Med-Surg HESI Practice, EXIT HESI HINTS

what is the first sign of hypoxia?

-agitation, restlessness -if these symptoms are present, check O2 sats

how can the nurse assess cerebellum function?

-finger to nose -arm swinging

what to assess after an upper endoscopy?

-gag reflex -fever -hypotension -bleeding from punctured esophagus

What are polyps?

-precursor to cancer -genetic -familial

what patients should get the inactivated flu vaccine?

-residents of nursing homes -pregnant women -pts who are immunocompromised or taking steroids

how to manage dizziness in a patient?

-sit down -give fluids -check BP -contact HCP

what to teach patients with acute sinusitis?

-take hot showers and use nasal saline spray to promote secretion drainage -sleep with head of bed elevated -take decongestants to relieve swelling

give an example of therapeautic communication for someone who is obese and trying to lose weight

-what factors led to your obesity? -have they had any changes in their diet or exercise pattern?

Daily urine output

1 mL per kg per hour Total daily UO: 1,500-2,000 mL

what is the normal total daily urine output for adults?

1,500-2,000 ml

Pain management

- drug therapy - NSAIDS - opioids

Neutropenia

- monitor BUN and serum creatinine levels - avoid potentiating drugs - alkalinize the urine by adding sodium bicarbonate to an IV infusion - give allopurinol or rasburicase for TLS prevention

Findings expected because of chemo

- myelosuppresson - neutropenia - thrombocytopenia - anemia - fatigue - constipation - diarrhea - nausea and vomiting

Anemia

A condition in which the blood is deficient in red blood cells, in hemoglobin, or in total volume.

what is crepitation?

A grading, popping, or crackling sound within a joint.

Magnesium lab value

1.5-2.5

Sodium lab value

135-145

HCO3

22-26

What is the mini-cog test?

3 item recall and clock drawing

Potassium lab values

3.5-5.0

what is a normal paCO2?

35-45

Calcium lab value

8.5-10.5

what is a normal PaO2?

80-100

what medicine should patients with jaundice limit?

Acetaminophen

Urinary tract obstruction (renal calculi)

Administer narcotic analgesics Apply moist heat to the painful area High oral fluid intake will help dislodge the stone Strain all urine and send stones to lab for analysis**** most important intervention

Clients at risk for pneumonia

Altered LOC Depressed or absent gag and cough reflexes Susceptible to aspirating oropharyngeal secretions (alcoholics, anesthetized individuals) Brain injury Drug overdose Stroke victims Immunocompromised

Methylxanthine

Aminophylline (IV); Theophylline (PO) Bronchodilation Adverse reactions: hyperactivity, tachycardia, sleeplessness, cardiac dysrhythmias Monitor therapeutic range Crosses placenta

Peptic ulcers

Avoid medications that increase the risk (salicylates, NSAIDs, corticosteriods in high doses, anticoagulants) Severe abdominal pain should be reported immediately - could denote perforation!

An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply) a. Monitor dryness of mucous membranes b. Check for changes in mentation c. Observe color of skin and nailbeds d. Note appearance of jugular veins e. Assess breathing patterns

B, C, E

Metatastic cancer

Cancer that spreads from where it started to a distant part of the body

tumor lysis syndrome

Chemotherapy can cause massive destruction of cells leading the creation of uric acid which can be toxic to the kidneys leading to Acute Tubular Necrosis. You can try to prevent this with hydration and allopurinol.

Urinary tract infection

Consume oral fluids up to 3 L/day Avoid urinary tract irritants such as alcohol, sodas, citrus juices, and spices

Dysarthria

Difficulty articulating

Hypokalemia

Dry mouth, thirst, weakness, drowsiness, lethargy, muscle aches, and tachycardia

Angina

EKG will show ST-segment depression and T-wave inversion during an attack Sexual activity may be resume after exercise is tolerated, usually when able to climb two flights of stairs without exertion

Rule of 9's

Each arm= 9%, Anterior leg=9%, Posterior leg=9% Head=9%, Back=18% Chest=18%, Perineum=1%

Joint replacement

INFECTION is the main concern postoperatively Joint pathology: OA, RA, fracture Pain unrelieved by medication Poor ROM in the affected joint A suction drainage device usually accompanies the client to the postoperative floor - check drainage often Monitor functioning of the extremity (circulation, sensation, movement) Provide proper alignment of the affected extremity Get client out of bed as soon as possible Do not flex the hip more than 90 degrees (hip replacement)*** Instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting after a hip replacement

NSAIDs

Ibuprofen (Motrin, Nuprin, Advil) Indomethacin (Indocin) Ketorolac tromethamine (Toradol) Naproxen (Naprosyn) Celecoxib (Celebrix) Anti-inflammatory, antipyretic, analgesic Take with food or milk Avoid alcohol Monitor increase in liver enzymes Prolonged coagulation time

Esophageal varices

Immediate management includes insertion of an esophagogastric balloon tamponade, vasopressors, vitamin K, coagulation factors, and blood transfusions

Dysphasia

Impairment of speech and verbal comprehension; difficulty swallowing

Digoxin (Lanoxin)

Indications: HF Increases the contractility of cardiac muscle, slows heart rate and conduction (chronotropic effect) Therapeutic range: 0.5-2.0 mg Check apical pulse for one full minute before administering and hold if below 60 bpm and notify healthcare provider Hypokalemia increases the risk for toxicity Antidote - Digibind

Epinephrine (adrenaline)

Indications: cardiac arrest

Alexia

Loss of the ability to read

Glasgow coma scale (GCS)

Maximum total is 15; minimum is 3 A score of 7 or less indicates coma*** Eye opening (spontaneous, to verbal command, to pain, no response) = 4 Motor response (to verbal command, to painful stimuli [localizes pain, flexes/withdraws, flexor posturing {decorticate}, extensor posturing {decerebrate}, no response]) = 6 Verbal response (oriented and converses, disoriented and converses, uses inappropriate words, incomprehensible sound, no response) = 5

Digoxin toxicity

N/V, anorexia, visual disturbances, restlessness, headache, cardiac dysrhythmias, pulse < 60 bpm 0.8 - 2.0 ng/mL

Corticosteroids

Prednisone (PO); Solu-Medrol (IV); Budesonide (Pulmicort); Fluticasone (Flovent); Triamcinolone (Azmacort) Anti-inflammatory Encourage oral care after use

Diabetic neuropathy

Primary cause of end-stage renal failure in US! Monitor BUN/creatinine in diabetics

End stage renal disease (ESRD)

Progressive, irreversible damage to the nephrons and glomeruli, resulting in uremia Accumulation of waste products from protein metabolism is the primary cause of uremia - protein must be restricted in ESRD clients****** However, if protein intake is inadequate, a negative nitrogen balance occurs, causing muscle wasting Labs: azotemia; increased creatinine/BUN; decreased calcium (function of the kidney to reabsorb calcium); elevated phosphorus and magnesium (decreased calcium = increased phosphorus); anemia Provide a low protein, low sodium, low potassium, low phosphate, high calorie diet Administer phosphate binders with food because client is unable to excrete phosphates No magnesium-based antacids Monitor for fluid overload Admister erythropoietin (Epogen) to treat anemia (due to decreased production of erythropoietin in ESRD); do not shake vial (shaking may inactivate the glycoprotein) Beware of digoxin toxicity (excreted by the kidneys)

how to do the incentive spirometer?

blow out, put your lips on device and then inhale as much as you can

what are the first signs of cerebral hypoxia?

irritability and restlessness

which vitamin deficiency is the most concerning for a patient with anorexia?

potassium

Choveks sign

touching cheek it twitches

Cancer stage 1

tumor limited to the tissue of origin; localized tumor growth

what to do for a patient with a subarachnoid hemorrhage and ICP?

-check for JVD for fluid overload -if pt has increased JVD, notify provider

what to do if someone gets c. diff after taking Prilosec?

-contact HCP -assess BP+HR -give PRN tyenol -put them on contact isolation

what to tell a patient who has crhonic back pain who lifts heavy things for a job?

-do exercises like squat at the gym to strength the back muscles

pt teaching for early alcoholic cirrhosis

-dont drink alcohol -do not share razors and eat small frequent meals

whar are the signs and labs you would see in someone with metabolic syndrome?

-impaired fasting glucose -obestiy -increased lipids, LDL, HDL, and lipo proteins

what to do for a patient with a pulmonary embolism and their O2 sat is decreasing?

-increase O2 flow rate -check all vital signs

what can an increased temperature do to the body?

-increases metabolism -increases the demand for O2 -can cause dehydrate because of the excessive fluid loss due to diaphoresis

what is included in the care for a patient with an NG tube?

-keep head of bed elevated -check for residual as prescribed

what are the risk factors for constipation?

-lack of exercise -laxative use

femur fracture concerns

-loss of distal pulses -SOB (embolism) -slow cap refill to foot

signs and symptoms of neurogenic shock?

-low BP -low HR (apical pulse less than 45bpm)

what to further assess after a fracture from a fat embolism occurs?

-lung sounds -SOB -O2 sats

what to do for a patient with metastatic bone cancer?

-monitor serum calcium level -support the leg when repositioning the patient -support the family during prognosis and treatment -treat pain with opioids

what can you delegate to the UAP in pre-op?

-obtain and document baseline vitals -remove all nail polish and apply pulse ox -transport by stretcher to operating room

signs of a bowel obstruction

-pain -hypoactive bowel sounds -abdominal distention

what type of patients will need a nutrition consult?

-pt taking appetite enhancer meds -pt with acute weight loss

where do the complications of ARDS begin? what should you assess?

-starts with the kidneys decreasing urinary output -make sure to check vital signs: BP, HP, O2

what to recommend for a smoking patient?

-stop smoking -get a CT to screen for cancer -get the yearly flu vaccine

what should the plan of care be for a patinet with a T2 spinal cord injury?

-urinary cath care -continuous cardiac monitoring -maintain warm room temperature -administer H2 receptor blockers

how to prevent SIRS?

-use aseptic technique -ambule post op patients -remove urinary catheters as soon as possible -administer antibiotics within 1 hour for sepsis patients

what are the major concerns for a patient given vasopressor therapy?

-vasopressin is a vasoconstrictor which decreases coronary artery perfusion, if pt complains of chest pain, this is an immediate concern

IBS: Crohn's disease

Subacute, chronic inflammation extending throughout all layers of intestinal mucosa, which has a cobblestone appearance of the GI mucosa with periods of remission Occurs during the teenage years and early adulthood; there is NO cure, treatment relies on medication to treat acute inflammation Symptoms include abdominal pain (unrelieved by defecation), diarrhea, steatorrhea, weight loss, constant fluid low, perforation of the intestine, malnutrition Provide a low-residue, low-fat, high-protein, high-calorie diet, with NO DAIRY PRODUCTS*** Administer vitamin supplements and iron Avoid milk products and spicy foods Administer aminosalicylates, antimicrobials, corticosteriods, immunosuppressants, and biologic therapy

Oral hypoglycemics

Sulfonylureas: lower blood sugar by stimulating the release of insulin by the beta cells of the pancreas and causes tissues to take up and store glucose more easily; hypoglycemia is a common adverse effect Biguanides: metformin (Glucophage); lowers serum glucose by inhibiting hepatic glucose production and increasing sensitivity of peripheral tissue to insulin; adverse effects include LACTIC ACIDOSIS; many drug interactions, use cautiously with preexisting renal or liver disease; D/C 48 hours before and 48 hours after diagnostic studies requiring IV iodine contrast media

Hypoglycemia

Symptoms: headache, nausea, sweating, tremors, lethargy, hunger, confusion, slurred speech, tingling around mouth Treat immediately with complex carbohydrates (CHO): one tube glucose gel , 120-180 mL fruit juice, 10-16 jelly beans, 10 gum drops, 5-7 lifesavers Check blood glucose May seize < 40

Stoma care

The more distal the stoma is, the greater the chance for continence (sigmoid colon) The lower the stoma's location in the GI tract, the more solid, or formed, is the effluence (drainage) A simple squirt bottle is used to remove effluence from the sides of the bag Pouch system is changed every 3 to 7 days when the bowel is inactive Pouch should be emptied when 1/3 to 1/2 full Those with descending-colon colostomies can irrigate to provide control over effluence; use warm water Ileostomy diet: chew food thoroughly; high-fiber foods can cause severe diarrhea Colostomy diet: resume regular diet gradually

Stroke

The number one cause of a stroke in hypertensive clients is noncompliance with medication regimen. Studies have shown that the more clients know about their hypertension medications, the more likely they are to take it.

Diuretics

Thiazide: useful in severe HTN; observe for postural hypotension; administer potassium supplements Loop: furosemide (Lasix); rapid action, causes volume depletion; adverse effects include hypokalemia, hyperuricemia, glucose intolerance, hypercholesterolemia, and sexual dysfunction Potassium-sparing: spironolactone (Aldactone); volume depletion without significant potassium loss; adverse effects include hyperkalemia and renal failure in those treated with ACE inhibitors or NSAIDs

Cholesterol

Total < 200 mg/dL LDL < 100 mg/dL HDL > 60 mg/dL Triglycerides < 150 mg/dL

Ascites

Treatment includes paracentesis and peritoneovenous shunts

breast cancer

a carcinoma that develops from the cells of the breast and can spread to adjacent lymph nodes and other body sites

which patient in the progressive care unit would the nurse be most concered about?

a patient prescribed tPA or IV heparin that has the opportunity to bleed out

after a hiatal hernia, what is indicated if there are absent breath sounds?

a pneumothorax, intervention is requied

1. You have a newborn showing signs of heart failure what should you do first?

a. Auscultate lung sounds before giving diuretic

1. Client w/ neuropathy because of venous insufficiency with numbness and tingling in the feet what is the plan of care

a. Goal is have them walk 30 mins a day before their next appointment,

Hypervolemia

abnormal increase in the volume of blood plasma in the body

symptoms of dysphasia

drooling, coughing, choking

what is DEXA?

dual-energy x-ray absorptiometry

what symptoms would be most concerning in an elder patient with the flu?

dyspnea and diffuse crackles (sign of pulmonary complications)

what should the plan of care be fore a patient with acute renal failure?

early ambulation, humidified O2, increase HOB to at least 30 degrees

tramatic brain injury concern?

elevated BP and low HR

how to treat gas and abdominal pain distention?

encourage the patient to ambulate as often as possible

what to teach young patients about meningitis?

encourage them to get vaccinated against neisseria meningitides

what should the home health nurse assess for with a patient post stroke?

ensure there is family support

Extravasation

escape of blood from the blood vessel into the tissue

what is the primary cause of COPD in the United States?

exposure to tobacco smoke

Cancer stage 3

extensive local and regional spread

what food should you give someone right after they come off NPO status?

gelitin

how to relieve a cluster headache?

give O2

what to do if a patient has a long bone fracture and is SOB?

give O2 (this is a possibly fat embolism)

what is the best way to encourage eating for a patient who has a poor appetite?

give them foods that they prefer

Trousseau's sign

hand/finger spasms with sustained blood pressure cuff inflation

respiratory alkalosis

high pH, low CO2

what is a common side affect of Prilosec in hospitalized patients??

high risk for c. diff

Hypernatremia

high sodium

1. Client uses heroine what in the history do you need to be aware of

history of suicide attempt

pt teaching for allergic rhinitis

identify and avoid environmental triggers

what is a concern with a wrist fracture (Colle's fracture)?

if capillary refill is dimished or prolonged, call HCP

how to know parents need education on bathing when child has a cast?

if they use a plastic bag around the cast this is a no

Osteoarthritis causes pain where at in the body?

in the joints

where is the spleen palpated?

in the left upper abdomen

what to do if respiratory secretions are thick?

increase fluid intake

sodium intake for addisions disease patients?

increase sodium intake

what does an elevated CEA mean?

increased CEA indicates a tumor is growing

what are we most concerned with during post op?

infection and bleeding

what is bursitis?

inflammation of a bursa

pt on a ventilator with respiratory failure, what can you delegate to the LPN?

insert indwelling urinary catheter

pt teaching for acute sinusitis with compounding upper respiratory infection

intervene if the patient states that they will continue to take their decongestants until the congestion is gone

how would a nurse compete a health history for a patient that is confused?

interview a lucid family member

what to do for a patient with respiratory problems who is decompensating?

intubate the patient

what does fibromyalgia do?

it disturbs sleep and is very painful

what does a fatty meal do to the gallbladder?

it will cause the gallbladder to contract and have colicky pain

Cancer stage 2

limited local spread

what is a concern with a lumbar vertebral compression?

loss of bowel of bladder function indicates an emergency

clinical manifestations of osteoporosis in a 55 y/o female?

loss of height

respiratory acidosis

low pH, high CO2

Hyponatremia

low sodium in the blood

which area of flaccidity would suggest lesions on L1?

lower legs

how to relieve a migraine headache?

lower stimulation

Cancer stage 4

metastasis

side effects of chemo

myleosuppression, nausea, vomiting, alopecia, skin rash, diarrhea, renal disease, and cardiomyopathy.

what should you notify the provider about if a patient has after a right radial fracture?

notify HCP if patient has an increased temp

what does a positive rombergs test indicate?

patient is at high risk for falls

how to know that nifedipine is working?

patient will have decreased exertional dyspnea

what patient should you turn first?

patient with septicemia who has intercostal and suprasternal retractions

intervention to prevent aspiration in high risk patients

place patient in a side-lying position

interventions to decrease ventilator-associated pneumonia

position the patient upright, either by elevating the head of the bed at least 30 degrees

what is indicated if a straight leg raising test is positive? what does it confirm?

positive if it causes sciatic pain, confirms herniated nucleus palposes

what to do if a patient gets an epidural hematoma?

prep them for an emergency craniotomy

What is osteoporosis?

progressive loss of bone tissue

who should the nurse assess first after a back surgery?

pt who has not voided for 8 hours after a laminectomy

what is an intervention for a patient having a seizure?

put them in the recovery position

patient teaching for trigeminal neuralgia?

-avoid triggers -eat luke-warm food -dont expose face to draft or air

metabolic alkalosis

pH > 7.45 HCO3 > 26

what does a low albumin indicate?

poor wound healing

SIADH

Small cell carcinoma of the lung

teenager overdosed on meds, what to ask?

what meds did he take

what question should you ask an elderly patient when assessing and teaching about nutrition needs?

"who grocery shops for you?"

what to say to a pt with a new diagnosis of esophageal cancer

-ackmowledge that learning about the new diagnosis must be hard for the patient

what to do if you stick yourself with a needle that was used on someone who is Hep B positive?

-administer the Hep B vaccine -test for antibodies to Hep B -give hep B immune globulin

what clients are at high risk for Pneumonia?

-altered LOC -brain injury -depressed or absent gag reflex -susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals -drug overdose -stroke victims -immunocompromised

if someone is going to get bariatrics surgery for obesity, what question would you ask them to help psychosocially counsel them?

-ask them what kind of resources they think that they might use post procedure

patient teaching for acute lower back pain

-avoid activities that require twisting or prolonged sitting -symptoms of acute low back pain usually resolve in a few weeks -use ibuprofen or acetaminophen to relieve pain

pt teaching for GERD

-avoid bedtime snacks -sleep with head of the bed elevated on 4-5 in blocks

Phosphorus lab value

2.5-4.5

Altered state of consciousness

A client with an altered state of consciousness is fed via ENTERAL routes because the likelihood of aspiration is high with oral feedings The presence of 100 mL or more of residual in an adult indicates poor gastric emptying, and the feeding should be withheld Paralytic ileus is common in comatose clients; a gastric tube aids in gastric decompression Any client on bed rest or immobilized must have ROM exercises every 4 hours and very frequent position changes - do not leave the client in any one position for longer than 2 hours; any position that decreases venous return, such as sitting with dependent extremities for long periods, is dangerous Position client for maximum ventilation: three quarters prone or semiprone position to prevent tongue from obstructing airway, and slightly to one side with arms away from chest wall Tachycardia can indicate infection, thrombus formation, or dehydration Rising blood pressure or widening pulse pressure can indicate increase ICP If temperature elevates, take quick measures to decrease it because fever increases cerebral metabolism and can increase cerebral edema Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia; do not oversedate, and report any symptoms of restlessness During all activities, tell the client what you are doing, regardless of the level of consciousness Rapid infusions of tube feedings may cause diarrhea; lack of fiber and inadequate fluids may cause constipation

An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply) a. Serum creatinine and blood urea nitrogen (BUN) b. Sensation in feet and legs c. Skin condition of lower extremities d. Visual acuity e. Signs of respiratory tract infection

A, B, C, D

An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds

A. A carotid bruit

Chronic bronchitis

Airway destruction Chronic sputum with cough production on a daily basis for a minimum of 3 months in 2 consecutive years Reduced responsiveness of respiratory center to hypoxemia stimuli Precipitating factor: higher incidence in smokers "Blue bloaters" - generalized cyanosis of lips, mucous membranes, face, and nail beds Right-sided heart failure (distended neck veins, crackles) Lowest FiO2 possible to prevent CO2 retention Monitor for fluid overload Maintain PO2 between 55 and 60 Administer bronchodilators and anti-inflammatory agents

Cholecystitis

Acute inflammation of the gallbladder Incidence greatest in "4 F's": fat, forty, female, flatus Symptoms: pain, vomiting, flatulence precipitated by ingestion of fried, spicy, or fatty food; fever, elevated WBCs Treatment consists of IV hydration, administration of antibiotics, and pain control with morphine Maintain NPO status and NG tube to suction

Tuberculosis

Airborne precautions***** Symptoms: fever with night sweats, anorexia, weight loss, malaise, fatigue, cough, hemoptysis, dyspnea, pleuritic chest pain with inspiration, positive sputum culture, repeated upper respiratory infection Client may return to work after 3 negative sputum cultures Place client in respiratory isolation while hospitalized (mask for anyone entering room; private room; client wears mask if leaving room) Isoniazid (INH): metabolism primarily by liver and excretion by kidneys; increased phenytoin (Dilantin) levels Rifampin (Rifadin): used in conjugation with at least one other antitubercular agent; suppression of effect of birth control fills; orange body secretions; increases metabolism of digoxin and oral hypoglycemics Ethambutol: vision check before starting therapy and monthly thereafter Pyrazinamide Rifapentine

Antihypertensives

Alpha-adrenergic blockers: Minipress, Cardura; used as peripheral dilator that acts directly on the blood vessels Combined alpha/beta blockers: carvedilol (Coreg); produces decrease in BP without reflex tachycardia or bradycardia; CI with HF, heart block, COPD, and asthma Beta blockers ("lol"): block the sympathetic nervous system, especially to the heart, produces a slower heart rate, lowers blood pressure, reduces O2 consumption during myocardial contraction; adverse reactions include bradycardia; check apical pulse daily, do not discontinue abruptly, monitor for shortness of breath and give cautiously with bronchospasm, CI with asthma Central-acting inhibitors: Catapres, Aldomet; decreases BP by stimulating central alpha receptors, resulting in decreased sympathetic outflow from the brain; monitor for rebound HTN if abruptly discontinued Vasodilators: hydralazine HCl (Apresoline); decreases BP by decreasing peripheral resistance; adverse effects include headache, tachycardia, and fluid retention Angiotensin II receptor blockers ("sartans"): blocks the vasoconstrictor and aldosterone-producing effects of angiotensin II in vascular smooth muscle Angiotensin-converting enzyme (ACE) inhibitors ("pril"): decreases BP by suppressing renin-angiotensin aldosterone system and inhibiting conversion of angiotensin I into angiotensin II; useful with clients diagnosed with diabetes; observe for acute renal failure, routine renal function tests Calcium channel blockers (CCB): inhibit calcium ion influx during cardiac depolarization, decreases SA/AV node conduction; avoid grapefruit juice with these drugs (increases serum levels, resulting in hypotension)***

Emphysema

Alveoli destruction Increased air trapping (increased AP diameter) Increased work, increased O2 consumption Precipitating factor: cigarette smoking "Pink puffers" Barrel chest, pursed-lip breathing, wheezing Lowest FiO2 possible to prevent CO2 retention Administer bronchodilators and anti-inflammatory agents Teach prolonged expiratory phase to clear trapped air

Antiulcer drugs

Antacids: aluminum hydroxide/ magnesium hydroxide (Maalox, Mylanta); treatment of peptic ulcers; work by neutralizing or reducing acidity of stomach contents; administer after meals Histamine-2 antagonists: Zantac, Tagamet, Pepcid; treatment of peptic ulcers; prophylactic treatment for at-risk clients (highly stressed or on steriods) Mucosal healing agents: sucralfate (Carafate): treatment of peptic ulcers; medication to be taken at least 1 hour before meals Proton pump inhibitors ("prazole"): pantoprazole (Protonix), omeprazole (Prilosec): treatment of erosive esophagitis associated with GERD; taken before meals

Antilipemics

Bile sequestrants: bind to lipids and eliminate in stool; alteration in absorption of other oral medications HMG-CoA reductase inhibitors ("statins"): block the production of cholesterol in the liver; may elevate liver enzymes Fibric acid derivatives: obtain baseline labs (liver function, CBC, electrolytes) every 3-6 months Water-soluble vitamins: decrease lipoprotein and triglyceride synthesis and increase HDL; give with milk or food to avoid GI irritation; hepatotoxicity with extended release forms

Transurethral resection of the prostate (TURP)

Bladder spasms frequently occur after TURP Inform client that the presence of the oversized balloon on the catheter (30 to 45 mL inflated) will cause a continuous feeling of needing to void. The client should not try to void around the catheter because this can precipitate bladder spasms Administer antispasmodics Check the urinary drainage system for clots Use only sterile saline for bladder irrigation after TURP because the irrigation must be isotonic to prevent fluid and electrolyte imbalance Urine should progress to clear yellow by the fourth day

CAUTION

C- changes In bowel/bladder habits A- a sore that does not heal U- unusual bleeding or discharge T- thickening or lump in breast or elsewhere I- indigestion or difficulty swallowing O- obvious changes in warts or moles N- nagging cough or persistent hoarseness

Cancer stage 0

Cancer in situ

Cushing syndrome (excessive adrenocortical activity)

Cause is usually chronic administration of corticosteriods or tumor growth Symptoms: moon face***, truncal obesity, buffalo hump, muscle atrophy, hirsutism, amenorrhea, edema, poor wound healing, impotence, HTN, susceptibility to infections, hyperglycemia, hypernatremia, hypokalemia, increased plasma cortisol (think S&S of corticosteriod overdose) Excess fluid volume/ risk for infection Teach client to protect from exposure to infection Provide a low-sodium diet; encourage consumption of vitamin D and calcium Wean from steroids

Amputation

Causes: PVD (clients with diabetes), trauma, congenital deformities, malignant tumors, infection Position client to relieve edema and spasms at residual limb (stump) site: elevate stump for the first 24 hours postoperatively Do not elevate the stump after 48 hours postoperatively Keep stump in extended position and turn client to prone position three times a day to prevent hip flexion contracture Provide passive ROM until client is able to perform active ROM

Dysrhythmias

Causes: drugs, acid-base and electrolyte imbalances, marked thermal changes, disease and trauma, and stress Determine serum electrolyte levels, especially K+ and Mg++ Atrial fibrillation: chaotic activity in the AV node, no true P wave visible, irregular ventricular rhythm; anticoagulant therapy to decrease risk for stroke, antidysrhythmic drugs, cardioversion Atrial flutter: saw-toothed waveform***, fluttering in chest, ventricular rhythm stays regular; cardioversion Ventricular tachycardia: synchronized cardioversion if pulse present (if no pulse, treat as ventricular fibrillation) Ventricular fibrillation: cardiac emergency! No cardiac output; defibrillate as quickly as possible Premature ventricular contractions (PVC): a contraction originating in an ectopic focus in the ventricles, wide and distorted in shape

Stroke

Cerebral vascular accident (CVA)/ brain attack Sudden loss of brain function resulting from a disruption in the blood supply to a part of the brain; classified as thrombotic or hemorrhagic Atrial fibrillation and atrial flutter produce a high incidence of thrombus formation, following dysrhythmia caused by turbulence of blood flow through all valves and heart chambers*** Presenting symptoms relate to the specific area of the brain that has been damaged Generally, motor loss exhibited as hemiparesis or hemiplegia, communication loss, perceptual disturbances, and impaired mental acuity Left hemisphere: aphasia, agraphia, unable to discriminate words and letters, reading problems, deficits in right visual field, slow, cautious behavior, anxious when attempting new tasks, depression, quick anger and frustration Right hemisphere: disoriented memory, cannot recognize faces, visual/spacial deficits, neglect of left visual field, loss of depth perception, impulsive, unaware of neurological deficits, euphoric, denies illness, overestimates abilities, loses ability to hear tonal variations Rehabilitation is begun as soon as the client is stable The quicker movement is recovered, the better the prognosis is for full or improved recovery Assess functional abilities (mobility, ADLs, elimination, communication) Risk for falls, risk for aspiration*** Control HTN to prevent further stroke Reassure client that bladder control tends to be regained quickly Reassure client that regaining speech is a very slow process Teach that swallowing modifications may include a soft diet (pureed foods, thickened liquids) and head positioning Steroids are administered after a stroke to decrease cerebra edema and retard permanent disability H2 inhibitors are administered to prevent peptic ulcers

Hearing loss

Conductive hearing loss: sound does not travel well to the sound organs of the inner ear; if volume is raised, hearing is normal; usually results from cerumen (wax) impaction or middle ear disorders such as otitis media Sensorineural hearing loss: sound passes properly through the outer and middle ear but is distorted by a defect in the inner ear or damage to cranial nerve VIII, or both; common causes include infections, ototoxic drugs, trauma, neuromas, noise, and aging; it involves perceptual loss, usually progressive and BILATERAL; it is detected by tuning fork When communicating with client, speak in a LOW-PITCHED voice, slowly and distinctly

Aphasia

Loss of the ability to speak

Agraphia

Loss of the ability to write

Glaucoma

Chronic open-angle glaucoma, also known as primary open-angle glaucoma, is a condition characterized by increased intraocular pressure (IOP), involving a gradual, painless loss of vision IOP > 22 mm Hg Can lead to BLINDNESS if left untreated Aqueous fluid is inadequately drained from the eye Generally ASYMPTOMATIC in early stages Late signs include loss of peripheral vision, seeing halos around lights, decreased visiual acuity not correctable with glasses, headache or eye pain that may cause N/V Tonometer measures IOP Gonioscope obtains direct visualization of the lens Glaucoma is a SIDE EFFECT of many medications (antihistamines, anticholinergics) Administer eye drops as prescribed to cause pupil constriction allowing aqueous humor to flow out PILOCARPINE is commonly used*** Caution the client that vision may be blurred for 1 to 2 hours after administration of pilocarpine and that adaptation to dark environments may be difficult due to pupil constriction*** Vision already lost cannot be restored Eye drops are needed for the rest of life Avoid activities that may increase IOP

Parkinson disease

Chronic, progressive, debilitating neurologic disease of the basal ganglia, affecting motor ability and characterized by tremor at rest, increased muscle tone (rigidity), slowness in the initiation and execution of movement (bradykinesia), and postural instability (difficulties with gait and balance) The pathophysiology involves an imbalance between acetylcholine and dopamine, so symptoms can be controlled by administering a dopamine precursor (levodopa) Symptoms include rigidity of extremities, MASKLIKE FACIAL EXPRESSIONS with associated difficulty in chewing, swallowing, and speaking, DROOLING, stooped posture and slow, shuffling gait, tremors at rest, "PILL-ROLLING" movement, emotional lability Focus on SAFETY*** Schedule activities later in the day to allow client to perform self-care activities without feeling rushed Encourage activities and exercise Serve a soft diet, which is easy to swallow Administer antiparkinsonian drugs: anticholinergics (atropine sulfate, Cogentin); dopamine replacements (levodopa, Sinemet) Adverse effects of anticholinergic drugs include increased HR, postural hypotension, dry mouth, constipation, urinary retention, and blurred vision; CI in narrow-angle glaucoma, urinary retention

Rheumatoid arthritis (RA)

Chronic, systematic, progressive deterioration of the connective tissue (synovium) of the joints, characterized by inflammation Joint involvement is BILATERAL and SYMMETRICAL Symptoms: morning stiffness, weight loss, fatigue, bilateral inflammation of joints with decreased ROM, joint pain, warmth, and edema, joint deformity Diagnosis is confirmed by elevated ESR, positive rheumatiod factor, presence of antinuclear antibody (ANA), and C-reactive protein Treatment includes corticosteroids for inflammation, splinting, immobilization, and rest for the joint, and NSAIDs for pain Implement pain relief measures (moist heat, diversionary activities) and periods of rest

Guilain-Barre syndrome

Clinical syndrome of unknown origin involving peripheral and cranial nerves Usually preceded by a VIRAL respiratory or GI infection 1 to 4 weeks prior to the onset of neurologic deficits Constant monitoring of these clients is required to prevent the life-threatening problem of acute respiratory failure*** Full recovery usually occurs within several months to a year after onset of symptoms About 30% of those diagnosed with Guilain-Barre are left with a residual disability Symptoms include paresthesia (numbness and tingling), muscle weakness of legs progressing to the upper extremities, trunk, and face, paralysis of the ocular, facial, and oropharyngeal muscles, causing marked difficulty in talking, chewing, and swallowing, increasing pulse rate and disturbances in rhythm, transient HTN, orthostatic hypotension, and weakness or paralysis of the intercostal and diaphragm muscles (may develop quickly)

Cataracts

Condition characterized by opacity of the lens Aging accounts for 95% of cases Leading cause of blindness in the world Surgical removal is done when vision impairment interferes with daily activities; intraocular lens implants may be used Operation is performed under local anesthesia on an outpatient basis Symptoms include blurred vision, decreased color perception, photophobia, diplopia, deduced visual acuity (progressing to blindness), clouded pupil, progressing to milky-white appearance Postoperative teaching should include teaching that glasses or shaded lens should be worn during waking hours and an eye shield should be worn during sleep; avoid any activity that increases IOP; avoid lying on operative side; keep water from getting into eye while showering

Monitor ABGs

PO2 > 80 mm Hg; PCO2 35-45 mm Hg; HCO3 21-28 mEq/L; pH 7.35-7.45

Which clinical manifestation further supports an assessment of a left-sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia.

D) Global aphasia.

what to do if a chest tube becomes disconnected?

DO NOT CLAMP -immediately place the end of the tube in a container of sterile saline or clear water until a new drainage system can be connected

Cirrhosis

Degeneration of liver tissue, causing enlargement, fibrosis, and scarring Causes: chronic alcohol consumption, viral hepatitis, exposure to hepatotoxins, infections, chronic severe right-sided HF Symptoms: jaundice***, dark-colored urine (bilirubin in urine), chalky colored stools (absence of bilirubin), palpable liver, weakness, malaise, fector hepaticus (fruity or musty breath resulting from the inability to detoxify amino acid)***, asterixis (hand-flapping tremor that often accompanies metabolic disorders), bruising/erythema, acites, peripheral neuropathy, palmar erythema, esophageal varices*** Ammonia is not broken down as usual; therefore serum ammonia level rises; can result in encephalopathy Lactulose (Cephulac) is used to decrease ammonia levels and bowel pH*** The metabolism of drugs is slowed down so they remain in the system longer Clotting defects noted in lab findings Administer vitamin supplements and teach client need for continuing supplements Observe mental status q2h Avoid initiating bleeding (use electric razor, hold pressure on venipuncture site for at least 5 min, prevent straining) Restrict fluids to 1,500 mL /day Restrict protein in diet

Multiple sclerosis (MS)

Demyelinating disease resulting in the destruction of CNS myelin and consequent disruption in the transmission of nerve impulses Onset is insidious, with 50% of client still ambulatory 25 years after diagnosis Symptoms involving motor function usually begin in the upper extremities with weakness progressing to spastic paralysis; bowel and bladder dysfunction occurs in 90% of cases Progression is not "orderly" Symptoms include optic neuritis (loss of vision or blind spots), visual or swallowing difficulties, gait disturbances, intention tremors, unusual fatigue, weakness, numbness (particularly on one side of face), impaired B&B control, speech disturbances Teach client that for muscle spasticity, stretch-hold-relax exercises are helpful, as are riding a stationary bike and swimming; take precautions against falls As incontinence worsens, client may need to learn clean self-catheterization, condom catheter Administer steroid therapy and chemotherapeutic drugs in acute exacerbations to shorten length of attack: ACTH, cortisone, cyclophosphamide (Cytoxan), and other immunosuppresive drugs Biologic response modifiers such as interferon-beta products are successful with MS relapses

Anemia

Diet lacking in IRON (red meats, organ meats, spinach), FOLATE (green vegetables, liver, citrus fruits), and/or VITAMIN B12 (glandular meats, yeast, green leafy vegetables, milk, cheese) Family history of genetic disease such as sickle cell or congenital hemolytic anemia Medication history of anemia-producing drugs, such as salicylates, thiazides, and diuretics Hgb < 10 g/dL Hct < 36% RBCs < 4 x 10^12 Administer blood products Instruct in food selection and need for vitamin supplementation Take iron on an empty stomach and with vitamin C to enhance absorption Give liquid iron through a straw to prevent staining of teeth Clients with pernicious anemia should receive vitamin B12 parenterally

Diabetes (continued)

Diet regiment: 45% to 50% carbohydrates, 15% to 20% protein, 30% or less fat; eat foods high in COMPLEX carbohydrate, fiber, and low in fat when possible Illness raises blood glucose, monitor blood glucose more frequently and monitor for hyperglycemia Feet should be washed daily, avoid soaking, air dry feet (especially between toes)

Myocardial infarction (MI)

Differs from anginal pain in its sudden onset; pain is unrelieved by nitroglycerin Serum cardiac markers: creatine kinase (CK) rises 3-12 hours after MI; troponin rises 3-12 hours after MI; CK-MB (recognized indicator of MI by most clinicians) onset 4-8 hours after MI EKG changes occur as early as 2 hours post-MI IV morphine sulfate acts as a peripheral vasodilator and decreases venous return Administer thrombolytic/ fibrinolytic agents within 1 to 4 hours of MI, but not more than 12 hours of MI

Colon cancer

Digital rectal exam every year after age 40 Stool blood test every year after 50 Colonoscopy or sigmoidoscopy examination every 10 years after the age of 50 in average-risk clients Rectal bleeding is an early sign of colon cancer! History of polyps is a risk

IBS: ulcerative colitis

Disease that affects the superficial mucosa of the large intestine and rectum, causing the bowel to eventually narrow, shorten, and thicken due to muscular hypertrophy Symptoms: diarrhea, abdominal pain and cramping, liquid stools containing blood, mucus, and pus (may pass 10 to 20 liquid stools per day), anemia Provide a low-residue, low-fat, high-protein diet with NO DAIRY PRODUCTS*** Avoid smoking, caffeine, pepper, and alcohol Allow complete bowel rest with IV hyperalimentation if necessary Administer corticosteriods, antidiarrheals, sulfasalazine, and other biologic treatments

Myasthenia gravis (MG)

Disorder affecting the neuromuscular transmission of impulses in the voluntary muscles of the body Autoimmune disease characterized by the presence of acetylcholine receptor antibodies, which interfere with neuronal transmission Symptoms include diplopia, ptosis, masklike affect (sleepy appearance due to facial muscle involvement), weakness of laryngeal and pharyngeal muscles (dysphagia, choking, food aspiration, difficulty speaking), muscle weakness improved by rest, respiratory failure, B&B incontinence Bed rest often relieves symptoms Myasthenic crisis: associated with undermedication; increase in symptoms (more difficulty swallowing, diplopia, ptosis, dyspnea); positive Tensilon test Cholinergic crisis: associated with anticholinesterase overdosage; symptoms include diaphoresis, diarrhea, fasciculations, cramps, marked worsening of symptoms; negative Tensilon test In clients with MG, be alert for changes in RESPIRATORY STATUS Administer cholinergic drugs (pyridostigmine bromide [Mestinon]) to inhibit the action of cholinesterase at the cholinergic nerve endings; cholinergic crisis with overdose Atropine is antidote for drug-induced bradycardia***

Diverticular disease

Diverticulosis: bulging pouches in the GI wall (diverticula), which push the mucosal lining through the surrounding muscle; the presence of pouches in the wall of the intestine; usually no discomfort and goes unnoticed Diverticulitis: inflamed diverticula, which may cause obstruction, infection, and hemorrhage; symptoms include LLQ pain, increased flatus, rectal bleeding; obstruction, ileus, or perforation confirmed by abdominal radiograph Provide a HIGH-FIBER diet with bulk forming laxatives (to prevent pooling of foods in the pouches) unless inflammation is present, in which case client is NPO, gradually to liquids, followed by low-residue bland food; avoidance of small, poorly digested foods such as popcorn, nuts, and seeds; increase fluid intake to 3 L/day

Hyperkalemia

Dizziness, weakness, cardiac irregularities, muscle cramps, diarrhea, and nausea Sodium polystyrene (Kayexalate) may be prescribed if potassium is too high

pt comes into the ER with a pole in his throat, what is the priority nursing action?

Do not pull out the pole, check for circulation

COPD

Emphysema and chronic bronchitis Characterized by bronchospasm and dyspnea Compensation occurs over time in clients with chronic lung disease and ABGs are altered The amount of O2 in the blood decreased (hypoxemia) and the amount of CO2 in the blood increases (hypercapnia) causing chronic respiratory acidosis, which results in metabolic alkalosis as compensation

Adrenergics and sympathomimetics

Epinephrine; Albuterol (Proventil); Terbutaline (Brethine); Salmeterol (Serevent); Metaproterenol (Alupent); Levabuterol (Xopenex) Bronchodilation Adverse reactions: anxiety, increased HR, N/V, urinary retention

Hyperthyroidism (Graves disease)

Excessive activity of the thyroid gland, resulting in an elevated level of circulating thyroid hormone Can result from a primary disease state; from the use of replacement hormone therapy; or from excess TSH being produced by an anterior pituitary tumor Symptoms: enlarged thyroid gland, acceleration of body processes (weight loss, increased appetite, diarrhea, heat intolerance, tachycardia, palpitations, increased BP, diaphoresis, nervousness, insomnia), exophthalmos*** T3 elevated above 220 ng/dL; T4 elevated above 12 ng/dL Thyroid storm is a life-threatening event that occurs with uncontrolled hypertension; symptoms include fever, tachycardia, anxiety, and HTN --> #1 nursing intervention is to maintain airway and adequate aeration PTU and methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm Maintain a calm environment After treatment, resulting hypothyroidism will require daily hormone replacement Eliminate caffeine from diet Radioactive iodine uptake to destroy thyroid cells is very irritating to GI tract and client will commonly vomit (vomitus is radioactive) Thyroidectomy: check frequently for bleeding, irregular breathing, neck swelling, frequent swallowing; keep a trach set by the bedside

Eye trauma

Explain that an eye patch may be applied to rest the eye; reading and watching TV may be restricted for 3 to 5 days Report a sudden increase in eye pain

hypertonic solution

Solute concentration is greater than that inside the cell; cell loses water

Anticoagulants

Heparin sodium: avoid IM injection (can be given SQ or IV), assess stools for occult blood, asses PTT to determine efficacy; antagonist - protamine sulfate Warfarin sodium (Coumadin): given orally, assess PT to determine efficacy, avoid sudden change in intake of foods; antagonist - vitamin K Low-molecular weight heparins (Lovenox): prevention of thrombolytic formation Advise client to wear medical alert symbol, avoid aspirin/ NSAIDs, avoid safety razors, and elevate extremity

Hepatitis

Hepatitis A (infectious hepatitis): contaminated food/water; vaccine YES Hepatitis B (serum hepatitis): contaminated blood products, needles; mother to child at birth; vaccine YES Hepatitis C: contaminated blood products, needles; vaccine NO Symptoms: jaundice, myalgia, abdominal tenderness in RUQ, fever, elevations in liver enzymes and bilirubin Provide a high-calories, high-carbohydrate diet with moderate fats and proteins and vitamin supplementation Emphasize importance of preventing spread to others (use own utensils, toothbrush, razors) Drug therapy must be scrutinized carefully (many drugs are metabolized in the liver)

Detached retina

Hole or tear in, or separation of the sensory retina from, the pigmented epithelium Resealing done by surgery Administer medication to inhibit accommodation and constriction - cycloplegics (mydriatics and homatropine) are given to dilate pupil before surgery

Aldosterone

Hormone that stimulates the kidney to retain sodium ions and water

Hypothyroidism (Hashimoto disease, myxedema)

Hypofunction of the thyroid gland, with resulting insufficiency of thyroid gland Iodine deficiency is the most common cause of hypothyroidism*** Symptoms: fatigue, dry hair, thin skin, thick brittle nails, bradycardia, hypotension, constipation, goiter, periorbital edema, facial puffiness, cold intolerance, weight gain, dull emotions, depression, husky voice*** (edema of the neck), slow speech T3 < 70; T4 < 5 Treated by daily hormone replacement therapy Levothyroxine (Synthroid): synthetic T4; adverse reactions include anxiety, insomnia, tremors, tachycardia, palpitations; avoid foods and products containing iodine; weigh daily Ongoing follow-up to determine serum hormone levels S&S of myxedema coma: hypotension, hypothermia, hyponatremia, hypoglycemia, respiratory failure Avoid sedating client*** (can lead to respiratory difficulties)

Ineffective breathing pattern

Inability of air sacs to fill and empty properly (emphysema, cystic fibrosis) Obstruction of the air passages (carcinoma, asthma, chronic bronchitis) Accumulation of fluid in the air sacs (pneumonia) Respiratory muscle fatigue (COPD, pneumonia)

Apraxia

Inability to perform purposeful movements in the absence of motor problems

Head injury

Increased ICP is the main concern in TBI; it is related to edema, hemorrhage, impaired cerebral autoregulation, and hydrocephalus Symptoms of increased ICP include change in level of responsiveness, slowing of respirations, increase or decrease in pulse, rising BP or widening PP, temperature rise, headache, PROJECTILE VOMITING, pupillary changes, seizures, ataxia, abnormal posturing (decorticate or decerebrate), and CSF leakage through nose or ear Keep HOB elevated 30 to 45 degrees to aid venous return from the neck and to decrease cerebral volume Position client semiprone or lateral recumbent to prevent aspiration If temperature increase, take immediate measures to decrease it (aspirin, acetaminophen, cooling blankets) When using intracranial monitoring, elevations of ICP over 20 mm Hg should be reported immediately Mannitol (Osmitrol) dehydrates the brain and reduces cerebral edema; use for SHORT-TERM therapy only; never give to clients with cerebral hemorrhage; never give to clients with no urine output (ANURIA) - if output is < 30 mL/hr, accumulation can cause pulmonary edema and water intoxication Steroids (dexamethasone, methylprednisolone sodium succinate [Solu-Medrol]) are used to reduce brain edema Barbituates are used to reduce brain metabolism and systemic BP Avoid narcotics because they mask the level of consciousness*** Passive hyperventilation on ventilator leads to respiratory alkalosis, which causes cerebral vasoconstriction and decreased cerebral blood flow, therefore decreasing ICP

Corticosteroids

Indications: autoimmune disorders, severe RA, hormone replacement therapy Adverse reactions: impaired wound healing, skin fragility, hyperglycemia, hirsutism, moon face, osteoporosis Wean slowly*** Weigh daily

Pericarditis

Inflammation of the outer lining of the heart Causes: MI, trauma, neoplasm, connective-tissue disease, heart surgery, infections Symptoms: sudden, sharp, severe pain aggravated by coughing or deep breathing and relieved by leaning forward, pericardial friction rub, fever Administer analgesics and anti-inflammatory drugs

Endocarditis

Inflammatory disease involving the inner surface of the heart, including the valves Causes: rheumatic heart disease, congenital heart disease, IV drug abuse, dental procedures Symptoms: murmurs, valvular stenosis or regurgitation, symptoms of HF, fever, chills, night sweats, arterial embolization Administer antibiotics IV for 4-6 weeks Inform dentist

Spinal cord injury

Injuries are described by location in the spinal cord Damage can range from contusion to complete transection Permanent impairment cannot be determined until spinal cord edema has subsided, usually by 1 week Physical assessment should concentrate on respiratory status, especially in clients with injury at C3 to C5, because the cervical plexus innervates the diaphragm Hypotension and bradycardia occur with any injury above T6 because sympathetic outflow is affected Maintain client in an extended position with cervical collar during any transfer High-dose corticosteriods are often given to help control edema during the first 8 to 24 hours Evaluate for spinal shock: a complete loss of all reflex, motor, sensory, and autonomic activity below the lesion; this is a medical emergency that occurs immediately after the injury! Symptoms include hypotension, bradycardia, complete paralysis, lack of sensation below lesion, bladder and bowel distention Evaluate for autonomic dysreflexia: exaggerated autonomic responses to stimuli Suction with caution to prevent vagus nerve stimulation, which can cause cardiac arrest A common cause of death after spinal cord injury is UTI - bacteria grow best in alkaline media, so keep urine dilute and acidic

Pacemaker

Instruct client to report pulse rate lower than set rate, avoid leaning over an automobile with the engine running, stand 4 to 5 feet away from electromagnetic sources (operating microwave overs), avoid MRI testing

Insulin

Insulin is prescribed in basal/bolus and correction factor therapy. Basal insulin (long-acting and intermediate-acting insulin) suppresses glucose production between meals and overnight. Bolus insulin or mealtime limits hyperglycemia after meals. Correction factor is the amount of insulin needed to correct hyperglycemia, usually given premeal. 1. Rapid-acting: human insulin lispro (Humalog), aspart (Novolog), glulisine (Apidra) Onset: 15-30 min (give within 15 min of meal***) Peak: 30-90 min Duration: 3-5 hr 2. Short-acting: regular insulin (Humulin R, Novolin R) [may be given IV] Onset: 30-60 min Peak: 2-3 hr Duration: 5-7 hr 3. Intermediate-acting: isophane insulin (Humulin N, Novolin N) Onset: 1-2 hr Peak: 4-6 hr Duration: 14-24 hr 4. Long-acting: glargine (Lantus), detemir (Levemir) [recommended to be given once daily subQ at bedtime; acts as basal insulin; do NOT mix with other insulins] Onset: 1 hr Peakless*** Duration 24 hr

Anticholinergics

Ipratropium (Atrovent); Tiotropium (Spiriva) Bronchodilator; control of rhinorrhea Adverse reactions: dry mouth, blurred visions, cough

Intestinal obstruction

Mechanical (volvulus, intussusception, hernia, adhesions); neurogenic (paralytic ileus); vascular (mesenteric artery occlusion) Symptoms: sudden onset of abdominal pain, tenderness, constipation altering with diarrhea, abdominal distention, anorexia, low-grade fever Client must remain NPO, with IV fluids and electrolyte therapy Foley catheter to monitor strict output Implement NG intubation, attach to low intermittent suction)

Addison disease (primary adrenocortical deficiency)

Medical emergency! Autoimmune process Characterized by lack of cortisol, aldosterone, and androgens Glucocorticoids (cortisol) influence ability to convert food fuels into energy, play a role in immune system's inflammatory response and help respond to stress Mineralocorticoids (aldosterone) maintain balance of sodium and potassium, BP Aldosterone regulates the balance of water and electrolytes in the body, encouraging the kidney to excrete potassium into the urine and retain sodium, thereby retaining water If ACTH production by the anterior pituitary has failed, it is considered secondary Addison disease Sudden withdrawal from corticosteriods may precipitate symptoms Symptoms: fatigue, weight loss, postural hypotension, hypoglycemia, hyponatremia (r/t lack of aldosterone), hyperkalemia, loss of body hair, hypovolemia, signs of shock Deficient fluid volume*** During Addison crisis, administer IV glucose with parenteral hydrocortisone, a steroid with both mineralocorticoid and glucocorticoid properties Maintain low-stress environment (patient cannot physiologically cope with stress) Lifelong hormone replacement High-sodium, low-potassium, high-carbohydrate diet; intake of 3 L/day Vascular collapse: administer IV fluids at a rapid rate Hypoglycemia: administer IV glucose Administer parenteral hydrocortisone to reverse crisis Aldosterone replacement: administer fludrocortison acetate (Florinef) PO with simultaneous salt (sodium chloride) administration

Osteoporosis

Metabolic disease in which bone demineralization results in decreased density and subsequent fractures POSTMENOPAUSAL WOMEN are at highest risk Classic dowager's hump or kyphosis of the dorsal spine; loss of height; back pain; pathologic fractures; compression fractures of the spine Encourage exercise, a diet high in CALCIUM and vitamin D, and supplemental calcium (Tums are an excellent source of calcium but they are also high in sodium) Hormone replacement therapy (HRT) has been used as a primary prevention strategy for reducing bone loss in the postmenopausal women; however, HRT may increase risk of breast cancer, CV disease, and stroke Biophosphonates ("dronate"): alendronate (Fosamax); inhibit osteoclast-mediated bone reabsorption, thereby increasing BMD

Abdominal aortic aneurysm

Most common symptom is abdominal pain or low back pain, with the complaint that the client can feel his or her heart beating Abdominal radiograph to confirm Symptoms of rupture: hypovolemic or cardiogenic shock with sudden, severe abdominal pain Assess peripheral pulses frequently

Valvular heart disease

Most commonly occurs on the left side of the heart (mitral valve) Causes: rheumatic fever, congenital heart disease, syphilis, endocarditis, HTN Instruct clients receiving valve replacement of the need for lifelong anticoagulant therapy; tissue (biologic) valves and autografts do not require lifelong anticoagulant therapy

hypotonic solution

Solute concentration is less than that inside the cell; cell gains water

Antianginals

Nitrates: nitroglycerin (NTG), isosorbide dinitrate (Isordil), isosorbide mononitrate (Imdur); anginal prophylaxis, acute attack; adverse effects include headache, flushing, dizziness, weakness, hypotension, and nausea; protect medication from light Beta blockers: propranolol HCl (Inderal), Atenolol (Tenormin), nadolol (Corgard), metoprolol (Toprol); anginal prophylaxis; monitor apical heart rate; do not stop medication abruptly; clients with HF, bronchitis, asthma, COPD or renal insufficiency have adverse reactions Calcium channel blockers: Verapamil, Procardia, Cardizem; anginal prophylaxis; monitor serum potassium; do not stop abruptly; adverse effects include dizziness hypotension, headache, syncope, hypokalemia, HF, and dysrhythmias

Pancreatitis

Nonbacterial inflammation of the pancreas; occurs when the pancreas is digested by its own enzymes, primarily trypsin Causes: alcohol ingestion, biliary tract disease*** Symptoms: severe, mid-epigastric pain radiating to back, rigid boardlike abdomen, elevated temperature, bluish discoloration of flanks and periumbilical area, elevated amylase, lipase, and glucose levels (hyperglycemia) Chronic pancreatitis has symptoms similar to diabetes mellitus Maintain NPO status Maintain NG tube to suction Administer TPN Administer hydromorphone (Dilaudid) or fentany Administer antacids, h-2 blockers, anticholinergics, PPIs Monitor blood sugar and administer insulin if needed Free fatty acids bind to calcium; monitor for neuromuscular manifestations of HYPOCALCEMIA (tetany, muscle twitching, cramping, spasm, seizure, and altered DTRs) Pain is located retroperitoneally; sitting up or leaning forward reduces the pain*** Administer pancreatic enzymes with meals or snacks (do not mix with proteins) Teach client to consume a bland, low-fat diet

Osteoarthritis (OA)

Noninflammatory arthritis; characterized by a degeneration of cartilage, a wear and tear process Joint pain that increases with activity and improves with rest; morning stiffness; ASYMMETRY of affected joints; crepitus; limited movement; joint enlargement and bony nodules Keep joints in functional position

Parathyroid gland

Normal serum calcium is 9.0 to 10.5 mEq/L The best indicator of parathyroid problems is a decrease in the client's calcium compared to the preoperative value If two or more parathyroid glands have been removed, the chance of tetany increases dramatically (HYPOCALCEMIA) Check for tingling of toes and fingers and around the mouth Twitching

O2 delivery

O2 must be humidified if given at >4 L/min or delivered directly to the trachea

Thrombocytopenia

Observe for signs of bleeding and monitor platelet counts

Acute renal failure (ARF)/ acute kidney injury (AKI)

Occurs when metabolites accumulate in the body and urinary output changes - may be reversible! Sodium and chloride are the primary extracellular ions; potassium and phosphate are the primary intracellular ions History of taking nephrotoxic drugs (salicylates, antibiotics, NSAIDs, ACE inhibitors, ARBs) Oliguric phase: increased BUN/creatinine; hyperkalemia; hyponatremia; acidosis; fluid overload; high urine specific gravity Diuretic phase: decreased fluid volume; hypokalemia; further hyponatremia; low urine specific gravity Monitor I&Os - give only enough fluids in oliguric phase to replace the losses (usually 400-500 mL/24 hr) Body weight is a good indicator of fluid retention and renal status***** Provide low protein, moderate fat, high carbohydrate diet

Insulin administration

Pinch skin Use 90 degree angle Rotate sites Draw regular insulin into syringe FIRST when mixing insulin (clear before cloudy)

Peripheral vascular disease // Arterial

Predisposing factors: arteriosclerosis, advanced age, Raynaud disease, Buerger disease, diabetes, acute occlusion Skin: smooth, shiny, loss of hair, thickened nails, dry, thin, cool Decreased or absent pulses Sharp pain that increases with walking and elevation Intermittent claudication relieved by rest Ulcers: very painful, small but deep, circular in shape, not edematous Treatment: elimination of smoking***, topical antibiotics, saline dressing, and bed rest Change positions frequently, wear non-restrictive clothing, avoid crossing legs or keeping legs in a dependent position, wear shoes

Peripheral vascular disease // Venous

Predisposing factors: history of DVT, valvular incompetence, varicose veins, thrombophlebitis, venous stasis ulcers Skin: warm, cyanotic when dependent Normal pulses Persistent, aching, full feeling, dull sensation Relieved when horizontal, nocturnal cramps Ulcers: weeping, uneven edges, superficial but large, marked edema, slightly painful Treatment: systemic antibiotics, compression dressing, limb elevation, fibrinolytic agents and anticoagulants for thrombosis Change positions frequently, wear non-restrictive clothing, avoid crossing legs or keeping legs in a dependent position, wear shoes

Cancer of the prostate

Rarely occurs rarely before 40 years of age, but it is the second leading cause of death from cancer in American men; high risk groups include those with a history of multiple sexual partners, STDs and certain viral infections

Right-sided HF

Results in peripheral congestion due to the inability of the right ventricle to pump blood out to the lungs (often results from left-sided failure or pulmonary disease) Symptoms: peripheral edema, weight gain, distended neck veins, nocturia, hepatomegaly, acites

Left-sided HF

Results in pulmonary congestion due to the inability of the left ventricle to pump blood to the periphery Symptoms: dyspnea, "wet" lung sounds, cough, fatigue, tachycardia

what does SBAR stand for?

S: Situation B: Background A: Assessment R: Recommendation

Fracture

Safety precautions: when using a nonwheeled walker, client should lift and move the walker forward and then take a step into it Therapeutic management is based on reduction of the fracture, maintenance of realignment by immobilization, and restoration of function 5 P's of neurovascular function: pain, paresthesia, pulse, pallor, and paralysis*** The risk for the development of a fat embolism is greatest in the first 36 hours of a fractures and is more common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis Throboembolism can be prevented with passive ROM exercises, use of elastic stockings, elevation of the foot of the bed, and low-dose heparin therapy Fractures of long bones predispose the client to anemia - monitor hematocrit levels

Dumping syndrome

Secondary to rapid entry of hypertonic food into jejunum (pulls water out of bloodstream), occurs 5 to 30 minutes after eating Characterized by vertigo, syncope, sweating, pallor, tachycardia, and/or hypotension Minimized by small, frequent meals Exacerbated by consuming liquids with meals, helped by lying down after eating

Lupus erythematosus

Systemic, autoimmune inflammatory connective-tissue disorder Discoid lupus erthematosus (DLE) affects skin only; dry, scaly rash on face or upper body (butterfly rash) Systemic lupus erthematosus (SLE) can cause major body organs and systems to fail; joint pain and decreased motility, fever, nephritis, pleural effusion, pericarditis, abdominal pain, photosensitivity, HTN Kidney involvement is the leading cause of death in clients with lupus*** Factors that trigger lupus: SUNLIGHT, stress, pregnancy, and drugs

Diabetes mellitus (DM)

Type 1: absolute insulin deficiency results from beta cell destruction Can become hyperglycemic and ketosis-prone easily DKA: precipitating factors include infection and inadequate control of glucose; serum glucose > 250, ketonuria in large amounts, arterial pH < 7.30, HCO3 < 15 mEq/L, Kussmaul's respirations; treated with fluid replacement*** isotonic IV fluids (0.9% NaCl solution) until BP stabilized and UO to 30-60 mL/hr, slow IV infusion of regular insulin (too rapid infusion of insulin can lead to cerebral edema!) Type 2: results from either inadequate production of insulin or lack of sensitivity to insulin being produced Rare development of ketoacidosis HHS: develops with extreme hyperglycemia; glucose > 600, dehydration, altered mental status, absent ketone bodies, plasma hyperosmolality; treatment with isotonic IV fluid replacement and careful monitoring of potassium and glucose levels; IV insulin given until blood glucose stabilizes at 250 mg/dL

Asthma

Unlike COPD, asthma is an intermittent disease with reversible airflow obstruction and wheezing

Administration of iron

Use Z-track method*** (to prevent staining the skin) Do not use deltoid muscle Do not massage injection site

Chest tubes

Used to remove or drain blood or air from the intrapleural space, to expand the lung after surgery, or to restore subatmospheric pressure to the thoracic cavity Keep all tubing coiled loosely below chest level Observe for air bubbling in the water seal chamber and fluctuations (tidaling) Do not strip or milk chest tubes Chest tubes are not clamped routinely. If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal If the chest tube is accidentally removed from the client, the nurse should cover with a dry sterile dressing Fluctuations (tidaling) in the fluid will occur if there is no external suction. These fluctuating movements are a good indicator that the system is intact; they should move upward with each inspiration and downward with each expiration. If fluctuations cease, check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client's position, because expanding lung tissue may be occluding the tube opening. When external suction is applied, the fluctuations cease.

cancer cachexia

Weight loss and wasting of body fat and muscle tissue; profound weakness, anorexia, and anemia

Brain tumor

Without treatment, benign as well as malignant tumors lead to death Symptoms include headache that is more severe on awakening, vomiting not associated with nausea, papilledema with visual changes, behavioral and personality changes, seizures, aphasia, hemiplegia, ataxia, cranial nerve dysfunction, and abnormal CT scan/ MRI Institute nursing interventions that are similar to those for increased ICP Elevate the HOB 30 to 45 degrees; maintain neutral head position Craniotomy preoperative medications: corticosteroids, osmotic diuretics (to reduce secretions), phenytoin, prophylactic antibiotics

what to alert to the HCP before a procedure about what a patient has eaten?

alert HCP about the use of garlic

what labs should be ordered after a pt gets hep a from contaminated food?

anti-hepatitis A virus immunoglobin M (anti-HAV IgM0

how to treat a knee meniscus injury?

apply a knee immobilizer to the affected leg

nursing intervention for epistaxis (nose bleeds)

apply direct pressure by squeezing the entire soft lower part of the nose together for 5-15 minutes

what to ask a patient with spinal pain complaint?

ask if they have neck pain in the clinic? ask about numbness or tingling in the arms

what to do with the family of an unconscious trauma patient with a head injury in the ER?

ask the family members if they would like to stay at bedside

1. Client who says they have a headache what do you ask them to assess the quality of pain

ask them to describe the type of pain

what to do after a patient had a stroke before giving them something to eat or drink?

assess gag reflex while the patient is in an upright position

what to assess for with a patient with a C-spine injury?

assess respiratory rate and effort

what to assess for in a patient with diarrhea?

assess the elasticity of their skin (bc they could be dehydrated)

how to assess if a patient can express secretions?

assess the patients cough effort

how to assess a patient post op day 1 from perineal resection due to colon cancer

assess wound for regularity and record bleeding, excess drainage, or odor

A male client who reports feeling chronically fatigued has a Hgb of 11.0 grams/dl, hematocrit of 34%, and microcytic and hypochromic red blood cells. Based on these findings, which dinner selection should the nurse suggest to the client? a) cheese pasta and a lettuce and tomato salad b) beef steak with steamed broccoli and orange slices c) broiled white fish with a baked sweet potato d) grilled shrimp and seasoned rice with asparagus salad

b) beef steak with steamed broccoli and orange slices

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the HCP? a) slight blood-tinged sputum b) dyspnea and dysphagia c) sore throat and hoarseness d) no gag reflex after thirty minutes

b) dyspnea and dysphagia

What does a DEXA scan measure?

bone mass density

what kind of breath sounds can you suction?

bronchial

how to prevent endocarditis in kids?

brush their teeth and visit the dentist regularly

how can restless leg syndrome (RLS) be prevented or reduced?

by exercising during the day

testicular cancer

cancer of the testicle, usually occurring in men 15 to 35 years of age

Ovarian cancer

cancerous tumor formed within ovary

right sided heart failure

causes swelling in extremities

CVAD

central venous access device

Hodgkin's lymphoma

chronic malignant disease of the lymph nodes

what temperature treatment is best for rheumatoid arthritis?

cold treatments

cancer of the cervix

common among women between the ages of 30 and 50. Risk factors include frequent cervical inflammation, sexually transmitted diseases, multiple pregnancies, and many sexual partners.

what to do when a patient comes in after a automobile accident, is tachycardia and has absent breath sounds over the right thorax?

connect the chest tube to suction

what is the isolation precautions for C-diff?

contact plus

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? a. Encourage frequent mouth care b. Cleanse the tongue and mouth with glycerin swabs c. Obtain a soft diet for the client d. Administer a topical analgesic per PRN protocol.

d. Administer a topical analgesic per PRN protocol.

metabolic acidosis

decreased pH in blood and body tissues as a result of an upset in metabolism

what's is the major difference between delirium and dementia?

delirium is sudden onset

Fluid Spacing

distribution of body water

what not to give a patient with a hemorrhagic stroke who has a severe headace?

do not give them aspirin or blood thinners

what would you include in a care plan for a patient with dementia?

reorientation

what is swan neck deformity a symptom of?

rheumatoid arthritis

what is the number 1 priority for a patient with parkinson's disease?

safety

how should a bed be positioned for a patient with dyspnea?

semi fowlers

1. Client who is reading normal sinus on tele but no spontaneous breathing and carotid pulse is 0

start compressions at 100 beat/min

how to treat course crackles on a patient?

suction if they are not able to cough it up

what to do if a patient cannot cough and expel secretions?

suction the patient

in what position should the patient be in when performing the straight leg raising test?

supine

pt with cirrhosis with jaundice and puritis, how should they bathe?

take cooler baths and put chamomile lotion on for relief

what to teach a patient about treating thrush pharyngitis?

teach pts to swish the preparation in their mouths without swallowing it

what to do if you see clear CSF?

test it for glucose

how is IBS different than a stomach bug?

the pain will last for at least 3 months

where on the body would you assess for a positive cullens sign?

the periumbilical area

which room should an elderly confused patient be assigned?

the room closest to the nurses station

post op morbid obeses patient, what should you worry about?

the wound edges seperating (dehiscence) is the biggest concern

how to know pt is going into hypovolemic shock? -what to do first to treat this patient?

they will be cool and clamy -initiate O2 therapy by non-rebreather

what is indicated if the patient has a LOC change?

this is an EMERGENCY (see this patient first)

how to position an obese patient with pneumonia?

turn to the left side if the pneumonia is on the right side

what to do for a Bell's palsy patinet during meal time?

understand that they cannot control their secretions and should eat in privacy

how to speak to a patient with lung cancer?

use therapeutic communication -open-ended questions like "tell me"

how to know when anaphylactic shock treatment is effective?

when the patients O2 sat increases

what to do with an ICU elderly patient with new onset confusion who is starting to go into ICU delirium?

-report this to the reciving nurse and continue to transfer the patient

which patient on ventilator weaning should the nurse be most concerned about?

-the pt who has recently been extubated with a decreased urinary output

how does the tongue and mouth appear if a patient has cancer of the larynx?

white, gray, dark brown or black, and may appear patchy

pt fell off a ladder and hit their head, they are offered acetaminophen but they want something stronger what do yo do?

tell them they cannot get an opioid bc they are waiting for results of CT scan -check pts pupils for dilation

which age groups are the most affected by pneumonia?

those 65 or older and infants under the age of 2 because their immune system is still developing

To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), what interventions should the nurse implement? a. initiate passive range of motion b. establish a regular routine c. teach the client breathing exercises d. perform chest physiotherapy e. encourage use of incentive spirometer

C, E

a patient with sepsis and petechiae is going into multiorgan failure, what is she at risk for?

DIC

where are bronchial breath sounds heard?

Over areas of density or consolidation

how to prioritize during CPR?

use CAB -Circulation -Airway -Breathing

how to manage a patient breathing over a vent?

verbally coach them

During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond? a. Ask for a demonstration of these exercises b. Explain that coughing should be avoided c. Review the client previous surgical history d. Document the clients understanding of teaching

a. Ask for a demonstration of these exercises

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Eating patterns and dietary intake b. Level and amount of physical activity c. Color and consistency of feces d. Presence and activity of bowel sounds

a. Eating patterns and dietary intake

The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease? a. Large waist circumference with central fat b. High serum insulin level c. Hyperpigmentation on neck skin folds d. Poor muscle tone

a. Large waist circumference with central fat

The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete? a. Manual dexterity and visual acuity b. Capillary refill time and radial pulse volume c. Deep tendon reflexes and skin color d. Skin elasticity and hand grip strength.

a. Manual dexterity and visual acuity

Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement? a. Patch one eye and then the other every few hours b. Encourage bedrest until the diplopia is resolved c. Instruct the client to limit intake of oral fluids d. Administer artificial tear drops to both eyes

a. Patch one eye and then the other every few hours

A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Schedule an appointment or the client to see the healthcare provider b. Advise the client to apply plastic wrap over the ointment to promote healing c. Instruct the client to continue the ointment until all erythema is relieved d. Explain the client need to complete all prescribed dose of the medication

a. Schedule an appointment or the client to see the healthcare provider

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium of 185 mEq/L b. Dry skin with inelastic turgor c. Apical rate of 110 beats/minute d. Polyuria and excessive thirst

a. Serum sodium of 185 mEq/L

1. Middle age man w/4 year old daughter and says he does not want any heroic act to save him youre the pallative care nurse. What's the priority

a. Take report on the patient b. Mark that they take no heroic effort on chart

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? a. Teach the client to elevate the head of the bed on blocks b. Remind the client to avoid high-fiber foods c. Encourage the client to lie down and rest after meals. d. Instruct the client to use antacids only as a last resort

a. Teach the client to elevate the head of the bed on blocks

1. Client with HF what kind of snack could they have

a. Unsalted almonds, apples

A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic? a. Elasticity of the skin b. Appearance of any moles c. Muscle aches and pains d. Pigmentation of the skin

b. Appearance of any moles

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? a. Cheese pasta and a lettuce and tomato salad b. Beef steak with steamed broccoli and orange slices c. Broiled white fish with a baked sweet potato d. Grilled shrimp and season rice with asparagus salad

b. Beef steak with steamed broccoli and orange slices

A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? a. Re-orient the client to his present location and circumstances b. Confirm that this is an effective technique to help with ambulation c. Assist the client to a carpeted area where he can walk more easily. Plan to assess the client's cognition after returning to his room.

b. Confirm that this is an effective technique to help with ambulation

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse. a. Strong foul-smelling flatus b. Gastroccult positive emesis c. Complaint of poor night vision d. Loose bowel movements

b. Gastroccult positive emesis

COPD patient with a head injury, be cautious when giving what med?

when giving opioids analgesics

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care? a. Provide assistive devices to empower client independence b. Implement measures to manage chronic pain c. Teach coping skills for living with a chronic illness d. Schedule rest periods between activates to minimize fatigue.

b. Implement measures to manage chronic pain

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? a. Black ulcers and dependent rubor b. Irregular ulcer shapes and severe edema c. Absent pedal pulses and shiny skin d. Hairless lower extremities and cool feet

b. Irregular ulcer shapes and sever edema

An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? a. IV pentamidine may offer protection to other AIDS-related conditions, such as Kaposi's sarcoma b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month c. IV pentamidine will be given until oral pentamidine can be tolerated d. AZT (Azidothymidine) therapy must be stopped when IV or aerosol pentamidine is being used.

b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? a. Glucose b. Platelet count c. White blood cell count d. Amylase

b. Platelet count

Two days following abdominal surgery a client c/o of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? a) encourage pt to ambulate b) offer ice chips or warm liquids c) auscultate abdomen d) assess temperature

c) Auscultate the client's abdomen

A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first? a. Teach the client about the importance of hydration b. Report the volume of emesis t the healthcare provider c. Administer ondansetron hydrochloride (Zofran) Encourage the client to limit the amount of move

c. Administer ondansetron hydrochloride (Zofran)

Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse's inspection the abdomen indicates slight distention. Which action should the nurse implement first? a. Encourage the client to ambulate b. Offer ice ships or warm liquids c. Auscultate the client's abdomen d. Assess the client's temperature

c. Auscultate the client's abdomen

A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? a. Teach client to use pursed lip breathing when episodes occur b. Assess client for signs and symptoms of upper airway infection c. Determine if the client is using an inhaler before exercising d. Review the client's routine asthma management prescriptions.

c. Determine if the client is using an inhaler before exercising

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? a. Continuous cardiac monitoring b. Perform passive range of motion c. Evaluate level of consciousness d. Assess lung sounds q4 hours.

c. Evaluate level of consciousness

1. A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? a. Consult with surgeon about increasing methadone in lieu of parenteral opioids. b. Use minimal parenteral opioids for surgical pain, in addition to oral methadone c. Maintain client's methadone, and medicate surgical pain based on pain rating d. Make no changes in the standard pain management for the surgery and hold methadone.

c. Maintain client's methadone, and medicate surgical pain based on pain rating

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? a. Assist with ambulation in the hallway b. Encourage active range of motion exercises c. Provide a bedside commode for toileting d. Teach to sleep in a slide-laying position

c. Provide a bedside commode for toileting

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? a. Teach a family member to administer eye drops b. Encourage deep breathing and coughing exercises c. Provide an eye shield to be worn while sleeping d. Obtain vital signs every 2 hours during hospitalization

c. Provide an eye shield to be worn while sleeping

An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor? a. Serum electrolytes b. Neutrophils and eosinophils c. Serum iron and ferritin d. Platelet count and hematocrit

c. Serum iron and ferritin

A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first a. Sevelamer (RenaGel) one tablet PO. b. Epoetin alfa, recombinant (Epogen) 2, 500 units SUBQ c. Sodium polystyrene (Kayexalate) 15 grams PO d. Calcium acetate (Phos-Lo) one tablet PO

c. Sodium polystyrene (Kayexalate) 15 grams PO

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements? a. Hard pellets of stool b. Clay-colored stool c. Stool with fatty streaks d. Blood in the stool

c. Stool with fatty streaks

A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation a. Low-sodium soups. b. Over all fluid intake c. Tea and hot chocolate d. Citrus fruit juices

c. Tea and hot chocolate

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply) a. Initiate passive range of motion exercises b. Establish a regular bladder routine c. Teach the client breathing exercises d. Perform chest physiotherapy e. Encourage use of incentive spirometer

c. Teach the client breathing exercises e. Encourage use of incentive spirometer

1. A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? a. Notify the healthcare provider b. Assure the client that such feelings occur with wound infections c. Visualize the abdominal incision d. Obtain sterile towels soaked in saline

c. Visualize the abdominal incision

A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide? a. Elevate the hands on two pillows at night b. Notify the healthcare provider as soon as possible c. Wear braces as both wriSts during the night d. Apply cold compresses for 30 min before bedtime

c. Wear braces as both wriSts during the night

A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which lab value is most important for the nurse to monitor following the procedure? a. Serum creatinine b. Blood urea nitrogen (BUN) c. White blood cell count d. Serum glucose

c. White blood cell count

1. The client says there are no risk of falls at home what to you do or they have never fallen at home what do you do?

continuous fall risk assessment

what to do if a chest tube is inadvertently dislodged from the client?

cover with a dry sterile dressing taped on three sides

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Auscultate for the presence of bowel sounds. b. Monitor hemoglobin and hematocrit c. Encourage turning and deep breathing d. Administer IV antibiotics as prescribed

d. Administer IV antibiotics as prescribed

Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement? a. Palpate the abdomen b. Measure hourly urine output c. Ambulate client in hallway d. Auscultate bowels sounds.

d. Auscultate bowels sounds.

The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? a. Uses only lactose-free dairy products. b. Enjoys fat free yogurt as an occasional snack food c. No longer includes grains in his daily diet d. Carefully cleans and peels all fresh fruit and vegetables

d. Carefully cleans and peels all fresh fruit and vegetables

An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first? a. Determine clients last dose of corticosteroids b. Determine neurological baseline prior to the fall c. Administer a PRN IV antiemetic as prescribed d. Complete head to toe neurological assessment.

d. Complete head to toe neurological assessment.

An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern? a. Encourage the family to offer to feed the client when she does not eat her entire meal. b. Suggest that the family bring foods from home that the client enjoys c. Explain that weight loss will be reversed after the acute phase of the stroke has ended. d. Demonstrate the use of visual scanning during meals to the client and family.

d. Demonstrate the use of visual scanning during meals to the client and family.

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse? a. Prepare for transcutaneous pacing b. Deliver another defibrillator shock c. Administer IV Epinephrine per ACLS protocol d. Give IV dose of adenosine rapidly over 1-2 seconds.

d. Give IV dose of adenosine rapidly over 1-2 seconds.

An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? a. Assist the lien tot a high Fowler's position in bed b. Observe the client for the presence of a barrel chest c. Prepare to transfer the client to a critical care unit d. Instruct the client to pursed lip breathing techniques

d. Instruct the client to pursed lip breathing techniques

When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider? a. Slight blood-tinged sputum b. Dyspnea and dysphagia c. Sore throat and hoarseness d. No gag reflex after thirty minutes

d. No gag reflex after thirty minutes

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. Glucose of 350 mg/dl b. White blood cell count of 15, 000 mm3 c. Blood PH of 7.30 d. Potassium of 2.5 mEq/L

d. Potassium of 2.5 mEq/L

1. The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan? a. Use a walker when weakness occurs b. Avoid extreme environmental temperatures c. Increase daily intake of sodium in diet d. Take prescribed cortisone accurately

d. Take prescribed cortisone accurately

A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse a. True urinary output of 50ml/hr b. Lower abdominal tenderness c. Blood urine output with clots d. Urine leaking around the meatus

d. Urine leaking around the meatus

A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series? a. Reports subjective symptom's during hemodialysis b. Documents his oral intake during dialysis treatments c. Demonstrates self-care of the arteriovenous (AV) Shunt d. Verbalizes understanding of the reasoning for dialysis

d. Verbalizes understanding of the reasoning for dialysis

pt w/ peripheral arterial disease pain in their legs at night

dangle their legs

1. P/t gouty arthritis in right knee what is the intervention

do not let them use the heating pad

what should people with COPD limit?

limit water

patient taking a medication for rheumatoid arthritis what should you look for in the patient?

look for signs of infection or fever

1. What kind of cough does a TB p/t have

mucopurulent

how to give an adult O2 greater than 4 L/min

must be humidified

1. A patient experiencing Phantom Limb you console them and calm them down, what meds do they need?

neuropathic medications

what to do when there is a Pediatric patient in hallway w/ mom and is yelling at p/t because patient had an accident in the hallway

provide a pull up and help calm the mom down

pt has urge incontinence, she had botox, what to teach?

teach her how to straight cath until botox wears off

1. Child in hospital in there for the fall and parents are worried hes regressing about potty training what should the nurse do?

tell parents they need to start potty training at home or to bring the potty chair to the hospital