locations for neuropathy and injury, so the nurse should inspect them for any signs of injury. After assessment, the nurse should document findings in the client's chart. Testing sensory perception in the hands may or may not be needed. The health care provider can be notified after assessment and documentation have been completed.

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I should increase my intake of vegetables with higher amounts of dietary fiber." b. "My intake of saturated fats should be no more than 10% of my total calorie intake." c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." d. "My intake of water is not restricted by my treatment plan or medication regimen."

ANS: C The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the client's breath has a "fruity" odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the client's intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.

ANS: C The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a "fruity" odor to the breath. Documentation should occur after all assessments have been completed. Using an incentive spirometer, increasing IV fluids, and performing pulmonary hygiene will not address this client's problem.

Cardiac Output (CO)

Amount of blood pumped by ventricles in 1 min; 5-6 L of blood.

Dementia

An abnormal condition marked by multiple cognitive defects that include memory impairment. No cure global impairment of intellect; brain cells die or no longer function. Sympt: severe memory loss & interference w/ ADLs.

Disease

An abnormal state in which the body is not functioning normally.

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury? a. "Examine your feet using a mirror every day." b. "Rotate your insulin injection sites every week." c. "Check your blood glucose level before each meal." d. "Use a bath thermometer to test the water temperature."

ANS: D Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How should the nurse respond? a. "I can give your injections to you while you are here in the hospital." b. "Everyone gets used to giving themselves injections. It really does not hurt." c. "Your disease will not be managed properly if you refuse to administer the shots." d. "Tell me what it is about the injections that are concerning you."`

ANS: D Devote as much teaching time as possible to insulin injection and blood glucose monitoring. Clients with newly diagnosed diabetes are often fearful of giving themselves injections. If the client is worried about giving the injections, it is best to try to find out what specifically is causing the concern, so it can be addressed. Giving the injections for the client does not promote self-care ability. Telling the client that others give themselves injections may cause the client to feel bad. Stating that you don't know another way to manage the disease is dismissive of the client's concerns.

After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "I have so many complications; exercising is not recommended." b. "I will exercise more frequently because I have so many complications." c. "I used to run for exercise; I will start training for a marathon." d. "I should look into swimming or water aerobics to get my exercise."

ANS: D Exercise is not contraindicated for this client, although modifications based on existing pathology are necessary to prevent further injury. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury. The client should not exercise too vigorously.

A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? a. Pioglitazone (Actos) b. Glimepiride (Amaryl) c. Glipizide (Glucotrol) d. Metformin (Glucophage)

ANS: D Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure. The nurse should hold the metformin dose and contact the provider. The other medications are safe to administer after receiving IV contrast.

A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this client's discharge education? a. "Test your urine daily for ketones." b. "Use only buffered insulin in your pump." c. "Store the insulin in the freezer until you need it." d. "Change the needle every 3 days."

ANS: D Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system. Having an insulin pump does not require the client to test for ketones in the urine. Insulin should not be frozen. Insulin is not buffered.

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg

ANS: D Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The client's serum osmolarity is high. The client's sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a. Serum chloride level of 98 mmol/L b. Serum calcium level of 8.8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

ANS: D Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium. The chloride level is normal. The calcium and sodium levels are slightly low, but this would not be related to hyperglycemia and insulin administration.

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 liters a day." b. "Animal organ meat is high in insulin." c. "Limit your carbohydrate intake to 80 grams a day." d. "Walk at a moderate pace for 1 mile daily."

ANS: D Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus. Restricting fluids and eating organ meats will not reduce insulin needs. People with diabetes need at least 130 grams of carbohydrates each day.

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? a. "I'll take this medicine during each of my meals." b. "I must take this medicine in the morning when I wake." c. "I will take this medicine before I go to bed." d. "I will take this medicine immediately before I eat."

ANS: D Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the client's blood glucose levels. The medication should be taken before meals instead of during meals.

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.

ANS: D The client's tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites. The damaged tissue is not caused by cellulitis or any type infection, and applying ice may cause more damage to the tissue. Insulin can only be administered subcutaneously and intravenously. It would not be appropriate or practical to change the administration route.

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

ANS: D The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.

A nurse cares for a client who has type 1 diabetes mellitus. The client asks, "Is it okay for me to have an occasional glass of wine?" How should the nurse respond? a. "Drinking any wine or alcohol will increase your insulin requirements." b. "Because of poor kidney function, people with diabetes should avoid alcohol." c. "You should not drink alcohol because it will make you hungry and overeat." d. "One glass of wine is okay with a meal and is counted as two fat exchanges."

ANS: D Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal. One alcoholic beverage is substituted for two fat exchanges when caloric intake is calculated. Kidney function is not impacted by alcohol intake. Alcohol is not associated with increased hunger or overeating.

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. "At my age, I should continue seeing the ophthalmologist as I usually do." b. "I will see the eye doctor when I have a vision problem and yearly after age 40." c. "My vision will change quickly. I should see the ophthalmologist twice a year." d. "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

ANS: D Diabetic retinopathy is a leading cause of blindness in North America. All clients with diabetes, regardless of age, should be examined by an ophthalmologist (rather than an optometrist or optician) at diagnosis and at least yearly thereafter.

Types and Sources of Loss

Actual loss-Can be recognized by others Perceived loss-Cannot be verified by others (Psychological)-Anticipatory loss

Loss

Actual or potential situation in which something that is valued is changed or no longer available. Significant other Body image Job Possessions Beliefs

Loss

Actual/potential situation in something that is valued changed or no longer available. Ex. Sig. other, body image, job, possession, beliefs, & loved one.

Being an Advocate for your patient

Advocate - one who expresses and defends the cause of another. Inform client's of their rights and protect their rights Support the client in their decisions Mediate and directly intervene on the client's behalf

Contrast Dye Allergy

Also will be allergic to shellfish & iodine.

Respiratory System- Function

Alveolar gas exchanged involves the diffusion of O2 & CO2 bt the alveoli & pulmonary capillaries. Transport of O2 & CO2 bt the tissues & lungs. Movement of O2 & CO2 bt the systemic capillaries & tissues.

Tripod Position

An upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward.

Piperacillin/Tazobactam (Zosyn) adverse/side effects

Anaphylaxis, bloody stool, fever, abd cramping-cdiff, seizures, & stevens johnson syndrome

Ampicillin/Sulbactam (Unasyn) adverse/side effects

Anaphylaxis, bloody stool, fever, abd cramping-cdiff, seizures, hepatotoxicity & stevens johnson syndrome

subarachnoid hemorrhage (SAH)

Aneurysm a catastrophic event w/ sig. morbidity/mortality.

Complications of DM

Angiopathy- damage to blood vessels. Macrovascular Complications: -large and medium sized blood vessels -Cerebrovascular -Cardiovascular -Peripheral vascular disease Ex- Coronary Artery Disease (MI) Decreasing risks -Obesity -Smoking -Hypertension -High Fat intake -Sedentary lifestyle Microvascular -thickening of vessel membranes in capillaries and arterioles -Retinopathy -Nephropathy -Dermopathy

Warfarin Sodium (coumadin) Therapeutic Use/Mechanism of Action

Antiphospholipid antibody syndrome, arterial thromboembolism prophylaxis, DVT, MI prophylaxis, after MI, stroke prophylaxis, thrombosis prophylaxis, pulmonary embolism Interferes with blood clotting by indirect means; depresses hepatic synthesis of vit K-dependent coagulation factors (II, VII, IX, X)

antibiotics meaning

Antibiotics are effective against bacterial infections

Types of Grief Responses

Anticipatory grief Disenfranchised grief Complicated grief

Warfarin Sodium (coumadin) Pharm Class

Anticoagulant

Lisinopril (zestril) Pharm class

Antihypertensive, angiotensin-converting enzyme 1 (ACE) inhibitor

Metoprolol (lopressor) Pharm Class

Antihypertensive, antianginal

Atorvastatin (lipitor) Pharm Class

Antilipidemic

Palliative Care

Approach improves the quality of life of pt facing life-threatening illness; pt can seek treatment. Prevention/relief of suffering through early id. & treatment of problems.

Atorvastatin (lipitor) Therapeutic Use/Mechanism of Action

As adjunct for primary hypercholesterolemia (types Ia, Ib), dysbetalipoproteinemia, elevated triglyceride levels, prevention of CV disease by reduction of heart risk in those with mildly elevated cholesterol Inhibits HMG-CoA reductase enzyme, which reduces cholesterol synthesis; high doses lead to plaque regression

Abdominal Paracentesis Indications

Ascites - large amount of fluid accumulates in the abdominal cavity

Thoracentesis Interpretation of findings

Assess general appearance, cell counts, protein & glucose content, abnormal cells & cultures

Nursing interventions for Bronchodilators

Assess lung sounds, pulse and BP prior and during peak of med Assess Sputum- color, amount, consistency, and odor(if any) Observe for paradoxical bronchospasms(wheezing) Notify MD of increasing dyspnea

Thoracentesis Nursing interventions

Assess prior to procedure for abnormal breath sounds and dull percussion sounds, ensure only 1L is removed max, assess for bleeding or drainage, monitor VS & Resp. status hourly, anticipate post procedure xray

Cannot Delegation to a UAP

Assessment Interpretation of data Nursing diagnosis Nursing care plan Evaluations Care of invasive lines Administering meds Inserting NG tubes Client education Telephone advice

Nursing Management for Loss/Grief

Assessment- Nursing history Assessment of coping mechanisms Physical assessment Mental status assessment Nursing Diagnosis- Grieving Complicated grieving/risk for complicated grieving Interrupted family process Risk-prone health behavior Risk for loneliness Planning- Setting goals Remember the loss without experiencing intense pain Adapt to the loss Implementation- Provide physical comfort Promote independence Therapeutic communication Provide emotional support Evaluation- Difficult due to long term nature of grieving Do client's behaviors indicate complicated grieving? Is the expected outcome unrealistic for the given time frame? Does the client have additional stressors previously not considered that are affecting grief resolution?

Active Euthanasia

Assisted suicide; actions to bring about a pt death directly w/ or w/o pt consent. Still viewed immoral to ANA.

Problem-Focused Coping

Attempting to alleviate stress directly by changing the stressor/the way we interact with that stressor; effective method.

Fasting blood/plasma glucose

BG taken after no caloric intake for at least 8 hours. BG>126mg/dl on two separate occasions is diagnostic of DM.

KIDNEY FUNCTION labs

BUN: 10-20mg/dL CREATININE: Males: 0.6-1.2mg/dL Females: 0.5-1.1mg/dL

AC

Before a meal

Mourning

Behavioral process through which grief is eventually resolved/ altered.

glycosylated hemoglobin (HbA1C)

Blood test used to diagnose diabetes and monitor its treatment by measuring the amount of glucose bound to hemoglobin in the blood.

Open Awareness

Both parties; family & pt know of upcoming death.

Alburterol (Proventil)

Broncholdilator; relaxes smooth muscle in airways. Relaxation leads to bronchodilation.

Highest suicide Rate?

Caucasian Men 75-85

CLASSES OF CARDIAC DISEASE

CLASS I - cardiac disease present but without limitation of acitivity - ordinary activity does not cause fatigue, palpitation, dyspnea, or angina CLASS II - cardiac disease with slight limitation of activity - comfortable at rest but physical activity results in fatigue, palpitation, dyspnea, or angina CLASS III - cardiac disease resulting in marked limitation of activity - comfortable at rest but less than ordinary physical acitvity causes fatigue, palpitation, dyspnea, or angina CLASS IV - cardiac disease resulting in inability to carry on any activity without discomfort - symptoms of cardiac insufficiency or the anginal sydrome may be present even at rest - physical activity increases discomfort

HR increases what also increases?

CO

OA-Imaging

CT & MRI.

Amputations

Can be elective or traumatic. Complications: hemorrhage, infection, phantom limb pain, neuroma, & flexion contractures.

Status of Asthmaticus

Can be life threatening if not treated properly.

Actual Loss

Can be recognized by others.

Pathophyisology of Diabetic Ketoacidosis

Cause: Profound deficiency of insulin and characterized by hyperglycemia , Ketosis, acidosis, and dehydration -More likely to happen to patients with type 1 DM Precipitating factors: -Illness -Infection -Inadequate insulin dosage -Undiagnosed Type 1 DM -poor self management -Neglect 1) Insufficient insulin - body breaks down fatty acids for energy in Kreb Cycle 2) Build up of ketones cause metabolic acidosis (ketones are acids) 3)Ketonuria- body attempts to neutralize acid. Cations are eliminated as well in attempt to neutralize acid 4)Insulin deficiency causes liver to produce more glucose from amino acids. - Increase in hyperglycemia 5)Extreme hyperglycemia leads to osmotic diuresis -Water cannot be reabsorbed from kidneys because sugar concentration is too strong. -More electrolytes (especially potassium) are excreted into urine as water rushes into kidneys. (Osmosis) 6) Osmotic Diuresis leads to severe depletion of sodium, potassium, chloride, magnesium, and phosphate. 7) Vomiting from acidosis results in additional fluid loses 8)Hypovolemia= shock/ renal failure 9)Renal failure leads to retention of ketones and glucose and acidosis process 10) Patient comes comatose from dehydration , electrolyte imbalance, and acidosis. 11) Death is inevitable if untreated

CVA- Hemorrhagic Stroke

Caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space.

Nonproliferative diabetic retinopathy

Causes structural problems in the retinal vessels, including areas of poor circulation, edema, hard fatty deposits, and retinal hemorrhages. Fluid and blood leak from the retinal vessels and cause retinal edema and hard exudates. Main source of vision loss is from macular edema, increased blood vessel permeability and deposits of hard exudates at the center of the retina.

Lumbar Puncture

Cerebrospinal fluid (CSF) is withdrawn from the spine (3rd - 4th) with a needle

Reporting

Change-of-Shift Reports SBAR Communication Tool Telephone Reports Telephone Orders Care Plan Conference Nursing Rounds

DM Macrovascular Complications

Changes in medium to large blood vessels: walls thicken, sclerose, occlude, MI, CVA, & PVD.

Serosanguineous

Clear & blood tinged; commonly seen w/ surgical incisions.

Evaluating

Collecting data Comparing data with desired outcomes Relating nursing activities to outcomes Drawing conclusions about problem status Continuing, modifying or terminating the nursing care plan

Sputum specimen

Collection of sputum to test for bacteria, viruses, or other lung/bronchi/trachea disorders

Types of Infection

Colonization Local infection Systemic infection Acute vs. chronic infection Nosocomial infections

Autonomic neuropathy in DM

Common GI problems include gastroesophageal reflux, delayed gastric emptying, gastric retention, early satiety, heartburn, nausea, vomiting, and anorexia. Slowed small intestinal movement increases rush of bacterial overgrowth, causing bloating, gas, and diarrhea. Gastroparesis (delayed gastric emptying) may cause hypoglycemia.

CAP

Community Acquired Pneumonia

Type 1 DM- Inheritance

Complex

HEMOGLOBIN (HGB) definition

Composed of a pigment (heme), which contains iron, and a protein (globin).

Stress

Condition an individual experiences changed in the normal balanced state.

stress

Condition in which an individual experiences changes in the normal balanced state

Heart Failure (HF)

Condition that develops if the heart cannot keep up with the body's need for oxygen & nutrients to the tissues. Occurs bc of myocardial infarction; may result from chronic overwork of the heart.

Infection

Contamination or invasion of body tissue by pathogenic organisms.

Systole

Contraction of the heart; ejects blood into the pulmonary & systemic circulation by ventricular contraction. Known as S1; 1st reading monitoring BP.

coping strategies

Coping mechanisms Problem-focused coping Emotion-focused coping Long-term coping strategies Short-term coping strategies Adaptive coping Maladaptive coping

Macrovascular complications of diabetes mellitus

Coronary heart disease Cerebrovascular disease Peripheral vascular disease

Glucagon

Counterregulatory hormone, triggers release of glucose from storage sites to increase blood glucose levels. Opposite effects of insulin.

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African-American c. A 44-year-old Asian d. A 48-year-old American Indian

Diabetes is a particular problem among African Americans, Hispanics, and American Indians. The incidence of diabetes increases in all races and ethnic groups with age. Being both an American Indian and middle-aged places this client at highest risk.

Diabetic nephropathy

DM is the leading cause of CKD and end stage kidney disease in the US. Risk factors: genetic predisposition, 10-15 year history of DM, poor blood glucose control, and uncontrolled hypertension. Drugs that protect the kidneys are ACE inhibitors and angiotensin receptor blockers (ABRs). Chronic hyperglycemia causes hypertension in the kidney blood vessels, leading to leaky vessels and albumin deposits in the kidney. Vessels narrow, causing kidney cell hypoxia and cell death. Scarring and loss of urine filtration ability leads to kidney failure.

symptoms of heart disease

DYSPNEA ON EXERTION (such as climbing stairs may be an early indicator of heart failure and may be the only symptom of women) ORTHOPNEA (dyspnea when lying flat - relieved when sitting up) PAROXYSMAL NOCTURNAL DYSPNEA - dyspnea after lying down for several hours PALPITATIONS - may be from SVTs, premature contractions, and sinus tach - may indicate heart disease (may though be induced by anxiety stress caffeine or alcohol) ASK WHAT CAUSES THEIR PALPITATIONS (what were they doing or drinking) EDEMA SYNCOPE - decreased perfusion to the brain (anything that reduces cardiac output) AGE RELATED - vagal response from turning head, shrugging shoulders, valsava maneuver, or anything that decreases blood pressure and heart rate - postural or postprandial (after eating) hypotension EXTREMETY PAIN - ischemia for athersclerosis and venous insufficiency of peripheral blood vessels

General Guidelines for Recording

Date & Time Timing Legibility Permanence Accepted Terminology Correct Spelling Signature Accuracy

Nursing assessment/document for stool specimen:

Date/time of collection Color Odor Consistency Amount Visible abnormalities

Prediabetes

Defined: Impaired glucose tolerance, impaired fasting glucose or both. Blood glucose levels are elevated, but not high enough to meet the diagnostic criteria for diabetes Diagnosis of PRediabetes IGT-2 hour oral glucose tolerance test values are 140-199mg/dL IFG- fasting glucose levels are 100-125 mg/dL Signs and Symptoms: - usually no signs -if there are signs, it will have to do with long-term damage to blood vessels and heart (Increased BP) Treatment: -BLood glucose and A1C tested regularly -Monitor for : Polydipsia(abnormally great thirst as a symptom of disease) Polyuria polyphagia ( is the medical term used to describe excessive hunger or increased appetite) -Maintain healthy weight -Exercise regularly (30 mins a day) -eat healthy diet.

rbc increased

Dehydration Polycythemia vera High altitude Cardiovascular disease

Clinical manifestations of DKA

Dehydration - poor skin turgor, dry mucus membranes, tachycardia, orthostatic hypotension, skin is dry and loose, eyes become soft and sunken Early symptoms- Lethargy and weakness Abdominal pain/ anorexia, nausea, vomiting Kussmaul Respirations (rapid, deep breathing associated with dyspnea)- body's attempt to eliminate CO2 (an acid) to lower acidosis Acetone breath (result of fatty acid break down)( sweet fruity odor) Labs: Blood glucose 250+ Blood pH- <7.3 Bicarbonate level- <16mEq/L Large to moderate ketones in urine or serum

Nursing Evaluation for nursing management for loss/ greif

Difficult due to long term nature of grieving Do client's behaviors indicate complicated grieving? Is the expected outcome unrealistic for the given time frame? Does the client have additional stressors previously not considered that are affecting grief resolution? f

Advance Directives

Direct caregivers as to the client's wishes about treatments and life saving measures if they have lost the ability to communicate their decisions DNR

Parkinson's disease- Stage V Complete ADL Dependence

Disease in in full effect throughout the nervous system.

Communicable Disease

Disease that is spread from one host to another.

Teaching on Rifampin (Rifadin)

Drug will stain skin and urine Contacts will become permanently stained (wear glasses) Decrease effects of Oral Contraceptives- use alternate form of BC NO ALCOHOl- treatment hard on liver Report s/sx of liver damage

Anhidrosis

Drying, cracking of skin

Very Long Acting: Giargine (Lantus)

Duration 24 hrs.

Male erectile dysfunction in DM

ED occurs at a much higher rate and earlier in patients with DM. Related to poor blood glucose regulation, obesity, hypertension, heavy cigarette smoking, and other vascular complications.

urine specimen nursing intervention

Educate client, document relevant info, delegation depends

supporting the family

Encourage family to participate in care of dying patient as much as they wish After client dies, the family should be encouraged to view the body

Supporting Family Members

Encourage family to participate in care of dying pt.; after pt dies, family should be encouraged to view the body.

Democratic

Encourage group discussion & decision making High creativity & autonomy

Democratic

Encourage group discussion & decision making. Highly creative & autonomy.

nurse implanting for stress

Encourage health promotion strategies- Exercise Nutrition Sleep

Urine specimen

Evaluates waste products from the kidney & detects urologic disorders

Shared

Everyone is equal & shared governance.

Types of Insulin: Rapid- Acting

Ex. Lispro (Humalog)-clear Aspart (Novolog)-clear Glulisine (Apidra)-clear Onset: 10-30 mins Peak: 30min-3hrs Duration: 3-5hrs Notes: -Used before meals

Glucosidase Inhibitors

Ex. Acarbose (Precose) Miglitol (Glyset) Action: -Slow down absorption of carbohydrates in small intestine -"Starch blockers" -Lower postprandial blood glucose Teaching: Take with first bite of each meal -Check effectiveness by measuring 2-hour postprandial blood sugar. Side-Effects: -Gas -Abdominal pain -diarrhea -Carry glucose tabs/gel for hypoglycemia because Carbohydrate absorption is blocked.

Noninsulin Injectable Agents: Glucagon- Like Peptide-1 (GLP-1) Receptor Agonist

Ex. Exenatide (Byetta)-Twice a day Exenatide Extended-Release (Bydureon)-every 7 days Liraglutide (Victoza)-Once a day Action: -Stimulate GLP-1 (Incretin hormone) (Decreased in Type 2 diabetic patients) -Causes increase insulin synthesis and release from pancreas -Inhibit glucagon secretion -Decrease gastric emptying -Reduce food intake by increasing satiety (not hungry) Teaching: -Effects medication that are absorbed through gastric absorption. Take oral medication 1 hour before injecting Exenatide or Liraglutide Side-Effects: -Nausea , Vomiting, hypoglycemia, diarrhea, headache Exenatide (Byetta) -Acute pancreatitis and kidney problems associated with use Liraglutide (Victoza) -Do not use in patients with a personal or family history of medullary thyroid cancer -Acute pancreatitis has been associated with use.

Sulfonylureas

Ex. Glipizide (Glucotrol, Glucotrol XL) Glyburide (Micronase, DiaBeta, Glynase) Glimepiride (Amaryl) Action: -Increases insulin production by pancreas. -Decreases Glycogenolysis and gluconeogenesis -Enhances cellular sensitivity to insulin Side Effects: -Gi symptoms -photosensitivity -hypoglycemia -weight gain

Oral Hypoglycemics: Biguanides

Ex. Metformin (Glucophage, Glucophage XR, Riomet, Fortamet, Glumetza) Action: -Reduces glucose production by liver -Enhances insulin sensitivity at tissue level and improves glucose transport into the cells. -Beneficial effects on plasma lipids. Side Effects -Weight loss (Nausea and decreased appetite) -Prevention of Diabetes in prediabetics -Diarrhea -Lactic Acidosis -NO hypoglycemia Teaching: -Needs to be held 1-2 days before IV contrast media given and for 48hrs after. -Do not use in patients with kidney disease, liver disease, or heart failure -Do not drink excessive amounts of alcohol.

Intermediate-Acting

Ex. NPH (Humulin N, Novolin N)-cloudy Onset: 1.5-4hrs Peak:4-12hrs Duration:12-18hrs Notes: -Can result in hypoglycemia because of peak -Only one that can be mixed with short and rapid acting insulins. -Cloudy- must agitate

Meglitinides

Ex. Repaglinide (Prandin) Nateglinide (Starlix) Action: -Increase insulin production by pancreas- Stimulate a rapid and short lived release of insulin. Teaching: -TAKE RIGHT BEFORE MEALS BECAUSE MEGLITINIDES ARE RAPIDLY ABSORBED. -Mimics normal insulin release -Take 30 minutes before each meal right up to the time of the meal. Side-Effects: -More likely to cause hypoglycemia because of fast absorption time. -Weight gain

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

Ex. Aka Gliptins Sitagliptin (Januvia) Saxagliptin (Onglyza) Linagliptin (Tradjenta) Alogliptin (Nesina) Action: -Block enzyme DPP-4 which is responsible for inactivating incretin -Incretin is responsible for increased insulin synthesis and release from pancreatic as well as decrease hepatic glucose production. -Result is Increase insulin release, decreased glucagon secretion, and decreased hepatic glucose production. Side-effects: -pancreatitis -Allergic Reaction -Lower risk for hypoglycemia (Insulin dependant action) -No weight gain

Response-Based Model/General Adaptation Syndrome

General arousal response of the body to a stressor characterized by certain physiological events and dominated by the sympathetic nervous system.

Stage III Pressure Ulcer

Full thickness skin loss, damage of SC tissue, & doesn't cross fascia.

Stool specimen Indications

GI bleed, unexplained diarrhea, CDEF

infection assessment

General Fever Chills ↑ HR and RR Fatigue Anorexia, N/V Abdominal cramping/diarrhea Enlarged Lymph Nodes Older Adult ↓ Inflammatory and ↓Immune Agitation/confusion/incontinence

Hormones that increase blood glucose

Glucagon (primary) Epinephrine Norepinephrine Growth hormone Cortisol

Assessment

HISTORY - POSTmenapause increases likelyhood of CAD JUST FUN FACT - FAT WOMEN THAT CARRY AROUND WAIST AND BELLY HAVE A GREATER LIKELYHOOD TO HAVE CVD THAN IF CARRY IN HIPS BUTT AND THIGHS Heart disease is directly related to diabetes-will also increase risk of stroke AMERICAN INDIANS AND ALASKA NATIVES ARE GREATES RISK FOR HEART DISEASE Take into account lifestyle (exercise, smoking, nutrition, and obesity) KNOW HOW TO CALCULATE PACK-YEAR = number of packs per day multiplied by number of years smoked 15 year of smoke free=normal as someone who never smokes JUST FUN FACT - EMOTIONAL UNSTABLE RELATES TO HEART DISEASE (anger, hostility, and stress) ANOTHER FUN FACT - ORAL CONTRACEPTIVES OR ESTROGEN REPLACEMENT WHILE SMOKING, DIABETES, OR HYPERTENSION INCREASES THE INCIDENCE OF MI AND STROKE IF OLDER THAN 35 - SO ASK POST MENAPAUSAL OR TRANSGENDER WOMEN IF ON HORMONE REPLACEMENT THERAPY GENETICS HAVE ALOT TO DO WITH CARDIOVASCULAR DISEASE - so ask about family history

Common Ethical Dilemmas

HIV/AIDS Abortion Organ and Tissue Transplantation End of life

Mycocardial Infarction (MI)

Heart attack; cardiac tissue necrosis owing to obstruction of blood flow to the heart. Causing tissue damage or death; causes blood clots or atherosclerosis.

Liver Biopsy Indications

Hepatitis, liver tumor, & autoimmune diseases

Nursing Interventions- Pt Positioning

High Fowler's & Orthopneic.

Foot deformities in DM

High arch, claw toes, hammer toes, shift of weight bearing to metatarsal heads and tips of toes

Furosemide (lasix) Adverse Actions

Hypokalemia, hypochloremic alkalosis, hypomagnesemia, hyperuricemia, hypocalcemia, hyponatremia, hyperglycemia, nausea, polyuria, rash, pruritus

Lumbar Puncture Indications

Identify some diseases (multiple sclerosis, syphilis, meningitis) reduce CSF pressure

platelet count decreased

Idiopathic (unknown cause) thrombocytopenic purpura Cancer Systemic lupus erythematosus (SLE) Some types of anemias

Glycosylated serum albumin, glycosylated serum protein, and fructosamine tests

Indicate short term glucose control for short term follow-up or in those with hemoglobin abnormalities.

Drug therapy in DM

Indicated when a patient with T2DM does not achieve glucose control with dietary, exercise and stress management. Not a substitute for dietary modification and exercise!

Sensory Deficit- Gradual

Individual may develop ways to compensate for the loss.

Local Infection

Infection that is limited to the specific part of the body where the microorganisms remain.

Systemic Infection

Infection when pathogens spread and damage different parts of the body.

platelet count increased

Infections Polycythemia vera Acute blood loss Splenectomy

Chain of Infection

Infectious agent, reservoir, portal of exit, means of transmission, portal of entry and susceptible host.

What happens when more glucose is present in the liver than can be used for energy or stored as glycogen?

Insulin causes the excess glucose to be converted to free fatty acids (FFAs) and deposited in fat cells.

Insulin Regimens : Once a day

Intermediate (NPH) at bedtime OR Long Acting in Am or bedtime Does not cover postprandial blood sugar levels

Types of Stressors

Internal stressors External stressors Developmental Stressors Situational Stressors

Beliefs

Interpretation/conclusions accepted to be true.

Beliefs

Interpretations/conclusions accepted as true

Stage IV Pressure Ulcer

Involves muscle, bone, ligament, or supporting structures.

Skin Traction

Involves using a boot, belt, or halter attached to the leg; ex Buck's traction. Purpose: Decrease painful spasms. Wt Limit: less than 10 lbs.

Tuberculosis treatment

Isoniazid (INH) Rifampin (Rifadin)

Osteoarthritis- Secondary

Joint injury, obesity, occupations, that require heavy manual labor or activity that requires repetitive stress to joints.

Urine tests in DM

Ketone bodies: product of fat metabolism, indicative of lack of insulin. Albumin: persistent albuminuria indicates early stage diabetic nephropathy.

urine specimen Pre-interventions

Know the purpose of the sample (clean vs midstream vs sterile) collect equipment

left coronary arteries

LAD-left anterior descending branch - supplies blood to portions of the left ventricle, ventricular septum, chordae tendineae, papillary muscles, and some to the right ventricle LCX-left cirumflex branch-supplies blood to the left atrium, lateral and posterior surfaces of the left ventricle, and some of the interventricular septum SUPPLIES THE SA NODE!!!!!!!!!!!!!!! AND IN SOME PEOPLE THE AV NODE

complicated grief

Lasts longer than 6 months, more likely to occur with those who lose their spouse, lost a loved one unexpectedly, or spent extended time with the person during the last stages

Eye and vision problems and DM

Legal blindness is 25 times more common in patients with DM. Diabetic retinopathy is related to the duration of diabetes and has few signs until vision loss occurs. Hyperglycemia may cause blurred vision. Hypoglycemia may cause double vision.

Don't exercise when Blood Glucose Levels?

Less than 80 or greater than 250.

Right Hemisphere Stoke- Hearing

Loss of ability of hear tonal variations.

Neurogenic bladder

Loss of bladder tone, urinary retention

Signs of impending clinical death

Loss of muscle tone Slowing of circulation Changes in respirations Sensory impairment

hypoclycemia

Low blood sugar. Side effects: tachycardia, irritability, restlessness, excessive hunger, & diaphoresis/depression.

Femur Fractures

Lower 2/3 of femur injury usually from trauma, seldom immobilized with casting. Increase risk of hemorrhage, long recovery rate; over 6 months. Surgical treatment: ORIF vs external fixator.

Insulin secretogogues: Meglitinide analogs

Lower fasting BG by triggering release of insulin from beta cells. Repaglinide (Prandin) Nateglinide (Starlix)

airborne precautions conditions

M-easles T-ubercolosis V-aricella

Nursing Intervention- Meds

May require ventilation assist. o2; collaborate RT.

Airway Resistance (Raw)

Measure of the impedance to ventilation caused by the movement of gas through the airway. Normal airway= Less resistance

Isolation

Measures designed to prevent the spread of infections/microorga nisms

Isolation

Measures designed to prevent the spread of infections/microorganisms.

Hgb normal lab values men

Men 13.5-18 g/dL

Hct normal values for males

Men 40-54%;

RBC normal lab values men

Men-4.6-6 million/mm3

Attitudes

Mental position or feelings.

attitudes

Mental positions or feelings

Euthanasia

Mercy Killing.

Orpharyngeal

Middle compartment of the pharynx, i.e. throat; it is the region of the throat between the nasopharynx (top compartment) and hypopharynx (bottom compartment).

Lisinopril (zestril) Therapeutic Use/Mechanism of Action

Mild to moderate hypertension, adjunctive therapy of systolic HF, acute MI Selectively suppresses renin-angiotensiin-aldosterone system; inhibits ACE, thereby preventing conversion of angiotensin I to angiotensin II

Acetylsalicylic Acid (aspirin) Therapeutic Use/Mechanism of Action

Mild to moderate pain or fever, including RA, osteoarthritis, thromboembolic disorders; TIAs, rheumatic fever, post-MI, prophylaxis of MI, ischemic stroke, angina, acute MI Blocks pain impulses by blocking COX-1 in CNS, reduces inflammation by inhibition of prostaglandin synthesis; antipyretic action results from vasodilation of peripheral vessels; decreases platelet aggregation

Nursing Implementation for death

Minimize loneliness, fear, depression Maintain client's sense of security, dignity, and self-worth Help the client accept losses Provide physical comfort

Abdominal Paracentesis Intra-Interventions

Monitor for hypovolemic shock and fluid

Nursing Intervention- Improve CO

Monitor nutrition & fluids; reduce Na+, limit fluids, daily wt, meds. Meds; diurectics, ace inhibitors, & morphine.

Cardiovascular disease and DM

Most DM patients die of a thrombotic effect, usually MI. Heart failure is also associated with DM.

Osteoarthritis- Primary

Most common in aging/genetics; affects wt-bearing joints like knees, hips, spine, & hands.

Distal Radial Fracture

Most common upper extremity fracture; usually in older adults over 65. Results from standing level fall, closed reduction w/ mod sedation, & cast edema decreases.

Skeletal Traction

Most effective traction; screws surgically attached/inserted directly into the bone. Must perform site pin care. Purpose: Bone alignment Wt Limit: 15-30 lbs.

Oral glucose tolerance testing

Most sensitive test for the diagnosis of diabetes. Often used to diagnose gestational DM.

Throat culture Mucosa of oropharynx or tonsillar area

Mucosa of oropharynx or tonsillar area

Mrs. Wee- Contact Isolation

Multi drug resistance organism Respiratory infection Skin Infection Wound Infection Enteric; C-Diff Eye infection

Three Times a day

NPH and regular or rapid before breakfast + Regular or rapid before dinner + NPH at bedtime Three injections provide coverage for 24hrs, particularly during early am hours. Decreased potential for 2-3am hypoglycemia

Twice a day

NPH and regular or rapid before breakfast and at dinner Two injections provide coverage for 24 hrs. -Patient must adhere to a set meal plan

Combination Therapy

NPH/Regular 70/30 NPH/Regular 50/50 Lispro Protamine/Lispro 75/25 Lispro Protamine/ Lispro 50/50 Aspart Protamine/ Aspart 70/30 Notes: -allows only 1 injection -Harder to control insulin because syringes have two insulins

CT (computed tomography) client education

NPO at least 4 hrs prior if using contrast dye or sedation, check for allergy to shellfish or iodine, more sensitive than x-ray

Proximal Humerus Fracture

Non-displaced; sling for immobilization. Displaced: ORIF w/ pins or prosthesis.

Acetylsalicylic Acid (aspirin) Pharm Class

Nonopioid analgesic, nonsteroidal antiinflammatory, antipyretic, antiplatelet

MRI- Nursing intervention

Nurses and techs must remove all metallic devices, assess for body tattoo's especially red in color (may become warm)

Planning-Stress

Nurses set pt goals: decrease/resolve anxiety, increased coping skills, improve role performance, & involve pt.

Assessment for Nursing Management for Loss/Grief

Nursing history Assessment of coping mechanisms Physical assessment Mental status assessment

Nonsurgical management of DM

Nutritional intervention BG monitoring Exercise program Drugs to lower BG levels

GENTAMICIN (Garamycin)

OTOTOXIC NEPHROTOXIC NEUROTOXIC PEAK: <10 mcg/mL TROUGH: <2mcg/mL

VANCOMYCIN (Vancocin)

OTOTOXIC NEPHROTOXIC PEAK: 20-40 mcg/mL TROUGH: 5-10 mcg/mL ANAPHYLAXIS REDMAN SYNDROME

Data Collection Methods

Observation Interviewing Directive vs. Nondirective interview Closed vs Open-ended questions Neutral vs. Leading questions Examining

Data collection Methods

Observation (every time you walk into the room) Interviewing

Thoracentesis pre-interventions

Obtain consent, assist client in appropriate position (sitting & leaning forward), anticipate an x-ray prior

Common Locations for bed sores

Occiput Scapula Elbows Sacrum Heels Ear Greater trochanter Knees

Diagnostic Testing

Occurs in many environments; Traditional sites include hospitals, clinics, and the primary care provider's office. Used to determine a specific disease/illness.

Rapid Acting: Lispro (Humalog)

Onset 15 min, Peak 30-90 min, & Duration 3-4 hrs.

Coagulation Labs

PT/INR: 11-12.5 SECS/0.7-1.8 PTT: 30-40 SECS

VENIPUNCTURE

PUNCTURE OF THE VEIN FOR PURPOSE OF BLOOD COLLECTION!

Liver Biopsy complications

Pain & site bruising, infection, bleeding, puncture of other organs (lungs), rectal bleeding

Central Pain

Pain resulting from any disorder that causes central nervous system damage.

Somatic Pain

Pain that originates in the skin, muscles, bone, or connective tissue.

Type 1 DM- Pathology

Pancreatic beta cells destruction.

Cognitive dysfunction in DM

People 65+ with diabetes have significantly higher risk of developing all types of dementia. Chronic hyperglycemia and microvascular disease contribute to neuron damage, brain atrophy, and cognitive impairment. Depression is highly prevalent in DM and associated with worse outcomes.

Abdominal Paracentesis Interpretation of findings

Peritonitis high levels of protein, WBC, & etc.

Physical Restraints

Physical/mechanical device attached to the pt body to restrict movement.

Sequential Compression Devices (SCD)

Plastic sleeve inflates/deflates; prevents DVTS. Apply with 2 finger space; not too loose/tight. Remove for assessing, bathing, & ambulation.

PLATELET COUNT definition

Platelets are basic elements in the blood that promote coagulation.

HGB increased

Polycythemia Dehydration Chronic obstructive pulmonary disease Heart failure

Classic clinical manifestations of diabetes

Polyuria, polydipsia, polyphagia

Delta Cells

Produce somatostatin, which inhibits both glucagon and insulin secretion.

Nursing Implementation for Nursing management for loss/ grief

Provide physical comfort Promote independence Therapeutic communication Provide emotional support

Withdrawing/Withholding Food & Fluids

Providing food & fluids typically a moral duty of all nurses. Nurses are morally obligated to w/hold food & fluids if determined to be harmful to pt.

Withdrawing or Withholding Food and Fluids

Providing food and fluids is typically a moral duty of all nurses However, nurses are morally obligated to withhold food and fluids if it is determined to more harmful to administer them than withhold them.

Termination of Life-Sustaining Treatment

Pt advance directives may indicate they don't wish to have life-sustaining treatment; antibiotics, transplants, or technological interventions.

Sensory Deficit- Sudden

Pt can be frighten & disoriented.

Mutual Awareness

Pt not informed; family know of upcoming death.

Nursing Assessment- Death

Pt/family awareness of situation.

Running Traction

Pulling force in 1 direction & force is altered when bed moves.

Balanced Suspension

Pulling force is not altered when bed moves.

Furosemide (lasix) Therapeutic Use/Mechanism of Action

Pulmonary edema; edema with HF, hepatic disease, nephrotic syndrome, ascites, hypertension Inhibits reabsorption of sodium and chloride at proximal and distal tubule and in the loop of Henle

Types of Knot used for Restraints?

Quick-Release Knot

Livor Mortis

RBCs break down causing discoloration of tissues.

CVA Planning

Rehabilitation begins 1st day of stroke; team should know what pt was like prior of stroke.

MRI-Client Education

Remove all metallic objects, remove transdermal patches w/ foil backing (for sedation only, NPO 4-8hrs before) client may have titanium or surgical stainless steel

Revision Arthroplasty

Remove old prosthesis; add new components.

Infection, Transmission, & Prevention

Resident flora (normal flora) Infection Disease Virulence Communicable disease Opportunistic pathogen

Ethical Decision-making

Responsible ethical reasoning is rational and systematic Decisions based on ethical principles and code rather than emotions or intuition. Decisions should have client's best interest and preserve integrity of all involved. Maximize client's well being Balance client's need for autonomy Support each family member and enhance family support system Carry out hospital policies Protect other client's well-being Protect nurse's own standards of care

Screenings

Retinopathy - Funduscopic - dilated eye examination - annual Fundus photography Nephropathy - urine for albuminuria / serum creatinine - Annual Neuropathy - Visual examination of foot- daily by patient/ every visit to healthcare provider Comprehensive foot -Visual examination -Sensory examination (monofilament + tuning fork) -Palpation (Pulses, temp, callus formation) -Annual Cardiovascular Disease -Risk factors assessment (hypertension, dyslipidemia, smoking , family Hx, micro/macro albuminuria ) annually Exercise Stress test (ECG) - as needed based on risk factors assessment

Right Side HF

Right ventricle is unable to empty completely.

Postmortem Care

Rigor mortis - Stiffening of the body that occurs 2-3 hours after death Algor mortis - Gradual decrease of the body's temperature after death Livor mortis - Red blood cells break down causing discoloration of tissues

Cerebrovascular disease and DM

Risk of stroke is 2-4 times higher with DM. High BG at the time of a stroke may lead to greater brain injury and increased mortality.

Why are we screenings so important for people with DM?

Routine ophthalmic exams can detect vision problems early, before vision loss occurs. Yearly eye exams are recommended for those with type 2 DM and those who have had type 1 DM for more than 5 years.

physical appearance

SKIN - decreased perfusion COOL PALE AND MOIST - pallor sign of anemia CYANOSIS - from decreased perfusion (dark skinned may appear as graying of tissues) RUBOR (dusky redness) may indicate peripheral arterial insufficiency TEMP decreased blood flow decreases temp EXTREMETIES - vascular changes, clubbing, and edema - dehydration and aging reduce skin turgor and edema decreases skin elasticity - Vascular changes may include paresthesia, muscle fatigue and discomfort, numbness, pain, coolness, and loss of hair from reduced blood supply. Clubbing of the fingers and toes is caused by CHRONIC o2 deprivation (may also be present in chronic pulmonary disease, congenital heart defects, and cor pulmonale (right sided heart failure)) Peripheral edema is common in cardio problems (BILATERAL EDEMA IN LEGS MAY BE HEART FAILURE OR CHRONIC VENOUS INSUFFICIENCY, ABDOMINAL AND LEG EDEMA MAY BE HEART DISEASE AND CIRHOSIS OF LIVER, LOCALIZED EDEMA IN ONE EXTREMITY MAY BE VENOUS OBSTRUCTION LIKE THROMBOSIS OR LYMPHEDEMA) Document pitting or nonpitting. pulse ox assesses o2 perfusion BLOOD PRESSURE - hypertension systolic>140 and diastolic > 90, Hypotension <90/60 - may not perfuse tissues with enough o2 and nutrients or get rid of wastes effectively, Postural hypotension when the BP is not adequately maintained while moving decrease of 20mmHg systolic and 10 of diastolic

Insulin

Secreted at low levels during fasting. Increased levels after eating (prandial). Insulin is like a key that opens locked membranes to glucose. Stimulates glucose uptake in skeletal and cardiac muscle. Suppresses liver production of glucose and very low density lipoprotein (VLDL). Promotes glycogenesis. Inhibits glycogenolysis. Inhibits ketogenesis (conversion of fats to acids) and gluconeogenesis (conversion of proteins to glucose). Promotes storage of protein and glycogen in muscle. Promotors triglyceride storage in fat cells.

Endogenous Insulin

Secreted by beta cells; transport & metabolizes glucose for ATP. Stimulates storage of glucose in liver & muscle; liver stop the release of glucose. Enhances storage of dietary fat in adipose tissue; accelerates transport of amino acids into cells. Insulin breakdown of stored glucose, protein, & fat.

Neuropathy

Sensory Neuropathy -Affects hands and feet -Stocking- glove neuropathy -Loss off sensation/ abnormal sensations/ pain/ paresthesias -Pain- burning , cramping , crushing, tearing - worse at night then morning -Paresthesias - tingling/ burning/ itching/ numb feet/ walking on pillows Foot damage is common- Loss of protective sensation (LOPS)- annual monofilament testing is suggested - ALSO AT RISK FOR PAD- peripheral artery disease- increases risk of amputation of legs or feet Treatment: -BG control

Nurse planning for Nursing Management for loss/grief

Setting goals Remember the loss without experiencing intense pain Adapt to the loss

Urine Testing is searching for

Specific gravity pH Glucose Ketones Protein Occult blood

Glycosylated hemoglobin (A1C)

Standardized test for how much glucose is permanently attached to hemoglobin--Hyperglycemia over time causes more glycosylated hemoglobin. A1C>6.5% is diagnostic of DM. Ongoing assessment of A1C is a good indicator of long term glycemic control.

Clean-catch or midstream urine specimen is for

Urine culture

Clean-Catch/Midstream: Urine Specimen

Urine culture; void the have pt hold & void into sample container.

rigor mortis

Stiffening of the body that occurs 2-3 hours after death

Rigor Mortis

Stiffening of the body that occurs 2-3 hrs after death.

Models of Stress

Stimulus-Based models Response-Based models- General Adaptation Syndrome Transaction-Based models

Cerebral Vascular Accident (CVA)

Stoke; sudden loss of brain function from a disruption of blood supply in part of the brain. Causing temporary/permanent loss of movement, thought, memory, speech, or sensation. May be hemorrhagic or ischemic & risk factors same as TIA.

Bereavement

Subjective response experienced by the surviving loved ones.

Delirium- Acute Confusion

Sudden onset; temporary, lasting hrs/days. Worsens @ night & sleep cycles are disturbed/often reversed. Alertness fluctuates- may be alert during day but confused @ night.

Nursing Intervention- Pt. Edu.

TCDB q2h; IS use.

Transient Ischemia Attach (TIA)

Temporary neurologic dysfunction due to brief interruption in cerebral blood flow. Typically resolved w/in 30-60 min.

Lung Recoil

Tendency of lungs to collapse away from the chest wall.

HEMATOCRIT (HCT) definition

The hematocrit or packed cell volume (Hct, PCV, or crit) is a fast way to determine the percentage of RBCs in the plasma. The Hct is reported as a percentage because it is the concentration of RBCs in the blood.

Transaction-Based Model

Theory that encompasses a set of cognitive, affective, and adaptive (coping) responses that arise out of person-environment transactions; the person and the environment are inseparable and affect each other.

Raloxifene (Evista): Bone Med

Therapeutic Class: Estrogen agonist/antagonist Therapeutic Effects: Prevention of osteoporosis in pt @ risk by producing estrogen-like effects on bone resulting in reduced absorption of bone & decreased bone turnover.

Calcitonin: Bone Med

Therapeutic Class: Hypocalcemic Therapeutic Effects: Decrease rate of bone turnover & lowers serum Ca+ levels. Can't take if allergic to salmon.

Nutritional Therapy for Patient with Diabetes

Total Carbohydrates: -Complex- 55%- minimum 130g/day (45-75 grams a meal_ -vegetables , grains, legumes, low-fat milk (Simple-fruit, sugars) -Fiber 25-30g/day -Use Glycemic Index (Rise in glucose levels after a person has consumed a carbohydrate.) Protein: -15-20% -High protein is not recommended for weight loss. Fat: -25% healthy fats -Limit saturated fats to <7% of total calories (fatty beef,lamb,pork,poultry with skin,beef fat (tallow),lard and cream,butter,cheese ) -Trans fat should be minimized (fried foods) -Dietary cholesterol <200mg/day ->2 servings of fish per week to provide polyunsaturated fats. Alcohol -Limit to moderate amount (1 for women or 2 for men a day) -Consume with food to reduce risk of nocturnal hypoglycemia -Inhibits gluconeogenesis- can cause severe hypoglycemia in patients on insulin or oral hypoglycemics that increase insulin secretion .

Emotion-Focused Coping

Type of coping in which people try to prevent having an emotional response to a stressor; short term method.

Thiazolidinediones

Type2 med Ex. Pioglitazone (Actos) Rosiglitazone (Avandia) Action: -Improve insulin sensitivity, transport, and utilization at target tissues (Most useful for people that have insulin resistance) -Increase glucose uptake in muscle; decrease endogenous glucose production. -Can lead to DKA if not careful- body is suddenly requiring more insulin than normal Side-Effects: -Weight gain -Pioglitazone- increased risk for bladder cancer and exacerbates heart failure -Rosiglitazone- Increases risk for cardiovascular events (MI, Stroke) -USUALLY NO HYPOGLYCEMIA -worsening edema and worsening CHF -liver damage -resume ovulation

LINEZOLID (Zyvox)

USE FOR VRE BLOODY STOOLS, FEVER, ABDOMINAL CRAMPING---CDIFF

urine specimen Indications

UTI, Kidney disease, low or high output, kidney function baseline

Maladaptive Coping

Unsuccessful attempts to decrease the anxiety without attempting to solve the problem - the anxiety remains; bad strategy.

Standard Precautions

Used for all patients when there maybe content w/; blood, body fluids, secretions, excretions, non-intact skin, & mucous membranes.

Methylprednisolone

Used to decrease inflammation for asthma pt. Avoid grapefruit juice. increase blood sugar, & may make signs of infection.

WBC decreased

Viral infections Hematopoietic diseases Rheumatoid arthritis

Bronchoscopy

Visual examination of the bronchi; using a camera.

Do children process grief same as adults?

Yes

Insulin a High Alert Med?

Yes

Does O2 need a doctor's order?

Yes, high alert drug.

CT scan

a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body, cross sectional images with or without contrast. images of specific parts of the body, distinguishes minor differences between tissues, findings include tumor, abnormalities, guided imagery education: lay flat, post education for dye complications: allergic reaction to dye

Nursing process

a systematic, rational method of planning and providing individualized nursing care

closed awareness

a type of awareness in which the client is unaware of impending death

mutual pretense awareness

a type of awareness in which the client, family, and health personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject

The nurse is taking a history on an adult pt who reports acute back pain. Which question is the nurse most likely to ask to identify causative factors? a. "Have you had a recent fall or accident or lifted a heavy object?" b. "Do you have a family history for neurologic disorders?" c. "Are you having trouble walking or maintaining your balance?" d. "Are you having pain that radiates down the back of your leg?"

a. "Have you had a recent fall or accident or lifted a heavy object?"

The nurse reviews the discharge and home care instructions with a pt who had conventional open back surgery. Which statement by the patient indicates further teaching is needed? a. "I will drive myself to the doctor's office next week." b. "I guess my wife will have to walk to dog for 6 more weeks." c. "I will try to increase fruits and vegetables and decrease fats." d. "I plan to get a new ergonomic chair at work."

a. "I will drive myself to the doctor's office next week."

The nurse has completed a community presentation about lung cancer. Which statement from a participant demonstrates and understanding of the information presented? a. "The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid secondhand smoke." b. "The overall 5 year survival rate fro all patients with lung cancer is 85%." c. "The death rate for lung cancer is less than prostrate, breast, and colon cancer combined." d. "Cures are most likely for patients who undergo treatment for stage III disease."

a. "The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid secondhand smoke."

The nursing student has just studied about carotid artery angioplasty with stenting. Which statement by the student indicates an understanding of the purpose of the procedure? a. "The stent opens the blockage enough to establish blood flow." b. "The stent occludes the abnormal artery to prevent bleeding." c. "The stent bypasses the blockage for collateral circulation." d. "The stent catches any debris, particularly embolic clots."

a. "The stent opens the blockage enough to establish blood flow."

The patient with COPD is undergoing pulmonary rehabilitation by walking. What does the nurse teach this patient about when to increase his walking time? a. "You should increase your walking time when your rest periods decrease." b. "you should increase your walking time when your heart rate remains less than 80/min." c. "You should increase your walking time when you do not need to use an inhaler."

a. "You should increase your walking time when your rest periods decrease."

Which pt's are at increased risk for stroke? Select all that apply. a. 66 year old man with diabetes mellitus b. 43 year old healthy woman who uses oral contraceptives c. 47 year old woman who exercises regularly d. 35 year old man with history of multiple TIAs. e. 25 year old woman with Bell's palsy. f. 53 year old man with chronic alcoholism

a. 66 year old man with diabetes mellitus b. 43 year old healthy woman who uses oral contraceptives d. 35 year old man with history of multiple TIAs. f. 53 year old man with chronic alcoholism

The nurse is caring for a pt at risk for IICP. Which sign is most likely to be the first indication of IICP? a. Decline in LOC b. Increase in SBP. c. Change in pupil size and response d. Abnormal posturing of the extremities

a. Decline in LOC

Which are key elements for a personal asthma action plan? Select all that apply. a. A schedule for prescribed daily controller drug and directions for prescribed reliever drug b. A list of possible triggers for each asthma attack c. Patient-specific daily asthma control assessment questions. d. Directions for adjusting the daily controller drug schedule e. Emergency actions to take when asthma is not responding to controller and reliever drugs. f. When to contact the HCP (in addition to regularly scheduled visits)

a. A schedule for prescribed daily controller drug and directions for prescribed reliever drug c. Patient-specific daily asthma control assessment questions. d. Directions for adjusting the daily controller drug schedule e. Emergency actions to take when asthma is not responding to controller and reliever drugs. f. When to contact the HCP (in addition to regularly scheduled visits)

1. How are outcomes written?

a. ALWAYS include "The patient will" b. Activity (one verb with measureable criteria) c. By deadline i. Ex: the patient will ambulate 20 feet assisted x 1 by 1200 today

Do NOT delegate to UAP/LPN

a. Assessment b. Interpretation of data c. Nursing diagnosis d. Nursing Care Plan e. Evaluation f. Care of invasive lines g. Administering parenteral mediacations h. Insertion of NG tubes i. Client Education j. Triage k. Telephone advice l. Discharge teaching

The nurse is participating in a committee to decrease back injuries among the staff. What recommendations should the nurse suggest? Select all that apply. a. Assign committee members to review OSHA guidelines for the prevention of back injuries. b. Develop policies and procedures for the therapeutic use of patient handling equipment c. Train all staff and family caregivers in the safe operation of all ergonomic-appropriate equipment. d. Assign all pts the responsibility for learning how to use assistive equipment e. Develop competency based assessments that demonstrate proficiency in patient handling. f. Encourage quality improvement projects and research that support safe and effective patient handling.

a. Assign committee members to review OSHA guidelines for the prevention of back injuries. b. Develop policies and procedures for the therapeutic use of patient handling equipment c. Train all staff and family caregivers in the safe operation of all ergonomic-appropriate equipment. e. Develop competency based assessments that demonstrate proficiency in patient handling. f. Encourage quality improvement projects and research that support safe and effective patient handling.

A patient has just undergone spinal fusion surgery and returned from the OR 12 hrs ago. Which task is best to delegate to UAP? a. Assist the nurse to log-roll the patient every 2 hrs. b. Help the pt dangle the legs c. Assist the pt to put on a brace d. Help the pt ambulate to the bathroom

a. Assist the nurse to log-roll the patient every 2 hrs.

A patient with COPD is likely to have which findings on assessment? Select all that apply. a. Body odor and unkempt hair. b. Sitting in a chair leaning forward with elbows on knees. c. unintentional weight gain. d. decreased appetite. e. unexplained weight loss f. crooked fingers

a. Body odor and unkempt hair. b. Sitting in a chair leaning forward with elbows on knees. d. decreased appetite. e. unexplained weight loss

A patient has sustained a major head injury, and the nurse is assessing the patient's neuro status every 2 hrs. What early sign of IICP does the nurse monitor for? a. Change in LOC b. Cheyne-Stokes respirations c. Cushing's triad d. Dilated and nonreactive pupils

a. Change in LOC

In obtaining a history for a patient with COPD, which risk factors are related to potentially causing or triggering the disease process? Select all that apply. a. Cigarette smoking b. Occupational and air pollution c. Genetic tendencies d. Smokeless tobacco e. Occupation f. Food or drug allergies

a. Cigarette smoking b. Occupational and air pollution c. Genetic tendencies e. Occupation

1. Evaluation

a. Collect data related to outcomes b. Compare data with outcomes c. Relate nursing actions to client goals/outcomes d. Draw conclusions about problem status e. Continue, modify or terminate care plan

A patient has developed pulmonary arterial hypertension. What is the goal of drug therapy for this patient? a. Dilate pulmonary vessels and prevent clot formation. b. Decrease pain and make the patient comfortable. c. Improve or maintain gas exchange. d. Maintain and manage pulmonary exacerbation.

a. Dilate pulmonary vessels and prevent clot formation

The nurse is caring for a pt who has been in a long-term care facility for several months following an SCI. the pt has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. What is an expected outcome of the training program? a. Does not experience a UTI b. Catheterizes himself independently c. Controls incontinence by decreasing fluid intake d. Takes initiative to call for help when needed

a. Does not experience a UTI

What are the goals for drug therapy in the treatment of asthma? Select all that apply. a. Drugs are used to stop an attack once it has started. b. Weekly drugs are used to reduce the asthma response. c. Combination drugs are avoided in the treatment of asthma. d. Some patients only require drug therapy during an asthma episode. e. Drugs are used to change airway responsiveness. f. Some drugs are used to decrease inflammation.

a. Drugs are used to stop an attack once it has started. d. Some patients only require drug therapy during an asthma episode. e. Drugs are used to change airway responsiveness. f. Some drugs are used to decrease inflammation.

Which of the following may be warning signs of lung cancer? Select all that apply. a. Dyspnea b. Dark yellow-colored sputum c. Persistent cough or change in cough d. Abdominal pain and frequent stools e. Use of accessory muscles for breathing f. Labored or painful breathing

a. Dyspnea c. Persistent cough or change in cough e. Use of accessory muscles for breathing f. Labored or painful breathing

A patient with a history of asthma enters the emergency department with severe dyspnea, accessory muscle involvement, neck vein distention, and severe inspiratory/expiratory wheezing. The nurse is prepared to assist the physician with which procedure if the patient does not respond to initial interventions. a. Emergency intubation b. Emergency needle thoracentesis c. Emergency chest tube insertion d. Emergency pleurodesis

a. Emergency intubation

A patient with asthma is repeatedly non-compliant with the medication regimen, which has resulted in the patient being hospitalized for a severe asthma attack. Which interventions does the nurse suggest to help the patient manage asthma on a daily basis? Select all that apply. a. Encourage active participation in the plan of care. b. Help the patient develop a flexible plan of care. c. Have the pharmacist establish a plan of care. d. Teach the patient about asthma and the treatment plan. e. Assess symptom severity using a peak flow meter 1-2 times a week. f. Educate the patient about implementation of his or her personal asthma action plan.

a. Encourage active participation in the plan of care. d. Teach the patient about asthma and the treatment plan. f. Educate the patient about implementation of his or her personal asthma action plan.

A pt who had a craniotomy develops the post-operative complication of SIADH. THe pt's sodium is 117 and the serum osmolality is decreased. In light of this development, which intervention would the nurse question? a. Encourage oral fluids b. Slow IV infusion of hypertonic sodium c. Strict intake and output d. Daily weights

a. Encourage oral fluids

The nurse is caring for a pt receiving medication therapy to prevent recurrence of stroke. Which medication is pharmacologically appropriate for this purpose? a. Enteric-coated aspirin b. Gabapentin c. Alteplase d. Acetaminophen

a. Enteric-coated aspirin

The nurse is taking a history from a patient with chronic cystic fibrosis. Which symptoms would the nurse expect? Select all that apply. a. Frequent respiratory infections b. Occasional respiratory congestion c. Decreased exercise tolerance d. ABGs that show respiratory alkalosis e. Increased sputum production f. Decreased carbon dioxide levels on ABGs

a. Frequent respiratory infections c. Decreased exercise tolerance e. Increased sputum production

The oncoming intensive care nurse is told that the pt with a TBI manifested Cushing's triad several minutes ago, just before shift change. Which intervention does the oncoming nurse anticipate? a. Helping family to prepare for imminent death b. Assisting with arrangements for hospice care c. Aggressive administration of osmotic diuretics d. Emergency transfer to the OR

a. Helping family to prepare for imminent death

Which drugs are essential for slowing the progression of the disease in a patient with pulmonary fibrosis? a. Immunosuppressants b. Opioids c. Antibiotics d. Bronchodilators

a. Immunosuppressants

different types of assessment

a. Initial assessment (AKA admission assessment) b. Problem focused assessment c. Shift assessment d. Emergency Assessment e. Time Lapsed Reassessment--several months later

The patient is receiving high-frequency chest wall oscillation (HFCWO). What are the actions of this therapy? Select all that apply. a. It dislodges mucous from the bronchial walls. b. It increases mobilization of mucous. c. It causes bronchodilation of the airways. d. It moves mucous upward toward the central airways. e. It decreases inflammation within the lung tissues. f. It thins secretions, making them easier to clear from the lungs.

a. It dislodges mucous from the bronchial walls. b. It increases mobilization of mucous. d. It moves mucous upward toward the central airways. f. It thins secretions, making them easier to clear from the lungs.

The nurse is caring for an intubated patient with IICP. If the pt needs to be suctioned, which nursing action does the nurse take to avoid further aggravating the IICP? a. Manually hyperventilate with 100% oxygen before passing the catheter b. Maintain strict sterile technique when performing endotracheal suctioning c. Perform oral suctioning frequently, but do not perform endotracheal suctioning d. Obtain an order for an ABG before suctioning the patient.

a. Manually hyperventilate with 100% oxygen before passing the catheter

The nurse is talking to the family of a stroke patient about home care measures. Which topics does the nurse include in this discussion? Select all that apply. a. Need for caregivers to plan for routine respite care and protection of own health b. Evaluation for potential safety risks such as throw rugs or slippery floors. c. Awareness of potential patient frustration associated with communication d. Avoidance of independent transfers by the pt bc of safety issues e. Access to health resources such as publications from the American Heart Association f. Referral to hospice and encouragement of family discussion of advance directives

a. Need for caregivers to plan for routine respite care and protection of own health b. Evaluation for potential safety risks such as throw rugs or slippery floors. c. Awareness of potential patient frustration associated with communication d. Avoidance of independent transfers by the pt bc of safety issues e. Access to health resources such as publications from the American Heart Association

The nurse is caring for a patient who has cystic fibrosis. Which assessment findings indicate the need for exacerbation therapy? Select all that apply. a. New onset crackles b. Increased activity tolerance c. Increased frequency of coughing d. Increased chest congestion e. Increased SaO2. f. At least a 10% decrease in FEV1.

a. New onset crackles c. Increased frequency of coughing d. Increased chest congestion f. At least a 10% decrease in FEV1.

A patient has been diagnosed with subarachnoid hemorrhage. Which drug does the nurse anticipate will be ordered to control cerebral vasospasm? a. Nimodipine b. Phenytoin c. Dexamethasone d. Clopidogrel

a. Nimodipine

what are nursing interventions?

a. Nursing interventions and activities are the actions that a nurse performs to achieve client goals b. Can focus on reducing signs and symptoms c. Can include physician orders in interventions but should be specific to nursing diagnosis

A patient has returned several times to the clinic for treatment of respiratory problems. Which action does the nurse perform first? a. Obtain a history of the patient's previous respiratory problems and response to therapy. b. Ask the patient to describe his compliance to the prescribed therapies. c. Obtain a request for diagnostic testing, including TB and HIV. d. Listen to the patient's lungs, obtain a pulse oximetry reading, and count the respiratory rate.

a. Obtain a history of the patient's previous respiratory problems and response to therapy.

1. Planning

a. Prioritize problems/diagnosis b. Formulate goals/desired outcomes c. Select nursing interventions d. Write nursing interventions

In assisting a patient with COPD to relieve dyspnea, which sitting positions are beneficial to the patient for breathing? Select all that apply. a. On edge of chair, leaning forward with arms folded and resting on a small table. b. In a low semi-reclining position with the shoulders back and knees apart. c. Forward in a chair with feet spread apart and elbows placed on the knees. d. Head slightly flexed, with feet spread apart, and shoulders relaxed. e. Low semi-Fowler's with knees elevated. f. Side lying to facilitate diaphragm movement.

a. On edge of chair, leaning forward with arms folded and resting on a small table. c. Forward in a chair with feet spread apart and elbows placed on the knees. d. Head slightly flexed, with feet spread apart, and shoulders relaxed.

Sources of Data

a. Patient- best source b. Support people c. Patient records d. Health care professionals e. literature

A pt with a right cerebral hemisphere stroke may have safety issues related to which factor? a. Poor impulse control b. Alexia and agraphia c. Loss of language and analytical skills d. Slow and cautious behavior

a. Poor impulse control

Which are the main purposes of asthma treatment? Select all that apply. a. Prevent asthma episodes b. Avoid secondhand smoke c. Improve airflow d. Relieve symptoms e. Improve exercise tolerance f. Control asthma episodes

a. Prevent asthma episodes c. Improve airflow d. Relieve symptoms f. Control asthma episodes

The nurse is caring for an older adult patient with a chronic respiratory disorder. Which interventions are best to use in caring for this patient? Select all that apply. a. Provide rest periods between activities such as bathing, meals, and ambulation. b. Place the patient in a supine position after meals to allow for rest. c. Schedule drug administration around routine activities to increase adherence to drug therapy. d. Arrange chairs in strategic locations to allow the patient to walk and rest. e. Teach the patient to avoid getting the pneumococcal vaccine. f. Encourage the patient to have an annual flu vaccination.

a. Provide rest periods between activities such as bathing, meals, and ambulation. c. Schedule drug administration around routine activities to increase adherence to drug therapy. d. Arrange chairs in strategic locations to allow the patient to walk and rest. f. Encourage the patient to have an annual flu vaccination.

The nurse is performing discharge teaching for the family and patient who had prolonged hospitalization and rehabilitation after a motorcycle accident. What important points does the nurse include? Select all that apply. a. Review seizure precautions b. Stimulate the pt with frequent changes in the environment c. Develop a routine of activities with consistency and structure d. Attend follow-up appointments with therapists. e. Encourage family to seek respite care if needed. f. Encourage the pt to wear a helmet when riding.

a. Review seizure precautions c. Develop a routine of activities with consistency and structure d. Attend follow-up appointments with therapists. e. Encourage family to seek respite care if needed.

A patient with a history of bronchitis for greater than 20 years is hospitalized. With this patient's history, what is a potential complication? a. Right-sided heart failure b. Left-sided heart failure c. Renal disease. d. Stroke

a. Right-sided heart failure

A pt received ateplase for the treatment of ischemic stroke. Following drug administration, the nurse monitors for which adverse affect? a. Severe headache and hypertension b. Hypotension secondary to anaphylaxis c. Respiratory depression and low O2 saturation d. Elevated hematocrit or hemoglobin

a. Severe headache and hypertension

1. Setting Outcomes, must be SMART

a. Specific i. Must be specific to nursing diagnosis you chose and specific to your patient ii. What NEEDS to be done what EXACTLY must patient do b. Measurable i. Must be able to know if patient met the outcome ii. Ask: how long?? How many? How much? c. Attainable i. Must be realistic d. Relevant i. The outcome you choose should MATTER ii. Ex: recovering from pneumonia, what would be most relevant? 1. Better breathing, productive couch, etc. e. Timed i. Give patient time frame to complete the outcome, a deadline ii. Short term vs. long term 1. Short term- prior to discharge, hours to days 2. Long term- weeks to months (uasually at minimum 1 week away

The nurse is caring for a pt who has decreased LOC with the medical diagnosis of epidural hematoma. During the shift, the pt becomes lucid and is alert and talking. The family reports that this is her baseline mental status. What is the nurse's next action? a. Stay with the pt and have the charge nurse alert the provider bc this is an ominous sign for the patient. b. Document the pt's exact behaviors, compare to previous nursing entries, and continue the neuro assessments every 2 hrs. c. Point out to the family that the dangerous period has passed, but encourage them to leave so the pt does not become overly fatigued. d. Monitor the pt for the next 48 hrs to 2 weeks bc a subacute condition may be slowly developing.

a. Stay with the pt and have the charge nurse alert the provider bc this is an ominous sign for the patient.

What are the most common symptoms of stroke? Select all that apply. a. Sudden dizziness, trouble walking or loss of balance of coordination b. Sudden numbness or weakness of the face, arm, or leg c. Sudden trouble seeing in one or both eyes d. Sudden SOB or trouble breathing e. Sudden confusion or trouble speaking or understanding others f. Sudden severe headache with no known cause

a. Sudden dizziness, trouble walking or loss of balance of coordination b. Sudden numbness or weakness of the face, arm, or leg c. Sudden trouble seeing in one or both eyes e. Sudden confusion or trouble speaking or understanding others f. Sudden severe headache with no known cause

Which patient handling situation has the greatest potential to lead to a subdural hematoma? a. Sudden vertical elevation of the head of bed of an older patient b. Log-rolling a patient who has a possible cervical spine injury c. Pulling on the affected flaccid arm of an older stroke pt. d. Keeping pt flat and alternating side-lying position every 2 hrs.

a. Sudden vertical elevation of the head of bed of an older patient

The nurse is performing discharge teaching for a pt who underwent a craniotomy for a brain tumor. What instructions does the nurse include? Select all that apply. a. Suggestions to make the environment safe, such as removing scatter rugs b. Seizure precautions and what to do if seizure occurs. c. Information about drugs such as dose, administration, and side effects. d. Doing regular physical exercise within limits of disability e. Advice about which OTC products are safe to use f. Referral to a resource such as the American Brain Tumor Association.

a. Suggestions to make the environment safe, such as removing scatter rugs b. Seizure precautions and what to do if seizure occurs. c. Information about drugs such as dose, administration, and side effects. d. Doing regular physical exercise within limits of disability f. Referral to a resource such as the American Brain Tumor Association.

Patients with asthma are taught self-care activities and treatment modalities according to the "step method." Which symptoms and medication routines relate to Step 3? a. Symptoms occur daily; daily use of inhaled corticosteroid and a long-acting beta agonist. b. Symptoms occur more than once per week; daily use of anti-inflammatory inhaler. c. Symptoms occur less than once per week; use of rescue inhalers once per week. d. Frequent exacerbations with limited physical activity; increased use of rescue inhalers.

a. Symptoms occur daily; daily use of inhaled corticosteroid and a long-acting beta agonist

A pt has just undergone spinal fusion and a laminectomy and has returned from the operating room. Which assessments are done in the first 24 hrs? Select all that apply. a. Take vital signs every 4 hrs and assess for fever and hypotension b. Perform a neuro assessment every 4 hrs with attention to movement and sensation c. Monitor I & O and assess for urinary retention d. Assess for ability and independence in ambulating and moving in bed e. Observe for clear fluid on or around the dressing f. Assess for and immediately report sudden onset of headache.

a. Take vital signs every 4 hrs and assess for fever and hypotension b. Perform a neuro assessment every 4 hrs with attention to movement and sensation c. Monitor I & O and assess for urinary retention e. Observe for clear fluid on or around the dressing f. Assess for and immediately report sudden onset of headache.

A pt is scheduled for lumbar surgery. Which key points must the nurse include in a pre-operative teaching plan for this patient? Select all that apply. a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. d. Restricted to bed rest for at least 48 hrs e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs

a. Techniques for getting in and out of bed b. Expectations for turning and moving in bed c. Limitations and restrictions for home activities. e. Immediately report any numbness and tingling f. Expect difficulties moving affected leg or both legs

The nurse is caring for a patient who is experiencing spinal shock. What are the expected findings that occur with the condition? a. Temporary loss of motor, sensory, reflex and autonomic functions. b. Stridor, garbled speech, or inability to clear airway c. Hypotension and a decreased LOC d. Bradycardia and decreased UO

a. Temporary loss of motor, sensory, reflex and autonomic functions.

A pt sustained a stroke that affected the right hemisphere of the brain. The pt has visual spatial deficits and deficits of proprioception. After assessing the safety of the pt's home, the home health nurse identifies which environmental feature that represents a potential safety problem for this patient? a. The handrail that borders the bathtub is on the right-hand side b. The pt's favorite chair faces the front door of the house. c. The pt's bedside table is on the left-hand side of the bed. d. Family has relocated the pt to a ground-floor bedroom.

a. The handrail that borders the bathtub is on the right-hand side

The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient? a. The patient is encouraged to cough and do deep-breathing exercises frequently b. "Stripping" of the chest tubes is done routinely to prevent obstruction by blood clots c. Water level in the suction chamber need not be monitored, just the collection chamber d. Drainage containers are positioned upright or on the bed next to the patient.

a. The patient is encouraged to cough and do deep-breathing exercises frequently

Which neuro assessment technique does the nurse use to test a patient for sensory function? a. Touch the skin with a clean paper clip and ask whether it feels sharp or dull. b. Ask the patient to elevate both arms off the bed and extend wrists and fingers. c. Have the patient close the eyes and move toes up or down, while identifying the positions. d. Have the patient sit with legs dangling; use a reflex hammer to test reflex responses

a. Touch the skin with a clean paper clip and ask whether it feels sharp or dull.

The nurse is caring for a pt who had a craniotomy. What interventions should the nurse use to prevent respiratory complications of atelectasis and pneumonia? a. Turn frequently and encourage frequent deep breaths. b. Perform deep suction frequently to keep airway patent c. Place in high Fowler's and apply oxygen d. Coach to perform deep coughin to expectorate secretions.

a. Turn frequently and encourage frequent deep breaths.

The nurse is providing discharge instructions to a patient with pulmonary fibrosis and the patient's family. What instructions are appropriate for this patient? Select all that apply. a. Using home oxygen b. Maintaining activity level as before. c. Preventing respiratory infections. d. Limiting fluid intake e. Energy conservation measures. f. Encouraging patient to complete all ADLs.

a. Using home oxygen c. Preventing respiratory infections. e. Energy conservation measures

Things RN CAN delegate

a. Vital signs b. Intake/output c. Transfers d. Ambulation and other ADL work e. Weighing f. Attending to safety (side rails up, call light within reach)

The home health nurse reads in the patient's chart that he has a mild hemiparesis and ataxia that are residual from a stroke that occurred several years ago. Based on this information, the nurse would assess for functionality and availability of what type of adaptive equipment for this patient? a. Walker and wheelchair for the mobility and handrails in the bathroom b. Picture boards, flash cards, or other methods of communication c. Cell phone, computer with internet access, or medical alert device d. Hearing aid, corrective eyeglasses, dentures and orthotic devices.

a. Walker and wheelchair for the mobility and handrails in the bathroom

A teenager dove head first into a rock quarry pond and is brought to the emergency department by EMS. Which questions will the nurse ask the EMS? Select all that apply. a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? c. Have the parents been notified to get permission for treatment? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route?

a. What were the location and position of the patient immediately after injury? b. Were there problems extricating the patient from the water? d. What symptoms were reported by bystanders and noted en route? e. What changes occurred at the scene or en route? f. What treatments were given at the scene or en route?

The home health nurse sees in the patient's record that he takes riluzole. Which question is the nurse most likely to ask? a. When were you first diagnosed with amyotrophic lateral sclerosis? b. Has the medication relieved any of the symptoms caused by multiple sclerosis? c. Has your acute back pain returned to the more familiar chronic pain? d. Have you always had neurogenic bladder problems since your spinal cord injury?

a. When were you first diagnosed with amyotrophic lateral sclerosis?

Which of the following are characteristics of chronic pulmonary emphysema? Select all that apply. a. Decreased surface area of alveoli b. chronic thickening of bronchial walls c. high arterial oxygen level d. hypercapnia e. ABGs show chronic respiratory acidosis f. increased eosinophils

a. decreased surface area of alveoli d. hypercapnia e. ABGs show chronic respiratory acidosis

Which are characteristics of asthma? Select all that apply. a. narrowed airway lumen due to inflammation b. increased eosinophils c. increased secretions d. intermittent bronchospasm e. loss of elastic recoil f. stimulation of disease process by allergies

a. narrowed airway lumen due to inflammation b. increased eosinophils d. intermittent bronchospasm f. stimulation of disease process by allergies

guidelines for setting outcomes

a. outcomes should be PATIENT focused, not nursing focused Ex: NOT: provide IV fluids ii. Correct: the patient will drink 600 mL of fluid by 1300 today b. Be sure outcome fits with nursing diagnosis c. Make sure goal is derived from only ONE nursing diagnosis d. Always have them DO something rather than verbalize understanding i. Ex: NOT: client will verbalize understanding of diabetic diet by 1300 today ii. CORRECT: client will verbalize 3 complex carbohydrates to include in a diabetic diet by 1300 today

Which position is therapeutic and comfortable for a patient with acute lower back pain from a herniated disc? a.Semi-Fowler's position with a pillow under the knees to keep them flexed. b. Supine position with arms and legs in a correct anatomical position. c. Orthopneic position; sitting with trunk slightly forward; arms supported with a pillow d. Modified Sim's position with upper arm and leg supported by pillows.

a.Semi-Fowler's position with a pillow under the knees to keep them flexed.

psychological loss

anticipatory loss

Bone Marrow Biopsy post-interventions

apply pressure to site and apply sterile dressing

Liver Biopsy nursing interventions

apply pressure until bleeding stops and apply sterile dressing, send sample to lab for analysis

Lumbar Puncture Nursing interventions

assess clients ability to remain in appropriate position, monitor client post-op for HA v/t CSF leakage & clotting, If bleeding apply epidural blood patch, notify doctor if client complains of headache

CT (computed tomography) nursing interventions

assess for allergy to shellfish or iodine contrast dye, assess for renal function if using contrast dye

The pt with a traumatic brain injury is receiving mechanical ventilation. Why does the provider order ventilator settings to maintain a partial pressure of PaCO2 at 35-38 mm Hg? a. Lower levels of arterial carbon dioxide are essential for gas exchange b. Carbon dioxide is a vasodilator that can cause IICP. c. CO2 is a waste product that must be eliminated from the body. d. Lower levels of arterial CO2 facilitate brain oxygenation

b. Carbon dioxide is a vasodilator that can cause IICP.

ASA

aspirin (acetylsalicylic acid)

PRE OP CATHETERIZATION

assess readiness and educate on sensations ( may have palpitations as catheter is passed into the left ventricle, feeling of heat or hot flash as medium is injected, and a desire to cough) MAKE SURE THEY UNDERSTAND BEFORE CONSENT IS SIGNED admitted the day of or earlier if renal problems Contrast may cause renal toxicity so hydration and administration of acetylcysteine pre and post (fluids 12-24 hrs prior) PRE op tests of chest xray, CBC, coags, electrolytes, BUN, creatinine and ECG NPO after midnight or only liquid bfast if in the afternoon Take vitals, ausculatate heart and lungs and assess peripheral pulses prior to procedure ASK FOR ALLERGIES TO IODINE!!!!! -may need antihistamine prior to test Mild sedative is administered before procedure HOLD DIGITALIS PREP OR DIURETIC BEFORE CATHETERIZATION

The pt with MS has dysarthria. What assessment would the nurse perform to monitor for a likely coexisting complication? a. Watch the patient walk and note smoothness of movement b. Check the pt's gag reflex and ability to swallow c. Ask the pt to use a pencil to write a sentence d. Have the pt stand and close eyes, and observe the pt for sway.

b. Check the pt's gag reflex and ability to swallow

A patient reports increased fatigue and stiffness of the extremities. These symptoms have occurred in the past, but they resolved and no medication attention was sought. Which question does the nurse ask to assess whether the symptoms may be associated with MS? Select all that apply. a. "Are you having persistent headaches that occur with stress?" b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" d. "Are you having trouble breathing with minimal exertion?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?"

b. "Do you have a persistent sensitivity to temperature?" c. "Do you ever have slurred speech or trouble swallowing?" e. "Has anyone in your family been diagnosed with multiple sclerosis?" f. "Do you have spasms at night that wake you from your sleep?"

Following a stroke, a pt demonstrates emotional lability. What is the family most likely to report? a. "He is so depressed all of the time that he hardly even eats anything." b. "He will laugh loudly and then suddenly start crying for no apparent reason." c. "He seems really cheerful, almost giddy and euphoric most of the time." d. "He is starting to behave and interact with us like he did before the stroke."

b. "He will laugh loudly and then suddenly start crying for no apparent reason."

The nurse is teaching a patient with COPD about his medications. Which statement by the patient indicates the need for additional teaching? a. "I will carry my albuterol with me at all times." b. "I will use my salmeterol whenever I start to feel short of breath." c. "I will check my heart rate before and after my exercise period." d. "I will use my ipratropium 4 times a day."

b. "I will use my salmeterol whenever I start to feel short of breath.

A pt with MS is prescribed oral fingolimod. Which key point must the nurse teach the patient about this drug? a. "You must be carefully monitored for allergic reactions bc the drug tends to build up in the body." b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate." c. "This drug will decrease the frequency of clinical relapses, but there is an increased risk for stroke." d. "The medication will improve your ability to walk, but it also increases the risk for seizures."

b. "We need to teach you how to monitor your pulse rate bc this drug can cause a slow heart rate."

The preferred administration time for intravenous fibrinolytic therapy is generally within what time frame of stroke symptom onset? a. 30-60 mins b. 3-4.5 hrs c. 6-8 hrs d. 24-30 hrs

b. 3-4.5 hrs

The nurse is caring for several patients on an orthopedic surgical unit. Which pt has the greatest risk for fat embolism syndrome? a. 66 year old who had laser-assisted laparoscopic lumbar discectomy b. 46 year old who had a spinal fusion for spine stabilization c. 52 year old who had a laminectomy to relieve back pain d. 62 year old who had minimally invasive surgery

b. 46 year old who had a spinal fusion for spine stabilization

A patient is undergoing diagnostic testing for possible cystic fibrosis. Which non-pulmonary assessment findings does the nurse expect to observe in a patient with CF? Select all that apply. a. Peripheral edema b. Abdominal distention c. Steatorrhea d. Constipation e. Gastroesophageal reflux f. Malnourished appearance

b. Abdominal distention c. Steatorrhea e. Gastroesophageal reflux f. Malnourished appearance

The nurse is working for a manufacturing company and is responsible for routine employee health issues. Which primary prevention is most important for those employees at high risk for occupational pulmonary disease? a. Screen all employees by use of chest x-ray films twice a year b. Advise employees not to smoke and to use masks and ventilation equipment c. Perform pulmonary function tests once a year on all employees. d. Refer at-risk employees to a social worker for information about pensions.

b. Advise employees not to smoke and to use masks and ventilation equipment

The nurse observes that a pt who had surgery for a benign hemangioblastoma has bilateral periorbital edema and ecchymosis. Bc this patient's care is based on the general principles of caring for the pt with a craniotomy, what is the nurse's first action? a. Immediately inform the surgeon. b. Apply cold compresses c. Check the pupillary response d. Perform a full neuro assessment

b. Apply cold compresses

The nurse is preparing to physically assess a pt's report of parasthesia in the lower extremities. To accomplish this assessment, which assessment technique does the nurse use? a. Use a doppler to locate the pedal pulse, the dorsalis pedis pulse, or the popliteal pulse. b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball. c. Use a reflex hammer to test for deep tendon patellar or Achilles reflexes. d. Ask the patient to walk across the room and observe gait and equilibrium.

b. Ask the patient to identify sharp and dull sensation by using a paper clip and a cotton ball.

A patient who was involved in a high speed motor vehicle accident sustained multiple injuries. He is transported to the emergency department by EMS with immobilization devices in place. There is a high probability of cervical spine fracture; the pt has altered mental status and extremities are flaccid. What is the priority assessment for this patient? a. Check the mental status using the Glasgow Coma Scale b. Assess the respiratory pattern and ensure a patent airway c. Observe for intra-abdominal bleeding and hemorrhage. d. Assess for loss of motor function and sensation.

b. Assess the respiratory pattern and ensure a patent airway

The nurse is caring for a patient who had a craniotomy. Which intervention targets the primary concern of postoperative care in the first 4-6 hrs after this procedure? a. Monitoring for periorbital edema and ecchymosis around eyes b. Assessing neurologic status and vital signs every 15-30 mins c. Monitoring CBC, electrolyte levels, and osmolarity. d. Orienting the pt to person, place, and time.

b. Assessing neurologic status and vital signs every 15-30 mins

A pt with an ischemic stroke is placed on a cardiac monitor. Which cardiac dysrhythmia places the pt at risk for emboli? a. Sinus bradycardia b. Atrial fibrillation c. Sinus tachycardia d. First-degree heart block

b. Atrial fibrillation

Which sites are commonly affected by lung cancer metastasis? Select all that apply. a. Heart. b. Bone c. Liver. d. Colon e. Brain f. Adrenal glands

b. Bone c. Liver. e. Brain f. Adrenal glands

A patient who is allergic to dogs experiences a sudden "asthma attack." Which assessment finding does the nurse expect for this patient? a. Slow, deep, pursed-lip respirations b. Breathlessness and difficulty completing sentences c. Clubbing of the fingers and cyanosis of the nail beds. d. Bradycardia and irregular pulse.

b. Breathlessness and difficulty completing sentences

The nurse is caring for a pt who sustained a TBI and is intubated. To prevent IICP, what would the nurse use to quickly detect hypercarbia? a. Pulse oximeter b. Capnography c. ABG d. Glasgow Coma Scale

b. Capnography

What is the most serious complication of cystic fibrosis? a. Pancreatic insufficiency b. Constant presence of thick, sticky mucous c. Intestinal obstruction d. Cirrhosis of the liver

b. Constant presence of thick, sticky mucous

The nurse is caring for a patient with chronic bronchitis and notes the following clinical findings: fatigue, dependent edema, distended neck veins, and cyanotic lips. These assessment findings are consistent with which disease process? a. COPD. b. Cor pulmonale c. Asthma d. Lung cancer

b. Cor pulmonale

Which patient behavior is most likely to occur with spinal shock? a. Demonstrates restlessness and is easily agitated b. Displays inability or difficulty moving extremities c. Is disoriented to person, place, and time d. Reports severe pain that radiates down the spine

b. Displays inability or difficulty moving extremities

The nurse is giving home care instructions to a patient who will be discharged with a halo device. What does the nurse instruct the patient to avoid? a. Going out in the cold b. Driving c. Sexual activity d. Bathing in the bathtub

b. Driving

The nurse is providing discharge teaching to a patient following carotid stent placement. The nurse would tell the pt to immediately report which symptoms to the provider? Select all that apply. a. Weight gain b. Drowsiness or new-onset confusion c. Muscle weakness or motor dysfunction d. Severe neck pain e. Neck swelling f. Hoarseness or difficulty swallowing

b. Drowsiness or new-onset confusion c. Muscle weakness or motor dysfunction d. Severe neck pain e. Neck swelling f. Hoarseness or difficulty swallowing

A pt who had a stroke several years ago continues to have the potential for aspiration. Which intervention is best to delegate to UAP? a. Monitor the pt for and notify the charge nurse of any occurrence of coughing, choking, or difficulty breathing b. Elevate the HOB and slowly feed small spoonfuls of pudding, pausing between each spoonful c. Check for swallow reflex by placing index finger and thumb on the Adam's apple and palpating during swallowing. d. Give the pt a glass of water before feeding solid foods, and have oral suction ready at the bedside.

b. Elevate the HOB and slowly feed small spoonfuls of pudding, pausing between each spoonful

The nurse is planning care for a 66 year old pt with SCI. Based on the nurse's knowledge of the most likely complication and cause of death for this patient, what would the nurse recommend? a. Increase calcium intake and exercise against resistance b. Ensure influenza and pneumococcus vaccinations are current c. Drink adequate liquids and eat a high-fiber diet d. Practice meticulous skin care; including frequent repositioning

b. Ensure influenza and pneumococcus vaccinations are current

The provider orders therapeutic hypothermia for a pt with TBI. What is the priority assessment during the rewarming process? a. Assess for change of mental status b. Monitor for cardiac dysrhythmias c. Watch for rebound elevation of temperature d. Observe for hypovolemic shock

b. Monitor for cardiac dysrhythmias

A patient has a history of COPD but is admitted for a surgical procedure that is unrelated to the respiratory system. To prevent any complications related to the patient's COPD, what action does the nurse take? a. Assess the patient's respiratory system every 8 hrs b. Monitor for signs and symptoms of pneumonia c. Give high-flow oxygen to maintain pulse oximetry readings. d. Instruct the patient to use a tissue if coughing or sneezing.

b. Monitor for signs and symptoms of pneumonia

A patient is receiving a chemotherapy agent for lung cancer. The nurse anticipates that the patient is likely to have which common side effect? a. Diarrhea b. Nausea c. Flatulence d. Constipation

b. Nausea

The ED nurse is caring for a trauma patient. The spinal board has been removed, but the provider indicates that spinal precautions should be maintained. What is included? Select all that apply. a. Bedrest with bathroom privileges b. No neck flexion with a pillow or roll c. No thoracic or lumbar flexion with head of bed elevation/bed controls d. No reverse Trendelenburg positioning e. Manual control of the cervical spine anytime the rigid collar is removed f. Log roll procedure to reposition patient.

b. No neck flexion with a pillow or roll c. No thoracic or lumbar flexion with head of bed elevation/bed controls e. Manual control of the cervical spine anytime the rigid collar is removed f. Log roll procedure to reposition patient.

The patient with chronic back pain is receiving ziconotide by intrathecal infusion with a surgically implanted pump. The patient develops hallucinations. What is the nurse's best first action? a. Request a psychiatric evaluation b. Notify the HCP c. Assess level of consciousness d. Decrease the dose of medication

b. Notify the HCP

The nurse is taking a history for a patient with chronic pulmonary disease. The patient reports often sleeping in a chair that allows his head to be elevated rather than going to bed. The patient's behavior is a strategy to deal with which condition? a. Paroxysmal nocturnal dyspnea b. Orthopnea c. Tachypnea d. Cheyne-Stokes

b. Orthopnea

Assessment of a patient with a lower spinal cord injury confirms that the patient has paralysis of the bilateral lower extremities. How does the nurse document this finding? a. Paraparesis b. Paraplegia c. Quadriparesis d. Quadriplegia

b. Paraplegia

The nurse is assessing a patient who presented to the emergency department reporting acute onset numbness and tingling in the right leg. How does the nurse document this subjective finding? a. Paraparesis b. Parasthesia c. Ataxia d. Quadriparesis

b. Parasthesia

The nurse is caring for a pt with an ischemic stroke. Which concept underlies the rationale for placing the patient in a supine position with a low HOB elevation? a. Comfort b. Perfusion c. Gas exchange d. Mobility

b. Perfusion

Which interventions does the nurse use for a pt with a left cerebral hemisphere stroke? Select all that apply. a. Teach the pt to wash both sides of the face b. Place pictures and familiar objects around the pt c. Reorient the pt frequently d. Repeat names of commonly used objects e. Approach the pt from the affected side f. Establish a structural routine for the pt.

b. Place pictures and familiar objects around the pt c. Reorient the pt frequently d. Repeat names of commonly used objects f. Establish a structural routine for the pt.

A patient has sustained a TBI. Which nursing intervention is best for this patient? a. Assess vital signs every 8 hrs b. Position to avoid extreme flexion of the neck c. Increase fluid intake for the first 48 hrs d. Restrict visitors until cognition improves.

b. Position to avoid extreme flexion of the neck

The home health nurse is assessing a pt who had a stroke that affected the right hemisphere. What would the nurse expect to observe? a. Pt is overly anxious and cautious when asked to do a new task. b. Pt is euphoric and smiling but disoriented to person, place and time. c. Pt is depressed and expresses ongoing worries about the future d. Pt has a flat affect but is able to answer most questions appropriately.

b. Pt is euphoric and smiling but disoriented to person, place and time.

A patient is receiving ipratropium and reports nausea, blurred vision, headache, and inability to sleep. What action does the nurse take? a. Administer a PRN medication for nausea and a mild PRN sedative b. Report these symptoms to the physician as signs of overdose. c. Obtain a physician's request for an ipratropium level. d. Tell the patient that these side effects are normal and not to worry.

b. Report these symptoms to the physician as signs of overdose.

Which statement is true about the relationship of smoking cessation to the pathophysiology of COPD? a. Smoking cessation completely reverses the damage to the lungs b. Smoking cessation slows the rate of the disease progression c. Smoking cessation is an important therapy for asthma, but not for COPD, d. Smoking cessation reverses the effects on the airways but not the lungs.

b. Smoking cessation slows the rate of the disease progression

The nurse is preparing a patient with quadriplegia for discharge and has taught the spouse to assist the patient with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught? a. Spouse assists the patient into a wheelchair or chair and coaches him to do deep coughing. b. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales. c. Spouse places her hands on the pt's lateral chest and pushes inward as the patient exhales. d. Spouse assists the pt into high Fowler's position and encourages him to take deep breaths.

b. Spouse places her hands below the patient's diaphragm and pushes upward as the patient exhales.

A patient admitted for a respiratory workup has baseline pulmonary function tests. After treatment with a bronchodilator the FEV1 increases by 14%. How does the nurse best interpret this value? a. The patient has emphysema b. The patient has asthma c. The patient has chronic bronchitis d. The patient has acute bronchitis

b. The patient has asthma

The patient is diagnosed with early pulmonary fibrosis. Which finding indicates that the patient's disease is progressing? a. The patient is short of breath with exertion b. The patient is becoming increasingly more short of breath c. The patient is experiencing respiratory infections d. The patient is experiencing side effects from his or her drugs.

b. The patient is becoming increasingly more short of breath

The nurse and nursing student are working together to bathe and reposition a pt who is in a halo fixator device. Which action by the nursing student causes the supervising nurse to intervene? a. Uses the log-roll technique to clean the pt's back and buttocks b. Turns the pt by grasping the top of the halo device c. Positions the pt with the head and neck in alignment d. Supports the head and neck area during the repositioning

b. Turns the pt by grasping the top of the halo device

The nurse teaches a patient with asthma to perform which intervention before exercising? a. Rest for at least an hour. b. Use the short-acting beta-adrenergic (SABA) medication. c. Dress in extra clothing during cold weather. d. Practice pursed lip breathing.

b. Use the short-acting beta-adrenergic (SABA) medication.

The nurse notices that a pt seems to be having trouble swallowing. Which intervention does the nurse employ for this patient? a. Limit the diet to clear liquids given through a straw b. Withhold food and fluids until swallowing is assessed c. Monitor the pt's weight and compare trends to baseline d. Observe the pt while eating and note problematic foods.

b. Withhold food and fluids until swallowing is assessed

BKA

below knee amputation

Hypo

below, less than

Sub

below/deficient

A pt has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hrs, the nurse is performing the change of shift assessment. Which post-op finding is immediately reported to the surgeon? a. Some serosanguinous drainage b. Pain along the incision site c. Swelling or bulging at the operative site d. Reluctance or refusal to cough and breath deeply

c. Swelling or bulging at the operative site

The home health nurse reads in the pt's chart that he has a spinal cord stimulator. What question would the nurse ask to evaluate the efficacy of the treatment? a. "Has the device helped you to gain control over the urinary incontinence?" b. "Does the device allow you to have sexual arousal that is satisfying?" c. "Have you been able to program the device to achieve maximum comfort?" d. "Have you programmed the device to achieve various levels of mobility?"

c. "Have you been able to program the device to achieve maximum comfort?"

The nurse is teaching a patient how to interpret peak expiratory flow (PEF) readings and to use this information to manage drug therapy at home. Which statement by the patient indicates a need for additional teaching? a. "If the reading is in the green zone, there is no need to increase the drug therapy." b. "Red is 50% below my 'personal best.' I should try a rescue drug and seek help." c. "If the reading is in the yellow zone. I should increase my use of my inhalers." d. "If frequent yellow readings occur, I should see my doctor for a change in medications."

c. "If the reading is in the yellow zone. I should increase my use of my inhalers."

A family member of a patient with COPD asks the nurse, "What is the purpose of making him cough on a routine basis?" What is the nurse's best response? a. "We have to check the color and consistency of his sputum." b. "We don't want him to feel embarrassed when coughing in public, so we actively encourage it." c. "It improves air exchange by increasing airflow in the larger airways." d. "If he cannot cough, the physician may elect to do a tracheostomy."

c. "It improves air exchange by increasing airflow in the larger airways."

A patient has been prescribed cromolyn sodium for the treatment of asthma. Which statement by the patient indicates a correct understanding of this drug? a. "It opens my airways and provides short-term relief." b. "It is the medication that should be used 30 mins before exercise." c. "It is not intended for use during acute episodes of asthma attacks." d. "It is a steroid medication, so there are severe side effects."

c. "It is not intended for use during acute episodes of asthma attacks."

The nurse is instructing a patient regarding complications of COPD. Which statement by the patient indicates the need for additional teaching? a. "I have to be careful because I am susceptible to respiratory infections." b. "I could develop heart failure, which could be fatal if untreated." c. "My COPD is serious, but it can be reversed if I follow my doctor's order." d. "The lack of oxygen could cause my heart to beat in an irregular pattern."

c. "My COPD is serious, but it can be reversed if I follow my doctor's order."

The nurse is conducting a presentation to a group of students on the prevention of head injuries. Which statement by a student indicates a need for additional teaching? a. "Drinking, driving, and speeding contribute to the risk for injury." b. " Males are more likely to sustain head injury compared to females." c. "Young people are less likely to get injured bc of faster reflexes." d. "Following game rules and not 'goofing around' can prevent injuries."

c. "Young people are less likely to get injured bc of faster reflexes."

The nurse is caring for a patient with a spinal cord injury who is experiencing neurogenic shock. The pt has a dopamine drip, but the systolic blood pressure is 88 mmHg. there is a new order to infuse 500 mL of dextran-40 over 4 hrs. At what rate does the nurse set the infusion pump? a. 75 mL/hr b. 100 mL/hr c. 125 mL/hr d. 150 mL/hr

c. 125 mL/hr

A patient is having pain resulting from bone metastases caused by lung cancer. What is the most effective intervention for relieving the patient's pain? a. Support the patient through chemotherapy b. Handle and move the patient very gently c. Administer analgesics around the clock d. Reposition the patient, and use distraction

c. Administer analgesics around the clock

The pt with MS states she is bothered by diplopia. Which intervention does the nurse expect to implement? a. Obtain an order for consultation or referral for corrective lenses b. Teach the pt scanning techniques, moving her head from side to side c. Application of an eye patch alternating from eye to eye every few hours d. Prophylactic bilateral patches to both eyes at night.

c. Application of an eye patch alternating from eye to eye every few hours

The nurse is working on a med-surg unit, and UAP tells the nurse that a pt who was dressing to go home suddenly developed slurred speech and left-sided weakness. What does the nurse do first? a. Instruct the pt to wait and initiate neuro checks every 2 hrs b. Call the provider to obtain a delay in the discharge order c. Assess the pt within 10 mins for signs/symptoms of a stroke d. Instruct the pt to follow up tomorrow with his provider

c. Assess the pt within 10 mins for signs/symptoms of a stroke

The pt with a spinal cord injury has an HR of 42 bpm. Which drug does the nurse expect to administer? a. Methylprednisolone b. Dextran c. Atropine d. Dopamine

c. Atropine

A patient is admitted with asthma. Which assessment findings are most likely to indicate that the patient's asthma condition is deteriorating and progressing toward respiratory failure? a. Crackles, rhonchi, and productive cough with yellow sputum b. Tachypnea, thick and tenacious sputum, and hemoptysis c. Audible breath sounds, wheezing, and use of accessory muscles. d. Respiratory alkalosis; slow, shalllow respiratory rate.

c. Audible breath sounds, wheezing, and use of accessory muscles.

For a patient who is a non-smoker, which classic assessment finding is particularly important in diagnosing asthma? a. Cough b. Dyspnea c. Audible wheezing d. Tachypnea

c. Audible wheezing

A patient is fearful that she might develop lung cancer because her father and grandfather died of cancer. She seeks advice about how to modify lifestyle factors that contribute to cancer. How does the nurse advise this patient? a. Not to worry about air pollution unless there is hydrocarbon exposure. b. Quit her job if she has continuous exposure to lead or other heavy metals c. Avoid situations where she would be exposed to secondhand smoke d. Not to be concerned because there are no genetic factors associated with lung cancer

c. Avoid situations where she would be exposed to secondhand smoke

A pt is diagnosed with an ischemic stroke. UAP reports the pt's BP is 150/100. The pt's BP prior to the stroke was normally around 120/80. What action does the nurse take first? a. Immediately report BP to the provider bc there is a danger of rebleeding. b. Ask UAP to recheck the BP in the other extremity with a manual cuff. c. Check the provider's orders to see is BP is within the acceptable parameters. d. Document BP and continue to monitor bc an elevated BP is necessary for cerebral perfusion.

c. Check the provider's orders to see is BP is within the acceptable parameters.

The nurse assesses a patient and finds a dusky appearance with bluish mucous membranes and production of lots of mucous secretions. What illness does the nurse suspect? a. Asthma b. Emphysema c. Chronic bronchitis d. Acute bronchitis

c. Chronic bronchitis

After the nurse has instructed a patient with COPD in the proper coughing technique, which action the next day by the patient indicates the need for additional teaching or intervention? a. Coughing upon rising in the morning. b. Coughing before meals. c. Coughing after meals. d. Coughing at bedtime.

c. Coughing after meals.

A pt is admitted for a closed head injury sustained during a fall down the stairs. The pt has no history of respiratory disease and no apparent respiratory distress. Howeer, the provider orders oxygen 2 L via NC. What is the nurse's best action? a. Use pulse oximeter and apply the oxygen if the saturation drops below 90% b. Question the order bc oxygen is unnecessary and therefore an extra cost to the pt. c. Deliver oxygen as ordered bc hypoxemia may increase ICP. d. Apply nasal cannula as ordered and wean from oxygen when pt is discharged.

c. Deliver oxygen as ordered bc hypoxemia may increase ICP.

An adolescent pt has quadriplegia as a result of a diving accident. The UAP reports that the pt starting yelling and spitting at her while she was trying to bathe him. He is angry and hostile, stating "Nobody is going to do anything else to me! I'm going to get out of this place!" What is the priority patient problem? a. Noncompliance with treatment plan b. Self-care deficit for hygeine c. Difficulties with situational coping d. Feelings of hopelessness

c. Difficulties with situational coping

Which are the most common early symptoms of pulmonary arterial hypertension a. Shortness of breath and dizziness b. Hypotension and headache c. Dyspnea and fatigue d. Chest pain and orthopnea

c. Dyspnea and fatigue

The nurse is developing a teaching plan for a patient with chronic airflow limitation using the priority patient problem of insufficient knowledge related to energy conservation. What does the nurse advise the patient to avoid? a. Performing activities at a relaxed pace. b. Working on activities that require using arms at chest level or lower. c. Eating three large meals a day. d. Talking and performing activities separately.

c. Eating three large meals a day.

Which pt is demonstrating an early indicator of change in LOC? a. Middle-aged pt with a brain tumor wanders naked in the halls. b. Older pt who had a stroke several days ago is snoring loudly c. Elderly pt is restless and irritable after a fall and bump to the head d. Adolescent pt is difficult to arouse after drinking and fighting.

c. Elderly pt is restless and irritable after a fall and bump to the head

A patient tells the nurse, "I have symptoms of multiple sclerosis, and I have been dealing with them for so long! Why won't anyone help me?" Which intervention should the nurse employ first? a. Help the patient to locate and make an appointment with a specialist b. Ask the patient to describe the symptoms and past treatments c. Encourage the patient to verbalize feelings and frustrations d. Give the patient a brochure about the diagnosis and treatment of MS.

c. Encourage the patient to verbalize feelings and frustrations

The nurse is caring for a patient at risk for IICP related to ischemic stroke. For what purpose does the nurse place the pt's head in a midline neutral position? a. Provide comfort for the patient b. Protect the cervical spine c. Facilitate venous drainage from brain d. Maintain presence of cerebrospinal fluid

c. Facilitate venous drainage from brain

A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly? a. Bubbles vigorously and continuously b. Bubbles gently and continuously c. Fluctuates with the patient's respirations d. Stops fluctuation, and bubbling is not observed.

c. Fluctuates with the patient's respirations

What is a potential adverse outcome of autonomic dysreflexia in a patient with a spinal cord injury? a. Heatstroke b. Paralytic ileus c. Hypertensive stroke d. Aspiration and pneumonia

c. Hypertensive stroke

The ED nurse is giving discharge instructions to the mother of a child who bumped his head on a table. Which statement by the mother indicates and understanding of the instructions? a. I should not let him fall asleep today or during the early evening. b. There's really nothing to worry about. It was just a bump on the head. c. I should take him back to the ED for weakness or slurred speech. d. He can run and play as he usually does, as long as he doesn't climb.

c. I should take him back to the ED for weakness or slurred speech.

A patient has COPD with chronic difficulty breathing. In planning this patient's care, what condition must the nurse acknowledge is present in this patient? a. Decreased need for calories and protein requirements since dyspnea causes activity intolerance. b. COPD has no effect on calorie and protein needs, meal tolerance, satiety, appetite, and weight. c. Increased metabolism and the need for additional calories and protein supplements. d. Anabolic state, which creates conditions for building body strength and muscle mass.

c. Increased metabolism and the need for additional calories and protein supplements.

Which statement is true about radiation therapy for lung cancer patients? a. It is given daily in "cycles" over the course of several months. b. It causes hair loss, nausea, and vomiting for the duration of treatment c. It causes dry skin at the radiation site, fatigue, and changes in appetite with nausea d. It is the best method of treatment for systemic metastatic disease.

c. It causes dry skin at the radiation site, fatigue, and changes in appetite with nausea

A patient with chronic bronchitis often shows signs of hypoxia. Which clinical manifestation is the priority to monitor in this patient? a. Chronic, non-productive dry cough b. Clubbing of fingers c. Large amounts of thick mucous d. Barrel chest

c. Large amounts of thick mucous

A patient had prolonged occupational exposure to petroleum distillates and subsequently developed a chronic lung disease. The patient is advised to seek frequent health examinations because there is a high risk for developing which respiratory disease condition? a. Tuberculosis b. Cystic fibrosis c. Lung cancer d. Pulmonary hypertension

c. Lung cancer

Which determination must be made first in assessing a pt with traumatic brain injury? a. Presence of spinal injury b. Hypovolemia with hypotension c. Patency of airway d. Glasgow Coma Score

c. Patency of airway

What is the priority concept for the interdisciplinary care and treatment of a patient who is suspected of having a stroke? a. Pain b. Cognition c. Perfusion d. Sensory perception

c. Perfusion

A patient presents to the walk-in clinic with extremely labored breathing and a history of asthma that is unresponsive to prescribed inhalers or medications. What is the first priority nursing action? a. Establish IV access to give emergency medications. b. Obtain the equipment and prepare the patient for intubation. c. Place the patient in high Fowler's position and start oxygen. d. Call 911 and report the patient has probable status asthmaticus.

c. Place the patient in high Fowler's position and start oxygen.

A patient with asthma has been prescribed a fluticasone inhaler. What is the purpose of this drug for the patient? a. Relaxes the smooth muscles of the airway. b. Acts as a bronchodilator in severe episodes. c. Reduces obstruction of airways by decreasing inflammation. d. Reduces the histamine effect of the triggering agent.

c. Reduces obstruction of airways by decreasing inflammation.

A pt is admitted to the critical care unit after a craniotomy to debulk a grade 3 astrocytoma. What is the priority patient problem? a. Risk for infection leading to septic shock b. Risk for memory loss and confusion c. Risk for IICP d. Risk for multi-organ failure

c. Risk for IICP

The physician's prescriptions indicate an increase in the suction to -20 cm for a patient with a chest tube. To implement this, the nurse performs which intervention? a. Increases the wall suction to the medium setting and observes gentle bubbling in the suction chamber. b. Adds water to the suction and drainage chambers to the level of -20 cm. c. Stops the suction, adds sterile water to the level of -20 cm in the water seal chamber, and resumes the wall suction d. Has the patient cough and deep breathe and monitors the level of fluctuation to achieve -20 cm.

c. Stops the suction, adds sterile water to the level of -20 cm in the water seal chamber, and resumes the wall suction

The patient has one gene allele for alpha-1 anti-trypsin (AAT) that is faulty and one that is normal. Which statement is true about this patient? a. The patient will have an alpha-1 anti-trypsin deficiency and is at risk for COPD. b. The patient will not be at risk for development of COPD. c. The patient will be a carrier for alpha-1 anti-trypsin deficiency. d. The patient will make enough alpha-1 anti-trypsin to avoid COPD even if exposed to smoking.

c. The patient will be a carrier for alpha-1 anti-trypsin deficiency.

The nurse is teaching a pt who will receive a disc-shaped wafer (carmustine) as part of the treatment for a brain tumor. Which statement by the pt indicates understanding of how the wafer works? a. I'll place the wafer under my tongue and allow it to dissolve b. The wafer will be taped to my chest and the drug will be absorbed c. The wafer will be placed directly into the cavity during surgery. d. The wafer is to be dissolved in water and taken with meals.

c. The wafer will be placed directly into the cavity during surgery.

The nurse is assessing a patient who sustained a relatively minor head injury after a bump to the head. the nurse has greatest concern about which symptom? a. Headache b. Nausea and vomiting c. Unequal pupils d. Dizziness

c. Unequal pupils

The nurse is taking history on a teenager who was involved in a motor vehicle accident with friends. The pt has an obvious contusion to the forehead, seems confused and is laughing loudly and yelling, "Ruby! Ruby!" What is the best question for the nurse to ask the pt's friends? a. Where and why did the accident occur? b. How can we notify the family for consent for treatment? c. Was the patient using drugs or alcohol prior to the accident? d. Who is Ruby, and why is the patient calling for her?

c. Was the patient using drugs or alcohol prior to the accident?

MRI contraindications

cardiac pacemakers, other implanted pumps or devices, contrast media cannot be iodine contrast

Stool specimen intra-interventions

collect pus, blood, & mucus, collect on opposite sides of the stool

Stool specimen

collection of a stool sample to test for blood, ova or parasites and bacteria

SPUTUM specimen complications

contamination and gathering saliva and not sputum

The nurse is taking a medical history on a new patient who has come to the office for a checkup. the patient states that he was supposed to take a medication called montelukast, but that he never got the prescription filled. What is the best response by the nurse? a. "When were first diagnosed with a respiratory disorder?" b. "Why didn't you get the prescription filled?" c. "Tell me how you feel about your decision to not fill the prescription." d. "Are you having any problems with your asthma?"

d. "Are you having any problems with your asthma?"

The nurse has provided teaching to the husband of a 33 year old woman who was recently diagnosed with MS. Which statement by the pt's husband indicates he needs additional teaching on the course of the illness? a. "She could fall bc she may lose her balance and have poor coordination." b. "Eventually she will not be able to drive because of vision problems." c. "She will probably have a decreased libido and diminished orgasm." d. "As the disease progresses, she could have intermittent short-term memory loss."

d. "As the disease progresses, she could have intermittent short-term memory loss."

The nurse is taking a report on a patient who had a pneumonectomy 4 days ago. Which question is the best to ask during the shift report? a. "Does the physician want us to continue encouraging use of the spirometer?" b. "How much drainage did you see in the Pleur-evac during your shift?" c. "Do we have a request to 'milk' the patient's chest tube?" d. "Does the surgeon want the patient placed on the operative or nonoperative side?"

d. "Does the surgeon want the patient placed on the operative or nonoperative side?"

A pt has been talking to the provider about drugs that could potentially be used in the treatment of low back pain. Which statement by the pt indicates a need for additional teaching? a. "The doctor may prescribe a muscle relaxant, so I should not drive or operate machinery until I see how it will affect me." b. "The doctor may suggest OTC ibuprofen; therefore I should watch for and report dark or tarry stools." c. "The doctor may prescribe an oral steroid such as prednisone; this would be short-term therapy, and the dose would gradually taper off." d. "The doctor may prescribe an opioid medication, and it may cause drowsiness; I should not drive or drink alcohol when I take it."

d. "The doctor may prescribe an opioid medication, and it may cause drowsiness; I should not drive or drink alcohol when I take it."

What is the purpose of pulmonary function testing, especially airflow rates and lung volume measurements, when classifying COPD? a. Determines the oxygen liter flow rates required by the patient. b. Measures blood gas levels before bronchodilators are administered. c. Evaluates the movement of oxygenated blood from the lung to the heart. d. Distinguishes airway disease (obstructive) from interstitial lung disease (restrictive).

d. Distinguishes airway disease (obstructive) from interstitial lung disease (restrictive).

Drugs for the treatment of COPD are the same as those used for the management of asthma. Which additional class of drugs would the nurse expect to administer for a patient with COPD? a. Beta-blocker drugs b. Corticosteroids c. Xanthines d. Mucolytics

d. Mucolytics

A patient has chronic bronchitis. The nurse plans interventions for inadequate oxygenation based on which set of clinical manifestations? a. Chronic cough, thin secretions, and chronic infection b. Respiratory alkalosis, decreased PaCO2, and increased PaO2. c. Areas of chest tenderness and sputum production (often with hemoptysis) d. Large amounts of thick secretions and repeated infections.

d. Large amounts of thick secretions and repeated infections.

A patient with cystic fibrosis is admitted to the med-surg unit for an elective surgery. Which infection control is best for this patient? a. It is best to put two patients with CF in the same room b. Standard Precautions including hand-washing are sufficient c. The patient is to be placed on contact isolation d. Measures that limit close contact between people with CF are needed.

d. Measures that limit close contact between people with CF are needed.

The nurse is caring for a patient with a chest tube in place. Over the past hour the drainage from the tube was 110 mL. What is the nurse's best action? a. Gently "milk" the tubing to remove clots b. Check the chest tube system for leaks. c. Instruct the patient to cough and deep breathe d. Notify the surgeon immediately.

d. Notify the surgeon immediately.

The nurse is assessing a pt who had a traumatic brain injury and observes that the patient's right pupil appears more ovoid in shape compared to the left and to previous assessments. What is the clinical significance of this observation? a. Ovoid pupil is not significant unless the nurse observes severe htn, change of mental status, or respiratory distress. b. Ovoid pupil is assumed to signal brain herniation in progress with a poor prognosis until proven otherwise. c. Ovoid pupil is considered a normal variation for a small percentage of patients who sustain minor head injuries. d. Ovoid pupil is regarded as midstage between a normal pupil and a dilated pupil and should be reported immediately.

d. Ovoid pupil is regarded as midstage between a normal pupil and a dilated pupil and should be reported immediately.

What is best practice for managing increased intracranial pressure in a pt ho experienced a stroke? a. Restrict visitors until LOC improves b. Keep the environment cheerful and stimulating c. Obtain an order for a low-fat and low-sodium diet d. Position HOB to less than 25 degrees

d. Position HOB to less than 25 degrees

The stroke patient is prescribed a stool softener every morning. What is the purpose of this drug specific to this patient? a. Stimulates peristaltic action to aid defecation b. Increases frequency of bowel movements c. Decreases fluid and fiber content of stool d. Prevents Valsava maneuver during defecation

d. Prevents Valsava maneuver during defecation

Which intervention promotes comfort in dyspnea management for a patient with lung cancer? a. Administer morphine only when the patient requests it. b. Place the patient in a supine position with a pillow under the knees and legs c. Encourage coughing and deep-breathing and independent ambulation d. Provide supplemental oxygen via cannula or mask

d. Provide supplemental oxygen via cannula or mask

What is the advantage of using aerosol route for administering short-acting beta2 agonists? a. Achieves a rapid and effective anti-inflammatory action. b. Reduces the risk for fungal infections. c. Increases patient compliance because it is easy to use. d. Provides rapid therapy with fewer systemic side effects.

d. Provides rapid therapy with fewer systemic side effects.

The nurse hears in report that the pt with a stroke had a score of 25 on the NIH Stroke Scale when assessed in the ED. After therapy and treatment, the most recent score is 20. How does the nurse interpret this information? a. Pt's condition can only be interpreted by trending several scores b. Pt should be carefully monitored for life-threatening symptoms c. Pt is possibly a little worse, but change is insignificant d. Pt is showing improvement and has fewer neuro deficits.

d. Pt is showing improvement and has fewer neuro deficits.

A pt had a brain tumor removed. Which position does the nurse place the pt in? a. Place on operative side to protect the unaffected side of the brain b. Place flat and repositioned on either side to decrease tension on the incision. c. Do not reposition unless specific positions are ordered by the surgeon. d. Reposition every 2 hrs but do not turn the pt onto the operative side.

d. Reposition every 2 hrs but do not turn the pt onto the operative side.

The nurse is providing post-op care for a pt who had a craniotomy. The nurse would immediately notify the surgeon of which assessment finding? a. Draining via JP of 45 mL/8hrs b. ICP of 15 c. PCO2 level of 35 d. Serum sodium of 119

d. Serum sodium of 119

What principle guides the nurse when providing oxygen therapy for a patient with COPD? a. The patient depends on a high serum carbon dioxide level to stimulate the drive to breathe. b. The patient requires a low serum oxygen level for the stimulus to breathe to work. c. The patient who receives oxygen therapy ata high flow rate is at risk for a respiratory arrest. d. The patient should receive oxygen therapy at rates to reduce hypoxia and bring SpO2 levels up between 88%-92%.

d. The patient should receive oxygen therapy at rates to reduce hypoxia and bring SpO2 levels up between 88%-92%.

Upon observation of a chest tube setup, the nurse reports to the physician that there is a leak in the chest tube and system. How has the nurse identified this problem? a. Drainage in the collection chamber has decreased b. The bubbling in the suction chamber has suddenly increased c. Fluctuation in the water seal chamber has stopped d. There was onset of continuous vigorous bubbling in the water seal chamber

d. There was onset of continuous vigorous bubbling in the water seal chamber

A child attending day camp has asthma, and her parent sent with her all of medicine in a small carry bag. The child has an asthma attack that is severe enough to warrant a rescue drug. Which medication from the child's bag is best to use for the acute symptoms? a. Omalizumab b. Fluticasone c. Salmeterol d. albuterol

d. albuterol

Nonrebreather Face Mask

delivers FiO2 70-100% flow rate 6-15 LPM, constantly cranking it up No rebreathing of exhaled gas maintain flow rate to keep the reservoir bag at least one third to one half full during inhalation

CT (computed tomography) Indications/Interpretations of findings

distinguishes minor differences in the density of tissues, identifies tumors & infarctions (blood supply distribution) detect abnormalities, response to treatment & to guide needles for biopsy

DNR

do not resuscitate

SPUTUM specimen nursing interventions

document relevant info (thickness, odor, color, & amount)

STRESS TEST

exercise electrocardiography - asses cario response to an increased workload PREP - make sure informed of purpose, procedure, and risks before consent is signed inform that is in a controlled environment where nursing and medical attention are available promptly GET PLENTY OF REST, NO SMOKING, CAFFEINE, ALCOHOL DAY OF TEST may eat light meal 2 hours prior USUALLY BETA BLOCKERS AND CALCIUM CHANNEL BLOCKERS ARE WITHELD DAY OF TEST educate to report chest pain, dizziness, sob, and irregular heartbeat during the test 12 lead ECG at rest obtain cardio history physical exam Ensure medical emergency supplies available - cardiac drugs, defibrillator, and other resuscitation equip available in the room PROCEDURE - Electrodes placed on chest and to multilead monitoring device baseline b/p, hr, and rr treadmill or bike b/p and ecg monitored during exercise as resistance is increased PATIENT EXERCISES UNTIL : -predetermined HR is reached and maintained -signs and symptoms appear -significant ST segment depression or T wave inversion occurs -the 20 minute protocol is completed FOLLOW UP- monitor ecg and b/p until they have recovered completely avoid hot shower for 1-2 hours - may cause hypotension admit to telemtry unit for observation if continues to have pain or ventricular dysrhythmias or unstable

Bone Marrow Biopsy

microscopic examination of a core of bone marrow removed with a needle, will feel a lot of pressure

urine specimen intra-interventions

midstream- void a little then catch, timed refrigeration or use preservative (timed means collecting each void except the first)

Naso

nose

Cheyne-Stokes respiration

pattern of breathing characterized by a gradual increase of depth and sometimes rate to a maximum level, followed by a decrease, resulting in apnea; near death.

Abdominal Paracentesis

puncture of the abdomen for aspiration of fluid in the peritoneal cavity

Liver Biopsy

removal of liver tissue for microscopic examination, Right side position post procedure to prevent patient from bleeding., complications include pain, infection, bleeding

what is the best source of evidence?

research

POST OP CATHETERIZATION

restricted to bed rest2-6 hrs and keep the insertion site extremety straight VERY IMPORTANT!!!!!!!!!!!! soft knee brace to prevent bending HOB may be elevated to no more than 30 degrees BUT CARDIOLOGIST MAY ONLY WANT SUPINE vitals every 15 minutes for 1 hour then every 30 mins for 2 hours or until stabel then every 4 hours ASSESS INSERTION SITE FOR BLOODY DRAINAGE OR HEMATOMA assess peripheral pulses, temp and color with every vital check Monitor urine output (medium acts like a diuretic) and plenty of oral and Iv fluids! (to excrete the medium) May give pain meds for discomfort HOME INSTRUCTIONS - limit activity for several ddays - no lifting or exercise, leave dressing in place for 1st day at home, ovserve site for increased swelling, redness, warmth, and pain. bruising or small hematoma is expected ALERT!!!!!! IF CHEST PAIN, DYSRHYTHMIAS, BLEEDING, HEMATOMA FORMATION, OR A DRAMATIC CHANGE IN PERIPHERAL PULSES CONTAT RAPID RESPONSE TEAM!!!!!!!!!!!!!!!!! ALSO NEURO CHANGES THAT INDICATE A POSSIBLE STROKE (visual disturbances, slurred speech, swallowing difficulties, and extremity weakness)

Thoracentesis post-interventions

send sample immediately to lab (max 1L)

Types of drainage

serous, sanguineous, serosanguineous, purulent

Cutaneo

skin

Brady

slow

Bradypnea

slow breathing

Lumbar Puncture intra-interventions

sterile process with anesthesia administered

Bone Marrow Biopsy Intra-interventions

sterile technique

Thoracentesis intra-interventions

sterile technique

Gastro

stomach

Stimulus-Based Model

stress is defined as a stimulus, life event, or set of circumstances that arouses physiological and/or psychological reactions that may increase the individual's vulnerability to illness.

SQ

subcutaneous

Types of Data

subjective and objective

right coronary artery

supplies the right atrium, right ventricle, and the inferior portion of the left ventricle SUPPLIES THE SA NODE AND AV NODE IN ALMOST EVERYONE!!!!!!!!!!!!!

Thoracentesis

surgical procedure to remove air from the thorasic cavity, Do not remove more than a Liter at 1 time, All samples must be labeled, complications include cant breath, respiratory distress, affected side will not move,

when you discontinue, what should you do

taper

disenfranchised grief

the emotion surrounding a loss that others do not support, share, or understand

Evidence based practice

the integration of the best current evidence to make decisions about patient care

Assisted suicide

the intentional assistance of any dying or suffering person in taking his or her own life

TID

three times daily

TRANSESOPHAGEAL ECHOCARDIOGRAPHY

through the esophagus to examine caridac structure and function with an ultrasound transducer placed behind the heart in the esophagus or stomach posterior views of cardiac structures SAME PREP FOR GI EDOSCOPE PROCEDURE

grief

total response to the emotional experience related to the loss.

chest pain

traditional symptom of heart diease but can also be due to pleurisy, pulmonary emboli, hiatal hernia, GERD, neuro abnormalities, and anxiety MI IS LIFE THREATENING!!!!!!!!! THOROUGHLY EVALUATE THE NATURE AND CHARACTERISTICS OF THE CHEST PAIN. ASK FOR SYMPTOMS SUCH AS DISCOMFORT, HEAVINESS, PRESSURE, AND INDEGESTION FUN FACT - some people, especially women, do not experience pain in the chest but feel discomfort or indigestion may also present with abdominal fullness, chronic fatigue even with rest, and feelings of SOB may also describe as the sensation as aching, choking, strangling, tingling, squeezing, constricting, or viselike IF THEY HAVE NEUROPATHY may just have SOB ASSESS _ did they begin suddenly or gradually? how long did they last? How often do they occur? Is it different than other pain? Point to where it hurts. Is it radiating? describe quality of pain. Describe intensity of pain (0-10) Check for other symptoms such as diaphoresis, sweating, N/V, dyspnea

Quality improvement

use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems

MRI (magnetic resonance imaging)

very detailed a technique that uses magnetic fields and radio waves to produce computer-generated images of soft tissue, bones, tumor. MRI scans show brain anatomy. lay flat contradicted for people with pacemaker.

Lumbar Puncture Client education

void prior to procedure, remain in lying position for several hours after procedure, remain curled & still during the procedure

Ć

with

Intra

within

An

without/not

Hgb normal lab values women

women: 12-15 g/dL

Hct normal values for women

women: 36-46%