NCLEX ,M. Klimek
How many nitro tabs can you take before you call the doctor?
3
1 tbs
3 tsp
What is the age range of pre-operational thinking? Hint: Think of PRE-schoolers.
3-6
middle adulthood
35 to 64 years of age
How long will it take for the person to see results when acne is being treated?
4 to 6 weeks
The symptoms of pyloric stenosis mostly commonly appear at age ______ to _____.
4 to 6 weeks
The preferred length of needle for SQ injection is_________.
5/8 inch
A CD4 count of under __________ is associated with the onset of AIDS-related symptoms.
500
How long can breast milk be frozen?
6 months
When pouring liquid onto a sterile field you should pour from a height of _____ to _____ inches above sterile field.
6 to 8
When will the client with an MI be allowed to engage in sexual intercourse after an MI?
6 weeks after discharge
late adulthood
64 years of age to death
Sickle-cell anemia symptoms do not appear before the age of ____ months due to the presence of _____ ______.
6; fetal hemoglobin
How long does it take for the umbilical stump to fall off?
7 to 14 days
What is the age range of concrete operational thinking?
7-11
What solution is commonly used for care of umbilical cord?
70% alcohol to promote drying (trend is toward soap and water)
Sutures in general are removed by the ___ day.
7th
If my blood pressure is 190/110, what is my pulse pressure?
80 mmHg
How much suction should be used for a child?
80 to 100 mm Hg
The recommended pressure setting for performing tracheostomy suctioning on an adult is
80-120
After clep lip repair, what device will the baby wear?
A Logan bow
What drug is used in pulmonary edema to reduce fluid in the lungs?
A diuretic (Lasix)
You are helping a client with an Spinal Cord Injury to establish a bladder-retraining program. Which strategies may stimulate the client to void?
1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle
Intrinsic factor
A substance produced by the mucosa of the stomach and intestines that is essential for the absorption of vitamin B12.
No nurse should attend the client with a cesium implant more than ____ per day.
1/2 hour
What temperature is appropriate for the water used to bathe an infant?
100 to 105
1 L
1000 cc
1 kg
1000 g, 2.2 lbs,1000 cc
1 gm
1000 mg, 15 gr
The diagnosis of anorexia is made when there is a weight loss of _______% or more of body weight.
15 (weigh < 85% of normal body weight), hospitalize if 30% weight loss
In what age range is spinal cord injury most common?
15 to 25
What gauge catheter would you use to start an IV in hypovolemic shock?
16 or larger
What does AKA mean?
above knee amputation
per-
by, through
a nurse is caring for clients on the surgical unit. Which client should the nurse assign to the LPN?
client with cellulitis receiving iv naficillin
A 10 on the apgar means the baby is
in terrific health
What is the top priority in the care of the client with anorexia nervosa?
intake of enough food to keep them alive, have them gain weight
A 0 on the apgar means the baby
is stillborn
DKA is
is the complicatiob for type 1 DM
Illeostomy
liquid stool odor mild stool very damaging to the skin continuous drainage high risk for fluid/electrolyte imbalances incontinent never irrigate
Children are at _____ risk for suicide.
low
What is cleft palate?
malformation resulting in an opening in the hard palate, soft palate or both. failure of fusing
At what age does BPH occur?
men over 50 years of age
Individuals who are ill are ________ sensitive to noise than individuals who are well.
more
Can a client who had recent bowel surgery get PD?
no
If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing?
no, bedrest until the client is stable!
To asess a patient choking afera meal the PN should
place a fist halfway between the xiphoid and umbilicus
What is the first sign of appendicitis?
right upper quadrant pain
-stasis
stopping; controlling; placing,standing,Stoppage
-centesis
surgical puncture to remove fluid for diagnostic purposes or to remove excess fluid
-plast
surgical repair
Colostomies performed for a gunshot are usually (temporary/permanent)
temporary
When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER?
the suspected poison
Syrups and elixirs are of particular concern to diabetic clients because....
they contain sugars
What are the four fat-soluble vitamins?
A,D,E,K
Fats carry vitamins
A,D,E,K (Remember FADE K!)
Six hours after birth, the infant is found to have an areas of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as: A. A cephalohematoma B. Molding C. Subdural hematoma D. Caput succedaneum
A. A cephalohematoma why? The swelling over the right parietal area is a cephalohematoma, an area of bleeding outside the cranium. This type of hematoma does not cross the suture line because it's outside the cranium but beneath the periosteum.
To ensure safety while administering a Nitroglycerin patch, the nurse should: A. Wear gloves B. Shave the area where the patch should be applied C. Wash the area thoroughly with soap and rinse with hot water D. Apply the patch to the buttocks
A. Wear gloves why? To protect herself, the nurse should wear gloves when applying a nitroglycerin patch or cream.
What blood type is the universal recipient?
AB
The diet of a patient with MS should be ____--ash.
Acid
What type of diet is used in BPH?
Acid ash- one of meat, fish, eggs, and cereals with little fruit or vegetables and no cheese or milk
Intimacy vs. Isolation (Erikson)
Adulthood: Young adults seek companionship or love or become isolated from others fearing rejection or disappointment 20-40 yrs, good: love, intimate relationships, commitment. bad: avoidance of commitment, alienation, distancing oneself Erikson's stage in which individuals form deeply personal relationships, marry, begin families
When does pre-eclampsia usually begin in pregnancy (week)?
After 20 weeks
When will bowel sounds return after a hysterectomy?
After 24 hours but before 72 hours
How often should the nurse clear the tubing during suctioning?
After each pass/entry/removal
When should the breast feeding infant be burped?
After feeding from each breast
The school-aged hospitalized child is afraid of separation from ___________.
Age group
What other disease can be confused with pernicious anemia?
Angina pectoris
Mom is A negative. Baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered A within 1 week of delivery B within 72 hours of delivery C within 2 weeks of delivery D within 1 month of delivery
B within 72 hours of delivery baby needs protection
Hearing aids are more useful in sensory or conductive hearing loss?
Conductive
How long does one episode/course of PD last?
Could be 10 hours
sepsis
Dangerous infection of the blood
What type of environmental modification is best for a migraine?
Dark and quiet environment
In hypovolemic shock the level of consciousness (LOC) is (increased/decreased).
Decreased
What lab findings are present in AIDS?
Decreased RBC's, WBC's and platelets
What causes angina pectoris?
Decreased blood supply to myocardium, resulting in ischemia and pain
These infants are prone to develop ______ and failure to ______.
Dehydration, thrive
Dantrium causes (constipation/diarrhea)
Diarrhea (hint: D's go together, Dantrium and Diarrhea)
To straighten the ear canal in the young CHILD under 3 the pinna should be pulled _______ and ________.
Down and back
What is the #1 treatment for autonomic dysreflexia?
Drain the bladder, empty the bowel
What are 4 signs and symptoms of mastoiditis?
Drainage from ear, high fever, headache and ear pain, tenderness over mastoid process
Young infants accept medication best when given with a _______.
Dropper
How should the temperature of the water be tested if no thermometer is available?
Dropping water on inside surface of your forearm.
"If I had to do it over again, I'd life my life just about the same," is an example of ____ ____________
Ego Integrity
With what device will the infant be restrained?
Elbow restraints
What are the two most common complications of hyperemesis gravidarum?
Electrolyte imbalance (dehydration) Starvation
If the client complains of abdominal pain during PD you would first...
Encourage them to move about
inability to control the flow of urine and involuntary urination
Enuresis
Will the man with BPH have enuresis, nocturia or hematuria?
Enuresis-No, Nocturia-Yes, and Hematuria-Maybe
What glands are affected in CF?
Exocrine glands
What is gynecomastia?
Female-type breasts
The change in the character of the sounds is known as the ________
First diastolic sound
Describe the typical child with pyloric stenosis.
Firstborn, full term, white, boys
To get a score of 1 on the APGAR for muscle tone the newborn must place their extremities in _______________.
Flexion
How long should it take for one unit of blood to infuse?
From one hour to three hours
In general, cancer drugs have side effects in which three body systems? y
GI Hematologic (blood) Integumentary
Penicillin
Give on empty stomach
Iron (without nausea)
Give on empty stomach with orange juice to increase absorption
Capoten
Give on empty stomach, one hour before meals (antihypertensive)
Non-steroidal anti-inflammatory drugs
Give with food (for arthrosis)
Aldactone
Give with meals (K--sparing diuretic)
Tagamet
Give with meals, remember Zantac does not have to be given with meals
Griseofulvin
Give with meals-- especially high fat meals (anti-fungal)
Steroids
Give with meals-- remember taper the patient off these drugs slowly
The client with celiacs cannot tolerate___________.
Gluten
What is hirsuitism?
Hair where you don't want it
Cytoxan cyclophosphamide
Hemorrhagic cystitis
What is the medical treatment for pernicious anemia?
IM injections of Vitamin B-12
Application of (warm H2O compress/ice packs) is the preferred treatment for breast engorgement.
Ice packs to decrease swelling
Does the heart rate increase or decrease in pulmonary embolus?
Increase
-scope; -scopy
Instrument for observation
The child with meningitis is most likely to be (lethargic/irritable) at first.
Irritable
Which type of medications are given by Z-track injection?
Irritating, staining
Is the client sedated for a cystoscopy?
It is done under LOCAL anesthesia. General anesthesia may be used for a child.
What is the sensori-motor stage of intellectual development?
It is the intellectual stage of children from birth to 2 years
What does homozygous mean?
It means you have the defective gene from both parents.
What happens to the pulse pressure in hypovolemic shock?
It narrows (becomes a smaller number)
What lubricant can safely be applied to the cracked lips of chemotherapy stomatitis?
K-Y Jelly
What is the #1 cancer that AIDS patients get?
Kaposi's sarcoma
When a client is unable to hold his dentures firmly in his mouth, the nurse should...
Leave them out
What is oliguria?
Less than 500 cc of urine in 24 hours
Milk is (high/low) in cholesterol.
Low
What will the facial appearance of a patient with MG look like?
Mast-like with a snarling smile (called a myasthenic smile)
When is a bad time to change dressings?
Mealtime
Before you give digitalis, what action must you take?
Measure the apical pulse
Pathogen (Define)
Micro-organism that causes disease
What does blood cross matching mean?
Mixing a little of the client's blood with the donor blood and looking for agglutination.
In Cushings syndrome, the client develops __________ face.
Moon
Diabetes with pregnancy is (more/less) common as the woman ages.
More
Pre-eclampsia makes the neuromuscular system more or less irritable?
More
What pain medication is given for the pain of a MI (Give three).
Morphine, Demerol, Nitroglycerine
To prevent eye medications from getting into the systemic circulation you apply pressure to the _______ for ______ seconds.
Nasolacrimal sac, 10 (press between the inner canthus and the bridge of the nose)
What is the #1 symptom of cast syndrome?
Nausea and vomiting due to bowel obstruction
What is cast syndrome?
Nausea, vomiting and abdominal distention that can result in intestinal obstruction
Besides pain, people with migraines complain of what other symptoms?
Nausea, vomiting and visual disturbances
In Myasthenia Gravis (MG) there is a disturbance in transmission of impulses at the _____ _____.
Neuromuscular junction
Can you microwave frozen breast milk in order to warm/thaw it?
Never
Should you massage the calves of the client with CHF?
Never
What drug treates angina pectoris?
Nitroglycerine
Do people without cell damage have troponin in their blood?
No it is only present when myocardial cells are damaged.
Should a client sleep with the hearing aide in place?
No, a client should not sleep with a hearing aide in place.
Are enemas required before cystoscopy?
No, but may be ordered.
If pre-eclampsia is mild will the woman be hospitalized?
No, just rest at home
Is it appropriate to massage the legs of the client to preven pulmonary embolus?
No, never
Do you need to call the doctor for autonomic dysreflexia?
No, only call the doctor if draining the bladder & removing impaction does not work
Should the nurse change the post-mastoidectomy dressing?
No, reinforce it. Physician changes first post op dressing
Is surgery done immediately upon diagnosis of cataract?
No, they usually wait until it interferes with ADLs .
Which one is associated with right side heart failure?
Nocturnal polyuria the fluid build up in the daytime& when they lie down at night pt has diuresis
What solution is used for CBI?
Normal saline (0.9 NaCl)
What is epitaxis?
Nose bleeds
What blood type is the universal donor?
O
What are the two major treatments of pulmonary embolus?
O2, anticoagulants
What are the top three nursing interventions in pemphigus?
Oral care, protection from infection, encouraging high fluid intake
What class of drugs can lead to pulmonary embolus?
Oral contraceptives
What is the #1 cause of death in pemphigus?
Overwhelming infection
What do you see during and after feeding?
Peristaltic waves from left to right
With what solution & when should a breast feeding mother cleanse the areola?
Plain water, before & after each feeding
Which cells are low in thrombocytopenia?
Platelets
The dyspnea of pulmonary embolus is accompanied by ____ _____.
Pleuritic pain
The four most common organisms that cause meningitis are...
Pneumococcus Meningococcus Streptococcus H. influenza
True, due to the effects of narcotics on central respiratory control
Post-operative pain, cancer pain, sickle-cell crisis pain
What is the big danger to staff when caring for a client with cesium implant?
Radiation hazard
What do you do first for the client experiencing autonomic dysreflexia?
Raise HOB
Flight of ideas is when the patient changes topics of conversation______.
Rapidly
What is the #1 medical treatment of hypovolemic shock
Replace blood and fluids
A dry cast is dull or resonant to percussion?
Resonant
What acid/base disorder is seen in Respiratory Distress Syndrome?
Respiratory acidosis (CO2 is retained)
Which blood gas disorder is most common in pneumonia?
Respiratory alkalosis, because the hyperventilation blows off more CO2, than the consolidation traps in the blood
The #1 danger in both Myasthenic and Cholinergic crisis is _____ ______.
Respiratory arrest
Give three reasons for a blood transfusion
Restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace specific blood components
The patient with a recent CVA is most likely to have fluids restricted or forced?
Restricted
What is the typical complexion of a client with polycythemia vera?
Ruddy red, almost purple
What is petechiae?
Small dot like pinpoint hemorrhages on the skin.
The group with the highest incidence of Buerger's disease is __________.
Smokers
What action will facilitate the trimming of brittle toenails?
Soaking in warm water
What agents are best for catheter care?
Soap and water
What solution should be used to clean a hearing aid?
Soap and water
What type of diet should the patient with MG be on?
Soft
The toddler and preschooler will think that illness is caused by_____________.
Something they did wrong.
The patient with spinal cord injury will have (flaccid/spastic) muscles.
Spastic
Will the muscles of MS clients be spastic or flaccid?
Spastic
Bactericide (Define)
Substance capable of destroying micro-organisms but not necessarily their spores
What special item do clients with CHF have to wear to decrease venous stasis in the legs?
TED hose
Which solution is used to irrigate a colostomy?
Tap water
Scoliosis MOST commonly affects _____ _____ (type of clients).
Teenage females
If PROM occurs before viability, what is the typical management?
Termination of pregnancy
What is the pulse pressure?
The difference between the systolic and the diastolic blood pressure
What behavior on the part of the client is the BEST indicator that they have accepted their stoma?
The noise will go away in a few days to a week.
What is the first phase in acute renal failure?
The oliguric phase
What part of your hand do you use to handle a wet cast?
The palm
What is methionine?
The precursor of the amino acid cystine (precursor = material out of which something is made)
To score a maximum score fo 2 on color the child must be ____________.
Totally pink
What does TURP stand for?
Transurethral resection of the prostate
Smoking increases the risk of CVA. (T/F)
True
What drugs are most commonly given before cystoscopy?
Valium or demerol
What three drugs can be given for muscle spasms?
Valium, Baclofen (Lioresal), Dantrium
What organism causes shingles?
Varicella--herpes zoster
Before administering vaginal medications the client is more comfortable if you ask them to _________ .
Void
What test confirms the ELISA?
Western Blot
Do clients in hypovolemic shock have to have a Foley inserted?
Yes, to measure urine output (when output is >30 cc per hour the shock has resolved)
How do you calculate the pulse pressure?
You subtract the diastolic from systolic
Which of the following roommates would be most suitable for the client with myasthenia gravis? A. A client with hypothyroidism B. A client with Chron's disease C. A client with pylonephritis D. A client with bronchitis
A. A client with hypothyroidism why? The most suitable roommate for the client with myasthenia gravis is the client with hypothyroidism because he is quiet.
Which lab test would be the least effective in making the diagnosis of myocardial infarction? A. AST B. Troponin C. CK-MB D. Myoglobin
A. AST why? AST is not specific for a myocardial infarction
This client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept during the test? A. Atropine sulfate B. Furosemide C. Prostigmin D.Promethazine
A. Atropine sulfate why? Atropine sulfate is the antidote for Tensilon and is given to treat cholenergic crises
The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40 mg IV stat. How should the nurse administer the prescribed furosemide to this client? A. By giving it over 1-2 minutes B. By hanging it IV piggyback C. With normal saline only D. By administering it through a venous access device
A. By giving it over 1-2 minutes why? Lasix should be given approximately 1mL per minute to prevent hypotesion
What is ecchymosis?
Bruising
What type of traction is most commonly used for hip fracture in adults?
Bucks
The nurse is assessing a client who is taking prescribed levothyroxine (Synthroid) and who has a low thyroid-stimulating hormone (TSH) level. The nurse should assess the client's a. nails for thickening b. skin for breakdown c. neck veins for distention d. pedal pulses for symmetry
C. The nurse should understand common manifestations of thyroid disease and risks for a client with thyroid disease. A client who is on Synthroid is at risk for hyperthyroidism. A low TSH is an indication of excess Synthroid and the client is at risk for dysrhythmias and heart failure. The nurse should assess the client's neck veins for distention.
The client with cirrhosis of the liver is receiving lactulose. The nurse is aware that the ratio for the order of lactulose is : A. To lower the blood glucose level B. To lower the uric acid level C. To lower ammonia level D. To lower the creatinine level
C. To lower ammonia level why? Lactulose is administered to the client with cirrhosis to lower ammonia levels.
When the spinal cord injury is at level of _____ to _____ the patient will be a quadriplegic.
C1 to C8
What would you do if the client had an increasing temperature and was to get blood?
Call the MD because blood is often held with an elevated temperature
What would you do if the client complains of flank pain (back pain) after hysterectomy?
Call the MD, probably had a ureter tied off accidentally in surgery
What type of oral/esophageal infections do AIDS patients get?
Candida
Pulmonary embolus is an obstruction of the pulmonary ______ bed by a dislodged _______ or foreign substance.
Capillary, thrombus
Pulmonary edema is a common complication of ______disorders.
Cardiovascular
Which information should be given to the client taking phenytoin (Dilantin)? A. Taking the medication with meals will increase its effectiveness. B. The medication can cause sleep disturbances C. More frequent dental appointments will be needed for special gum care. D. The medication decreases the effects of oral contra- ceptives.
C. More frequent dental appointments will be needed for special gum care. Gingival hyperplasia is a side effect of phenytoin. The client will need more frequent dental visits.
When 2 values are given in a blood pressue, the bottom number stands for the change in sounds or cessation of sounds?
Cessation of sounds
What must be done to the equipment before injecting by Z-track method?
Change the needle
What does blood-typing mean?
Check for surface antigen on the red blood cell
The nurse is assessing a client with heart failure who is taking prescribed hydrochlorothiazide (HydroDIURIL). The client states, "I do not know where I am. I don't feel good." The nurse should immediately review the results of which of the following laboratory tests? a. erythrocyte sedimentation rate (ESR) b. serum protein c. uric acid d. blood urea nitrogen (BUN)
D. A client who is on HydroDIURIL is at risk for renal dysfunction. The onset of confusion and malaise may indicate that the client has renal dysfunction. The nurse should immediately check the results of the client's BUN.
A 5 year old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery? A. Decreased appetite B. A low-grade fever C. Chest congestion D. Constant swallowing
D. Constant swallowing
A client with glomerulonephritis is placed on a low sodium diet. Which of the following snacks is suitable for the client with low sodium restritctions? A. Peanut butter cookies B. Grilled cheese sandwich C. Cottage cheese and fruit D. Fresh peach
D. Fresh peach why? The fresh peach is the lowest in sodium of these choices
The nurse is teaching the parent of a 4-hour-old, full term infant about feeding the infant. The parent has decided to only formula-feed the infant. Which of the following statements would be correct for the nurse to make? a. "Burp your infant often during the feeding." b. "The baby should sleep on the abdomen after eating." c. "Unopened cans of formula should be stored in the refrigerator." d. "You can prefill bottles with about two ounces of formula."
D. Principles of newborn feeding include filling the bottles with enough formula for each feeding, typically 2 to 3 ounces the first week of life; burping the infant after approximately 1/2 ounce of formula, placing the infant on the back after eating and storing unopened cans of formula in a cabinet.
Give three eye interventions for the client with Bell's Palsy.
Dark glasses, artificial tears, cover eye at night
Leaving a would open to air decease infection by eliminating what 3 environmental conditions?
Dark, warm, moist
What test CONFIRMS the presence of syphilis?
Dark-field illumination of the treponema palladium
Vasodilation will ____________ blood pressure.
Decrease
What do you do for dehiscence?
Decrease HOB (but not flat); cover with sterile gauze moistened with sterile saline, call MD
What do you do, in order, for evisceration?
Decrease HOB (but not flat); cover with sterile gauze moistened with sterile saline, call MD
**Acid Ash diet - ** Alk Ash diet-
Decrease pH (makes urine acid) Chz, eggs, Meat, fish, oysters, poultry, Bread, Cereal, Whole Grains, Pastries, Cranberries, Prunes, Plums, Tomatoes, Peas, Corn, Legumes.
Cushings clients will have (increased/decreased) resistance to infection.
Decreased
What are the top 2 nursing diagnoses for a client with CF?
Decreased airway clearance Alteration in nutrition or absorption
-pathy
Disease, suffering
What syndrome results when too much fluid is exchanged during hemodialysis too quickly?
Disequilibrium syndrome
What are the three principles to protect yourself from radiation hazard?
Distance Shielding Time
What will you see when you observe the neck of a client with CD of pregnancy?
Distended neck veins -JVD
What are the three most common drugs given to women with CD in pregnancy?
Diuretics Heparin Digitalis
Name the three groups of drugs used to treat CHF?
Diuretics Vasodilators Digitalis
What is a common side effect of mastoidectomy?
Dizziness (vertigo)
If ear medications are not given at room temperature the client may experience...
Dizziness, nausea
If the adult client's apical pulse is below 60, what should you do?
Do not give digitalis For a child don't give for a pulse under 70 For an infant don't give for a pulse under 90
Tetracycline
Do not give with milk products, do not give to pregnant women or children before age 8 or damage to tooth enamel occurs
What positions are okay after cataract surgery?
Do not lie on operative side; do not lie on back
Aphasia is most common if the stroke occurred in the (dominant/non-dominant) hemisphere of the brain.
Dominant
What is the first sign of pulmonary embolus?
Dyspnea
What are the four classic signs of pulmonary edema?
Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, coughing
Why is final repair of the palate delayed until 4 to 5 years?
Earlier surgery would interfere with tooth development.
What is the developmental task for later adulthood?
Ego Integrity vs. Despair
What is an MI?
Either a clot, spasm or plaque that blocks the coronary arteries causing loss of blood supply to the heart and myocardial cell death
Bed side rails should be up for the following individuals...
Elderly clients, unconscious, babies, young children, restless, confused
Clients on heparin should use an electric razor or safety razor?
Electric razor
Besides the Tensilon Test, what other diagnostic tests confirm a diagnosis of MG?
Electromylogram (EMG)
What cardiac enzymes indicate an MI?
Elevated CPK, LDH, SGOT (Serum glutamic oxaloacetic transaminase)
Name the three types of CVA
Embolus Thrombus Hemorrhage
Generativity vs. Stagnation
Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service
How often should the neurovascular status of the extremities of a client in a Risser cast be measured? Fresh post-operatively?
Every 2 hours
For which type aphasia is careful listening and needs anticipation most useful?
Expressive
When the CVA client understands your question but can't respond verbally correctly, he is said to have ___________ aphasia.
Expressive
What is another name for Vitamin B-12?
Extrinsic factor
Liquid doses of medications should be prepared at _______level.
Eye
With which body part do you begin when bathing an infant?
Eyes always
What unusual post-operative complication can result from mastoidectomy?
Facial nerve paralysis due to accidental damage during surgery (law suit time!)
What is meant by decompensation?
Failure of the heart to maintain adequate circulation.
The mother's insulin requirements will (fall/rise) markedly after delivery.
Fall
In the diuretic phase, K+ levels fall or rise?
Fall- remember diuresis always causes hypokalemia
Family history of liver disease increases the risk of heart disease. (T/F)
False
When using restraints with clients who object, don't forget about _____- _____.
False imprisonment
Pillows are sterilized between uses. (T/F)
False just cleaned
It is safe practice to recap needles after injection. (T/F)
False, Never re-cap
The best way to prevent thrombophlebitis is TED hose. (T/F)
False, ambulation/exercise are the best ways.
Strict sterile technique is required when administering a drug per rectum. (T/F)
False, clean or medical asepsis
The best way to decrease nosocomial infection is sterile technique. (T/F)
False, hand washing is the best way.
Pneumonia is only caused by bacteria. (T/F) False, it can be caused by viruses and aspiration.
False, it can be caused by viruses and aspiration.
You may use friction to remove vernix caseosa from an infant's skin. (T/F)
False, it causes damage/bruising
Aging decreases the risk of hypertension. (T/F)
False, it increases the risk
A major disadvantage of PCA pump is that the client can take too much medication. (T/F)
False, it is not possible for the client to overdose due to the lock-out feature
When putting on the second of a set of sterile gloves, you should grasp the cuff. (T/F)
False, reach under the cuff with the tip of the gloved fingers.
The mother with mastitis should stop breast feeding. (T/F)
False, the mother must keep breast feeding. (Offer unaffected breast first)
The CVA patient should be turned onto his paralyzed side no longer than 2 hours. (T/F)
False, the patient should not be on their paralyzed side for more than 20 minutes
When PD is being used the client must be on heparin. (T/F)
False, you do not need to be heparinized for peritoneal, but you do need to be heparinized for hemodialysis
To prevent urinary incontinence; the CVA patient should be catheterized. (T/F)
False- remember incontinence will never be allowed as a reason for catheterization
Vitamins and minerals provide energy for the body. (T/F)
False- they are necessary for a body's chemical reactions.
ROM exercises should occur every 2 hours in CVA patients. (T/F)
False-- every 4 hours or 3 times a day is enough
Strict aseptic techniques is required when administering a vaginal medication. (T/F)
False-- only "clean" technique or medical asepsis is necessary
The client should remain supine for 5 minutes after having received a rectal suppository. (T/F)
False-- they should be lying on their side for 5 minutes, not supine
Post-menopausal females have a lower risk of heart disease than males aged 25-40. (T/F)
False. They have a higher risk.
What is the appearance of the stool in a client with CF? remember the 4 Fs
Fat Frothy Foul-smelling Floating Steatorrhea
The symptoms of sensory overload and sensory deprivation are...
Fear, panic, depression, inability to concentrate, restlessness, agitation
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a ventricular rate of 150 beats/min. The nurse should next assess the client for which finding?
Hypotension The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/min is at risk for low cardiac output owing to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
What medical intervention is necessary in pyelonephritis?
IV antibiotics for one to two weeks, must get urine culture 2 weeks after antibiotic therapy is over
Will the post prostectomy patient be impotent?
If TURP, no impotence, if perineal prostatectomy, yes impotence
When the client asks about the use of glassess or contacts after cataract surgery what would you say?
If an introcular lens is implanted they will NOT need glasses. If no lens is implanted, then contacts will be fitted for 3 months post-op, temporary thick glasses given immediately but will get a different prescription in 2 to 3 months
How should a nurse carry soiled linen?
In a neat bundle held away from the body.
Can ice packs to the scalp prevent chemotherapy alopecia?
In some cases, yes
When is infant hypoglycemia most likely to occur during labor and delivery?
In the hours immediately following delivery
When you are not at the bedside the bed should always be...
In the lowest position
What are the dietary modifications for the diuretic phase of acute renal failure?
Increased carbohydrates, increased protein. Moderate potassium & sodium. (May need to increase fluids in diuresis results in dehydration.)
What force causes the pulmonary edema in left ventricular failure?
Increased hydrostatic pressure in the pulmonary capillaries
Celiac's disease is a __________ disease
Malabsorption
Who is at higher risk for suicide, a man or a woman?
Man
Can drugs be piggybacked into central --TPN?
No, use another lumen.
What would you do if you noticed a small amount of blood come out in the first few bottles that were infused?
Nothing, this is normal: the blood is due to the initial puncture of the abdomen
Severe cases of Respiratory Distress Syndrome requires ventilation with _________.
PEEP (Positive end expiratory pressure) & CPAP. (Continuous positive airway pressure), to keep alveoli open while on the ventilator. High frequency jet ventilation is sometimes used.
How would you palpate the uterus to see if the eclamptic woman was having contractions?
Place the hand flat on the abdomen over the fundus with fingers apart and press lightly
If you see an increase in blood content of urine coming out of the catheter, you would first ___________.
Pull carefully on the catheter to apply local pressure on the prostate with the Foley balloon.
If the nurse accidentally runs the IVs at the shock phase rate during the diuretic phase the patient will experience?
Pulmonary edema
The most common complication of deep vein thrombosis _______ ________.
Pulmonary embolism
The best way to ensure effectiveness of a rectal suppository is to...
Push the suppository against the wall of the rectum
How often should you measure the vital signs, vaginal bleeding, fetal heart rate during Abruptio Placenta>?
Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress
For which type of aphasia are slow, short, simple directions most useful?
Receptive
What would you do if the client had any one of the following after cystoscopy: bladder spasm, burning, frequency?
Record it but no need to call the MD
At what time of year does rheumatoid arthritis flare up?
Spring
How should a client's toenails be trimmed?
Straight across
When do you need goggles with AIDS?
Suctioning, central line start, arterial procedures
The nurse is assessing a client who had a closed liver biopsy. The nurse should understand that the client is at increased risk for a. altered peripheral tissue perfusion b. sensory-perceptual alteration c. altered urinary elimination d. ineffective airway clearance
The correct answer is A. A client who had a liver biopsy is at risk for hemorrhage. Altered peripheral tissue perfusion is the nursing diagnosis associated with hemorrhage.
The home health nurse is checking an adult client who is receiving small-bore nasogastric (NG) tube feedings. The nurse should immediately report that the client has a. a dry cough b. hypoactive bowel sounds c. nasal crusting d. pale yellow urine
The correct answer is A. A client who is receiving a NG feeding is at risk for aspiration pneumonia which may be indicated by the presence of a dry cough. Hypoactive bowel sounds do not require immediate action.
The nurse is assessing a 7-day-old, full term infant who is breastfeeding. Which of the following observations should the nurse recognize as normal? a. The infant's weight is equal to the birth weight. b. The infant's conjunctivae are pale. c. The infant does not turn the head when the face is stroked. d. The infant has a bald spot over the occiput.
The correct answer is A. A full term infant who is breastfeeding typically regains weight and by one week is at the birth weight. A bald spot over the occiput may indicate child maltreatment associated with leaving the child supine in the crib for prolonged periods of time.
What is the most challenging aspect of combination of drug therapy for HIV disease?
The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used.
Of first, second and third degree burns which has less pain? Why?
Third degree burns, nerve damage has occured
What is another name for Buerger's disease?
Thromboangiitis obliterans Which extremities are affected by it? Lower only
What solution is put onto the skin to protect it from the irritating effects of the tape?
Tincture of benzoin
What solution should be used on the skin where the brace rubs?
Tincture of benzoin or alcohol,no lotions of ointments-you want to toughen the skin not soften it
Why is morphine given to clients with pulmonary edema?
To decrease apprehension and decrease preload, this rests the heart
Why is digitalis given to women with CD of pregnancy?
To increase the strength of the heart and to decrease the rate, rest the heart while making it more efficient
Contaminate (Define)
To make something unclean or unsterile
What is the purpose of a Logan Bow?
To prevent stress on the suture line
How is the catheter taped in a male client?
To the lateral thigh or abdomen
To remove tape always pull (toward/away) from the wound.
Toward (this way you don't put pressure/pull on the suture line.)
-atresia
absence of a normal body opening; occlusion; closure
When a woman is hospitalized for severe pre-eclampsia the nurse should test...
#1 reflexes, the urine for protein
a healthy 18 y/o is entering college in the fall. Which immunization would the health care provider recommend prior to college? SATA
-human papillomavirus HPV -Tdap -meningococcal conjugate vaccine -seasonal influenza vaccine
What ending do anticholinesterases have?
-stigmine
The total apgar score can range from
0 to 10
During menstruation, the average daily loss of iron is _____ mg.
0.5 to 1.0 mg
If a child swallows a potentially poisonous substance, what should be done first?
call medical help
If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours?
check the distal extremity (far from center) for color, temperature, pain and PULSE, also MUST document
Baclofen causes (constipation/diarrhea)
constipation
Anorexics are usually __________ under the age of _____.
females, 25
Early stage hepatitis often looks like the _______.
flu
Should fluids be forced or restricted in BPH?
forced
The man with BPH has a _________-stream of urine
forked
An aneurysm can result from an _____________ and from ____________.
infection, syphilis
During pregnancy what complications is most dangerous for the fetus of a diabetic?
ketosis
What is the common name for pediculosis?
lice
Should CSF contain blood?
no
Should a client who is having breathing problems receive PD?
no
Should the drainage bag ever touch the floor?
no
When men get MG they are usually old or young?
old
Before the client with suspected appendicitis sees the physician what should be avoided?
pain meds, enemas, laxatives, food! NPO
If after a right BKA, the client c/o pain in his right tow, he is experiencing _____________.
phantom limb sensation (which is normal)
Bleomycin
pulmonary fibrosis
What is a hysterectomy?
removal of the uterus, cervix, fallopian tubes, ovaries, and other structures
How much suction should be used for an adult?
120 to 150 mm Hg
What is the normal adult blood pressure?
120/80 mmHg
How many days after ovulation does menstruation begin?
14 days
Apendicitis occurs most in what age group?
15 to 35
If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use?
18 (in preparation to give blood if necessary)
1 YEAR OLD SHOULD BE BLE TO SAY 3 TO 5 WORDS
18 month old should be able to say 10 or more words
In the rule of nines, the front trunk gets_____, the posterior trunk gets_____, each leg gets ______ and the genitalia gets________.
18%, 18%, 18%, 1%
While performing an admission assessment on a patient with type 2 diabetes, he tells you that he routinely drinks 3 beers a day. What is your priority follow-up question at this time? 1. "Do you have any days when you do not drink?" 2. "When during the day do you drink your beers?" 3. "Do you drink any other forms of alcohol?" 4. "Have you ever had a lipid profile completed?"
2. "When during the day do you drink your beers?" Alcohol has the potential for causing alcohol-induced hypoglycemia. It is important to know when the patient drinks alcohol and to teach the patient to ingest it shortly after meals to prevent this complication.
How is the bleeding of Abruptio Placenta different from that in placenta previa?
usually pain; bleeding is more voluminous in previa
What precaution must the nurse take when administering topical nitro paste?
wear gloves, nurse may get a dose of the med
intra-
within, inside, into
Are enemas common before a hysterectomy?
yes
Can cleft lip /palate babies sleep on their backs?
yes
How often do you measure vital signs during PD? Every 15 minutes during the first cycle and every hour
thereafter
People with sickle cell TRAIT only carry the disease,
they DO NOT have symptoms. (T/F) True-usually it has occurred that in times of SEVERE stress, the TRAIT does cause some symptoms but not usually.
Surfactant prevents the _________ of the alveoli.
to collapse
Clients with AIDS (gain/lose) weight?
to lose
What is the #1 treatment of CD during pregnancy?
to rest
Chancres disappear without treatment. (T/F)
true
Hormones of pregnancy work against insulin. (T/F)
true
Hypertension is often fatal if untreated. (T/F)
true
If the mother has an open abscess on her breast, must not breast-feed. (T/F)
true
Obesity increases the risk of hypertension. (T/F)
true
Sterile gloved hands must always be kept above the waist. (T/F)
true
T/F: AIDS patients get lymphomas?
true
-oma
tumor, swelling
a client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. within 1 hr of admission, the clients legs are numb all the way up to the hips. the nurse should do which of the following next? 1. call the family to come in to visit 2. notify the health care provider of the change 3. place resuscitation equipment in the clients room 4. check for advancing levels of paresthesia 5. have the client perform ankle pumps
2. notify the health care provider of the change 3. place resuscitation equipment in the clients room 4. check for advancing levels of paresthesia client has clinical manifestation of GUILLIAN BARRE SYNDROME (an autoimmune disease). family does not need to visit until client is stable.
the admitting nurse is making room assignments for a client admitted with aplastic anemia. the nurse appropriately selects which of the following room assignments for this client? 1. semiprivate room with strict hand washing 2. private room, protective isolation, and hepa filtration 3. semiprivate room with no special precautions 4. private room with ecg monitoring on a cardiac care unit
2. private room, protective isolation, and heparin filtration The aplastic anemia client has neutropenia and needs protection from other clients and staff. A private room with protective isolation and special air filtration is ideal.
which of the following is the best indicator of the dx of HIV? 1. ELISA 2. western blot
2. western blot the most definitive diagnostic tool is western blot. elisa is a SCREENING exam
An L/S ratio greater than _______indicates lung maturity.
2.0
When coumadin is therapeutic, the INR should be between _______ and _______.
2.0 and 3.0
Effective heparin therapy rises the PTT to approximately _______ times normal.
2.5
1 in
2.54 cm
What L/S ratio indicated fetal lung maturity?
2/1
The goal is for the infant to breast feed for __________ minutes per side.
20
What age group usually gets MS?
20 to 40
A CD4 count of under _______ is associated with the onset of opportunistic infections.
200
The preferred gauge of needle for injection for SQ injection___________.
25 gauge
In hypovolemic shock the output of urine will be less than _______cc per hour.
25 to 30 cc
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? 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.
3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. at this level of anxiety client is unable to process thoughts and feelings for problem solving
Pregnancy requires a __________ increase in the cardiac output.
30-50%
What is the simple formula for calculating fluid replacement needs in the first 24 hours?
3cc X Kg X % burned per day
1 tsp
4 to 5 cc
How long does the average dialysis last?
4 to 6 hours
How long must a woman wait before having intercourse after hysterectomy?
4 to 6 weeks
What sign would indicate the presence of thrombophlebitis?
A hard, red swelling in the posterior calf
The nurse is teaching a client with primary hypertension about methods to prevent hypokalemia since the client will start taking furosemide (Lasix) as prescribed. The nurse should advise the client that which of the following foods is highest in potassium per serving? a. dry milk b. dried beans c. apples d. strawberries
A. Dry milk is highest in potassium per serving of the foods listed.
The nurse has just received a change of shift report. Which client should the nurse assess first? A. A client 2 hours post-lobectomy with 150 cc drainage B. A client 2 days post-gastrectomy with scant drainage C. A client with pnuemonia with a oral temp of 102 F D. A client with a fractured hip in Bucks traction
A. A client 2 hours post-lobectomy with 150 cc drainage why? The first client to be seen is the one who recently returned from surgery.
The nurse is teaching a 50-year-old client about the scheduled screening colonoscopy. Which of the following statements would be correct for the nurse to make? a. "Before the test begins, an intravenous catheter will be placed into your arm." b. "You will be able to return home after the test is completed and you are able to urinate." c. "A full liquid diet is permitted the night before the test." d. "The test will be rescheduled if you have any rectal itching."
A. A client who is scheduled for a colonoscopy is advised that a intravenous catheter will be inserted before the test so that medications can be given as needed prior to and during the procedure. The client is discharged when fully awake and when the vital signs are stable.
The nurse is distributing between-meal snacks to several clients. Which of the following snacks would be best for the nurse to offer each client? a. fresh vegetable sticks to a client with a white blood cell (WBC) count of 11,300/cu mm b. diced watermelon to a client with a hemoglobin (Hgb) level of 8.0 mEq/L c. graham crackers for a client with stomatitis d. plain gelatin to a client with end-stage renal disease (ESRD)
A. A client with an elevated WBC can eat fresh vegetables as a between-meal snack. Fresh fruit and vegetables would not be given if the client was immunosuppressed. A client with ESRD should receive high-quality proteins and calories to help maintain nitrogen balance.
When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain? A. A history of radiation treatment in the neck region B. A history of recent orthopedic surgery C. A history of minimal physical activity D. A history of the client's food intake
A. A history of radiation treatment in the neck region why? Previous radiation to the neck might have damaged parathyroid glands, which are located on the thyroid gland and interfered with calcium and phosphorus regulation.
Which action by the novice nurse indicates need for further teaching? A. A nurse fails to wear gloves to remove a dressing B. The nurse applies the oxygen saturation monitor to the earlobe C. The nurse elevates the head of the bed to check blood pressure D. The nurse places the extremity to a dependent position to acquire a peripheral blood sample
A. A nurse fails to wear gloves to remove a dressing why? The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction
What is the most common retinoid given to people with acne?
Accutane
For the client with calcium nephrolithiasis the diet should be _________ash.
Acid
What unusual nursing diagnosis is high priority in pemphigus?
Alteration in fluid and electrolyte balance
Should steroids be given with meals?
Always
Define Meniere's Disease
An increase in endolymph in the inner ear, causing severe vertigo.
Which pressure is most damaging, an increased (systolic/diastolic)?
An increased diastolic
How long does an ovarian cycle last?
Average of 28 days
When applying restraints remember to...
Avoid bruising skin, cutting off circulation, accidental entangling
What drug is use to treat bladder spasm?
B&O suppositories (Belladonna & Opiates)
a nurse on a medical unit receives report at 0700 from the previous shift's nurses and is assigned a group of clients. In which order should the nurse attend these clients ?
B) A client who was given OJ at 0630 for a blood glucose of 45 mg/dl c) a client who is prescribed Regular insulin before 0800 breakfast tray d) a client who is scheduled for IV CEPHALOZIN at 0900 E) a client who missed s scheduled dressing change on his central line at 0600 due to staff's time constraints a) a client who needs education about using a metered-dose inhaler
The nurse employed in the ER is responsible for triage for 4 clients injured in a motor vehicle accident. Which of the following clients should receive priority in care? A. A 10 year old with lacerations to the face B. A 15 year old with sternal bruising C. A 34 year old with fractured femur D. A 50 year old with dislocation of the elbow
B. A 15 year old with sternal bruising why? The teenager with sternal bruising might be experiencing airway and oxygenation problems and, thus, should be seen first.
An older adult with a hx of heart failure is admitted to the ED with pulmonary edema. On admission which of the following should the nurse asses first? 1. BP 4. urine output
BLOOD PRESSURE it is a priority to assess BP first b/c people with pulmonary edema typically experience severe HTN that requires early intervention.
Which artery is most commonly used to measure blood pressure?
Brachial
What four organs does hypertension affect the most?
Brain (stroke) Eyes (blindness) Heart (MI) Kidney (renal failure)
Define contusion.
Bruise (internal)
The Cushings syndrome patient will have a _________ on their upper back.
Buffalo hump
Sulfamyon cream__________.
Burns
Which is the best method for identifying clients accurately?
By ID name-band
How should drugs that stain teeth be administered?
By a straw
The MORE colon is removed the more _________ the stool.
By the 3rd to 4th day, they should be looking at it and asking questions by day 2.
The child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy? A. "She is very irritable lately." B. "She sleeps quite a bit of the time." C. "Her gums look too big for her teeth." D. "She has gained about 10 pounds in the last 6 months."
C. "Her gums look too big for her teeth."
The nurse has reinforced teaching with a client with bacterial conjunctivitis. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I need to sleep in a different bed than my spouse until this infection resolves." b. "I can wear my contact lenses after twenty-four hours of treatment." c. "I should clean my eyes using a different section of my washcloth for each eye." d. "I will rest in bed until the redness is gone."
C. A client with bacterial conjunctivitis needs to know methods to control the infection. This includes wiping each eye with a separate section of a washcloth to help prevent cross-contamination. Contact lenses should not be worn until the infection is resolved (typically after 7 days).
Which test is the best indicator of the progress of HIV disease?
CD4 count
Of CPK and LDH which rises earliest?
CPK
What other things are appropriate after a reaction?
Call MD, get a blood sample, get urine sample, monitor vitals, send blood to lab
Name the two most common dietary prescriptions used to treat hypertension?
Calorie reduction for weight loss Sodium restriction
Name the 3 most common reasons for a colostomy.
Cancer Diverticulitis Ulcerative Colitis
Increasing dietary fiber lowers the risk of ___________ of the __________.
Cancer, colon
Name the 5 criteria that are recorded on an apgar scale
Cardiac status, respiratory effort, muscle tone, neuromuscular irritability, and color
The client's skin will be _____, ______, and ________.
Cool, pale, clammy (due to arterial constriction to shunt blood from skin to vital organs)
What test identifies Rh factor?
Coombs test detects antibodies to Rh
What is the most common complication of malpositioned lenses in the comatose or confused patient?
Corneal ulceration
A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving? A. "My sister still has episodes of crying and it's been 3 months since daddy died." B. "Sally seems to have forgotten the bad things that daddy did in his lifetime." C. "She really had a hard time after daddy's funeral. She said that she had a sense of longing." D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened."
D. "Sally has not been sad at all by daddy's death. She acts like nothing has happened at all." why? Abnormal grieving is exhibited by a lack of feeling sad; if the client's sister appears not to grieve, it might be abnormal grieving. This family member might be suppressing feelings of grief.
Which of the following roommates would be best for the client with gastric resection? A. A client with Chron's disease B. A client with pneuomia C. A client with gastritis D. A client with phlebitis
D. A client with phlebitis why? The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious.
The physician has order that the client's medication be administered intrathecally. The nurse is aware that the medications will be administered by which method? A. Intravenously B. Rectally C. Intramuscularly D. Into the cerebrospinal fluid
D. Into the cerebrospinal fluid why? Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections.
What is the #1 cause of maternal death in CD of pregnancy?
Decompensation
Shock will ___________ blood pressure.
Decrease
What will the abdomen of clients with celiac's disease look like?
Distended with flatus
What class of drugs is used to first treat hypertension?
Diuretics
MG affects men more than women. (T/F)
False, affects women more than men
The severe muscle weakness of MG gets better with exercise. (T/F)
False, it is worse with activity
The eye should be irrigated so that the solution flows from outer to inner canthus. (T/F)
False, it must flow from inner canthus to outer (alphabetical: I to O)
Respiratory Distress Syndrome occurs in full-term infants. (T/F)
False, it occurs in premature infants
If insulin is used, the dose is the same in all 3 trimesters. (T/F)
False, it varies
Clients on PCA pumps use more medication than those receiving IM injections. (T/F)
False, they use less
What vitamins need to be replaced in CF?
Fat soluble in water soluble form -- A,D,E,K
With what solution should the client with chemotherapeutic stomatitis rinse pc (after meals)?
H2O2 - hydrogen peroxide
If the dialysate does not drain out well, you would first...
Have them turn side to side
What does bacteriocidal mean?
Having the capability to kill bacteria.
What does bacteriostatic mean?
Having the capability to stop growth of the bacteria
Define cataract
Opacity of the crystalline lens
What are the #1 and #2 causes of sickle cell crisis?
Hypoxia, dehydration
Pneumonia is an ______ in the ______ of the ______. Infection, alveoli, lungs
Infection, alveoli, lungs
What is the name of the RLQ abd pain where appendicitis pain finally localizes?
McBirney's point
What is mastoiditis?
Inflammation/infection of the mastoid process
What time of day can be particularly dangerous for the Parkinson's patient?
Mealtime, due to choking
Client in labor admits to using alcohol throughout pregnancy. The most recent use was the day before. Based on the pt history, the nurse should give priority to assessing the newborn for: A respiratory depression B wide set eyes C jitteriness D low set ears
JITTERINESS If the pt's last intake of alcohol was less than 24 hrs then we would go with respiratory. But bc it's more than 24 hours the baby is starting to go through withdrawals
-rhapy; -rrhapy
Joining in a seam, suturation
a client undergoes laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?
KEEP THE STOMA MOIST such as by applying a thin layer of petroleum jelly around the edges, b/c a dry stoma may become irritated.
Late syphilis attacks which 3 body organs?
Liver, heart, brain
Oral medications have a (faster/slower) onset of action that IM drugs.
Longer
What is hemianopsia?
Not being able to see one half of the field of vision.
e-; ex-
Out from, away from, outside
What is the classic symptom of Placenta Previa?
Painless 3rd trimester bleeding (hint: Painless Placenta Previa)
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.
Palpate the uterus frequently. oxytocin stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus
Which age group(s) are most likely to experience PIH?
Patients under 18 and over 35
What exercises should the post prostectomy patient do upon discharge? Why?
Perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op
Vincristine
Peripheral neuropathy (foot drop, numbness and tingling, hoarseness, jaw pain) constipation (adynamic ileus due to neurotoxicity)
Cisplatin
Peripheral neuropathy, constipation, ototoxicity
What is the most common complication of appendicitis?
Peritonitis
What visual symptom will the patient with meningitis have?
Photophobia (over-sensitivity to light)
A father express concern that his 3 day old infant is yellow.What information is the PN needs to provide
Physiologic jaundice occur with normal reduction in RBC
What is the classic motor manifestation of Parkinson's?
Pill-rolling and tremors
What chemical is added to the bath water of a client with pemphigus?
Potassium permanganate
Is vomiting projectile or non-projectile in patients with pyloric stenosis? Is the vomiting bile-stained or not bile-stained?
Projectile, not bile-stained
How often should central line dressings be changed?
QOD- every other day
A first degree burn is pale or red?
Red
A second-degree burn is pale or red?
Red
What are the instructions given to clients recovering from hyperemesis gravidarum in relation to mealtime?
Remain seated upright for 45 minutes after each meal
What are the signs and symptoms of a hemolytic transfusion reaction?
Shivering, HA, low back pain, increased pulse & respirations, decreasing BP, oliguria, hematuria
What are the 3 complications of placenta previa?
Shock Maternal death Fetal death
If the fallopian tube ruptures due to ectopic pregnancy, nursing care is the same as that for___________.
Shock and peritonitis
What safety measures should be followed with Meniere's?
Side rails up x 4, ambulate only with assistance
para-
Similar, beside
What is the surgery for mastoiditis called?
Simple or radical mastoidectomy
Silver nitrate cream___________ the ________.
Stains, skin
What is systole?
The MAXIMAL force of blood on artery walls
The nurse is preparing to administer enoxaparin (Lovenox) as prescribed to a client. Which of the following actions would be appropriate for the nurse to take? a. Check the client's activated partial thromboplastin time (APTT) before giving the Lovenox. b. Inject the Lovenox at a 90 degree angle into the client's abdomen. c. Pull the plunger on the syringe backward to check for blood before injecting the Lovenox. d. Verify the client's current weight.
The correct answer is B. Lovenox is injected either at a 45 or 90 degree angle into the client's abdomen. The APTT is not routinely monitored when Lovenox is administered.
Several clients have asked the nurse for a between-meal snack. The nurse should offer the client with a. lactose intolerance a milk shake b. diabetes mellitus a frozen fruit bar c. hyperthyroidism a liquid nutritional supplement d. moderate dysphagia a cup of diced fruit
The correct answer is C. A client with hyperthyroidism is expending extra energy with high levels of activity. A liquid nutritional supplement would be appropriate to provide nutrients to help prevent weight loss.
Elastic stockings should be removed for the bath. (T/F)
True
Family history of diabetes increases the risk fo heart disease. (T/F)
True
In general, males have a higher risk of heart disease than females. (T/F)
True
In general, the nurse should wear gloves when applying skin preparations such as lotions. (T/F)
True
Is it permissible to give lidocaine viscous ac (before meals) if the patient has chemotherapeutic stomatosis? (T/F)
True
MS can lead to impotence in males. (T/F)
True
MS can lead to urinary incontinence. (T/F)
True
PCA pumps allow a more constant level of serum drug than conventional analgesia. (T/F)
True
Preschoolers may require physical restraint during painful procedures. (T/F)
True
Rectal suppositories with an oil base should be kept refrigerated. (T/F)
True
Routine exercise decreases the risk of heart disease. (T/F)
True
Spinal cord injuries are more common in males. (T/F)
True
Surgical aseptic techniques render and keep articles free from all organisms. (T/F)
True
Syphilis is a fatal disease if untreated. (T/F)
True
Syphilis is sexually transmiteed. (T/F)
True
The hair loss due to chemotherapy is usually temporary? (T/F)
True
Toddlers may require physical restraint for painful procedures. (T/F)
True
You must never turn your back to a sterile field. (T/F)
True
Subcutaneous injection must be given at 45 degrees. (T/F)
True (for boards), false- whatever angle gets it SQ without going IM
It is common practice to regard the edges of any sterile field as contaminated. (T/F)
True, the outer 1 inch is considered contaminated. You must not touch it with your sterile gloves.
Oral hypoglycemics should never be used during pregnancy. (T/F)
True, they cause birth defects (teratogenic)
Increasing fluids to over 3000 cc per day is more effective in treating renal calculi ( kidney stones) than any dietary modification. (T/F)
True. It's more important to flush the urinary tract than worry about what you're eating.
Accurate blood pressure is obtained by using a cuff that has width of __________ of the arm.
Two-thirds
What blood test must be done before a transfusion?
Type and cross match
What is the most common problem due to catheterization?
UTI
What is the best and safest way to confirm placenta previa?
Ultrasound
When a patient is in a Buck's traction they may turn to the _________ side.
Unaffected
The client is (awake/under local anesthesia/under general anesthesia) during ECT?
Under general anesthesia -- must be artificially ventilated
Insight means the ability of the patient to ________his problem.
Understand
Are migraine headaches usually unilateral or bilateral?
Unilateral
What is the most common sign of fallopian tube ectopic pregnancy?
Unilateral pelvic pain
How long will the patient with meningitis be on these precautions?
Until they have been on an antibiotic for 48 hours
In hemophilia, the PTT is (up/down), the coagulation or clotting time is (up/down) and the platelet count is (up/down).
Up (increased or longer) Up (increased or longer) Neither (hemophilia does not affect platelets)
To straighten the ear canal in the ADULT, the nurse should pull the pinna______ and ________.
Up and back
Due to increased destruction of RBC's seen in polycythemia vera what blood level will be increased?
Uric acid levels will be high (remember - uric acid levels are always high when cells are being destroyed as in hemolysis, chemotherapy or radiation therapy)
Give three appropriate indications for bladder catheterization?
Urinary retention, to check for residual, to monitor hourly output
What is conservation? In what stage does it develop?
When the child realized that number, weight, volume remain the same even when outward appearances change; Concrete Operational
When will the artificial airway be removed in the recovery room?
When the gag reflex returns
What does self-disclosure mean?
When the nurse tells the patient personal information about self.
What is the icteric stage?
When the patient exhibits jaundice.
By what day post-op should the client begin to take care of their own stoma?
When they do their own stoma care
Do you give anticholestinerases with or without food?
With food, about 1/2 hour ac; giving ac helps strengthen muscles of swallowing
When should the child with CF take his pancreatin/viokase/pancreas?
With meals, so it is in the gut while the food is present, the whole purpose is to increase absorption of ingested food.
Does Meniere's occur more in men or women?
Women
Multigravida
a woman who has had two or more pregnancies
primigravida
a woman who is pregnant for the first time
When a client voices embarrassment over the noises that their colostomy makes on the first post-op day, what would you say?
The noise will go away in a few days to a week.
If a patient has MG, what will be the results of the Tensilon Test?
The patient will show a dramatic sudden increase in muscle strength
What is phlebotomy?
The process of drawing blood Drain off 200-500 cc of blood from body (opposite of transfusion).
What is the purpose of restricting activity after spinal tap?
To prevent headache due to CSF loss
What is the reason for giving post MI patients ASA?
To prevent platelets from forming clots in the coronary arteries
What is the major objective in caring for a client after surgical cataract removal?
To prevent pressure in or on the eyes
Fibromatosis
also called desmoids tumor -> soft tissue tumor composed of proliferating fibroblast -> histologically appear benign -> invade locally but do not metastasize
What is the apgar scale?
appearance, pulse, grimace, activity, respiration quick objective way to evaluate the vital functions of the newborn
Out from,
away from, outside
What does BKA mean?
below knee amputation
inter-
between, among
-desis
binding, fixation (of a bone or joint)
When the AIDS patient has a low platelet count, what is indicated?
bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions
On what do lice feed?
blood
-emia
blood condition
What is polycythemia vera?
blood disorder that results in uncontrolled RBC production causing hyperviscosity & hypercoagulation. Causes thick blood. A blood disease in which there is an increase in erythrocytes, leukocytes and platelets
What is the action of nitro?
dilates coronary arteries to increase blood supply (O2 supply) and reduces preload.
To prevent post-op swelling, the stump should be __________.
elevated
-ase
forms names of enzymes
septicemia
growth of bacteria in the blood
What do caffeine and smoking do to blood pressure?
increase it
IN BPH the man has (increased/decreased) frequency of urination
increased
In Cushings the blood sugar is (increased/decreased).
increased
In Cushings the sodium level is (increased/decreased)
increased
Kaposi's sarcoma
malignant tumor of the blood vessels associated with AIDS
Cushings Man aka Cush Man
moon face with infection buffalo hump on back big trunk thin extremities loses potassium keeps glucose and salt has striations on abdomen and breasts
ec-
out, outside, outer,out of
Hyper-reflexia
overactive reflexes
To test amniotic fluid the nurse should check the ________ of the fluid.
pH
Who is the most common subjective symptoms of shingles?
pain
The chancres of syphilis are (painful/painless).
painless
Colostomies performed for cancer tend to be (temporary/permanent).
permanent
In a double-barrel colostomy, from which stoma (barrel) will the stool come out?
proximal
-gram; -graphy
recording, written record
by age 6 months, the infant should be able to roll over. sitting up without support also begins around
roll over. sitting up without support also begins around 6 months
Tht PN assess a patient with poor self concept.What behaviors will the pt demonstrate?
scalation of anxiety
In later stages of hepatitis, the ______ turns dark.
urine
If a post-operative patient complains of gas and
cramping you should first _______ then ________. Assess then ambulate
-cis
cut, kill
What hormones are active during follicular phase?
FSH and Estrogen
What is meant by "cardiac decompensation"?
It means that the compensatory mechanisms - hypertrophy, dilation, tachycardia are not working and the heart has failed.
What does left sided CHF mean?
Left ventricle has decompensated
Pulmonary edema usually results from ______ failure.
Left ventricular
What is the #1 treatment of cast syndrome?
NPO and NG tube for decompression
What is the most important thing to remember about giving Mestinon and other anticholestinerases?
They must be given EXACTLY ON TIME; at home, they might need to set their alarm
Do people recover from AGN?
Yes, the vast majority of all clients recover completely from it
Which 2 classes of drugs are given in combination for HIV sero-positivity?
NRTI's (nucleoside reverse transcriptease inhibitors) and PI's (protease inhibitors) They prevent viral replication.
What does stenosis mean?
Narrowed
following the acute stage of diverticulosis which foods should the nurse encourage a client to incorporate into the diet?
-BRAN CEREAL -BROCCOLI -NAVY BEANS are encourage to eat a high fiber diet
In the emergent phase do you cover burns? (in the field)
Yes, with anything clean and dry.
What instructions do you give to a client taking tetracycline?
Take it on an empty stomach and avoid the sunlight (photosensitivity)
Which medication order for a client with a pulmonary embolism is most important to clarify with the prescribing physician before administration? 1. Warfarin (Coumadin) 1.0 mg by mouth (PO) 2. Morphine sulfate 2 to 4 mg IV 3. Cephalexin (Keflex) 250 mg PO 4. Heparin infusion at 900 units/h
1. Warfarin (Coumadin) 1.0 mg by mouth (PO) Rationale: The Institute for Safe Medication Practices (ISMP) guidelines indicate that the use of a trailing zero is not appropriate when writing medication orders because the order can easily be mistaken for a larger dose (in this case, 10 mg). The order should be clarified before administration. The other orders are appropriate, based on the client's diagnosis.
Is it possible to have only one: cleft lip or cleft palate?
Yes, you can have one or or the other or both
a nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an IV line that is supplying hydration and antibiotics. the client has a vest restraint and bilateral soft wrist restraints. Which nursing actions would be appropriate? SATA 1. perform face to face evaluation every hour 2. tie the restraints in quick-release knots 3. tie the restraints to the side rails of the bed 4. document the client's condition 5. document alternative methods used before the restraints were applied 6. document the client's response to the intervention
1. perform face to face evaluation every hour 2. tie the restraints in quick-release knots 4. document the client's condition 5. document alternative methods used before the restraints were applied 6. document the client's response to the intervention restraints should never be secured to side rails b/c doing so can cause injury is the side rail is lowered without untying the restraint.
Mastitis is accompanied by a fever over _________.
102 degrees
Vricella vaccine is given around
12 to 15 mo
If an AIDS patient's blood contaminates a counter top, with what di you clean?
1:10 solution of bleach and water
The maximum score and infant can receive on any one of the criteria is
2
How many nurses are requried to check the blood?
2 nurses
How long does the fluid mobilization or diuretic phase of a burn last?
2 to 5 days
If mastitis occurs 1+ weeks after delivery, when does breast engorgement occur?
2 to 5 days after delivery
At what age are accidental poisonings most common?
2 years old
The nurse is caring for a client with Cushing's syndrome the nurse should carefully assess the client for signs of? 1. Hypoglycemia 2. Infection 3. Hypovolemia 4. Hyperinsulinemia
2. Infection clients with cushings syndrome have an increase in cortisol levels that predispose them to infection
A client who was diagnosed with type 1 diabetes mellitus 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. which finding is most likely to accompany this blood glucose level? 1. Cool, moist skin 2. Rapid, thready pulse 3. Arm and leg trembling 4. Slow, shallow respirations
2. Rapid, thready pulse (HYPERGLYCEMIA)= DEHYDRATION (HYPOVOLEMIC) the clients abnormally high blood glucose level indicates hyperglycemia, which typically causes Polyuria, polyphagia, and polydipsia. Because Polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as rapid, thready pulse, decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respiration--not slow, shallow ones--- are associated with hyperglycemia.
You can administer up to ____ cc of a drug per site by IM injection in adults.
3 cc
What test confirms the diagnoses of gestational diabetes?
3 hour glucose tolerance test
How often do clients with renal failure undergo dialysis?
3 times per week
How long does a lady have to wait before driving after a hysterectomy?
3 to 4 weeks
A client says to the nurse "I know that I'm going to die". which response by the nurse would be best? 1. "We have special equipment to monitor you and your problem." 2." Don't worry. We know what we're doing and you aren't going to die." 3. "Why do you think you're going to die?" 4. "Oh no, you're doing quite well considering your condition."
3. "Why do you think you're going to die?" the other answer choices offer false reassurance.
A client is in hypovolemic shock. The nurse position the client: 1. Supine 2. semi-Fowler's 3. Supine with the legs elevated 15 degrees 4. Trendelenburg
3. Supine with the legs elevated 15 degrees Brings peripheral blood into the central circulation
During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which symptom as typical of the disease? 1. Diarrhea 2. Hypermenorrhea 3. Abnormal bleeding 4. Abdominal distention
4. Abdominal distention abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.
The nurse learns that patients from a motor vehicle accident are being transferred to the emergency department (ED). The nurse performs triage in the ED. Which of the following patients should the nurse see FIRST? 1. A patient with ecchymosis and lacerations to the facial area. 2. A patient complaining of shortness of breath and pressure in the chest. 3. A patient with blood pressure of 90/60 and apical pulse of 120 bpm. 4. A patient complaining of dizziness and nervousness.
A PT WITH BP OF 90/60 AND APICAL PULSE OF 120 BPM. vital signs indicate shock; most unstable patient
What is pyelonephritis?
A bacterial infection of the kidneys
The connecting tube of a hearing aid can be cleansed with__________.
A pipe cleaner
What is meant by the term "double barrel" colostomy?
A procedure where the colon is cut and both ends are brought out onto the abdomen.
Disinfectant (Define)
A substance used to destroy pathogens but not necessarily their spores (in general not intended for use on persons)
Once the patient is admitted for attempted suicide should you ever discuss the attempt with them?
No, you should not focus on the attempt, focus on the present and future.
Should vomiting be induced after ingestion of gasoline?
No- not for gas or any other petroleum products
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: A. Take blood pressure, pulse, and temp B. Ask the client to rate his pain from 1-5 C. Watch the client's facial expression D. Ask the client if he is in pain
B. Ask the client to rate his pain from 1-5 why? The best way to evaluate pain levels is to ask the client to rate his pain on a scale.
In order to score a 0 on HR the infant must have a rate of _________.
Zero
A new nursing graduate indicates in charting enteries that he is a licensed practical nurse, although he has not received the results of the licensing exam. The graduate's actions can result in what type of charge? A. Fraud B. Tort C. Malpractice D. Negligence
A. Fraud why? Identifying oneself as a nurse without a license defrauds the public and can be prosecuted. A tort is a wrongful; malpractice is failing to act appropriately as a nurse or acting in a way that harm comes to the client; and negligence is failing to perform care.
A patient with chronic hepatitis is admitted to the hospital due to his declining status. The nurse assesses the patient and will most likely note: A. Muscle wasting B. Weight gain C. Reduced bleeding tendencies D. Increased axillary hair
A. Muscle wasting Chronic hepatitis will eventually cause extensive damage to the liver. The patient will often have muscle wasting, weakness, fatigue, weight loss, increased bleeding, decreased body hair, and peripheral edema
A 70 year old man who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggested of unilateral neglect? A. The client is observed by shaving only one side of his face B. The client is unable to distinguish between two tactile stimuli presented simultaneously C. The client is unable to complete a range a vision without turning his head side to side D. The client is unable to carry out cognitive and motor activity at the same time
A. The client is observed by shaving only one side of his face why? The client with unilateral neglect will neglect one side of the body
Should you assess for Homan's sign?
No. Homan's sign is no longer recommended as a test for thrombophlebitis because it can cause a clot to embolize
The meats that are second highest in cholesterol are the ___________
Shell seafood- shrimp, crab, lobster
A dry cast is dull or shiny?
Shiny
A second-degree burn is dull or shiny?
Shiny
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin? A. Cyanocobalamine B. Protamine sulfate C. Streptokinase D. Sodium warfarin t.
B. Protamine sulfate why? The antidote for heparin is protamine sulfate. Cyanocolbalamine is B12, Strptokinase is a thrombolytic, and sodium warfarin is an anticoagulan
What is the medical treatment for mastoiditis?
Systemic antibitoics
Sterile (Define)
An item on which all micro-organism have been destroyed
To prevent germs from getting into or out of a wound you should use what type of dressing?
An occlusive dressing
When 2 values are given in a blood pressure the first is the __________measurement.
Systolic
Beta blocker side effects
B- BRONCHOSPAMS E-Erectyle dysfunction T-temperature, cold extremities A-Alimentary ;GI effects B-bed,vivid dreams, nightmares E-Energy, hypoglycemia TA-temple achem headache
When pressure is auscultated the first sound heard is the ____________ measurement.
Systolic
The AIDS virus invades helper ____________.
T-lymphocytes (or CD4 cells)
The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement by the client indicates a need for follow-up after discharge? A."I live by myself." B." I have trouble seeing." C. "I have a cat in the house with me." D. " I usually drive myself to the doctor."
B. "I have trouble seeing" why? A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help.
The nurse is caring for a client with a diagnosis of Hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention? A. Suggest that the client take warm showers b.i.d. B. Add baby oil to the client's bath water C. Apply powder to the client's skin D. Suggest a hot water rinse after bathing.
B. Add baby oil to the client's bath water why? Oil can be applied to help with the dry skin and to decrease itching, so adding baby oil to bath water is soothing to the skin.
The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. which action should receive priority? A. starting an IV? B. Applying oxygen C.Obtaining blood gas D. Medicating the client foe pain
B. Applying oxygen why? the client with burns to the neck needs airway assessments and supplemental oxygen, so applying oxygen is priority. the next action should be to start an IV and medicate for pain.
The nurse in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients? A. Measure the amount of a client's residual urine after voiding B. Cleanse the perineal area of a client with urinary incontinence C. Insert a straight catheter to obtain a urine specimen for culture D. Provide catheter care for a client with a suprapubic catheter
B. Cleanse the perineal area of a client with urinary incontinence
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery? A. Hearing aid B. Contact lenses C. Wedding ring D. Artificial eye
B. Contact lenses why? It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended wear lenses.
The nurse is teaching a client about prescribed insulin lispro (Humalog). Which of the following statements would be correct for the nurse to make? a. "If you are nauseated, do not take this insulin until you are able to eat a meal." b. "This type of insulin can cause hypoglycemia within an hour." c. "This insulin normally looks cloudy." d. "If you need to change to an insulin pump, a different type of insulin will be required."
B. Humalog insulin peaks within an hour therefore this is the time interval that the client is at increased risk for hypoglycemia. Humalog insulin should be clear and should not be used if it is cloudy.
A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170 meq/L. What behavioral changes would be common for this client? A. Anger B. Mania C. Depression D. Pyschosis
B. Mania why? The client with serum sodium of 170 meq/L has hypernatrimia and might exhibit manic behvior.
What vitamin should patients on Levodopa avoid?
B6, pyridoxine - Vitamin B6 reduces the effectiveness of levodopa
When during the day should TED hose be applied?
Before the client gets out of bed
The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential? A. "You cannot eat food prepared in a microwave." B. "You should avoid moving the should on the side of the pacemaker site for 6 weeks." C. "You should use your cellphone on your right side." D. "You will not be able to fly on a commercial airliner with the defibrillator in place."
C. "You should use your cellphone on your right side." why? The client with an internal defibrilliator should learn to use any battery operated machinery on the opposite side. He should also take his pulse rate and report dizziness or fainting.
The physician has order sodium warfrin ( Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at: A. 0900 B. 1200 C. 1700 D. 2100
C. 1700 why? Sodium warfarin is administered in the late afternoon, at approximately 1700 hours. this allows for accurate bleeding times to be drawn in the morning.
The nurse if caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis? A. Foul breath B. Dysphagia C. Diarrhea D. Chronic hiccups
C. Diarrhea why? Diarrhea is not common in clients with mouth and throat cancer
The nursing is participating in a discharge teaching for the post-partal client. The nurse is aware that an effective means of managing discomfort associated with a episiotomy after discharge is: A. Promethazine B. Aspirin C. Sitz bath D. Ice bath
C. Sitz bath why? A sitz bath will help with swelling and improve healing
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis? A. "tell me about the pain" B."what does his vomit look like?" C." Describe his usual diet." D. " have you noticed changes in his adominal size?"
C." Describe his usual diet." why? The least-helpful questions are those describing his usual diet. A, B, and D are useful in determining the extent of disease process and thus, are incorrect
What will the nurse auscultate over the lungs when pulmonary edema occurs?
Crackles (rales)
Define laceration.
Cut
A client with cancer develops xerostomia. The nurse can help alleviate the discomfort associated with xerostomia by: A. Offering a hard candy B. Administering an analgesic medication C. Splinting swollen joints D. Providing saliva substitue
D. Providing saliva substitute why? Xerostomia is dry mouth, and offering the client a saliva substitute will help the most.
A third-degree burn is wet or dry?
Dry
When fluid accumulates in the abdomen during PD what problem does the client experience first?
Dyspnea - SOB or difficulty breathing, due to the inability of the diaphragm to descend
How often should the patient use the incentive spirometer?
Every 1-2 hours
How often are vital signs measured in hypovolemic shock?
Every 15 minutes
How often should mouth care be performed for those clients on oxygen?
Every 2 hours
How often should the CVA patient be turned or repositioned?
Every 2 hours
How often should the bedridden post-operative patient do leg exercises?
Every 2 hours
How often should the client cough and deep breath post-operatively?
Every 2 hours
How often should the nurse auscultate the lung sounds post-operatively?
Every 4 hours
What is the #1 contracture problem after BKA?
Flexion of the knee
DTIC- dome
Flu-like symptoms Chemo-therapeutic Agent Toxicities
Pulmonary edema is accumulation of _______in the lung.
Fluid
What is the #1 therapy in the shock phase?
Fluid replacement/resuscitation
Which two nutrients is breast milk lower in?
Fluoride and iron
Name the two phases of ovarian cycle.
Follicular phase (first 14 days) Luteal phase (second 14 days)
How long must the client receive treatment for pernicious anemia?
For the rest of life
What is the typical of the lesions of pemphigus?
Foul-smelling, blisters break easily, seen in the elderly, cause unknown
Name the symptoms that pyelonephritis and cystitis have in common?
Frequency, urgency, burning, cloudy, foul smelling urine
When does spinal shock occur?
Immediately or within 2 hours of injury
The #1 goal in emergency treatment of spinal cord injury is...
Immobilization of the spine
How fast does the dialysate usually flow into the peritoneum?
In 10 minutes
If the client absorbs too much of the dialysate the client will experience...
Increased blood pressure (circulatory overload)
Hypertension is an ________ or sustained elevation in the (systolic/diastolic) __________.
Intermittent, diastolic blood pressure
What is the developmental task for early adulthood?
Intimacy vs. Isolation
What factor do clients with pernicious anemia lack?
Intrinsic factor
What is the classic test for CF?
Iontophoresis - sweat test
Clients with celiac's disease do not absorb what mineral?
Iron
What occurs during the follicular phase of the ovarian cycle?
It accomplishes maturation of the graafian follicle which results in ovulation
When PROM occurs, the age of the fetus must be determined. The best way to assess lung maturity is to check the ________ ratio.
L/S (lecithin/sphingomyelin)
What lab test assesses the risk of Respiratory Distress Syndrome?
L/S ratio (Lecithin/Sphingomyelin ratio)
Drugs Used in Gestational HTN LAME AND LAZY
LA Labethanol ME Methyldopa ND Nifidipine LAZ Hydralazine
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. Crusting at the pin sites B. Loosening of the pins C. Tenting of skin at the pin sites D. Purulent drainage from the insertion sites E. Muscle spasms
LOOSENING OF THE PIN SITES TENTING OF THE SKIN PURULENT DRAINAGE FROM THE INSERTION SITES MUSCLE SPASMS
which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
LYING ON THE ABDOMEN WITH TOES POINTED INWARD this positioning promotes muscle relaxation
What is the surgery done for Meniere's?
Labyrinthectomy
Deep vein thrombosis is most common in what type of surgery?
Low abdominal or pelvic
What are the signs and symptoms of a febrile transfusion reaction?
Low back pain, shaking HA, increasing temperature, confusion, hemoptysis
Which of the following are signs of transfusion reaction? Bradycardia, Fever, Hives, Wheezing, Increased Blood Pressure, Low Back Pain
Low back pain, wheezing, fever, hives
What is the primary dietary prescription for calcium nephrolithiasis?
Low calcium diet
What type of diet will people with polycythemia vera be on?
Low iron
The primary diet treatment for uric acid nephrolithiasis is _________ -________.
Low pruine
What type of diet is this woman with a cesium implant on?
Low residue (decrease bowel motility )
What is the most severe complication of otitis media?
Meningitis or mastoiditis
Which acid-base disorder is MOST commonly associated with hypovolemic shock?
Metabolic acidosis (due to lactic acid accumulation- no oxygen = anaerobic metabolism)
When cancer spreads to a distant site it is called?
Metastasis
The client with uric acid nephrolithiasis should have a diet low in ___________.
Methionine
Aerobe (Define)
Micro-organisms requiring free oxygen to live
Anaerobe (Define)
Micro-organisms that do not require free oxygen to live
What part of the ear is involved in otitis media?
Middle ear
What should you tell a breast feeding mother about her milk supply when she goes home from the hospital?
Milk should come in postpartum day 3. Breastrfeed every 2-3 hours to establish good milk supply.
Name two foods high in methionine.
Milk, eggs
What type of brace is most commonly used for scoliosis?
Milwaukee
Patient's with Parkinson's have ______ speech.
Monotone
In spinal cord injury never ______ the neck.
Move, hyperextend
What is scanning?
Moving the head from side to side to see the whole field of vision.
Syphilis first infects the _____ ______.
Mucous membranes (mouth, vulvar)
Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________.
Multigravida, 35 (HTN, trauma, cocaine)
In whom is Placenta Previa most likely to occur? Primigravida's or multigravida's?
Multigravidas
What nutrient is lost in highest amounts during PD?
Protein
Of protein, fat, and carbohydrates, which ones (percent-wise) increase in the diet of gestational diabetics?
Protein, fat
What two lab tests monitor coumadin therapy?
Prothrombin time (PT) and the INR
What complication is common in CHF?
Pulmonary edema
What grains are allowed in a gluten-free diet?
Rice and corn
If the client has right homonymous hemaniopsia, the food on the ____ side of the tray may be ignored.
Right
Scoliosis in the thoracic spine is usually convex to the (left/right).
Right
If the patient has right hemiplegia, he cannot move his ____ ____ and ____ ____ and the stroke was on the _________ side of the brain.
Right arm and right leg, left
What does right sided CHF mean?
Right ventricle has decompensated Dependent Edema (legs and sacrum) Jugular venous distention Abdominal distention Hepatomegaly Splenomegaly Anorexia and nausea Weight gain Nocturnal diuresis Swelling of the fingers and hands Increased BP
What must the mother do after feeding the baby who has had cleft lip/palate repair?
Rinse the infant's/child's mouth with water
What type of cast is used post-operatively?
Risser cast
What is the permanent EKG change seen post MI?
ST wave changes
What major sense is affected most in MS (besides vision)?
Tactile (touch)-- they burn themselves easily
What do CF clients need to do (ingest) in hot weather?
Take NaCl tablets
Define dehiscense
Separation of the incisional edges
Hyperemesis Gravidarum is ______ and ________ vomiting that persists into the _____ trimester.
Severe and prolonged; 2nd trimester (normal vomiting should be gone before 2nd trimester)
What is the #1 symptom of an MI?
Severe chest pain unrelieved by rest and nitroglycerine
In eclamptic client what ominous sign almost always precedes a seizure?
Severe epigastric pain
The #1 sign of MG is ______ ______ _____.
Severe muscle weakness
What are the post-operative signs of hemorrhage into the eye?
Severe pain Restlessness
The inheritance patterns for hemophilia is:
Sex linked recessive
The first sign that a fallopian ectopic pregnancy had ruptured is...
Sharp abdominal pain
What equipment should be at the bedside of an MG patient?
Suction apparatus (for meals), tracheostomy/endotube (for ventilation)
The cause of RDS is a lack of _______.
Surfactant
What is the only IM given to a burn patient?
Tetanus toxoid- if they had a previous immunization; tetanus antitoxin- if they have never been immunized before (or immune globulin)
What is the antibiotic most commonly given to clients with acne?
Tetracycline
The home health nurse has reinforced teaching with a pregnant client who is starting heparin sodium as prescribed. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I should keep a medical alert with me at all times." b. "I can no longer eat green leafy vegetables." c. "I should purchase an electric toothbrush." d. "I must limit my intake of carbonated beverages."
The correct answer is A. A client who starts heparin sodium should carry a medical alert with them at all times in case of injury or bleeding. Food precautions exist with warfarin sodium and an electric razor is recommended.
The nurse is reinforcing teaching with a client recently diagnosed with gout. The nurse should encourage the client to minimize the intake of a. alcoholic beverages b. citrus juices c. dairy products d. processed foods
The correct answer is A. A client with gout should minimize the intake of alcoholic beverages that may exacerbate the pain.
Peritoneal Dialysis (PD)
The removal of wastes, electrolytes and fluids from the body using peritoneum as dialysis membrane
What organ will be enlarged in polycythemia vera?
The spleen, because it is destroying the excessive RBC's.
What does pre-icteric mean?
The stage BEFORE the patient exhibits jaundice.
How will you know the patient has entered the fluid mobilization or diuretic phase?
The urine output will increase
How is an infant delivered when Abruptio Placenta is present?
Usually C-section
Is otitis a disease of the adult or child?
Usually the child
Hemophilia A is a deficiency of Factor # __________.
VIII
The most common type of crisis that occurs is a ______-______ crisis.
Vaso-occlusive
Would vasodilators or vasoconstrictors treat hypertension?
Vasodilators (decreases resistance)
Micro-organisms grow best in a _______, _______, _______place.
Warm, dark, moist
If a unit of blood is infused through a central line it must be__________.
Warmed
Before allowing the dialysate to flow into the peritoneal cavity it must be _____ to _____ temperature.
Warmed, body
How warm should the irrigation solution be?
Warmer than body temperature, ie, 99-100F
The nurse makes a home visit for a client with an abdominal wound. When irrigating the draining wound with a sterile saline solution, which of the following sequences is MOST appropriate for the nurse to follow? 1. Pour the solution, wash hands, and remove the soiled dressing. 2. Wash hands, prepare the sterile field, and remove the soiled dressing. 3. Prepare the sterile field, put on sterile gloves, and remove the soiled dressing. 4. Remove the soiled dressing, flush the wound, and wash hands.
Wash hands, prepare the sterile field, and remove the soiled dressing
Hepatitis C
Watch those needles Incubates 2 to 23 weeks Transmitted by blood only No vaccine, immune globulin doesn't work
A sign of gestational diabetes is excessive (weight gain/weight loss)
Weight gain
What test/exam CONFIRMS the diagnosis of scoliosis?
X-rays of the spine
Can skin traction be removed for skin care?
Yes
Can the client turn side-to-side after a spinal tap?
Yes
what finding is associated with tay sachs disease ?
cherry red spots in the macula
What other disease is related to shingles?
chickenpox
How often should a stump be washed?
daily
Define leukopenia
decrease in wbc, indicated viral infection
In BPH the force of the urinary stream is (increased/decreased).
decreased
The child with the diagnosis of CF probably had a history of _________ ________ at birth.
Meconium ileus-- bowel obstruction due to the thickness of the stool.
In the menstrual cycle, day 1 is the day on which...
Menstrual discharge begins
What acid-base disorder is seen in the shock phase of a burn?
Metabolic Acidosis
If airway obstruction occurs at the accident site and you suspect spinal cord injury, what maneuver is used to open the airway?
Modified jaw thrust
Gestational diabetics tend to get ________ infections.
Monilial (yeast)
When do you need a mask with AIDS?
Not usually unless they have an infection caused by an airborne bug
Is dietary protein limited in AGN?
Not usually, however if there is severe azotemia then it may be restricted
(Obese/very thin) women are most likely to become diabetic during pregnancy.
Obese
In Cushings syndrome, the trunk is ________ and the extremities are _________.
Obese, thin
During bleeding into the joints you should
(mobilize/immobilize) the extremity. Immobilize to prevent dislodging the clots that do form.
What will be used to feed the infant after cleft lip repair?
A dropper/syringe with rubber tip to discourage sucking
Antibiotic (Define)
A drug that destroys or inhibits growth of micro-organisms
When staff assignments are made for the care of patients who are receiving chemotherapy, what is the major consideration regarding chemotherapeutic drugs? 1. During preparation, drugs may be absorbed through the skin or inhaled. 2. Many chemotherapeutic drugs are vesicants. 3.Chemotherapeutic drugs are frequently given through central venous access devices. 4. Oral and venous routes of administration are the most common.
1. During preparation, drugs may be absorbed through the skin or inhaled. Rationale: Chemotherapy drugs should be given by nurses who have received additional training in how to safely prepare and deliver the drugs and protect themselves and others from exposure. The other options express concerns, but the general principles of drug administration apply.
The nurse cares for a client diagnosed with Cushing's syndrome. Which of the following nursing actions is the priority?
1. Implement measures to prevent skin breakdown. 2. Plan measures to prevent infections. 3. Teach the client signs and symptoms of hyperglycemia. 4. Instigate measures to prevent fluid overload. Like Instigate measures to prevent fluid overload. respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention
a client with diarrhea should avoid which of these foods? 1.tuna 2. macaroni 3. eggs 4. orange juice
4. orange juice b/c it increases the motility of the GI. the other foods are less irritating.
the nurse has just received a prescription to transfuse a unit packet of RBCs for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring ?
15 minutes
when the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes ? 1. increased HR 2. decline in visual acuity 3. decreased RR 4. decline in long term memory 5. increased susceptibility to UTI 6. increased incidence of awakening after sleep onset
2. decline in visual acuity 5. increased susceptibility to UTI 6. increased incidence of awakening after sleep onset
In planning care for an infant, the nurse is aware that the 6 month old infant's development of trust is met PRIMARILY by providing: 1. food 2. warmth 3. security 4. comfort
3. security
a nurse is performing an assessment on a client dx with placenta previa. which of the following assessment findings would the nurse expect to note? SATA 1. uterine ridigity 2.uterine tenderness 3.severe abdominal pain 4.bright red vaginal bleeding 5. soft, relaxed, non-tender uterus 6.fundal height may be greater than expected for gestational age
4.bright red vaginal bleeding 5. soft, relaxed, non-tender uterus 6. fundal height may be greater than expected for gestational age placenta previa is an improperly planted placenta in the lower uterine segment near or over the cervical os. painless, bright red vaginal bleeding in the second third trimester of pregnancy is a sign of placenta pre via. In abruption placentae, severe abdominal pain is present. uterine tenderness, the abdomen feels hard and board like on palpitation
The nurse cares for clients in the emergency department (ED). An 82-year-old client comes to the ED complaining of muscle weakness and drowsiness. The nurse notes decreased deep tendon reflexes and hypotension. Which of the following actions should the nurse take FIRST? 1. Escort the client to an emergency room unit. 2. Ask the client if he has been taking antacids. 3. Assess for Chvostek's sign. 4. Measure client's intake and output
ASK THE CLIENT IF HE HAS BEEN TAKING ANTACIDS CORRECT— increased intake of MAGNESIUM-containing antacids and laxatives can cause hypermagnesemia (> 2.5 mEq/L); depresses CNS and cardiac impulse transmission; discontinue oral Mg, support ventilation, administer loop diuretics or IV calcium, teach about OTC drugs that contain Mg
Virulence means....
Ability of an organism to produce disease
Asepsis (Define)
Absence of organisms causing disease
When the patient with spinal cord injury is in tongs or on a stryker frame or on a circoelectric bed they are on......
Absolute bed rest
How long should you stay with the patient after beginning a transfusion?
At least 15 to 30 minutes
How long must the woman with CD of pregnancy be on bed rest after delivery?
At least one week
When a doctor takes three different blood pressure readings at different times, how far apart must the measurements be made?
At least one week
How many measurements must be made before you can say a person has hypertension?
At least three
Where are head lice most commonly found?
At the back of the head and behind the ears
Where is the pyloric sphincter?
At the distal (duodenal) end of the stomach
How fast do you run the CBI?
At whatever rate it takes to keep the urine flowing and free of clots
What is the most common sign of neurosyphillis?
Ataxia (gait problems)
PI's (Protease inhibitors)
Atazanavir Darunavir Fosamprenavir Indinavir Nelfinavir Ritonavir Saquinavir Tipranavir most potent of antiviral meds, inhibit cell protein synthesis that interferes with viral replication, does not cure but slows progression of AIDS and prolongs life, used prophylactically, used in AIDS to decrease viral load and opportunistic infections
Antiinfectives
Atovaquone (Mepron), Trimethoprim/sulfamethoxazole (Bactrim) used o treat imfections
What heart problem can lead to pulmonary embolus?
Atrial fibrillation (RIGHT atrial fibrillation casues pulmonary embolus; LEFT atrial fibrillation causes cerebral embolus)
The inheritance pattern of sickle-cell anemia is _____ _____.
Autosomal recessive
What can PREVENT the attacks of Meniere's?
Avoid sudden movements
What class of drugs is used to treat mastitis?
Antibiotics
What class of drugs is used to treat MG?
Anticholinesterases
Clients on what class of drugs should use an elastic razor?
Anticoagulants (heparin/coumadin/lovenox)
What does BPH stand for?
Benign Prostatic Hypertrophy
What type of traction is most commonly used for hip fractures in children?
Bryants
The infant with cleft lip/palate needs more frequent ___________.
Bubbling, burping
How often must you assess the lung sounds during the first stage of labor? During active labor? During transition labor?
Every 30 to 10 minutes
For the patient with neurogenic bladder you should straight catheterize every ____ hours.
Every 6 hours
How often should the drainage bag be emptied?
Every 8 hours
What is the most dangerous toxicity of Kwell?
CNS toxicity
Airborne microorganisms travel on ________ or ______particles.
Dust or water
Respiratory Distress Syndrome is also know as ....
Hyaline Membrane Disease (HMD)
Prolonged intervals between breast-feeding (decrease/increase) the incidence of mastitis.
Increase
Increased intracranial pressure will _________ the pulse pressure.
Increase or Widen
If you see clots in the tubing you would first ____________.
Increase the flow-rate.
The stools of a client with celiac's disease are ______, ______ and _____- _____.
Large Greasy Foul-smelling
What are bullae?
Large blisters
Women who have gestational diabetes tend to deliver infants who are (small/large).
Large for gestational age
What gauge needle is used with a blood transfusion?
Large gauge, 18 gauge
What is the characteristic lesion of pemphigus?
Large vesicular bullae
Describe the nipples on bottles used to feed babies with cleft lip?
Large-holed, soft nipples
The most radical prostate surgery is the ____________ prostatectomy.
Perineal
If the client complains of dyspnea during PD you would first __________, then __________.
Slow the flow, elevate HOB
When a person increases fiber in the diet they should do so____________.
Slowly
What surgery CAN be done for MG?
Thymectomy (removal of thymus)
Is CF hereditary?
Yes
List the most common gynecologic symptom of anorexia nervosa?
amenorrhea
a pt is seeking an herbal solution that stimulates the immune system and lowers BP. What herb should the nurse suggest the pt. investigate?
cat's claw
-osis
condition of
aseptic technique
method used to make the environment, the worker, and the patient as germ-free as possible
In the chain of infection, hand washing breaks the mode of ____________.
mode of transmission
What is the treatment of choice for syphilis?
penicillin
Kaposi's sarcoma is a cancer of the ___________.
skin
Males are more likely to get an MI than females. (T/F)
true
Use of oral contraceptives increases the risk of CVA (T/F).
true
How often should the client with acne wash his face each day?
twice a day
Hyper-reflexia is a sign of
upper-motor neuron syndrome associated with spinal cord compression
A CVA is a __________ of the brain cells due to decreased _____ _____ and ______.
Destruction; blood flow and oxygen
Which types of client should have their toenails trimmed only by an MD?podiatrist
Diabetics, peripheral vascular disease, very thick nails
The solution introduced into the peritoneum during PD is called...
Dialysate
What are the two main treatment methods in gestational diabetes?
Diet, insulin
The man with BPH has hesitancey. What does this mean?
Difficulty starting to void
What is the best way to screen men for BPH?
Digital rectal exam
Since pulmonary edema is caused by left ventricular failure what drug is given?
Digitalis
Will fluid resuscitation (administering large amounts of IV fluid) treat cardiogenic shock?
No, you must use cardiac drugs (giving IVs and blood will not help this kind of shock)
Portal of entry (Define)
Part of the body where organisms enter
Cloudy drainage in the dialysate commonly means...
Peritonitis (Not good, call MD)
What is the BIG danger with pyelonephritis?
Permanent scarring and kidney damage
For what reason are Montgomery straps used?
Permit you to remove & replace dressings without using tape (protects the skin)
To prevent irritation of the skin near the edges of a cast the edges should be ____________.
Petaled
Which of these symptoms are NOT seen in hemophilia? Prolonged bleeding, petechiae, ecchymosis or hematoma?
Petechiae
What are mast trousers?
Pneumatic device placed around the legs and lower body that is inflated to force blood centrally
During what phase should the nurse examine his/her own feelings?
Pre-interaction phase
(Multi/prima) gravida clients are most likely to get PIH.
Primagravida
Coagulate (Define)
Process that thickens or congeals a substance
What four symptoms in a patient with a cesium implant should be reported to the physician?
Profuse vaginal discharge Elevated temp Nausea Vomiting (these indicate infection and perforation)
During the luteal phase of the ovarian cycle, which of the following hormones increase: estrogen, progesterone or LH?
Progesterone and LH
What type of vomiting is present in meningitis?
Projectile
What is meant by orthopnea?
SOB when lying flat
Name the four most common parenteral routes of administrations.
SQ, IM, IV, ID (intradermal)
Which age group engages in stalling tactics before painful procedures most?
School-Age
Which age groups are most likely to physically resist the nurse during procedures?
School-age, adolescents
Would sympathetic stimulators or sympathetic blockers treat hypertension?
Sympathetic blockers (decrease cardiac output and decrease resistance)
For breast engorgement, the non-breastfeeding mother should be told to express breast milk. (T/F)
No, that would increase milk production and would make the problem worse (warm compresses or warm shower to let milk "leak" is okay- Ice is best)
Will the client with a MI need 100% O2 for their entire stay in the hospital?
No, just moderate flow (42% or 3 to 6 liters for first 48 hours)
Can we cure pernicious anemia?
No, just treat the symptoms.
Can hypertension be cured?
No, just treated
Can 3 cc of fluid be administered per IM into the deltoid of an adult?
No, maximum of 1 cc
Should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area?
No, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced.
Is having the client verbally identify himself considered adequate safety?
No, only identification bands are acceptable.
The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of NEPHROTIC SYNDROME. Which assessment findings should the nurse expect to observe? Select all that apply. 1. Pallor 2. Edema 3. Anorexia 4. Proteinuria 5. Weight loss 6. Decreased serum lipids
1. Pallor 2. Edema 3. Anorexia 4. Proteinuria
1 kg
2.2 lbs
How long does it take for shingles to heal?
30 days
How far should the HOB be up after CVA?
30 degrees
1 oz
30 ml/cc
A female client is diagnosed with human papillomavirus (HPV). Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness? 1. "I will need to take antibiotics for at least a week." 2. "I will use only prescribed douches to avoid a recurrence." 3. "I will return for a Pap smear in six months." 4. "I will avoid using tampons for eight weeks."
3. "I will return for a Pap smear in six months." several strains of HPV are associated with cervical cancer
Before administering calcium gluconate 10% 500 mg IV stat, it is MOST important that the nurse assess for which of the following? 1. Stability of the respiratory system. 2. Adequacy of urine output. 3. Patency of the vein. 4. Availability of magnesium sulfate injection.
3. Patency of the vein. if injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn
To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard? 1. The client is maintained on strict bed rest. 2. The head of the bed is at 30-degree angle. 3. The client receives a complete bed bath each morning. 4. The nurse checks the applicator's position every 4 hours.
3. The client receives a complete bed bath each morning. the client shouldn't receive a complete bed bath while the applicator is in place. in fact she shouldn't be bathed below the waist b/c of the risk of radiation exposure to the nurse. during this tx, the client should remain on strict bed rest. the nurse should check the the applicator's position every 4 hours to ensure that it remains in proper place.
Erythromycin
Give on empty stomach (antibiotics)
When surgery is performed for Meniere's, what are the consequences?
Hearing is totally lost in the surgical ear
What are the 2 common subjective signs of otitis media?
Hearing loss Feeling of fullness in the ear
Give another name for an MI.
Heart attack
Name 4 exercises used to treat mild scoliosis.
Heel lifts; sit-ups; hyperextension of the spine; breathing exercises
What is the BIG danger in renal failure?
Hyperkalemia and it's effect on the heart
What are the 2 common objective signs of otitis media?
Hyperpyrexia (fever) Drainage from ear
Abnromally high blood pressure is called____________.
Hypertension
The patient with pyelonephritis will have (hypertension/hypotention)?
Hypertension
Name the three symptoms of PIH.
Hypertension, weight gain (edema), proteinuria
If ketosis is a big problem for the baby during pregnancy what the big problem after delivery?
Hypoglycemia
What is the #1 cause of infant illness when the mother has diabetes?
Hypoglycemia
What types of chemicals cause burns to oral mucosa when ingested?
Lye, caustic cleaners
What positions are to be avoided after cataract surgery?
Lying face down. Also, do not lie on operative side for a month.
What will prevent hip flexion contracture after AKA?
Lying prone several times a day
Hepatitis B
Watch those needles HBsAg (this is what blood tests show) Hepatitis B surface antigen HBIG - vaccine Vaccination available, can give immune globulin after exposure Transmitted by blood and body fluids Incubates 5 to 35 weks
Do patients experiencing a CVA have a headache?
Yes
Do you need an informed consent for a spinal tap?
Yes
Is O2 given in pulmonary edema?
Yes
Is a signed informed consent required for cystoscopy?
Yes
Is an informed consent necessary for ECT?
Yes
Is it okay to use powder with TED hose?
Yes
Is milk allowed on a gluten-free diet?
Yes
Will the woman with a cesium implant have a foley?
Yes
Does AIDS require a single room?
Yes - if WBC counts are low
Have intrauterine devices to prevent pregnancy ever been linked to ectopic pregnancy?
Yes and so have pelvic infections.
Can letting IVs run too fast cause pulmonary edema?
Yes in the client with poor cardiovascular function
Can a client on PD: Sit in a chair? Eat? Urinate? Defacate?
Yes to all
Is bed rest necessary when a woman has cesium implant in place?
Yes, absolute bed rest
Should a woman with placenta previa be hospitalized?
Yes, always if bleeding
Will the client with pyelonephritis have daily weights?
Yes, as would any client with kidney problem
Ego Integrity vs. Despair
(Erikson) People in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived
1 tbs
15 cc
Gluten is a __________.
Protein
When blood is administered by IV, the needle/catheter should be ________gauge.
18 gauge
early adulthood
19 to 35 years of age
What may be added to the IV to correct the acidosis?
Bicarbonate
When sponge-bathing with tepid water the correct temp is _____________.
98.6 F
The typical post-operative inflammatory temperature elevation is in the range of ________.
99.8 to 101 degrees
What are the three major treatment objectives in eclampsia
? Decrease blood pressure Control convulsions Diuresis
What is done in a graft for hemodialysis? .
A blood vessel is sutured between an artery and a vein
What type of cast causes cast syndrome?
A body cast
Spore (Define)
A cell produced by a micro-organism which develops into active micro-organisms under proper conditions.
What is meant by the term "temporary colostomy"?
A colostomy that is not intended to be permanent-- the bowel will be reconnected at a later date and the client will defecate normally
What is automatic dysflexia or hyperreflexia?
A common complication of quadriplegics in response to a fulle bladder or bowel.
What group of people get cast syndrome?
ANYONE in a body cast
Amniotic fluid is (acidic/alkaline)
Alkaline
What electrolyte is given to people with Meniere's?
Ammonium chloride
What is the name of frozen factor VIII given to hemophiliacs?
Cryoprecipitate
What causes or precedes pyelonephritis?
Cystitis always does
The post op thoracic aneurysm is most likely to have which type of tube?
Chest tube, because the chest was opened
The three meats lowest in cholesterol are _________, _________ and __________.
Chicken, pork, mutton
Anticholestinesterases will have (sympathetic/cholinergic) side effects.
Cholinergic (they will mimic the parasympathetic nervous system)
Name the two types of crises that a MG patient can have.
Cholinergic (too much Mestinon) Myasthenic (not enough Mestinon)
MS usually occurs in (hot/cool) climates .
Cool
When the client is taking diuretics, what mineral is the CHF client most likely to lose?
Potassium--K+
At what age is death most likely in sickle cell anemia?
Young adulthood
Which vital signs are most important to measure in clients with aneurysm?
The pulse and blood pressure
What structures are involved in acne vulgaris?
The sebaceous glands
A second-degree burn has vesicles? (T/F)
True
The infant fears _________ most when hospitalized.
sep. from love object (toy?)
What is the typical skin care of pemphigus?
Cool wet dressing
What disease often follows labyrinthectomy?
Bell's palsy-- facial paralysis, will go away in a few months
Name 3 types of skeletal traction
Cranial tongs Thomas splints with Peason attachments 90 degrees to 90 degrees
What shape does Hgb S make the RBC's?
Crescent-shaped
A high score of 2 is given for respiratory effort if the newborn_____________.
Cries vigorously
How long can a unit of blood be on the unit before it must be started?
Less than 1/2 hour
What is anuria?
Less than 50 cc of urine in 24 hours
How much suction should be used for an infant?
Less than 80 mm Hg
Name four drugs used to treat Parkinson's
Levodopa, Sinement, Symmetrol, Cogentin, Artane, Parlodel
What drug will be used to treat PVCs of MI?
Lidocaine
Identify the activity restriction necessary after lumbar puncture?
Lie flat for 6 to 12 hours
How does the client evaluate the activity of their pancreas?
Observe stools for steatorrhea
The adolescent who is hospitalized fears separation from _________ and loss of ___________.
Peers, independence
Scoliosis is a ______ curvature of the ______.
Lateral, spine
When giving a Z-track injection, the overlying skin is pulled (up/down/medially/laterally).
Laterally
Is the client NPO before cystoscopy?
No, not unless a child with a general anesthetic-- in fact with adults you should encourage fluids.
Should the nurse self-disclose if the patient asks the nurse to?
No, not unless it is specifically therapeutic.
Premature rupture of membranes (PROM) is a ________ break in the amniotic sac __________ the _________ of contractions.
Spontaneous, before, onset
Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred?
Yes, when lye or caustic agents have been ingested
What are the top 2 diagnoses for a client with a catheter? Which is #1?
#1- Potential for infection; Potential impairment of urethral tissue integrity
How many pounds per week is the diabetic allowed to gain the 2nd and 3rd trimesters?
1 pound a week
The preferred length of needle to administer an IM injection is...
1 to 2 inch
The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST? 1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago. 2. A client diagnosed with right-sided heart failure and glaucoma. 3. A client diagnosed with chronic obstructive pulmonary disease and psoriasis.
1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago. both diseases are in the dynamic phase and require close monitoring; most unstable client
An eight-year-old has been receiving chemotherapy for six months. During her nursing care she asks: "Am I going to die?" Which of the following responses by the nurse is BEST? 1. "Are you afraid of dying?" 2. "Why do you ask that question?" 3. "Only God knows that answer." 4. "We won't leave you alone."
1. "Are you afraid of dying?"encourages ventilation of thoughts and feelings regarding the concern
A client who suffered a brain injury after falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). what findings indicate that the treatment he's receiving for SIADH is effective? SATA 1. Decrease body weight. 2. Rise in blood pressure and drop in heart rate. 3. Absence of wheezes in the lungs. 4. Increase in urine output. 5. Decrease in urine osmolarity
1. Decrease body weight 4. Increase in urine output. 5. Decrease in urine osmolarity SIADH is an abnormality involving an abundance of antidiuretic hormone. The predominant feature is water retention with oliguria, edema, and weight gain. Successful treatment should result in weight reduction, increased urine output, and decrease in the urine concentration (urine osmolarity).
A client is about to begin hemodialysis. Which measure(s) should the nurse employ in the care of the client? SELECT ALL THAT APPLY. 1. Using sterile technique for needle insertion 2. Using standard precautions in the care of the client 3. Giving the client a mask to wear during connection to the machine 4. Wearing full protective clothing such as goggles, mask, gloves, and apron 5. Covering the connection site with a bath blanket to enhance extremity warmth
1. Using sterile technique for needle insertion 2. Using standard precautions in the care of the client 3. Giving the client a mask to wear during connection to the machine 4. Wearing full protective clothing such as goggles, mask, gloves, and apron Infection is a major concern with hemodialysis. For that reason, the use of sterile technique and the application of a face mask for both nurse and client are extremely important. It also is imperative that standard precautions be followed, which includes the use of goggles, mask, gloves, and an apron. The connection site should not be covered; it should be visible so that the nurse can assess for bleeding, ischemia, and infection at the site during the hemodialysis procedure.
the nurse is assessing a pt. who has a closed head injury and showing symptoms of confusion, drowsiness, and unequal pupils. Which of the following nursing dx takes priority? 1. altered cerebral tissue perfusion 2. altered level of cognitive function 3. high risk for injury 4. sensory perceptual alteration
1. altered cerebral tissue perfusion the pt. is showing signs of increased ICP
a client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early post op period. the nurse should do which of the following? 1. check the post op CBC, INR, PTT, platelet levels 2. monitor the mediastinal chest tube drainage 3. confirm availability of blood products 4. administer warfarin 5. start a dopamine drip for a systolic BP<100
1. check the post op CBC, INR, PTT, platelet levels 2. monitor the mediastinal chest tube drainage 3. confirm availability of blood products Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.
The loss of the ability to perform purposeful, skilled acts, ie brushing teeth, is called __________.
Apraxia
a client with a suspected pulmonary embolus is brought to the emergency department complaining of SOB and pleuritic chest pain. Select all of the assessment data that would support this diagnosis. (SATA) 1. low-grade fever 2. thick green sputum 3. bradycardia 4. frothy sputum 5. tachycardia 6. blood-tinged sputum
1. low-grade fever 5. tachycardia 6. blood-tinged sputum
A rectal suppository is inserted ______ inches in an adult and ________ inches in a child.
4,2
Hypertension is more common in blacks or whites?
Blacks
When the Absolute Neutrophil Count ANC is below________ the person on chemotherapy will be placed on reverse isolation.
500
What is the most common NRTI used?
AZT (zidovudine)
How soon after cell damage does troponin increase?
As soon as 3 hours (can remain elevated for 7 days)
How would you, the nurse, assess for developing cast syndrome?
Ask the client if they are experiencing any abdominal symptoms-keep track of bowel movements & passing flatus (if not having BMs or passing flatus, cast syndrome is suspected)
The greatest danger in placing water in the mouth of the unconscious patient during oral hygiene is...
Aspiration
A PN drains the urinary bedside drain .What part in the nursing process doeas the PN is using?
Assessement
The long term treatment of migraine focuses upon...
Assessing things that bring on stress and then planning to avoid them.
When unwrapping a sterile pack how should you unfold the top point?
Away from you
What are the 3 subjective complaints of clients with scoliosis?
Back pain, dyspnea, fatigue
What structures in the brain are most affected in Parkinson's?
Basal ganglia
What is the activity order for clients with CHF?
Bed Rest
Hemophilia is a ___________ disorder.
Bleeding
What is otitis media?
Chronic infectious/inflammatory disease of the middle ear
What is the most common cause of mastoiditis?
Chronic otitis media
Patients with hepatitis have an aversion to _________.
Cigarettes
What movements are to be avoided after cataract surgery?
Coughing Sneezing Bending at the waist Straining at stool Rubbing or touching eyes Rapid head movements
A drug for long term anticoagulation in any disorder would be?
Coumadin
What words will the client use to describe the pain of an MI?
Crushing, heavy, squeezing, radiating to left arm, neck , jaw, shoulder
To score the maximum of 2 points on nueromuscular reflex irritability the infant must ______________.
Cry
How does pyelonephritis differ from cystitis in meaning?
Cystitis means bladder infection; pyelonephritis means an infection of kidney pelvis
What conditions does ECT treat?
Depression primarily
the client presents to the ED with hyphema. which action by the nurse would be best?
ELEVATE THE HOB AND APPLY ICE TO THE EYE hyphema is blood in the anterior chamber of the eye and around the eye
What is the first test for HIV antibodies?
ELISA
What is the best way to prevent pulmonary embolus in post-operative patients?
Early ambulation
If your client suddenly goes into pulmonary edema what would you do first?
Elevate the HOB, then increase O2, then call the MD
Before applying elastic hose the nurse should...
Elevate the clients legs for 3 to 5 minutes to decrease venous stasis
To treat hemarthrosis you should _______ the extremity above the __________.
Elevate, heart
What drug can you apply topically to stop bleeding?
Epinephrine, or topical fibrin foam
Apresoline
Given with meals (antihypertensive)
Upon walking the patient with Buerger's experiences _______ _________.
Intermittent Claudication
A first degree burn has vesicles (T/F)?
False
Side effects of a high fiber diet include__________ and malabsorption of ____________.
Gas (flatus), minerals
What is the developmental task for middle adulthood?
Generativity vs. stagnation.
What name is is given to diabetes that is brought on by pregnancy?
Gestational diabetes
If an aneurysm ruptures what is the #1 priority?
Get them to the operating room ASAP
What is the biggest challenge in nursing care of the client with hyperemesis gravidarum?
Getting them to eat
Rifampin
Give on empty stomach (anti-tuberculosis) remember Rifampin causes red urine
Culture means....
Growing colony of organisms, usually for the purpose of identifying them
The use of _____, _______, and ______ to kill self, make high risk suicide.
Guns, ropes, knives
Men with Cushings develop______________.
Gynecomastia
If an ovum is fertilized during the luteal phase what hormone will be secreted?
HCG (human chorionic gonadotropin)
What drugs can cause a Parkinson-like syndrome?
Haldol, major tranquilizers -- drugs that end in -azine
If the MD orders 2,800 cc of fluid in the first 24 hours after a burn, one-_____ of it must be infused in the first 8 hours.
Half (or 1,400 cc)
Which disease has more severe symptoms-- Hepatitis A or B?
Hepatitis B
If a surgeon delays doing a C-section for Placenta Previa it is due to: (reason for delay).
Immaturity of the fetus (they will want the child to mature)
With severe pulmonary embolus the client will look as though they are __________.
In Shock
What happens to the blood pressure in hypovolemic shock?
It decreases
Meningitis is an inflammation of the _______ of the _______ and spinal ___________.
Linings, brain , cord
After corrective SURGERY how is the client turned?
Log rolled (in a body cast)
What the two most common causes of whistling and squealing of a hearing aid?
Loose earmold Low battery
The use of pills makes the patient (low/moderate/high) risk for suicide.
Moderate
What is the initial diet order for clients with hyperemesis gravidarum?
NPO
What signs or symptoms would you report if they were present after cast application?
Numbness Tingling Burning Pallor Unequal or absent pulses Unequal coolness
The basis for a therapeutic nurse/patient relationship begins with the ______, self______ and ______ _______.
Nurse's, awareness, self understanding
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. 4. Determine the client's blood glucose leveL
Obtain a pulse oximetry reading. assessment; symptoms indicate reduced oxygen levels
When a patient is taking Levodopa he should have assistance getting out of bed because...
Of orthostatic hypotension
What are the processes occurring in migraines?
Reflex constriction then dilation of cerebral arteries.
Define debridement.
Removal of necrotic tissue from a wound.
In what type of container should breast milk be stored?
Sealed plastic bags
The cessation of sounds is known as the _________
Second diastolic sound
Without leukopenia the AIDS patient will be on ____________ precautions.
Standard precautions or blood and body fluid precautions
Which organism most commonly causes mastitis?
Staph
When swabbing an incision you would start at the incision or 1 Inch away from the incision?
Start at the incision and move outward.
What type of dressing is applied to a central line insertion site?
Sterile occlusive
What solution is best to use if you intend to remove a client's contact lenses?
Sterile saline
What solution should be used to clear the tubing during suctioning?
Sterile saline
What is diastole?
The LOWEST force of blood on artery walls
What neurologic test do they do for this anemia?
The Romberg test (a test for balance), in normal people this test is negative, in the client with pernicious anemia this test becomes positive
What unique urine test is done to diagnose pernicious anemia?
The Schilling test
What information does the measurement of skin fold thickness yield?
The amount of body fat
Why are diuretics given to women with CD of pregnancy?
To promote diuresis which will: -lower circulating blood volume -decrease preload -decrease the amount of blood the heart pumps.
Hepatitis A,B,C and D are all (bacterial/viral) diseases.
Viral
Second to rest, what is very important treatment for CD of pregnancy?
Weight control
Why is the child with CF receiving pancreas/viokase/pancreatin?
They are enzymes which aid absorption of nutrients.
Why do the crescent-shaped RBCs cause occlusion of the vessels?
They clump together and create a sludge.
An infant is given a score of 0 for respiratory effort if __________.
They do not breathe
What do NRTI's and PI's do?
They prevent viral replication
The feedings for an infant with pyloric stenosis should be thick or thin?
Thickened
In what trimester does Abruptio Placenta most commonly occur?
Third
Scoliosis is MOST common in the _______ and ______ sections of the spinal column.
Thoracic and lumbar
Which patients should be forbidden to smoke? Smoke alone?
Those with oxygen in the room, confused, sleepy, drugged clients
You should tell the client with CHF to immediately report to his/her doctor if he/she gains _____pounds in one week.
Three
What type of pain is typical of migraines?
Throbbing
Patients in Russell's traction are particularly prone to ____________.
Thrombophlebitis
What is a TIA?
Transient Ischemic Attack Warning sign of impending CVA (transient neurologic deficits of any kind can last 30 seconds to 24 hours)
In the chain of infection, hand washing breaks the mode of ____________.
Transmission
What organism causes syphilis?
Treponema palladium
What serum protein rises soonest after myocardial cell injury?
Troponin
A dry cast is gray or white?
White
The best goal to evaluate the progress of the client with anorexia nervosa?
an adequate weight gain
NRTI (nucleoside reverse transcriptease inhibitors)
an antiviral drug used against HIV (is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs)
What artery is widened in a thoracic aneurysm?
aorta
What is the #1 complication of cleft lip/palate?
aspiration
Adriamycin
cardiotoxicity
How often should the post-operative patient turn?
every 2 hours
Antibiotics are used to treat breast engorgment? (T/F)
false
The #1 contracture problem in AKA is ____________ of the _____________
flexion, hip
chain of infection model
infectious agent - reservoir - portal of exit - means of transmission - portal of entry - susceptible host - new reservoir
Define azotemia?
nitrogenous wastes in the blood (increased creatinine, BUN) Azotemia = abnormal high levels of nitrogen-containing compounds (urea, creatinine, various body waste compounds) in the blood. It is largely related to insufficient filtering of blood by the kidneys.
Does the client have to be sedated before a spinal tap?
no
Name ways to toughen a stump so it will not breakdown due to the wear of the prosthetic leg?
push the stump against the wall, hitting it with a pillow
A fresh new stoma is _________, __________ and __________.
red, large, noisy
-lysis
separation; destruction; loosening
septic shock
sepsis and uncontrollable decreased blood pressure
What is the common name for Herpes Zoster?
shingles
Transverse Colostomy
soft stool typical stool odor stool damages the skin empties several times per day may or may not be at risk for fluid/electrolytes imbalances may irrigate
-ology
study of, science
By what route do you take nitro?
sublingual
What is the only treatment recommended for appendicitis?
surgery - appendectomy
An aneurysim is an abnormal _______________ of the wall of a(n) artery.
widening (it is also weakening)
Should the nurse provide perineal care for the client
with a cesium implant? No, risk of radiation hazard
Levodopa should be given with or without food?
with food
Can nurses be held liable for an accident resulting from a client not being told how to use the call light?
yes
Can pregnancy convert a non-diabetic woman into a diabetic?
yes
Can the stroke victim be turned side-to-side?
yes
Does stress make acne worse?
yes
Is I&O important to record during PD?Yes
yes
Is the woman likely to have a foley catheter in after a hysterectomy?
yes
Should you encourage fluids after cystoscopy?
yes
Should you raise the HOB to increase drainage of the dialysate?
yes
Will the patient with meningitis have a headache?
yes
Will the client with a MI be nauseated?...diaphoretic?
yes, yes
Humalog peak time
2 tp 4 hrs
The charge nurse on the night shift receives a call from one of the nurses who is to report the next morning. The day-shift nurse reports that she has been diagnosed with strep throat and placed on antibiotics. Which of the following responses by the charge nurse is MOST appropriate? 1. "How long have you had the sore throat?" 2. "How long have you been on antibiotics?" 3. "Do you have an elevated temperature?"
2. "How long have you been on antibiotics?" after 24 hours of antibiotic therapy, strep throat is no longer contagious and a health care provider can resume responsibilities
Which of the following statements by an adult client indicates to the nurse the need for further teaching regarding care of a sigmoid colostomy? 1. "I hope to be able to go without a pouch soon." 2. "I'm irrigating my colostomy after each meal." 3. "My stoma is looking better all the time." 4. "It's not hard to change my pouch every several days."
2. "I'm irrigating my colostomy after each meal." irrigation of sigmoid colostomy is not necessary more than once a day and sometimes every two or three days, if at all
The nurse answers the psychiatric unit's desk phone. The caller identifies himself as the spouse of a patient and inquires about the patient's condition. Which of the following responses by the nurse is MOST appropriate? 1. "I cannot deny or confirm any patient's presence in this hospital." 2. "Patients are not allowed to use this phone. Please call the patient's phone number directly." 3. "I cannot give information over the phone. If you come in, we can discuss her condition." 4. "I will have to ask her if she wishes for me to give out that information."
2. "Patients are not allowed to use this phone. Please call the patient's phone number directly." psychiatric patient retains civil rights to communicate with outside world and have reasonable access to telephones
The nursing team consists of an RN, an LPN, and 2 nursing assistants. Which of the following clients should RN care for? 1. A child recovering from surgical repair of a hypospadias 2. A client recovering from excision of a malignant melanoma 3. A client diagnosed with MI requiring assistance to the bathroom 4. A client diagnosed with utility oasis recovering from lithotripsy
2. A client recovering from excision of a malignant melanoma may require a wide excision that requires nurse to anticipate the need for analgesics medications; psychological support is also necessary b/c of diagnosis of cancer 1. lpn 3. NA 4. LPN
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.
2. A client with full-thickness burns to the face. Face, neck, chest, or abdominal burns result in severe edema, causing airway restriction
Parents of an infant infected with human immunodeficiency virus (HIV) tell the nurse that they aren't going to inform the day care providers about their son's infection. How should the nurse respond to the parent's plan? 1. Teach parents how to wear facial mask and gown during diaper changes. 2. Agree that the parents have the legal right to confidentiality. 3. Tell them there is a greater risk of HIV transmission to other infants in the daycare setting. 4. Notify the director of the daycare of the infant's HIV status.
2. Agree that the parents have the legal right to confidentiality. parents have the legal right to decide whether they will inform daycare providers of the infant's HIV status. If they decide not to inform the facility, the nurse can't breach client confidentiality and notify the daycare director herself. Standard precautions should be followed in the daycare facility for all children. Gloves should be worn during diaper changes. There isn't an increased risk for HIV transmission among infants in the daycare setting.
The community health nurse plans visits for the day. Which of the following clients should the nurse see FIRST? 1. A client diagnosed with type 2 diabetes who is complaining of GI upset after taking chlorpropamide (Diabinese). 2. A client who is complaining of vomiting after chemotherapy. 3. A client with a tonometer reading of 21 mm Hg. 4. A client with a laryngectomy who is complaining of a greenish-yellow discharge.
4. A client with a laryngectomy who is complaining of a greenish-yellow discharge.
When should a diabetic be delivered?
Between 37 and 39 weeks
What are comedones?
Blackheads and white heads
Sickle cell anemia is most commonly seen in (blacks/whites).
Blacks
What does hemarthrosis mean?
Bleeding into the joints
What oral problem will people with polycythemia vera have?
Bleeding mucous membranes
The nurse is preparing to administer a prescribed medication to a client with severe Alzheimer's disease. The client is not wearing an identification bracelet. Which of the following actions would be most appropriate for the nurse to take? a. Monitor the client's response when the name is stated. b. Compare the name on the medication record with the name on the foot of the bed. c. Return the medication to the medication cart. d. Ask another licensed staff member to confirm the client's identity.
C. A client with severe Alzheimer's disease is unable to provide reliable information. Based on the 5-rights of medication administration, if the client is not wearing an identification bracelet, the nurse should return the medication to the medication cart until a new bracelet is obtained.
A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for: A. Trendelenburg position B. Ice to the entire extremity C. Bucks traction D. An abduction pillow
C. Bucks traction why? The client with a fractured femur will be placed in Bucks traction to realign the leg and decrease spasms and pain.
What is present when rebound tenderness is present?
Peritoneal inflammation
With what is a round closed in first intention?
Sutures or steri-strips, staples
What is Lordosis?
Swayback in the lumbar region (Lumbar, Lordosis)
What are the vital sign changes seen in autonomic dysreflexia?
Sweating, headache, nausea & vomiting, gooseflesh, and severe HYPERtension
What is meant be the phrase "advance the drain 1 inch"?
You pull the drain out 1 inch.
When women get MG they are usually old or young?
Young
When will phantom limb sensation subside?
a few months
What assessment finding is found under the right rib cage?
An olive sized bulge (the hypertrophied pylorus)
People between 25 and 50 years are (low/moderate /high) risk for suicide.
Low to moderate
Women have a (higher/lower) incidence of stroke than men?
Lower
What is the #1 purpose of a tepid sponge bath?
Lower body temperature during fever.
Is severe carbohydrate restriction required in gestational diabetics?
No, it could lead to ketosis
Can you use alcohol on the earmold of a hearing aid?
No, it dries and cracks it
What are the 3 objective symptoms/signs of thrombocytopenia? Hint: P.E.E.
Petechiae Epistaxis Ecchymosis
Does anything exit the skin in an AV shunt?
Yes, the plastic tube that connects the artery and vein outside the arm
chain of infection
infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host
-itis
inflammation
acne vulgaris
inflammation of sebaceous glands and hair follicles
Peritonitis
inflammation of the peritoneum
Apendicitis is an _________ of the appendix due to __________.
inflammation, obstruction
Why is cleft lip repaired early?
Feeding is easier after repair and appearance after repair is more acceptable to parents.
Name the five signs/symptoms that pyelonephritis has that cystitis does not have?
Fever, flank pain, chills, increased WBC, malaise
In what type of chair should Parkinson's patients sit?
Firm, hard-backed
In Placenta Previa the placenta is implanted _______ than it should be and lays over the ________ ________.
Lower, cervical os
What is the definitive diagnostic test for meningitis?
Lumbar puncture with culture of CSF (cerebro-spinal fluid)
Will the typical post-operative client have lung sounds? Bowel sounds? Increased temperature?
Lung - yes; bowel sounds - no; Low grade temperature - yes
In which two systems/organs are the most problems in CF?
Lungs Pancreas
Two purposes of bed bath are...
Cleanses the skin Provides comfort
What outcomes would indicate that suctioning was effective?
Clear even lung sounds, normal vital signs
People who are (hetero/homo) have sickle cell trait.
Heterozygous
The abnormal hemoglobin produced by people with sickle cell anemia is called Hgb ______.
Hgb S-it "sickles"
Adolescents are (low/high) risk for suicide
High
Being alkaline means have a (high/low) pH
High
If you use too narrow of a cuff the reading will be too high or low?
High
People over 50 year are (low/high) risk for suicide.
High
What is the typical diet for CF client?
High calorie High protein Modified fat
In what position should the child with Pyloric Stenosis be during feeding?
High fowlers
Young adults are (low/high) risk for suicide.
High to moderate
In the oliguric phase, blood volume is ______, sodium is _____, and potassium is ________.
High, high, high
Im-; in-
"Not" or "into"
When teaching the parents of a child dx with Tetralogy of Fallot about the cardiac defects involved with this condition, which defects would the nurse describe? SATA
"VarieD PictureS Of A RancH" Ventricular septal Defect Pulmonary Stenosis Overriding Aorta Right ventricular Hypertrophy
Can blood be given immediately after removal from refrigeration?
No, it has to be warmed first for only about 20 to 30 minutes.
The nurse is assessing a 4 month old suspected of having cerebral palsy. upon initial interview, which of the following statements by the mother would indicate that the infant may have cerebral palsy ?
"my baby cannot lift her head up, she is floppy" hypotonia is an early clinical manifestation of cerebral palsy. the infant should be able to support their head by age 4 months.
the nursing working in a women's health clinic is returning telephone calls. which client should the nurse contact first?
"the 27 y/o primigravida client who is complaining of blurred vision" blurred vision is a symptom of preeclampsia, and this is the client's first pregnancy.
The home care nurse visits a client in a large apartment complex. During the visit, the area experiences a major earthquake. Which of the following clients should the nurse see FIRST? 1. A restless client with a rigid abdomen and absent bowel sounds. 2. An unconscious client with left-sided tracheal shift from midline. 3. A client complaining of excruciating pain with an obvious deformity of the left leg. 4. A client clutching her chest and complaining of severe chest pain. Like 2. An unconscious client with left-sided tracheal shift from midline.
(2) CORRECT—first sign of a tension pneumothorax; airway and breathing take priority
During a nonstress test (NST), the nurse observes several late decelerations. Which of the following nursing actions is MOST appropriate? 1. Reposition the client on her right side. 2. Notify the physician for further evaluation. 3. Document these results in the nurse's notes. 4. Stop the oxytocin (Pitocin) immediately.
(2) correct—appearance of any decelerations of the fetal heart rate (FHR) during NST should be immediately evaluated by the physician (1) does not resolve the immediate problem (3) does not resolve the immediate problem (4) incorrect for this test; oxytocin (Pitocin) is not used for the nonstress test
If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why?
High, venous congestion makes the arterial pressure higher (increases resistance)
With what solution should blood be transfused?
0.9 normal saline
What IV solution is hung with a blood transfusion?
0.9 normal saline (No glucose)
A nurse reinforces to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further instruction? 1. "I will place a steam vaporizer in my child's room." 2. "I will take my child out into the cool, humid night air." 3. "I will place a cool-mist humidifier in my child's room." 4. "I will place my child In a closed bathroom and allow my child to inhale steam from the running water."
1. "I will place a steam vaporizer in my child's room." steam vaporizers present a danger of scalding burns
The nurse instructs a prenatal client about the importance of prenatal vitamins. It is MOST important for the nurse to include which of the following instructions? 1. "Take prenatal vitamins with orange juice at bedtime." 2. "Take the prenatal vitamins at breakfast with coffee." 3. "Take the prenatal vitamins with milk at lunch." 4. "Take the prenatal vitamins with water at dinner."
1. "Take prenatal vitamins with orange juice at bedtime."(1) correct—taking the vitamins with something acidic increases the absorption of iron; taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep
a client is admitted to the ED after falling down a flight of stairs at home. the client's VS are stable, and the hx states that the client had a gastric stapling 2 years ago and takes neomycin for acne. the client jokes about being clumsy lately and trips over things. the nurse should ask the client which of the following? SATA 1. "are your experiencing numbness in your extremities ?" 2."how much vitamin B12 are you getting?" 3. "are you feeling depressed?" 4."do you feel safe at home?" 5."are you getting sufficient iron in your diet?"
1. "are your experiencing numbness in your extremities ?" 2."how much vitamin B12 are you getting?" 3. "are you feeling depressed?" 4."do you feel safe at home the nurse should ask the client about symptoms r/t pernicious anemia b/c the client had the stomach stapled 2 years ago and shows no hx of of supplemental vitamin B12.
The nursing assistant reports to the nurse that four of the patients are vomiting. Which of the following patients should the nurse see FIRST? 1. A client 2 days postop after abdominal surgery with a nasogastric tube attached to low suction. 2. A client diagnosed with cirrhosis of the liver with extensive ascites. 3. A client diagnosed with lung cancer undergoing chemotherapy. 4. An elderly client diagnosed with irritable bowel syndrome (IBS).
1. A client 2 days postop after abdominal surgery with a nasogastric tube attached to low suction. assess for patency of the NG tube; muscle spasms associated with vomiting causes severe pain and can threaten the integrity of the wound
How long is the needle kept inserted during Z-track injection?
10 seconds
On heart rate or cardiac status, a 2 means that the HR is above _______ BPM.
100
1 gm
1000 mg
the nurse is assessing a client following a CABG. The nurse should give priority to reporting: 1. chest drainage of 150 ml in the past hour 2. confusion and restlessness 3. pallor and coolness 4. urinary output of 40 ml per hour
1. chest drainage of 150 ml in the past hour chest drainage greater than 100ml/hr is excessive, and the doctor should be notfied regarding possible hemorrhage.
the nurse should instruct a young female with sickle cell anemia to do which of the following? 1. drink plenty of fluids when outside in hot weather 2. avoid travel to cities where the O2 level is lower 3. be aware that since she is homozygous for Hbs, she carries the sickle cell trait. 4. know that pregnancy with sickle cell disease increases the risk of a crisis. 5.avoid flying in commercial airlines
1. drink plenty of fluids when outside in hot weather 2. avoid travel to cities where the O2 level is lower 4. know that pregnancy with sickle cell disease increases the risk of a crisis. people who are homozygous for Hbs have sickle cell anemia; the heterozygous form is the sickle cell carrier trait. a client with sickle cell anemia may fly on commercial airlines; the airplane is pressurized for an adequate oxygen level.
With what size catheter should an adult's airway be suctioned?
12 to 16 French
How long should the stump be elevated to prevent post op swelling?
12-24 hours
1 mL
15 gtt 1 cm^3 1 cc
If you were told to start the IV on the woman admitted for Placenta Previa, what gauge needle would you use?
18 gauge, or any other large enough to administer blood
How long should a woman wait before lifting heavy objects after a hysterectomy?
2 months
a pt ARDS is receiving o2 by non-rebreather mask but ABG measurements still show poor oxygenation. As the nurse responsible for this pt's care, you would anticipate a physician order for what action? 1. perform endotracheal intubation and initiate mechanical ventilation 2. immediately begin CPAP via the pt's mouth and nose 3. call a code for respiratory arrest
1. perform endotracheal intubation and initiate mechanical ventilation a non-rebreather mask can deliver nearly 100% oxygen. when the pt's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the pt is working very hard to breathe and may go into respiratory arrest unless health care providers intervention by providing intubation and mechanical ventilation to decrease the pt.'s work of breathing.
which intervention would a nurse include when preparing a care plan for a child with HEPATITIS 1. providing a low fat, well balanced diet 2. notifying the physician if jaundice is present 3. teaching the child effective hand washing techniques 4. scheduling playtime in the playroom with other children 5. instructing the parents to avoid administering meds unless prescribed 6. arranging an indefinite homeschooling b/c the child will not be able to return to school
1. providing a low fat, well balanced diet 3. teaching the child effective hand washing techniques 5. instructing the parents to avoid administering meds unless prescribed b/c hepatitis can be viral the child should be discouraged from sharing toys, so playtime with other children is not part of the care plan. child will be able to return to school. jaundice is an expected finding and would not warrant notification of the physician
the student nurse is to teach a patient how to use an MDI without a spacer. put in correct order the steps the that the student nurse should teach the patient.
1. remove the inhaler cap and shake the inhaler 3. breath out completely 2. open your mouth and place the mouthpiece 1 to 2 inches away. 5. press down firmly on the canister and breathe deeply through your mouth 4. hold your breath for at least 10 seconds 6. wait at least 1 minute between puffs
a clients glucose is unexpectedly low. what nursing intervention should be first? 1. repeat accu check to verify results 3. hold insulin and give orange juice
1. repeat accu check to verify results an unexpectedly low level of a test should first be verified for accuracy of the finding prior to taking significant action.
you are preparing to teach a patient with a new dx of osteoporosis about strategies to prevent falls. which teaching points will you be sure to include? SATA 1. wear a hip protector when ambulating 2. remove throw rugs and other obstacles at home 3. exercise to help build your strength 4. expect a few bruises and bumps when you go home 5. rest when you are tired
1. wear a hip protector when ambulating 2. remove throw rugs and other obstacles at home 3. exercise to help build your strength 5. rest when you are tired
You are caring for a diabetic patient admitted with HYPOGLYCEMIA that occurred at home. Which teaching points for treatment of hypoglycemia at home would you include in a teaching plan for the patient and family before discharge? (SATA) 1.Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL. 2.Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or 1/4 cup of fruit juice. 3.Retest blood glucose in 30 minutes. 4.Repeat the carbohydrate treatment if the symptoms do not resolve. 5.Eat a small snack of carbohydrate and protein if the next meal is more than an hour away.
1.Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60 mg/dL. 4.Repeat the carbohydrate treatment if the symptoms do not resolve. 5.Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. The manifestations listed in option 1 are correct. The symptoms should be treated with carbohydrate, but 10 to 15 g (not 4 to 8 g). Glucose should be retested at 15 minutes; 30 minutes is too long to wait. Options 4 and 5 are correct.
an elderly man is prescribed oral morphine sulfate for acute pain mngmt. the pt. is on bed rest and is NPO. The nurse is most concerned about which side effect of morphine sulfate? 1.constipation 2.dizziness 3.HTN 4.nausea
1.constipation opioid analgesics commonly cause constipation, especially in the elderly and pt's on bed rest. opioid analgesics can cause nausea and dizziness, but this pt is at higher risk for constipation.
How far above the ear canal should you hold the dropper while administering ear drops?
1/2 inch
Mastitis usually occurs at least _______days after delivery.
10
How long does it usually take for the dialysate to drain out of the peritoneum?
10 minutes: (10 minutes flow in, 30 minutes in abdominal cavity, 10 minutes flow out = total of 50 minutes)
For how long should suction be applied during any one entry of the catheter?
10 seconds
A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply 1. Restrict fluids 2. Assess for airway patency 3. Administer oxygen as prescribed 4. Place a cooling blanket on the client 5. Elevate extremities if no fractures are present 6. Prepare to give oral pain medication as prescribed
2. Assess for airway patency 3. Administer oxygen as prescribed 5. Elevate extremities if no fractures are present
Which of the following are normal age-related physiological changes? 1. Increased heart rate. 2. Decline in visual acuity 3. Decreased respiratory rate. 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset
2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset
The nurse is caring for a client with hemiparesis caused by a stroke. The client is barely responsive. which intervention takes highest priority? 1. Performing passive range-of-motion 2. Placing the client on the affected side. 3. Using hand rolls or pillows for support. 4. Applying antiembolism stockings as ordered.
2. Placing the client on the affected side. To help prevent airway obstruction and reduce the risk of aspiration, the nurse should position a client with hemiparesis on the affected side. Although performing ROM exercises, providing pillows for support, and applying antiembolism stockings may be appropriate interventions for a client who had a stroke, maintaining a patent airway is the first concern.
The nurse is preparing a client for a cataract removal. Mydriatic eye drops are ordered. What observation by the nurse indicates the medication is having the desired effect? 1. The client states his vision is blurred. 2. The pupil on the clients affected eye is dilated. 3. The client says his eye feels irritated 4. The pupil on the client unaffected eye is pinpoint size
2. The pupil on the clients affected eye is dilated. before cataract surgery a mydriatic is administered to promote pupil dilation. This is necessary to obtain access to the lens for removal.
the nurse is evaluating the following four clients for the development of a pressure ulcer. Which of the following clients is at greatest risk for the development of a pressure ulcer? 1. a 52-year-old obese female, 2 days post-op for a knee replacement, who has an indwelling urinary catheter 2. a 74-year-old thin male, who is awaiting surgery for a fractured left hip 3. a 91-year-old emaciated female with a blood sugar of 160 mg/dl, who is sitting in a wheelchair 4. a 67-year-old obese male, who has cellulitis of his right lower leg
2. a 74-year-old thin male, who is awaiting surgery for a fractured left hip risk factors for the development of pressure sores include bony prominences, inability tochange position independently, and a bed-rest status. these factors pose the highest risk for the client.
the nurse is preparing a plan of care for a client with diabetes mellitus who has HYPERGLYCEMIA. The nurse places highest priority on which client problem? 1. lack of knowledge 2. inadequate fluid volume 3. compromised family coping 4. inadequate consumption of nutrients
2. inadequate fluid volume hyperglycemia will cause the kidneys to excrete glucose in the urine leading to dehydration. "High and dry" (sugar's too high) =hyperglycemia "Cold and clammy (need some candy)= hypoglycemia
a nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? 1. diarrhea 2. polyuria 3. polyphagia 4. weight gain
2. polyuria hypercalcemia is a hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria.
The preferred gauge of needle for IM injection is...
21 to 22 gauge
What solution should be used on the skin where the brace rubs?
23
If labor does not begin within ________ hours after PROM, labor will likely be induced.
24
Unless contraindicated the patient should be out of bed no later than ______ hours post-operatively.
24
Usually labor starts within ________hours of rupture membranes.
24
How long can breast milk be refrigerated?
24 hours
How long does it take a cast to dry?
24 hours
The shock phase lasts for the first ________ to ________ hours after a burn.
24 to 48 hours
Children should receive no more than _______ cc per site by IM injection.
2cc
The onset of post operative infection is on the ______ or ______ day post-operative day.
2nd or 3rd, never before that (remember elevated temperatures earlier than the 2nd post-operative day is NOT infection)
The first exercise that should be performed by a client with a mastectomy is: A. Walking the hand up the wall B. Sweeping the floor C. Combing her hair D. Squeezing a ball
D. Squeezing a ball why? The first exercise that should be done by the client with a mastectomy is squeezing the ball
The nurse cares for client diagnosed in stage I chronic renal failure. During the nursing assessment, the nurse expects the client to state which of the following? 1. "I don't seem to urinate as much as I used to." 2. "I seem to have more swelling in my feet and ankles." 3. "I urinate more at night." 4. "The doctor told me I need dialysis."
3. "I urinate more at night." stage I is diminished renal reserve; renal function is reduced but healthier kidney is able to compensate; since kidney not as able to concentrate urine, client has polyuria and nocturia
A 25-year-old G2P1 patient has come to the obstetric triage room at 32 weeks reporting painless vaginal bleeding. You are providing orientation for a new RN on the unit. Which statement by the new RN to the patient would require your prompt intervention? 1. "I'm going to check your vital signs." 2. "I'm going to apply a fetal monitor to check the baby's heart rate and to see if you are having contractions." 3. "I'm going to perform a vaginal examination to see if your cervix is dilated." 4. "I'm going to feel your abdomen to check the position of the baby."
3. "I'm going to perform a vaginal examination to see if your cervix is dilated." Painless vaginal bleeding can be a symptom of placenta previa. A digital vaginal examination is contraindicated until ultrasound can be performed to rule out placenta previa. If a digital examination is performed when placenta previa is present, it can cause increased bleeding. The other statements reflect appropriate assessment of an incoming patient with vaginal bleeding.
A client has a nasogastric tube in place after extensive abdominal surgery. The client complains of nausea. The nurse notes the client's abdomen is distended and there are no bowel sounds. Which of the following actions should the nurse take FIRST? 2. Irrigate the nasogastric tube with normal saline. 3. Determine if the nasogastric tube is patent and draining. 4. Check the placement of the nasogastric tube by auscultation.
3. Determine if the nasogastric tube is patent and draining. should first assess if the tube is open and draining to determine if there is a problem with the nasogastric tube; if it is patent and draining, it does not need to be irrigated
The nurse counsels a mother breast feeding her 4 week old infant about birth control. The nurse determines further teaching is necessary if the client states which of the following: 1." I have decided to be fitted for a diaphragm" 2. "I'll speak with my husband about using a condom" 3. I think that oral contraceptives will be the best for me" 4. "I shall determine my fertile time and will practice abstinence."
3. I think that oral contraceptives will be the best for me" The mother is CURRENTLY BREASTFEEDING a 4 week old infant. If the mother begins oral contraceptives, it can suppress the milk production..... IT WILL INTERFERE WITH THE INFANTS FOOD SUPPLY if she starts the oral contraceptives now
A client has severe second- and third-degree burns over 75% of his body. The nurse would be MOST concerned if which of the following was observed? 1. Epigastric pain. 2. Restlessness. 3. Tachypnea. 4. Lethargy.
3. Tachypnea. body responds to early HYPOVOLEMIC SHOCK by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color
The nurse prepares a 25-year-old woman for a cesarean section. The patient says 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 reduced amounts of sedatives and hypnotics than are given before general surgery. 3. contains reduced amounts of narcotics than are given before general surgery. 4. contains medications similar in type and dosages to those given before general surgery.
3. contains reduced amounts of narcotics than are given before general surgerydecreased so less narcotic crosses the placental barrier causing respiratory depression in the infant
when caring for a client who is receiving TPN, which of the following complications would be most important for the nurse to assess? 1. chest pain 2. hemorrhage and air embolus 3. electrolyte and sepsis 4. pneumonia and hyperglycemia
3. electrolyte and sepsis electrolyte imbalance as well as catheter-related sepsis, air embolus, and pneumothorax are potential complications of TPN. hemorrhage and pneumonia is not a common complication although, hyperglycemia can occur.
The nurse is working with a client who has just indicated a wish to kill herself. The client then asks the nurse not to tell anyone. The nurse's BEST response should be to 1. encourage the client not to do anything without thinking it through very carefully. 2. explain to the client that anything she tells the nurse is kept strictly confidential. 3. report this to staff members in order to protect the client. 4. encourage the client to tell the nurse more about what she is feeling.
3. report this to staff members in order to protect the client- nurse must let the client know that this information will be shared with the staff so that the client's safety can be preserved
the nurse is assisting with bone marrow aspiration and biopsy. In which order, from first to last, should the nurse complete the following tasks?
3. verify the client has signed an informed consent 1. position the client in a side-lying position 2. clean the skin with an antiseptic solution 4. apply ice to the biopsy site
Pain medications should be administered _______ before ________ care.
30 minutes, wound care
Respiratory Distress Syndrome hardly ever occurs after week ____ of gestation.
37
In the diuretic phase: urine output can=________ to ________ liters/24 hours.
4-5 liters per 24 hours
In hypovolemic shock there is a ________ in the circulating __________ volume -- this _______ tissue perfusion with ________.
Decrease; blood; decreases; oxygen
The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider (HCP).
4. Assess for hypovolemia and notify the health care provider (HCP). Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the HCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition.
When auscultating a client's chest, the nurse assesses a second heart sound (S2). This sound results from: 1. Opening of the mitral valve and tricuspid valves. 2. Closing of the mitral and tricuspid valves. 3. Opening of the aortic and pulmonic valves. 4. Closing of the aortic and pulmonic valves.
4. Closing of the aortic and pulmonic valves.
What is important in the plan of care for a client who has glaucoma? 1. Prevent secondary infection. 2. Maintain good visual acuity 3. Prevent injury to unaffected eye. 4. Control intraocular pressure.
4. Control intraocular pressure. Client with glaucoma experience an increase in intraocular pressure that is controlled by miotic eye medication such as Timoptic
The client is admitted with CVA and has facial paralysis. Nursing care should be planned to prevent which of the following complications. 1. Inability to talk. 2. Inability to swallow caused by loss of gag reflex. 3. Inability to open the affected eye. 4. Corneal abrasion.
4. Corneal abrasion. client will be unable to close eye, voluntarily. Facial nerve (CN VII) is affected , the lacrimal gland will no longer supply secretions that protect the eye.
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination. 1. At the end of her menstrual cycle. 2. On the same day each month. 3. On the 1st day of the menstrual cycle. 4. Immediately after her period.
4. Immediately after her period. premenopausal women should do their self-examination immediately after the menstrual period, when the breast are least tender and least lumpy. On the 1st and the last days of the cycle, woman's breast are still very tender. Postmenopausal women because their bodies lack fluctuation of hormones levels, should select one particular day of the month to do breast self-examination.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 ml/hour. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 ml. The nurse is MOST concerned by which of the following? 1. A CVP reading of 12 and bradycardia. 2. Tachycardia and hypotension. 3. Dyspnea and oliguria. 4. Rales and tachycardia.
4. Rales and tachycardia. correct—indicate cardiovascular fluid overload
When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen? 1. Bread 2. Carrots 3. Oranges 4. Strawberries
4. Strawberries common food allergens include berries, peanuts, Brazil nuts, cashews, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions.
When ready to walk with crutches after knee surgery, the client will probably be taught: 1. swing-through gait 2. Two-point crutch walking 3. Four-point walking 4. three-point crutch walkng
4. three-point crutch walking requires considerable arm strength, is used when a limb cannot bear weight. the affected leg and crutches are advanced together, and the strong leg swings through.
A nurse is assisting in admitting a client who has a diagnosis of hypothermia. The nurse anticipates that this client will exhibit which vital signs? 1.Increased heart rate and increased blood pressure 2.Increased heart rate and decreased blood pressure 3.Decreased heart rate and increased blood pressure 4.Decreased heart rate and decreased blood pressure
4.Decreased heart rate and decreased blood pressure Rationale: The heart rate and blood pressure are decreased because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases.
A patient is diagnosed with iron deficiency anemia. The physician prescribes ferrous sulphate. Which of the following is a contraindicated for ferrous sulphate? 1. Pregnancy 2.old age 3.Cirrhosis 4.ulcerative colitis
4.ulcerative colitis
A person should have a yearly work up exam for cancer detection over the age of __________.
40
What is the normal pulse pressure?
40 (+ or -10)
If J. Doe's blood pressure is 100/60, what is his pulse pressure?
40 (100-minus 60 equals 40)
What age group in Meniere's highest in?
40 to 60
Once you have stopped the bleeding into the joint, how long should the hemarthrosis patient wait before bearing weight or doing range of motion?
48 hrs
How long does spinal shock last?
5 days to 3 months
Average duration of menstrual flow is _____. The normal range is _____ to ______ days.
5 days, 3 to 6
How many minutes should lapse between the nitro pills you take?
5 minutes - take one nitro tab every 5 minutes 3 times, if no relief, call MD
The postoperative patient should void by _____hours post-operatively or you must call the MD.
6 to 8
The comfort range of temperature is...
68 to 74 degrees
a client with a positive skin test for TB is not showing signs of active disease and is treated with isoniazid, 300 mg daily. The nurse explains to the client that the medication should be taken for how long?
9 - 12 months
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.
9 months
In the rule of nines, the head and neck receive _______: each arm receives_______.
9%, 9%
The preferred angle of injection to to be used for IM administration is___________.
90 degrees
an 8 y/o sustained a femur fraction with an open wound. what type of traction should the nurse expect to be used?
90-90 traction is often used for femur or tibia fractures. This involves suspending the thigh in the vertical plane and bending the knee at a 90 degree angel.
Death from Respiratory Distress Syndrome most commonly occurs within _____ hours of birth.
96
Nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for A careful handling to prevent fractures B additional calcium in the diet
A careful handling to prevent fractures
What does the physician hope to achieve with NRTI's and PI's for HIV?
A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years)
What vital sign changes are most ominous after cystoscopy?
A fall in the blood pressure and increase in the pulse-- increasing hemorrhage
What will the client be wearing after cataract surgery?
A protective patch/shield on the operative eye for 24 hours, then a metal shield (AT NIGHT only) for 3 weeks
Antiseptic (Define)
A substance used to destroy or inhibit the growth of pathogens but not necessarily their spores (in general safe to use on persons)
What is done in an AV fistual?
A surgical anastomosis is made between the artery and a vein.
What is a colostomy?
A surgically created opening of the colon out onto the abdomen wall.
What type of rash occurs with shingles?
A vesicular rash over the pathway of a sensory nerve
The nurse is conducting discharge teaching related to a new prescription for phenytoin (Dilantin). Which statements are appropriate to include in the teaching for this patient and his family? Select all that apply. A) "Be sure to call the clinic if you or your family notice increased anxiety or agitation." B) "You may have some mild sedation. Do not drive until you know how this drug will affect you." C) "This drug may cause easy bruising. If you notice this, call the clinic immediately." D) "It is very important to have good oral hygiene and visit your dentist regularly." E) "You may continue to have wine with your evening meals but only in moderation."
A, B, D Patients receiving an antiepileptic drug are at increased risk for suicidal thoughts and behavior beginning early in their treatment. The U.S. Food and Drug Administration (FDA) advises that patients, families, and caregivers be informed of the signs that may precede suicidal behavior and be encouraged to report these immediately. Mild sedation can occur in patients taking phenytoin even at therapeutic levels. Carbamazepine(Tegretol), not phenytoin, increases the risk for hematologic effects, such as easy bruising. Phenytoin causes gingival hyperplasia in about 20% of patients who take it. Dental hygiene is important. Patients receiving phenytoin should avoid alcohol and other central nervous system depressants because they have an additive depressant effect.
The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer's B. A client with pnuemonia C. A client with appendicitis D. A client with thrombophebitis
A. A client with Alzheimer's why? The client with Alzheimer's disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living.
The nurse is planning care for a client with bacterial pneumonia. The client is receiving oxygen therapy as prescribed via nasal cannula and a prescribed parenteral anti-infective medication. Which of the following nursing diagnoses should be included in the client's plan of care? a. Activity intolerance. b. Altered peripheral tissue perfusion. c. Sensory-perceptual alterations. d. Decreased cardiac output.
A. A client with bacterial pneumonia has nursing diagnoses that include ineffective airway clearance, ineffective breathing pattern, activity intolerance and pain.
A removal of the left lower lobe of the lung is performed on a client with lung cancer. Which post-operative measure would usually be included? A. Closed chest drainage B. A tracheostomy C. A mediastinal tube D. Percussion vibration and drainage
A. A closed chest drainage why? The client with a lung resection will have chest tubes and a drainage-collection device. He probably will not have a tracheoostomy or mediastinal tube, and he will not have an order for percussion, vibration, or drainage.
If too much fluid is removed during PD, the client will experience...
Decreased blood pressure (hypotension)
A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure? A. Bradycardia B. Tachycardia C. Premature ventricular beats D. Heart block
A. Bradycardia why? Suctioning can cause a vagal response and bradycardia.
The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action? A. Call the surgeon and ask him or her to see the client to clarify the information B. Explain the procedure and complications to the client C. Check in the physician's progress notes to see if understanding has been documented. D. Check with the client's family to see if they understand the procedure fully
A. Call the surgeon and ask him or her to see the client to clarify the information why? It is the responsibility of the physician to explain and clarify the procedure to the client.
The nurse is caring for a client with cerebral plasy. The nurse should provide frequent rest periods because: A: Grimacing and withering movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest C. Stretch reflexes become more increases with rest D. Fine motor movements are improved
A. Grimacing and withering movements decrease with relaxation and rest. why? Frequent rest periods help to relx tense muscles and preserve energy
The physician has prescibed tranylcypromine sulfate (Parnate) 10 mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause: A. Hypertension B. Hyperthermia C. Melanoma D. Urinary retention
A. Hypertension why? If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, and alpha-adrenergic blocking agent.
The nurse is assigned to care from infant with physiologic jaundice. Which action by the nurse would facilitate elimination of the bilirubin? A. Increase the infant's fluid intake B. Maintain the infant's body temp at 98.6 F C. Minimize tactile stimulation D. Decrease caloric intake
A. Increase the infant's fluid intake why? Bilirubin is excreted through the kidneys, thus the need for increased fluids. Maintaining the body temp is important but will not assist in eliminating bilirubin.
What will you auscultate over the lungs of the neonate with Respiratory Distress Syndrome?
Decreased lung sounds with crackles
What is the most common dietary modification for the woman with CD who shows signs of decompensation?
Decreased sodium, decreased water (restriction)
The nurse is caring for an adult client with acute gastroenteritis. Which of the following observations by the nurse may indicate that the client is becoming dehydrated? a. pulse change from 68 to 80 b. blood pressure change from 110/78 mm Hg to 120/80 mm Hg c. musty urine odor d. hypoactive bowel sounds
A. Indications of dehydration include flushed skin, skin tenting, dry mucous membranes, hypotension or tachycardia. The increasing pulse rate may indicate the client is becoming dehydrated.
The graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. Which goal should receive priority? A.Maintain the client's systolic blood pressure at 70 mm/Hg or greater B. Maintain the client's urinary output greater than 300 cc/hr C. Maintain the client's body temp of greater than 33 F rectal D. Maintain the client's hematocrit less than 30%
A. Maintain the client's systolic blood pressure at 70 mm/Hg or greater why? When the cadaver client is being prepared to donate and organ, the systolic blood pressure should be maintained at 70 mm/Hg or greater to ensure a blood supply to the donor organ.
The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough? A. Mask B. Gown C. Gloves D. Shoe covers
A. Mask why? If the nurse is exposed to the client with a cough, the best item to wear is a mask. If the answer had included a mask, gloves, and a gown, all would be appropriate.
The nurse is assessing an adult client who was just diagnosed with primary hypertension. Which of the following questions would be essential for the nurse to ask the client? a. "When was your last eye examination?" b. "How often do you receive pedicures?" c. "What medication do you take when you have a headache?" d. "Have you ever had difficulty urinating?"
A. Primary hypertension causes changes in blood flow to target organs, such as the eyes and kidneys. It would be essential for the nurse to ask when the client had an eye examination. It would be most important for the nurse to identify the frequency and severity of headaches rather than the treatment of headaches since the client is at risk for a CVA.
The nurse is conducting a community education program regarding cancer. Which of the following statements would be correct for the nurse to make? a. "Prostate cancer is more common in African-American males." b. "Breast cancer risks increase for women if oral contraceptives have been used during adolescence." c. "Testicular cancer is common after the age of sixty years." d. "Colon cancer screening begins after the age of fifty years regardless of ethnic origin."
A. Prostate cancer is more common in African-American males and usually has a poor prognosis at the time of diagnosis. Colon cancer screening typically begins at the age of 50 years but is recommended starting around 40 years if the individual is African-American.
The doctor orders 2% nitroglycerin ointment on a 1-inch dose over 12 hours. Proper application of nitroglycerin ointment includes: A. Rotating application sites B. Limiting applications to the chest C. Rubbing it into the skin D. Covering it with a gauze dressing
A. Rotating application sites why? Sites for the application of nitroglycerin should be rotated, to prevent skin irritation. It can be applied to the back and upper arms, not to the lower extremities.
The nurse is making assignments for the day. Which client should be assigned to the pregnant nurse? A. The client receiving linear accelerator radiation therapy for lung cancer. B. The client with a radium implant for cervical cancer C. The client who has just been administered soluble brachytherapy for thyroid cancer D. The client who returned from the placement of iridium seeds for prostate cancer
A. The client receiving linear accelerator radiation therapy for lung cancer why? The pregnant nurse should not be assigned to any client with radioactivity present. Therefore, the client receiving linear accelerator therapy is correct because this client travels to the radium department for therapy, and the radiation stays in the department; the client is not radioactive
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available? A. The client with Cushing's disease B. The client with diabetes C. The client with acromegaly D. The client with myxedema
A. The client with Cushing's disease why? The client with Cushing's disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immune suppressed
The nurse has reinforced teaching with a client who is scheduled for a cardiac catheterization via the femoral artery. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I should avoid coughing or sneezing for several days after the procedure is completed." b. "I will be asked to hold my breath when the catheter is removed from my groin." c. "I can sit in a chair when I am in the recovery area after the procedure is completed." d. "I may have temporary residual numbness in my leg due to irritation of the nerves caused by the contrast dye."
A. The femoral artery is the most common site of catheter insertion for a cardiac catheterization. A client is discouraged from coughing or sneezing after the procedure to help minimize bleeding at the catheter insertion site. The client does not need to hold the breath during the procedure.
The nurse is caring for a client who has end-stage chronic obstructive pulmonary disease (COPD). The client receives continuous oxygen via nasal cannula and bronchodilators via nebulizer q.i.d as prescribed. Which of the following actions by the nurse would increase the risk for a charge of negligence? a. using a container of acetone to remove adhesive from the client's skin b. allowing the client to use an electric razor to shave c. making sure that the client's undershirt is made from cotton d. mixing a hydrogen-peroxide solution for the client to use as a mouth rinse
A. The nurse must remain aware of standards of care for clients who are receiving oxygen therapy and take action to minimize the risk for injury to the client. Negligence is defined as failure to provide care that meets the standard and that places the client at risk for injury. Using acetone is a potential fire hazard when oxygen is being used so this action increases the risk for a charge of negligence if the client and/or others are adversely affected by this action.
The home health nurse is checking a client who had an open cholecystectomy and insertion of a biliary drainage tube (T-tube). Which of the following actions would be appropriate for the nurse to take? a. laying a plastic garbage bag across the client's legs before removing the T-tube dressing b. rotating the T-tube 90 degrees before cleaning around the tube c. applying gentle pressure on both sides of the T-tube to check for leaks d. obtaining a specimen for culture and sensitivity testing from the yellow drainage in the T-tube
A. The nurse should maintain infection control procedures when dressings are changed in a client's home. A water-proof bag, such as a trash bag, can be placed over the client's legs to place soiled dressings and to minimize contamination of the immediate area.
A 24 year-old female client is scheduled for surgery in the morning. Which of the following is the primary responsibility of the nurse? A. taking the vital signs B. obtaining the permit C. explaining the procedure D. Checking the lab work
A. taking the vital signs why? the primary responisblity of the nurse is to take the vital signs before any surgery. answers B,C and D are the responsibility of the doctor.
For acute exacerbations of MS _______ per IV is often used.
ACTH (Corticotropin)
a pt has labored breathing, has clear lungs and an arterial oxygen saturation of 96%. which is the cause? 1. anemia 2. poor peripheral perfusion 3. psychosomatic disorder 4. left-sided heart failure
ANEMIA an individual with anemia could have a normal SaO2 and still be dyspneic. poor peripheral perfusion would cause low SaO2.
Name the four most common toxic effects of digitalis.
Anorexia N&V-- very common Yellow vision Arrythmia
An early sign of hepatitis A is ________.
Anorexia or fatigue
Give 6 symptoms of HIV disease.
Anorexia, fatigue, weakness, night sweats, fever, diarrhea
The goal of action while the suicidal patient is still of the phone is to get _______ person _______ the ______.
Another person on the scene (then immediately decreases risk) Remember: people who are alone are always high risk
What two non-dietary lifestyle changes are used commonly to treat hypertension?
Decreases stress Increase activity
Surfactant _____ surface tension inside ________.
Decreases, alveoli
Of: married, divorced, and separated, which marital status is highest risk for suicide? Lowest risk of suicide?
Highest-separated then divorced Lowest-married
Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa?
Highter
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis? A. A weight loss of 10 pounds in 2 weeks. B. Complaints of numbness and tingling in the extremities. C. A red, beefy tongue. D. A hemoglobin level of 12.0 gm/dL
C. A red, beefy tongue why? A red, beefy tongue is characteristic of a client with pernicious anemia.
The activity order in early management of CVA is __________.
Absolute Bed Rest
What is the classic pattern in formal operational thinking?
Abstract reasoning
What causes the itching seen in renal failure?
Accumulation of wasted in the blood and the associated signs. This occurs in the end stage renal failure.
What neurotransmitter is problematic in MG?
Acetylcholine
The nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be changed with: A. Negligence B. Tort C. Assault D. Malpractice
C. Assault why? Assault is defined as striking or touching the client inappropriately, so a nurse assistant striking a client could be charged with assault.
After treatment how long do you have to inspect for lice?
Inspect for 2 weeks to be sure that they are all gone
Is it okay to give B12 orally to a client with pernicious anemia?
No, it will never be absorbed due to a lack of intrinsic factor
The client is receiving total parenteral nutrition (TPN). Which lab should be evaluated while the client is receiving TPN? A. Hemoglobin B. Creatinine C. Blood glucose D. White blood cell count
C. Blood glucose why? When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose.
Or Tylenol, Morphine, Demoral, Aspirin which is
NEVER given to a sickle-cell patient? Aspirin-it can cause acidosis which makes the crisis and sickling worse
In vaso-occlusive crisis the vessels become occluded with ______ ______.
Abnormal RBC'sb
What position is contraindicated after cleft lip repair?
NEVER lie on their abdomen
Is the infant restrained BEFORE repair?
No, just AFTER repair
The client is having Electroconvulsive therapy for tx of severe depression. Prior to the ECT, the nurse should?
APPLY A BLOOD PRESSURE CUFF TO THE ARM the client that is having ECT is given a sedative. When the BP cuff is inflated the fingers twitch when he has a grand map seizure.
What drug should NOT be given to the patient with chemotherapeutic thrombocytopenia?
ASA (aspirin)
What are 3 ways to gain access to the circulation in hemodialysis?
AV shunt AV fistula AV graft
What urinary pH prevents UTI?
Acidity, low pH
What is the #1 cause of hypovolemic shock?
Acute blood loss
Hepatitis is an _____, ______ disease of the _______.
Acute, inflammatory, liver
What three drugs are given for shingles?
Acyclovir (anti-infective) Tegretol (anticonvulsant--given to stabilize nerve cell membranes) Steroids (anti-inflammatory)
If not contraindicated, what action by the nursing before suctioning would most likely reduce hypoxia during suctioning?
Administer a few breaths at 100% oxygen before beginning
Pemphigus
An acute or chronic disease of adults, characterized by occurence of successive crops of bullae that appear suddenly or apparently normal skin and disappear, leaving pigmented spots. It may be attended by itching and burning and constitutional disturbance. The disease if untreated is usually fatal. A characteristic finding is a positive Nikolsky sign: When pressure is applied tangential to the surface of affected skin, the outer layer of epidermis will detach from the lower layer. (Probably autoimmune)
Children with cleft lip/palate should be fed in what position?
An almost upright position
Host (Define)
An animal or a person upon which or in which micro-organisms live
What is dentifrice?
Agents which promote adherence of dentures to gums, ie, Polygrip What is sordes?
For a woman who doesn"t have retracted nipples, is towel drying or air drying better?
Air drying of the nipples is best
Besides a thrombus what else can cause an embolus in the lung?
Air, fat, tumor cells
Clients with cystine nephrolithiasis should have a (n) _________ ash diet.
Alkaline
The best a PN way to implement an IV therapy ordered for a 7 yr old
Allow child to participate in inj play
Ectopic pregnancy is (usually/almost never) carried to term.
Almost never
What is the #1 integumentary side effect of chemotherapy?
Alopecia
What is the #1 nursing diagnosis with shingles?
Alteration in comfort: pain, #2 Impaired skin integrity
A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________.
Altered body image
When halo traction is being used to immobilize the spinal cord the client is allowed to _______.
Ambulate
If the client complains of abdominal gas after a hysterectomy, the best intervention is.....
Ambulation
What drug is used to increase ventilation in clients with pulmonary edema?
Aminophylline (bronchodilator)
What other test is used to confirm fetal lung maturity?
Amniotic fluid is analyzed for presence of PG
What two classes of drugs are given in Meniere's?
Antihistamines and diuretics (Diamox)
What class of drugs is the client with an aneurysm most likely to be on?
Antihypertensives
What causes cast syndrome?
Anxiety and stress leading to sympathoadrenal shut-down of the bowel
Valsalva maneuver
Any forced expiratory effort against a closed airway such as when an individual holds his or her breath and tightens his or her muscles in a concerted, strenuous effort to move a heavy object or change positions in bed. forcible exhalation against a closed glottis, resulting in increased intrathoracic pressuremm
What blood pressure is considered to be hypertension?
Anything greater than 140/90 mm Hg
What is opisthotonos?
Arching of back (entire body) from hyperextension of the neck and ankles, due to severe meningeal irritation.
The post op abdominal aneurysm repair client is most likely to have which type of tube?
NG tube for decompression of bowel
The nurse is obtaining a history of an 80 year old client. Which statement made by the client might indicate a possible fluid and electrolyte imbalance? A. "My skin is always so dry." B. "I often use laxatives for constipation." C. "I have always liked to drink ice tea." D. "I sometimes have a problem with dribbling urine."
B. "I often use laxatives for constipation." why? Frequent use of laxatives can lead to diarrhea and electrolyte loss.
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session? A. "You will be sitting for the examination procedure." B. "Portions of the procedure will cause pain or discomfort." C. "You will be given some medication to anesthetize the area." D. "you will not be able to drink fluids for 24 hours before the study."
B. "Portions of the procedure will cause pain or discomfort." why? Portions of the exam are painful especially when the sample is being withdrawn so this should be included in the session with the client.
The client is scheduled for a pericentesis. Which instruction should be given to the client before the exam? A. "You will need to lay flat during the exam." B. "You need to empty your bladder before the procedure." C. "You will be alseep during the procedure." D. "The doctor will injuect a medication to treat your illness during the procedure."
B. "You need to empty your bladder before the procedure." why? The client scheduled for a pericentesis should be told to empty the bladder, to prevent the risk of puncturing the bladder when the needle is inserted. A pericentesis is done to remove fluid from the peritoneal cavity.
Due to a high census, it had been necessary for a number of clients to be transferred to another unit within the hospital. Which client should be transferred to the post-partum unit? A. A 66 year old female with gastroenteritis B. A 40 year old female with a hysterectomy C. A 27 year old male with sever depression D. A 28 year old male with ulcerative colitis
B. A 40 year old female with a hysterectomy why? The best client to transport to the postpartum units it the 40 year old female with a hysterectomy. The nurses on the postpartum unit will be aware of moral amounts of bleeding and will be equipped to care for this client.
The nurse is assessing a client who had a partial thyroidectomy 24 hours ago. The nurse must a. check the client's pupillary reaction to light b. observe the response when the client's cheek is tapped c. measure the client's neck circumference d. auscultate the client's carotid pulses
B. A client who had a partial thyroidectomy is at risk for a calcium imbalance. The nurse should tap the client's cheek and observe for muscle twitching (Chvostek's sign) which may indicate hypocalcemia. The client's neck circumference is not measured.
The nurse is assessing a client who is receiving total parenteral nutrition (TPN). The nurse observes that the client's skin is warm and the client's pulse rate is increased. The client reports feeling weak and confused. The nurse should first check the client's a. pupillary response to light b. glucose level c. urine output d. oral temperature
B. A client who is receiving TPN is at risk for fluid and electrolyte imbalances. Hyperglycemia may be indicated by warm skin, tachycardia, muscle weakness and change in mental status. The nurse should first check the client's blood glucose level so that appropriate care can be initiated. The client's oral temperature can be checked after the blood glucose level is checked.
The nurse is assessing an adult client with hypothyroidism who is taking prescribed levothyroxine (Synthroid). Which of the following would indicate that the client's treatment has been effective? a. sleeping 6 hours a day b. daily bowel movements c. neck fullness d. pulse, 100
B. A client with hypothyroidism may experience weight gain, anorexia, cold intolerance, constipation, lethargy or slowed movements. Having a daily bowel movement would indicate that the client's treatment has been effective. Sleeping 6 hours a day requires additional information to help determine if this is a change in the typical sleep pattern since excess thyroid hormone replacement can cause insomnia.
The nurse is reviewing the record of a client who has several new prescriptions. The client has a history of coronary artery disease (CAD) and renal insufficiency. Which of the following new medications would be contraindicated based on this history and should be clarified by the nurse? a. metoprolol (Toprol XL) b. hydrochlorothiazide (HydroDIURIL) c. atorvastatin (Lipitor) d. clopidogrel (Plavix)
B. A client with renal disease should not take HydroDIURIL since this medication further compromises renal function.
Which contraindication should a nurse assess for prior to giving a child immunizations?
B. Allergy to eggs C. Depressed immune system DEPRESSED IMMUNE SYSTEM who have depressed immune system related to HIV or chemotherapy should not be given routine immunizations. The allergy to eggs is the white of the egg, not the entire egg.
The nurse in a coronary care unit interprets information from hemodynamic monitoring. The client has a cardiac output of 2.4L/min. Which of the following actions should be taken by the nurse? A. No intervention is needed; this is a normal reading. B. Collaborate with the physician to administer a positive inotropic agent. C. Administer a stat dose of metoprolol (Lopressor). D. Ask the client to perform the Valsalva maneuver.
B. Collaborate with the physician to administer a positive inotropic agent. A positive inotropic agent will increase the force of contraction, thus increasing cardiac output. normal cardiac output is 4-8 l/m
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority? A. Continue to monitor the vital signs B. Contact the physician C. Ask the client how he feels D. Ask the LPN to continue the post-op care
B. Contact the physician why? The vital signs are abnormal and should be reported to the doctor immediately.
The client with a myocardial farction comes to the nurse's station stating that he is ready to go come because there is nothing wrong with him. Which defense mechanism is the client using? A. Rationalization B. Denial C. Projection D. Conversion reaction
B. Denial why? The client who says he has nothing wrong is in denial about his myocardial infarction.
The nurse overhears the patient care assistant speaking harshly to the client with dementia. The charge nurse should: A. Change the nursing assistant's assignment B. Explore the interaction with the nursing assistant C. Discuss the matter with the client's family D. Initiate a group session with the nursing assistant.
B. Explore the interaction with the nursing assistant why? The best action for the nurse to take is to explore the interaction with the nursing assistant. This will allow for clarification of the situation.
The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should: A. Call the Board of Nursing B. File a formal reprimand C. Terminate the nurse D. Charge the nurse with a tort
B. File a formal reprimand why? The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step.
A client with cancer is a, admitted to the oncology unit. Stat lab values revel Hgb 12.6, WBC 6500, K+1.9, uric acid 7.0, Na+136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following? A. Hypernatremia B. Hypokalemia C. Myelosuppression D. Leukocytosis
B. Hypokalemia why? Hypokalemia is evident from the lab values listed. The other laboratory findings are within normal limits. making answers A,C and D incorrect
What are some classic and unique signs of pernicious anemia?
Beefy red tongue Numbness and tingling of the hands Sores in the mouth Chest pain
When should a patient put on TED hose?
Before getting out of bed (before the swelling occurs).
The nurse is reinforcing preoperative teaching with a client who has signed a surgical consent and is scheduled for a radical prostatectomy. Which of the following statements by the client would increase the risk for a charge of battery if the surgery is performed as scheduled? a. "I know that I may have pink-colored urine for several weeks after surgery." b. "I will be able to resume sexual activity within six weeks of surgery." c. "I should avoid becoming constipated after surgery." d. "I can donate my own blood for transfusion since this surgery can cause severe anemia."
B. Informed consent means that the client has received and understands the surgical procedure as well as the risks and benefits of treatment to include specific details regarding complications. Battery is touching a person without consent with or without harm to the client. A radical prostatectomy increases the risk for sexual dysfunction. The client's statement about resuming sexual activity indicates the client does not have a correct understanding of the surgical procedure and increases the risk of a charge of battery if the surgery proceeds without providing the client with additional information regarding sexual function after surgery.
A client with pancreatitis has been transferred to the intensive care unit. Which order would the nurse anticipate? A. Blood pressure every 15 minutes B. Insertion of a levine tube C. Cardiac monitoring D. Dressing changes 2x per day
B. Insertion of a levine tube why? The client with pancreatitis frequently has nausea and vomiting. Lavage is often used to decompress the stomach and rest the bowel, so the insertion of a levine tube should be anticipated.
During the change of the shift, the ongoing nurse notes a discrepancy in the number of Perocept (oxycodone) listed in the number present in the narcotics drawer. The nurse's first action should be to: A. Notify the hospital pharmacist B. Notify the nursing supervisor C. Notify the board of nursing D. Notify the director of nursing
B. Notify the nursing supervisor why? The first action the nurse should take is to report the finding to the nurse supervisor and follow the chain of command.
The physician prescribes captopril (Capoten) 25 mg PO TID for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten? A. Tinnitus B. Persistent coughing C. Muscle weakness D. Diarrhea
B. Persistent coughing why? A persistent cough might be related to an adverse reaction to Captoten.
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion? A. Secrurity guard B. RN C. LPN D. The nursing assistant
B. RN why? The RN is the only one of these who can legally put the client in seclusion. The only other healthcare worker who is allowed to initiate seclusion is the doctor.
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the RN? A. Notify the police department as a robbery B. Report this behavior to the charge nurse C. Monitor the situation and note whether any items are missing D. Ignore the situation until items are reported missing
B. Report the behavior to the charge nurse why? The best action at this time is to report the incident to the charge nurse. Further action might be needed, but it should be determined by the charge nurse.
The client is receiving peritoneal dialysis. If the dialysis returns cloudy the nurse should" A. Document the finding B. Send a specimen to the lab C. Strain the urine D. Obtain a complete blood count
B. Send a specimen to the lab why? If the dialysate returns cloudy, infection might be present and must be evaluated
Assuming no mastitis, on which side should the breastfeeding begin?
Begin nursing on the side that the baby finished on the last feeding
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant? A. Taking the vital signs of the 5 month old with brochiolitis B. Taking the vital signs of a 10 year old with a 2 day post- appendectomy C. Administering medication to the 2 year old with periorbital cellulitis D. Adjusting the traction of a 1 year with a fractured tibia
B. Taking the vital signs of a 10 year old with a 2 day post-appendectomy why? The client with the appendectomy is the most stable of these clients and can be assigned to a nursing assistant. The client with bronchiolitis has an alteration in the airway, the client with periorbital cellulitis has an infection, and the client with a fracture might be an abused child.
Which nurse should be assigned to care for the postpartal client with preeclampsia? A. The nurse with 2 weeks of experience on postpartum B. The nurse with 3 years of experience in labor and delivery C. The nurse with 10 years of experience in surgery D. The nurse with 1 year of experience in the neonatal intensive care unit
B. Th nurse with 3 years of experience in labor and delivery why? The nurse in answer B has the most experience with possible complications involved with preeclampsia.
Several clients are admitted to the ER following a three- car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster? A. The schizophrenic client having visual and auditory hallucinations and the client with ulcerative collitis B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm C. A child whose pupils are fixed and dilated and his parents, and the client with a frontal head injury D. The client who arrives with a large puncture wound to the abdomen and the client with chest pain
B. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm why? Out of all these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room.
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because: A. The client is at risk for evisceration B. The client will require frequent dressing changes C. The straps provide support for drains that are inserted into the incision D. No sutures or clips are used to secure the incision.
B. The client will require frequent dressing changes why? Montgomery straps are used to secure dressing that require frequent dressing changes because the client with a cholescystectomy usually has a large amount of drainage on the dressing. Montgomery straps are also used for clients who are allergic to several types of tape.
A home health nurse is making preparations for morning visits. Which of the following clients should the nurse visit first? A. A client with brain- attack (stroke) with tube feeding B. A client with congestive heart failure complaining of nighttime dyspnea C. A client with a thoracotomy 6 months ago D. A client with Parkinson disease
B. The client with congestive heart failure complaining of nighttime dyspnea why? The client with congestive heart failure who is complaining of nighttime dyspnea should be seen first because airway si number one in nursing care
The parent of an 8-day-old infant watches television in the room while the home health nurse completes a weight check on the infant. The infant's weight is the same as the birth weight and the parent reports that the infant does not like to be touched. Which of the following additional observations of the infant by the nurse would indicate that child protective services must be contacted? a. dried formula on the chin b. reddened occiput c. cheesy substance in the axilla d. edematous breasts
B. The home health nurse must remain alert for indications of child maltreatment, such as failure to gain weight, avoidance of contact with the infant and indications of bruising that may indicate inappropriate aggression toward the infant. Child protective services must be contacted by law if the infant's occiput is reddened since this indicates pressure associated with the infant remaining in the supine position. Vernix caseosa is a cheesy substance that is normally present in the axilla and other skin folds of a newborn.
Which information should be reported to the state Board of Nursing? A. The facility fails to provide literature in both Spanish and English B. The narcotic count has been incorrect on the unit for the past 3 days. C. The client fails to receive an itemized account of his bills and services received during his hospital stay D. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath
B. The narcotic count has been incorrect on the unit for the past 3 days. why? The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result.
The nurse is preparing the client for a mammogram. To prepare the client for a mammogram, the nurse should tell the client: A. Restrict her fat intake for one week before the test B. To omit creams, powders, or deodorants before the exam C. The mammography replaces the need for self breast exams D. That mammography requires higher does of radiation than an x-ray.
B. To omit creams, powders, or deodorants before the exam. why? The client having the mammogram should be instructed to omit deodorants or powders beforehand because powders and deodorants can be interpreted as abnormal.
The nurse is reinforcing teaching with a client who has a prescription to begin metoprolol (Toprol XL). The nurse should advise the client that Toprol XL may cause a. urinary retention b. bronchospasms c. photophobia d. paresthesias
B. Toprol XL can cause bronchospasms, urinary frequency and joint pain, and orthostatic hypotension.
The tremors of Parkinson's will get better or worse when they purposefully move or perform a task?
Better, they tremor more when not performing an action
When will the cleft lip be repaired?
Between 10 weeks and 6 months
Lidocaine is a medication frequently ordered for the client experiencing: A. Atrial tachycardia B. Ventricular tachycardia C. Heart block D. Ventricular brachycardia
B. Ventricular tachycardia why? Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrhythmic effect by increasing the electric stimulation threshold of the ventricle without depressing the force of ventricular contractions.
What precaution must be taken with potassium permanganate?
Be careful that no undissolved crystals touch the client; it will burn the skin
The nurse should limit the client's efforts to ________ ______ during labor when CD is present.
Bear down
Why is the dorsogluteal site not recommended for IM injection the children less than 3 years of age?
Because the muscle is not well developed yet.
Why isn't Vitamin B-12 absorbed in pernicious anemia?
Because these patients lack intrinsic factor
What should the client do if they get a Meniere's attack?
Bed Rest
What activity order will the client with sickle cell CRISIS have?
Bed rest
What is the activity order after labyrinthectomy?
Bed rest
What treatment modality can lead to pulmonary embolus?
Bed rest
What will the activity order be for the post-MI client?
Bed rest with bedside commode
What is the most important intervention in treating AGN?
Bedrest - they can walk if hematuria, edema and hypertension are gone.
What activity order is the client with an aneurysm supposed to have?
Bedrest. do not get these people up
Fluid moves from the___________ to the _______ in the SHOCK phase.
Bloodstream, interstitial space
When pulmonary edema is severe what does the sputum look like?
Bloody and frothy
Amniotic fluid turns nitrazine paper deep _________ (color).
Blue
What is the first sign of MS?
Blurred or double vision
What vision problem do women with pre-eclampsia have?
Blurred vision
The uterus feels _______ after rupture of a fallopian ectopic pregnancy?
Boggy- tender, also
When you take the blood pressure of the client with hypertension you would measure _____- _______, with the client _____, _______ and _______.
Both arms; lying, sitting and standing
What is global aphasia?
Both receptive and expressive
Which will bring on a MS exacerbation: over-heating or chilling?
Both will; but they tend to do better in cool weather (summer will always be a bad time for MS patients)
Is hemodialysis short term or long term?
Both- but most short term dialysis is achieved by hemodialysis
The pulse rate of anorexics is tachycardic or bradycardic?
Bradycardic
Why is hypoglycemia such a dangerous problem?
Brain cells die without glucose, brain damage
What is the best treatment for breast engorgement?
Breast-feeding - it will balance supply and demand
Lack of surfactant causes the neonate to lose lung capacity with each _______.
Breath
You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing.
Bright thick blood, persistent clots, persistent urine on dressing (don't call MD for transitory clots and urine on dressing.)
Name 3 types of skin traction
Bucks Bryants Pelvic
-otomy
Butting
How can AGN be prevented?
By having all sore throats cultured for strep and treating any strep infections
How is pyelonephritis prevented?
By preventing or treating all cystitis (UTI's)
The nurse is talking with a client who has small oat cell lung cancer. The client states, "I have decided to stop my radiation therapy and will use an herbal treatment to help cure my cancer." Which of the following responses would be most appropriate for the nurse to make first? a. "What comments have your family members made about this?" b. "Do you understand your prognosis without radiation?" c. "How did you decide on this treatment?" d. "Has your primary health care provider been advised of this decision?"
C. A client has a right to make decisions regarding care based on accurate information about treatment alternatives. When a client decides to use alternative therapies rather than conventional therapies, it would be most appropriate for the nurse initially to explore how the client made the decision regarding the alternative treatment. The nurse should not initially ask if the primary health care provider has been advised about the decision since this may block communication.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first? A. A client with AIDS being treated with Foscarnet B. A client with a fractured femur in a long leg cast C. A client with a laryngeal cancer with a laryngetomy D. A client with diabetic ulcers to the left foot
C. A client with a laryngeal cancer with a laryngetomy why? The client with laryngeal cancer has a potential airway alteration and should be seen first.
The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal a pH of 7.36, CO2 at 45, O2 at 84, HCO3 at 28. The nurse would assess the client to be in: A. Uncompensated acidosis B. Compensated alkalosis C. Compensated respiratory acidosis D. Uncompensated metabolic acidosis
C. Compensated respiratory acidosis why? The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, so it is on the acidic side. The CO2 level is elevated, the oxygen level is below normal, and the bicarb level is slightly elevated. In respiratory disorders, the pH will be in inverse of the CO2 and bicarb level. This means that if the pH is low, the CO2 and bicarb levels will be elevated.
The nurse is performing discharge teaching on a client with diverticulitis who has been placed on low-roughage diet. Which food would have to be eliminated from this client's diet? A. Roasted Chicken B. Noodles C. Cooked Broccoli D. Custard
C. Cooked Broccoli why? the client with diverticulitis should avoid eating foods that are gas forming and that increase abdominal discomfort, such as cooked broccoli.
A 25 year old male is brought to the ER with a piece of metal in his eye. Which action by the nurse is correct? A. Use a magnet to remove the object B. Rinse the eye thoroughly with saline C. Cover both eyes with paper cups D. Patch the affected eye only
C. Cover both eyes with paper cups why? Covering both eyes prevents consensual movement of the affected eye.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate? A. Reinsert the protruding organ and cover with 4x4s B. Cover the wound with a sterile 4x4 and ABD dressing C. Cover the wound with a sterile saline-soaked dressing D. Apply an abdominal binder and manual pressure to the wound
C. Cover the wound with a sterile saline-soaked dressing. why? If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing.
The nurse is assisting a client with diverticulosis to select appropiate foods. Which food should be avoided? A. Bran B. Fresh Peaches C. Cucumber salad D. Yeast Rolls
C. Cucumber salad why? the client with diverticulitis should avoid foods with seeds.
The nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period? A. Assessment of the client's level of anxiety. B. Evaluation of the client's exercise tolerance C. Identification of peripheral pulses. D. Assessment of bowel sounds and activity.
C. Identification of peripheral pulses why? The assessment that is most crucial to the client is identification of peripheral pulses because aorta is clammed during surgery. This decreases blood circulation to the kidneys and lower extremities. The nurse must also assess for the return of circulation to the lower extremities.
"The nurse is reviewing the medication record of a female client with acute gastritis. Which medication, if noted on the client's record, would the nurse question? A. Digoxin (Lanoxin) B. Furosemide (Lasix) C. Indomethacin (Indocin) D. Propranolol hydrochloride (Inderal)"
C. Indomethacin (Indocin) is an NSAID and can cause ulceration of the esophagus, stomach, or small stomach, or small intestine. indomethacin is contraindicated in a client with gastrointestinal disorders.
Will a simple mastoidectomy worsen hearing?
No, a radical mastoidectomy may
The nurse is providing discharge teaching for a client who is taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating: A. Peanuts, dates, raisins B. Figs, chocolate, eggplant C. Pickles, salad with vinaigrette dressing, and beef D. Milk, cottage cheese, ice cream
C. Pickles, salad with vinaigrette dressing, beef why? The client taking antabuse should not eat or drink anything containing alcohol or vinegar
The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). Which instructions should be given to the client A. rest in bed after taking the medication for at least 30 mins B. Avoid rapid movements after taking the medication C. Take medication with water only D. Allow at least 1 hour between taking the medicine and taking other medications
C. Take medication with water only why? Fosmax should be taken with water only. The client should also remain upright for at least 30 mins after taking the medication.
The LPN is observing a graduate nurse as she assess the central venous pressure. Which observation indicates that the graduate needs further teaching? A. The graduate places the client in a supine position to read the manometer B. The graduate turns the stopcock to the off position from the IV fluid to the client C. The graduate instructs the client to perform the Valsalva manuever during the CVP reading D. The graduate notes the level at the top of the meniscus
C. The Graduate instructs the client to perform the Valsalva manuever during the CVP reading. why? The client should breathe normally during a central venous pressure monitor reading.
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which labatory value might be a indicate a serious side effect of this drug? A. Uric acid of 5mg/dL B. Hematoccrit of 33% C. WBC 2,000 per cubic millimeter D. Platelets 150,000 per cubic millimeter
C. WBC 2,000 per cubic millimeter why? Tegratol can suppress the bone marrow and decrease the white blood cells count; thus, a lab value of WBC 2,000 per cubic millimeter indicates side effects of the drug.
When the spinal cord injury is between _____ and _____, there is permanent respiratory paralysis.
C1 and C4
A nurse is caring for client who is pregnant and has a hx of MITRAL VALVE DISEASE. the client has marked limitation of physical activity. the nurse should recognize that the clients symptoms can be classified according to the New York heart association as:
CLASS III (3) means marked limitation in activity due to symptoms, even during less-than-ordinary activity.
a client with a herniated intervertebral disk would experience a sudden increase in pain when: 1. coughing and sneezing 2. sitting on cold surfaces 3. standing for extended periods 4. lying supine with the knees flexed
COUGHING AND SNEEZING these actions, as well as lifting and straining, cause an increase in the intraspinal pressure, resulting in pain. the rest of the choices will not increase pain.
The three most common complications after MI are ____ _____,_____, and _______.
Cardiogenic shock, arrhythmia, CHF
What is a common complication of a client in a body cast (like a Risser cast)?
Cast syndrome
The first sign of CVA is usually a___________.
Change in LOC
What are the symptoms of disequilibrium syndrome?
Change in LOC N/V Headache Twitching
What are the first two sings of hypovolemic shock?
Change in LOC and tachycardia
What do you do secondfor the client experiencing autonomic dysreflexia?
Check the bladder, check the bowel
Another name for medical asepsis is...
Clean technique
Will a woman with active bleeding in Placenta Previa be given any systemic pain relief during labor?
No, don't want to depress the fetus
What is the normal color of cerebrospinal fluid?
Clear, colorless
What three most common visual defects occur with cataract?
Cloudiness Diplopia (double vision) Photophobia (sensitivity to light)
Give some signs of infection in a Foley catheter
Cloudy urine, foul smelling urine, hematuria
What does the eye look like when a client has cataracts?
Cloudy, milky-white pupil
What type of rigidity is typical of Parkinson's?
Cogwheel
What kinds of fluids will clients with pemphigus drink best?
Cold fluids
What will the extremities of the client with a MI feel like?
Cold, clammy
Surfactant prevents the _________ of the alveoli.
Collapse
What technique is used to remove feces and flatus from the bowel through a colostomy?
Colostomy irrigation
Give three reasons for giving a back rub.
Comfort Stimulate circulation and muscles Relaxation
When assessing a dark skin client for Cyanosis , the nurse should be examine ?
Conjunctiva, lips, and oral mucous membranes
Eye drops should be placed directly into the _______ _______.
Conjunctival sac
What must you do if you reach across a sterile field?
Consider the area contaminated and not use the articles in the area
Patients with Parkinson's tend to have constipation or diarrhea?
Constipation
On what type of isolation will the patient with meningitis be?
Contact and respiratory precautions
If a woman is admitted with active bleeding with Placenta Previa you should monitor fetal heart tones _________.
Continuously via fetal monitor
Heparin is used in the acute phase of pulmonary embolus. What drug is used for 6 months after pulmonary embolus?
Coumadin
What will you hear when you auscultate the lungs of the client with CD of pregnancy?
Crackles-rales
Name foods that make acid urine
Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine)
An infant weighs 7 pounds at birth. The excpectd weight by 1 year should be: A. 10 pounds B.12 pounds C. 18 pounds D. 21 pounds
D. 21 pounds why? A birth weight of 7 pounds would indicate 21 pounds in 1 year or triple the his birth weight.
the pt has GERD and is admitted to the hospital for evaluation. The nurse should instruct the client in which of these laboratory tests that is the most accurate way for evaluating GERD? A. Esophageal manometry B. Endoscopy C. Bernstein's test D. 24-hour pH monitoring
D. 24-hour pH monitoring
The licensed practical nurse is working with a RN and a patient care assistant. Which of the following clients should be cared for by the RN? A. A client two days post-appendectomy B. A client one week post-thyroidectomy C. A client 3 days post- splenectomy D. A client 2 days post- thoracotomy
D. A client 2 days post-thoracotomy why? The most critical client should be assigned to the RN; in this case, that is the client 2 days post-thoracotomy.
The nurse is assessing a client who had a colonoscopy an hour ago. The client reports feeling weak and dizzy and the client's blood pressure has changed from 118/70 mm Hg to 104/56 mm Hg. Which of the following actions should the nurse take first? a. Notify the client's primary health care provider b. Check the client's temperature c. Auscultate the client's bowel sounds d. Elevate the client's legs above the level of the heart
D. A client who had a colonoscopy is at risk for bowel perforation and hemorrhage. The onset of weakness, dizziness and a decreasing blood pressure indicates possible hypovolemia and the nurse should elevate the client's legs above the level of the heart to help maintain cerebral tissue perfusion.
The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a post-patrum client. Which of the women is not a candidate for the RhoGam? A. A gravida IV para 3 that is Rh negative with a Rh postivie baby B. A gravida I para I that is Rh negative with a Rh positive baby C. A gravida II para 0 that is Rh negative attempted after a still birth delivery D. A gravida IV para II that is Rh negative with a Rh negative baby
D. A gravida IV para II that is Rh negative with a Rh negative baby why? The mother in answer D is the only one who does not require a RhoGam injection.
Which of the following post-op diets are most appropriate for a client who has had a hemorroidectomy? A. High fiber B. Low-residue C. Bland D. Clear liquids
D. Clear liquids why? After surgery, the client will be placed o n a clear-liquid diet and progressed to a regular diet. stool softeners will be included in the plan of care, to avoid constipation.
The nurse is assisting while an adult client has a thoracentesis. Which of the following actions would be correct for the nurse to take? a. Ask the client to hold the breath as the needle is inserted. b. Position the client on the side with a pillow support under the waist. c. Check the client's blood pressure while the pleural fluid is extracted. d. Attach a pulse oximetry probe to the client's finger.
D. During a thoracentesis, the client's respiratory status is monitored. Attaching a pulse oximetry probe to the client's finger would be appropriate. The client is not required to hold the breath as the needle is inserted.
When cleansing an infant's eye, cleanse from outer to inner canthus?
No, inner to outer
A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period? A. Teaching how to irrigate the illeostomy B. Stopping electrolytes loss in the incisional area C. Encouraging a high fiber diet D. Facilitating perineal wound drainage
D. Facilitating perineal wound drainage why? the client with a perineal resection will have a perineal incision. Drains will be used to facilitate wound drainage. This will help prevent infection of the surgical site. The client will not have an illestomy. as in answer A he will have some electrolyte loss, but treatment is not focused on preventing the loss, so answer B is incorrect A high fiber diet in answer C is not ordered at this time.
The physician has ordered a culture for the client with suspected Gonorrhea. The nurse should obtain what type of culture? A. Blood B. Nasopharyngeal secretions C. Stool D. Genital secretions
D. Genital secretions why? A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea
Which assignment should not be performed by the licensed practical nurse? A. Inserting a Foley catheter B. Discounting a nasogastric tube C. Obtaining a sputum specimen D. Initiating a blood transfusion
D. Initiating a blood transfusion why? A LPN should not assigned to initiate a blood transfusion. The LPN can assist with the transfusion and check ID numbers for the RN. The LPN can be assigned to insert Foley and French urinary catheters, discontinue Levine and Gavage gastric tubes, and obtain all types of specimens.
The client is admitted to the ER with shortness of breath, anxiety, and tachycardia. His ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. Te doctor orders quinidne sulfate. While he is receiving quinidine, the nurse should monitor his ECG for: A. Peaked P waves B. Elevated ST segment C. Inverted T wave D. Prolonged QT interval
D. Prolonged QT interval why? Quinidine can cause widened Q-T intervals and heart block. Other signs of myocardial toxicity are notched P waves and widened QRS complexes. The most common side effects are diarrhea, nausea, and vomiting. The client might experience tinnitus, veritgo, headache, visual disturbances, and confusion.
A client with acute leukemia develops a low white blood cell count. In addition to the institute of isolation the nurse should: A. Request that food be served with disposable utensils B. Ask the client to wear a mask when visitors are present C. Prep IV with mild soap, water, and alcohol D. Provide foods in seal single serving packages
D. Provide foods in seal single serving packages why? Because the client is immune-suppressed, foods should be served in sealed containers, to avoid food contaminants.
A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should: A. Request that foods be served with disposable utensils B. Ask the client to wear a mask when visitors are present C. Prep IV sites with mild soap and water and alcohol D. Provide foods in sealed, single-serving packages
D. Provide foods in sealed, single-serving packages Because the client is immune suppressed, foods should be served in sealed containers, to avoid food contaminants.
A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which lab finding indicates that the medication is having the desired effect? A. Neutrophil count of 60% B. Basophil count of 0.5% C. Monocyte count of 2% D. Reticlocyte count of 1%
D. Reticlocyte count of 1 % why? Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect.
119. A client has been receiving cyanocobalamine (B12) injections for the past six weeks. Which laboratory finding indicates that the medication is hav- ing the desired effect? ❍ A. Neutrophil count of 60% ❍ B. Basophil count of 0.5% ❍ C. Monocyte count of 2% ❍ D. Reticulocyte count of 1%
D. Reticulocyte count of 1% Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. Answers A, B, and C are white blood cells and have nothing to do with this medication.
What is cleft lip?
It is a birth defect that usually appears as a missing part of the upper lip extended toward the nose. People call this a "harelip," which is now generally considered offensive.
The home health nurse is planning for the day's visits. Which client should be seen first? A. The 78 year old who had a gastrectomy 3 weeks ago with a PEG tube B. The 5 month old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension C. The 50 year old with MRSA being treated with Vancomycin via a PICC line D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter
D. The 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter why? The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications.
The nurse is caring for a new mother. The mother asks why her baby has lost weight since he was born. The best explanation of the weight loss is: A. The baby is dehydrated due to polyuria. B. The baby is hypoglycemic due to glucose. C. The baby is allergic to the formula the mother is giving him. D. The baby can lose up to 10% of weight due to meconium still, loss of extracelluar fluid, and initiation of breast-feeding.
D. The baby can lose up to 10% of weight due to meconium still, loss of extraceullar fluid, and initiation of breast-feeding. why? After birth, meconium stool, loss of extracellular fluid, and initiation of breastfeeding cause the infant to lose body mass. There is no evidence to indicate dehydration, hypoglycemia, or allergy to the infant formula
Which client can be best assigned to the newely licensed to the Practical Nurse? A. The client receiving chemotherapy B. The client post-coronary bypass C. The client with a TURP D. The client with diverticulitis
D. The client with diverticulitis why? The best client to assign to the newly licensed nurse is the most stable client; in this case, it's the client with diverticulitis.
The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? A. The solution's rate is too rapid B. The client has phlebitis C. The infusion site is infected D. The infusion site is infiltrated
D. The infusion site is infiltrated
What IV solution is used during labor for the diabetic?
D5W
How often should anti-embolism hose (TED) be removed?
Daily
What daily measurement best indicates the amount of fluid the client is retaining?
Daily weight
The #1 danger when using the dorsogluteal site for IM injection is___________.
Damage to the sciatic nerve
The room of a patient with meningitis should be _______ and ______.
Dark and quiet
The urine output of the eclamptic client will (decrease/increase).
Decrease
The neurotransmitter imbalance that causes Parkinson's is a ______ in ______ ______
Decrease, dopamine activity
If there are any signs of infection after PROM, what must occur immediately?
Delivery of fetus
Prednisone
Deltasone Anti-inflammatory
MS is a progressive _____ disease of the CNS.
Demyelinating
Define Cystoscopy?
Direct visualization of the urethra and bladder through a cystoscope.
Which organism causes pyelonephritis?
E. Coli
What is the most common organism to cause UTI with catheterization?
E. coli
When you plan to use gloves for a procedure you do not need to wash hands before it. (T/F)
False, always wash even if you plan to use gloves
It is not necessary to use electronic fetal monitoring when there is active bleeding in Placenta Previa. (T/F)
False, infant must always be monitored
Eye medications can be given directly over the cornea. (T/F)
False, into the conjunctival sac, never the cornea; hold the dropper 1/2 inch above the sac
The primary reason why an infant is draped during the bath is to provide privacy. (T/F)
False, the primary purpose of draping is to prevent chilling.
When discontinuing a PCA infusion it is acceptable to discard the drug cartridge. (T/F)
False, the whole cartridge system must be returned to the pharmacy due to federal narcotic control laws.
Hearing aids make sounds more distinct and clear. (T/F)
False, they only amplify--make it louder, they do not clarify
Oral contraceptives decrease the risk of heart disease. (T/F)
False, use increases the risk
Myelin promotes _____, _____ _____ of nerve impulses.
Fast, smooth conduction
Is heart rate fast or slow in pulmonary edema?
Fast, tachycardia
Hepatitis A
Enteric precautions Fecal/oral route of transmission Incubates 3 to 5 weeks Vaccine available (Can give immune globulin after exposure) HAsAg (this is what the blood test show) Hepatitis A surface Antigen
The first thing a nurse should do when a client objects to side rails is...
Explain why they are being used.
Name the surgery performed for an ectopic pregnancy.
Exploratory laparotomy
The school-aged child perceives the cause of illness to to be external or internal?
External, she knows that illness is not a result of bad behavior.
If the child's _______ are ______ and the trunk -face abdomen are ________, the child scores 1 on color
Extremities are blue (cyanotic), Pink
The most common site for ectopic pregnancy is in the _________ __________.
Fallopian tube - 90%
Dietary indiscretions and uncleanliness are causes of acne?
False
Everyone with angina needs bypass surgery? t/f
False
It is safe practice to administer drugs prepared by another nurse. (T/F)
False
PROM always occurs in a gush of fluid. (T/F)
False
Uncleanliness is a cause of acne (T/F)
False
A disadvantage of PCA pumps is that the client does not ambulate as early due to the machine. (T/F)
False, PCA clients ambulate earlier and they pull their machine with them.
MS affects men more than women. (T/F)
False, affects women more than men
Carafate and sulcrafate
Give on empty stomach 1 hour before meals and at bedtime -- remember these coat the GI tract and interfere with the absorption of other medications (give them by themselves)
Antacids
Give on empty stomach I hour ac and hs
Ipecac
Give with 200-300 cc water-- not related to mealtime -- this is an emetic (to make you vomit after ingestion of poisons -- don't give if the poisons were caustic, or petroleum based)
Iron with nausea
Give with meals
Colchicine
Give with meals -- anti gout, remember if diarrhea develops, stop the drug
Allopurinol
Give with meals and give with lots of water--anti uric acid--- used to treat gout and the purine build up seen in chemotherapy for cancer
Theophylline derivative
Give with meals, ie, Aminophylline, Theodur (anti-asthmatic bronchodilator)
Pancreas pancreatin isozyme
Give with meals-these are oral enzymes used with children with cystic fibrosis to increase the absorption of the food they eat
Para-amino salicylate sodium (PAS)
Give with meals/food-- anti tuberculosis
What is another name of second intention?
Granulation
What force is used to introduce the dialysate into the peritoneum?
Gravity only, no pumps
What are 2 common psychological reactions to hysterectomy?
Grief, depression
If the neonate ____________, they will score a 1 on neuromuscular irritability.
Grimaces
which finding should the nurse report immediately for a pt with burns over 60 %? 1. moderate to severe pain 2. complaints of intense thirst 3. urine output of 70 ml/ hour 4. hoarse voice
HOARSE VOICE is a sign of injury to the respiratory system and may require immediate intubation. thirst following burns is expected b/c of the fluid loss and dehydration.
A third degre burn is hard or soft?
Hard
When mastitis is present the breasts are ________, _________, and __________.
Hard, swollen, warm
-sclerosis
Hardening of a tissue by: inflammation, deposition of mineral salt; an infiltration of connective tissue fibers
What kind of rod is used to "fix" curvature?
Harrington Rod
What should you do to assess for facial nerve paralysis post-mastoidectomy?
Have the patient smile and wrinkle forehead.
What are three signs of polycythemia vera?
Headache Weakness Itching
What are the 3 causative factors in acne vulgaris?
Heredity, Bacterial, Hormonal
Which type of paralysis is typical of CVA- paraplegia, hemiplegia or quadriplegia?
Hemiplegia
What are three types of transfusion reactions that can occur?
Hemolytic, febrile, allergic
Women with Cushings develop?
Hirsutism Amenorrhea
What are the signs of symptoms of an allergic reaction to a transfusion?
Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia)
Name the 5 risk groups for AIDS
Homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women
People who are (hetero/homo)zygous have sickle cell disease.
Homozygous
If PROM occurs after viability but before 36 weeks, what is the typical management?
Hospitalize, watch for infection, try to gain time for the infant to mature
If there is inflammation under a cast, it will be evident in a _______ spot.
Hot
When shaving a client, water used should be more (hot/cold) than bath water?
Hot
The burn patient will be on _______urine output and daily __________.
Hourly, weight
What is Kyphosis?
Humpback in the thoracic area
The infant with pyloric stenosis appears ______ even after vomiting.
Hungry
When pre-eclampsia gets worse the deep tendon reflexes will be (hyper/hypo) reflexia.
Hyper-reflexia
The Cushings syndrome patient will have ________ natremia, _________kalemia and _______glycemia.
Hyper; hypo; hyper
What causes cast syndrome, specifically in a Risser cast?
Hyperextension of the spine by a body cast: the hyperextension interrupts the nerve & blood supply to the gut
The nurse prepares to admit a 6-month-old diagnosed with ROTAVIRUS, severe diarrhea, and dehydration. The nurse should place the infant in which of the following rooms? 3. In a private room that is close to the nurse's station. 4. In any private room that is available.
IN A PRIVATE ROOM THAT IS CLOSE TO THE NURS'S STATION rotavirus is spread by fecal-oral route and requires contact precautions if client is diapered or incontinent
a nurse is caring for a client who is pregnant and positive for HIV. What information about the transmission of HIV to the fetus does a nurse include in the client's plan of care?
INFANTS INFECTED WITH HIV ARE USUALLY ASYMPTOMATIC AT BIRTH
What is spinal shock?
It is a common occurrence in spinal cord injury in which the spinal cord swells above and below the level in injury
What is lovenox?
It is a low-dose Heparin used for anticoagulation in POST-OP THROMBOPHLEBITIS PREVENTION NOT USED FOR PULMONARY EMBOLUS
When do you need a gown with AIDS?
If you are going to get contaminated with secretions
What is intermittent claudication?
Impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest. The perceived level of pain from claudication can be mild to extremely severe. Claudication is most common in the calves but it can also affect the feet, thighs, hips, buttocks, or arms. MC caused by PAD.
Which practice is most dangerous to a 3month-old infant? A. Being fed formula that is not mixed correctly. B. Car seat in a rear-facing position. C. Sitting in a cardboard box on the floor. D. Being put to sleep with a pacifier.
Improper mixing of formula can cause severe electrolyte imbalance.
What is Curlings ulcer? Why is it a problem in burn patients? What drug prevents it?
It is a stress GI ulcer, you get these with any severe physical stress. Tagamet, Zantac, Pepcid (any H2 receptor antagonist), Protonix Prilosec
Will the client with pyelonephritis have hematuria?
It is common but not always present
Can scalp tourniquets prevent chemotherapy alopecia?
In some cases, yes
When are hemolytic transfusion reactions likely to occur?
In the first 10 to 15 minutes
Define renal failure.
Inability of the kidney to excrete wastes & maintain fluid & electrolyte balance
Oral contraceptives (increase/decrease/do not effect) the blood pressure.
Increase
Vasoconstriction will ___________ blood pressure.
Increase
In gestational diabetes the client experiences a (decrease/increase) in thirst
Increase (polydipsia)
In gestational diabetes the client experiences a (decrease/increase) in urine output.
Increase (polyuria)
If the blood pressure (systolic) falls below 80 mmHg, what would you do first in hypovolemic shock?
Increase the oxygen flow rate
Is hemoglobin increased or decreased in this disease?
Increased
What are the dietary modifications for the oliguric phase of acute renal failure?
Increased carbohydrates, decreased protein, decreased sodium, decreased potassium, decreased water.
What are the dietary modifications for the recovery phase of acute renal failure?
Increased carbohydrates, increased protein.
What type of diet is indicated for a woman with pre-eclampsia?
Increased protein/normal salt intake (no restriction typically)
Patient's with MS should have (increased/restricted) fluids.
Increased to dilute urine and reduce incidence of UTI.
The major problem in CF is _______________.
Increased viscosity of the secretions of exocrine glands lead to obstruction.
During shock phase of a burn is potassium increased or decreased? Why?
Increased, because of all the cells damaged- the K+ is released from damaged cells.
If the patient has meningitis, the CSF shows _______ pressure, _____ WBC, ______ protein, ______ glucose.
Increased, increased, increased, decreased
The patient with Cushings Syndrome will have (increased/decreased) blood pressure.
Increased, remember retaining water and sodium
Pregnancy (decreases/increases) the body's insulin requirements.
Increases
How long can an AV fistula be used?
Indefinitely
What is the danger with PROM?
Infection
What does nosocomial infection mean?
Infection acquired through contact with contamination in the hospital
What is the most common side effect of accutane? And what is most important in health teaching in adminstration?
Inflammation of the lips; Causes birth defects
Give five causes of catarcts?
Injury Congenital Exposure to heat Heredity Age
Name the two sites used for intradermal injection.
Inner forearm Upper back
What type of movement should be used for cleansing eyes?
Inner to outer canthus
Should the suction be continuous or intermittent?
Intermittent to prevent mucosal damage
What nutrients should be supplied in the diet of the pregnant woman with CD?
Iron Folic acid Prevent anemia (anemia always makes the heart work more)
What does gluten do to the intestines of the client with celiac's disease?
It destroys the lining of the intestine
Why does the pyloric valve become stenosed in pyloric stenosis?
It hypertrophies
What is the dietary order for the woman with severe pre-eclampsia?
Low salt, high protein
How do you tell which side of the person's brain is dominant?
It is the side that controls their dominant hand, ie, a left handed person has a dominant right hemisphere and conversely a right hand person has a dominant left hemisphere
What does heterozygous mean?
It means you only have 1 defective gene from 1 parent.
What is the most effective way to decrease UTI with catheters?
Keep the drainage system closed, do not disconnect junction of tubing
What body position should be avoided after hysterectomy? Why?
Knee flexion (because it increases the chance of thrombophlebitis)
Kernig's sign is positive when there is pain in the _____ when attempting to straighten the leg with ____ flexed.
Knee; hip
Vinegar. Nits are the eggs of lice that adhere to the hair shaft
Kwell
With which other two spine deformities is scoliosis associated?
Kyphosis (humpback), Lordosis (swayback)
The 2 most common surgeries used to treat spinal cord injury are ____ and ______.
Laminectomy and spinal fusion
What are the two common treatments of cataract?
Laser, surgical removal. Surgery called intraocular or extraocular lens extraction
In what position should the client be during a spinal tap?
Lateral decubitus (on their side) position and knees to chest
Which nonfood item is the most common cause of respiratory arrest in young children? A. Broken rattles B. Buttons C. Pacifiers D. Latex balloons
Latex balloons
Scoliosis in the lumbar spine is usually convex to the (left/right).
Left (*Hint: curve Left in Lumbar)
If a central line is found accidentally open the patient should be positioned on his ______ ______.
Left side
What is the activity order for a woman with severe pre-eclampsia?
Left side lying
Are migraines more or less common in men?
Less
The patient who has NO definite plan is (low/high) risk for suicide.
Low
What type of diet is the client with Meniere's on?
Low salt
What might Levodopa do to patients urine?
Make it very dark
Which sex does it affect by Buerger's disease the most often?
Males
How would you tell if the woman with PROM had an infection?
Maternal fever Fetal tachycardia Foul smelling vaginal discharge
Should the client roll the elastic stocking down to wash legs? Why or why not?
No, it can cause a constricting band around the ankle/foot.
Should a child in sickle-cell crisis wear tight clothes?
No, it can occlude vessels even more.
The patient who has a definite plan is (low/high) risk for suicide.
Moderate to high, depends upon feasibility and ease of plan
After meals, the nurse must always check _______ of the CVA client for _________.
Mouth (cheek), food
In order to get a score of 2 on muscle tone the infant must_________________.
Move spontaneously (actively)
What will you hear when you auscultate the heart of the client with CD of pregnancy?
Murmurs
The preschooler fears separation as well as _________ when hospitalized.
Mutilation- remember preschoolers have vivid imaginations...fantasy
When the lens is to be extracted for cataracts, what drugs are given preoperatively?
Mydriatics Dilators Antibiotic drugs (gtts)
What drug is most commonly used in polycythemia vera?
Myleran -- (this is usually used for bone marrow cancer)
What follows the RUQ abd pain of appendicitis?
N/V
What are the 3 most common chemotherapeutic GI side effects?
N/V Diarrhea Stomatitis (oral sores)
What is important about the level of the urinary drainage bag?
Never have the bag at a higher level than the bladder.
Can the client be removed from skeletal traction?
No
Does anything exit the skin in an AV fistula?
No
Does the client have to be NPO before a spinal tap?
No
Is a C-section mandatory for delivery of a woman with CD of pregnancy?
No
Is cholesterol a triglyceride?
No
Is it ok to routinely irrigate indwelling catheters?
No
Is urinary incontinence an indication for catheterization?
No
Should pregnant staff care for a client with a cesium implant?
No
Should you cover a wet cast?
No
Should you use a heat lamp or hair dryer or fan to help dry a cast?
No heat lamp and hair dryer Yes fan
A newborn receives a score of 0 on muscle tone when there is__________
No movement (limp)
Should you take a rectal temp after prostatectomy? Give stool softeners?
No rectal temperatures, yes stool softeners
To receive a 0 on reflex (neuromuscluar) irritability the neonate must exhibit _______
No response
Should the client ambulate independently after cataract surgery?
No the patient should not ambulate independently, depth perception is altered.
What should be avoided in the arm of the client with an AV shunt?
No venipuncture or blood pressure allowed in the arm with a shunt, graft or fistula.
AFTER repair of cleft lip is infant allowed to cry? To breast feed?
No, the infant should be held to PREVENT CRYING; the infant is not allowed to breast-feed because sucking is not good after lip repair.
Should lemon and glycerine swabs be used to cleanse the mouth?
No, they are not cleansing agents. They are used AFTER cleansing as a moistening agent
Is it always bad for the nurse to self-disclose?
No, you can self-disclose as long as you do it cautiously and you are 100% sure it is therapeutic.
Immediately after opening a bottle of sterile water, can you pour it directly into a sterile basin?
No, you must pour a few cc's out of the bottle into a waste container before you pour into the sterile basin. (This is called "lipping" the bottle)
What are the three signs of increased intraocular pressure?
Pain (moderate to severe) Restlessness Increased pulse rate
To insure that Bryant's traction is working the child's hip/sacrum should be _________
Off the bed enough to slip a hand between the sacrum and the bed
An emulsion is a mixture of ______ and ______.
Oil and H2O
Which is more dangerous, oliguria or anuria? Why?
Oliguria, because since you are losing more fluids you are actually hemo-concentrating the hyperkalemia more
Give 3 stages of acute renal failure.
Oliguric, diuretic, recovery
In what position would you place a client in suspected hypovolemic shock?
On back with arms and legs elevated
In the recovery room (PACU) the patient should be positioned....
On either side
What is the best location in a client's room to set up a sterile field?
On the over-bed table
How many times per day will the client irrigate his colostomy?
Once
What is the routine for vital sign measurement with a transfusion?
Once before administration Q15 x 2 after administration is begun Q1 x1 after transfusion has stopped
When is pre-eclampsia called eclampsia?
Once convulsions have occured
Due to MI occurs within _____ of symptom onset in 50% of all patients.
One hour
How can the woman with cesium implant move in bed?
Only from side to side
Of all the following, which one(s) increase in hypovolemic shock? Blood pressure, output, heart rate, pH, LOC, pulse pressure, respiratory rate
Only the heart rate and respiratory rate
When should the nurse WITHHOLD IM injections in the client on chemotherapy?
Only when their PLATELET count is down.
Liquid drugs should be poured out of the side (opposite of/the same as) the label.
Opposite
How long does the woman have to be off oral contraceptives before hysterectomy?
Oral contraceptives should be discontinued 3 to 4 weeks preoperatively.
What does evening or hour of sleep (HS) care consist of?
Oral hygiene Washing face/hands Back rub Tightening linens
The meats that are highest in cholesterol are _________ meats.
Organ meats liver, heart, brains, kidneys
Termination phase begins in the _______phase.
Orientation
The nurse should introduce information about the end of the nurse/patient relationship during the _____phase.
Orientation
What is the #1 side effect of antihypertensives?
Orthostatic hypotension (means you feel weak when you rise to a standing position because your blood pressure falls)
Ectopic pregnancy is implantation of a fertilized ovum ________ the _________.
Outside, uterus
Cushings syndrome is __________ secretion of _______, _______ and _______ _______ by the _______ _______.
Oversecretion; glucocorticoids, mineralocorticoids, androgenic hormones; adrenal gland
Clients on what type of therapy must use a safety blade razor (non electric)?
Oxygen therapy, since an electric razor could cause sparks
What are the top 3 priorities in care of the client with sickle-cell crisis?
Oxygenation, hydration, and PAIN control
What is the causative organism of acne?
P. acnes (propionibacterium acnes)
Coumadin therapy is monitored by what daily test?
PT (prothrombin time)
Heparin therapy is monitored by daily measurement of the _______.
PTT (partial thromboplastin time)
What is the difference between whole blood and packed cells?
Packed cells don't have nearly as much plasma or volume as whole blood does
Give three possible causes of hyperemesis gravidarum.
Pancreatitis Multiple pregnancies Hydatidiform mole
What is paralytic ileus?
Paralysis of the bowel due to surgery (common --especially in abdominal surgery)
Spinal cord injury in the thoracic/lumbar regions result in ___plegia.
Paraplegia
Are anticholinesterases sympathetic or parasympathetic?
Parasympathetic
What is the famous triad of symptoms in Meniere's?
Paroxysmal whirling vertigo -- sensorineural hearing loss--tinnitus (ringing in the ears)
Who is the most likely to receive a graft for dialysis?
People with diabetes mellitus.
What commonly happens secondary to otitis media?
Perforation of the ear drum
What procedure is done to relieve symptoms in polycythemia vera?
Phlebotomy
If the kidney stone is calcium phosphate the diet must be low in _____ too.
Phosphorous
What would you do if the cesium implant came out?
Pick it up with forceps only - never touch with hand even if you are wearing gloves.
Upon what do you support a cast while it dries?
Pillows (no plastic covers)
Name a new drug with anti-platelet activity.
Plavix
The typical pneumonia of AIDS is caused by ___________ ____________.
Pneumocystic carinii
The most common intervention for the CF client with a diagnosis of decreased airway clearance is _________________.
Postural drainage
Medical asepsis (Define)
Practices that help reduce the number & spread of micro-organisms (synonym for clean techniques)
Clean technique (Define)
Practices that help reduce the number & spread of micro-organisms (synonym for medical asepsis)
Surgical asepsis (Define)
Practices that render & keep objects & areas free from all micro-organisms (synonym for sterile techniques)
What are the steps of the nurse/patient therapeutic relationship?
Pre-interaction phase Orientation phase Working phase Termination phase
What is the most common arrhythmia after a MI?
Premature ventricular contractions (PVCs)
During an acute bleeding episode, you should apply________ for 15 minutes and apply________.
Pressure, ice
Gestational diabetes is associated with what OB history?
Previous large baby (over 9 lbs), unexplained stillbirth, miscarriage, congenital anomalies
What are the stages of syphilis?
Primary, secondary, latent, late
Why is penicillin administered with Procaine? With Probenecid?
Procaine makes the shot less painful; Probenecid blocks the excretion of penicillin
Define evisceration
Protrusion of abdominal contents through a dehiscence.
What skin symptoms do you see in hepatitis? (Give 2)
Pruritis (itching) Jaundice (Both are due to bilirubin accumulation)
Where does the pain of appendicitis finally end up?
RLQ
What is the most common site for an AV shunt?
Radial artery to radial vein
When a patient does not understand INCOMING language he is said to have ______ aphasia.
Receptive
Within in minutes of birth, what 3 respiratory difficulties occur?
Retractions, nasal flaring, and grunting
In what position should a child with pyloric stenosis be after a feeding?
Right side with HOB up
What would you do if the client's urine was pink-tinged after cystoscopy?
Record it in the notes, no need to call the MD.
A pt is admitted for depression about resenty life events.He remains silent ,looks to the floor and soes not answer the PNs questions.What ineterventions is best to implement
Record this in the medical records under DSM IVAxis IV
What is the common finding with pediculosis pubis?
Reddish-brown dust in the underwear
Traction is used to _______ and _______ a fracture, relieve ________ _______ and prevent ________.
Reduce and immobilize, muscle spasm; deformities
A nurse is assisting a health care provider (HCP) during the examination of an infant with hip dysplasia. The HCP performs the Ortolani maneuver. Which of the following best describes the action/purpose of the Ortolani maneuver?
Reducing the dislocated femoral head back into the acetabulum
If a family member asks to have the side rails down while they are in the room you should...
Remember that you are responsible for the client's safety-- not his family, it might be unwise to permit this
How do you prevent flexion contracture of the knee after BKA?
Remide the patient to straighten their knee constantly while standing
What is the purpose of a wound drain?
Remove secretions from the area so healing occurs.
How do you care for an infant with a Logan Bow?
Remove the gauze before feeding and cleanse after feeding with peroxide and saline.
What do you do if you get blood in the syringe upon aspiration?
Remove the syringe immediately and apply pressure; you must discard the syringe and redraw medication in a new syringe
What is the most dangerous side effect/complication of fallopian ectopic pregnancy?
Rupture of the fallopian tube
What is the BIG danger with aneurysms of any type?
Rupture, leads to shock and death
ANTHRAX can be transmitted via which route:
SKIN, INHALATION, GASTROINTESTINAL
What are the two most common subjective complaints of the woman who is decompensating during labor?
SOB Palpitations
A nurse is providing care for an older adult client. Which of the following findings indication fluid imbalance? Select all that apply. A. Tenting of skin on back of hand B. Sunken eyes C. Oliguria D. Capillary refill greater than 5 seconds E. Moist mucous membranes F. Flattened neck veins
SUNKEN EYES OLIGURIA CAPILLARY REFILL GREATER THAN 5 SECONDS FLATTENED NECK VEINS
a nurse manager is educating a group of nurse about how a medication acts by decreasing the destruction of a neurotransmitter btw neurons. The nurse manager correctly states that the space btw the axon of one neuron and dendrite of another is called the
SYNAPSE
What is a major nursing diagnosis post-mastoidectomy?
Safety
What will be a high priority nursing diagnosis for a client post cataract surgery?
Safety
What precautions are important in the care of the client receiving PD?
Safety, because they get dizzy
Name a drug given to treat migraine?
Sansert (methsergide), Cafergot (Prophylaxis: Imipramine)
The client with hemianopsia should be taught to ____________.
Scan
What are the four classic suicide precautions?
Search personal belongings for drugs & alcohol, remove any sharp objects, remove any device for hanging or strangling; must be on constant one-to-one observation (NEVER out of sight)
What types of precautions will be in effect for a woman with severe pre-eclampsia?
Seizure precautions
The client with meningitis can develop________.
Seizures
In which position should a woman with CD in labor be?
Semi recumbent, HOB up
The best client position during airway suctioning is _______.
Semi-fowlers
In what position should the bed be if the patient is in pelvic traction?
Semi-fowlers with knee gatched
In Abruptio Placenta, the placenta _______________ from the uterine wall ____________.
Separates, prematurely
The toddler fears _______ most when hospitalized.
Separation from family
How does the mother break the suction of the breast feeding infant?
She inserts her little finger into the side of the infant's mouth
What measurement must the woman with pre-eclampsia make every day?
She must weigh herself
Name the 3 phases of burn
Shock, diuretic, recovery
How are cleft lip and cleft palate primarily treated?
Surgical repair
What medication is given to NB? By what route?
Survanta (Surfactant) via ET tube. Repeat doses are often required
If the nurse uses self-disclosure it should be ______ and the conversation should be...
Short, quickly refocused back on the patient
What is meant by dyspnea on exertion?
Shortness of breath when active.
After advancing a Penrose drain you (should/should not) cut off the excess drain?
Should
The typical hospital client (should/should not) wear their dentures.
Should
Can a woman on oral contraceptives breastfed?
Should not use OCP during the first 6 weeks after birth because the hormones may decrease milk supply. Estrogen is not recommended. Non-hormonal methods are recommended. Remember, breastfeeding is an unreliable contraceptive.
How high should the dialysate bag be when its infused?
Shoulder height
What type of gait is seen in Parkinson's?
Shuffling slow gait
What genetic disorder can lead to pulmonary embolus?
Sickle cell anemia
After receiving ear drops the client should remain in ________position for ________minutes.
Side lying, 5
Should a CVA patient have all four side rails up at all times? Should they be restrained?
Side rails yes. Restraints- no, unless they are a danger to themselves or others When
If a patient has opisthotonos, in what position would you place them?
Side-lying
The unconscious client should assume what position during suctioning?
Side-lying, facing nurse
In what position should the client be when they irrigate their colostomy?
Sitting
An infant is given a score of 1 if their respirations are _______ or ________.
Slow or irregular
How should you change the position of the spinal cord injury patient after he has an order to be up? Why?
Slowly, because of severe orthostatic hypotension (they use a tilt table)
Another name for surgical asepsis is...
Sterile technique
What kind of lubricant should be used on the suction catheter?
Sterile water-soluble
Chronic _____________therapy imitates Cushings.
Steroid
pemphigus medication treatement
Steroids
What is the most common musculo-skeletal symptom of meningitis?
Stiff neck- nuchal rigidity
What three drugs are given post-operatively for surgical cataract removal?
Stool softeners Antiemetics Analgesics (mild to moderate)
In hepatitis the ________ are light colored.
Stools: remember the urine is dark and stools are light. (Bilirubin ends up in the skin and urine instead of the stool where it should have gone.)
What would you do first if you suspected transfusion reaction?
Stop the blood and start the saline
If a transfusion reaction occurs what should the nurse do first?
Stop the blood flow & start running the saline
What color is the dialysate when it comes out?
Straw-colored - clear
What is seen on the abdomen of the patient with Cushings?
Striae--purple horizontal lines
What is the difference between structural and functional scoliosis?
Structural-you are born with; Functional-you get from bad posture
Into what space is the needle inserted during a spinal tap?
Subarachnoid space
Bacteriostatic (Define)
Substance that prevents or inhibits the growth of micro-organisms
Name 5 things included in seizure precations.
Suction machine in room O2 in room Padded rails up X 4 Must stay on unit Ambulation with supervision only No More than 1 pillow
What is meant by paroxysmal nocturnal dyspnea?
Sudden episodes of difficulty breathing
What should the client avoid after labyrinectomy?
Sudden movements and increased Na food
If the client with CD of pregnancy experiences sudden heart failure what is the MOST common thing you will see?
Sudden onset of SOB (dyspnea).
After administration of a vaginal durg the client should remain _____ for______ minutes.
Supine, 10
After using nose drops, the client should remain ______ for _______ minutes.
Supine, 5
What is done to correct pyloric stenosis?
Surgery (pyloromyotomy)
The nurse should use (medical/surgical) asepsis during airway suction?
Surgical asepsis (sterile technique)
What kind of treatment is done for severe scoliosis?
Surgical fusion with rod insertion
-ectomy
Surgical removal of
The most common medical-surgical treatment for ectopic pregnancy is___________.
Surgical removal of fetus and some surrounding tissue
What are the two most common medical treatments for otitis media?
Systemic antibiotics Antibiotic ear drops
the client in the PACU has noisy and irregular respirations with a pulse Ox 89 %. which intervention should the PACU nurse implement first? 1. increase the clients O2 rate via nasal cannula 2. tilt the head back and push forward on the angel of the lower jaw.
TILT THE HEAD BACK AND PUSH FORWARD ON THE ANGEL OF THE LOWER JAW the client is exhibiting s/s of hypopharengeal obstruction , and this maneuver pulls the tongue forward and opens the air passage.
Which heart rate is associated with hypovolemic shock, bradycardia or tachycardia?
Tachycardia
Thorazine
Take with LOTS OF WATER regardless of meals to prevent constipation. All drugs that end in "-zine" are major tranquilizers that also cause Psuedo Parkinson's or extra-pyramidal effects.
Sulfonamides
Take with LOTS OF WATER regardless of whether you give it at mealtime or not -- Bactrim, Septra, Gantricin, ie, used to treat UTI
Stool Softeners
Take with lots of water regardless of mealtim
Codeine
Take with lots of water rergardless of meals -- to prevent constipation
What is meant when the physician/nurse use the terms total (complete) or partial (incomplete) in reference to placenta previa?
Total or complete: placenta covers the whole cervical opening Partial or incomplete: placenta covers only part of the cervical opening
Methotrexate
Toxic to just about every organ except to heart, toxicity made worse with aspirin
Where is the pain of migraine most likely located?
Temporal, supraorbital
Acrocyanosis
Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.
If mastitis is caused by an organism, what causes breast engorgement?
Temporary increase in vascular and lymph supply to the breast in preparation for milk production
What is the lesion like in primary syphilis?
The chancre (pronounced shanker)
What is egocentricity? In what stage is it found?
The child views everything from his frame of reference, common in pre-operational thinking
The nurse is teaching a health promotion class to a group of clients. The nurse should recognize that the risk for developing pneumonia is increased if a client has a. moderate Alzheimer's disease b. an ileostomy c. unstable angina pectoris d. renal stents
The correct answer is A. Risk factors for pneumonia include altered mental status, diabetes mellitus, chronic lung disease, and cancer. The client with moderate Alzheimer's disease has altered mental status.
The nurse is participating in a community-based health fair. The nurse should recognize that which of the following clients is at increased risk for suicide and should receive a depression screening questionnaire? a. an 80-year-old client with mild Alzheimer's disease (AD) b. a 48-year-old client with psoriasis c. a 16-year-old client who has changed schools d. an 8-year-old client with diabetes mellitus, type 1
The correct answer is A. Risk factors for suicide include being elderly, chronic illness, social isolation and individuals who misuse alcohol or other drugs. The 80-year-old client with mild AD is at increased risk for injury since the client is aware of the cognitive changes that are occurring. Also, this individual typically has multiple losses. This client should receive a depression screening questionnaire. A client who changed schools is at lower risk for depression based on the answer choices given.
The nurse is preparing a 3-year-old child for a bone marrow aspiration from the iliac crest. Which of the following statements would be appropriate for the nurse to make to help ensure the child's cooperation during the procedure? a. "You will feel like someone is pressing the lower part of your tummy." b. "A small needle will be used to get important cells from your bone." c. "Take several deep breaths when I tell you to so you won't feel any pain." d. "After the dressing is put on your skin you will be able to go home."
The correct answer is A. A toddler needs simple explanations about what will be seen, heard, and felt. Advising the child that it will feel like someone is pressing on the lower part of the tummy will help the child understand the location of the procedure and the sensation to expect. The toddler is less likely to understand what a dressing means.
The home health nurse has assessed a client with a stage 3 pressure sore on the left foot that has been present for over 3 months without any improvement. The client has a normal serum protein level and has been non-weight bearing on the left foot since the pressure sore was diagnosed. The client is currently applying a topical medication and dry dressings to the site as prescribed. Which of the following individuals would be appropriate to consult initially regarding the client's care? a. enterostomal therapist b. plastic surgeon c. registered dietician d. orthopedic surgeon .
The correct answer is A. An enterostomal therapist is trained to evaluate and develop treatment plans for complex wounds, such as the wound described in the question
The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The client has lost about 5 kg (11 lb) during the past two months and reports moderate muscle weakness. Which of the following actions would be most appropriate for the nurse to take? a. Encourage the client to add cheese to steamed vegetables. b. Encourage the client to perform ankle circling exercises while seated. c. Ask the client to drink a liquid nutritional supplement at the beginning of meals. d. Ask the client to consider enrolling in a water-aerobic exercise class in the community.
The correct answer is A. COPD is a high-energy disease and the client needs a higher caloric intake to help maintain weight and to prevent muscle weakness. Adding cheese to steamed vegetables adds calories. Steamed vegetables are also soft and easy to chew. Liquid nutritional supplements should be consumed at the end of meals or between meals. Drinking the supplement at the beginning of the meal may cause fatigue or early satiety resulting in decreased food intake by the client.
The nurse is contributing to a staff development conference regarding legal responsibilities of health care providers. Which of the following information, if documented in a client's record, should the nurse identify as increasing the risk for a charge of libel? a. Court date pending for charge of child molestation. b. Stab wound to the chest after incidence of domestic violence. c. Unprotected intercourse with multiple sexual partners. d. Use of crack cocaine in social settings.
The correct answer is A. Defamation of character is making false or malicious (intentionally harmful) statements that may harm another person's character or reputation. Oral statements are considered slander and written statements are considered libel. Documenting that a client has a pending charge for child molestation would increase the risk for a charge of libel. The history of unprotected sex with multiple sex partners is pertinent to the client's care.
The unit clerk informs the nurse about the following client requests. The nurse should first check the client with a. primary hypertension who requests an analgesic for a headache b. peripheral vascular disease who requests lotion for burning in the feet c. diabetes mellitus who requests powder for a red area of skin in the axilla d. chronic obstructive pulmonary disease (COPD) who requests water for the humidifier
The correct answer is A. Maslow's hierarchy of human needs provides a framework to determine priorities. The client with hypertension who requests medication for a headache may be developing a potentially life-threatening change in cerebral perfusion, such as a cerebrovascular accident and should be checked first. The client with COPD should have increased humidity to help minimize drying of secretions but this request, if delayed, is not life-threatening.
A drug given by a parenteral route acts outside the GI tract. (T/F)
True
The nurse is feeding a full term newborn who is on continuous cardiac monitoring. The infant starts to cough, the alarm on the monitor starts to ring and the newborn resumes sucking. The nurse should next a. silence the alarm b. check the monitor settings c. gently pat the newborn's back d. replace the electrodes on the newborn's chest
The correct answer is A. The cardiac alarm may sound whenever there is a change in infant activity, such as coughing. Coughing is a protective reflex and indicates an effort to clear the airway. Based on the question, the nurse should next silence the alarm and then check the electrodes.
The nurse is completing a neurological assessment on a client who sustained a closed head injury 2 hours ago. Which of the following actions by the nurse would be correct? a. using a tongue blade to check the client's glossopharyngeal nerve b. using the tip of a sterile needle to check the client's facial nerve c. checking the client's patellar deep tendon reflexes after extending the client's leg d. checking the client's biceps reflex after turning the client's palm downward
The correct answer is A. The glossopharyngeal and vagus nerves are checked using a tongue blade. The facial nerve is tested by asking the client to make various facial movements and to identify several different tastes. The client's knee should be flexed before checking the patellar deep tendon reflex. The client's palm should be upward before checking the biceps reflex.
The nurse is preparing to administer a unit of packed red blood cells to a client as prescribed. The nurse should ask the client to immediately report the onset of a. a dry mouth b. back pain c. yawning d. urinary urgency
The correct answer is B. A client who is receiving blood products is at risk for an acute transfusion reaction, such as a hemolytic reaction, that may be life-threatening. The client should immediately report the onset of chills, headache, backache, dyspnea or chest pain.
The nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a client as prescribed. Which of the following should the nurse have immediately available? a. a latex-free tourniquet b. epinephrine (Adrenaline) 1:1000 c. a commercial cold pack d. methylprednisolone (Solu-Medrol)
The correct answer is B. A client who is receiving injectable medications and vaccines is at risk for an immediate hypersensitivity reaction. The nurse should have epinephrine 1:1000 immediately available to administer to help prevent airway collapse.
The home health nurse is administering an intravenous anti-infective as prescribed to a client with osteomyelitis. Which of the following observations would indicate that the client's peripheral intravenous catheter site needs to be changed before the nurse completes the infusion as prescribed? a. ecchymosis distal to the site b. pallor proximal to the site c. a margin of redness outside of the site's transparent dressing d. skin blisters visible underneath the site's transparent dressing
The correct answer is B. A client who is receiving medications via a peripheral intravenous site needs to be monitored for indications of infiltration. This is manifested by localized swelling, coolness, pallor and discomfort at the IV site. If an infiltration is present, the infusion is stopped, the catheter is removed and the infusion is restarted at a new site. Blisters under the dressing may indicate reaction to the adhesive but is not an indication that the site needs to be changed.
The home health nurse is checking an adult client with chronic obstructive pulmonary disease (COPD). Which of the following observations would require intervention by the nurse? a. oxygen saturation 91% via pulse oximetry b. oxygen at 5 liters/minute via nasal cannula c. clubbing of the nail beds d. discolored nail beds
The correct answer is B. A client with COPD should have oxygen flowing no higher than 3 liters/minute via nasal cannula to help maintain the respiratory drive. Clubbing of the nail beds is a normal finding for a client with COPD.
The nurse is teaching a client who was recently diagnosed with a generalized seizure disorder. Which of the following should the nurse state has been associated with the onset of seizure activity? a. drinking cold beverages b. sunlight flickering through tree branches c. working in a noisy environment d. the smell of burning debris
The correct answer is B. A client with a generalized seizure disorder should be taught methods to help minimize seizure activity. Flickering lights have been identified as a stimulus for seizure activity.
The charge nurse in the long-term care facility is scheduling procedures for several clients as prescribed. Which of the following clients should the nurse make sure is scheduled for the first appointment in the morning? a. A client with an elevated blood urea nitrogen (BUN) level who needs to have a renal ultrasonography. b. A client with a low white blood cell count (WBC) who needs to have a chest radiography. c. A client with dark-colored bowel movements who needs to have a colonoscopy. d. A client with severe heartburn who needs to have an upper endoscopy.
The correct answer is B. A client with a low WBC is at risk for infection and should have procedures scheduled at the first available appointment time to help minimize the client's risk for infection in a busy or crowded waiting area. The client with an elevated BUN is at lower risk for a potentially life-threatening infection.
The nurse has assessed a client with acute renal failure. The nurse should immediately report that the client has a. voided urine that looks like water b. frothy pink sputum c. not had a bowel movement in 3 days d. 1+ sacral edema
The correct answer is B. A client with acute renal failure is at risk for heart failure and pulmonary edema. The presence of frothy pink sputum requires immediate action by the nurse.
The home health nurse is talking with a client who has hepatic cirrhosis and esophageal varices. The client reports losing about 2.2 kg (5 lbs) during the past 4 weeks without any attempt at weight loss. Which of the following should the nurse recommend to help the client maintain weight? a. adding butter to popcorn b. eating fruit canned in syrup c. adding cheese to raw vegetables d. eating toasted wheat bread with jelly
The correct answer is B. A client with hepatic cirrhosis and esophageal varices is at risk for altered nutrition. The client should avoid foods that are hard, like popcorn and fresh fruit, since this may increase the risk for bleeding. Eating fruit canned in syrup would help to add calories and vitamins with minimal risk for bleeding.
CHF can result from MI. (T/F)
True
Cigarette smoking increases the risk of heart disease. (T/F)
True
Clients with a Milwaukee brace should avoid vigorous exercise. (T/F)
True
The nurse is caring for a client with severe rheumatoid arthritis. Which of the following actions would be appropriate for the nurse to take while the client is resting in bed? a. Place a rolled washcloth in the client's hands. b. Support the client's forearms on a small pillow. c. Position a folded towel under the client's knees. d. Use a rolled sheet along the client's thighs.
The correct answer is B. A client with rheumatoid arthritis is at risk for increased joint deformities due to incorrect positioning and lack of exercise. The nurse should support the client's forearms on a small pillow while the client is resting in bed to help minimize strain on the shoulder region and to promote blood flow. A rolled washcloth in the client's hands will increase stiffness of the hands.
The nurse is conducting a community-based health fair. The nurse should recognize that which of the following is an appropriate age-based screening? a. breast cancer screening for a 16-year-old female who has anorexia nervosa b. skin cancer screening for a 27-year-old female who is a bridge construction worker c. prostate cancer screening for a 30-year-old male who is Asian d. colorectal cancer screening for a 35-year-old male who is Caucasian
The correct answer is B. Cancer screening is an important role for the nurse in the community. Skin cancer screening is appropriate for a 27-year-old female construction worker since the client works outdoors. Prostate cancer screening begins between 45 and 50 years of age, colorectal cancer screening begins at 50 years of age and breast cancer screening begins at 18 years of age.
The home health nurse is reinforcing teaching with the parents of a child who has a new permanent tracheostomy. Which of the following statements should the nurse make? a. "The portable suction unit should be set at 15 mm Hg." b. "A routine tracheostomy tube change should be scheduled prior to a feeding or at least an hour after a feeding." c. "Wait at least four hours between suctioning intervals." d. "Each new tracheostomy tube is inserted by holding one edge of the tube at the lateral edge of the stoma then gently lifting the tube until it is centered over the stoma."
The correct answer is B. Changing a tracheostomy tube may cause episodes of coughing. Scheduling the change prior to a meal or at least an hour after a meal may help to minimize vomiting.
The nurse is assessing a client who takes prescribed furosemide (Lasix). Which of the following statements by the client may indicate that the client may be experiencing an adverse effect and would require follow-up? a. "My weight is unchanged." b. "I feel so tired." c. "My urine looks like water from the faucet." d. "I have greenish-colored bowel movements."
The correct answer is B. Clients who take Lasix are at risk for anemia and hypokalemia. The report of being tired may indicate an adverse effect of Lasix and would require follow up. A stable weight indicates the medication is effective.
The nurse is assessing a client who is taking hydrochlorothiazide (HCTZ). Which of the following questions would be essential for the nurse to ask the client? a. "Do bright lights hurt your eyes?" b. "Have you noticed any change in your appetite?" c. "How much water do you drink during the day?" d. "Do you have a dry cough?"
The correct answer is B. Hydrochlorothiazide may cause hypokalemia. Hypokalemia may be indicated by muscle cramps, abdominal distention, anorexia, and constipation. Asking the client about a change in appetite would be essential to help identify potential fluid and electrolyte imbalances. The client's intake of water has lower priority than identifying indications of fluid and electrolyte imbalances.
The nurse is preparing a client for discharge after the client had a colonoscopy with removal of a rectal polyp. Before the client is discharged, the nurse must a. measure the client's abdominal girth b. check the client's blood pressure c. determine if the client has expelled any flatus d. assess the client's gag reflex
The correct answer is B. Prior to discharging a client, the nurse must make sure that a client is not experiencing any complications. After a colonoscopy, the client is at risk for hemorrhage and bowel perforation. The nurse must check the client's blood pressure before the client is discharged. The client is not required to expel flatus prior to discharge.
The nurse is caring for a 72-year-old client who is receiving percutaneous endoscopic gastrostomy (PEG) tube feedings. The client has residual dysphagia and hemiparesis due to a cerebrovascular accident (CVA). The nurse observes that the client is having difficulty remaining alert and has the new onset of confusion. The nurse should immediately check the client's a. abdominal girth b. oxygen saturation level c. peripheral pulses d. gastric residual
The correct answer is B. Risk factors for pneumonia include immobility, advanced age, aspiration of gastric contents and a suppressed immune system. Geriatric-aged clients have a suppressed immune system and may not have typical fever and respiratory changes when an infection develops. Based on the history presented in the question, the nurse should immediately check the client's oxygen saturation level since a change in mental status may indicate hypoxia associated with aspiration pneumonia.
The nurse is assessing a 72-year-old male client before the client's annual physical examination. The nurse should understand that which of the following changes is a normal part of the aging process? a. increased rapid eye movement (REM) sleep b. decreased bladder capacity c. increased difficulty remembering events d. decreased muscle tone
The correct answer is B. The normal aging process causes a decrease in the bladder capacity. Memory loss is not considered a normal part of the aging process.
The nurse is conducting a staff development conference regarding internal disasters. The nurse should state that if building evacuation is required, priority should be given to evacuating clients who are a. receiving continuous oxygen b. ambulatory c. comatose d. sitting in wheelchairs
The correct answer is B. The nurse must establish evacuation plans in case of an internal disaster. Priority is given to evacuating the ambulatory clients. This can be accomplished by having a staff member lead the clients to the designated exit.
The nurse is assessing a client with bacterial pneumonia. The client has been receiving 0.9% normal saline and an anti-infective via IV piggyback as prescribed for 24 hours. The nurse must intervene if the client's a. oxygen saturation level via pulse oximetry is 92% b. cough is productive of green sputum c. peripheral IV site is cool to touch d. skin is pale
The correct answer is C. A client with bacterial pneumonia who is receiving fluids and medications via IV should be monitored for complications. A cool IV site would require intervention since this indicates an infiltration. The client's sputum color is expected based on the client's diagnosis and length of treatment.
In order to leave drugs at the bedside you must have a physician's order. (T/F)
True
The nurse has been reassigned to the emergency department (ED) due to a staff shortage. The nurse is assigned to irrigate a superficial stab wound but the nurse has never performed a wound irrigation. To help prevent a charge of negligence, the nurse should initially a. refuse to irrigate the client's wound b. review the procedure for wound irrigation c. ask another staff member to help d. ask the nursing supervisor to come to the ED
The correct answer is B. The nurse must possess the appropriate knowledge, skills and abilities to safely provide care to assigned clients. When a nurse is asked to float to an unfamiliar area and complete an unfamiliar task, the nurse should review the procedure for wound irrigation. The nurse can be charged with negligence if the task is not completed according to the agency policy. The nurse is responsible for the correct performance of an assigned task by the nurse or if delegated to another staff person. Asking for help would be appropriate after the nurse reviews the procedure.
The nurse is reviewing home safety with a 79-year-old client. Which of the following should the nurse identify as a safety hazard for the client that needs to be corrected? a. an unopened can of a liquid nutritional supplement is sitting next to the gas stove b. a bottle of paint thinner is stored next to a can of cooking oil c. a towel soaked with alcohol is sitting next to the washing machine d. a tube of denture adhesive is stored next to a tube of toothpaste
The correct answer is B. The nurse should remain alert to safety hazards in a client's home. Storing potentially toxic chemicals with food items is a safety hazard.
The home health nurse is assessing a 2-week-old infant who was born at 35 weeks gestation. The parent states, "It seems like I just got home. I have not been able to do anything that I need to do. If I am not taking care of the baby then I am trying to clean the house. I feel overwhelmed." Which of the following responses would be appropriate for the nurse to make initially? a. "Do you have anyone to help?" b. "Let's talk." c. "The hardest days are in the past." d. "Are you sleeping?"
The correct answer is B. The transition to parenthood requires an opportunity to talk about common concerns and joys. Based on the question, the nurse should initially encourage the parent to continue talking by indicating that the nurse is available to talk. Asking questions that can be answered "yes" or "no" block communication if stated initially.
The nurse is reinforcing teaching with a client who has a prescription to begin metoprolol (Toprol XL). The nurse should advise the client that Toprol XL may cause a. urinary retention b. bronchospasms c. photophobia d. paresthesias
The correct answer is B. Toprol XL can cause bronchospasms, urinary frequency and joint pain, and orthostatic hypotension.
The nurse is reinforcing teaching with a client who is receiving chemotherapy. The nurse should reinforce that which of the following vitamins may increase the risk for bleeding? a. vitamin B 6 b. vitamin C c. vitamin E d. vitamin K
The correct answer is B. Vitamin C can increase the risk for bleeding.
The nurse is conducting a staff education conference regarding end-of-life care of clients who practice a variety of religions. The nurse should state that which of the following practices is commonly associated with the Mormon religion? a. Cremation is required within 24 hours of death. b. The Burial Society washes the client's body after death. c. Last rites may be given when the client develops Cheyne-Stokes respirations. d. A white garment is placed on the client when the skin begins to look mottled.
The correct answer is C. A client from the Church of Jesus Christ of Latter-Day Saints (Mormonism) often receives last rites or communion as part of the death ritual. Cheyne-Stokes respirations are associated with impending death.
The nurse is assessing a client who is at 39 weeks gestation and reports the onset of contractions 12 hours ago. The nurse observes a linear bruise on the client's legs and the client reports this occurred when she fell down 2 steps on the front porch. Which of the following questions would be essential for the nurse to ask the client? a. "When did you fall?" b. "Do you have any other injuries?" c. "Are you being mistreated by someone you love?" d. "How many prenatal vitamins are you taking each day?"
The correct answer is C. A client who is pregnant is at risk for domestic violence. Linear bruises on the legs is an injury that is not consistent with the client's report of the injury. It would be essential for the nurse to ask the client about being mistreated by another person.
The nurse is confirming an appointment with a client who is scheduled for her first Papanicolaou smear. Which of the following statements would be appropriate for the nurse to make? a. "This test will help to determine if you have any sexually transmitted diseases." b. "A vaginal irrigation can be done the morning of the test." c. "Do not use any vaginal medications for at least twenty-four hours before the test." d. "An over-the-counter analgesic will help minimize cramping during the test."
The correct answer is C. A client who is scheduled for a Papanicolaou smear is instructed to not douche or use any vaginal medications prior to the test to help ensure reliability of the results.
The nurse is reviewing the record of a client who was just admitted with a traumatic brain injury. Which of the following prescriptions should the nurse clarify? a. Keep the head of the bed elevated 30 degrees. b. Deep breathing exercises without coughing every hour while awake. c. Start IV with D5W 1,000 ml every 8 hours. d. Bisacodyl (Dulcolax) 5 mg, po, q.d.
The correct answer is C. A client with a traumatic brain injury is at risk for increased intracranial pressure. The nurse should verify the prescription for D5W since this is contraindicated if a client is at risk for increased intracranial pressure. A stool softener may be given to help prevent straining with bowel movements which can increase the intracranial pressure.
The nurse is reviewing the record of a client who has prescriptions to begin the following medications. Which of the following medications should the nurse verify since the client reports a previous allergic reaction to sulfonamides? a. carbidopa/levodopa (Sinemet) b. carvedilol (Coreg) c. glimepiride (Amaryl) d. metronidazole (Flagyl)
The correct answer is C. A client with an allergic reaction to sulfonamides may have a cross-sensitivity reaction to Amaryl.
The nurse is assessing a client who is at 28 weeks gestation. Which of the following tests is common at this stage of pregnancy? a. alpha-fetoprotein (AFP) level b. contraction stress test (CST) c. glycosylated hemoglobin (HbA1C) level d. one-hour glucose tolerance test (GTT)
The correct answer is D. A one-hour GTT is typically performed at this stage of pregnancy. AFP is performed during an amniocentesis if fetal anomalies are suspected.
The nurse is admitting a client with a metastatic brain tumor who just had a craniotomy. Which of the following actions should the nurse take first? a. Assess the client's level of consciousness. b. Assess the client's vital signs. c. Determine if the client has an advance directive. d. Determine if the client has family members in the waiting room.
The correct answer is C. A client with cancer who had a craniotomy is at risk for multiple potentially life-threatening postoperative complications. The nurse should first determine if the client has an advance directive so that appropriate actions can be planned if an emergency occurs during the shift. An advance directive provides information about how staff members should respond if a life-threatening emergency develops. The client's level of consciousness has lower priority based on the information presented in the question.
The nurse is planning care for a client who was recently diagnosed with hypothyroidism. Which of the following should the nurse include in the client's plan of care? a. showing the client how to monitor urinary output b. encouraging the client to rest until symptoms resolve c. teaching the client about high fiber foods d. demonstrating foot care to the client
The correct answer is C. A client with hypothyroidism often experiences constipation. The nurse should teach the client about high fiber foods to help regulate bowel movements. Hypothyroidism does not affect urinary output.
The home health nurse is assessing a client who is at 32 weeks gestation and who is being treated for preterm labor. Which of the following is an expected finding? a. low back pain b. yellow-colored vaginal discharge c. yellow discharge from the nipples d. suprapubic pressure
The correct answer is C. A normal finding for a client who is at 32 weeks gestation is yellow nipple discharge, since colostrum may be excreted from the breasts during the last trimester of pregnancy. The other findings may indicate uncontrolled preterm labor, a urinary tract infection and/or a vaginal infection.
The nurse has reinforced teaching with the spouse of a client who will start prescribed donepezil (Aricept). Which of the following statements by the spouse would indicate a correct understanding of the teaching? a. "Water exercises are not permitted while this medication is taken." b. "Memory loss is reversed when this medication is taken daily." c. "This medication should not be discontinued abruptly." d. "Elevated blood glucose levels are common when the medication is first started."
The correct answer is C. Aricept is used to stabilize and slow memory loss associated with dementia. This medication should not be discontinued abruptly.
The nurse is teaching a client who was recently diagnosed with hyperlipidemia and diabetes mellitus. The client has new prescriptions for atorvastatin (Lipitor) and rosiglitazone (Avandia). Which of the following statements would be correct for the nurse to make? a. "You will need to stop taking Avandia if you need to start taking insulin." b. "A common side effect of Lipitor is a metallic taste in your mouth." c. "Avandia may need to be changed to a different medication if your legs swell." d. "Lipitor may cause your blood glucose level to increase."
The correct answer is C. Avandia may cause peripheral edema that may necessitate changing to a different medication. Lipitor has not been associated with altered taste.
The nurse is completing the preoperative check list on a client who is scheduled for a cystectomy and urinary diversion. The nurse observes that the operative consent is signed by the client and was witnessed, the client's laboratory test results are within the normal range and the client's electrocardiography (EKG) is normal. The nurse should immediately report which of the following statements by the client? a. "My biggest fear is not waking up after surgery." b. "I hope I don't need a blood transfusion since I was not able to bank my own blood." c. "I am glad that I will only have a tube in my bladder for a couple of days." d. "My last bowel movement was two days ago."
The correct answer is C. During the preoperative time interval the nurse must make sure that the client's record is complete and that the client has completed any preoperative preparation that is required. The nurse should immediately report the client's statement regarding the tube in the bladder since this indicates the client does not understand that a cystectomy and urinary diversion means the client's bladder is being removed. If the nurse fails to report this, the facility is at risk for a charge of battery. The statement regarding the potential need for a transfusion indicates that the client understands the preoperative teaching and does not require notification of any members of the surgical team.
The nurse in the long-term care facility is caring for the following assigned clients. The nurse would increase the risk of a charge of false imprisonment if the nurse administers a. a sedative prescribed p.r.n. to a client with moderate Alzheimer's disease who is agitated at sundown b. a sedative prescribed p.r.n. to a client with an inoperable brain tumor who is too restless to sleep c. an opioid analgesic prescribed p.r.n. to a client with metastatic bone cancer who refuses to sleep during the night d. a skeletal muscle relaxant prescribed p.r.n. to a client with fibromyalgia who reports skin sensations of crawling bugs
The correct answer is C. False imprisonment is confining or restricting a client's movement by using physical or verbal constraint without the client's consent. Administering medications to control a client's behavior for the convenience of staff is a form of false imprisonment, such as administering an analgesic to a client who refuses to sleep at night.
The nurse is caring for a client with chronic low back pain. The client reports pain rated 8 on a scale of 0 (no pain) to 10 (severe pain). The client received a prescribed oral analgesic 5 minutes ago. Which of the following actions by the nurse may enhance the client's comfort? a. turning the client onto the left side with both knees flexed to the chest b. elevating the client's legs above the level of the heart while lying in bed c. placing a rolled towel behind the client's back while sitting d. assisting the client to lay on the abdomen with the arms raised above the head
The correct answer is C. Nonpharmacologic methods to enhance the comfort of a client with low back pain include sitting with a pillow to support the back, resting supine with pillows under the legs and resting in the lateral position with a pillow between the knees. If there is leg pain, the painful leg is flexed while the client is in the lateral position.
What happens when patients with pernicious anemia don't absorb Vitamin B-12?
Their RBC's do not mature and they become seriously anemic.
The nurse enters the room of a client who has metastatic cancer and who has a prescription not to resuscitate. The nurse observes that the client has sighing respirations and the client's extremities are cool. There has been no urine in the client's indwelling urinary catheter in over 12 hours. The nurse should a. dim the lights in the client's room before returning to the nurse's station b. elevate the client's legs above the level of the head c. remain at the client's bedside until the family member returns from the cafeteria d. administer an analgesic prescribed p.r.n. for pain
The correct answer is C. Palliative care for a client with terminal cancer includes offering comfort and dignity to the client during the dying process. The information in the question is an indication that the client's body systems are shutting down and that death is imminent. The nurse should remain at the client's bedside until the family member returns. The information in the question does not indicate the client is in pain, such as agitation, therefore the nurse should not administer an analgesic unless requested by a designated family member.
The nurse is teaching a client who is to start total parenteral nutrition (TPN). The client asks the nurse how the decision is made to use TPN compared to nasogastric (NG) tube feedings. Which of the following statements would be correct for the nurse to make? a. "Total parenteral nutrition is more cost effective for a client than NG tube feedings since the nutritional value is higher quality." b. "Nasogastric tube feedings cause a client to have more oral infections than TPN." c. "Total parenteral nutrition is chosen when a client is not able to absorb nutrients from the intestinal tract." d. "Nasogastric tube feedings are beneficial for clients who do not have a gag reflex but who require enteral nutrition for less than a month."
The correct answer is C. TPN is provided when a client is not able to absorb nutrients through the gastrointestinal tract, such as with inflammatory bowel disorders, cancer and malnutrition. TPN requires regular laboratory tests to determine the appropriate components based on evaluation of the client's changing nutritional needs. There is no evidence to support that TPN is more cost effective than NG feedings. NG tube feedings are administered when a client's protective reflexes are intact, such as the gag reflex and is used when the client needs nutritional support for less than 5 days. In addition, the client's gastrointestinal tract must be able to absorb the nutrients.
The charge nurse has reviewed several irregular occurrence reports during the past month associated with unwitnessed falls. To help resolve these occurrences, the nurse should first a. evaluate the layout of each client care area. b. interview the staff members who completed the irregular occurrence reports. c. identify what prescribed medications were given to the clients. d. determine if any equipment repairs have occurred in the areas of falls.
The correct answer is C. The charge nurse should be familiar with the problem-solving process when irregular occurrences are identified. The first step in the problem solving process is assessing client characteristics, such as types of medications that the clients received. Risk for falls include medications, lighting, muscle weakness and delay of staff in answering call lights. Interviewing staff members who discovered the incidents has lower priority than identifying client characteristics.
The home health nurse is checking a client with chronic obstructive pulmonary disease (COPD). The client is using oxygen around-the-clock. Which of the following information would indicate to the nurse that the client's condition is worsening? a. The client reports being able to breath better while leaning forward. b. The client uses purse-lipped breathing during conversations. c. The client reports chest pain with deep breathing. d. The client speaks with short sentences.
The correct answer is C. The client with COPD is at risk for pneumonia and pneumothorax. Painful breathing is an indication that the client's condition has worsened and requires follow up. The answers are consistent with this stage of illness that requires continuous oxygen. Pursed-lip breathing is characteristic for a client with COPD.
The nurse is reviewing the laboratory test results of an adult client who had an annual physical examination. Which of the following laboratory test results is within the normal range? a. white blood cell (WBC) count, 23,000/cu mm b. glycosylated hemoglobin (HgbA1C), 8.2% c. serum potassium, 3.7 mEq/L d. urine specific gravity, 1.000
The correct answer is C. The normal serum potassium level is 3.5 to 5 mEq/L; HgbA1C less than 6% is normal or less than 7% indicates glycemic control for a client with diabetes mellitus; a normal WBC is 5,000 to 10,000/cu mm; and the urine specific gravity is typically between 1.010 to 1.025.
The nurse is caring for a client who has an abdominal aortic aneurysm. The client requests medication for back pain rated 8 on a scale of 0 (no pain) to 10 (severe pain). Which of the following actions should the nurse take first ? a. Assist the client into the lateral recumbent position. b. Determine how long it has been since the client received an analgesic. c. Ask the client if the pain has a knife-like quality. d. Offer the client a small pillow to support the back.
The correct answer is C. The nurse must be able to identify a client's risk for complications associated with an abdominal aortic aneurysm. If the client reports back pain, the nurse must first identify the quality of the pain to help identify if a potentially life-threatening emergency is occurring, such as aortic dissection. If the client's pain is knife-like, this is an emergency that requires action to prevent hemorrhage.
The nurse has completed discharge teaching with a 76-year-old client with dysphagia who will be discharged with percutaneous endoscopic gastrostomy (PEG) tube feedings. Which of the following statements by the client would indicate that the client is at increased risk for injury after discharge and would require intervention by the nurse? a. "I will coil the PEG tube under my clothing when I am gardening outdoors." b. "I plan to clamp the PEG tube when I resume my swimming classes next month." c. "I will keep the PEG tube feeding bags on top of my refrigerator." d. "I can fill the PEG tube feeding bag with enough formula to last eight hours." .
The correct answer is C. The nurse must be able to identify a client's risk for injury in the home. A client who is 76 years old is at risk for falls and should be discouraged from reaching overhead to get frequently needed objects. Storing the PEG tube feeding bags on top of the refrigerator is a risk that requires intervention by the nurse. The feeding bags can be filled with enough formula to last 8 hours without risk to the client
Neoplasm refers to benign and malignant tumors. (T/F)
True
Some women experience discomfort when wearing contact lenses during pregnancy or menstrual periods. (T/F)
True
The woman must avoid sexual intercourse if PROM has occurred. (T/F)
True
The home health nurse is providing care to an active 2-year-old client who has a tracheostomy. Which of the following actions by the nurse would increase the risk for a charge of negligence? a. flexing the client's neck before making the square knot b. positioning the square knot on the side of the client's neck c. securing the tracheostomy faceplate in place using Velcro-type ties d. removing the soiled ties from the tracheostomy faceplate after the parent has the clean ties in place
The correct answer is C. The nurse must remain aware of standards of care for clients with a tracheostomy and take action to minimize the risk for injury to the client. Negligence is defined as failure to provide care that meets the standard and that places the client at risk for injury. Velcro ties should not be used to secure the tracheostomy tube for a 2-year-old client since the client can easily reach and manipulate the Velcro. The neck should be flexed prior to securing the square knot to help ensure adequate room for expansion of the neck during movement.
The nurse is reviewing the record of a 62-year-old female client who was just admitted. The client had a cerebrovascular accident (CVA) and also has osteoporosis. The client receives continuous percutaneous endoscopic gastrostomy (PEG) tube feedings and the client's prescribed medications are administered via the PEG tube. Which of the following prescribed medications should the nurse clarify before administering the medication to the client? a. oxybutynin (Ditropan) b. paroxetine (Paxil) c. warfarin sodium (Coumadin) d. estrogen (Premarin)
The correct answer is D. A cerebrovascular accident may be caused by hemorrhage or thrombus. The nurse should clarify the prescription for Premarin since a history of thrombus is a contraindication for Premarin. Coumadin can be administered via the PEG tube and is not contraindicated based on the information presented in the question.
The home health nurse is talking with family members about the nutritional needs of a client who is receiving mechanical ventilation. Which of the following statements would be correct for the nurse to make? a. "Increased protein needs can be met by offering the client a liquid fruit-flavored gelatin beverage." b. "The caloric needs for the client are lower than the needs of a healthy client who is the same age." c. "Water-soluble vitamins are lost during suctioning so they need to be replaced with an oral supplement." d. "Eating high carbohydrate meals can cause the client's oxygen saturation level to fall."
The correct answer is D. A client on mechanical ventilation is at risk for imbalanced nutrition. The client needs to be on a diet that has increased protein, calories, vitamins and minerals. However, a high carbohydrate intake can cause increased carbon dioxide production and result in a low oxygen saturation level.
The nurse is assessing a client who had a total hip arthroplasty 2 days ago. The nurse observes that the client's pulse is increased, the client reports feeling anxious and has pain in the operative leg. The nurse's initial response should be based on an understanding that the client may have a. a wound infection b. a dislocated hip prosthesis c. atelectasis d. a pulmonary embolism
The correct answer is D. A client who had a hip prosthesis is at risk for deep vein thrombosis and pulmonary embolism. A pulmonary embolism may be indicated by the development of tachycardia and anxiety. The nurse's initial response should be based on an understanding of pulmonary embolism since this is a potentially life threatening condition. A wound infection is not life-threatening and should not be the basis for the nurse's first response.
The nurse has taught a client who just had drainage of a pilonidal cyst. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I need to rest with my legs elevated on pillows." b. "I should refrain from sexual activity until the pain is gone." c. "I cannot use any rectal medications until this is healed." d. "I should sit in a warm tub of water several times a day."
The correct answer is D. A client who had a pilonidal cyst drained should sit in a warm tub of water to help enhance healing. The client may be more comfortable by sitting on cushioned surfaces which minimize pain in the region of the coccyx.
The nurse is assessing a client with preterm labor at 32 weeks gestation. The client is receiving terbutaline sulfate (Bricanyl) as prescribed. The client reports feeling palpitations and leaking urine when coughing or sneezing. Which of the following actions should receive priority by the nurse? a. measuring the client's fundal height b. checking the client's weight c. obtaining a electrocardiography (EKG) on the client d. using nitrazine paper to check the moisture in the client's underwear
The correct answer is D. A client who is being treated for preterm labor is monitored for indications of a change in status associated with medications and effectiveness of the treatment regime. The nurse should give priority to using nitrazine paper to check the moisture in the client's underwear since this may be an indication of leaking or rupture of amniotic membranes. A potentially life-threatening infection can develop if the client has prolonged rupture of membranes. Palpitations are a common side effect of Bricanyl. The nurse should check the client's vital signs.
The nurse is assessing a client who reports frequent sore throats and swollen glands beneath the jaw. The nurse observes that the client is 20% above the ideal body weight and that the client's weight has fluctuated by about 4.5 kg (10 lb) during the past few months. Which of the following questions would be essential for the nurse to ask the client? a. "Have you noticed any change in your vision?" b. "How often do you eat?" c. "What type of beverages do you enjoy?" d. "Do you feel any heart palpitations?"
The correct answer is D. A client with a binge-purge eating disorder may have frequent sore throats and a chipmunk facial appearance due to swelling of the parotid glands. The nurse should ask the client about palpitations since a client with a binge-purge eating pattern is at risk for cardiac dysrhythmias.
The nurse is helping to evaluate the effectiveness of bumetanide (Bumex) for a client with heart failure. Which of the following questions would provide the best information from the client? a. "Do your clothes fit differently?" b. "Do you have any ringing in your ears?" c. "How often during the day does your mouth feel dry?" d. "How many pillows do you use under your head while sleeping?"
The correct answer is D. A client with heart failure may report difficulty sleeping unless the head is supported on several pillows at night. To determine the effectiveness of Bumex, a diuretic, the nurse should ask about the number of pillows used during the night to sleep.
The nurse is caring for a client who had an abdominal hysterectomy 48 hours ago. The client reports abdominal pain rated 8 on a scale of 0 (no pain) to 10 (severe pain). Which of the following medications prescribed p.r.n. would be appropriate for the nurse to administer to the client? a. ketorolac (Toradol) b. metoclopramide (Reglan) c. bisacodyl (Dulcolax) d. meperidine hydrochloride (Demerol)
The correct answer is D. Demerol should be administered for moderate to severe pain. A pain scale is used to determine the severity of pain and a rating of 8 indicates moderate to severe pain.
The nurse is reinforcing teaching with a client who is at 38 weeks gestation with her first child. The client asks what changes should be reported prior to the next regular obstetrical appointment. The nurse should advise the client to report a. head congestion b. urinary frequency c. yellow-colored nipple discharge d. right upper quadrant abdominal pain
The correct answer is D. During the last few weeks of pregnancy the client continues to monitor for any indication of pregnancy-induced hypertension. The development of right upper quadrant abdominal pain may indicate liver congestion associated with PIH and would require reporting prior to the next scheduled appointment.
The nurse is participating in a disaster drill. The nurse is advised that a chemical spill occurred on the third floor of a large business. The nurse should understand that during the disaster drill priority should be given to the client with a. a bone protruding from the foot b. blood oozing from a hand c. red sclerae d. a dry cough
The correct answer is D. Maslow's hierarchy is used to establish priorities during a disaster. A chemical spill releases caustic fumes into the air. A client with a dry cough may have chemical burns in the airway and should receive priority. Blood oozing from a hand has lower priority than profuse bleeding.
The nurse is caring for a client who is receiving a dose of prescribed vancocin (Vancomycin) via IV piggyback. The nurse observes that the client's vital signs remain within the client's baseline and the client has facial flushing. Which of the following actions would be appropriate for the nurse to take? a. Obtain the emergency cart. b. Stop the infusion. c. Slow the rate of flow. d. Inform the client that this is normal.
The correct answer is D. Red man's syndrome may occur with vancomycin and this causes a flushed appearance to the face or neck. The client should be reassured that this is a common, non life-threatening side effect.
The nurse is assessing a 35-year-old client who has scheduled an annual physical examination. The client reports a history of mild pregnancy-induced hypertension (PIH) during two pregnancies and that both infants weighed over 4.0 kg (9 lb). Before the primary health care provider examines the client, the nurse should give priority to a. reviewing the client's record for a recent echocardiography report b. reviewing the client's record for a recent electrocardiography (EKG) report c. obtaining a urine specimen from the client d. checking the client's capillary glucose level
The correct answer is D. Risk factors for type 2 diabetes mellitus include giving birth to an infant that is large-for-gestational age. Based on the client's history and age, the nurse should give priority to checking the client's capillary glucose level. The client's history does not indicate a risk for urinary problems therefore obtaining a urine specimen is not a priority.
The charge nurse has completed the shift assignments for nursing assistants. Which of the following statements by the charge nurse would provide the best directions to help ensure that the task is completed as assigned? a. "The client with right-sided hemiparesis must be assisted to walk in the hallway." b. "Make sure that the client with Alzheimer's disease is assisted to the bathroom several times this shift." c. "Snacks are in the refrigerator for clients who are receiving insulin." d. "The client with multiple sclerosis needs to get out of bed for each meal."
The correct answer is D. The charge nurse must provide specific, detailed information to nursing assistants to help ensure that the client care assignment is completed appropriately and within the required time frame. Informing the nursing assistant that the client needs to get out of bed for each meal is specific. The charge nurse needs to be more specific regarding when snacks should be given to clients who are receiving insulin.
The nurse is talking with the parent of a child who just died. The parent states, "Just get out of here. No one can bring my child back to life." Which of the following should the nurse do first? a. Tell the parent anger is a normal response. b. Ask if the parent would like to talk. c. Slowly exit the room. d. Remain silent.
The correct answer is D. The death of a loved one can cause a variety of emotions. Anger is a common emotion and the nurse should initially remain silent to see if the parent will continue talking. Exiting the room is not a therapeutic initial response.
The nurse is reviewing the laboratory test results of a client who had a transurethral resection of the prostate (TURP) 2 days ago. Which of the following laboratory test results is within the normal range? a. white blood cell (WBC) count, 3,000/cu mm b. red blood cell (RBC) count, 4.0 million/cu mm c. hemoglobin (Hgb), 20.0 grams/dl d. hematocrit (HCT), 46%
The correct answer is D. The normal hematocrit for a male is 42 to 52 %; WBC 5,000 to10,000/cu mm; RBC, 4.7 to 6.1 million/cu mm; and Hgb 14 to 18 grams/dl.
The nurse is completing oral care on a client who is comatose. Which of the following actions would be appropriate for the nurse to take? a. Brush the client's tongue with a medium bristle toothbrush. b. Use one moist gauze pad to gently wipe both cheeks inside of the client's mouth. c. Irrigate the client's mouth with normal saline after flossing the client's teeth. d. Turn the client onto the side with the head slightly lower than the shoulders.
The correct answer is D. The nurse completes oral care on a client who is comatose by turning the client onto one side with the head slightly lower than the shoulders. This helps to prevent aspiration. The client's tongue, roof of the mouth and cheeks are each cleaned with a separate gauze pad to minimize cross-infection. Oral irrigation is not performed due to the risk of aspiration.
Name the 3 hematologic side effects of chemotherapy.
Thrombocytopenia Leukopenia Anemia
The nurse has been advised that a client is being admitted with severe diarrhea. There are no private rooms available on the unit. It would be most appropriate for the nurse to assign the client to share the room with a client a. who is receiving total parenteral nutrition (TPN) b. with an open abdominal wound c. who is receiving percutaneous endoscopic gastrostomy (PEG) tube feedings d. with acute pancreatitis
The correct answer is D. The nurse is required to assist in determining the correct room assignments for clients based on an understanding of infection control procedures. A client with severe diarrhea requires contact precautions as does the client with acute pancreatitis. It would be most appropriate for these two clients to share a room. Clients with open wounds and who are receiving TPN or PEG feedings would not be appropriate roommates for the client with severe diarrhea based on the choices given.
The nurse is reinforcing teaching with a client who will start warfarin sodium (Coumadin) due to the new diagnosis of atrial fibrillation. Which of the following statements would be appropriate for the nurse to make? a. "Multiple vitamin supplements are recommended while you take Coumadin." b. "Orange juice should be limited since this contains a high amount of vitamin K." c. "Avoid using antibacterial soap on your skin." d. "You should get a shower chair to use in your bathtub."
The correct answer is D. The nurse must be able to identify a client's risk for injury in the home. A client with atrial fibrillation may develop dizziness during activities. In addition, the client is at risk for potentially life-threatening bleeding due to the therapeutic effects of Coumadin. It would be appropriate for the nurse to recommend that the client get a shower chair to use in the bathtub.
The nurse is assessing a 78-year-old client with prostate cancer. The client lives with an adult child in a ground-level apartment. Which of the following statements by the client should increase the nurse's suspicion regarding elder abuse and would require follow-up? a. "I don't know how I got all of these bruises on my hands." b. "I am home alone all day during the week." c. "My last haircut was about a month ago." d. "My friends are not allowed to visit."
The correct answer is D. The nurse must be observant for indications of elder abuse. A 78-year-old client is at risk for harm by others and the report of friends not being allowed to visit requires additional information to determine if the client is being isolated. Capillary fragility causes easy bruising on the hands of the elderly.
The nurse is preparing to change the dressing on a client's triple lumen central venous catheter. Which of the following actions would be correct for the nurse to take? a. removing the client's old dressing using sterile gloves b. lowering the client's head before removing the dressing c. applying triple-antibiotic ointment to the catheter insertion site d. putting on a face mask after opening the prepackaged dressing kit
The correct answer is D. The nurse should put on a face mask when the dressing is changed on a client's central venous catheter. It would be appropriate to put on the mask after the dressing kit has been opened. The client's head should be turned away from the catheter insertion site when the dressing is removed.
The nurse is present when an adult client stops eating, grabs the throat and falls to the floor. The nurse should immediately a. open the client's mouth b. get a stretcher c. start abdominal thrusts d. determine if the client can speak
The correct answer is D. The question should increase the nurse's suspicion that the client has an obstructed airway. The nurse should immediately determine if the client can speak.
The nurse is conducting a staff development conference regarding death and dying. The nurse should indicate that a school-aged child typically views death as a. a deep sleep b. punishment c. a part of mortality d. final
The correct answer is D. The school-aged child typically views death as final.
The nurse is working in an immunization clinic. The nurse should inform parents that the varicella vaccine is recommended at a. 2 months of age b. 4 months of age c. 9 months of age d. 12 months of age
The correct answer is D. The varicella vaccine is recommended at 12 months of age.
The nurse is admitting an adult client with a wound infection. The client has a prescription for intravenous vancomycin. The nurse should ask the nursing assistant to closely monitor the client's a. voice tone and quality b. gait c. daily weight d. intake and output
The correct answer is D. Vancomycin can cause elevated blood urea nitrogen (BUN) and creatinine levels as well as diarrhea. The nurse should ask the nursing assistant to closely monitor the client's intake and output.
Which hand should hold the suction catheter? Which should hold the connecting tube?
The dominant, the non-dominant
What is the unique adjective given to describe the early signs of MG?
The early signs (difficulty swallowing, visual problems) are referred to a BULBAR signs.
From where should the nurse talk to the client?
The entrance to the room
When giving a bed bath, on which body party should the nurse begin to work?
The eyes
From where should the nurse provide care to the client with cesium implant?
The head of the bed
hematocrit and dehydration
The hematocrit is an accurate method to measure exact dehydration % of a patient.
Where do the emboli that cause pulmonary embolus usually come from?
The legs
What are two major complications of a hysterectomy besides hemorrhage?
Thrombus and pulmonary embolus Urinary retention
What is the best indicator of renal function?
The serum creatinine
Sensitivity (susceptibility) means...
The susceptibility of an organism to the bacterial action of a particular agent
A patient taking Dilantin (phenytoin) for a seizure disorder is experiencing breakthrough seizures. A blood sample is taken to determine the serum drug level. Which of the following would indicate a sub-therapeutic level? A. 15 mcg/mL. B. 4 mcg/mL. C. 10 mcg/dL. D. 5 mcg/dL. B. 4 mcg/mL.
The therapeutic serum level for Dilantin is 10 - 20 mcg/mL. A level of 4 mcg/mL is sub-therapeutic and may be caused by patient non-compliance or increased metabolism of the drug. A leve of 15 mcg/mL is therapeutic. Choices C and D are expressed in mcg/dL, which is the incorrect unit of measurement.
What is ECT?
The use of electrical shock current delivered to the brain to induce a seizure that treats depression.
Why are Adrenocorticotropic Hormone (ACTH) and prednisone given during acute MS?
To decrease edema in the demyelination process
What is the major function of the luteal phase of the ovarian cycle?
To develop and maintain the corpus luteum which produces progesterone to maintain pregnancy until placenta is established.
For what purpose do you use the rule of nines?
To estimate the percentage of body surface burned; is NOT used for children.
What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP?
To keep the catheter clear of clots and to drain urine
What are the 2 purposes of a spinal tap?
To measure or relieve pressure and obtain a CSF sample
Why are anticoagulants (heparin only) given to women with CD of pregnancy?
To prevent thrombophlebitis due to venous congestion, usually in legs.
When Inderal is given in migraine headache, it is used to prevent or treat an attack?
To prevent. It DOES NOT treat.
Which way would you turn the client hear to suction the right mainstem bronchus? The left mainstem bronchus?
To the left, to the right
How is the catheter taped in a female client?
To the upper thigh
Should children with cleft palate BEFORE surgery be allowed to cry? To breast-feed?
Yes, they can cry; may breast feed with simple cleft lip however palate interferes with feeding
The client on a PCA pump is less likely to have post-operative complications than the client without a PCA pump. (T/F)
True, because the comfortable patient moves around more and is less likely to get thrombophlebitis, pulmonary embolus, fatigue, ileus and pneumonia
When a dressing saturated, germs can enter the wound from the outside. (T/F)
True, by a process called capillary action
Medical aseptic technique are aimed at reducing the number of organisms (T/F)
True, doesn't eliminate all of it just decreases the number
Clients with COPD are not good candidates for PCA pumps. (T/F)
True, due to the effects of narcotics on central respiratory control
Atrial fibrillation increases the risk of CVA (T/F
True, emboli particularly
A suppository given rectally must be lubricated with a water soluble lubricant. (T/F)
True, lubricant fingers also
When changing central line tubing the patient should be told to_________?
Turn his head away from the site, hold breath, and perform the Valsalva maneuver
How often should a woman visit the doctor prenatally if diabetes is present?
Twice a month, then once per week in the 3rd trimester
In how many surgeries is cleft palate repaired?
Two surgeries one at 12 to 18 months the last at 4 to 5 years
What is the most common route for organisms to enter the blader when a catheterization is used?
Up through the inside of the catheter in the days following catheterization
What test is done to confirm a diagnosis of pyloric stenosis?
Upper GI series (barium swallow)
What drug can be given to treat urinary retention in MS?
Urecholine, Bethanocol
As the prostate enlarges it compresses the ___________ and causes urinary ________.
Urethra, rentention
If a transfusion reaction is suspected, what two samples are collected and sent to the lab?
Urine & blood
List ways to ensure privacy...
Use drapes and screens during care in semi-private rooms
Can AIDS patients leave the floor?
Yes, unless WBC's are very low
When is cleft palate repaired?
Usually between 12 and 18 months of age. or between 1 and 5 years of age •Rationale: The time of cleft palate repair is individualized according to the size, shape, and degree of deformity. Most surgeons prefer to postpone the repair until 12 to 18 months of age to take advantage of palatal changes that occur with normal growth.
The preferred IM injection site for children under 3 is the _________ ___________.
Vastus lateralis
What causes thrombophlebitis after hysterectomy?
Venous stasis in the abdomen (the woman was in the vaginal lithotomy position for hours)
When cardiac output fails, name three ways the heart will try to compensate.
Ventricle hypertrophy Dilate and heart rate will increase
What common household solution is used to remove nits?
Vinegar. Nits are the eggs of lice that adhere to the hair shaft
Meningitis can be caused by _______, _____, and _____.
Viruses, bacteria, chemicals
What should the nurse measure before starting a transfusion?
Vital signs
Accutane is an analog of which vitamin?
Vitamin A
Name 3 drugs given for acne?
Vitamin A, Antibiotics, Retinoids
What vitamin is not absorbed in a patient with pernicious anemia?
Vitamin B-12
Malabsorption of which vitamin leads to bleeding disorder?
Vitamin K, remember do not mix up potassium with Vitamin K
The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize the pancreatic enzymes should be taken.
WITH EACH MEAL OR SNACK to allow for digestion of all foods that are eaten.
After you remove soiled dressings and before you put on the sterile dressing you must....
Wash your hands and put on sterile gloves
A Second degree-burn is wet or dry?
Wet
When using silver nitrate, the dressings must be kept __________.
Wet
What grains are not allowed in a gluten-free diet?
Wheat Oats Rye Alfalfa Barley
When is insulin used in the treatment of gestatinal diabetes?
When dietary control does not keep the blood sugar within normal limits
How often should the client's airway be suctioned?
When it needs to be, for example moist lung sounds, tachycardia, restlessness (hypoxia), ineffective cough
In addition to the things you assess for in every woman during labor, what additional assessment must you make for a woman with CD?
You must assess lungs sounds frequently
When does typing and cross matching need to be done?
Whenever a client is to get a blood product. It is only good for 24 hours.
What does a type and cross match indicate?
Whether the client's blood and donor blood are compatible.
The suction should be delivered while (inserting/removing) the catheter.
While removing the catheter
A third-degree burn is white or red?
White
Patients with MS should be taught to walk with a ____-____ gait.
Wide based
When is a febrile reaction likely to occur?
Within 30 minutes of beginning the transfusion
Are diuretics used for women with pre-eclampsia?
Yes
Can the patient with spinal cord injury at C7 level have respiratory arrest?
Yes, because even thought his injury was below C4, spinal shock can lead to loss function above the level, however the will not be permanently ventilator dependent-he will breath on when once spinal shock goes away.
Should hearing aids be removed before going for surgery?
Yes, but just before surgery
HIV is present in all body fluids?
Yes, but not transmitted by all, only blood, semen and breast milk
Can the thigh EVER be used to obtain a blood pressure?
Yes, but this is rare.
Are meats allowed on a gluten-free diet?
Yes, but watch for breaded meats and hot dogs/lunch meats- may have grain in them and are not allowed
Should the client drink after a spinal tap?
Yes, encourage fluids to replace CSF
Can morphine be given to a woman with CD during labor?
Yes, even though it negatively affects the fetus, remember morphine decreases preload and pain which rests the heart.
Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room?
Yes, if available you can get them into antishock trousers but not if this causes a delay in getting them to the operating room
Can a woman with CD of pregnancy be given analgesics during labor?
Yes, in fact they should be given analgesics, may get too anxious which is bad for the patient
Do you assess for suicide potential whenever a patient makes any statement about wanting to die or kill self?
Yes, in fact whenever a patient makes a statement about wishing or wanting to die or kill self you must ALWAYS AND FIRST assess for suicide potential*-stop everything and assess for suicide patient (except CPR, or course)
Has hyperemesis gravidarum ever been associated with mixed feelings about pregnancy?
Yes, increased incidence of it in women who are ambivalent about pregnancy
Are nurses permitted to give perineal care to clients of the opposite sex?
Yes, nurses are permitted to give perineal care to clients of the opposite sex.
Should clients with CHF have a Foley catheter?
Yes, on diuretics and fluid balance is important
Can the woman with a cesium implant have the HOB elevated?
Yes, only 45 degrees maximum
Can too tight bras lead to mastitis?
Yes, preventing emptying of ducts
Does breast engorgement interfere with nursing?
Yes, the infant has a difficult time latching on (getting nipple in its mouth)
a nurse is instructing the mother of a child with cystic fibrosis about the appropriate dietary measures. which is the most appropriate?
a piece of fried chicken and a loaded baked potato need high calorie, high protein diet
The most common symptom of abdominal aneurysm is:
a pulsating mass above the umbilicus
AIDS is trasmissible through what four routs?
blood, sexual contact, breast feeding, across placenta in utero
What anatomical fact accounts for the left side of the
body being controlled by the right brain? The motor-pyramidal-tracts cross over to the other side (decussate in the medulla)
Chronic abuse of alcohol increases risk of CVA. (T/F)
false
After appendectomy, document in the nurses notes the return of __________
bowel sounds (peristalsis)
the nurse teaches a primigravid women how to measure the FREQUENCY of uterine contractions. the nurse should explain to the client that the frequency of uterine contractions is determined by which of the following.
by the number of contractions that occur within a given period of time.
The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action? a) Ask the client his name. b) Check the client's name band. c) Straighten the client's pillow behind his back. d) Give the client his medications.
c) Straighten the client's pillow behind his back.--The nurse should first help the client into a position of comfort even though the primary purpose for entering the room was to administer medication. After attending to the client's basic care needs, the nurse can proceed with the proper identification of the client, such as asking the client his name and checking his armband, so that the medication can be administered.
A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: a) provide instructions on eye patching. b) assess the client's visual acuity. c) demonstrate eyedrop instillation. d) teach about intraocular lens cleaning.
c) demonstrate eyedrop instillation.- Eyedrop instillation is a critical component of self-care for a client with glaucoma. After demonstrating eyedrop instillation to the client and family, the nurse should verify their ability to perform this measure properly. An eye patch isn't necessary unless the client has undergone surgery. Visual acuity assessment isn't necessary before discharge. Intraocular lenses aren't implanted in clients with glaucoma.
As charge nurse you observe the LPN/LVN providing all of these interventions for the patient with Paget's disease. Which action requires that you intervene? a. Administers 600mg of ibuprofen to the patient b.Encourages the patient to perform PT recommended exercises c. Applies ice and gentle massage to the patient's lower extremities d. Reminds the patient to drink milk and eat cottage cheese
c. Applies ice and gentle massage to the patient's lower extremities Application of heat, not ice, is the appropriate measure to help reduce the patient's pain. Ibuprofen is useful to manage mild to moderate pain. Exercise prescribed by the PT is non-impact in nature and provides strengthening for the patient. A diet rich in calcium promotes bone health. Focus: Delegation/supervision
Clients with celiac's disease don't absorb fats; therefore they don't absorb _____ ______ ______.
fat-soluble vitamins
Describe the pain of angina pectoris
crushing substernal chest pain that may radiate
Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________.
drugs, insecticides
What are the three adult stages of development called
early adulthood, middle adulthood and later adulthood
-penia
decrease, deficiency
If an aneurysm is ruptured how would you know it?
decreased LOC (restlessness), tachycardia, hypotension - all signs of shock
"Time is too short to start another life, though I wish I could," is an example of ___________.
despair
When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________.
distally (far from the center), proximally (neareast to the point)
ante-
forward,before, in front of Before in time or place (ie. "antepartal - before giving birth)
To lessen pain of appendicitis place the client in ___________ position.
fowlers (a sitting position) (also use post op)
On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100
greater, less than
What are the top 2 side effects of nitro?
headache and hypotension
Children with cleft lip and cleft palate have long-term problems _____, _____ and _____.
hearing speech teeth
Never apply __________ to the area of the appendix.
heat (it causes rupture)
What blood value will dictate IV flow rate?
hematocrit
-cele
hernia, tumor, swelling Combining form meaning a tumor or swelling or a cavity
With PD there is a high/low risk of peritonitis?
high
An elderly client is a (high/low) risk for accidental poisoning? What about a school age child?
high - due to poor eyesight, high
What is found over the body of the client with anorexia nervosa?
lanugo (soft downy hair)
A primigravida goes to the clinic for her prenatal visit. which of the following prenatal assessment procedures is NOT routinely included? a. CBC B. HIV testing c. nutritional needs d. pelvimetry
pelvimetry is NOT routinely assessed unless pt is at high risk and needs c-section
Mastitis and breast engorgement are more likely to occur in (primipara/multipara).
primapara
-genic
produced by or in Produce, originate, become
If the patient had an AKA they should lie ____________ several times per day.
prone (to prevent flexion contracture)
If the AIDS patient has leukopenia they will be on _____________ ________________.
protective (reverse) isolation
-pexy
surgical fixation
-ostomy
surgical opening
5 month old goes to the ER w a temp of 103.6f! Mother states the child had a seizure on the way to the hospital. A lumbar puncture confirms bacterial meningitis. The nurse should assess
tenseness of the anterior fontanel this indicated Increased ICP. periorbital edema is not associated with meningitis
Which aneurysm is most likely to have no symptoms?
the abdominal is most often "silent"
Where does the organism that causes mastitis come from?
the infant's nose and or mouth
How do you tell if a client has angina or an MI?
the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. For angina, nitro and rest relieve the pain, for MI, nitro and rest do not relieve the pain
An aneurysm will most affect which of the following, the blood pressure or the pusle?
the pulse (many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change.
Symptoms indicative of an alcohol-related problem
tremors, elevated temperature, nocturnal leg cramps, complaints of pain symptoms.
As soon as Placenta Previa is diagnosed, most pregnancies will be terminated via C-section if the fetus is mature. (T/F)
true
When putting on the first glove of a set of sterile gloves, you should grasp the cuff. (T/F)
true
When putting on the second glove of a set of sterile gloves, you must not use the thumb of the first hand. (T/F)
true
The client returns to the recovery following supratentorial surgery for tx of brain tumor. which action should the nurse initially take? 1.check the client's LOC 2. elevate the HOB ELEVATE THE HOB
tumor located within the cerebral hemisphere; HOB should be elevated 45 degrees to promote venous drainage, prevents increased ICP; avoid hip or neck flexion; keep head in midline position