HESI MS 1-2

Hyperthyroidism s/s

*exophthalmos *photophobia *eyelid retraction (eyelid lag) *globe (eyeball) lag *goiter *fine, soft, silky hair ---- thinning of scalp hair *smooth, warm, moist skin *muscle weakness *hyperactive deep tendon reflexes *increased SBP, tachycardia, dysrhythmias, decreased DBP *diaphoresis, palpitations, rapid, shallow respirations *HEAT INTOLERANCE *dyspnea

aplastic anemia implementations?

-give soft bristle tooth brush -give blood as ordered -monitor for bleeding -give electric razor for shaving *will need bone marrow transplant

A client is receiving chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment finding warrants intervention by the nurse? A. Leukopenia B. Polycythemia C. Ascites D. Nystagmus

A

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next? A. Prepare the client to return to the operating room B. Obtain a sample of the drainage to send to the lab C. Auscultate the abdomen for bowel sound activity D. Bring additional sterile dressing supplies to the room

A

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Pitting ankle edema C. Quarter size blood spot on dressing D. Purple marks on skin of the abdomen

A

A client with chronic cirrhosis has esophageal varies. It is most important for the nurse to monitor the client for the onset of which problem? A. Brown, foamy urine B. Anorexia C. Clay-colored stool D. Hematemesis

A

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care? A. Begin straining all urine B. Implement seizure precautions C. Administer a PRN dose of a laxative D. Initiate cardiac telemetry

A

A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment finding is most often associated with hyperthyroidism? A. Increased pulse rate B. Diarrhea stools C. Atrophied thyroid gland D. Periorbital edema

A

A female client who works as a data entry clerk is concerned as to how her recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client? A. Use a space heater to keep the workplace warm B. Obtain a keyboard designed to limit wrist flexion C. Keep both hands elevated during work breaks D. Take a multivitamin that contains vitamin D daily

A

A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? A. Review client's history for possible exposure to TB B. Instruct the client to return for a repeat test in 1 week C. Refer client to a healthcare provider for isoniazid (INH) therapy D. Document negative results in the client's medical record

A

An adult client comes to urgent care clinic 5 days after being diagnosed with influenza. The client is short of breath, febrile, and coughing green-colored sputum. Which intervention should the nurse implement first? A. Obtain a sputum sample for culture B. Check his oxygen saturation level C. Auscultate bilateral lung sounds D. Administer an oral antipyretic

A

The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tells the nurse his PEFR is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? A. Albuterol 2.5 to 5 mg per nebulization B. Epinephrine auto-injector 0.15 mg C. Salmeterol 2 puffs per measured-dose inhaled D. Oxygen at 6 liter/minute by nasal cannula

A

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? A. Has everyone at home already had varicella? B. Have the anti fungal creams been effective? C. Do your family members share combs and brushes? D. Do you have any dry patches on your feet and hands?

A

The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred-vision. Which outcome should the nurse include in the plan of care for this client? A. The client's daily blood pressure will be less than 140/80 mmHg this month B. The nurse will encourage the client to walk 30 minutes every day C. The client's blood pressure readings will be less than 160/90. mmHg D. The client will take up to 4 nitroglycerine tablets sublingually for chest pain

A

Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? A. Fortified milk and cereals B. Citrus fruits and juices C. Red meats and eggs D. Green leafy vegetables

A

While caring for a client with a full-thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provide, the nurse should review which of the client's laboratory values? A. White blood cell count B. Blood pH level C. Platelet count D. Hematocrit

A

What would indicate a sign of dementia in a client with AIDS?

A change in writing

During the admission assessment, the nurse identifies multiple bruises at various stages of healing on a male client recently diagnosed with aplastic anemia. The nurse reviews his stat serum laboratory values which reveal platelets 50,000/mm^3, white blood cells 3,000/mm^3, and red blood cells 2.5 million/mm^3. Which actions should the nurse implement? (Select all that apply) A. Initiate sepsis protocol B. Provide a soft-bristle tooth brush C. Monitor for signs of bleeding D. Implement contact precautions E. Infuse blood products as prescribed

A,B,C,E

An older client who us agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular respirations 38 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to the treatment? (Select all that apply) A. Oxygen saturation B. Skin elasticity C. Pain scale D. Lung Sounds E. Urinary output

A,D,E

The nurse learns in change of shift report that the x-ray report for a newly admitted client indicates consolidation in the left lower lung. What action should the nurse take?

Administer a PRN dose of a bronchodilator.

A client has a pain of 8 out of 10 on the pain scale...?

Administer opioids and non pharmacological interventions

Two days following abdominal surgery a client begins to complain of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first?

Auscultate the client's abdomen (might actually be inspect....) *inspect for abdominal distention, which could indicate internal bleeding

What to avoid with Raynaud's?

Avoid caffeine *can use space heater

A client has an absolute neutrophil count (ANC) of 500/mm^3 after completing chemotherapy. Which intervention is most important for the nurse to implement? A. Implement bleeding precautions B. Place the client in protective isolation C. Assess vital signs every 4 hours D. Review need for pneumococcal vaccine

B

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? A. Irregular pulse rate B. ST elevation in three leads C. Complaint of radiating jaw pain D. Bile colored emesis

B

Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is important for the nurse to include in the discharge teaching plan? A. Avoid driving a car for 2 weeks B. Drink 3 liters of water each day C. Eliminate all spicy foods from your diet D. Clamp the catheter when taking a shower

B

The nurse auscultates a client's heart sounds and hears a mid-systolic click associated with mitral valve prolapse. Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe? A. 12-lead electrocardiogram B. 2D-echocardiograhy C. Troponin and CK-MB levels D. . CT scan of the chest

B

The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? A. Ecchymotic area B. Enlarged vein C. Pulselessness D. Redness

B

The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions? A. Liver B. Oranges C. Leafy green vegetables D. Kidney beans

B

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? A. Surgical consent form is not signed B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L) C.Preoperative chest x-ray report is not available D. Client's pulse oximeter reading is 96%

B

When planing care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing problem of, "visual sensory/perceptual alterations." This problem is based on which etiology? A. Limited eye movement B. Decreased peripheral vision C. Blurred distance vision D. Photosensitivity

B

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the healthcare provider? A. Slight blood-tinged sputum B. Dyspnea and dysphagia C. No gag reflex after 30 minutes D. Sore throat and hoarseness

B

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include? A. Reduces the inflammatory process improving nerve transmission and function B Increases the amount of dopamine available for muscles to function correctly C. Slows the scarring in the myelin sheath improving muscle tone and strength D. Acts as an antiseizure medication reducing the tremors caused by the disease

B

While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem? A. Diminished blood flow B. Compression of a nerve C. Irritation of nerve endings D. Ischemic tissue changes

B

The nurse is assessing a client who has a bowel obstruction. Which observations should the nurse expect to find? (Select all that apply) A. Peristaltic waves observed B. Abdominal distention C. High-pitch bowel sounds D. Dullness on percussion E. Abdomen soft on palpations

B,C,D

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply) A. Hypothyroidism B. Increased triglyceride levels C. Hyperglycemia D. Blood pressure of 150/96 E. Elevated high density lipoproteins F. Abdominal obesity

B,C,D,F

patient with hypertension. what is a goal?

BP less than 140/80

Heart failure acute exacerbation. How to Reduce Cardiac Workload?

Bedside Commode

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110 mmol/L or SI), hematocrit of 34% and microcytic and hypochromic red blood cells. Based on the findings, which dinner selection should the nurse suggest for the patient?

Beef steak with steam broccoli and orange slices

A client is diagnosed with diverticulosis following a colonoscopy. The client denies any symptoms, and asks the nurse what to expect. Which is the best response by the nurse? A. Episodes of burning pain are commonly experienced B. Appetite loss, with resultant feelings of weakness, are common problems C. Symptoms may not occur unless sacs become inflamed D. As the sacs enlarge pain may be experienced in the lower abdomen

C

A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? A. Reduced pain in eczematous areas : B. Decreased weeping of ulcerations in affected areas C. Healing with a return to normal skin appearance D. Hydration of affected dry skin areas

C

A male client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for his oral temperature of 103 degrees F and an infusion of normal saline is initiated at 250 mL/hour. Which assessment finding should the nurse report to the healthcare provider immediately. A. Severe headache with photosensitivity B.Petechial hemorrhage under client's eyes C. Right lower abdomen rebound tenderness D. Dark green color emesis

C

One hour after major abdominal surgery, a client in the post anesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mmHg. Fifteen minutes later it is 114/72 mmHg. Which action should the nurse take first? A. Increase frequency of BP assessments B. Review the client's baseline BP trends C. Check the abdominal surgical dressing D. Encourage the client to breathe deeply

C

The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take? A. Obtain a specimen of the drainage for culture B. "Milk" the tube to remove any clots C. Maintain the current IV antibiotic schedule D. Schedule a portable chest x-ray per PRN protocol

C

The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? A. Administer initial dose of broad-spectrum antibiotic B. Instruct the client to force fluids hourly C. Obtain results of culture and sensitivity of CSF D. Assess the client for symptoms of hyponatremia

C

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a Thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Administer IV fluid bolus as prescribed by the healthcare provider B. Medicate for pain and monitor vital signs according to protocol C. Encourage the client to splint the incision with a pillow to cough and deep breathe D. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter

C

The nurse is developing plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client? A. The nurse will encourage the client to walk 30 minutes every day B. The client's blood pressure readings will be less than 160/90 mmHg C. The client's hemoglobin A1c will be less than 7.0% in 3 months D. The nurse will demonstrate the procedure for accurate eye care

C

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? A. Whit blood cell count B. Glucose C. Platelet count D. Amylase

C

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? A. Encourage the client to lie down and rest after meals B. Remind the client to avoid high-fiber foods C. Teach the client to elevate the head of the bed on blocks D. Instruct the client to use antacids only as a last resort

C

Which laboratory test result is most important for the nurse to report to the surgeon prior to a client's scheduled abdominal surgery? A. Potassium level of 4 mEq/liter B. Blood glucose of 90 mg/dl C. Serum creatinine of 5 mg/dl D. Hemoglobin level of 13 grams

C

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? A. Observe for lacerations to the tongue B. Document details of the seizure activity C. Observe for prolonged periods of apnea D. Evaluate for evidence of incontinence

C

An older adult recently diagnosed with type 2 diabetes mellitus (DM) suddenly becomes confused and weak, with cool, clammy skin. The client is unable to remember what to do for such symptoms and is taken to a near-by urgent care facility by a neighbor. Which nursing interventions should the nurse implement? (select all that apply) A. Prepare to administer regular insulin B. Palpate for bladder for pain or distention C. Check a blood sample for glucose level D. Report any changes in blood pressure E. Observe respiratory rate and pattern

C,D,E

Carpel Tunnel Syndrome patho?

Compression of median nerve *intervention for pain and tingling that worsens at night is to wear brace on both hands OR shaking hands *associated with activities requiring continuous wrist movement *women are more likely to develop this *s/s : weakness, pain, numbness, impaired sensation of median nerve, clumsiness in fine hand movements *positive Tinel's sign and Phalen's sign

A client is admitted with a deep and productive cough, hemoptysis, and a low-grade fever. The client's Mantoux skin test has a 15mm induration. Which intervention should the nurse implement first? A. Administer the initial dose of rifampin and isoniazid B. Collect a sputum specimen for acid-fast bacillus C. Provide a mask for the client to wear in public areas D. Initiate airborne particulate isolation precautions

D

A client is being treated for acute kidney injury. On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and exhibits changes in mental status. Which intervention should the nurse implement? A. Monitor daily sodium intake B. Assess for dependent pitting edema C. Record usual eating patterns D. Obtain serum creatine levels daily

D

A client who fractured the right femur from a fall at home is placed in a skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement? A. Insert an indwelling catheter preoperatively B.Release the traction so the client can use a bedpan C. Log roll the client and place adult disposable briefs beneath the client D. Maintain traction while the client uses a female urinal

D

A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority? A. Risk for aspiration related to vomiting B. Nutritional deficit related to nausea C. Impaired renal function related to pain D. Acute pain related to real calculus

D

A female client who recently married returns to the clinic with recurrent cystitis and urethritis. The client presents with pain on urinating, urinary frequency, and urgency. Which additional information should the nurse obtain? A. Review a recent urinalysis for calcium oxalate B. Examine a client's history for any genetic renal disease C. Ask if she has recently has a streptococcus infection D. Inquire about hygiene practices after sexual intercourse

D

A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question? A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages

D

A young adult male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. Which information should the nurse include in the teaching plan? A. Avoid penile contact with the rectal area B. Epididymitis is a pre-cancerous condition C. Obtain an annual prostate digital exam D. Surgical intervention is often indicated

D

After several days of coughing and taking acetaminophen to treat temperature of 101 F, a client with diabetes mellitus (DM) is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first? A. Reassess vital signs B. Administer an antipyretic C. Obtain a sputum for culture D. Obtain a fingerstick glucose

D

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l

D

An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the acute phase of the client's burn recovery? A. 5% dextrose in water B. total parenteral nutrition C. 5% dextrose in 0.25 normal saline D. Lactate Ringers

D

Following a lumbar puncture, a client voices several concerns.Which concern indicates to the nurse that the client is experiencing a complication from the procedure? A. "My throat hurts badly when I swallow and when I talk" B. "I feel sick to my stomach and am going to throw up" C. "I am having pain in my lower back when I move my legs" D. "I have a headache that gets worse when I sit up"

D

The nurse is caring for a client on a rehabilitation unit who has right cerebrovascular accident and is struggling with independent self-care. The nurse places a large mirror in the client's room. Which instruction should the nurse provide the client? A. Mirrors reflect light to brighten the room so you can see better B. A hoe-like environment helps you relax and feel more confident C. Check your appearance before leaving the room D. Use the mirror to watch yourself while dressing

D

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include? A. Schedule rest periods between activities to minimize fatigue B. Teach coping skill for living with a chronic illness C. Provide assistive devices to empower client independence D. Implement measures to manage chronic pain

D

Discharge teaching after TURP?

Drink 3 L of water *TURP = several small incisions are made into prostate gland to expand urethra and improve urine flow *s/s of TURP syndrome : n/v, confusion, bradycardia, and hypertension *TURP syndrome is due to hyponatremia from prolonged bladder irrigation *bleeding and clots are complications !!!! *MUST stop taking anticoagulants several days before surgery *BPH meds are stopped after the procedure *REPORT FRESH BLOOD IN URINE

A client with eczema is using an OTC topical product with urea 10% OTC (Aqua Care Cream) to the affected skin areas. Which finding reflects the expected therapeutic response.

Hydration of affected dry skin areas

A male client is admitted to the emergency department with vomiting of dark brown, foul-smelling emesis. He reports he had surgical repair of a recurrent inguinal hernia one week ago and complains of intense abdominal pain. After assessing that his bowel sounds are hyperactive, which prescription should the nurse implement first.

Insert a nasogastric tube (NTG) and attach to low intermittent suction. *he has s/s of intestinal obstruction (possibly inguinal hernia) *FIRST thing to do is NG tube!!! then IV fluids *complications: gangrene, perforation of bowel, shock, death

A client has 40% of burns. Which fluid is needed during the acute phase?

Latated Ringers

Postop care for patient with abdominal pain, fever, n/v after gastric surgery?

NG tube *continue monitoring for n/v, feeling full/bloated, increasing shortness of breath, increase in abdominal girth ---- these indicate excess fluids and gases aren't being removed properly *too much suction can pull gastric mucosa into drainage openings *use LOW suction unless indicated otherwise *coffee-ground material in tube = TEST FOR BLOOD

Patient with CVA is having trouble with independent self-care. What should nurse tell the patient?

Place mirror in room and watch yourself as you get dressed *risk factors for stroke : diabetes, hypertension, obesity, hyperlipidemia, a. fib, MI, and valvular disease

A client has a positive guaic stool. What lab to review?

Platelets

Whats priority for a patient who is allergic to bananas?

Replace latex

what are carcinogens?

a substance capable of causing cancer in living tissue.

a patient with long history of GERD reports new onset of trouble swallowing. What should nurse ask?

are you taking your medication? *tell patient that antacids will neutralize the acid in stomach

a newly married female has recurrent cystitis and urethritis. what is most important for nurse to assess?

ask about hygiene before and after sex

how to avoid IV extravasation?

assess IV frequently

female admitted with dysuria and burning and lower bank pain. what should nurse do first?

assess perineal for erthyema....

patient education for GERD?

avoid tight clothing. wear loose-fitting ones instead

What to report with a Bronchoscopy?

bloody sputum (chocolate-brown color) *used to view airway structures and obtain tissue samples ---- used to diagnose pulmonary diseases *MUST HAVE SIGNED CONSENT *NPO 8 hours before !!!!!! *remove dentures *give sedatives as ordered *NPO after until gag reflex returns *complications include: bronchospasm or bronchial perforation. (facial or neck crepitus, dysrhythmias, hemorrhage, hypoxemia, and pneumothorax), fever, infection, aspiration, hypotension, and cardiac arrest *monitor vitals every 15 min for 2 hours after *small amount of blood is expected *NPO until gag reflex returns

in a patient with COPD, what should patient be taught to report to HCP?

change in color of sputum

Patient with diabetes forgot what to do when feeling cold and clammy. What is priority?

check blood glucose level

positive rheumatoid factor means what?

diagnosis for RA

patient education for lupus?

don't abruptly stop taking corticosteroids *use HEAVY SUNBLOCK, cover skin *pat the skin dry, don't rub *use non-perfume lotion *don't use alcohol based skin products *inspect daily for rashes and open areas *exacerbations of FEVER *oral contraceptives, antimicrobials, and penicillin exacerbate it *WEAKNESS

after TURP, what should nurse tell patient to avoid until after first postoperative appointment?

driving

Following bariatric surgery, patient's BP is low. what should nurse do?

give IV fluids *preop care : assess mental health, cognitive ability, neurologic status, reinforce health teaching *post op care : AIRWAY MANAGEMENT, pain (PCA, oral opioids, liquid drug therapy is preferred), extra wide bed, additional personnel for moving patient, bed rails should not be touching patient, monitor skin folds *some may have NG tube --- NEVER reposition tube *serious complication : LEAKS (increasing back, shoulder, or abdominal pain, restlessness, unexplained tachycardia and oliguria)

postop cataract extraction. What should nurse implement?

give stool softeners *avoid heavy lifting

what is a goal for patient with diabetes?

glucosylated hemoglobin (A1c) less than 7%

a patient has herpes zoster. what is important for the nurse to ask?

have family members had varicella? *people who haven't had chicken pox are at risk!! *increased incidence in lymphoma, leukemia, or AIDS *may have residual pain (postherpetic neuralgia) and itching *could have loss of sight if facial nerves are involved

a patient has cirrhosis and esophageal varices. what should nurse monitor for?

hematemesis

patient with asthma has increased sputum due to exercising. what should nurse ask?

if they are using inhaler before exercising

elevated neutrophils means?

infection

patient on chemotherapy; which is most important to monitor for?

leukopenia *goal of chemo is to reduce tumor size *monitor neutrophil count (less than 500/mm3 = SEVERE risk for infection) *initiate precautions if neutrophils < 1000 *fever may be only sign of infection if neutropenic *IV infusion complication: extravasation --- pain, infection, tissue loss *^^ cold/warm compresses, give antidotes *Nurse should wear PPE when preparing, giving, and discarding chemo drugs

for a preop checklist, what requires immediate intervention?

low potassium *A low level is concerning.

what procedure is done to test for bacterial meningitis?

lumbar puncture *patient should be side-lying with knees flexed and pulled toward trunk *nurse should support patient's head bent forward to chest

a female client who fractured her right femur when she fell at home is placed in skeletal traction while awaiting surgery. when the client tells the nurse that she needs to urinate, which intervention should the nurse implement?

maintain traction while client uses female urinal *remember never to release the traction *tell her to use trapeze bar to lift hips

main priority for rheumatoid arthritis?

manage chronic pain

a patient has hypothyroidism. what should nurse implement?

monitor blood pressure

A patient is having a seizure is assisted to the floor. Which is priority?

monitor for apnea

for a patient on thrombolytic therapy, what should nurse do?

monitor for bleeding

HIV?

number of T cells decrease and die *releases new retrovirus that can spread HIV infection *affects the CD4+ T cell!!!! *HIV is spread through direct contact of body fluids

a patient has renal calculi. what is a priority?

pain management *s/s: blood-tinged urine, dysuria, CVA tenderness, flank pain, n/v *drink 2-3 L a day *record I & O's *STRAIN ALL URINE

patient comes in with chemical in eyes. after flushing and calling HCP, what should nurse do?

place eye shield on patient

diverticulosis patho?

pouches in wall of intestine *no discomfort *usually goes unnoticed *s/s : changes in bowls habits (constipation, diarrhea), rectal bleeding, pain in lower left abdomen, n/v, urinary problems *diverticulitis = inflammation on pouches

perforation after colon surgery. nurse already put sterile wet dressing on. what should nurse do next?

prepare client for surgery *do not try to reinsert tissues or organs *FIRST, cover with sterile, wet dressing *notify surgeon *keep patient on bed rest in semi-fowler's position with knees bent, avoid coughing!!! *maintain NPO status *anticipate surgery

COPD???

prepare for surgery *change in sputum color = respiratory infection *Monitor ABG ^^ PaO2 60-65 mmHg, PaCo2 50-60 mmHg = respiratory acidosis

carvidopa-levodopa mode of action?

reduces tremors associated with Parkinson's *use caution in patients with history of MI or ventricular arrhythmias *adverse effects: GI hemorrhage, psychiatric disorders, bronchospasm *kava kava reduces effects of this drug

patient with Parkinson's has masked face. what is most important to assess for?

swallowing ability

best exercise for osteoarthritis?

swimming

A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation?

tea and hot chocolate

how to tell if furosemide is effective?

urine output O2 sat measure abdominal girth weigh daily

How to tell if AV fistula was effective?

vein engorgement *never measure BP, insert IV, or venipuncture in extremity with AV fistula or graft ---- prevents infection and clotting * ^^ be sure to hang a sign / label arm with band with this info *complication: thrombosis ---- give tPA

what to watch for in patient with adrenocorticol insufficiency?

watch BP *s/s have SLOW onset : anorexia, progressive weakness, fatigue, weight loss, abdominal pain, diarrhea, headache, orthostatic hypotension, salt craving, hyponatremia, and joint pain *HYPOTENSION = MOST DANGEROUS *skin hyper pigmentation *risk for Addisonian crisis ---- life threatening (can be triggered by stress, sudden withdrawal of corticosteroid hormone therapy, adrenal surgery, or pituitary gland destruction) *^^ treatment: shock management and high-dose hydrocortisone replacement

patient with carpal tunnel experiences pain at night. what should nurse tell patient to do?

wear wrist braces

patient education for diabetes insipidus?

weight yurself every day at the same time wearing the same clothes