Med Surg HESI Hints

causes of bowel obstructions

mechanical: due to disorders outside the bowel (hernia, adhesions) caused by disorders within the bowel or by blockage of the lumen in the intestine (intussusception, gallstone) nonmechanical: due to paralytic ileus (no actual physical obstruction but results from inability of bowel to function)

risks of CSF leakage

meningitis signs of increased ICP may not occur

What is the most important factor relating to benign uterine tumors?

menorrhagia

During mechanical ventilation, what are 3 major nursing interventions?

monitor respiratory status and secure connections establish a communication mechanism with the client keep airway clear by coughing and suctioning

How often should testicular self-examination be performed?

monthly after 14 after shower

relationship of fat embolisms and fractures

more likely in 36 hrs after fracture more common in clients w/ multiple fractures

differentiating quality of orthopedic wound drainage

more ooze than other wounds a suction drainage device usually accompanies the client to the post op floor

tests for Myasthenic crisis and chronlinergic crisis

myasthenic crisis = positive Tensilon test cholinergic crisis = negative Tensilon test

Is paralysis always a consequence of spinal cord injury?

no

most common complication of hip fractures

thromboembolism

key to resolving UTIs with most antibiotics

to keep the blood level of the antibiotic constant take around the clock; don't skip doses

s/s of laryngeal cancer

tongue and mouth often appear white, gray, dark brown, or black and may appear patchy

features of Parkinson's disease

tremors (a coarse tremor of fingers and thumb on one hand that disappears during sleep and purposeful activity; also called "pill rolling"), rigidity, hypertonicity, and stooped posture. Focus: safety!

risk factor for testicular cancer

undescended testes after age 6

feeding for clients with altered states of consciousness

via enteral routes because the likelihood of aspiration is high with oral feedings. Residual feeding is the amount of previous feeding still in the stomach.The presence of 100 mL of residual in an adult usually indicates poor gastric emptying, and the feeding should be withheld.

anticoagulant antagonists

warfarin: vitamin K heparin: protamine sulfate

MONA

when administering meds in MI patients: Morphine Oxygen Nitroglycerin Aspirin

Is multiple sclerosis thought to occur because of an autoimmune process?

yes

s/s of excess fluid

-dyspnea -tachycardia -JVD -peripheral & pulmonary edema -weight gain

Describe an autograft.

Use of client's own skin for grafting.

patient teaching for ethambutol

(TB drug) check vision before starting therapy and then monthly course of treatment may be 1-2 years

patient teaching for isoniazid

(TB drug) increased phenytoin (Dilantin) levels

patient teaching for rifampin

(TB drug) reduces effectiveness of oral contraceptives orange-tinted body fluids stains contact lenses

effects of liver damage on ammonia levels

serum ammonia rises

colic

excruciating spastic-type pain

What is the most common cause of nongonococcal urethritis?

Chlamydia trachomatis

diverticulitis

inflammation of the diverticula can lead to perforation of the bowel

3. What is the only IV fluid compatible with blood products?

Normal saline

glucose levels in response to illness in stress

levels rise; illness results in hyperglycemia

2. Write two nursing diagnoses for the client suffering from anemia.

Activity intolerance and ineffective tissue perfusion

List four categories of burns.

Thermal, radiation, chemical, electrical

clients at high risk for pneumonia

-altered LOC -depressed or absent gag and cough reflexes -susceptible to aspirating oropharyngeal secretions, including alcoholics, anesthetized individuals -brain injury -drug overdose -stroke victims -immunocompromised

patient teaching following hip replacement regarding positioning/movement

After hip replacement, instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting.This upward motion can pop the prosthesis out of the socket.

basal insulin

long and intermediate acting insulin glargine (Lantus) detemir (Levemir)

A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is diagnosed as having diverticulitis. What are the nutritional needs of this client throughout recovery?

Acute phase: NPO, graduating to liquids Recovery phase: no fiber or foods that irritate the bowel Maintenance phase: high-fiber diet with bulk-forming laxatives to prevent pooling of foods in the pouches where they can become inflamed; avoidance of small, poorly digested foods such as popcorn, nuts, seeds, etc.

normal rate of kidney excretion of urine

1 mL/kg/hr

pneumonia preventives

1) Older adults: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants (dust, smoke, and aerosols); no smoking 2) Immunosuppressed and debilitated persons: Flu shots, pneumonia, immunizations, infection avoidance, sensible nutrition, adequate intake, balance of rest and activity 3) Comatose and immobile persons: Elevation of head of bed to feed and for 1 hour after feeding; frequently turning 4) Patients with functional or anatomic asplenia*: Flu and pneumonia immunizations asplenia - absence of normal spleen function and is associated with serious infection risks

5 nursing interventions after chest tube insertion

1. Maintain a dry occlusive dressing on chest tube 2. Keep all tubing connections tight 3. Keep all tubing connections taped 4. Monitor client's clinical status 5. Encourage the client to breathe deeply periodically.

volume of fluid loss and fluid filtration in the GI tract

100-200 mL of fluid loss filtration of 8L

normal range of daily urine output for adults

1500-2000 mL

8. Describe care of invasive catheters and lines.

Use strict aseptic technique. Change dressings two or three times per week or when soiled. Use caution when piggybacking drugs; check purpose of line and drug to be infused.When possible, use lines to obtain blood samples to avoid "sticking" client.

Differentiate between acute renal failure and chronic renal failure.

Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic renal failure: irreversible, slow deterioration of kidney function characterized by increasing BUN and creatinine. Eventually dialysis is required.

What is the priority nursing intervention used with clients taking NSAIDs?

Administer or teach client to take drugs with food or milk.

Describe pain management of the burned client.

Administer pain medication, especially prior to dressing wound.Teach distraction and relaxation techniques. Teach use of guided imagery.

effect of cataracts on lenses

become opaque light can't be filtered vision is blurred

Following transurethral resection of the prostate gland (TURP), hematuria should subside by what postoperative day?

4th

Bradycardia is defined as a heart rate below _____ bpm. Tachycardia is defined as a heart rate above _____ bpm.

60 100

normal serum calcium levels what does a decrease indicate?

9-10.5 increase indicates parathyroid problems

Hold digitalis at what pulse rate?

<60 or >120 or has markedly changed rhythm

List the parameters of BP for diagnosing HTN.

?140/90

What is the most important indicator of increased ICP?

A change in the level of responsiveness

In a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. List six relevant nursing interventions.

Avoid injections; use small-bore needles for IV insertion; maintain pressure for 5 minutes on all venipuncture sites; use electric razor; use soft-bristle toothbrush for mouth care; check stools and emesis for occult blood.

What are the most important nursing interventions for the postoperative client who has had a hysterectomy with an A&P repair?

Avoid taking rectal temperatures and rectal manipulation; manage pain; and encourage early ambulation.

Describe nursing care for the client who is experiencing phantom pain after amputation.

Be aware that phantom pain is real and will eventually disappear. Administer pain medication; phantom pain responds to medication.

nursing interventions for postoperative thyroidectomy

Be prepared for the possibility of laryngeal edema. Put a tracheostomy set at the bedside along with O2 and a suction machine; calcium gluconate should be easily accessible.

What discharge instructions should be given to a client who has had urinary calculi?

maintain high fluid intake of 3-4L/day pursue follow up care for recurrent stones prescribe diet avoid supine position

What are the three most important tools for early detection of breast cancer? How often should these tools be used?

Breast self-examination monthly; mammogram baseline at age 35, followed by exams every 1 to 2 years in 40s and every year after age 50; physical examination by a professional skilled in examination of the breast

bolus insulin

mealtime insulin

A client in renal failure asks why he is being given antacids. How should the nurse reply?

Calcium and aluminum antacids bind phosphates and help to keep phosphates from being absorbed into the bloodstream, thereby preventing rising phosphate levels; must be taken with meals.

A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by his very hyperactive dog. He is wondering what symptoms would indicate the need to visit an emergency department. What should the nurse tell him to do?

Call his physician now and inform him or her of the fall. Symptoms needing medical attention would include vertigo, confusion or any subtle behavioral change, headache, vomiting, ataxia (imbalance), or seizure.

Write four nursing interventions for the care of the blind person and four nursing interventions for the care of the deaf person.

Care of blind: announce presence clearly, call by name, orient carefully to surroundings, guide by walking in front of client with his or her hand in your elbow. Care of deaf: reduce distraction before beginning conversation, look and listen to client, give client full attention if he or she is a lip reader, face client directly.

What activities and situations that increase ICP should be avoided?

Change in bed position, extreme hip flexion, endotracheal suctioning, compression of jugular veins, coughing, vomiting, and straining of any kind

Identify five foot-care interventions that should be taught to a client with diabetes.

Check feet daily, and report any breaks, sores, or blisters to health care provider; wear well-fitting shoes; never go barefoot or wear sandals; never personally remove corns or calluses; cut or file nails straight across; wash feet daily with mild soap and warm water.

How do clients experiencing angina describe that pain?

Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged

11. Describe the method of collecting the trough and peak blood levels of antibiotics.

Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of peak: Draw blood 30 minutes after administration of antibiotic.

Identify two types of hearing loss.

Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to eighth cranial nerve)

symptoms of pneumonia in an older client

Confusion, lethargy, anorexia, rapid respiration rate

List five important teaching aspects for clients who are beginning corticosteroid therapy.

Continue medication until weaning plan is begun by physician; monitor serum potassium, glucose, and sodium frequently; weigh daily, and report gain of >5 lb/wk; monitor BP and pulse closely; teach symptoms of Cushing syndrome.

Craniotomy preoperative medications

Corticosteroids to reduce swelling Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate [Robinul]) Agents to reduce seizures (phenytoin) Prophylactic antibiotics

4 components of teaching for the client with tuberculosis

Cough into tissues and dispose of immediately in special bags. Long-term need for daily medication. Good hand washing technique. Report symptoms of deterioration, e.g., blood in secretions.

What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis?

Diarrhea

1. List three potential causes of anemia.

Diet lacking in iron, folate, or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents, such as lead or insecticides

What activity recommendations should the nurse provide a client with rheumatoid arthritis?

Do not exercise painful, swollen joints. Do not exercise any joint to the point of pain. Perform exercises slowly and smoothly; avoid jerky movements.

Describe the priority nursing care for a client who has had radiation implants.

Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by small children. Confine client to room. Nurse must wear radiation badge. Nurse limits time in room. Keep supplies and equipment within client's reach.

effects of aortic aneurysm repair on the kidneys (reason + nursing interventions)

During aortic aneurysm repair, the large arteries are clamped for a period of time, and kidney damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dL, and normal creatinine is 0.6 to 1.2 mg/dL. The ratio of BUN to creatinine is 20:1. When this ratio increases or decreases, suspect renal problems.

List 4 symptoms of digitalis toxicity.

Dysrhythmias, headache, nausea, and vomiting

Describe postoperative residual limb (stump) care (after amputation) for the first 48 hours.

Elevate residual limb (stump) for first 24 hours. Do not elevate residual limb (stump) after 48 hours. Keep residual limb (stump) in extended position, and turn client to prone position three times a day to prevent flexion contracture.

patient teaching for preventing osteoporosis

Encourage exercise, a diet high in calcium, and supplemental calcium. Tums are an excellent source of calcium, but they are also high in sodium, so hypertensive or edematous individuals should seek another source of supplemental calcium.

immediate management of esophageal varices

Esophageal varices may rupture and cause hemorrhage. Immediate management includes insertion of an esophagogastric balloon tamponade (a Blakemore- Sengstaken or Minnesota tube). Other therapies include vasopressors, vitamin K, coagulation factors, and blood transfusions.

Differentiate between essential and secondary HTN.

Essential HTN has no known cause; secondary HTN develops in response to an identifiable mechanism.

What is the most important principle in a bowel management program for a client with neurologic deficits?

Establishment of regularity

Complications of immobility include the potential for thrombus development. State three nursing interventions to prevent thrombi.

Frequent range-of-motion exercises, frequent (every 2 hours) position changes, and avoidance of positions that decrease venous return.

What are the common food intolerances for clients with cholelithiasis?

Fried, spicy, and fatty foods

best indicator of level of protein consumption

GFR

What are the common side effects of salicylates?

GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation

CNS involvement related to cause of stroke:

Hemorrhagic: Caused by a slow or fast hemorrhage into the brain tissue; often related to HTN Embolic: Caused by a clot that has broken away from a vessel and has lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (so it may occur again).

Which STD is characterized by remissions and exacerbations in both males and females?

Herpes simplex type II

List three of the most common joints that are replaced.

Hip, knee, finger

List four groups who have a high risk for contracting hepatitis.

Homosexual males, IV drug users, those who have had recent ear piercing or tattooing, and health care workers

List five symptoms of hypoglycemia.

Hunger, lethargy, confusion, tremors or shakes, sweating

State three symptoms of hyperthyroidism and three symptoms of hypothyroidism.

Hyperthyroidism: weight loss, heat intolerance, diarrhea; Hypothyroidism: fatigue, cold intolerance, weight gain

When making rounds at night, the nurse notes that a client prescribed insulin is complaining of a headache, slight nausea, and minimal trembling.The client's hand is cool and moist.What is the client most likely experiencing?

Hypoglycemia/insulin reaction

What condition increases the likelihood that digitalis toxicity will occur?

Hypokalemia (which is more common when diuretics and digitalis preparations are given together)

What are the symptoms of spinal shock?

Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion

What condition results from all treatments for hyperthyroidism?

Hypothyroidism, requiring thyroid replacement

A client comes into the clinic with a chancre on his penis.What is the usual treatment?

IM dose of penicillin (such as benzathine penicillin G, 2.4 million units). Obtain a sexual history, including the names of his sex partners, so that they can receive treatment.

What vital sign changes are indicative of increased ICP?

Increased BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities, and temperature increase

List four nursing diagnoses for the comatose client in order of priority. (Remember Maslow's Hierarchy of Needs to help determine priorities.)

Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output

response of the immunosuppressed patient to infection

Infection in the immunosuppressed person may not be manifested with an elevated temperature.Therefore, it is imperative that the nurse perform a total and thorough assessment of the client frequently.

Describe the nurse's discharge instructions to a client with venous PVD.

Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm (but do not use heating pad), change position often, avoid crossing legs, wear unrestrictive clothing.

A 24-year-old is admitted with large areas of ecchymosis on both upper and lower extremities. She is diagnosed with acute myelogenous leukemia.What are the expected laboratory findings for this client, and what is the expected treatment?

Lab: Decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high) Treatment: Prevention of infection; prevention and control of bleeding; high-protein, high-calorie diet; assistance with ADL; drug therapy

Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac failure.

Left-sided failure results in pulmonary congestion due to backup of circulation in the left ventricle. Right-sided failure results in peripheral congestion due to backup of circulation in the right ventricle.

10. Describe the use of leucovorin.

Leucovorin is used as an antidote with methotrexate to prevent toxic reactions.

A client admitted with complaints of constipation, thready stools, and rectal bleeding over the past few months is diagnosed with a rectal mass.What are the nursing priorities for this client?

NPO NG tube (possibly an intestinal tube such as a Miller-Abbott) IV fluids Surgical preparations of bowel (if obstruction is complete) Foods and fluids are restricted for 8 to 10 hours before surgery if possible. If the patient has a bowel obstruction or perforation, bowel cleansing is contraindicated. Oral erythromycin and neomycin are given to further decrease the amount of colonic and rectal bacteria. If possible, all clients who require surgery for obstruction undergo NG intubation and suction before surgery. However, in cases of complete obstruction, surgery should proceed without delay Teaching (preoperative nutrition, etc.)

What diagnostic test is used to determine thyroid activity?

T3, T4

What measures should the nurse encourage female clients to take to prevent osteoporosis?

Possible estrogen replacement after menopause, high calcium and vitamin D intake beginning in early adulthood, calcium supplements after menopause, and weight-bearing exercise

Who is at highest risk for osteoporosis?

Postmenopausal, thin white women

Why are H2 inhibitors administered after a stroke?

Prevent peptic ulcers

12. List four nursing interventions for care of the client with Hodgkin disease.

Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional support to client and family.

Outline admission care of the burned client.

Provide a patent airway because intubation may be necessary. Determine baseline data. Initiate fluid and electrolyte therapy. Administer pain medication. Determine depth and extent of burn.Administer tetanus toxoid. Insert NG tube.

Identify the peak action time of the following types of insulin: rapid-acting regular insulin; intermediate-acting insulin; long-acting insulin.

Rapid-acting regular insulin: 2 to 4 hours; immediate-acting insulin: 6 to 12 hours; long-acting insulin: 14 to 20 hours

List five symptoms indicative of colon cancer.

Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss

indications of restlessness in patients with altered consciousness

Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not oversedate, and report any symptoms of restlessness.

Effect of sodium restrictions on vascular volume and preload

Restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload

Differentiate between rheumatoid arthritis and OA in terms of joint involvement.

Rheumatoid arthritis occurs bilaterally. OA occurs asymmetrically.

List the common clinical manifestations of jaundice.

Scleral icterus (yellow sclera), dark urine, chalky or clay-colored stools

What are the indications for a hysterectomy in a client who has fibromas?

Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain

Outline a teaching plan for a client with an STD.

Signs and symptoms of STD; mode of transmission; avoiding sex while infected; providing concise written instructions regarding treatment, and requesting a return verbalization to ensure that the client understands; teaching safer sex practices

List four signs of an inhalation burn.

Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs, including asymmetry of respirations, rales, or wheezing

List 3 nursing interventions for the client with a hiatal hernia.

Sit up while eating and for 1 hour after eating. Eat frequent, small meals. Eliminate foods that are problematic.

communicating techniques with older adults

Speak in a low-pitched voice, slowly and distinctly. Stand in front of the person, with the light source behind the client. Use visual aids if available.

3. Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client.

Stage I (emergent phase): Replacement of fluids is titrated to urine output. Stage II (acute phase): Patent infusion site is maintained in case supplemental IV fluids are needed; saline lock is helpful; colloids may be used. Stage III (rehabilitation phase): No extra fluids are needed, but high-protein drinks are recommended.

When preparing a client with diabetes for discharge, the nurse teaches the client the relationship between stress, exercise, bedtime snacking, and glucose balance. State the relationships among each of these.

Stress and stress hormones usually increase glucose production and increase insulin need. Conversely, exercise may increase the chance of an hypoglycemic reaction; therefore, the client should always carry a fast-acting source of carbohydrate, such as glucose tablets or hard candies, when exercising.

2. Burn depth is a measure of severity. Describe the characteristics of superficial partial-thickness, deep partial-thickness, and full-thickness burns.

Superficial partial-thickness, first degree: pink to red skin (e.g., sunburn), slight edema, and pain relieved by cooling Deep partial-thickness, second degree: destruction of epidermis and upper layers of dermis; white or red, very edematous, sensitive to touch and cold air, hair does not pull out easilyFull-thickness, third degree: total destruction of dermis and epidermis; reddened areas do not blanch with pressure; not painful; inelastic; waxy white skin to brown, leathery eschar

How should the head of the bed be positioned for postcraniotomy clients with infratentorial lesions?

Supratentorial: elevated; infratentorial: flat

List the symptoms and conditions associated with a cystocele.

Symptoms include incontinence or stress incontinence, urinary retention, and recurrent bladder infections. Conditions associated with cystocele include multiparity, trauma in childbirth, and aging.

What type of fracture is more difficult to heal: an extracapsular fracture (below the neck of the femur) or an intracapsular fracture (in the neck of the femur)?

The blood supply enters the femur below the neck of the femur.Therefore, an intracapsular fracture heals with greater difficulty, and there is a greater likelihood that necrosis will occur because the fracture is cut off from the blood supply.

What is the relationship of the kidneys to the cardiovascular system?

The kidneys filter about 1 L of blood per minute. If cardiac output is decreased, the amount of blood going through the kidneys is decreased; urinary output is decreased. Therefore, a decreased urinary output may be a sign of cardiac problems. When the kidneys produce and excrete 0.5 mL of urine/kg of body weight or average 30 mL/hr output, the blood supply is considered to be minimally adequate to perfuse the vital organs.

During the oliguric phase of renal failure, protein should be severely restricted.What is the rationale for this restriction?

Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly from protein catabolism.

differentiating teaching point with lupus erythematosus from other connective tissue diseases

avoiding sunlight

Which type of vaccine of invalidates a TB test?

bacillus Calmette-Guerin (BCG) leads to false positive; must do chest radiograph

high-potassium foods to avoid in hyperkalemic patients

bananas orange juice cantaloupe strawberries avocados spinach fish salt substitutes

physical findings with emphysema

barrel chest dry/productive cough decreased breath sounds dyspnea crackles

pink puffer

barrel chest indicative of emphysema caused by use of accessory muscles to breath oxygen intake is still adequate for perfusion

assessment for patients with myasthenia gravis

be alert for changes in respiratory status; the most severe involvement may result in respiratory failure.

What are frequent post-op complications of transurethral resection of the prostate gland (TURP)?

bladder spasms Inform the client that the presence of the oversized balloon on the catheter (30 to 45 mL inflated) will cause a continuous feeling of needing to void.The client should not try to void around the catheter because this can precipitate bladder spasms. Medications to reduce or prevent spasms should be given. bleeding large amounts should be reported

Why do clients with diabetes have trouble with wound healing?

blood glucose contributes to damage of the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary elasticity and promotes problems such as diabetic retinopathy, poor healing of breaks in the skin, and cardiovascular abnormalities.

_________ is a good indicator of fluid retention and renal status; obtain it on all clients with renal failure.

body weight measure at the same time on the same scale

Instillation of the hypertonic or hypotonic solution into a body cavity will cause a shift in ___________.

cellular fluid. Use only sterile saline for bladder irrigation after TURP because the irrigation must be isotonic to prevent fluid and electrolyte imbalance.

most commonly communicable disease in the US

chlamydia

blue bloater

chronic bronchitis insufficient oxygenation leads to generalized cyanosis and right-sided heart failure

tracheostomy care

cleansing the inner cannula suctioning applying clean dressings

purpose of a Holter monitor

continuous observation of heart rate

What should you do if a chest tube becomes disconnected from the patient?

cover with dray sterile dressing cover 3 sides; do not occlude notify the provider

Why are steroids administered after a stroke?

decrease cerebral edema and retard permanent disability

4 nursing interventions for assisting the client to cough productively

deep breathing 3L/day fluid in take humidifier suction airway

How does the nurse prevent hypoxia during suctioning?

deliver 100% oxygen before and after suctioning

cardioversion

delivery of synchronized electrical shocks to the myocardium

effects of opiate drugs on gastric motility

depress gastric motility assess for abdominal distention, pain, rigiditiy increased HR, decreased BP (signs of shock that indicate possible perforation)

Which medication's serum level is of particular importance in renal failure?

digoxin toxicity

What affect does decreased blood flow have on lower extremities?

diminished sensation any heat source can cause severe burns before the client realizes the damage is being done

fetor hepaticus

distinctive breath odor of chronic liver disease furisty or musty odor that results from the damaged liver's inability to detoxify mercaptan

s/s of hyperkalemia

dizziness weakness cardiac irregulatrities muscle cramps diarrhea nausea

What should you do if a chest tube becomes disconnected from the box?

do not clamp place the end of the tube in a container of sterile water

important aspect of treatment for Parkinson disease

drug therapy acetylcholine dopamine

What symptoms should the nurse expect to find in a client with hypokalemia?

dry mouth thirst drowsiness/lethargy muscle weakness and aches tachycardia

major emphasis in nursing management of cancers of the reproductive tract

early detection

Why does fever cause dehydration?

excessive fluid loss due to diaphoresis increased temperature increased metabolism increase O2 demands

location of pain in relation to kidney stones (flank, abdomen)

flank = stone is in kidney or upper ureter abdomen/scrotum = ureter or bladder

What does tidaling in the chest tube indicate?

fluctuations in the fluids will occur if there is no external suction this is a good indicator that the system is intact if fluctuations cease, check for kinked tubing, accumulation of fluid, or client repositioning

List 5 essential elements of a teaching plan for clients with frequent urinary tract infections.

fluid intake 3L/day handwashing void every 2-3 hours while awake take all prescribed medicaitons wear cotton underwear

ROM with bed rest or immobilized clients

frequent ROM and very frequent position changes any position that decreases venous return is dangerous

signs of pericarditis

friction rub ST-segment elevation T-wave inversion

risk factors for hypertension

heredity race age alcohol abuse increased salt intake obesity use of oral contraceptives

signs of a fat embolism

hypoexemia Assess for respiratory distress, restlessness, irritability, fever, and petechiae.

If in doubt as to whether a client is hyperglycemic or hypoglycemic, treat for ________________.

hypoglycemic

Side effects of digitalis are increased when the client is ________________.

hypokalemic

signs of worsening COPD

hypoxemia hypercapnia respiratory acidosis

common complication of joint replacement

infection

Describe preoperative nursing care for a client undergoing a laryngectomy

invovle family in manipulation of equipment before surgery plan communciation methods refer to speech pathologist discuss rehab program

Why are chest tubes not used following the resection of large lung tumors?

it is helpful if the mediastinal cavity, where the lungs used to be, fills up with fluid this helps to prevent the shift of the remaining chest organs into filling the empty space

A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client suffered a lesion?

left

nursing interventions during oliguric phase of ARF

limit protein intake minimizes protein breakdown and prevents rise in BUN

mitral valve stenosis

narrowing of the mitral valve from scarring, usually caused by episodes of rheumatic fever blood is regurgitated back into the left atrium from the left ventricle In the early period, there may be no symptoms, but as the disease progresses, the client will exhibit excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema. There will be a rumbling apical diastolic murmur, and atrial fibrillation is common.

elevation of residual limbs

one pillow too high = contracture

5 Ps of neurovascular functioning

pain, paresthesia, pulse, pallor, and paralysis

treatment for ascites

paracentesis, and peritoneovenous shunts

common complication in comatose clients

paralytic ileus

major difference between dialysate for hemodialysis and peritoneal dialysis

peritoneal dialysis is much higher in glucose if left in the peritoneal cavity too long, hyperglycemia may occur

primary intracellular ions

potassium and phosphate

diverticulosis

presence of pouches in the wall of the intestine no discomfort and unnoticed until radiology

antithyroid drugs

propylthiouracil and methimazole

early sign of colon cancer

rectal bleeding

After kidney surgery, what are the primary assessments the nurse should make?

respiratory status (breathing is guarded because of pain) circulatory status (the kidney is vascular and excessive bleeding can occur) pain assessment urinary assessment (most important, assessment of urinary output)

signs of increased ICP

restlessness irritability confusion

What is the highest priority nursing diagnosis for clients in any type of renal failure?

risk for imbalanced fluid volume

Which bed position facilitates a productive cough and comfort?

semi-Fowler high-Fowler

positioning that reduces acute pancreatic pain

sitting up or leaning forward pain is located retroperitoneally

common complications with immobile clients

skin integrity urinary calculi venous thrombosis

primary cause of COPD

smoking

primary extracellular ions

sodium and chloride

diets for respiratory dysfunction

soft mechanical

What are the most important nursing interventions for clients with possible renal calculi?

straining urine accurate I/O documentation administer analgesics as needed

After the urinary catheter is removed in the TURP client, what are 3 priority nursing actions?

strict Is/Os observe for hematuria inform client burning and frequency may last for a week

What precautions should clients with valve disease take prior to invasive procedures or dental work?

take prophylactic antibiotics

patient teaching for steroids

take with meals to prevent gastric irritation never skip doses if N/V persists 12-24+ hours, contact HCP

patient teaching for coughing with laryngectomy clients

teach glottal stop technique: - take deep breath - momentarily occlude the tracheostomy tube - cough - simultaneously remove the finger from the tube

patient teaching for drug combination to treat TB

teach reasoning for increased compliance resistance to drugs develops slowly if several are being used at once

Blood pressure is created by _______

the difference in pressure of the blood as it leaves the heart and the resistance it meets flowing out to the tissues

i pact of laryngectomy on air humidification

the natural humidifying pathway is gone for the client secretions thicken and crust

List three problems associated with immobility.

Venous thrombosis, urinary calculi, skin integrity problems

Define stroke.

A disruption of blood supply to a part of the brain, which results in sudden loss of brain function

What is the primary cause of uremia?

Accumulation of waste products from protein metabolism Restrict protein in CRF clients

#1 cause of stroke in HTN clients

noncompliance with medication regimen

s/s of glaucoma

often painless and symptom free usually detected as part of a regular eye examination

A woman who had a stroke 2 days earlier has left-sided paralysis. She has begun to regain some movement in her left side.What can the nurse tell the family about the client's recovery period?

"The quicker movement is recovered, the better the prognosis is for full or improved recovery. She will need patience and understanding from her family as she tries to cope with the stroke. Mood swings can be expected during the recovery period, and bouts of depression and tearfulness are likely."

s/s of deficient fluid

- decreased urine output - reduction in body weight - decreased skin turgor - dry mucous membranes - hypotension - tachycardia - weight loss

patient teaching for TB

- long term drug therapy (6+ months) - drug adherence is vital (public health hazard can result from premature termination)

signs of digoxin toxicity

- nausea/vomiting - anorexia - visual disturbances - restlessness - headache - cardiac dysrhythmias - bradycardia (<60bpm)

List four rationales for the appearance of restlessness in the unconscious client.

Anoxia, distended bladder, covert bleeding, or a return to consciousness

American Cancer Society recommendations for early detection of colon cancer

A digital rectal examination (DRE) every year after 40. A stool blood test every year after 50. A colonoscopy or sigmoidoscopy examinationevery 10 years after the age of 50 in average-risk clients, or more often based on the advice of a physician.

A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have?

A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae

What precautions are required for clients with TB when placed on respiratory isolation?

A mask for anyone entering room; private room; client must wear mask if leaving room.

percutaneous nephrostomy

A needle or catheter is inserted through the skin into the calyx of the kidney. The stone may be dissolved by percutaneous irrigation with a liquid that dissolves the stone or by ultrasonic sound waves (lithotripsy) that can be directed through the needle or catheter to break up the stone, which then can be eliminated through the urinary tract.

Drug therapy for MS clients:

ACTH, cortisone, cyclophosphamide (Cytoxan), and other immunosuppressive drugs. Nursing implications for administration of these drugs should focus on the prevention of infection.

To make assessment of the Holter monitor's rhythm strips most meaningful, teach the client to keep a record of:

• Medication times and doses • Chest pain episodes: type and duration • Valsalva maneuver (straining at stool, sneezing, coughing) • Sexual activity • Exercise and other activities

Cite two nursing diagnoses for a client undergoing a hysterectomy for cervical cancer.

Altered body image related to uterine removal; pain related to postoperative incision

In your own words, describe the Glasgow Coma Scale

An objective assessment of the level of consciousness based on a score of 3 to 15, with scores of 7 or less indicative of coma

List 4 categories of medications used in the treatment of PUD.

Antacids, H2 receptor blockers, mucosal healing agents, proton pump inhibitors

What types of drugs are used in the treatment of myasthenia gravis?

Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to promote the accumulation of acetylcholine at receptor sites; this should improve neuronal transmission to muscles.

Words that describe losses in strokes:

Apraxia: inability to perform purposeful movements in the absence of motor problems Dysarthria: difficulty articulating Dysphasia: impairment of speech and verbal comprehension Aphasia: loss of the ability to speak Agraphia: loss of the ability to write Alexia: loss of the ability to read Dysphagia: dysfunctional swallowing

Name three priorities to include in a discharge plan for a client who has had a mastectomy.

Arrange for Reach to Recovery visit. Discuss the grief process with the client. Have physician discuss with client the reconstruction options.

Diet recommended by the American Cancer Society to prevent bowel cancer:

Eat more cruciferous vegetables (those from the cabbage family, such as broccoli, cauliflower, Brussels sprouts, cabbage, and kale). Increase fiber intake. Maintain average body weight. Eat less animal fat.

State four independent nursing interventions to maintain adequate respiration, airway, and oxygenation in the unconscious client.

Position for maximum ventilation (prone or semiprone and slightly to one side); insert airway if tongue is obstructing; suction airway efficiently; monitor arterial Po2 and Pco2; and hyperventilate with 100% O2 before suctioning.

What lifestyle changes can the client who is at risk for HTN initiate to reduce the likelihood of becoming hypertensive?

Cease cigarette smoking, if applicable; control weight, exercise regularly, and maintain a low-fat, low-cholesterol diet.

Identify two nursing interventions for the client on hemodialysis.

Do not take BP or perform venipuncture on the arm with the AV shunt, fistula, or graft. Assess access site for thrill and bruit.

What instructions should be given to a client following radiation therapy?

Do not wash off lines; wear soft cotton garments; avoid use of powders and creams on radiation site.

9. List three safety precautions for the administration of antineoplastic chemotherapy.

Double-check order with another nurse. Check for blood return prior to administration to ensure that medication does not go into tissue. Use a new IV site daily for peripheral chemotherapy.Wear gloves when handling the drugs, and dispose of waste in special containers to avoid contact with toxic substances.

What bowel sound disruptions occur with an intestinal obstruction?

Early mechanical obstruction: high-pitched sounds; late mechanical obstruction: diminished or absent bowel sounds

Develop a teaching plan for a client taking antihypertensive medications.

Explain how and when to take medication, reason for medication, necessity of compliance, need for follow-up visits while on medication, need for certain lab tests, and vital sign parameters while initiating therapy.

use of eye drops in glaucoma

Eye drops are used to cause pupil constriction because movement of the muscles to constrict the pupil also allows aqueous humor toflow out, thereby decreasing the pressure in the eye. Pilocarpine is commonly used. Caution client that vision may be blurred for 1 to 2 hours after administration of pilocarpine and that adaptation to dark environments is difficult because of pupillary constriction (the desired effect of the drug).

How should the nurse administer pancreatic enzymes?

Give with meals or snacks. Powder forms should be mixed with fruit juices.

7. Name three food sources of vitamin B12.

Glandular meats (liver), milk, green leafy vegetables

What are the symptoms of autonomic dysreflexia?

HTN, bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia

13. List four topics you would cover when teaching an immunosuppressed client about infection control.

Handwashing technique.Avoid infected persons.Avoid crowds. Maintain daily hygiene to prevent spread of microorganisms.

Headache and vomiting are symptoms of many disorders.What characteristics of these symptoms would alert the nurse to refer a client to a neurologist?

Headache that is more severe upon awakening, and vomiting not associated with nausea are symptoms of a brain tumor.

Nutritional status is a major concern when caring for a burned client. List three specific dietary interventions used with burned clients.

High-calorie, high-protein, high-carbohydrate diet; medications with juice or milk; no "free" water; tube feeding at night. Maintain accurate, daily calorie counts.Weigh client daily.

In fewer than 10 steps, describe the method of drawing up a mixed dose of insulin (regular with NPH).

Identify the prescribed dose and type of insulin per physician order; store unopened insulin in refrigerator. Opened insulin vials may be kept at room temperature. Draw up regular insulin first; rotate injection sites; may reuse syringe by recapping and storing in refrigerator.

effect of fever on cerebral metabolism/edema

If temperature elevates, take quick measures to decrease it, because fever increases cerebral metabolism and can increase cerebral edema.

List four nursing interventions for postoperative care of a client with a colostomy.

Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap and water after each ostomy bag change; ensure that pouch opening extends at least 1⁄8 inch around the stoma.

What nursing interventions prevent corneal drying in a comatose client?

Irrigation of eyes PRN with sterile prescribed solution, application of ophthalmic ointment every 8 hours, close assessment for corneal ulceration or drying

early signs of cerebral hypoxia

Irritability and restlessness

Nonsurgical management of a client with cholecystitis includes:

Low-fat diet Medications for pain and clotting if required Decompression of the stomach via NG tube

Describe the physical appearance of clients who have Cushing syndrome.

Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin skin

Identify the categories of drugs commonly used to treat arthritis.

NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteroids (used when arthritic symptoms are severe)

Why should narcotics be avoided in clients with neurologic impairment?

Narcotics mask the level of responsiveness and pupillary responses.

Which cardiac medications would be appropriate for acute angina

Nitroglycerin - causes dilation of the coronary arteries, allowing more oxygen to get to the heart muscle NOT APPROPRIATE: digoxin, atropine, propranolol

What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?

Notify physician stat, draw blood gases, administer O2 according to blood gas results, assist with endotracheal intubation and treatment of respiratory failure.

Name the necessary elements to include in teaching a client newly diagnosed with diabetes.

The underlying pathophysiology of the disease; its management and treatment regimen; meal planning; exercise program; insulin administration; sick-day management; symptoms of hyperglycemia (not enough insulin); symptoms of hypoglycemia (too much insulin, too much exercise, not enough food); foot care

Describe the method of extinguishing each of the following burns: thermal, chemical, and electrical.

Thermal: Remove clothing, immerse in tepid water. Chemical: Flush with water or saline. Electrical: Separate client from electrical source.

6. Identify two sites that should be assessed for infection in immunosuppressed clients.

Oral cavity and genital area

What lab values should be monitored daily in a client with thrombophlebitis who is undergoing anticoagulant therapy?

PTT PT Hbg Hct platelets

Describe intermittent claudication.

Pain related to PVD; the pain occurs with exercise and disappears with rest.

Clinical manifestations of GI bleeding:

Pallor: conjunctival, mucous membranes, nail beds Dark, tarry stools Bright red or coffee-ground emesis Abdominal mass or bruit Decreased BP, rapid pulse, cool extremities (shock), increased respirations

What screening tool is used to detect cervical cancer? What are the American Cancer Society's recommendations for women ages 30 to 70 with three consecutive normal results?

Pap smear.Women ages 30 to 70 with three consecutive normal results may have Pap smears every 2 to 3 years (screening for HPV).

American College of Obstetricians and Gynecologists (ACOG) 2009 recommendations regarding cervical cancer

Pap smears should begin at age 21 and women younger than 30 should be screened every 2 years; women 30 and older may be screened every 3 years after they have had three consecutive negative cervical cytology tests. Women ages 65 to 70 may stop Pap smears if they have three consecutive normal tests in a row and no abnormal Pap smears in the last 10 years. Women with high risk factors may need more frequent screenings.

What are the classifications of the commonly prescribed eye drops for glaucoma?

Parasympathomimetic for pupillary constriction; beta-adrenergic receptor-blocking agents to inhibit formation of aqueous humor; carbonic anhydrase inhibitors to reduce aqueous humor production; and prostaglandin agonists to increase aqueous humor outflow

List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems.

Passive ROM exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return

Who is at risk for stroke?

Persons with histories of HTN, previous TIAs, cardiac disease (atrial flutter or fibrillation), diabetes, or oral contraceptive use; and older adults

What immediate actions should the nurse implement when a client is having a myocardial infarction?

Place the client on immediate strict bed rest to lower O2 demands on heart; administer O2 by nasal cannula at 2 to 5 L/min; take measures to alleviate pain and anxiety (administer PRN pain medications and antianxiety medications).

List five symptoms of hyperglycemia.

Polydipsia, polyuria, polyphagia, weakness, weight loss

Describe three nursing interventions to help decrease edema postmastectomy.

Position arm on operative side on pillow. Avoid BP measurements, injections, and venipunctures in operative arm. Encourage hand activity and use.

Safety features for immobilized clients:

Prevent skin breakdown by frequent turning. Maintain adequate nutrition. Prevent aspiration with slow, small feedings or NG feedings. Monitor neurologic signs to detect the first signs that ICP may be increasing. Provide ROM exercises to prevent deformities. Prevent respiratory complications; frequent turning and positioning provide optimal drainage.

environments conductive to eating for patients who are anorexic or nauseated

Remove strong odors immediately; they can be offensive and increase nausea. Encourage client to sit up for meals; this can decrease the propensity to vomit. Serve small, frequent meals. Give antiemetic prior to eating.

What is the action of hyperosmotic agents (osmotic diuretics) used to treat ICP?

They dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent reabsorption, and by drawing fluid from the extravascular spaces into the plasma.

Difference in synchronous and asynchronous pacemakers

Synchronous, or demand: Pacemaker fires only when the client's heart rate falls below a rate set on the generator. Asynchronous, or fixed: Pacemaker fires at a constant rate.

relationship of synovial tissue to rheumatoid arthritis

Synovial tissues line the bones of the joints. Inflammation of this lining causes destruction of tissue and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction. Often the disease goes into remission. Decreasing the amount of bone and joint destruction reduces the amount of disability.

4 common symptoms of pneumonia

Tachypnea, fever with chills, productive cough, bronchial breath sounds

Develop a teaching plan for a client taking nitroglycerin.

Take at first sign of anginal pain. Take no more than three, 5 minutes apart. Call for emergency attention if no relief in 10 minutes.

What is the causative organism of syphilis?

Treponema pallidum (spirochete bacteria)

Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD?

Trichomonas vaginalis

effects of restraints and narcotics on patients with head injuries

Try not to use restraints; they only increase restlessness. Avoid narcotics because they mask the level of responsiveness.

4. What actions should the nurse take if a hemolytic transfusion reaction occurs?

Turn off transfusion.Take temperature. Send blood being transfused to lab. Obtain urine sample. Keep vein patent with normal saline.

Which type of diabetes always requires insulin replacement?

Type 1

Which type of diabetes sometimes requires no medication?

Type 2

common cause of death after SCI

UTI Bacteria grow best in alkaline media, so keeping urine dilute and acidic is prophylactic against infection.Also, keeping the bladder emptied assists in avoiding bacterial growth in urine that has stagnated in the bladder.

List the symptoms of upper and lower GI bleeding.

Upper GI: melena, hematemesis, tarry stools; lower GI: bloody stools, tarry stools; common to both: tarry stools

5. List three interventions for clients with a tendency to bleed.

Use a soft toothbrush, avoid salicylates, do not use suppositories.

A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the nurse use, and which methods would the nurse not use?

Use inspection, palpation, and strength testing. Do not assess range of motion (ROM); this activity promotes pain because ROM is limited.

Self-monitoring of blood glucose (SMBG):

Uses techniques that are specific to each meter Frequency of monitoring based on treatment regimen, change in meals, illness, and exercise regimen Requires recording results and reporting results to health care provider at time of visit Results of monitoring used to assess the efficacy of therapy and to guide adjustments in medical nutrition therapy, exercise, and medications to achieve the best possible blood glucose control

considerations during an addisonian crisis

Vascular collapse: Hypotension and tachycardia occur; administer IV fluids at a rapid rate until stabilized. Hypoglycemia: Administer IV glucose. Essential to reversing the crisis: Administer parenteral hydrocortisone. Aldosterone replacement:Administer fludrocortisone acetate (Florinef) PO (available only as oral preparation) with simultaneous administration of salt (sodium chloride) if client has a sodium deficit.

A client is admitted with severe chest pain and states that he feels a terrible tearing sensation in his chest. He is diagnosed with a dissecting aortic aneurysm.What assessments should the nurse obtain in the first few hours?

Vital signs every hour Neurologic vital signs Respiratory status Urinary output Peripheral pulses

key to respiratory status

assessment of breath sounds visualization of client if breath sounds are clear but the client is cyanotic and lethargic, adequate oxygenation is not occurring

What is often the underlying cause of an abdominal aortic aneurysm?

atherosclerosis

Identify pain relief interventions for clients with arthritis.

Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and medications

Why is the burned client allowed no "free" water?

Water may interfere with electrolyte balance. Client needs to ingest food products with highest biologic value.

When can a comatose client on IV hyperalimentation begin to receive tube feedings instead?

When peristalsis resumes as evidenced by active bowel sounds, passage of flatus or bowel movement

What is the anatomic significance of a prolapsed uterus?

When the uterus is displaced, it impinges on other structures in the lower abdomen.The bladder, rectum, and small intestine can protrude through the vaginal wall.

When do PVCs present a grave danger?

When they begin to occur more often than once in 10 beats, occur in twos or threes, land near the T wave, or take on multiple configurations

clinical manifestations of jaundice

Yellow skin, sclera, or mucous membranes (bilirubin in skin) Dark-colored urine (bilirubin in urine) Chalky or clay-colored stools (absence of bilirubin in stools)

assessment for TB skin test

a positive test is exhibited by an induration of 10mm or greater after 48-72 hours

precipitating factors for myxedema coma

acute illness withdrawal of thyroid medicaiton anesthesia/sedatives hypoventilation

pain medication for kidney stone attacks (PRN vs. scheduled)

administer at regularly scheduled intervals rather than PRN to prevent spasm and optimize comfort

When does permanent paralysis being to occur with a compressed spinal cord?

after 12-24 hours

Preexisting conditions that might influence burn recovery

age, chronic illness (diabetes, cardiac problems, etc.), physical disabilities, disease, medications used routinely, and drug or alcohol abuse.

correction factor

amount of insulin needed to correct hyperglycemia, usually given pre-meal

common complication of bone fractures

anemia check hct every 3-4 days to monitor erythropoiesis

Where are bronchial breath sounds located?

areas of density or consolidation