HESI MED SURG FINAL
pt education for phenytoin {Dilantin} - how often will levels be checked, when thery are leveled how often are they going to be checked - what not to consume - what not to consume medication WITH - what can it cause to muscles at first - what to avoid until effects of the drug are known
- brush and floss teeth after every meal [to prevent gingival hyperplasia] - med levels will be checked monthly until leveled which will be taken q 6 months after - do not drink alcohol - do not drink med w/ milk products - can cause muscle unccordination at first - avoid hazardous task until the drug has been regulated
COPD teaching to pt
- call provider if sputum color changes
A client had a laparoscopic cholecystectomy. Postoperatively the client experiences nausea and vomiting and is admitted overnight for observation and hydration. What should the nurse include in the teaching plan when preparing this client for discharge? Select all that apply.
- call the HCP if you have a fever - check the puncture sites for redness, tenderness, swelling or drainage - apply heating pad for 20 minutes out of the hour to the right shoulder [to decrease gas]
what meds can increase digoxin levels
- captopril - diltiazem
loss of cardiac function as we age
- cardiac outout is decreased - dysrrhythmias [tachycardia] are poorly tolerated - tachycardic or bradycardic dysrrhymia places the client at high risk for syncope and falling as well as confusion
STROKE pt slurred speech and frightened. which clinical manifestations should the RN expect to find if symptoms are caused by a stroke - bruit where - BP is - DTR are - vision is aka
- carotid bruit - elevated BP - hyporeflexic Deep tendon reflexes - doplopia [double vision]
positive trusseaus sgn
- carpal spasm - indicates hypocalcemia - always requires further assessment and intervention - acute pancreatitis pts experience hypocalcemia
beta adrenergic blockers
- causes decreased heart rate and decreased contractility - Eg. propanolol (Inderal)
valvular heart disease causes
- cerebral emboli
A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching?
- change the bag when the seal is broken [seal must be maintained to prevent the leakage of irritating liquid stool onto the skin[
ventricular ectopy - characterixed by - what is exacerbated by
- characterized by multiple PVCs - caused my mmyocardial ischemia exacerbated by hypokalemia
pt has history of DM and becomes confused, RN action
- check blood sugar
pt w/ tenderness and swelling in the legs
- check for erythema and warmth
RN is caring for a pt w/ a PEG tube. which intervention should the RN inclide in the plan of care - how often to check for placement and residual
- check for tube placement and residual volume q 4 hours
A nurse is caring for a client who has just returned from the postanesthesia care unit after having a thyroidectomy. Which action has priority during the first 24 hours after surgery when the nurse is concerned about thyroid storm?
- checking VS 1 2 hours after they stabilize
compartment syndrome s/sx
- circulatory, sensory and motor alterations r/t execessive interstitial fluid
when conducting an admission interview with a pt, what actions would be facilitate the process?
- clarify the info by questioning the pt to verify the info - sit at the chair on a bedside [eye level with the pt] - let the pt do most of the talking and actively listen - use close ended questions to keep the patient from straying from the topic
cardiac tamponade
- collection of fluid in the pericardial sac that results in a reduction in CO [complication of pericarditis]
pt with fasting blood glucose of 140, RN action
- come back in 2 weeks to do the test again
which milestone indicates to the RN successful achievement of young adulthood
- completes education and becomes self supporting
s/sx of low Na
- confusion - lethargy - HA - dizziness
hypoglycemia/hyperglycemia - causes what - d/t
- confusion and dizziness d/t lack of O2 in the brain
ELDERLY pt admintted w/ a dx of bacterial pneumonia. The RNs assessment of the pt will most likely reveal which s/sx
- confusion and tachycardia
- pt with emphysema has cehst tube and secretions and the color chages from green to clear. what does this indicate
- continue IV abx [it is working]
pt w/ a DNR order is not breating and does not have a apical pulse. which interventino should the RN implement FIRST?
- continue to stay w/ the pt and support the family
pts in oncology unit receiving infusion.which client receiving which infusion should be assessed first?
- continuous epidural infusion of morphine
synchronized cardioversion
- converts the cardiac rhythm bak to normal sinus rythms
left sided HF s/sx
- cool extremeties
adrenal cells produce
- cortisol - aldosterone - catecholamines
acute bronchitis s/sx
- cough - fever - fatigue
creatinine and GFR
- creatinine is a product of muscle metabolism that is filtered by the glomerulus - elevate creatinine strongly indicates nephron loss, reducing filtration
why do hyporeflexic deep reflexes occur in a stroke
- d/t to initial flaccid paralysis resulting in hyporeflexic DTH
pt w/ seizures. which client teaching goal is most important to determine pts understanding when discharging them - what should the pt describe
- describe five strategies to prevent seizure activity [ best way to evaluate if teaching was effective. - goals must be manageable , stating the correct dosage, side effects. when to call the HCP, imp. of follow up visits are appropriate goad when evaluating the effectiveness of teaching]
While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Select all that apply.
- diaphoresis - weight loss - protruding eyes - diarrhea - heat intolerance
pt w/ uncontrolled Afib is admitted to tele unit. What initial medication should the RN anticipate administering to the pt
- digoxin
pt c/o lower abd pain and nausea, severe HA, blurry vision, and he feels really tired. pt has an irregular HR of 56 bpm: what labs does the RN anticipate the HCP will prx
- digoxin serum level - K+ level
how to administer 25 mg of IV phenytoin (Dilantin) on a pt who has D5W running at 100 mL - dilantin is compatible w/ what fluid - how to administer
- dilute the med and flush the tubing before and after with NS [dilantin is ONLY compatible w/ NS - flush with NS before and after administration]
RN caring for a pt w/ stroke w/ right sided paresis and aphasia. pt attemps to use L hand for feeding and other ADLs. spouse become frustrated and insists on doing everything for the pt. Which RN dx should the RN doc for this pt
- disabled family coping r/t dissonant coping style of significant person
49 yo female pt arrives at the clinic for an annual exam and asks the RN why she becomes excessively diaphoretic and feels warm during nightime. what is the nurses best response
- discuss perimenopause and related comfort measures
Pt w/ seizure prx valproic acid (Depakote). which action should the RN include when providing discharge teaching - what kind of tests should the pt have while on this med
- discuss the importance of having liver funtion tests on this mediaction
PT education for GERD
- elevate HOB w/ blocks
what to do before meals for pt w/ stroke, hemiperisis, dysphagia
- elevate head before meals (should be erect)
pancreatic injury indicated by
- elevated serum amylase and lipase levels
Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.) - what kind of bath to take .. why?
- encourage annual physical and pap smear - take antiviral medication as prx - use condoms to avoid transmission to others - warm sitz baths may relieve itching
The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.)
- encourage etoh and smoking cessation = promote regular weight bearing exercises - implement home safety plan to prevent falls
what intervention should the RN implement for a female pt dx w/ pelvic relaxation disorder
- encourage the pt to perform kegel exercises 10x daily
having children and being epileptic
- epilepsy does not prevent women from having children - preconception counseling will be needed, pt will require special care and guidance before, during, and after pregnancy
post op pt slurring speeck. which action should the RN take
- evaluate BP, HR, and RR [resp status]
ADH deficiency s/sx
- excessive urine - low urine specific gravity
pt dx w/ a suspected stroke and prx CT scan WITHOUT contrast STAT. which intervention should the RN implement when preparing pt for procedure - how is the pt required to lie
- explain the procedure required the pt to lie completely still [pt may reuqire head support to accomplish this]
primary cause of COPD
- exposure to tabocco smoke
s/sx of hyperglycemia in older adults
- fatigue - infection - and evience of neuropathy [sensory changes]
s/sx of elevated phosphorous
- fatigue - SOB _ anorexia - n/v - sleep disturbances
s/sx of elevated BUN
- fatigue - edema - SOB - confusion - dehydration
a pt who has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the RN write a goal "the client verbalize symptoms of pacemaker failure" Which symptoms are most important to teach the pt
- feelings of dizziness [can occur as a result of decreased heart rate and cardiac output"
inhalation antrhax s/sx
- fever - fatigue - dry cough [bacterial infection]
why is digoxin administered - what does digoxin do to the rate of heart contractons - what does digoxin prolong [what period] - what does digoxin decrease [HR, CO]
- for uncontrolled, symptomatic atrial fibrilation resulting in a decreased cardiac output - digoxin slow sthe rate of conduction by prolong the refractory period of the AV node allowing for a ventricular response, decreasing the HR and cardiac output
when to use lidocaine when a pt has heart issues
- for ventricular irritability
s.sx of pneumonia in an older pt
- general deterioration - confusion - tachycardia - increased resp rate
pt who has a skeletal traction that needs to pee
- give female urinal
female patient w/ skeletal traction needs to use the BR - what is the RN action
- give female urinal, DO NOT take out traction
pt w/ expressive aphasia cant communicate what to do
- give picture chart
what lab value to monitor when pt s on TPN
- glucose
low purine diet
- good for pt w/ uric acid renal calculin - avoid organ meats, extracts
client admitted to the hosp w/ a med dx of pneumoccoccal pneumonia. The RN knows that the prognosis of gram negative pneumonias (such as E coli, k liesiella, pseudomonas, and proteus) is very poor because
- gram negative organisms are more restinant to abx therapy
peritonitis - is this a medical emergency
- hard rigid abdome - elevated WBC - MEDICAL EMERGENCY
RN completing on adminssion interview and assessment on a client w/ a history of Parkinson's disease. Which question provides information relevant to the pts plan of care
- have you ever been frozen in one spot unable to move
a middle aged male client w/ diabetes continues to eat an abundance of foods that are high in sugar and fat. according to the health belief model, which event is most likely to increase the client's willingness to become compliant w/ the prx diet
- he visits his diabetic brother who just had surgery to amputate an infected foot [ the loss of a limg by a family memebr will be the strongest "cue to action]
81 yo pt w/ has emphysema. when making a home visit the RN notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. what RN intervention is indicated?
- help the pt determine ways to increase his fluid intake
what does adding PEEP achieve
- helps improve O2 while reducing FiO2 to a less toxic level
what is an expected finding for rupture of kidney cysts
- hematuria
brown color in the distal lower extremeties indicate
- hemochromatosis [deposition of Fe salts]
What are the primary causes of adrenal insufficiency? Select all that apply.
- hemorrhage - TB - AIDS
diet for burnxs
- high calories - liberal K+ [to prevent hypokalemia]
modifiable risk factors for stroke - history of what heart condition
- high cholesterol levels - diet - lifestyle - history of AFib - smoking
menstrual cycle and seizure activity - fluctuation in what can cause seizures
- hormone levels can cause seizures - increased hormone levels that alter the excitability of neurons in the cerebral cortex - pt should be instructed to keep a record to determine if this pattern continues
why monitoring BG on post stroke pts
- hyperglycemia associated w/ poor neurologic outcomes in acute strokes pts - glucose levels > 140 should be treated
tumor lysis syndrome - K+ - Ca - uric acid - P
- hyperkalemia, hypocalcemia, hyperuricemia and hyperphosphatemia
cushings syndrome results from
- hypersecretion of glucocorticoids in the adrenal cortex - cushings syndrome pts dev. DM
CN XII disease - difficulty doing what 2 things [ch,tal,swa]
- hypoglossal CN - difficulty chewing, talking, and swallowing
what lab values can be attributed to confusion, generalized weaknenss, fatigue, palpations and anorexia
- hyponatremia - hypokalemia - high BUN - hyperphosphatemia
a pt is placed on a mechanical ventilator following a cerebral hemorrhage and vecoronium bronide (Norcuron) 0.04 mg/kg q12h IV. what is the priority RN dx for this pt
- impaired communication related to paralysis of skeletal muscles
pt w/ left sided paralysis has facial drooping with dysphagia, left visual field deficit and aphasia. which RN diagnosis has the highest priority
- impaired swallowing [maslows hierarchy of need - physiological needs should be addressed first] - pt is at risk for asp
pt newly dx w/ DM, ,what is the pts outcome goal
- in 3 mos have a A1C level of < 7
pt female c/o severe abd pain before her mentrual period, painful intercoursea and painful defecation. which additional hisotry should the RN obtain that is consistent w/t the pts ocmplaints
- inability to get pregnant [dysmenorrhea, dyspareunia or painful defecation are common symptoms of endometriosis]
diet for diverticulosis
- incrase fiber and fluid in diet
The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which intervention should the nurse implement first?
- increase the pts O2 flow rate
vitamin k deficiency s/sx
- increased PT and INR [prothrombin and prolonged bleeding]
compartment syndrom
- increased pressure and constriction of the nerves and vessels within an anatomic compartment - causes pain uncontrolled by opioid - causes neurovascular compromise
which data would the RN expect when reviewing lab values for an 80 yo male - increased what in the urine
- increased protein in the urine - increased serum glucose level (slight)
changes in pupil size and reactivity indicate what
- increasing ICP
BUN levels
- indicates the effectieness of the kidneys in filtering the waste from the blood - dehydration [caused by vomiting] would cause an increase in BUN level
sarcoidosis - what is formed [granules] where [lu]
- inflammatory condition that is characterized by the formation of widespread granulomatous lesions involving a pulmonary primary site
a pt w/ HF is admitted w/ a serum K+ level of 2.9 which action is most imp for the RN to implement
- initiate continuous cardiac monitoring
abd assessment order
- inspection - auscultation - percussion - palpation
What order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder?
- inspection of the motuh - observe the rise and fall of the soft palate - assess the symetry of enlarged tonsions [if present] - inspect neck symetry - palpate the lymph nodes
pt education prior to an EEG - what should the pt NOT consume
- instruct pt to refrain from consuming caffeine prior to the EEG
islet cells procude
- insulin - glucagon
during an interview w/ a pt planning elective surgery, the pt asks the RN what is the advantage of having preferred provider organization insurance plan? which response is the best for the RN to provide
- insurance coverage of employees is less expensive to employers
hypoxia s/sx early
- irritability and restlessness
swimming and seizures - the pt should swim with who?
- it is recommeneded that a swimming partner be present who is knowledgeable about what to do during a seizure
pts susceptibility to ulcerative colitis is most likely d/t which aspect of the pts history?
- jewish european ancestry or Ashkenazi ancestry [4-5 x more common]
left sided hemiparesis who can walk in a straight line
- judge distance for transfers
correct placement fo the hands during chest compressions of CPR - in relation to the xyphoid process - what part of the sternum
- just above the xyphoid process on the lower third of the sternum
The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Select all that apply.
- keep HOB 30-45 - connect tube feed to pt and pump - check for diarrhea - flush w/ warm water - check prx for correct formaula - set correct rate and initiate pump
RN educating pt on how to reduce the incidence of seizure activity and how to promote safety during a seziure. which health promotion activity should the RN discuss w/ Alana - what should the pt learn to ID
- learn to identify seizure triggers
pt ordered for an MRI of the head. which data warrants immediate intervention by RN concerning this test
- left hip replacement [metal containing item - lead shield must be used during the procedure]
what effects does aortic regurgitation produce in the body
- left ventricular hypertrophy - pulmonary edema - decreased cardiac output - SOB - increased contractility
systemic altered inflammatory response in impaired wound healing
- leukemia
ventricular fibrillation
- life threatening dysrhythmia - start CPR until crash cart is available
fissures
- linear cracks in the epidermis that extend into the dermis
which lab dx tests require the pt to be NPO
- lipid profile [12 hours before test] - fasting blood glucose levels [NPO 8 hours prior to test]
diabeti patient wants toenails cut, RN action
- look for lesions and refer to specialist
homonymous hemianopsia - loss of visual field where ... same side as what? - the pt neglect which side of the body -
- loss of visual field on the same side as the paralyzed side - this results in the pt neglecting that side of the body, it is beneficial to put it on that side - pt had a right hemisphere stroke so his left side is his weak side
The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply.
- low Na diet - daily abd girth measurement - daily weights
what requires immediate intervention for a pt w/ hypothyroidism
- low Na requires immediate intervention
compromised venous return s/sx
- lower extremity edema
pt adx for further testing to confirm sarcoidosis. which dx test provides definitive info that the RN should report to the provider
- lung tissue bipsy
what is heard in whispered pectoriloquy when pt has pneumothorax or emphyseam - voice sounds are .... why?
- lung tissue is filled w/ more air than norma - voice sounds are absent or very diminished
Which hormone elevations indicate Turner syndrome? Select all that apply.
- lutropin - follitropin
CKD & Magnesium
- magnesium NOT used for pts w/ CKD d/t risk of hypermagnesemia.
hematocrit levels
- males - 42-52% - (females) 37-47% | (*critical*) < 18% or > 54%
health promotion for COPD
- mechanically soft diets - assist w/ feedings - avoid crowd or contact w/ persons who have infectious diseases - avoid resp irritants - report changes in characteristics of sputum - drink 3L of water a day - obtain immunications prn
how to admin meds via a central line
- medication an be administered via a central line without additional fluids - line should first be flusing with NS to ensure patency - Insifficient evidence exists on the effectiveness of flushing catheters with heparin
despite many surgeries to the eye, a 78 yo pt has persistent vision problems. the visiting RN is discussing home safety hazards with the pt. the nurse suggests that the edges of the steps be painted which color?
- medium yellow
increased temp effects
- metabolism - demand for O2 - dehydration
Which conditions in a client are associated with a bluish color of the mucous membranes? Select all that apply.
- methemoglobinemia - cardiopulmonary disease
which abnormal lab finding indicates that a pt w/ diabetes needs further evaluation for diabetic nephropathy
- microalbuminuria
post stroke pt w/ decreased Cardiac output. HCP needs to be notified regarding decreased cardiac output to decide whether to initiate IV fluid if hypovolemia is suspected. which RN intervention would be a priority? - LOC should be - how often to monitor I/Os - capillary refill should monitored how often? - VS how oten?
- monitor LOC - monitor I/Os q 1 hours - monitor capillary refill q 2-4 hours - monitor pulse oximetry - VS q 1-2 hours
pt w/ tumor lysis syndrome is receiving IV infusion containing insulin. which assessment should the RN complete first
- monitor the pts K+ and blood glucose levels
morphine and astham
- morphine is a histamine releasing opioid - should be avoided when the pt has asthma
20 yo female pt calls the RN to report lump she found in breast. Which response is the best for the RN to provide
- most lumps are benign. but it is always best to ocme in for an examination
hyperglycemia s/sx
- n/v - abd cramps
laryngectomy breathing
- neck breathing -if the pt has a cardiac arrest, mouth to nekc breathing needs to be done
s/sx of migraine HAs
- neck rigidity - vertigo - phonophobia
pt w/ renal calculi d/t uric acid - what to teach about avoiding in diet
- no shellfish
pt w/ history of DM is having renal function tests ebcause of recent fatigue, weakness and elevated BUN and creatinine. which finding should the RN conclude as an early symtom of renal issufienciency
- nocturia
RN is assessing a pt who smokes ciggarettes dx w/ emphysema. Which finding would the RN expect the pt to exhibit - skin color
- normal skin coloring
after initial interventions are implemented, pt continues having a tonic clonic seizure. what action should the RN implement next
- note the time, duration and type of seizure [to determine where ti focus interventions - important to document whether the beginning of the seizure was observed]
RN notes the only ECG for a 55yo pt scheduled for surgery is dated 2 years ago. pt reports he has a history of "heart trouble" hospital required that those over 50 should have a recent ECG prior to surgery. What RN action is best for the RN to implement
- notify surgery that the ECG is over two years old
which pt is most likely to experiece sleep apnea
- obese older male w/ a short thick neck
causes of pancreatitis
- obstructive cholelithiasis - alcoholism
post stroke pt dies. the pt wanted to be an organ donor. what action should the RN implement? - what to obtian - who to notify? - a stroke pt can only be what kind of donor
- obtain permits and notify the organ donor center - explain that the pt can only be a tissue donor and not an organ donor [ the client must be on a ventilator and be declared brain dead prior to donating organs]
An older adult is brought to the emergency department after being found in the street without a coat during a snowstorm. What actions should the nurse implement? Select all that apply.
- obtain rectal temp - assess for frostbite - determine LOC - ask for pts client identifications
surgery for preventing strokes - what kind of stroke - s/sx of what other stroke [Transient]
- only done for small strokes - indicated for pts w/ symptoms of TIAs [mild stroke' found to be d/t severe carotid artery stenosis or moderate stenosis w/ other significant risk factors
foods high in Vit C
- oranges - strawberries - cantalaoupe
which hormone acts on the mammary glands
- oxytocin
starchy foods
- peas - corn - potatoes
how do you know if bucks traction is working
- pedal pulses are present
emphysema s/sx - pink bu.... - what kind of respiration - lung capacity is.... d/t - abgs are - what kind of sputum
- pink buffer - normal color but puffing respirations - increased lung capcity [d/t pt having hyperinflated lungs] - abnormal abg's - thick white sputum a lot
secondary cases of adrenal insufficiency
- pituitary tumors - postpartum pituitary necrosis
stroke pt [right hemisphere stroke] is experiences homonymoys hemianopsia as the result of the stroke. which RN intervention would the RN iplement? - objects should be placed on which side of the pt
- place ADL objects near the pt on the right side of the table
which intervention should the RN plant to implement when caring for a pt who has undergone a right above the knee amputation - what to place at the bedside
- place a large touniquet at the clients bedside [in case severe bleeding occurs, tourniquet will be applied to control a hemorrhage]
when teaching diaphragmatic breathing to a pt w/ COPD. which information should the RN provide? - what to place on the abd - how to inhale
- place a small book or magazine on the abdomen and make it rise while inhaling deeply
polyphagia and DM
- polyphagia [excessive humfer] is a consequence of cellular malnourishment when insulin deficiency prevent utilization of grlucose for enegy so the outcome state should include stabilization of adequate cellular nutrition
presence of a U wave - when is it present
- positive deflection follwing the wave - present in HYPOKALEMIA
RN assess a pt prx furosemide for a cardia disease. which ECG change would be a concer for a pt taking a diuretic
- presence of a U wave
treatment for a flail chest
- preventing atelectaiss - related complications of compromied ventilation by encouraging coughing and deep breathing
treatment for tamponande
- pricardial tap
during a health fait a 72 yo male client tells the RN that he is experiencing SOB. ausculatation revelas crackles and wheezing in both lungs. suspecting the pt might have chronic bronchitis which classic symptoms would the nurse expect this client to have - productive / nonproductive - color - when does it occur
- producing cough w/ grayish white sputum [occurs in the morning]
TB s/sx - productive/non productive cough - sputum has what - when do they sweat - living situation
- productive cough - blood tinged sputum - night sweats - homelessness
CKD
- progressiver irreversible destruction of nephrons - caused by HTN and DM
older adults kidney function
- protein found in the urine slightly rises - pts experience asymptomatic bacteruria and puyra and a result of incomplete bladder emtyping
kidney changes in the older adult - sepcific gravity [dec/inc]
- protein found in the urine slightly rises as a result of kidney changes or subclinical UTIs - serum glucose increases slightly d/t changes in the kidney - specific gravity declines in older adults [1.032 -> 1.024]
penrose drains
- provide a sinus tract or opening and are often used to provide drainage of an abscess
pt w/ acute diverticulitis. which assessment data would warrant immediate nursing intervention - abdome is what - what is elevated
- pt w/ a rigid hard abdomen and elevated WBC
basillar skull fractures
- pts are at high risk for infection of the brain - fracture leaves the mininges open to bacterial invasion
thrombolytic therapy contraindications for post stroke pts - initiate within how many hours of the start of symptoms
- pts w/ symptom onset longer than 3 hours prior to admission - must be initiatited within 3 hours of the onset of symptoms
RN monitoring post stroke pt. which finding would require inmmediate intervention by the RN - O2 sat reading where - K+ is what? - glucose is what?
- pulse ox reading 90% for the past two hours - serum K+ = 3.0 - serum glucose 150
what to do if a chest tube is dislodged
- put in sterile water
provider prx aluminum and magnesium hydroxide (Maalox) 1 tab PO PRN for a pt w/ chronic disase c/o indigestion. what intervention should the RN implement
- question the HCP prx [maalox is contraindicated for renal disease]
fibrocystic changes in breast tissue
- r/t excess fibrous tissue, proliferation of mammary ducts and cyst formation that cause edema and nerve irritation. - these changes obscure typical dx tests [mammography] d/tincreased density - fibrocystic breasts DO NOT increase the risk of breast ca - normal discharge is often milky or watery milky
RN interventions when pt is on resp disterss
- raise head of stretcher to semi fowlers - apply partial rebreather mask, 10 L per minute - monitor O2 sat level - auscultate the pts lung sounds
A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision?
- reassigning the PN until the resident can be assess more completely for reality orientation
stage 1 pressure ulcer
- reddened area over a bony prominence
pt w/ MS has exacerbation of symptpoms. which instruction should the RN provide
- schedule extra rest periods
pt w. MS has exacerbation of symptoms [parethesias, diplopia, nystagmus] which instruction should the RN provide
- schedule extra rest periods [exacerbation of the symptoms of MS occur mostly as the result of fatigue and stress]
autolytic debridement devide
- semi occlusive or occlusive dressings to soften dry eschar by autolysis
dx finding of pancreatitis
- serum amaylase and liipase levels that are 2-5 times higher than the normal value
46 yo female pt admitting for acute renal failure s/t DM and HTN. which test is the best indicator of adequate glomerular filtration
- serum creatinine
an RN working of a tele unit finds a pts unconscious and in pulseless ventricular tachycardia [VT]. the pt has an implanted automatic defibrilator. what action should the RN implement
- shock the pt w/ 200 joules per hosp policy [automatic defibrilator is malfunctioning]
pts w/ angle closure glaucoma - what meds should they NOT take - why? what do they increase
- should NOT take meds that dilate the pupils - they can precipitate and acute and severely increased intraocular pressure
tidaling in the water seal chamber
- should be reported to the HCP before the chest tube is removed to r/o an unresolved pneumothorax or persistent air leak - characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure
vecuronium bromide
- skeletal muscle relaxant - increases the pts tolerance of endotracheal intubation and or mechanical ventilation
digoxin action
- slows the rate of conduction by prolonged the refractory period of the AV node - slow ventricular response, decreasing the HR and effecting cardiac output
smoking and ulcer formation
- smoking causes ulcers
in preparing a d/c paln for a 22 yo male pt dx w/ buergers disease [thromobantitis obliterans] which referral is most imp
- smoking cessation program
can smoking lead to a stroke?
- smoking is a modifiable risk factor that could increase chances of having a stroke - smoking increases risk for HTN --> that can lead to a stroke
foods that are high in iron
- spinach - beef liver - dried cranberries - legumes - whole grain and enriched breads and cereals - beans
female pt receiving IV vasopressin (Pitressin) for esophgeal varice rupture reports to the RN that she feel substernal tightness and pressure across her chest. which PRN protocl should the RN initiate
- start IV nitro infusion
PTH
- stimulates bones to promote osteoclastic activity - promotes bone resorption
stooped posture in older adults
- stooped posture results in the upper torso becoming the center of gravity for older persons - caused by osteoporosis and normal bone degeneration - knees, elbow, hips flex. - these changes put the older adult at high risk for falls
which age related change in the older adult has the highest safety implication for the client
- stopped posture
tracheal constriction and obstruction sounds
- stridor
buergers disease
- strongly related to smoking - the most effective means of controlling s/sx and disease progression is through smoking cessations
emboli resulting from Afib causes
- sudden and complete occlussion of the vessels
s/sx of a client w/ trigeminal neuralgia [tic douloreux]
- sudden, stabbing, severe pain over lip and chain [pain in the trigeminal nerve - 5th CN]
the RN is preparing a teaching plan for a pt who is newly dx w/ type I DM. which s/sx should the RN describe when teaching the pt about HYPOGLYCEMIA - HR
- sweating, trembling, tachycardia
pt w/ osteoarthritis taking NSAIDs not relieved by pain
- switch to a different NSAID - proceed differently to everyone
which tasks should be delegated to the UAP when it comes to pt who has had a stroke - VS? - bed bath - measure I/Os
- take VS - give pt a bed bath and change linens - measure I/Os
ECG changes in hyperkalemia
- tall spiked T waves - prolonged QT interval - widening QRS complex
RN dx of "urinary retention r/t sensorimotor deficit" for a pt w. MS. which intervention should the RN implement. - what to teach the pt
- teach the pt techniques for intermittent self cath [to prevent bladder distention]
postural drainage pt education
- tell the pt that it will be 5 different positions
when preparing a client who has had a TOTAL laryngectomy for d/c. what instruction is most important for the RN to including in the teaching?
- tell the pt to carry a medic alert card stating that he is a total neck breather
a pt who has taken steroids for 12 years to help manage COPD. when making a home visit, which nursing fucntion is of greatest importance to this pt. Asses the pts - assess what VS , why
- temperature [infection is the most common factor precipitating respiratory distress] - pts w/ COPD who are on maintenance doses of corticosteroids are predisposed to infection
why is an MRI ordered for a seizur ept - rules out what - what are causes of seizures that can be seen in an MRI [tum, conge lesion, edem, infarc, hemorh, artious malfor, struct deviat]
- test will r/o many causes of seizure [tumor, congenital lesions, edema, infarct, hemorrahge, arterious malformation, structural deviation]
58 yo pt who has no health problems asks the RN about the pneumovax vaccine. The RNs response to the pt should be based on which information
- the immunixation is administered once to older adults and persons w/ a history of chronic illness
hydration effects
- thins out the mucus trapped in the bronchioles and alveoli [facilitating expectoration] - essential for patients experiencing fever - 300-400 mL of fluid is lost by the lungs through evaporation
magnesium sulfate given for
- torsades de pointes [form of polymorphic ventricular tachycardia, associated with a prolong QT interval that occurs with hypomagnesemia
after 3 min seizure pt has no apparent injury but is lethargic. what intervention should the RN implement? - what to do to maintain airway and prevent asp
- turn the pt to the side [to maintain airway and prevent aspiration] , and allow him to sleep
best time to plan sexual intercourse in order to conceive
- two weeks before menstruation
After reviewing the client's laboratory reports, the physician concludes that the client has primary hypofunction of the adrenal gland. Which clinical manifestation is likely to be observed in that client?
- uneven patches of pigment loss [vitiligo]
systemic impaired cellular proliferation responses in impaired wound healing
- uremia - cirrhosis - hypovolemia
what d/c instruction is most important for a pt after a kidney transplant?
- use daily reminders to take immunosuppressants
pt trouble w/ using left arm. which RN intervention should the RN implement to address self care deficit - what to use when the pt is eating - why?
- use plate guards when pt is eating [prevent food from being pushed off the plate - this will encourage independence]
vasopressin leading to angina - why does it lead to angina
- used to promote vasoconstriction, thereby reducing bleeding - vasocostriction of the coronary arteries can lead to angina and MI and should be counteracted by IV nitro prn
how to reinsert the tracheostomy tube
- using a hemostat to open the tracheostomy or by gradping the retention sutured (if present) to spread the opening in insert a replacement tube with its obturator into the stoma
when to you a defillibrator
- ventricular fibrilation
s/sx of left sided stroke - what kind of apahasia
- visual field deficit on right side - parethesia on left side - global aphasi
RN is planning care for a pt w/ new dx DM that requires insuling. which assessment should the RN identify before beggining the teaching session
- willingness of the pt to learn the injection sites
which info about mammograms is most imp to provide a post menopausal pt - when should mammograms be done
- yearly mammograms should be done regardless of previous normal xrays
the RN believes in the ethical principle of veracity for the pt. how should the RN respond when pt asks when she should tell a bf about having epillepsy
-- you should tell him the truth on the first date so he will know
after 4th dose of gentamaycin sulfate IV. the RN nurse draws blood samples to determine peak and trough levels. when are the best times to draw these samples?
-5 minutes before and 30 minutes after the next dose
question most imp for RN to ask pt who just had a seizure after pt is awake or aler - have you ??
-have you been taking your meds regularly? [dilantin level is low - helps establish therapeutic relationship w/ pt without assuming she hasnt taken her medications]
what instruction should the RN give a pt who is dx w/ fibrocytic changes to the breast?
-perform a breast self exam [BSE] procedure monthly
A client presents to the emergency room with coughing and sudden wheezing. The nurse notes the client is progressing quickly into respiratory distress. The nurse identifies that the client is experiencing what problem?
an accute asthma attack
The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding
anorexia and vomiting for the past 2 days
During auscultation of the heart, where does the nurse expect the first heart sound (S1) to be the loudest?
apex of the heart [closure of mitral and tricuspic valves]
Tests reveal that a client has phosphatic renal calculi. The nurse teaches the client that the diet may include which food item?
apples [low in phosphorous]
One day after a Billroth II surgery, a male client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take?
apply 2L O2 via NC
A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2 to 4 mg IV push, while in recovery for pain level over 5." Which intervention should the nurse implement?
call the anesthesia provider for a different medication pain
Which sexually transmitted infection is caused by Chlamydia trachomatis?
cervicitis
Pt w/ banana allergy is going to surgery, RN action
change latex gloves to synthetic
pt on TPN blood glucose is 300
check if they have an insulin scale
Pt w/ abdominal surgery had low BP, priority nursing intervention
check the back of the pt for bleeding
During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take?
check the tube to ensure that the tube is not kinked
What is the most commonly reported sexually transmitted infection (STI)?
chlamydia
A client reports disturbed sleep due to itching caused by an allergy. Which medication would be prescribed to help the client sleep well and treat the allergic symptoms?
chlorpheniramine
An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client?
confusion and tachycardia
A client on a telemetry unit demonstrates a regular sinus rhythm (RSR) with an occasional premature atrial contraction (PAC). What action should the nurse take?
continue to monitor the pt
During the shift report, the charge nurse informs a nurse that she has been assigned to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings as she prepares to leave, making it known that she is very unhappy about being floated to the other unit. What is the best immediate action for the charge nurse to take?
continue w/ shift report and talk to the nurse about the incident at a later time
A nurse evaluates that a client with chronic kidney disease understands an adequate source of high biologic-value (HBV) protein when the client selects which food from the menu?
cottage cheese [you want them to have more protein]
A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response?
cover you cough w/ your forearm
The nurse is caring for a client who is admitted with the diagnosis of mild heart failure. Which type of lung sounds should the nurse expect to hear?
crackles
client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side?
decreased sounds
pt w/ fracture right elbow. which assessment finding has the highest priority requiring nursing intervention
deep unrelenting pain in the right arm
Which medical condition could most probably result in clients developing primary diabetes insipidus (DI)?
defect in hypothalamus [thirst center]
The home health nurse is assessing a male client being treated for Parkinson disease with carbidopa-levodopa. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which intervention should the nurse implement
document the presence of these assessment findings
Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing?
eaustachian tubes [connect the nasopharynx to the middle ears]
The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up?
elevated serum amylase and lipase levels
right hemisphere stroke pt experiences pain on left should. which intervention should the RN implement when addressing this condition? - which hand should the pt clasp - what should be raised above the head [one or both arms]
instruct pt to clast left hand w/ right hand and raise both hands above the head [this exercise helps prevent frozen shoulder and will aid the RN when oving or positioning the pt]
Which is the target tissue for the parathyroid hormone?
intestines
Which is a clinical manifestation of a cluster headache?
ipsilateral tearing of the eye [tearing on the same side as the HA]
A student nurse is caring for a client with chronic kidney failure who is to be treated with continuous ambulatory peritoneal dialysis (CAPD). Which statement by the student nurse indicates to the primary nurse that the student nurse understands the purpose of this therapy?
it uses the peritoneum as a semipermeable membrane to clear toxin by osmosis and diffusion
A male client has just undergone a laryngectomy and has a cuffed tracheostomy tube in place. When initiating bolus tube feedings postoperatively, when should the nurse inflate the cuff?
just prior to tube feeding [to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy] - should remain inflated throughout the feeding to prevent aspiration of food into the resp system
A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct?
keep the drainage system lower than the levels of the pts chest [to allow gravity to drain the pleural space]
hich component of skin maintains optimal barrier function?
keratin
A client with type 1 diabetes is transported via ambulance to the emergency department of the hospital. The client has dry, hot, flushed skin and a fruity odor to the breath and is having Kussmaul respirations. Which complication does the nurse suspect that the client is experiencing?
ketoacidosis
Which predisposing condition may be present in a client with pitting edema?
kidney disease
An older adult fell at home and fractured the left hip. Which response should the emergency department nurse identify as a typical clinical indicator associated with a fractured hip?
left leg is
A pathology report states that a client's urinary calculus is composed of uric acid. Which food item should the nurse instruct the client to avoid?
liver
which benign tumor forms on the epithelium
papilloma
Which cells does the nurse identify as producing thyrocalcitonin hormone?
parafollicular cells
Which complication may be caused by sepsis in burns?
paralytic ileus
Which hormone promotes bone resorption in a client?
parathyroid hormone
What should the nurse do to help alleviate the distress of a client with heart failure and pulmonary edema?
place the pt in the orthopneic position [allows for max lung expansion]
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority?
place the pt on NPO status
A client is admitted with a brain attack (cerebrovascular accident, CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?
teaching the pt to use head movements to scan the left field of vision
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care?
the disease process and breathing exercises
A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure?
were you aware of anything different or unusual just before your seizure began
The nurse is assessing a male client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse?
while the RN is taking the pts BP, he has a carpal spasm
A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response?
your joints are still inflamed and physical therapy can be harmful
risks associate w/ major abd surgery
- PE - pneumothorax
CN VIII disease - ringing in the ears - loss of balance or akak - difficulty doing what
- aka M ni re's - tinnitus, bertigo and hearing difficulty
during suctioning, a pt w. an uncuffed tracheostomy tube beings to cough violently and dislodges the tracheostomy tube. Which action should the RN implement first
- attempt to reinsert the tracheostomy tube
androgen therapy side effects
- baldness - gynecomastia - acne
DVT initial care - activity - extremity should be
- bedrest - evation of the extremity
CN VII disease - aka bells - weakness and paralysis where
- bells palsy - facial weakness and paralysis
third spacing in a burn injury
- blister formation
chronic bronchitis s/sx - what color - edema? - low O2 or cya - what kind of respirations - sputum?
- blue bloated - edematous, cyanotic, shallow respiration - absence of sputum
first intervention for patients with diabetes
- check sugar first before anything
what foods to avoid w/ cystine renal calculi
- cheese or animal protein
which type of breast ca has the poorest prognosis
- inflammatory w/ peau d'orange
calcitonin
- inhibits bone resportion - increases renal excretion of Ca and phosphorous
Which functions does the nurse associate with the epidermis? Select all that apply.
- inhibits proliferation of microorganisms - allows the photoconversion of dehydrocholesterol to vit D
RN working w/ 71 yo obese pt with bilateral OA of the hips. What recommendation should the RN make that is most beneficial in protecting the pts joints?
- initiate a weight reduction diet to achieve a healthy body weight
what happens when there is distention in the belly
- insert NG tube
pt taking cholestyramine (Questran) for hyperlipidiam should be evaled for what defficiency
-vit K
pt with stroke w/ left sided weakness has difficulty walking, pt education
teach about spatial and distance judgement
Pt w/ blindness of both eyes asks to go to the Bathroom nursing intervention
take him to the bathroom
when providing discharge teaching for a pt w/ osteoporosis. The RN should reinforce which home care activity?
elimination hazards to home safety
A nurse is caring for several postoperative clients who had abdominal surgery. What independent nursing intervention can help prevent the development of thrombophlebitis?
helping the pt perform in bed exercises
how to know if bucks traction is effective
- pedal pulses are palpable
pt with hearing aid cant understand RN, what to do
= pronounce consonants clear and rephase
what is the most promiment and universal sign of hypokalemia
HTN
what should the RN assess prior to administering furosemide IV
- IV site for patency - baseline BP and pulse - pts urinary output -
RN assess pt w/ bacterial meningitis. Which assessment finding indicated the pt may have developed a septic emboli
- cyanosis of the fingertips
early indicator of disease in the small airways
- forced mid expiratory flow rate
pt w/ primary aldosteronism. the RN expects which lab test results to indicate a decreased serum level of which substance
- K+
Rn assessing pt w/ chronic kidney disease. Which finding is most imp for the RN to respond to first
- K+ 6.0 mEq
TSH deficiency s/sx
- hirsutism and mestrual abnormalities
Which skin infection would cause facial paralysis?
herpes zoster [Bells palsy]
neurogenic bladder
- major complication is infection - infection results from stasis of urine and susequent catheterization
estrogen stimulates
- osteoblastic activity (bone building) - inhibits PTH
patient that has a high fasting blood sugar
- check fasting blood sugar two weeks later
what is used to monitor bronchoconstriction in asthma
- peak expiratory flow rate
A client with cancer is scheduled for a bone scan to determine the presence of metastasis. The nurse evaluates that the teaching before the scheduled bone scan is effective when the client makes which comment?
"A substance of low radioactivity will be injected into my vein and my body inspected by an instrument to detect where it is deposited."
Hemoglobin levels
(males) 14-18 g/dL (females) 12-16 g/dL (*critical*) < 6 or > 18
T4
- (males) 4-12 mcg/dL - (females) 5-12 mcg/dL
creatinine lab values
- 0.6-1.2
BUN lab values
- 10-20
therapeutic levels of phenytoin (Dilantin)
- 10-20
K+ levels
- 3.5-5
t3 levels
- 70-205
ammonia in pts w/ liver disease
- breakdown of glutamine in the intestine and increased activity of colonic bacteria from digestion of proteins INCREASE ammonia levels - removal of blood, a protein source, from the intestine results in a reduced level of ammonia
cardiac tamponade s/sx
- breath sounds clear on asuscultation - JVD - muffled heart sounds
calf pain when taking contraceptives
- calf pain is indicative of thrombophlebitis - this required further assessment and immediate medial intervention
a pt who is receiving chemotherapy asks the RN why is so much of my hair falling? which response best explains the reason for alopecia - what cells of the body does chemo affect
- chemotherapy affects the cells of the body that grow rapidly, both normal and malignant
hypocalcemia and CKD d/t what P levels
- chronic hyperphosphatemia in CKD - increased phosphate levels cause the peripheral deposition of Ca2+ and resistance to vit D absoption needed for Ca2+ absoption
primary aldosteronism serum electrolyte levels
- decline in serum levels of K+ - HTN is the most prominent and universal sign - serum Na level is normal or elevated ,depending on the amount of water resorbed with the sodium
GH deficiency s/sx
- decreased muscle strength - decreased bone denisty
are there any activities that should be avoided when diagnosed w/ epillepsy - what does it depend on
- depends on how well epilepsy is controlled
change in shape occurs in what kind of colon cancer
- descending and sigmoid colon cancer
a pt w/ uncontrolled Afib is admitted to the tele unit. what initial med should the RN anticipate administering to the pt
- digoxin
A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply. - what happens at night
- distended abdomen - dependent edema - urinating at night - distended neck veins
RN teaching a female pt about using a contraceptive diaphram about reducing the risk of toxic shock syndrom - how long can it stay in place - when to replace old diaphragm
- do not leave in place for more than 8 hours - replace the old diaphtam q 3 mos
pt ed for recent cataract surgery
- dont bend over or strain
post cataract surgery precautions
- dont strain when having a BM
how to rectify thick sticky mucus in pt
- drink and increase fluids
consolidation in the lower bases assessment
- dullness with percussion
flail chest
- dx in pts with three or more rib fractures - resulting in paradoxic movement of a sgement of the chest wall
Which symptoms are common during the fulminant stage of inhalation of anthrax? Select all that apply.
- dyspnea - diaphoresis - high temp
DoT and seizure disorders
- each state has different laws, some states will allow a drivers license after being seizure free for 6 mos to 2 years. States require letters from the physician or nurse practitioner
microalbuminuria - earliest sign of what
- earliest sign of diabetic nephropathy - indicates the need for follow up evaluation
what happens when GFR decreases
- early renal insufficiency, metabolic waste products, including urea, creatinine, and other substances [phenols, hormones, electrolytes, accumulate in the blood] - early stages of renal insufficincy polyuria results from the inability of the kidneys to concetrate urine that leads to nocturia
To help prevent long-term complications associated with gastric bypass surgery, the nurse needs to educate the client. Identify the factors that should be included in the nurse's teaching plan for this client. Select all that apply.
- eat foods rich in Ca 2+ [decreased Ca levels d/t decreased absorption] - consume diet high in protein - receive cyanocobalamin injections routinely
white color in the mucus membranes indicate
- edema
what intervention should the RN do prior to beggining a feeding through a gastrostomy tube
- elevate HOB 30-40 degrees
RN action necessary is necessary for the pt w/ a flail chest
- encourage cough and deep breathing
what is the correct procedure for performing an opthalmoscopic examination on a pts right retina
- from a distance of 12-15 in and slightly to the side, shine the light into the pts pupil [pt should focus on a distant object behind the examine who should stand at 12-15 inches away and to the side of his/her line of vision]
kosher food RN considerations
- kosher foods should not come into contact w/ non kosher foods and are not inadvertently served on dinnerwar used for non kosher foods
nephrogenic etiliogical factor of DI
- lithium therapy
multiple myeloma - what causes to bone mineralization - what electrolyte level goes UP - how much urine output should there be / day
- malignancy of plasma cells that infiltrate bone casuing deminizeralization and hypercalcemia - maintaning urinary output 1.5-2 L per day requires an intake of 3-4 L day to promote excretion of serum Ca
onset of pneumonia in the elderly - what VS are increased
- may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate
during lung assessment the RN places stethoscope on a pts chest and instructs him to say 99. What would be the correct interpretation if the RN hears the spoken words 99 very clearly through the stethoscope? - what disease does it indicate
- may indicate pneumonia
how should the RN position the electrodes for modified chest lead one [MCL I] telemetry monitoring - where does negative polarity go [which shoulder] - positive polarity - chest nipple line [what side] - ground left goes where what side of chest nipple like
- negative polarity left shoulder, positive polarity right chest nipple line, ground left chest nipple line
pt w/ etoh related liver disease. which prx shold the RN call the provider about reverification
- nembutal Na at bedtime for rest
which assessming finding by the RN dring a breast exam required a follow up
- newly retracted nipple
which interventions should the RN implement to prevent joint deformities in post stroke pt w/ total left side paralysis - i what position to place .... how many times, how long - elbow should be placed where in relation to the shoulder ... why [to prevent what] - what to apply to arms and legs at night to prevent flexion
- place in prone postion for 15 mins 4x day [promotes hyperextension of the hip joints - which prevents knee and hip flexion contractures] - place elbow higher than the shoulder and the wrist higher thna the elbow on the affected side [elbow should be higher than the shoulder and the wrist higher than the elbow to prevent edema and possible joint fibrosis that will occur and limit ROM] - apply splints to the arms and legs at night [to prevent flexion and maintain correct positioning during sleep] -
pt is leaning forward in the wheelchair. pale, somnolent, having difficulty breathing
- place pt on the stretcher and open airway
supine position when abd bleeding
- placing the pt in a supine position reduces the diaphragmatic pressure, thereby enahncing O2 - allows for examination of the abd would
s/sx of hypoglycemia
- plapitations - tachycardia - nervousness [sympathetic nervous system is stimulated by the desire for sugar] - hungry - cool and moist skin
pt w/ right knee placed on a skeletal traction. RN dx is "potential for impairment of skin integrity r/t immobility from traction" Which RN intervention is indicated based on this dx
- provide back and skin care while maitaining traction [traction must be left intact]
acute severe diverticulitis
- pt is at risk for peritonitis and intestinal obstruction - should be made NPO to reduce risk of intestinal rupture
how does the client appear after a seizure [post ictal phase]
- pt is very tired and should be allowed to rest quietly and sleep
RN working w/ post op pt assess a woman who had a left radical mastectomy for breast ca. which factor puts the pt at greatest risk for dev. lymphedema
- pt sustained an insect bit to her left arm y-day
tumor lysis syndrone
- pts experience hyperkalemia
pt admitted to burn uni w/ partial and full thickness burns over 40% of the pts body. in assessing for potential skin regeneration, what should the RN remember about full thickness burns?
- regenerative function of the skin is absent because the dermal layer has been destroyed [tissue does not regenerate, skin grafting necessary]
what should the RN remember about full thickness burns>
- regenerative skin function is absent because the dermal layer has been destroyed
how to achiver normal blood glucose levels in pt who is NPO
- regular insulin dosing based on the pts blood glucose levels [sliding scale]
IV insulin
- regular insulin is the ONLY insulin administered via the IV route -
what to advise pt w/ COPD
- report changes in sputum color changes
pt in PACU w/ dark concetrated urine, output of 54 mL in last 2 hours. what priority RN action should be implemented
- report findings to the surgeon [normal urine output is 60mL/hour]
what requires an intervention in elder pt
- reports caloric intake of 1200
during CPR when attempting to ventilate a pts lungs. the RN notes the chest is not moving. What action should the RN take first
- reposition the head to validate that the head is in proper position to open airway
pt w/ cirrhosis dev increasingly pedal edema and ascites. what deitary modification is most important for the RN to teach the pt
- restrict salt and fluid intake
highest priority RN dx for older pt admitted to the hosp for a new onset cardia dysrhythmia
- risk for injury r/t syncope and confusion
SEIZURE DISORDER pt having a tonic clonic seizure [entire body is rigid, arms and legs are contracting and relaxing - he is making guttural sounds] prioritize RN actions - where should pt be moved to - what to do to keep env safe - remove the pt from a crowded plac e - what to do at the end [VS}
- savely move pt to the floor - push furniture away from pt - remove pt from the waiting room - assess pts BP
flat bones
- scapula - sternum
in preparing to administer IV albumin to a pt following surgery. what is the priority RN intervention. SATA - how long should it infuse over - what kind of catheter - what CBC levels should be monitored - what to assess for after admin
- set the infusion pump to infuse albumin within four hours - administer through a large gauge catheter - monitor hemoglobin and hematocrit levels - assess for increased bleeding after administration
stage 4 pressure ulcer
- sinus tract
s/sx of RIGHT sided stroke - visual field deficit and parethesia [numbness] on which side - deficit in what [spa/percep] - distractibility is
- visual field deficit on the left side - spatial perceptual deficit - parethesia on left side - increased distractibility -
what is an aura - warning that can either v... or aud
- visual or auditory warning that a seizure is about to start
K+ low s/sx
- weakness - fatigue - palpitations
pt w/ CHF transferred to the unit... what can be delegated??
- weight pt on scale - place cardiac monitor on pt - place a sign at the bedside of fluid restriction
s.sx of asthma attack -
- wheexing - coughing - dyspnea - chest tightness
circulating nurse in the OR role
- will do an OR timeour
A nurse receives a telephone report from the postanesthesia care unit for a client status following a colon resection with anastomosis. Place the nursing actions in order of priority when the nurse receives this client from the postanesthesia care unit.
1. assess LOC 2. assess airway 3. monitor resp rate and quality 4. obtain HR and BP 5. Check abd dressing
pt prx lasix IVP at 1815 administered over 15 minutes and repeat an hour after. when should the next dose be admnistered
1930 [IVP done over 15 mins]
TSH levels
2-10
which finding should the RN identify as most significant for a pt dx w/ polycystic kidney disease
3+ bacteria in urine
normal serum albumin
3.5-5.0 or 35-50
normal cardiac output to ensure cerebral blood flow and O2 delivery
4-8 L/min
which postmenopausal pts complain should the RN refer to the HCP
= episodes of vaginal bleeding [may indicate endometrial cnace]
yellow color in the soles of the feet indicate
DM
which hormone acts on all body cells
GH
Which hormonal deficiency causes breast atrophy in female clients?
LH
pt at the hospital w/ a dx of severe acute diverticulitis. Which assessment finding should the RN expect this pt to exhibit - pain where - temp [high or low]
LLQ pain and low grade fever [sigmoid colon is the most common area for diverticula] [inflammation of the diverticular causes low grade fever]
The nurse is performing an abdominal assessment on a client. Where on the abdomen should the nurse assess for McBurney point?
RLQ [extreme sensitivity in acute appendicitis]
pt with diabetes has prn antihypertensive, give rationale on why
diabetes is a risk factor for cardiac disease
A client with hypertension has been receiving ramipril (Altace), 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take?
aadminiter the prx dose at a scheduled time
scleroderma
abnormal blood flow in response to cold [Raynaud phenomenon] is precipitated in pts w/ scleroderma
A nurse writes a goal of preventing renal calculi in a care plan for a client with paraplegia. Which information most likely caused the nurse to write this goal?
accelerated bone demineralization
pt w/ DM is experiencing polyphagia. which outcome statement is the priority for this pt
adequate cellular nourishment
Which hormone does the nurse state binds to the receptor site on the surface of a target cell?
adrenaline [water soluble hormone]
The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO2). Which other parameter can be determined using this technique?
arterial O2 sat
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take?
assess for kinks or dependent loops in the tubing [least invasive RN action to determine why the drainage has diminished] - though it is expected that there is a decrease in drainage - other issues should be ruled out first to make sure that there isnt another reason for the decrease
A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished?
assess the pts breathing
A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. Which postoperative intervention on the day after surgery is appropriate for the nurse to implement?
assist the pt w/ ambulation
wheezes heard
asthma
Which condition may cause the gradual occlusion of the internal or common carotid arteries, manifested by transient ischemic attacks?
atherosclerosis of the vascular system
The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication?
bronchodilator
The nurse is aware that the Cowper gland is also often referred to by which other term?
bulbourethral gland
client who is receiving combination chemotherapy for stage II Hodgkin disease is at risk for stomatitis. Which information should the nurse include in the teaching plan?
clean the motuh w/ a soft tooth brush or gentle spray
Pt having an active seizure you turn them to the left, next action
clean up the area around them to prevent injury
Which sexually transmitted disease is caused by the human papilloma virus?
condylomata acuminata
The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention?
cross country skiing
Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate (Mexate) therapy?
decrease in Hgb level
Which physical changes may cause longitudinal nail ridges?
decreased blood flow to the nails
pt with open angle glaucoma can suffer from
decreased peripheral vision
The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect?
decreased serum ammonia levels
ulcers
deep erosions that extend beneath the epidermis
A 77-year-old female client is admitted to the hospital with confusion and anorexia of several days' duration. She has symptoms of nausea and vomiting and is currently complaining of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication?
digoxin
Pt postop hip surgery, excited to see cat, what is the most important discharge instruction?
do not bend to pick up the cat, teach them to jump
uric acid stones what to do
eat lo purine foods
pt adx for dx of MI. the pts history indicates infarction ocurred 10 years ago. which lab test result would the NR expect this pt to exhibit
elevated CK-MB
A nurse may find that for optimum nutrition a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do?
encourage the pt to participate in the feeding process
A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide?
expand the abd on inhalation
client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate?
fluctuating weakness of muscles innervated by the cranial nerves
A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication?
flush the line with NS
Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction?
forced expiratory volume, forced vital capacity ration
A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have?
fracture of the nose
The echoviruses can cause which diseases in clients? Select all that apply.
gastroenteriitis aseptic meningitis
While in the postanesthesia care unit after surgery to create a colostomy, a client requests that no one be allowed to visit. To support the client, what should the nurse do?
give assurance of respect for the pts wishes
registered nurse assesses a client's electronic medical record (EMR) and observes increased blood pressure, severe myopia, and blood glucose levels. Which type of eye disorder will the nurse most likely observe written in the EMR?
glaucoma
A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure?
glomerulus
The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication?
hold the med in your moth for a few minutes before swallowing
During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for?
hyperkalemia hyponatremia [K+ is released from the damaged cells into ECF]
pt w/ CKD. before his scheduled dialysis treatment, which electrolye imbalance should the RN anticipate
hypocalcemia [hypernatremia & hyperkalemia as well]
A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. Which statement made by the client shows that teaching was effective?
i should control by sugar w/ diet, exercise, and medication
In preparation for discharge, a client who had a total hip replacement is taught wound care by the nurse. Which statement from the client indicates a correct understanding of the nurse's instructi
i will inspect the incision for healing when i change the dressing
somatostatin and NE inhibits the synthesis of what
insulin
friction rubs are heard where
pleurisy
A 43-year-old homeless, malnourished female client with a history of alcoholism is transferred to the ICU. She is placed on telemetry, and the rhythm strip shown is obtained. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer?
magnesium sulfate
Which test is used to specifically detect intracranial aneurysms in clients?
magnetic resonance angiography [evaluates blood flow and blood vessel abnormalities]
RN planning care to prevent complication for a pt w/ multiple myeloma. which intervention is most important for the RN to include fluid intake should be
maintain fluid intake 3-4 L / day
A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately take to promote maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?
maintain the pt in a supine postion to reduce diaphragmatic pressure and visualize the would
An obese client has had an abdominal cholecystectomy. How does the nurse plan to alleviate tension on the surgical wound after surgery?
maintaining NG tube patency
In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take?
notify the HCP of the finding immediately
The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which intervention should the nurse implement first?
obtain IVF for infusion per protocol [pt at risk for hypovolemic shock]
A nurse teaches about osteochondroma. Which information should the nurse include in the teaching session?
occurs most oftne in the age of 10-25
A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?
osteoporosis resulting from declining hormone levels
priority dx for arthritis
pain related to disease
After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?
parietal lobe
A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find?
pedal pulses will be weak or absent in the left foot
In which part of the client's body is the amphiarthroidial joint located
pelvis
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment?
perform synchronized cardioversion
Which disease is caused by Escherichia coli?
peritonitis
ABG - pH - CO2 - HCO3
ph: 7.35-7.45 CO2: 35-45 HCO3: 21-28
Which organism is responsible for causing dermatitis related to a sexually transmitted infection?
phthirus pubis
Which gland secretes melatonin?
pineal gland
Which phase of the woman's sexual response is characterized by elevation of the uterus?
plateau phase [after the excitation phase]
A client is admitted to the hospital with a diagnosis of a large cancerous tumor of the sigmoid colon, and surgery for a colon resection is scheduled. What clinical finding does the nurse expect when completing this client's nursing admission history and physical?
rectal bleeding
diabetic pt enters clinic w/ very long thick toenails. what do you do?
refer to foot specialist
A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period?
regular insulin subcut per sliding scale
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first?
reposition the pt to her side [least invasive to determine if the tube is functioning properly]
The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first?
review the medication actions and interactions
Which surgery is used to treat excessive wrinkling or sagging of facial skin?
rhytidectomy
The nurse includes frequent oral care in the plan of care for a client scheduled for an esophagogastrostomy for esophageal cancer. This intervention is included in the client's plan of care to address which nursing diagnosis?
risk for infection
developmental defects of the arterial walls associated with
saccular aneurysms
what foods should be avoided w/ amlodipine and losarta
salt substitutes [increase risk of hyperkalemia]
A client's burn wounds are scheduled to be debrided mechanically. Which equipment will the nurse prepare?
scissors and forces [physical removal]
Pt presents with 200-300 FSBS, what to do
see if theres sliding scale of insulin
A client is transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort?
semi fowler
the RN would be correct in withholding a dose of digoxin in a pt w. CHF without instruction from provider IF the clients
serum K+ level is 3
small bowel obstruction is a condition characterized by which finding?
severe fluid and electrolyte imbalances
A client is admitted to the ambulatory surgery unit for a liver biopsy. The nurse recalls that which assessment finding will be a cause for the biopsy to be postponed?
signs of bruising
Which diagnostic test does the nurse consider to help in identifying the abnormalities of the sella turcica in hyperpituitarism?
skull x ray
A client's serum albumin value is 2.8 g/dL (28 g/L). Which food selected by the client indicates that the nurse's dietary teaching is successful?
sliced turkey
A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home?
spirometry [used to dx early lung transplant rejections or infection and helps monitor lung functions]
A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions?
sputum is free of acid fast bacteria [disease can no longer by spread by the airborne route]
21. A client's laboratory report reveals a CD4+ T-cell count of 520 cells/mm3. According to the Centers for Disease Control and Prevention (CDC), which stage of human immunodeficiency virus (HIV) disease is present in the client?
stage 1
The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which intervention should the nurse implement first?
start CPR
During administration of an enema, a client reports having intestinal cramps. What should the nurse do?
stop the fluids until the cramps subside
stage 3 pressure ulcer
subcut tissue becomes damaged or necrotic
Which clinical indicator is the nurse most likely to identify when assessing a client with a ruptured cerebral aneurysm?s
sudden severe HA
Which may cause a foreign body sensation in the eye?
superficial corneal erosion
A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase?
the client will maintain present muscle strength
A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyst of the pancreas. The client asks, "What is a pseudocyst?" Which information should the nurse include in a response to this question?
walled off space of pancreatic enzymes and exudate
client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause
warfarin [anticoagulant medication that could result in blood in the urine]
A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client?
whole blood products
During admission a client appears anxious and says to the nurse, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best response?
you seem concerned about your dx
two days post op a pt reports aching pain in his left lef. the RN assesses redness and warmth on the lower left calf. what intervention would be most helpful for the pt - what to assess for in each leg
- assess for positive homans sign in each leg
What are the roles of an unlicensed assistive personnel in skin care? Select all that apply.
- assist the pt in bathing - apply wet dressing to the skin - report changes in the skin appearance
peak drug levels of IV admin of aminoglycosides
- 30 mins after IV admin - best time to draw trough is the closest time to the next administration
while working in the ER the RN is exposed to a pt w/ active TB. when should the RN plan to obtain a tb test
- 4-6 weeks after the exposure
assessing cancer risk. the RN IDs which woman as being at greatest risk for developing breast cancer
- 50 yo whose mother had unilateral breast cancer
suction presure
- 80-120 mmHg
a pt who is HIV + asks the RN, "how will I know if I have aids?" Which reponse is best for the RN to provide - what is found in a healthy person
- AIDS is dx when a specific opportunistic infection is found in an otherwise healthy individual
How can AFib lead to seizures - predisposes the pt to formation of what - why is it modifiable... because it can be treated w/
- Afib = heart disease - can predispose the client to clot formation on the wall of the heart or valve leaflets - treated w/ medication [modifiable]
which dx tests does the RN expect to be done when transferred from ED to the floor
- CBC - UA - liver function tests
hypersecretion of adrenocorticotropic hormone results in
- Cushings disease
pt w/ htn. which additional med sx in the pts history presents the greatest risk for dev. a CVA?
- DM
what hormones act on sympathetic effectors
- E - NE
pt w/ suspected stroke being reasessed q 15 mins. Which assessment finidng would warrant immediate intervention by RN ? - coma scale changes from what number - what reflex is present bilaterally - pt cannot .... RN questions - response to painful stimuli is
- GCS [coma scale] changes from 12 to 9 - positive Babinski reflex bilaterally - pt unable to verbalize responses to the RNs questions - decrease response to painful stimuli
pituitary cells produce
- GH - prolactin - adrenocorticotropic hormone
side effects of bromocriptine
- HA - gastric irritation - orthostatic hypotension
which symptoms should the RN expect a pt to exhibit who is dx w/ pheochromocytoma - ache where - diap - pal
- HA, diaphoresis, and palpitations
what should the RN do for a pt w/ stroke - assist w/ what activity - assiss w/ what motor activity [also can be done by what team]
- assist w. eating his breakfast [pt has dysphagia, this is a high risk task for the UAP] - assist pt in getting in the chair [should be performed by the PT]
in assessing a pt dx w/ primary hyperaldosteronism. the RN expects the lab test results to indicate a secreased serum levels of which substance?
- K+
pt taking a thiazide diuretic for the past 6 mos has serum K+ level of 3.0. the RN anticipates which chnag ein prx for the pt
- K+ supplement
pt w/ a thiazide diuretic for the past 6 mos has a serum K+ level of 3. the RN anticipates which change in prx for the pt
- K+ supplement will be prx
s/sx of diverticulitis - pain where - temperature is - what do they refuse to do - n/v
- LLQ pain - elevated temp - refusal to eat - nausea
what should be established immideately when a head injury happens
- LOC [level of consciousness] - spontaneous eye opening is a simple measure of alerness that indicate arousal mechanisms are intact
priority RN interventions to include in post stroke pts plan of care [SATA] - treatment with what meds ... what labs to do w/ this treatment - how often to assess neuro status - HOB should be - BG should elevated how often?
- PTT / INR [heparin or coumadin treatment] - assess neuro status q 1 hours - keep HOB elevated - monitor blood glucose daily
cor pulmonale s/sx
- SOB with exertion - lowe leg of edema - chest pain - heart palpitations
the RN is assesssing a pts lab values following admin of chemotherapy. Which lab values leads the RN to suspect the the pt is experiencign tumor lysis syndrome
- Serum Ca of 5mg/dL
RN witnesses a baseball player receive a blunt trauma to the back of the head. which assessment data would the RN collect immediately
- ability to open the eyes spontaneuously before any tactile stimuli are given
AV shunt for dialysis
- absence of thrill or bruit indicates the shunt is obstructed - HCP needs to be contact so that an intervention can be initiated to restore function of the shunt
What is the function of IgG in the b
- activates the classinc complement pathway
nephrotoxins cause
- acute tubular necrosis - reversible acute renal failure which creats renal tubular obstruction from endothelial cells that are sloughe or become edematous
Which information should the nurse consider about rabies when planning care for this client?
- acute viral infection - convuslsions - difficulty swallowing - affects the nervous system
A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, he is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which intervention should the nurse implement first?
- add 5 cm positive end expiratory pressure (PEEP)
female pt taking PO contraceptives reports to the RN that she is experiencing calf pain. What action should the RN implement?
- advise the pt to notify HCP for immediate medical attention
RN is taking a history if a newly dx Type II diabetic who is beginning treatment. Which subjective information is most important for The RN to note allergy to what kind of drugs
- allergy to sulfa drugs [may make the pt unable to use some common anithyperglycemic agents]
RN assisting a pt oob for the first time after surgery. Which action should the RN do FIRST?
- allow pt to sit w/ the bed in high Fowlers position [allows for venous return to compensate from lying flat and vasodilating effects of periop drugs]
pts at high risk for pneumonia
- altered LOC - brain injury - depressed or absesnt gag or cough reflexes - susceptible to aspirating oropharyngeal secretions [alcoholics, anethesized individuals] - drug overdose - stroke victims - immunicompromised
female pt requests infor about using the calendar method of contraception. which assessment is most imp for the RN to obtain
- an accurate menstraul cycle diary for the past 6-12 mos
methotrexate - action - side effect
- an immunosuppressant - bone marrow deppression which would be reflected by a decrease in a Hbg level
how to prevent pneumonia
- annual flu vaccines - immunossuppressed and debilitated persons - comatose and immovile persons -
the RN is reviewing med for pt w/ chronic angle closure glaucoma. which med should the RN question
- anticholinergic w/ a side effect of pupillary dilation
medical history qs to ask to determine why seizure activity started?
- are you taking any type of illegal drugs - have you had any type of head injury - do you have a history of drinking etoh - does anyone in your family have seizure disorders
when are bronchial breath sounds heard
- areas of density or consolidation
RN is suspicous of elder abuse, what is the RNs next action
- ask the person about their bruises
pt w/ Hep C is getting blood transfusion. what to ask them
- ask them when the frist time was they got a transfusion[before 1992 they did not have precautions]
pt w/ paralytic ileus, what to do
- assess BS
A blood transfusion of packed cells has been prescribed for a client. The client shows signs of hemolytic reaction. Place the appropriate nursing actions in order.
1. stop the transfusion 2. change the IV admin set 3. run NS at a rapid rate 4. notify the HCP and blood bank
What is the normal value of functional residual capacity?
2.5 L
Which hormone synthesis does the nurse state is inhibited by hypokalemia?
aldosterone
radical mastectomy
= interrupts lymph flow - increased lymph flow occurs in response to the insect bit increases the risk for the occurrence of lymphedema
how to increase compliance post op
= let them know they need to get OOB the day after srgery
When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess
B [the most stable pt] ACD are all at risk for increased intracranial pressure and require the expertise of an RN
whispered pectoriloquy normal results - how are sounds heard
NORMAL - spoken words is not well transmitted through lung tissue - sound is heard a muffled and unclear ABNORMAL - increased clarity indicates a consolidation process [tumor or pneumonia]
Which electrolyte deficiency triggers the secretion of renin?
Na
elderly pt c/o pain in his left calf. RN notices reddened area on the calf of his right lef, which is warm to the touh and suspects it might be throbophlebitis. Which type of pain would further confirm this suspicion
pain in the calf upon exertion which is relieved by rest and elevating the extremity
A client is admitted to the hospital for the implantation of radon seeds in the oral cavity. Which intervention is most important when the nurse is caring for this client after the procedure?
administering RN care in a short period
Which hormonal deficiency reduces the growth of axillae and pubic hair in female clients?
adrenocorticotropic hormone
When caring for a client who had abdominal intestinal surgery, which concept of postoperative management does the nurse recall?
air swallong causes gastric distention
The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan?
attend an ostomy support group within 2 weeks
A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement?
auscultate the lungs
An older male client comes to the outpatient clinic complaining of pain in his left calf. The nurse notices a reddened area on the calf of his right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform?
auscultate the pts breath sounds [pt may have a PE s/t DVT]
Which side effect should the nurse monitor for when administering androgen therapy?
baldness
S2 sound heard
base of heart [closure of aortic and pulmonic valves]
hich immunomodulatory is beneficial for the treatment of clients with multiple sclerosis?
beta interferon
Which prostaglandin agonist is used in the treatment of clients with glaucoma?
bimatoprost
. A client has a craniotomy for a meningioma. For which response should the nurse assess the client in the postanesthesia care unit?
blurred vision
what is used to treat hyperpituitarism
bromocriptine
Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply.
burns osteomyelitis diabetic ulcer
A client is admitted to the hospital with a recurrence of chronic arterial insufficiency of the legs. Which clinical manifestations does the nurse expect to identify when performing an admission history and physical?
pain when exercising and thickening of the toenails [intermittent claudication]
A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family?
follow exposure precautions [d/t radioactive seeds]
A client has a femoropopliteal bypass graft. The nurse assesses vital signs, and the client's blood pressure is 200/110 mm Hg. The nurse notifies the surgeon. What is the rationale for the nurse's action?
graft is leaking or ruptures
While a nurse is teaching a client with diabetes about food choices, the client states, "I do not like broccoli." Which food should the nurse suggest to substitute for broccoli?
green beans
Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on?
having the pt breathe into a paper bag [bag is used to CO2 can be rebreathed to resolve resp alkalosis]
diverticulosis diet
high fiber. and increase liquids
What will the nurse expect diagnostic studies of a client with Cushing syndrome to indicate?
high lvels of 17 ketosteroids in a 24 hour urine
The nurse on a medical-surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain?
if the pts wound is infections
A client is placed on a mechanical ventilator following a cerebral hemorrhage, and vecuronium bromide, 0.04 mg/kg every 12 hours IV, is prescribed. What is the priority nursing diagnosis for this client?
impaired communication r/t paralysis of skeletal muscle
A client with Laënnec cirrhosis has a Sengstaken-Blakemore tube in place. The client becomes increasingly confused and tries to climb out of bed. The client's breath becomes fetid. What is the nursing priority?
implement fall precautions/preventions meausures
When preparing a client for a liver biopsy, the nurse explains that during the test the client will be placed in what position?
in the supine position, with the RA raised behind the head
A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation?
increase O2 flow via NC
pt w/ DM who has a URI
increase insulin
Pt w/ diabetes and being treated for upper respiratory infection, priority RN actio
increase insulin because infection increases glucose
During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest?
increased muscular weakness
Which process that most likely caused the ascites should the nurse consider when planning care?
increased pressur ein the portal vein
The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit?
infection
Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder?
infection
51 yo truck driver smokes 2 packs/day and is 30 lbs overwieght. he is DC wirth a gastric ulcer. what content is most important for the RN include in the discharge teaching for this pt
info about smoking cessation
While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?
initiate O2 via NC [until the cause of the prob is IDd]
pt two day post op has no BS, RN action
insert an NG tube
A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique?
inserts the catheter until resistance or coughing occurs
A client is diagnosed with condyloma acuminatum. Which finding in the client supports the diagnosis?
moist fleshy projections in the penis
What is the most essential nursing care for a client who just had a cardiac catheterization?
monitor BP and HR
Which feature in the client indicates hypersecretion of adrenocorticotrophic hormone?
moon face
A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit implement first?
move pts and visitors into hallways and close all doors to pts rooms
A client with pain and paresthesia of the left leg is scheduled for an electromyogram. What should the nurse discuss with the client before the test is performed?
needles will be inserted into the affected muscles during the test
A female client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if she will need dialysis for the rest of her life. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides?
nephron obstruction
A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture?
oral temp of 102
67 yo woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of the femur
osteoporosis resulting from hormonal changes [most common cause of a fractured hip in an elderly woman is osteoporosis resulting from reduced calcium in the bones]
A client is admitted to the postanesthesia care unit after surgery, and electronic blood pressure monitoring is to be performed. How frequently should the nurse assess the client's blood pressure?
q 10-15 mins
A client reports burning sensation and sharp pain on the sole of a foot. Which condition does the nurse suspect in the client?
plantar fascitis
A client with a history of a herniated nucleus pulposus is scheduled for total hip replacement surgery. To prevent the most common complication associated with this type of surgery, the nurse should instruct the client to perform which acti
plantar flexion and dorsiflexion
classic s/sx of hypeglycemia in normal people
polyuria, polydipsia weight loss
adrenoccorticotropic hormone deficiency causes
postural hypotension - hypoglycemia - anorexia
During a party, an individual reports intense chest pain and begins to perspire profusely. Which nursing action is priority when the client is brought to the emergency department?
prepare the client for continuous ECG monitoring
During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which intervention should the nurse implement?
prepare the pt for a pericardial tap
Which key feature does the nurse associate with a stage 2 pressure ulcer?
presence of nonintact skin
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 agains a pillow pweriodically
a splint is prx for night time use for a pt w/ RN. which statment by the RN provides the most accurate explanation for the use of splints?
prevention of deformities
A client's tibia is fractured in a motor vehicle accident, and a cast is applied. The nurse should assess for which manifestation indicating damage to major blood vessels caused by the fractured tibia?
prokonged reperfusion of the toes after blanching
pt w/ heard disease on tele unit has dev. sinus bradycardia. In determining the possible cause, the RN assesses the pts AMR. which med would most likely cause bradycardia
propanolol (Inderal)
Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)?
provide a room that can be kept warm
During a client's routine physical examination, an abdominal aortic aneurysm is diagnosed. The client is admitted to the hospital immediately, and surgery is scheduled for the next morning. Which clinical finding should the nurse expect when completing the admission assessment?
pulsating abd mass
Pt w/ nausea and vomiting taking digoxin, lasix, what to do
put on cardiac/tele monitoring
A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse?
resp rate of 12bpm and O2 sat 85%
A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client?
restrict salt and fluid intake
The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement
return the solution to the pharmacy
A nurse is notified that the latest potassium level for a client in acute kidney injury is 6.2 mEq (6.2 mmol/L). Which action should the nurse take first?
take VS and notify the HCP
77 yo female pt, confused, no appetiet, n/v and is c/o HA. pulse is 43 bpm. Which questions is a priority for the nurse to ask the pt or her family. does the pt ....
take digitalis
A client with rheumatoid arthritis asks the nurse about ways to decrease morning stiffness. What should the nurse suggest?
taking a got tub bath or shower in the morning [moist hear increases circulation and decreases muscle tension]
pt w/ early breast ca receives the results of a breast biopsy and asks the RN to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the RN provide
the tumors estrogen receptor guides treatment options
RN is planning to initiate a socialization group for older residents of a long term facility. Which info would be most useful to the RN when planning activities for the group
the usual activity patterns of each member of the group
A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which purpose will the nurse explain to the client?
this limits muscle contractions that may force causative organisms into the blood stream
Which hormone increases the rate of protein synthesis in a client?
thyroxine
he nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed?
tidaling of water in a water seal chamber
Why would a client with acquired immunodeficiency syndrome (AIDS) be prescribed diphenoxylate hydrochloride?
to manage diarrhe a
When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do?
turn from side to side
A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first?
turn off the continuous feeding pump
The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate intervention by the nurse?
unilateral pupil that is dilated and nonreactive to light
which area contains the older person center of gravity
upper torso
Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old man who is in good health overall
urinalysis revelas slight protein in the urine and bacteriuria with pyuria
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?
wear cotton underpants
