399 Exam 2

Sickle Cell Disease -RBC action -s/s -risk factors -nursing actions

- cells sickle(change shape) under stress -cells get stuck everywhere -ischemia, infarct, - full body pain - high risk for clot formation, infection (put on SCDs) - anemia (20days not 120)- hypoxemia - motior oxgenation status - high risk for gallstones -don't let patient eat (NPO) HOP treatment (Hydration, Oxygen PRN, Pain) - watch for NSAIDS s/e (GI bleeds, sodium+water retention)

Client positve for DVT, what are the nursing interventions?

-heparin immediately -montior aPTT levels (normally between 25-40 seconds; we want to be longer 50-80 seconds) -Give more heparin if not in therapeutic range -Start PO Warfarin to prepare for discharge -monitor INR (2-3 normal) (3-4 for mechanical valves) -turn heparin off once warfarin is in therapeutic range(3-5 days)

Viral infection treatment

-nasal decongestives(vasoconstriction of nasal blood vessels) - pseudoephedrine(SUDAFED) -cannot stay on for more than 3/4 days -antitussives (cough relief) - codiene, Dextromethorphan

Commonalities of Fluoroquinoones and tetracyclines?

-pregant women cannot take -cannot take with metal ions(milk, laxitives, antacids)

Blood transfusion nursing implications:

1) stop transfusion and notify HCP 2) Change IV tubing at the hub and begin NS. 3) treat symptoms (O2, fluids, epinephrine) 4)check vitals every 15 minutes

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply. A. Administer Anticholinesterase inhibitor AC B. Encourage solid food consumption C. Teach the importance of avoiding the annual flu vaccination D. Anticipate administer opioids for muscle pain E. Develop a bladder training schedule

A -administer semi-solid foods -bladder function training only with CNS impairement

Which of the following are signs and symptoms of liver failure? Select all that apply A. Steatorrhea B. Jaundice C. Decreased liver enzymes D. Nausea and vomiting E. Pruritus F. Abdominal pain G. Petechiae H. Confusion

A, B, D, E, F, G, H Fats pass through due to no bile Bilirubin build up (no bile production) *patient will have increased blood levels of liver enzymes common symtom (nausea) itching is common abdominal pain is common bleeding due to liver not producing clotting factors confusion due to ammonia buildup (liver converts ammonia to urea)

A parent calls the nurse telehealth triage line with concerns about an allergic reaction to something a child ate. Which symptoms should the nurse instruct the parent to assess for to determine if the child is having an anaphylactic reaction? Select all that apply A. Wheezing B. Diffuse urticaria C. Fever D. Lightheadedness E. Dyspnea

A. B. (full body hives) D. E.

Which of the following snacks should be avoided in a patient with hepatic encephalopathy? A.High-protein B.High-fat C.High-carbohydrate D.High-fiber

A. (buildups up more ammonia) -makes brain function worse

Patient on long term broad-spectrum antibiotics is at high risk for?

A. oral candidisis (fungal oportunisic infection)

uThe nurse caring for a client who is taking an Gentamicin should monitor the client for which adverse effects of the medication? uA. Ototoxicity uB. Brown urine uC. Hepatotoxicity uD. Neutropenia

Aminoglycoside(ears, mice) uA. Ototoxicity

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client? A. "Do you have a history of alcohol use?" B. "Have you had a recent gastrointestinal infection?" C. "Have you traveled to South America recently?" D. "Have you taken NSAIDs in the past week?"

B

A nurse is assessing a client who has systemic lupus erythematosus and is taking hydroxychloroquine. The nurse should report which of the following adverse effects to the provider immediately? A. Diarrhea B. Blurred vision C. Pruritus D. Fatigue

B DMARD (Disease Modifying anti-rheumatic drug)

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? A. A grey-colored, papular rash across the trunk and back B. A dry, red rash across the bridge of the nose and on the cheeks C. Pitting edema of the hands and fingers D. Subcutaneous nodules on the ulnar side of the arm

B butterfly rash, macular rash

Multiple clients present to the emergency department. Which client should the triage nurse prioritize for diagnostic testing and definitive care? (all have infections look for an immunosupressed patient) A. 25 yo drug user with right arm swelling and redness reporting fever B. 30 yo kidney transplant patient reporting generalized aching and a low-grade fever C. 70 yo with diverticulosis reporting left lower quadrant pain and fever D. 75 yo client with knee replacement reporting fever and a swollen knee

B is correct (suppressed immune system & infection) A. assume infection due to needles (antibiotics) C. episode of diverticulosis (antibiotics) D. Infection (antibiotics)

A nurse is caring for a client who is to start taking cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can have an adverse interaction with this medication? A. Aged cheese B. Orange juice C. Grapefruit juice D. Smoked salmon

C

Which of the following is integral to the rapid secondary immune response we see following vaccinations? A. Helper T cells encountering the antigen for the first time B. Inflammation at the injection site promoting phagocytosis C. Memory B cells responding immediately to antigen D. Antibody production that peaks after 2-3 weeks

C

Which of the following statements is true regarding adaptive immunity? A. Cytotoxic T cells promote opsonization of Helper T Cells B. Macrophages produce antibodies in response to antigens C. Helper T cells activate B cells to produce antibodies D. B lymphocytes differentiate into plasma B cells and T cells

C

uA clinic nurse examines a client with a tentative diagnosis of primary Sjögren's syndrome. Which finding observed by the nurse would most likely be associated with this syndrome? uA. lower back pain uB. joint stiffness uC. xerostomia uD. thickening of skin

C

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? A. Administer an anticholinesterase medication B. Instruct the client to perform the pursed lip breathing C. Prepare the client for mechanical ventilation D. Prepare to administer a liter of 0.9% NaCl

C Crisis situation- diaphragm is close to not working in a crisis situation, Plasmaphoresesis, thymectomy, and IVIGs are also used during a crisis situation.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? A. Client report of feelings of depression B. Dry, raised rash on the face C. Presence of peripheral edema D. Joint pain in hands and knees

C Lupus nephritis - - Kidneys aren't working properly

A nurse is reviewing the lab findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider? A. Hemoglobin of 12 B. Platelet count of 175,000 C. White blood cell count 2,300 D. Potassium of 4.7

C Normal range 5000-10000

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection? A. Temperature 97.0° F ( 36.1° C) B. Insomnia C. Oliguria D. Weight loss

C Urine output less than 400cc/day

A patient with a history of liver transplantation has been receiving cyclosporine, prednisone, and mycophenolate for over a year. Which finding is most concerning? A. Gums that bleed easily when brushing teeth B. A blood glucose of 162mg/dL C. A nontender lump above the clavicle D. 1+ pitting edema in the feet and ankles

C immunosupressants, corticosteroid high glucose = corticosteroid lump = could be cancer (high risk) edema = corticosterioid

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? A. Increased intracranial pressure B. Confusion C. Weakness D. Increased urine output

C ptosis-eye droop along with PAINLESS muscle weakness

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? A. Facial flushing and diaphoresis B. Hypoactive bowel sounds C. Inability to lift head or cough D. Warm, tender, swollen leg

C most pressing issue

The nurse receives a hand-off report from the night shift nurse. Which client should the nurse assess first? A. Client with anemia who began receiving 1 unit of packed red blood cells 1 hour ago B. Client with a hemoglobin of 7 who needs an IVPB of ferrous sulfate C. Client with seizure activity who received lorazepam 20 minutes ago D. Client with suspected leukemia scheduled for a bone marrow biopsy in 1 hour

C.

The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? A. Fever, hypotension, and polyuria B.Hypertension, polyuria, and thirst C.Fever, hypertension, and graft tenderness D.Hypotension, graft tenderness, and hypothermia

C. Fever, hypertension, and graft tenderness Kidneys not working properly(not producing urine) hypervoleimia leads to hypertension and edema

A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching? A. Given the infant frequent cool baths to control fever B. If the infant develops another seizure, wait 15 minutes and then call 911 C. Give acetaminophen or ibuprofen every 6 hours to control fever D. Place ice packs under the arms and around the groin for fever control

C. Give acetaminophen or ibuprofen every 6 hours to control fever -Can give acetaminophen or ibuprofen 6-24 months (NO ASPIRIN) and if it persists for more than 1 day call HCP Cool/cold are not good for infants b/c shivers (good for adults) Waiting longer than 5 minutes can lead to neurological damage

Venous Clots s/s: DVT & PE

PE: dypsnea, chest pain, cough, bloody sputum DVT: swelling, pain, warmth, blue-purple discoloration - develops in calfs, grows, femoral/popliteal veins - Ultrasound (Venous Dopplers) are used for diagnosis - D-dimer levels: high # means high levels of clot formation

What should cephalosporins not be used with? and what can they be used with?

Cannot be used with penicillins Can be used with immunospressants -diphenhydramine -corticosteroids Never give epineephrine prophylactically

Upon infection what needs to be done before anmisistering any antibiotic?

Culture and Sensitivity testing Assess for allergies

Which of the following is NOT an element of the innate immune system? A Macrophages B. Natural Killer cells C. Epithelial cells of the skin D. T lymphocytes

D

The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first? A. Client with multiple sclerosis and bladder incontinence last night B. Client with Guillain-Barre syndrome who has "0" deep tendon patellar reflexes C. Client with Parkinson's disease who is drooling D. Client with dementia who has new onset of confusion and agitation

D Expected Guillian-Barre starts in the peripherals (expected) Expected New onset is not bueno

A toddler is exposed to a sibling who has varicella zoster and contracts the disease. When exposed to another toddler at school months later, the toddler does not develop clinical indicators of the disease. What type of immunity is being described? A.Artificially acquired passive immunity B.Artificially acquired active immunity C.Naturally acquired passive immunity D.Naturally acquired active immunity

D.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care? A. Client receiving radiation therapy with a 6 cm laceration that is not actively bleeding B. New parent who is crying and overwhelmed but denies suicidal ideation C. Client with purulent drainage and crusted eyelids with no visual impairement D. 7-day-old fussy infant with a rectal temperature of 100.6F (38.1C) and 6 wet diapers today

D.

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child? A. A child reporting nuchal regidity and fever B. A child with rheumatic fever following Strep throat C. A child with cystic fibrosis and productive, yellow sputum D. A child with chronic kidney disease and anemia

D. Immunocomprimised

Astrid is a 27 year-old college student who lives in a dormitory on UW-Milwaukee's downtown campus. She called her primary HCP complaining of fever, nuchal rigidity, photosensitivity, and headache, x 24 hours. Astrid has no known medical history but she reports that she has been feeling nauseous for the past 2 months. -You suspect Astrid has what acute condition given the signs and symptoms? By the time you get Astrid settled in the hospital bed she is lethargic, but is asking for a glass of water. -What are your priority actions at this point?

GET HER in what isolation? VS including temp and pulse ox Assessment - find out how bad the nuchal rigidity is - pain rating Place an IV AMS - keep NPO and explain why Low stim environment, no pillow, HOB elevated

breast feeding mother give what antibody

IgA

What immunoglobulin is abundant during the early stages of humoral immunity? What immunoglobulin eventually becomes the most abundant as the infection progresses?

IgM then IgG takes over

cyclosproine and Tacrolimus Infliximab Etanercept

Immunosupressants

The nurse cares for a client with an exacerbation of inflammatory bowel disease (IBD). The client tells the nurse about being infected with tuberculosis (TB) 10 years ago but never being medicated. Which medication that the client takes is of concern and prompts the nurse to notify the health care provider (HCP)? uA. Allopurinol uB. Prednisone uC. Hydrocodone uD. Ondansetron

Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), can convert LTBI to active disease

Arterial clots s/s: Stroke & Heart Attack & Peripheral arterial clot

Stroke: - less than 24hr= TIA (trasient ishemic attack) = ministroke -more than 24hr=stroke people with Afib are at increased risk Heart attack: MI = myocardial infaraction Peripheral arterial clot = gangrene extremity is painful, cold & pale then black

Latex Alergy avoidances

Tropical Fruits: -bannanas, kiwis, avocados, chesnuts, tomatoes

What to do incase of a clot?

Venous: elevate legs Arterial: sit at side of bed or in a chair DO NOT walk around

"-stigmine"

acetylcholinesterase inhibitor

Acetominophen treats? not a?

anti-pyretic and analgesic Not an NSAID

SaO2 vs. SpO2

arterial saturation pulse oximetry reading

NSAIDs

aspirin, ibuprofen, naproxen(alieve), meloxicam, diclofenac, ketorolac, indomethacin

NSAIDS

aspirin, ibuprofen, naproxen, meloxicam, diclofenac, ketorolac, indomethacin

Sjogren's syndrome

autoimmune destruction of minor salivary glands and lacrimal glands need artificial tears/saliva

Warfarin

avoidances: - grapefruit juice - vitamin K(precursor to clotting factors) -NSAID's: aspirin, acetaminophen - antibiotics, Azoles, - cimetidine (histamine atagonist-stomach ulcers)

allergy to Ceftriaxone, what antibiotic class(es) should be avoided? if must be taken what can minimize discomfort?

cephalosporines -Cefazonlin antihistamines and corticosteroids -Diphenhydramine, famotidine, acetaminophen - have epinephrine available in case of analphylaxis

Immunosupressed patients

chemotherapy corticosteroids transplant rejection

CHEAP TORCHES

chickenpox hepatitis enteroviruses AIDS Parovirus (5th disease) Toxoplasmosis other rubella cytomegalovirus herpes every std syphilis

Finding a GI bleed and post GI surgery

colonostomy for lower esophegeal for upper (coffee ground vomit) - complains of abdominal fullness/cramping afterwards (gas) - hungry bc multiple days without eating - feel drowsy and grogy (cannot be syncopal, or unstable) -possible chance of infection (peritinitous) -lightheadedness, abdominal distention, syncopal episodes -temperature and BP is best measure

"-sone" or contains 'pred' in the name

corticosteroids

treating alergic reactions mild? severe?

ephinephrine for severe(anaphylaxis) -reduces histamine and reverses effects corticosteroids and antihistamines

any patient telling you they are experiencing an allergic reaction to something - you MUST assess whether or not they have EVER been exposed to that something before. A PRIORITY piece of assessment.

first exposure = no response second exposure = inflamatory response

Whos at risk for clots?

following surgical procedures individuals with mechanical heart valves

A female client comes to the clinic with a suspected lower urinary tract infection; urinalysis confirms a diagnosis of cystitis. Which symptoms reported by the client would be most consistent with this condition? Select all that apply. uA. Flank pain uB. Chills and vomiting uC. Hematuria uD. Urinary urgency

idk

Seretonin syndrome

increase body temperataure--sweating increase agitation and reflexes and tremors dilated pupils avoid SSRIs and tyamine results from linezolid

Hepatotoxicity effects

increased bilirubin levels steatorrhea increased ammonia levels jaundice nausea/vomiting

"-mab"

monoclonal antibody

C Diff colitis s/s

most common HI dirrheal infection watery stool 5-10 times per day, abdominal cramps, fever, blood/mucus in stool high risk for dehydration and electrolyte imbalance

Criteria for SLE? How many drugs to use for SLE?

must have 4 out of the 11: photosensitivity, malar rash, positive ANA titer, neurological, serotis, oral ulcers, Nephritis, blood disorders., etc. combination of 3 or 4 drugs

Lupus Nephritis

occurs in 50% of Lupus patients creatinine and BUN is up Urine output goes down RBC's, protein, WBC is urine analysis need immunosupressants ASAP or increase dosing if already taking them

Where is Tyamine found

red wines, animals meats, cheeses, beer, soy, cured meat

Ischemia & Infarct

reduced blood flow, tissue death from complete lack of blood can result from aterial thrombi

uThe nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis? uA. A client with asthma receiving inhaled bronchodilators uB. A septic client receiving receiving IV broad-spectrum antibiotics uC. A client who drinks several sugary beverages per day uD. An elderly client with poor dental hygiene and malnutrition

uB. A septic client receiving receiving IV broad-spectrum antibiotics

A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? uA. Advise the client to soak the site in hydrogen peroxide uB. Ask the client if he ever sustained a bee sting in the past uC. Tell the client to call an ambulance for transport to the hospital uD. Tell the client not to worry unless he has difficulty breathing

uB. Ask the client if he ever sustained a bee sting in the past

uA client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse should take? uA. Place the client on 100% oxygen and prepare for intubation uB. Assess for anaphylaxis and prepare for emergency treatment uC. Teach the client about the relationship between asthma and allergies uD. Obtain an arterial blood gas and immunoglobulin E (IgE) blood level

uB. Assess for anaphylaxis and prepare for emergency treatment

uThe nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? uA. Eggs uB. Milk uC. Yogurt uD. Bananas

uD. Bananas

How to decrease rhinorrhea?

vasoconstriction of nasal blood vessels pseduephedrine-cannot stay on for more than 3/4 days

Co-Boarding Key is identifying immunocomprimized patients

which patient can share a room immunocomprimized never with contagious, potentially infectious clients same infection clients can co-board