Nclex Cram
Hypocalcemia
CATS Convulsions, Arrythmias, Tetany, spasms and stridor
Hypo-parathyroid
CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet
laparoscopy
CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup
Myxedema coma
COLD (hypothermia)
Paralytic ileus
Can occur due to the absence of GI peristaltic activity caused by abdominal surgery or other physical trauma
Beneficence:
Care that is in the best interest of the client
Causes for Deep vein thrombosis
Caused by dehydration, stress response that leads to hypercoagulability of the blood, immobility, obesity, trauma, malignancy, history of thrombosis, hormones, and use of indwelling venous catheter
Cholinergic Crisis
Caused by excessive medication ---stop giving Tensilon...will make it worse.
A nurse is reinforcing teaching to a pt who is starting amitriptyline for tx of depression. Which of the following should the nurse include?
Change position slowly to minimize dizziness and chew sugarless gum to prevent dry mouth
Alcohol W/D
Chlordiazeproxide (librium)
A nurse is caring for a pt who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Cleanse from the center outward
A 23 year old woman at 32 weeks gestation is seen in the outpatient clinic. Which of the following findings if assessed by the nurse, would indicate a possible complication?
Clients urine test is positive for glucose and acetone
A 69 year old client is undergoing his second exhange of intermittent PD. Which of the following would require an intervention by the nurse?
Cloudy dialysate outflow
Intussusception
Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements
A patient with newly diagnosed type 1 DM is being seen by the home health nurse. The physician orders include: 1200 calorie diet, 15 units of NPH before breakfast, check blood sugar QID. When the nurse visits the pt at 5 the blood sugar is 50. The nurse would expect the pt to be?
Confused with cold, clammy skin and pulse of 110
What is the nursing action for dehiscence?
Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's .
Prednisone toxicity
Cushings (buffalo hump, moon face, high blood sugar, HTN)
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting
D
A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
D
An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24 hr postop to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift C. providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump
D
Tetrology of Fallot
DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis)
Hypoxia
Decrease in ox stats Nursing Considerations: Monitor ox stat and admin ox as prescribed Encourage coughing and deep breathing to prevent atelectasis Position client with head of bed elevated and turn every 2hr to facilitate chest expansion
Baclofen therapeutic outcome
Decrease the frequency and severity of muscle spasms
A 23 year old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY?
Decreased LOC
The client is exhibiting symptoms of myxedema. The nursing assessment should reveal
Decreased temp
4.
Deep vein thrombosis
Stages of grief
Denial, Anger, Bargaining, Depression, Acceptance.
Diabetes lab values
Diagnostic criteria for diabetes includes two findings (on separate days) of one of the following: -Manifestations of DM plus casual blood glucose concentration greater than 200 -Fasting >126 -2 hour glucose >200 with an oral glucose tolerance test Hgb A1C -reference range - 4-6% -acceptable target for clients with DM may be 6.5-8%, with target goal of less than 7% (normal fasting glucose for diabetic - 90-130)
Living Will:
Directive documents for medical treatment per the client's wishes
Action to avoid with neutropenic patient
Discarding an empty blood bag and blood tubing in the client's beside trash can.
Disseminated herpes zoster localized herpes zoster
Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered!
Fluid overload
Distended neck veins, increased blood pressure, tachycardia, SOB, crackles in the lungs, edema, additional finding varying with the IV solution
Alcohol Abstinence
Disulfiram (antabuse)
LLQ
Diverticulitis
Lb-kg
Divide pounds by 2.2 to get kg
What should be avoided during pregnancy?
Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby
Pharmacological and Parenteral Therapies Expected actions/outcomes of Parkinson's: Effects of Levodopa Levodopa is a
Dopaminergic Due to medication tolerance and metabolism the dosage, form and administration times must be adjusted to avoid periods of poor mobility NURSING ACTION: Monitor for the "wearing off" phenomenon and dyskinesias, which can indicate the need to adjust the dosage, time, or medication holiday
A nurse is caring for a pt who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the pt to?
Drink liquids only between meals
Dont delegate when
EAT - evaluate, assess, teach
Hematoma
Ecchymosis at the site
Better peripheral perfusion?
EleVate Veins, DAngle Arteries
Establishing Priorities---Facility Protocols: Triage evaluation of peds
Emergent: Urgent Nonurgent: Expectant:
A pt returns to his room following a myelogram. The nursing care should include which of the following?
Encourage oral fluid intake
Hepatitis A
Ends in a vowel, comes from the bowel
What are good sources of folic acid?
Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils.
Narcolepsy
Exercise regularly, Eat small meals high in protein, Avoid sitting too long/warm environments /alcohol, Avoid accidents, driving or heights, Take naps when drowsy, Take stimulants
Anticipatory loss:
Experienced before the loss happens
S/S of hip fx
External rotation, shortening adduction
centigrade to Fahrenheit conversion
F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40
Where does smallpox rash begin?
Face
Emergency Response Plan
Facility Protocols: Appropriate client for discharge in event of community disaster First discharge or relocate ambulatory clients requiring minimal care. Next, make arrangements for continuation of care for clients who require some assistance which could be provided in the home or tertiary care facility Do not discharge or relocate clients who are unstable of require continuing nursing care and assessment unless they are in imminent danger. Discharge on the fact that some will likely be able to stay
Justice:
Fair treatment in matters related to physical and psychosocial care and use of resources
3 hrs oral glucose test
Fasting - give glucose - test BG q1h
A nurse is caring for a pt who decides not to have sx despite significant blockages in his coronary arteries. The nurse understands that this pt choice is an example of what?
Fidelity
Priority after IV pump malfunction
Fill out incident report
Turner's sign
Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis
Which of the following is a correctly stated nursing diagnosis for a pt with abuptio placentae?
Fld volume deficit related to bleeding
Benzo antidote
Flumazenil
Handling Hazardous and Infectious materials Cancer treatment options: Implanted internal radiation device
Follow protocol for proper removal of dressings and bed linens from the room Waste products should not be touched by anyone Place the client in a private room and keep the door closed as often as possible Place a radiation warning sign on the door Wear a dosimeter film badge that records personal amount of radiation expose Pregnant nurses or children should not come into contact with the client or radiation source Limit visitors to 30 min visits and maintain 6 feet from the source Wear a lead apron while providing care keeping the front of the apron facing the radiation source Keep a lead container in the client's room if the delivery method could allow spontaneous loss of radioactive material. Tongs should be available for placing material into this container
Formula preparation
Formula -Prepared formula can be refrigerated up to 8 hr -Discard unused formula when finished due to risk of bacterial contamination -use tap water to mix powder or concentrated formula -wash lid of concentrated formula can with hot soapy water before opening it
Health Promotion and Maintenance Ante/Intra/Post-Partum and Newborn Care Newborn Nutrition: Effective breastfeeding
Gain of 100 to 200 g/week for the first 3 months Fluid intake of 100 to 140mL/kg/24hrs 110kcal/kg/day the first 3 months 100kcal/kg/day for 3-6 months Breast milk and formula provide 20kcal/oz Carbos should make up 40-50% of the newborn's total caloric intake. Lactose is the most abundant carb in breast milk and formula At least 15% of calories must come from fat Protein: 2.25 to 4 g/kg/day Solids should not be introduced until 6 months of age Newborns should be breastfed every 2-3hrs Awaken the newborn at least every 3hrs, during the day and every 4hrs at night Breastfeeding should occur 8 to 12 times within a 24hrs window
Long term effects of NSAIDS
Gastric ulcerations, perforations, hemorrhage, hypertension
Tape test pinworm
Get specimen asap when awaking in AM Return it in plastic bag Get it before bathing and pooping
What do you do if patient questions med?
Go back to nurse's station and check all meds against provider's orders
CABG
Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart.
cystic fibrosis diet
HIGH calorie, HIGH protein ,HIGH fat + fat vitamin - need higher abx dose - regular exercise - give 3 meals + snacks, pancreatic enzymes given within 30 min, increase dose if high calorie, watch 1-2 stools/day for effectiveness, can sprinkle on food - tend to have pulm infection
CSF meningitis
HIGH protein LOW glucose
Ventilatory alarms
HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc
Thyroid storm
HOT (hyperthermia)
Apgar measures
HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate
preeclampsia
HTN, proteinuria, HA, blurred vision, facial edema, oliguria, hyperactive DTR
pre-eclampsia
HTN, proteinuria, edema report facial and peripheral edema and decrease U/O, side-lying, fetal kick count,
Stoma care
Healthy stoma: pink, red moist, out 2 cm (dusky, black,white not good) Peristoma skin: mild soap, or just water ( no alcohol, iodine, oil based products- skin breakdown) Diet: low residual, avoid high fiber food
Emergent:
Highest priority, life threatening injuries but also have high survival rate once stable
if HR is <100 (children)
Hold Dig
Characteristics of managers:
Hold formal positions of authority and power, Possess clinical expertise, Network with members of the team, Coach subordinates, Make decisions for the organization: Resources, Budget, Hiring, and Firing
Using cane
Holding the quad cane on the stronger side of the body and moving the cane in unison with the weaker leg gives support and helps to maintain stability for the client.
Cushings
Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump
Addison's
Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress.
Oxygen toxicity
Hypo ventilation,bradypnea
Trousseau and Chvostek's signs observed in
Hypocalcemia
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following?
Hypotension
shock
Hypotension, tachypnea, tachycardia
1.
Hypovolemic shock
6.
Hypoxia
ICP and Shock
ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp
What is the most appropriate method for contraception for an adolescent?
IUD or implant
never give K+ in
IV push
A pt who has started lithium a month ago tells the nurse she has begun multiple daily ibuprofen for tension headache. Should the pt client avoid this drug?
Ibuprofen increases renal reabsorption of lithium and can lead to lithium toxicity therefore the pt should avoid NSAIDs
Which of the following is essential when caring for a pt who is experiencing delerium?
Identifying the underlying causative condition or illness
Rest and Sleep—Promoting Sleep Factors that interfere with sleep
Illness: Can require more sleep or disrupt sleep Current life events: Traveling or work hours change Emotional stress: Anxiety, fear, grief Diet: Caffeine consumption, heavy meals before bedtime Exercise: Promotes sleep if at least 2 hours before bedtime Fatigue: Exhausting or stressful work makes falling asleep difficult Sleep environment: Too light, wrong temp or too noisy Medications: Some can induce sleep, some can interfere Bedtime routine, Limit waking clients, Promote quiet, Help with hygiene, CPAP, Sleep products Limit alcohol, caffeine and nicotine at least 4 hours before bedtime. Limit fluids 2-4 hours before bed time Engage in muscle relaxation if anxious or stressed
Angiotenson II
In the lungs...potent vasodialator, aldosterone attracts sodium.
With what type of foods should enzymes increase?
Increase dosage of enzymes when eating high fat foods
Intravenous Therapies Assessing the IV site
Infiltration or extravasation Pallor, local swelling at the site, decreased skin temperature around the site, damp dressing, slowed rate of infusion Phlebitis or thrombophlebitis Edema, throbbing, burning or pain at the site, increased skin temperature, erythema, a red line up the arm with a palpable band at the vein site, slowed rate of infusion Hematoma Ecchymosis at the site Fluid overload Distended neck veins, increased blood pressure, tachycardia, SOB, crackles in the lungs, edema, additional finding varying with the IV solution Cellulitis Pain. Warmth edema, induration, red streaking, fever, chills, malaise Catheter embolus Missing catheter tip on removal, severe pain at the site with migration, absence of findings if no migration
Directing:
Influences and motivates people to perform
A nonstress test is scheduled for pt at 34 wks who developed HTN, periorbital edema, and proteinuria. Which nursing action should be included in the care plan in order to BEST prepare the pt for the dx test?
Instruct pt to push a button when she feels fetal mvm
Medication administration Diabetes Mellitus management: Teaching self-administration for insulin
Instruct the client to check the accuracy of the strips with the control solution provided Instruct the client to use the correct code number in the meter to match the strip bottle number Instruct the client to store strips in the closed container in a dry location Instruct the client to obtain an adequate blood sample when performing the test Keep a record of the SMBG, Date time, glucose, dose, food and other events Rotate Injection sites, Inject at a 90 degree angle, 45 degrees if the client is thin, Advise the client to eat at regular intervals, avoid alcohol intake, and adjust insulin to exercise and diet to avoid hypoglycemia
Skin infections/infestations Expected findings of pediculosis capitits
Intense itching, Small, red bumps on the scalp, Nits (White specks on the hair shaft)
Peritoneal dialysis
Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok
A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all pts waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle
Justice
What is fairness in care delivery and use of resources?
Justice
A client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider?
K 5.2
Fidelity:
Keeping one's promise to the client about care that was offered
Meningitis--check for
Kernig's/ brudinski's signs
Prolapsed cord
Knee to chest or Trendelenburg oxygen 8 to 10 L
EDD= estimated date of delivery
LMP - 3 mo + 7 days + 1 yr
Nagele's rule
LMP - 3 months + 7 days
corh's disease
LOW fiber, HIGH protein, HIGH calories hydration
makes very few decisions and does little planning motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation
Laissez faire
Speaking to a client who has a hearing Impairment
Learn the clients' preferred method of communications and make accommodations. Avoid covering your mouth Sit and face the client Speak slowly and clearly Encourage the use of hearing devices Try lowering vocal pitch before increasing volume Do not shout Use brief sentences with simple words Minimize background noise Ask for a sign language interpreter if necessary Write down what clients do not understand
Advance directives:
Legal documents that direct end of life issues
Prioritizing Care for multiple home care clients
Life before limb Acute before Chronic Actual problems before potential problems Listen carefully to clients and don't assume Trends vs Transient findings Complications vs expected findings
What is important about the diet of someone taking ACE inhibitors?
Limit potassium due to causing high levels.
Organizing:
Lines of authority, communications, and where decisions are made
Expectant:
Lowest priority, expected to die, Comfort care, but not restorative care
Contact precaution
MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves
Airborne precautions
MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB
Hyperkalemia
MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes
When providing family education for those who have a relative with AD about minimizing stress, which of the following suggestions is most relevant?
Maintain consistency in enviornment,routine and caregivers
The nurse is caring for an 80 year old pt with parkinsons disease. Which of the following nsg goals is MOST realistic and appropriate in planning care for this client?
Maintain optimal function within the pt limitations
Preparing the body for viewing
Maintain privacy Remove all tubes Remove all personal belongings to be given to the family Cleanse and align the body supine with a pillow under the head Place the arms outside of the blanket palms down, Keep dentures in place Close eyes Apply fresh linens with absorbent pads on bed and a gown Brush the client's hair, Place hair pieces Remove excess supplies, equipment, and soilded linens Dim the lights and minimize noise
Medication effecting urinary output Indications for use of diuretics
Management of blood pressure Excretion of edematous fluid related to heart failure, Kidney and Liver disease Prevention of kidney failure
Examples when an incident report should be filed:
Medication errors, Procedure/treatment errors, Equipment related injuries/errors, Needlestick injuries, Client falls, Visitor/Volunteer injuries, Threat made to client or staff, Loss of property.
Nonurgent:
Minor injuries that are not life threatening and do not need immediate attention
Catheter embolus
Missing catheter tip on removal, severe pain at the site with migration, absence of findings if no migration
Multiple Sclerosis Patient
Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug) * Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone) * Vomiting = causes dehydration * Hair Loss = emotional distress * Amenorrhea = emotional distress
Nursing Considerations: for Paralytic Ileus
Monitor bowel sounds Encourage ambulation Advance the diet as tolerated when bowel sounds, or flatus are present The client can have an NG tube inserted to empty stomach contents Administer prokinetic agents such as metoclopramide as prescribed Wound dehiscence or evisceration Caused by spontaneous opening of the incisional wound Can progress to the protrusion of the internal organs through the incision Monitor for risk factors (Obesity, coughing, moving without splinting, poor nutritional status, diabetes mellitus, infection, hematoma, steroid use) If wound dehiscence or evisceration occurs, call for help, stay with the client, cover the wound with a sterile towel or dressing, do not attempt to reinsert organs, place in a low fowlers position with hips and knees bent monitor for shock, and notify the provider immediately
Nursing Considerations: for airway obstruction
Monitor for choking, noisy irregular respirations, decreased ox stats, cyanosis Implement a head tilt, chin lift, to open the airway Keep emergency equipment at the bedside in the PACU Notify the anesthesiologist, elevate head of bed if not contraindicated, provide oxygen, and plan for reintubation with endotracheal tube
Medication administration Cystic Fibrosis: Teaching about pancrelipase
Monitor stools for adequate dosing (1/2 stools/day) Administer capsules WITH ALL MEALS AND SNACKS Client can swallow or sprinkle capsules on food Teach about diet and ways increase calorie intake
TO PN
Monitoring findings Reinforcing client teaching Tracheostomy Care Suctioning NG tube patency Enteral Feedings Insert Catheter Administering Meds
What are the values and beliefs that guide behavior and decision making?
Morals
Munchausen syndrome vs munchausen by proxy
Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child
Weighted NI (naso intestinal tubes)
Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris
Addesonian crisis
N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP
Adverse effects of verapamil
NO grapefruit juice
3-4 cups of milk a day for a child?
NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA
Cardiac cath
NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr
Myelogram
NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site
Meds that cause GI irritation
NSAIDs corticosteroids
serum electrolytes normal values
Na 136-145 K+ 3.5-5 Ca 9-10.5 Mg 1.3-2.1 PO4 3-4.5 Cl 98-106
Opioid O/D
Narcan
PE
Needs O2!
what to check with pregnancy
Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope.
Glaucoma
No atropine
type 1 DM
No cold therapy
A nurse is providing discharge instructions to a pt who has rx for the use of o2 in his home. Which should the nurse teach the pt about using o2 safely in his home?
No nail polish near pt receiving o2 No smoking sign on door Fire extinguisher readily avail in home
A nurse is caring for a pt who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain F/E balance?
Normal saline
A nurse is caring for a pt with active upper GI bleeding. What is the appropriate diet for this pt during the first 24 hr after admission?
Nothing by mouth
One hour ago, a nurse administered morphine sulfate 4 mg IVP to a client who reported pain of 9 on a scale of 10. The client now reports pain of a 7 on a scale of 10. What is the priority intervention at this time? a. Reposition the client b. Notify the provider of the client's report c. Reassess pain level in 30 minutes d. Administer antiemetic as prescribed
Notify the provider of client's report IV pain medication has a fast onset and the client's pain should have improved better than 7 on a scale of 0-10
A pt who has parkinsons disease is prescribed levodopa/carvidopa and pramipexole for which of the following should the nurse monitor this client?
Orthostatic hypotension
thrombocytopenia
PLT < 100,000 (normal is 150,000-450,000)increased risk of bleeding; if IV being d/c apply pressure for at least 5 mins -bleeding precautions; avoid IM injections
McBurney's point
Pain in RLQ with appendicitis
Murphy's sign
Pain with palplation of gall bladder (seen with cholecystitis)
Cellulitis
Pain. Warmth edema, induration, red streaking, fever, chills, malaise
2.
Paralytic ileus
The nurse should consider the hierarchy of human needs when prioritizing interventions, which are?
Physiological first (o2, shelter, food) Safety and Security Love and belonging (self esteem/actualization)
Maslow's Hierarchy
Physiological, Safety and Security, Love and Belonging, Self-esteem, Self-Actualization
A nurse is caring for a client who has TB. which of the following actions should the nurse take?
Place the pt in a neg pressure room Wear gloves when assisting the pt with oral care Use antimicrobial sanitizer for hand hygiene
Concepts of management—Strategies to identify solutions to community health problems
Planning Organizing: Controlling: Directing: Staffing:
Hypovolemic shock
Post op shock can result from a massive loss of circulating blood volume Nursing Considerations: Monitor for decreased blood pressure and urinary output, increased heart and respiratory rates, narrowing of pulse pressure, and slow cap refill Administer oxygen Place the client in a supine position with legs elevated Administer IV Fluids and vasopressors as prescribed
Position of the baby by fetal heart sounds
Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis.
A 38 year old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patients beside is nonessential?
Potassium Chloride for IV admin
Preload/Afterload
Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.
Health Promotion and Maintenance Priority Assessment: Membrane Rupture Ante/Intra/Post-Partum and newborn care Early Onset of Labor
Premature rupture of membranes (PROM): Spontaneous rupture of the amniotic membranes 1hr or more prior to the onset of true labor. Temperature elevation Increased maternal heart rate or FHR Foul smelling fluid or vaginal discharge Abdominal tenderness Assess for a prolapsed umbilical cord Abrupt FHR variable or prolonged deceleration Visible or palpable cord at the introitus A positive nitrating paper test (blue, pH6.5 to 7.5) or Positive ferning test is conducted on amniotic fluid to verify rupture of membranes
Nursing Care: for early rupture of membranes
Prepare for birth if indicated: Evidence of infection or fetal or maternal compromise Obtain vaginal and rectal cultures for strep B Obtain vaginal culture for chlamydia and Neisseria gonorrhoeae Avoid vaginal exams Provide reassurance to reduce anxiety Assess vital signs every 2hrs, Notify the provider of a temperature greater than 100 Assess FHR and uterine contractions Advise the client to adhere to bed rest with bathroom privileges Encourage hydration Obtain a CBC Instruct the client to perform daily fetal kick counts and notify the nurse of uterine contractions
When caring for a pt dx with delirium, which condition is the most important for the nurse to investigate?
Prescription drug intoxication
1.
Private room
Infant with Spina Bifida
Prone so that sac does not rupture
Nursing considerations: for DVT
Prophylactic measures include administration of low molecular weight heparin, low dose heparin or low dose warfarin, antiembolism stocking, pneumatic compression devices, range of motion, exercises, and early ambulation Avoid any form of pressure behind the knee with a pillow or blanket, which can cause constriction of blood vessels and decreased venous return Avoid dangling the client's legs for long periods of time Provide adequate hydration by administering IV fluids or encouraging increased oral fluid intake
A client has a history of oliguria, hypertension, and peripheral edema. Lab values BUN 25, K 4.0. Which should be restricted in the pt diet?
Protein
Tube feeding with decreased LOC
Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration)
A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation.
R supervision/eval R direction/communication R circumstances
CBC
RBC: males 4.7-6.1 million; female 4.2-5.4 million Hbg: males 14-18 female 12-16 Hematocrit: male 42-52% female 37-47% WBC: 5,000-10,000 ESR: <20 mm/hr
Sprain or Strain
RICE Rest Ice Compress Elevate
A client is admitted with a diagnosis of acute appendicitis. When assessing the abd, the nurse would expect to find rebound tenderness at which location?
RLQ
McBurney's point
RLQ
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign to this client? A. Charge nurse B. RN C. LPN D. AP
RN
codes for pt care
Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival
CF chief concern?
Respiratory problems
A pt is scheduled for a left lower lobectomy. The physician ordered valium for anxiety. The nurse would determine that the med is needed if the pt displays which of the following?
Restlessness and increased HR
Non Dairy calcium
Rhubarb sardines collard greens
Flail chest
Ribs come off, paradoxic chest movement
Cor pumonae
Right sided heart failure caused by left ventricular failure (edema, jugular vein distention)
OSA complication
Risk for hypoxia, CHF, dysrythmias
crutches
Rubber shoes, three point gait
Hypernatremia
S (Skin flushed) A (agitation) L (low grade fever ) T (thirst)
Air or Pulmonary Embolism
S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.)
Autonomic Dysreflexia/Hyperreflexia
S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!
Cranial nerves
S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More
Urgent:
Second highest priority can wait 40-60 mins for treatment
Which characteristic may impede learning?
Self-confidence
An 8 year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
Semi Fowler's position
Herpes zoster vaccind
Shingles. Older adults > 60
electroconvulsive therapy
Short term memory loss side eff
Fractures: Care for a new Cast
Show the procedure on a doll Assist with crutches and use Assess for warmth Assess skin Apply ice for 24hrs Assess Neuro Status Elevate the cast for the first 48 hours to prevent swelling Cover area of cast with plastic Use mole skin over rough areas Provide skin and perineal care The cast will feel warm but will not burn client Report pain that is not relieved in one hour Turn client every 2 hrs to dry Monitor for drainage Teach the parent to perform neuro checks
pressure ulcer stages
Stage 1: non-blanchable redness Stage 2: partial thickness loss Stage 3: full thickness loss, w/o undermining, see fat Stage 4: 3+ undermining, see tendon, muscle
What are the precautions for vanco resistant enteroccus?
Standard precautions, hand hygiene and gloving
postpartum: DVT
Stocking until ambulate, elevate legs when sitting, no cross legs, fluids, no smoking
A woman at 38 weeks' gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding? 1. "I feel fine, but the bleeding scares me." 2. "I've been more nauseated during the past few weeks." 3. "The bleeding started after I carried four bags of groceries." 4. "I've been having severe abdominal cramps."
Strategy: All answers are assessments. Think about what each phrase is describing and how it relates to a placenta previa. (1) correct—placenta previa is characterized by painless vaginal bleeding (2) nausea not a symptom of placenta previa (3) bleeding is not necessarily related to activity (4) pain not characteristic of placenta previa
The nurse supervises the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.
Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct—contact precautions required for diapered or incontinent clients (2) do not remove toys from room, possibly contaminated (3) diet should be high in carbohydrates and protein and low in fat (4) contact precautions required in addition to standard precautions
A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following? 1. Prepare to administer IV Pitocin to the client. 2. A reduction in the amount of pain medication administered. 3. Check the client's blood pressure every 5 minutes. 4. Prepare an isolette for the infant.
Strategy: Answers are a mix of assessments and implementations. Does the assessment make sense? No. Determine the outcome of each intervention. (1) uterine contractions not affected by MS (2) correct—less pain medication is required because of overall decrease in pain perception due to MS (3) no reason to assess this frequently (4) baby's outcome not affected by MS
The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 × 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions? 1. Remove the dressing, and replace it with a more absorbent dressing. 2. Collect a culture and sensitivity specimen of the drainage. 3. Observe the wound for dehiscence. 4. Reinforce the dressing with an 8 × 10 dressing.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each implementation. (1) correct—expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry (2) drainage described is bile, which is expected; no indication of infection (3) doesn't usually occur (4) reinforcing dressing might cause infection; change dressing to keep site clean and dry
The nurse cares for a child several hours after the application of a hip spica cast. The patient turns on the call light and complains of pain in the left foot. Which of the following actions should the nurse take FIRST? 1. Elevate the left leg on two pillows. 2. Palpate the cast for warmth and wetness. 3. Administer pain medication as ordered. 4. Check the blanching sign on both feet.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation; done to prevent swelling and venous congestion, not helpful to reduce pain due to circulatory impairment (2) assessment; not helpful to reduce pain due to circulatory impairment, should not palpate wet cast, would result in depressions causing pressure (3) implementation; pain important diagnostic symptom, should not be suppressed or masked (4) correct—assessment; pain main symptom of circulatory impairment from cast; pressing nail of great toe indicates circulatory function, compare speed with which color returns with result on the opposite side; sluggish return indicates circulatory impairment, too rapid return indicates venous congestion
The nurse is assigned to work with the parents of a child diagnosed with mental retardation. Which of the following should the nurse include in the care plan for the parents? 1. Interpret the grieving process for the parents. 2. Discuss the reality of institutional placement. 3. Assist the parents in making decisions and long-term plans for the child. 4. Perform a family assessment to assist in the planning of intervention.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) inappropriate before the assessment; action can be taken only when the circumstances are known (2) inappropriate before the assessment; action can be taken only when the circumstances are known (3) inappropriate before the assessment; action can be taken only when the circumstances are known (4) correct—assessment; this will help the nurse to know where the family is in regard to grieving, coping, etc.
The nursing assistant reports to the nurse that a client who is 1 day postoperative after an angioplasty refuses to eat and states, "I just don't feel good." Which of the following actions by the nurse is BEST? 1. Talk with the client about how the client is feeling. 2. Instruct the nursing assistant to sit with the client while the client eats. 3. Contacts the physician to obtain an order for an antacid. 4. Evaluate the most recent vital signs recorded in the chart.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is the assessment appropriate? Yes. (1) correct—assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias (2) assess cause of problem before implementing (3) assess cause of problem before implementing (4) more important to assess what is happening now
The nurse cares for a client with type 1 diabetes. The client receives nasal oxygen at 4 L/min. The student nurse reports that the client has pulled out the nasogastric tube and is picking at the bed covers. The client's BP is 150/90 and pulse is 90. Which of the following actions by the nurse is MOST appropriate? 1. Obtain a pulse oximetry reading. 2. Apply soft wrist restraints. 3. Reorient the client to person and place. 4. Determine the client's blood glucose level.
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) correct—assessment; symptoms indicate reduced oxygen levels (2) implementation; must assess first to determine problem; all other interventions must be tried before using restraints (3) implementation; must determine the cause of the behavior before implementing (4) assessment; symptoms indicate decreased oxygen levels
The nurse cares for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST? 1. "That must have been a real shock to you." 2. "You should be tested for hepatitis B." 3. "You'll receive the hepatitis B immune globulin (HBIG)." 4. "Have you had unprotected sex with your boyfriend?"
Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) nurse is interjecting own feelings (2) will require testing; not best response initially (3) implementation; receive HBIG for postexposure prophylaxis; may also receive HBV vaccine (4) correct—assessment
Which of the following statements should the nurse make to a client who is going to self-administer continuous ambulatory peritoneal dialysis (CAPD) at home? 1. "Check your weight daily." 2. "Maintain clean technique at all times during the procedure." 3. "Milk the catheter to encourage extra fluid to be removed from the abdomen." 4. "Eat a well-balanced, low-protein diet."
Strategy: Answers are a mix of assessments and implementations. Is assessment required? Yes. Is the assessment appropriate? Yes. (1) correct—assessment; daily weight necessary with peritoneum empty to assess fluid volume status, guidelines for weight gain/loss set by physician (2) implementation; strict aseptic technique required to prevent contamination, sterile = aseptic, clean = antiseptic (3) implementation; don't milk catheter, drainage by gravity only (4) implementation; encouraged to eat a high-protein diet because of protein loss with CAPD
The nurse cares for clients on the neurology unit. What is the MOST appropriate action for the nurse to take after noting that a client suddenly develops a fixed and dilated pupil? 1. Reassess in 5 minutes. 2. Check the client's visual acuity. 3. Lower the head of the client's bed. 4. Contact the physician.
Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment or validation? No. Determine the outcome of the implementations. (1) assessment; situation does not require validation (2) assessment; has symptoms of increased intracranial pressure (ICP) (3) implementation; would increase the ICP (4) correct—implementation; fixed and dilated pupil represents a neurological emergency
The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST? 1. Withhold the medication. 2. Decrease the dose by half. 3. Administer the medication. 4. Wait 15 minutes, and then recheck the rate.
Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? No. Determine the outcome of each answer choice. (1) correct—maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure (2) should never change a prescribed dosage of medication (3) should not be given with a high pulse rate (4) assessment; maternal tachycardia is a side effect of Brethine; medication should be withheld
A nurse cares for a client diagnosed with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0 g/dL. 4. The patient's hemoglobin is 8.5 g/dL.
Strategy: Determine how each answer choice relates to nutritional status. (1) appetite is not the best indicator (2) weight gain may be fluid retention (ascites) (3) correct—albumin levels are best indicators of long-term nutritional status (4) low levels are caused by chemotherapy or cancer, not a good indicator because it takes long time to increase levels
The nurse cares for clients on a medical/surgical unit and determines that several situations need to be addressed. Which of the following situations should the nurse attend to FIRST? 1. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift. 2. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week. 3. The physician calls the unit to ask the nurse to obtain a client's latest serum electrolyte results from the lab. 4. The husband of a client reports to the nurse that his wife's nose began bleeding after she returned from radiation therapy.
Strategy: Determine the least stable situation (1) important issue that needs to be addressed after tending to the client who is bleeding (2) patients take priority over personnel issues (3) can be delegated to another staff member (4) correct—should assess client to determine amount and cause of bleeding
Myasthenia gravis
Subjective Data ◯ Progressive muscle weakness ◯ Diplopia ◯ Difficulty chewing and swallowing ◯ Respiratory dysfunction ◯ Bowel and bladder dysfunction ◯ Poor posture ◯ Fatigue after exertion ● Objective Data ◯ Physical Assessment Findings ■ Impaired respiratory status (difficulty managing secretions, decreased respiratory effort) ■ Decreased swallowing ability ■ Decreased muscle strength, especially of the face, eyes, and proximal portion of major muscle groups ■ Incontinence ■ Drooping eyelids - unilateral or bilateral *ptosis*
A patient who has undergone colostomy sx is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?
Suggest fld intake of at least 2 L per day
Airway Obstruction
Swelling or spasm of the larynx or trachea, mucus in the airway or relaxation of the tongue into the nasopharynx
A client has undergone an aortofemoral bypass for the treatment of peripheral arterial disease. Which of the following findings should be reported to the surgeon immediately? a. Systolic blood pressure 110 mmHg b. Redness of the incision line c. Systolic blood pressure 160 mmHG d. Edema of the affected limg
Systolic blood pressure 160 mmHg (Mild edema of the affected limb will be present as a result of increased blood flow)
What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given?
TDAP
The nurse is caring for a pt following an appendectomy. The pt takes deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient is BEST?
Take 3 deep breaths, hold incision, and then cough
INH can cause peripheral neuritis
Take vitamin B6 to prevent. Hepatotoxic
Teaching points for naltrexone (Vivitrol)?
Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen.
A nurse is caring for a client following an acute MI. The pt is concerned that providing self care will be difficult due to extreme fatigue. Which should the nurse implement to promote the pt independence?
Teach pt to gradually resume self care tasks
A nurse responsible for a pt receiving a antihypertensive medication is to
Teach the pt to change position slowly to avoid dizziness or fainting
Imprisonment
Telling the client you cannot leave the hospital
Crohn's disease diet
Tender, ground, well-cooked meat, eggs, fish, poultry, refined pasta and cereal, white rice and bread, canned or cooked vegetables without skin or seeds and juices without pulp.
shilling test
Test for pernicious anemia
Guthrie test
Tests for PKU. Baby should have eaten protein first
Autonomy:
The ability of the client to make personal decisions, even when those decisions might not be in the client's own best interest
Controlling:
The evaluation of performance and unit goals to ensure outcomes are met
What are some ways to identify a patient before giving a medication?
The joint commission requires 2 pt identifiers: -pt name - assigned ID number - phone - DOB
Veracity:
The nurse's duty to tell the truth
Nonmaleficence:
The nurse's obligation to avoid causing harm to the client
A nurse is caring for a 37 yr old woman with metastatic ovarian CA admitted for N/V. The doc orders TPN, a consult with nutrition and diet recall. Which is the BEST indication that the pt nutritional status has improved after 4 days?
The patients albumin level is 4.0
The home care nurse is instructing a pt recently dx with TB. It is MOST important for the nurse to include which of the following as a part of the teaching plan?
The pt will be required to take prescribed meds for 6-9 months
The nurse is observing care given to a pt experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations?
The staff helps the pt identify thoughts or feelings that occurred prior to the onset of the anxiety
FHR patterns for OB
Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill
Brachytherapy:
This can be placed in vagina, abdomen or IV with radionuclide iodine which is absorbed by the thyroid.
Post-Partum Physiological Adaptations Pertussis booster recommendations
This vaccine is recommended for women who have not previously received it. Administration prior to discharge or ASAP in the post-partum period is recommended
Assault
Threatening to give pt. medication putting another person in fear of a harmful or an offensive contact.
A nurse is caring for a pt who prescribed daily dose of both digoxin and furosemide. The K level is 3.2 for which of the following med interaction is the pt at risk for?
Toxic level of digoxin
Hypo Mg
Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity)
crutch use going up stair
Tripod position, transfer wt to crutch, advance unaffected leg to stair, then put wt on unaffected leg and crutch, advance affected leg and crutch
A pt is receiving TPN. To determine the pt tolerance of this tx, the nurse should assess which?
Urine output of at least 30 mL/hr
Skin infection
VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies
infants IM site
Vastus lateralis
Toddler 18 months+ IM site
Ventrogluteal
A nurse is caring for an older adult client who has a new prescription for dig and takes multiple other medications. Concurrent use of which of the following meds places the pt at risk for dig toxicity?
Verapamil
Signs for meningococcemia
Vomiting, febrile, petechial rash (unstable)
LAB
WBC: 5.0 - 10 Rbc: 4.0 - 5.0 , 4-6 Hgb: 12 - 16 (female), 14-18 (male) Hct: 37 - 47, 42- 52 (high-loss of V/dehydration) Plt: 150,000 - 450,000 blood glucose: 70-110 (<70: do sth) BUN: 10-20, Cr: 0.5-1.2 trop: < 0.2 for MI CK-MB: 30-170 INR: 0.9-1.2 (2-3 on coumadin) aPTT: 30-40 PTT: 60-70 (heparin: 30-45) ALT: 8-20 AST: 5-40 amylase: 56-90 lipase: 0-110 Mg: 1.3 - 2.1 P: 3 - 4.5 digoxin level: 0.8 - 2 lithium level: 0.8-1.4 (initial maniac episode), 0.4-1 (maintenance level), toxic >1.5 valproric acid: 50-100
When should clients take pancrelipase
WITH ALL MEALS AND SNACKS
Medication Administration Self-medication administration: Error Reduction Eye Drop administration
Wait 5-10 minutes between eye drops Avoid touching the tip of the application bottle to the eye Always wash hands before and after use Place pressure on the inner corner of the eye
Radiation skin
Wash with mild soap and water NO lotion
An adolescent client is ordered to take tetracycline. Which of the following instructions should be given to the pt by the nurse?
Wear sunscreen and a hat when outdoors
Planning:
What needs to be done, and who is going to do it
Do not delegate
What you can EAT E-evaluate A-assess T-teach
3.
Wound dehiscence or evisceration
Can pancrelipase capsules be broken?
Yes, they can be swallowed or sprinkled in food
A 59 year old woman with bipolar disorder is receiving haldol 2 mg. She tells the nurse, "milk is coming out of my breasts". Which is the BEST response by the nurse?
You are experiencing a side effect of haldol
Myesthenia Gravis
a positive reaction to Tensilon---will improve symptoms
eclampsia is
a seizure
A nurse is caring for a client who has difficulty swallowing following a cerebrovascular accident (CVA). Which of the following interventions should the nurse implement? Select all that apply. a. Assess swallowing reflexes before feeding b. Elevate the HOB 90 degrees before feeding c. Maintain suction equipment at the bedside d. Encourage client to place food in the front of the mouth e. Encourage client to flex hean and neck back when swallowing
a, b, c
A nurse is caring for a newborn client who is experiencing severe hyperbilirubinemia. Which of the following are symptoms of kernicterus? Select all that apply. a. Backward arching of the neck and trunk b. Hypotonic c. Lethargy d. Temperature instability e. Low birth weight
a, b, c
A nurse is caring for an intraoperative client. Which of the following are basic principles of sterile technique? Select all that apply. a. Once a sterile package is opened, the edges are considered unsterile b. Surgical gowns are sterile from the chest to the level of the sterile field c. Sterile surfaces may touch other sterile surfaces d. A six-inch perimeter should be maintained around the sterile field e. Hands must stay below waist level once sterile glovs are applied
a, b, c
A nurse is feeding a client with dysphagia. Which of the following should the nurse do to prevent aspiration? Select all that apply. a. Consult with a speech pathologist for evaluation b. Assist the client to flex the head to a chin-down position c. Place food on the weaker side of the mouth d. Position the client in an upright, seated position in a chair e. Provide a brief rest period before eating
a, b, d
A nurse is transferring a client with a diagnosis of CVA. Which of the following safety measures should be implemented? Select all that apply. a. Utilize an assistive device to facilitate transfer b. Detach arm and foot rests from wheelchair c. Assist client to move toward weaker side d. Engage locks on wheelchair and bed e. Pull on the arm of the client for stabilization
a, b, d
A charge nurse is delegating a task. The nurse understands which of the following represents effective delegation? Select all that apply. a. Delineating the desired outcomes of the delegation b. Asking the nurse if they are capable of completing the delegated task c. Referring to the ANA Code of Ethics for effective delegation practices d. Delegating a task that should be assigned to a manager e. Monitoring how the delegated task is being accomplished
a, b, e
A nurse is caring for a client immediately following an amniotomy. Which of the following interventions are appropriate? a. Document any unusual color in the amniotic fluid b. Assess fetal heart for rate and variable decelerations c. Prepare for an intrauterine pressure catheter insertion d. Assess maternal intake and urinary output e. Observe for the presence of an odor in amniotic fluid
a, b, e
A nurse is educating a client who is scheduled for a NST. Which of the following statements are correct? Select all that apply. a. The NST is a primary method of antenatal fetal assessment b. The NST measures the relationship of the fetal heart rate to fetal movement c. The NST is not useful after 38 weeks gestation d. The NST is useful in calculating gestational age e. The NST can easily be performed in an outpatient setting
a, b, e
A nurse is providing pin site care for a client with skeletal traction for a tibia-fibula fracture. Which of the following findings should the nurse report to the provider? Select all that apply. a. Muscle spasms b. Purulent drainage from the insertion sites c. +1 edema of skin at the pin sites d. Crusting at the pin sites e. Loosening of the pins
a, b, e
A nurse is providing education to a group of pregnant women. The nurse is teaching clients when to contact their provider. Which of the following should be included? Select all that apply. a. Dimming vision b. Evening lower extremity edema c. Chloasma d. Epigastric pain e. Severe continuous headaches
a, d, e
Which of the following diseases should the nurse anticipate using droplet precautions? Select all that apply? a. Scarlet Fever b. Varicella c. Tuberculosis d. Mumps e. Pertussis
a, d, e
A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? a. "I will remove the condom 30 minutes after intercourse." b. "My partner will put the condom on while his penis is erect." c. "My partner should leave an empty space at the tip." d. "I can use spermicidal gels or creams to increase effectiveness."
a. "I will remove the condom 30 minutes after intercourse." To avoid any semen spillage onto the vulva or the vaginal area, the condom must removed the same time as the penis
A nurse is caring for a client who is taking furosemide for heart failure. Which of the following statements by the client indicates a need for further instruction? a. "I will take my medication before I go to bed." b. "I will eat an orange each day with my breakfast." c. "I will call my provider if I gain 2 pounds in one day." d. "I will drink at least 8 ounces of water with each meal."
a. "I will take my medication before I go to bed." This statement indicates a need for more education. Clients who are taking furosemide should be instructed to take their medication in the morning. Dosing in this manner is done to minimize nocturia
A nurse is caring for a client who is recovering from a surgical procedure. Which of the following indicates that the client is experiencing orthostatic hypotension? a. A decrease in systolic pressure when changing positions b. Client reports leg discomfort when ambulating c. An increase in diastolic pressure when chaning positions d. A client reporting feelings of weakness when standing for the first time after surgery
a. A decrease in systolic pressure when changing positions The signs and symptoms of orthostatic hypotension include a decrease in blood pressure. This data needs to be collected prior to ambulation as this is a safety concern for the client and the risk for injury associated
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin? a. A pearly, waxy nodule b. An irregular border on a cariegated-colored leasion c. A firm, nodular, crusty, or ulcerated lesion d. A weeping vesicle
a. A pearly, waxy nodule A client who has basal cell carcinoma will have a nodular lesion with well-defined borders that has a pearly or waxy appearance, caused from overexposure to the sun on the face, neck, or arms
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) following a severe burn injury. The client's TPN bag is almost empty and a new bag of TPN is temporarily unavailable. Which of the following actions should the nurse take while waiting for the new bag of TPN? a. Administer a bag of dextrose 10% in water (D10W) b. Place the infusion device on hold c. Obtain liver function tests d. Slow the infusion rate of the TPN
a. Administer a bag of dextrose 10% in water (D10W) The nurse should administer D10W to prevent rebound hypoglycemia and dehydration if a new bag of TPN is unavailable. TPN solution contains greater than 10% dextrose and additives such as insulin, trace elements, minerals, and electrolytes. The nurse should monitor the client's blood glucose levels every 4 to 6 hr during the infusions
A nurse is caring for a client who is intubated and receiving ventilatory assistance. The high pressure alarm is sounding on the ventilator. Which of the following would have the highest priority? a. Assess the clients need for suctioning b. Check the endotracheal tube (ETT) to be sure there is no disconnection c. Assess the ETT cuff for proper inflation d. Administer sedation to calm the client's fears
a. Assess the clients need for suctioning
A client is admitted to the medical unit from the convalescent center for treatment of urosepsis. The client's adult daughter reports to the nurse, "I don't know what to do. I love my mom and would like to have her live in my home, but I just can't be with her every minute and that's what she needs now." Which of the following would be the best approach to improve integration of the elderly mother into the family structure? a. Determine if the daughter would consider having the client visit in her home one day a week b. Offer to refer the daughter to a counselor in an effort to better deal with her feelings of guilt c. Assist the daughter in finding a caregiver who can assist the client in the convalescent center d. Suggest that the daughter move the client into the family home on a trial basis for several weeks
a. Determine if the daughter would consider having the client visit in her home one day a week While it may not be feasible for an elderly parent to live in the same residence with adult children, it is generally possible for the adult children to incorporate the elderly parent into the family structure in other ways
A nurse is caring for a client with Addison's disease. Which of the following diets should the nurse teach the client to follow? a. High sodium, low potassium and increased fluids b. Low sodium, high potassium and decreased fluids c. Low sodium, high calcium and decreased fluids d. High sodium, low calcium and increased fluids
a. High sodium, low potassium and increased fluids The client with Addison's disease should have a diet high in sodium, low in potassium and increased fluids. In addition, these clients should be encouraged to consume small frequent meals to prevent hypoglycemia
A client is admitted to the hospital with a diagnosis of Grave's disease. Which of the following findings should be reported to the provider immediately? a. Increase in temperature from 99.5 F to 100.5 F b. Hyperactive deep tendon reflexes c. Increased number of stools d. Increase in WBC count from 6,000 to 8,000
a. Increase in temperature from 99.5 F to 100.5 F An increase in body temperature of even one degree should be reported to the provider immediately as it can signify the onset of "thyroid storm"
A nurse is teaching a client who has a new diagnosis of diabetes mellitus. The nurse should instruct the client that which of the following findings is a manifestation of hyperglycemia? a. Increased thirst b. Decreased urine output c. Dry skin d. Tremors
a. Increased thirst The nurse should teach the client that increased thirst is a manifestation of hyperglycemia, which can lead to dehydration. Other manifestations of hyperglycemia can include vomiting, abdominal pain, and rapid respirations
A client is discharged following a cardiac catheterization procedure. Which of the following should the nurse include in the discharge teaching? a. Limit activity for several days after the procedure b. Tub baths the night following the procedure are acceptable c. Notify provider if bruising is noted at the site d. Remove dressing the evening of the procedure
a. Limit activity for several days after the procedure The client should limit activity for several days after the procedure (avoiding lifting and exercise) to prevent bleeding of insertion site
A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client? a. Maternal history of cytomegalovirus b. Increased size of neonate's heart c. Documented birth trauma d. A decreased number of functional alveoli
a. Maternal history of cytomegalovirus Cytomegalovirus can be transferred via the placenta directly onto the fetal circulatory system and transmitted directly from infected amniotic fluid
A client who has been experiencing prolonged vomiting has the following ABG results: pH 7.48; pCO2 40 mm Hg; HCO3 34 mEq/L; pO2 85 mm Hg. The nurse determines that the client is experiencing which of the following imbalance? a. Metabolic Alkalosis b. Metabolic Acidosis c. Respiratory Alkalosis d. Respiratory Acidosis
a. Metabolic Alkalosis Alkolosis is reflected by an arterial pH greater than 7.45. Because the client has an increase in the base component, HCO3, this is a metabolic alkalosis
A nurse is caring for a client who has just undergone a bone marrow transplant. Neutropenic precautions are implemented to prevent infection. Which of the following is not a precautionary neutropenic measure? a. Monitor platelets b. Screen visitors c. Frequent, thorough hand hygiene d. Restric foods that may be contaminated with bacteria
a. Monitor platelets In patients with neutropenia, WBCs should be monitored
A client with gestational diabetes gave birth to a 9 lb neonate 12 hours ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurse's priority intervention? a. Offer the neonate breast milk or formula b. Administer subcutaneous insulin c. Place the neonate under a radiant warmer d. Provide oxygen via oxyhood
a. Offer the neonate breast milk or formula A neonate of a diabetic mother is at risk for hypoglycemia. High glucose loads are present in the infant in utero. When maternal blood glucose via the placenta abruptly stops at birth, the neonate experiences a rapid drop in blood sugar. Signs of hypoglycemia in the neonate are jitteriness, lethargy, poor muscle tone, apnea, high-pitched cry, and vomiting. Nursing interventions should focus on monitoring for signs of complications associated with hypoglycemia
A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a further need for teaching? a. Once my baby begins to roll over it is okay to use a small pillow in the crib b. I should always support my baby's head when I pick him up c. My baby's car seat should be in the back seat facing backwards d. I should never leave my baby unattended with pets or other children
a. Once by baby begins to roll over it is okay to use a small pillow in the crib It is never safe to have a pillow or a soft surface in the crib because of the danger of suffocation
A nurse is caring for a client who is having difficulty swallowing. Which intervention is effective in preventing injury? a. Position in high-Fowler's for meals b. Weigh the patient weekly c. Observe for evidence of aspiration d. Discourage visitors at meal time
a. Position in high-Fowler's for meals Clients with dyspnea are at risk for aspiration and need more assistance with feeding and swallowing. The client should be positioned upright, seated position in a chair or the HOB should be raised to 90 degrees at mealtime. Flexing the head to a chin-down position also helps prevent aspiration
A nurse is caring for a client who is 6 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse include in the plan of care? (Select all that apply) a. Reposition the client frequently b. Secure the drainage tube to the client's thigh c. Monitor for the client's temperature every 4 hr d. Administer antispasmodics for bladder spasms e. Restrict fluid intake to 1,500 mL/day
a. Reposition the client frequently b. Secure the drainage tube to the client's thigh c. Monitor for the client's temperature every 4 hr d. Administer antispasmodics for bladder spasms Repositioning is part of standard postoperative care for any client to prevent cardiovascular, pulmonary, and integumentary complications To prevent excessive traction on the catheter balloon and to minimize postoperative bleeding, secure drain tube to leg
A nurse is caring for a cclient with a partial hearing impairment. The nurse understands which of the following is the best way to communicate with this client? a. Speak slowly in a low-pitched voice b. Have a family member present c. Conduct only the physical assessment at this time d. Provide assessment questions in a written format
a. Speak slowly in a low-pitched voice Facing the client directly while addressing the client and speaking in a low pitched voice is the best way to communicate with a hearing impaired client
A client is receiving chemotherapy for the treatment of breast cancer. which of the following findings should be reported to the provider immediately? a. Temperature 38.1 C b. Absolute neutrophil count 8,000 c. Mucositis d. Alopecia
a. Temperature 38.1 C Neutropenia secondary to disease and/or treatment, which greatly increases the client's risk for infection. Report temperature greater than 37.8 C
During a home visit, a 10-day postpartum client reports pain and tenderness with redness and swelling to her right breast. A localized hard mass is also noted upon palpation. How should the nurse respond to this client? a. These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider b. Please mention this to your HCP at your 2-week check-up c. You will need to stop breastfeeding immediately until swelling and redness subside d. This is normal breast engorgement and should subside within another week or two
a. These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider These symptoms are suggestive of mastitis and should be reported to HCP
A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? a. We will need to remove the babys ankle identification band during diaper changes b. When the baby is returned to us from the nursery, we should check the baby's identification band c. We will request to see picture identification badges for all facility staff who care for our baby d. When the baby is born, my thumb print will be taken along with the baby's footprint
a. We will need to remove the baby's ankle identification during diaper changes The mother, newborn, and significant other are identified by plastic id bands
Blood transfusion reactions
a. circulatory overload - distended jugular veins b. hemolytic reaction - low back pain c. allergic reaction - itching, urticaria, bronchospasms d. febrile or bacterial transfusion reaction - fever (increase in temp. of 0.5 or 1 degree C)
Grave's Disease/ hyperthyroidism
accelerated physical and mental function. Sensitivity to heat. Fine/soft hair.
How does atropine work?
accelerates HR by interfering with vagal impulses
salicylate (aspirin) overdose
acetazolamide
DKA
acetone and keytones increase! once treated expect postassium to drop! have K+ ready
acetaminophen poisoning antidote
acetylcysteine
What is the difference between respiratory acidosis and alkalosis?
acidosis- excess acid causing ph to fall below 7.35 alkalosis- excess base causing ph to rise above 7.45
Liver biopsy
administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk
Prevent bleeding esophageal varices
administer stool softener to client who has portal hypertension to reduce straining, which increases vascular pressure and can precipiate bleeding esophageal varices
MMR and varicella immunizaions
after 15 months!
Measles
airborne precautions
what to ask before flu shot
allergy to eggs
what to ask before MMR
allergy to eggs or neomycin
If a pt has anorexia and works out constantly
allow them to workout and continue regimen
A. fib, SVT, or v.tach w/ HR
amiodarone, adenosine and verapamil synchronized cardioversion
v. tach w.=/o HR or v.fib
amiodarone, lidocaine or epinephrine defibrillation
trycyclic antidepressants TCAs
amitryptline, doxepine, clomiprame, imipramine avoid ETOH and st. John's wort; contraindicated seizure disorders; SE: anticholinergic, decreased seizure threshold, sedation, wt gain
Contraindication for Hep B vaccine
anaphylactic reaction to baker's yeast
What kind of medications are indicated for abstinence maintenance of alcohol?
antabuse, naltrexone, acamprosate
discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss
anticipatory grief
Glucagon increases the effects of?
anticoagulants
Amantadine
antiparkinson med used to treat EPS manifestations that can occur with chlorpromazine therapy
clozapine, Clozaril
antipsychotic anticholinergic
newborn
apnea < 20s, acrocyanosis is normal not: grunt, tachy, flaring
RLQ
appendicitis watch for peritonitis
Which of the following techniques should the nurse use when performing nasotracheal suctioning for a pt?
apply intermittent suction when w/d the catheter
ARDS and DIC
are always secondary to another disease or trauma
detached retina
area of detachment should be in the dependent position
nurse case manager
arrange services, apt, supplies
gullian-barre syndrome
ascending muscle weakness
Gullian -Barre syndrome
ascending paralysis. watch for respiratory problems.
Latex allergies
assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches
Crisis intervention priority
assess potential for suicide or homicide
When does D/C planning begin?
at admission
The physician orders ranitidine for a pt. The nurse should advise the pt the BEST time to take this medications is
at hs (bedtime)
Most managers can be categorized as
authoritative, democratic, and laissez faire
What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest
autonomy
Lithium (Category D)
avoid NSAIDs bc increasing lithium, drink lots H2O, take w/ food Adverse: NV, tremor, increased thirst, polyuria, renal toxicity (hypoNa), hypoTN/brady, goiter and hypothyroidism later
A client is being discharged with sublingual Nitro. The pt should be cautioned by the nurse to
avoid abrupt changes in posture
Peri care on indwelling catheter for patient with spinal cord injury
avoid inadvertently advancing catheter into bladder
Health promotion
avoid plastic, no balloons, crib slats 6cm (2.4in), remove mobiles by 4-5 mo, no pillows, on back to sleep, no small parts, remove drawstrings
A nurse is educating a client on how to perform Kegel exercise therapy for unrinary incontinence. Which of the following points should be included in teaching? Select all that apply. a. Complete exercises in only a sitting position b. During exercise, tighten pelvic muscles for a count of 10 and then relax for a count of 10 c. Improvement in incontinence may be seen after 6 weeks of exercise therapy d. Have a designated time and place for completing therapy e. While sitting on the toilet, strain down to help identify pelvic muscles
b, c, d
The nurse will need to wear a standard mask when caring for a client with which of the following disorders? Select all that apply. a. Tuberculosis b. Pharyngeal diphtheria c. Respiratory viral influenza d. Meningococcal pneumonia e. Hepatitis A Virus
b, c, d
A nurse is administering magnesium sulfate to a client diagnosed with preeclampsia. Which of the following signs and symptoms would indicate possible magnesium toxicity? Select all that apply. a. Hyperactive tendon reflexes b. Diminished tendon reflexes c. Prolonged PR interval d. Hypertension e. Hypotension
b, c, e
A nurse is aware that priorities need to be continuously set and reset in order to meet the needs of multiple clients. Which priniciples of client care should the nurse use for prioritization when giving report? Select all that apply. a. Prioritize potential problems before actual b. Prioritize systemic before local c. Prioritize acute before chronic d. Recognize and respond to transient findings e. Listen carefully and don't assume
b, c, e
A nurse is caring for a neonate who is 34 weeks gestation. The nurse correctly understands which of the following are consistent with prematurity? Select all that apply. a. Mongolian spots on shoulders b. Prominent clitoris and labia minora c. Large amount of vernix present d. Inner eye canthus level with pina e. Abundant lanugo
b, c, e
A nurse is teaching a new mother breastfeeding techniques. Which of the following teaching tips are appropriate to discuss with a new mother who is breastfeeding? Select all that apply. a. Two or three wet diapers per day are the norm b. Burp the newborn between each breast c. Avoid use of a pacifier to prevent nipple confusion d. Dark, firm stools are the norm e. Avoid a specific length of time to breastfeed
b, c, e
A nurse is caring for a client with a tracheostomy. In which order should the following interventions be performed when providing tracheostomy care? a. Document the type and amount of secretions b. Suction the tracheostomy c. Clean the inner cannula with hydrogen peroxide followed by sterile saline d. Apply an oxygen source loosely to prevent desaturation e. Change tracheostomy ties if soiled f. Apply a split 4x4 dressing around the tracheostomy
b, d, c, f, e, a
A nurse is caring for a client diagnosed with hyperemesis gravidarum. Which of the following are expected findings for this client? Select all that apply. a. Increased BP b. Ketosis c. Persistent diarrhea d. Weight loss e. Dehydration
b, d, e
What are characteristics of the fetus that are reviewed to determine the biophysical profile (BPP) during an ultrasound? Select all that apply. a. Fine body movement b. Fetal tone c. Fetal tidal volume d. Reactive FHR e. Qualitative amniotic fluid volume
b, d, e
A nurse is obtaining a sterile specimen from an indwelling urinary catheter. Place the following steps in the order the nurse should use to obtain this specimen: a. Remove clamp to resume drainage b. Drain the catheter's tubing of urine c. Place urine sample in sterile container d. Clamp the catheter's tubing port for 20 minutes e. Clean the injection port cap of the catheter drainage tubing with antiseptic f. Attach a sterile syringe to the port and aspirate quantity of urine required
b, d, e, f, c, a
A nurse is caring for a client who is scheduled for an electroencephalogram (EEG). Which statement by the client inidcates a need for further education? a. "I should wash my hair on the morning of the test." b. "I will not eat or drink anything after midnight." c. "I will expect the procedure to be painless." d. "A tracing will be obtained to evaluate my brain activity."
b. "I will not eat or drink anything after midnight." The client should be instructed not to drink caffeine-containing fluids, such as coffee or tea, on the day of the test. There are no other restrictions on diet before the test
A nurse is teaching bladder managment to a client who has a lumbar spinal cord injury (SCI). Which of the following statements should indicate to the nurse the client understands the teaching? a. "I will perform self-catheterization once a day." b. "I will watch for cloudy urine." c. "I will drink 1 L of fluid every day." d. "I will remove the condom catheter for cleaning every 48 hours."
b. "I will watch for cloudy urine." A client who has a SCI might not be aware of infection because he cannot feel dysuria, urgency, or back pain and must rely on other manifestations, such as cloudy and foul-smelling urine
A nurse is completing an admission assessment of an older adult client and notes a stage 2 pressure ulcer on the client's lumbosacral area. Which of the following findings should the nurse identify as a stage 2 pressure ulcer? a. A defined area of reddned but intact skin b. A shallow crater involving the epidermis c. Reddened area that does not blanch d. Leakage of cloudy fluid from abraded skin
b. A shallow crater involving the epidermis A client who has a stage 2 ulcer will have partial-thickness skin loss involving the epidermis, dermis, or both
A client who is 32 weeks pregnant presents to the emergency room with bright red vaginal bleeding for the last 3 hours. The client reports feeling fetal movement since the bleeding started. Which of the following is the nurse's priority action? a. Assess fetal heart tones b. Assess maternal vital signs c. Administer a 500 mL fluid bolus d. Perform a vaginal exam
b. Assess maternal vital signs Since the client is feeling the baby move the most important step would be to establish a baseline vital sings to determine potential blood loss and signs of shock
A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing actions should have the highest priority? a. Call the lab for a stat glucose level b. Assess the client's blood glucose level c. Give the client 4 ounces of orange juice d. Administer 50% dextrose via IV push
b. Assess the client's blood glucose level Check the patient's blood glucose. Although it is most likely that this patient is experiencing hypoglycemia, the blood glucose must be checked to confirm the problem and also to document HOW LOW the blood glucose is, which further helps determine the best treatment.
A postpartum client is reporting heavy vaginal blood flow. The nurse correctly understands which of the following assessments has the highest priority? a. Assess episiotomy for bleeding b. Assess the fundus for tone and position c. Assessing vital signs both lying and sitting d. Assess the client's last void
b. Assess the fundus for tone and position The most common cause of early postpartum bleeding is uterine atony. Even before assessing vital signs, the nurse should determine if the uterus is firm and midline in the abdomen. If it is not, fundal massage is urgently indicated, as a full bladder will displace the uterus and contribute to uterine atony
A nurse is assessing a client in the immediate postpartum period. The fundus is boggy and deviated to the left of the umbilicus. Which of the following is the most appropriate intervention? a. Assess lochia b. Assist client to void c. Reassess client in 30 min d. Begin an oxytocin infusion
b. Assist client to void A displaced and boggy uterus most likely indicate a full bladder and assisting the client to void would have the highest priority
A nurse is assessing a client's ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document? a. First-degree heart block b. Atrial fibrillation c. Complete heart block d. ventricular tachycardia
b. Atrial fibrillation In arial fibrillation, multiple rapid impulses from many different foci cause depolarization of the atria in a rapid, disorganized manner. This cause a chaotic rhythm on the ECG strip that has no clear P waves, no atrial contractions, and in irregular rhythm
A nurse is caring for a client recovering from an abdominal aortic aneurysm repair. Which of the following findings would have the highest priority? a. Pedal pulse amplitude 2+ b. Blood pressure 136/90 mm Hg c. Urine output 28 ml/hr d. Respiratory rate 12 breaths/min
b. Blood pressure 136/90 mm Hg
A nurse is providing discharge teaching to a client who has a new prescription for warfarin. For which of the following findings should the nurse instruct the client to monitor as an adverse effect of the medication and report to the provider? a. Tinnitus b. Bruising c. Blurred vision d. Constipation
b. Bruising A major adverse effect of warfarin therapy is bleeding. Therefore, the nurse should instruct the client to report any bruising which can indicate inadequate clotting and internal bleeding
A client experiencing intermittent chest pain has been admitted to the hospital. Which of the following laboratory values should the nurse report to the health care provider immediately? a. Creatine kinase (CK) 90 units/L b. Cardiac troponin T 1.2 ng/mL c. total myoglobin 60 mcg/L d. C-reactive protein (CRP) 0.2 mg/dL
b. Cardiac troponin T 1.2 ng/mL Normal range for cardiac troponin T is <0.20 ng/mL
A nurse is caring for a client who has sustained abdominal trauma. Whicch of the following actions should the nurse take to prevent increased intr-abdominal pressure? a. Auscultate the client's abdomen for a bruit b. Check the client for fecal impaction c. Place the client in a supine position d. Administer IV hypotonic fluids to the client
b. Check the client for fecal impaction The nurse should monitor bowel movements and check the client for fecal impaction that cause an increase in intra-abdominal pressure
A nurse is caring for a post-operative client who underwent thoracic surgery 7 hours prior, and now has in place a chest tube for drainage. What finding would require the nurse to contact the provider immediately? a. Diminished breath sounds auscultated in left lower lobe b. Chest tube drainage measures 80 ml/hr of red blood c. Chest tube and tubing become disconnected during client transfer d. Client complains of left-sided chest pain of 7 on pain scale when performing incentive spirometry
b. Chest tube drainage measures 80 ml/hr of red blood The client is 7 hours post-operative. The drainage should be tapering off at approximately 30 mls an hour. This is an indication of hemorrhage and the provider needs to be contacted immediately
A nurse is caring for a client who has Parkinson's disease and is taking benztropine. When the client reporst a dry mouth, which of the following recommendations should the nurse make? a. Increase intake of high-fiber foods b. Chew sugarless gum c. Moisten the mouth with lemon-glycerin swabs d. Rinse the mouth with nystatin
b. Chew sugarless gum Benztropine is an anticholinergic medication that blocks cholinergic receptors, which can cause dry mouth. The nurse should recommed the client chew sugarless gum to stimulate salive production
A nurse is caring for a client who is receiving peritoneal dialysis. When caring for the client's dialysis catheter, which of the following actions should the nurse plan to take? a. Apply clean gloves when removing old dressing from the catheter site b. Cleanse the area by using a circular motion beginning at the catheter site and moving outward c. Use warm water to cleanse the catheter site d. Place an occlusive dressing over the catheter site after cleansing
b. Cleanse the area by using a circular motion The nurse should use a circular motion while cleansing around the catheter site, starting at the catheter site and moving outwards to reduce the risk of infection The nurse should then place a precut gauze pad over the catheter site and secure only the edges with tape
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery? a. Oral temperature of 37.2 C (99 F) b. Clear drainage on the dressings c. Drain output 75 mL in 4 hr d. Decreased bowel sound in all quadrants of the abdomen
b. Clear drainage on the dressings The nurse should identify clear drainage on or around the dressing as an indication of a cerebral spinal leak and should report this finding to the provider immediately
A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching? a. Schedule controlled coughing exercises after meals b. Consume a diet that is high in calories c. Practice breath-holding d. Perform arm-reaching exercise
b. Consume a diet that is high in calories Dyspnea decreases energy available for eating. Therefore, the nurse should ecnourage the client to eat soft, high-calorie and high-protein foods to prevent weight loss
A client is admitted to the hospital for treatment of an acute asthma attack. The client is receiving an aminophylline infusion. Which of the following assessment findings indicate the client is experiencing the desired effect of aminophylline? a. Decreased heart rate b. Decreased wheezing c. Increased blood pressure d. Increased mucous production
b. Decreased wheezing This indicates increased bronchial dilation and imporved air movement
A client diagnosed with cervical cancer is prescribed a loop electrosurgical excision procedure (LEEP). Following the procedure, which of the following findings should the nurse instruct the client to report to the provider? a. Clear vaginal drainage b. Elevated temperature c. Mild pelvic pain d. Spotting of blood
b. Elevated temperature The client should be instructed to report any heavy vaginal bleeding, foul-smelling discharge or fever
A nurse is caring for a client post aortofemoral bypass surgery. Which of the following interventions would be contraindicated? a. Maintain NPO status until first postoperative day b. Encouraging client to sit in high Fowler's position c. Monitor client for changes in blood pressure d. Coughing and deep breathing every 1 to 2 hr
b. Encouraging client to sit in high Fowler's position Follwing an aortofemoral bypass surgery, the nurse should instruct the client to limit bending of the hip and knee to decrease the risk of clot formation
A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider? a. BP 138/80 mm Hg, contractions every 3-4 minutes b. FHR 120 bpm with late decelerations, contractions every 1-2 minutes c. FHR 140 bpm; good variability, contractions every 3-4 minutes d. BP 110/60 mm Hg, trace protein, contractions every 3-4 minutes
b. FHR 120 bpm with late decelerations, contractions every 1-2 minutes Late decelerations are signs of placental insufficiency which can cause fetal hypoxemia. The nurse should notify the PCP immediately
A breastfeeding mother develops engorgement on her second postpartum day. Which of the following statements by the client indicates the need for further teaching? a. I will feed my baby every 2 hours b. I will offer my baby a bottle following each feeding c. I will use a breast pump if my breasts do not soften d. I will apply warm packs to each breast prior to feeding
b. I will offer my baby a bottle following each feeding Bottle feeding while breastfeeding could lead to nipple confusion and interfere with successful breastfeeding. This mother needs further teaching
A nurse is teaching a client who has a new prescription for colesevelam powder for oral suspension. The nurse should include which of the following instructions? a. Take the medication on an empty stomach b. Increase fiber in your diet c. Discard the oral suspension if it is cloudy after mixing d. Avoid drinking grapefruit juice
b. Increase fiber in your diet Colesevelam is a lipid-lowering agent that can cause constipation, bloating, and indegestions. Therefore, the nurse should instruct the client to increase fluid and fiber intake
A nurse is teaching a client the correct use of a diaphragm as a method of contraception. Which of the following statements is correct? a. Insert diaphragm at least 8 hours prior to sexual intercourse b. Leave diaphragm in place at least 6 hours post coitus c. Douche promptly after removing the diaphragm d. Do not use any cream or jelly with the diaphragm
b. Leave diaphragm in place at least 6 hours post coitus The diaphragm should be left in place for at least 6 hours post intercourse
A client diagnosed with pregnancy induced hypertension has been receiving a Magnesium Sulfate infusion for three days. Serum drug levels have been between 8-10 mg/dL. Which of the following findings should the nurse expect to assess in the infant after delivery? a. Hypothermia and bradycardia b. Lethargy and respiratory distress c. Hyperactivity and irritability d. Tachycardia and respiratory distress
b. Lethargy and respiratory distress Mag. Sulfate blocks neuromuscular transmission and is a CNS depressant. Therefore, the infant will exhibit the same signs we assess for in a pregnant client: lethargy and respiratory depression. Therapeutic levels are 4-8 mg/dL
A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? a. High lipase b. Low urine specific gravity c. Low hemoglobin d. High creatine kinase-MB (CK-MB)
b. Low urine specific gravity A client who has hyponatremia as a result of diuretic overuse will have a low urine specific gravity. The increased excretion of water alters the ratio of particulat matter, which affects the specific gravity
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? Select all that apply a. Wear a protective gown when suctioning the client b. Monitor for oral secretions every 2 hr c. Provide oral care every 2 hr d. Maintain the client in low-Fowler's position e. Assess the client daily for readiness of extubation
b. Monitor for oral secretions every 2 hr c. Provide oral care every 2 hr e. Assess the client daily for readiness of extubation
A nurse is assessing a client who has Cushing's syndrom following long-term use of glucocorticoids for the treatment of an autoimmune disorder. Which of the following findings should the nurse expect? a. Vitiligo b. Osteoporosis c. Myxedma d. Heat intolerance
b. Osteoporosis Osteoporosis is a common finding in clients who have Cushing's syndrome. Bones become thinner as a result of mineral loss due to long-term glucorticoid therapy
The nurse is planning care for a client who is prescribed antiembolic stocking following abdominal surgery. Which of the following interventions should the nurse include? a. Ensure stockings are loose fitting over the client's calves b. Remove stockings one to three times per day for skin care and inspection c. Encourage client to only wear stockings when out of bed d. Remove stocking every 2 hours then reapply after 1 hour off
b. Remove stockings one to three times per day for skin care and inspection Antiembolic stockings should be removed one to three times per day to allow for skin care and assessment. The client's extremities should be monitored for calf pain, warmth, erythema and edema
A client is admitted to the emergency room after falling outside his home. The clients is complaining of a severe headache with pain above his left eye. The client is restless and intermittently looses consciousness. Pupils are dilated; pulse 56 and BP 168/98. An x-ray of the head confirms a skull fracture. Which of the following is a priority assessment? a. Pupillary changes b. Respiratory status c. Changes in level of consciousness d. Blood alcohol and toxicology screening
b. Respiratory status
A nurse is evaluating a client who has a history of type 2 diabetes mellitus. The nurse should indentify the following findings as an indication of a microvascular complication? a. Coronary artery disease b. Retinopathy c. Cerebrovascular accident d. Hypertension
b. Retinopathy Diabetic retinopathy is a microvascular complication of type 2 diabetes mellitus resulting from pathologic changes in small blood vessels, which eventually cause tissue damage and cell death of the retina
A nurse is caring for a toddler who is being treated for hypovolemia. Which of the following demonstrates to the nurse the desired response to fluid replacement? a. Urine output 48 mL for the past 4 hr b. Specific Gravity 1.025 c. Apical heart rate 130 bpm d. Central Venous Pressure 2 mm Hg
b. Specific Gravity 1.025 Within normal range and demonstrates the desired response to fluid replacement
A nurse is positioning a client on the operating room table in preparation for a cesarean birth. Which of the following is a correct position? a. Left lateral position with a foam wedge between the legs b. Supine position with foam wedge positioned under one hip c. Modified Trendelenburg position with a foam wedge under the legs d. Lithotomy position with a foam wedge behind the shoulders
b. Supine position with foam wedge positioned under one hip The supine position is appropriate for abdominal surgery (cesarean birth), and a wedge under on hip laterally tilts the client and reduces uterine weight on the vena cava and descending aorta. This helps maintain optimal perfusion of oxygenated blood to the fetus during the procedure
Which of the following should the nurse use to determine the neurological status of a client with a head injury? a. Manifestations of seizure activity b. The Glasgow Coma Sclae c. Client's reported pain scale d. Respiratory rate
b. The Glasgow Coma Scale The Glasgow Coma Scale is used to determine the client's level of consciousness. This is done with a head injury client at regular intervals, because LOC changes precede all other changes in vital and neurological signs. Each response is scored to predetermined criteria. The score is calculated numerically and the higher the score the higher the functioning
A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion has started, contractions ceased. Which of the following is the best analysis of this data? a. Deep tendon reflexes should be assessed b. The drug is having a therapeutic effect c. The medication dose should be increased d. The medication dose should be decreased
b. The drug is having a therapeutic effect A cessation of labor is the desired therapeutic effect of a tocolytic
The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? a. The purpose of the NST is to determine fetal breathing b. The purpose of the NST is to assess the fetal CNS c. The purpose of the NST helps to determine gestational age d. The purpose of the NST is to determine fetal lie
b. The purpose of the NST is to assess the fetal CNS This is the primary purpose of a NST. The test monitors the response of the FHR to fetal movement. This allows the nurse to assess the FHR in relationship to the fetal movement
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching? a. The stool will have a pasty texture b. The stool will have a high volume of liquid c. The stool will be solid and well-formed d. The stool will appear bloody with clots
b. The stool will have a high volume of liquid The nurse should include in the teaching that when peristalsis returns, a client can have an initial period of high-volume liquid stool output. Up to 1,800 mL/day. Later, as the proximal small bowel adapts, stool volume should dropt about 800 mL/day
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? a. Instruct the client to lift no more than 6.8 kg (15 lb) when at home b. Turn the client by log rolling with a turning sheet c. Inform the client to shower on the second postoperative day d. Remove sterile adhesive strips before discharge
b. Turn the client by log rolling with a turning sheet The nurse should turn the client by log rolling with a turning sheet to keep the client's back straight and to prevent back spasms from occurring
A client is admitted to the inpatient care unit with a diagnosis of diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? a. Serum glucos 200 mg/dL b. Urine ketones positive c. Serum pH 7.40 d. Low serum osmolality
b. Urine ketones positive DKA is an acute, life-threatening condition characterized by hyperglycemia (greater than 300 mg/dL) resulting in the breakdown of body fat for energy and an accumulation of ketones in the blood and urine
A client comes to the emergency department reporting epistaxis. Which of the following medications should the nurse suspect as contributing to the epistaxis? a. furosemide b. ibuprofen c. montelukast d. alprazolam
b. ibuprofen
vitamin K
baby has low vitamin K so can bleed
intussusception Tx
barium enema: pressure created by barium enema may force bowel to resume normal configuration
emphysema
barrel chest
COPD
barrel chest, anorexia, wt loss, Res acidosis (bradypnea)
sources of potassium
beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas
DVT/thrombophlebitis
bed rest, elevate extremity above heart level (no pillow under knee), warm moist compression, No massage, give anticoagulants
Shock
bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)
perform amniocentesis
before 20 weeks to check for cardiac and pulmonary abnormalities
pathological jaundice occurs: physiological jaundice occurs:
before 24 hours (lasts 7 days) after 24 hours
Where should the cath bag be placed when urinary cath is placed?
below the pt bladder to avoid reflux
flumazenil, Romazicon
benzo overdose
dipheria, tetanus, pertussis vaccine
between ages 4-6, around this age blood titers drop d/t decreasing antibodies
clang association
big back bop bouncing
Cold stress and the newborn
biggest concern resp. distress
Colesevelam
bile acid sequestrant -lipid-lowering agent -can cause constipation, bloating, indigestion - increase fluid and fiber intake -take with meals to increase absorption
upper GI bleed
black stool
hemianopia
blind 1/2 vision flied
Fat embolism
blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids.
Chadwick's sign
bluish vagina
cystic fibrosis and celiac disease
both have steatorrhea (foul-smelling, fatty stool) -cystic fibrosis only one that has elevated sweat chloride
Hypervolemia
bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's
IVP requires
bowel prep so bladder can be visualized
O2 toxicity
bradypnea
when phenylaline increases
brain problems occur
lower GI bleed
bright red stool
theopylline
bronchodilator - toxicity: anorexia, tachy, albuminuria, hypoTN
antiplatelet drug hypersensitivity
bronchospasm
Addison's
bronze like skin pigmentation
Lymes disease
bullseye rash
atypical antidepressant
bupripone SE: psychotic symptoms
What medications can be taken to help with smoking cessation?
bupropion
Nicotine W/D
bupropion (wellbutrin)
sle (systemic lupus)
butterfly rash
A nurse is educating a client about implementation of bowel training program. Which of the following interventions should be included in the plan of care? Select all that apply. a. Drink hot milk before defecation time b. Avoid the use of time limits for defecation c. Take stool softeners daily d. Choose a regular toileting time based on the clien'ts pattern e. Advise the client to lean forward at the hips while sitting on the toilet
c, d, e
A laboring client reports suddenly feeling something in her vagina. Upon assessment, the nurse identifies a prolapsed cord. Place the following interventions in the correct order that they should be performed. a. Prepare the client for a cesarean birth b. Administer oxygen 8-10 L via face mask c. Notify provider if the prolapsed cord d. Reposition the client in either a knee-chest or Trendelenburg position e. Using sterile glove, insert two fingers into the vagina to reduce pressure off the cord
c, d, e, b, a
A nurse is caring for a client who has reported difficulty sleeping. Which statement made by the client requires further assessment? a. "I drink a cup of chamomile tea to help relax at bedtime." b. "I make a point of getting to bed at the same time every night." c. "I have been really stressed out at work lately." d. "I try not to nap during the day, even though I'm tired"
c. "I have been really stressed out at work lately." Assessment of the related factor or probable cause of the sleep disturbance is a key step in caring for a client who has difficulty sleeping. These causes become the focus of interventions for minimizing or eliminating the problem.
A nurse is caring for a client with newly diagnosed diabetes mellitus. Which of the following client statements demonstrates understanding of self-glucose monitoring? a. "I will check my blood sugar before dinner each day." b. "I only need to check my blood sugar when I feel dizzy." c. "I will check my blood sugar at the same times each day." d. "I can use my wife's blood glucose meter as long as I use my test strips."
c. "I will check my blood sugar at the same times each day." While frequency of testing varies with prescribed drug therapy and blood glucose goals, checking the blood sugar at the same times each day will yield the most accurate information
A nurse is teaching lifestyle modifications to a client diagnosed with hypertension. Which of the following statements made by the client indicates a need for further teaching? a. "I don't like to walk, but I do aerobics and work out at the gym during the week." b. "We have a glass of wine a couple of times a week with dinner." c. "I will substitute mushrooms for the bacon in my daily omelets." d. "Losing weight is so hard, but so far I am losing 2 pounds a week."
c. "I will substitute mushrooms for the bacon in my daily omelets."
A nurse is providing discharge instructions to a client following cataract surgery. Which of the following statements by the client indicates the need for further teaching? a. "I will report pain accompanied with nausea/vomiting." b. "I will report a yellow or green discharge." c. "I will wear my bi-focal glasses when sitting outside on the deck." d. "I will avoid rapid, jerky movements such as vaccuming."
c. "I will wear my bi-focal glasses when sitting outside on the deck." This statement indicates the need for further teaching. Sunglasses should be worn outside or in brightly lit areas due to light sensitivity
A nurse is providing teaching to a client about strategies to manage menopausal symptoms. Which of the following instructions should the nurse include in the teaching? a. "Drink green tea to relieve menopausal hot flashes." b. "Take vitamin D supplements to relieve menopausal hot flashes." c. "Use water-based lubricant during intercourse to reduce discomfort." d. "Apply estrogen cream during intercourse to reduce discomfort."
c. "Use water-based lubricant during intercourse to reduce discomfort." The nurse should instruct the client to use water-based lubricants to help relieve vaginal dryness and irritation during sexual intercourse. Atrophic vaginitis is a common complication of menopause
A client diagnosed with diabetes mellitus reports feeling shaky. Further assessment reveals diaphoresis, tachycardia, and a glucose level of 70 mg/dL. Which of the following should the nurse administer to prevent a hypoglycemia reaction? a. 2 pieces whole grain toast b. 1 tablespoon of peanut butter c. 6 ounces of orange juice d. 1 cup of whole milk
c. 6 ounces of orange juice The recommendation for treatement of hypoglycemia is for 10 to 15 g of a fast-acting, simple carbohydrate orally, succh as three or four commercially prepared glucose tablets; 4 to 6 oz of fruit juice or regular soda; 6 to 10 hard candies; or 2 to 3 tsp of sugar or honey
A client is recovering from acute respiratory distress syndrome (AARDS). Which clinical manifestation requires immediate attention by the nurse? a. Increased oxygen saturation b. Increase in pulse rate c. A decrease in blood pressure d. A decrease in temperature
c. A decrease in blood pressure Hypotension is commonly a result of hypovolemia. This reaction requires immediate intervention secondary to the leakage of fluid into the interstitial space causing a depressed cardiac output
A nurse manager is inspecting client rooms for electrical hazards as part of the facility's quality imporvement plan. Which of the following findings should the nurse identify as a safety hazard? a. A continuous passive motion (CPM) machine has a three-prong plug attached to the cord b. A protective cover is inserted into an unused outlet c. An IV pump is plugged into an outlet near a sink d. An electrical cord is coild and secured to the floor
c. An IV pump is plugged into an outlet near a sink
A client is having an exercise electrocardiography (stress test) performed. The nurse recognizes the need to stop the test if which of the following occurs? a. The client experiences an increase in heart rate b. QRS complexes being to occur more frequently c. An ST segment depression or T wave inversion on the EKG d. The client begins to breathe harder
c. An ST segment depression or T wave inversion on the EKG Significant ST segment depression or T wave inversion are indications of myocardial ischemia and the stress test should be stopped
A nurse is caring for a client on the telemetry unit who is two days post coronary artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. Which of the following should be completed first? a. Prepare a diltizem drip b. Prepare the client for cardioversion c. Assess the client's blood pressure d. Notify the health care provider
c. Assess the client's blood pressure Atrial fibrillation frequently occurs after CABG. In A-Fib the atrial kick is lost and cardicac output (CO) is decreased by 30%. Clients react differently to A-Fib and the decreased CO. Some clients become hypotensive and develop shock-like symptoms: changes in LOC; cool, clammy skin; dyspnea; and chest pain. While other clients are normotensive despite the decrease in CO, they are asymptomatic or considered stable. Treatement for A-Fib depends on the status of the client. The first action the nurse should take with a client who has converted from NSR to A-Fib is to assess the client's BP
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? a. WBC count 8,000/mm3 b. RBC count 6 million/mm3 c. BUN 24 mg/dL d. Potassium 3.5 mEq/L
c. BUN 24 mg/dL
A nurse is caring for a client who underwent a right below the knee amputation yesterday. Which of the following should the nurse report to the provider immediately? a. Redness of the incision site b. WBC count of 10,000 c. Blood glucose 200 mg/dL d. Quarter size spot of blood on dressing
c. Blood glucose 200 mg/dL Hyperglycemia impairs healing and can increase risk of infection
Following a TURP with CBI (continuous bladder irrigation), the client states he has severe lower abdominal cramping. Which of the following actions should the nurse take first? a. Discontinue the bladder irrigation b. Irrigate the catheter c. Check the catheter for kinks d. Increase the flow of the irrigate
c. Check the catheter for kinks With CBI, the catheter drains urine and allows for instillation of normal saline (isotonic) or another prescribed irrigating solution to keep the catheter free of obstruction
A nurse is preparing to obtain blood cultures from a client who has a central line and is receiving an antibiotic infusion. Which of the following actions should the nurse plan to take? a. Place the infusion on hold and withdraw the clood culture from the central line b. Withdraw the blood culture from the central line using a vacuum tube with a needle c. Cleanse the connections with 70% alcohol d. Flush the client's central line using 5 mL syringe
c. Cleanse the connections with 70% alcohol The nurse should cleanse the connections prior to drawing blood with a vigorous action for a 15-second scrub using 70% alcohol in order to remove bacteria, fungi, and viruses The nurse should obtain the blood culture from the client's central line by using a needleless 3-mL syringe
A nurse is caring for a client diagnosed with pre-eclampsia. The client is receiving Magnesium Sulfate IV. Which of the following assessment findings is the first sign of Magnesium toxicity? a. Nausea and vomiting b. Respiratory depression c. Decreased deep tendon reflexes d. Visual blurring
c. Decreased deep tendon reflexes Mag Sulfate reduces striated muscle contractions due to a depressant effect of the CNS. It blocks neuromuscular transmission. Toxic signs of mag sulfate include diminished tendon reflexes, hypotension, and prolonged PR intervals. Later signs include absence of reflexes
A nurse is reinforcing teaching with a client who has been recently diagnosed with osteoporosis. Which of the following should be included? a. Long-term estrogen replacement therapy will be required b. Walking for one to two hours daily is recommended c. Eliminate safety hazards in the home d. Increase intake of dietary calcium
c. Eliminate safety hazards in the home The client must be caregul to prevent falls and other activities that can cause a fracture. Teach client about the importance of having a hazard-free environment, including avoiding scatter rugs, cluttered rooms, and wet floor areas
A nurse is providing education to a client with coronary artery disease. Which of the following cholesterol values should the nurse identify as a goal for this client? a. LDL-C level 120 mg/dL b. HDL-C level 20 mg/dL c. HDL-C level 60 mg/dL d. LDL-C level 98 mg/dL
c. HDL-C level 60 mg/dL HDL is the "good" cholesterol. Normal values range from 35-80 mg/dL
A client diagnosed with atrial fibrillation has a pacemaker set at a ventricular rate of 70 beats per minute. Which of the following findings should the nurse immediately report to the provider? a. HR=96 bpm and irregular b. HR=76 bpm and irregular c. HR=60 bpm and regular d. HR=96 bpm and regular
c. HR=60 bpm and regular If the client's rhythm is regular and within the normal range of 60-100, this is a GOOD thing!
A nurse is caring for a client who develops a sudden onset of dyspnea. Which of the following findings should the nurse expect if the client has a pulmonary embolus? a. Expiratory rhonchi b. Petechiae over the lower extremities c. Hemoptysis d. Flattened neck veins
c. Hemoptysis The nurse should expect a client who has a pulmonary embolus to have hemoptysis, which is an indication of a pulmonary infarction
A nurse is caring for a client with a new onset bowel obstruction. What assessment finding would be anticipated when completeing an abdominal assessment? a. Hypoactive bowel sounds b. Absent bowel sounds c. Hyperactive bowel sounds d. Normal bowel sounds
c. Hyperactive bowel sounds Hyperactive bowel sounds are characteristic of early stage bowel obstruction Hypoactive bowel sounds are characteristic of late stage bowel obstruction
A nurse is caring for a client recently diagnosed with diabetes mellitus. Which of the following is the physiologic basis for the polyuria manifested by individuals with untreated DM? a. Chronic stimulation of the detrusor muscle by the ketone bodies b. Inadequate secretion of antidiuretic hormone c. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia d. Early-stage renal failure causes a loss of urine concentrating capacity
c. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia
A nurse is caring for a client following a spinal cord injury. Which of the following findings would alert the nurse to the development of neurogenic shock? a. Hypertension b. Hypoglycemia c. Hypotension d. Hyperglycemia
c. Hypotension
A nurse is completing discharge teaching with a client who has a new prescription for enoxaprin to treat unstable angina. Which of the following instructions should the nurse include in the teaching? a. Administer this medication into your leg muscle b. Expel the excess air in the syringe before you administer the medication c. Insert the entire needle into your skin to administer medication completely d. Take ibuprofen for fever following administration of this medication
c. Insert the entire needle into your skin to administer medication completely The nurse should advise the client to insert the entire needle into the skin to administer the medication completely. A small needle is used so that the medication does not go into the muscle
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following actions should the nurse include in the plan of care? a. Assess the client to determine the need for endotracheal suction every 4 hr b. Check the ventilator settings every 12 hr c. Keep the head of the client's bed elevated 30 degrees d. Perform oral hygiene with chlorhexidine every 3 hr
c. Keep the head of the client's bed elevated 30 degrees The nurse should keep the head of the client's bed elevated at least 30 degrees to promote increased lung expansion and to help prevent ventilator-associated pneumonia
A client is undergoing cystoscopy. Which of the following interventions should the nurse include in the client's plan of care? a. Increase oral fluid intake to flush contrast dye from system b. Provide education on home urinary catheter care c. Monitor for infection for 48-72 hours following procedure d. Educate client on the need for anticoagulant therapy
c. Monitor for infection for 48-72 hours following procedure Instrumentation of the urinary tract increases the risk of infection so this client should be monitored for s/s of infection for several days following the procedure
A nurse is caring for a client who is receiving a transfusion of packed RBCs. The nurse notes that the client's blood type is AB positive and the blood infusing is labeled type B negative. Which of the following actions should the nurse take? a. Stop the blood transfusion immediately b. Prepare to administer antipyretics c. Monitor the client for any adverse reactions d. Transfuse the blood over 6 hr
c. Monitor the client for any adverse reactions Although a client is considered a universal recipient because ha can receive any ABO blood type, the nurse should continue to monitor the client for any adverse reactions, which is standard procedure for any blood transfusion
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade? a. Fever b. Atrial fibrillation c. Paradoxical pulse d. Pericardial friction rub
c. Paradoxical pulse Cardiac tamponade occurs from an excess of fluid in the pericardial cavity and causes a sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or greater between expiration and inspiration and is a manifestation of cardiac tamponade. The nurse should report manifestations of cardiac tamponade to the provider immediately
A nurse is caring for a client with heart failure. Which of the following interventions should the nurse take if the client is experiencing dyspnea? a. Perform coughing and deep breathing exercises every 8 hours b. Place client in the reverse trendelenberg position c. Place client in high-Fowler's position d. Obtain serial ABGs every 8 hours
c. Place client in high-Fowler's position Placing a client with dyspnea in a high-Fowler's position will maximize chest expansion and improve oxygenation
A client diagnosed with chronic obstructive pulmonary disease (COPD) is reporting shortness of breath upon exertion. The client is prescribed oxygen at 3 L/min and his oxygen saturation level is measuring 86%. The nurse understands which of the following is the priority intervention? a. Increase oxygen from 3 L/min to 6 L/min b. Encourage the client to stop smoking c. Position the client in the high-Fowler's d. Teach the client to eat several small meals a day
c. Position the client in high-Fowler's Clients with COPD should be positioned in the high-Fowler's position in order to maximize ventilation
The nurse is observing sibling adaptation behaviors to the newborn infant during a family visit. To facilitate sibling acceptance, which action by the parents can assist with bonding? a. Discuss with the sibling the importance of being more independent b. Create new traditions and routines c. Provide the sibling a stuffed animal that they care for while parents nurture the newborn d. Encourage the sibling to spend time primarily with the babysitter
c. Provide the sibling a stuffed animal that they care for while parents nurture the newborn This will help the sibling feel they are a part of the new family experience
Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. Which of the following is the correct priority nursing intervention? a. Assess vital signs and apply O2 via facemask b. Notify provider and prepare for an emergency cesarean birth c. Stop oxytocin infusion and assess contractions and fetal heart rate d. Stop oxytocin infusion and administer terbutaline 0.25 mg
c. Stop oxytocin infusion and assess contractions and fetal heart rate If there are any signs of fetal maternal distress the priority intervention would be to stop the Pitocin infusion. Pitocin should be discontinued with any of the following: prolonged or excessively strong contractions; signs of any fetal hypoxia and or fetal distress; signs of uterine or placenta abruptio; evidence of an antidiuretic effect; and hypertension
A nurse is caring for a client who has been prescribed magnesium sulfate for pregnancy induced hypertension. On admission the client's BP is 160/90 mm Hg and urine output is 25 mL/hr. Following initiation of magnesium sulfate, which of the following symptoms should be reported to the provider? a. The client is voiding 40 mL/hr b. The client reports feeling flushed and warm c. The client is drowsy and difficult to wake d. The client's blood pressure is 130/70
c. The client is drowsy and difficult to wake If the client is sleepy and difficult to rouse she may be experiencing symptoms of magnesium sulfate toxicity. This should be immediately reported to the provider
A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that the behaviors must likely indicate which of the following? a. The taking-hold phase of maternal psychosocial adaptation b. Positive mother-infant bonding c. The taking-in phase of maternal postpartum adjustment d. Postpartum role transition
c. The taking-in phase of maternal postpartum adjustment The taking-in phase begins immediately following birth and lasts a few hours to a couple of days. It is characterized by the mother being excited and talkative, reliving her birthing experience, and focusing on her own needs and the overall health of her newborn
A nurse is caring for a client who is reporting lower abdominal pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy? a. Edematous face, hands, and ankles b. Absence of fetal heart tones and fetal movement c. Unilateral stabbing abdominal lower abdominal pain d. Steady bleeding with lower abdominal pain
c. Unilateral stabbing abdominal lower abdominal pain As the fetus develops, it eventually exceeds the diameter of the fallopian tube and ruptures the tube, creating an internal hemorrhage. There may or may not be blood from the vagina. The symptoms may include unilateral stabbing pain and tenderness in the lower abdominal quadrant, and commonly referred shoulder pain from blood irritation of the diaphragm or phrenic nerve. There may be nausea and vomiting, and symptoms of shock
A charge nurse is orienting a newly licensed nurse about mechanical debridement of a burn wound through hydrotherapy. The charge nurse should identify that which of the following actions by the newly licensed nurse indicates an understanding of the teaching? a. Uses fingers to remove loose tissue b. Opens small blisters to expose aire c. Washes the burn with a mild detergent d. Applies wet-to-dry dressing
c. Washes the burn with a mild detergent The nurse should wash the burn with a mild and unscented detergent and rinse thoroughly while performing hydrotherapy to decrease bacterial growth. Perfumed detergents can irritate the skin and can interfere with wound healing
A client in her first trimester is encouraged to increase intake of proteins and folic acid as essential nutrients for basic fetal growth. Which foods would the nurse identify as high in folic acid? a. avocados b. tomatoes c. lentils d. fish
c. lentils This food is high in folate. Folic acid is crucial for neurological development and prevention of fetal neural tube defects
A positive Chvosteks sign is found in a patient. The nurse would anticipate IV admin of
calcium gluconate (tx for hypocalcemia-cause for chvosteks)
Thorazine and Haldol
can cause EPS
oral steroids
can result in decreased linear growth
PVC's
can turn into V fib.
Hodgkin's disease
cancer of the lymph. very curable in early stages
Food with high potassium content
cantaloupe
What values would a nurse possess to be a client advocate?
caring, autonomy, respect, empowerment
retino blastoma
cat's eye reflex
during Continuous Bladder Irrigation (CBI)
catheter is taped to the thigh. leg must be kept straight.
pernicious anemia
caused by lack of intrinsic factor needed to absorb vitamin b12 by Gi tract; monthly vitamin b12 injections definitive tx
Isoniazid
causes peripheral neuritis
Addison's
causes sever hypotension!
CVA
cerebriovascular accident. brain tissue dies.
SIADH (increased ADH)
change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics
Probable sign of pregnancy
changes that make examiner suspect woman is pregnant -positive pregnancy test -chadwick sign -goodell sign -hegar sign -ballottement -braxton hicks contractions -abdominal enlargement -fetal outline fetl by examiner
Presumptive sign of pregnancy
changes women experiences that make her think that she might be pregnant -amenorrhea -fatigue -n/v -urinary frequency -breast changes -quickening -uterine enlargement
nephrotic syndrome
characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay
before IV antibiotics?
check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose.
After endoscopy
check gag reflex
Food to avoid with chronic renal failure
cheddar cheese
acid ash diet
cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
The nurse caring for a child in bucks traction will keep the:
child pulled up in the bed
bryant's traction
children <3 y <35 lbs with femur fx
NCLEX answer tips
choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment.
hypocalcemia
chvostek sign, numbling, tingling
Projection
client attirbutes undesired impulses to another -unconsciously transferring unaccpetable feelings, thoughts, or traits in oneself onto another person
anterior fontanel
closes at 18 months if closes early measure head circumference
crepitus "SQ emphysema"
coarse crackling sensation palpated over skin surface, indicates an air leak into SQ tissue often indicating pneumothorax
Fill in the blank __________ is used by interdisciplinary team to make health care decisions about clients with multiple problems. _________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone
collaboration
Dopaminergics may be
combined with carbidopa to decrease peripheral metabolism of levodopa requiring a smaller dose to make the same amount available to the brain
lithium toxicity
confusion, coarse hand tremor, sedation
A/e of Iron
constipation, nausea, black/tarry stool, temp teeth staining
Ingestion of PCP
continuous gastric lavage
breast engorgement
cool compression between feedings, warm before shower to milk letdown
Variable decels
cord compression
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is the MOST important for the nursing care plan to include that the pt
cough and deep breathe
hemoptysis
cough up blood
cognitive therapy
counseling
Sucking stab wound
cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo!
MI
crushing stabbing chest pain unrelieved by nitro
angina
crushing, stabbing chest pain relieved by nitro
when on nitroprusside monitor:
cyanide. normal value should be 1.
tetralogy of fallot
cyanotic heart defect; polycythemia (increased RBCs) expected to have elevated hematocrit
A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? a. "Have you felt fetal movement over the last 24 hours?" b. "What happens to your contractions when you move about?" c. "When did your contractions begin?" d. "Have you noticed any bloody show or fluid coming from your vagina?"
d. "Have you noticed any bloody show or fluid coming from your vagina?" Vaginal discharge of blood or fluid may indicate cervical dilation, and potentially rupture of membranes. False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? a. "I should not remove the yellow exudate on the end of the penis." b. "I will clean his penis with each diaper change." c. "The circumcision will heal completely within a couple of weeks." d. "I can give him a tub bath in two days."
d. "I can give him a tub bath in two days." The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks
A client is prescribed warfarin daily. Which of the following statement made by the client indicates to the nurse a need for further teaching? a. "I have two pairs of anti-embolic stockings so that one pair can be washed each day." b. "I will report any sign of Purple Syndrome to my physician." c. "Instead of a safety razor, I have been using an electric razor to shave." d. "I have been eating more salads and other green, leafy vegetables to prevent constipation."
d. "I have been eating more salads and other green, leafy vegetables to prevent constipation." Warfarin inhibits the synthesis of vitamin K dependent clotting factors (factors II, VII, IX, and X). Green, leafy vegetables contain vitamin K which is an antagonist to coumadin. The patient can eat foods with vitamin K but the intake must remain consistent. Not "more" as stated in this answer. Foods low in vitamin K include roots, bulbs, fleshy parts of nuts, and fruit juices
A nurse is providing education about oral glucose tolerance testing (OGTT) to a client who has diabetes mellitus. Which of the following statements should indicate to the nurse that the client understands the teaching? a. "I will eat a light breakfast the morning of the test." b. "I should expect to drink a beverage containing glucose before the first blood draw." c. "I can expect to have my blood drawn at 15-minute intervals during the test." d. "I will report dizziness if it occurs during the test."
d. "I will report dizziness if it occurs during the test." The client should report dizziness that occurs during the test because this can indicate a drop in blood sugar and a need to obtain a blood glucose level. Transient reactions can include dizziness, sweating, weakness, and giddiness
A nurse is providing discharge teaching to a client who is starting parenteral nutrition (PN) therapy at home following a total gastrectomy. Which of the following statements should indicate to the nurse the client understands the teaching? a. "I will adjust the rate of infusion based on my urinary output." b. "I will need to have a 60-milliliter syringe to administer my PN." c. "I will keep additional solution bags at room temperature." d. "I will use aseptic technique when administering my PN."
d. "I will use aseptic technique when administering my PN"
A client is scheduled for surgery. Which of the following findings should the nurse report to the provider prior to surgery? a. A missing identification band b. Increased anxiety level c. Serum potassium of 3.8 mEq/L d. A decrease in BP
d. A decrease in BP A decrease in BP outside should be reported to the provider prior to surgery. This is an indicator of a potential complication and surgery may need to postponed
A nurse is caring for a client who is 11 weeks pregnant. Which of the following is an appropriate psychological task for the client? a. Begin to think about names for the baby b. View morning sickness as tolerable c. Verbalize concerns about the health care facility d. Accept the fact that she is pregnant
d. Accept the fact that she is pregnant The developmental task during the first trimester is to accept the reality of the pregnancy. Accepting the reality of being pregnant allows the client to see a provider and get prenatal care
A nurse is caring for a client who has had a gastric resection to treat peptic ulcer disease. What is the priority intervention when caring for the client in the immediate postoperative period? a. Monitor pain levels b. Inspect the operative site for redness or swelling c. Auscultate the lungs for adventitious sounds d. Assess NG tube for patency
d. Assess NG tube for patency
A nurse in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the first manifestation of a change in nuerological status? a. Sudden, severe onset of hypertension b. Bradycardia c. Widened pulse pressure d. Change in level consciousness
d. Change in level consciousnous When using the urgent vs nonurgent approach to client care, the nurse should determine the priority action is to assess a client's change in level of consciousness. An altered level of consciousness is the first manifestation of increased intracranial pressure
A nurse is preparing a bolus tube feeding for a client with a gastrostomy tube. Which of the following would be an appropriate action? a. Assess the blood glucose before administering the feeding b. Flush tubing with a small amount of saline before feeding c. Don sterile gloves when adding feeding to the system d. Check gastric pH to assess placement of gastrostomy tube
d. Check gastric pH to assess placement of gastrostomy tube Checking the pH of the aspirate is currently a preferred method for placement after a x-ray has confirmed placement. If the correct position of the tube is in question, x-ray should be utilized to confirm placement
A client with chronic obstructive pulmonary disease (COPD) has oxygen therapy ordered. Which principle should guide the nurse in managing the delivery of oxygen to this client? a. The concentration of oxygen should be low since the stimulus to breathe in clients with COPD is an elevated PaCO2 b. Clients with COPD require higher concentrations (6-8 L) of oxygen since hypoxemia is their stimulus to breathe c. The concentration of oxygen should be high since the stimulus to breathe in clients with COPD is an elevated PaCO2 d. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2
d. Clients with COPD should receive low concentrations (2-3 L) of oxygen since their stimulus to breathe is their low PaO2
A client presents to the emergency department with an abdominal stab wound. The nurse visualizes intestines protruding through the wound. Which of the following is an appropriate action for the nurse? a. Place sterile gauze and an abdominal binder over the wound b. Apply pressure to the wound with wet sterile sponges c. Irrigate the wound with a normal saline solution d. Cover the wound with warm saline-soaked gauze
d. Cover the wound with warm saline-soaked gauze
A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed aqueous vasopressin. Which of the following outcomes indicates treatment has been effective? a. Blood pressure of 90/50 mm Hg b. Urine output of 200 mL per hour c. Pulse rate of 126 beats/minute d. Fluid intake of 2,400 mL in 24 hr
d. Fluid intake of 2,400 mL in 24 hr DI is characterized by polyuria (up to 8L/day), constant thirst, and an unusually high oral intake of fluids. Treatement with Lypressin should decrease the urine output and oral fluid intake
A nurse is reviewing a client's lab results. Which finding would lead a nurse to suspect the client iis experiencing dehydration? a. BUN 20 mg/100 mL b. Serum sodium 130 mEq/L c. Urine specific gravity of 1.025 d. Hematocrit 55%
d. Hematocrit 55% An increased hematocrit level (>50%) is expected with dehydration
A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associated with this condition? a. Negative Startle reflex b. Increased drowsiness c. Diminished tendon reflexes d. Hypothermia
d. Hypothermia Thermal regulation issues are noted with this condition, such as hypothermia or hyperthermia
A client is admitted to the surgical unit after sustaining a compound fracture of the left femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20, B/P 94/58. The nurse notes a 4 cm area of bright red blood on the pressure dressing on the left lower extremity. The client is receiving intravenous fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused and combative. Which of the following is the most likely cause of the change in the client's condition? a. Hypovolemic shock related to hemorrhage from the open wound b. Fluid overload related to aggressive isotonic volume replacement c. Infectious process related to contamination of the open wound d. Hypoxia related to fat embolism from the fractured bone
d. Hypoxia related to fat embolism from the fractured bone While it is possible for hypovolemic shock to occur following a fracture, the most likely cause of combativeness and confusion with a long bone fracture is fat emboli
A client is prescribed TPN to be infused through a single lumen PICC. Which of the following actions should the nurse take if the client is prescribed intravenous antibiotic therapy? a. Administer the antibiotic through the TPN line b. Stop the TPN to administer the antibiotic as ordered c. Request the provider insert a second PICC line d. Identify alternative methods of administration
d. Identify alternative methods of adminstration The nurse should seek out alternative methods of administration and then collaborate with the provider
The client asks the nurse to explain the difference between true and false labor. Which of the following is an example of true labor? a. In true labor walking will cause contractions to slow down b. In true labor contractions are felt in the abdomen above the umbilicus c. In true labor the presenting part is engaged d. In true labor the cervix will dilate and efface
d. In true labor the cervix will dilate and efface Progressive changes in dilation and effacement are the ultimate signs of true labor
A nurse is evaluating placement of a nasogastric (NG) tube. Which of the following is the least reliable method to determine correct NG tube placement? a. Ask the client to talk b. Aspirate to collect gastric content c. Test pH of gastric contents d. Inject air into tube and listen over abdomen
d. Inject air into tube and listen over abdomen Ausculation of air bolus is the least reliable method of checking NG tube placement because the nurse may mistake bowel sounds for the air bolus
A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate? a. Apply cold compresses to the affected extremity b. Apply warm compresses to the affected extremity c. Keep the affected extremity above the level of the heart d. Keep the affected extremity below the level of the heart
d. Keep the affected extremity below the level of the heart The affected extremity should be kept lower than the level of the heart to enhance arterial blood flow to the feet
A nurse is providing care for a client with a Jackson-Pratt drain. Which of the following nursing interventions has the highest priority? a. Securing the tubing and drainage bulb to the client b. "Milking" the tubing before emptying the drain c. Cleansing the insertion site of the tube with beltadine d. Keeping the drainage bulb depressed to manual suction
d. Keeping the drainage bulb depressed to manual suction Decompressing the bulb exerts pressure and allows drainage to be pulled from inside of the body to outside of the body. Without keeping the bulb kept to suction, the drain will not function properly
A nurse is teaching a client who has a new prescription for lovastatin. Which of the following diagnostic tests should the nurse instruct the client to complete before starting the medication? a. Potassium level b. Hemoglobin level c. Kidney function tests d. Liver function tests
d. Liver function tests Lovastatin is an HMG-CoA reductase inhibitor that can cause hepatotoxicity. Therefore, the nurse should teach the client to have liver function tests obtained prior to therapy and to monitor and report manifestations of liver injury, such as anorexia, jaundice, and abdominal pain. Statins increase the low density lipoprotein (LDL) receptors in the liver cells, which reduces LDL levels and can increase the risk or liver damage
A nurse is caring for a client with dementia who has just returned from the postanesthesia care unit (PACU). Which of the following would be appropriate during the initial pain assessment? a. Asking the client to rate the pain on a scale of one to ten b. Asking the client to rate the pain using a faces scale c. Assessing the client's vital signs d. Observing the client's facial expressions
d. Observing the client's facial expressions The American Geriatrics Society Panel found six common indicators that should be assessed in the cognitively impaired client: facial expressions (grimacing, crying); vocalizations (screaming); body movements (restlessness); changes in interpersonal interactions; changes in activity patterns or routines; mental status changes (increased confusion)
A client diagnosed with diabetes mellitus consumed less than 50% of the lunch tray and reports feeling shaky. Which of the following is the first action the nurse should take? a. Observe for signs of hypoglycemia b. Notify the charge nurse c. Provide a low carbohydrate snack d. Obtain a blood glucose reading
d. Obtain a blood glucose reading Obtaining a blood glucose reading is necessary for the client demonstrating signs of hypoglycemia
Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? a. Hold and comfort the infant to stop the crying b. Feed the infant oral feeding c. Obtain an order for a drug screening blood test d. Perform a heel stick to check serum glucose
d. Perform a heel stick to check serum glucose The priority action is to confirm the serum glucose before proceeding. A blood glucose level less than 40-45 mg/dL by heel stick is an urgent situation requiring therapy with glucose --generally orally
A nurse is caring for a client at risk for atelectasis. Which of the following should the nurse monitor for manifestations of atelectasis? a. Lung sounds b. Daily weight c. Intake and output d. Pulse oximetry
d. Pulse oximetry Monitoring pulse oximetry is necessary when observing for the manifestation of atelectasis. An alteration in pulse oximetry will occur because of the impaired gas exchange related to atelectasis
A nurse is caring for a client who has a fractured hip and was placed in continuous Buck's traction 2 hr ago. Which of the following actions should the nurse take? a. Inspect the client's skin underneath the boot every 12 hr b. Remove the weights from the traction while repositioning the client in bed c. Assess the client's circulation every 4 hr d. Request the client to perform dorsiflexion of the affected extremity every 1 hr
d. Request the client to perform dorsiflexion of the affected extremity every 1 hr The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hr to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage. If this occurs, the nurse should notify the provider immediately
A nurse is preparing to teach about postoperative exercises to a client who had a mastectomy of the left breast with axillary lymph node dissection the previous day. Which of the following exercises should the nurse recommend for the client to start on the first postoperative day? a. Brushing her hair using her left hand b. Flexing and extending the fingers of her left hand c. "Walking" up a wall with both hands d. Squeezing and releasing a ball in her left hand
d. Squeezing and releasing a ball in her left hand The client should begin to squeeze and release a ball in her left hand by the first postoperative day. The client can regain arm function on the affected side after a mastectomy and axillary lymph node dissection by performing a progressive series of arm and shoulder exercises to prevent contractures, maintain tone, and improve blood and lymph circulation
A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? a. The fundus will be one centimeter above the umbilicus b. The fundus will be two centimeters below the umbilicus c. The fundus will be at the level of the umbilicus d. The fundus will be one centimeter below the umbilicus
d. The fundus will be one centimeter below the umbilicus The fundus descends 1-2 cms per day, so from the highest point of 1 cm above the umbilicus at 12 hours, it should be 0-1 cms below the umbilicus on day two
Myasthenia gravis
decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration.
1st sign of mag toxicity
decreased DTRs
Findings in infant to immediately report
decreased UOP
DIC- can't stop bleeding
decreased platelets & fibrinogen, increase PTPT Tx: fluid, platelets, splenectomy, uterotonic agents
Iron toxicity reversal
deferoxamine
IM site for children
deltoid and gluteus maximus
Decisions are made with the group, communication occurs up and down chain of command, work output by staff is usually of good quality
democratic
What are the five stages of grief?
denial, anger, bargaining, depression, acceptance
Hyper Mg
depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY
myasthenia gravis
descending musle weakness
Hirschprung's
diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools
MDMA use (methamph)
diaphoresis, tactile sensitive, cramping,, teeth clenching, chills, hallucination
Moderate-level anxiety
difficulty concentrating and focusing
caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days
FHR <110 for 10 min
discontinue oxy, side lying, oxygen mask 8-10L, give tocolytic med
short cord
discontinue pictocin
RN jobs
do plan of care, evaluate, assess, teach
After total hip replacement
don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows.
BABY
dont bathe daily, cover body when washing hair, suction mouth 1st then nose,
birth weight
doubles by 6 months triples by 1 year
9 month
drinks well from a cup
Rubella
droplet precautions
SSRI
duloxetine, fluoxetine, escitalopram, sertraline, paroetine -no ETOH, do not stop abruptly, monitor serotonin syndrone (agitation, confusion, hallucinations w/in 1st 72 hours) -se: wt gain, sex dysfunction, fatigue, drowsiness
advance directives=
durable power of attorney (who makes decision when I cant) + living will (choose what Tx)
Basophils reliease histamine
during an allergic response
involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of time
dysfunctional grief
Cullen's sign
ecchymosis in umbilical area, seen with pancreatitis
What therapy will be useful for patients with bipolar?
electroconvulsive for the suicidal pt who has taken lithium, has rapid cycling and has proven ineffective.
Head Injury
elevate HOB 30 degrees to decrease ICP
Buck's Traction (skin)
elevate foot of bed for counter traction
AKA (above knee amputation)
elevate for first 24 hours on pillow. position prone daily to maintain hip extension.
wilm's tumor
encapsulated above kidneys...causes flank pain
pt with leukemia may have
epistaxis due to low platelets
Transesophageal fistula
esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis)
What is the study of conduct and character?
ethics
Interaction of diuretics and ACE
excessive reduction in BP and symptomatic hypotension or hyperkalemia
Diabetes insipidus (decreased ADH)
excessive urine output and thirst, dehydration, weakness, administer Pitressin
peripheral arterial disease PVD
exercise intolerant, DONT elevate feet or cross leg (ischemia distally), straight toe nail, apply lubricating lotion, loose clothing,
Reaction formation
exhibit behavior or emotion that is opposite of how the perosn feels
hyperthyroidism/ grave's disease
exophthalmos
Glasgow coma scale
eyes, verbal, motor Max- 15 pts, below 8= coma
Hyper-parathyroid
fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet
otitis media
feed upright to avoid otitis media!
russell traction
femur or lower leg
lumbar puncture
fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache.
pneumonia
fever and chills are usually present. For the elderly confusion is often present.
Fat overload syndrome
fever, increased triglycerides, multisystem organ failure
What is an agreement to keep promises
fidelity
What are the S/S of lithium toxicity? (depakote for bipolar disorder)
fine hand tremors, mild GI upset, slurred speech, and muscle weakness
when a pt comes in and is in active labor
first action of nurse is to listen to fetal heart tones/rate
nagelles rule to calculate due date
first day of LMP - 3 months + 7 days + 1 year example: November 23, 2015- 3 months=August 23,2015 + 7 days & 1 year= August 30th 2016 -to have a summer baby- get pregnant in september, october, november!
pancreatitis
first pain relief, second cough and deep breathe
laboring mom's water breaks?
first thing--worry about prolapsed cord!
Pt with heat stroke
flat with legs elevated
retinal detachment
floaters and flashes of light. curtain vision
What should the nurse do when one member of a support group expresses anger repeatedly?
focus on the group members with a positive outlook, speak to the angry one privately
Taking Coumadin. Which foods should the client limit?
foods containing Vitamin K.
BKA (below knee amputation)
foot of bed elevated for first 24 hours. position prone to provide hip extension.
Rho(D) immune globulin
for Rh- mom at 28 wks
phenytoin
for partial/tonic-clonic seizure - cause CNS depression, gingival hyperplasia - report nystagmus (unsual eye movement)
Med that interacts with lithium
furosemide
variable or late deceleration, fetal tachy
give O2, side-lying, discont oxytocin
neostigmine OD
give atropine
IV Pyelogram
give laxative to clear system, NPO midnight, allergic to seafood
varicella vaccine
given to susceptible children (not yet hand chicken pox) at 12 months
up stairs with crutches? down stairs with crutches?
good leg first followed by crutches(good girls go to heaven) crutches with the injured leg followed by the good leg.
variable acceleration of FHR
good, baby is reacting, healthy, exchanging oxygen
Somatropin
growth hormone deficiency
blood transfusions
hang blood w/ D5W
What foods should you avoid if you have diverticulitis?
hard to digest foods eat foods high in fiber
burns rule of Nines
head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1%
Early decels
head compression
Mild anxiety
heightened perceptual field
TB drugs are
hepatotoxic!
Asperger's syndrome
high functioning form of autism spectrum disorder, typically child will have normal to high cognitive skills; a structured environment can help to minimize problems experienced w/ sudden schedule changes, socialization requirements and preference for ritualistic behavior
heat/cold
hot for chronic pain; cold for accute pain (sprain etc)
Bowel sounds with early bowel obstruction
hyperactive
What to monitor for when taking enoxaparin (lovenox)
hyperkalemia, headache, bleeding, alopecia, hepatocellular and cholestatic liver injury
Pheochromocytoma
hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor)
increased ICP
hypertension, bradypnea,, bradycarday (cushing's triad)
SIADH
hypervolemia, decreased sodium; Tx fluid restriction, Na replacement w/ sodium chloride and IV lasix
Cardinal sign of ARDS
hypoxemia
secondary prevention
identify pt who have manifestations of disease or condition so referral can be made for proper Tx; early detection thru secondary prevention may minimize impact of disease
FHR>160 for 10 min
if fever, give antipyretic - oxygen mask - IV bolus
Spinal shock occurs
immediately after injury
DKA is rare
in DM II (there is enough insulin to prevent fat breakdown)
Edema is located
in the interstitial space, not the cardiovascular space (outside of the circulatory system)
Chest tubes are placed
in the pleural space
Early sign of schizophrenia relapse
inability to concentrate
Dumping syndrome
increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink
Opioid agonists can cause constipation
increase fluid/fiber intake and physical activity
the first sign of ARDS
increased respirations! followed by dyspnea and tachypnea
Thyroid storm
increased temp, pulse and HTN
Hypovolemia
increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030
Hypernatremia
increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution.
Digitalis
increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion
Toddlers need to express
independence!
pt decides to leave AMA
inform risks, sign AMA, document
Incentive spirometer
inhale slowly and hold breath for 3-5 seconds -improve lung expansion and prevent alveolar collapse
SSRI AE
insomnia
thyroid med side effects
insomnia. body metabolism increases
disconnected tubing from drainage unit
instruct pt to exhale and cough then submerge the end of chest tube in 1 inch of sterile water until u can cleanse the tips and reconnect quickly.
Which of the following should indicate to a nurse the need to suction a pt trach?
irritability
Heroin withdrawal neonate
irritable, poor sucking
normal PCWC (pulmonary capillary wedge pressure)
is 8-13 readings 18-20 are considered high
Defamation
is a false communication or careless disregard for the truth that causes damage to someone's reputation. in writing(Libel) or Verbally(Slander)
orange tag in psych
is emergent psych
MMR
is given SQ not IM
When pt is in distress....medication administration
is rarely a good choice
Arterial disease
keep extremity BELOW level of heart
buck's traction
knee immobility
prolapsed cord
knee-chest position, push forward
What is the nurses contribution to an interdisciplinary team?
knowledge of nursing care and its mgmt holistic understanding of the pt, their healthcare needs and healthcare systems
measles
koplick's spots
DKA
kussmal's breathing (deep rapid)
positioning for pneumonia
lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!)
give an enema
left SIM position, R knee flexed, adult 7-10 cm in
autism
limit stimuli, promote calm and quiet
pain with diverticulitis
located in LLQ
appendicitis pain
located in RLQ
hyponatremia
loss of H20, Na follows H20 --> dehydrated
PTB
low grade afternoon fever
after Thyroidectomy
low or semi-fowler's position, support head, neck and shoulders.
cirrhosis
low protein, high calorie (encephalopathy restrict protein)
Appropriate food choices for ulcerative colitis
low residue diet - low fiber -broiled liver and white rice -grilled salmon and cooked apricots -roast chicken and cooked spinach
What do you do when a pt has a seizure?
lower bed, protect head, provide privacy, place on side, loosen clothing, stay with pt and call for help, admin meds, note duration, sequence and type of seizure
varicella zoster "chicken pox"
maculopapular rash that progresses to vesicles on erythematous bases which eventually rupture and crust over; vesicular rash
preschooler
magical thinking simple clear language choices and independence thought its punishment
A nurse is reinforcing teaching regarding the use of a cane to a pt who has left leg weakness. Which of the following should the nurse include in the teaching?
maintain two points of support on the floor
baby bath
max 120 F, nothing except for clothes when sleeping
Serotonin syndrome s/sx
may begin 2-72 hour after start of tx -mental confusion, difficulty concentrating -abdominal pain -diarrhea -agitation -fever -anxiety -hallucinations -hyperreflexia, incoordination -diaphoresis -tremors
zalcitabine for AIDS
may cause peripheral neuropathy (numbness, tingling, burning or pain of extremities), Also, common issue w/ didanosine (antiviral treats AIDS) -if zalcitabine not d/c promptly when pt begins to show manifestations of peripheral neuropathy, it may become progressive and irreversible -after d/c med, if manifestations improve, reintroduce at 1/2 dose
Iatragenic
means it was caused by treatment, procedure or medication
early sign of cystic fibrosis
meconium in ileus at birth
detached retina
medical emergency in which retina (thin layer of light sensitive tissue on back of wall of eye) of eye peels away from its underlying layer of support tissue. -w/o Tx, entire retina can detach leading to permanent vision loss -S&S: sudden onset of decreased peripheral or central vision, dark floaters, flashes of light & shadow or "curtain" over part of visual field
Heroin W/D
methadone (dolophine)
alk ash diet
milk, veggies, rhubarb, salmon
pacemaker teaching
minimize shoulder movement intially, assess hiccup, make sure grounded connection - permanent: carry ID card, first 2 weeks (wear sling, avoid raising arm above shoulder), no heavy lifting for 2 mo. - dont place alarm, magnet, stereo speaker, generators, garage opener on top of pacemaker -inform dentist
A nurse is preparing to care for a pt in the surgical unit who will be receiving lorazapam. For what a/e should the nurse monitor this client
monitor for resp depression
How to prevent a/e of oxycodone?
monitor vital signs, stop meds for resp rate less than 12, have naloxone and resuscitation, avoid use of meds with cns depressants
Cushing's
moon face, buffalo hump
bowel obstruction
more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids)
Prealbumin
more susceptible measure used to assess critically ill clients who are at higher risk for malnutrition; reflects more actue cahnges -normal: 23-43 mg/dL -moderate depletion: 5-9 mg/dL
Halo sign
most reliable test to determine if discharge is CSF
tourette's syndrome
motor & verbal tics impair social fnc, communicate
multiple sclerosis
motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia
Ventricular septal defect
murmur at left sternal border
hypoK
muscle weakness, <<DTR
hypokalemia
muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery)
Hypercalcemia
muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency!
Liver biopsy (prior)
must have lab results for prothrombin time
multiple sclerosis
myelin sheath destruction. disruptions in nerve impulse conduction
Hyponatremia
nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids
Aminoglycoside AE
nephrotoxicity
mandatory to do erythromycin on baby
no
cataract extraction
no aspirin (bleed), use cold compress when itchy eyes, avoid lifting > 10 lbs and avoid bend at waist due to risk of increase IOP,
asthma kid
no aspirin, highest reading flow meter, vaccine
for neutropenic pts
no fresh flowers, fresh fruits or veggies and no milk
Neutropenic pts
no fresh fruits or flowers
Head injury or skull fx
no nasotracheal suctioning
NOT breastfeeding
no nipple stimulation, tight bra, cold compress, no express milk daily
uric acid food restriction
no organ meat/chicken/alcohol - citrus food is ok
breach of confidentality
no paper copies
antisocial
no remorse
ECG
no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure.
with allopurinol
no vitamin C or warfarin!
What is avoidance of harm or injury?
non-maleficence
S3 sound
normal in CHF. Not normal in MI
Unstable Angina
not relieved by nitro
trach suctioning
not routinely done; if nurse auscultates coarse crackles or rhonchi, identifies moist cough, hears or sees secretions in trach tube, pt's airway should be suctioned
Before starting IV antibiotics
obtain cultures!
chest tube pulled out?
occlusive dressing
intraosseous infusion
often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist.
TYRAMINE FOOD
ok: yogurt, cream cheese - aged cheese, beer, soy sauce, ferment/air-dried meat, red wine,avocado, fig, banana, No maoi w coffee, chocolate, ginseng, fava beans
pyloric stenosis
olive like mass
During internal radiation
on bed rest while implant in place
TPN
only PICC/Central, BS q4h
romberg balance test
open/close eyes, sense balance, feet together, arms side
A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the pt to avoid?
orange sherbert
ABGs
pH 7.35-7.45 PaCO2 35-45 PaO2 80-100 HCO3 21-28
verify placement for NG tube placement
pH of gastric content
DVT
pain, edema, warmth, red - encourage ambulate, elevate legs above heart (circulation), avoid pressure in site, intermitten warm moist compression, stocking or compression - no pillows beneath LE
glaucoma
painful vision loss. tunnel vision. halo
Bladder CA
painless hematuria
placenta previa
painless vag bleeding
lithotomy position
pap smear
hemophilia is x linked
passed from mother to son
What is the process of taking telephone order from a provider?
patient name, drug, dose, route, frequency and read back to them
In an emergency
patients with a greater chance to live are treated first
Autonomic dysreflexia
patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above)
The nurse is teaching a 40 yr old man dx with a lower motor neuron disorder to perform intermittent self cath at home. The nurse should teach the pt to
perform the valsalva maneuver before doing the cath
Battery
performing procedure without consent
If a pt develops cor pulmonale, the nurse would expect to observe
peripheral edema and anorexia
Glaucoma patients lose
peripheral vision.
abruptio placentae
persistent uterine contraction, dark red bleeding, board-like abdomen
MAOI
phenelzine isocarboxazid tranylcypromine selegiline (transdermal patch)
MAOI
phenelzine, tranylocoprime, isocarboxizid -avoid tyramine foods (aged cheese, wine, beer) can lead to hypertensive crisis -SE: CNS stimulation, orthostatic hypotension
pulmonary edema
pink frothy sputumsputum, clammy cyanotic skin, crackles, tachycardia
A nurse is caring for a pt receiving iv fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which should the nurse take next?
place a warm compress over the iv site
complications of mechanical ventilation
pneumothorax, ulcers
post spelectomy
pneumovax 23 is administered to prevent pneumococcal sepsis
DM
polyuria, polydipsia,polyphagia
Right BKA - which measure prevents infection?
position affected limb in dependent position
Cleft Lip
position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.
After Myringotomy
position on the side of AFFECTED ear, allows drainage.
Thoracentesis:
position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing
A nurse is caring for a client who is having difficulty voiding following removal of an indwelling catheter. Which intervention should the nurse take?
pour warm water over the pt perineum
CPM- Continous passive motion
prescribed setting, can be turned off at meals
total hip arthroplasty abduction pillow purpose
prevent adduction beyond midline of body during position changes and pt movement to prevent dislocation of new hip joint
leukemia
primary cancer of bone marrow; large number of immature white cells found and small number of RBCs, platelets and granulocytes; confirm Dx w/ bone marrow aspiration
Airborne precautions protective equip
private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB
Koplick's spots
prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth
glomerulonephritis
protein in urine
downs syndrome
protruding tongue
diptheria
pseudo membrane formation
After lumbar puncture and oil based myelogram
pt is flat SUPINE (prevent headache and leaking of CSF)
administration of enema
pt should be left side lying (Sim's) with knee flexed.
After Cateract surgery
pt sleep on UNAFFECTED side with a night shield for 1-4 weeks
WBC left shift
pt with pyelo. neutrophils kick in to fight infections
instill ear drop
pull upward and back in >3 y.o (down in <3), massage tragus after, don't instill cold gtt/ wait to room temp
brachial pulse
pulse area on an infant
Best method to monitor for atelectasis
pulse oximetry
when drawing an ABG
put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2
pancreatitis pts
put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids
What is appropriate for an adolescent in the hosptial?
puzzles and books
restraint
quick-release to bedframebedframe, movable but not rail
Cushing's triad
r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)
Cushings ulcers
r/t brain injury
Inappropriate for Kosher diet
rabbit
What can prevent MI, stroke, or death in high-risk patients
ramipril
car seat
rear-facing until 2, 45 degrees, snug harness, clip at armpit level, dont cross infant neck or abd - no swaddle blanket before securing
pernicious anemia
red beefy tongue
kawasaki disease
red tongue/eye/sole, unrelieved fever, peeling skin, rash trunk
patients with hallucinations patients with delusions
redirect them distract them
Displacement
redirection of thoughts, feelings, and impulses from an object that causes anxiety to a safer, more acceptable one
BPH
reduced size and force of urine
What is the safest way to thaw out frozen foods?
refrigerator
Which of the following is a realistic short term goal to be accomplished in 2-3 days for a pt with delirium?
regain orientation to time and place
LVN
reinforce teaching
Splitting
relating to others as if they are all good or all bad
What do the nurse need to keep in mind about the client when being their advocate?
religion and culture
Buck's traction
remove q8h for skin breakdown, apply lotion to back, foot exercise
home safety older adults
remove throw rugs, loose carpets, install stool riser, nonskid mat and footwear
Cooling blanket - appropriate to delegate to UAP
report shivering by client
variable deceleration
reposition L-R, or knee-chest - discont. oxy, give oxygen, vag exam, amnioinfusion
umbilical cord compression
reposition side to side or knee-chest
RACE
rescue, alarm, contain, extinguish
ROME
respiratory opposite metabolic equal respiratory alkalosis: increased pH, decreased CO2 respiratory acidosis, decreased pH, increased CO2 metabolic alkalosis: increased pH&HCO3 metabolic acidosis: decreased pH and HCO3
fractures: RICE
rest, ice (intermittent- 20 to 30 min to decrease bleeding/swelling, if apply too long reduces healing), compression, elevate
cholera
rice watery stool
boggy uterus
risk for uterine atony --> massage now
typhoid
rose spots on the abdomen
lochia after birth
rubra (dark red): 3-4 days serosa (pinkish brown) : 4-10 alba (whitish yellow) 10-28
incivility
rude, insulting, teasing, dirty look
pneumonia
rusty sputum
Identifying s/s of TIA
s/s r/t affected area., rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters b/4 stroke
five interventions for psych patients
safety setting limits establish trusting relationship meds least restrictive methods/environment
cystic fibrosis
salty skin
12 months
says 2 words; has 6 teeth
Bupropion AE
seizures
borderline personality disorder
self-mutilating behavior
William's position
semi Fowler's with knees flexed to reduce low back pain
Paracentesis
semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia
pulmonary embolus
semi-Fowler, oxygen, thrombolytic meds
Post-Thyroidectomy
semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside
narcissistic personality disorder
sensitive to rejection
toddler
separate anxiety give choices
The nurse is caring for a manic pt in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?
serve the meal to the pt in the seclusion room
What type of infectious diseases are required to be reported?
severe Staph Aureus including MRSA
S/sx of opioid withdrawal
severe muscle cramps, yawning, rhinorrhea, pupillary dilation
children 5 and up
should have an explanation of what will happen a week before surgery
Lumbar spinal surgery drainage
should have no more than 250 mL in 8 hr from a drain in first 24 hr
late deceleration (utero insufficiency)
side-lying, discont. oxy, oxygen
8 months..
sits unsupported, stranger anxiety
dunlap traction
skeletal or skin
Myxedema/ hypothyroidism
slowed physical and mental function, sensitivity to cold, dry skin and hair.
Goodell's sign
softening of cervical lip
Hegar's Sign
softening of uterus
Droplet precautions
spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask)
triage
stable vs unstable acute vs chronic
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is W/D from alcohol dependence?
steadily increasing VS
malaria
stepladder like fever--with chills
When performing nasotracheal suctioning what technique should be used?
sterile asepsis
Methylergononvine
stimulates uterine contractions for client who is experiencing PPH
infant
stranger anxiety 6-18mo
kawasaki syndrome
strawberry tongue
TPN given in
subclavian line
What comorbidities may be observed with a patient who is bipolar?
substance use disorder (rapid cycling), anxiety disorders, eating disorders, ADHD
Newborn care - bulb syringe
suction mouth before nose to prevent aspiration during the gasp response that occurs when nose is suctioned
first sign of PE
sudden chest pain followed by dyspnea and tachypnea
bethamethasone (celestone)
surfactant. premature babies
Hypotension is classified with a reading below
systolic less than 90 (result of fld depletion, HF, vasodilation
SSRI's
take about 3 weeks to work
a nurse makes a mistake?
take it to him/her first then take up the chain
portal hypertension
take stool softner QD to prevent esophageal varices (prevent bleeding by straining)
milieu therapy
taking care of pt and environmental therapy
lead poisoning
test at 12 months of age
hypocalcemia
tetany, cramps; paresthesia or numbness; abdominal cramps; hypotension; dysrhythmias; trousseau's sign and chvostek's sign; seizures, hyperreflexia; impaired clotting time seizure precautions
doxycycline
tetracycline antibiotic; AE is photo-sensitivity
glomuloneprhitis
the most important assessment is blood pressure
placenta previa s/s placental abrution s/s
there is no pain, but there is bleeding there is pain, but no bleeding (board like abd)
Describe pre-albumin
this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks)
assault
threatening, make sb scared
A client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication?
thrombocytes (platelets), amylase and liver function
When taking MAOI's, limit your consumption of
thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar...
Paget's disease
tinnitus, bone pain, elnargement of bone, thick bones
No phenylalanine
to a kid with PKU. No meat, dairy or aspartame
never give potassium
to a pt who has low urine output!
Rh mothers receive Rhogam
to protect next baby
Triamcinolone ointment
topical glucocorticoid -monitor for thinning of skin and delayed healing
battery
touch
FFP
transfuse STAT, 1 unit/30-60min
TIA
transient ischemic attack....mini stroke, no dead tissue.
Imipramine hydrochloride
tricyclic antidepressant
if there is excessive bubbling in water seal chamber
try to locate the leak by clamping the tube momentarily at various points along its length go from proximal
Peritoneal Dialysis (when outflow is inadequate)
turn pt from side to side BEFORE checking for kinks in tubing
nitrazine paper
turns blue with alkaline amniotic fluid. turns pink with other fluids
sickle cell crisis
two interventions to prioritize: fluids and pain relief.
situ keratomileusis (LASIK) surgery
type of refractive eye laser surgery opthalmologists perform to correct myopia, hyperopia, and astigmatism which all common causes of nearsightedness; however many people develop presbyopia (farsightedness) w/ age and may need reading glasses despite having Lasik surgery
cryptorchidism
undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence
O-
universal donor
AB+
universal receiver
Kernicterus
untreated hyperbilirubinemia with bilirubin at or higher than 25 mg/dl -lethargy -hypotonia -high-pitched cry -tonic motions such as backwards arching of neck or trunk
Hyper reflexes absent reflexes
upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue
A nurse is caring for a pt who has dementia. Which intervention should the nurse take to minimize the r/f injury for this pt?
use a bed exit alarm system
dumping syndrome?
use low fowler's to avoid. limit fluids
for phobias
use systematic desensitization
Tensilon
used in myesthenia gravis to confirm diagnosis
Buck's traction
used preoperatiely for hip fractures for immobilization in adult clients -Ensure that all weights are free hanging. -Prevent wrinkling of the traction bandage. -Have client perform dorsiflexion of affected extremity every 1 hour - assess if client is experiencing nerve damage
Levothyroxine effects
used to restore pt metabolic rate * toxic effects-heat intolerance, tachy, wt loss, HTN
Late decels
uteroplacental insufficiency
Nationally Notifiable Disease
varicella
no cold application to
vascular insufficency, raynaud
injection site for 2 month year old
vastus lateralis
A nurse recognizes that an initial positive outcome of tx for a victim of sexual abuse by one parent would be that the pt
verbalizes that it his not her fault for the abuse
vaso-occlusive crisis
visual disturbance, hematuria, painful swelling extremities, fever, tachy, PAIN
Parathyroid relies on
vitamin D to work
albuterol inhaler
wait 1 min between each inhale, clean mouthpiece qd, take long slow deep breath, take 5-20 min prior to exercise
ventriculoperitoneal shunt
watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees
Tamoxifen
watch for visual changes--indicates toxicity
clozapine s/e
weight gain, hypotension, hyperglycemia, agranulocytosis
the best indicator of dehydration?
weight---and skin turgor
Cerebral angio prep
well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids.
asthma
wheezing on expiration
anaphylactic transfusion rxn
wheezing, rash
Raynaud's disease
white finger, blue tips when exposing to cold or emotional stress
COPD and O2
with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe.
pancreatic enzymes are taken
with each meal!
The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the pt
with his neck in a midline position and the head of the bed elevated 30
Myesthenia Gravis
worsens with exercise and improves with rest
A nurse is reinforcing teaching to a pt who is prescribed diazepam for anxiety. Which of the following statements indicates the pt understands the teaching
""I will tell my doc before i stop taking the medication"
Addison's disease: Cushing's syndrome:
"add" hormone have extra "cushion" of hormone
A nurse is caring for a pt who needs a 24 hr urine collection. Which of the following pt statements indicate an understanding of the procedure?
"i flushed what i urinate at 7 am and have saved the rest since"
A nurse is reinforcing a teaching on a pt who has a rx for verapamil which of the following statement by the pt indicated need for further teaching
"i should decrease the amount of calcium in my diet while taking the med"
How should you respond when a pt wants to d/c dialysis
"what has changed?" and seek clarification from pt to establish mutual understanding
sodium
'neuro electrolye' first sign of decreased Na is change in LOC
The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary? 1. "The poison control center number is stored on all the phones in our house." 2. "I should induce vomiting if my child swallows lighter fluid." 3. "If I carry medication in my purse, it should be in a child-proof container." 4. "Proper storage is the key to poison prevention in the home."
(1) Appropriate action; terminate exposure to the poison and then contact poison control for further instructions (2) correct—vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration (3) 'poison-proofs' the medication (4) store in locked cabinets
The physician orders sucralfate (Carafate) 1 g PO bid for a client taking digoxin (Lanoxin) 0.25 mg daily. The client asks the nurse if both pills can be taken together at breakfast so that the client doesn't forget to take them. The nurse should advise the client to take which of the following actions? 1. Take the Carafate and Lanoxin before breakfast. 2. Take the Lanoxin 1 hour before breakfast and the Carafate 1 hour after breakfast. 3. Take the Carafate 1 hour before breakfast and the Lanoxin 1 hour after breakfast. 4. Take the Carafate and the Lanoxin after breakfast.
(1) Carafate forms a barrier on the gastrointestinal mucosa, would decrease absorption of other medications, separate by 2 hours (2) Carafate best results on empty stomach (3) correct—Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption (4) Carafate best results on empty stomach, medications should be separated by 2 hours for maximum absorption
A young adult is involved in a motorcycle accident and is brought to the emergency room. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25 mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12h."
(1) H1 receptor blocker, used as an antiemetic (2) correct—narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure (3) stool softener, used for an immobilized patient (4) H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers
A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed? 1. Kussmaul respirations and diaphoresis. 2. Anorexia and lethargy. 3. Diaphoresis and trembling. 4. Headache and polyuria.
(1) Kussmaul respirations are signs of hyperglycemia (2) not indicative of hypoglycemia (3) correct—regular insulin peaks in 2 to 4 hours; indicates hypoglycemia; give skim milk (4) not indicative of hypoglycemia
Malnourished COPD patients
(1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup
The physician orders ranitidine hydrochloride (Zantac) 150 mg PO daily for the client. The nurse should advise the client the BEST time to take the medication is which of the following? 1. Prior to breakfast. 2. With dinner. 3. With food. 4. At hour of sleep.
(1) absorption is not affected by food (2) absorption is not affected by food (3) absorption is not affected by food (4) correct—best results when taking once a day
A client diagnosed with AIDS is seen in the emergency room with complaints of mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the physician to order which of the following? 1. Metronidazole (Flagyl) 7.5 mg/kg q6h. 2. Ketoconazole (Nizoral) 200 mg daily. 3. Trimethoprim-sulfamethoxazole (Bactrim) 800 mg PO q12h. 4. Rifampin (Rifadin) PO 10 mg/kg daily.
(1) anti-infective, used in treatment of intestinal amebiasis, trichomoniasis, inflammatory bowel disease (2) correct—drug of choice for treatment of candidiasis (3) treatment for PCP; symptoms of dyspnea, tachypnea, persistent dry cough, fever, fatigue (4) treatment for tuberculosis; symptoms of fever, chills, night sweats, weight loss, anorexia
The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following? 1. Atropine sulfate (Atropine) IV. 2. Isoproterenol (Isuprel) IV. 3. Verapamil (Calan) IV. 4. Lidocaine hydrochloride (Xylocaine) IV.
(1) antidysrhythmic, used for bradycardia (2) antidysrhythmic, used for heart block, ventricular dysrhythmias (3) antihypertensive, calcium-channel blocker (4) correct—lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia
An elderly client returns from surgery after a hysterectomy due to cancer, and there is an order for antiembolism stockings. Which of the following should the nurse include when instructing the client about wearing the support stockings? 1. "Wear the stockings when your legs cramp." 2. "Wear the stockings during your hospitalization." 3. "Put the stockings on prior to going to bed." 4. "Put the stockings on after you get out of bed in the morning."
(1) antiembolism stockings should be worn to prevent any discomfort and to increase the blood flow (2) correct—stockings should be worn the entire time that client is in the hospital; should be removed for baths and replaced after the skin is dry, and before the client gets out of bed (3) stockings should be worn during the day and when client is nonambulatory (4) stockings should be applied before getting out of bed
A client takes perphenazine (Trilafon) by mouth for 2 days and now displays the following: head turned to the side, neck arched at an angle, and stiffness and muscle spasms in neck. The nurse expects to give which of the following as a PRN medication? 1. Promazine (Sparine). 2. Biperiden (Akineton). 3. Thiothixene (Navane). 4. Haloperidol (Haldol).
(1) antipsychotic medication, would not relieve the side effects (2) correct—antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing (3) antipsychotic medication, would not relieve the side effects (4) antipsychotic medication, would not relieve the side effects
A client is admitted to the outpatient unit in the cancer center for chemotherapy. The client is lethargic, weak, and pale. During chemotherapy, which of the following nursing interventions is MOST important? 1. Establish emotional support. 2. Position for physical comfort. 3. Maintain droplet precautions. 4. Perform hand washing prior to care.
(1) appropriate but not a priority (2) appropriate but not a priority (3) unnecessary during chemotherapy (4) correct—chemotherapy can lead to immunosuppression, which predisposes client to infection; hand washing is one of most effective means of decreasing infection transmission
The nurse cares for clients in outpatient surgery. The mother of a 4-year-old asks the nurse how to prepare her daughter for eye surgery. Which of the following statements by the nurse is BEST? 1. "Draw a picture of the eye to explain what will happen." 2. "Tell your daughter that the procedure will take 1 hour." 3. "Use dolls or puppets to explain how to get ready for surgery." 4. "Read an age-appropriate illustrated book about eye surgery to your daughter."
(1) appropriate for school-aged child (2) preschooler can't relate to the concept of 1 hour (3) correct—use puppet or doll to show where procedure is performed; explain procedure in simple terms and what the child will see, hear, taste, smell, and feel (4) appropriate for school-aged child
The nurse observes care given to a client experiencing severe to panic levels of anxiety. The nurse should intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.
(1) appropriate nursing action for this level of anxiety (2) appropriate nursing action for this level of anxiety (3) correct—at this level of anxiety, client is unable to process thoughts and feelings for problem solving (4) appropriate nursing action for this level of anxiety
Which of the following nursing actions is important for safe administration of oxytocin? 1. Assess respirations and urine output. 2. Administer oxytocin parenterally as the primary IV. 3. Have calcium gluconate available as an antidote. 4. Palpate the uterus frequently.
(1) assessment; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (2) implementation; oxytocin is always given via an infusion pump and is never allowed to be the primary IV (3) implementation; pertinent to the care of a client receiving magnesium sulfate for pre-eclampsia (4) correct—assessment; oxytocin stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus
The nurse recognizes which of the following as a positive response to fluoxetine HCl (Prozac)? 1. The nurse notes hand tremors and leg twitching. 2. The client states that he is able to sleep for longer periods of time. 3. The client has an increased energy level and participates in unit activities. 4. The nurse observes that the client is hypervigilant and scans the environment.
(1) can be side effect of the medication (2) not an effect of Prozac, can actually inhibit sleep; is useful with clients who experience increased sleeping and psychomotor retardation and lethargy (3) correct—fluoxetine HC (Prozac) is an "energizing" antidepressant; as client begins to demonstrate a positive response, he has an increased energy level, is able to participate more in milieu (4) can be side effect of medication
The nurse returns to the desk and finds four phone messages to return. Which of the following messages should the nurse return FIRST? 1. A woman in the first trimester of pregnancy complains of heartburn. 2. A man complains of heartburn that radiates to the jaw. 3. A woman complains of hot flashes and difficulty sleeping. 4. A boy complains of knee pain after playing basketball.
(1) caused by reflux of gastric contents into esophagus, treatment is small, frequent meals, don't consume fluids with food, don't wear tight clothing (2) correct—indicates chest pain, needs to seek medical attention immediately (3) caused by menopause, treat with hormone replacement therapy (HRT) (4) should treat with rest and ice
A client diagnosed with a peptic ulcer has a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the nurse should caution the client about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids.
(1) client should recline for 30 minutes after eating (2) fluids should be given between meals (3) intake of carbohydrates should be reduced along with highly spiced foods (4) correct—basic guidelines to teach a postgastrectomy client are measures to prevent dumping syndrome, which include: lying down for 30 minutes after meals, drinking fluids between meals, and reducing intake of carbohydrates
A client is seen in the clinic for treatment of chronic back pain. The client mentions to the clinic nurse that at home he applies an ointment prepared from several different herbs that relieves his lower back pain. He asks the nurse, "Should I continue using it?" Which of the following responses by the nurse would be BEST? 1. "No. It might do you more harm than good." 2. "Yes. Continue using it, but I don't see how it could help your condition." 3. "You may think it works, but I don't believe home remedies work." 4. "Pain can be relieved in several ways. Consult your physician regarding this home remedy
(1) closed statement (2) closed statement; casts doubt on efficiency of alternative therapy (3) focus should be on client, not on nurse's beliefs (4) correct—herbal medication can interact with other medication
If a client develops cor pulmonale (right-sided heart failure), the nurse expects to observe which of the following? 1. Increased respiration with exertion. 2. Cough producing large amount of thick, yellow mucus. 3. Peripheral edema and anorexia. 4. Twitching of extremities.
(1) common assessment finding of the patient with chronic lung disease (2) describes a complication of pneumonia (3) correct—right-sided heart failure is manifested by congestion of the venous system, resulting in peripheral edema; also, there is congestion of the gastric veins, resulting in anorexia and eventual development of ascites (4) is not seen with this client
An older client undergoes the second exchange of intermittent peritoneal dialysis (IPD). Which of the following requires an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.
(1) common complaint, moderate pain is frequently experienced as fluid is instilled during first few exchanges (2) common complaint due to inactivity, decreased nutrition, use of medications; high-fiber diet and stool softeners help prevent (3) correct—indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity (4) caused by subcutaneous bleeding, common during first few exchanges
A school-aged child injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. The child's right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy is diagnosed with hemophilia A. The nurse identifies which of the following medications is BEST for this patient? 1. Oxycodone terephthalate (Percodan). 2. Ibuprofen (Motrin). 3. Enteric-coated aspirin. 4. Codeine phosphate (Paveral).
(1) contains aspirin, contraindicated for persons with bleeding disorders (2) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (3) increases bleeding time by decreasing platelet aggregation, contraindicated for persons with bleeding disorders (4) correct—analgesic used for moderate to severe pain
A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. re-establishes a trusting relationship with his/her other parent. 3. verbalizes that he/she is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse.
(1) continues the myth of "badness" and that he/she deserved the abuse and actively consented to it (2) outcome that would be positive but usually is not an initial result of treatment (3) correct—victim needs assistance to challenge "belief of victims," which includes "I am bad and deserve the abuse" (4) expected outcome
To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube? 1. Suction equipment. 2. Blood pressure cuff. 3. Levine tube. 4. Emesis basin.
(1) correct—Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration (2) not a high priority (3) not a high priority (4) not a high priority
A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says that she feels pressure against her diaphragm when the baby moves.
(1) correct—abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency (2) not unusual, caused by pressure of enlarging uterus on veins returning blood from lower extremities (3) common near term with increased vascularity of vagina and perineum, only abnormal if bloody, foul-smelling, or abnormally colored (4) not unusual, due to pressure of enlarging uterus
The nurse cares for clients in the pediatric clinic. The mother of a child calls the nurse to say that after administering Dimetane-DC cough syrup to her child, her child becomes very excitable and restless. Which of the following actions by the nurse is MOST appropriate? 1. Report the child's behavior to the physician to alert the physician to the potential need for a change in medication. 2. Instruct the mother to administer half the ordered amount in all future doses to limit this behavioral response. 3. Instruct the mother to give the child a glass of warm milk to dilute any medication left in the stomach. 4. Chart the child's response to the medication, and alert the staff about the mother's phone call.
(1) correct—although this type of response to antihistamines is not uncommon in young children, it is undesirable and must be reported to the physician so that a change in drug therapy can be initiated (2) is not within the realm of the nurse's scope of practice; physician must order dose changes (3) inappropriate (4) response must be charted, and the child's intolerance to the drug documented and reported to other nurses; this is not enough, physician must be alerted so that preventive action can be taken
A 2-year-old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse identifies which of the following as a priority nursing action? 1. Report the findings to the child protection agency. 2. Share this information only with other health care professionals. 3. Document this information in the chart. 4. Share the information with the pediatric social worker.
(1) correct—any suspicion of child abuse should be reported to the child protection agency (2) does not provide or plan for protection of the child (3) does not provide or plan for protection of the child (4) does not provide or plan for protection of the child
An extremely agitated client receives haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. It is MOST important for the nurse to take which of the following actions? 1. Monitor blood pressure every 30 minutes. 2. Remain at the client's side to provide reassurance. 3. Tell the client the name of the medication and its effects. 4. Assess for anticholinergic effects of the medication.
(1) correct—assessment; monitoring vital signs is of utmost importance to ensure client safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension (2) implementation; should be done but is not highest priority (3) implementation; should be done but is not highest priority (4) assessment; circulatory system takes priority
A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements? 1. The catheter can be removed during the day. 2. External catheters are uncomfortable. 3. The catheter would drain into a bag at the bedside or on the wheelchair. 4. The external condom catheter is easy to apply.
(1) correct—being free from any drain bags during the day would appeal to a 13-year-old (2) is negative (3) would be embarrassing to a 13-year-old (4) it would be impossible for a teen with muscular weakness to put on an external catheter
client comes to the health clinic and tells the nurse that the client has taken acetaminophen (Aspirin-Free Excedrin) daily for 5 months. The nurse is MOST concerned by which of the following lab results? 1. AST (SGOT) 30 units/L, ALT (SGPT) 27 units/L. 2. Hgb 16.2 g/dL, Hct 46%. 3. WBC 7,000/mm3. 4. BUN 9 mg/dL.
(1) correct—can cause liver damage, normal AST (formerly SGOT) 8 to 20 units/L, normal ALT (formerly SGPT) 8 to 20 units/L (2) normal Hgb male 13.5-17.5 g/dL, female 12-16 g/dL, normal Hct male 41 to 53%, female 36 to 46% (3) normal WBC 5,000 to 10,000/mm3 (4) normal BUN 7 to 18 mg/dL
A child returns to the recovery room after a bronchoscopy. The nurse should position the client in which of the following positions? 1. Semi-Fowler's position. 2. Prone with the head turned to the side. 3. Head of the bed elevated 45° with the neck extended. 4. Supine with the head in the midline position.
(1) correct—check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm) (2) would limit respiratory excursion and assessment of breathing (3) extension of neck could obstruct airway because tongue falls in back of mouth (4) not best position after procedure
The nurse knows which of the following observations is indicative of chronic cocaine use? 1. Nasal septum disruption. 2. Lack of coordination. 3. Constricted pupils. 4. Craving for sweets and carbohydrates.
(1) correct—chronic inhalation creates sores, burns, disruption of mucous membranes, and holes in the nasal septum (2) barbiturate abusers typically suffer from lack of coordination (3) narcotic abusers demonstrate constricted pupils (4) clients who abuse marijuana, hashish, and/or THC experience cravings for sweets and carbohydrates
A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are BUN 25 and K+ 4.0 mEq/L. The nurse should restrict which of the following in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium.
(1) correct—decreased production of urea nitrogen can be achieved by restricting protein; metabolic wastes cannot be excreted by the kidneys (2) decreases the nonprotein nitrogen production; these foods are encouraged (3) decreases the nonprotein nitrogen production; these foods are encouraged (4) should not be restricted
The nurse cares for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient in which of the following positions? 1. With the client's neck in a midline position and the head of the bed elevated 30°. 2. Side-lying with the client's head extended and the bed flat. 3. In high Fowler's position with the client's head maintained in a neutral position. 4. In semi-Fowler's position with the client's head turned to the side.
(1) correct—decreases intracranial pressure (2) decreases venous blood return (3) too elevated, would increase intracranial pressure (4) head should be maintained in neutral position
The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective? 1. The client swallows air and then eructates it while forming words with his mouth. 2. The client places a battery-powered device against the side of his neck. 3. The client places a finger over the tracheostomy, forcing air up through the vocal cords. 4. The client covers the stoma in the tracheoesophageal fistula and moves his lips
(1) correct—describes esophageal speech (2) describes electric larynx (3) method of speech for patient with a tracheostomy (4) describes tracheoesophageal fistula (TEF)
The nurse cares for clients in the skilled nursing facility. Which of the following clients requires the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired 2 days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization.
(1) correct—duration of Coumadin 2 to 5 days, client at risk for a repeat CVA (2) anticoagulant takes priority, client still receiving pain medication (3) painful urination, may indicate infection (4) anticoagulant takes priority
The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? 1. Place a trochanter roll on the outer aspect of the thigh. 2. Perform resistive range of motion of the left leg. 3. Adduct and internally rotate the left leg. 4. Instruct the patient to maintain the left leg in a neutral position.
(1) correct—holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee (2) exercise would not prevent future external rotation of the leg (3) adduction (add to midline of body) does not change external rotation, internal rotation is not beneficial, normal alignment is required (4) leg will externally rotate unless propped in proper alignment
The nurse cares for a 26-year-old woman immediately after delivery of 8-lb, 4-oz baby girl. The patient's history indicates that she was diagnosed with type 1 diabetes at age 12. The nurse expects which of the following changes to occur in the patient? 1. The blood sugar will fall because of a sudden decrease in insulin requirements. 2. The blood sugar will rise because of a rapid decrease in circulating insulin. 3. The blood sugar will gradually rise because of a decreased level of metabolic stress. 4. The blood sugar will gradually fall because of a decrease in food intake.
(1) correct—hormonal interference in glucose metabolism during pregnancy causes insulin requirements to increase then decrease after delivery (2) blood sugar will fall after delivery (3) blood sugar level will fall after delivery (4) fall in blood sugar not primarily caused by decrease in food intake
A patient is returned to the room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy setup. 4. Suction equipment.
(1) correct—hypokalemia is not expected after this surgery (2) used to treat tetany resulting from possible damage to parathyroid glands (3) essential equipment to provide for airway (4) needed to maintain a patent airway
A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side.
(1) correct—implementation; fluids should be encouraged to facilitate dye excretion and to maintain normal spinal fluid (2) implementation; clients are not placed in the prone position (3) implementation; bed rest is maintained for several hours after the test (4) assessment; an extremity was not used for injection of the dye
Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep.
(1) correct—indication that the client is approaching delirium tremens, which can be avoided with additional sedation (2) describes normal mild withdrawal symptoms (3) would contraindicate giving more sedation (4) describes expected symptoms of alcohol withdrawal, which will subside as the alcohol is excreted from the body
The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply."
(1) correct—most effective way of deep breathing and coughing, dilates airway and expands lung surface area (2) should splint incision before coughing to reduce discomfort and increase efficiency (3) partial answer, should take three deep breaths before coughing (4) implies coughing routine is adequate, incision needs to be splinted
When administering antipsychotic medications parenterally, the nurse should take which of the following actions? 1. Monitor the client's blood pressure while the client is sitting and standing before and after each dose is given. 2. Caution the client not to drink or operate machinery that requires mental alertness for safety. 3. Have an emergency cart available in case of an adverse reaction. 4. Reassure the client that side effects are only temporary.
(1) correct—primary concern with postural hypotension caused by medication and preventing an injury from a fall; monitoring vital signs will provide data to address this concern (2) not relevant with this classification of medications (3) not relevant with this classification of medications (4) not relevant with this classification of medications
A 4-month-old child is admitted with a tentative diagnosis of meningitis. To confirm the diagnosis, a lumbar puncture (LP) is ordered. While assisting the physician with the procedure, it is MOST important for the nurse to take which of the following actions? 1. Appropriately restrain the child. 2. Instruct the parents about the procedure. 3. Provide support to the child. 4. Elevate the head of the bed.
(1) correct—primary objective is to prevent trauma to child during the procedure; child must be restrained (2) not as high a priority as preventing injury to the child (3) should be done before and/or after the procedure (4) elevating the head of the bed for a 4-month-old will not expose the spinal column
The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care? 1. Standard precautions. 2. Testing for HIV. 3. Transfer to an acute care nursery facility. 4. Request AZT from the pharmacy.
(1) correct—provides immediate protective care for the staff members (2) might be employed, safety is the priority (3) might be employed, is not a priority (4) this medication is not used in infancy
Which nursing intervention is a priority in preventing complications after a cesarean birth? 1. Turn, cough, and deep breathe. 2. Limit fluid intake. 3. Supply a high-carbohydrate diet. 4. Evaluate skin integrity.
(1) correct—represents preventive care for respiratory congestion resulting from anesthesia and shallow respirations due to the abdominal incision (2) fluids should be encouraged (3) will not prevent complications (4) does not address a common complication
The clinic nurse performs diet teaching for an older client with acute gout. The nurse should teach the client to limit the intake of which of the following? 1. Red meat and shellfish. 2. Cottage cheese and ice cream. 3. Fruit juices and milk. 4. Fresh fruits and uncooked vegetables.
(1) correct—should be on low-purine diet, should avoid red and organ meats, shellfish, oily fish with bones (2) calcium-rich foods are not limited with gout (3) no restriction with gout (4) high-roughage foods are not limited with gout
The nurse completes client assignments for the day. The nurse should assign an LPN/LVN to which of the following clients? 1. A client who had a total hip replacement and requires assistance with ambulation. 2. A client with type I diabetes mellitus who has bilateral 4+ pitting edema of the feet. 3. A client with cholelithiasis scheduled for a cholecystectomy and receiving IV morphine. 4. A client 6 hours postoperative after cystoscopy to remove a mass in the bladder.
(1) correct—stable patient with expected outcome (2) requires the assessment skills of the RN (3) requires assessment and teaching (4) requires assessment skills of RN
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse considers the assignments appropriate if the nursing assistant is assigned to care for which of the following clients? 1. A client diagnosed with Alzheimer's requiring assistance with feeding. 2. A client diagnosed with osteoporosis complaining of burning on urination. 3. A client diagnosed with scleroderma receiving a tube feeding. 4. A client diagnosed with cancer who has Cheyne-Stokes respirations.
(1) correct—standard, unchanging procedure (2) requires assessment; should assign to an RN (3) stable patient with expected outcome; should assign to an LPN/LVN (4) unstable patient, requires assessment and nursing judgment; should assign to an RN
When assisting with a bone marrow aspiration, the nurse should take which of the following actions? 1. Drop additional sterile supplies onto a sterile tray. 2. Unwrap all sterile packs for the procedure in case they are needed. 3. Reach over the tray, and remove contaminated supplies. 4. Place the bottle of sterile liquid on the sterile field so that it does not splash.
(1) correct—sterile articles should be dropped at a reasonable distance from the edge of the sterile area (2) sterile packs should be opened only as needed (3) never reach an unsterile arm over a sterile field (4) outside of a bottle containing sterile liquid is not considered to be sterile
The home care nurse visits a client with newly diagnosed type 1 diabetes. The physician orders include 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the client perform a blood sugar analysis. The result is 50 mg/dL. The nurse should observe for which of the following? 1. Confusion; cold, clammy skin; and an elevated pulse. 2. Lethargy; hot, dry skin; rapid deep respirations. 3. Alert and cooperative, blood pressure and pulse within normal limits. 4. Shortness of breath, distended neck veins, and a bounding pulse of 96.
(1) correct—symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (2) symptoms of hyperglycemia, blood sugar above 110 mg/dL (3) normal appearance and vital signs (4) symptoms of fluid overload caused by heart failure, rapid infusion of IV fluids
The nurse identifies which of the following is MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment? 1. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups. 2. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking. 3. Tell the family that it is not their fault that the client behaves inappropriately. 4. Involve the family in the assessment of the client when he/she is first admitted to the hospital.
(1) correct—this group provides ongoing support and educational information; people who attend have common needs and goals focused on managing the clients' behavior at home (2) would be helpful but will not have the ongoing impact of the support group (3) would be helpful but will not have the ongoing impact of the support group (4) would be helpful but will not have the ongoing impact of the support group
The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations is expected with scoliosis? 1. The girl's thoracic area is asymmetrical. 2. The girl walks with a waddling gait. 3. The girl's lower legs are edematous. 4. The girl has a protruding sternum.
(1) correct—thoracic area becomes noticeably distorted (2) seen with hip dislocation (3) seen with circulatory or inflammatory processes (4) seen with pigeon breast, or pectus carinatum
Which of the following techniques is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain? 1. Remove the dressing layers one at a time. 2. Clean the wound with Betadine solution and hydrogen peroxide. 3. Clean the drain area first. 4. If the dressing adheres to the wound, pull gently and firmly.
(1) correct—to avoid dislodging drain, remove the dressing layers one at a time (2) do not clean a wound with both Betadine solution and hydrogen peroxide (3) cleansing of the wound is from the center outward to the edges and from the top to the bottom (4) incorrect; may dislodge drain
The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed-upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement.
(1) correct—to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program (2) not of primary importance in designing an effective behavior modification program (3) not of primary importance in designing an effective behavior modification program (4) not of primary importance in designing an effective behavior modification program
During preadmission planning for a client scheduled for a renal transplant, the client should be educated by the nurse regarding which of the following? 1. Remind family and friends that there is restricted visiting for at least 72 hours postoperatively. 2. Arrange all live plants received postoperatively in one section of the room. 3. Continue intermittent peritoneal dialysis for 3 months following surgery. 4. Limit consumption of sodium-free liquids for 1 year postoperatively.
(1) correct—transplant clients require protective isolation following surgery (2) can't have live plants in the room at all (3) no need for dialysis following transplant (4) need to force fluids, not restrict them
The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section 1. contains a lower overall dosage of medication than is given before general surgery. 2. contains lower amounts of sedatives and hypnotics than are given before general surgery. 3. contains lower amounts of narcotics than are given before general surgery. 4. contains medications similar in type and dosages to those given before general surgery.
(1) decreased dosage of narcotics are used (2) dosages of sedatives and hypnotics will be similar (3) correct—decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant (4) dosages of narcotics are reduced
A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following? 1. The nurse's opinion regarding the mental and emotional status of the client. 2. Data addressing the client's emotional state. 3. Data addressing a biopsychosocial approach, including a family system assessment. 4. Specific data detailing the client's mental status.
(1) depends on opinions that are not based on a complete assessment (2) limits the degree of information that is obtained from the client (3) correct—complete nursing history includes biopsychosocial data; client's psychosocial and physical status are evaluated along with an assessment of the client's family system and social support network; evaluation of the client's cognitive ability is important during the physiological status assessment (4) is necessary information about mental status but is also an incomplete assessment
Which of the following symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin? 1. Severe cravings, depression, fatigue, hypersomnia. 2. Depression, disturbed sleep, restlessness, disorientation. 3. Nausea and vomiting, tachycardia, coarse tremors, seizures. 4. Runny nose, yawning, fever, muscle and joint pain, diarrhea.
(1) describes cocaine withdrawal (2) describes amphetamine withdrawal (3) describes barbiturate withdrawal (4) correct—narcotic withdrawal is very much like the symptoms of the flu
An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following? 1. High-protein, low-residue diet. 2. Position client on unaffected side. 3. Exercise the client's arms and legs. 4. Encourage the client to cough and deep breathe.
(1) diet should be high residue to prevent constipation due to inactivity (2) may be positioned on affected side after incision heals (3) foot flexion exercises should be done every hour to prevent complications (4) correct—prevents respiratory complications due to immobility following surgery
The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions? 1. Reduce the client's diet to 1,500 calorie ADA. 2. Order three additional units of NPH insulin at 10 P.M. 3. Order an additional 10 units of regular insulin at 8 P.M. 4. Eliminate the client's bedtime snack.
(1) diet should not be reduced (2) correct—dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia (3) peaks in 4 to 6 hours, would not prevent dawn phenomena (4) would adjust snack, not eliminate it
The nurse prepares to perform peritoneal dialysis on an older patient. The patient states that he/she had pain the last time the procedure was done. It is MOST appropriate for the nurse to take which of the following actions? 1. Administer a warm drink to the patient. 2. Administer a warm bath to the patient. 3. Warm the bag of dialysate solution with a heating pad. 4. Warm the bag of dialysate solution in a microwave oven.
(1) does not affect pain with fluid infusion (2) does not affect pain with fluid infusion (3) correct—temperature can be regulated, warming reduces pain caused by cold solution (4) contraindicated because of unpredictable warming patterns
Which of the following assessments does the nurse expect to make regarding the developmental stage of a 40-year-old male? 1. Cognitive skills are starting to decline. 2. A balance is found among work, family, and social life. 3. Bone mass begins to increase at this age. 4. The client starts to measure life accomplishments against goals.
(1) does not occur (2) occurs earlier in development (3) at age 40, bone mass begins to decrease (4) correct—may precipitate a mid-life crisis
The nurse plans care for a client on bed rest. To promote evening rest and sleep for this client, it is MOST important for the nurse to take which of the following actions? 1. Provide privacy. 2. Give back rubs at bedtime. 3. Assist with a bath every day. 4. Encourage daytime activities.
(1) excessive privacy can limit sensory input (2) will help client to relax but is not most important (3) should encourage client to do as much of his care as he can to maintain independence (4) correct—provides relief from tension, ensures client naps less during the day, helps client relax
The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED? 1. The boy holds his head erect when sitting on the examination table. 2. The boy tries to grasp a toy just out of reach. 3. The boy turns his head to try to locate a sound. 4. The boy smiles spontaneously when he sees his mother.
(1) expected at 3 months (2) correct—unexpected until 6 months of age (3) expected at 3 months of age (4) expected at 3 months of age
The nurse supervises the staff caring for four clients receiving blood transfusions. Which of the four clients should the nurse see FIRST? 1. A client complaining of a headache. 2. A client vomiting. 3. A client complaining of itching. 4. A client with neck vein distention.
(1) febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin (2) correct—hemolytic reaction; most dangerous type of transfusion reaction, symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and renal perfusion (3) allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give Benadryl, and administer oxygen (4) circulatory overload; treatment is to stop blood, position in an upright position, and administer oxygen
A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge?" 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication."
(1) hallucinations usually not seen with patients with bipolar disorder; seen with psychotic disorders (2) assumption that patient just wants attention (3) correct—side effects include galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands) (4) indicates a side effect, not effectiveness of medication
The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster? 1. A 19-year-old with a broken tibia in Buck's traction. 2. A 50-year-old with a diabetic foot ulcer. 3. A 62-year-old heart transplant with suspected rejection. 4. An 84-year-old with chronic obstructive pulmonary disease.
(1) has an acute trauma, is not immunocompromised (2) has a bacterial infection, is not immunocompromised (3) correct—immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus (4) has chronic disease, is not immunocompromised
A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions? 1. Head of bed elevated 30-45°. 2. Head of bed elevated 60-90°. 3. Side-lying with head elevated 15°. 4. Lying flat with head turned to the left side.
(1) head of bed not elevated enough (2) correct—facilitates swallowing and movement of tube through gastrointestinal tract (3) not the best position (4) not the best position
A young adult asks the nurse in the AIDS clinic what to do for the multiple small, painless purplish-brown spots on the right leg and ankle. The nurse should instruct the client to take which of the following actions? 1. Clean the spots carefully with soap and warm water twice a week, and cover them with a sterile dressing. 2. Clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine), and leave them open to the air. 3. Shower daily using a mild soap from a pump dispenser, and pat the skin dry. 4. Soak in a warm tub three times a day, and rub the spots with a washcloth.
(1) if lesions are open and draining, they must be cleaned and dressed daily to prevent secondary infection (2) treatment for herpes simplex virus abscess, not Kaposi's sarcoma (3) correct—important to keep the skin clean and prevent secondary skin infection (4) increases risk of secondary skin infection
A client receives total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 ml/h.
(1) if the pulse rate increases, may indicate fluid overload (2) if the diastolic blood pressure decreases, it might indicate shock or lack of blood volume (3) temperature should remain within normal limits (4) correct—if the client is being properly hydrated with hypertonic IV such as TPN, urine output needs to be at least 30 ml/h; other nursing action includes assessment of blood glucose levels
The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action? 1. Remove reading material to decrease eyestrain. 2. Ask the client if he is nauseated. 3. Assess color of drainage from the affected eye. 4. Maintain sterility during q3h saline eye irrigations.
(1) implementation; would be ineffective (2) correct—assessment; is important to prevent nausea and vomiting, would increase intraocular pressure, could cause damage to area repaired (3) assessment; refers to an eye infection, would be important after initial operative day (4) implementation; eye irrigations are not commonly done following this procedure
Which of the following is a correctly stated nursing diagnosis for a client with an abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding.
(1) inaccurate for the situation (2) incorrectly stated (3) incorrectly stated (4) correct—abruptio placentae is premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients
A 2-month-old with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is related to the immunization. The nurse's response should be based on which of the following? 1. If a fever does occur in a child after a DPaT, it usually occurs within the first 2 hours. 2. An elevated temperature is very rarely seen in a child after a DPaT immunization. 3. If there is a fever after a DPaT, it is usually low-grade and appears within the first 48 hours. 4. The child's high fever is a direct response to the DPaT immunization and should be treated.
(1) inaccurate; low-grade fever is expected within 24 to 48 hours (2) inaccurate; low-grade fever is expected within 24 to 48 hours (3) correct—low-grade fever and irritability frequent response to immunization (4) symptoms should be reported to physician, antipyretic usually prescribed
A client is admitted diagnosed with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness.
(1) indicates brainstem damage (2) late sign of brainstem damage (3) late sign of increased intracranial pressure (4) correct—may be confused and stuporous
The nurse monitors the fluid status of an older patient receiving IV fluids following surgery. Which of the following symptoms suggests to the nurse that the patient has fluid volume overload? 1. Temperature 101°F (38.3°C), BP 96/60, pulse 96 and thready. 2. Cool skin, respiratory crackles, pulse 86 and bounding. 3. Complaints of a headache, abdominal pain, and lethargy. 4. Urinary output 700 ml/24 h, CVP of 5, and nystagmus.
(1) indicates dehydration (2) correct—will see bounding pulse, elevated BP, distended neck veins, edema, headache, polyuria, diarrhea, liver enlargement (3) symptoms could be from causes other than volume overload (4) slightly reduced output, CVP would be elevated, normal CVP 3 to 12 mm/H2O, involuntary eye movements not seen
A client takes gemfibrozil (Lopid) 600 mg PO bid. It is MOST important for the nurse to monitor which of the following? 1. Serum creatine. 2. Erythrocyte sedimentation rate (ESR). 3. Aspartate aminotransferase (AST) (or formerly SGOT). 4. Arterial blood gases (ABG).
(1) indicates renal function, normal 0.6 to 1.2 mg/dL (2) indicates inflammation, normal 0 to 20 mm/h (3) correct—indicates liver function, normal 8-20 units/L; lipid-lowering agent used with patients with high serum triglyceride levels, side effects include abdominal pain, cholelithiasis; take 30 minutes before breakfast and supper (4) indicates acid/base balance
The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following? 1. "My son plays the tuba in the grade school band." 2. "My son loves to help his dad rake leaves." 3. "My son participates in after-school activities 3 days a week." 4. "My son walks 1 mile to school every day with his friends."
(1) involves forced expiration; would not cause problems with asthma (2) correct—main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves (3) school activities should be encouraged to help development (4) walking is good exercise; running could be a problem if he has exercise-induced asthma
A client who is positive for human immunodeficiency virus (HIV) is to be discharged and will be taking zidovudine (AZT) at home. Which of the following actions by the nurse is BEST? 1. Review the importance of adhering to a 4-hour schedule. 2. Advise the client to buy a timed pill dispenser. 3. Write the schedule of when the medicine should be taken. 4. Encourage self-medication prior to discharge.
(1) less helpful in the overall teaching-learning process (2) less helpful in the overall teaching-learning process (3) correct—planned and written schedule of administration is more effective for adherence to time frames (4) less helpful in the overall teaching-learning process
The nurse counsels an elderly client who comes to the outpatient clinic for a routine examination. The history indicates the client takes a laxative tablet twice a day and a laxative suppository once a day. The nurse should suspect which of the following about the client? 1. The client has an anal fixation resulting from recent loss of a spouse. 2. The client is depressed because of alterations in intestinal absorption and excretion. 3. The client is experiencing excessive concern with body function because of physical changes. 4. The client has regressed because of a fear of losing the ability to have bowel movements.
(1) makes judgment without information (2) constipation common finding in elderly; no information about depression (3) correct—physical changes occur in late adulthood causing changes in body image; constipation frequent problem of elderly, but reaction by this client is excessive (4) no information provided about regression
A woman has been recently diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST? 1. "Most women find that they feel better when they are pregnant." 2. "How long have you been in remission?" 3. "Women with lupus frequently have slightly longer gestations." 4. "It is best to become pregnant within the first 6 months of diagnosis."
(1) maternal morbidity and mortality are increased with SLE (2) correct—should be in remission for at least 5 months prior to conceiving (3) gestation not affected by SLE (4) recommended that a woman wait 2 years following diagnosis before conceiving
After a client has a positive Chlamydia trachomatis culture, the client and partner return for counseling. It is MOST important for the nurse to ask which of the following questions? 1. "Do you have contacts to identify?" 2. "What is your understanding regarding how chlamydia is transmitted?" 3. "Do you have questions about the culture and its validity?" 4. "Do you have allergies to the medications?"
(1) may be part of follow-up (2) correct—means of transmission of chlamydia may or may not have been made clear to both partners; nurse should assess this first; is a sexually transmitted disease (3) most cultures used today have few false positives (4) would be done later in the nursing assessment
An adult client has regular insulin ordered before breakfast. The nurse notes that the client's blood glucose level is 68 mg/dL and the client is nauseated. Which of the following actions should the nurse take? 1. Immediately give the client orange juice to drink. 2. Administer the insulin on time. 3. Withhold the insulin, and notify the physician. 4. Return the breakfast tray to the kitchen.
(1) may cause vomiting (2) correct—take insulin or oral agent as ordered, check blood glucose or urine ketones every 3 to 4 hours, sip 8 to 12 oz liquid per hour, substitute easily digested soft foods, liquids if solids not tolerated (3) blood glucose increases during illness; even though client can't eat, administer insulin (4) does not address the client's problem
In planning anticipatory guidance for parents of a beginning school-aged child, it is MOST important for the nurse to include which of the following? 1. Teach the child to read and write. 2. Teach the child sex education at home. 3. Give the child responsibility around the house. 4. Expect stormy behavior.
(1) may require some assistance from the parents, but children this age learn at their own rate (2) unnecessary at this early age (3) correct—giving children responsibilities allows them to develop feelings of competence and self-esteem through their industry (4) does not occur until about age 11
A client is scheduled for a left lower lobectomy. The physician orders diazepam (Valium) 2 mg IM for anxiety. The nurse determines the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure.
(1) more indicative of preoperative complications, should be reported before medications are given (2) more indicative of preoperative complications, should be reported before medications are given (3) correct—observation most indicative for antianxiety drugs is restlessness and increase in heart rate due to circulating catecholamines (fight or flight) (4) hostility may be treated best by ventilating feelings
The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.
(1) no indication of hemorrhage, will require a tetanus shot (2) correct—disoriented, requires immediate assessment to determine underlying cause (3) splint; cover wound with sterile dressing; check temperature, color, sensation; give narcotic (4) hyperglycemic, give IV fluid, regular insulin
The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST? 1. Notify the physician. 2. Inform surgery. 3. Contact the father to obtain consent. 4. Continue the child's preoperative preparation.
(1) no reason to notify the physician (2) no reason to call the OR (3) consent from either divorced parent is sufficient (4) correct—parent or legal guardian required to give informed consent prior to surgical procedure
The nurse teaches a well-baby class to a group of parents with toddlers. The nurse should encourage the parents to do which of the following? 1. Exercise their children daily. 2. Use a playpen whenever possible. 3. Provide a safe play area for their children. 4. Teach their children noncompetitive activities.
(1) no specific exercise program is necessary; children of this age in good health are naturally active (2) limits a child's interaction with the outside world, should be used judiciously (3) correct—safety is fundamental issue with this age group; they are exploratory in their play (4) unnecessary; children learn by observing and by participating
A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5°C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.
(1) normal for the first year of life (2) correct—high-pitched cry is one of the first signs of an increase in the intracranial pressure in infants (3) fontanelle should be closed by the third month (4) with increased pressure, the pupil may respond to light slowly, rather than with the usual brisk response
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), the nurse notes a decrease in muscle tone. The nurse determines which of the following nursing diagnoses is priority? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes.
(1) not a priority (2) correct—leading cause of skin breakdown is a decrease in tissue perfusion (3) not a priority (4) would be more relevant to right-sided hemiparesis
A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? 1. Administer oxygen. 2. Turn her to the right side. 3. Provide adequate hydration. 4. Start antibiotics.
(1) not a priority (2) not a priority (3) correct—adequate hydration is a priority for any client with sickle cell crisis (4) not a priority
A client is in cardiogenic shock after a myocardial infarction (MI). Which of the following is a correctly stated nursing diagnosis for the client? 1. Activity intolerance: related to impaired oxygen transport. 2. Altered tissue perfusion related to decreased heart-pumping action. 3. Altered cardiac output related to cardiac ischemia. 4. Potential fluid volume deficit related to decreased intake.
(1) not best (2) correct—correctly stated, appropriate nursing diagnosis (3) altered cardiac output is not a commonly accepted nursing diagnosis (4) not appropriate for this client
The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following? 1. Signs and symptoms of infection. 2. Fluid and electrolyte balance. 3. Seizure precautions. 4. Steroid replacement.
(1) not most important (2) not most important (3) not most important (4) correct—steroid replacement is the most important information the client needs to know
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a 5-year-old is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse 3 hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.
(1) not priority (2) correct—indicates a rupture of meninges and presents a potential complication of meningitis (3) not priority (4) is not a change in assessment
The nurse cares for clients in the emergency department of an acute care facility. Four clients have been admitted during the previous 10 minutes. Which of the following admissions should the nurse see FIRST? 1. A client complaining of chest pain that is unrelieved by nitroglycerine. 2. A client with full-thickness burns to the face. 3. A client with a fractured hip. 4. A client complaining of epigastric pain.
(1) not the highest priority; airway most important (2) correct—face, neck, chest, or abdominal burns result in severe edema, causing airway restriction (3) airway is most important (4) requires further assessment; airway is a priority
When a nurse is using restraints for an agitated/aggressive patient, which of the following items should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.
(1) nurse should follow the policies of the institution (2) must get written permission from the patient for restraints; if patient has been judged incompetent, permission is obtained from the legal guardian (3) correct—the need for restraints is based on patient's behavioral status and condition, not the patient's voluntary/involuntary status (4) must first try less restrictive means to control patient before using restraints
The nurse cares for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked". The nurse should assess which of the following cranial nerves? 1. III. 2. V. 3. VII. 4. XI.
(1) oculomotor; provides innervation for extraocular movement (2) trigeminal; provides sensation to facial muscles (3) correct—facial; provides motor activity to the facial muscles (4) spinal accessory; provides innervation to the trapezius and sternocleidomastoid muscles
The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. The client should cover the mouth and nose when coughing or sneezing during the first 2 weeks of treatment. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for 6 to 9 months.
(1) on airborne precautions during hospitalization; can send home with family because they are already exposed (2) not required (3) important, but not as important as taking medication (4) correct—necessary to take medication for 6 to 9 months
Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge? 1. The client shaves and brushes his teeth. 2. The client transfers himself into and out of his wheelchair. 3. The client maneuvers the wheelchair without difficulty. 4. The client prepares well-balanced meals.
(1) paraplegic has full use of his upper body, so this activity presents no problem (2) correct—essential if client is to perform ADLs (3) done with the arms and presents no real problem (4) is a necessary requisite for living alone and performing ADLs but is not directly hindered by paraplegia
The nurse cares for a client just returning to the postsurgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which of the following actions? 1. Determine the stage of loss and grief. 2. Analyze the quality and quantity of pain. 3. Instruct the client to cough and deep breathe. 4. Ask the client to lift his head off the pillow.
(1) physical needs take priority (2) not most important (3) implementation; should first assess (4) correct—should assess whether there are any remaining effects of neuromuscular blocking agents; may block ability to breathe deeply
A client is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse identifies which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares." 2. "I have a headache, and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am, and I don't know where I live."
(1) posttraumatic stress disorder (PTSD) is characterized by anxiety and stress symptoms that occur after an intense traumatic event; characteristic symptoms are hypervigilance, insomnia, and recurring nightmares (2) somatoform disorder (or hypochondria) is concerned with physical and emotional health, accompanied by various bodily complaints for which there is no physical basis (3) reflects the compulsive checking behavior of the anxiety associated with obsessive-compulsive disorder (4) correct—dissociative disorders characterized by either a sudden or a gradual disruption in the integrative functions of identity, memory, or consciousness; disruption may be transient or may become a well-established pattern; development of these disorders is often associated with exposure to a traumatic event
The nurse knows that the client diagnosed with drug-induced Cushing's syndrome should FIRST be instructed about which of the following? 1. Compression fractures from increased calcium excretion. 2. Decreased resistance to stress. 3. The schedule for gradual withdrawal of the drug. 4. Changes in secondary sex characteristics.
(1) problems associated with Cushing's syndrome but are not the first priority (2) problems associated with Cushing's syndrome but are not the first priority (3) correct—if steroids are withdrawn suddenly, the client may die of acute adrenal insufficiency (4) not seen with this medication
A client in the ICU is given procainamide HCl (Pronestyl) slowly by IV push. The nurse should withhold the next dose if which of the following is observed? 1. Presence of premature ventricular contractions. 2. Occurrence of severe hypotension. 3. Recurring paroxysmal atrial tachycardia. 4. A sedimentation rate of 10.
(1) procainamide is given to treat premature ventricular contractions or atrial tachycardia (2) correct—severe hypotension or bradycardia are signs of an adverse reaction to this medication (3) procainamide is given to treat premature ventricular contractions or atrial tachycardia (4) lab value is within normal limits
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Counseling regarding problems of body image. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. 4. Encourage peers to visit on a regular basis.
(1) psychosocial, not highest priority (2) physical, use standard precautions (3) correct—safety is a priority for the client who is at high risk for infection (4) psychosocial, important for an adolescent but is not highest priority
The nurse in a psychiatric emergency room cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following? 1. Encourage the client to verbalize feelings. 2. Assess for physical trauma. 3. Provide privacy for the client during the interview. 4. Help the client identify and mobilize resources and support systems.
(1) psychosocial, priority is physical injury (2) correct—physical, victim may have physical trauma and concealed injuries; assessment is of utmost importance so that the client's physiologic integrity is maintained (3) psychosocial, done concurrently as the nurse is assessing for physical injury (4) psychosocial, priority is physical injury
A client at the health clinic asks the nurse if he should get a flu shot. Which of the following factors, if learned by the nurse in the history, would NOT be a reason for the client to receive the flu vaccine? 1. The client is 69 years old. 2. The client had bronchitis twice last year. 3. The client volunteers at a preschool. 4. The client lives with two large dogs.
(1) recommended for people over 65 (2) recommended for people with chronic respiratory or cardiovascular disease (3) recommended for people who come in contact with young children (4) correct—not at risk for getting the flu from a dog
The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery? 1. The nurse restrains an agitated, confused patient in the emergency room with a physician's order. 2. The nurse chases a patient who tries to run away while outside for a walk. 3. The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance. 4. The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison.
(1) restraining a client to prevent injury to self or others is appropriate (2) appropriate behavior (3) restraining a client to prevent injury to self or others is appropriate (4) correct—battery is harmful or offensive touching of another's person; unless court ordered, clients have the right to refuse medication, even if client is psychotic
The nurse in the outpatient clinic instructs a client diagnosed with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is effective? 1. The client advances the cane 18 inches in front of the foot with each step. 2. The client holds the cane in the left hand. 3. The client advances the right leg, then the left leg, and then the cane. 4. The client holds the cane with elbows flexed 60°.
(1) should advance cane 6-10 inches with body weight on both legs (2) correct—should hold cane on strong side, widens base of support, reduces stress on affected side (3) should advance cane, weaker leg, stronger leg (4) should flex no more than 30°
The nurse administers morphine 6 mg IV push to a patient for postoperative pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via face mask or nasal prongs. 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside.
(1) should be given Narcan for low respiratory rate (2) problem is low respirations; this may be administered after medication (3) correct—IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action (4) unnecessary
A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication 5 minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture.
(1) should be taken immediately when pain is felt (2) presence or absence of a stinging sensation is not indicative of the effect of the drug (3) should be taken when pain is experienced (4) correct—nitroglycerin can cause hypotension; client should avoid changing positions quickly to decrease the chances of falling
An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to the client by the nurse? 1. "Take the medication on a full stomach or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for 2 weeks."
(1) should be taken on an empty stomach (2) correct—photosensitivity occurs with the use of this medication (3) should be taken as directed (4) unnecessary
The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique? 1. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes. 2. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing. 3. The nurse packs wet gauze into the incision without overlapping it onto the skin. 4. The old dressing is saturated with sterile saline before it is removed.
(1) should clean from the center of wound to the outside using sterile equipment (2) dressings should be soaked before application (3) correct—if wet dressing touches skin, it could cause skin breakdown (4) should be removed dry so that wound debris and necrotic tissue are removed with old dressing
Prochlorperazine maleate (Compazine) 10 mg IM is ordered for a client. The client is also to receive butorphanol (Stadol) 2 mg IM. Before administering these medications, the nurse should take which of the following actions? 1. Obtain respirations and temperature. 2. Dilute with 9 ml of NS. 3. Draw the medications in separate syringes. 4. Verify the route of administration.
(1) should monitor blood pressure and heart rate for orthostatic hypotension; respiration and temperature are not as high a priority (2) inappropriate (3) correct—Compazine should be considered incompatible in a syringe with all other medications (4) unnecessary
The nurse prepares to administer an injection of haloperidol decanoate (Haldol D) to a client. Which of the following actions by the nurse is MOST appropriate? 1. Massage the injection site. 2. Give deep IM in a large muscle mass. 3. Use a 2 inch 25 gauge needle. 4. Administer the medication in divided doses.
(1) should not be done because medication is very irritating to subcutaneous tissue (2) correct—medication is very irritating to subcutaneous tissue (3) should use a 2 inch 21 gauge needle (4) should administer in single dose; patient should lie in recumbent position for one-half hour after administration of IM haloperidol decanoate
The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client that he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room.
(1) should remain in the seclusion room (2) should have meal at regular time (3) should have meal at regular time (4) correct—should eat at regular time; remain in the seclusion room for client's safety
The nurse instructs a client diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should include which of the following instructions? 1. Use a new, sterile catheter each time the client performs a catheterization. 2. Perform the Valsalva maneuver before doing the catheterization. 3. Perform the catheterization procedure every 8 hours. 4. Limit oral fluids to reduce the number of times a catheterization is needed.
(1) should use clean (not sterile) technique, used for clients with lower motor neuron disorders resulting in flaccid bladder (2) correct—client holds breath and bears down as if trying to defecate, or uses Credé maneuver (places hands over bladder and pushes in and down), done to try to empty bladder before catheterization (3) usually done every 2 to 3 hours initially, and then increased to every 4 to 6 hours (4) should encourage fluids
During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1. Wash the burn with an antiseptic soap and water. 2. Remove clothing, and wrap the victim in a clean sheet. 3. Leave the blisters intact and apply an ointment. 4. Take no action until the victim arrives in a burn unit.
(1) soaps and ointments should not be applied to second-degree burns in an emergency situation (2) correct—after fire is out, remove clothing and cover victim with a clean sheet (3) soaps and ointments should not be applied to second-degree burns in an emergency situation (4) does not prevent infection
Which of the following is a correct instruction by the nurse to the parent of a 4-year-old client regarding collecting a specimen to be tested for pinworms? 1. Collect the specimen 30 minutes after the child falls asleep at night. 2. Save a portion of the child's first stool of the day and take it to the physician's office immediately. 3. Collect the specimen in the early morning with a piece of Scotch tape touched to the child's anus. 4. Feed the child a high-fat meal, and then save the first stool following the meal.
(1) specimen should be collected early in the morning after the child awakens (2) unnecessary; pinworms are not routinely found in the stool (3) correct—pinworms crawl outside the anus early in the morning to lay their eggs (4) inappropriate for this situation
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate? 1. Encourage the patient to establish trust with one staff person with whom therapeutic interventions should occur. 2. Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors. 3. Ignore the patient when the patient exhibits attention-seeking behavior. 4. Rotate the staff so that the patient will learn to relate to more than one nurse.
(1) staff should use a consistent undivided approach (2) correct—reward non-attention-seeking behaviors by giving the patient unsolicited attention (3) remain nonjudgmental, carry out limit-setting (4) staff should use a consistent undivided approach
A mother brings her 2-year-old to the pediatrician's office. Which of the following symptoms suggests to the nurse that the child has strabismus? 1. The child places his head close to the table when drawing. 2. The child rubs his eyes frequently. 3. The child closes one eye to see a poster on the wall. 4. The child is unable to see objects in the periphery of his visual field.
(1) suggestive of refractive error, myopia (nearsightedness), able to see objects at close range (2) suggestive of refractive error (3) correct—visual axes are not parallel, so the brain receives two images (4) suggestive of cataracts or problem with peripheral vision
An older woman comes to the outpatient clinic because she has not been feeling well for several days. During the admission interview, the nurse learns that the client has a history of heart failure (HF), is on a low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg PO daily for 6 months. Diagnostic tests indicate sodium 127 mEq/L, potassium 3.8 mEq/L, glucose 110 mg/dL, and normal chest x-ray. It is MOST important for the nurse to assess for which of the following? 1. Sticky mucous membranes; decreased urinary output; and firm, rubbery tissues. 2. Cool, moist skin; fine hand tremors; and mental confusion. 3. Headache, apprehension, and lethargy. 4. Shortness of breath, chest pain, and anxiety.
(1) symptoms of hypernatremia, along with restlessness, weakness, coma, tachycardia, flushed skin, oliguria, fever (2) symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL (3) correct—symptoms of hyponatremia along with muscle twitching, convulsions, diarrhea, fingerprinting of skin (4) symptoms of CHF, chest x-ray clear, no other information provided
The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis? 1. Tenderness at the IV site. 2. Increased swelling at the insertion site. 3. Reddened area or red streaks at the site. 4. Leaking of fluid around the IV catheter.
(1) tenderness at the IV site is common (2) increased swelling at the insertion site may indicate infiltration (3) correct—characterized by inflammation and reddened areas around site and up length of vein (4) not indicative of phlebitis
The RN makes nursing assignments for the burn unit. Which of the following indicates the MOST appropriate assignment for a client with a positive cytomegalovirus (CMV) titer? 1. A nurse with an upper respiratory infection. 2. A young nurse who is 8 weeks pregnant. 3. A male nurse who is CMV-negative. 4. An older nurse with 30 years of experience.
(1) those with a cytomegalovirus-positive titer are often immunosuppressed clients who should be protected from other pathogens (2) CMV is fetotoxic; should inform client of risks (3) this nurse is at increased risk for developing the disease (4) correct—most appropriate option due to decreased risk
The nurse's INITIAL priority when managing a physically assaultive client is which of the following? 1. Restrict the client to the room. 2. Place the client under one-to-one supervision. 3. Restore the client's self-control and prevent further loss of control. 4. Clear the immediate area of other clients to prevent harm.
(1) time out or room restriction might be a useful strategy before the client becomes assaultive; once client is assaultive, he/she may continue this behavior in his/her room without any redirection and support (2) may not stop assaultive behavior (3) correct—most important priority in the nursing management of an assaultive client is to maintain milieu safety by restoring the client's self-control; a quick assessment of situation, psychological intervention, chemical intervention, and possibly physical control are important when managing the physically assaultive client (4) is helpful but may not be realistic if the situation escalates quickly
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions is MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube.
(1) tube would be irrigated with normal saline after the position of the tube was evaluated (2) correct—to confirm placement, nurse should aspirate and test the pH of the aspirate; results should be 0 to 4 (3) does not assess status of nasogastric tube (4) does not assess status of nasogastric tube
The nurse should explain to a client that glipizide (Glucotrol) is effective for diabetics who 1. can no longer produce any insulin. 2. produce minimal amounts of insulin. 3. are unable to administer their injections. 4. have a sustained decreased blood glucose.
(1) type 1 insulin-dependent diabetic is unable to produce insulin (2) correct—oral hypoglycemic agents are administered to type 2 (non-insulin-dependent) clients who are able to produce minimal amounts of insulin (3) type 1 diabetics who cannot administer their injections need alternate plans to be made for them to receive the injection from a family member (4) Glucotrol is administered for an increase in blood glucose
The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which of the following ages? 1. 5 months of age. 2. 6 months of age. 3. 9 months of age. 4. 12 months of age.
(1) unable to sit unsupported until 8 months (2) unable to sit unsupported until 8 months (3) correct—can pull self up and assume a sitting position at 8 months, can say few words (4) would be able to say three to five words in addition to dada and mama
The nurse cares for an elderly client diagnosed with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client.
(1) unrealistic (2) correct—irreversible disease that leads to permanent physical limitations (3) unnecessary; disease usually is not terminal (4) unrealistic; disease is progressive, cannot be arrested
An elderly patient is admitted to the hospital for treatment of a fractured femur. The patient's spouse tells the nurse that the patient has become very hard of hearing. The nurse might expect the patient to exhibit which of the following characteristics? 1. The patient prefers to be left alone. 2. The patient appears suspicious of strangers. 3. The patient communicates best in writing. 4. The patient's speech is difficult to understand.
(1) unrelated to hearing deficit (2) correct—suspiciousness results from interference with communication (3) writing may be difficult for patient, depends on intellectual capacity (4) diminished hearing late in life does not cause speech difficulties
When caring for a client with a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which of the following the MOST important initial goal for the client? 1. Within 3 to 5 months, the client will state that the memory of the event is less vivid and distressing. 2. The client will indicate a willingness to keep a follow-up appointment with a rape crisis counselor. 3. The client will be able to describe the results of the physical examination that was completed in the emergency room. 4. The client will begin to express her reactions and feelings about the assault before leaving the emergency room.
(1) valid goal that needs to be addressed but after the initial goal has been met (2) valid goal that needs to be addressed but after the initial goal has been met (3) valid goal that needs to be addressed but after the initial goal has been met (4) correct—is nurse's initial priority to encourage client to begin dealing with what happened by verbalizing her feelings and gaining some acceptance and perspective
A middle-aged woman, mother of two, has a mastectomy for breast cancer. When she returns to the physician's office a month later for a routine checkup, the nurse asks the client how she has been. Which of the following responses, if made by the client to the nurse, indicates that the client is experiencing a normal reaction to the surgery? 1. "I have been helping my family deal with their feelings about the surgery." 2. "I have been having difficulty coping with the surgery and cry frequently." 3. "I have been unable to leave the house or talk to my friends about the surgery." 4. "I am doing just great since the surgery and have gone back to work at my job."
(1) will not be able to help others this soon after surgery (2) correct—normal reaction 1 month later (3) excessive, abnormal reaction (4) indicates integration, too early for this stage
The parents of a 1-month-old boy bring their son to the clinic for evaluation of a possible developmental dysplasia of the right hip. The nurse should observe for which of the following? 1. Limited adduction of the right leg. 2. Uneven gluteal fold and thigh creases. 3. Increase in length of the right limb. 4. Internal rotation of the right leg.
(1) will see limited abduction (2) correct—folds and creases will be longer and deeper on affected side (3) will be decrease in limb length (4) may or may not see internal rotation
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation? 1. Perform passive range-of-motion exercises before walking. 2. Encourage partial weight bearing while ambulating. 3. Immobilize the extremity between activities. 4. Restrict the amount of time and the distance the man walks.
(1) would aggravate pain (2) correct—would relieve weight, pressure, and stress on affected leg, may use walker (3) would increase stiffness (4) immobility would aggravate pain and inflammation
A nonstress test is scheduled for a client at 34 weeks' gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1. Start an intravenous line for an oxytocin infusion. 2. Obtain a signed consent prior to the procedure. 3. Instruct client to push a button when she feels fetal movement. 4. Attach a spiral electrode to the fetal head.
(1) would be appropriate for an oxytocin (stress) test (2) is incorrect because this is noninvasive (3) correct—nonstress test is a noninvasive test to evaluate the response of the fetal heart rate to the stress of fetal movement; response will be reflected on the fetal monitor (4) prepares for internal fetal monitoring
Which of the following nursing interventions is MOST important for a client diagnosed with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position the client on the abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist the client with heat application and ROM exercises.
(1) would result in contractures due to the strength of flexor muscles (2) should encourage range of motion in all joints, not just hip flexors (3) massaging inflamed joints will add to inflammation and pain (4) correct—reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility
The nurse cares for clients in the antepartal clinic. A client at 34 weeks' gestation comes to the clinic for treatment of a sprained ankle. The nurse should question which of the following orders? 1. ASA (aspirin) 650 mg PO q4h prn for pain. 2. Return to the clinic in 2 weeks. 3. Apply ice to sprain for 20 minutes qh for 24 hours. 4. Teach client three-gait crutch walking.
(1)correct—aspirin can cause fetal hemorrhage; do not use during pregnancy (2) routine follow-up (3) treat sprain with rest and elevation of affected part; intermittent ice compresses for 24 hours (4) appropriate gait if client unable to bear weight
ALS
(amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems
After infratentorial surgery
(incision at the nape of neck) position pt flat and lateral on either side.
After supratentorial surgery
(incision behind hairline on forhead) elevate HOB 30-40 degrees
Kawasaki disease
(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.
Woman in labor (un-reassuring FHR)
(late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
To prevent dumping syndrome
(post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals.
Autonomic Dysreflexia
(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
Case Management nursing involves
*Decreasing cost by improving client outcomes * Providing education to optimize health participation * Advocating for services + client's rights
Anorexia nervosa
- -supervise during and after meals -establish specific meal times -structured meal plan
snellen chart
- 20 ft - with glasses first - pass: >4 letters - both eyes open
What is the proper nutrition during pregnancy?
- Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida - green leafy vegetables and brown rice
blood glucose tolerance test
- NPO midnight - avoid caffeine
diaper rash
- air dry, apply zinc oxide ointment to protect skin
ovarian CA
- back pain, postcoital bleeding, abd bloating/pain/urinary urgency (early s/sx)
baby heat loss
- conduction: thru surface - convection: thru air - evaporation: right after birth - radiation to close proximity: windows, doors
basal body temperature method of birth controlling
- drop in 0.5 F prior to ovulation - Temp highest after ovulation, remain elevated 2-4 days prior to start of period
celiac disease
- gluten free - rice is okay
estrogen therapy
- help osteoporosis but risk for breast + endometrial cancer, DVT
prenatal discomfort
- high fiber food, rash is common due to hormone, sleep on firm mattress on side, wear supportive bra overnight, acetaminophen for HA, ginger for NV
sealed radiation therapy implant
- limit visitors 30 min/day, stay 6 ft away from clients - no powders, lotion, cream, ointment - RN wear film badge all the time - no pregnant RN - wear lead apron, avoid turning away from clients
time management
- most important: planning activities
oxygen home therapy
- no electrical razors, radio, TV hearing aids, no gas range (prefer electric range), no extension cord to oxygen, hook it directly to ground outler -->sparking potential - no woolen blankets, synthetic fabric. Cotton is good - no oil, alcohol based products - oxygen tanks stored upright, not on their sides
Cane
- on normal side - cane 6-10 in front of feet - advance weak one first - advance normal one past the cane
tonsillectomy
- place in lateral/prone (head lower than chest) prevent aspiration - pain med Q4H 1st day - avoid coughing, blowing nose, NO straw - sign of bleeding: frequent clearing throat, bright red emesis - NO red stuff and milk
knee ambutation
- prone q4h - dont elevate residual leg after 48hr OR, elevate during the 1st 24hrs - firm mattress - dressing distal to proximal
hip arthroplasty
- raised seat to prevent hip dislocation and reduce hip flexion - keep hip angle < 90
What are some things to teach about home safety with elderly patients?
- remove rugs -cords up against walls - steps/sidewalks good repair - grab bars near toilet and in bathtub - nonskid mat in tub - shower chair in shower - lighting adequate in and out
maternal attachment
- taking-in (24-48hr)- personal needs - taking-hold (on 2-3d, last 10d-wks)- baby care - letting go - family role
baby reflexes
- tonic neck: turn side to side to see arm/leg extend - rooting: touch R, head turns R
osteoporosis
- vitamin D (fish, egg yolk, milk, cereal), calcium (milk, green, beans, figs) -
myasthenia gravis
- weakened muscle, facial troop - small bites/eat slowly - take meds 45-60 min before - monitor wt every day
Toddlers
-1000 cals/day -2 oz of protein daily -no more than 3 cups of milk per day -1 cup of veggies per day
Gross motor skills of toddler
-15 months - walk without help, creeps up stairs -18 months - assumes a standing position, throws a ball overhand -2 years - walks up and down stairs by placing both feet on each step -2.5 years - jumps in place with both feet, stands on one foot momentarily
Labs to monitor with valproic acid
-AST and ALT (hepatotoxic) -PTT - can alter coagulation
Preventing respiratory issues
-Ambulate the client regularly, daily., -Use a humidifier to moisten the air in the client's room, when needed., -Reassure the client during respiratory distress.
Dig toxicity
-An older adult client may experience the toxic effects of digoxin even though the drug level is within normal limits (0.5 - 1.5 ng/ml). -Bradycardia is a sign of digoxin toxicity and is the reason an apical pulse is taken prior to administration of this drug. -Clients with digoxin toxicity often have disturbed color vision or see halos.
Transfusing blood for an older adult client
-Assess VS more frequently because changes in pulse, BP, and respiratory rate may indicate fluid overload, or may be sole indicators of transfusion reactoin -older adult clients who have cardiac or renal dysfunction are at increased risk for HR and fluid volume excess when receiving blood transfusoin
Meconium aspiration
-Assess neonate's respiratory efforts, muscle tone, and heart rate. -Suction mouth and nose using bulb syringe if respiratory efforts strong, muscle tone good, and heart rate greater than 100/min. -Suction below the vocal cords using an endotracheal tube before spontaneous breaths occur if respirations are depressed, muscle tone decreased, and heart rate less than 100/min
Rectal temperature
-Assist the client to Sims' position with the upper leg flexed. Wearing gloves, expose the anal area while keeping other body areas covered. Spread the buttocks to expose the anal opening. -Ask the client to breathe slowly and relax when placing a lubricated thermometer (with a rectal probe) into the anus in the direction of the umbilicus 2.5 to 3.5 cm (1 to 1.5 in) for an adult. If you encounter resistance, remove it immediately. Once inserted, hold the thermometer in place until you hear the signal. -Clean the anal area to remove feces or lubricant. -Use the rectal site to obtain a second measurement if the temperature is above 37.2º C (99º F). SAFETY MEASURE: -Do not use for clients who have diarrhea, are on bleeding precautions (such as those who have a low platelet count), or have rectal disorders
dialysis disequillibrium syndrome DDS
-CNS disorder, complication may develop in new dialysis pts d/t rapid removal of solutes and blood pH level changed; pt beginning hemodialysis at greatest risk esp. if BUN > 175 -characterized by CNS manifestations of varying severity d/t cerebral edema including h/a, nausea, disorientation, restlessness, blurred vision, asterixis
IV therapy - bag changes
-Change secondary IV infusion set every 24 hours if not attached to primary infusion -Change continuous infusing IV bag every 24 hours -Change primary infusion IV set every 96 hours -Change extension tubing every 96 hours
Nurse responsibilities for advance directives
-Confirm that the advance directive is current., -Document the client's advance directive in the medical chart., -Provide written information to the client about advance directives.
sequence for PPE-droplet precautions
-DON gown, mask, googles, gloves, enter room -REMOVE: gloves, googles, gown, mask, leave room
Addison's disease
-Diet high in sodium, low in potassium, increased fluids -encourage to consume small frequent meals to prevent hypoglycemia
Household items that contain latex
-Dishwashing gloves -Erasers -Carpeting
fresh frozen plasma (FFP) blood transfusion
-FFP is rich in clotting factors, it is given to treat acute clotting disorders and desired effect in decreased prothrombin time
Aspects of BPP
-Fetal tone, reactive FHR, fetal breathing movements, gross body movements, and qualitative amniotic fluid volume are physical and physiological characteristics of the BPP.
Red man syndrome
-Flushing of the face and neck are symptoms of red man or red neck syndrome occurring with too rapid infusion of Vancomycin. -Vancomycin can cause two types of hypersensitivity reactions, the red man syndrome and anaphylaxis. -Red man syndrome has often been associated with rapid infusion of the first dose of the drug and was initially attributed to impurities found in vancomycin preparations. -First action should be to stop the infusion. Contacting the health care provider is necessary after the infusion is stopped. The client should be monitored for serious reactions such as hypotension, dyspnea, anaphylaxis, renal failure or hearing loss. Other minor reactions are chills, dizziness, fever, pruritis, and tinnitus.
Polyhydramnios
-GI malformations and neuro disorders in fetus
S/sx of increased ICP in school-age child
-HA -nausea, vomiting -increased clumsiness -lethargy -double vision -decreased school performance of learned tasks -decreased level of consciouness -seizures
Dig toxicity in infant
-HR less than 90 -Withhold med, notify physician, obtain rhythm strip to assess for heart block
Assess true labor vs. false labor
-Have you noticed any bloody show or fluid coming from your vagina?
Mannitol
-Mannitol is an injectable medication, given slow IV push or via continuous IV infusion. Mannitol may crystalize (form white or icy looking precipitate) in the vial if exposed to extreme temperatures, and this precipitate could be dangerous to the client. For this reason, all mannitol must be drawn up with a filter needle, and then the nurse should remove the filter needle and use the injection port to administer the medication.
When should I file an incident report
-Medication errors -Procedure/treatment errors -Equipment-related injuries/errors -Needlestick injuries -Client falls/injuries -Visitor/volunteer injuries -Threat made to client or staff -Loss of property (dentures, jewelry, personal wheelchair)
Ileostomy complications - stomal swelling and decreased drainage
-Moist towels should be applied to the abdomen to facilitate drainage. -Abdominal massage should be initiated to promote drainage. -Hot tea may facilitate drainage and should therefore be encouraged.
Who can be delegated?
-Obtain vital signs every 4 hours for a client with ulcerative colitis., -Assist a client with a new transurethral prostectomy with perineal care., -Transport a client who is utilizing oxygen and has a peripheral IV catheter.
S/sx of hypocalcemia
-Paresthesia of fingers and lips (early sx) -Muscle twitches/tetany -Frequent, painful muscle spasms at rest -Hyperactive DTRs -Positive Chvostek's sign -Positive Trousseau's sign -CV - decreased myocardial contractility (decreased HR and hypotension) -GI - hyperactive BS, diarrhea, abdominal cramping (neuromuscular irritability can progress to seizure activity) -can lead to brittle bones and fractures
Prioritizing care
-Prepare a written list., -Postpone items that do not have immediate deadlines
Moving client from stretcher to bed
-Raise stretcher no more than 0.5 inch above level of bed -Lower head of bed if possible -Slider board if client has hemiparesis, extremity amputation, postoperative -Air-assisted transfer device if obese
Sterile field
-Sterile surfaces may touch other sterile surfaces. -Once a sterile package is opened, the edges are considered unsterile. -Surgical gowns are sterile from the chest to the level of the sterile field; sleeves are considered sterile from 2 inches above elbow to stockinette
In-home oxygen equipment
-Store in upright position -At least 8 feet from heat source -Pt should not change oxygen flow rate -Check equipment daily
Chlamydia treatment
-The client's instructions should include the need for abstinence from sexual intercourse until the client and partner have completed treatment. -Monitor for possible complication of PID -Sx of reinfection may include yellow vaginal d/c
Cholesterol labs
-Total cholesterol - <200 -LDL - <130 (if have CVD or diabetic - <70) -HDL - females > 55, males > 45 -Triglycerides - females - 35-135, males - 40-160
Hearing impaired clients
-Turn off the TV and close the door to the hallway - eliminate background noise -Provide the client with detailed written instructions - reinforce and clarify instructions -Include the client's spouse in the teaching session -speak clearly and slowly -offer video presentations with closed captioning -face client when speaking
Antidotes
-Warfarin - vit K -Heparin - protamine sulfate -Magnesium sulfate - calcium gluconate
S/sx of severe dehydration
-absence of tears when crying -sunken eyeballs -parched mucous membranes -oliguria -sunken fontanels -hyperpnea
Metformin contraindication
-alcohol use disorder -metformin inhibits breakdown of lactic acid, and alcohol further inhibits this breakdown - can lead to life-threatening lactic acidosis -d/c metformin 24-48 hour prior to contrast procedure
amblyopia & strabismus
-amblyopia is disorder of eye in which unilateral central blindness occurs as result of another condition such as strabismus -in strabismus, muscle weakness allows one eye to wander so child cannot focus on an object w/ both eyes at same time. this confusion causes brain to ignore signals from weak eye in favor of strong one, this will result in central blindness if not treated by age of 6 -to strengthen weak eye muscle unaffected eye is patched
Highest priority to evacuate first
-ambulatory first
Ipratropium inhaler
-anticholinergic bronchodilator -AE - xerostomia
lamotrigine
-antiepileptic drug: rash is 1st indication of Stevens-Johnson syndrome and toxic epidermal necrolysis; can occur first 2-8 weeks of Tx- report STAT
Zidovudine
-antiretroviral agent used in tx of HIV -suppresses bone marrow - anemia, neutropenia, thrombocytopenia -can cause severe neutropenia - avoid people who have infections -other AE - lactic acidosis, n/v/d, hepatomegaly
episitaxis
-apply cold cloth to bridge of nose-causes vasoconstriction, which decreases bleeding
Sulfasalazine AE
-arthralgia -n/v
Dumping syndrome
-ass'd with bariatric surgeries -s/sx - cramps, diarrhea, tachycardia, dizziness, fatigue -Encourage client to consume food in low Fowler's position and remain in this position for 30 minutes after eating to delay stomach emptying and dumping syndrome; lay down following meals -eat high protein, high fat, low fiber, low to moderate carb diet (avoid salty and sugary foods and milk) -eat small meals and limit taking liquids with meals and for one hour before and after meals -can have iron-deficiency anemia - absorption issues
Autonomic dysreflexia
-ass'd with spinal cord injury; lesion or injury above T6 -stimulation of sns: extreme HTN, sudden severe HA, pallor below level of spinal cord's lesion dermatome, blurry vision, diaphoresis, restlessness, nausea, piloerection -stimulation of pns: bradycardia, flushing above corresponding dermatome to the spinal cord lesion (face and neck), nasal stuffiness -nurse: sit client up to decrease BP, notify provider, determine cause (distended bladder, impaction, cold stress, undiagnosed injury or illness)
Patient on vent
-assess need for suctioning every 2 hours -check vent settings every 8 hours -HOB at least 30 degrees -oral hygiene with chlorhexidine every 2 hours
Wt gain for pregnancy
-avg BMI - 25-35 lb
Foods high in tyramine
-avocado -banana -figs -salami, peperroni -aged cheese -smoked fish, protein -some dietary supplements -some beers, red wine
dissecting aortic aneurysm
-back pain is cardinal sign that will cause nurse to suspect dissecting aortic aneursym -other key manifestations are hypotension and tachycardia
fifth disease "erythema infectiosum"
-begins w/ bright red cheeks producing "slapped-cheek" appearance; following this, rash appears on extremities and trunk, rash fades centrally giving lacy "reticulated" appearance to rash
Bowel training
-best time to toilet a client to encourage bowel training is when the client has the urge to defecate -Take stool softeners daily., -Choose a regular toileting time based on the client's pattern., -Advise the client to lean forward at the hips while sitting on the toilet. -offer drinks such as hot tea or fruit juice (esp. prune) to stimulate peristalsis
Hydrochlorothiazide
-can cause hyperglycemia and other electrolyte imbalances -may need to increase insulin dosages or add oral antidiabetic
IV acyclovir
-can cause reversible nephrotoxicity -monitor BUN and creatinine -encourage fluid intake -admin. over 1 hour
Misoprostol
-can induce uterine contractions (check for pregnancy in female) -reduces gastric acid secretions so ulcers can heal -causes diarrhea
anticholinergic side effects
-can't spit (dry mouth) -can't pee (urinary retention) -can't poop (constipation) -can't see (blurred vision)
macular degeneration glaucoma detached retina cataract retinal detachment
-cant see central - cant see around, halo around lights - floating dark spot - cloudy visions - painless, develop suddenly
S/sx of dehydration in older adult
-cap refill > 5 sec -oliguria -sunken eyes
Acetazolamide
-carbonic anhydrase inhibitor -reduces production of aqueous humor by causing diuresis through renal effects -quickly lowers IOP -promotes renal excretion of sodium, potassium, and bicarb, increasing client's risk of electrolyte and acid-base imbalance
acute-closure glaucoma
-caused by sudden shift in position of iris of eye that blocks outflow of aqueous humor leading to acute onset of severely painful rise in IOP emergency -signs: sudden onset of redness, decreased vision, colored halos, h/a
Chondroitin with glucosamine
-caution: anticoagulants - can increase risk of bleeding CI -HTN -hyperglycemia -shellfish allergy
False labor
-characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes. -Contractions are felt in the lower back or above the umbilicus and often stop with comfort measures (like oral hydration). -There is usually no vaginal discharge with false labor.
nephrotic syndrome
-characterized: weight gain over days-weeks; facial and periorbital edema (decreases thru-out day); ascites; edema in ankles; anorexia; diarrhea; irritability; lethargy; decreased frothy urine; BP normal or slightly below; proteinuria (2+ or >), urinalysis-hyaline casts, few RBCs & oval fat bodies -hypoalbuminemia (decreased serum protein and albumin), hyperlipidemia, hemoconcentration (increased H&H and platelets), hyponatremia, GFR normal or elevated -administer albumin as ordered to facilitate diuresis
chest tube water seal chamber
-check for tidaling in water-seal chamber as pt breathes - expect continuous bubbling initially then occasionally bubbling, constant=leak
Topotecan
-chemo agent - kills cancer cells by interrupting DNA synthesis -AE - bone marrow suppression, GI discomfort, alopecia -apply granisetron patch - help to prevent n/v
doxurubicin
-chemo, cause thrombocytopenia (bleeding risk) -inject over 5min, give antiemetic 30-60min before -
congenital hypothyroidism
-child does not manufacture an adequate amount of thyroid hormone to maintain appropriate metabolic rate; if an appropriate, daily and life-long dose of thyroid hormone given, metabolism should be close to normal
Hearing aid care
-clean with mild soap and water while keeping hearing aid dry -turn off or remove batteries when not in use
D/c - anterior-posterior colporraphy
-client should tighten and support pelvic muscles when coughing or sneezing to help reduce stress on stitches. -avoid standing for prolonged periods of time. -increase daily fluid intake -do NOT increase fiber
cataracts
-clouding that develops in lens of eye over time, slowly impair vision and lead to blindness if untreated -signs: decreased contrast, glaring and blurred vision
Nephrotic syndrome
-decreased liver function -increased glomerular permeability -decreased protein level
DKA s/sx
-decreased serum pH -Kussmaul breathing -increased serum K (potassium shifts out of the cells to compensate for the increased hydrogen ion concentration which leads to an increase serum potassium)
Internal radiation therapy - brachytherapy
-describes internal radiation that is placed close to target tissue -waste products are radioactive until isotope has been completely eliminated from the body -place client in private room away from other clients when possible; keep door closed -place warning sign on door -wear dosimeter film badge that records personal amount of radiation exposure -limit visitors to 30-minute visits, and have visitors maintain distance of 6 ft from source -visitors and health care personnel who are pregnant or under age 18 should not come into contact with client or radiation source -wear lead apron while providing care keeping front of apron facing source of radiation -keep lead container in client's room if delivery method could allow spontaneous loss of radioactive material -save linens in room until after removal of radiation source
Signs of pregnancy-induced HTN to report to provider
-dimming vision -severe continuous HA -epigastric pain
Meds to avoid with glaucoma
-diphenhydramine -methylphenidate -scopolamine
Rifampin
-discolors feces, sputum, tears, sweat red-orange color -hepatotoxic - report jaundice -take on empty stomach, 1 hr before or 2 hr after meal, with 240 mL of water -avoid alcohol completely
Allopurinol
-drink 2-3 L of fluid/day to prevent kidney injury
Acetaminophen toxicity
-early sign - diaphoresis, abdominal discomfort, n/v/d -later manifestations - liver failure (increased AST and ALT)
Education to school age child with type 1 DM
-eat extra food on busy days when more active -increase intake of sugar-free fluids when sick -eat snack 30 minutes before activity -prolonged activities will require food intake every 45-60 minutes
Hemodialysis for CKD patient
-eat well-balanced meals to include foods high in folate (beans, green veggies) and take supplements. Each exchange during dialysis depletes protein requiring client to increase protein intake over predialysis limitations -needs complete proteins to prevent negative nitrogen balance and muscle wasting -allowed 1-1.5 g protein/kg/day
mechanical ventilation: low-pressure alarms
-either tubing has come apart or pt has become disconnected from ventilator tubing, result of malfunction or displacement of connections somewhere between endotracheal or tracheostomy tube and ventilator (leak in ventilator circuitry)
AV fistula arm
-elevate it for circulation, ROM, no venipuncture
Methadone use during pregnancy
-encourage to breastfeed - helps with withdrawal symptoms
Osteoporosis prevention
-ensure diet includes adequate amounts of calcium and vit D, esp. before age 35 -encourage client to take clicium supplement with vit D if dietary intake is inadequate -encourage client to limit amount of carbonated beverages - contain phosphates and can cause calcium loss -encourage client to expose areas of skin to sun 5-30 min twice a week -encourage female clients to discuss pros and cons of HRT
Group roles
-evaluator: measures obj - orienter: note progress toward goals - info giver: share experience - initiator-contributor: offer new ideas
Meningitis s/sx
-excruciating, constant HA -nuchal rigidity -photophobia -fever and chills -n/v -alt. LOC -positive Kernig's sign - resistance and pain with extension of client's leg from flexed position -positive Brudzinski's sign - flexion of knees and hips occuring with deliberate flexion of client's neck -hyperactive DTRs -tachycardia -seizures -red macular rash -restlessness, irritability
Communicating with client who has partial hearing impairment
-face client directly, speak slowly in low-pitched voice -Sit and face client and keep mouth visible -Have the client use hearing devices -Speak slowly and clearly, no shouting -Lower your pitch before you increase your volume -Use brief sentences and simple words -Write down what is not understood -Minimize background noises -Ask for a sign language interpreter if necessary
Saw palmetto
-false low PSA
S/sx of heart failure in infant
-feeding difficulties -mottling -tachypnea
Positive sign of pregnancy
-fetal heart tones -visualization of fetus by US -fetal movement palpated by experienced examiner
Prenatal visits
-first visit in first trimester and montly until week 28 -every 2 weeks until week 36 -every week until birth of newborn
SSRI and diabetics
-fluexotine may affect blood glucose levels in diabetics, may need to adjust anti-diabetic meds
Cushing syndrome s/sx
-fluid retention, hypertension, weight gain, and fat redistribution with truncal obesity, 'moon face', and 'buffalo hump.' -Additional symptoms may include: susceptibility to infection, hyperglycemia, osteoporosis, menstrual irregularities, thin fragile skin, and hirsutism.
TAPE TEST
-for enterobius vermiculans (pinworm) -instruct parents to place transparent tape over child's anus at night and remove tape following morning before tolieting/bathing; if possible apply tape after child has gone to sleep and remove before they wake up -pinworm is helminthic infection manifested by perianal itching, enuresis, sleeplessness, restlessness, irritability d/t itching -transmission is via fecal-oral route
Alendronate
-get client to chair before administering -cause esophagitis -must be able to stand or sit upright for 30 minutes after taking
betamethasone
-glucocorticoid used in prevention of respiratory distress syndrome in premature infants -causes hyperglycemia in mother which predisposes neonate to hypoglycemia
enteral feeding baby
-gravity method <10 cc/hr - residual <25% is goodgood - after feed, side-lying, HOB 30
Dependent personality d/o
-great need to be taken care of, which leads to fears of separation, difficulty making decisions, and avoidance of taking responsibility
Surgical aseptic hand hygiene
-hands kept above elbows to encourage water and soap to flow away from clean hands -Lathering hand and arms with soap to 5 cm (2 in) above elbow -Cleaning under nails of both hands with a nail pick while under running water. -Drying with a sterile towel moving from the hands to the elbows. -Scrub hands first and work toward elbows -Nails scrubbed with 15 strokes and each other part of hand with 10 strokes
1st trimester US
-have full bladder - helps lift gravid uterus out of pelvis
Mechanical restraints
-have staff member wtih them -review rx every 4 hours -assess pt every 15-30 minutes
Tracheomalacia
-have weakened trachea, which leads to collapse -s/sx - barking cough, stridor, wheezing, cyanosis, apnea
Amiodarone
-hepatotoxic
ECG of electrolyte imbalances
-hypocalcemia: prolonged QT interval -hypercalcemia: shortened QT interval -hypokalemia: flattened T-waves & cardiac dysrhythmia -hyperkalemia: widened QRS
Neurogenic shock
-hypotension -dependent edema -loss of temperature regulation
Magnesium toxicity
-hypotension -prolonged PR interval -diminished DTRs
dehydration
-hypovolemia - elevated urine specific gravity
First aid for snake bites
-ice, tourniquets, heparin, and corticosteroids are contraindicated in first 6-8 hours -antivenom is most effective if administered within 4-12 hr
Nonreactive NST
-identified after 40 min of continuous monitoring without accelerations in FHR despite vibroacoustic stimulation
Fundal height
-immediately after delivery - at umbilicus -12 hour postpartum - 1 cm above umbilicus -Every 24 hr, the fundus should descend 1-2 cm. It should be haflway between the umbilicus and symphysis pubis by sixth day.
subtotal thyroidectomy emergency bedside equipment post-op
-in event of laryngeal edema or tetany, respiratory distress could result in airway obstruction, emergency intubation may be difficult d/t laryngeal swelling & endotracheal intubation may increase risk for hemorrhage by increasing tension on incision during insertion -a tracheostomy tray should be easily accessible
mech vent: high-pressure alarms
-increase in resistance each time ventilator administers a breath to pt -excessive airway secretions, decreased lung compliance
S/sx of osteomyelitis
-increased ESR -leukocytosis -positive wound culture -boring, constant pulsating bone pain
Cystic fibrosis
-increased protein intake
Gingko baloba
-increases effects of warfarin -CI for use with clopidogrel
Filgrastim
-increases neutrophil production -given to treat neutropenia and reduce risk of infection for clients undergoing chemo
Tamoxifen
-indication - estrogen receptor blocker - stops growth of breast cancer cells, which are estrogen-dependent; used to tx or prevent breast cancer -monitor calcium level - increases risk of hyperkalemia -increase risk for PE -obtain routine eye exams - can cause irreversible eye damage -may cause hot flashes -can cause endometrial cancer
autonomic dysreflexia
-injury at T6 or above -causes: distended bladder, constipation, skin stimulation -sit pt upright (SOB), correct cause (ex: cath distended bladder) -S&S: sudden increase in bp; bradycardia, pounding h/a, flushing above cord injury, pallor below cord injury
EEG procedure
-instruct client to wash hair prior to procedure and eliminate oils, gels, sprays -if indicated, instruct client to be sleep deprived -increased electrical activity can be stimulated with exposure to bright flashing lights or by requesting client to hyperventilate for 3-4 min. -instruct client to avoid taking any stimulant or sedative med 12-24 hour prior to procedure
tertiary prevention
-involves care of established diseases w/ attempts made to restore pt optimal level of function, decrease negative effects of disease & prevent disease related complications
New pacemaker
-keep cell phone 6 inches away from pacemaker while in use to prevent interference with generator -prevent wire dislodgment - do not raise arm above shoulder for 1-2 weeks -take pulse daily at same time -report signs of dizziness, fainting, fatigue, weakness, CP, hiccuping, palps, dyspnea,, wt. gain -no contact sports or heavy lifting for 2 months -do not place items that generate magnetic field directly over pacemaker generator
umbilical cord care
-keep clean, dry, clean stump with water, watch swelling/redness/purulent d/c - fold diaper edge down to keep stump dry - will fall of after 10-14 days
S/sx of hyperemesis gravidarum
-ketosis -weight loss -dehydration
measles
-koplik spots, a transient cephalocaudal rash of maculopapulr eruptions of upper trunk and face, becoming more confluent as it spreads to lower areas of body
SIADH
-leads to renal reabsorption of water and suppression of renin-angiotensin mechanism, causing renal excretion of sodium leading to water intoxication, cellular edema, and dilutional hyponatremia
Diaphragm
-leave in place for at least 6 hours post coitus
Hypoglycemia findings in infant
-lethargy -hypotonia -jitteriness -twitching -poor feeding -temp instability -apnea -resp. distress -seizures
Guillain-Barre syndrome - complications of immobility
-loss of joint motion and contractures - prevent by performing ROM exercises on ankles, knees, and hips -decreased gastrointestinal motility and constipation - assess bowel sounds and frequency of stools -deep vein thrombosis with erythema and swelling of the calf areas -skin breakdown with early evidence of pallor, erythema, blistering over bony prominences - observe skin color over sacrum, heels, and scapula
What are the signs and symptoms of fluid volume deficit?
-loss of total body Na (vomiting, diarrhea, diuretic use, sweating, kidney failure) -s/s- decreased skin turgor, dry mucus membranes, tachy, orthostatics
Acute glomerulonephritis
-low protein, high carb diet -restrict sodium intake to 4 grams or less
Vaso occlusive crisis
-maintain child on bed rest - decrease oxygen consumption -administer O2 as prescribed if hypoxia present -maintain fluid and electrolyte balance - monitor I&O, give oral fluids, administer IV fluids with electrolyte replacement -administer blood products and exchange transfusions per protocol -treat and prevent infection
Hip arthroplasty
-maintain in abduction -do not flex more than 90 degrees at any time -maintain in neutral position
Combination oral contraceptives
-may have breakthrough bleeding
Mechanical soft diet
-modified in texture -includes foods that require minimal chewing before swallowing (ground meats, canned fruits, softly cooked vegetables) -excludes harder foods (dried fruits, most raw fruits and veg, foods containing seeds and nuts) -indications: limited chewing ability, dysphagia, poor fitting dentures and patients without teeth, surgery to head/neck/mouth
Lisinopril
-monitor K - can cause hyperkalemia -Suppression of angiotensin II leads to a decrease in aldosterone levels. Since aldosterone is responsible for increasing the excretion of potassium, ACE inhibitors can lead to elevated serum potassium.
lithium
-mood-stabilizer used to treat bipolar disorder therapeutic level between 0.8-1.4 mEq/L
Droplet precautions
-mumps -pertussis -rubella -scarlet fever -diphtheria -resp. viral influenza -meningococcal pneumonia
Chlorothiazide AE
-muscle weakness (r/t hypokalemia)
seclusion and restraints
-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min
Disulfiram - acetaldehyde syndrome
-n/v -weakness -sweating -palpitations -hypotension -can progress to respiratory depression, CV suppression, seizures, death
Albumin (lab value)
-normal: 3.5-5 g/dL -moderate depletion: 2.1-2.7 g/dL
Amitriptyline
-obtain ECG -can cause tachycardia and EKG changes
balanced skeletal traction
-offer diet high in fluids and fiber b/c immobilized pt at risk for constipation -provide pin care w/ one of following solutions: chlorhexidine, povidone-iodine; half-strength hydrogen peroxide
Hydroxychloroquine
-opthalmic AE -have eye exam q. 6 months
Warfarin
-oral contraceptives, glucocorticoids decrease effectiveness of warfarin -monitor intake of foods high in vit k -avoid cimetidine, aspirin, naproxen - all increase effects of warfarin
flail chest
-paradoxical movement of chest wall of patient who has fractured 2 or more ribs in 2 or more places resulting in segment of chest wall that moves inward on inspiration and outward on expiration
Atropine and ECT
-parasympatholytic agent - increase HR by blocking Ach -admin. 30 min prior to ECT to counteract bradycardia caused by vagal stimulation -also decreses secretions and prevents aspiration during procedure
IV morphine
-peaks in 20 min -can cause resp. depression within 7 min -withhold if RR less than 12/min -administer via IV bolus over 4-5 min
Basal cell carcinoma
-pearly, waxy nodule -nodular lesion with well-defined borders
Disaster readiness supply kit
-pencil and paper -household bleach -whistle -copies of insurance cards -1 gallon of water per person per day (3 days worth) -clean clothing -personal identification -matches -prescription meds
circumcision care
-petroleum jelly in 1st 24hrs - loose diaper - no soap, commercial wipes until 5-6days later - dont remove yellow exudate
Lower extremity BP
-place bladder of cuff over posterior aspect of thigh -position cuff 2.5 cm (1 inch) above popliteal artery -measure BP with client prone if possible (if not, lie supine with knee flexed) -auscultate at popliteal artery
Nursing interventions for late decels
-place client in side-lying position -insert an IV catheter if not in place, and icnrease rate of IV fluid administration -D/c oxytocin if being infused -Administer oxygen by mask at 8-10 L/min via nonrebreather face mask -Elevate client's legs -Notify provider -Prepare for an assisted vaginal birth or cesarean birth
Precautions for surgical client with latex allergy
-place monitoring devices in stockinet -schedule case for early in day -use glass syringes -cover IV tubing ports with tape
Phenytoin IV
-place particulate micron in-line filter between catheter and tubing before administering phenytoin via intermittent bolus to reduce risk of precipitate entering bloodstream -administer no faster than 50 mg/min -add to no more than 50 mL of NS
Diabetes insipidus
-polyuria (up to 8 L/day) -constant thirst -unusually high oral intake of fluids -tx with vasopressin to decrease urine output and oral fluid intake
Diabetes insipidus
-polyuria, hypernatremia Tx hypotonic sodium chloride and vasopressin/DDAVP
Thoracentesis
-position client on unaffected side after procedure - facilitate lung expansion -small, sterile dressing over puncture site -can raise HOB to 30 degrees for at least 30 min to facilitate lung expansion
Spironolactone
-potassium sparing diuretic -careful with salt substitutes -can cause hyperkalemia -muscle weakness is indication
rheumatic endocarditis teaching
-preventing a reoccurrence of rheumatic endocarditis is goal of notifying provider prior to invasive surgery or dental procedures -prophylactic antibiotics given prior to invasive/dental procedures d/t risk of streptococci
primary prevention
-prevention before disease (immunizations)
acute glmerulonephritis
-proteinuria; hematuria-expected finding -monitor for HTN
Cardiac tamponade
-pulsus paradoxus
Appendicitis s/sx
-rebound tenderness -constipation -increased WBC -anorexia - n/v
Trach care
-remove ties when visibly soiled
PUD diet
-restrict acid-producing foods: milk products, caffeine, decaf coffee, spicy foods, NSAIDs
macular degeneration
-result in loss of vision in center of visual field (macula) b/c damage to retina -signs: gradual, mild to moderate reduction of central vision
Risk factors for preeclampsia
-rheumatoid arthritis -maternal age <19 or >40 -first pregnancy -morbid obesity -multifetal gestation -chronic renal disease -chronic hypertension -familiar history of preeclampsia -diabetes mellitus -SLE
preschoolers (3-6 yrs old)
-routines very reassuring to preschoolers b/c allows child to be able to anticipate their environment and adapt appropriately -bedtime routines: use stable relaxing routine (bath/storytime before bed) to help child settle down prior to bedtime & provide parental-child interaction -use nightlight b/c preschoolers are imaginary thinkers and often have many fears -do not allow child to sleep w/ you in bed b/c child needs to learn to settle to sleep in own bed and use of a transitional object (blanket/toy) often gives sense of comfort, security and reassurance allowing to fall asleep alone and quickly -do not let cry themselves to sleep
Neuroleptic malignant syndrome
-s/sx: sudden high fever, BP fluctuations, diaphoresis, tachycardia, muscle rigidity, drooling, decreased LOC, coma, tachypnea -actions: stop antipsychotic, monitor VS, apply cooling blanket, admin. antipyretic, increase fluid intaek, admin. dantrolene or bromocriptine to induce muscle relaxation, admin. med to treat arrythmias, immediate transfer to ICU -life-threatening medical emergency from antipsychotic med
HERBS
-saw palmetto: primarily used for symptoms r/t prostatic conditions (BPH) to promote urinary health -echinacea: decrease symptoms and duration of colds/flu-like illnesses; stimulate immune system -ginkgo bilbia: increase cognitive function in elderly, delay progression of AD & improving memory (enhance cognition and memory) -ginseng: improves energy & vitality
tonsillectomy preparation for 7 year old:
-schedule child a pre-op visit to hospital: concrete experiences are most meaningful learning for school-aged child (6-12 years old)
friction rub
-scratching or squealing sound that persists throughout respiratory cycle and doesn't clear w/ coughing, may indicate pericarditis or pleurisy
clozapine
-second generation anti-psychotic used to relieve symptoms of schizophrenia and to reduce suicidal behaviors in pts w/ schizophrenia/schizoaffective disorder -AE: tachycardia, weight gain, sedation, agranulocytosis (low WBC- <5,000) -agranulocytosis: decrease in one of WBCs called neutrophils, reduces ability to fight infection and can be fatal; WBC & absolute neutrophil count monitored weekly during 1st 6 months of therapy then every 2 weeks during next 6 months
Post-op TURP
-secure drainage tube to thigh - catheter taped tightly to leg to create traction so that balloon will apply firm pressure to prostatic fossa to prevent bleeding -reposition frequently -monitor temp. every 4 hours -administer antispasmodics for bladder spasms, analgesics for pain, antibiotics for prophylaxis, stool softeners to avoid straining -increase fluid intake to 2-2.5 liters/day -adjust rate of CBI to keep irrigation return pink or lighter (birght red - increase rate) -if catheter becomes obstructed, turn off CBI and irrigate with 50 mL irrigation solution -ambulate ASAP - reduce risk of DVT
Raloxifene
-selective estrogen receptor modulator (same category as tamoxifen) -lower the risk of breast cancer for women who are postmenopausal and have high risk of developing estrogen-receptive types of breast cancer -also used to prevent and treat postmenopausal osteoporosis -can cause hot flashes -ass'd with several significant CV and resp. effects (including clots)
Severe-level anxiety
-sense of impending doom
pancreatitis
-severe upper left quadrant pain -labs: elevation in serum amylase and lipase up to 2-3x expected, also increased liver enzymes and blood glucose levels
Pacemaker
-should fire when native HR less than set number ("demand" rate determines when they will begin to fire if the heart itself has not supplied an electrical impulse)
Panic level anxiety
-somatic complaints - SOB
Defense mechanism
-sublimation: negative thing --> hobby - rationalization: make sense as convenient - displacement: place anger somewhere else
anaphylaxis signs
-tachycardia, hypotension, nausea, urticaria, stridor, dyspnea
Lithium
-take with meals or milk to decrease GI upset -contact provider if develop diarrhea -have blood levels drawn -drink 8-12 glasses of water/day
isoniazid prophylactic tb therapy
-taken for about 9 months to a year; ensure compliance for entire treatment period
Therapeutic serum lithium level
-therapeutic - 0.8-1.4 -maintenance level - 0.4-1.0
S/sx of hyponatremia
-think hypovolemia - hypothermia, tachycardia, rapid thready pulse, hypotension, orthostatic hypotension, diminished peripheral pulses -neuromuscular - HA, confusion, lethargy, muscle weakness to point of possible resp. compromise, fatigue, decreased DTRs, seizures, lightheadedness, dizziness -GI - increased motility, hyperactive bowel sounds, abd. cramping, nausea
Bladder retraining for the treatment of urge incontinence:
-timed voidings to increase intervals between voidings/decrease voiding frequency -kegels -relaxation techniques -undergarments while retraining -dont ignore urge -positive reinforcement -eliminate/decrease caffeine drinks -DIURETICS IN AM
blood lipid levels
-total serum cholesterol: desirable < 200 mg/dL; risk for cardiac or stroke event w/ levels > 150mg/dL is target range therapy & has been shown to be cut point to decrease Cerebrovascular or arterial incidences -LDL: <1304 -HDL: males 35-65; females 35-80 -triglycerides: desirable < 150; males 40-160; females 35-135
Danazol
-treat endometriosis and fibercystic breast disease -cause fluid retention --> edema -GI effects -CV effects - hypertension
Celiac disease
-unable to digest protein gluten -s/sx - diarrhea, steatorrhea, abdominal distention, anemia, impaired growth, fatigue, lack of appetite -tx - eliminate gluten (found in barley, wheat, rye -safe to eat milk, eggs, rice, cheese, corn, potatoes, fruits, veggies, fresh meats and fish, dried beans
ABGs
-uncompensated: pH & one other abnormal -partial: all three abnormal -fully: pH normal & other 2 abnormal
Nifedipine - preterm labor
-unlabeled use of the drug. -calcium channel blocker, more commonly used to treat high blood pressure and heart disease. -Smooth muscle tissue, like the uterus, needs calcium to contract. Nifedipine blocks the passage of calcium into certain tissues, relaxing the uterine muscles and smooth muscles of blood vessels throughout the body.
Didonasine
-use for tx of HIV
Indicators of imminent violence
-uses profanity to express emotions (or loud, rapid talking) -clenches and unclenches jaw -maintains intense eye contact (or no eye contact at all) -paces floor, restlessness - hyperactivity -facial expressions (frowning, grimacing) -aggressive postures -drug or alcohol intoxication
Preschooler concept of death
-usually believe death is temporary and reversible
tactile fremitus
-vibration felt on palpation of chest while patient repeats syllable like nine-nine; fremitus increased over solid tissue or a tumor
paracentesis in ABD
-void before procedure, position in Fowler's position
S/sx of brain tumor
-vomiting -clumsiness -irritability -persistent HA
schizophrenia: appropriate activity
-walking w/ staff around gated grounds -encourage to participate in nonthreatening, noncompetitive physical activities, provide opportunity for verbal interaction w/ health care team member
Nonpharmacolgic method for preschool age
-watch favorite cartoon or television
Chest tube insertion and monitoring
-water seal - sterile fluid to 2 cm line; keep upright and below level of insertion -tidaling is expected; cessation of tidaling in water seal chamber signals lung reexpansion or obstruction within system -continuous bubbling should only occur in suction chamber -excessive drainage= >70 mL/hr
hypovolemia
-weak pulse, hypotension -decreased CVP, CO, urine output -increased BUN, serum osmolality, urine SG & urine osmolality and HCT
Juvenile idiopathic arthritis
-wear splints during night - prevent joint deformities and reduce and minimize pain from inactivity -apply moist heat to relieve pain and stiffness -give prednisone on scheduled basis -rest during day but do not take naps
Methotrexate
-wear two pair of gloves when handling medication
Clozapine
-weekly hematologic monitoring required - increases risk of agranulocytosis -after first 6 months, can be over other week
crackles "rales"
-wet, popping sound created by air moving thru liquid or by collapsed alveoli snapping open on inspiration, indicates fluid or mucus in smaller airways
Digoxin
-will cause heart to beat slower -call provider if experience excessive nausea, visual changes -use to tx a. fib and a. flutter; do not give if patient has second degree heart block
How should infant be fed after cleft palate repair?
-with cup - prevents trauma and injury to suture line
Nursing actions for aspiration of formula from NG tube
-withhold feeding -turn client to side -suction airway -provide oxygen if indicated -monitor vitals for elevated temp. -monitor for decreased oxygen sats or increased resp. rate -auscultate breath sounds for increased congestion -notify provider -obtain CXR
A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14, para 2 gravida 2, and regular periods every 28 to 30 days. The client is divorced and works full time as a bank teller. The nurse identifies the MOST probable cause of the client's symptom is which of the following? 1. Emotional trauma and stress. 2. Onset of menopause. 3. Presence of uterine fibroids. 4. Possible tubal pregnancy.
.(1) not enough information given in question to assume that symptoms are caused by stress (2) correct—ovarian function gradually decreases and then stops, usually 45 to 50 years old (3) benign tumors arising from muscle tissue of uterus, menorrhagia (excessive bleeding) most common symptom along with backache, constipation, dysmenorrhea (4) usually see history of missed periods or spotting with abdominal pain
The client exhibits symptoms of myxedema. The nursing assessment should reveal which of the following? 1. Increased pulse rate. 2. Decreased temperature. 3. Fine tremors. 4. Increased radioactive iodine uptake level.
..(1) pulse will decrease (2) correct—with myxedema there is a slowing of all body functions (3) associated with hyperthyroidism (4) associated with hyperthyroidism
ERIKSON
0-1= trust vs mistrust 1-3: autonomy vs shame/doubt 3-6: initiative vs guilt 6-12: industry vs inferiority 12-20: identity vs role confusion 20-35: intimacy vs isolation 35-65: generativity vs stagnation 65+: integrity vs despair
What are the normal creatinine levels? BUN?
0.8-1.4, 8-25
A nurse is assessing a client during her first prenatal visit. The client reports that her last normal period began on April 22. Use Nagele's rule to calculate this client's expected date of birth. a. 0729 b. 0129 c. 0722 d. 0122
0129 To use Nagele's rule subtract 3 months and add 7 days
. The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for 1. a client with Alzheimer's requiring assistance with feeding. 2. a client with osteoporosis complaining of burning on urination. 3. a client with scleroderma receiving a tube feeding. 4. a client with cancer who has Cheyne-Stokes respirations.
1
An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially blood pressure, every 30 minutes. 2. remain at the client's side to provide reassurance. 3. tell the client the name of the medication and its effects. 4. monitor the anticholinergic effects of the medication.
1
The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.
1
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.
1
Droplet Precautions
1. A private room or room with clients with the same disease a. Ensure that clients have their own equipment 2. Masks for providers and visitors
Contact Precautions
1. A private room or room with the same illness 2. Gloves and gown worn by caregivers, and visitors 3. Disposal of infectious dressing material into a simple non porous bag without touching the outside of the bag.
Standard Precautions----
1. All body fluids, except sweat 2. Nonintact skin and mucous membranes 3. These apply to all clients regardless of condition 4. If hands are not viably soiled alcohol hand rub should be used 5. Antimicrobial soap should be used if hands are soiled or contaminated with spores 6. Remove gloves and complete hand hygiene between each client 7. Masks, eye protection, and face shields are required when care might cause splashing or spraying of body fluids 8. This client does not require a private room unless they are unable to maintain appropriate hygienic practices
Prolapse cord
1. Call for assistance immediately and notify provider 2. Using sterile glove, insert two fingers into the vagina to reduce pressure off the cord 3. Reposition client in knee-chest or trendelenburg position 4. Apply warm, sterile, saline-soaked towel to visible cord to prevent drying and maintain blood flow 5. Provide continuous electronic monitoring of FHR for variable decels, which indicate fetal asphyxia and hypoxia 6. Administer oxygen at 8-10 L/min via face mask 7. Initiate IV access and administer IV fluid bolus 8. Prepare for immediate vaginal birth if fully dilated or c-section if not
Steps for obtaining sterile urine specimen from indwelling urinary catheter
1. Drain catheter's tubing of urine 2. Clamp catheter's tubing below port for 20 minutes 3. Clean the injection port cap of the catheter drainage tubing with antiseptic 4. Attach a sterile syringe to the port and aspirate quantity of urine required 5. Place urine sample in sterile container 6. Remove clamp to resume drainage
Categories of triage during mass casualty
1. Emergent - highest priority given to clients who have life-threatening injuries but also have high possibility of survival once stabilized; RED tag (shock, airway obstruction) 2. Urgent - second-highest priority given to clients who have major injuries that are not yet life-threatening and can usually wait 45-60 min. for treatment; YELLOW tag (open fracture, major wound) 3. Nonurgent - next highest priority given to clients who have minor injuries that are not life threatening and do not need immediate attention; GREEN tag (sprains, strains, closed fracture, abrasion) 4. Expectant - lowest priority given to clients who are not expected to live and are allowed to die naturally; comfort measures can be provided but restorative care is not; BLACK tag (severe head trauma, extensive/severe burns, already dead)
Isolation Guidelines:
1. Hand hygiene and the use of barrier precautions 2. These precautions apply to every client, regardless of the diagnosis 3. Change PPE after contact with each client and between procedures with the same client, if in contact with large amounts of blood or blood fluids (compromising the PPE) 4. Higher risk for loneliness explain the reason for isolation and provide sensory stimulation
Some complications of surgery are
1. Hypovolemic shock 2. Paralytic ileus 3. Wound dehiscence or evisceration 4. Deep vein thrombosis 5. Airway obstruction 6. Hypoxia
Contraindication to influenza vaccine
1. Live spray for adults >50, children <2, immunocompromised, pregnant 2. Hx of Guillain-Barre Syndrome 3. Allergy to eggs 4. Severe allergy
Medication Administration Bipolar: Teaching about mood stabilizers
1. Monitor plasma lithium levels during treatment, at least 5 days after starting and after any dosing changes until therapeutic level has been achieved then every 1 to 3 months 2. Blood for monitoring should be obtained in the morning usually 12hrs after the last dose 3. Maintenance level range is between 0.4 and 1.0, Greater than 1.5 can be toxicity 4. Hemodialysis may be indicated for toxic lithium levels 5. Monitor CBC, serum electrolytes, renal function tests, and thyroid function tests 6. Advise clients to take lithium as prescribed 7. Taking lithium with food can help decrease gastric distress 8. Advise clients that effects take 7 to 14 days 9. Encourage clients to adhere to lab appts 10. Emphasize the high risk of toxicity due to the narrow therapeutic range 11. Provide nutritional counseling, Stress the importance of adequate fluid and sodium intake 12. Instruct clients to monitor for manifestations of toxicity and when to contact the provider 13. Clients should withhold medication and seek medical attention if experiencing diarrhea, vomiting or excessive sweating 14. Conditions that cause dehydration such as exercising in hot weather, or diarrhea, put client at risk for lithium toxicity
Disaster management steps
1. Prevention 2. Preparedness 3. Response 4. Recovery
Airborne Precautions
1. Private room 2. Masks and respiratory protections (N95 for TB) 3. Negative pressure airflow exchange of at least 6-12 exchanges per hour 4. If splashing or spraying is possible wear full face protection
Steps for cleaning contaminated surgical instrument
1. Rinse the instrument under cold water 2. Wash the instrument with soap and water 3. Remove organic materials with a brush 4. Rinse the instrument in warm water 5. Dry the instrument thoroughly
Use of restraints/ Safety Devices Client safety: Appropriate use of physical restraints
1. Shortest duration necessary and only if less restrictive measures are not sufficient. 2. They are for the physical protection of the client of the other clients and staff 3. A client may voluntarily request temporary seclusion if environment is too stimulating 4. Restraints can be either physical, vest, belt, mitts, or chemical such as sedatives 5. The prescription must include the reason for the restraints, the type of restraints, the location, and how long to use and the type of behavior that warrants using restraints 6. The prescription allows only 4hrs of restraints for an adult, 2 hrs for clients ages 9 to 17, and 1 hour for clients under the age of 9 7. These prescriptions can be renewed for a max of 24 consecutive hours. 8. Providers cannot write PRN prescriptions for restraints 9. Explain the need for the restraints to the client and family, emphasizing that the restraints keep the client safe and are temporary 10. Ask the client or guardian to sign a consent form 11. Assess skin integrity, provide skin care every 2 hours 12. Offer food and fluids, Provide hygiene and elimination 13. Monitor Vitals, and offer range of motion exercises 14. Pad bony prominences to prevent skin breakdown 15. Use a quick-release knot to tie the restraints to the bed frame where they will not tighten when raising and lower the bed. 16. Fit two fingers between the restraint and the client 17. Never leave the client alone without the restraints
Steps for trach care
1. Suction the tracheostomy tube, if necessary, using sterile suctioning supplies. 2. Apply the oxygen source loosely if the client's SaO2 decreases during the procedure. Use surgical asepsis to remove and clean the inner cannula with ½ strength hydrogen peroxide and rinse it with a sterile saline solution. 3. Clean the stoma site and the tracheostomy plate with ½ strength hydrogen peroxide followed by sterile saline. 4. Place a split 4X4 dressing around the tracheostomy. 5. Change ties if they are soiled. 6. Document the type and amount of secretions, the general condition of the stoma and surrounding skin, the client's response to the procedure, and any teaching or learning that took occurred.
A nurse is providing home safety instructions to a group of older adult pts. Match the safety risk with the appropriate instruction. 1. Passive 2. Carbon monoxide poisoning 3. Food poisoning
1. avoid enclosed areas with others smoking 2. have water heaters inspected on an annual basis 3. cook all meat at an appropriate temp
prolapsed umbilical cord: nursing actions
1. call for help STAT 2. notify HCP 3. use sterile-gloved hand & insert 2 fingers into vagina & apply finger pressure on either side of cord to fetal presenting part to elevate it off cord 4. re position pt in knee-chest, trendelenburg, side-lying w/ rolled towel under right or left hip to relieve pressure of cord 5. apply warm, sterile, saline-soaked towel to visible cord to prevent drying & maintain blood flow 6. provide continuous FHR monitoring for variable deceleration (indicate fetal asphyxia/ hypoxia) 7. administer O2 at 8-10 L/min via face mask 8. initiate IV access and administer IVF bolus 9. prepare for c/s if all other measures fail
Older adult assessment
1. functional ability 2. economic social status 3. environmental factors 4. physical assessment
Albuterol MDI sequence
1. remove cap and shake canister 2. hold mouth piece 1/2-2 in from mouth 3. tilt head back slightly then open mouth 4. press inhaler while taking deep breath 5. hold breath for 10 sec 6. resume normal breathing
Urine specific gravity normal range
1.010-1.030
1 g (gram)
1000 mg
FHR
110-160
1 tablespoon
15 mL
I lb
16 oz
What temp should pork be cooked at?
160
What is normal pre-albumin values? Mag? Potassium?
17-40 1.5-2.5 3.5-5
anterior fontanel closes at..
18 months
anterior fontanelle closes by...posterior by..
18 months, 6-8 weeks
Kidney glucose threshold
180
The nurse is performing triage on a group of pts in the ED. Which of the following pts should the nurse see FIRST?
19 year old with a fever of 103.8 who is able to identify her sister but not the place or time.
Stages of labor
1st stage: complete when 10 cm dilated, 100% decent (latent-active-transition) Latent: slow deep breath Transition: pattern paced breathing
A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.
2
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.
2
The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? 1. The client advances the cane 18 inches in front of her foot with each step. 2. The client holds the cane in her left hand. 3. The client advances her right leg, then her left leg, and then the cane. 4. The client holds the cane with her elbow flexed 60°.
2
1 pint
2 cups
IM injection
2 in needle for mixture big meds; - deltoid: < 1 cc
1 quart
2 pints
During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.
2, 3, 4
crutch education
2-3 fingers between axillary bars and axilla flex elbow 30 when palms rest on the handles
Developmental
2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup
1 kg
2.2 lbs
gastric NG lavage
200-300 cc (h20 or Nacl) lay on left side to prevent aspiration
COPD patients and O2
2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less
The nurse's INITIAL priority when managing a physically assaultive client is to 1. restrict the client to the room. 2. place the client under one-to-one supervision. 3. restore the client's self-control and prevent further loss of control. 4. clear the immediate area of other clients to prevent harm.
3
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.
3
Bowel elimination how to get a specimen
3 times from 3 different stools and come from fresh stools that are not contaminated
When suctioning a client with a tracheostomy tube, a nurse would perform the following steps: (Place in order of priority; may use each answer more than once) 1. Check the suction source and adjust pressure dial to 80-120 mm HG 2. Assess breath sounds 3. Wash hands 4. Hyperoxygenate with 100% oxygen 5. Set up sterile field 6. Quickly insert catheter until resistance is met 7. Document procedure and client's response 8. Explain procedure to the client 9. Withdraw catheter using intermittent suctiion
3, 2, 8, 1, 5, 4, 6, 9, 4, 2, 3, 7
minimum albumin level
3.5
What position is good to use for a patient who is at high risk for pressure ulcer
30 degrees, lateral position
1 oz
30 mL
At what age does bone loss begin with osteoporosis? what are normal Calcium levels?
35, 8.6-10
HCT normal labs
35-45 (increased HCT > 50% experienced with dehydration)
Infant temperature up to 1 y.o
36.5-37.2 (99.4-99.7)
What is the normal hematocrit in a female? Normal Hgb in female? Normal WBC?
37-48 12-16 5-10
gestation week
38-42 weeks
A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares." 2. "I have a headache and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am and I don't know where I live."
4
Therapeutic levels of magnesium sulfate
4-8 mg/dl
1 teaspoon
5 mL
1 tsp
5 mL
hungtington's
50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure
What are total serum protein values (normals)
6-8 g/dL
Alzheimer's
60% of all dementias, chronic, progressive degenerative cognitive disorder.
PTT reference range
60-80 sec
Tidal volume is
7-10 ml/kg
Stranger anxiety is greatest at what age?
7-9 months..separation anxiety peaks in toddlerhood
1 cup
8 oz
1 cup= 1 oz=
8 oz 30 cc
trach suction pressure
80-120 -intermitten 10-15 sec each pass
Actual Loss
: Any loss of a values person, item or status
hypotonic hyponatremia
< 130 (regular Na: 135-145)
Cardiac troponin normal range
<0.20
Absolute neutrophil count values
<2000 - increased risk for infection <500 - severe risk of infection
thrombocytopenia
<<<<<<plt
Lithium toxicity
>1.5 -s/sx - confusion, coarse hand tremors, ECG changes, sedation -NOTE: decreased sodium intake increases lithium levels
postpartum hemorrhage
>500ml (vag birth) >1000ml (C/S) - If boggy uterus, massage fundus - elevate legs 20-30degrees to promote venous return - give oxytocin, uterine stimulants : methylergonovine (Methergine -not for HTN pt), Misoprostol (Cytotec), carboprost (Hemabate)
blood lead toxic
>5: social services >20: poison control >45: chelation therapy
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside
A
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardia c) Warm moist skin d) Polyuria
A
When should planning discharge process begin? a. at time of admission b. 2 days after client is admitted c. whenever the nurse has the time to do planning d. when the physician has the discharge order
A
Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle.
A
Health Care Proxy/Durable Power attorney:
A document that appoints someone to make medical decisions when the client is no longer able to do son on his own behalf.
Which of the following situations can be identified as an ethical dilemma?
A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill
What is an interdisciplinary team?
A group of health care professionals from different disciplines
Necessary Loss:
A loss related to a change that is part of the cycle of life
Delegation for effective task management.
A nurse is responsible for providing clear directions when a task is initially delegated and for periodic reassessment and evaluation of the outcome of the task. RNs must delegate tasks so that they can complete higher level tasks. RNs may delegate to other RNs, PNs or APs. PNs may delegate to other PNs or APs. Predictability of outcome: Is this routine, or is this new, is there potential for complications Potential for harm: Is the client stable? Risks? Aspiration, Bleeding Complexity of Care: Does the delegatee have the license to perform the task, and the training? Need for problem solving: Does this require the nursing process? Assessment skills or judgment Level of client interaction: Is there psychosocial support needed?
TB
A positive Mantoux test indicates pt developed an immune response to TB. Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by a positive culture for M TB A chest x-ray may be ordered to detect active lesions in the lungs QuantiFERON-TB Gold: DIAGNOSTIC for infection, whether it is active or latent
The nurse is caring for pts in the skilled nursing facility. Which of the following pts require the nurses IMMEDIATE attention?
A pt admitted for a CVA whose RX for warfarin expired 2 days ago
What can be delegated to assistive personnel?
ADLS, feeding (unless swallowing precautions), positioning, specimen collection, I&Os, VS (in stable)
TO AP
ADLs Bathing, Grooming, Dressing, Toliet Ambulating Feeding Positioning Routine tasks Bed making Specimen Collection, I and Os Vitals For stable clients
Alkalosis/ Acidosis and K+
ALKalosis=al K= low sis. Acidosis (K+ high)
Nurses must follow what code of standards in delegating and assigning tasks
ANA Codes of standards
arterial vs venous
ARTERIAL: S&S= decreased pulses, claudication, thin, shiny skin, pale and cool, painful ulcers NOT bleed, thick toe nails; intervention= exercise program, no smoking, no cold temps DEPENDENT LEG POSITION VENOUS: S&S-edema, stasis dermatitis (brown, itchy), thickened skin, painless bleeding ulcers, risk skin breakdown & infection, red warm skin ELEVATE LEGS, stocking in morning, wound care and weight management BOTH: FOOT CARE
Addison's & Cushings
Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia
Staffing:
Adequate staffing, and staffing mix
A client is given morphine for postop pain. Following admin of the drug, the nurse observes a HR 68, RR 8, BP 100/68, pt sleeping quietly. Which is MOST appropriate?
Admin Narcan
What is the nsg intervention and/or pt education for constipation?
Admin stimulant/laxative or stool softener to prevent
A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which nursing actiion would be most appropriate at this time? a. Administer 0.9% Normal Saline b. Provide oral hygiene and comfort measures c. Monitor for diminished breath sounds d. Encourage water and other fluids
Administer 0.9% Normal Saline In clients who are experiencing hyponatremia the appropriate nursing intervention would be to restrict water intake
Lumbar Puncture
After the procedure, the pt should be supine for 4-12 hours as prescribed.
The physician orders risperidone for a pt with Alzheimers disease. The nurse anticipates administering this med to help decrease which of the following behaviors?
Agitation and assaultiveness
draw up regular and NHP?
Air into NHP, air into Regular. Draw regular, then NHP
The ABC framework identifies, in order, the three basic needs for sustaining life
Airway Breathing Circulation
5.
Airway obstruction
Prioritizing Care for post op clients
Airway, Breathing, Circulation, Disability, Examination/Exposure
A nurse is reviewing the med records of a pt who has a pressure ulcer. Which of the following is an expected finding?
Albumin 3g
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan?
Alteration in skin integrity r/t decrease in tissue O2
Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair"
Anger
Vector based Transmission:
Animals or insect's transmission: Ticks ---Lyme disease, Mosquitoes--- West Nile and Malaria
What are the therapeutic effects of protamine?
Antidote to severe heparin overdose + Reversal of heparin administered during procedures
Maturational or developmental loss:
Any loss expected of life. (Child leaving for college)
Perceived loss:
Any loss that is not obvious to others
Situational loss:
Any unanticipated loss caused by an external event (home loss by tornado)
APGAR
Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent)
MAOI
Appropriate snack cheddar cheese and crackers
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
Aspirate gastric contents with a syringe
A nurse is obtaining a medication history from a pt who is to start a new rx for warfarin. Which of the following otc med should the nurse instruct the pt to avoid
Aspirin
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the clients safety while walking in the halls, the nurse should do which of the following?
Assess the pt gait for steadiness
Which of the following nursing interventions is MOST important for a 45 year old woman with RA?
Assist her with heat application and ROM exercises
makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings
Authoritative
A client with a peptic ulcer had a partial gastrectomy and vagotomy. In planning the D/C teaching the pt should be cautioned by the nurse about which?
Avoid eating large meals that are high in sugars and liquids, at risk for dumping syndrome, lay down 30 min after eating
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning
B, C, D
Hepatitis b
B= blood and body fluids (hep c is the same)
hypoglycemia
BG < 70; weakness, hunger, shakiness, diaphoresis, nausea, confusion
Which Grief Process when Client acknowledges the impending loss while remaining hopeful "If I could just make it through this, I'd never smoke again"
Bargaining
A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that his aspect of care delivery is an example of which of the following ethical principles?
Beneficience
What are the positive actions to help others?
Beneficience
A pt should receive a dose of flumazenil to treat s/s of?
Benzo OD
What is bipolar disorder?
Bipolar disorder is a mood disorder with recurrent episodes of depression and mania.
The nurse is assessing a client with a bleeding gastric ulcer. When examining the pt stool, which characteristics are expected?
Black and tarry
Alcohol Use Manifestations of Withdrawal
Body burns 0.5 oz of alcohol per hour * Withdrawal appears within 4-12 hours * Irritability + Tremors + Anxiety * Nausea + Vomiting + HA * Diaphoresis * Sleep Disturbances * TACHYCARDIA + HTN Use Benzodiazepines = tx Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium)
What does a newborns poop look like?
Breastfed-yellow green creamy
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an assistive personnel (AP)? A. Feeding a client who was admitted 24 hrs ago w/aspiration pneumonia B. Reinforcing teaching w/a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer
C
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver
C
