NCLEX

creatinine levels

0.8-1.3

every 2.2 lbs of weight lost or gained = ? fluid

1 L

umbilical cord info

2 arteries: carry deoxygenated blood and waste FROM fetus 1 vein: oxygenated blood and oxygen and nutrients TO fetus

urinary output for kids

2 ml/kg/hr

1 kg = ? lbs

2.2

ratio of hydrogen ions to body fluid

20:1

wbc

4500-10,000

bun levels

8-21

continuous air bubbles in chamber c - what does that mean

•There is an air leak showing changes in intrathoracic pressure

condition that develops as a result of an inadequate amount of serum iron

anemia

joint commision is updated

annually

5 heart spaces

aortic, pulmonic, erbs points, tricuspid and mitral base at the top and apex on bottom

Which action would be most appropriate for preventing urinary tract infections in an elderly female client?

avoid tight fitting underwear (not void every 6 hours)

antidote for mag sulfate

calcium gluconate

when chest tube - when should a hcp be notified

if drainage is more than 70-100 ml/hr or if drainage becomes bright red or increases suddenly

outcomes of amniotomy

increased efficiency in contractions need frequet fetal heart rate monitor to detect presence of prolapsed cord

The plan of care for a client with hypertension taking propranolol hydrochloride should include:

instructing the client to notify the hcp if irreg or slowed pulse rate

isonic, hypotonic and hypertonic dehydration

iso: water and dissolved electrolytes are lost equally hypo: electrolyte loss is more

strategies used in health care delivery that reduce the costs of health care

managed care

A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding would support this diagnosis?

orthostatic blood pressure changes

what do the ovaries form and expell

ova

cranial nerves

page 184 & 185

what is used to confirm placenta previa

prepare for ultrasound

projectile vomitting can indicate what

pyloric stenosis or iicp

trach care how often to reduce risk fo infection

q 8 hours

tx for this

relieving the chronic constipation with stool softeners and rectal irrigations (many kids need surgery)

if opiod prescribed post surgery what do you assess

rr and pain relief every 30 minutes

what is quality of pain described as

sharp or dull

management of neuroblastoma

surgery

oxygen therapy - where does the ball aline

the middle of the ball with meter level

insensible water loss is

unaware of losing it

Who see first -sharp chest pain with sob and cough Lower back pain w hematuria - Elevated ST segment, troponin 2.0 and chest pain 10/10 - THIS IS HEART ATTACK. (over 0.4 is bad) SEE THIS FIRST Complaining of migraine with visual disturbances and bp of bp 190/90

(sharp cp with cough isn't emergent) SECOND BC WANT MORE INFORMATION THIRD

medication reconcilliation is

- chart that has all meds from home and make sure mirror what they are taking at home to what in hospital

therap range for digoxin

0.5-0.8

when does a kid start to see a dentist

1 year old

how amny hours of sleep does a preschooler get

12 hr

hyperbilirubinemia is when serum level is great than

12 mg.dl

hemoglobin men vs women

14-17 12-15 w

platelets

140,000-450,000

intake of liquids per day

2300-2900 mg/day

albumin levels

3.5-5.5

hematocrit for men vs women

41-51% 36-44%

hemorrhage is how many ml of blood

500 ml or more

prioritization steps

ABCs hierarchy of needs (self actualization, self esteem, love and belonging, security and safety, physiological needs) nursing process (assessment, diagnoses, plan, implement, evaluate)

A client believes she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about what symptom?

Tension and fatigure before menses and through the second day of mentsral cycle

fluid volume deficiet interesting fact

a client with ileostomy or colostomy

hyponatremia signs

ab cramping/weakness, lethargy, hadache and nausea

what is produced as the end product of metabolism

acids

what meds are prescribed for this

aspirin

respect for persons right to self determination

autonomy

assessment with parenteral nutrition

blood sugar, electrolyte levels, daily wt since large volume of fluid When get bag - look at order and ingredients

dressing changes and pain meds

can give them 30-60 min before

A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance?

decreae food high in k - k sparing diuretic

when inserting a peripheral catheter put the arm in

dependent postion bc veins will dilate due to gravity

tests to determine presence of antibodies to HIV

elisa (not used by itself) -> if reactive, repeat it -> then follow up with Western blot or IFA to confirm

when is breast milk used

first 6 months

A child underwent a tonsillectomy 4 hours ago. Which assessment finding should make the nurse suspect postoperative hemorrhage?

frequent swallowing

kid with cleft palate is at risk for developing

frquent otitis media

most bodily fluids are where

intracellular

what medication is given for alcohol withdrawl

lorzaepam (ativan)

nephroblastoma (wilms tumor) is

most common intraabdominal nad kidney tumor in kids

bacterial infections that extend to bladder and followed untreated uti

pyelonephritis

what happens to the lab results for iron def anemia

rbc are microcytic and hypochromic

who is at risk for low sodium levels

someone taking diuretics

heparin is injected where

subq of abs

Which finding would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning?

substernal retractions

interventions of newborn

suction mouth and nose dry and stimulate wrap in warm blankeys

what does PN consist of

tpn and ppn

unreliable method for glucose testing

urine glucose testing - only use this when kid is ill or when glucose level is consistently over 200

The nurse is caring for a client who is receiving parenteral nutrition. Which assessment is mostimportant for the nurse to make to detect early signs of metabolic complications?

urine output

how does parenteral nutrition supply nutrients

via the veins

what is key to do pre and post procedures

•ALWAYS GO BACK AND REASSESS VITALS BEFORE AND AFTER PROCEDURE

first sign of parkinsons

◦Pill-rolling, tremor resembles rotary motion; often first sign

how many g of protein are needed for wound healing

0.8 g/kg/day

level 1,2,3 disaster

1 - massive disaster 2 - moderate 3 - minor

when is weight loss regained for a baby

10-14 days after birth

how long seal things with lice

2 weeks

closure of cleft lip is performed when

3-6 months

how quickly give prbc

350 ml/unit (inc oxygen carrying capacity)

when do first lower teeth come in

6-10 months

developmental level of a 2 yr old - what do they observe -fork to eat -cup to drink -pours own milk -knife to eat

CUP TO DRINK - BY 2, CUP AND SPOON ARE USED 3-4=fork end of preschool- pour milk and knife

Patient had ab surgery and dishisence - what do first?

Help the pt lie with his head slightly elevated with knees bent When do an ab assessment, should bend their knees

when pts are experiecing acid and base imbalances what do u monitor

K levels

when receiving anticoagulants, what labs are monitored

PTT and PT

An infant is admitted to the hospital with dehydration secondary to viral gastroenteritis. Which room assignment is the most appropriate for this infant?

a private room

advocacy does what

assures the clients safety, health and rights

A client is receiving spironolactone to treat hypertension. Which instruction should the nurse provide?

avoid salt substitutes (this is a salt sparing diuretic)

decreasing discomfort on the right side when have a respiratory infection by

encouraging the child to lie on the right side

infection in the lining of the uterus during postpartum period

endometriosis

what provides concentrated and a stored form of energy

fatts

meq is

gram of medication contained in 1 ml of a solution

hepatitis d infection occurs in kids already infected with

hbv

voiding before sugery is done

immediatley before

sequence of solid foods for babies

iron fortified rice cereal, fruits, vegetables, meats 12 months - eggs

what should parents know about kids and conjunctivities wit school

kept home from school or day care until antibiotics have been administered for 24 hours

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

manual resus bag

can you heat formula bottles

no

if you see a co worker about to shoot up who do you call

nursing supervisor

perferred psoiton for pregnant mom

on her side to increase perfusion

what comes before pn is initiated (to try)

orally or NG tube

hytrin and sinemet drugs for parkinsons can cause

ortho hypo

ppn vs tpn

ppn is used as a supplement, enteral nutrition is when they are using a feeding tube. tpn iis used when this is the only source of nutrition

peripheral iv catheter is removed

q 72-96 hours and replace if needed to prevent an infection

Which statement describes the term fetal position?

relationship of the fetus presenting part to the mothers pelvis

insulin prescription says regular and nph insulin needed...

remember RN - draw regular first and then nph

The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia?

restlessness

early shock sign

restlessness

what to do to reduce respiratory distress

sit upright

when assessing for fundal ht - what is monitored

supine hypotension when in supinie position

lightening during labor

the is a mechanism of labor -aka dropping aka engagemtn

what is a poorly contracted uterus called

uterine atony

vitamin c and iron

vitamin c enhances iron absorption

how to assess Insufficient vascular perfusion

•cap refill, pulses, color, warmth

A client recovering from surgery needs to be ambulated in the room twice a day. For which reason should the nurse question the use of a gait belt when ambulating this client?

child coming back after ab surgery

post op a tonsilectomy or adenoidectomy

lie the kid prone or side lying to facilitate drainage -do not give the kid red, brown or purple liquids -avoid milk -do not give straws forks or sharp objects

The physician has prescribed amiodarone for a client with cardiomyopathy. The nurse should monitor the client's rhythm to determine the effectiveness of the medication in controlling:

life threatening ventricualr dysrhythmias

ages for newborn, infant, toddler, preschooler, schoolaged , adolescent

newborn: 0-4 weeks infant: 4 weeks -1 yr toddler - 12-24 months preschooler: 2-5 yrs school: 6-12 yr old adol: 13-19

The nurse is instructing the client with a new colostomy about protecting the skin around the colostomy. Which skin barrier should the nurse tell the client is best to apply around the colostomy?

adhesive skin barrier

what is the fastest growing regulatroy system

buffer systm

The caregiver of a 2-month-old client calls stating that the client is "fussy and has a runny nose." The caregiver states that the client has been sleeping poorly at night and is not eating as well. Which of the following interventions will the nurse teach the caregiver?

bulb syringe to suction out the nasal passages

a child with lactose intolerance can develop

calcium and vitamin d deficiency

rhonchi is heard with

chronic bronchitis (sounds like snoring)

lub dub action

closure of mitral and tricuspid valves = ventircular systole (lub aka s1) closure of aortic and pulmonic valves = ventricular diastole (relaxation) = s2

A client receives radiation implants into the prostate gland during an ambulatory care procedure. Which instruction should the nurse provide to the client before returning home?

condom for 2 weeks

conductive vs sensorineural hearing loss

conductive: physical obstriction to the transmission of sound waves sensorineural - defect in cochlea, eighth cranial nerve or the brain

important to hispanic and latin americans

confidentiality

ductus arteriosus does what

connects pulmonary artery to aorta - bypass LUNGS

strabismus aka

cross eye

botulism

death can occur within 24 hours spread thru air or food

lightening during pregnancy means

descent of the fetus towerd the pelvic inlet before labor

anthrax trasmission

direct contact with spores (carried by lymph nodes) can come with undercooked meat

autocratic leader

dominates the group

vegetarian deficiencies

energy vitamin b12 protein calcicium

how to prevent otitis media

feed infants upright to prevent reflux maintain immunizations encourage breast feeding fro 1st 6 months avoid exposire to tobacco and smoke

positive signs of preg

fetal heart rate detected at 10-12 weeks active movements are felt

assess skin turgor on babies ab assesses for

hydration status

0.9% ns is

isotonic

coordinated sequence of involuntary intermittent uterine contractions is known as

labor

orthopneic position is

leaning over a table

appendectomy post op

maintain npo status until bowel function has returned monitor temperature position the kid on right side lying or low to semi fowlers position

airborne precautions people wear

mask and respiraotry protection

The nurse is administering 2000 medications which include an anticoagulant and a stool softener. Which of the following should the nurse do FIRST before administering the medication?

match nme and dob to that on the order

station of the baby during labor

measurement of progress station 0 = ischial spine minus station = above ischial spine

methylergonovine maleate is

med for pp hemoorhage

can you use rule of nines on kids

no - kids the % of total body surface area is used

statuates that have been enacted by each state legislature to regulate the practice of nursing in that state

nursing practice act

if you are assigned a patient that is not in your practice and no one is listening who do you go to for help

nursing supervisor

foramen ovale is

opening bt the riht and left atria of the heart - bypassing the lungs

when have threatened abortion - do you have strict bedrest

no

does insulin cross the placenta

no - only maternal glucose (fetus produces own insulin)

signs of dehydration with patients with heart disease

nonelastic skin turgor dry mucus membranes decreased tear production dry mucus mebranes decreased urine output CONCENTRATED URINE

Pica refers to

nonfood substances eaten by preg moms

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what?

nonmalefience (do no harm) - not informed consent

obligation to do or cause no harm to naother

nonmalenficience

episodic accelerations from a baby is

normal

qod, ms or mso4, mgso4

qod - every other day ms - morphine mgso4 - magnesium sulfate

blood gas values - ph, po2, pco2, hco3

ph: 7.35-7.45 po2: 80-100 pco2 - 35-45 hco3 - 22-28

how to prevent the spread of viral hepatitis

proper hand washing and standard precautions

pt fell, nurse fills out incident report...then what

reassess patient

receptive vs expressive aphasia

receptive: cant comprehend verbal or written communication expressive: cant articulate words but can understand

The nurse needs to assess an infant's height to determine if the infant is meeting appropriate growth and development parameters. To obtain the most accurate measurement of an infant's height (length), the nurse measures the:

recombent height with infant supine

effects of respiratory, gi, integumentary, reproductive systems

respiratory: emphysema and atelectasis occur in airways gi: meconium ileus in newborns are the earliest manifestation integumen: high na and chloride in sweat reproductive: delay puberty in girls effects pancreas - pancreatic enzyme deficiency

largest single fluid constituent of the body is

water

bmi calculated by

wt (kg) / height in m squared

pregnancy infections (torch)

t - toxoplasmosis - get from raw meat or handling liter boxes o- other infections like hiv or stds r-rubella c- cytomegalovirus h- herpes (give acyclovir)

early sign of hf

tachycardia

dehydration vitals

tachycardia, hyperthermia, hypotension (same as fluid volume deficiet)

Ibuprofen is prescribed for a client with osteoarthritis. Which instruction about ibuprofen should the nurse include in the client's teaching plan?

take food with it or antacids

Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. What should the nurse instruct the client to do?

take nitroglycerin tablet befroe going up the steps

A client is scheduled for an EEG after having a seizure for the first time. Client preparation for this test should include which instruction? You Selected:

"Avoid stimulants and alcohol for 24 to 48 hours before the test."

A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to carry it out and pleads with the nurse not to tell anyone. What is the nurse's best response?

"For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe.

foods for hypoglycemia

1/2 c of oj 8 oz of milk 2 or 3 glucose tablets 4 sugar cubes 1 tsp of honey

The nurse notes the discontinuation of a prescription for total parenteral nutrition (TPN), which a client has been receiving for 2 weeks. Which type of intravenous fluid does the nurse expect to be prescribed for this client?

10% dextrose

Before surgery, a neonate is to receive an IM injection of an antibiotic. Which gauge and size of needle should the nurse select?

25 and 5/8

A client with acute lymphocytic leukemia is receiving vincristine. Prior to infusing the drug, the nurse administers diphenhydramine. What should the nurse tell the client about the purpose of taking diphenhydramine?

Diphenhydramine decreases incidence of a reaction to the vincristine.

tb is transported how

airborne tb test - safe during pregnancy

medications for gerd

antacids for symptom relief, proton pump inhbiors and histamine 2 receptor antagonists to decrease gastric acid secretion

when do parents give th iron supplements

between meals for maximal absorption - give with multivitamin or fruit juice because vitamin c increases absorption

what can and cant pass thru the placenta

can: nutrients, meds, alcohol, antibodies and viruses cant: bacteria and large particles

when membranes rupture, assess for

fhr because risk of prolapsed cord and assess color of fluid

causes of cleft lip

herediatry and envt factors

episiotomy is

incision ********** to make the coochie bigger

what part of the body plays a major role in regulating fluid and electrolyte balance

kidneys

who is less likely to get epiglottitis

kids with hib immunization - occurs in the winter

sounds of healthy lung tissue

resonance

leveling of meds for continuous drugs - vasoactive drugs (titrated and not)

-vasoactive if they are titrated in ICU that is the only place u can titrate them becaue need 2:1 ratio and need to see monitor and have the equipment when titrating -NOT TITRATED AND JUST DRIP- can be in intermediate step down

when are apgar scores calculated

1 min and 5 min and 10 min if needed

how many ml/hour is concerning for u/o

<30 ml/hr for more than 2 hours

preterm labor is when

after the 20th week but before 37th week

white people health issues

cancer heart disese diabetes obesity

increasing and decreasing light and pupils

decreased = pupul dilation

what to check for when giving fat emulsions (lipids)

egg youlk allergy

communication for school aged children

establish limits, use photos books dolls or videos to explain procedures

rigors when

have fever

hepatitis is

inflamation of the liver that may be caused by a virus, a med reaction or another disease processs

kohlbergs theory of development is

moral development

pleural friction rub is heard during

pleurisy (inflammation of pleural space)

suction control chamber

provides negative pressure to the chest gentle bubbling = there is suction (pg 250)

early sign of iicp

vomitting

labeling lab specimen

•Initials, date, time, pt label •Before labeling: at the bedside and ask name and dob as labeling

what should b checked after amniotomy

fetal heart rate

fundal ht is measured to evaluate

gestational age of the fetus cm = fetal age in weeks plus or minus 2

sbar stands for

situation background assessment reccomendations

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?

limiting fluid intake

hypermagnesia signs

neurological depression (drowsiness, sedatio, lethargy resp depression, muscle weakness and areflexia)

nursing action when cord coming thru vagina

place client in trendenlenbrg

aspirin is taken daily for who

to prevent dvt and pe and cardiac patients

The nurse is helping to prepare a client for nonemergency surgery. What should the nurse do?

verify the client understand the informed consent form

steroids increase what

wbc count and glucose

What are we looking for with anticoags

- 1.5-2x the normal is what we like to have them be on when on anticoags

what to assess on a patient with CHF

- weight for fluid volume, lung sounds and wob, cardiac assessment (ejection fraction - stage of chf they are in), gold standard: BNP (anything >100 = chf)

What is the best nursing response to a client who is experiencing an acute myocardial infarction (MI) and asks why the nurse is administering intravenous morphine?

-"Morphine decreases the heart's need for oxygen and also makes your heart not work as hard."

amniotic fluid does what

-800-1200 ml of fluid by end of preg--surrounds, cushions and protects fetus and allows for movement -body temp -used to measure fetal kidney function

nurse is preparing to adminster meds thru ng tube - what actions should be taken before giving meds

-check residual volume -aspirate stomach contents -turn off suction of ng tube -test stomach ph acidity

A nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching

-if my breasts are uncom, ill limit tie I spend breast feeding

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse?

-soft and seedy stool are normal for this age and thru breastfeeding

what do pregnant people that are obese need

-subq shots of heparin throboembolism socks

maximum amount to do an im injection

.5 ml

standard medication doses for children are rounded to nearest

0.1 (tenth)

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than

0.5 An FO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air F IO 2 0.18 to 0.21.

The nurse prepares to administer the prescribed aspirin to a client. Which client conditions cause the nurse to hold the medication? (Select all that apply.) ANSWER SELECTION 1. The client has a history of being in multiple alcohol treatment programs. 2. The client is receiving heparin for the presence of deep vein thrombosis. 3. The client experiences severe pain related to a diagnosis of osteoarthritis. 4. The client takes an oral hypoglycemic for treatment of type 2 diabetes mellitus. 5. The client has a recent history of a respiratory infection and elevated temperature.

1,2,4

postpartum temps for mom

100.4 is normal in first 24 hours because of dehydration after 24 hours -> infection

what injection is known to decrease risk of preterm delivery

17p

the physician orders a chest tube to be clamped for 4 hours to determine pt readiness fro tube removal. 10 min go by and the patient went to 89% sat. firs thting to do -apply 2l nasal cannula Unclamp chest tube Call RRT (rapid response) Increase HOB to 30 degrees

2 - *** since this was the first change and they tolerated for a lil 2nd option = code - rrt is before code

when is daytime nap stopped

3

1 oz = ? ml

30

how many words are known by 2 years old

300 words

reaction of how many mm is considered positive for tb

5 mm or more

when are solid foods introduced

5-6 months of age, introduce solid foods one at a time over 4- 5 days

A man weighs 165 pounds and is being treated for acute decompensated heart failure. The nurse is preparing a milrinone (Primacor) infusion to start at 0.25 mcgs/kg/min. The nurse has prepared the following to infuse: milrinone 20 mg in 100mL of normal saline? At what rate of infusion will the nurse set the pump to deliver the prescribed dose of milrinone?

5.625 ml/hr

A nurse is caring for a client who is prescribed 1 unit of regular insulin for every 6 g of carbohydrates consumed at mealtime and 1 unit of regular insulin for every 30 mg/dL increase of blood sugar above 130 mg/dL. For lunch, the client ate a hamburger bun (20 g carbohydrates), a 3-oz burger (10 g carbohydrates), and a 12-oz diet soda (0 g carbohydrates). The client's blood sugar is now 190 mg/dL. How much total insulin will the nurse administer? Record your answer using a whole number.

7 According to the guidelines, 30 g carbohydrates/6 = 5 units regular insulin blood sugar 190-130 = 60 mg above 1 unit for each 30 mg/dl elevation = 2 5 + 2 = 7 units of regular insulin. It is important to calculate the required insulin to be given as a corrective dose with each meal

blood pressure cuff should be surrounding

80% of arm circumference

A nurse is teaching the parents of a 6-month-old infant about usual growth and development. Which statements about infant development are true? Select all that apply.

A 6-month-old infant can usually roll from prone to supine and supine to prone positions. A teething ring is appropriate for a 6-month-old infant. Lack of visual coordination usually resolves by age 6 months.

A 29-year-old multigravida at 37 weeks' gestation is being treated for severe preeclampsia and has magnesium sulfate infusing at 3 g/h. What is the priority intervention to maintain safety for this client?

Assess reflexes, clonus, visual disturbances, and headache.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?

Contractions will be stronger and more uncomfortable and will peak more abruptly.

maternal condition where clotting cascade is activated

DIC

Ventricular tachy - is the patient profusing those beats?

Sometimes! Some are conscious in vtach bc expect them not to be - sometimes have pulse Start code on patient right away First thing do after call code - compressions if no pulse

When interviewing the parents of an injured child, which sign is the strongest indicator that child abuse may be a problem?

The injury isn't consistent with the child's history or age.

The nurse is assessing a client with viral meningitis. Which of the following findings would the nurse expect to observe? Select all that apply. a)nausea b)vomiting c)piloerection (goose bumps) d)bradycardia e)photophobia

a, b, e

find a fire - first thing you do

activate the fire alarm

what is tpa

clot buster (tpa is for strokes and theirs hemorrhagic vs clot stroke)

most appropriate activity for a 5 year old

crayons and coloring book radio and sports video - adolescent large picture books - infant

what causes folic acid deficient

crohns and methotrexate

2 types of iv fluid

crystalloids (isotonic, hypotonic, hypertonic), colloids aka plasma expanders (albumin, hespan, ffp, prbc)

interventions to help infants and toddlers in the hospital

cudling and otuching and talking softly provide routines and rituals close to what used to at home

A client has atrial fibrillation. The nurse should monitor the client for which condition?

cva

skin colors: cyanosis, erythema, pallor, jaundice

cyan: blue erythema: red pallor: white jaundice: yellow

copd patients and their diaphram on a cxr

diaphram is flat

bacterial form of croup is

epiglottitis

A healthcare provider (HCP) has prescribed valproic acid for a client with bipolar disorder who has achieved limited success with lithium carbonate. Which information should the nurse teach the client about taking valproic acid?

follow up blood tests are neccesary

osmotic pressure

force that draws the solvent from a less concentrated solute to a more concentration

medication reconciliation is

form mandatory so when a pt gets admitted that asks drug on at home, dose, how often they get and we match in hospital

What position should the nurse use for the client with peripheral arterial disease (PAD) to enhance blood supply?

fowlers with lower extremities in neutral position

pediculosis capitis aka

lice

Agnosia

loss of comprehension of audiotiry, visual or other sensations

syncope means

loss of consciousness

post op complication and intervention: hemmorhage

loss of large amounts of blood in short time pressure and then notify

what happens to diet with alcohol use disorder

low protein and thiamin

client is being positioned for a thoracentesis - how position

lying in bed on the unaffected side

An adolescent presents with a large round ring with a swollen border on the left arm. The adolescent often plays ball games in a field behind the school. What condition does the nurse suspect?

lyme disease

A child, age 5, is diagnosed with chronic renal failure. When teaching the parents about diet therapy, the nurse should instruct them to restrict which foods from the child's diet?

measts (hgih protein)

caliborated syringe is for

meds to kids

what drug is avoided w sickle cell anemia

meperidine for pain because can put client at risk for normeperidine-induced seizures

if someone has severe diarrhea what do you monitor for with acid and base

metabolic acidosis

what is the folic acid antagonist for ectopic pregnancy

methotrexate

unit of measurement that expressesthe combining activity of an electrolyte

milliequivalent (meq)

tpn vsreg fluids

more sugar

bolus feed resembles

normal meal feeding patterns - administered over 30-60 min

hospitalized adolescent seperation anxiety

not sure whether they want parents with them, get upset if friends exclude them - seperation from friends is source of anxiety

The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem

notify the hcp

paralysis of both lower limbs

paraplegia

chronic, progressive, neurodegenerative presented with tremor at rest, and increased muscle tone

parkinsons

wht is it when there is an improper implant in the lower uterine segment near or over the internal vervical o

placenta previa

what is the form of nutrition when there is no other alternative

pn

symptoms of CF

pnacreatic enzyme deficiency and pancreatic fibrosis, progressive chronic lung disease and sweat gland dysfunction

excretion

removed from the body

hyperventilating is a result of

resp alkalosis

hypertonic solutions to peripheral veins can cause

sclerosis (stiffening of tissues), phlebitis or swelling

stages of cognitive developemnt

sensorimotor (birth to 2), preoperational (2-7), concrete (7-11), formal operations (11-adulthood)

A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolbutamide. Which laboratory test is the most important for confirming this disorder?

serum osmolarity

The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply.

serum troponin and myoglobin

icreased icp vs shcok

shock: decrease bp, increase pulse, increase rr cushings triad: increased bp, decreased pulse and decrease rr

bradykinesia

slow movement

interventions with amish people

speak to both husband and wife or unmarried women and her father for health care decisions

Given the following information which of the following actions should the nurse perform FIRST? A.Administer Tylenol B.Increase the flow of oxygen via nasal cannula C.Call for a rapid response team (fever, elevated hr and low bp)

spetic shock so b

what to do if trach is dislodged

spread the opening by grasping the retention sutures

Autonomic dysreflexia

sudden increase in bp

palpable vibrations aka

thrills

what to monitor for when mom on mag sulfate

toxicity signs - call hcp if rr <12

freuds level of awareness

unconscious, preconscious(subconscious), conscious

if urine specimen and antibiotic - which do u do first

urine speciment

what is the best place to put an im injection in baby

vastus lateralus or ventrougluteal bc big muscles

obligation to tell the truth

veracity (city and the truth)

To follow standard precautions, the nurse should carry out which measure?

wear gloves when giving IM meds

what is used to prevent maternal to neonata hiv transmission

zidovudine

renal function of older people

•Decline in renal function •Decrease in GFR •Prolonged half-life of medication (not cleared as fast) •NEED creatinine clearance (can be calculated) •http://nephron.com/cgi-bin/CGSI.cgi •Baroreceptor reflex response •Decreases with age •Orthostatic hypotension Not cleared fast so could retain and can have too much drug in body - that's why doses are lower usually Creatinine clearance - function pt has Baro - helps regulate bp (since dereaess, cant sense changes from lying to sitting quick enough and have more orthohypotensive)

what to do with transfusion rxn

•Stop transfusion •Change IV to normal saline •Notify HCP and blood bank •Stay with client- VS every 5 minutes •Emergency meds •Labs drawn - need to draw blood to see what kind of rxn is happening •Documentation

Central venous pressure - measures?

•measures pressure of right atrium •Why measure this? Helps us with fluid volume in patient (for dehydrated or overloaded)

medication therapy for parkinsons is aimed at

◦Aimed at correcting imbalance of neurotransmitters in brain-dopamine

heart failure signs

--heart cant pump enough blood to meet the needs of the body tachycardia tachypnea profuse scalp diaphoresis fatigue and irritability weight gain (usually 1 lb in 1 day caused by fluid accumulation)

post op this surgery parents hsould know

-kids cant blow nose for 7-10 days after -if he tubes fall out - it isnt an emergncy but tell the hcp

rubella titer is asked to be given to pregnant mom before discharge - info to tell

-pregnancy avoided for 1-3 months -vaccine is subq -exposure to immunosuppressed ppl -hypersensitivity rxn can occur with ppl to egg allergys

stridor wheezing and crowing sound means... vs crackles or rhonchi

1 - partial obstruction, brocho or laryngospasm 2- pulmonary edema

stage 1 -unstageable pressure ulcer

1 - unblanchable erythema 2 - blister, cut or superficial opening area 3 - full thickness, damage to subq area 4 - damage to muscle/tissue necrosis unstageable - full thickness/tissue loss

The nurse performs a health history assessment for a client in high school. Which statement by the client prompts the nurse to intervene due to safety concerns? (Select all that apply.) ANSWER SELECTION 1. "It is really exciting that my best friend has a car and driver's license." 2. "Both my parents have evening jobs, so I frequently eat out for my dinner." 3. "I like to hang around with my friends on the weekend and play video games." 4. "There is a kid at school who constantly bullies me. I cannot stand it anymore." 5. "My parents seem to understand that I am older and need more independence."

1 and 4

During surgery, a client develops sinus bradycardia. The physician orders atropine sulfate. Which dose and route should the nurse use?

1 mg IV

Which questions will assist the nurse in identifying and planning culturally sensitive care when conducting an initial health history and physical assessment for a newly admitted client? (Select all that apply.) "What is your ethnicity or cultural background?" "What is your preferred identification pronoun?" "What symptoms caused you to seek medical care?" "How will your beliefs affect your medical treatment choices?" "Can you tell me about previous hospitalizations and illnesses?" "Who is the family member who makes decisions for your family?"

1,2,4,6 CORRECT - Asking about a client's ethnicity or cultural background will aid in providing culturally sensitive care. However, the nurse needs to be aware that not all persons of a specific culture will always practice the same practices, and that further assessment is needed. CORRECT - When caring for clients that belong to the lesbian, gay, bisexual, and transgender (LGBT) community, it is important for the nurse to ascertain by which identification pronoun (i.e., he, she, other) the client wishes to be addressed. Failure to address the client according to client wishes will be a source of discomfort. Inquiring about the symptoms that caused the client to seek medical care is not a cultural based assessment. The nurse should make this assessment for all clients. CORRECT - In order to provide culturally sensitive care, the nurse must be aware of how beliefs will affect a client's medical treatment choices. Learning about the client's previous hospitalizations and illnesses will not provide information that will support culturally sensitive care. CORRECT - In some cultures, a specific family member is responsible for making decisions for the family. The role may also include medical decisions. Therefore, it is important for the nurse to address the appropriate family member.

The nurse performs a physical assessment on a client admitted for notable weight loss related to a reluctance to eat. Which assessment finding will provide the nurse with the best insight to the client's condition? The client has a slight hand tremor related to Parkinson disease. The client has missing teeth and multiple cavities with an abscess. The client expresses a dislike for cooking and cleaning up afterward. The client has unidentified allergies and is unaware of foods to avoid.

2

The nurse provides care for a client admitted with a diagnosis of sepsis. Which assessment data does the nurse recognize as the early development of systemic inflammatory response syndrome (SIRS) when providing client care? Blood glucose level rises from 180 mg/dL (9.99 mmol/L) to 220 mg/dL (12.2 mmol/L) in one hour. Temperature is 101°F (38.3°C), pulse is 98 beats/minute, and respirations are 26 breaths/minute. Bleeding from IV sites and body orifices indicating disseminated intravascular coagulation (DIC). Hourly urinary output continues to decrease, and last urinary output assessment indicates 5 mL/hour.

2 - The criteria for sepsis with SIRS can include a temperature of more than 101°F (38.3°C) or less than 96.8°F (36°C). Other indicators of SIRS is a pulse greater than 90 beats/minute, and a respiratory rate greater than 20 breaths/minute.

A client is treated in the emergency department for an anaphylactic reaction and receives two doses of epinephrine. The client's medical health history indicates that the client takes human regular insulin for a diagnosis of diabetes mellitus. Which action is most appropriate if the client begins to exhibit restlessness, irritability, diaphoresis, and tremors? ANSWER SELECTION Administer a prescribed dose of lorazepam for anxiety. Obtain a blood glucose level to determine hypoglycemia. Initiate safety measures to prevent injury related to restlessness. Use therapeutic communication techniques to decrease irritability.

2 The nurse should recognize the client's collective symptoms as an indication of hypoglycemia. Therefore, it is most appropriate to obtain a blood glucose level and respond accordingly. The nurse must remember that epinephrine is a drug that will antagonize hypoglycemic effects. Other drugs to consider are corticosteroids and thyroid hormones.

how many servings of milk a day for todders

2-3 servgings or 700-800 ml

avg expected weight gain during preg / calorie increase

25-35 lbs 300 cals a day 500 cals a day for lactation period

normal osmolality of plasma is

275-295

A client, diagnosed with Graves disease, is prescribed propylthiouracil (PTU). Which existing client condition causes the nurse to contact the prescribing health care provider before giving the initial dose of PTU? ANSWER SELECTION The client exhibits slurred speech when talking to the nurse. The client's baseline blood pressure is indicative of hypertension. The client takes an anticoagulant for a diagnosis of atrial fibrillation. The client requests extra blankets and increased room temperature.

3

The nurse provides care for a client diagnosed with tuberculosis (TB). Which information does the nurse consider when determining if the client's treatment is effective? ANSWER SELECTION The client has been on a regimen of isoniazid (INH) for 7 days. The client's chest x-ray is clear and without the presence of lesions. The client's sputum culture is negative after 3 months of medication. The client no longer has a cough that produces blood streaked mucus.

3

The nurse assesses vital signs for multiple clients. Which assessment and client condition will cause the nurse the most concern? ANSWER SELECTION The postoperative client medicated 3 hours prior for pain with a blood pressure of 194/88 mm Hg. The older adult client diagnosed with bacterial pneumonia with a temperature of 100.8°F (38.2°C). The adult client receiving patient controlled administration of morphine who has a respiratory rate of 9 breaths/minute. The adult client admitted through the ED following a car accident with a pulse rate of 92 beats/minute.

3 - Morphine is a narcotic drug used for pain control. One adverse effect of morphine is respiratory suppression. A respiratory rate of 9 breaths/minute is low and the nurse should be most concerned about this client. The client may need to have the dosage of morphine decreased or have the time between doses increased.

what is used to confirm gestational diabetes

3 hour oral glucose test -maintain blood glucose between 65 - 130

A nurse is planning staffing for a nursing unit in which the primary need of the clients is learning how to manage their health problems. Which combination is the ideal mix of staff for this unit?

3 rns

urinary ouput post surgery should be

30ml/hr - expect them to void eithin 6-8 hours and make sure it is 200 ml

A client is to receive 100 mg of cefazolin following an open reduction and internal fixation for repair of a fractured femur. The pharmacy has sent 100 mg of cefazolin in 50 ml of dextrose. The medication is to be administered over 30 minutes. Calculate the drip rate (gtt/min) using a set with a drop factor of 20 gtt/ml. Record your answer using a whole number.

33

normal blood glucose for babies

40-60 in 1 day old 50-90 in older

how long hold off on solid food and liquid before general anesthesia

6-8 hours and 3 hours before surgery with local anesthesia

The nurse is caring for a client who has a prescription for lactated Ringer's solution 1,000 mL, IV, to be infused over 24 hours. The nurse has tubing with a drop factor of 12 gtt/mL available. How many gtt/min should the nurse administer to the client? Record your answer using a whole number.

8 drops (ml/min * drop factor)

cd-4 levels

800-1200 for HIV if <500 - immunosuppressed <200 = AIDS

when planning care for a group of clients, the nurse notes that which client is most susceptible to infection?

86 year old with burns from heating pad

how long is isoniazid needed to be taken for tb

9 months

A client with a positive skin test for tuberculosis (TB) is not showing signs of active disease and is being treated with isoniazid, 300 mg daily. The nurse explains to the client that the medication should be taken for

9-12 months

fetal brady and tachy and what to do about it

< 110/bpm >160 if this happens: change position of mom, give o2 and assess mothers vital signs

The nurse providing care for clients with diabetes mellitus receives report. Which client does the nurse see first? A female client who reports urinary frequency and burning with urination. A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch. A client with a BP of 120/50 mm Hg and who reports frequent urination and thirst. A client who reports experiencing constant hunger.

A client with a BP of 90/60 mm Hg and whose skin is hot and dry to touch. (Correct Answer) The lower blood pressure and hot, dry skin indicate dehydration caused by hyperglycemia. This is the first stage of diabetic ketoacidosis (DKA). This client has a circulatory concern and is the highest priority.

A client is discharged home following treatment in an acute care facility for emboli in the lower extremities. The client is directed about how to take a prescribed anticoagulant. Which home management instructions does the nurse include for this client? (Select all that apply.) 1. Refrain from contact sports. 2. Do not sit with crossed legs. 3. Use a soft bristle toothbrush. 4. Avoid tight or restrictive clothing on legs. 5. Avoid contact with pets that bite or scratch. 6. Report swelling or pain in lower extremities.

CORRECT - A client on anticoagulant therapy should refrain from contact sports, or any activity that can cause bumps and/or bruising. CORRECT - A client with a history of emboli in the lower extremities should avoid sitting with crossed legs. This position hinders circulation, causes swelling, and can contribute to clot formation, even when on anticoagulant therapy. CORRECT - A client on anticoagulant therapy needs to use a soft bristle toothbrush to prevent bleeding gums. CORRECT - A client with a history of emboli in the lower extremities should avoid tight or restrictive clothing on the legs. Prevention of emboli due to hindered circulation, even while on anticoagulant therapy, is important. CORRECT - A client on anticoagulant therapy needs to avoid any situation that creates a danger for the skin being broken. Pets that bite or scratch should be avoided to prevent bleeding. CORRECT - A client with a history of emboli in the lower extremities needs to be aware that swelling or pain can be indicative of new clot formation. The client needs to be aware even while on anticoagulant therapy.

A client is being treated for heart failure with diuretic therapy. Which of the following assessments BEST indicates to the nurse that the client's condition is improving? a)The client's weight has remained stable since admission b)The client's systolic blood pressure has decreased c)There are fewer crackles heard when auscultating the client's lungs d)The client's urinary output is 1,500 mL per day

HEART FAILURE : WATER WEIGHT IS KEY Blood pressures oft hese patients are high since fluid overload Heart failure pt have crackles in lung - but have rt and left failure and don't know 1500 is normal - we would want to see 3000 ml (800 to 2000 is normal)

The nurse reviews telephone messages in the pediatric clinic. Which message will the nurse return first? Parent states the extremities of a 2-day-old client extend and return to the previous position when the crib is bumped. Parent states that the circumcision site of a 3-day-old client is covered with yellowish exudate. Parent states that a 4-day-old client who is formula fed has had one stool per day for the past 2 days. Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red.

Parent states that the umbilical cord stump of a 5-day-old client is moist at the base and slightly red. (Correct Answer) A moist and red umbilical cord stump in a client of this age indicates an infection or other problem with the umbilical stump. The cord should be dry and without redness. fromula fed is 1 stool a day, breast feeding is 3-5 days

An elderly non-English speaking woman is being admitted to the hospital with worrisome symptoms. She is accompanied by family members who speak English. The nurse admitting the client needs to ask some general questions. It would be MOST appropriate for the nurse to take which of the following actions? a)Call the hospital's interpreter services to assist in asking the client questions in her native language. b)Ask family members the questions and document their responses. c)Ask family members to translate and ask the questions for the nurse. d)Document "Unable to obtain response due to language barrier".

a

A little daily practice goes a long way. The nurse in labor and delivery provides care for a client who is Muslim and in active labor. The client's labor is long and difficult. Which cultural practice will the nurse expect after the birth? The parents will pin an amulet with a blue stone to the neonate's clothing. The mother will call out to the neonate by the name selected prior to birth. The father will not engage in close contact with the neonate for one month. The mother will ask the nurse about sterilization to avoid future pregnancies.

a - Since infant mortality is high in developing countries, protection of the neonate is important. The Muslim parents may pin an amulet with a blue stone to the neonate's clothing for protection.

ventricular septal defect (VSD) is

abnormal opening between right and left ventricule

premature seperation of the placenta from the uterine wall after then 20th week of gestation and bfore delivery is called

abruptio placentae

K and H in acidosis and alkalosis

acid: K out and H in alkalosis: K in and H out

ph and rr and depth in acidosis vs alkalosis

acidosis: rr and depth increase and ph increases to exhale acids alkalosis: ph increases and rr and depth decrease

A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should respond to the client by understanding that in the Asian culture which is the intended outcome of acupuncture?

acupuncture restores teh balance of energy

complementary therapy is

acupuncture, massage, music therapy

A physician orders prednisone to control inflammation in a client with interstitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience

acute adrenal insufficiency

what causes vomiting

acute infectious diseases, iicp, toxic ingestions, food intolerance,mechanical obstruction of gi tract

causes of acute diarrhea

acute infectious disorders of the gi tract, antibiotic therapy, rota virus, parasitic infestation

most freq type of cancer in kids

acute lymphocytic leukemia

person who speaks up on the behalf of a client, protects their rights and upholds principle of fidelity

advocate

A child has been exposed to varicella. Which precaution should the nurse institute for infection control?

airborne precautions

how to assess nutrition status

albumin and prealbumin to check their nitrogen balance

health risks for native americans

alcohol abuse obesit heart disease diabetes tb

cage questionaire is for

alcohol use and used for all (2 or more yes is a problem)

alcohol withdrawl can lead to

alcohol withdrawl delirium and then heart problems and then death

blood rxns

allergic ( hives, itchy, flushing), febrile and hemolytic (back pain, tachy, decrease bp)

conjunctivitis caused by

allergy, infection or trauma bacterial and viral both are contagious

3 year old kid still wants bottle before nap and bed - what does mom do

allow bottle if has water in it

diaper dermatitis interventions

allow the butt to dry

maternity nurse explains psychosocial development to newborn infant - using eriksons psyschosocial development - what measure should the mom tkae

allow the newborn to signal a need

ambivalence, acceptance and emotional liability

ambivalence: dependence-independence conflict with role changes acceptance: readiness emotional -frequent changes in emotional states

what can occur if strabismus isnt treated early

amblyopia (reduced visual acquity) since the brain reecives 2 messages and a result of nonparallel visual axes

presumptive pregnancy signs

amenhorea n&v boobs big urinary frequency quickening (first movement of body at 16-20 weeks)

amnion vs chorion

amnion: inner membrane, forms fluid filled sac that surrounds embryo and later the fetus chorion: outer membrane

A client with metastatic ovarian cancer is ordered cisplatin. Before administering the first dose, the nurse reviews the client's medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin?

an aminoglycoside (that can cause nephrotoxicity and ototoxicity

cystitis is

an infection in the bladder that can occur in postpartum period

signs of dig toxicity

anorexia poor feeding n/v bradycardia dysrhythmias

To prepare the community for the possible threat of anthrax, a nurse must teach that

anthrax can effect integ, gi and respiratory systm (bacteria disease from sheep and cattle effecting skin and lungs)

what can anthrax infect

anthrax can infect the integumentary, GI, and respiratory systems.

anthropoid vs android vs platypelloid pelvid

anthro: oval shape android: heart shaped (male pelvis) platy: flat wit oval inlet

The nurse is providing dietary instructions for a client who is taking warfarin. Which menu choice would be most appropriate for this client?

anything made of vitamin k bc activates clotting factors - green leafy veggies are a no go

heart sign locations

aortic (right 2nd ics) pulmonic (sternal) erbs point (sternum) tricuspid (sternum) mitral/atrial (midclavicular)

The nurse is preparing to administer the initial dose of digoxin PO to a client. What is the nurse's priority assessment before administering this medication?

apical hert rate

why can you tell the gender of the baby at 12 weeks gestation

appearance of fetal external genitalia

after nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema?

apply cold compresses to area

The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client?

apply firmly to the site for 5 min after removal

A client recovering from a stroke is prescribed a leg brace and needs to be transferred out of bed to a chair. Which action should the nurse take first before beginning this transfer?

apply leg splint before transferring

A client who had abdominal surgery 4 days ago reports that "something gave way" during a sneeze. The nurse observes a wound evisceration. What should the nurse do next?

apply sterile moist dressing

corticosteroid is given for atopic dermatitis - instructions

apply thin layer of cream and rub it into the area thoroughly

After receiving an I.M. injection, a client complains of burning pain at the injection site. Which nursing action would be most appropriate at this time?

apply warm compliress to dilate the BV

A client lives in a group home and visits the community mental health center regularly. During one visit with the nurse, the client states, "The voices are telling me to hurt myself again." Which question by the nurse is most important to ask?

are u gonna hurt urself

A nurse is caring for a client with schizophrenia who states, "I can't handle the voices anymore! It's over! I've done all I can." Which statement by the nurse is best?

are you thinking of hurting yourself

arterial end vs venous end of capillary and hydrostatic pressure

arterial end: hydro is higher than osmotic

AMNIOTOMY IS

artificial rupture of membrane

A client who is allergic to penicillin has a prescription to receive cefazolin. What should the nurse do first?

ask the client if they took the drug without an adverse effects

removing NG tube from patient

ask the client to take deep breath and hold it - remove it slowly and evently in3-6 seconds (coil around hands while doing it)

An infant is brought to the emergency department. The infant is limp and has central cyanosis, a heart rate of 60 beats/minute, and a respiratory rate of 12 breaths/minute. The parents state that they have an advance directive for their infant, who has a terminal illness. A nurse's initial action should be to:

ask to see copy of adv directive

amniocentesis

aspiration of amniotic fluid -determines genetic disorders, metabolic defects and fetal lung maternity

safety priorities for parkinsons

aspiration risk, fall risk, andn eed for med rec

what shouldnt be prescribed for these kids

aspirin because risk of reyes syndrome

The nurse provides care for a client diagnosed with prerenal acute kidney injury. Which action will the nurse perform first?

ass cleints blood pressure

threatening something in the health care field is called

assault

assault vs battery

assault - when person puts anotherp erson in fear of harmful or offensive contact battery - intentional touching of antoehrs body without the others consent

post op complication and intervention: constipation

assess bowl sounds, drink 3000 ml of water

before cardiac cath...

assess heihgt and weight because helps with size of cath obtain hx of presense of allergic rxn to iodine

poison tx in emergency department

assess kid terminate exposure to the poision identify the poison abcs are vitals are assessed administer activated charcoal

A nurse completes the initial assessment of a full-term newborn and finds that the infant has increased vernix covering the newborn's body. Which of the following would be a priority action for the nurse?

assess mothers due date in medical record

A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:

assessfeet for neurovascular impairment

A nurse is delegating activities to unlicensed assistive personnel (UAP). Which activities can be appropriately delegated? Select all that apply.

assist client with oral care befroe breakfast measur and record intake and otput thru the shift

The nurse is caring for a client with inflammatory bowel disease. Which action is appropriate for the nurse to delegate to the nursing assistant?

assistance with ambulation

wheezing is heard with

asthma

molding of a new born

asymmetry of the head from pressure in the birth canal

symptoms of tb

asymptomatic or devlop symptoms like malaise, fver, cough, wt loss, anorexia

when is gerd supposed to go away

at 1 year old

at 20-22 weeks gestation, where is the fundus

at location of umbulicus

dimished breath sounds in lower lobes of lungs =

atelectasis

importance of deep breathing and coughing techniques are to prevent

atelelectasis and pneumonia

how often do oral care after surgery

atleast every 2 hours

eczema aka

atopic dermatitis

abnormal opening between atria causes an increased flow of oxygenated blood to the right side of the heart

atrial septal defect

incomplete fusion of endocardial cushions is

atrioventricular canal defect

common potassium (k) food sources

avocado, banana, organges, mushrooms, spianch

A nurse is talking to a neighbor who asks about reoccurring symptoms of gnawing epigastric pain following meals and heartburn. Recognizing these symptoms, what suggestion could the nurse make?

avoid alcohol and nsaids

interventions for eczema

avoid expoosure to skin irritants like soaps, diaper wipes and powder -skin should be lubricated immediately after the bath -intermitt apply cool wet compresses for shrot periods to soothe the skin and alleviate itching

The nurse is teaching a client with Parkinson's disease about the nutritional modifications to make in the diet because the client is taking levodopa. The nurse should instruct the client to:

avoid food high in b12

when given the rubella shot before discharge ater birth

avoid pregnancy for 1-3 months

preventing supone hypotension

avoid supine position position them side positon

The physical therapist arrives to evaluate Mr. Conley with you. It is determined that he can transfer from the bed to the chair with assistance and he should begin chair exercises. Mrs. Conley questions why he has to do this. What would be the best explanation to provide Mrs. Conley? A.To prevent post-operative complications and help his mood B.Exercise is neuroprotective and can prevent surgical complications C.To support wound healing and decrease risk of aspiration D.That is a good question to ask the physical therapist

b Isotonic exercises build strength Provide pictures of exercises to include at home Gait training is essential-take big steps Decreases risk of post-operative complications such as atelectasis and pneumonia

which method should the nurse use to feed an infant after surgical repair of a cleft lip

bottle with high flow nipple

iron rich foods

bread and cerel dark green vegetables dried fruit egg yolks kidney beans

how often should breast feeding be done compared to bottle

breast 2-3 hours bottle 304 position baby on right side after feed

After receiving report from the night nurse, which of the following clients should the nurse see FIRST? a)A 31- year-old woman refusing sucralfate (Carafate) before breakfast b)A 40-year-old man with left-sided weakness asking for assistance to the commode c)A 52-year-old female complaining of chills who is scheduled for a cholecystectomy d)A 65-year-old man with a nasogastric tube who had a bowel resection yesterday

c Might have an infection and cant do surgery so have to assess her left sided weakness guy isnt a new case

A 21-year-old is newly diagnosed with type I insulin dependent diabetes mellitus and has been home sick for several days with flu like symptoms. She comes into the ED to seek treatment. If the client is experiencing ketoacidosis, the nurse would expect to see which of the following lab results? a)Serum glucose of 140 mg/dL. b)Serum creatinine of 3.2 mg/dL. c)Blood pH of 7.28. d)Hematocrit 38%.

c blood ph is acidic

A client, diagnosed with Graves disease, is prescribed propylthiouracil (PTU). Which existing client condition causes the nurse to contact the prescribing health care provider before giving the initial dose of PTU? ANSWER SELECTION The client exhibits slurred speech when talking to the nurse. The client's baseline blood pressure is indicative of hypertension. The client takes an anticoagulant for a diagnosis of atrial fibrillation. The client requests extra blankets and increased room temperature.

c The nurse needs to recognize that Graves disease is a condition manifested by hyperthyroidism, which is treated with propylthiouracil (PTU).

The nurse is teaching a client who had a subtotal gastrectomy about ways to prevent dumping syndrome. Which of the following foods would be appropriate for the nurse to recommend to eliminate from the client's diet? a)cheese b)red meat c)ice cream d)yellow vegetables

c - sugar triggers dumping

ebola

can be a thing is the person traveled (fever, headache, vomitting...) - needs private room

What is one disadvantage of using the rectal route?

can result in incomplete drug absrption

antabuse

can treat chronic alcoholism - if drink with alcohol can have affects: throbbing headache, facial flushing, sweat, n/v, vertigo

aphasia means

cant understand speech

if a child has fluid volume deficiet - how do we know their issue is resolving

cap refill is less than 2 seconds

preferred source of energy is from

carbs

To reduce the risk of dumping syndrome, what should the nurse teach the client to do?

carbs decreased

what invasive diagnostic procedure is used to determine cardiac defects

cardiac catheterization

K imbalance can cause

cardiac dysrhythmias that can be life threatening

digoxin is used to treat

cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fb

A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority nursing assessment?

cardiac rhythm most significant result is K

what is the artery between the trachea and sternocleidomastoid muscle

carotid

A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking?

carvedilol - beta blockers can mask hypoglycemia

A new nurse on orientation asks for an example of a collaborative health care team. Which members would be included on this team? Select all that apply.

case manager primary doc and nurse

catholics, orthodox church, muslum, jehovahs witness, orthodox jews and ORGAN DONATIONS

catholics - yes orth church - discourages it muslim - body parts not removed jeh - organ transplant is accepted as long as cleansed with non blood solutuon orth jew - only allowed with rabbis approval

what must be the same for homeostasis to occur

cations and anions

aplastic crisis

caused by diminished prodution and increased destruction of red blood cells triggered by viral infection of depletion of folic acid profound anemia and pallor

variable decelerations:

caused by restricted flow from umbilical cord -fall and rise abruptly -significant when <70 bpm if see this: stop oxytocin, change position, give oxygen

stage 2 of labor

cervical dilation complete mom wants to bear down

metabolism

changed into a form that can be excreted

what assessment findings would indicate the presence of a hematoma

changes in vital signs - hypovolemia

A client who underwent a lobectomy and has a water seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. What should the nurse do next?

check to make sure tubing is kinked and the client isnt lying on i

to determine if fluid resus is adequate...

check vital signs (hr), urine output, cap refill, sensorium status is assessed

what to do when transfusion rxn with blood

clamp the blood at the patient and get new bag of ns to run through since the line has more blood in it

umbilical cord clamping

clamped for the 1st 24 hours after birth and should be removed when dry

clear liquid vs full liquid diet

clear liquid = 1st post op diet (no fiber) and for kids this is popsicles/jello) full - minimal work of food indigestion ( no need to chew so less energy) - milk, yogurt, custurd, cereals, juices

who is involved in deleloping plan of care

client and fam

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

client needs immune injection wihtin 72 hours

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatestrisk for developing pneumonia?

client ng tube bc of aspiration when putting it down

When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery?

client passes flatus

For the client with catatonic behaviors, which outcome would indicate a medication has been most effective in improving long-term behavior?

client simple activities without direction

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?

clients respiratort center is so used to high carbon dioxide and low o2 levels that changing may elimiminate stimulus for breathing

closed vs open suction -how often -how many times -what are we watching for

closed is when catheter is in a sleeve -as needed -3-5 (depends patient) watching for pulse ox and vitals before during and after

use of mag sulfate for pregnant moms

cns depressant meant for antiseizure meds

hemophilia is deficiency of

coagulation proteins

The nurse is assessing the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which finding is expected?

coarse crackles and rhonchi

clients with mouth sores should be served food

cold

assessment of intussusception is

colicky ab pain, vomitting, jelly like stools (bright red blood and mucus in stools)

The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. (0700) Monday and end at 7 a.m. (0700) Tuesday?

collect and save urine voided at 7 am on tuesday

how do you get rheumatic fever

comes 2-6 weeks after an untreated or partially treated group a strep infection of upper respiratory - SO ASK ABOUT HAVING A RECENT SOR THROAT

complementary vs alternative medicine

complementary = tai chi alternative = homeopathic dr vs reg

CAM stands for

complementary and alternative medicine

diabetic ketoacidosis

complication of DM that develops when a severe insulin deficiency occurs hyperglycemia that progresses to metabolic acidosis bg level is >300 and urine ketones are postiive

vaso-occlusive crisis

complication: cased by stais of blood with clumping of cells fever, painful swelling of hands feet and joints and ab pain

splenic sequestration

complication: caused by pooling and clumping of blood in spleen profound anemia, hypovolemia, and shock

The nurse is assigning a room for a client admitted with hepatitis A. Which diagnosis would be an appropriate roommate for this client?

congestive hf

ductus venoosus

connects umbilical vein and inferior vena cava bypassing LIVER

A client with rheumatoid arthritis states, "I cannot do my household chores without becoming tired. My knees hurt whenever I walk." Which goal for this client should take priority?

conserve energy

precautions for impetigo

contact isolation allow these lesions to dry by skin exposure

The nurse is planning care for a client with severe postoperative pain. There is a prescription for morphine written as "10 mg MSO4" on the medical record. What should the nurse do first?

contact the hcp who presecribed it

The nurse is caring for a client after surgery. The surgeon has written "resume pre-op meds" as an order on a client's chart. What should the nurse do next?

contact the surgeon since not a complete order

impetigo is

contagious bacterial infection that occurs during hot months -this can occur because of poor hygiene

A nurse caring for a client in labor notes that her blood pressure (BP) rises during contractions. Which should be the nurse's next action?

continue to monitor bp

A parent is concerned about spoiling a 2-month-old child by picking up the child each time the child cries. Which suggestion should the nurse offer?

continue to pick up the child bc needs love

hytrin is used for

control HTN and decreases symptoms of BPH

sinemet is used for

controlling parkinsons symptoms ◦levodopa with carbidopa crosses the blood-brain barrier & converts to dopamine. Carbidopa inhibits an enzyme that would breakdown the levodopa

A primigravid client at 16 weeks' gestation visits the clinic for a routine examination. The client tells the nurse that she knows someone whose baby was born with congenital toxoplasmosis. What should the nurse instruct the client to do to prevent transmission of the toxoplasmosis protozoan?

cook all meats thoroughly

during time out before surgery what do they confirm

coorect client and right surgical site

copd vs anxiety

copd they have trobule breathing and take breaks when talking anxiety is get to end of sentence withut breathing

reasons for decreased fetal heart rate

cord compression head compression contractions

betamethasone and dexamethasone are

corticosteroids that increae production of surfactant to accelerate lung maturitiy usuelly for preterm birthp

what is a multisystem disorder characterized by exocrine gland dysfunction

cystic fibrosis -mucus production is thick,tenacious and copious causing obstruction in small passageways of the affected organs

A client with inflammatory arthritis who takes prednisone is scheduled for an elective surgery. Which client teaching is most important for the nurse to provide? ANSWER SELECTION The purpose of coughing and deep breathing after anesthesia. The resources that are available to assist with care after discharge. The signs and symptoms that indicate the development of infection. The explanation of a precise schedule for stopping steroid medication.

d

A 21-year-old woman is in active labor and admitted to labor and delivery floor. The nurse observes a glistening white cord protruding from the vagina. Which of the following actions should the nurse take FIRST? a)Return to the nurse's station and place an emergency call to the physician. b)Administer oxygen by mask at 10-12 L/min and assess the mother's vital signs. c)Place a clean towel over the cord and wet it with sterile normal saline. d)Apply manual pressure to the presenting part and have the mother assume a knee-chest position.

d Knee chest relieves pressure of cord and the cord is their oxygen and blood flow supply

The nurse is teaching clients at a community health fair about risk factors for developing cancer. The nurse should recognize that at highest risk is the a)30-year-old client who consumes a diet high in selenium and has a history of an ovarian cyst b)49-year-old client who drinks 2 to 3 cups of coffee daily and has a family history of fibrocystic breast conditions c)51-year-old client who has hypertension and teaches an aerobic exercise program d)62-year-old client who consumes 5 to 6 alcoholic beverages daily and is an opera singer

d alcohol increases risk for cancer

A cast is applied to a 9-month-old for the treatment of talipes equinovirus. Which of the following instructions is MOST essential for the nurse to give to the child's mother regarding her care? a)Offer appropriate toys for her age. b)Make frequent clinic visits for cast adjustment. c)Provide analgesic as needed. Do circulatory checks of the casted extremity.

d temp, pulse, cap refull, color disease is distractor - asking about cast care

An older adult woman who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy. She appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/min, and her skin is cold and clammy. Based on these findings, the nurse should further assess the client for which condition?

delirium

The nurse is teaching the family of a client with a psychiatric disorder about traditional antipsychotic drugs and their effect on symptoms. Which symptom would be most responsive to these types of drugs?

delusions

A client is admitted to the emergency department after being sexually assaulted. The nurse notes that the client is sitting calmly and quietly in the examination room and recognizes this behavior as a protective defense mechanism. What defense mechanism is the client exhibiting?

denial

diabetes mellitus - type 1

destruction of pancreatic beta cells which produce insulin - results in absolute insulin deficiency

hypoglycemia signs and what to do

diaphoresis, shaky, irritability, confusion, anxiety to do: check sugar, give 10-15 g of glucose orally OR dextrose 50% iv or glucagon IM check again in 15 min

The client has been taking magnesium hydroxide to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids?

diarrhea - magnesium salts in this drug are found in laxatives

salmonella infection

diarrhea for 1 week and virsu for 5 oral rehydration (pedalyte) is given

DASH diet stands for and is used for

dietary approaches to stop htn - help to control htn, hypercholesterolemia and obesity

dyspneic means

difficult breathing

dystocia is

difficult labor that is prolonged or more painful

post op complication and intervention: dihisecne and evisceration

dihisence: seperation of wound edges evis: common with obese patients, parts come out

droplet precautions

diptheria, flu, meningitis, mumps, pnuemonia

A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). What should the nurse tell the client when the client says that she wants to breast-feed her neonate?

discourage breast feeding

where is the umbilical cord displaced when prolapsed cord

displaced between presenting part and the amnion or protruding through the cervix causing compression of the cord and compromising fetal circulation

What is the expected outcome of thrombolytic drug therapy for stroke?

dissolved emboli

how to treat pulmonary edema

diuretic

reference interval for hga1c

do every 3 monhs and should be under 6

if child vomits after digoxin

do not give

after giving anticoagulant what cant you do

do not massage the area because u can bruise (enoxaparin/lovenox)

how not to place a pt with head injury

do not place flat or in trendelenbergs bc of the risk of increased intracranial pressure

While caring for a healthy female neonate, the nurse notices red stains on the diaper after the baby voids. Which action should the nurse take next?

do nothing bc this is normal

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. What should the nurse do next?

document - this is normal

braden and numeric scoring for patients are

done on all inpatient clients

donning and removing ppe

donning: gown, mask, gloves removal: gloves goggles gown mask

the nurse is caring for a 2-year-old child with cancer. The parents have been told that the child will need an allogeneic bone marrow transplant and want to know what this means. What is the best response by the nurse?

donor is determind after testing for similar human leukocyte antigens

pt undergoing induction of labor and has contractions 2-3 min with 60 second durations. fhr is 120-122 what is priority nursing action

doscontinue oxytocin

what to make sure of before giving anticoags

dosing is right and that they dont contraindicate

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first?

droplet precautions

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated?

droplet precautions

when does discharge planning begin

during admission process

cyclical feeding is

during day or night for 8-16 hours

german measles (rubella) and a pregnant mom

during the 1st 8 weeks of gestation carries the highest rate of fetal infection this vaccine is not given during the prgnancy tho

medicaitons that parkinsons patients are on can cause

dyskinesia (◦involuntary muscle movements) Uncontrolled movements of face, eyelids, mouth

A nurse is teaching a client, who has Parkinson's disease, and their family about dietary practices. Which signs and symptoms are most important for the nurse to address? Select all that apply.

dysphagia and choking

soft diet is given to patients with

dysphagia, poor dentures or no teeth

assessment of asthma

dyspnea, wheezing, breathlessness, chest tightness, cough (night or morning)

On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for which symptoms?

early morning stiffness

early adulthood, middle "", later adult

early: late teens to mid 30s middle: 30s to 60s later: 65-death

The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.

ease client to floor, maintain airway, obtain vitals, record

A client with type 2 diabetes has just started to take dulaglutide. The client reports having severe nausea. What should the nurse instruct the client to do to manage the nausea? Select all that apply.

eat small freq meals drink ginger tea avoid fried food

Which recommendation would be the most appropriate preventive measure to suggest to a primigravid client at 30 weeks' gestation who is experiencing occasional heartburn?

eat smaller more frequent meals during the day

In an initial screening for lead poisoning, a toddler is found to have a minimally elevated lead level. What is the most important action the nurse should take?

educate the parents to reduce lead in envt

preschoolers ways of thnking

egocentric and magical thinkers (egocentric perspctive and only think of themselves)

intevention for diabetic ketoacidosis

electrolyte replacement therapyvom

burns on extremities - how work with bed

elevate extremities above heart

if have burns on face and head how do you elevate the bed

elevate head of the bed to prevent or reduce edema

post op complication and intervention: pulmonary embolism

embolus blocking the pulm artery and disrupting blood flow to 1 or mor lobes notif surgeon since can be life threatening

what is interpersonal process of enabling others to do for themselves

empowerment

Which of the responsibilities related to the care of a client with a Foley catheter are appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

empty drainage bag and record apply cath to leg make sure urine bag is below provide foley cath and care each shift

interventions with school aged kids in hospital

encourage rooming in, encourage them to be involved with their care

when the kids sick and the urine is postive for ketones what do u do

encourage the kid to drink liquids

surfactant replacement therapy is given thru

endotracheal

hat happens to the right atrum and ventricle

enlarge

A nurse is assessing a neonate. When maternal estrogen has been transferred to the fetus which sign will the nurse see in the neonate?

enlarged breast tissue

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do?

enroll in supervised exercise training program

infectious period of scabies

enstire course of infestation

A nurse is caring for a client of the Buddhist faith who is dying. The client's family is at the bedside. Which intervention would the nurse implement to support the client's death with dignity?

ensure the room is calm, dim the light and quiet

The client with a major burn injury receives total parenteral nutrition (TPN). What is the expected outcome of TPN?

ensures calories and protein intake

how make the deicison form parenteral vs enteral

enteral is the ideal way to give nutrition - if they dnt have functioning GI track, then will choose parenteral

contact precautions

enteric infections - c diff respiratory infections, wounds, skin, eye infections

what isolation for diarrhea

enteric isolation

layers of the skin

epidermis, dermis, subq, muscle

esophageal atresia and tracheoesophageal fistula

esophagus stops before it reaches the stomach or a distula is present that forms an unnatural connection with trachea causes oral intake to enter the lungs or a large amount of air to enter the stomach presenting a risk of coughing and choking w severe ab distention

codes that direct and govern nursing actions

ethical principles

branch of philosophy concerned with the distinction between right and wrong on the basis of a body of knowledge

ethics (right and wrong)

The nurse is receiving shift report on four clients on an antenatal unit. The four clients are: (1) a 35-week-gestation mother with severe preeclampsia started on a maintenance dose of magnesium sulfate 1 hour ago; (2) a 30-week-gestation client with preterm labor on an oral tocolytic and having no contractions in 6 hours; (3) a hyperemesis client with emesis 4 times in the past 12 hours; and (4) a 33-week-gestation client with placenta previa who began to feel pelvic pressure during change of shift report. Which action should the nurse take first?

evaluate the placenta previa

how often check person who has hand restraints

every 30 minutes

schedule for antepartum health visits

every 4 weeks for the 1st 28 - 32 weeks every 2 weeks for 32-36 weeks every week 36-40 weeks

A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. What should the nurse tell the client that the test results indicate?

evidence of fetal wellbeing

hypervolemia means

excessive fluid or isotonic overhydration

placenta does what

exchange nutrients and waste products from fetus to mom forms at implantation and complete by week 12

if a pneumothorax is known - intermittent bubbling =

expected but continuous means air leak

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby?

express a small amount of breast milk (not apply ice)

A nurse is caring for a client in the manic phase of bipolar disorder who's ready for discharge from the psychiatric unit. As the nurse begins to terminate the nurse-client relationship, which client response is appropriate?

express feeligns of anxiety

exercise and diabetes

extra food needs to be consumed for increased activity, usually 10-15 g of carbs for every 30-45 min of activity

A nurse is communicating with a client who has aphasia after having a stroke. Which action should the nurse take?

face the client and make eye contact - do not talk slowly and enunciate each word

common types of hemophilia

factor viii deficiency or hemo a factor ix deficiency or hemo b

subinvolution is

failure for the uterus to return to its normal size and contidition after labor

post op complication and intervention: paralytic ileus

failure of appropriate forward movement of bowel contents monitor i&o, mainitain npo until they come back *vomiting, ab distention and absence of bowel sounds all signs of this*

clinical manifestation of imperforated anus

failure to pass meconium stool in the frist 24 hours after birth

fetal distress during pregnancy is and interventions

fetal heart rate lower than 110 or greater than 160 meconium stained amniotic fluid discontinue oxytocin, place in laeral position and administer oxygen -prepare mom for c secrtion

The nurse is discharging a client at 35 weeks' gestation after a reactive nonstress test. The client asks the nurse how the fetus is doing. What is the nurse's best response?

fetal heart rate went up so baby is doing well

presentaton of the baby during labor

fetal structure that lying near the cervix cephalic (head first) breech (butt present first) shoulder

assesment for bronchitis

fever dry, hacking and nonproductive cough that is worse at night and becomes productive in 2-3 days

signs of shock

fever (infection) confused output is lowered if they fall

what precipitates sickling

fever, dehydration and emotional/physical stress and any condition that increases the need for oxygen

assessment of infiltration of bone marrow is

fever, pallor, fatigue, anorexia and hemorrhage and bone and joint pain

fetal monitor monitors

fhr, uterine activity and assesses frequency, duration and intensity of contractions

duty to do what one has promised

fidelity

What should the nurse expect to find in a premature female neonate born at 30 weeks' gestation who is small for gestational age?

fine downy hair on upper back and arms

what to worry about at home with oxygen

fires

A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit?

firm fundus when gentle massge is used

when give blood when can rxn occur

first 15 min (check vitals q 5 min for 15 min) and 1st 50 cc

naegles rule for estimating delivery date

first day of last menstral cycle -3 months +7 days + 1 yr

client with diarrhea is at high risk for

fluid and electrolyte balance

severely burned kids are at increased risk for

fluid and heat loss dehydration metabolic acidosis

When assessing a client with a chest tube inserted for a hemothorax, the nurse would expect which findings? Select all that apply.

fluid drainage in first chamber dry dressing at chest wall insertion tidaling in water seal chamber during respirations

intravascular compartment refers to

fluid inside the blood vessel

If give fluid fast to a person wht do nurses worry about

fluid overload (symptoms: edema, 1st thing is fluid in lungs, sob), edema (CANT LEAVE THESE PATIENTS) - usually septic patients need this

clients with hyponatremia and renal disorders need what types of diets

fluid restriction

what to do after ng feeding

flush with 30-60 ml of water or NS

adverse effects of mag sulfate

flushing, depressed respirations and extreme muscle weakness

A client with a long history of ulcerative colitis takes sulfasalazine to control the condition. The nurse should evaluate the client for which nutritional deficit that can occur as a result of taking this drug?

folic acid deficiency

akinesia

freezing or no movement

rule of nines in adults

front and back of head and neck = 9% front and back of arm and hand = 9% chest = 9% stomach = 9% upper back = 9% lower back = 9% front and back of each leg and foot = 18% groin = 1%

assessment for this

frothy saliva from mouth 3 c's - coughing, choking during feedsings and unexplined cyanosis

kussmauls key thing

fruity breath

When developing the plan of care for a toddler who has taken an acetaminophen overdose, which intervention should the nurse expect to include as part of the initial treatment?

gastric lavage

leading cause of life threatening perinal infections

gbs - group b strep

drug names that the nclez tests on

generic names

what is off about amish people

genestic disorders because of inbreeding

phenylketonuria

genetic disroder that results in cns damage from toxic levels of phenylalaine (aa) in the blood (>20)

A laboring client at -2 station has a spontaneous rupture of the membranes, and a cord immediately protrudes from the vagina. What should the nurse do first?

gentle pressure upward on the fetal head

what is the time from fertilization of the ovum until the estimated date of delivery

gestation (280 days)

gestational htn vs preeclampsia

gestational is blood pressure elevated without proteinuria

purpose of placental functioning

get babys food and oxygen provides exchange of nutrients and waste products between mother and fetus

plus side of amish people and diseases

get fewer diseases bc of labor

when somene comes in feeling weak or dizzy what do you think

get pressure and hydration

digoxin early manifestatons

gi distrurbances - anorexia, nausea, vomitting OR neuro abnoralities (fatigue, headache, depression, weakness, drowsy confusion and nightmares.

progressive diet is used for

gi problems (DAT = diet as tolerated)

nec syndrome in babies

gi tract inflammation - increased ab girth, decreaed bowel sounds

what shouldnt parents do if their kid has this

give cough medicine or syrup becuaes it can dry and thicken secretions

contact precautions people wear

gloves and gowns

The adrenal cortex is responsible for producing which substances?

glucocorticoids and androgens

on steroid what labs are checked

glucose

urine specimen for pregnant moms

gluocse and protein determinations

low purine diet is for

gout, kidney stones, elevated uric acid levels

how is this characterized

gradual onset that may be preceded by upper respiratory infection

A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

granulocytopenia

what are a good source of iron

green leafy vegetables

normal pelvis for chics

gynecoid (most favorable for labor and birth)

how is c diff spread

hand to hand contact (f take multiple antibiotics for a long time)

The nurse is caring for a preschooler. Which technique will the nurse apply as most effective in preventing hospital-acquired infections in this population?

hand washing

A client with schizophrenia tells the nurse that he does not go out much because he does not have anywhere to go and he does not know anyone in the apartment where he is staying. Which action is most beneficial for the client at this time?

have the client do the day treatment program

The nurse is teaching the client with Addison's disease to anticipate the need for increased glucocorticoid supplementation. When will the client likely need to increase the dose of glucocorticoids?

having oral surgery addision - when body doenst produce enough hormones (adrenal glands produce too litle cortisol and aldosterone)

sickle cell anemia risk factors

having parents that are heterozygous for hemoglobin S or being AA

client has mild preeclampsia - what signs make her want to contact hcp

headache and blurred vision

signs of hypoglycemia

headache, nausea, sweating, tremors, lethargy, huger, confusion, slurred speech, tinginly and anxiety

atropine is good for

heart and secretions

probable signs fo pregnancy: -hegars sign -goodells sign chadwicks ballottement braxton hicks

hegars:softening of uterus goodells: softening of cervix chad: violet color of membranes ballottment - rebounding of the fetus braxton: irregular painless contractions

preeclampsia can lead to

hellp syndrome (increase liver, hemolysis (decrease rbc), decrease platelets)

clients with hemmorhagic and ischemic strokes - hob

hem: elevated to 30 degrees ische: kept flat

A client is to receive epoetin injections. What laboratory value should the nurse assess before giving the injection?

hematocrit (drug stimulates the creation of rbc)

A client has left-sided paralysis. The nurse should document this condition as left-sided

hemiplagia (one side of the body)

transfusion rxns

hemolytic (do to abo compatiility) allergic bacterial febrile (not associated with hemolysis)

32 The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem?

hemorrhage

what is a risk associated with placenta previa

hemorrhage

hemoorhagic vs thrombolytic strokes

hemorrhagic: head is affected thrombo: head is not affected

heparin values vs warfarin values

hep: ptt and platelets warfarin: pt/inr

heparin and warfarin labs

heparin - ptt warfarin - inr

von willebrands disease is

hereditary bleeding disorder that is characterized by a deficiency of or a defect in a protein termed von willebrand factor

omphalocele and gastroschisis

herniation of the ab contents herniation of intestine

when do you give blood

hgb of 8 or less

alkalytic conisition is when ph is

high

diet for CF clients

high calorie high protein diet

assessment of epiglottitis

high fever sore, red, inflamed throat

person with NG tube - position of bed

high fowlers position

if autonomic dysrflexia occurs - how place bed

high fowlers position (sudden spike in blood pressure - usually happens with spinal surgerys)

bacterial vs viral meningitis

high grade fever for bacterial

anemia patients have what diet

high iron diet

what contains large amounts of phenylalanine

high protein foods (meat and dairy) and aspartame

A nurse is caring for a client with scabies. Which information about scabies should the nurse consider when planning care for this client?

highly contagious

After surgical repair of a myelomeningocele, which position should the nurse use to prevent musculoskeletal deformity in the infant?

hips abducted (out)

patients with respiratory and cardiac disorders should be positioned with

hob elevated

mastectomy - how to elevate head of the bed

hob elevated 30 degrees (semi fowlers) with affected arm elevated

The nurse is caring for a client who entered the hospital with a diagnosis of dehydration. The client's serum potassium is 5.2 mmol/L this morning and the healthcare provider orders the primary I.V. fluid as D5 1/2 NSS with 20 mEq/KCL (mmol/L). What will the nurse do? Select all that apply.

hold iv fluid clarify order with hcp review labr esults

A client with lung cancer develops Horner's syndrome when the tumor invades the ribs and affects the sympathetic nerve ganglia. When assessing for signs and symptoms of this syndrome, the nurse should note

horners is an eye problem

fasting for specimen collection - how long

hours of fasting for fasting blood test: 12 hours

While receiving disulfiram therapy, the client becomes nauseated and vomits severely. Which question should the nurse ask first

how much alcohol did you drink today this drug blocks the processing of alcohol in the body

five vitals of apgar scoring

hr rr muscle tone reflex irritability skin color want +2 on all

health risks for asain americans

htn heart disease cancer lactose intolerance thalassemia

health risks for hispanics americans

htn heart disease diabetes obesity lactose intolerance

hydrazaline is for

htn and can cause tachycardiac

signs of preelcampsia

htn and proteinuria

interventions for mild htn vs mild preeclampsia

htn: monitor bp and fetal activity pre: bed rest and place in lateral position, monitor bp and weight

what assessment finidng shows that the client is at risk for preterm labor

hx of cardiac disease

what is vital to life and expressed as ph

hydrogen ions

hypo and hypertonic overhydratiion

hyper - excessive sodium intake hypo - water intoxication

Which condition should a nurse expect to find in a client diagnosed with hyperparathyroidism?

hypercalcemia

intractable n&v during 1st trimester is called

hyperemesis gravidarum

complication with parenteral nutrition

hyperglycemia -usually d10 or d50 but normal iv fluid is d5 so more sugar), electrolytes/insulin and minerals in it -D50 - central line, d10 can go thru iv (with central: worry about a pneumothorax) -Insulin added since so much sugar, want to balance -Parenteral only good for 24 hours - risk for infection bc of high sugar

manifestations of ketoacidosis

hyperglycemia signs, kussmaul respirations, acetone (fruity) breath increase lethargy and decreased loc

clients in renal failure are at increased risk for

hyperkalemia since they cant excrete K

when administering enemas - monitorfor what

hypernatrmia and hyperphosphatemia

what to do when extubating a patient

hyperoxygenate the cleint and suction the endotrach tube after removal - have them cough and deep breathe to remove extra secretions in the throat

what sound on percussion is found with acute asthma attack

hyperresonance

how to solve hypo and hypertonic dehydration

hypo - give hypertonic solutions

hypotonic vs isotonic vs hypertonic dehydration

hypo - low na levels isotonic = diarrhea/vomiting hypertonic = more water is lost or fever

hypotonic contractions vs hypertonic contractions

hypo: short, irreg and weak - amniotomy and oxytocin infusion may be treatment measures hyper: painful, frequent and uncoordinated

The nurse assesses a patient with a diagnosis of parathyroid disease. The client is having abdominal cramping, positive Chovstek's and Trousseau's sign and tingling in the extremities. The nurse understands these symptoms may be due to which of the following? a)Hypermagnesemia. b)Hypophosphatemia. c)Dehydration. d)Hypocalcemia.

hypocalcemia

what happens when taking furoseide

hypocalemia

A neonate, admitted to the neonatal intensive care nursery for probable meconium aspiration syndrome (MAS), weighs 10 lb, 4 oz (4,650 g), and is at 42 weeks' gestation. The neonate has a heart rate of 110 bpm and a respiratory rate of 40 breaths/min with periods of apnea. The nurse should further assess the neonate for which condition?

hypoglycemia

abrupt disconnection from PN leads to

hypoglycemia

postterm newborn you are worried about

hypoglycemia

A client has had an exacerbation of ulcerative colitis with cramping and diarrhea persisting longer than 1 week. The nurse should assess the client for which complication?

hypokalemia

A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible?

hypokalemia (bronchodilator)

After a head injury, a client experiences enuresis, polydipsia, and weight loss. Based on these findings, the nurse should monitor closely for signs and symptoms of

hypokalemia (enuresis = urinating by accident)

hyperactive bowel soinds are seen with

hyponatremia

A client has received an overdose of sympathomimetic agents. The nurse should assess the client for which late signs of an overdose? Select all that apply.

hypotension seizures profound pyrexia - fever

dehydration can lead to

hypovolemic shock

3 systems of personality - freud

id: sources of drive ego: reality testing and problem solving superego: socialization that develops during phallic stage

A 14-year-old client in skeletal traction for treatment of a fractured femur is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

identitiy

After being examined and fitted for a diaphragm, a 24-year-old client receives instructions about its use. Which client statement indicates a need for further teaching?

if i gain or lost 20 lbs, i can still use the same diaphragm

when do you need fluid resus for burns

if more than 10% of kids total body is burned

A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which factor?

immature cardiac spchincter

A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation?

immediate isolation in a privte room

management of aplastic anemia is

immunosuppressive therapy and bone marrow transplantation

The nurse is developing a plan of care for an older child who had a colostomy surgically created 6 months ago. Which nursing diagnosis is a priority for this client?

impaired body imagine related to the colostomy

The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:

improved circulation to the area

intervention for late deceleration

improving placenal blood flow and fetal oxygen

how do you hold the infant

in an upright position and direct the formula to the side and back of the mouth to prevent aspiration

interstital fluid is wehre

in between cells

ng tube - dont want this tube going

in the trachea

apraxia

inability to perform purposeful movements in absence of sensation

premature dilation of cervix is called

incompetent cervix

A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction?

increaes carb intake

During a routine prenatal visit, a pregnant client reports constipation, and the nurse teaches her how to relieve it. Which statement indicates the client's understanding of the nurse's instructions?

increaes intake of unrefined grains

encoaurge what with bronchitits

increase fluid intake

early sign of excessive blood loss after labor

increase in pulse since heart pumps faster to compensate for loss of blood

what lab results are involved with hemophiliar

increase is ptt

wht is the first sign of digoxin toxicity

increased blood pressure

when a prescribed iv rate is increased, nurse should check for

increased hr, respirations, lung congestion for fluid overload

early sign of hypovolemic shock

increased pulse rate, decreased blood pressure (this kinda shock is when fluid is leaked from blood)

what is it characterized by

increased tendency to bleed

irritable bowel syndrome results from

incresed motility which can lead to spasm and pain

incubation period for lice and how long cna they survive

incub: 7-10 days live for 48 hours away from host, nits (eggs) shed in the envt and can hatch in 7-10 days

emancipated minor is

independece from parents thru marriage, pregnancy or armed forces

Which nursing diagnosis takes the highest priority for a client with parkinsonian crisis?

ineffective airway clearance

A nurse must assess skin turgor in an older adult client. What would the nurse keep in mind when assessing this client?

inelastic skin turgor is a part of aging

An infant is to have moderate sedation for an outpatient procedure. The nurse knows that

infant should respond to gentle tactile and verbal stimulation

bacterial pneumonia in infant vs child

infant: irritabiltiy, lethargy, poor feeding, abrupt fever older kid: headache, chills, ab pain, chest pain, meningeal symptoms hacking, non productive cough

when to withhold digoxin

infants and young kids: if apical pulse is less than 90-110 older kids: less than 70 kids usually receive more than 1 ml of digoxin in 1 dose

The mother of an infant with flat feet asks the nurse what she can do about the problem. Which response from the nurse is the most appropriate?

infants hav a fat pad below the arch making it look like they are flat when they arent

infants and children with tet of fallot

infants: acute episodes of cyanosis and hypoxia called blue spells or tet spels when oxygen supplies exceed the blood supplies children: increasing cyanosis, squatting (compensatory mechanism to increase blood flow to heart), clubbing of fingers

redness at the catheter site means

infection

post op complication and intervention: thrombophlebitis

inflammation of vein minitor legs elevate

mastitis is

inflammaton of the breast from infection

rhuematic fever is

inflammatory autoimmune disease that affects connective tissues of the heart, joints, skin, blood vessles and cns

otitis media is caused by

inflammatory disorder caused by infection of the middle ear that happens from blocked eustachian tube

A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through

inhalation of aerosols

tuberculosis is transmitted by

inhalation of droplets

immediate action when coarse ventricular fibrillation occurs

initiate cpr

A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?

initiating weight bearing exercises

if drainage system cracks or breaks

insert chest tube into bottle of sterile water, remove crakced or broken system and replace it with new system

A client is prescribed a bisacodyl suppository. When administering the suppository, the nurse will include what actions?

insert suppository 1 inch into the recum or past the anal sphincter (not right sided in sims position)

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

inserting a foley catheter

physical exam assessment

inspection, palpation, percussion, auscultation (except abs - inspect, auscultate, palpate, percuss)

A nurse is assisting with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client?

instruct to take a deep breathe and hold it

what happens to the cells in sickle cell

insufficient oxygen casues the cells to assume a sickle shape and the cells become rigid and clumped together obstructiing capillary blood flow

how does insulin deficiency lead to ketoacidosis

insulin deficiency (impaired metabolsim of fats, proteins and carbs) hyperglycemia (fatigue, hunger and wt loss) polyuria, cellular starvation ketones are produced in response to cellular starvation ketoacidosis

type 2 arises because

insulin resistance where body fails to use insulin properly, combined with relative insulin deficiency

menieres disease is

inter ear imbalance - infection - overload of fluid

what requires rupture of membranes and attaching an electrode to presenting part of the fetus

internal fetal monitoring

brain tumors are and whwere is one most commonly found in kids

intratentorial tumor that is found in the psterior 3rd of the brain (cerebellum or brain stem) and accounts for frequency of symptoms resulting from increased icp

Which nursing intervention is essential while caring for an infant with cleft lip or palate?

involve parents in feeding as soon as possible

The nurse asks a school-age child with Guillain-Barré syndrome to cough and also assesses the child's speech for decreased volume and clarity. The underlying rationale for these assessments is to determine which finding?

involved facial and cranial nerves

A nurse is planning care for an adolescent client who is 12 weeks' gestation. The nurse will monitor this client closely for the development of which complication during this stage of the pregnancy?

iron deficiency anemia

iron deficiency anemia

iron stores are depleted and decreased supply of iron for the manufacture of hemoblobin in rbc

apneustic respirations

irreg respirations with pauses at the end of inrpiration and expiration

isotonic, hypotoic and hypertonic solutions

iso: equal hypo: lower solute so more concentrated solution hyper: higher concentration of solute and less concen solution

hypovolemia is

isotonic dehydration (most common type) - fluid depletion

a patient has a 3 lumen picc and they are getting blood and antibiotics at the same time for the first time, is this ok

it is okay but dont do it becaue dont no if have allergy to this med or the blood (if say took it 4 days prior and is ok, then go for it)

After the nurse teaches a client with bipolar disorder about lithium therapy, which client statement indicates the need for additional teaching?

it is okay to double dose i forgot

is CF curable

it is progressive and incurable w respiratory failure being a cause of death

While making a home visit to a primiparous client and her 3-day-old infant, the nurse observes the mother changing the baby's disposable diaper. Before putting the clean diaper on the neonate, the mother begins to apply baby powder to the neonate's buttocks. Which information about baby powder should the nurse relate to the mother?

it may cause pneumonia to develop

A nurse is caring for a child who is 1 day post-op after having a colostomy. The parents are concerned that the stoma has not drained any stool. What is the most appropriate response by the nurse?

it may take several days for the stoma to function

what is not given thru the pn line

iv meds and blood

how to give potassium

iv push, im or subq - always diluted too

For an 8-month-old infant, which toy promotes cognitive development?

jack in the box

distribution of benefits and tasks for what clients should be cared for

justice

electrolytes: k, na, ca

k: 3.5-5 na: 135-145 ca: 9.0-10.5

waht do buffers do

keep ph in normal limits when acids and bases arent at normal levels

A nurse is caring for a client with a history of falls. The nurse's first priority when caring for a client at risk for falls is

keeping the bed at lowest possible level

A client newly diagnosed with diabetes mellitus asks why they need ketone testing when the disease affects their blood glucose levels. How should the nurse respond?

ketones tell us if you body is using other tissues for energy - they are a byproduct of fat metabolism and that ketone testing can determine whether the body is breading down fat to use for energy

organ responsbile for excretion

kidneys

the health care provider (HCP) orders an amniocentesis for a primigravid client at 37 weeks' gestation to determine fetal lung maturity. Which is an indicator of fetal lung maturity?

l/s ration

precipitous labor and delivery

labor lasting less than 3 hours

A client is to be discharged with a prescription for lactulose. The nurse teaches the client how to administer this medication. Which statement would indicate that the client has understood the information?

lactulose = decreases ammonia levels it treats constipation

newborn looks like.... when diabetes mellitus

large in size and at risk for hypoglycemia, hyperlipidemia, respiratory issues, hypocalcemia

4 stages of labor - stage 1

latent: contractons every 15-30min active: contractions 3-5 min transition:contractions 2-3 min

After teaching a client how to instill nose drops, the nurse evaluates that the client's technique is correct when the client:

lay supine for several minutes afterwards

A nurse is attending a seminar at the local senior center. The nurse knows the presenter has a good understanding of genitourinary changes in the elderly when the presenter makes which statement?

leave a light on in the bathroom at night

The mother of a toddler asks the nurse what she should do with her toddler when he has a temper tantrum. Which suggestion would be most appropriate?

leave hte toddler alone during tantrum as long as he is safe

left sided hf vs right sided

left think lung -crackles, cough, dyspnea, grunting in infants, head bobbing right sided -ascites, hepatosplenomegaly, jugular vein distention, weigth gain

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, what is an expected outcome?

less difficulty breathing

A child with a cardiac defect assumes a squatting position. The nurse should determine that the position is effective for the child by noting which finding?

less dyspnea

The parents of an 8-month-old infant have brought the child to the emergency department after falling from the high chair. The nurse takes immediate actions for increased intracranial pressure (ICP) based on what assessment finding?

lethargy and slgugish pupils

manifistations of respiratory alkalosis

lethargy, lightheaded, confusion, tachy

leukemia is increase in number of

leukocytes prliferating immature wbc depress the bone marrow causing anemia from decreased erythrocytes, infection from neutropenia and bleeding from decrease platelet production (throbocytoenia)

potassium deficiency

life threatening since every body system is effected

To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to demonstrate which skill?

lift head to prone

A woman tells the nurse, "There has been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer?

light bleeding or watery discharge

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

lightly tape the eyelids shut

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes

limiting abbreviations to those approved for use by the institution

hyponatremia causes what in people taking lithium

lithium toxicity

The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which postion?

lithotomy

what organ is in charge of metabolism

liver

ast/alt levels talk about

liver function •Assess ration of alanine aminotransferase (ALT) to aspartate aminotransferase (AST) to determine liver function •0.8 approximately normal; >2 disease; >3 advanced liver cirrhosis •Drug metabolism

what type of edema comes after a accident/surgery/burns

local edema

The nurse is talking with a client who had a colostomy created 2 days ago. Which of the following statements by the client would indicate ineffective coping? Select all that apply. a)"I am not touching that disgusting bag." b)"I am glad I can still go to the gym just as I used to." c)"I really like raw vegetables, and it will be hard for me to limit them." d)"I understand the need for the colostomy, but I am afraid that the bag will leak." e)"I do not understand why I cannot have a nurse perform the colostomy bag changes for me."

looking for coping answer e

The nurse assesses the client for active phase of labor who has just received continuous epidural anesthesia. What common side effects would the nurse teach the client about with this type of anesthesia? Select all that apply.

loss of bladdar control pruritis - itch hypotension

intrauterine fetal demise is

loss of fetal movement

When planning a presentation on the topic of osteoporosis to a group of middle-aged women, the nurse should include which information in the presentation?

loss of height is an early symptom of the disease

A 4-month-old infant is taken to the pediatrician by the parents because they're concerned about the infant's frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the infant has failed to gain expected weight and recommends that the infant have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that:

low intensity, painless electrical current is applied to skin

A hospitalized 5-year-old is pulseless, and after verifying the child is not breathing, the nurse begins chest compressions. Where should the nurse apply pressure?

lower sternum with heel of hand

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness?

lubricant jelly

second defense of the body that interacts with buffer system to maintain acid base balance

lungs

why cant give iv on side of body with masectomy

lymphedema

what are examples of tocolytics

magnesium sulfate and nifedipine

endotracheal tube is used to

maintain a patent airway (this is used when person needs mechanical ventilation)

After an amniotomy, which client goal should take the highest priority?

maintain adequate fetal tissue perfusion

interventions for sickle cell anemia

maintain adequate hydration and blood flow with fluids electrolyte replace is also provuded sometimes oxygen and blood transfusions encourage a high calorie, high protein diet with folic acid supplementation

planning care for a baby of a mom that has gestational diabetes. priority nursing consideration

maintain safety bc low glucose level

severe dehydration tx

mainttain npo to place the bowel at rest and provide fluid and electrolyte replacement by iv route

what is the proper answer for seizure precautions

make sure have suction equipment ready

if miss a dose of dig

make sure less than 4 hours has passed sinc supposed to take it and then give it if less than 4

consent with surgery

make sure the surgeon obtained the consent and witness teh signaure on the form as a nruse

what does a vesicant do to the iv site

makes burn when injection

causes of chronic diarrhea

malabsorption syndromes, inflammatory bowel disease, immunodeficiencies, food intolerances and nonspecific factors

droplet precautions - what do people wear

mask for providers and visitors

general anesthesia does what to a mother

maternal danger of respiratory depression,vomitting and aspiration

During labor, a primigravid client receives an epidural anesthetic, and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?

maternal hypotension

A primigravid client in a preparation for parenting class asks how much blood is lost during an uncomplicated vaginal birth. What should the nurse should tell the client?

max blood loss within normal limits is 500 ml

sutures on newborns

may be overlapping but should not be widened fontanels are at the junction of the sutures

airborne precautions

mealses, chickenpox (varicella), tb

tb test shouldnt be done at the same time as

measles immunization

meconium , transitional stool and breast fed stool

mec: 1st 24 hours and green tarry trans: green brown and loose seedy and yellow = breast fed

clients with dental problems, surgery of head or neck or dysphagia require what diet

mechanical

tocolytics are

medications that help uterine relaxatin and suppress uterine activity (halt uterine contractions and prevent preterm birth)

hirschsprungs disease and its most serious complication

megacolon and a complication is enterocolitis (foul smelling ribbon like stool)

For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance?

metabolic alkalosis

vomitting causes

metabolic alkalosis

piagets theory of congitive delveopment is when

mind organizes and adpats to its envt

jones criteria for diagnosis of rheumatic fever

minor: fever, arthralgia, elevted erythrocyte sedimentation rate or postiive c-reactive protein, prolonged pr interval major: carditis, arthalgia, chorea (involuntary movements of extremities and face), erythema marginatum (red lesions on trunk), subcutenous nodules page 486

The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which vaccine if prescribed would the nurse question?

mmr (cant given before 12 months)

The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore?

mobility status

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply.

monitor assess for hemoptysis and frank bleeding without food and fluids until the gag reflex comes back

post op complication and intervention: wound infection

monitor temperature

priority with dystocia

monitoring fetal heart rate

paralysis of one extremity is called

monoplegia

A client is treated for cardiac dysrhythmias. The health care provider prescribes the calcium channel blocker verapamil, 80 mg orally every 6 hours. Which assessment finding does the nurse identify as a serious adverse effect of the medication? ANSWER SELECTION Dizziness. Flushed skin. Mood changes. Peripheral edema.

mood changes

A client is treated for cardiac dysrhythmias. The health care provider prescribes the calcium channel blocker verapamil, 80 mg orally every 6 hours. Which assessment finding does the nurse identify as a serious adverse effect of the medication?

mood changes - Mood changes are an indication that the client is experiencing a serious adverse effect related to verapamil. The nurse should report the assessment finding to the health care provider. Other serious adverse effects include hepatotoxicity, heart failure, myocardial infarction, and confusion.

behavior in accordance with customs or tradition, reflecting personal or religious beliefs

morals (personal)

school aged kids and play

more competitive, rules and rituals are important

hospitalized school aged child speration anxiety

more concerned aboutmissed school and fear about friends forgetting htme protest, despair and detachment do not happen with them

osteosarcoma is

most common bone cancer in kids (most tumors found in femur)

laryngotracheobronchitis is

most common type of croup - inflammation of larnyx, trachea and bronchi

newborns are at risk for hbv or hep b if

mother is infected with hbv or was a carrier of hbv during pregnancy

bureaucratic leadeer

motivated by external forces

what part of the baby do you suction first

mouth then nose

distribution

moved into various tissues - protein binding

Which assessment finding would advise the nurse of a need to change from the prescribed intranasal route to an injection of desmopressin acetate for a child with diabetes insipidus?

mucus membrane irritation

somatic symptom disorder

multiple persistent physical complaints that are associated with excessive and maladaptive thoughts, feelings, and behaviors related to those symptoms. The symptoms are not intentionally produced or feigned and may or may not accompany known medical illness.

when blood volume is increased in the heart it is called

murmur (blowing or swishing it sounds like) - best listened with bell

The nurse should instruct a client who is taking dexamethasone and furosemide to report which symptom?

muscle weakness - The nurse should instruct the client who is taking dexamethasone and furosemide to observe for signs and symptoms of hypokalemia, such as malaise, muscle weakness, vomiting, and a paralytic ileus, because both dexamethasone and furosemide deplete serum potassium

areflexia

muscles overreact to stimuli

A client with Addison's disease comes to the clinic for a follow-up visit. When assessing this client, the nurse should stay alert for signs and symptoms of

na and k abnormalities

meds to decrease alcohol cravings

naltrexone and topiramate

aortic stenosis is

narrowing of aorta that causes resistance to blow flow from left ventricle to aorta resulting in decreased cardiac output, left ventricular hypertrophy and pulmonary vascular congestion

body languiage is important to

native americans

Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin?

nausea and vomitting

promethazine is for

nausea and vomitting - im med that makes u sleepy

first line agents to halt preterm labor contractions

nifedipine (calcium channel blocker)

do you need sterile procedure for wound care

no

what fluid is given with blood

normal saline

what is the fluid compatible with blood

normal saline solution (.9 NS)

normal temp for a kid and what is considered a fever

normal: 36.4-37 fever is 38 or 100.4

epistaxis

nose bleed

epistaxis aka

nosebleed

how is rsv transferred

not airborne but is highly communicable and transferred by direct contact with respiratory secretions

A client is admitted to the health care facility with abdominal pain, a low-grade fever, abdominal distention, and weight loss. Based on the diagnosis of acute pancreatitis the nurse will provide which explanation for the prescribed interventions?

not allowed anything by mouth so pancreas can rest

post op complication and intervention: hypoxemia

not enough oxygen in the arterial blood nofify the surgeon

clients with hx of copd and emphysema and oxygen

not given more than 2 liters on a cannula sicne it can lead to respiratory acidosis and co2 retention

kid has a dressing on after removal of brain tumor. nurse finds colorless drainage on the back of the dressing- what do

notfiy the provider because this could be csf

4th stge of labor, fundus firm and bleeding excessive - nursing action

notify hcp

pt having contractions every 3 min for 45 seconds. fhr between contractions is 100 bpm - what should the nurse do

notify hcp - fetal brady in between needs attention

Important teaching for a client receiving risperidone should include advising the client to:

notify the physician if the client noticed an increase in bruusing

osmolality is

number of osmotically active particles per kg of water

who is responsible for obtaining consent for surgery

nurse

Which clinical characteristic affects client compliance?

nurse client relationship

what can not be delegated

nursing judgement / nursing process -assessments -care plans -pt teaching

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

oa is noninflammatory and ra is inflammed swollen joint

A client had surgery for a bowel obstruction 4 days ago. The nurse assesses that the client has not passed any flatus, and there are no bowel sounds. Even though the abdomen has become more distended, the client feels little discomfort. In considering the plan of care, what is the most appropriate first step for the nurse to take?

obtain an order for ng tube insertion

The nurse is caring for a client with an exacerbation of ulcerative colitis. The nurse should instruct the client to:

obtain freq rest periods

death of patient process

obtain prounce death from dr, remove tubes and lines, clean thebody, ask family if want to view, place a name tag

day 1 post op for hip replacement - best position for them to be in

on nonopertive side with legs abducted (away from mid line)

avoid positioning the child with cleft lip on what side

on the side of repair pr in the prone position becaseut eh ycan cause rubbing of the surgical site on the mattress position them on back upright

While making rounds, the nurse finds a client with chronic obstructive pulmonary disease sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, what should the nurse do next?

open the childs airways

respiratory condition ph and pco2

oposite effects

The client with retinal detachment in the right eye is extremely apprehensive and tells the nurse, "I am afraid of going blind. It would be so hard to live that way." What factor should the nurse consider before responding to this statement?

optimisim is justifed bc surgiacl tx is 90-95% successful

water enters the body in 3 ways

orally ingested liquods water in food water formed by oxidation of foods

Which suggestion would be most appropriate in helping parents to prepare their children for entry into school?

orient child to schools physical envt

What should the nurse do to ensure safety for a hospitalized blind client?

orient the person to the room

A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply.

orthopnea (sob) cough crackles

palliative care vs hospice

palliative: treats pain and symptoms/no life expectancy/comfort (does not mean end of lfie care) hospice: theres and end date

A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will

palpate bladdar above the symphysis pubis

leopolds maneuver is

palpation to determine presentation and position of the fetus and aid in the location of fetal heart sounds

scabies

parasitic skin disorder cuased by itch mite fine gray lines

parenteral vs enteral

parenteral: iv enteral: gi tract

play for toddlers

parrallel play

laissez- faire leader

passsive

when patching the eyes to help this, which is patched

patch the good eye so the weak eye can get stronger

relationship with ph and pco2 and hco3

pco2 = opposite

low salty food

peas, nuts, cauliflower

inteventions for lice

pediculicide product is used

During a childbirth preparation class, a primigravid client at 36 weeks' gestation tells the nurse, "My lower back has really been bothering me lately." Which exercise suggested would be most helpful?

pelvic rocking

drug used for anthrax

pennicillin

appendicitis - when it becomes inflamed or infected

perforatio may occur in hours leading to peritonitis, sepsis, septic shock and potentially death

stage 4 of labor

period 1-4 hours after birth -monitor lochia

phi stands for

personal health info

why do pregnant women take folic acid supplements

pevent neural tube defects and orofacial clefts in the fetus

abg levels ph, pco2, hco3, pao2

ph: 7.35-7.45 35-45 21-28 80-100

every state in the us requires screening for what

phenylketo..

what are key signs of meningitis

photophobia and stiff neck

assess for skin turgor

pinch large fold of skin and it needs to return - if too long = severe dehydration or weight loss cap refill - needs to be under 3 seconds

if chest tube is pulled out of chest

pinch skin opening together, apply occulsive sterile dressing and cover the dressing with overlapping peices of 2 inch tape and call hcp

The nurse is evaluating the pin insertion site of a client's skeletal traction. Which finding indicates a complication?

pins moving slightly at insertion site

if hypercyanotic spells occuring in infants waht do you do

place child in knee to chest position administer 100% oxygen adinister morphine suldate give fluids intravenously

A child has just returned to the pediatric unit following placement of a ventriculoperitoneal shunt for hydrocephalus. The child is placed in a supine position. What is the nurse's priority intervention?

place the child on opposite side of shunt

A parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to:

place the chld in a sitting position and face down holding pressure to septum

Upon assessment of third-degree heart block on the monitor, what should the nurse do first?

place transcutaneous pads on the client

A neonate was born to a mother diagnosed with hydramnios in utero. When the first feeding was given, the newborn began coughing, became cyanotic, and was having difficulty breathing.The nurse suspects esophageal atresia. Which is the priority nursing action for this neonate?

placing the infant in an upright 60 degree angle

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

platelet count, prothrombin time, and partial thromboplastin time

A 9-month-old infant with eczema has lesions that are secondarily infected. Which recommendation is the most appropriate to help the parents best meet the needs of the child?

play with the child everyday

A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (select all that apply)

pnemoncoccal immunization yearly eye exam periodic mental health screening annual fecal occult blood test

post op complication: pneumonia and atelectaisis intervention:

pneumonia - inflammation of the alveoli can come 3-5 days after atelec - collapsed state of lung that comes 1-2 days after - assess lung sounds, resposition

crackles are heard with

pneumonia, heart failure, asthma

what causes leukocytosis (increase wbc)

pneumonia, infection, bowel perf, solumedrol (steroid)

complicatins with central line palcemens

pneumothorax and air embolism

hyperglycemia signs

polydipsia, polyuria, polyphagia, blurred vision, weakness, wt loss, syncope

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

position client on side with knees flexed

What should the nurse do first after an 18-month-old child returns to his room following insertion of a ventriculoperitoneal shunt?

position him on side opposite the shunt

administer ng tube feedings: position of bed, assess tube placement, for bolus feeds, for continuous feeds

position: hgih fowlers psoiton asses tube place: aspirating gastric contents and measuring the PH (should be 3.5 or lower) bolus: high folowers for 30 min after feeding continuous: semi fowlers at all times

A 34-year-old client birthed a healthy baby boy 5 days ago. The client is experiencing insomnia and weepiness, lasting for short periods of time each day. What factor/condition does the nurse believe is causing this experience?

postpartum baby blues

rombergs test

posture and balance

The nurse has assisted a multigravida with a precipitous birth of a term neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication?

precipitous = rapid lbaor encourage the mother to breast feed infant

anemia in a pregnant mom

predisposes clien to postpartum infection and hbg and hematocrit are low

A young adult client diagnosed with bipolar disorder has been managing the disorder effectively with medication and treatment for several years. The client suddenly becomes manic. The nurse reviews the client's medication record. Which new medication may have contributed to the development of his manic state?

prednisone

what medicaiton cant be stopped 24 hours before going npo before surgery

prednisone because stopping corticosteroids like that is bad

if a mom has hepatitis b - what is the mom at risk for

prematurity, low birth weight and neonatal death increaes

what would you assign a new RN

premedication before reduction of a fracture - child has been crying and is resistant to any touch to the arm or other procedures

A client with atrial fibrillation is prescribed warfarin. How should the nurse explain the purpose of this medication to the client?

prescribed to reduce risk of having a stroke

how do you make sure otic meds get into inner ear

press down of tragus

A nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should

press the right upper ab As the right upper abdomen (the area over the liver) is compressed for 30 to 40 seconds, the nurse observes the internal jugular vein. If the internal jugular vein becomes distended, a client has positive hepatojugular reflux. Hepatojugular reflux, a sign of right-sided heart failure, is assessed with the head of the bed at a 45-degree, not 90-degree, angle.

decreased pulmonary blood flow causes

pressure on the right side of the heart to increase exceeding pressure on the left side allowing desaturated blood to shunt right to left causing desaturation in the left side of the heart and systemically causing deoxygenated blood to be pumped systemically

difference between placenta previa and abruptio placentae

previa - painless, bright red veginal bleeding, uterus is soft and relaxed and nontender abrup- there is dark red bleeding, uterine pain or tenderness or both and uterine rigidity

An employee health nurse is assisting a stressed working mother with value clarification. Which best defines value clarification?

process which people understand other own values

hydrocolloid dressings

promote healing in stage 2 pressure ulcer injuries since want moist bed

Amantadine does wht

promotes effects of dopamine

why does a fertilized ovum stay in the fallopian tube for 3 days

promotes fertilized ovums normal implantation in the top portion of the uterus

high risk conditions for sids

prone positon, use of soft beeding, overheating, cosleeping, mother who smokes, exposure to tobacco

chronic kidney disease - what is restricted

protein (kidney = high protein and high k)

hospitalized infant and todder - seperation anxiety

protest: crying screaming despair: withdrawn, uninterested in envt detachment: becomes interested in envt, plays with others, and adjusts

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which action should the nurse take to best ensure the safety of the client while complying with policy?

provide a bed that is low to the floor - not give call bell

A school-age child has been diagnosed with Graves' disease and is to start drug therapy. Which instruction should the nurse include in the teaching plan for the child's parent and teacher?

provide client with calm non stimulating envt

A 75-year-old woman is having difficulty remembering to take all of her medications. Which of the following nursing interventions will assist her to improve adherence to the medication schedule?

provide med administration aid

what to do for kid with mild to moderate dehydration

provide oral rehydration therapy with pedialyte

hypertonic contractins - what is the intervention

provide pain relief measures

maselows hierarchy of needs

psychological needs safety and security low and belonigng self esteem self actualization`

freuds stages - dvelopement

psychosexual oral (birth-1) anal (1-3) phallic (3-6) latency (6-12) gential (12-puberty)

erik eriksons theory

psychosocial development - each crisis must be resolved to progress emotionally. if not, can leave the person emotionally disabled

testing ears of an adult (otoscope)

pull pinna up and back

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level?

pulse rate

A client diagnosed with glaucoma and receiving beta-adrenergic blocking ophthalmic drops makes each of these comments. Which one requires immediate follow-up by a nurse?

pulse rate is low today because of digoxin -beta adrenergic blocking agents may decrease heart rate and blood pressure)

during pregnancy what happens to : -pulse -bp -rr

pulse: increase about 10-15 bpm bp: decreases in 2nd tri then increases in 3rd but not permanent rr: unchanged and slightlt increases

kohlberg: what factor motivates good and bad actions for the hcild at preconventional level -peer pressure -social pressure -parents behavior -punishment and reward

punishment and reward

pustule vs vesicle

pustule is the same as vesicle expect it has purulent fluid drainage (lesions begin as both of these w impetigo)

paralysis of all four extremities and usually also the trunk.

quadriplegia

A client who weighs 175 lb (79.4 kg) is receiving aminophylline (400 mg in 500 ml) at 50 ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician, who instructs the nurse to change the dosage to 0.45 mg/kg/hour. The nurse should

question the dose bc too low

An intoxicated client is admitted to the hospital for alcohol withdrawal. What should the nurse do to help the client become sober?

quiet room to sleep in

race and pass with fires

race - rescue clients, activate alarm, confine the fire, extinguish pass - pull pin, aim, squeeze, sweep

foods high in potassium

raisins, potatoes, cantaloupe and strawberries

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl (26.1 mmol/L). Which finding is most likely to accompany this blood glucose level?

rapid and thready pulse

nonstress test and contraction stress test results

reactive non stress test = normal, negative negative contracton stress test (normal)

A registered nurse is caring for a group of clients on a psychiatric unit. Which task can the nurse delegate to the licensed practical/vocational nurse?

redressing lacerations

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching?

reduce the risk of post op complications

A client asks why a 2.5% hydrocortisone cream prescribed for eczema can't be used for longer than 1 week. What is the nurse's best response?

reduces adverse effects such as skin atrophy and fragility

A nurse determines that a client has 20/40 vision. Which action by the nurse is most appropriate?

refer to hcp - sees 20 when normal ppl see 40

A nurse plans a conference to discuss the care plan for an infant admitted to the hospital with a diagnosis of nonorganic failure to thrive. Appropriate participants in the care conference include the:

registered dietitian rn physician infants primary caregiver

Pacemakers: what does it do

regulates hr and makes it go at a reg rate. (reglate intensity (how much stimulated to fire), external ones during code, internal ones in cath lab, inplantable permenant for 10-15 years)

the lie of the baby during labor

relationshop of the spine of the fetus to the spine of the mom -longitudnal or transverse (c section needed)

An expected outcome of theophylline ethylenediamine when administered to a client with chronic obstructive pulmonary disease is:

relax bronchial smooth muscle

The nurse provides care for a client who receives chemotherapy as treatment for a diagnosis of cancer. Which alternative/complementary therapy will the nurse recommend for the client if assessment data includes BP 186/92 mm Hg, P 102 beats/minute, and verbal expression of anxiety? Imagery. Meditation. Relaxation. Biofeedback.

relaxation - known to lower blood pressure and heart rate, reduce manifestations of stress, (such as muscle tension), improve mood and state of wellbeing, and reduce manifestations of distress, including anxiety. Relaxation is easily learned and can be quickly applied for therapeutic effects. imagery: mind-body connection, which is helpful in reducing pain and nightmares and improving sleep. meditation - reduce alcohol/drug treatment relapses, and to help clients with post-traumatic stress disorders or with chronic pain

major goals of therapy for eczema

relieve pruritus, lubricate the skin, reduce inflammation and prevent or control secondary infections

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first?

removing the client from the room

client at risk for getting K deficiet bc of

requiring ng suctioning

if obstruction of airway or depression of respiratory system =

resp acidosis

assessment of cares for a newborn

respirations apgar score

what are the effects of mag sufate toxicity

respirations of 10 urine output of 20 ml/hour

adverse effect of morphine sulfate

respiratory depression and cough reflex issues

The nurse is assessing a client who is receiving normal saline intravenously at 100 mL/hr through the right forearm. The nurse observes that the forearm is swollen, cold to the touch, and pale. What action would the nurse take?

restart infusion at a diff site

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?

restrict sodium

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?

restrict sodium (cushings is too much cortisol)

Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)?

restrict staff and visitors with active infections

post op complication and intervention: urinary retention

result of loss of muscle tone minitor assees for distended

initial manifestations of rsv

rhinorrhea (NASAL cavity filled with fluid) eye or ear drainage pharyngitis coughing sneezing wheezing intermittent fever

A client is taking acetylsalicylic acid (ASA) for pain control. Which finding should the nurse report to the healthcare provider immediately?

ringing in the ears

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

rising bp an brady (cushings triad)

Which nursing diagnosis is the priority for a client with burns to 35% of the body surface area?

risk for infection

why avoid lying supine when pregnant during 2nd and 3rd trimester

risk for supine hypotension as a result of pressure of the uterus on the inferior vena cava

plague is found in

rodents and fleas and can be contracted by being biten

A client with type 1 diabetes mellitus must learn how to self-administer insulin. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

rotate inhection sites in same anatomic region

isotnoic vs hypotonic vs hypertonic

same osmolality as the body and increases extracellular fluid more dilute than body, causes movement into the cells and should be given slowly. Cellular edema. (for dka since cells dehydrated) more concentrated than body; moves water from cells to extracellular fluid by osmosis (dehydration)

scapegoating triangulation multigenerational issues

scapegoating: one child who has not completed his chores may be blamed for the entire family not being able to go on an outing (Small to big) triang: one parent may become strongly allied with a child and other parent uninvolved multi: emotional issues with the family that continue for atleast 3 generations

schema, schemata, assimilation, accomidation defintions to cognitive development

schema: cognitive structure or framework of thought schemata: categories to organize and understand the world assimilation: incorporate new ideas into thoughts accom: change chema to introduce new ideas

A toddler is brought to the emergency department after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which intervention first?

securign the airways

An older client reports episodes of severe anxiety resulting in shortness of breath, palpitations, chest pain, dizziness, and nausea. The physician prescribes lorazepam. What effect of this medication would be most important for the nurse to monitor on this client?

sedation

communcation for preschoolers

seek oppurtunities to offer choices

magnesium sulfate is given for

seizure precautions and high blood pressure prepare them to feel "stuck"

semi fowlers vs fowlers vs hgh fowlers

semi - 30 fowlers - 45-60 high - 60-90

When assessing a client who has had spinal anesthesia, which finding is expected?

sensation resturns to the toes first then progresses to the perinatal area

hospitalized preschooler seperation anxiety

seperation anxiety is less obvious and less serious but with more stress, jarder to leave parents protest: less directive then toddler despair: quiet, depressed and uninterested similar to toddler

rotavirus is a cause of

serious gastroenteritis and is a nosocomial pathogen that happens to kids from 3-24 months

When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value?

serum creatinine

The nurse is developing interventions to prevent a client with an eating disorder from developing refeeding syndrome. Which interventions are appropriate? Select all that apply

serum electrolytes, administer fluid replacement and monitor vitals

A woman is taking oral contraceptives. The nurse teaches the client to report which complication?

severe calf pain

A diagnosis of hemophilia A is confirmed in an infant. Which of the instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?

sew thick padding on elbows and knees of childs clothes

quick relief meds for astham

short acting b2 agonists (for bronchodilation) anticholinergics (for relief of bronchospasm) systemic corticosteroids

After instructing a primiparous client who is breastfeeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she makes which statement?

should position the baby the same way during every feeding

if pulmonary vascular resistance is higher than systemic resistance =

shunt is from right to left

health risks for AA

sickle cell anemia htn heart disease cancer lactose intolerance diabetes mellitus obesity

screening for sickle cell anemia

sickle-turbidity test (sickledex) - get results in 3 min if the test is positive hgb electrophoresis is needed

side effect vs adverse effect

side effct: expect to happen adverse: unintended effect (dont want it to happen)

The nurse provides care to a client who is being prepared to receive an epidural patch for a postlumbar puncture headache. In which position will the nurse place the client?

side lying

monitor kids receiving chemo for

signs of infection, infection is a cause of death in immunosuppressed kids

cleansing enema from fecal impaction - before giving enema what positon

sims position

The nurse is instructing a competent client in their legal rights regarding ECT (electroconvulsive therapy). Which statement by the client suggests further explanation is needed

since i was in emergency involuntary committment, i will be unable to sign ect form myself

why does baby need vitamin k injection

since they are deficient, they need to prevent bleeding

isolation for child with rsv

single room or place in a room with another kid with rsv contact and standard precautions

kick counts for preg moms

sits or lies down on side and counts fetal kicks -fewer than 10 kicks in 2 consecutive 2 hour periods is bad

A nurse observes two 2-year-old children playing. The nurse documents what form of play as normal for this age group?

sitting side by side making sand castles

listening to heart sounds - what positioning should patients be in

sitting/leaning forward, supine or on left side (best for picking up extra heart sounds/murmur)

rhabdomyolysis is

skeletal muscle break down - creatine kinase verifys this

right eye cataract surgery - what should the pt do to position the right way for sleeping

sleep on left side

normal temperature of scrotum

slightly colder than body temp

COMT inhibitors do what

slow the breakdown of levodopa, thus prolonging its action

how to measure distance vision

snellen chart

clients who have a hard time chewing or swallowing should be on what diet

soft diet

prostaglandins do what for preg moms

soften the cervix causing it to dilate and efface given vaginally

solute vs solvent

solute is the one that is dissolved solvent is what the solute is dissolving in

diffusion is

solute may spread thru the solution or solvent spread from high to love concentration

babies with lactose intolerance use

soy formaula

A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?

spontaneous accelerations, fhr increases by 15 bpm lasting at least 15 seconds

what is a definitive test for tb

sputum culture bc it shows the presence of mycobacteria in culture

child is unconscious

squeeze cake frosting on gums and if still unscnscious give glucagon

liquid iron preparation

stains teeth - teach parents and kids that liquid iron should be taken thru a straw and teeth brushed after administration

what are guidelines that identify what the client can expect to receive in terms of nrusing care

standards of care

Streptokinase is ordered for a client diagnosed with a pulmonary embolus (PE). The client has I.V. heparin running at 1500 units/hr. Which intervention should the nurse anticipate implementing?

start a second iv

what is acute asthma attack called

status asthmaticus that is a medical emergency

oxytocin does what

stimulates smooth muscle of the uterus and increases the force frquenct and duration time mag sulfate should be accessable

A client is being discharged from the acute inpatient unit but needs further continuous supervision that is less intense than inpatient hospitalization. The nurse should refer the client to which setting?

subacute unit

When assessing a 13-year-old adolescent, what is an expected finding?

subjective judgements of right and wrong

subq and im gauge and needle length

subq: 3/8-5/8, 25-27 gauge im: 1-1.5, 22-25

when do minors not neeed consent

substance abuse, tx for sti, hiv, aids, birth control, preg and psych services

indication of perforated appendix is

sudden relief od pain and then increaes in pain accompanied by right guarding of ab

A client walks into the clinic and tells the nurse she has run out of money for crack, has crashed, and wants something to help her feel better. Which factor is most important for the nurse to assess?

suicidal ideation

client receiving continuous tube feedings needs to be placed

supine when providing care (bed bath, change linens) and shut off the feeding to prevent aspirtion turn back on and put into fowlers or semmi fowlers

what position is a client placed in for c section

supine with wedge untder right hip

What should the nurse teach the client with neutropenia to avoid?

suppositories or enemas

respiratory distress in babys is inability to produce

surfactant causing hupoxia and acidosis

myringotomy is

surgical incision to provide drainage of the purulent middle ear fluid

angioplasty

surgical repair or unblocking of blood vessel

tx for osteosarcoma is

surgical resection and chemo

Sudoriferous glands secrete which type of substance?

sweat

what is the diagnostic test for CF

sweat chloride test - increase in sodium and chloride in sweat and saliva

assessment of nephro

swelling or mass in the ab (firm, nontender, on 1 side) AVOID PALPATION OF THE AB

A 12-year-old with asthma wants to exercise. Which activity should the nurse suggest to improve breathing?

swimming

when are systolic mumurs heard vs diastolic murmurs

systolic after s1, dias after s2

The parent of a 2-month-old infant with colic states, "I don't know what to do anymore. She's up in the middle of the night crying all the time." What should the nurse tell the parent to do?

take baby for a drive (common for babies with colic - cry alot)

A group of people arrives at the emergency department reporting extreme periorbital swelling, cough, shortness of breath, and tightness in the throat. They report that someone threw a bomb that exploded at their feet. What is the best action by the nurse?

take them to decontamination room

absorption

taken into the body, affected by route

democratic leader

talk with the members

recephin and ampicillin

they are related so if allergic to one they are allergic to other

why is parkinsons patient administered lexapro

they can experience depression

An older adult is constipated and tells the nurse that this has not happened before. What should the nurse tell the client?

this can be a more serious problem (new onset can be tumor)

The client with heart failure asks the nurse about the reason for taking enalapril maleate. The nurse should tell the client:

this drug will dilate your bv and lower ur bp

drainage collection chamber of the chest tube

this is where the drainage collects

Which statement by a client who has been taking buspirone as prescribed for 2 days indicates the need for further teaching?

this medication can help my tight achy muscles

water seal chamber

this prevents the air from entering the pleural space -EXCESSIVE BUBBLING = AIR LEAK

What factor has the potential to lead to chronic respiratory acidosis in older adults?

thoracic skeletal changes

oral contraceptives are contraindicated for ppl w

thrombophlebitis, thromboemolic disorders, cardiovacular or cerebrovascular diseases, cancer, liver tumors, liver, htn and diabetes

The mother asks the nurse for advice about discipline for her 18-month-old. Which discipline strategy should the nurse suggest that the mother use?

time out

Which sign is an early indication that a client has developed hypocalcemia?

tingling in the fingers Neuromuscular irritability is usually the first indication that a client has developed a low serum calcium level. Numbness and tingling around the mouth as well as in the extremities is an early sign of neuromuscular irritability.

example of external fetal minitoring

toco or doppler

when does a kid master fine motor skills

toddler age

when is lordosis (pot belly) happen in kids

toddler age

hypoglycemia results from

too much insulin, not enough food or excessive activity

A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having which procedure?

tooth extraction

nurse executive

top level nurse manager

total vs partial vs marginal (low lying) placenta previa

total - internal cervical o's are covered by the placenta when cervix is dilated partial - lower border if within 3 cm of the internal cervical but not fully covering marginal - placenta implanted in th elower uterus

A mother comes to the clinic with her 5-year-old child who is complaining of a fever and sore throat. The nurse documents the client's tonsils as 3+. This rating means they're

touching the uvula

toxic dose of acetaminophen

toxic dose is 150 mg/kg or higher in children

A client's caregivers state that they childproofed their home for their 2-year-old. During a home visit, the nurse discovers some situations that show the caregivers don't fully understand the developmental abilities of their toddler. Which situation displays misunderstanding by the caregivers?

toy chest in front of second story locked window

if a pt is malnourished, what is their nutrition

tpn and lipids (extra calories to maintain nutrition)

if a person needs artificial airway for more than 10-14 days...

trache created to avoid mucosal and vocal cord damage that can be caused by endotrach tube

bronchitis is inflammation of

trachea and bronchi and occurs in association with upper respiratory infection (usually viral infection)

what is done for severe respiratory distress

tracheostomy and intrubation

3rd trimester and diseases after birth

transfer of maternal immunoglobulin provides fetus wit immunity to diseases for first few months after birth

primary assessment for emergency

trauma, chest pain, respiratory distress or cardiac arrest, limb amputation, acute neurological deficiets or if chemicals splash in eyes

trendelenburgs, fowlers, reverse trendelenburgs and semi fowlers

tren: feet elevated fowlers: 90 reverse tren: slighly elevated head semi fowlers: 30-45

true pelvis vs false pelvis

true: consists of pelvic inlet, midpelvis and pelvis outlet false: shallow protion about pelvic brim, supports ab viscera

true vs fake labor

true: contractions are back pain false: contractions in abs and groin (contractions are irregular and no dilation, effacement and descent

erik eriksons stages

trust vs mistrust autonomy vs shame and doubt initiative vs guilt industry vs inferirority identity vs role confusion intimacy vs isolation generativity vs stagnation intregrity vs despair (8) pg 258

how to determine length of ng tube

tube of tube at nose, extend to earlobe and then down to xiphoid process

tests for tb

tuberculin skin test or mantoux test -test determines whether a kid has been infected and has developed a sensitivity to the protein 9DOESNT CONFIRM THE PRESENCE OF ACTIVE DISEASE

neuroblastoma

tumor that develops in adrenal gland or retroperitoneal sympathetic chain

if a client is unable to get out of bed post surgery..

turn them every 1-2 hours

preventing pressure ulcer - turing and elevating

turning every 90 min and elevate hob at 30 degrees

interventions

tx and care are similar to hemophilia - administrating clotting factors child with bleeding disorder needs to wear medicalert bracelet

hodgkins disorder

type of lymphoma - malignancy of the lymph nodes that originates in a single lymph node or a single chain of nodes characterized by reed-sternberd cells

A client is receiving IV magnesium sulfate for severe preeclampsia. The nurse prioritizes what assessment finding as requiring immediate notification of the health care provider?

u/o of 20 ml/hr

vocational nruse

under a nurse - lpn

middle man manager

unit manager ad supervisor

adminstering chemo drugs, the provider needs

unless signed off and certified to be chemo nurse, cant administer chemo drugs - to be certfidied

how does this happen - 3 ways

urinary output wound drainage gi tract

What is a priority nursing assessment for an infant receiving phototherapy?

urine output (loose stool, rash and loss of insensible water loss)

client admitted 1 hour ago to post op area - what is mst carefully watched

urine output of 20 ml

The nurse is caring for a child with osteomyelitis who will be receiving high-dose intravenous antibiotic therapy for 3 to 4 weeks. What should the nurse plan to monitor?

urine specific gravity

low na = ? urine specific gravity

urine specific gravity is decreased

bishop score

used to determine maternal readiness of labor

local anethsia for laboring moms

used to lbock pain given just before birth

causes of postpartum hemorrhage

uterine atony lacteration hematoma

what assessment finidng should the nurse expect to note of placena abruptio

uterine tenderness

A primigravid client is 8 weeks' pregnant and has had her first examination. The healthcare provider stated the client has a positive Hegar's sign. The client is concerned that this sign means something is wrong. How should the nurse respond to this client's concerns?

uterus is softened. good sign

what to avoid after rupture membranes

vaginal exams

nurse is assisting hcp with removal of chest tube - what should the pt do

valsalva meaneuver (pinch nose and close mouth)

beliefs that influence behavior and process of deciison making

values

fluctuations in the baseline fhr is

variability

umbilical cord compression means waht

variable decelerations

Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice?

vbac is possible if not having classic uterine incisions

viral pneumonia vs bacterial pneumonia vs aspiration

viral: happens more often bacterial: serious infection that needs hospitalization when pleural effusion or empyema accompanies it aspiration pneumonia: food, secretions, liquids or other materials enter the lung and cause inflammation

The pediatric nurse is providing care for an infant who has been diagnosed with respiratory syncytial virus (RSV). What action best prevents the spread of this infectious microorganism?

wearing a face mask in close contact (not gown, gloves and goggles)

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant?

weighing an unclothed infant at the same time everyday

The client has heart failure and is taking a diuretic to promote fluid loss. Which is the most accurate method of determining the extent of a client's fluid loss?

weighing the client

thiamin deficiency can cause

wernicki korsakoff = encepalopathy or permanent brain damage

children with celiac disease have life long diet without

wheat, rye, oats, barley need vitamin supplements for iron, folic acid and fat soluble vtaimisn a,d,e,k

viral pneumonia assessment

wheezes or fine crackles productive or nonproductive cough

what to tell patients beofre going home on warfarin

when eat green leafy veggies it lowers the effect

A client who is a gravida 4 para 3 has been admitted to the maternity unit with contractions starting 4 hours ago. Which question is most appropriate during the assessment?

when is the baby due

what makes a critical test result critical

when out of the range of normal and is an extreme value that can impact patient in dsafety - can harm them if we don't act on results

full compensation

when ph is in normal range

polypharm

when shop for diff pharmacie for cheaper prices and they aren't keeping track so is there a risk for interactions

what is a fluid challenge

when someone is hypovolemic so we have to bump up their fluid (so maybe have low bp and need this to get them up

Which client statement indicates effective teaching about burping a breastfed neonate?

when switch boobs, burp baby

uterine inversion is

when uterus completely or partially turns inside out

If patient codes first thing they are going to want to know is

who isi taking care and the lab and vitals

children with respiratory disorders should be monitored for

wt loss and signs of dehydration

can patients family call rrt

yes

is breatfeeding okay with hep b

yes after neonate gets treatment

what is important to know about this tumor

you do not want to rupture it because is can cause cancer cells to spread thru ab, lymph system and blood

administering ear meds to kid younger than 3 vs older

younger is down and back older = up and back

what position helps kids during asthma attack

younger kids - tripod position older kids - sit upright with shoulders in hunched positon and hands on bed

general LPN guidelines

¡Administer oral medication ¡Administer IM/ SQ injections ¡Administer intradermal medications ¡Administer rectal, vaginal, eye, ear, nose or topical meds ¡Administer medication by a gastrointestinal tube ¡Administer some IV piggyback medications ¡Change dressings ¡Irrigate wounds ¡Monitor IV flow rate ¡Suction ¡Teach about basic hygiene and nutritional measures ¡Use the nursing process - data collection, planning, implementing, evaluation

general UAP guidelines

¡Ambulation ¡Basic skin care ¡Bathing ¡Client transport ¡Grooming ¡Hygiene measures ¡Positioning ¡Range of motion exercises ¡Some specimen collections, such as urine or stool

what can be delegated

¡Depends on organization & state laws ¡Taking vital signs ¡Feeling a patient (depends on dysphagia etc) ¡Medication administration (cant do this!!) ¡Discontinue an peripheral IV (in the ER we are allowed to but need to know if on any blood thinners) ¡ADLs, ROM, grooming, ambulation ¡Measuring I and O ¡Non-pharamacologic pain measures (ex: dimming lights etc) ¡Back rub, quiet environment Reporting changes in the status of a patient

age related changes to older people

•Decreased gastric acidity •Increase gastric pH •Lack of absorption of meds that require a lower pH •Decreased blood flow and surface area •Decreases absorption •Diminished gastric emptying •May diminish effectiveness of short-lived medications (could be inactive by the time they hit the small intestine) •Meds stay in stomach longer (increases risk of N/V) •Vomiting = elimination of med in emesis (fluid volume deficit) •Poor circulation •Parenteral (IV) meds are slowly absorbed •Can and will change peak serum drug levels •May require greater doses to produce therapeutic effect (consider metabolism and clearance) •Less muscle mass •Abnormal blood concentrations of IM medications•Diminished Cardiac Output •Increased body fat •Decreased body mass, fluid and serum albumin •Lipid soluble meds stay in fat longer (anesthesia) •Water soluble (antibiotics) are distributed in smaller volumes due to the decrease in total body fluid - increases risk of toxicity due to greater drug concentrations •Many meds bind to serum albumin = increase amount of free drug and a more intense drug effect

Ostomy assessment and care ostomy in descending colon vs ascending and transverse

•stoma: pink and since mucus membrane, moist, skin around is clean •Ostomy in descending colon - what expected drainage: more solid •Transverse: mix •Ascending: more watery

how to reduce aspiration risk

◦Assess gag reflex ◦OOB to chair for meals ◦Full Fowler's position when possible ◦Speech/swallowing consult ◦Administer medications on time to improve muscle control

how high should patient go on incentive spirometer

600-900

insulin dependence per trimester of pregnancy

1st: decreases 2nd and 3rd: increases after delivery: decreases

steps of oxygn therapy

Nasal cannula (1-6L) -> non rebreather (6-11 L) -> venturi mask (4-12 L)

what is a side effect of beta blockers

lower hr

im injection - how many is the max ml/injection site

no more than 3 ml

primary tx is

replacement of the missing clotting factors

encopresis is

constipation with fecal incontience - kids poop involuntarily and occurs without warning

sites for impetigo

face and around mouth, hands neck and extremities

what is the tricupid atresia

failure of tricuspid valve to develop and no communication exists between right atrium to right ventricle

high doses of oxytocin can cause

hypotension w rebound htn monitor vitals q 15 min

id, im and subq injection angles

intradermal: 10-15 subq: 45-90 im: 90

normal jaundice on a baby occurs when

after 24 hours in full term newborns and after 48 hours in premature babies

A client has had a cerebrovascular accident, which has affected the left side of the client's brain. The nurse should assess the client for which symptom?

aphasia (brocas area = excessive speech on the lft side)

beta blockers end in

-lol

where do africans perfer to die

at home

A client with major depression is taking tranylcypromine sulfate, a monoamine oxidase (MAO) inhibitor. The nurse understands that additional teaching is needed when the client reports eating which food?

aged cheese

small pox trasmitted thru

air droplets (papules are seen)

priority for acute epiglottis

airway patency is priority

Before administering a tube feeding to a toddler, which method should the nurse use to check the placement of a nasogastric (NG) tube?

check the ph of fluid aspirated from the tube

presbycusis

hearing loss

what lab values are monitored with type 2 diabetes

liver

what is scary about doing a pacemaker in thru the subclavian vein

could get a pneumothorax and puncture lungs

12 month old has a respiratory infection and rr of 35 breaths/min..what do

document finidngs - 20-40 bpm is normal

who is this most common with

down syndrome

lumbar puncture - during and after surgery pisition

during the surgery laterla (side lying) after: supine for 4-12 hours

lovenox is given for

dvt

asain americans and death

dying at home is bad luck

communication with infant vs toddler

infant: respond to nonverbal behaviors like holding, cuddling and touching toddler: approach them cautiously, take things literally, use play for demonstrations

positive bernigs sign means

memningeal irritaion client passively flexes the hip and knee in response to neck flexion and reports pain in vertebral column

fetal positions: -mentoanterior -sacroanterior

mento: face sacro:breech

excessive vomitting or gi suctioning can lead to

metabolic alkalosis

what needs to be kept at the bedside of a client with endotrach tube

resusitation (ambu bag)

ileostomy is located on what side

right side (liquiod form of stool)

A 28-year-old male is diagnosed with acute epididymitis. What should the nurse assess the client for when conducting a focused assessment?

severe tenderness and swelling in the scrotum

normal magnesium levels

1.5-2.5

what controls the amount of sodium reabsorbed by the kidneys

adrenal glands

total body fluid amounts to body weight in an adult vs older adult vs infant

adult: 60% older: 55% infant: 80%

irregular contractions in women during pregnancy

beginning after 16 weeks

what is key when a nurse delegates

follow up

anasarca aka

generalized edema

brown fat deposits on newborns produce

heat

what happens when rupture of amniotic membranes is done before term

infection becomes a risk

hypoventilation causes

resp acidosis

what is a common cause of bronchiolitis

rsv (acute viral infection)

unexpected death for a health baby younger than 1

sids - occurs in winter and during sleep periods

preventing infection w c diff requires

using bleach to clean it

atelectasis

when alveoli collapses

beers criteria is

•List of medications that are potentially inappropriate for older adults •Associated with falls, confusion and mortality •List is applicable to all older adults except those receiving palliative and hospice care •Lists are not comprehensive or would be rather extensive

t/f: contractions increae in duration and intensity during true labor

yes

Who see first -sharp chest pain with sob and cough Lower back pain w hematuria - Elevated ST segment, troponin 2.0 and chest pain 10/10 Complaining of migraine with visual disturbances and bp of bp 190/90

(sharp cp with cough isn't emergent) SECOND BC WANT MORE INFORMATION THIRD - THIS IS HEART ATTACK. (over 0.4 is bad) SEE THIS FIRST

how does protein binding work with meds

"taking turns" - inside blood vessel protein = albumin (some drugs have protein binding) - body breaks drug down it binds to protein and once hits albumin cant go thru the bv wall - so when drug is albumin bound = not going to tissues once unbinds -> goes to tissue

Q: purewick catheter what can a UAP do?

-place a purewick catheter and document ouput from them

interventions for epiglottitis

- do not measure temp oral route, try to visualize posterior pharnyx or obtain throat culture -maintain npo -avoid supine position

bowel and bladder control as a kid

bowel before bladder control age 3- fairly good control of both

The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." How should the nurse respond?

-You're frightened. This is a hospital and these people are staff members. You're safe here.

how to improve communication with parkinsons patient

-be patient -dont let others finish sentences for them -intentional effort to be loud

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods?

-fats

A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer, is concerned about developing cancer. As a member of the oncology multidisciplinary team, the nurse should suggest that the client ask the physician about which topic?

-genetic counseling

The question by the nurse that demonstrates the nurse's understanding of Mallory-Weiss tearing i

-has your partner has recent forceful vomitting

The nurse is participating in a blood pressure screening event. After three separate readings taken at least 2 minutes apart, the nurse determines that a client has a blood pressure of 160/90 mm Hg. What should the nurse advise the client to do?

-have blood pressure evaluated within a month

A nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-damp dressing. Which guideline is appropriate for a wet-to-damp dressing?

-should keep the wound moist

some assessment findings for abortion

-spontaneous bleeding -low uterine cramping -blood clots -hemorhage and shock if bleeding a lot

pitting edema: +1, +2, +3, +4

1 - 2 mm 2- 4 mm (few seconds) 3- 6 mm (10-20 seconds) 4- 8 mm (>30 seconds)

The nurse works in an extended care facility with older adult clients. Which recommendations by the nurse will promote better sleep for this population? (Select all that apply.) -Get out of bed if sleep does not occur within 15 to 30 minutes. -Avoid taking naps unless they are scheduled activities every day. -Close the door or listen to quiet music to mask environment noise. -Consider the routine use of sedatives or hypnotics to promote sleep. -Take an analgesic 30 minutes prior to bed to decrease aches and pains.

1,2,3,5

fhr for fetus first trimester and after

160-170 per min and slows 110-160 near or at term

when do you change the feeding contiainer and tubing for NG tubes

every 24 hours

fertilization or 2 ova or spliting of 1 fertilized ovum

2 ova = fraternal or dizygotic 1 - identical or monozygotic

kid can run by what age

2 years old

For a client with an acute pulmonary embolism, the physician orders heparin 25,000 units in 500 ml of dextrose 5% in water (D5W) at 1,100 units/hour. The nurse should administer how many milliliters per hour?

22 - To determine the number of units per milliliter: 25,000 units of heparin divided by 50 units/ml equals 500 ml of fluid. Because each milliliter of D5W contains 50 units of heparin and the nurse must deliver 1,100 units/hour, perform this calculation to determine the milliliters per hour of I.V. solution flow: 1,100 units/hour ÷ 50 units/ml = 22 ml/hour.

positive and nehative forces for asain americans

yin and yang - illnesses are an imbalance bt the two

The nurse provides care for clients from multiple cultural backgrounds. Which nursing action reflects the delivery of culturally congruent care? Applies general cultural knowledge to clients of that culture. Explains the necessity of using set schedules for medications. Explores sources of possible client discomfort with personal care. Accepts the limitations of always providing culturally sensitive care.

3 Culturally congruent care may require the nurse to explore sources of client discomfort with personal care. A common source of discomfort is related to care provided by a person of the opposite sex as the client.

The nurse provides care for a pregnant client who is at 18 weeks' gestation. Which assessment finding is most likely to cause the nurse to suspect the presence of a hydatidiform mole? The health care provider is unable to detect fetal movement. The nurse is unable to detect a fetal heartbeat using a Doppler. An ultrasound of the uterus reveals fluid filled grape-like clusters. The fundus of the uterus is one finger breadth above the umbilicus.

3 - A diagnostic ultrasound that reveals fluid filled grape-like clusters is indicative of the presence of a hydatidiform mole.

adequate renal perfusion (ml/hr)

30 ml/hour for preg person

+4,3,2,1 pulses

4 - bounding 3 - full pulse and increased 2 - normal 1 - weak and barely palpable

rbc men vs women

5-6 mill w 4-5 mill

closure of cleft palate occurs

6-24 months to allow for palatal changes that occur with normal growth

Which hospitalized client is at risk to develop parotitis?

80 year old with poor oral hygiene and dehydration

why getting peaks and troughs

Antibiotics to make sure its at a therapeutic level and that they are metabolizing and excreteing it

burst of energy 24-48 hours befor labor is called

nesting

sustained release capsules and enteric coat pills

never crushed

A nurse is developing a care plan for a client with injury to the frontal lobe of the brain. Which nursing actions would be part of the care plan? Select all that apply.

Damage to the frontal lobe of the brain affects personality, memory, reasoning, concentration, and motor control of speech. The client will not experience a loss in sensory data. Damage to the temporal lobe, not the frontal lobe, causes hearing and speech problems. Damage to the occipital lobe causes vision disturbances. Damage to the brain stem affects vital functions.

celebrex is used for

Decrease inflammation and pain of degenerative joint disease

A client is experiencing autonomic dysreflexia. The nurse should first:

place in fowlers posotion (elevate the hob first)

furosemide is taken with

potassium - need k level

aa - prolonged eye contact =

rudeness

A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (select all that apply)

Increase protein intake to increase muscle mass Increase calcium intake to prevent osteoporosis Limit sodium intake to prevent edema Increase fiber to prevent constipation

interventions for preschoolers in hospital

safe and secure envt take time for communicaton allow them to express anger

A client is brought to the ED with complaints of pressure in his chest. Vital signs: 140/64, HR 96, RR 20. The nurse administers 0.4mg sublingual nitroglycerin as ordered. Five minutes later repeat vital signs: 100/60, HR 98, RR 20. What should the nurse do first? a)Notify the physician the client is hypotensive and obtain an order for a fluid challenge. b)Place the client in Trendelenburg position and apply oxygen at 6 L/min. c)Administer a second dose of nitroglycerin d)Document the results and continue to monitor the client.

Nitroglycerin is a vasodilator for angina Expect the bp to drop since giving vasodilator (once dissolves, every vessel dilates and the volume of blood drops which drops bp) Importatnt to reassess chest pain number

hypoxic relation

same as holding a pillow over someones face

steps of pulmonary circulation

Pulmonary circulation is the movement of blood from the heart, to the lungs, and back to the heart again. Deoxygenated blood is ejected from the right ventricle into the pulmonary artery and then into the lungs via the arterioles and alveoli. The pulmonary vein then carries oxygenated blood back to the left atrium for circulation throughout the body

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then

advance both crutches

The nurse provides care for a client who receives chemotherapy as treatment for a diagnosis of cancer. Which alternative/complementary therapy will the nurse recommend for the client if assessment data includes BP 186/92 mm Hg, P 102 beats/minute, and verbal expression of anxiety?

Relaxation, either passive or progressive, is a complementary/alternative therapy known to lower blood pressure and heart rate, reduce manifestations of stress, (such as muscle tension), improve mood and state of wellbeing, and reduce manifestations of distress, including anxiety. Relaxation is easily learned and can be quickly applied for therapeutic effects.

how to ensure continuty of care

SBAR

what system returns negative pressure to the intrapleural space

chest tube drainage system removes abnormal accumulations of air and fluid from the pleural space

When administering a beta-adrenergic agonist to a patient older than 65 years of age, what response do you anticipate?

The dosage will need to be increased to provide an effective response.

first stage of labor phases

The first stage of labor is categorized into three phases: latent, active, and transition. During the active stage of labor, intermittent fetal monitoring is performed every 30 minutes to detect changes in fetal heart rate such as bradycardia, tachycardia, or decelerations in a low risk labor. If complications develop, more frequent or continuous electronic fetal monitoring may be needed. During the latent phase, intermittent monitoring is usually performed every 1 hour because contractions during this time are usually less frequent. During the transition phase, intermittent monitoring is performed every 5 minutes because the client is getting closer to the birth of the baby. Pushing occurs in stage II of labor, and monitoring continues to occur every 5 to 15 minutes.

how to relieve thirst

chew gum freeze fluids add lemon juice to water gargle with mouthwash

rhythmic respirations with apnea

cheyne-stokes respiations

A patient is informed that he has benign prostatic hyperplasia (BPH) and the practitioner prescribes finasteride (Proscar). The patient states that he would like to take saw palmetto instead of the Proscar. The nurse should inform him that this herbal supplement: A.May be taken after consultation with the practitioner B.Should be taken on an empty stomach for best results C.Will relieve symptoms by altering the size of the prostate D.Can cause a regrowth of hair lost to male pattern baldness

a

The nurse in labor and delivery provides care for a client who is Muslim and in active labor. The client's labor is long and difficult. Which cultural practice will the nurse expect after the birth? The parents will pin an amulet with a blue stone to the neonate's clothing. The mother will call out to the neonate by the name selected prior to birth. The father will not engage in close contact with the neonate for one month. The mother will ask the nurse about sterilization to avoid future pregnancies.

a

The nurse is assigning unlicensed assistive personnel (UAP) to assist the following clients to ambulate. It would be most important for the nurse to review safety precautions with the UAP prior to ambulating the a)44-year-old client with Meniere's disease b)59-year-old client with a unilateral cataract c)62-year-old client with presbycusis d)65-year-old client with sinusitis

a

The nurse manager is concerned about cultural awareness among staff nurses. Each nurse is given a questionnaire to help identify the areas of personal cultural awareness that need to be examined. Which question will provide the staff nurses with important information to promote cultural awareness? "Do you have an in-depth understanding of your own background?" "How do you assess clients for cultural beliefs that influence medical care?" "What methods are useful in providing client teaching regarding your beliefs?" "How do you protect your cultural beliefs when caring for a client of a different culture?"

a

A local disaster results in multiple injuries that will require hospitalization. The nurse manager at the only acute care facility in the community will need to clear beds for the new admissions. Which clients will the nurse manager decide to discharge? (Select all that apply.) ANSWER SELECTION 1. A client who delivered her third child vaginally 18 hours prior. 2. A middle-age client who had a hip replacement 24 hours prior. 3. An adult client diagnosed with pneumonia receiving IV antibiotics. 4. An older adult client diagnosed with a stroke due to a brain bleed. 5. A school-age client who was just admitted due to an asthma attack.

a - 3rd child and can get teaching for signs b- 24 hours post op

A client presents to the clinic for a follow-up visit for hospitalization due to uncontrolled diabetes. Which of the following assessment findings indicates a complication of diabetes mellitus?

bp high

when doing cpr - where check pulse and how deep are compressions

brachial artery 1/3 of chest depth (1.5 inch)

MAO-B Inhibitors: (Eldepryl, Azilect) do what

breakdown dopamine

The nurse performs a health history assessment for a client in high school. Which statement by the client prompts the nurse to intervene due to safety concerns? (Select all that apply.) "It is really exciting that my best friend has a car and driver's license." "Both my parents have evening jobs, so I frequently eat out for my dinner." "I like to hang around with my friends on the weekend and play video games." "There is a kid at school who constantly bullies me. I cannot stand it anymore." "My parents seem to understand that I am older and need more independence."

a, d

A new nurse working on a mental health unit observes a senior nurse administer a parenteral dose of haloperidol to a client against the client's wishes. What should the new nurse do in response to this observation?

advise the nruse that a change of batttery could be made

A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?

acute pain (not risk for constipation)

otitis media is a complicaiton of what

acute respiratory infection

kawasaki siase is

acute systemic inflammatory disease that involve cardiac prlbmes

acetylsalicyclic acid or aspirin acute vs chronic ingestion

acute: 300-500 mg/kg chronic: ingestion of ore than 100 mg/kg per day fr 2 days or more

acute vs subacute vs convalescent tage

acute: fever, red throat, swollen hands, rash, conjunctival hyperemia subacute: cracking lips, dequamation, joint pain conn: normal but inflammation present

low/high potassium diet for patients w

addisons for low and cushings for high

if see late deceleration in a mom, what does nurse do

administer oxygen

pt complains of sudden sharp chest pain and dyspnea. client is tachycardic and rr is elevated. pulmonary embolism is happening - initial nursing action

administer oxygen 8-10 l/min by face mask

when give rh immune globulin

administered to rh ngative patient at 28 weeks gestation and 72 hours after delivery

Which measure is likely to provide the most relief from the pain associated with renal colic?

administering morphine (not increase fluid)

when nitroglyceride tablet doesnt work

adminster another nitroglycerin tablet - can give 3 5 min apart (this will lower bp - this is expected)

what is a childs behavior that is formal operations stage

ability to think abstractly understanding envt - sensorimotor stage classify order and sort - concrete operations think past present and future - preoperational phase

signs for readiness for toilet training

able to stay dry for 2 hours, wake up dry from nap, recognizes urgent

absent variability, decreased variability and temporary decrease

absent: nonreassuring decreased: comes from hypoxemia, acidosis and meds temp: when fetus is sleeping minimal: no more than 5 bpm moderate: 6-25 bpm marked: >25 bpm

When performing a physical assessment on a postterm neonate, the nurse expects to find

abundant subq fat

brief, increase in fhr or atleast 15 bpm and lasts 15 seconds

accelerations - usually are fetal movement

The nurse is caring for a client newly diagnosed with human immunodeficiency virus (HIV) obtained during unprotected sex. The nurse is in the room when the client is explaining the disease to another person. Which statement by the client would the nurse clarify? Select all that apply.

afraid to give disease to nephew and meds can cure me

banana bag is given to

alcoholic patients

A charge nurse is making arrangements for an elderly client newly admitted from the emergency department for treatment of suspected pyelonephritis. The charge nurse notes that the client has been assigned to a semiprivate room with another client who has the same last name. What should the nurse do first?

ask admissions department to assign to a new room

children and the latinos

ask permission to touch becaseu prevent evil eye

if the ng tube is incorrectly placed - what are they at risk for

aspiration

A nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to avoid breast engorgement?

breast feeding whenever the baby is hungry - not apply warm compresses

triage for emergency

brief assessment of victims

findings on assessment for placenta previa

bright red vaginal bleeding seoft relaxed nontender uterus fundal height greater than expected for gestational age

inflamation of bronchioles that causes production of thick mucus

bronchiolitis

bronchophony vs egophony

broncho - ask to say 99 ego - E sounds

blowing or swishing sounds hear with bell of steth

bruit

A 14-month-old client weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the client's room, the nurse anticipates using which traction system?

bryant traction

low residue diet is

same as low fiber diet and avoid whole wheat pasta since has most fiber

A 14-month-old client weighing 26 lb (11.8 kg) is admitted for traction to treat congenital hip dislocation. When preparing the client's room, the nurse anticipates using which traction system?

bryants traction (kids)

toxic effect

build up of body not being able to metabolize or excrete so have high level of it

how is scabies transmitted

by close personal contact with an infected person - household members and contact of an infected child need to be treated simultaneously

The nurse is performing a nutrition assessment of a client from the Middle East. What may the nurse expect as a traditional breakfast consumed by a client from the Middle East?

cheese and olives

what happens to the fetal heart monitor when prolapsed cord

irregular and slow variable declerations or brady after rupture of membranes

ataxic respirations

irregular in rhythm and depth

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel. The nurse should develop a teaching plan that includes which points? Select all that apply.

bleeding and works to prevent platelets from forming

what is crucial to teach with antibiotics

bleeding precautions

Which antiparkinsonian drug can cause drug tolerance or toxicity if taken for too long?

levidopa-cardiopa

coaractation of aorta looks like

blod pressure is high in upper extremities rather than lower bounding pulses in the arms and weak in femoral cool extremities

A client has been diagnosed with septic shock. The nurse would anticipate implementing which order?

blood chem of serum lactate

hyperglycemia signs/causes/nursing

blurred vision, polyuria, polydipsia, dry membranes causes: infection or stress nursing: review nutritional intake, assess signs and perform testing

how is the diagnosis definitive

bone marrow aspiration

preferred site for IM injections

ventrogluteal of < 2 ml

car safety for 8 year old and 4 ft tall

booster seat - when reach 4 ft 9 inch or between 8-12 is booster seat rear facing car seat until 20 lbs or atleast 1 year old

A primigravid client at 26 weeks' gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which factor?

backflow of stomach contents into the esophagus

A client receiving a loop diuretic should be encouraged to eat which foods to prevent potassium loss? Select all that apply.

banana, dry fuit and oj

situational leader

based on current circumsances and events

While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first?

bathe the newborn (usually done 2-4 hours after birth)

why is fetal circulation bypass present

bc of nonfunctioning lungs -must close after birth to allow blood to flow thru the lungs and liver

why are kids more vulnerable to fluid volume deficiet

because most of their fluid is extracellular

late decelerations

begin after contraction and goes back to baseline when contraction ends

signs of icp

behavioral changes

popliteal pulse is located

behind the knee

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area?

below cheek bones

A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?

below normal urine osmolality level and above normal serium osmolality

duty to do good to others

beneficence

The nurse teaches the parents of a preschool child diagnosed with lactose intolerance how to incorporate dairy products into their child's diet. Which statement by the parent reflects the need for more teaching?

best to drink milk alone and not with meals

Aluminum hydroxide gel is prescribed for the client with chronic renal failure to take at home. What is the expected outcome of this drug?

binding phosphate in the intestines

An arterial blood gas for a client receiving oxygen at 4 L/min via nasal cannula has been ordered. Results show pH 7.37, pCO2 38, pO2 90. Which of the following should the nurse do first? a)Increase the flow of oxygen to 6 L/min b)Elevate the head of the bed c)Document the results d)Perform chest physiotherapy

c

The nurse has been made aware of the following client situations. The nurse should first assess the client: a)with diverticulitis who is reporting left lower quadrant (LLQ) pain. b)with chronic obstructive pulmonary disease (COPD) who is reporting hemoptysis. (coughing up blood) c)who had an evacuation of a subdural hematoma (brain bleed) 8 hours ago and has become agitated. who had a total knee replacement 8 hours ago and whose affected extremity is internally rotated

c 1st sign that the bleeding is worse is agitation next person would b copd

The nurse is caring for a client who is scheduled for a lumbar puncture. It would be most important for the nurse to assess the client for: a)bowel and bladder function. b)presence of Trousseau's sign. c)signs of increased intracranial pressure (ICP). d)circulation, movement and sensation of the legs.

c icp can hernate the brain when tap it

A construction worker is admitted to the hospital for treatment of active tuberculosis (TB). The nurse is educating the patient about TB. Which of the following indicates the client requires further teaching? a)"I will need medication for 6 months" b)"I should cover my nose and mouth when coughing or sneezing" c)"I will remain in isolation for at least 6 weeks" d)I will always have a positive TB skin test"

c only on for 2 weeks

A postoperative client has exhibited decreased urine output, hypotension, and tachycardia. Which nursing assessment is the priority?

chekc hte dressing

what are signs of patent ductus arteriosus

widened pulse pressure and bounding pulses

for early stages how do we tx

with extensive external radiation of the involved lymph node regions

The health care provider prescribes clomiphene citrate for a woman who has been having difficulty getting pregnant. When teaching the client about this drug, the nurse should discuss what potential adverse effects?

chance of multiple gestation

common adverse effect to medication in older adult

change in mental status

why is an older adult at risk for falls in genral

changes in neurological and musculoskeletal systems

frontline manager

charge nurs team leader client care coordinator

nursing actions for hypoglycemia

check bg level, give kid 1/2c of fruit juice, take vitals, give small carb or protein snack

what to do before given methyer maleate

check bp since can cause htn

A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should:

check the child at irreg intervals

A client with a gravida 1 para 0 term pregnancy was discharged home last evening in false labor. The client returns to the hospital stating she has had strong contractions for the past 2 hours. Which assessments will indicate to the nurse that the client is in true labor?

cervical dilation and effacement

what assessment tells the nurse a mom is in second stage of labor

cervix dilated urge to push is initiated

A client arrives in the clinic with a possible parathyroid hormone (PTH) deficiency. When analyzing client lab data, which electrolytes would the nurse anticipate to be abnormal? Select all that apply.

calcium and phosphorus

You are working on a medical-surgical floor. The nurse to patient ratio is 1:5, with minimal use of ECG monitoring. ACLS is not a requirement to work on this unit. A patient is having frequent seizures and a physician is asked to come see the patient. The patient has a seizure during the medical resident's assessment and asks the nurse to administer midazolam (Versed) 5 mg IVP. The nurse should:

call RRT Versed is not used to stop seizures, lorazepam (Ativan) or diazepam (valium) are used to stop a seizure. Then a long term anticonvulsant would be used after the short term use of benzodiazepines.

For a hospitalized client, the physician orders morphine, 4 mg I.V., every 2 hours as needed for pain. However, the client refuses to take injections. Which nursing action is most appropriate?

call the physician and get oral meds

leveling on meds for IVP meds - metopolol and tikosyn

can only give this if you can see the ecg monitor to watch if the patient gets brady - cardiac med that monitors cardiac responses for 3 days

cmv and pregnant people

cant b around cat liter

bacterial infection in the amniotic cavity

choirioamnionitis (pregnancy risk)

what to do first when client has air embolism

clamp all the ports and then turn them to left side lying position and lower their head past their feet (valsalva posiiton)

ng tube pt that is connected to suction needs meds - what does the nurse do

clamp ng tube for 30-60 min after giving meds

stge 3 of labor

contractions until placenta expelled placenta comes occur 5-30 min after birth of infant

The nurse provides care for a client who has immigrated from another country and is admitted to an acute care facility for medical management. The nurse is aware that it is important to assess the client's interpretation of the illness and treatment. Which question from the nurse is least helpful? ANSWER SELECTION "What are the main problems the illness has caused?" "What do you call the problem caused by your illness?" "How do you think this illness works inside your body?" "Are you the decision maker for your illness treatment?"

d - Asking the client if they are the decision maker for illness treatment is the least helpful question when assessing the client's interpretation of the illness and treatment. The question would be appropriate when determining cultural impact on health care.

What do we do with bradycardia:

determine if symptomatic, check manual bp -If have hr of 30, can start compressions If brady - next best thing is to check bp, not check lead placement bc have clear ptqrs wave

insufficient supply of insulin in someone with diabetes mellitus is

diabetic ketoacidosis

levin tube vs salem sump tube for NG

levin: normal one with one oepning - in nose or mouth to stomach salem sump: double lumen tube

signs of decreased c/o

decreased peripheral pulses exercise tolerance feeding problems hypotension irritability oliguria plae, cool extremities tachycardia

What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate?

decreased secretions Glycopyrrolate is an anticholinergic given for its ability to reduce oral and respiratory secretions before general anesthesia

how do you know asthma is worsening

decreased wheezing

early decelerations:

decreases in fhr below baseline -they happen during contractions, THEY USUALLY TRACE THE CONTRACTION

how to compensate for acidosis

deep and rapid respirations (kussmauls) to exhale the excess co2

aplastic anemia is

deficiency of circulating erythrocytes and all other formed elemens of blood - resulting from arrested development of cells in bone marrow

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

deficient fluid volume (could be dehydration)

A unlicensed assistive personnel (UAP) in an extended care facility reports to the nurse on the condition of an older adult client. The UAP states the client's respiratory rate is 22 breaths/minute and the oral temperature is 100.5°F (38.1°C). The client is also confused and disoriented. The nurse recognizes the probability of which client condition? Dehydration. Pneumonia. Infection. Stroke.

dehydration

The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse should tell them?

dehydraton is expected in the dying process

¡The process for a nurse to direct another person to perform nursing tasks and activities

delegation

induction is

deliberate initiation of uterine contractions that stimulate labor -can stop once contraction frequeny is <1 min

A client has been admitted to the emergency department. The client's family tells the nurse that the client has suddenly become lethargic and is "not making sense." The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has which problem?

delirium

if placenta abruptio is found, what is the intervention

deliver the baby

immunizations are given in what part of the body

deltoid

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance?

demonstrating control over agressive behavior

what type of preg people are most at risk for developing DIC

dead fetus syndrome severe preeclampsia hemorrhage

celebrex (nsaid) for parkinsons can cause

decrease effectiveness of hytrin

A client admitted with a diagnosis of schizoaffective disorder, manic phase, who is currently taking fluoxetine, valproic acid, and olanzapine as prescribed, has had an increase in manic symptoms in the past week. The health care provider prescribes a valproic acid blood level to be drawn at once. What does the nurse understand is the rationale for this prescription?

decrease level of acid could explain increase manic symptoms

vital signs of fluid volume deficit

decreased bp increased pulse decreased u/o

An 8-year-old child has been admitted to the oncology unit with a suspected diagnosis of acute lymphoblastic leukemia. The nurse is obtaining a health history from the parents. During the interview, the parents ask the nurse if any of the factors discussed would make their child more at risk for this type of leukemia. What information about potential risk factors is correct for the nurse to share with the parents?

diagnosis of down syndrome at birth

implantation of a fertilized ovum outside the uterine cavity is called

ectopic pregnancy (recognized by missed period)

The health care provider (HCP) prescribes intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which interval?

every 30 min during active phase

gpal

gravida =preg parity = nuber of births >20 weeks whether born or alive abortions: <20 weeks L-living

how to lessen the pain for gluocse monitoring in kids

hold the finger under warm water for few seconds before puncturing use the ring finger or thumb to obtain a blood sample because it flows easier

what increases the need for more insulin

illness, infection and stress increase it

what is given for tb

isoniazid, pyrazinamide and ridampon daily for 9 months - for preg mom, take py and iso to prevent neurotoxicity

post op complication and intervention: shock

loss of circulatory fluid volume, caused by hemmorhage elevate legs notify surgeon

The nurse teaches a postpartum client about how to intervene with complications that can occur with breastfeeding. What action, if stated by the client, would indicate to the nurse that the teaching was effective?

massage the milk ducts while feeding

what profession helps with adls

occuoaptional therapust

assessment of hodgkins

painless enlargement of lymph nodes enlarged, firm, nontender, movable nodes in the supraclavicular area non productive cough

what attracts and releases hydrogen ions

plasma

4 major factors tht interact with birth _4 p's

powers - contractions -effacement: thinning of cervix (1st stage) -dilation: enlargement of cervix (1st stage) -pushing of mother (2nd stage) passageway: external openig passenger: fetus, membranes and the placenta psyche: emotional structure

prealbumin and albumin difference

prealbumin is more recent protein albumin is longer

if client is pregnant and rh-

repeat antibodies screening and receive rhogam at 28 weeks

digoxin should be given

same time everyday

interventions for scabies

scabicide topical lindane shampooo permethrin is used and applied to cool dry skin atleast 30 min after bathing

A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which statement made by the parent would be most consistent with the diagnosis of Hirschsprung's disease?

she gets constipated often

child with integ disorder needs to be monitored for

signs of skin infection or systemic infection

dysphagia patients cant drink with

straws because risk of aspiration

after the infant can walk - what toysplay with

stuffed animals, crib mobiles, squeeze toys, muscle toys, rattles, water toys during bath, larg picture books and push toys

subjective vs objective data

subjective - waht they say objective - what you find

A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan?

teach the client how to prevent problems caused by immbobility

if patient is unable to give consent themselves...

telephone from legal guardian or power of attorney is ok

intussusception is

telescoping of one portion of the bowel into another

A nurse is caring for a 4-year-old child with end-stage leukemia. The child's physician has ordered a lumbar puncture. His mother, who has legal custody, has refused to give consent for the child to undergo the procedure. However, the child's father is demanding that the procedure be performed. What should the nurse do first?

tell dad that cant happen bc mom didnt sgn

A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:

tension and irritability

Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"?

test bg every 4 hours

sick day rules for diabetic kid

test bg every 4 hours, test ketones in urine with every void

how to identify rsv or bronchiolotis

testing of nasal or nasopharngeal secretions

isolation for kids with upper respiraotyr infections until..

the cause of it is known

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions?

the client will show no self harm or harm to staff (not oriented to person place and time)

a patient with increased uric acid means

they are a gout patient and need to be given alopurinol since low purine diet

what does it mean when patients gain 5 lbs in a week when have PN

they are having fluid retention (normal is 1-2)

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time?

this is normal (blue or purple hands bc of slow circulation)

uring a routine prenatal examination, a client who is at 32 weeks' gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action?

turning th epatient on her left side

iron is taken with

vitamin c to increaes the absorption. - also best absorbed in between meals

antidote for abnormal ptt/pt

vitamin k

when somene comes in with diarrhea what do u think

vitamin k

tetralogy of fallot involves 4 defects

vsd, pulmonary stensosis, overriding aorta, right ventricular hypertrophy

safety toys for a 3 year old

wagon - nothng small to choke on

A 14-month-old child has a severe diaper rash. Which recommendation should the nurse provide to the parents?

wash butt with mild soap

if theres a mother with terminal cancer receiving chemo and their child wants to come in what can they do

wash hands before snuggling the mom for a short period - it is ok since going to die

The mother of a 2-year-old who has been bitten by the family dog asks the nurse what to do about the bite, which appears to be a minor injury. What should the nurse tell the mother?

wash with water and call hcp

A client had a cystoscopy to remove a renal stone. Which laboratory data warrants immediate intervention by the nurse?

wbc of 14,000

The nurse is reviewing discharge instructions with a postpartum breastfeeding client who is going home. She has chosen depot medroxyprogesterone acetate (DMPA) inections as birth control. Which statement by the client identifies that she needs further instruction concerning birth control?

you give me the first dose before i leave today (they get it when return 6 weeks after birth)

what does the nurse tell the mom with HIV abut feeding her newborn

you must bottle feed

A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. What should the nurse tell the client about the anticipated treatment plan?

you will need tetanus toxoid

when is strabismus normal

young infants but shouldnt be present after 4 months

older adult definition

•65 years of age or older •Largest consumer of health care •Treatment of co-morbid conditions = POLYPHARMACY (5 or more) •30% of elderly hospital admissions are linked to drug reactions •Physiologic changes that affect absorption, distribution, metabolism and excretion of medications •Decrease function of vital organs for the pharmacokinetic process •The more physically active the less likely to experience altered drug responses

aspiration - how to assess this

•Small sip of water and then Swallow study

skin breakdown - how to assess/score

•braden score (can they move around themselves, are they sliding, are we keeping them dry?)

leveling medication adminisitration

◦Criteria for medication administration is based upon the degree and type of monitoring necessary to administer the medication, credentialing of those administering the medication (e.g. ACLS) ◦Emergent situations restricted medications may be given if a physician, medical resident, RRT nurse is present

what happens in brain wit parkinsons

◦Generalized slowness-loss of dopamine, a neurotransmitter in brain needed to initiate movement

preop check list

◦H&P, signed consent form, pre-anesthesia assessment, diagnostic tests 100% of the time need a time out that the circulating nurse stops and asks name,dob,surgery and wehre it is being done and the surgeon is doing it

why aspiration risk for parkinsons

◦Known Parkinson's Disease- ◦Slurred speech, drooling- control of muscles ◦Post anesthesia

To Reduce Risk of Falls

◦Out of bed with assistance ◦Make position changes slowly ◦Use of walker to increase stability ◦Call bell within reach ◦Use of soled shoes ◦Ask for Physical Therapy consult ◦Administer medications on time to improve muscle control

why must parkinson meds be on time

◦When medications work, the patient is "on" and able to initiate movements; Once levels drop, patient experiences "off" time and unable to initiate movements The "on-off" phenomenon in Parkinson's disease (PD) refers to a switch between mobility and immobility in levodopa-treated patients, which occurs as an end-of-dose or "wearing off" worsening of motor function or, much less commonly, as sudden and unpredictable motor fluctuations

why fall risk for parkinsons

◦postural instability ◦Sticky feet-inability to initiate movement ◦Post-operative/post-anesthesia/bed rest ◦IV infusing ◦Frail appearance ◦Medication risks?