Nursing 309 Final Set
A pt with multiple sclerosis (MS) is prescribed oral fingolimod (Gilenya). Which key point must the Rn teach the pt about this drug?
"We need to teach you how to monitor your pulse rate because this drug can cause a slow heart rate."
A patient asks the nurse how insulin injection site rotation should be accomplished. What is the nurse's best response?
"rotation within one site is preferred to avoid changes in insulin absorption."
Normal Creatinine
0.7 - 1.3
Drugs for GBS
1. IV Immunoglobulin
Process of Return to Consciousness after General Anesthesia in order.
1. Muscular irritability. 2. Restlessness and delirium 3. Recognition of pain. 4. Ability to reason and control behavior.
Order of Return of Motor/Sensory Functioning after Local or Regional Anesthesia
1. Touch 2. Pain 3. Warmth 4. Cold 5. Ability to move
Normal Sodium
135 - 145
Normal Sodium Range
136 - 145 mEq/L
According to the American Diabetes Association, which lab finding is most indicative of DM?
2 hour glucose tolerance blood glucose - 210 mg/dL
The nurse is reviewing lab results fro a patient with a new onset PE. What is the INR therapeutic range?
2.0 to 3.0
Normal Potassium Range
3.5 - 5.0 mEq/L
Normal Hematocrit (Female)
35% - 45%
A patient with DKA is on an insulin drip of 50 units of regular insulin in 250 mL of normal saline. The current glucose level is 549 mg/dL. According to insulin protocol, the insulin drip needs to be changed 8 units per hour. At what rate does the nurse set the pump?
40 mL/hr
Normal Hematocrit (Male)
42% - 52%
MG patients should eat
45 mins after ChE inhibitor admin
Which woman is at greatest risk for dysfunctional uterine bleeding?
45 year old attorney with a stressful life.
Which woman is at greatest risk for developing pelvic organ prolapse?
48 year old obese mother of four children
A nurse screens a preoperative patient for conditions that may increase the risk for complications during the perioperative period. Which conditions are possible risk factors?
67 years old, obesity, pulmonary disease
Normal arterial pH range
7.35 - 7.45
Normal Glucose (fasting)
70 - 110 mg/dL
Which man has the highest risk for prostate cancer?
A 75 yo African American man whose brother had prostate cancer.
Nursing interventions for Neurological infections
ABC's VS/Neuro Q12h (Maintain Droplet Isolation for Meningitis) Cranial Nerve assessment Pain management Monitor I/O
Renal Disease and Hypertension: Medications
ACE inhibitors Diuretics Prevention of hyperkalemia
What types of examinations are done to reveal the presence of uterine enlargement related to fibroids?
Abdominal examination Vaginal examination Rectal examination Transvaginal ultrasound with saline infusion
Polycystic Kidney Disease: Manifestations
Abdominal or flank pain Hypertension Nocturia Increased abdominal girth Constipation Bloody or cloudy urine Kidney stones
The nurse is giving discharge teaching to a patient who had a transvaginal repair for pelvic organ prolapse using a surgical mesh. What does the nurse include?
Abstain from sexual intercourse for 6 weeks.
The nurse is assessing a patient with kidney injury and notes a marked increase in the rate and depth of breathing. The nurse recognizes this as Kussmaul respiration, which is the body's attempt to compensate for which condition?
Acidosis.
Which factor/manifestation is primarily associated with acute pyelonephritis?
Active bacterial infection
Causes of Status Epilepticus
Acute alcohol withdrawal, head trauma, cerebral edema, metabolic disturbances.
The nurse is assessing a patient who reports chills, high fever, and flank pain with urinary urgency and frequency. On physical examination, the patient has costovertebral angle (CVA) tenderness, pulse is 110 bpm rr 28/min. How does the nurse interpret these findings?
Acute pyelonephritis
Renal Disease and Hypertension: treatment
Adequate fluid intake Reduce salt intake Education on hypertension Education on diabetes
A pt with arthritis reports receiving the following dietary suggestions over the years. Which recommendation for a daily diet should the RN reinforce?
Adequate foods in a variety of different food groups.
The nurse is caring for a patient who had a nasoseptoplasty. Which action is best to delegate to the licensed practical nurse?
Administer a stool softener to ease bowel movements.
What is the priority intervention for a patient with DKA?
Administer insulin.
Main concern for cervical vertebrae surgeries
Airway
Nursing interventions for GBS
Airway, respiratory status. Plasmaphoresis preparation. Cardiac status. Assess dysphagia. Pain management. Prevent muscle atrophy.
Which is the BEST referral that the nurse can suggest to a client who has been newly diagnosed with DM?
American Diabetes Association.
Which combination of drugs is the most nephrotoxic?
Aminoglycoside antibiotics and NSAIDS.
The nurse is caring for a patient with a nephrostomy. The nurse notifies the health care provider about which assessment finding?
Amount of drainage decreases and the patient has back pain.
Nursing care of a client with a fractured hip should include the assessment of pedal pulses. The nurse should assess for which important characteristics of the pedal pulses?
Amplitude and symmetry.
Although the etiology of RA is unknown, it is considered to be what type of disorder?
An autoimmune disease
For the patient with PKD, which antihypertensive medication may be used because it helps control the cell growth aspects of PKD and reduce microalbuminuria?
Angiotensin-converting enzyme inhibitors
Second line of drugs for anaphylaxis
Antihistamines. Corticosteroids
Medications that increase risk for surgical complications.
Antihypertensives, tricyclic antidepressants, anticoagulants, nonsteroidal anti inflammatory drugs
You are supervising an RN who floated from the medical surgical unit to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN?
Apply direct lateral pressure to the nose for 5 minutes. Maintain standard body substance precautions. Apply ice or cool compresses to the nose. Instruct the patient not to blow the nose for several hours.
A patient with swelling in the perineal area is diagnosed with Bartholin cyst. Nonsurgical management is recommended. What does the nurse instruct the patient to do?
Apply moist heat to the vulva (sitz baths or hot wet packs).
A patient in the emergency department with laryngeal trauma has developed shortness of breath with stridor and decreased oxygen saturation. What is the priority action?
Apply oxygen and stay with the patient.
The Rn is preparing to physically assess a pt's subjective report of paresthesia in the lower extremities. In order to accomplish this assessment, which assessment technique does the RN use?
Ask the pt to identify sharp and dull sensation by using a paper clip and cotton ball.
Which medication usage could cause metabolic acidosis?
Aspirin overdose
The nurse is assessing a patient with glomerulonephritis and notes crackles in the lung fields nad neck vein distention. The patient reports mild shortness of breath. Based on these findings, what does the nurse do next?
Assess for additional signs of fluid overload
A patient has been diagnosed with DM. Which aspects does the nurse consider in formulating the teaching plan for this patient?
Assessing visual impairment regarding insulin labels and markings on syringes. Assessing manual dexterity to determine if the patient is able to draw insulin into a syringe. Assessing patient motivation to learn and comprehend instructions. Assessing patient's ability to read printed material.
Which nursing action can the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 DM?
Assist the client with washing the feet and applying moisturizing lotion.
Following a uterine embolization using a vascular closure device, what patient care would the nurse provide?
Assist the patient to ambulate 2 hours after the procedure. Assess the patient's pain level and administer analgesics as needed. Raise the head of the bed.
A patient is receiving external radiation therpay for treatment of endometrial cancer. What task does the nurse delegate to the UAP?
Assist the patient to ambulate if she feels fatigue or tiredness.
You observe a student nurse who is caring for a client who has an intracavitary radioactive implant in place to treat cervical cancer. Which action by the student requires that you intervene immediately?
Assisting the client to the beside commode for a bowel movement.
A nurse in the ambulatory preoperative unit identifies that a client is more anxious than most clients. What is the nurse's BEST intervention?
Attempt to identify the client's concerns.
What action should the nurse take to assess for atelectasis?
Auscultate the client's breath sounds.
Pylonephritis: Preventative education
Avoid causes of infections: hygiene, avoid fomites Describe role of antibiotics and self admin of drugs. Explain techniques to ensure adequate nutrition and hydration
A pt has undergone eternal beam radiation (EBRT) for palliative treatment of prostate cancer. What suggestions does the nurse make to help the pt manage acute radiation cystitis secondary to EBRT?
Avoid consumption of caffeine drinks
The nurse teaches a patient with BPH to follow which instructions?
Avoid diuretics, avoid sex, avoid caffeine, avoid drinking large amounts of fluid in a short time
Nursing interventions for back pain.
Avoid opioids, Ice then heat compress. Weight control Antiepileptics -gabpentin (neurontin)
A patient who had a total abdominal hysterectomy is anxious to resume her activities because she has young children at home. What postprocedure information does the nurse provide to the patient?
Avoid sitting for prolonged periods. Do not lift anything heavier than 5 to 10 pounds. When sitting, do not cross the legs.
A pt who has testicular cancer is likely to have which common problem?
Azoospermia
A pt with MS tells the UAP after physical therapy that she is too tired to take a bath. What is the priority nursing diagnosis at this time?
Bathing self care deficit related to fatigue and neuromuscular weakness
A patient is receiving warmed and humidified oxygen. The respiratory therapist informs the nurse that several other patients on other units have developed hospital acquired infections and Pseudomona aeroginosa has been identified as the organism. What does the nurse do?
Change the humidifeier every 24 hours.
A pt who has sustained a traumatic amputation of the left leg expresses concern about working and taking care of his family after his injury. What resources does the RN recommend to help the pt adjust to his lost limb?
Chaplain Medical social worker National amputation foundation
A patient with COPD needs instruction in measures to prevent pneumonia. What information does the nurse include?/
Clean all respiratory equipment you have at home. Avoid indoor pollutants such as dust and aerosols. Get plenty of rest and sleep daily.
In order to ensure the safety of a patient with metabolic alkalosis, which task is best to delegate to the UAP?
Clean up spills immediately
The Rn is caring for a pt with skeletal pins that have been placed for traction. What does the Rn expect to see in the first 48 hours?
Clear fluid drainage weeping form the pin insertion site
The nurse has just taken change of shift report on a group of clients on the medical surgical unit. Which client does the nurse assess first?
Client taking glyburide (Diabeta) who is dizzy and sweaty.
A patient with type 1 DM is taking a mixture of NPH and regular insulin at home. The patient has been NPO for surgery since midnight. What action does the nurse take regarding the patient's morning does of insulin?
Contact the health care provider for an order regarding the insulin
After being discharged from the hospital, a patient is diagnosed with TB at the outpatient clinic. What is the correct procedure regarding public health policy in this case?
Contact the public health nurse so that all individuals who have come in contact with the patient can be screened.
As the nurse obtains the informed consent, the client asks, "Now what exactly are they going to do to me?" What is the nurse's response?
Contact the surgeon
CRAB Drugs (for MS)
Copaxone Rebif Avonex Betaseron
A male patient has a scar on his forehead from a third-degree burn. What is the correct classification for this surgery?
Cosmetic Surgery
For which finding should you notify the health care provider immediately?
Crackles in both lower and middle lobes
Which complications of DM are considered emergencies?
DKA Hypoglycemia Hyperglycemic-hyperosmolar state (HHS)
Because the pt is at risk for spinal shock, what does the RN monitor for?
Decreased blood pressure, bradycardia, and decreased bowel sounds.
What change in diabetic therapy may be needed for a patient who has diabetic nephropathy?
Decreased insulin dosages.
A 75 year old patient is having an exploratory laparotomy tomorrow. The wife tells the nurse that at night the patient gets up and walks around his room. What priority action does the nurse take after hearing this information?
Develops a plan to keep the patient safe.
Which medical condition increases a patient's risk for surgical wound infection?
Diabetes Mellitus
A female patient is having a biopsy of a nodule found in the right breast. Which classification identifies this surgery?
Diagnostic
A patient with an abdominal aortic aneurysm is having surgical repair. What is the correct classification for this surgery?
Emergent surgery
The nurse observes that the hemovac drain is full of sanguineous drainage. What action should the nurse implement first?
Empty the drain and measure the amount of drainage.
What should the RN do to prevent deformities of the knee in a pt with an exacerbation of arthritis?
Encourage motion of the joint. Maintain joints in functional alignment when resting.
A Rn suspects the development of compartment syndrome for a client who has sustained blunt trauma to the forearm. For which early sign of compartment syndrome should the Rn asses the client?
Escalating pain in the fingers
A Rn is assessing a client with the dx of scleroderma for the signs of CREST syndrome. What clinical indicators should the nurse expect to identify?
Esophageal reflux Spider like hemangiomas Episodic blanching of the fingers
The nurse is taking a history of a patient at risk for kidney failure. What does the nurse ask the patient about during the interview?
Exposure to nephrotoxic chemicals. History of DM, hypertension, systemic lupus erythematosus. Recent surgery, trauma, or transfusions. Recent or prolonged use of antibiotics and NSAIDS.
Factors that DECREASE serum INR
Extensive cancer
Pylonephritis: acute signs/symptoms
Fever, chills Tachycardia, tachypnea Abdominal discomfort, flank, back, loin pain Nausea, vomiting Burning, urgency, frequency, nocturia General malaise, fatigue
The RN is caring for a pt with acute osteomyelitis. What assessment findings typically accompany this medical diagnosis?
Fever; temperature usually above 101 F. Erythema of the affected area. Swelling around the affected area.
Which clinical manifestation in a patient with an obstruction in the urinary system is associated specifically with a hydronephrosis?
Flank asymmetry
As a pt with ESKD experience isothenuria, what must the nurse be alert for?
Fluid volume overload.
A patient has sustained a kidney injury. In order to assist the patient to undergo the best diagnostic test to determine the extent of injury, What does the nurse do?
Give an explanation of computed tomography.
A patient who underwent a right above the knee amputation 4 days ago also has a diagnosis of depression. Which order would you clarify with the health care provider.
Give fluoxetine (Prozac) 40 mg once a day.
A 15 old adolescent tells a school nurse, "I have persistent pain during my periods." What should the nurse encourage her do to?
Have a gynecologic examination.
Which disorder could be a complication form AKI?
Heart failure.
When preparing an individualized teaching plan for a pt with RA, which topic should the RN omit from the generalized teaching plan for clients with arthritis?
Heberden Nodes
The nurse plans to refer a client diagnosed with osteoporosis to which community resource? A. American Bone Society B. CanSurmount C. I Can Cope D. Hospital support group
Hospital support group
The nurse is teaching a pt who had an open radical prostatectomy about how to manage the common potential long term complications. What does the nurse teach the pt?
How to perform Kegal perineal exercises
Which symptoms indicate that a pt with a SCI is experiencing autonomic dysreflexia?
Hypertension Severe headache blurred vision
A patient has been informed by the health care provider that treatment will be needed for renal artery stenosis. The nurse prepares to teach about a variety of treatment options. What treatments will the nurse include in the teaching plan?
Hypertension control. Balloon angioplasty. Renal artery bypass surgery. Synthetic blood vessel graft.
Glomerulonephritis: Contributing factors
Hypertension, fluid overload, circulatory congestion
What are common causes of prerenal kidney injury?
Hypovolemic shock Sepsis Severe Burns
What intervention is required for hyperacute rejection of a kidney transplant?
Immediate removal of the transplanted kidney.
Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus?
Impaired neural functioning.
A client has a total knee replacement, and a continuous passive motion device is being used. The nurse concludes that the teaching was effective when the client states, "The goal of this therapy to--"
Improve joint flexion."
An older adult male patient reports an acute problem with urine retention. The nurse advises the patient to seek medical attention because permanent kidney damage can occur in what time frame?
In less than 48 hours
In which situations is regional anesthesia used instead of general anesthesia?
In patients who have had an adverse reaction to general anesthesia. In some cases when pain management after surgery is enhanced by regional anesthesia. In patients with serious medical problems. When the patient has a preference and a choice is possible.
A patient with PKD would exhibit which signs/symptoms?
Increased abdominal girth Hypertension Kidney stones
In PKD, the effect on the renin-angiotensin system in the kidney has which result?
Increased blood pressure
Which factors are considered hazards associated with oxygen therapy?
Increased combustion. Oxygen toxicity. Absoprtion atelectasis. Oxygen induced hypoventilation.
A patient with PKD usually experiences constipation. What does the nurse recommend?
Increased dietary fiber and increased fluids.
The nurse reviews the ECG and cardiovascular status of a patient. Which findings are early changes associated with mild acidosis?
Increased heart rate and increased cardiac output.
A patient with AKI has a high rate of catabolism. What is this related to?
Increased levels of catecholamines, cortisol, and glucagon.
The nurse is preparing an educational program for student nurses on the orthopedic unit. Which three signs of hip dislocation would be included in this offering?
Increased pain. Leg rotation. Shortening of affected leg.
A pt is having diagnostic testing to determine the probability of Paget's disease. If the disease is present, which lab result does the nurse expect to see?
Increased serum alkaline phosphatase (ALP)
The nurse is reviewing laboratory results for a patient who has pneumonia. Which laboratory value does the nurse expect to see for this patient?
Increased white blood cells
Which test result indicates a patient has clinically active TB?
Induration of 12 mm and positive sputum
Arthrocentesis done on the pt with RA may reveal which elements in the synovial fluid of the joint?
Inflammatory cells and immune complexes. Increased WBCs
Which definition is appropriate for local anesthesia?
Injection of an anesthetic agent directly into the tissue around an incision, wound, or lesion.
Types of regional Anesthesia: Spinal Anesthesia
Injection of an anesthetic agent into the cerebrospinal fluid in the subarachnoid space. Used for lower abdominal, pelvic, hip, and knee surgery.
During surgery, what things do anesthesia personnel monitor, measure and assess?
Intake and output. Cardiopulmonary function. Level of anesthesia. Vital Signs.
A client is admitted with a fracture of the neck of the femur. In what position should the nurse maintain the client's affected extremity?
Internal rotation with extension of the knee and hip.
Which assessment tool is commonly used to ask patients about the effect of urinary symptoms on their quality of life?
International Prostate Symptom Score
The nruse notes bright red blood with numerous clots in the urinary drainage bag for a patient who had a TURP. After notifying the surgeon, what does the nurse do next?
Irrigate the catheter with normal saline per protocol.
Kidney tissue changes in chronic glomerulonephritis are caused by which factors?
Ischemia. Hypertension. Infection.
The pt and family are referred to the RN for education about amyotrophic lateral sclerosis (ALS). What information does the RN included in the educational session?
It is a progressive disease involving the motor system. The cause of ALS is unknown. There is no known cure for ALS.
Which statement is true about insulin?
It is necessary for glucose transport across cell membranes.
Why is glucose vital to the body's cells?
It is used by cells to produce energy.
Patient has BPH. Which information about this condition is important to consider?
It predisposes to hydronephrosis
The older adult client has had a right open reduction internal fixation (ORIF) of a fractured hip. Which intervention will the nurse implement for this client? A. Keep the client's heels off the bed at all times. B. Reposition the client every 3 to 4 hours. C. Administer preventive pain medication during deep-breathing exercises. D. Prohibit the use of antiembolic stockings.
Keep the client's heels off the bed at all times.
What instructions should the nurse provide when the client is allowed out of bed after an above the knee amputation?
Keep the hip in extension and alignment.
Family education for MG
Know CPR
A client has an amputation of a lower limb. What instructions should the nurse give the client to prevent a hip flexion contracture?
Lie on the abdomen 30 minutes four times daily.
A pt had a transrectal ultrasound with biopsy earlier in the day. What urine characteristics does the nurse expect to see?
Light pink urine
A pt with quadriplegia is placed on a tilt table daily. Each day the angel of the head of the table gradually is increased. What should the RN identify as its purpose when the pt asks the reason for the tile table?
Limits loss of calcium from the bones.
To reduce the incidence of patients with a known history of malignant hyperthermia. What best practices are put in place in the OR?
List of medications available for emergency treatment of MH. Dedicated MH cart with treatment medications. Treatment before, during, and after surgery if the patient has a known history or risk. Additional nursing support on call if MH develops. Available MH hotline number.
A pt has just undergone spinal fusion surgery and returned form the operating room 12 hours ago. Which task is best to delegate to the UAP?
Log roll the pt every 2 hours.
The Rn is caring for a pt with a recent SCI. Which intervention does the Rn use to target and prevent the potential SCI complication of autonomic dysreflexia?
Loosen or remove any tight clothing. Monitor stool output and maintain a bowel program. Monitor urinary output and check for bladder distention.
A nurse is caring for a client who developed aseptic necrosis after a fracture of the head of the femur. The nurse understands that aseptic necrosis is associated with which factor?
Loss of blood supply to the head of the femur.
Waht does a nurse expect to be the PRIORITY concern of a 28 year old woman who is to undergo a laparoscopic bilateral salpingo oophorectomy?
Loss of childbearing potential.
Stress incontinence
Loss of control in urinating from too little muscle tone (sphincter) in bladder
The pt has an indwelling catheter in place following a TURP. Wha instructions will the nurse give to the UAP with regards to the catheter?
Maintain traction of the catheter.
What is the priority nursing intervention for a client during the immediate postoperative period?
Maintaining a patent airway.
In developing an individualized meal plan for a patient with DM, which goals will be focal points of the plan?
Maintaining blood glucose levels at or as close to the normal range as possible. Patient food preferences. Patient cultural preferences. Limiting food choices only when guided by scientific evidence.
Which nursing intervention is applicable for a patient with acute glomerulonephritis?
Measuring weight daily.
After an abdominal cholecystectomy, a client has a T-tube attached to a collection device. On the day of surgery, at 10:30 PM, 300 mL of bile is emptied from the collection bag. At 06:30 AM the next day, the bag contains 60 mL of bile. What should the nurse consider in response to this information?
Mechanical problems may have developed with the T-tube.
Glomerulonephritis: Education
Medication Dietary - electrolyte balance, protein restriction BP Dialysis
The nurse is performing an assessment on a pt with organic ED. What are the possible causes of this condition?
Meds for HTN Thyroid disorders Diabetes Mellitus
Which class of antidiabetic medication should be given 1-30 minutes before meals?
Meglitinides, includes nateglinide (Starlix)
The nurse is caring for a patient with excessive alcohol ingestion and salicylate intoxication. What is the most likely acid base imbalance this patient will have?
Metabolic acidosis
Untreated hyperglycemia results in which condition?
Metabolic acidosis
Which cultures tend to have a higher incidence of DM?
Mexican American African American American Indian
Which are considered the early signs of diabetic nephropathy?
Microalbuminuria Elevated serum uric acid
All patients with hypertension or diabetes should have yearly screenings for which factor?
Microalbuminuria.
A patient has an inner maxillary fixation. The nurse encourages the patient to eat which kind of food?
Milkshakes
In late RA, the pt may have systemic involvement called "flare ups." How are these characterized?
Moderate to severe weight loss. Fever and fatigue.
What interventions are included in the plan of care for a patient with metabolic ketoacidosis?
Monitor ABG levels for decreasing pH level, as appropriate. Maintain patent IV access. Administer fluids as prescribed.
Nursing interventions for MG
Monitor Respiratory status Administer medications on time Monitor dysphagia Avoid stress, infection, fatigue.
Nursing Interventions for Drug Therapy
Monitor respiratory status, BP, GI motility, urine output, electrolyte balance, neurological status.
Which are interventions for the med surg nurse to use in preventing hypoxemia for the postoperative patient?
Monitor the patient's oxygen saturation. Encourage the patient to cough and breathe deeply. Get the patient up ambulating as soon as possible.
A patient is receiving a high concentration of oxygen as a temporary emergency measure. Which nursing action is the most appropriate to prevent complications associated with high flow oxygen?
Monitor the prescribed oxygen level and length of the therapy.
After undergoing a modified radical mastectomy, a client is transferred to the postanesthesia care unit. Which nursing action is best to delegate to an experienced LPN?
Monitoring the client's dressing for any signs of bleeding.
Factors that DECREASE serum K+
NPO status, diuretics, vomiting, malnutrition, diarrhea, alkalosis
Client pulls out urinary catheter. What should the nurse do first?
Notify the health care provider
Symptom in early stages of MS
Nystagmus
The client has undergone an elective below-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? A. Observation of a large amount of serosanguineous or bloody drainage B. Mild to moderate pain controlled with prescribed analgesics C. Absence of erythema and tenderness at the surgical site D. Ability to flex and extend the right knee
Observation of a large amount of serosanguineous or bloody drainage
During the postoperative assessment, the nurse observes Ms. Jackson's surgical site. The left hip dressing has a moderate amount of sanguineous drainage. What actions should the nurse implement?
Observe the linens under the hip. Mark the amount of drainage on the dressing.
A pt with a lower extremity injury is being treated by external fixation. What nursing assessment is of particular concern in the care of this pt with this type of system?
Observing the points of entry of the pins and wires
The 50 year old pt recently diagnosed with ALS is prescribed riluzole (Rilutek). When should the Rn teach the pt to take this drug?
On an empty stomach.
Which factor carries the greatest risk for hip fracture?
Osteoporosis
A patient has had diarrhea for the past 2 days. Which acid base abnormalities would the nurse monitor for ?
Overelimination of HCO3 Metabolic acidosis
The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction?
Pain medication will take away my pain."
People with GERD should avoid*
Peppermint, citrus, caffeine, and chocolate
Renal failure causes
Perfusion reduction (pre) Kidney Damage (intra) Urine Flow obstruction (post)
Why may a patient with PKD experience constipation?
Polycystic kidneys enlarge and put pressure on the large intestine.
Which electrolyte is most affected by hyperglycemia?
Potassium
SCIP Infection-2
Prophylactic Antibiotic Selection for Surgical Patients
A Rn is caring for a pt with chronic kidney failure. What should the RN teach the pt to limit the intake of to help control uremia associated with ESRD?
Protein
Which patient is the most likely candidate for CVVH?
Pt who is chronically ill.
Which action is correct when drawing up a single does of insulin?
Pull back plunger to draw air into the syringe equal to the insulin dose.
A pt has recently started PD therapy and reports some mild pain when the dialysate is flowing in. What does the RN do next?
Reassure that pain should subside after the first week or two.
The Rn is monitoring a pt's PD treatment. The total outflow is slightly less than the inflow. What does the nurse do next?
Record the difference as intake.
What is the most common cause of death in pt with SLE?
Renal failure.
Which behavior is the strongest indicator that a patient with ESKD is not coping well with the illness and may need a referral for psychological counseling?
Repeatedly misses dialysis appointments.
What should the RN include in the plan of care for a pt who just had a posterior lumbar laminectomy?
Reposition the pt by log rolling.
Category for surgery for a total knee replacement
Restorative surgery
Distinct characteristic of appendicitis*
Right upper quadrant pain
Which statement about insulin administration is correct?
Rotating injection sites improves absorption and prevents lipohypertrophy.
A patient with PKD reports sharp flank pain followed by blood in teh urine. How does the nurse interpret these signs/symptoms?
Ruptured cyst.
The UAP is assisting the orthopedic physician to cut a window in a pt's cast. What does the RN instruct the UAP to do?
Save the plaster piece that was cut so it can be taped in place.
A patient is admitted to the hospital with cough, purulent sputum production, temperature of 100.3 F, and reports of shortness of breath. Which intervention does the nurse provide first?
Set up oxygen equipment and administer oxygen.
The acute, life-threatening complication of MH results from the use of which agents?
Succinylcholine and inhalation agents.
The nurse is caring for several postoperative patients with high risk for a PE. All of these patients have preexisting chronic respiratory problems. What is a unique assessment finding for a clot in the lung?
Sudden dry cough.
A pt has just undergone a laminectomy and returned from surgery at 1300 hours. At 1530 hours, the RN is performing the change of shift assessment. Which postoperative findings are reported to the surgeon immediately?
Swelling or bulging at the operative site. Moderate clear drainage on the postoperative dressing.
Which sign or symptom is associated with advanced prostate cancer?
Swollen groin lymph nodes
First line drugs for anaphylaxis
Sympathomimetics: Epinephrine, Isoprotrenol, Ephedrine sulfate
A patient is brought to the emergency department after being involved in a fight in which the patient was kicked and punched repeatedly in the back. What does the nurse include in the initial physical assessment?
Take complete vital signs. Check apical and peripheral pulses. Inspect both flanks for asymmetry or penetrating injuries of the lower chest or back. Inspect the abdomen for bruising or penetrating wounds. Inspect the urethra for gross bleeding.
What nursing intervention may help to prevent the complication of pneumonia for a surgical patient?
Teaching coughing, deep-breathing exercises, and use of incentive spirometry.
Diagnosis test for MG
Tensilon testing
You are assessing a long term care client with a history of BPH Which patient information requires prompt action?
The bladder is paplable above the symphysis pubis. The client is restless.
The nurse is reviewing PSA results for a pt who had a prostatectomy for prostate cancer several weeks ago. The PSA level is 40 ng/mL. How does the nurse interpret this data?
The cancer is most likely reoccuring
Which principle should the nurse consider when assisting a client with crutches to learn the four point gait?
The client must be able to bear weight on both legs.
The advanced practice nurse is preparing to examine a patient's prostate gland. Before the exam, what does the nurse tell the patient?
The gland will be massaged to obtain a fluid sample for possible prostatitis.
The RN is teaching a pt about antibiotic therapy for osteomyelitis. What information does the RN give to the pt?
The infected wound may be irrigated with one or more types of antibiotic solutions.
You assess a 24 year old pt with RA who is considering using methotrexate (Rheumatrex) for treatment. Which pt information is most important to communicate to the health care provider?
The pt has been trying to get pregnant
During assessment of a pt with fractures of the medical ulna and radius, you find all of these data. Which assessment finding should you report to the health care provider immediately?
The pt reports pressure and pain.
A pt has returned to the med surg unit after having a dialysis treatment. The RN notes that the pt is also scheduled for an invasive procedure on the same day. What is the primary rationale for delaying the procedure for 4 to 6 hours?
The pt was heparinized during dialysis.
A pt with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would you instruct the UAP to report immediately?
The traction weights are resting on the floor.
Which descriptions are true about sprains?
They involve an injury to a ligament. Second and third degree sprains require immobilization. Sprains are usually precipitated by twisting motions from a sports injury.
Which explanation best assists a client in differentiating type 1 DM from type 2?
Those with type 2 diabetes make insulin, but in inadequate amounts.
A patient has been compliant with drug therapy for TB and has returned as instructed for follow up. Which result indicates that the patient is no longer infectious/communicable?
Three negative sputum cultures
A client is ready to walk with crutches after knee surgery. Which crutch walking technique will the nurse most likely have to reinforce after the client returns from physical therapy?
Three-point
At what times is oxygen therapy needed for a patient?
To treat hypoxia. To treat hypoxemia. When the normal 21% oxygen level in the air is inadequate.
A nurse is caring for a client who has had an open reduction internal fixation of a fractured hip. Which nursing assessment of the affected leg is most important after this surgery?
Toes for mobility.
Normal White Blood Cell Count
Total: 5,000 - 10,000/mm3
Which neurologic assessment technique does the Rn use to test a pt for sensory function?
Touch the skin with a clean paper clip and ask whether it is a sharp or dull sensation.
A patient has had a pelvic examination and needs an additional diagnostic test for possible uterine leiomyomas. The nurse prepares the patient for which first choice diagnostic test?
Transvaginal ultrasound
People with headaches should avoid foods with
Tyramine
What potential complication does a nurse anticipate when admitting a client with the diagnosis of severe procidentia (prolapse of the uterus)?
Ulcerations
A patient with bilateral lower lobe pneumonia is diagnosed with respiratory acidosis based on ABG results. What is the cause of patient's respiratory acidosis?
Under elimination of CO2 from the lungs.
A client has a total hip replacement. Which clinical indicators of pulmonary embolism indicate that the plan to prevent postoperative thrombus formation has been ineffective?
Unilateral chest pain. Sudden onset of shortness of breath.
SCIP Infection-9
Urinary Catheter Removed on Postoperative Day 1 or POD 2 with Day of Surgery Being Day Zero
The nurse is caring for a patient who had hypovolemic shock secondary to trauma in the ED 2 days ago. Based on the pathophysiciolgy of hypovolemia and prerenal azotemia, what does the nurse assess at least every hour?
Urinary output
A patient is newly diagnosed with type 2 DM. Which screening recommendation does the nurse give to the patient regarding the early detection of diabetic kidney disease?
Urine should be tested annually for protein and microalbuminuria.
A pt has an enlarged prostate. Which procedure does the nurse anticipate that the HCP will order to test for bladder obstruction?
Urodynamic pressure flow study
What techniques are essential to performing a proper surgical scrub of the hands by the surgeon, assistants, and scrub nurse?
Use a broad-spectrum, surgical antimicrobial solution. Hold hands higher than the elbows during the scrub and rinse. Scrub for 3-5 minutes, followed by a rinse with water.
Which nursing assessment finding indicates a worsening of respiratory acidosis?
Use of accessory respiratory muscles
The client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction will the nurse plan to include in this client's teaching plan? A. Use pain medication as prescribed to control pain. B. Clean the pin site when any drainage is noticed. C. Wear the same clothing that is normally worn. D. Apply Neosporin (bacitracin, neomycin, and polymyxin B) if signs or symptoms of infection develop around pin sites.
Use pain medication as prescribed to control pain.
Client has indwelling urinary catheter. What is the most important action for the nurse to implement when irrigating the bladder?
Use sterile equipment.
Ramsay Sedation Scale
Used for Assessing post sedation consciousness
What are the characteristics of continuous venovenous hemofiltration (CVVH)?
Uses a pump to drive blood from the patient catheter into the dialyzer. Risk of air embolus. More commonly used for patients who are critically ill
The client has a grade III compound fracture of the right tibia. To prevent infection, which intervention will the nurse implement? A. Applying Neosporin (bacitracin, neomycin, and polymyxin B) ointment to the site daily with a sterile cotton-tipped swab B. Using strict aseptic technique when cleaning the site C. Leaving the site open to the air to keep it dry D. Assisting the client to shower daily and pat the wound site dry
Using strict aseptic technique when cleaning the site
Grade II Uterine Prolapse
Uterus bulges into vagina, but the cervix does not protrude.
Support drugs for anaphylaxis
Vasopressors: Norepinephrine, dopamine
The nurse is giving discharge instructions to an adult patient diagnosed with the flu. What does the nurse instruct for the patient to prevent contaminating others?
Wash hands after sneezing, coughing, or blowing noise. Avoid contact Cough or sneeze into upper sleeve. Use disposable tissues rather than cloth. Dispose of tissues.
The nurse is providing discharge teaching to a patient about self monitoring of blood glucose (SMBG). What information does the nurse include?
Wash hands before using the meter. Do a retest if the results seem unusual. Do not share the meter.
The nurse monitors a CKD patient's daily weights because of the risk for fluid retention. What instructions does the nurse give to the UAP?
Weigh the patient daily at the same time each day, same scale, with the same amount of clothing.
After the nurse instructs a patient with PKD on home care, the patient knows to contact the health care provider immediately when what sign/symptom occurs?
Weight has increased by 3 pounds in 2 days.
Which are characteristics of regular insulin?
When mixing types of insulin, this insulin is always drawn up first. This insulin should be given 30 minutes before meals.
A client recently admitted with new onset type 2 DM will be discharged with a self monitoring blood glucose machine. What is the BEST time for the nurse to explain to the client the proper use of the machine?
While performing the test in the hospital.
When a patient is requiring oxygen therapy. What is important for the nurse to know?
Why the patient is receiving oxygen, expected outcomes, and complications.
A client with a fractured hip is helped from the bed to a chair after surgery. The nurse instructs the client to bear most of the weight on the unaffected leg before sitting in a chair. What should the nurse explain is the benefit of bearing most of the weight on the unaffected?
Will help maintain the strength of the unaffected limb
outpatient/ambulatory
a patient who goes to the surgical area the day of surgery and returns home the same day.
NaHCO3 is given for
acid-base imbalance of diabetic ketoacidosis
Acute pyelonephritis
active infection acute tissue inflammation, tubular cell necrosis, possible abscess formation
A client newly diagnosed with scleroderma states, "where did I get this from?" The RN's BEST response is "Although no cause has been determined for scleroderma, it is thought to be the result of:
autoimmunity
Patients receiving interferon-beta drugs should
avoid large crowds, people who are ill. Monitor for allergic reactions.
Intervention for stress incontinence
behavioral interventions diet modification - weight reduction Kegel exercises Drug therapy Vaginal cone therapy Surgery
What glucose level range does the American Association of Clinical Endocrinologists recommend for a critically ill patient?
between 140 and 180 mg/dL
HCO3
bicarbonate
Mucosal barrier fortifiers
bismuth subsalicylate (peptobismol) sucralfate (sulcrate)
75% of urolithiasis contains
caclium
Peritoneal dialysis
catheter placed in abdominal cavity for infusion of dialysate. Filters fluid into a waste bag. CAPD or CCPD
Dialysis disequilibrium syndrome
caused by a rapid fluid shift and change in electrolytes
Lifestyle changes for gastritis
eat a well balanced diet avoid drinking excess alcohol, coffee Do not take large amounts of NSAIDS, Corticosteroids Avoid food borne illnesses smoking cessation
azotemia
elevated BUN in blood
Habit training
establishing a predictable pattern of bladder emptying to prevent incontinence
Dysfunctional Uterine Bleeding assessment
excessive uterine bleeding - greater than 80 mL blood loss per cycle. longer than 21 days of bleeding.
CRAB drug side effects
flu like symptoms
Nursing priorities for DM focus on
helping the patient achieve and maintain lifestyle changes that prevent long term complications by keeping blood glucose levels and cholesterol levels as close to normal as possible.
Hemodialysis can be done
in center or in the home
duodenal ulcers are more likely to have ___ than gastric ulcers
melena
amnesia
memory loss
Acute exacerbation of MS should be treated with*
methyprednisone
post op hernia repair care
monitor vital signs: focus on blood pressure to detect bleeding assess incisional pain encourage deep breathing encourage ambulation apply ice packs to surgical area do not life more than 10 pounds
Incretin mimetics
natural "gut" hormones that lower plasma glucos levels
After nephrostomy
notify the physician immediately when drainage decreases or stops, drainage is cloudy or foul smelling surgical site leaks blood or urine pt has back pain.
ventral hernia (incisional)
occur at a site of previous hernia
Extent of surgery: Simple
only the most overtly affected areas involved in the surgery.
Myomectomy
the removal of leiomyomas from the uterus with a laser
Evisceration
total separation of all wound layers and protrusion of internal organs through the open wound
Older adults should not receive
triclyclic drugs
Which pre operative tests are performed for a patient scheduled to undergo a total hip arthroplasty (THA)?
x-ray of operative hip. Computed tomography (CT) of operative hip. Magnetic resonance imaging (MRI) of operative hip.
The night shift nurse sees a patient with kidney failure sitting up in bed. The patient states, "I feel a little short of breath at night or when I get up to walk to the bathroom." What assessment does the nurse do?
Auscultate the lungs for crackles, which indicate fluid overload.
Which intervention for a patient with a pulmonary embolus could be delegated to the LPN/LVN on your patient care team?
Auscultating the lungs for crackles.
Nursing Interventions for General Anesthesia Stage: 2
Avoid auditory/physical stimuli. Protect the extremities. Stay with the patient. Assist the CRNA with suctioning as needed.
What self management strategy would the nurse recommend to a a patient to prevent vulvovaginitis?
Avoid wearing tight fitting clothing
A nurse is caring for a client with end stage renal disease. Which clinical indicators of end stage renal disease should the nurse expect?
Azotemia Hypertension
renal failure manifestations
Azotemia Oliguria Fluid Overload: edema, pulmonary crackles, decreased SpO2 increased creatinine abnormal specific gravity for urine.
The nurse begins the preoperative assessment by taking Ms. Jackson's vital signs. Which vital sign requires follow-up by the nurse?
BP of 160/88
The nurse is caring for a patient receiving gentamicin. Because this drug has potential for nephrotoxicity, which lab results does the nurse monitor?
BUN Creatinine Drug peak and trough levels.
Pylonephritis: common causes
Bacteria
Which type of meningitis is a medical emergency?
Bacterial
Insects that commonly cause anaphylaxis
Bees, wasps, hornets, fire ants, snake venom
After Ms. Jackson ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse review the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves?
Before cleansing the client's hip incision.
When should the nurse begin the process of rehabilitation when a client is scheduled for an amputation?
Before the surgery.
Description of General Anesthesia Stage 4 (DANGER)
Begins with depression of vital functions and ends with respiratory failure, cardiac arrest, and possible death. Respiratory muscles are paralyzed; apnea occurs. Pupils are fixed and dilated.
Description of General Anesthesia Stage 3 (Operative Anesthesia, Surgical Anesthesia)
Begins with generalized muscle relaxation and ends with loss of reflexes and depression of vital functions. Jaw is relaxed, breathing is quiet and regular. Sensations of pain and hearing are lost.
Description of General Anesthesia Stage 1 (Analgesia and Sedation, Relaxation)
Begins with induction and ends with loss of consciousness. Patient feels drowsy and dizzy, has a reduced sensation to pain, and is amnesic. Hearing is exaggerated.
Description of General Anesthesia Stage 2 (Excitement, Delirium)
Begins with loss of consciousness and ends with relaxation, regular breathing, and loss of the eyelid reflex. Patient may have irregular breathing, increased muscle tone, and involuntary movement of the extremities. Laryngospasm or vomiting may occur. Patient is susceptible to external stimuli.
What is the best description of the nurse's role in delivery of oxygen therapy?
Being familiar with the devices and techniques used in order to provide proper care.
Antimicrobials for H. pylori
Biaxin, Amoxicillin, Tetracycline, Metroniadazole
Which class of anti diabetic medication must be held after using contrast media until adequate kidney function is established?
Biguanides, includes metformin
The nurse is preparing patient teaching for several young women who will undergo surgical procedures for gynecologic problems. Which surgical procedure is most likely to induce menopausal symptoms?
Bilateral Salpingo-oophorectomy
The nurse assesses an acidotic patient's lower extremities for strength as part of the nursing shift assessment. What finding does the nurse expect to see?
Bilateral weakness
The RN is assessing a pt who has just returned form hemodialysis. Which assessment finding is cause for greatest concern?
Bleeding at the access site.
What is the most common cause of embolism?
Blood clot
Aspirin is prescribed for a pt with RA. Which clinical indicators of aspirin toxicity should the RN teach the pt to report?
Blood in the stool. Ringing in the ears.
Factors that DECREASE serum Hemogoblin, and Hematocrit?
Blood loss, anemia, renal failure
The student is assisting in the postoperative care of a patient who had a recent nephrectomy. The student demonstrates a reluctance to move the patient ot change the linens because "the patient seems so tired." The nurse reminds the student that a priority assessment for this patient is to assess for which factor?
Blood on the linens beneath the patient
Renal Disease and Hypertension: assessments
Blood pressure (160/10) urinalysis, serum albumin (decreased) Creatinine (elevated)
The nurse transfers a patient to the PACU with an incision and drainage of an abscess in the right groin under general anesthesia. Blood pressure is 80/47 mmHg, heart rate 117/min in sinus tachycardia, respiratory rate 28/min, pulse oximetry reading 93% on oxygen at 3 L nasal cannula, temp is 38.5 C. The Jackson-Pratt drain has 70 mL of a ream colored output. Normal saline is infusing at 150 mL/hr. The surgeon orders a bolus of 500 mL IV over 1 hour of normal saline, two sets of blood cultures, and culture drainage from the Jackson-Pratt drain. The patient's history includes vulva cancer with a needle biopsy of the right groin, hypertension treated with lisinopril (Zestril) 5 mg PO daily, and no known drug allergies. The patient is a full code. Using SBAR, which information should be included in the assessment?
Blood pressure 80/47. Heart rate 117/min. Sinus tachycardia. Respirations 28/min. Pulse oximetry 93% on O2 at 3 L nasal cannula. Temp 38.5 C. Jackson-Pratt drain with 70 mL cream colored output.
The RN is providing postdialysis care for a pt. In comparing vital signs and weight measurements to the predialysis data, what does the RN expect to find?
Blood pressure and weight are reduced.
A 22 year old patient comes to the clinic for a wellness check up. History reveals taht the patient's parent has the autosomal dominant form of polycystic kidney disease (PKD). Which vital sign suggests that the patient should be evaluated for PKD?
Blood pressure of 136/88 mmHg
What are common sites of metastasis for prostate cancer?
Bones of the pelvis Liver Lungs
What should the RN take into consideration when planning nursing care for a pt experiencing an acute episode of RA?
Bony ankylosis of a joint is irreversible and causes immobility.
The nurse is caring for a patient with AKI and notes a trend of increasingly elevated BUN levels. How does the nurse interpret this information?
Breakdown of muscle for protein which leads to an increase in azotemia.
The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? A. Balanced skin traction B. Buck's traction C. Overhead traction D. Plaster traction
Buck's traction
A RN is interviewing a client who was diagnosed with SLE. Which common responses to this disease can the RN expect the client to exhibit?
Butterfly facial rash Inflammation of the joints.
It is important to monitor which lab tests for patients on anticoagulant therapy with LMWH after TJA?
CBC. Platelet count.
Factors that increase serum CO2
COPD, Intestinal obstruction, vomiting, nasogastric suctioning, metabolic alkalosis
Tumor marker for Ovarian/Endometrial cancer
Ca-125
A pt is prescribed calcitonin for treatment of Paget's disease. What does the RN teach this pt regarding this drug?
Calcitonin is given by subcutaneous injection.
A patient has AKi related to nephrotoxins. In order to maintain cell integrity, improve GFR, and improve blood flow to the kidneys, which type of medication does the nurse anticipate the health care provider will prescribe?
Calcium channel blockers
The patient with laryngeal trauma develops stridor. What is the nurse's highest priority intervention?
Call the RRT
The PACU nurse is caring for a postoperative patient. The patient's oxygen stauration drops from 98% to 88%. What is the nurse's priority action?
Call the Rapid Response Team.
The nurse is caring for a patient and suspects anaphylaxis. What first priority action does the nurse take at this time?
Call the Rapid Response Team.
In recalling dietary intake for a recent 24 hour period, a female patient describes eating eggs, whole milk, and bacon for breakfast; fried chicken and french fries for lunch. This type of diet places her at increased risk for which disorder?
Cancer of the Ovaries.
A nurse is applying a dressing to a client's surgical wound using sterile technique. While engaging in this activity, the nurse accidentally places a moist sterile gauze pad on the cloth sterile field. What physical principle is applicable for causing the sterile field to become contaminated?
Capillary.
SCIP Infection-4
Cardiac Surgery Patients with Controlled 6am Postoperative Blood Glucose
A patient with CKD has a K+ level of 8 mEq/L. The nurse notifies the health care provider after assessing for which sign/symptom?
Cardiac dysrhythmias
A pt comes to the Ed with crush syndrome form a crush injury to his right upper extremity and right lower extremity when heavy equipment fell on him at a construction site. The pt has signs and symptoms of hypovolemia, hyperkalemia, and compartment syndrome. Management of care for this pt will focus on preventing which complications?
Cardiac dysrhythmias Acute kidney failure
Factors that increase serum Na+
Cardiac failure, kidney impairment, hypertension, excessive IV fluids, Edema, dehydration
An older adult pt has a fractured humerus. The physician is considering the use of electrical bone stimulation and asks the RN to take a medical history on the pt. Which specific condition, which is a contraindication for this therapy does the RN ask the pt about?
Cardiac pacemaker
A patient with type 1 DM is planning to travel by air and asks the nurse about preparations for the trip. What does the nurse tell the patient to do?
Carry all necessary diabetes supplies in a clearly identified pack aboard the plane.
A client newly diagnosed with DM is not ready/willing to learn diabetes contorl during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family?
Causes and treatment of hypoglycemia
Which descriptors are typical of type 2 DM?
Cells have decreased ability to respond to insulin Most patients diagnosed are obese adults.
Clear drainage from a wound dressing after spinal surgical can indicate:
Cerebrospinal fluid leakage (notify surgeon)
The nurse encourages a teenage patient to receive the HPV vaccine (Gardasil) because it protects against which type of Cancer?
Cervical Cancer
Young women who have intercourse as teenagers and/or have multiple sex partners are at high risk for which disease?
Cervical Cancer
Postrenal kidney injury can result from which conditions?
Cervical Cancer Nephrolithiasis or ureterolithiasis Neurogenic bladder Prostate Cancer
What is the most common area of involvement of RA in the spine?
Cervical spine.
An older adult has been admitted with a hip fracture. Approximately 20 hours post injury, the pt develops a symptom recognized as an early sign of fat embolism syndrome. Which symptom is the pt displaying?
Change in mental status.
The patient has a diagnosis of mild sleep apnea. Which interventions will the nurse teach the patient that may correct this condition?
Change sleeping positions Look into a weight loss program A position fixing device can prevent tongue subluxation
A patient who has sustained a traumatic amputation of the left leg expresses concern about working and taking care of his family after his injury. What resources does the nurse recommend to help the patient adjust to his lost limb?
Chaplain. Medical Social Worker. National Amputation Foundation.
The patient with diabetes has a foot that is warm, swollen, and painful. Walking cause the arch of the foot to collapse and gives the foot a "rocker bottom" shape. Which foot deformity does the nurse recognize?
Charcot foot
Nursing intervention regarding plasmaphoresis
Check arteriovenous shunt for bruits every 2 to 4 hours. Pt are at risk for hypovolemia. Monitor I & O, fluid status, vital signs.
Client is an older adult taking contraindicated drugs with confusion. What do you do?*
Check oxygen
A client with type 1 DM arrives in the ED breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4 F, P 112 bpm, R 38 bpm, Bp 91/54 mmHg, and O2 Sat 99% on room air. Which action does the nurse take first?
Check the blood glucose
A client is admitted to the emergency department after a motorcycle accident with a compound fracture of the left femur. Which action will be most essential for the nurse to take first? A. Check the dorsalis pedis pulses. B. Immobilize the left leg with a splint. C. Administer the prescribed analgesic. D. Place a dressing on the affected area.
Check the dorsalis pedis pulses.
The nurse is caring for a patient after a nephrectomy. The nurse notes that the urine flow was 50 mL/hr at the beginning of the shift, but several hours later has dropped to 30 mL. What would the nurse do first?
Check the drainage system for kinks or obstructions to flow.
A patient develops respiratory distress after having a left total knee replacement. The patient develops labored breathing and a pulse oximetry reading is 83% on 2 L oxygen via nasal cannula. Which intervention is appropriate for the nurse to delegate to unlicensed assistive personnel?
Check the patient's vital signs.
The home health nurse has been caring for a patient with a chronic respiratory disorder. Today the patient seems confused when she is normally alert and oriented. What is the priority nursing action?
Check the pulse oximeter reading.
Which nursing action will the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.
Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.
The nurse is caring for a pt requiring PD. In order to monitor the pt's weight, what does the nurse do?
Check the weight after a drain and before the next fill to monitor the pt's "dry weight".
A pt with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this pt, the RN may delegate which action to a LPN?
Checking the pt's neurologic status for changes. Observing the halo insertion sites for signs of infection. Cleaning the halo insertion sites with hydrogen peroxide.
The RN is helping to evaluate several pt to determine candidacy for the Ilizaroz external fixation device. Which pt is the best candidate?
Child with a congenital bone deformity whose mother is a licensed practical nurse.
The nurse has just received change of shift report on the endocrine unit. Which client does the nurse see first?
Client with type 1 DM whose insulin pump is beeping "occlusion"
Nursing Interventions for General Anesthesia Stage: 1
Close operating room doors, dim the lights, control traffic in the operating room. Position Patient securely with safety belts. Keep discussion about the patient to a minimum.
A pt is admitted with acute gouty arthritis. Which medication does the RN anticipate the health care provider may prescribe to prevent and treat an acute attack of gout?
Colchicine (Colsalide)
The nurse is interviewing an older adult with a history of osteoporosis who reports falling and catching her weight on her outstretched dominant hand. This patient is most likely to have sustained what type of fracture?
Colles' wrist fracture.
What is the RN's primary consideration when caring for a client with rheumatoid arthritis?
Comfort
Most powerful and slowest regulator of acid base balance
Compensation by the kidneys.
The nurse is providing discharge instructions about pneumonia to a patient and family. Which discharge information must the nurse be sure to include?
Complete antibiotics as prescribed, rest, drink fluids, and minimize contact with crowds.
Which description illustrates the beginning of the postoperative period?
Completion of the surgical procedure and transfer of the patient to the postanesthesia care unit (PACU).
For a patient with AKI, the nurse would consider questioning the order for which diagnostic test?
Computed tomography with contrast dye.
post renal failure
Condition after affecting the kidneys ex. Kidney stone, sudden obstruction of urine
pre renal failure
Condition prior to kidneys being affected ex. Heart failure, interruption of blood flow to the kidneys
The nurse observes that the word, "Yes" has been marked on Ms. Jackson's left hip, and the word "no" has been written on the right hip. What action should the nurse implement?
Confirm that the left hip is the site of the scheduled surgery.
A patient who was in a motor vehicle accident and sustained laryngeal trauma is being treated in the emergency department with humidified oxygen and is being monitored every 15 to 30 minutes for respiratory distress. Which assessment finding indicates the urgent need for further intervention?
Confused and disoriented, difficulty producing sounds, pulse oximetry 80%.
What is the basic principle of meal planning for a patient with type 1 DM?
Considering the effects and peak action times of the patient's insulin.
When shock or other problems cause an acute reduction in blood flow to the kidneys, how do the kidneys compensate?
Constrict blood vessels in the kidneys. Activate the renin-agntiotensin-aldosterone pathway. Release antidiuretic hormones.
Renal transplant: patient educaiton
Continue immunopressant medications (corticosteroids, anti-lymphocyte, monoclonal antibodies, cyclosporine) follow nutrition therapy Routine follow up
Standard treatment for acute renal failure in the critically ill:
Continuous arteriovenous hemofiltration Continuous venovenous hemofiltration.
Increased risk for oxygen toxicity is related to which factors?
Continuous delivery of oxygen at greater than 50% concentration. Delivery of a high concentration of oxygen over 24 to 48 hours. The severity and extent of lung disease. Neglecting to monitor the patient's status and reducing oxygen concentration as soon as possible.
Postoperative care for total knee replacement may include which technique?
Continuous passive motion used immediately or several days post operatively. Ice packs or cold packs to the incisional area. The use of CPM machine in the daytime and an immobilizer at night.
A patient has been diagnosed with airway obstruction during sleep. The nurse will likely include patient education about which device for home use?
Continuous positive airway pressure to deliver a positive airway pressure.
Which conditions may cause patient to be at risk for aspiration pneumonia?
Continuous tube feedings. Bronchoscopy procedure. Decreased level of consciousness. Stroke.
The health care team is using a collaborative and interdisciplinary approach to design a treatment plan for a patient with PKD. What is the top priority?
Controlling hypertension
In collaboration with the registered dietitian, the nurse teaches the patient about which diet recommendations for management of CKD?
Controlling protein intake. Limiting fluid intake. Restricting potassium. Restricting phosphorus.
Which duties are within the scope of practice of the circulating nurse in operative setting?
Coordinates, oversees, and participates in the patient's nursing care while the patient is in the operating room.
Which characteristics occur with the foot disorder hammertoe?
Corns may develop on the dorsal side of the toe. Insertion of wires or screws is required for fixation.
A patient is admitted to the hospital for treatment of pneumonia. Which nursing assessment finding best indicates that the patient is responding to antibiotics?
Cough, clear sputum, temp 99, O2 96% on room air.
A RN expects a pt with a herniated intervertebral disk to report report a sudden increase in pain with which activities?
Coughing or sneezing. Straining when having a bowel movement.
When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound with evisceration. The nurse places the client in the low Fowler position with the knees slightly bent and encourages the client to lie still. What is the next nursing action?
Cover the wound with a sterile towel moistened with normal saline.
Three days after undergoing a pelvic exenteration procedure, a client reports dizziness after experiencing a sudden "giving" sensation along her abdominal incision. You find that the wound edges are open and loops of intestine are protruding. Which action should you take first?
Cover the wound with saline soaked dressings.
Which electrolyte laboratory result does the nurse report immediately to the anesthesiologist?
Creatinine, 1.9 mg/dL
Which typical clinical manifestation does the nurse expect to observe for a client with a right tibial fracture? A. Flaccid extremity B. Crepitation of extremity C. Mild pain D. No evidence of edema
Crepitation of extremity
A nurse provides discharge teaching for a client who had a total hip replacement. Which activities to avoid identified by the client indicate an understanding of the teach?
Crossing the legs. Sitting in a low chair.
An appendectomy is being performed on a patient with appendicitis. What is the correct classification for this surgery?
Curative Surgery
A pt in a body cast reports nausea, vomiting, and epigastric pain. The Rn notifies the physician for orders. Which intervention is the most conservative, and therefore the first thing to try, to address this pt's symptoms?
Cut a window over the abdominal area of the cast.
What does the nurse monitor for in a patient with PE?
Cyanosis, Rapid heart rate dyspnea crackles in the lung fields
The nurse is caring for a diabetic patient in the ED. The patient's lab values include serum glucose 353 mg/dL, positive serum ketones, and positive urine ketones. What complication does the nurse suspect?
DKA
What is the best description of CAPD? (continuous ambulatory peritoneal dialysis)
Daily infusion of four L exchanges of dialysate every 4 to 6 hours while awake.
A patient is diagnosed with hydronephrosis. What is a complication that could result from this condition?
Damage to the nephrons
The surgical team understands that time is crucial in recognizing and treating an MH crisis. Once recognized, what is the the treatment of choice?
Dantrolene sodium (Dantrium)
Your patient with RA is taking prednisone (Deltasone) and naproxen (Aleve) to reduce inflammation and joint pain. Which symptom is most important to communicate to the health care provider?
Dark-colored stools
What should the RN consider as the goal of thearpy when administering allopurinol (Zyloprim) to a pt with gout?
Decrease uric acid production.
Assessment of pt after dialysis reveals all of these findings, Which assessment finding necessitates immediate action?
Decreased level of consciousness
The nurse is interpreting the ABG results of a patient with acute respiratory insufficiency. As the PaCO2 level increases, which result would the nurse expect?
Decreased pH
Which problems occur with acute kidney injury (AKI)?
Decreased peristalsis Anemia Metabolic acidosis Peripheral edema
A patient who has a decreased amount of hydrogen ions and a decreased amount of CO2 in the body will have what response?
Decreased rate and depth of respirations
The nurse is making home visits to an older adult recovering from a hip fracture and identifies the priority patient problem of risk for respiratory infection. Which condition represents a factor of normal aging that would contribute to this increased risk?
Decreased strength of respiratory muscles.
A patient sustained extensive burns and depletion of vascular volume. The nurse expects which changes in vital signs and urinary function?
Decreased urine output, hypotension, tachycarida.
A patient with PKD reports nocturia. What is the nocturia caused by?
Decreased urine-concentrating ability.
A pt with RA has been taking a steroid med for the past year. For which complication of prolonged use of this med should the RN assess the pt?
Decreased white blood cells
A patient has a new onset of shallow and slow respirations. While the patient's body attempts to compensate, what happens to the patient's pH level?
Decreases
A pt with an SCi has paraplegia and paraparesis. The Rn has identified a priority pt problem of inability to ambulate. The RN assesses the calf area of both legs for swelling, tenderness, redness, or possible complaints of pain. This assessment is specific to the pt's increased risk for which condition?
Deep vein thrombosis
What is the most common site of origin for a clot to occur, causing pulmonary embolism?
Deep veins of the legs and pelvis.
Factors that increase serum K+
Dehydration, kidney impairment, acidosis, cell/tissue damage, hemolysis
The provider orders transtracheal oxygen therapy for a patient with respiratory difficulty. What does the nurse tell the patient's family is the purpose of this type of oxygen delivery system?
Delivers oxygen directly into the lungs.
The nurse talks with Ms. Jackson about what to expect the day of surgery and during immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. Ms. Jackson performs a return demonstration by breathing in deeply through her mouth and exhaling forcefully and rapidly through pursed lips. What action should the nurse implement?
Demonstrate the deep breathing and coughing technique again.
The Rn is caring for a pt who has been in a long term care facility for several months following an SCI. The pt has had problems with urinary retention and subsequent overflow incontinence, and a bladder retraining program was recently initiated. Which are expected outcomes of the training program?
Demonstrates a predictable pattern of voiding. Is able to empty the bladder completely Does not experience a UTI
A client with urinary retention, BPH, and delirium related to urosepsis. The HCP orders a catheter to be placed. What nursing action is most important for the patient's safety?
Determine if any unsafe behavior pattern exists.
A client had an above the knee amputation of the left leg because of trauma from a motor vehicle collision. The health care provider orders ambulation with crutches until the residual limb is healed and the client can be fitted with a prosthesis. What should be the nurse's FIRST intervention?
Determine if the client has ever used crutches before.
After abdominal surgery a client reports pain. What action should the nurse take first?
Determine the characteristics of the pain.
What should the nurse do INITIALLY when obtaining consent for surgery?
Determine whether the client's knowledge level is sufficient to give consent.
The community health nurse is designing programs to reduce kidney problems andkidney injury among the general public. In order to do so, the nurse targets health promotion and compliance with therapy for people with which conditions?
Diabetes mellitus and hypertension.
Complications of hemodialysis
Dialysis disequilibrium syndrome Infection - HIV, Hep B, C
The nurse completes the preoperative checklist on a client scheduled for general surgery. Which factor contributes the greatest risk for the planned procedure?
Diet-controlled diabetes mellitus
Raynaud's phenomenon in a pt with scleroderma may present as which signs/symptoms?
Digit necrosis Excruciating pain Autoamputations of digits Perjungual lesions
Immediately after receiving spinal anesthesia, a client develops hypotension. What physiologic change does the nurse attribute the decreased blood pressure?
Dilation of blood vessels.
A post operative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis?
Diminished breath sounds on auscultation.
intra renal failure
Directly affecting the kidney ex. trauma, direct damage to the kidneys
A client has an anterior and posterior surgical repair of a cystocele and rectocele and returns from the PACU with an indwelling catheter in place. What should the nurse tell the client about the PRIMARY reasons for the catheter?
Discomfort is minimized. Urinary retention is prevented. Pressure on the suture line is relieved.
Care for cytotoxic reactions
Discontinuing offending product. Plasmapherisis to remove antibodies.
The nurse is caring for several patients who had total abdominal hysterectomies. All patients are coming to the clinic for their 6 week follow up appointment. Which patient demeanor is the strongest indicator that there is a need for psychological referral?
Disheveled and lackluster, and displays a lack of interest in questions.
Which statements are true about dislocations?
Dislocation of a joint occurs when two bones are moved away from each other. Partial dislocation of a joint is referred to as "subluxation" A health care provider performs closed reductions on dislocated joints.
Which characteristics are appropriate to the anesthetic agent ketamine HCL?
Dissociative emergence reactions; can induce nausea and vomiting.
Intervention for urge incontinence: Drugs
Ditropan, Detrol, Vesicare, Probanthine Anticholinergics (caution with elderly, bladder obstructions, urinary retention, and cardiac disease) Possibly antihistamines
The nurse is caring for a patient with ESKD and dialysis has been initiated. Which drug order does the nurse question?
Diuretic
The nurse is designing a teaching plan for a pt with an enlarged prostate and obstructive symptoms. What does the nurse teach the pt to avoid?
Diuretics
Which type of medication increases an older adult patient's risk for acid base imbalance?
Diuretics
A client has a long leg cast. What instructions should the Rn give the client in preparation for crutch walking?
Do exercises in bed to strengthen the upper extremities
The nurse is teaching a pt who had an open retroperitoneal lymph node dissection. What instructions does the nurse give to the patient?
Do not drive a car for several weeks Perform monthly testicular self exams on the remaining testes Have follow up diagnostic testing for atleast 3 years after the surgery.
To prevent back injury
Do not lift 10+ pounds. Push objects rather than pull. Do not twist your back while moving. Use handles. Avoid sitting or standing for long periods No high heels. Posture
The RN is caring for a pt with an arteriovenous fistula. What instructions are given to the UAP regarding the care of this pt?
Do not take blood pressure readings in the arm with the fistula.
A patient with a massive PE has hypotension and shock, and is receiving IV crystalloids. However, the patient's cardiac output is not improving. The nurse anticipates an order for which drug?
Dobutamine (Dobutrex)
The nurse determines that Ms. Jackson's bowel sounds are hypoactive. What action should the nurse implement in response to this finding?
Document the assessment finding in the chart.
Polycystic Kidney Disease: Types
Dominant form, Recessive form
What do you do with a HALO device when moving a patient?
Don't touch it.
The patient is a middle aged man with a history of uncontrolled diabetes. His right foot is a dark brownish purple color and there is no palpable dorsalis pedis or posterior tibial pulse. The nurse prepares the patient for which diagnostic test.
Doppler ultrasound.
You are supervising a new nurse on orientation to the unit who is providing care for a pt after their return from surgery to create a left forearm access for dialysis. Which action by the new nurse requires that you intervene?
Drawing blood for lab studies from the temporary dialysis line.
Urotlithiasis prevention
Drink 3+ liters of fluid per day, Diet modification - avoid foods high in oxalates
A patient with PKD has nocturia. What does the nurse encourage the patient to do?
Drink at least 2 liters of fluid daily.
The nurse's young neighbor who smokes is going on an overseas flight. The neighbor knows he is at risk for DVT and PE, and asks the nurse for advice. What does the nurse suggest?
Drink water and get up every hour for at least 5 minutes during the flight.
Polycystic Kidney Disease: Interventions
Drug therapy - NSAIDS, cipro, antibiotics - trimethoprim/sulfamethoxazole, relaxation techniques promote fluid intake, dietary fiber, avoid excess protein drug therapy for hypertension,
Pylonephritis: treatments
Drug therapy: Antibiotics Broad spectrum Specific antibiotics based on sensitivities Diet therapy: Adequate caloric intake 2-3 liters fluid per day Surgical: Pyelolithotomy = Stone removal from kidney Nephrectomy = Removal of kidney Ureteroplasty = Repair or revision
Renal failure treatment
Drug therapy: Cardioglycides Vitamins/Minerals Synthetic erythropoietin Phosphate binders Dialysis: Peritoneal or Hemodialysis
Bacterial Cystitis (UTI): treatment
Drug therapy: Macrodantin, macrobid (Nitrofurantoin) (interferes with bacteria metabolism, inhibits protein and cell wall synthesis of bacteria) Urinary elimination, pain relief (warm sitz baths) Cystoscopy (surgical)
Intervention for urge incontinence
Drugs Diet therapy - avoid caffeine and alcohol Behavioral interventions
Which assessment finding would indicate urinary retention?
Dullness heard on percussion below the umbilicus.
The RN is assessing an older Caucasian man and notes there are flexion contractures of the fourth and fifth fingers. The pt reports that he had a similar problem on the other hand and had a fasciectomy which improved the function. What is this condition known as?
Dupuytren's contracture
The pt with MS has dysarthria (slurred speech). For which complication must the RN monitor in this pt?
Dysphagia Ataxia
A pt with scleroderma may have which problems?
Dysphagia Smooth tongue Spiderlike hemangiomas
A patient is seen in the health care provider's office and is diagnosed with community acquired pneumonia. What are the most common symptoms the patient will have?
Dyspnea Hypoxemia Chest discomfort
The nurse is taking a history on a patient with probable gynecologic cancer. Which clinical manifestation is a sign of metastasis?
Dysuria.
90% of UTI's are caused by
E. Coli 10% from staph, klebsiella pneumoniae, proteus and enterobactor species.
A pt is prescribed the luteinizing hormone releasing hormone (LH - RH) agonist leuprolide (Lupron) for treatment of a prostate tumor. What possible side effect of this med does the nurse advise the pt about?
ED
The nurse is teaching a pt who is taking finasteride (Proscar), an 5-alpha reductase inhibitior (5-ARI). What medication side effects does the nurse include in the teaching?
ED Dizziness Decreased libido
Increased BUN and creatinine, hyperkalemia, and hypernatremia are all characteristics of which stage of kidney disease?
ESKD
The RN is performing an assessment of a pt with RA. Which findings does the nurse expect?
Early morning joint pain.
Lifestyle changes for GERD
Eat 4 to 6 small meals a day. Limit/eliminate fatty foods, coffee, tea, cola, chocolate. Reduce spicy foods Limit alcohol/tobacco Do not eat/snack 2 to 3 hours before bed
A Rn is providing counseling to a client with the diagnosis of SLE. What recommendations are essential for the nurse to include?
Eat foods high in vitamin C. Take your temp daily. balance periods of rest and activity.
A diabetic patient is scheduled to have a blood glucose test in the next morning. What does the nurse tell the patient to do before coming in for the test?
Eat the usual diet but have nothing after midnight.
A client past menopause undergoes an anterior posterior colporrhaphy. What should the discharge teaching include?
Eating a high fiber diet.
The nurse is assessing a patient with possible acute glomerulonephritis. During the inspection of the hands, face, and eyelids, what is the nurse primarily observing for?
Edema
You are the admitting nurse for a patient with nephrotic syndrome. Which assessment finding supports this diagnosis?
Edema formation.
The pain a patient experiences from a bone fracture results from which processes?
Edema. Muscle spasms.
A client has just been diagnosed with DM. Which factor is MOST important for the nurse to assess in the client before providing instruction about the disease and its management?
Education and literacy level
The Rn must adjust a pair of crutches to properly fit a pt. Which description illustrates correct crutch adjustment?
Elbow is flexed no more than 30 degrees when the palm is on the handle.
Bacterial Cystitis (UTI): Populations at risk
Elderly pt. pt. with indwelling catheters female gender
A 76 year old patient is having a bilateral cataract removal. What is the correct classification for this surgery?
Elective surgery
A nurse is caring for a client in the evening after the client has had a below the knee amputation. What action should be implemented by the nurse?
Elevate the foot of the bed.
The nurse is caring for a pt who had an open radical prostatectomy. During the assessment, the nurse notes that the penis and scrotum are swollen. What does the nurse do next?
Elevate the scrotum and penis, intermittently apply ice to the area for 24-48 hours
Lab indicators for testicular cancer
Elevated AFP, LDH, presence of HCG
The nurse notes an abnormal laboratory test finding for a patient with CKD and alerts the health care provider. The nurse also consults with the registered dietitian because an excessive dietary protein intake is directly related to which factor?
Elevated BUN
A patient is diagnosed with chronic glomerulonephritis. The patient's spouse reports that the patient is irritable, forgetful, and has trouble concentrating. Which assessment finding does the nurse expect on further examination?
Elevated blood urea nitrogen (BUN).
A pt with SLe is admitted to the hospital for evaluation and management of acute joint inflammation. Which information obtained in the admission lab testing concerns you the most?
Elevated blood urea nitrogen level.
The nurse is reviewing the lab results for a pt with prostate cancer. Which lab results suggests metastasis to the bone?
Elevated serum alkaline phosphatase
The pt had several diagnostic tests to evaluate report of LUTS. Which finding suggests that the pt may have kidney disease?
Elevated serum creatinine
A patient has a low pH level. Which other concurrent change does the nurse expect to see in this patient?
Elevated serum potassium
A patient with type 2 DM often has which laboratory value?
Elevated triglycerides
The RN is caring for a pt with an arteriovenous fistula. What is included in the nursing care for this pt?
Encourage routine range of motion exercises. Avoid venipuncture or IV administration on the arm with the access device. Assess for manifestations of infection of the fistula.
A patient receiving chemotherapy treatments reports fatigue, loss of energy, and experiencing an "emotional crisis every day and my hair is falling out." What does the nurse do first to help the patient adapt to body changes?
Encourage the patient to ventilate feelings.
A pt with Paget's disease has a kidney problem associated with increased serum calcium. What is the nursing priority for this pt?
Encourage the pt to increase fluids, unless contraindicated.
Which interventions does the nurse implement to improve mobility for a patient who has undergone a THR?
Encourage use of assistive devices such as a walker when ambulating. Instruct in the use of a raised toilet seat.
A client experiences abdominal distention following surgery. Which nursing actions are appropriate?
Encouraging ambulation. Auscultating bowel sounds.
A nurse is caring for a client who had a total hip replacement. What nursing action should be incorporated into the plan of care to prevent thrombus formation?
Encouraging the client to perform ankle exercises.
The nursing diagnosis for a pt with a fracture of the right ankle is Impaired Physical Mobility. As charge nurse, you observe a newly graduated RN perform all of these interventions. For which action should you intervene?
Encouraging the pt to go form a lying to a standing position
You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the nursing diagnosis of Activity Intolerance. Which action should you delegate to the UAP?
Encouraging, monitoring , and recording nutritional intake.
Glomerulonephritis: Potential complications
End stage kidney failure Sepsis
The home health nurse is reviewing the patient's medication list and sees that the patient was given doxorubicin (Adriamycin) at the hospital. What gynecologic diagnosis would the nurse expect to see as part of the patient's history?
Endometrial Cancer
What disease is strongly associated with prolonged exposure to estrogen without the protective effects of progesterone?
Endometrial Cancer
A patient has excessive bleeding from uterine fibroids. Which therapy stops the blood flow to the fibroids?
Endometrial ablation.
An obese 57 year old patient describes excessive menstrual bleeding that occurs approximately every 10 days. The nurse educates the patient for which diagnostic test that is used to evaluate for endometrial cancer?
Endometrial biopsy
Which patient would be a candidate for moderate sedation?
Endoscopy. closed fracture reduction. Cardiac catheterization. Cardioversion.
The nurse admits a client diagnosed with Paget's disease. The nurse anticipates that the client will have which condition? A. Progressive muscle weakness B. Low body weight, thin build C. Enlarged thick skull D. Bone infection
Enlarged thick skull
The nurse's plan of care for a pt with RA includes which interventions?
Ensure optimal pain relief. Encourage frequent rest periods.
Which is most important for the nurse to do when providing care to a client who has had a transurethral resection of the prostate?
Ensure patency of the indwelling catheter.
A patient is receiving low molecular weight heparin therapy to prevent post operative deep vein thrombosis (DVT). Which routine assessments are most important for this patient during anticoagulation therapy?
Ensure that anti-embolic stockings or sequential compression devices are in use. Monitor complete blood count (CBC) and platelets counts. Check stools for occult blood. Monitor the surgical site for bleeding.
A patient is receiving oxygen therapy through a nonrebreather mask. What is the correct nursing intervention?
Ensure that valves and rubber flaps are patent, functional, and not stuck.
To avoid electrical safety problems during surgery, what does the nurse do?
Ensures proper placement of the grounding pads.
Which task associated with 24 hour urine collection is appropriate to delegate to the UAP?
Ensuring that all urine obtained for the test is kept on ice.
First line of drug for anaphylaxis.
Epinephrine (1:1000) 0.3 to 0.5 mL in IM or IV. May be repeated every 5 to 15 minutes.
The nurse is caring for an older adult client diagnosed with osteomalacia. The nurse anticipates that the physician will request which medication? A. Ascorbic acid (vitamin C) B. Ergocalciferol (calciferol) C. Phenytoin (Dilantin) D. Prednisone (Deltasone)
Ergocalciferol (calciferol)
The nurse is caring for a patient with kidney cell carcinoma who manifests paraneoplastic syndromes. What findings does the nurse expect to see in this patient?
Erythrocytosis. Hypercalcemia. Liver dysfunction. Hypertension.
Drug therapy for stress incontinence
Estrogen Anticholinergic Antispasmodics Tricyclic antidepressants
A patient with a PE is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform?
Examine skin every 2 hours for evidence of bleeding.
On postoperative assessment, the nurse notes that the patient with a rhinoplasty repatedly swallows. What is the nurse's best first action?
Examine the throat for bleeding
A nurse is caring for a client who had a total hip replacement. What is the priority assessment when monitoring the client for hemorrhage?
Examining the bedding under the client
Which side effects would a patient with obstructive sleep apnea report?
Excessive daytime sleepiness. Inability to concentrate. Irritability.
Factors that DECREASE serum Chloride
Excessive nasogastric drainage, vomiting, diuretics, diarrhea
The nurse is reviewing urinalysis results for a patient who is in the early stages of CKD, What results might the nurse expect to see?
Excessive protien, glucose, red blood cells, and white blood cells.
What should be included in the nurse's instructions to help a client prepare for walking with crutches?
Exercises with or without weights to strengthen the muscles of the upper extremities.
Intervention for urge incontinence: Behavioral
Exercises, bladder training, habit training, electrical stimulation
A pt is prescribed low intensity pulsed ultrasound treatments for a very slow healing fracture of the right lower leg. What instructions does the RN give this pt related to this treatment?
Expect to dedicate approximately 20 minutes a day for one treatment.
Which assessment finding indicates that a patient with chronic respiratory acidosis responding favorably to treatment?
Expectorating clear, thin mucus
The nurse reviews the medications taken by Ms. Jackson. She has been taking two medications; hydrochlorothiazide, and warfarin. What nursing action is most important?
Explain the need to withhold the warfarin prior to surgery.
Extent of surgery: Radical
Extensive surgery beyond the area obviously involved. Directed at finding a root cause.
A 30 year old pt who is hospitalized for repair of a fractured tibia and fibula reports shortness of breath. Which complication related to the injury might the pt be experiencing?
Fat embolism
A nurse receives a change of shift report for a client who had a total hip replacement 24 hours ago. After reviewing the client's clinical record and completing a physical assessment, which complication should the nurse conclude that the client is experiencing?
Fat embolism
After several weeks of not feeling well, a patient is seen in the provider's office for possible TB. If TB is present, which assessment findings does the nurse expect to observe?
Fatigue Night Sweats Low grade Fever
MS Nursing interventions
Fatigue, Self-care deficits, urinary retention, constipation, impaired physical mobility, sexual dysfunction, interrupted family processes, disturbed sensory visual perception
Key features of Paraesophageal hernias
Feeling of fullness after eating breathlessness after eating feeling of suffocation chest pain that mimics angina worsening of manifestations in a recumbent position
The Rn is providing discharge teaching for a pt with a SCI who will be performing intermittent self-catheterizations at home. Which signs and symptoms will the RN instruct the pt to report immediately to the primary health care provider?
Fever Foul smelling urine
The pt is diagnosed with acute bacterial prostatitis. What assessment findings does the nurse expect to find?
Fever Chills Dysuria Urethral Discharge
Urotlithiasis: Discharge teaching
Finish antibiotics Diet that prevents further stone formation Pt may have bloody urine for several days after surgery Drink at least 3+ liters of fluid a day
The nurse is caring for the kidney transplant pt in the immediate postoperative period. During this initial period, the nurse will assess the urine output at least every hour for how many hours?
First 48 hours.
The nurse is teaching a pt at risk for prostate cancer about food sources of omega 3 fatty acids. Which food does the nurse suggest?
Fish
A pt has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the RN expect to identify when assessing the pt immediately after the injury?
Flaccid paralysis Lack of reflexes below the injury.
The nurse is caring for a patient with kidney cell carcinoma. What does the nurse expect to find documented about the patient's initial assessment?
Flank pain, gross hematuria, palpable kidney mass, and renal bruit.
On the first postoperative day after a total hip replacement, a client asks for assistance onto the bedpan. What should the nurse instruct the client to do?
Flex the knee on the unoperated leg and pull on the trapeze to lift the pelvis.
The care plan for a client with a fractured hip includes nursing actions to prevent which type of contracture?
Flexion of the hip.
The Rn case manager is making a home visit to assist an older pt with a hip fracture. During the home visit, the RN reviews home environment safety. Which observation indicates a need for additional teaching?
Floors are clean and shiny and covered with throw rugs.
Glomerulonephritis: Treatments
Fluid electrolyte balance - lower K+, dialysis, kidney transplant
Glomerulonephritis: Manifestations
Fluid overload, circulatory congestion Elimination pattern Activity tolerance
The critical care nurse is caring for an older patient admitted with HHS. What is the first priority in caring for this patient?
Fluid replacement to increase blood volume
What principle must a nurse consider when caring for a client with a closed wound drainage system?
Fluids flow from an area of higher pressure to lower pressure.
Hypersensitivites Type III: Immune complex-mediated
Formation of immune complex of antigen+antibody which deposits in walls of vessels and results in complement release and inflammation. Examples: Serum sickness, Vasculitis Systemic lupus erythematosus, Rheumatoid arthritis.
Which crutch gait should the nurse teach the client wearing a prosthesis after a single leg amputation?
Four point.
When glucagon is administered, what does it do?
Frees glucose from hepatic stores of glycogen.
A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?
Frequent changes of position.
Comfort care for a patient with a NG tube by UAP*
Frequent oral care
Bacterial Cystitis (UTI) assessment
Frequent urge to urinate Dysuria Urgency Urine characteristics Risk factors present Vital signs Palpate lower abdomen Inspection
For a patient with acute glomerulonephritis , a 24 hour urine test was initiated and the GFR results are pending. What are the clinical implications of the test results?
GFR is low; the patient is at risk for fluid overload.
A patient is admitted for a posterior nosebleed. Posterior packing is in place and the patient is on oxygen therapy, antibiotics, and opioid analgesics. What is the priority assessment?
Gag and cough reflexes
The nurse is teaching a pt about the common side effects of chronic salicylate and NSAID therapy. Which body system side effects does the RN focus on in the teaching plan?
Gastrointestinal
A 49 year old patient is in the PACU following a frontal craniotomy for repair of a ruptured cerebral aneurysm. The nurse assesses that the patient's eyes open on verbal stimulation. Pupils are equal, reactive to light, and diameter is 3 mm. The patient's hand grasps are equal and strong. The patient's hand grasps are equal and strong. When the nurse asks the patient to state name, the patient states names correctly. The patient has had one episode of nausea and vomiting. Incision edges are dry and approximated with sutures. Lung sounds are slightly diminished per auscultation and the nurse observes the patient is using abdominal accessory muscles to breathe. Which body systems has the nurse assessed?
Gastrointestinal. Neurologic. Integumentary. Respiratory.
First MS oral drug
Gilenya (Fingolimod) - antineoplastic
A patient with Dm has signs and symptoms of hypoglycemia. The patient is alert and oriented with a blood glucose of 56 mg/dL. What does the nurse do next?
Give 8 oz of skim milk and then a carbohydrate and protein snack.
An 18 year old college student with an exacerbation of SLE has been receiving prednisone (Deltasone) 20 mg daily for 4 days. Which medical order should you question?
Give a "catch-up" dose of varicella vaccine.
The nurse is caring for a patient who had a nephrectomy yesterday. To manage the patient's pain, what is the best plan for analgesia therapy?
Give parenteral medications on a schedule.
The nurse is caring for an older pt who had a urinary catheter inserted after a TURP. The pt is intermittently confused, and pics at the IV tubing and the catheter. What should the nurse try first?
Give the pt a familiar object to hold, such as a family picture.
Which insulins are considered to have a rapid onset of action?
Glulisine Aspart Lispro
Which laboratory test is the best indicator of a patient's average blood glucose level and or compliance with the DM regimen over the last 3 months?
Glycosylated hemoglobin (HbA1C)
The ED nurse is preparing for a patient with kidney trauma for emergency surgery. What is the best task to delegate to the UAP?
Go to the blood bank and pick up the units of packed red cells.
After a 2 hour glucose challenge, which result demonstrates impaired glucose tolerance?
Greater than 140 mg/dL
A patient is admitted to the hospital to rule out TB. What type of mask does the nurse wear when caring for this patient?
HEPA respirator mask
The nurse is assessing a patient with uremia. Which gastrointestinal changes does the nurse expect to find?
Halitosis Hiccups Anorexia Nausea Vomiting
A patient is diagnosed with renal osteodystrophy. What does the nurse instruct the UAP to do in relation to this patient's diagnosis?
Handle the patient gently because of risk for fractures.
Which nursing intervention is best to prevent increased pain in a patient experiencing phantom limb pain?
Handle the residual limb carefully when assessing the site or changing the dressing.
Which nursing action is contraindicated when caring for a client with a newly applied long leg cast?
Handling the cast with fingertips
Patient is prescribed a transfusion of 2 units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells as is ready the nurse obtains the blood from the blood bank. When the nurse enters the room to begin the transfusion, the UAP is giving them a partial bath. What action should the nurse take?
Hang the transfusion of packed cells while the UAP continues to complete the client's personal care.
The pt with SLE is taking hydroxychloroquine (Plaquenil). What essential teaching point must the nurse include when teaching the pt about this drug?
Have eye examinations before and every 6 months after starting this drug.
The nurse notes that the pt has just started taking an alpha blocker med to treat BPH. What instruction, related to the med side effects, will the nurse give to the UAP who will assist the pt with ADLs?
Have him sit up slowly and pause before standing
A patient with an active nosebleed is admitted to the emergency department. Which intervention does the nurse use first to attempt to stop the nosebleed?
Have the patient sit upright with the head forward.
An older adult patient often coughs and chokes while eating or trying to take medication. The patient insists that he is ok, but the nurse identifies the priority patient problem of risk for aspiration. Which nursing interventions are used to prevent aspiration pneumonia?
Head of bed should always be elevated during feeding. Monitor the patient's ability to swallow small bites. Consult a nutritionist and obtain swallowing studies. Monitor the patient's ability to swallow saliva.
A patient is diagnosed with uterine leiomyomas. What does the nurse expect to see in the documentation for this patient as the chief presenting symptom?
Heavy vaginal bleeding.
A regimen of rest, exercise, and physical therapy is ordered for a pt with RA. What should the RN explain is the intended purpose of this regimen?
Help prevent the crippling effects of the disease.
What might the nurse notice if the pt is experiencing reduced perfusion and altered urinary elimination related to AKI?
Hemodynamic instability, especially persistent hypotension and tachycardia. Urine output of less than 0.5 mL/kg/hour for 6 or more hours. Abnormal serum and urine potassium and sodium values.
What CBC lab values does the RN expect to be low for a pt with RA?
Hemoglobin Hematocrit RBC
The nurse notifies the surgeon of wound drainage. What lab data is important for the nurse to report to the surgeon?
Hemoglobin and hematocrit.
During the first 24 hours after prostatectomy, what is the priority assessment in the nursing care plan?
Hemorrhage
The nurse is caring for a patient who had hysteroscopic surgery. The patient reports severe lower abdominal pain, she appears pale, and has trouble focusing on the nurse's questions about pain. Vital signs show: T 98.6, P 120/min, R 24/min, BP 103/60. Which complication does the nurse suspect?
Hemorrhage
Which additional manifestations would the nurse expect in clients with Benign Prostatic Hyperplasia?
Hesitancy when starting the urine stream. Decrease in the size and force of urine stream. Frequent urination, including nocturia.
Renal Disease and Hypertension: interaction
High blood pressure can result from narrow blood vessels. Less blood flow from this condition will increase tissue hypoxia chronically. Ischemia and fibrosis develop over time.
Urotlithiasis: Causes
High urine acidity High urine alkalinity Drugs Poor fluid intake
Normal GFR
Higher than 90
You are taking an initial history for a client seeking surgical treatment for obesity. Which finding should be called to the attention of the surgeon before proceeding with an additional history taking or physical assessment?
History of counseling for body dysmorphic disorder
Which condition causes a patient to have the greatest risk for community acquired pneumonia?
History of tobacco use
A patient is at risk for aspiration related to open vocal cord paralysis. What does the nurse teach the patient to do?
Hold the breath during swallowing.. Tuck the chin down and tilt the head forward during swallowing.
A pt reports having uncomfortable and unsettling episodes of hot flashes after receiving hormonal therapy for a prostate tumor. To alleviate this symptom, which prescription med does the nurse assist the pt in obtaining?
Hormonal inhibitor drug such as megestrol acetate (Megace)
The patient is receiving oxygen at 5 L/min by nasal cannula. What priority intervention must the nurse use at this time?
Humidify the oxygen with sterile water.
The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient's comfort for this problem?
Humidify the patient's oxygen.
In determining if a patient is hypoglycemic, the nurse looks for which characteristics in addition to checking the patient's blood glucose?
Hunger Irritability Palpations Profuse Perspiration
An older pt reports that he has an enlarged prostate with chronic urinary retention, but declines to seek treatment because "it's been that way for a long time." The nurse would encourage a follow up appointment to prevent which complication of this chronic condition?
Hydronephrosis
Bacterial Cystitis (UTI): Education
Hygiene (wiping, hand washing) Urinate after intercourse Avoid transferring from anal to vagina intercourse Avoid catheter use Avoid spermacide use
You are caring for pt 1 day postop after a kidney tranpsplant. On assessment, her temp is 100.4 F, her blood pressure is 168.92 mmHg, and the pt tells you she has pain around the transplant site. What is the best interpretation of these findings?
Hyperacute rejection
Pt has acute kidney failure. The RN review's the pt lab data, performs a physical assessment, and takes vital signs. What should the RN conclude the pt is most likely experiencing?
Hyperkalemia
What are the key features associated with chronic pyelonephritis?
Hypertension Inability to conserve sodium Decreased urine concentrating ability, resulting in nocturia. Tendency to develop hyperkalemia and acidosis.
Pylonephritis: chronic signs and symptoms
Hypertension Inability to conserve sodium Decreased concentrating ability Tendency to develop hyperkalemia and acidosis
Glomerulonephritis: Nursing Priorities
Hypertension Infection control Prevent Renal failure Control fluid overload/edema
What is a potential adverse outcome of autonomic dysreflexia in a pt with a SCI?
Hypertensive stroke
Factors that DECREASE serum CO2
Hyperventilation, diabetic ketoacidosis, diarrhea, lactic acidosis, renal failure, Salicylate toxicity
Which type of electrolyte imbalance does the nurse expect to see in a patient with metabolic alkalosis?
Hypocalcemia
A patient is admitted with a blood glucose level of 900 mg/dL. IV fluids and insulin are administered. Two hours after treatment, the blood glucose level is 400 mg/dL. Which complication is the patient most at risk for developing?
Hypoglycemia
Most common cause of medical emergency in clients with diabetes
Hypoglycemia
A patient is undergoing large volume bladder irrigation. During and after the procedure, the nurse observes the pt for confusion, muscle weakness, and increased GI motility related to which potentially adverse effect of large volume irrigation?
Hyponatremia
The nurse is reviewing a patient's lab results. In the early phase of CKD, the patient is at risk for which electrolyte abnormality?
Hyponatremia
The nurse is assessing a client with osteomalacia. Which findings will the nurse expect to observe? Select all that apply. A. Hyperparathyroidism B. Hyperuricemia C. Hypophosphatemia D. Looser's lines or zones E. Unsteady gait
Hypophosphatemia Looser's lines or zones Unsteady gait
The nurse is caring for a patient in the intensive care unit who sustained blood loss during a traumatic event. For early identification of signs and symptoms that would suggest the development of kidney dysfunction, what does the nurse observe for?
Hypotension Decreased urine output Decreased cardiac output
A patient with a fever, myalgia, sore throat, and sunburn like rash is admitted with the diagnosis of toxic shock syndrome. What additional clinical manifestation should the nurse assess for?
Hypotension.
A patinet who ahs advanced muscular dystrophy may develop which complications related to the disease?
Hypoventilation Respiratory acidosis
A patient is diagnosed with pneumonia. During auscultation of the lower lung fields, the nurse hears coarse crackles and identifies the patient problem of impaired oxygenation. What is the underlying physiologic condition associated with the patient's condition?
Hypoxemia
A patient with cancer has also been diagnosed with uterine leiomyomas. Which procedure does the nurse prepare the patient for?
Hysterectomy.
A patient diagnosed with renal cell carcinoma that has metastasized to the lungs is considered to be in which stage of cancer?
IV
Drug treatment for Status epilepticus
IV Diazepam (valium) IV Lorazepam (Ativan) Phenytoin (Dilantin) - not compatible with a lot of drugs and D5W
The nurse is caring for a patient with metabolic alkalosis secondary to diuretic medication. which equipment does the nurse obtain to administer the correct therapy to this patient?
IV catheter and IV start kit.
After a nephrectomy, a patient has a large urine output because of adrenal insufficiency. What does the nurse anticipate the priority intervention for this patient will be?
IV fluid replacement because of subsequent hypotension and oliguria.
A patient receives dialysis therapy and the health care provider has ordered sodium restriction to 3 g daily. What does the nurse teach the patient?
Identify foods that are high in sodium. (bacon, potato chips, fast foods)
On which concern should the nurse focus when caring for a client after abdominal surgery?
Identifying signs of bleeding
You are preparing a nursing care plan for a pt with an SCI for whom the nursing diagnoses of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. The pt tells you, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing diagnosis takes priority?
Impaired Individual Resilience related to spinal cord injury.
Which statement about sexual intercourse for patients with diabetes is true?
Impotence is associated with DM in male patients.
The Rn questions a pt with RA about pain. When should the RN expect the pt to experience increased pain and limited movement of the joints?
In the morning on awakening
A pt comes to the ED after slipping on some chalk in her classroom. She did not fall far and was able to walk with the assistance of one of her students. What type of fracture does this pt likely have?
Incomplete.
For which conditions will the plasma pH decrease?
Increase in PaCO2 Decrease in HCO3 Increase in lactic acid
As a result of kidney failure, excessive hydrogen ions cannot be excreted. With acid retention, the nurse is most likely to observe what type of respiratory compensation?
Increased depth of breathing.
The nurse teaches Ms. Jackson safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. What is the rationale for the inclusion of these actions in Ms. Jackson's plan of care?
Increased mobility will promote an improved sense of control.
The nurse is taking a history on a patient with DM and hypertension. Because of the patient's high risk for developing kidney problems, which early sign of chronic kidney disease does the nurse asses for?
Increased output of very dilute urine.
After receiving the subcutaneous Mantoux, a patient with no risk factors returns to the clinic for test results. Which assessment finding indicates a positive result?
Induration/hardened area measure 10 mm or greater
Glomerulonephritis: Causes
Infection from: (can occur up to 10 days prior) Group A beta-hemolytic Strep Saph Mycoplasma, Pneumococcal, STI Toxoplasmosis
Which conditions will increase the body's need for more oxygen?
Infection in the blood. Body temperature of 101 F. Hemoglobin level of 8.7 g/dL
Pylonephritis
Infection of the kidney or effects of the infection
Which are contraindications for TJA?
Infection. Advanced osteoporosis. Severe inflammation.
In RA, autoantibodies (rheumatoid factors RFs) are formed that attack healthy tissue, especially synovium, causing which condition?
Inflammation
How does a continuous peripheral nerve blockage (CPNB) device work?
Infuses a local anesthetic into the surgical site.
Types of regional Anesthesia: Epidural Anesthesia
Injection of an agent into the epidural space. Commonly used for anorectal, vaginal, perineal, hip, and lower extremity surgeries.
Types of regional Anesthesia: Nerve Block
Injection of the local anesthetic agent into or around one nerve or group of nerves in the involved area. Used for limb surgery or to relieve chronic pain.
A client who underwent an abdominal hysterectomy 3 days ago reports burning with urination. Her urine output during the previous shift was 210 mL, and her temperature is 101.3 F. Which of these actions prescribed by the health care provider will you implement first.
Insert a straight catheter PRN for output of less than 300 mL/8 hr.
You are the team leader supervising an LPN. Which nursing action should you delegate to the LPN?
Inserting a catheter intermittently to assess for residual urine.
The Rn is caring for several orthopedic pt who are in different types of traction. What should the RN do in assessing the traction equipment?
Inspect ropes and knots for fraying or loosening every 8 to 12 hours. Check the amount of weight being used against the prescribed weight. Observe the traction equipment for proper functioning.
The client is in skeletal traction. Which nursing intervention ensures proper care of this client? A. Ensure that weights are attached to the bed frame or placed on the floor. B. Ensure that pins are not loose, and tighten as needed. C. Inspect the skin at least every 8 hours. D. Remove the traction weights only for bathing.
Inspect the skin at least every 8 hours.
During PD, the nurse notes slowed dialysate outflow. What does the nurse do to troubleshoot the system?
Inspect the tubing for kinking or twisting. Ensure that the tubing for kinking or twisting. Turn the pt to the other side. Make sure the pt is in good body alignment.
The nurse is preparing to assess an obese patient who reports subjective symptoms and urinary patterns associated with BPH. Which technique does the nurse use to perform the physical assessment?
Instruct pt to void and then use bladder scanner.
Which nursing intervention helps to prevent the incidence of osteomyelitis for a client receiving hemodialysis? A. Instructing the client to brush teeth after every meal B. Maintaining clean dressing change technique for long-term IV catheters C. Using clean technique D. Using Standard Precautions
Instructing the client to brush teeth after every meal
Which statement about insulin is true?
Insulin's effectiveness depends on the individual patient's absorption of the drug.
A patient with COPD has just developed respiratory distress. Vital signs: O2 sats 88% on 2 L nasal cannula o2, dyspnea at rest, RR 32, Patient reports shortness of breath. Which statements apply to this clinical solution?
Interference in alveolar capillary diffusion results in CO2 retention. The nurse should instruct the patient to use pursed lip breathing. Interference in alveolar capillary diffusion results in acidemia.
The nurse is caring for a postoperative nephrectomy patient. The nurse notes during the first several hours of the shift a marked and steady downward trend in blood pressure. How does the nurse interpret this finding?
Internal hemorrhage is possible.
The health care provider has orderd intraperitoneal heparin for a pt with a new PD catheter to prevent clotting of the catheter by blood and fibrin formation. How does the RN advise the Pt?
Intraperitoneal heparin does not affect clotting times.
The home health nurse is reviewing the medication list of a patient with CKD. The nurse calls calls the health care provider as a reminder that the patient might need which nutritional supplements?
Iron Calcium Vitamin D Water soluble vitamins
A patient has an HIV infection, but the Tb skin test shows an induration of less than 10 mm and no clinical symptoms. Which medication does the patient receive for a period of 12 months to prevent TB?
Isoniazid (INH)
Descriptions of the perioperative period
It begins when the patient is scheduled for surgery. It ends at the time of transfer to the surgical suite. It is a time during which the patient receives testing and education related to impending surgery.
AN older adult patient has skin traction in place for a hip fracture. What is the main purpose of this type of traction?
It decreases painful muscle spasms.
A chronic complication of bone healing is called avascular necrosis. Which statements about this complication are true?
It involves disrupting the blood supply to the bone. It results in the death of bone tissue. It is most often a complication of hip fractures.
Which statements regarding rheumatoid arthritis (RA) are true?
It is a chronic, progressive, systemic, inflammatory process.
What criteria guide the handoff report when a patient is transferred from the OR to the PACU?
It is a two way verbal interaction. The language is clear. Standardized reports help avoid omissions. Receiving nurse repeats information to verify what was said.
Which statements about type 1 DM are accurate?
It is an auto immune disorder. Age of onset is typically younger than 30. Etiology can be attributed to viral infections.
The RN is caring for a pt with an external fixation of a bone fracture. What are the advantages of this type of treatment?
It is less painful than other treatments. It allows for earlier ambulation. It maintains bone alignment. It stabilizes commuted fractures that require bone grafting .
Which statement best describes discoid lupus?
It is not a systemic condition and is limited to involvement of the skin.
An older adult patient asks the nurse how often one should receive the pneumococcal vaccine for pneumonia prevention. What is the nurse's best response?
It is usually given once, but some older adults may need a second vaccination after 5 years.
Which statements about spinal shock are accurate?
It lasts for less than 48 hours, up to a few weeks. There is temporary loss of motor and sensory function. There is temporary loss of reflex and autonomic function.
Which statemetns about type 2 DM are accurate?
It peaks at about the age of 50 most people with type 2 DM are obese people with type 2 Dm have insulin resistance It can be treated with oral antidiabetic medications and insulin
The nurse is assessing a pt admitted with RA. Which manifestations indicate to the RN that the patient is experiencing late RA?
Joint deformities. Vasculitis. Subcutaneous nodules. Anemia.
Which characteristics describe a ganglion hand disorder?
Joint discomfort after strain. Surgical release is required. Painless on palpation.
Setting up rooms for patients with Mysasthenia Gravis
Keep a bag-valve-mask equipment for O2 admin/suction equipment by the bedside.
A pt had a TURP and has a thre way urinary catheter taped to the left thigh. What does the nurse instruct about the position of the left leg?
Keep the leg straight
An older adult client is discharged from the hospital for treatment of osteoporosis. What will the nurse include in client teaching related to the client's home safety? A. Use area rugs on tile floors. B. Keep walkways free of clutter. C. Walk slowly on wet floor areas after mopping. D. Keep light low to prevent glare.
Keep walkways free of clutter.
A nurse is preparing to change a client's dressing. What is the reason for using surgical asepsis during this procedure?
Keeps the area free of microorganisms.
A patient has been diagnosed with AKI, but the cause is uncertain. The nurse prepares patient educational material about which diagnostic test?
Kidney biopsy
Which conditions cause the underproduciton of HCO3
Kidney failure, Liver failure Dehydration
In a patient with hyperglycemia, the respiratory center is triggered in an attempt to excrete more CO2 and acid, thus causing a rapid and deep respiratory pattern. What is the term for this respiratory pattern?
Kussmaul respiration
A patient is hospitalized with hyperglycemia and has a blood glucose of 476 mg/dL. Which signs and symptoms does the nurse expect to see in this patient?
Kussmaul's respirations Hypotension Metabolic acidosis
Which signs and symptoms would the nurse expect to assess in a patient with metabolic acidosis?
Kussmaul's respirations Warm, flushed skin Decreased bicarbonate
What are the common serum tumor markers that confirm a diagnosis of testicular cancer?
LDH, AFP, hCG
Urotlithiasis Diagnosis:
Labs: Ca, Phos, Na, K, HC03, Uric acid, creatinine, BUN, pH, X-rays, renal ultrasound, CT, IV pyelogram
A patient in naphylaxis who is going into respiratory failure will demonstrate which symptoms?
Laryngeal edema Hypoxemia crackles Wheezing
The patient has a documented allergy to bananas and avocadoes. What specific priority precaution must the nurse take when providing care for this patient? Ask the patient about:
Latex allergies.
A Rn finds a victim under the wreckage of a collapsed building. The individual is conscious, supine, breathing satisfactorily, and reporting back pain and an inability to move the legs. Which action should the RN take FIRST?
Leave the individual lying on the back with instructions not to move, and seek additional help.
While assessing the patient, the nurse observes that the surgical dressing is in place on her left hip, with no visible drainage. How should the nurse document this finding?
Left hip dressing clean, dry and intact.
A RN is caring for a client with chronic kidney failure. Which clinical findings should the nurse expect when assessing the client?
Lethargy Muscle twitching
The nurse is assessing a client with Ewing's sarcoma. Which finding will the nurse expect to observe? A. Bradycardia B. High fever C. Leukocytosis D. Migraine headaches
Leukocytosis
A client who has a diagnosis of endometriosis is concerned about the side effect of hot flashes from her prescribed medication. She tells the nurse that her mother found them very uncomfortable during her menopause. Which medication causes this side effect?
Leuprolide (Lupron)
Which parameters does the nurse monitor to ensure that a patient's response to oxygen therapy gas exchange is adequate?
Level of consciousness. Respiratory pattern. Pulse oximetry.
Which factors differentiate DKA from HHS?
Levle of hyperglycemia Amount of ketones produced
Urotlithiasis treatment:
Lithotripsy, Ureter stents, Ureteroscopy and stone removal. Open ureterolithotomy
Which foods should the nurse teach a client with gout to avoid to limit painful attacks?
Liver Shellfish
What does the patient need to know about using finasteride Proscar?
Liver function studies need to be monitored frequently. Most clients see significant change in BPH symptoms in 4 months. The medication should not be handled by women or children. Clients have experience breast tenderness and nipple discharge.
Urge incontinence
Loss of control in urinating from too much activity in detrusor muscle in bladder
Mixed incontinence
Loss of control in urinating from too much detrusor muscle activity AND too little muscle tone.
Overflow incontinence
Loss of control in urinating from too much urine in bladder
Which statements about sensory alteration in patients with diabetes are accurate?
Loss of pain, pressure, and temperature sensation in the foot increases the risk for injury. Sensory neuropathy causes loss of normal sweating and skin temperature regulation. It can be delayed by keeping the blood glucose level as close to normal as possible.
What is the safest way to administer O2 to a patient with chronic respiratory acidosis?
Low flow O2 2 L/min via nasal cannula
The patient with CKD reports chronic fatigue and lethargy with weakness and mild shortness of breath with dizziness when rising to a standing position. In addition, the nurse notes pale mucous membranes. Based on the patient's illness and presenting symptoms, which lab result does the nurse expect to see?
Low hemoglobin and hematocrit.
The nurse is administering oxygen to a patient who is hypoxic and has chronic high levels of carbon dioxide. Which oxygen therapy prevents a respiratory complication for this patient?
Lower concentration of oxygen (1 to 2 L/min) per nasal cannula.
After a pt is treated for SCI, the health care provider informs the family that the pt is a paraplegic. The family asks the RN what this means. What explanation should the RN provide?
Lower extremities are paralyzed.
The Rn is caring for several pt on orthopedic trauma unit. Which conditions have a high risk for development of acute compartment syndrome?
Lower legs caught between the bumpers of two cars. Massive infiltration of IV fluid into forearm Multiple inset bites to lower legs Severe burns to the upper extremities.
Intensive therapy with good glucose control results in delays in which diabetic complications?
Macrovascular disease. Cardiovascular disease. Retinopathy. Nephropathy. Neuropathy.
For a patient with endometriosis, which supplement might offer relief of the muscle cramping?
Magnesium
The nurse is reviewing the medication list and appropriate dose adjustments made for a patient with CKD. The nurse would question the use and/or dosage adjustment of which type of medication?
Magnesium antacids
What is the best diagnostic test to determine musculoskeletal and soft tissue damage?
Magnetic resonance imaging. (MRI)
The nurse is caring for a patient with AKI that developed after a severe anaphylactic reaction. What is a primary treatment goal of the initial phase that will help to prevent permanent kidney damage for this patient?
Maintain a mean arterial pressure (MAP) of 65 mmHg.
A patient arrives at the PACU and the nurse notes a respiratory rate of 10 with sternal retractions. The report from anesthesia personnel indicates that the patient had received fentanyl during surgery. What is the nurse's best priority first action?
Maintain an open airway through positioning and suction if needed.
Which are modifiable risk factors for type 2 DM?
Maintaining ideal body weight maintaining adequate physical activity
A patient with breast cancer is scheduled for a left mastectomy. The patient has informed the surgeon and nurse that she is a Jehovah's Witness and does not want any blood transfusions. In preparation for intraoperative care of this patient, what measures does the nurse take?
Make provider aware of patient's request for no blood transfusions. Ensure autotransfusion device is in place intraoperatively.
What signs/symptoms does the nurse assess in a patient with dysfunctional uterine bleeding?
Male hair pattern. Thyroid enlargement. Abdominal pain. Abdominal masses.
Family history that increase risk for surgical complications.
Malignant hyperthermia, cancer, bleeding disorder
A patient reports dramatic changes in color and temperature of the skin over the left foot with intense burning pain, sensitive skin, excessive sweating, and edema. The physician makes a preliminary medical diagnosis of complex regional pain syndrome. What is the priority for nursing care?
Management of pain.
A patient is diagnosed with acute pyelonephritis. What is the priority for nursing care for this patient?
Managing pain.
What interventions are appropriate for Excess Fluid Volume?
Measure weight daily. Review daily intake and output. Restrict sodium intake with meals. Assess for crackles and edema every shift.
Which action would you intervene from a UAP?
Measuring vital signs after the pt drinks fluids.
Pt is readmitted to the unit from hemodialysis (HD). Which nursing care action should you delegate to UAP?
Measuring vital signs and postdialysis weight
Drugs for MG
Mestinon (TIME sensitive) Prednisone
Low HCO3 = High HCO3 =
Metabolic Acidosis Metabolic Alkalosis
The nurse is admitting a patient with acute kidney injury to the medical unit. Which ABG results would she expect for this patient?
Metabolic acidosis
A patient who has pancreatitits with nausea and vomiting will likely have which related alterations in acid base balance?
Metabolic acidosis Serum pH value that is directly related to the concentration of hydrogen ions Underproduction of HCO3
A patient has taken antacids for the past 3 days to relieve heartburn. What alteration in acid base balance would the nurse expect for this patient?
Metabolic alkalosis
A patient with anemia has completed a blood transfusion of 2 units of packed red blood cells. Which imbalance should the nurse monitor for after the blood transfusion?
Metabolic alkalosis
Which oral agent may cause lactic acidosis?
Metformin
A pt is undergoing a dialysis treatment and exhibits a progression of symptoms which include: headache, nausea, vomiting, and fatigue. How does the RN interpret these symptoms?
Mild dialysis disequilibrium syndrome.
A patient with type 1 mellitus is scheduled for surgery at 0700. Which actions must the nurse perform for this patient before they go to the operating room?
Modify the dose of insulin given based on the patient's blood glucose. Complete the preoperative checklist before transfer to surgical site. Delegate obtaining the patient's Accucheck and vital signs to the unlicensed assistive personnel. Check if the patient has any jewelry on and call security to secure valuables.
The RN is caring for a pt who had a kyphoplasty. What does the postoperative care for this pt include?
Monitor and record vital signs. Perform frequent neurologic assessments. Assess the pt's pain level and compare it to the preoperative level. Monitor for bleeding at the puncture site.
A pt with type 2 DM develops gout, and allopurinol (zyloprim) is prescribed. The pt is also taking metformin (Glucophage) and an over the counter NSAID. When teaching about the administration of allopurinol, what should the nurse instruct the pt to do?
Monitor blood glucose levels more frequently .
A patient is newly admitted with nephrotic syndrome and has proteinuria, edema, hyperlipidemia, and hypertension. What is the priority for nursing care?
Monitor fluid volume and the patient's hydration status.
A patient is diagnosed with interstitial nephritis. Which nursing action is relevant and specific for this patient's medical condition?
Monitor for fever.
A pt with an SCI at level C3-C4 is being cared for in the ED. What is the priority assessment?
Monitor respiratory effort and O2 Sat
A pt was prescribed the combo drug probenicid (Lannett's Probalan) and colchicine (Colcrys) for the treatment of gout. How does the health care team evaluate the effectiveness of the therapy?
Monitor the serum uric acid level.
Renal transplant: Post-op management
Monitor urine output hourly for 48 hours Urinalysis - Glucose, acetone, specific gravity, color
renal failure assessment
Monitor: creatinine RIFLE (Creatinine increases,GFR decreases) Blood pressure (decreases) Orthostatic hypotension Fluid volume (decreases) urine output (decreases) BUN (increases) Nephrotoxic substances that patient may have ingested
What is the priority nursing care most commonly seen preoperatively and postoperatively in a patient with leiomyomas?
Monitoring for bleeding.
A patient is in the diuretic phase of AKI. During this phase, what is the nurse mainly concerned about?
Monitoring for hypovolemia and electrolyte loss.
Which are the most accurate ways to monitor kidney function in the pt with CKD?
Monitoring intake and output Checking urine specific gravity Reviewing BUN and serum creatinine levels
Pyelonenphritis: Bacteria responsible
Most often: E Coli, E Faecalis Hospital: P. Mirabilis, Klebsiella, P. aeruginosa Bloodborne: S. aureus, Candida, Salmonella
Which description of the recessive form of PKD is correct?
Most people with this form of PKD die in early childhood.
A patient injured a lower extremity and has been placed in a running traction. What instructions does the nurse give to the UAP?
Moving the patient or the bed during care can alter the countertraction.
Factors that DECREASE serum Creatinine
Muscle atrophy
Which is a potentially fatal complication of acute compartment syndrome?
Myoglobinuric renal failure
Factors that DECREASE serum Na+
Nasogastric drainage, vomiting, diarrhea, laxatives, diuretics, Syndrome of antidiuretic hormone
A patient's ABG results show an increase in pH. Which condition is most likely to contribute to this laboratory value?
Nasogastric suction
A patient with CKD is taking digoxin (Lanoxin). Which signs of digoxin toxicity does the nurse vigilantly monitor for?
Nausea and vomiting. Visual Changes. Restlessness or confusion. Headache or fatigue. Tachycardia.
The nurse assessing a pt with fibromyalgia identifies the trigger poitns by palpation. In which specific areas does the nurse expect to elicit pain and tenderness?
Neck Trunk Lower Back
Which statements about the precautions of caring for a hospitalized patient with tuberculosis are true?
Negative airflow rooms are required for these patients. Health care workers must wear an N95 or high efficiency particulate air (HEPA) mask. Gown and gloves are included in appropriate barrier protection.
The patient's urinalysis shows proteinuria. Which pathophysiology does the nurse suspect?
Nephropathy
After an above the knee amputation of a leg, a client reports pain in the foot that is no longer there. What should the nurse include about phantom limb pain in a discussion with the client?
Nerve endings in the limb are still intact and react to stimuli.
The nurse is caring for a patient receiving humidified oxygen. Which precaution does the nurse take to prevent bacterial contamination and infection?
Never drain fluid from the water trap back into the nebulizer.
Signs of ICP from Encephalitis
New bradycardia, widened pulse pressure, large and less responsive pupils, irregular respiratory effort.
A pt reports having ED and is seeking a prescription for sildenafil (Viagra). Because of the potential for drug-drug interactions, the nurse asks the pt specifically if he is taking which type of drugs?
Nitrates
Dyspnea Classification: Class I
No significant restrictions in normal activity. Employable. Dyspnea occurs only on more than normal or strenuous exertion.
A patient has a family history of the autosomal dominant form of PKD and has therefore been advised to monitor for and reports symptoms. What is an early symptom of PKD?
Nocturia.
What type of exercise does the nurse recommend for a patient with diabetic retinopathy?
Non-weight bearing activities such as swimming.
The older pt has a fracture that has failed to heal. Which fracture complication best describes this situation?
Nonunion
Early treatment of DKA and HHNS includes IV administration of which fluid?
Normal Saline
The nurse is reviewing arterial blood gas results of a patient with acute glomerulonephritis. The pH of the sample is 7.35. As acidosis is likely to be present because of hydrogen ion retention and loss of bicarbonate, how does the nurse interpret this data?
Normal pH with respiratory compensation
The pt is prescribed trimethoprim/sulfamethoxazole (Bactrim, Septra) for prostatitis. Which lab result indicate the med is having the desired therapeutic effects?
Normalization of WBC
A patient has an MH incident during surgery. To whom does the nurse report this incident?
North American Malignant Hyperthermia Registry.
During preoperative screening, the nurse discovers that the patient is allergic to shellfish. What is the nurse's best first action?
Notifies the surgeon
The pt with chronic back pain is receiving ziconotide (Prialt) by intrachecal infusion with a surgically implanted pump. The pt develops hallucinations. What is the RN's best first action?
Notify the health care provider
The patient with a nasal fracture has clear fluid draining from the nose which dries on a piece of filter paper and leaves a yellow "halo" ring at the dried edge of the fluid. What is the nurse's best first action?
Notify the health care provider.
The UAP report to you that a pt with myasthenia gravis has an elevated temp 102.2, increased heart rate 120 bpm, and a rise in blood pressure 158/94, also was incontinent of urine and stool. What is your best first action at this time?
Notify the physician immediately.
The patient in the OR holding area tells the nurse that his surgery is for the right foot. The patient's chart states that the surgery is for his left foot. What is the nurse's best action?
Notify the surgeon immediately before the patient goes into the OR about his discrepancy.
What lab values would the nurse interpret for a patient experiencing problems with urinary elimination as a result of acute pyelonephritis?
Observe complete blood count for elevation of differentials. Observe for elevation of BUN and serum creatinine levels. Observe urinalysis for bacteria, leukocyte esterase, nitrate, or red blood cells.
The RN is assessing a pt with a spinal deformity. Which technique does the RN use to accomplish inspection of the spine?
Observe the pt from the front and back while standing and during forward flexion from the hips.
A pt who tripped and fell down several stairs reports having hear a popping sound and fears that she has broken her ankle. How does the RN initially assess for fracture in this pt?
Observing for deformity or misalignment
What is the common problem of hydronephrosis, hydroureter, and urethral stricture in kidney function?
Obstruction
A pt with a long leg cast that was applied in the ED is being admitted to the orthopedic unit. Which task is best for the RN to delegate to the UAP?
Obtain a fracture pan and use caution to prevent spillage on the cast.
A patient with a facemask at 5L/min is able to eat. Which nursing intervention is performed at mealtimes?
Obtain a provider order for a nasal cannula at 5L/min.
A client reports severe pain 2 days after surgery. Which INITIAL action should the nurse take after assessing the character of the pain?
Obtain the vital signs.
The nurse is taking a history on a patient with chronic glomerulonephritis. What is the patient most likely to report?
Occasional edema and fatigue.
The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? Select all that apply. A. Occupational therapist B. Physical therapist C. Psychologist D. Respiratory therapist E. Speech therapist
Occupational therapist Physical therapist Psychologist
For patients who have TJAs, the risk of DVT is high. Which statements are true?
Older adults are at high risk for DVT and compromised circulation. Patients with a history of DVT are at high risk for recurrence. Leg exercises must be started in the immediate post operative period.
Which signs/symptoms does the nurse expect to see in the patient with AKI that has progressed in severity?
Oliguira Shortness of breath Pulmonary crackles
A client has surgery to repair a fractured right hip. Where should the nurse stand when assisting the client to ambulate?
On the client's left side.
When assessing the older postoperative patient for hydration status, where must the nurse assess for tenting of the skin?
On the forehead. ON the sternum.
An older pt's family is trying to find an appropriate cane for the pt to use because of chronic pain in the right ankle. The Rn instructs the family to purchase which type of cane?
One with the top being parallel to the greater trochanter of the femur.
What is the primary purpose of a PACU?
Ongoing critical evaluation and stabilization of the patient.
A pt comes into the ED after falling off his four wheeler. His lower leg is obviously broken; it is bleeding and bone fragments are protruding from the skin. What type of fracture does this pt likely have?
Open (compound)
A patient is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient?
Opening in the trachea that enables breathing
A current treatment of nonemergent dysfunctional uterine bleeding includes which medication?
Oral or patch contraceptives
A patient with AKI is ill and has a poor appetite. What would the health care team try first?
Oral supplements designed for kidney patients.
A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's BEST action?
Orient the client to the unit environment.
Which position should a nurse avoid placing a client who had surgery for a total hip replacement?
Orthopneic
A patient developed flu symptoms less than 24 hours ago. Which drug therapy does the nurse expect the health care provider to order at this time?
Oseltamivir (Tamiflu)
An x ray shows the presence of radiolucent bands (Looser's line or zones) in a pt. What is this diagnostic finding specific for?
Osteomalacia
A pt comes to the ED after accidentally puncturing his hand with an automatic nail gun. Which disorder is this pt primarily at risk for?
Osteomyelitis
What common musculoskeletal health problem is often associated with RA?
Osteoporosis
What are the hazards of administering oxygen therapy?
Oxygen supports and enhances combustion. All electrical equipment in the room must be grounded to prevent fires. Solutions with high concentrations of alcohol or oil cannot be used in the room.
What therapy is contraindicated in ALS?
Oxygen therapy
The patient has been on oxygen therapy at 70% for over 2 days. For which complication must the nurse monitor?
Oxygen toxicity.
The nurse is teaching a pt diagnosed with ED about the common treatment and therapies. Which topics does the nurse include?
PDE-5 inhibitors, Intraurethral applications, vacuum devices, penile implants
An older pt is scheduled for an annual physical including a PSA and a digital rectal examination (DRE). How are these two test scheduled for the pt?
PSA is drawn before the DRE is performed
A patient is following up on a postoperative complication of PE. The patient must have blood drawn to determine the therapeutic range for Coumadin. Which lab test determines this therapeutic range?
PT and INR
A patient is being treated with heparin therapy for a PE. The patient has the potential for bleeding with the administration of heparin. What does the nurse monitor in relation to the heparin therapy?
PTT values for greater than 2.5 times the control and or the patient bleeding.
A patient requires home oxygen therapy. When the home health nurse enters the patient's home for the initial visit, he observes several issues that are safety hazards related to the patient's oxygen therapy. What hazards do these include?
Package of cigarettes on the coffee table. Several decorative candles on the mantelpiece Electric fan with a frayed cord in the bathroom.
A middle aged male patient has a tight cast on his left lower leg. An early assessment variable requiring further evaluation for compartment syndrome would be:
Pain more intense than that of the injury itself.
When a patient has RA of the temporomandibular joint, what is the major complaint?
Pain on the chewing and opening the mouth.
Which clinical indicator does the Rn expect to identify when assessing a pt admitted with a herniated lumbar disk?
Pain radiating to the hip and leg.
Polycystic Kidney Disease: Priority concerns
Pain, constipation, hypertension, end stage kidney disease
A nurse is assessing a client who is being admitted for surgical repair of a rectocele. What signs or symptoms does the nurse expect the client to report?
Painful intercourse. Bearing down sensations.
Which classic symptom is indicative of invasive gynecologic cancer in an older patient?
Painless vaginal bleeding
Colostomy schedule to be done on a patient who has severe Crohn's Disease. What is the classification for this surgery?
Palliative surgery
A Rn is teaching crutch walking to a client who had arthroscopic surgery of the knee. On which part of the body should the RN instruct the client to place weight?
Palms of the hands
A nurse is teaching crutch walking to a client who had arthroscopic surgery of the knee. On which part of the body should the nurse instruct the client to place weight?
Palms of the hands
The nurse is caring for a client with prostate cancer who has bone metastasis. The nurse anticipates that the physician will prescribe which medication? A. Calcitonin (Calcimar) B. Medroxyprogesterone (Prempro) C. Pamidronate (Aredia) D. Tamsulosin hydrochloride (Flomax)
Pamidronate (Aredia)
The nurse is caring for a pt who had minimally invasive sx (MIS) for testicular cancer. The nurse is also caring for a pt who had an open radical retroperitoneal lymph node dissection for testicular cancer. The nurse anticipates that the second pt has more of risk for which condition?
Paralytic Ileus
Assessment of a pt with a lower spinal cord injury confirms that the pt has paralysis of the bilateral lower extremities. How does the RN document this finding?
Paraplegia
Upon diagnosis of a PE, the nurse expects to perform which therapeutic intervention for the patient?
Parenteral anticoagulant therapy
The client has had a sequestrectomy of the right fibula for osteomyelitis 1 day ago. Which assessment finding requires the nurse to immediately contact the surgeon? A. Swelling of the right lower extremity B. 1+ to 2+ bilateral palpable pedal pulses C. Pain of right lower extremity on movement D. Paresis of right lower extremity
Paresis of right lower extremity
The Rn is assessing a pt who presented to the ED reporting acute onset of numbness and tingling in the right leg. How does the RN document this subjective finding?
Paresthesia
The nurse is assessing a postoperative patient's gastrointestinal system. What is the best indicator that peristaltic activity has resumed?
Passing of flatus or stool.
A patient is admitted to the hospital with pneumonia. What does the nurse expect the chest x ray results to reveal?
Patchy areas of increased density
A female pt with osteoporosis comes to the ED after falling suddenly while opening her car door. She said it felt as though her "leg gave way" and caused her to fall. What type of fracture does this pt likely have?
Pathologic (spontaneous)
What is the top priority for nurses during the perioperative period?
Patient Safety
(Ramsay Score) RSS 5
Patient exhibits a sluggish response to stimulus.
(Ramsay Score) RSS 4
Patient exhibits brisk response to stimulus.
(Ramsay Score) RSS 6
Patient exhibits no response to stimulus. The RSS must be reapplied at intervals until full consciousness is achieved.
The nurse reads in the patient's chart that he has acute on chronic kidney disease. How does the nurse interpret this information?
Patient has chronic kidney disease and has sustained an acute kidney injury.
Which patient is most likely to have respiratory alkalosis
Patient having a panic attack
Pylonephritis: Assessments
Patient history UTIs, DM, stones Physical assessment Assess flanks Costovertebral angle Clinical manifestations Psychosocial assessment Anxiety Embarrassment Guilt Laboratory assessment UA Blood cultures Imaging assessment KUB
Glomerulonephritis: Assesments
Patient history: Recent infections, illnesses, surgery Known systemic diseases Physical assessment/Clinical manifestations: Skin survey Fluid overload, circulatory congestion Elimination pattern Vital signs Activity tolerance Laboratory assessment: UA, 24 hr urine GFR Chemistries Other diagnostic tests: Biopsy
RSS 1 (Ramsay Score)
Patient is anxious and agitated, restless, or both.
RSS 2
Patient is cooperative, oriented, and tranquil.
Which patient has the greatest risk of developing a kidney abscess?
Patient is diagnosed with acute pyelonephritis.
The nurse is caring for a patient with a radioactive implant in the uterus. Which instruction will the nurse give to unlicensed assistive personnel (UAP)?
Patient is on bedrest and excessive movement is restricted.
An older adult pt had a TURP at 8 am. At 3 pm, the nurse assesses the pt. Which finding does the nurse report to the HCP?
Patient keeps moving and ketchup like output is noted
A patient with prerenal azotemia is administered a fluid challenge. In evaluating response to the therapy, which outcome indicates that the goal was met?
Patient produces urine soon after the initial bolus.
What might the nurse notice if the patient is experiencing problems with urinary elimination as a result of acute pyelonephritis?
Patient reports pain and burning on urination. Patient reports back or flank pain. Urine is cloudy and foul-smelling. Urine may be darker or smokey or have obvious blood in it.
(Ramsay Score) RSS 3
Patient responds quickly, but only to commands.
Which patient showing symptoms of an acid base imbalance must the nurse see first?
Patient showing activity weakness and lethargy
Which patient is most likely to develop metabolic alkalosis as a result of base excess?
Patient who had a massive blood transfusion
Which factors may lead to an anesthetic overdose in a patient?
Patient who is older. Slowed metabolism and drug elimination. Liver or kidney disease.
Which patient with the highest risk for acidosis must the nurse care for first?
Patient with COPD, pulse oximetry 88% on 2 L O2.
Which patient requires assessment related to inadequate chest expansion that would place the patient at risk for respiratory acidosis?
Patient with emphysema Severely obese patient on prolonged bed rest
Which patient is most likely to have respiratory acidosis?
Patient with multiple rib fractures
Which patient is most likely to have a decrease in HCO3?
Patient with pancreatitis
For which patient should the health care provider avoid prescribing rosiglitazone (Avandia)?
Patient with symptomatic heart failure
An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle accident. Which pain medication does the nurse anticipate will be requested for this client? A. Cyclobenzaprine (Flexeril) B. Ibuprofen (Advil, Motrin, Dolgesic, others) C. Meperidine (Demerol) D. Patient-controlled analgesia (PCA) with morphine
Patient-controlled analgesia (PCA) with morphine
Adlea is a refined capsaicin product. What is the advantage of infusing this drug directly into the surgical joint during knee surgery?
Patients experience less acute post operative pain.
SMBG levels is most important in which patients?
Patients taking multiple daily insulin injections. Patients with hypoglycemia unawareness. Patients using a portable infusion device for insulin administration. Patients with acute illnesses. Pregnant patients.
Foods that commonly cause anaphylaxis
Peanuts, shellfihs, eggs, legumes, nuts, grains, berries, preservatives, bananas
The nurse caring for 4 DM clients has all of these activities to perform. Which is appropriate to delegate to UAP?
Perform hourly bedside blood glucose checks for a client with hyperglycemia.
The Rn is reviewing the orders for a pt who was admitted for 24 hour observation of a leg fracture. A cast is in place. Which order does the RN question?
Perform neurovascular assessments (cir checks) every 8 hours.
A patient is admitted to the same day surgery unit following a meniscectomy. What does post operative care for this patient include?
Perform neurovascular checks every hour for the first few hours and then every 4 hours. Check the surgical dressing for bleeding. Teach about signs and symptoms of infection.
The nurse is caring for a postoperative patient and is evaluating the patient's intake and output as a measure to prevent AKI. The patient weighs 60 kg and has produced 180 mL or urine the past 4 hours. What should the nurse do?
Perform other assessments related to fluid status and record the output.
A patient arrives in the emergency department with a severe crush injury to the face with blood gurgling from the mouth and nose and obvious respiratory distress. The nurse prepares to assist the provider with which procedure to manage the airway?
Performing a tracheotomy
A patient with CKD develops severe chest pain, an increased pulse, low grade fever, and a pericardial friction rub with a cardiac dysrhythmia and muffled heart tones. The nurse immediately alerts the health care provider and prepares for which emergency procedure?
Pericardiocentesis
Intervention for ALS
Pharm - Rilutek (Riluzole) antiglutamate. Slows down deterioration
What member of the health care team will be consulted to teach a pt about proper use of the cane?
Physical therapist Registered Nurse
The nurse is assessing a patient who reports being struck in the face and head several times. During the assessment, a pink tinged drainage from the nares is observed. Which nursing action provides relevant assessment data?
Place a drop of the drainge on a filter paper and look for a yellow ring.
Which nursing interventions will prevent the potential intraoperative complication of radial joint stiffness, pain, and inflammation?
Place pillow or foam padding under bony prominences. Maintain good body alignment. Slightly flex joints and support with pillows, trochanter rolls, and pads.
A patient with CKD is restless, anxious, and short of breath. The nurse hears crackles that begin at the base of the lungs. The pulse rate is increased and the patient has frothy, blood-tinged sputum. What does the nurse do first?
Place the patient in a high-Fowler's position.
A patient returns from surgery following a rhinoplasty. The UAP places the patient in a supine position to encourage rest and sleep. Which action should the nurse take first?
Place the patient in semi Fowler's position and assess for aspiration.
Which is an example of the principles of body mechanics that the nurse uses when caring for immobilized clients?
Placing the feet apart to increase the stability of the body.
A pt who is a long distance runner reports severe pain in the arch of the foot, especially when getting out of bed with weight bearing. What does the RN suspect in this pt?
Plantar fasciitis
A pt with Paget's disease has complications related to bony enlargements of the skull. Which complication is potentially the most serious and life-threatening?
Platybasia, or basilar invagination with brainstem manifestations
Which complication of pneumonia creates pain that increases on inspiration because of inflammation of the parietal pleura?
Pleuritic chest pain
A patient with DM presents to the ED with a blood sugar of 640 mg/dL and reports being constantly thirsty and having to urinate "all of the time." How does the nurse document this subjective finding?
Polydipsia and Polyuria
In pt with RA, where might Baker's cysts be located?
Popliteal bursae
What should the RN do when caring for a pt who is receiving peritoneal dialysis?
Position the client form side to side if fluid is not draining adequately.
Following surgery, your patient is admitted to the PACU. The operative report indicates that the patient had a left hip replacement under general anesthesia. The initial nursing assessment reveals that the patient is not responding to verbal stimuli. Her vital signs are T 97.6 F, Pulse 88, Respirations 14, BP 130/70. What action should the nurse implement first?
Position the client on her side.
A patient is at risk for aspiration. Which instructions must the nurse provide to the UAP prior to feeding the patient?
Position the patient in the most upright position possible. Provide adequate time; do not hurry the patient. Encourage the patient to tuck his or her chin down and move the forehead forward while swallowing. if the patient coughs, stop the feeding until he or she indicates that the airway has been cleared.
Which patient is the least likely to be at risk for developing pneumonia?
Postoperative patient with a bedside commode
The nurse is talking to an older adult male patient who is reasonably healthy for his age, but has BPH. Which condition does the BPH potentially place him at risk for?
Postrenal acute kidney injury.
A client had extensive, prolonged surgery. Which electrolyte level should the nurse monitor most closely?
Potassium labs.
An intensive care client with DKA is receiving an insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make?
Potassium level
Which is problem for the older adult client diagnosed with bone cancer? A. Potential for injury related to weakness and drug therapy B. Altered self-esteem related to fear of death and dying C. Reduced mobility related to weakness and fatigue D. Chronic Pain related to tumor invasion on other organs
Potential for injury related to weakness and drug therapy
The nurse is teaching incisional care to patient who has been discharged after abdominal surgery. Which priority instruction must the nurse include?
Practice proper handwashing.
A pt with RA has severe pain and swelling of the joints in both hands. Range of motion exercises for this pt should be:
Preceded by the application of heat or cold.
The nurse is preparing a community information packet about "bird flu". What information does the nurse include for public dissemination?
Prepare a minimum of 2 weeks supply of food, water, and routine prescription drugs. Listen to public health announcements and early warning signs for disease outbreaks. Avoid traveling to areas where there has been a suspected outbreak of disease. In the even of an outbreak, avoid going to public areas such as churches or schools.
Nursing Interventions for General Anesthesia Stage: 4
Prepare for and assist in treatment of cardiac, and or pulmonary arrest. Document occurrence in the patient's chart.
A 36 year old patient is diagnosed with dysfunctional uterine bleeding. During the pelvic exam, the health care provider determines that the bleeding is acute and heavy. What is the nurse's priority action?
Prepare to administer combination hormonal therapy.
A 79 year old patient with type 2 diabetes is scheduled for surgery to remove his left great toe. Which risk factors for complications of surgery does the nurse assess for this patient?
Presence of chronic illness. Problems with hearing. Dehydration, electrolyte imbalances.
A patient with AKI is receiving total parenteral nutrition (TPN). What is the therapeutic goal of using TPN?
Preserve lean body mass.
A nurse is caring for a client with a below the knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?
Press the end of the residual limb against a pillow periodically.
A pt has paraplegia as a result of a motorcycle accident. What is the reason the RN care plan should include turning the pt every 1 to 2 hours?
Prevent pressure ulcers.
In the event of a new severe acute respiratory syndrome (SARS) outbreak, what is the nurse's primary role?
Prevent the spread of infection to other employees and patients.
Focus areas for SCIP
Prevention of infection. Prevention of serious cardiac events. Prevention of venous thromboembolism.
Polycystic Kidney Disease: Treatments
Prevention of kidney failure, infection, stones, and UTI Kidney transplant Liver transplant
What is the primary treatment for dysfunctional uterine bleeding in perimenopausal women?
Progestin or combination hormone therapy.
The nurse is caring for a patient with an above the knee amputation (AKA). In order to prevent hip flexion contractures, how does the nurse position the patient?
Prone position every 3 to 4 hours for 20 to 30 minute periods.
A Rn should expect a pt with a SCI to have some spasticity of the lower extremities. What should the RN include in the plan of care for this pt to prevent the development of lower extremity contractures?
Proper positioning
SCIP Infection-1
Prophylactic Antibiotic Received within one hour prior to surgical incision
SCIP Infection-3
Prophylactic Antibiotics Discontinued Within 24 hours after Surgery End Time.
The nurse is reviewing the lab results from a pt being evaluated for LUTS. What does an elevated prostate specific antigen (PSA) level and serum acid phosphatase level in this pt indicate?
Prostate Cancer
Patient has prostate cancer. Which serum level should both the nurse and the client monitor?
Prostate specific antigen
The nurse requests a dietary consult to address the patient's high rate of catabolism. Which nutritional element is directly related to this metabolic process?
Proteins
The nurse is reviewing laboratory results for a patient with PKD. Which lab abnormality indicates glomeruli involvement?
Proteinuria
The nurse is reviewing the lab results for a patient with chronic glomerulonephritis. The serum albumin level is low. What else does the nurse expect to see?
Proteinuria
The nurse is reviewing the patient's history, assessment findings, and laboratory results for a patient with suspected kidney problems. Which manifestation is the main feature of nephrotic syndrome?
Proteinuria greater than 3.5 g of protein in 24 hours.
Which nursing intervention is most appropriate for the patient in the operative setting?
Provide a climate of privacy, comfort, and confidentiality when caring for the patient.
For pre operative care of a patient scheduled for TJA. What does the nurse plan to do?
Provide written or videotaped information about the procedure. Assess the patient's understanding of the procedure. Assess and include the patient's support people or family. Include interdisciplinary providers, if possible.
The diabetic patient experiences early morning hyperglycemia (Somogyi effect) as a result of the counterregulatory response to hypoglycemia. What treatment does the nurse expect for this condition?
Provided an evening snack to ensure adequate dietary intake. Evaluate insulin dosage and exercise program.
Which factors affect bone healing after a fracture has occurred?
Pt age Type of bone injured How the fracture is managed Presence of infection at the fracture site
The pt had a TURP several days ago and the urinary catheter was removed 6 hours ago. Which sign/symptom must be resolved before the pt is discharged?
Pt has not voided since catheter was removed.
A pt has a fracture of the right wrist. What is an early sign that indicates this pt may be having a complication?
Pt reports a subjective numbness and tingling.
Which pt with kidney problems is the best candidate for peritoneal dialysis (PD)?
Pt with a history of difficulty with anticoagulants
Which pts are likely to be excluded from receiving a transplant?
Pt with advanced and uncorrectable heart disease. Pt with a chemical dependency.
Which pt is mostly likely to be a candidate for hyperbaric oxygen therapy?
Pt with chronic, unremitting osteomyelitis
Which patients with CKD are candidates for intermittent hemodialysis?
Pt with fluid overload who does not respond to diuretics. Pt with symptomatic toxin ingestion. Pt with uremic manifestations such as decreased cognition. Pt with symptomatic hyperkalemia and calciphylaxis.
The nurse suspects a patient has a PE and notifies the provider who orders an arterial blood gas. The provider is en route to the facility. The nurse anticipates and prepares the patient for which additional diagnostic test?
Pulmonary angiography
An older pt with a lower leg fracture is having difficulty performing the weight bearing exercises. Based on the fracture pathophysiology and the pt's abilities, which condition could the pt develop?
Pulmonary embolism
Which signs are considered postoperative complications?
Pulmonary embolism. Hypothermia. Wound evisceration.
The nurse is caring for a patient with a post operative complication of PE. The patient has been receiving treatment for several days. Which factors are indicators of adequate perfusion in the patient?
Pulse oximetry of 95% Absence of pallor or cynaosis Mental status at patient's baseline.
To improve a patient's oxygenation to a normal level, the amount of oxygen administered is based on which of the following factors?
Pulse oximetry reading. Respiratory assessment. Arterial blood gas results.
A Rn is caring for a pt attending a community based health center and reviews the pt's medical record. What should the nurse encourage the pt to do?
Push with the palms rather than the fingers when rising from a chair.
The student nurse is assessing a pt with a probable fractured tibia-fibula. What assessment technique used by the SN causes the supervising RN to intervene?
Pushes on the leg to elicit pain response.
While discussing postoperative pain management strategies with Ms. Jackson, the nurse observes Ms. Jackson. She begins to cry. What action should the nurse take?
Quietly sit with the client
RIFLE GFR
R - GFR decreases over 25% I - decreases over 50% F - decreases equal or over 75%
RIFLE Creatinine
R - increases x 1.5 I - increases x 2 F - increases x3
RIFLE
RISK, Injury, Failure, Loss, End stage
The health care provider advises the patient that diagnostic testing is needed to identify the possible presence of a renal abscess. Which test does the nurse prepare the patient for?
Radionuclide renal scan
The RN is assessing a pt with a SCI and recognizes that the pt is experiencing autonomic dysreflexia. What is the RN's first priority action?
Raise the head of the bed.
The nurse has given the ordered preoperative medications to the patient. What actions must the nurse take after administering these drugs?
Raise the side rails. Place the call light within patient's reach. Instruct the patient not to get out of bed. Place the bed in its lowest position.
The Rn is teaching a pt with MS and her family about her exercise program. Which points must the Rn include?
Range of motion exercises are an important component. Increased body temperature can lead to increased fatigue. Stretching and strengthening exercises will be part of your program.
Which postoperative interventions will the nurse typically teach a patient to prevent complications following surgery?
Range-of-motion exercises. Incision splinting. Deep breathing exercises.
Hypersensitivites Type I: Immediate
Reaction of IgE anitbody on mast cells with antigen. Results in release of meiators, espeicially histamines. Examples: Hay fever, Allergic asthma, anaphylaxis.
Hypersensitivites Type II: Cytotoxic
Reaction of IgG with host cell membrane or antigen adsorbed by host cell membrane. Examples: Autoimmune hemolytic anemia, Goodpasture's syndrome, Myasthenia gravis (MS).
Hypersensitivites Type IV: Delayed
Reaction of sensitized t-cells with antigen and release of lymphokines, which activates macrophages and induces inflammation. Examples: Poison ivy, Graft rejection, Positive TB skin tests, Sarcoidosis.
The nurse is giving discharge instructions to patient who had a TURP. What does the nurse include in the instructions?
Reassurance that loss of control of urination or dribbling of urine is temporary.
The provider orders heparin therapy for a patient with a relatively small PE. The patient states, "I didn't tell the physician my complete medical history." Which condition may affect the provider's decision to immediately start heparin therapy?
Recent cerebral hemmorrhage.
A pt reports pain in the lower legs and pelvis which is aggravated by activity and worse at night. The Rn observes muscle weakness which appears to be causing a waddling and unsteady gait. What additional information supports the likelihood of osteomalacia in this pt?
Recent immigration from a country where famine is common.
A client at the women's health clinic tells the nurse she has endometriosis. What factors associated with endometriosis does the nurse anticipate the client will report?
Rectal pressure. Abdominal pain.
Rectocele
Rectum is displace, bulging of posterior wall.
The nurse is caring for several patients at risk for DVT and PE. Which condition causes the patient to be a candidate for placement of a vena cava filter?
Recurrent bleeding while receiving anticoagulants.
What is the recommended protocol for patients with type 2 DM who must lose weight?
Reduce calorie intake moderately and increase exercise.
A pt with RA asks the RN why it is necessary to inject hydrocortisone into the knee joint. What reason should the RN include in a response to this question?
Reduce inflammation
A client is being prepared for gastrointestinal surgery and undergoes a bowel preparation. Why is this preoperative procedure done?
Reduce the number of intestinal bacteria
A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in a buck extension. What explanation does the nurse give the client for why the traction is being used?
Reduces muscle spasms.
What type of insulin is used in the emergency treatment of DKA and HHNS (hyperglycemic hyperosmolar nonketotic syndrome)?
Regular Insulin
A pt who has intermittently been having painful, swollen knee and wrist joints during the past 3 months is diagnosed with RA. What type of diet should the RN expect the health care provider to order?
Regular diet with vitamins and minerals
A nurse in the postanesthesia care unit observes that after an abdominal cholecystectomy a client has serosanguineous drainage on the abdominal dressing. What is the next best nursing action?
Reinforce the dressing.
The morning after a patient's lower leg surgery, the nurse notes that the dressing is wet from drainage. The surgeon has not yet been in to see the patient on rounds. What does the nurse do about the dressing?
Reinforces the dressing by adding dry, sterile dressing material on top of the existing dressing.
Complications of post surgical kidney transplant
Rejection Acute tubular necrosis Thrombosis Renal artery stenosis
A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the purpose of the traction?
Relieve muscle spasm and pain.
Post op care for pt having Stretta Procedure (hernia repair)
Remain on clear liquids for 24 hours Post op day 2: consume soft diet Avoid NSAIDS/Aspirin for 10 days Use proton pump inhibitors (protonix), use liquid meds No NG tubes for at least 1 month
Which term related to the fracture healing process is the process of bone building and resorption?
Remodeling.
You are working in the ED when a client with possible toxic shock syndrome is admitted. Which prescribed intervention will you implement first?
Remove the client's tampon.
In the emergency care of a pt with a fracture, which action does the Rn implement first?
Remove the pt's clothing to inspect the affected area while supporting the injured area above and below the injury. Do not remove shoes because this can cause increased trauma.
Care for delayed hypersensitivity reactions
Removing of offending antigen. Corticosteroids to reduce discomfort.
You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?
Removing the inner cannula and cleaning using standard precautions.
Which statements correctly apply to acid base balance in the body?
Renal mechanisms are stronger in regulating acid base balance, but slower to respond than respiratory mechanisms The immediate binding of excess hydrogen ions occurs primarily in the red blood cells. Acid base balance occurs through control of hydrogen ion production and elimination
A patient's ABG results reveal respiratory acidosis. How does the body compensate for this imbalance?
Renal reabsorption of HCO3
A patient is suspected of having PKD. Which diagnostic study has minimal risks and can reveal PKD?
Renal sonography
A patient is very ill and is admitted to the ICU with rapidly progressing glomerulonephritis. The nurse monitors the patietn for manifestations of which organ system failure?
Renal system
A patient cared for in the PACU has had a colostomy placed for treatment of Crohn's disease. The nurse assesses that an abdominal dressing is 25% saturated with serosanguineous drainage and notes that the incision is intact. An IV is infusing with D5/lactated Ringer's at 100 mL/hr through a 20-g peripheral IV access. Auscultation of abdomen reveals hypoactive bowel sounds in all four quadrants, abdomen soft, and no distention. Foley catheter is in place an draining yellow urine with sediment, 375 mL output in FOley bag. Which body systems have been assessed by the nurse?
Renal/urinary. Gastrointestinal. Integumentary.
The nurse is giving instructions to the UAP about hygienic care for an older adult patient who is uncircumsized. What does the nurse instruct the UAP to do?
Replaced the foreskin over the penis after bathing.
The patietn with type 2 diabetes is prescribed sitagliptin for glucose regulation. Which key changes does the nurse teach a patient to report to the health care provider immediately?
Report any signs of jaundice. Report any blue-grey discoloration of the abdomen. Report any sudden onset of abdominal pain.
A pt had a transrectal ultrasound with a biopsy. After this procedure, what does the nurse instruct the pt to do?
Report fever, chills, bloody urine, and any difficulty voiding Avoid strenuous physical activity
The nurse is giving discharge teaching to a woman who had a local cervical ablation. What information would be included?
Report heavy vaginal bleeding or foul smelling drainage. Showering is permitted, but no tub baths. Avoid lifting heavy objects for 3 weeks.
A patient with chronic peylonephritis returns to the clinic for follow-up. Which behavior indicates the patient is meeting the expected outcomes to conserve existing kidney function?
Reports taking antibiotics as prescribed.
L stage of RIFLE
Requires renal replacement therapy for over 4 weeks
E stage of Rifle
Requiring dialysis over 3 months
Which occurence can be a result of hyperventilation?
Respiratory alkalosis
Low PaCO2 = High PaCO2 =
Respiratory alkalosis Respiratory acidosis
Factors that increase serum Chloride
Respiratory alkalosis, dehydration, kidney impairment, excessive IV fluids
The client is brought to the emergency department (ED) via ambulance after a motor vehicle accident. What condition will the nurse assess for first? A. Bleeding B. Head injury C. Pain D. Respiratory distress
Respiratory distress
The RN is caring for a pt with muscular dystrophy. Although all body systems can be affected, the nurse is alert and carefully assesses for which major problem?
Respiratory failure.
Nursing interventions for ALS
Respiratory insufficiency (Bipap, trach, ventilator) assist with ADL, dysphagia. (fatigue) Pain management Dysarthria - use alternative communication. Depression.
A postoperative patient in the PACU has had an open reduction internal fixation of a left fractured femur. Vital signs are blood pressure 87/49 mmHg, heart rate 100/min sinus rhythm, respirations 22/min, temperature 98.3 F. The Foley catheter has a total amount of 110 mL of clear, yellow urine in the last 4 hours. Which body systems have been assessed by the nurse?
Respiratory, Cardiovascular, Renal/urinary.
The health care provider tells a pt that she has a mild first degree sprain to the ankle. What instructions does the nurse give to the pt about the treatment for the injury?
Rest Apply ice for the first 4 to 6 hours. Apply a compression bandage for a few days to reduce swelling and provide joint support. Elevate the foot.
The nurse is assessing a patient with significant and obvious facial trauma after being struck repeatedly in the face. Which finding is the priority and requires immediate intervention?
Restlessness with high pitched respirations.
A client is extubated in the post anesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?
Restlessness.
PACU nurse is assessing an older adult post operative patient for pain. Which nonverbal manifestations by the patient suggest pain to the nurse?
Restlessness. Profuse sweating. Confusion. Increased blood pressure.
A client that has prostate cancer attempts to urinate frequently, but voids in very small amounts. What is the most likely causative factor?
Retention.
functional incontinence intervention
Reverse causes (back pain, arthritis, clothing, proximity of restroom) Bladder training habit training catheterization
According to the pt's chart, there is a family history of osteoporosis. In order to plan interventions related to this finding, what action does the RN take?
Review the pt's dietary intake of calcium.
Once the OR team has assembled in the room, the circulating nurse calls for a time out. What action should the nurse take during the time out?
Review the scheduled procedure, site, and client.
What should the nurse do to control edema of the residual limb 1 week after a client has an above the knee amputation?
Rewrap the elastic bandage as necessary.
A pt with Paget's disease has been prescribed drug therapy. The RN prepares pt teaching information for which medication as a first line therapy?
Risedronate (Actonel)
After suffering an SCI, a pt develops autonomic dysfunction, including a neurogenic bladder. What is the priority pt problem for this condition?
Risk for UTI
Patient is transferred to a stretcher and taken to the OR. The nurse assists patient off the stretcher and onto the OR table. After general anesthesia is induced the nurse positions patient. Which nursing diagnosis has the highest priority at this time?
Risk for perioperative-positioning injury
According to the RIFLE ccclasssifcation (Risk, injury, failure, loss, end-stage kidney failure), how would hte nurse interpret the following data? Serum creatinine increased x 1.5 GFR decrease over 25% Urine output is less than 0.5 mL/kg/hr for over 6 hours.
Risk stage
What might a psychosocial exam of a pt with advanced RA reveal?
Role changes Poor self esteem and body image Grieving and depression Loss of control and independence
A patient will be using an external insulin pump. What does the nurse tell the patient about the pump?
SMBG levels should be done three or more times a day.
The nurse has identified the priority patient problem of ineffective airway clearance with bronchospasms for a patient with pneumonia. The patient has no previous history of chronic respiratory disorders. The nurse obtains an order for which nursing intervention?
Scheduled and prn aerosol nebulizer bronchodilator treatments.
Which class of antidiabetic medication is most likely to cause a hypoglycemic episode because of the long duration of action?
Second generation sulfonylureas, which include glipizide
A nurse caring for a client with gomerulonephritis. What should the nurse instruct the client to do to prevent recurrent attacks?
Seek early treatment for respiratory tract infection.
A patient had a rhinoplasty and is preparing for discharge home. A family member is instructed by the nurse to monitor the patient for postnasal drip by using a flashlight to look in the back of the throat. If bleeding is noted, what does the nurse tell the family member to do?
Seek immediate medical attention for the bleeding.
While playing football at school, a patient injured his nose resulting in a possible simple fracture. The patient's parents call the nurse seeking advice. What does the nurse tell the parents to do?
Seek medical attention within 24 hours to minimize further complications.
What potential adverse effect prevents meperidine (demerol) from being used in older adults?
Seizures
Which position is therapeutic and comfortable for a pt with lower back pain?
Semi Fowler's position with a pillow under the knees to keep them flexed.
Most common symptoms of MS
Sensory loss Optic Neuritis Weakness Paraesthesias Diplopia Fatigue (affects all MS)
For which clinical indicator should the RN assess a pt who just had a microdiskectomy for a herniated lumbar disk?
Sensory loss in legs.
The early stage of incomplete breakdown of glucose occurs whenever cells metabolize under anaerobic conditions to form lactic acid. based on this knowledge of pathophysiology, which conditions could cause the patient to develop acidosis?
Sepsis Hypovolemic Shock Hypoventilation
An older adult sustained injury to the lower legs after being trapped underneath a fallen bookcase. Because this pt is at high risk for crush syndrome, which lab values will the RN specifically monitor?
Serum K+ level and myoglobin in urine.
You review pt lab results, which lab finding is of most concern?
Serum Potassium level of 7.1 mmol/L
The nurse is reviewing the lab results of a patient with chronic glomerulonephritis. The phosphorus level is 5.3 mg/dL. What else does the nurse expect to see?
Serum calcium level below normal range.
The patient with DM had a pancreas transplant and takes daily doses of cycloporine (neoral). For which key lab assessment does the nurse monitor?
Serum creatinine
the nurse observes tall peaked T waves on the ECG of a patient with metabolic acidosis. Before notifying the health care provider, the nurse would assess the results of which laboratory test?
Serum potassium
Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the physician? A. Thighs have multiple oozing abrasions. B. Serum potassium level is 7 mEq/L. C. The client is describing pain at a level 4 (0 to 10 scale). D. Hemoglobin level is 12.0 g/dL.
Serum potassium level is 7 mEq/L.
A pt with Paget's disease comes to the clinic for evaluation. Which symptom reported by the pt alerts the nurse to the possibility of osteogenic sarcoma?
Severe bone pain.
Which characteristics are associated with ESKD?
Severe fluid overload Renal osteodystrophy Dialysis or transplant needed to maintain homeostasis Excessive waste products
Glucagon is used primarily to treat the patient with which disorder?
Severe hypoglycemia.
The nurse suspects that a client may have plantar fasciitis if the client has which finding? A. Lateral deviation of the great toe; first metatarsal head becomes enlarged B. Dorsiflexion of any metatarsophalangeal (MTP), with plantar flexion of the adjacent proximal interphalangeal (PIP) joint C. Severe pain in the arch of the foot, especially when getting out of bed D. A small tumor in a digital nerve of the foot
Severe pain in the arch of the foot, especially when getting out of bed
An LPN under your supervision is providing nursing care for a pt with GBS. What observation should you instruct the LPN to report immediately?
Shallow respiration and decreased breath sounds.
You are working on the PACU caring for a 32 year old client who has just arrived after undergoing dilation and curetagge to evaluate infertility. Which assessment finding should be immediately communicated to the surgeon?
Sharp, continuous, level 8 out of 10 abdominal pain.
Which nursing interventions are appropriate during stage 2 of anesthesia?
Shield patient from extra noise and physical stimuli. Protect the patient's extremities. Assist anesthesia personnel as needed. Stay with patient.
Which clinical indicator should the nurse expect to identify when assessing a client with a fracture of the neck of the femur?
Shortening of the affected extremity with external rotation.
A patient has been diagnosed with sleep apnea. Which assessment findings indicate that the patient is having complications associated with sleep apnea?
Side effects of hypoxemia, hypercapnia, and sleep deprivation.
Which clinical features are found in an MH crisis?
Sinus tachycardia. Tightness and rigidity of the patient's jaw area. Lowering BP. Skin mottling and cyanosis. Tachypnea.
The nurse is assessing a pt with an injury to the shoulder and upper arm after being thrown from a horse. What is the best position for this pt's assessment?
Sitting to observe for shoulder droop
The nurse is assisting Ms. Jackson to the bedside commode on the second postoperative day. Ms. Jackson states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." In response to these remarks, the nurse plans care for Ms. Jackson based on the identification of which nursing diagnosis?
Situational low self esteem.
The RN is assessing a pt who reports moderate bone pain in the hip and has family history of Paget's disease. In performing a musculoskeletal assessment, the nurse pays particular attention to which element?
Size and shape of the skull
Which lab test is the only significant test for diagnosing a pt with discoid lupus?
Skin biopsy.
The nurse assesses a postoperative TKR patient for neurovascular compromise. Which assessments must the nurse document?
Skin color and temperature. Presence or absence of distal peripheral pulses. Capillary refill of operative leg. Comparison of operative leg to nonoperative leg.
After an open reduction and internal fixation of a fractured hip. What assessments of the client's affected leg should the nurse make?
Skin temperature. Sensation in the toes. Presence of pedal pulse.
The nurse is caring for a patient with a nasal fracture. The patient has clear secretions that react positively when tested for glucose. Which complication does the nurse suspect?
Skull fracture.
The client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? A. Surgical repair of the rotator cuff B. Prescribed exercises of the affected arm C. Sling for the affected arm D. Patient-controlled analgesia with morphine
Sling for the affected arm
While cleansing the incision, the nurse observes that the staples are intact, but a 2 cm gap has opened at the bottom of the incision. How should the nurse document this finding?
Small area of dehiscence at bottom of incision.
What type of breath odor is most likely to be noted in a patient with CKD?
Smells like urine
Which factors contribute to sleep apnea?
Smoking A short neck. Enlarged tonsils or adenoids.
A patient with acute glomerulonephritis is required to provide a 24 hour urine specimen. What does the nurse expect to see when looking at the specimen?
Smoky or cola colored urine.
Which medication should you be prepared to administer to lower the pt potassium level?
Sodium polystyrene sulfonate (Kayexalate), 15 g PO
What are the characteristics of primary gout?
Sodium urate deposited in the synovium. Affects middle aged and older men.
The home health nurse is evaluating the home setting for a pt who wishes to have in home hemodialysis. What is important to have in the home setting to support this therapy?
Specialized water treatment system to provide a safe, purified water supply.
A pt has a long history of chronic back pain and has undergone several back surgeries in the past. At this point, the surgeon is recommending a surgical procedure for spine stabilization. Which procedure does the RN anticipate this pt will need?
Spinal fusion
After a traumatic spinal cord severance, a young pt is having difficulty accepting the paralysis. One day the pt has severe leg spasms and says, "My strength is coming back and I know I will walk again." The Rn's response should be based on what understanding?
Spinal shock has subsided and the pt's reflexes are hyperactive.
What can be expected fro a pt with recently diagnosed systemic lupus erythematosus (SLE)?
Spontaneous remission and exacerbations
A patient had loop electrosurgical excision procedure (LEEP) for treatment and diagnosis of cervical cancer. In the discharge instructions, what does the nurse tell the patient to expect after the procedure?
Spotting
Which diagnostic tests are most likely to be done for a patient suspected of having community acquired pneumonia?
Sputum gram stain Chest X Ray
A patient is admitted to the hospital to rule out pneumonia. Which infection control technique does the nurse maintain?
Standard precautions and no respiratory isolation.
A nurse is caring for a client who had an open reduction and internal fixation of a femoral neck fracture. The client has an order for ambulation with slight weight bearing on the affected extremity. During the physical assessment the nurse identifies that the client has kyphosis and strong upper arm strength. What assistive devise does the nurse expect the health care provider to order for this client?
Standard walker
A patient is admitted with toxic shock syndrome. What organism is frequently associated with this syndrome when it occurs as a menstrually related infection?
Staphylococcus aureus.
The older dulat with DM asks the nurse for advice about beginning an exercise program. What is the nurse's best response?
Start low intensity activities in short sessions. Be sure to include warm up and cool down periods. Changes in activity should be gradual.
The nurse is caring for several postoperative patients at risk for developing PE. Which interventions does the nurse use to help prevent the development of PE in these patients?
Start passive and active range of motion exercises for the extremities. Ambulate postoperative patients soon after surgery. Use antiembolism devices postoperatively. Administer drugs to prevent episodes of Valsalva maneuver.
Steps to take for caring for wound evisceration.
Stay calm and stay with the client. Put the client into semi Fowler position with knees slightly flexed. Check the vital signs, especially blood pressure and pulse. Have a colleague gather sterile supplies and contact the physician. Cover the intestine with sterile moistened gauze. Prepare the client for surgery as ordered.
After a nephrectomy, one adrenal gland remains. Based on this knowledge, which type of medication replacement therapy does the nurse expect if the remaining adrenal gland function is insufficient?
Steroid
A patient experience MH immediately after induction of anesthesia. What is the nurse anesthetist's first priority action?
Stop all inhalation anesthetic agents and succinylcholine.
Ms. Jackson is currently receiving Lactated Ringer's solution IV at a rate of 75 mL/hour. In transfusing the 250 mL unit of packed red blood cells, what action should the nurse implement?
Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution.
A patient in the hospital being treated for a PE is receiving a continuous infusion of heparin. When the nurse comes to take vital signs, the patient has blood on the front of his chest and nose, and is holding a tissue saturated with blood to his nose. What is the first priority action the nurse must take?
Stop the heparin IV infusion.
Following a meniscectomy, the nurse assists a patient to immediately start performing which exercises?
Straight leg raises on both legs.
The pt has a musculoskeletal injury that resulted from excessive stretching of a muscle or tendon. Which type best describes this pt's injury?
Strain
When a client is in the right side lying position after the insertion of a left hip prosthesis, the nurse ensures that the client has a pillow placed between the thighs and that the entire length of the upper leg is supported. What does this pillow prevent?
Strain on the operative site.
A pt is diagnosed with plantar fasciitis. What instruction does the RN give to the pt about self care for this condition?
Strap the foot to maintain the arch.
Which patient history factor is considered causative for acute glomerulonephritis?
Strep throat 3 weeks ago.
When taking the health history of a client who is admitted for repair of a cystocele and rectocele, the nurse should expect the client to report the occurrence of
Stress incontinence and low abdominal pressure.
A patient with suspected TB is admitted to the hospital. Along with a private room, which nursing intervention is appropriate related to isolation procedures?
Strict respiratory isolation and use of specially designed facemasks.
You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the pt to void?
Stroking the pt's inner thigh. Pulling on the pt's pubic hair. Pouring warm water over the pt's perineum Tapping the bladder to stimulate the detrusor muscle.
To prevent a DVT, several types of anti coagulant medications can be ordered. Which is the most commonly used drug during hospitalization?
Subcutaneous LMWH
Patient with a continuous bladder irrigation. What is the most important nursing action?
Subtracting irrigant from output to determine urine volume.
A 53 year old patient is newly diagnosed with renal artery stenosis. What clinical manifestation is the nurse most likely to observe when the patient first seeks health care?
Sudden onset of hypertension
What is the primary role of the nurse when caring for the adult client with muscular dystrophy (MD)? A. Pain management B. Supportive care C. Teaching the importance of keeping appointments D. Advocating for the client and the family
Supportive care
What should the RN assess for when a pt with a cervical injury reports a severe headache and nasal congestion?
Suprapubic distention
SCIP CARD-2
Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Reccieved a Beta-Blocker during the Periooperative period
SCIP Venous thromboembolism-2
Surgery Patients who Received Appropriate Venous Thromboembolism Prophylaxis within 24 hours prior to surgery to 24 hours after surgery.
SCIP Infection-6
Surgery Patients with Appropriate Hair Removal
SCIP Infection-10
Surgery Patients with Perioperative Temperature Management
SCIP Venous Thromboembolism-1
Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered
Extent of surgery: Minimally invasive surgery
Surgery performed in a body cavity/area through one or more endoscopes. Can correct problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems; is a fast growing and ever changing type of surgery.
SCIP
Surgical Care Improvement Project
A patient is diagnosed with kidney cancer and the health care provider recommends the best therapy. Which treatment does the nurse anticipate teaching the patient about?
Surgical removal
For what clinical findings of compromised circulation should the RN assess in a client with a long leg cast?
Swelling of the toes Prolonged capillary refill
What is the primary factor for the low survival rates for patients who are diagnosed with ovarian cancer?
Symptoms are mild and vague, therefore the cancer is often not detected until its late stage.
A daughter is considering donating a kidney to her mother for organ transplant. What information does the RN give to the daughter about the criteria for donation?
Systemic disease and infection must be absent. There must be no history of cancer. Hypertension or kidney disease must be absent. There must be adequate kidney function as determined by diagnostic studies. The donor must understand the surgery and be willing to give up the organ.
A patient is admitted for acute glomerulonephritis. In reviewing the patient's past medical history, which systemic conditions does the nurse suspect may have caused acute glomerulonephritis and will include in the overall plan of care?
Systemic lupus erythermatosus and diabetic nephropathy
Which type of surgery is most commonly used to treat BPH?
TURP
The nurse is instructing a client who has been prescribed calcium citrate (Citracal). The nurse plans to include which instruction? A. Take Citracal with food. B. For best absorption, take Citracal with a carbonated beverage. C. One third of the daily dose is best taken during the day. D. Milk of magnesia (MOM) should be taken with Citracal.
Take Citracal with food.
The nurse is teaching self care management to a 39 year old woman who had an abdominal hysterectomy. Which point would be emphasized to avoid complications of this surgery?
Take temperature twice a day for the first 3 days after surgery.
A pt has just undergone a spinal fusion and laminectomy and has returned from the operating room. Which assessments are done in the first 24 hours?
Take vital signs every 4 hours and assess for fever and hypotension. Perform a neurologic assessment every 4 hours with attention to movement and sensation. Monitor intake and output and assess for urinary retention. Observe for clear fluid on or around the dressing.
UTI prevention
Taking cranberry substrates Apple cider vinegar Topical estrogen to perineal area D-mannose 500 mg tab
You are floated form the ED to the Neurologic floor. Which action should you delegate to the UAP when providing nursing care for a pt with SCI?
Taking the pt's vital signs and recording every 4 hours
An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first?
Talk to the client.
In going through the preoperative checklist, the nurse notices that the client's armband does not match the handwritten name on the informed consent, but it matches the stamped name. What does the nurse do first?
Talk to the operating team
Which intervention will the nurse suggest to a client with a leg amputation to help cope with loss of the limb? A. Talking with an amputee close to the client's age who has had the same type of amputation B. Drawing a picture of how the client sees himself or herself C. Talking with a psychiatrist about the amputation D. Engaging in diversional activities to avoid focusing on the amputation
Talking with an amputee close to the client's age who has had the same type of amputation
The nurse is developing a teaching plan for a patient with PKD. Which topics does the nurse include?
Teach how to measure the record blood pressure. Assist to develop a schedule for self-administering drugs. Explain the potential side effects of the drugs.
A patient with a history of PKD reports dull, aching flank pain and the urinalysis is negative for infection. The health care provider tells the nurse that the pain is chronic and related to enlarging kidneys compressing abdominal contents. What nursing intervention is best for this patient?
Teach methods of relaxation such as deep breathing.
A preoperative client smokes a pack of cigarettes a day. What is the nurse's teaching priority for the best physical outcomes?
Teach the importance of incentive spirometry.
The patient is receiving isoniazid to treat TB. Which nursing teaching points are essential when giving this drug?
Teach the patient not to take medications such as Maalox with this medication. Avoid drinking alcoholic beverages. Take a multivitamin with B complex.
A pt is receiving internal radiation therapy (brachytherapy ) and has had a low dose radiation seed implanted directly into the prostate gland. What nursing implication is related to this therapy?
Teach the patient that fatigue is common, but should pass after several months
A client experiences a traumatic amputation of a leg in a motor vehicle accident. Which nursing intervention INITIALLY should receive the lowest priority?
Teaching residual limb care.
A patient recently received anticoagulant therapy for complications of PE after knee surgery. The patient is now in a rehabilitation facility and is receiving Warfarin. What is the nursing responsibility related to Warfarin?
Teaching the patient about foods high in Vitamin K.
A pt is scheduled for lumbar surgery. Which key points must the RN include in a preoperative teaching plan for this pt?
Techniques for getting in and out of bed. Expectations for turning and moving in bed Limitations and restrictions for home activities Report any numbness and tingling to the nurse immediately.
You delegate the measurement of vital signs to an experienced UAP. Osteomyelitis has been diagnosed in a pt. Which vital sign value would you instruct the UAP to report immediately?
Temp of 101 F.
A 40 year old pt is admitted for acute osteomyelitis of the left lower leg. What does the Rn expect to find documented in the pt's admitting assessment?
Temperature greater than 101 F; swelling, tenderness, erythema, and warmth of area
The advanced practice nurse is performing a testicular exam on a young Caucasian male patient. The practitioner finds a lump, which the pt reports as painless. This finding is considered the most common manifestation of which disease or disorder?
Testicular Cancer
An 86 year old woman had an anterior and posterior colporrhaphy (A & P repair) several days ago. Her retention catheter was removed 8 hours ago. Which assessment finding requires that you act most rapidly?
The abdomen is firm and tender to palpation above the symphysis pubis.
Your assessment reveals all of these data when you are admitting a pt with Paget Disease. Which finding should you notify the physician about first?
The base of the skull is invaginated (platybasia).
When assessing a client with cervical cancer who had a total abdominal hysterectomy yesterday, you obtain the following data. Which information has the most immediate implications for planning of the client's care?
The client's right calf is swollen, and she reports calf tenderness.
A RN is caring for a client with acute kidney failure who is receiving a protein restricted diet. The client asks why this diet is necessary. What information should the RN include in response?
The diet supplies only nonessential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.
A patient with type 2 DM, usually controlled with a second generation sulfonylurea, develops a UTI. Due to the stress of the infection, the patient must be treated with insulin. What additional information about this treatment does the nurse relay to the patient?
The insulin is necessary to supplement the second generation sulfonylurea until the infection clears.
The nurse is providing teaching for a pt with RA who is receiving methotrexate (Rheumatrex). Which teaching points must the nurse include?
The medication is give n in a low dose once a week. Methotrexate is an immunosuppressant medicaiton. Avoid crowds of people and people who are ill. Report any mouth sores to the health care provider immediately.
The nurse is caring for a patient who has had abdominal surgery. After a hard sneeze, the patient reports pain in the surgical area, and the nurse immediately sees that the patient has a wound evisceration. What priority action must the nurse do first?
The nurse calls for help and stays with the patient.
Description of collaborative roles of the nurse and surgeon when obtaining the informed consent
The nurse may serve as witness to the patient's signature after the physician has the consent form signed before preoperative sedation is given and before surgery is performed.
The nurse is reviewing the lab results for a pt being evaluated for trouble with passing urine. The urinalysis shows tubular epithelial cells on microscopic examination. How does the nurse interpret this finding?
The obstruction is prolonged
The nurse has received a patient in the holding area who is schedule for a left femoral-popliteal bypass. What are the priority safety measures for this patient before surgery?
The operative limb is marked by the surgeon. The patient is positively identified by checking the name and date of birth. The patient is asked to confirm the marked operative limb.
The nurse is testing the muscle strength of a patient at risk for acid-base imbalance. Which technique does the nurse use to test arm strength?
The patient flexes the arms against the chest; the nurse tries to pull the arms from the chest.
The med surg nurse is caring for a post op patient whose lab values reveal an increase in band cells (immature neutrophils). What is the nurse's best interpretation of this value?
The patient is developing an infection.
The nurse on the med surg unit is caring for a post operative patient. Which assessment criteria indicate to the nurse that the patient is experiencing respiratory difficulty?
The patient is using accessory muscles to breath. The patient makes a high pitched crowing sound when breathing. The patient's respiratory rate is 26/min.
Which intervention for postsurgical care of a patient is correct?
The patient should splint the surgical wound for support and comfort when getting out of bed.
You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient's history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
The patient was recently in a motor vehicle crash.
Which patient is most at risk for post operative nausea and vomiting (PONV) ?
The patient with a history of motion sickness.
The patient received moderate sedation (conscious sedation) by IV prior to a bronchoscopy procedure. Before allowing the patient to have oral liquids, what must the nurse assess in this patient?
The patient's gag reflex is working.
A pt has a fractured femur. Which finding would you instruct the UAP to report immediately?
The pt appears confused
The RN is assessing a pt's extremity with an arteriovenous graft. The RN notes a thrill and a bruit, and the pt reports numbness and a cool feeling in the fingers. How does the RN interpret this information in regard to the graft?
The pt has "steal syndrome" and may need surgical intervention.
A Rn in a rehab center teaches pt with quadriplegia to use an adaptive wheelchair. Why is it important that the Rn provide this instruction?
They usually will never walk.
A patient who is 2 days post op for abdominal surgery states, "I coughed and heard something pop." The nurse's immediate assessment reveals an opened incision with a portion of large intestine protruding. Which statements apply to this clinical situation?
This is an emergency situation. The wound must be kept moist with normal saline-soaked sterile dressings. Incision evisceration has occurred.
A client is ready to walk with crutches after knee surgery. Which crutch walking technique will the RN most likely have to reinforce after the client returns form physical therapy?
Three-point
The RN is caring for the kidney transplant pt who is 3 days postsurgery. The RN notes a sudden and abrupt decrease in urine. The RN alerts the health care provider because this is a sign of which anomaly?
Thrombosis.
The charge nurse is assigning the nursing care of a patient who had a left below the knee amputation 1 day ago to an experienced LPN, who will function under your supervision. What will you tell the LPN is the major focus for the patient's care today?
To monitor for signs of sufficient tissue perfusion.
A patient requires long term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure and mechanism that are associated with this long term therapy. Which piece of equipment does the nurse most likely use for this patient teaching session?
Tracheostomy tube
Diagnosis of Endometrial and Ovarian Cancers
Transvaginal Ultrasound
Which diagnostic tests are considered the gold standard tests for determining the presence of endometrial thickening and cancer?
Transvaginal ultrasound. Endometrial biopsy.
Which are the risk factors for pulmonary embolism and deep vein thrombosis?
Trauma Heart Failure Cancer (particularly lung or prostate)
What should the nurse do to promote early and efficient ambulation after a client has a midthigh amputation?
Turn the client to the prone position routinely.
The RN is caring for a pt in Buck's (skin) traction. Which task is best to delegate to the UAP (without supervision)?
Turning and repositioning
The Rn and the nursing student are working together to bathe and reposition a pt who is in a halo fixator device. Which action by the nursing student needs intervention?
Turns the pt by pulling on the top of the halo device.
Which finding will the nurse expect to observe for a client with suspected common chronic osteomyelitis? A. Erythema of the affected area B. Fever; temperature usually above 101° F (38° C) C. Ulceration of the skin D. Constant, localized, and pulsating bone pain
Ulceration of the skin
The nurse is assessing the skin of a patient iwth ESKD. Which clinical manifestation is considered a sign of very late, premorbid, advanced uremia syndrome?
Uremic frost
A 47 year old patient is having surgery to remove kidney stones. What is the correct classification for this surgery?
Urgent surgery
Polycystic Kidney Disease: Assessments
Urinalysis (proteinuria, hematuria, bacteria) Chem panel Renal ultrasound, CT, MRI to detect cysts Physical assessment Psychosocial assessment Detailed patient/family history
Bacterial Cystitis: Diagnoses
Urinalysis needed when testing for leukocyte esterase Type of organism confirmed by urine culture
Which diagnostic tests and results does the nurse expect to see with acute glomerulonephritis?
Urinalysis revealing hematuria. Microscopic red blood cell casts.
The nurse is preparing the patient for surgery. Which common laboratory tests does the nurse anticipate to be ordered?
Urinalysis, Electrolyte levels, Clotting studies, Serum creatinine
What problem is the RN primarily attempting to prevent when encouraging a pt with a SCI to increase oral fluid intake?
Urinary Tract Infection.
The nurse applies bandages to a patient's residual limb in order to help shape and shrink the limb for a prosthesis. What is the proper technique for the nurse to use?
Use a figure eight wrapping method to prevent restriction of blood flow.
An older adult patient on anticoagulation therapy for a PE is somewhat confused and requires assistance with activities of daily living. Which instruction specific to this therapy does the nurse give to the UAP?
Use a lift sheet when moving or turning the patient in bed.
A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the patient with ADLs?
Use a lift sheet when moving/positioning the patient. Use electric razor when shaving. Use soft toothbrush/tooth sponge for oral care. Be sure the patient's footwear has a firm sole when the patient ambulates.
A client has a total hip arthroplasty. What should the nurse do when caring for this client after surgery?
Use a pillow to keep the legs abducted.
To reduce a hip fracture, the client is placed in traction before surgery for an open reduction and internal fixation. Because the client keeps slipping down in bed, increased countertraction is ordered. How does the nurse increase the countertraction?
Use a slight Trendelenburg position.
Which interventions can the nurse use to prevent or manage infections in patients who have undergone total joint replacement?
Use aseptic technique for wound care and emptying of drains. Wash hands thoroughly when caring for patients. Culture drainage fluid if a change is observed. Report excessive inflammation or drainage to the provider.
The Rn is caring for a pt with an open fracture. Which intervention does the Rn perform to prevent infection of the fracture?
Use clean or aseptic technique for dressing changes and wound irrigations.
The surgical procedure for stage I disease of endometrial cancer involves removal of which components?
Uterus. Fallopian tubes. Ovaries.
Aging with SCI
Vaccinate. Health Screenings (PAP) Skin care Osteoporosis prevention. Elimination. Adjust for exercise.
The nurse is teaching a patient who is being discharged after having a total abdominal hysterectomy. Which conditions does the nurse tell the patient to immediately report to the surgeon?
Vaginal drainage that becomes thicker or foul smelling. Temperature over 100 F Burning during urination.
The nurse is caring for several patients on a general medical surgical unit. The nurse would question the need for oxygen therapy for a patient with which condition?
Valve replacement with increased cardiac output.
Because of the inflammatory process in RA, a pannus forms in the joint. What is a pannus?
Vascular granulation tissue in the joint.
A patient can develop intrarenal kidney injury from which causes?
Vasculitis Pyelonephritis Exposure to nephrotoxins
The nurse is preparing an educational session for a patient who is scheduled to undego hip replacement. Which potential complications does the nurse make the patient aware of?
Venous thromboembolism. Hip dislocation. Neurovascular compromise. Infection.
Factors that increase Prothrombin Time
Vit K deficiency, Coagulation defect
The nurse is reviewing the laboratory results for an older adult patient with pneumonia. Which laboratory value frequently seen in patients with pneumonia may not be seen in this patient?
WBC 12 to 18
The Rn is caring for a pt with osteomyelitis. Which lab results are of primary concern for this disorder?
WBC and erythrocyte sedimentation rate.
Which serum lab value requires follow-up by the nurse?
WBC of 14,000/mm3
The nurse is teaching a client newly diagnosed with osteoporosis about dietary and lifestyle interventions to decrease risk factors for osteoporosis. Which is the best way to decrease the risk for osteoporosis? A. Increase nutritional intake of calcium. B. Engage in high-impact exercise, such as running. C. Increase nutritional intake of phosphorus. D. Walk for 30 minutes three times a week.
Walk for 30 minutes three times a week.
An older patient is discharged to home following an orthopedic injury. Which mobilization device is usually preferred for older patients who need additional support for balance?
Walker
After receiving IV heparin anticoagulant therapy, patients are generally not discharged from the hospital without a prescription instructions for which drug?
Warfarin (Coumadin)
What medication order for a client with a pulmonary embolism is most important to clarify with the prescribing physician before administration?
Warfarin 1.0 mg by mouth
Sequence of steps of continuous ambulatory peritoneal dialysis (CAPD) in order.
Warm the dialysate bags before instillation by using a heating pad to wrap the bag. 1 to 2 L of dialysate is infused by gravity over a 10 to 20 minute period. Fluid stays in the cavity for a specified time prescribed by the health care provider. Fluid flows out of the body by gravity into a drainage bag.
The nurse sees that a patient has been advised by the health care provider to apply lindane to the affected area. What is a self care measure for this patient to ensure that the symptoms do not return after using the medication?
Wash clothes, linens, and disinfect the home environment.
A patient has undergone a total hysterectomy with vaginal repair. The nurse advises her about careful intercourse and which OTC product to decrease sexual discomfort related to intercourse?
Water based lubricants.
Myasthenia Gravis Assessment
Weakness/fatigue Dyshphagia Ptosis/Diplopia Weak, hoarse voice Respiratory issues (paralysis, diminished, failure)
The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information will the nurse include in the teaching plan? A. Avoid contact sports. B. Avoid rigorous exercise. C. Wear helmets when riding a motorcycle. D. Avoid driving in inclement weather.
Wear helmets when riding a motorcycle.
At home interventions for back pain.
William's Position. Firm mattress. Exercise. Muscle relaxants - Cyclobenzaprine/Flexiril
A patient has had an inner maxillary fixation for a mandibular fracture. Which piece of equipment should be kept at the bedside at all times?
Wire cutters.
The nurse is taking the history of an adult female client. Which factor places the client at risk for osteoporosis? A. Consuming 12 ounces of carbonated beverages daily B. Working at a desk and playing the piano for a hobby C. Having a hysterectomy and taking estrogen replacement therapy D. Consuming one alcoholic drink per week
Working at a desk and playing the piano for a hobby
An excited group of teenagers brings a friend to the ED who severed a finger while playing sports. The bleeding from the site is well controlled and the patient is alert and stable. What does the nurse do with the severed finger?
Wrap it in dry gauze, place it in a waterproof bag, and put the bag in ice water.
Urotlithiasis: Population at risk
Younger adults (Caucasian Men)
Mean Arterial Pressure Calculation
[SBP + (2 x DBP)] / 3
irreducible hernia
a hernia that cannot be place back into the abdominal cavity
A patient with crush injuries to his lower extremities is at high risk for
acute kidney injury
Most common case of endometrial cancer
adenocarcinoma (80%)
Huntington Disease interventions
admin med (antipsychotics, meds for depression) Impaired physical mobility, speech/dysphagia
Nursing intervention for hyperkalemia
administer 10 units of insulin
Polycystic Kidney Disease
an inherited disorder in which fluid-filled cysts develop in the nephrons cysts may occur in other tissues (liver, blood vessels)
Drugs for peptic ulcer disease
antacids, H2 antagonists, mucosal barrier fortifiers, proton pump inhibitors, prostaglandin analogs, antimicrobrials
Drugs that cause anaphylaxis
antibiotics, adrenocorticotrope hormone, insulin, vasopressin, muscle relaxants, angiotensin receptor blockers, chemotherpay agents, whole blood, opiates.
Local anestheisa
any form of anesthesia that is not general or monitored anesthesia.
ABG
arterial blood gas
A cold, mottled toe may indicate ___ in DM patients
arterial occlusion secondary to arterial occlusive disease/embolization
Surgery for stress incontinence
artificial device insertion repositioning the urethra and bladder
First priority for client who has mechanic obstruction and is in pain?*
assess bowel sounds and palpate for rigidity
Because glucose levels will increase quickly in clients who use continuous insulin pumps, the nurse should
assess this client and the insulin pump first to avoid diabetic ketoacidosis
nephrectomy intervention:
assess urine output hourly for first 24 hours after surgery assess Hgb, Hct, WBC every 6 to 12 hours Monitor vital signs, bleeding, pain infection control
Nursing assessment for Pt on peritoneal dialysis
assess vital signs, weight, labs, respiratory distress, pain, symptoms of infection Dialysate assessment: outflow amount and pattern of fluid.
Treatment for autonomic dysreflexia*
ativan
If cardiac arrest/dysrhythmias occur during a tensilon test, treat with
atropine sulfate
pedunculated leiomyomas
attached to pedicle to outside of uterus, may break off and attach to other organs
Vascular access (arteriovenous fistula/graft) for hemodialysis precautions
avoid taking BP on arm with access site. Infection control when assessing catheter
A patient diagnosed with TB agrees to take the medication as instructed and to complete the therapy. When does the nurse tell the patient is the best time to take the medication?
bedtime
A pt with a SCI has paraplegia. The RN assesses for which major problem the pt may experience early in the recovery period?
bladder control
Grade III Uterine Prolapse
body of uterus protrudes through entrance of vagina.
upper GI bleeding
bright red/coffee ground vomitus melena (tarry stools) increased heart rate/decreased blood pressure weak peripheral pulses
A client acute kidney failure states, "Why am I twitching and my fingers and toes tingling?" The nurse should respond, "This is caused by...
calcium depletion
Which statement about dietary concepts for a patient with DM is true?
carbohydrate counting is emphasized.
carboxylhemoglobin
carbon monoxide on oxygen binding sites
After a radical prostatectomy, a client is ready to be discharged. what should be delegated to an LPN?
check patient temperature daily.
A pt with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (169/94) and decreased heart rate (48 bpm), diaphoresis, and flushing of the face and neck. What action should you take first?
check the Foley tubing for kinks or obstruction.
The RN is teaching a pt about performing PD at home. In order to identify the earliest manifestation of peritonitis, what does the RN instruct the pt to do?
check the effluent for cloudiness.
Best nursing action to prevent infection from a urinary catheter
cleansing around the meatus routinely
A patient has come to the clinic for follow up of acute pyelonephritis. Which action does the nurse reinforce to the patient?
complete all antibiotic regimens.
What should the RN do to asses the neurovsascular status of an extremity casted from the ankle to the thigh?
compress and release the client's toenails.
Complications of spinal involvement in RA may be seen as which signs/symptoms?
compression of the phrenic nerve that controls the diaphragm. Resulting subluxation of the first and second vertebrae. Becoming quadriplegic or quadriparetic.
Nephrotic syndrome
condition of iincreased glomerular permeability that allows larger molecule to pass through the membrane into the urine. Affects GFR, proteinuria, and edema formation
Which patients are at risk for developing health care acquired pneumonia?
confused patient patient with gram-negative colonization of the mouth. malnourished patient
Herbs for gastritis/peptic ulcer disease
cranberry, ginger, licorice, probiotics, slippery elm, vitamin C
In alkaline conditions, potassium levels ____
decreases
nephrostomy tubes
drains urine from the kidneys to the outside of the body
Truss should be worn*
during the daytime
leiomyomas are caused by
excessive growth of smooth muscle cells
bilateral salpingo-oophorectomy
fallopian tubes and ovaries are removed
Polycystic Kidney Disease: Dominant form
few cysts until age 30's
HbA1C
glycosylated hemoglobin
After esophageal surgery, make sure that the pt
has a gag reflex before giving anything orally
Which are signs and symptoms of MILD hypoglycemia?
headache weakness irritability
Key features of sliding hiatal hernias
heartburn regurgitation chest pain dysphagia belching
Client has low back pain, treat with*
heat 4 times a day
gastric ulcers are more likely to have _____ than duodenal ulcers
hematemesis
Distinct Crohn's manifestation*
high pitched bowel sounds
Common complications of DM
hyperlipidemia. hypertension
Post hemodialysis assessment
hypotension, headache nausea malaise vomiting dizziness cramps bleeding
Factors that DECREASE serum WBC
immune disorder, immunosuppressant therapy
In acidic conditions, potassium
increases
Bladder training
increasing the bladder's ability to hold urine and the patient's ability to suppress urination
anesthesia
induced state of partial or total loss of sensory perception, with or without the loss of consciousness
Urolithiasis can become
infected
hyperglycemia correlates with
infection
It is important for patients to be provided
information necessary to understand the nature of and the reason for the surgery has been provided.
Do NOT do this with patients going into seizures
insert things into their mouths. restrain them.
Functional urinary incontinence
leakage or urine caused by factors other than disease of lower urinary tract
African American Woman are more susceptible to
leiomyoma (fibroid)
Diabetic peripheral neuropathy causes
loss of sensory perception evidenced by pain, loss of sensation, and muscle weakness.
Antacids
magnesium hydroxide, aluminum hydroxide
Urotlithiasis: Patient priority
managment of pain and prevention of urinary obstruction and infection
Status Epilepticus is a
medical emergency
Chronic pyelonephritis
occurs from structural deformities, urinary stasis, obstruction, or reflux, repeated infections
A patient with facial trauma has undergone surgical intervention to wire the jaw shut. In performing discharge teaching with this patient, which topics does the nurse cover?
oral care Use of wire cutters Communication Aspiration prevention
Cholinergic crisis in MG cause
overmedication with anticholinesterase drugs
A patient is admitted to the hospital for DKA. Which ABG results should the nurse expect?
pH 7.32 Bicarbonate 18
Which ABG results would the nurse interpret as within normal limits?
pH 7.45, PaCO2 41, HCO3 25, PaO2 97
Which ABG results would the nurse interpret as metabolic alkalosis?
pH 7.52, PaCO2 45, HCO3 36, PaO2 95 pH 7.45, PaCO2 50, HCO3 42, PaO2 80
A patient is at risk for acid base imbalance. Which laboratory value indicates that the patient is acidotic?
pH = 7.30
Which ABG values indicate an alkaline condition?
pH = 7.55
analgesia
pain relief or pain suppression
Dehiscence
partial or complete separation of the outer wound layers
direct inguinal hernia
passes through a weak point in the abdominal wall
autologous donations
patient donates parts of body to self
Most important patient teaching for gastroenteritis*
patient should finish course of antibiotics
inpatient
patient who is admitted to a hospital
Patients with cardiac disease may require
perioperative therapy with beta blocking drugs recommended by SCIP CARD-2
Peritoneal dialysis complicatations
peritonitis pain exit site/tunnel infections fibrin build up dialysate leakage
Elective surgeries are
planned for correction of a nonacute problem
Perioperative experience includes
preoperative, intraoperative, postoperative
subserosal leiomyomas
protrude through outer surface of uterine wall
femoral hernia
protrude through the femoral ring
Gas bloat syndrome
pt has difficulty belching to relieve distention
H2 antagonists
ranitidine (zantac) famotidine (Pepcid) nizatidine (Axid)
Acute gastritis
rapid onset of epigastric pain nausea/vomiting vomiting blood (hematemesis) gastric hemorrhage heartburn (dyspepsia) anorexia
Choreiform
rapid, jerky movements
emergence
recovery from anesthesia
indirect inguinal hernia
sac formed from the peritoneum that contains a portion of the intestine
oliguria
scant amount of urine
morbidity
serious problem
With insulin therapy, ___ ___ levels fall rapidly as potassium and glucose shifts into the cells.
serum potassium
Peptic ulcer disease pt should go to the ED if:
sharp, sudden, severe abdominal pain bloody/black stools bloody vomit vomit that looks like coffee grounds
The nurse is teaching a pt about self care following a radical prostatectomy. What does the nurse include in the health teaching?
teach how to care for the indwelling catheter and manifestations of an infection Walk short distances Maintain an upright position and do not walk bent or flexed Shower rather than soak in a bath for the first 2-3 weeks
The nurse is assessing a patient with metabolic alkalosis. Which neuromuscular finding is the most ominous and warrants immediate notification of the health care provider?
tetany
The Rn is preparing a quadriplegic pt for discharge and has taught the pt's spouse to assist the pt with a "quad cough" to prevent respiratory complications. Which observation indicates that the spouse has understood what has been taught?
the spouse places her hands below the pt's diaphragm and pushes upward as the pt exhales.
A patient tells the nurse that he was diagnosed with BPH. Based on this medical diagnosis, which symptom is the patient most likely to report?
trouble passing urine
90% of people with DM have this type
type 2 DM
Regional anesthesia
type of local anesthesia that blocks multiple peripheral nerves and reduces sensory perception in a specific body region.
Parkinson Patients should avoid foods containing
tyramine (aged cheese, smoked foods) and red wine/beer
Cryptochidism
undescended testes
urema
urea in the blood
A patient reports straining to pass very small amounts of urine today, despite a normal fluid intake, and reports having the urge to urinate. The nurse palpates the bladder and finds that it is distended. Which condition is most likely to be associated with these findings?
urethral stricture
Glomerulonephritis: Lab values
urinalysis - proteinuria, hematuria GFR = decline Bactera - inflammation
Cystocele
urinary bladder is displaced downward. Bulging of anterior wall
Devices to support pelvic organ prolapse
vaginal pessary
Chronic gastritis
vague report of epigastric pain relieved by food anorexia nausea/vomiting intolerance of fatty/spicy foods pernicious anemia
Drug therapy for spinal cord injuries
vasopressors, methylprednisolone
Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? A. "A callus is quickly deposited and transformed into bone." B. "A hematoma forms at the site of the fracture." C. "Calcium and vascular proliferation surround the fracture site." D. "Granulation tissue reabsorbs the hematoma and deposits new bone."
"A hematoma forms at the site of the fracture."
A patient who is very upset asks the nurse, "My doctor says I have endometriosis. What does it mean?" What is the nurse's best response?
"A special type of tissue, called endometrial tissue, is outside of your uterus."
The RN is talking to a pt with ESKD. The pt frequently displays weight gain and increased blood pressure beyond the baseline measurements. Which question is the RN most likely to ask to determine if the pt is doing something that is contributing to these assessment findings?
"Are you controlling your salt intake?"
A patient reports the sensations of feeling "something is falling out." along with painful intercourse, backache, and a feeling of heaviness/pressure in the pelvis. Which question does the nurse ask to assess for a cystocele?
"Are you having urinary frequency or urgency?"
The nurse is talking to a group of healthy young college students about maintaining good kidney health and preventing AKI. Which health promotion point is the nurse most likely to emphasize with this group?
"Avoid dehydration by drinking at least 2 to 3 L of water daily."
The male diabetic patient asks the nurse for advice about alcohol consumption. What is the nurse's best response?
"Avoid more than two drinks a day and have them with or shortly after meals."
The nurse is teaching a group of women about prevention of toxic shock syndrome. What preventive measures does the nurse include?
"Avoid the use of superabsorbent tampons." "Use sanitary napkins at night." "Avoid using internal contraceptives."
When the nurse begins teaching about the benefits of early mobilization following surgery, Ms. Jackson states, "oh, I know if I stay in bed very long, I will get bed sores." How should the nurse respond?
"Bedsores are one of many problems that can occur from prolonged bedrest."
The client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? A. "Simple fracture involves a break in the bone, with skin contusions." B. "Compound fracture does not extend through the skin." C. "Simple fracture is accompanied by damage to the blood vessels." D. "Compound fracture, grade I, involves minimal skin damage."
"Compound fracture, grade I, involves minimal skin damage."
Patient tells the nurse that he has cut back on drinking fluids to reduce his symptoms of BPH The nurse responds
"Decreasing fluid intake may increase your risk of developing a urinary tract infection."
A patient's lab results show and elevated creatinine level. The patient history reveals no risk factors for kidney disease. Which question does the nurse ask the patient to shed further light on the lab result?
"Did you take any type of antibiotics before taking the test?"
After a hysterosalpingo-oophorectomy, a client wants to know whether it would be wise for her to take hormones right away to prevent symptoms of menopause. What is the nurse's MOST appropriate action?
"Discuss this with your health care provider, because it is important to know your concerns."
The Rn is taking a history on an older adult pt who reports chronic back pain. The Rn seeks to identify factors that are contributing to the pain. Which question is the most useful in eliciting this information?
"Do you have a history of osteoarthritis?"
The nurse is interviewing a patient to determine the presence of lower UTI symptoms associated with BPH. Which questions would the nurse ask?
"Do you have difficulty starting and continuing urination?" "Do you have reduced force and size of the urinary stream?" "Have you noticed postvoid dribbling or leaking?" "How many times do you have to get up and urinate during the night?" "Have you noticed blood at the start or at the end of voiding?"
A 20 year old woman is being evaluated for possible toxic shock syndrome. What question would the nurse ask?
"Do you use internal contraceptives?"
The home health nurse is visiting a pt who independently performs PD. Which question does the RN ask the pt to assess for the major complication associated with PD?
"Have you noticed any signs or symptoms of infection?"
The patient reports itching, change in vaginal discharge, and an odor. The nurse suspects that the patient has vulvovaginitis. Based on knowledge about the common causes of vulvovaginitis, which question would the nurse ask?
"Have you recently been taking antibiotics?"
The nurse hears in shift report that the pt had a transurethral needle ablation. Which question would the nurse ask the patient to determine if the procedure achieved the intended therapeutic goal?
"Have your problems with urination been resolved?
The nursing instructor asks a nursing student to identify risk factors that are shared by clients who have osteoporosis or osteomalacia. Which statement by the student is correct? A. "High alcohol intake is a risk factor for both conditions." B. "A history of smoking is a risk factor for both conditions." C. "Inadequate exposure to sunlight is a risk factor for both conditions." D. "Being homeless is a risk factor for both conditions."
"High alcohol intake is a risk factor for both conditions."
A 22 year old patient reports abdominal pain that stems to start several days before her menstrual period. What questions does the nurse ask in order to obtain a thorough menstrual history?
"How old were you when you started menstruation?" "Typically, how long does your period last?" "How would you describe your menstrual flow?"
The nurse is providing discharge teaching to a client with DM about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching?
"I can break in my shoes by wearing them all day."
A patient has been receiving erythropoietin (Epogen). Which statement by the patient indicates that the therapy is producing the desired effect?
"I can do my housework with less fatigue."
A client is in skin traction while awaiting surgery for repair of a fractured femur. The client reports leg discomfort and asks the nurse to release the traction. Which is the nurse's BEST INITIAL response?
"I can't because the eights are needed to keep the bone aligned."
During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks?
"I had a heart attack 4 months ago."
A patient had an anterior colporrhaphy and is returning to the clinic for the follow up appointment. Which patient statement indicates that the procedure has achieved the desired therapeutic outcome?
"I have good control over my urination."
Which statement made by the patient indicates that he or she may have an alkaline condition?
"I have tingling in my fingers and toes."
The nurse is teaching a client with DM about proper foot care. Which statement by the client indicates that teaching was effective?
"I must inspect my shoes for foreign objects before putting them on."
Which statement by a patient with DM indicates an understanding of the principles of self care?
"I plan to get my spouse to exercise with me to keep me company."
The nurse is teaching a client with type 2 DM about the importance of weight control. Which comment by the client indicates a need for further teaching?
"I should begin exercising for at least an hour a day."
The nurse is teaching a client about the manifestations and emergency treatment of hypoglycemia. In assessing the client's knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates a correct understanding of hypoglycemia management?
"I should eat three graham crackers."
You are preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching?
"I will avoid exercise because the pain gets worse."
After discussing renal replacement therapies with the health care provider and RN, the pt is now considering hemodialysis. Which statement indicates that pt needs additional teaching?
"I will be able to eat and rink what I want once I start dialysis."
The Rn reviews the discharge and home care instructions with a pt who had back surgery. Which statement by the pt indicates further teaching is needed?
"I will drive myself to my doctor's office next week."
The nurse is teaching a patient about post rhinoplasty care. Which patient statement indicates an understanding of the instruction?
"I will have bruising around my eyes, nose, and face."
The nurse is teaching a patient about the combination drug therapy that is used in the treatment of TB. Which patient statement indicates the nurse's instruction was effective?
"I will take three drugs: isoniazid, rifampin, and pyrazinamide, then ethambutol may be added later."
During morning care, a patient with a below the knee amputation asks the UAP about prostheses. How will you instruct the UAP to respond?
"I'll ask the nurse to come in and discuss this with you."
The client with bone cancer is scheduled for a right upper extremity amputation. Which statement by the client's spouse indicates an effective coping strategy? A. "I'll have to find ways to help my spouse focus on positive aspects of his or her body." B. "The family will avoid direct discussion of the spouse's amputation." C. "I'll try to limit visitors." D. "The family will use diversional methods to help my spouse not focus on the amputation."
"I'll have to find ways to help my spouse focus on positive aspects of his or her body."
The RN is instructing a teenage pt with a tibia-fibula fracture that was treated with internal fixation and a long leg cast. He is anxious to know when the cast will be removed so that he can resume football practice. Which statement by the pt indicates a need for additional teaching?
"I'll use crutches for 2 weeks and then the cast will be removed."
The nurse is providing discharge teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet?
"If I become hypoglycemic, I could become unconscious."
A patient has late stage chronic glomerulonephritis. Which educational brochure would be the most appropriate to prepare for the patient?
"Important points to know about dialysis"
The nurse is interviewing a patient with suspected PKD. What questions does the nurse ask the patient?
"Is there any family history of PKD or kidney disease?" "Have you had any constipation or abdominal discomfort?" "Have you noticed a change in urine color or frequency?" "Have you had any problems with headaches?"
A patient with a PE asks for an explanation of heparin therapy. What is the nurse's best response?
"It increases the time it takes for blood to clot, therefore preventing further clotting and improving blood flow."
Nurse is preparing to teach a diabetic patient how to select appropriate shoes. Which points must be included in the teaching plan?
"It is best to have the shoes fitted by an experienced shoe fitter such as a podiatrist." "the heels of the shoes should be less than 2 inches high." "Avoid tight fitting shoes, which can cause tissue damage to your feet." "You should get at least two pairs of shoes so you can change them midday and in the evening."
A patient has sustained a mandible fracture and the surgeon has explained that the repair will be made using a resorbable plate. The patient discloses to the nurse that he has not told the surgeon about his substance abuse. What is the nurse's best response?
"It is important for your surgeon to know about this information."
Which statement by the nursing student indicates an understanding of the purpose of administering oxygen by nasal cannula?
"It is often used for chronic lung disease and for any patient needing long term oxygen therapy."
After Ms. Jackson stops crying she states, "My father was in so much pain before he died. Talking about pain brings back so many memories." How should the nurse respond?
"It sounds as if you went through a difficult time when your father died."
A student nurse is caring for a pt with chronic kidney failure who is to be treated with CAPD. Which statement by the student nurse indicates to the RN that the student understands the purpose of this therapy?
"It uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."
The client is recovering from an above-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? A. "My spouse will be the only person to change my dressing." B. "I can't believe that this has happened to me. I can't stand to look at it." C. "I do not want any visitors while I'm in the hospital!" D. "It will take me some time to get used to this."
"It will take me some time to get used to this."
The pt is a woman in her early 30s who has recently been diagnosed with MS. The RN has taught the pt's husband about the course of the illness and what problems might occur in the future. Which statement made by her husband indicates the need for additional teaching?
"Later on she could have intermittent short term memory loss."
A client expresses fear and anxiety over life changes associated with DM stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the BEST response?
"Let's tackle it piece by piece. What is most scary to you?"
A patient requires oxygen therapy with a nasal cannula. Which interventions will the nurse teach the student nurse providing care for this patient?
"Make sure that the prongs on the nasal cannula are properly positioned in the nares." "Apply a water soluble gel to the nares as needed." "Be sure to assess that both nares are patent." "Assess the patient for any changes in respiratory rate and pattern."
A pt and family are trying to plan a schedule that coordinates with the pt's dialysis regimen. The pt asks, "How often will I have to go and how long does it take?" What is the nurse's best response?
"Most pt require about 12 hours per week; this is usually divided into three 4-hour treatments."
Which pt reported symptoms are typical of RA?
"My hands are stiff, swollen, and tender." "My pain and stiffness is worse in the morning." "My knees are swollen and stiff." "I am weak and fatigued."
A patient with a right above the knee amputation asks you why he has phantom limb pain. What is your best response?
"Phantom limb pain is not explained or predicted by any one theory."
The nurse is caring for a client with bone cancer of the right hip who has undergone radical resection of the tumor and has received a prosthetic implant. Which client statement indicates effective coping after the procedure? A. "After I recover, I'll be just as strong as I was before the surgery." B. "I won't be able to go out in public like I did before." C. "Physical therapy and counseling will help me adjust to my prosthesis." D. "I'll be able to return to work and drive without assistance."
"Physical therapy and counseling will help me adjust to my prosthesis."
An older pt's wife is very upset because "my husband was just told that he had prostate cancer. He feels fine now, but the dr told him to watch and wait. Why are we just watching? What are we watching for?" What is the nurse's best response?
"Prostate cancer is slow growing. Your husband needs regular DRE and PSA testing and here is a list of symptoms to watch for."
What is an important health teaching point for a patient with TJA?
"Protect the joint."
You are supervising a nurse on orientation to the unit who is discharging a patient admitted with kidney stones who underwent lithotripsy. Which statement by the nurse to the patient requires that you intervene?
"Report any signs of bruising to your physician immediately, since this indicates bleeding.
A client is diagnosed with uterine fibroids, and the health care provider advises a hysterectomy. The client expresses concern about having a hysterectomy at age 45 because she has heard from friends that she will undergo severe symptoms of menopause after surgery. What is the nurse's MOST appropriate response?
"Some women may experience symptoms of menopause if their ovaries are removed with their uterus."
A pt needs surgical intervention for an enlarged prostate, but also needs to maintain his anticoag therapy. Which brochure would be the most appropriate to prepare for the pt?
"Talking to your dr about Holmium Laser Enucleation of the Prostate (Ho-LEP)"
A pt has been talking to this physician about drugs that could potentially be used in the treatment of acute low back pain. Which statement by the pt indicates a need for additional teaching?
"The Doctor may prescribe hydromorphone and it may cause drowsiness; I should not drive or drink alcohol when I take it."
A pt is informed by the physician that he must have a fiberglass cast applied to the lower extremity. What does the nurse teach the pt about the procedure before the cast is applied?
"The cast material will dry and become rigid in a few minutes."
The nurse is educating a pt who will have external fixation for treatment of a compound tibial fracture. What information does the RN include in the teaching lesson?
"The device allows for early ambulation."
A patient has had one kidney removed as a treatment for kidney cancer. The patient asks, "Does the good kidney take over immediately? I know a person can live with just one kidney." What is the nurse's best response?
"The other kidney will provide adequate function, but this may take days or weeks."
A patient diagnosed with TB has been receiving treatment for 3 weeks and has clinically shown improvement. The family asks the nurse if the patient is still infectious. What is the nurse's reply?
"The patient is not infectious but needs to continue treatment for at least 6 months."
The nurse discusses postoperative pain management with Ms. Jackson and explains the use of a patient-controlled analgesia pump. Ms. Jackson expresses fear that she might accidentally overdose herself. How should the nurse respond?
"The pump has a control device that prevents you from taking too much medicine."
The RN is providing teaching for a pt with a forearm cast. What information does the nurse give to the pt?
"The sling should distribute the weight over a large area of the shoulders and trunk."
A patient returning to the unit after a left radical nephrectomy for kidney cell carcinoma reports having some soreness on the right side. What does the nurse tell the patient?
"The soreness is likely to be from being positioned on your right side during surgery."
A mother is a carrier of muscular dystrophy (MD) and has a daughter. The client asks the nurse what the daughter's genetic risk is for having MD. What is the nurse's best response? A. "Because you are a carrier of the MD gene, your daughter will develop MD." B. "She will not have MD nor will she be a carrier." C. "There is a 50% chance that your daughter may carry the gene." D. "Your daughter is X-linked dominant for the MD gene."
"There is a 50% chance that your daughter may carry the gene."
The nurse is instructing a client about the use of antiembolism stockings. Which statement by the client indicates the need for further teaching?
"These stockings will prevent blood clots."
A CBC, urinalysis, and x-ray examination of the chest are ordered for a client before surgery. The client asks why these tests are done. Which is the BEST reply by the nurse?
"They are done to identify other health risks."
The off going nurse is giving shift report to the oncoming nurse about the care of a patient who had a nephrostomy tube placed 3 days ago and it is to remain in place until the urinary obstruction is resolves. What is the most important point to clearly communicate about the urine drainage?
"Urine is draining only into the collection bag, not the bladder; therefore the minimum expected drainage is 30 mL/hour."
A young patient had a great toe amputated because of severe injury. The patient is depressed and withdrawn after the physician tells him that the amputation will affect balance and gait. What is the nurse's best response?
"When the doctor was explaining things to you, what were you thinking about?"
A pt is receiving scheduled and prn narcotics for severe pain related to a musculoskeletal injury. The RN finds that the pt's abdomen is distended and bowel sounds are hypoactive. Because the RN suspects that the pt is having a medication side effect, which question does the RN ask the pt?
"When was your last bowel movement?"
A 35 year old male patient with no health problems states that he had a flu shot last year and asks if it is necessary to have it again this year. What is the best response by the nurse?
"Yes, because the vaccine guards against a specific virus and reduces your chances of acquiring flu and is only effective for one year
The nurse is giving instructions to a patient who is undergoing brachytherapy for cervical cancer. What information does the nurse include?
"You are not radioactive between treatments." "Report any blood in the urine or severe diarrhea immediately." "You will be on bedrest during the treatment session."
A patient is requesting moderate sedation for repair of a torn meniscus and has no medical contraindications. How does the nurse respond to this patient's request?
"You can discuss your request for moderate sedation with your surgeon and anesthesiologist."
A preoperative patient tells the nurse that she is afraid that she may experience a reaction if she must receive blood during or after her surgery. What is the nurse's best response to the patient's concern?
"You could donate some of your own blood a few weeks before your surgery."
A patient is reluctant to consider hip surgery because of fear of blood transfusion reaction. What is the nurse's BEST response?
"You could donate your own blood for several weeks before surgery."
An older adult male patient calls the clinic because he has "not passed any urine all day long." What is the nurse's best response?
"You could have an obstruction, so you should come back in to be checked."
A patient has a positive skin test result for TB. What explanation does the nurse give to the patient?
"You have been infected, but this does not mean active disease is present."
The patient is scheduled to have minimally invasive surgery for a laparoscopic cholecystectomy. Part of this surgery is the injection of air (insufflation) into the abdomen to separate and better see the organs. What patient teaching must the nurse do about insufflation?
"You may experience some abdominal discomfort from the air injected with the surgery."
Pt is preparing for discharge. You are supervising a student nurse who is teaching the pt about her discharge medications. For which statement by the student will you intervene?
"You must take the epoetin alfa three times a week by mouth to treat anemia."
While receiving a preoperative enema, a client starts to cry and says "I'm sorry you have to do this messy thing for me." What is the nurse's BEST response?
"You seem upset."
A patient has been treated for pneumonia and the nurse is preparing discharge instructions. The patient is capable of performing self care and is anxious to return to his job at the construction site. Which instructions does the nurse give to this patient?
"You will continue to feel tired and will fatigue easily for the next several weeks."
A client with type 2 DM has been admitted for surgery, and the health care provider has placed the client on insulin in addition to the current does of metformin (glucophage). The client wants to know the purpose of taking the insulin. What is the nurse's BEST response?
"Your body is under more stress, so you'll need insulin to support your medication."
The nurse is talking to a 35 yo African American man about PSA testing. The pt tells the nurse that his father and older brother with diagnosed with prostate cancer in their 50s. What should the nurse tell the pt?
"Your genetic and racial risk factors suggest testing should begin at 40"
The nursing student is explaining principles of hemodialysis to the nursing instructor. Which statement by the student indicates a need for additional study and research on the topic?
"bacteria and other organisms can also pass through the membrane, so the dialysate must be kept sterile."
What information should be included when teaching a patient about using tamsulosin (Flomax)?
"change positions slowly, such as when standing up."
Patients who are at high risk for TB would be asked which questions upon assessment?
"do you have an immune dysfunction or HIV?" "do you use alcohol or inject recreational drugs?" "do you work in a crowded area such as a prison or mental health facility?"
Ms. Jackson arrives at the surgery center 3 hours before her scheduled surgery. Which question is most important for the nurse to ask during the admission interview?
"have you had anything to eat or drink since midnight?"
The nurse is preparing a teaching plan for the patient and family on how to care for an automatic epinephrine injector. Which essential points must the nurse include?
"keep the device with you at all times." "You can inject the drug right through your pants.'' "protect the device from light and avoid temperature extremes." "Keep safety cap in place until you are ready to use the device."
A 25 year old female patient with type 1 DM tells the nurse, "I have 2 kidneys and I'm still young, I expect to be around for a long time, so why should I worry about my blood sugar?" What is the nurse's BEST response?
"keeping your blood sugar under control now can help to prevent damage to both kidneys."
A DM client has a HbA1C of 9.4%. What does the nurse say to the client regarding this finding?
"what are you doing differently?"
A patient with diabetic nephropathy reports having frequent hypoglycemic episodes "my doctor reduced my insulin, which means my diabetes is improving." What is the nurse's best response?
"when kidney function is reduced, the insulin is available for a longer time and thus less of it is needed."
The nurse is caring for a patient with CKD. The family asks about when renal replacement will begin. What is the nurse's best response?
"when the kidneys are unable to maintain a balance in body functions."
The nurse is caring for a patient with DM. The patient's urine is positive for ketones. What does the nurse instruct the patient with regard to exercise?
"when urine ketones are present, you should not exercise."
Normal Creatinine (Female)
0.5 - 1.1 mg/dL
Normal Creatinine (Male)
0.6 - 1.2 mg/dL
Normal INR
0.7 - 1.8
A pt was put in to traction at 0800 hours. Hourly neurovascular checks were ordered for the first 24 hours and then every 4 hours there after. At what time can the nursing staff start performing the 4 hour checks?
0800 hours next day.
In reviewing the health care provider admission requests for a client admitted in a HHS, which request is inconsistent with this diagnosis?
1 ampule NaHCO3 IV now
Immediate intervention of autonomic dysreflexia
1. Place pt in sitting position. Notify HCP Monitor BP every 10 - 15 minutes. Reurrent ADF may recieve an alpha blocker
Normal Blood Urea Nitrogen
10 - 20 mg/dL
In the immediate post operative period after a gastrectomy, the client's nasogastric tube is draining a light red liquid. For how long should the nurse expect this type of drainage?
10 to 12 hours
Nursing intervention for Cluster headache
100% O2 with mask at 5 L/min for 15 minutes. (client sitting) Consistent sleep schedule.
Polycystic Kidney Disease: Recessive form
100% of nephrons have cysts from birth
Normal Prothrombin time
11 - 12.5 seconds, 85% - 100%, or 1: 1.1 patient control ratio
A client with type 1 DM received regular insulin at 7am. The client should be monitored for hypoglycemia at which time?
11am
Normal Hemoglobin, total (female)
12 - 16 g/dL
The Rn is caring for a pt with a SCI who is experiencing neurogenic shock. The pt's systolic blood pressure is 88 mm/Hg despite starting a dopamine drip 2 hours earlier. There is a new order to infuse 500 mL of Dextran-40 over 4 hours. At what rate does the Rn set the infusion pump?
125 mL/hr
Review of client's prescription states that Lactated Ringer's solution at 75 mL/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 10 drops/mL and resets the IV. At what rate should the IV infuse?
13 drops per minute.
Normal Hemoglobin, total (male)
14 - 18 g/dL
The prescription is for 2 grams of cefazolin, which arrives from the pharmacy diluted in 100 mL of normal saline and is to be administered over 30 minutes. At what rate should the infusion pump be set?
200 mL/hour.
Normal arterial HCO3 range
21 - 28 mEq/L
Normal Carbon Dioxide
23 - 30 mEq/L
As charge nurse, you must rearrange room assignments to admit a new patient. Which two patients would be best suited to be roommates?
24 year old with acute pyelonephritis and severe flank plan. 76 year old with urge incontinence and a UTI.
Along with exercise, what is the recommended calorie reduction for a patient with diabetes who must lose weight?
250 - 500 calories a day.
The pt has a continuous bladder irrigation via a 3 way urinary catheter. At 7 am the urine drainage bag was emptied and 1000 mL of irrigation fluid was started. At 11 am, 350 mL of irrigation fluid was administered through the catheter. The urinary drainage bag contains 600 mL. How many mL of urine has the pt produced in the past 4 hours?
250 mL
Normal Partial thromboplastin time, activated (aPTT)
30 - 40 sec
Normal rate of blood filtered by the kidney
30 mL/hr
Which patient is at highest risk for developing pneumonia?
32 year old trauma patient on a mechanical ventilator.
Normal arterial PaCO2 range
35 - 45 mmHG
The nurse and the dietitian are planning dietary intake for a patient with AKI who is currently not on dialysis therapy. The dietitian informs the nurse that 0.6 g/kg of body weight of protein are needed. The patient weighs 130 pounds. How many grams of protein should the patient receive?
35 grams
Which patient has the greatest risk for developing chronic pyelonephritis?
36 year old woman with diabetes mellitus who is pregnant
The health care team determines a patient's readiness for discharge from the PACU by noting a postanesthesia recovery score of at least 10. After determining that all criteria have been met, the patient is discharged to the hospital unit or home. Review the patient profile after 1 hour in the PACU listed below. Which patient should the nurse expect to be discharged from the PACU first?
42 year old woman, colonoscopy. IV conscious sedation. Awake and alert. Up to bathroom to void. IV discontinued. Resting quietly in chair. VS are within normal limits.
As a charge nurse, you would assign the nursing care of which patient to an LPN working under the supervision of an RN?
48 year old with cystitis who is taking oral antibiotics
Which description of the autosomal-dominant form of PKD is correct?
50% of people with this form of PKD develop kidney disease by age 50.
Which individual is at greatest risk for developing type 2 DM?
56 year old Hispanic woman
Normal BUN
7 - 20
Which blood pH value does the nurse interpret as within normal limits?
7.37
The nurse is caring for several patients on a med surg unit. None of the patients currently has any acute or chronic kidney problems. Which patient has the greatest risk to develop AKI?
73 year old male who has hypertension and peripheral vascular disease.
Which diabetic patient is at greatest risk for diabetic foot ulcer formation?
75 year old African American male with history of cardiovascular disease.
Normal Chloride Range
98 - 106 mEq/L
Which of these clients with DM does the endocrine unit charge nurse assing to an RN who has floated from the labor/delivery unit?
A 70 year old who needs blood glucose monitoring and insulin before each meal.
If a patient experiences a wound dehiscence, which description illustrates what is happening with the wound?
A partial or complete separation of outer layers is present at incision site.
Types of regional Anesthesia: Field Block
A series of injections around the operative field. Most commonly used for chest procedures, hernia repair, dental surgery, and some plastic surgeries.
Which statement best describes pneumonia?
A serious inflammation of the bronchioles from various causes.
Which data set indicates that the patient with diabetes is achieving the goals of care to prevent the development of microalbuminuria and delay the progression to end stage kidney disease?
A1C less than 7%, BP is 125/75 mmHg, LDL cholesterol is 90 mg/dL
nephrectomy assessment:
ABCDE's, signs of bleeding in kidney region
From which injection site is insulin absorbed most rapidly?
Abdomen
A patient has been receiving insulin in the abdomen for 3 days. On day 4, where does the nurse give the insulin injection?
Abdomen, but in an area different from the previous day's injection.
An older adult patient who is talking and laughing while eating begins to choke. What is the initial emergency management for this patient?
Abdominal thrusts (Heimlich maneuver)
The nurse is caring for a patient with open reduction and internal fixation (ORIF) for a hip fracture. Because the patient is at risk for hip dislocation, the nurse ensures that the hip is maintained in which position?
Abduction
Seven warning signs of Gynecologic Cancer
Abnormal bleeding Pelvic Pain Urinary/Gastro disturbances abdominal swelling changes in vulva/vagina low back pain.
The intensive care nurse is caring for the kidney transplant pt who was just transferred from the recovery unit. Which finding is the most serious within the first 12 hours after surgery and warrants immediate notification of the transplant surgeon?
Abrupt decrease in urine.
The PACU nurse is assessing a patient transferred in from the OR. Which assessment findings apply to assessment of the cardiovascular system?
Absent dorsalis pedis pulse left foot. Monitor shows normal sinus rhythm. Apical pulse 85 beats/minute.
A nurse plans care to prevent deformities in a client with RA. Which intervention should be alternated with periods of rest?
Active exercise.
The nurse is assessing a patient with an acid-base imbalance by using Gordon's Functional Health Patterns. What primary areas are affected?
Activity-Exercise Elimination Sleep-rest
A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? Select all that apply. A. Acute compartment syndrome (ACS) B. Fat embolism syndrome (FES) C. Congestive heart failure D. Urinary tract infection (UTI) E. Osteomyelitis
Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Osteomyelitis
A pt with a leg cast denies pain; toe are pink; capillary refill is brisk and toes move freely; the leg is elevated with an ice pack. Six hours later, the pt reports worsening pain unrelieved by medication. The pt's toes are cool and capillary refill is sluggish. What does the RN suspect is occurring with this pt?
Acute compartment syndrome.
In which situations does the nurse teach a patient to perform urine ketone testing?
Acute illness or stress. When symptoms of DKA are present. When a diabetic patient is in a weight loss program.
Patients with which condition meet the criteria for having a TURP?
Acute urinary retention, hydronephrosis, hematuria
The nurse is caring for several patients who are at risk because of problems related to the upper airway. Which are the priority assessments and actions for these patients?
Adequacy of oxygenation; ensure an unobstructed air passageway.
Postoperative total hip replacement patients can develop numerous complications. Which interventions are most important in preventing complications?
Adequate diet and fluid intake. Getting out of bed on the first post operative day. Frequent assessment of the patient's pain.
A patient with DM has signs and symptoms of hypoglycemia. The patient has a blood glucose of 56 mg/dL, is not alert but responds to voice, and is confused and is unable to swallow fluids. What does the nurse do next?
Administer D50 IV push
A patient hopsitalized for pneumonia has the prioirty patient problem of ineffective airway clearance related to fatigue. What nursing intervention helps to correct this problem?
Administer bronchodilator therapy in a timely manner to decrease bronchospasms.
You are checking med orders that were received by telephone for a pt with RA who was admitted with methotrexate toxicity. Which order is most important to clarify with the physician?
Administer chlorambucil (Leukeran) 4 mg PO daily
The nurse is caring for a patient with nephrotic syndrome. What interventions are included in the plan of care for this patient?
Administer mild diuretics. Assess for edema. Administer antihypertensive medications.
A patient has had a posterior colporrhaphy. What is included in the nursing care of this patient?
Administer pain medication before a bowel movement. Instruct to avoid straining during a bowel movement. Provide sitz baths. Promote a low residue (low fiber) diet.
In order to assist a patient in the prevention of osteodystrophy, which intervention does the nurse perform?
Administer phosphate binders with meals.
The nursing diagnosis of Constipation related to compression of the intestinal tract has been identified in a patient with polycystic kidney disease. Which nursing care action should you delegate to a newly trained LPN?
Administering docusate sodium (Colace) 100 mg by mouth twice a day.
The nurse is caring for a patient with AKI who does not have signs or symptoms of fluid overload. A fluid challenge is performed to promote kidney perfusion by doing what?
Administering normal saline 500 to 1,000 mL infused over 1 hour.
The nurse is conducting an in service for the hospital staff about practices that help prevent pneumonia among at risk patients. Which nursing intervention is encouraged as standard practice?
Administering vaccines to patients at risk.
The health care provider tells the nurse that the patient with PKD has salt wasting. Which intervention is the nurse likely to use related to nutrition therapy?
Advise that a low sodium diet is not currently necessary.
After being treated in the emergency department for posterior nosebleed, the patient is admitted to the hospital. The nasal packing is in place and vital signs are stable. The patient has an IV of normal saline at 125 mL/hr. What is the priority for nursing care?
Airway management.
Which class of antidiabetic medication should be taken with the first bite of a meal to be fully effective?
Alpha-glucosidase inhibitors, include miglitol (glyset)
A pt arrives in the Ed reporting pain and immobility of the right shoulder. The pt reports a history of recurrent dislocations of the same shoulder. The RN observes for which other signs and symptoms that are associated with a dislocation injury?
Alteration in contour of the joint. Deviation in length of the extremity.
Which infection control measures must the nurse teach a patient who will be performing SMBG?
Always wash hands before monitoring glucose. Regular cleaning of the meter is critical. Do not re-use lancets. Do not share blood glucose monitoring equipment.
You are teaching a patient how best to prevent renal trauma after an injury that required a left nephrectomy. Which points would you include in your teaching plan?
Always wear a seat belt. Avoid all contact sports. Practice safe working habits. Use caution when riding a bicycle.
Which ethnic groups are mostly likely to develop end stage kidney disease related to hypertension?
American Indians African Americans
The nurse plans to refer a client with an amputation and the client's family to which community resource? A. American Amputee Society (AAS) B. Amputee Coalition of America (ACA) C. Community Workers for Amputees (CWA) D. National Amputee of America Society (NAAS)
Amputee Coalition of America (ACA)
Which people are at greatest risk for developing TB in the US?
An alcoholic homeless man who occasionally stays in a shelter. A person with immune dysfunction or HIV. Foreign immigrants (especially those from Philippines and Mexico).
After an abdominal hysterectomy the client returns to the unit with an indwelling catheter. The nurse identifies that the urine in the client's collection bag has become increasingly sanguineous. What complication does a nurse suspect?
An incisional nick in the bladder.
A pt with acute kidney failure becomes confused and irritable. Which does the RN determine is the most likely cause of this behavior?
An increased BUN level.
For a patient who is having a an anaphylactic reaction, which common symptoms will manifest almost immediately after being exposed to an allergen?
Angioedema Apprehension Urticaria
What information would the nurse give to a sexually active 22 year old woman about conventional Papanicolaou (Pap) smear testing?
Annual screening is recommended.
The nurse is providing care for a patient scheduled for a THA. Which medications should the patient receive before surgery?
Anti-hypertensive tablet orally.
Glomerulonephritis: Interventions
Antibiotic therapy Diuretics Antihypertensives Dialysis: To treat uremia, fluid overload Plasmapheresis Antibody removal
Factors that increase INR
Anticoagulant therapy
A pt is prescribed amitriptyline (Elavil) for the diagnosis of fibromyalgia. What kind of drug is in this medication?
Antidepressant.
Drugs for seizures
Antieplileptic/Anticonvulsants: Introduce one drug at a time. Dilantin, Ativan, Depakote, Klonopin
Care for immune complex reactions
Antihistamines for itching. Aspirin for arthralgias. Prednisone for severe manifestations.
A Rn is caring for a pt with RA. Based on the pt's dx, the RN should review the result of which lab test?
Antinuclear antibody
Urotlithiasis: Size of stone that will not pass through ureter
Anything larger than 4 mm
A patient enter the emergency department after being punched in the throat. What does the nurse monitor for?
Aphonia.
The pt with MS states she is bothered by diplopia (double vision). Which intervention does the Rn expect to implement?
Application of an eye patch alternating from eye to eye every few hours.
Which pain management strategy does the nurse teach a patient who has pain from infected kidney cysts of PKD?
Apply dry heat to the abdomen or flank.
The nurse is providing postoperative nursing care for a patient with surgical correction of a deviated septum. Which intervention is part of the standard care for this patient?
Apply ice to the nasal area and eyes to decrease swelling and pain.
A client with a third degree uterine prolapse is scheduled for a vaginoplasty. What should the nurse anticipate the surgeon will order?
Apply moist compresses to the uterus
The nurse is teaching a patient with DM about proper foot care. Which instructions does the nurse include?
Apply moisturizing cream to the feet after bathing, but not between the toes. Do not go barefoot. Inspect the feet daily.
Which interventions must the operating room nurses provide for patient physiological integrity during the intraoperative period?
Apply padding to the OR bed to protect skin integrity. Monitor patient's airway, vital signs, ECG, O2 Sats during and after surgery. Assess and document skin condition before transferring patient to the postanesthesia care unit.
The patient has returned from the post anesthesia care unit after TJR. Which interventions will the nurse use to prevent venous thromboembolism?
Apply sequential compression devices (SCDs). Administer subcutaneous enoxaparin (Lovenox) as ordered. Teach the patient to perform leg exercises such as flexion and dorsiflexion.
The charge nurse observes an LPN providing all of these interventions for a pt with Paget disease. Which action requires that the charge nurse intervene?
Applying ice and gentle massage to the pt lower extremities.
The nurse sees that the patient is taking tamsulosin (Flomax). Which question would the nurse ask to determine if the med is achieving the desired therapeutic effect?
Are you having any trouble passing urine?
The nurse is evaluating a patient's treatment response to erythropoietin (Epogen). Which hemoglobin reading indicates that the goal is being met?
Around 10 g/dL
A young patient has been diagnosed with testicular cancer. He and his wife had been trying to conceive a child for several months. What information does the nurse give the couple about sperm storage?
Arrangements for sperm storage should be made as soon as possible after diagnosis
When should triptan drugs be taken?
As soon as a migraine headache starts.
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. What medication does the nurse anticipate will be prescribed for this client?
Ascorbic acid (Ascorbicap)
In a long term care facility for older adults and immunocompromised patients, one employee and several patients have been diagnosed with influenza. What does the supervising nurse do to decrease risk of infection to other patients?
Ask employees with flu symptoms to stay at home for up to 5 days after onset of symptoms.
After completing the admission interview, the nurse reviews patient's medical record and notes that the surgical consent form is filled out but is not signed by the client. What action should the nurse take?
Ask patient if she received sufficient information to sign the consent form.
A patient had a total abdominal hysteretomy. Which patient behavior is the best indicator that she is coping and adapting successfully?
Ask questions about the wound care, but seems reluctant to do self care.
The UAp notifies the nurse that hte patient with emphysema on O2 at 2L nasal cannula is short of breath after morning care. What is the best nursing action.
Ask the UAP to check the patient's Sao2
A client with type 2 DM who is taking metformin (glucophage) is seen in the DM clinic. The fasting blood glucose is 108 mg/dL, and the HbA1c is 8.2%. Which action does the nurse plan to take next?
Ask the client about current dietary intake and medication use.
A patient has chronic glomerulonephritis. In order to assess for uremic symptoms, what does the nurse do?
Ask the patient to extend the arms and hyper-extend the wrists.
The health care provider removed a patient's original surgical dressing 2 days after surgery and is discharging the patient home on daily dressing changes. Which actions does the nurse take for this patient's discharge teaching?
Ask the patient's family or significant other to observe the dressing change. Instruct that the drainage will appear sero-sanguineous. Have the case manager arrange for a home health nurse to ensure that dressing changes are done and there are no complications of infection.
An immigrant has been admitted to the ED with DKA. On intake assessment, the patient cannot recall the medication they take. What first action should be taken?
Ask the patient's significant other to bring the patient's medications from home.
The SN is assisting with the care of a pt with musculoskeletal pain related to soft tissue injury and bone disruption. The Sn sees that the pt has a prn order for pain medication. What does the Sn do first in order to decide when to give the pain medication?
Ask the pt about types of activities that increase the pain.
The rn is assessing a pt for severe pain in the right wrist after falling off a step stool. How does the RN assess this pt's motor function?
Asking the pt to move the fingers
Which medication should the RN anticipate the health care provider will prescribe to relieve the pain experienced by a pt with RA?
Aspirin
Patient has anaphylaxis, what is your first priority?*
Assess airway
A patient arrives in the PACU. Which action the nurse performs first?
Assess for a patent airway and adequate gas exchange.
The nurse's neighbor comes running over because her husband "cut his finger off with a power saw." After calling for help, what is the first priority action when the nurse gets to the neighbor's house?
Assess for airway or breathing problems.
A patient with PKD reporrts a severe headache and is at risk for a berry aneurysm. What is the nurse's priority action?
Assess for neurologic changes and check vital signs.
A pt has had an anterior cervical diskectomy with fusion and has returned from the recovery room. What is the priority assessment?
Assess for patency of airway and respiratory effort.
A patient with acute glomerulonephritis has edema of the face. The blood pressure is moderately elevated and the patient has gained 2 pounds within the past 24 hours. The patient reports fatigue and refuses to eat. What is the priority for nursing care?
Assess for signs and symptoms of fluid volume overload.
A patient tells the nurse taht she was told that she had a "chocolate" cyst. Which assessment is the nurse most likely to perform?
Assess onset and description of pain.
The nurse prepares to perform a neurovascular assessment on the client with closed multiple fractures of the right humerus. Which technique will the nurse use? A. Inspect the abdomen for tenderness and bowel sounds. B. Auscultate lung sounds. C. Assess the level of consciousness and ability to follow commands. D. Assess sensation of the right upper extremity.
Assess sensation of the right upper extremity.
The client's left arm is placed in a plaster cast. Which assessment will the nurse perform before the client is discharged? A. Assess that the cast is dry. B. Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. C. Check the fit of the cast by inserting a tongue blade between the cast and the skin. D. Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.
Assess that the cast is dry.
A patient with uterine leiomyomas reports a feeling of pelvic pressure, constipation, and urinary retention. She says, "I can't button my pants anymore." What does the nurse assess for to further evaluate the patient's symptoms?
Assess the abdomen for distention or enlargement.
A patient had a nephrostomy and a nephrostomy tube is in place. What is included in the postoperative care of this patient?
Assess the amount of drainage in the collection bag.
A pt in traction reports severe pain form a muscle spasm. What is the Rn's priority action?
Assess the pt's body alignment.
The Rn is caring for a pt with a plaster splint applied to the ankle. The pt received oral pain medication at 0900. At 1100, the pt reports that the pain is getting worse, not better. What is the RN's priority action?
Assess the pulses and skin temperature distal to the splint.
A pt involved in a hihg speed motor vehicle accident with sustained multiple injuries and active bleeding is transported to the ED by ambulance with immobilization devices in place. There is a high probability of cervical spine fracture; the pt has altered mental status and extremities are flaccid. What is the priority assessment for this pt?
Assess the respiratory pattern and ensure a patent airway.
When educating a patient about total joint arthroplasty (TJA), what does the nurse do first?
Assesses the patient's knowledge about TJA.
Nursing Interventions for General Anesthesia Stage: 3
Assist CRNA with intubation. Place patient into operative position. Prep the patient's skin over the operative site as directed.
A pt is diagnosed with prostatitis. Which intervention does the nurse use to alleviate the discomfort associated with this condition?
Assist with comfort measures such as sitz baths for pain
What does the RN do for a pt with a cervical laminectomy that differes from the nursing care for a pt with a lumbar laminectomy?
Assist with the removal of oral secretions.
The postoperative care of a morbidly obese client is being planned. Which task best utilizes the expertise of the LPN?
Assisting in the planning of toileting, turning, and ambulation.
