NCLEX

assessment of non-responsive client response to pain

-begin with least noxious stimulation and proceed to more -start with speaking to them then trapezius squeeze, supraorbital pressure, mandibular pressure, sternal rub -if not response to central, then try peripheral -place pencil sideways on top of nailbed and push hard

medical asepsis

-clean technique (inhibits growth and spread of pathogens) -example: (3 minute handscrub before entering newborn nursery, use of hand sanitizer when caring for newborns, changing linens 1x day)

what should be offered to child who is vomiting

-clear liquids first -then full liquids

absence of fluctuation in water seal chamber

-client either has re-expanded lung -or there is a blockage in the drainage tube -most common obstruction: client laying on the tube (kinking, loops, clot, fibrin)

esophageal speech

-a method of swallowing air, trapping it in the esophagus, and releasing it to create sound -used with total laryngectomy

anhydrosis

-absence of sweat

cardiac assessment

-inspect, palpate, auscultate

tonometer

-instrument used to measure intraoccular pressure -diagnoses glaucoma -normal pressure is 10-21 mmHg

secondary health intervention for hypertension

-monitor BP -monitor cholesterol

furosemide

-morning medication or 6-8 hours before bed

uric acid stones

-occur in patients with gout -avoid high purine diet like organ meats

1 hour after 7 units of insulin the patient presents with diaphoresis, pallor, and tachycardia, what is the nurses best action

-offer milk and crackers -give glucagon if the client is unresponsive

patients likely to experience complications with general anesthesia

-older -smokers -obese -sleep/seizure disorders -co-morbid hypertension or diabetes mellitus -undergoing complex/lengthy procedures

paradoxical reactions

-opposite effect as was intended -elderly clients are prone to these reactions

phlebitis

-pain and redness at IV site and along the vein -trt: remove IV immediately, apply warm soaks to decrease pain and swelling, stop infusion, notify HCP if signs are severe, if not severe just document

first action for nurse when client reports water breaking

assess and auscultate fetal heart rate -need to assess fetal well-being -should be between 120-160

best time to take prenatal vitamins

at bedtime with some food or something acidic to increase iron absorption and decrease nausea

intervention post trach placement

auscultate lungs then x-ray to verify placement

nursing interventions for apsirin OD

charcoal, if given within two hours of aspirin OD will bind to aspirin and absorb it

cirrhosis

liver disorder caused by cell damage risk: portal hypertension, esophageal varices, ascites, hepatic encephalopathy, death

non-stress test

looks for acceleration of fetal heart rate in reaction to fetal activity good results: 2+ fetal HR accelerations of 15 bpm lasting 15 sec over a 20 minute interval

diverticulosis diet

low fat, high fiber

food for hyperemesis gravidarum

low-fat foods and easily digested carbs

p24 antigen assay

indicates how well the immune system is working

care post lumbar puncture

-fluids are not restricted before test -remain flat for 8 hours after to prevent headache -nerve endings may be touched -analgesics provided after

permethrin cream

-for scabies

when should the client notify the HCP about fetal movements

-if the client notices the fetus moving less frequently -if it takes longer to note 10 movements -if the fetus doesn't move in the morning -less than 3 movements in 8 hours

nursing intervention for fetal hear decelerations with nonstress test

-immediately report to HCP

lactose intolerance

-impaired ability to digest lactose due to reduced amounts of the enzyme lactase -undigested lactose builds up in colon causing gas production s/s: bloating, abdominal pain, flatulence need: calcium and vitamin D, salmon, rhubarb, spinach, cereal, non-dairy creamer, lactaid, yogurt with bacterial lactaid

surgical time out

-in OR -includes at least all staff agreeing on client identity, correct site, and procedure to be performed

interventions for abdominal aortic aneurysm

-increase intake of fluid and fiber -prevents constipation and decreases risk of straining during bowel movements

s/s of panic attack

-increased BP -increased HR -narrow visual field -diaphoresis -fear of going crazy

cushings syndrome

-increased infection risk -diet: low carb, low sodium, high protein

diet for patient with respiratory failure

-increased protein -decreased carbs (metabolism of carbs can cause increased carbon dioxide production)

cushings triad

-increased systolic BP, widening pulse pressure, bradycardia -all are signs of increased ICP, normal ICP is 5-15

client with depression saying things are better and they will be leaving soon

-indicates they may be making an indirect suicide threat with a plan -nurse should clarify statement as this client could be in immediate danger

acid-fast bacillus

-indication of pulmonary tuberculosis -place in airborne precautions with 6-12 air exchanges per hour

how soon should client ambulate post hysterectomy

-indwelling cath first 24 hours -early ambulation to prevent thromboembolism -use incentive spirometry -cough/deep breathe -avoid heavy lifting/strenuous activity

best way to prevent community acquired pneumonia

-influenza vaccine

incentive spirometer

-inhale and hold breath for 3-5 seconds -used post surgically to expand alveoli and prevent atelectasis

worst way to be exposed to chemical

-inhaling (results in immediate absorption and can impair oxygen exchange, client should be assessed fist to ensure airway patency and adequate breathing)

important assessment post thyroidectomy

-injury to parathyroid gland may cause decreased serum calcium -assess tingling around mouth, toes, fingers, and muscular twitching

nursing action if salem sump tube has stomach contents in it

-insert 30 mL of air into the air vent and re-establish proper suction

proper technique for endotracheal tube suctioning

-insert suction catheter unit until resistance is met without applying suction -withdraw 0.4-0.8 inches -apply intermittent suction with twirling motion

if chest tube to water-seal drainage comes unattached while moving client, what is the best response

-insert the tubing into a container of sterile water solution

first instruction for client with abdominal pain before palpating abdomen

-instruct client to breathe slowly

what happens if PN nutrition is abruptly stopped

-insulin levels remain high while glucose levels decline -may lead to hypoglycemia -s/s: diaphoresis, confusion, tachycardia, restlessness, headache, weakness, irritability, apprehension, decreased muscle coordination

what does a bruit heard over an abdominal aorta indicate

-most often means that an aneurysm is present -notify HCP immediately -s/s: back or lower abdominal pain, SOB, difficulty swallowing, hypertension, serious risk of aortic hypertension

result of bacterial infection in older client on labs

-minimal leukocytosis -an increased in the number of WBC -older adults may not develop leukocytosis

interventions for client with heartbeat of 160 bpm

-monitor BP -alert RRT -obtain 12 lead ECG

external electric fetal monitor

-monitors fetal heart rate -monitors changes r/t length and strength of contractions -1st step: get baseline fetal heart rate

pernicious anemia

-monthly vitamin b12 injections -s/s: pallor, slight jaundice, glossitis, fatigue, weight loss, paresthesias of hands and feet, change in balance/gait

The client is admitted to the emergency room reporting crushing chest pain, shortness of breath, and left arm pain. Which action, if taken by the nurse, is BEST?

-morphine sulfate.

cleft palate

-most common birth defect in the US causes: genetics and environmental factors (maternal cigarette smoking, alcohol use, prescription drugs, steroids, retinoids, anticonvulsants) -surgical repair occurs at 2-3 months old -after surgery, provide suture line protection and care -avoid prone position -use a soft-flow nipple, plastic squeeze bottle, and syringe feedings until the suture line heals -no tongue depressors, thermometers, small spoons, or straws for 6 weeks after surgery -no cookies, toast, or other hard foods immediately after -feed in upright position

lyme diseae

-most common tick-borne disease -bullseye rash is common -test is done 4-6 weeks after the bite to observe for antibody formation process

acute hemolytic reaction

-most dangerous type of reaction s/s: nausea, vomiting, lower back pain trt: stop blood, obtain urine, maintain blood volume and kidney perfusion

post AKA care

-prosthesis may be fitted immediately or after further healing -phantom limb pain is common -early ambulation is encouraged with or without a prosthetic -anti-seizure medications can be good for phantom limb pain

primary goal in acute care of spinal cord injury

-protect spine from strain and further damage while spine injury heals

expected orders for VTE

-warm, moist pack to affected leg -elevate foot of bed 6 inches -bed-rest until heparin therapy is started -elastic stockings on unaffected leg

good gift for parkinson patient

-warming trays for food -client with parkinson eats slowly and this choice is a good gift for them

interventions for cystic fibrosis

enzyme replacement therapy increase salt in the diet physical activity as tolerated unrestricted fat diet multi-disciplinary care like social service referral

how often should incentive spirometer be used post knee replacement

every 1-2 hours

sub-involution

failure of uterus to return to normal size in the postpartum period

initial indications of hepatic dysfunction

fatigue, dark urine

what does passing stool in utero indicate

fetal distress, nurse should suction with bulb syringe as soon as possible

positive sweat test

finding for cystic fibrosis, positive for chloride in the sweat

naegles rule

first day of LMP - 3 day +7 days + 1 year (example: if LMP was may 5, edd= february 12)

moist to dry dressing

free dressing dry surrounding skin moisten the prescribed number of gauze w/ solution apply moist gauze as a single layer cover with dry dressing

how to prevent uti

frequent voiding wipe front to back avoid baths, shower instead avoid coffee and alcohol take vitamin c (1000 mg/day) or drink cranberry juice

if you have an attention seeking client, what is the best response from the nurse

give patient unsolicited attention when displaying appropriate behavior

when to give oxytocin for placental expulsion

given after placenta separates from uterine wall s/s: gush of blood, cord extending from vagina, uterus contracting

removing PPE

gloves, goggles, gown, mask, wash hands

GTPAL

gravida (# of pregnancies) term (38th-42nd week) preterm (preterm deliveries, from viability to 37 weeks) abortion (both surgical and miscarriages) living (living children)

lead levels

greater than 5mcg/dL: need for further testing greater than 45 mcg/dL: need for treatment If elevated can lead to neurologic impairment, poor coordination, sleep disturbance.

color of stool during first week of newborn life

greenish during the transition from meconium to breastfed

fetal alcohol syndrome

group of birth defects caused by the effects of alcohol on an unborn child s/s: smooth philtrum (between nose and upper lip), thin upper lip, upturned nose, flat nasal bridge and midface, epicanthal folds, small palpebral fissures, small head, low birth weight, hyperactivity)

best therapy for survivors of intimate partner violence

group therapy

normal breathing sounds over trachea

harsh, hollow sound

purpose of round foam disk on central venous catheter

has anti-microbial properties (chlorhexidine) to help prevent infection -disc should not be changed more than once a week unless client reports pain

ECT expected effects

headache, disrupted memory (short/long term), general confusion

meniere's syndrome

inner ear disorder causing episodes of spinning -trt: low sodium, no tobacco, no caffiene, no chocolate, use diuretics, antihistamines, and sedatives

s/s of cannabis withdrawal

insomnia, hyperactivity, decreased appetite

best way to observe for jaundice in biocultural patients

inspect the hard palate -signs of early jaundice are best observed on the posterior hard palate in patients of asian descent

battery

intentional touching without consent

mongolian spot

irregular blue/gray area over the sacrum of a newborn -gradually fades over months-years -common with mediterranean, latin, or asian descent -assure parents it is normal and will go away

biot respirations

irregular breathing pattern like 3-4 normal respirations and then a short period of apnea with cycles lasting 10 seconds to 1 minute expected in head trauma patients

nursing interventions for detached retina

medical emergency 1) bed rest 2) lay on affected side 3) elevate HOB to relieve eye pressure 4) patient is NPO

heart rate for normal rhythm

count the number of small boxes between two R waves 1500/# of boxes = heart rate

when can isolation be stopped with client with meningitis

-24 hours after the start of antibiotic therapy

sign of complication post craniotomy

-4000 mL urine/24 hours -indicates surgically induced DI

catheter with distended bladder

-clamp device after 500 mL of drainage has been released to avoid damage to bladder wall -resume 5-10 minutes later

effect of potassium on cardiac monitor

hypokalemia: prominent U waves hyperkalemia: P wave flattening, wide QRS, peaking of the T wave

Disseminated Intravascular Coagulation (DIC)

-abnormal blood clotting in small vessels throughout the body that cuts off the supply of oxygen to distal tissues, resulting in damage to body organs -adverse effect of septic shock, causes bleeding at cath site -early signs: full bladder, pulse with increased RR, cool clammy or pale skin

tardive dyskinesia

-abnormal facial/tongue movements -trt: decrease or discontinue antipsychotic medication

important nurse intervention before spinal anesthesia

-adequately hydrate patient -strong side effect is hypotension

intervention prior to spinal anesthesia

-adequately hydrate the patient to prevent hypotensive problems after the spinal anesthesia is initiated

post-amputation care

-administer pain meds and evaluate effectiveness -teach relaxation, visualization, and deep breathing -splint, support, and elevate extremity -prone position to avoid hip contractures -if bloody or increase in drainage, notify HCP -initial post operative period: elevate limb to decrease edema -do not elevate for more than 24 hours -during first 24 hours, client should lay prone for a short period of time -after 24 hours, client should lay prone for 30 minutes, 3 times a day -perform active ROM exercises to strengthen non-operative leg

when should pregnant client receive rubella vaccine

-after delivery

what increases the risk of thrombosis with pregnancy

-age over 35 -c-section birth -obesity -varicose veins -forcep use during delivery -woman is at risk for another 6 weeks post delivery

risks for developing chronic kidney disease

-age over 60 years old -family history -older african americans -vascular and autoimmune disorders -hypertension -urinary obstructions -diabetes mellitus

what is happening when IV tube is detached, client is cough, SOB, and cyanotic

-air embolism -s/s: respiratory distress, chest pain, hypotensive, tachycardic -trt: give oxygen, clamp catheter, put client on left side with head down -valsalva maneuver during CVC removal to prevent air from entering

which substance would the nurse give first to a client with a history of alcoholism and cirrhosis of the liver being admitted for ascites

-albumin -hyperosmotic protein solution, given to pull fluid back into blood vessels -when fluid has been pulled into the vessels then the diuretics can be given to excrete excess fluid

terminal client on unit with restricted visiting hours for children has a 12 year old child, what nursing action has the highest priority

-allow flexibility with family members visitation

supine hypotensive syndrome

-also called aortocaval compression or vena cava syndrome -uterus compresses the vena cava -pregnant women should not lay with their legs elevated, should lay on their sides instead

pyorrhea

-also periodontitis -inflammation of the tissue around the teeth, often causing shrinkage of the gums and teeth

school nurse

-always validate information with the parent or guardian -with eye inflammation, contact the parents, report condition, provide rationale for medical attention and suggest care

promethazine

-antiemetic -used with closed head injury

nystatin

-antifungal -swish around mouth and then swallow to disinfect esophagus as well

PTSD

-anxiety disorder following a traumatic event -s/s: persistent anxiety, irritability, exaggerated startle response, sleep changes, social disturbances -treatment: assess for suicidal thoughts if having flashback, calm and quiet environment, reduce stimuli

when does nurse report child abuse to CPS

-anytime there is suspicion of child abuse -after validation from assessment

jaundice

-appears first on the head and progresses cephalocaudal (head to toe) -jaundice during first 24 hours of life indicates hemolytic disease of the newborn

at home care for newborn

-applies water to clean umbilical cord -avoids submerging the umbilical cord in water -positions the neonates diaper below the umbilicus -washes hands before and after changing diaper -applies petroleum jelly and gauze to circumcision site to prevent adherence to diaper

how to relieve itching with a cast

-apply cool air under the cast with a blow-dryer

cred e maneuver

-apply manual pressure to the bladder -perform at same time each day to establish bladder control

nursing actions if chest tube is pulled from pleural space

-apply pressure with dressing tented on one side to decrease the chance that atmospheric air will enter and also allows for escape of pleural air

blood pressure readings

-arm supported at heart level -take two readings 5 minutes apart for hypertension screening

first action for nurse at clinic receiving call that friend of caller has overdosed

-ask caller to determine if client is responsive and alert

intervention for client with depression who is not eating

-ask client what are favorite foods -provide pleasant surroundings and companionship during meals -offer more frequent feedings

medications for alcohol withdrawal

-ask when the last drink was consumed -CIWA scale -anticipate giving benzodiazepine, thiamine, magnesium, IV fluids

responsibility of nurse in PACU post open cholecystecomy

-assess client for signs of pain

bulge test

-assess swelling in knee joint -patient in supine position -check for fluid in the knee

guillaine barre syndrome

-autoimmune disorder that manifests as acute inflammatory polyneuropathy s/s: weakness and strange neuro sensations in both legs, urinary retention (if upper leg issues result, this indicates that bladder control issues are likely next) hiccup: a sign of respiratory failure -progression: ascending fashion (feet to head) cause: immunizations

MS interventions

-avoid overexertion -avoid heat/humidity -sleep on stomach to minimize spasms of the flexor muscles -spastic extremities should not be forced into an extended position, instead should be gently rotated in the direction to which it is being drawn and then the opposite direction -repeat and incrementally increase the degree of rotation with each repetition

AV fistula home care

-avoid sleeping with affected arm under pillow -dont lift heavy objects on affected side -dont use arm for BP or IV

opisthotonus

-back is rigid and arching, and the head is thrown backward -indicates meningeal irritation

garlic and insulin

-bad -insulin has a direct hypoglycemic effect and can potentiate the action of diabetic drugs

surgical time out

-before any procedure -goals: identify patient, verify operative site and side, verify OR team is in agreement on procedure -before sedation, patient can be involved

best action if nurse before you forgets to document

-begin documenting on line below, leave no spaces -nurse can fill in the space later

alcohol withdrawal

-begins within a few hours after reduction of alcohol intake -peaks 24-48 hours later s/s of withdrawal: tremors, insomnia, anxiety, alcoholic hallucinations, anorexia s/s of delirium tremens: tremors, anxiety, hallucination, vomiting, diarrhea, possible suicide attempts, seizures care: monitor vitals, administer sedatives, anticonvulsants, IM/IV thiamines, glucose, orient frequently, place client in a quiet/well lit place

testicular exam

-best to do in shower when muscles are relaxed -1x a month -testes are supported in palm of one hand and palpated between thumb and forefinger -testicular cancer is the most common solid tumor in males ages 15-34

if client with new trach has trach tube displaced, what is the best action by the nurse

-biggest issue is loss of an airway -first action is open the airway, may use hemostats

discharge instructions with cesium implant for cervical cancer

-bleeding should stop after 48 hours -avoid sexual intercourse and tampons for 6 weeks -avoid activities that cause abdominal strain for 6-8 weeks -avoid baths for 6 weeks

what vital sign should be monitored with elevated BUN

-blood pressure -dehydration is a common cause of elevated BUN

vital sign important to monitor with mechanical ventilation

-blood pressure -may experience hypotension from decreased cardiac output, monitor BP closely

what is important to monitor post-adrenalectomy

-blood pressure alteration -important to notice if this indicates shock

equipment to keep close during paracentesis

-blood pressure cuff -continually monitor BP to be aware of shock s/s -client is also weight before and after procedure

peptic ulcer pain

-boring pain in the back of neck -burning, gnawing, feeling in midepigastric region

cystic fibrosis

-both parents are carriers -25% chance of passing the gene to offspring -autosomal recessive gene

rectal suppository

-breathe through mouth and relax -position suppository to touch wall of clients rectum -insert 3-4 inches into rectum -apply lubricant before inserting

what does elevation of fontanelle indicate

-bulging or elevation may indicated increased intracranial pressure -must be immediately addressed

shoe selection for diabetics

-by shoes in the afternoon when feet are larger than in the morning -measure each foot everytime you buy shoes -buy the correct size -leather is better than plastic or other materials because it breathes -vinyl can lead to infections

which vitamins are vegans at risk for deficiency

-calcium -vitamin b12 -iron -vitamin d

-intervention if ER nurse gets a call about radioactive exposure

-call director of nursing to activate disaster plan

normal drainage post chest surgery

-can have 500-1000 mL of drainage

licorice

-can increase potassium loss and can cause digoxin toxicity and arrythmia

symptoms of ADHD

-cant follow directions -doesnt listen when spoken to -interrupts/intrudes -difficulty with schoolwork -on the go like a toddler

assessment for vitamin K deficiency

-carefully check the clients arm after taking the BP

pregnancy risk for having a cat

-cat presents a toxoplasmosis risk to the pregnancy client -toxoplasmosis is a parasitic disease transported in cat feces that have eaten infected mice and animals -wash hands after touching cats -have litter box changed daily by someone other than pregnant woman (takes 1-5 days for feces to become infected) -prevent cats from eating raw meat or wild animals -wear gloves when gardening, do not garden in areas frequented by cats -avoid undercooked meats and contact with stray animals

waxy flexibility

-catatonia, associated with schizophrenia and bipoloar -tendency to remain in immobile posture

role of nurse with suspected abuse

-chain of command, report to nurse manager

gentamycin adverse reaction

-change in hearing

side effects of estrogen therapy

-change in libido -weight gain (patients should decrease salt to decrease their edema) -dry eyes

full thickness burn

-charred, waxy, white appearance of skin

closed head injury home treatment

-check LOC every 3-4 hours -avoid strenuous activity for 48 hours -avoid blowing nose or cleaning ears for two days

most important assessment with ruptured membranes

-check for prolapsed cord

dr orders chest restraint for client with alzheimers, but client refuses

-check on the client frequently -try other methods to engage client in activities to reduce wandering

radium implant

-check position q8h -bowel movement may dislodge implant so patient should consume a low residue diet -strict bedrest -high fluid intake

cisplatin

-chemo agent used to treat cancer -hold if platelets are less than 100,000 -hold if WBC is less than 4,000 -hold if creatinine is less than 1.5 mg/dL

nonorganic failure to thrive

-child is not secure in receiving the required feed and care -help child feel loved and cared to by assigning same staff members each day if possible -staff can then model behavior to parents

A father brings his 15-month-old son to the well-baby clinic for a routine checkup. The father confides to the nurse that he is concerned that his son still crawls and does not walk. Which response, if made by the nurse to the father, is best?

-children frequently set their own pace for development -children are individuals and usually begin walking between 12-15 months

most common cause of hypomagensemia

-chronic alcohol use

korsakoff psychosis

-client experiences memory lapses because of chronic alcohol abuse -client will make up events to fill the gaps -due to wernicke syndrome from chronic alcohol abuse -often causes hypotension not hypertension -memory loss, confabulations, personality change -nurse: don't argue with client, orient client to reality when possible -watch for withdrawal symptoms

psych client involuntarily committed wants to mail letter to president to mention how he disagrees with his view of homosexual role in military

-client retains the right to communicate with elected officials -nurse cannot open letter -nurse must discourage client from sending the letter but mail it if the client insists -client retains the right to communicate with elected officials

mastoidectomy

-client scheduled to undergo mastoidectomy likely experiences chronic ear infections, which are often accompanied by dizziness or vertigo -due to the potential for injury related to falls, the client scheduled for mastoidectomy should be assessed first.

genital herpes

-clusters of painful blisters -client may have difficulty voiding and there may be recurrence during periods of stress, menses, and infection

LPN/LVN with singles

-come to work -able to care for non-high risk clients, cover lesions and don't care for pregnancy clients, premature infants, or immunocompromised clients

how to prevent leg cramps during third trimester of pregnancy

-common during sleep trt: elevate legs often during the day to improve circulation, extend affected leg with knee straight, bend the foot toward the body, stand and apply pressure on the affected leg with knee straight normal

cytomegalovirus

-common virus affecting all ages -over 1/2 adults by age 40 have been affected -once infected, stays for life or can be reactivated

fat embolism

-common with fractures of long bones -results in pulmonary or cerebral emboli, interferes with adequate circulation -confusion is the first symptom

kaposi sarcoma

-commonly seen with AIDS infection -red, purple, or brown skin blotches trt: clean and dress open lesions daily to prevent secondary infection

root of anxiety for generalized anxiety disorder

-conflict between expressing unacceptable impulses and the need to hold on to social approval -family members should be patient and accepting and avoid placing undue emphasis on the anxiety

symptoms that would cause concern to the nurse for patient with lung cancer

-confusion, weight, urine output of 15 mL per hour -indicate that the client is experiencing SIADH -most common cause of SIADH is cancer, especially lung cancer

oculogyric crisis

-fixation of the eyeballs in an upward position -an acute dystonic reaction -notify HCP to obtain anticholinergic medication

reason for increased temperature post labor

-fatigue and dehydration

GERD risk factors

-female -over 45 years old -obese -caucasian -smoking -NG tube

water-seal chamber

-fluid will fluctuate with client respirations (rise with inspiration, fall with expiration)

s/s of parkinsons

-propulsive gait (Don Johnson), stooped, stiff with head and neck bent forward -tremors -bradykinesia -slurred speech

what does PSA test for

-prostate specific antigen (tests for prostate cancer)

if portion of PICC catheter breaks off during removal, what is the appropriate action by the nurse

apply a tourniquet to the upper arm

strabismus

cross-eyed, look in different directions s/s: double vision, eye strain, headache, may close one eye to see straight

osteomalacia

softening of bones through calcium or vitamin d deficiency

best time to feed an infant with congenital heart disease who tires easily with feeds

soon after awakening

most common side effects of general anesthesia

sore throat, nausea, vomiting

melena

-dark feces containing partly digested blood

anasarca

-extreme generalized edema -swelling of the whole body

s/s of increased ICP in 4 month old

-high pitched cry

vitreous hemorrhage

-s/s: red haze in visual field

endemic regions to Tb

asia, middle east, africa, latin ameria, caribbean

s/s of hypocalcemia

muscle cramps chvostek sign

how to stop nosebleed

pinch nose closed for 10-15 minutes with ice-cold washcloth

what foods should diverticular disease patients avoid

seeds

slander

speaking falsely about another person

A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, "I am so afraid my baby is going to die." Which response by the nurse to the client is best?

"Finding out your baby has a serious health problem must be painful." -acknowledges the clients pain and gives the client an opportunity to talk about her feelings

A health care provider (HCP) notifies the charge nurse of an inpatient unit that the city mayor is being admitted. The HCP states that one of the nurses on the unit is "disheveled and unkempt" and asks that the nurse be reassigned during the mayor's hospitalization. Which response does the charge nurse provide to the HCP in this situation?

"I am unable to comply with your request." -client care assignments are made based on knowledge and experience of staff

if nurse makes patient assignments and returns to find everything changed, what is the proper response to staff

"I noticed the assignments were changed, did something happen while I was gone?"

As the nurse administers medications to a group of clients, an unlicensed assistive personnel (UAP) approaches the nurse to report that a client has a large amount of thick, dry mucus on one side of the tracheostomy tube. Which response does the nurse provide the UAP in this situation?

"Is the client having difficulty breathing or appear different? " -UAP can observe whether the client is in distress. If not, the nurse can continue med pass and go to patient later.

The parents of the child just diagnosed with a chronic illness share with the nurse that they are concerned about the sibling's sudden change in behavior. Which is the best response by the parent to the nurse?

"Our other child is feeling left out right now, but we plan to include them in the care of their sibling." -total family participation is accomplished when the nurse includes the sibling

what is a concerning statement for client with anorexia

"the faster I gain weight, the faster I can return to school" -initial target is 85% of ideal weight -exercise can prevent weight gain and can be dangerous -client needs slow, steady weight gain of no more than 2 lb per week as rapid weight gain can put stress on the heart

trigeminal neuralgia

"tic doulereux" -chronic, intense, intermittent pain affecting cranial nerve 5 -instruct patient to chew on opposite side, provide carbamazepine (anti-convulsant)

insulin locations for absorption from quickest to slowest

(abdomen, arm, thigh, buttocks) -abdomen should be checkerboard using every 0.5-1inch of space -use shortest needle possible -hold needle at 45-90 degree angle

parenteral nutrition

(hyperalimentation) -if bag is empty, infuse 10% dextrose in water to prevent hypoglycemia -may add water, regular insulin, or heparin -if to be discontinued, gradually decrease flow rate for 1-2 hours -IV meds and blood are not given through PN line -monitor blood glucose q4-6 hours -refrigerate solution and administer within 24 hours

internal radiation (brachytherapy) implant

- Wear a lead shield, wear a dosimeter badge to measure amount of radiation, bed linens and dressings removed from the client are saved in case the implant was accidently dislodged, needs to be placed in a privage room, 30 mins per 8 hr shift -complete in 1-3 days -strict bed rest, HOB elevated no more than 20 degrees -indwelling catheter is inserted

eye exams

- adults over 65 annually w/ dilation - pts w/ glaucoma every 6 mons -40-60 year olds: glaucoma test every 2 years -with diabetes: dilated eye exam every year

The nurse administers oral medications to an elderly, confused client. The client states, "These pills look funny. They belong to the lady down the hall." Which response by the nurse is best?

-"ill be back after I check your medications again" -even a confused client should have his/her medications rechecked when there is any possibility of an error; always observe the six rights of medication administration

rate of uterine fundus involution

-1 cm/day

how long are extremities elevated after the application of a cast

-24-48 hours -protects from pressure and flattening of the cast

dietary needs when pregnant

-3-5 servings a day of veggies -1 must be dark green or deep yellow for vitamin A intake

nutritional supplements in pregnancy

-30 mg iron ferrous supplement -slight sodium requirement increase -consume good sources of zinc to aid in cell growth

what can ultrasound detect during pregnancy

-fetal breathing movement -estimated weight of fetus -fetal tone (flexion and extension) -presence of amniotic fluid

black/tarry stools

-GI bleed

assessment for buergers disease

-I should inspect my fingers and toes every day -Check for ulcer formation and gangrene; disease involves recurring inflammation of arteries and veins in upper and lower extremities, results in thrombus and occlusion, seen in men 20-35 years old; smoking is a causative factor; pain at rest and coldness major symptoms

medications for allergic reaction to bee sting

-IM epinephrine (good with anaphylactic shock, causes peripheral vasoconstriction and bronchodilation) -IV diphenhydramine (blocks histamine release) -IV methylprednisolone (treats inflammation and elevates BP if needed) -albuterol (opens airway and promotes oxygenation)

treatment of vaso-occlusive crisis with sickle cell anemia

-IV and oral fluids are primary treatment -activity is limited to decrease oxygen needs -eat high-calorie, high-protein diet to support metabolic demands -provide opioid and non-opioid therapy to manage pain -oxygen

meconium

-first stool of the newborn -greenish-black -usually between 12-24 hours

Hypoparathyroidism and effects of decreased calcium

-PTH regulates serum calcium -PTH stimulates bone resorption and inhibits bone formation resulting in the release of calcium and phosphate into the blood -if decreased PTH, decreased calcium s/s: tingling of lips/fingers, increased muscle tension and stiffness nurse: monitor airway obstruction, infused IV calcium slowly, attach to cardiac monitor

patho of sickle cell disease

-RBC assume sickle shape -alter oxygen-carrying capacity and enhances ability of cells to become stuck in capillaries causing pain -sickling enhances lysis of circulating RBC so body increases process of creating new cells which are released into bloodstream before maturity

MI symptoms for females

-SOB -abdominal pain -nausea -vomiting -diabetics may be asymptomatic

impetigo

-contagious, superficial bacterial skin condition that is contracted by other children -primary or secondary infection -caused by staph or strep -bacteria often enter when skin is already irritated/injured by eczema, etc. trt: use good handwashing, topical antibiotics, antibacterial soap, loosen scab with Burrow's solution, compress and gently remove complication: acute glomerulonephritis if left untreated

exercise during pregnancy

-continue regular exercise program but stop when tired -exercise 10-15 minutes, rest for 2-3 minutes, then exercise for 10 minutes -stretch before exercising to warm up

sign of postpartum hemorrhage

-continuous trickling of bright red blood with a firm fundus

normal suction control chamber

-continuous, gentle, slow but steady bubble

goal of end of life care

-control symptoms -promote meaningful interactions -facilitate a peaceful death -encourage family to express grief

surgery with spina bifida

-corrective surgery cannot change child's physical disability -spinal nerves that have been destroyed by myelomeningocele cannot be corrected -nothing will return function to portions of the body that are innervated by the spinal nerves below the meningocele

immediate anaphylaxis reaction to flu shot

-coughing and clearing the throat -tachypnea and feeling of impending doom -dizziness upon standing

if client continues to interrupt during group therapy session, what is the best way for the nurse to assess if this is improving

-count how many times the client does not interrupt -count successes, not failures

evisceration of bowel

-cover open area with sterile gauze soaked in normal saline

ways to prevent varicose veins

-cross legs at ankles -avoid tight fitting socks -elevate legs 3-6 inches above the heart -frequently change positions

MAOI food interactions

-cured, processed, aged, smoked foods, hot dogs, bacon -cheese, alcohol, pickles, fish sauce, overripe fruits, wine, beer -causes hypertensive crisis

diabetic foot care

-cut toes straight across or have doctor do it -never barefoot -inspect feet daily -bathe feet daily -no heat pads -warm socks

interventions for tube feeding

-d/c if signs and symptoms of hyoxemia -if aspiration, verify NG tube placement position -elevate HOB 30-45 degrees during feed and for 30-60 minutes after -may cause diarrhea

interventions for stage 3 HF

-daily weights -low-sodium diet -daily digoxin therapy -cardic rehab program -assess for adverse effects of ACE inhibitors

highest factor for stress on social readjustment rating scale

-death of a spouse

symptoms of the onset of labor

-decreased fetal movement -gush of fluid running down legs -bloody show in vaginal discharge -low backache

anatomic changes shortly after birth

-decreased pulmonary vascular resistance -closure of foramen ovale -closure of ductus arteriosus -closure of ductus venosus

dermatologic complications of DM, asthma, and high dose corticosteroids

-decreased wound healing (steroids) -erythematous plaques on legs (DM) -decreased sub-q fat in extremities (DM and steroids)

clopidogrel

-decreases clot formation -limits chance of stroke -need regular blood tests -adverse effect: increased BP -no contact sports, bleed risk

effect of morphine sulfate during MI

-decreases preload and afterload pressures and cardiac workload -causes vasodilation and pooling of fluid in extremities and provides anxiety relief

bracytherapy

-delivery of radiation to target tissue with minimal extra exposure -client is in lead-lined room -intravaginal = strict bedrest -limit direct contact with patient -no direct line of radioactive material AKA nurse should not stand at the foot of the bed -limit time -staff should wear a film badge -time, distance, and shielding are important

stages of grief (elisabeth kubler ross)

-denial -anger -bargaining (wants to change behavior to get more life) -depression -acceptance

care for client with opioid addiction

-determine which opioids are used -administer opioids around the clock

lethicin/sphingomyelin ratio

-determines fetal lung maturity -ratio over 2-2.5 means fetal lungs are mature

when to call HCP when infectious diarrhea

-development of dry skin -pulse increases to 100 bpm -cold extremities -increased thirst

concussion

-diagnosed clinically with symptoms -headache may continue for 2+ weeks -repeated vomiting may indicate that condition is worsening -refrain from contact sports -common to forget daily details -amnesia is common if severe, concussion can lead to CTE (chronic traumatic encephalopathy)

hallmark sign of schizophrenia

-difficulty forming relationships, cannot trust people

24 hour urine specimen

-discard first morning specimen -collect all urine for 24 hours then place the urine in one container

Reye Syndrome (RS)

-disorder defined as a metabolic encephalopathy associated with other characteristic organ involvement. -characterized by fever, profoundly impaired consciousness, and disordered hepatic function -occurs when children have aspirin

milia

-distended white sebaceous glands -normal and disappears in days/weeks with no treatment

meds held before surgery

-diuretics (increase risk for hypovolemia and hypokalemia) -anticoagulants (held to prevent excess bleeding intraoperatively)

intervention if clients peritoneal dialysis outflow is inadequate

-first, turn client from side to side -then, check for kinks in tubing

care of forensic patient

-document all wounds, mechanism of injury, time of and collection of evidence -dont cut clothes -cover hands with paper bag to preserve evidence -dont give clothing back to family -dont use plastic bags -keep all tubes and drains in place (IV, foley, etc.) until medical examiner comes

proper newborn teaching

-dont offer formula if you are breastfeeding, the infant will be confused and may start to resist breastmilk -if milk has not come in yet, the newborn will still get nutrient rich colostrum until the mothers milk comes in -if the baby keeps sucking after feed, give pacifier -pacifier can decrease the risk of SIDS -newborn should sleep in crib or bassinet, not parents bed -right-side position after feed will assist with digestion

trt for constipation

-drink 1500-2000 ml of fluids daily -bulk forming foods (veggies, fruits, cereal) -establish normal time at home for elimination -exercise regularly

client with type 1 diabetes who continues to vomit should do what

-drink liquids as often as possible -DKA is often associated with dehydration, encourage fluids

how to examine thyroid gland

-drinking water will facilitate swallowing during thyroid gland examination

signs a family is ready for toilet training

-dry diapers after a nap -parents have time available to devote to training -client can sit for 5-10 minutes uninterrupted -regular bowel movements -motor skills to pull clothes off and on

leading cause of death post MI

-dysrhythmias, need pharmacologic intervention

constipation

-eat high fiber diet (fruits, veggies, nuts) -avoid prolonged enema use -establish a bowel routine -drink 8-10 glasses of water/day -follow regular exercise program

first test to monitor seizure activity

-electroencephalogram -records electrical activity of brain -nursing prep: wash hair, avoid stimulant medications and stimulants like coffee, tea, cola, cigarettes

informed consent

-emancipated minors can provide informed consent -over 14 years old and pregnant, it is the womans decision -written consent is needed before surgery or a procedure -clients needs all questions answered before signing -a married minor is considered emancipated -mentally ill clients can refuse treatment until a court declares them incompetent -the nurses role is to witness the signature and the ability of the patient to provide consent

intervention for psych client with anger and increasing anxiety

-encourage client to discuss feelings, avoid disagreeing, decrease the threatening components of the clients environment

interventions for newborn with jaundice

-encourage the mother to breastfeed frequently -if eye color around eyes is diminished, indicates that cover is not correctly applied -monitor the neonate for six wet diapers and three stools per day as an indication of elimination of bilirubin (loose, greenish stools are indication of bilirubin excretion) -observe for jaundice (sclera and skin) and monitor diagnostic bilirubin tests. Initiate phototherapy and exchange transfusion as prescribed if levels of bilirubin are severe -teach parents about physiological jaundice, signs of hyperbilirubinemia, and actions to take -turn off bilirubin lights for blood draws and before oral feedings, eye patch also removed for oral feeds

what is included in surgical safety checklist for nurse prior to surgery

-ensure consent form is signed and witnessed -skin prep completed -dentures removed -pre-op medications delivered

steps for tube feeding

-ensure formula is at room temp -check risidual volume to determine if gastric emptying is delayed -flush with 30 mL water before and after feeding -evaluate fluid balance daily -check lab values periodically

effect of epidural on BP

-epidural blockage produces vasodilation and typically causes a decreased BP -IV fluid bolus is given before epidural block to offset potential hypotension -administer IV over 20-30 minutes and begin epidural procedure shortly after

medication of choice for anaphylaxis

-epinephrine IV, IM, Sub q

peptic ulcer disease

-erosion of GI mucosa resulting from digestive -action of HCl acid and pepsin -usually stomach, lower esophagus, and duodenum risks: NSAIDS, corticosteroids, anticoagulants, SSRI's, lifestyle factors like stress and alcohol consumption can also increase risk

treatment of client with eating disorders

-establish trust and provide unconditional care -monitor VS and food intake, elimination, daily weights, skin condition -observe client before, during, and after meals -be matter-of-fact -avoid food discussions, especially while eating -require consumption in specific time frame -refer to community support -NG tube if necessary

s/s of cocaine abuse

-euphoria -hyperactivity -insomnia -rhinorrhea -tachycardia

pneumonia risk factors

-excessive alcohol use (alc suppresses gag reflex, ciliary motion, and WBC mobilization) -surgery (increases pharyngeal colonization of organisms) -dysphagia

contraindications for thrombolytic therapy

-experienced a trauma in the last 2 months -active internal bleeding -history of hemmorhagic stroke -intracranial or intraspinal surgery -intracranial neoplasm -AV malformation -aneurysm -severe hypertension

umbilical cord

-expose cord to air frequently to dry and prevent infection

treatments for exopthalmus

-eye drops

chovetek sign

-facial movement when the muscles of the facial nerve or branches of the nerve are tapped -indicates low serum calcium

what events require incidence reporting

-falls -medication errors -IV infiltration -all legal and medical occurrences

Tb patient visitation

-family allowed to visit if they follow proper precautions -isolation cart kept at doorway -N95 mask and gloves -remove waste articles (tissues) often

buddhist death ritual

-family chants last rites around patient -nurse/family calls priest

external beam radiation therapy

-form of cancer treatment using highly charged electrons to penetrate malignant tumors with pinpoint accuracy s/e: erythema, desquamation, ulceration (radiation dermatitis) trt: monitor for infections and wash site with water only

iron sources

-fortified cereals -oysters, clams, scallops -dark, leafy vegetables (spinach, collard greens) -red meat -egg yolks -giblets

flail chest

-fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment -s/s: inadequate ventilations -trt: supplemental O2, analgesia, ET tube and mechanical vent may be required -oropharyngeal suction -deep breathing

foods to avoid with pancreatitis

-fried food -fatty good -whole milk

dumping syndrome

-gastric contents empty too quickly into the small intestine -occurs after surgery s/s: weakness, diaphoresis, palpitations, dizziness nurse: 6 small meals a day, avoid fluids, avoid sweets, increase protein and fat in the diet

TENS (transcutaneous electrical stimulation)

-gel is used -electrodes are placed over, above, and below painful area -battery-operated device that delivers small currents to skin and underlying tissues -used for localized pain like low back pain -"pins and needles sensation is the max, should not cause twitching" -apply all electrodes, set parameters, and then turn on machine

male urinary cath

-general size: 16-18 french -hold penis perpendicular to body -use sterile technique -insert cath 6-7 inches

interventions for emphysema patients

-get annual flu vaccine to limit infection risk -stop smoking completely -conserve energy when possible (sit instead of stand at sporting events) -increase fluid intake (more than 8 cups/day) -perform exercises like thai chi which allow for relaxation and exercise -eat small frequent meals to avoid pressure on diaphragm

interventions with patient on chemo meds

-give anti-emetics to decrease nausea -teach client to rinse mouth with saline solution mixed with baking soda to decrease stomatitis effects -high protein, high calorie, nutrient-dense diet is recommended -increase fluid intake to decrease cystitis effects -perform mild to moderate exercise with frequent rest periods to manage fatigue

APGAR calculation

-given at 1 and 5 minutes after birth -HR: 0-no heart rate 1-less than 100 bpm 2-above 100 -RR 0-not breathing 1-weak cry 2-strong cry -Muscle tone 0-flaccid 1-some flexion 2-actively moving -Reflex 0-no response 1-grimace upon stimulation 2-crying -Skin color 0-blue/pale 1-blue extremities with pink body 2-pink

percussion and postural drainage for cystic fibrosis

-goal: facilitate the movement of the thick secretions from the lungs -positions: head is in dependent position -ex: side lying with right side of chest elevated on pillows, head in dependent position, prone with thorax and abdomen elevated, knee-chest position with pillows under chest

greatest danger following TURP

-hemorrhage, should not have sanguinous fluid

cytomegalovirus

-herpes-type virus that usually causes disease when the immune system is compromised -fetotoxic, no pregnant nurses

diet with celiac

-high calorie, high protein, restrict rye, oats, wheat, and barley

gout prevention

-high carb diet to excrete uric acid -drink 2000-3000 mL fluid/day -stop or decrease intake of alcohol -drug therapy: colchine, allopurinol, NSAIDS

diet for post-surgery and wound healing

-high protein -high vitamin C -sufficient calories

nutrition needs post surgery

-high protein -high calories -high vitamin C

food for patient with spinal cord injury at S3

-high-fiber diet -prevents constipation -examples: whole-grain foods, bran, fresh/dried fruits

contraindications to warfarin therapy

-history of peptic ulcer disease (increased risk for uncontrolled gastric bleeding) -alcohol abuse -liver dysfunction -aspirin use

soapsuds enema

-hold 12-18 inches above clients rectum -insert 3-4 inches -position client in left sims position -water should be slightly hotter than body temp

what side is the cane held on

-hold cane on strong side -widens the base of support -elbow should flex no more than 30 degrees

doppler ultrasound

-hold probe at 45 degree angle -don't press firmly -gel is warmed -mark where the pulse is found

what temperature increases risk for lithium toxicity

-hot weather, need to monitor sodium level

what happen with tyramine and MAOI

-hypertensive crisis

mag deficiency

-hypertonic reflexes -blood pressure increase

electrolyte imbalances of anorexia patients

-hypocalcemia -hypokalemia -hyperuricemia (increased BUN) -hypophosphatemia

muscle spasms in legs and tingling lips post thyroidectomy

-hypocalcemia, urgent need to fix

what is newborn at risk for if mom has diabetes

-hypoglycemia

risk after lower GI series

-hypovolemia -prep for the test is a low-residue or clear liquid diet for 2 days, NPO after midnight before the test, enemas and laxatives -places client at risk for dehydration -laxatives post-test to remove the barium will further increase the risk of dehydration

bad fluids for client with graves disease

-ice coffee -diet cola -hot tea (stimulants will increase metabolic rate)

infant cow milk allergy

-if allergic to milk, avoid soy and goats milk due to cross-sensitivity -do consider predigested formula -never dilute formula with too much water

ipecac syrup

-if no vomiting after 20 minutes, repeat dose

The elderly client constantly comes to the nurse's station with varying reports and requests. Which action by the nurse is best?

-interact with the client at consistent intervals -client is probably fearful of being abandoned, interact with the client at consistent intervals when the client is not reporting problems will reduce the amount of calling, requesting, and reporting behaviors

celiac disease

-intolerance for gluten -restrict: rye, oats, wheat, barley

when should glaucoma patients schedule appts

-intraoccular pressure is higher in early morning hours -early morning assessment is best

feosol

-iron supplements -change color of stool -may interfere with fecal occult blood test

braxton hicks contractions

-irregular prelabor contractions of the uterus -with hand on abdomen, abdomen will tense and relax

first action to establish normal urinary pattern

-keep a record of fluid intake -record each time the client urinates

umbilical cord care

-keep clean, dry, clean stump with water -watch swelling/redness/purulent d/c - fold diaper edge down to keep stump dry - will fall of after 5-15 days -no tub baths until stump as fallen off

epiglottitis care

-keep licensed provider with patient at all times -never insert a tongue blade or check gag reflex as this can block airway -minimize crying trt: moist air, IV antibiotics, pulse ox

intervention for client with tetrology of fallot who is diaphoretic and short of breath

-knee-chest position for cyanotic spells -this enhances systemic venous return, dilates the right ventricle, and decreases the obstruction

feeding infant with tetrology of fallot

-large bore nipple

ways to prevent dumping syndrome post gastrectomy

-lay down for 30 minutes after meals -drink fluids between meals -reduce carb intake

permethrin treatment for nits/lice

-leave cream on hair for 10 minutes before washing out -use once a week -wash linens in hot water and dry in dryer -s/e of permethrin are erythema and skin irritation -check all family members/roommates -itching will stop when lice/nits are killed

position to decrease air embolism

-left side lying trendelenburg

pain meds and MS labor patients

-less pain medication b/c of decrease in pain perception

pheochromocytoma and arrythmia

-life threatening d/t catecholamine release -pheochromocytoma is a tumor of the adrenal gland

probiotics

-live microbes applied to or ingested into the body, intended to exert a beneficial effect -can enhance immune response and stabilize mucosal barrier in digestive tract example of diseases that probiotics are used with: antibiotic associated diarrhea, IBS, lactose intolerance

preventative measures for DVT

-low molecular weight heparin -ambulation -no massaging of the legs -compression stockings -SCD's

diet for severe liver disease

-low protein, high carbohydrate

tepid

-lukewarm

nursing management of assaultive client

-maintain milieu safety by restoring client self-control -assess situation -psychological intervention -chemical intervention -physical control

gynecologic fistula interventions

-maintain urinary catheter -warm sitz bath -perinneall hygiene -increase oral fluids

risk factors for SIDS

-male gender -preterm or low birth weight -native american or african american descent -prone or side-lying position for sleep -soft bedding -pillows, blankets, stuffed animals in crib -overheating -bed sharing -mother who smoked prenatally and/or continues to smoke -maternal use of alcohol/substances -infants who experienced an apparent life-threatening event that presented with cyanosis, pallor, flaccid muscle tone, choking, gagging

multiple myeloma

-massage and music can help

interventions for relaxed uterus

-massage fundus until firm -put infant to clients breast -assess the bladder for fullness

organ transplant patient interventions

-may have corticosteroids prescribed post-transplant to aid in immunosuppresion, may cause peptic ulcer formation -should avoid crowds to avoid infection risk -cyclosporine is hepatotoxic so pt should avoid alcohol -symptoms of graft vs. host begin with itching/painful rash on palms and soles of feet -cardiovascular problems like hypertension are common after surgery

high AFP or alpha feto-protein in pregnancy

-may indicate a neural tube defect -abnormally high AFP level may mean that the fetus has a chromosomal disorder or neural tube defect, such as spina bifida or anencephaly -may also indicate that the fetus has an omphalocele, which is an abdominal wall defect with organ exposure -maternal serum alpha-fetoprotein (MS-AFP) screening is a blood test performed between 15 to 20 weeks (second trimester) -diagnostic testing such as a high-resolution ultrasound or amniocentesis may be recommended if the AFP levels are elevated

HIV with Kaposi

-means it has transferred to AIDS disease -may also have burkitt lymphoma

aPTT

-measures effectiveness of heparin - typical aPTT value is 30 to 40 seconds. If you get the test because you're taking heparin, you'd want your PTT results to be more like 120 to 140 seconds, and your aPTT to be 60 to 80 seconds -if your number is higher than normal, it could mean several things, from a bleeding disorder to liver disease

rhabdomyolosis

-medical condition that may arise from breakdown of muscle tissue and release of the muscle cells' contents into the bloodstream. -process can damage the kidneys and may lead to renal failure or death in rare cases -trt: iv fluids, blood volume expanders, IV cacl, bicarbonate, inuline, glucose ostmotic diuretics like mannitol to excrete myoglobin and potassium

cyclophosphamide

-medication for MS -patients usually develop alopecia 4-5 weeks after treatment

myelomeningocele

-most severe form of spina bifida in which the spinal cord and meninges protrude through the spine -pouch of neural tube protrudes through the spine risk for development: genetic link, intrauterine exposure to seizure and acne meds, alcohol, poor folic acid intake, obesity, diabetes nurse: measure head as their is a risk for hydrocephalus, place infant prone with face to one size and cover area

risk for cholelithiasis

-native american or us southwester hispanic ethnicity -obesity -multiparous clients -age over 40 -fasting (decreases gallbladder movement and bile becomes overly concentrated with cholesterol leading to stones)

foods with phenalzine sulfate

-need high potassium, low tyramine -spinach and tuna fish salad is good

acute pancreatitis

-need high protein, high carb, low fat diet to prevent -may lead to flare-ups or chronic pancreatitis -may cause transient hyperglycemia -avoid alcohol -NPO during acute phase -BEDREST is strict to decrease metabolic rate and secretion of pancreatic enzymes

meniere disease

-need low sodium diet to decrease fluid retention (endolypmatic fluid which is clear, intracellular fluid in the inner ear) -patient should avoid (MSG, chinese food, fast food)

fixed and dilated pupil

-neuroligical emergency -contact HCP

fetal macrosomia

-newborn significantly larger than average -birth weight more than 8 lbs, 13 ounces (4000 grams) regardless of gestational age risks to look for in prental care: diabetes mellitus, excessive weight gain during pregnancy, previous pregnancies possible complications: labor difficulties, post-partum hemorrhage, genital tract laceration, uterine rupture

if client is hypoglycemia and drowsy

-no NO fluids -need to administer glucagon IM

caloric intake during pregnancy

-no additional calories during 1st trimester -2nd trimester increase by 340 calories -3rd trimester increase by 462 calories

jewish meal preference

-no milk/milk products served at the same meal with meat

post-op nursing care

-no oral fluids until bowel sounds are heard -early ambulation to help pass flatus -do not cath unless necessary, wait 6-8 hours for client to void

osteoarthritis (degenerative joint disease)

-noninflammatory, localized, progressive disorder involving deterioration of cartilages and bone and formation of new bone (osteophytes) at joint surfaces -aging increases incidence; nearly all adults older than 60 have some signs of it -risk factors: age, repetitive joint movement, obesity, inactivity trt: determine mobility level, assist to plan regular exercise, balanced diet to improve strength, refer to PT/OT, possible joint replacement surgery

buck traction

-noninvasive method to stabilize a fracture of the hip -purpose is to maintain bone alignment and immobilize the bone which promotes comfort by reducing muscle spasms -boot or wrap/straps are applied to the lower extremity and the pulley with weights is applied to this -reposition client every 2 hours -assess vital signs and promote lung expansion

non-stress test

-noninvasive test that looks to evaluate the response of the fetal heart rate to the stress of fetal movement -response is reflected on fetal monitor -client presses button when she feels fetal movement

secondary stuttering

-normal phase of language development -parent should slow down speech and speak calmly to daughter

treatment of DKA

-normal saline until blood glucose reaches 250 mg/dL then add dextrose -potassium levels will decline with fluid replacement so potassium replacement may be necessary -monitor BG every hour -ECG is indicated to monitor effects of elevated potassium on the heart

nursing action when viewing colorless drainage post brain surgery

-notify HCP immediately -assess for glucose -if there is blood in the drainage there will be glucose anyways so allow liquid to leak onto white gauze pad to look for halo sign

necessary nursing intervention for client with command hallucinations

-nurse must ask what the voices are saying in order to determine safety risk

sequential compression stockings

-nurse should fit two fingers between sleeve and leg -apply anti embolism stockings prior to SCD sleeves -opening should be at the knee (front) and the popliteal pulse point (back) -to measure nurse should measure largest part of clients lower leg (calf) and length of clients leg from top of lower leg to heel

dizziness with irrigation of the ear

-nurse should warm the solution, dizziness is a common effect when water that is too cool comes in contact with the tympanic membrane

risks for urinary incontinence

-obesity, smoking, advanced age, gender (females more likely), pelvic muscle weakness, menopause, dementia, Parkinsons

best nursing intervention for infant having trouble gaining weight

-observe the child at mealtime

for client who repeatedly lowers herself to the floor post hip-replacement, what is the best intervention by the nurse

-observe the client rise from a sitting to standing position to determine if client is safe to perform this activity

polycystic ovary syndrome

-occurs just after puberty -a condition caused by a hormonal imbalance in which the ovaries are enlarged by the presence of many cysts formed by incompletely developed follicles -s/s: acne, mood changes, stubborn weight gain, hair growth on face/body, can cause brown skin ring on back of neck -hormonal changes: increased androgens (male hormones), insulin resistance, too little progesterone -weight management is very important -exercise is important to decrease insulin resistance

risk for post-surgical respiratory complications

-older age -smoking (decreased mucociliary clearance) -thoracic type of surgery (CABG, etc) -lung trauma (chest tubes, etc)

how should we assess carotid pulse

-one artery at a time -palpating both at the same time could cause an occlusion and reduce blood flow to cerebrum, this reduces HR

birth control info

-oral contraceptives (combination and progestin-only pills0 can reduce menstrual cramps and menstrual flow -smoking cessation is recommended to decrease risk of clots with oral contraceptives -vasectomys are not immediately effective and it can take up to three months for seminal fluid to be sperm negative (use other methods until negative seminal fluid sample is obtained) -allow space at end of condom for semen collection

priority for new client on psych unit with depression

-orient to unit briefly -do not overload with information -try to provide consistent, daily care with same nurse if possible -provide structured, written schedule

crohns interventions

-pain will be increased if patient lies with their leg supine -massaging abdomen can help -relaxation techniques can be utilized -take antispasmodic medications to help with pain

herpes zoster (shingles)

-painful skin rash that appears in a band or strip on the face or body -meds: NSAIDS for pain, anti-viral meds like acyclovir -standard precautions, have nurse with immunity if possible, slow rhythmic breathing to cope with pain

why no oral temp with rhinoplasty

-patient cant breathe

risk factors for latex allergy

-people who use condoms -rubber industry workers -avocado allergy -history of asthma -history of multiple procedures -healthcare workers -defect in bone marrow cells -deformed bladder or urinary tract -urinary cath with rubber tip -allergies, asthma, eczema -allergies to bananas, avocados, kiwi, chestnuts

kegel exercises

-perform 2-3 times per day -best done while sitting, standing, and lying -breathing should be relaxed and normal during kegel contractions -pretend to keep intestinal gas or flatus from escaping automatically to use these muscles

sign in impetigo that suggests poststreptococcal pneumonia

-periorbital edema

post-partum care

-peripads should be changed everytime the client uses the bathroom regardless of if it is soiled or not -s/s of complication: fever, foul-smelling lochia, large blood clots, severe headaches, blurred vision, calf pain, dysuria, SOB, depression

lochia serosa

-pink/brown discharge -3-10 days after delivery

oxytocin

-pituitary hormone causing uterine contractions -used to stimulate uterine contractions for labor induction -causes an increase in calcium ion concentration that increases contractions -contractions should occur no more frequently than every 2 minutes and last no longer than 70 seconds, or if there are 5 or more contractions within 10 minutes -if contractions become more frequent or last longer, stop IV infusion or if there are signs of fetal distress -sustained contractions can lead to ruptured uterus or fetal distress

how to clean intubation supplies after respiratory arrest

-place intubation blade in a bag and arrange for gas sterilization

how to log role a patient

-place pillow between legs -cross clients arms over their chest -one person on the side of the draw sheet -two people on the other side to support the spine during the turn

post-op care for cataract removal

-position on back or unaffected side to prevent trauma to surgical eye -assess clients LOC post anesthesia

position for entering central line

-position supine with head low and head turned to opposite side -this produces dilation of neck and shoulder vessels, makes entry easier, and prevents air embolus

positive/negative babinski

-positive: dorsiflexion of great toe and fanning of other toes (abnormal in children over 2, indicates CNS disease) -negative: plantar flexion of toes

what should client increase in diet when taking hydrochlorothiazide and dexamethasone

-potassium -need fruits, greens, and vegetables

foods restricted with renal failure

-potassium (citrus fruits, dried fruits) -phosphorus -protein -sodium

coombs test

-prenatal test for pregnant women to detect antibodies against foreign RBC -also used before blood transfusion

why do we place eyedrops in newborns eyes after delivery

-prevents chlamydial and gonorrheal infections potentially acquired from the vagina during delivery -protects against opthalmia neonatorum, inflammation of the eyes resulting from STI infections contracted while going through the birth canal

why z-track

-prevents meds from leaking into tissues -used to protect skin when giving highly irritating medications

hindu death ritual

-priest pours water in mouth -family washes body

RBC transplant

-prime tubing with 0.9% NaCl -obtain and document baseline vitals -infuse 1 unit within 4 hours -need large catheter like 20-24 guage -stay with client for first 15 minutes as this is when reaction is most likely to occur -need to verify blood compatibility with another licensed person

nurse intervention for client with bee sting, sneezing, cough, hives, feels warm

-priority is to establish IV access to provide an infusion to support circulatory status, maintain BP, and provide IV access for emergency drugs -then IV corticosteriods

obsessive compulsive disorder

-priority is to establish a trusting relationship -nurse must provide care with unconditional regard -monitor for s/s of a change in anxiety level -if ritualistic behavior is harmless work toward increasing the insight about anxiety and compulsion and gradually decrease the time available for the behavior -encourage distraction from habit and involvement in non-ritualistic behavior

sterile technique

-process and procedures that destroy all microorganisms -example: (catheter insertion, instrument sterilization, operative site prep, inserting a central venous cath)

medications that counteract glimepiride (diabetic medications)

-propranolol (beta blockers can mask symptoms of hypoglycemia) -gemifibrozil increases hypoglycemic effect of sulfonylureas -ginseng (increases hypoglycemia effect of sulfonylureas -ibuprofen (increases hypoglycemic effect of oral antidiabetic medications)

interventions for care of pediatric patient

-provide age-appropriate book for child to read during IV med -call parents out of room to discuss test results -offer a visit to hospital chaplain -encourage parents to bring blanket from home for patient in isolation

treatment of cluster headaches

-provision of 100% oxygen at a rate of 6-8 liters per minute for 10 minutes -may be repeated after a 5 minute rest -relieves the headache by causing vasoconstriction and increasing the synthesis of serotonin in the CNS -sumatriptan can also help

safest laxative

-psyllium is a bulk-forming laxative from the category of laxative that is usually considered the safest, even when taken on a routine basis -psyllium is a fiber and works by increasing water absorption or retention within the stool, increasing the bulk and stimulating peristalsis

thoracentesis complications

-pulmonary edema, hypoxia, hemothorax, pneumothorax, subcutaneous emphysema, liver puncture

how to assess for carpal tunnel syndrome (Phalen maneuver)

-put back of hands together and bend both wrists at the same time -produces paresthesia of the median nerve distribution within 60 sec -80% of clients with carpal tunnel have a positive result

first action when assisting patient with anterior cervical fusion out of bed

-raise head of bed

breathing with pneumothorax

-rapid breathing

buergers disease

-rare disease within arteries and veins of arms and legs -blood vessels get inflamed, swell, and block with thrombi -can lead to infection/gangrene -s/s: digital cold sensitivity

human papilloma virus

-recommended to provide immunity before exposure -reduces the risk of cervical cancer -recommended for males and females at 11-12 years old -HPV virus can cause cervical or penile cancer as well as genital warts

struvite stones

-referred to as infection stones because they form in urine that is alkaline and rich in ammonia -common in people with chronic UTI infection

escharotomy

-removal of burn scar tissue -goal is to alleviate the compartment syndrome that occurs when edema forms under the nondistendable eschar in this type of burn

laryngectomy

-removal of the larynx (house vocal cords, produces sound) -patient should cough and deep breathe after surgery, will communicate by writing initially after surgery -will require tube feeding initially with laryngectomy tube (then oral foods) -will eventually use esophageal speech -may notice a change in sense of taste/smell -no singing, laughing, or whistling

dressing change

-remove dirty dressing with clean gloves -remove clean gloves -wash hands -apply sterile gloves -apply new dressing

phototherapy

-remove eye patches q2-3 hours -place infant 12-16 inches below light -reposition every 2 hours -wears diaper only -cluster care to avoid disturbance

treatment for hemophilia

-replace factor 8 -RICE (rest, ice, elevate, compression)

when discharging woman post labor, how many supplies is nurse responsible for giving to client

-responsible for maintaining cost-effectiveness, give enough supplies to last until woman can get others -insurance companies may not pay for extra supplies so only provide enough supplies to last about one hour

how long is protective isolation following transplant surgery

-restrictive visitation for at least 72 hours post-operatively

calcium oxalate stones

-result from increased calcium intake or conditions that raise serum calcium concentrations

morning sickness

-result of hormonal changes -higher hCG production during first trimester than any other trimester -begins about 4 weeks after LMP and ends by 14th week -may be linked to mothers acceptance of pregnancy trt: eat a dry carb upon waking up, eating more protein at night, avoid fried/spicy/greasy foods, avoid excess fluid consumption early in the day, avoid sudden movements when getting out of bed/chair, avoid skipping meals, try eating ginger/flavored popsicles/drink tea, avoid teeth brushing immediately after eating -if uncontrolled, HCP may prescribe vitamin b6 and doxylamine

SIRS (systemic inflammatory response syndrome)

-results from a variety of life-threatening conditions -sepsis, shock, MI -goal: keep MAP higher than 65 mmHg -causes: burns, crush injuries, major surgeries, bowel ischemia -causes a release of inflammatory mediators that direct damage to the endothelium, hypermetabolism, increased vascular permeability, and activation of coagulation cascade -SIRS can lead to MODS (multiple organ dysfunction syndrome)

cushing syndrome

-results from chronic exposure to corticosteroids (too much cortisol) -s/s: weight gain, accumulation of fat in the trunk (centripetal obesity), face (moon face), and cervical region (buffalo hump), hyperglycemia diet: high-protein, low-carb, high-potassium, low-sodium, low-calorie

ecchymosis around umbilicus and flank

-retroperitoneal bleeding (EMERGENCY)

immediate burn care

-rinse with tap water to decrease the heat in the burn -was with soap and water if necessary

what is precipitous labor

-risk for early postpartum hemorrhage and amniotic fluid embolism -defined as a labor pattern that progresses quickly and ends less than 3 hours after it began

risk with myelomeningocele patietn

-risk for meningitis -watch for signs of increased temperature, irritability, lethargy, change dressing every 2-4 hours with aseptic technique, place infant on pressure reducing surface, measure head circumference, lotion and gentle massage to skin can decrease irritation, keep perineum clean and dry

peripheral arterial occlusion with diabetes

-s/s: client cannot distinguish between sharp and dull pressure on the right leg -s/s: pain, pulselessness, pallor, paresthesia, paralysis

what does it mean if pulse drops below the preset rate on the pacemaker

-the pacer is malfunctioning example: set at 72 bpm, hr comes out to be 68 bpm

air embolism during CVC removal

-s/s: coughing, pale/dyspneic, tachycardia -trt: place client in left lateral position with head of bed lowered to prevent air from entering right atrium and pulmonary artery, if air goes into there it would create an air lock or obstruction and stop the heart, give oxygen -keep in position for 20-30 minutes

hypokalemia with burns

-s/s: muscle weakness, lethargy -occurs usually around the third day -caused by diuresis

how to collect specimen for pinworms

-scotch tape to childs anus early in the morning -collect in morning -found in stool

glucose tolerance test

-screening tool used to assess for gestational diabetes -tested between 24-28 weeks gestation -eat/drink normally 8 hours before test -fasting BG, drink glucose solution, level drawn one hour later -if BG is greater than 140, client is referred for 3 hour oral GTT

midazolam

-sedative used for cardioversion -no driving 24 hours -hold digitalis for 48 hours to avoid ventricular fibrillation

risk factors for HHNK (hyperglycemia hyperosmolar nonketotic syndrome)

-seen after 50 years of age, age-related changes in thirst perception results in dehydration and decrease in urine-concentrating abilities of the kidney

order of morning medications

-seizure meds first -then antibiotics to avoid decrease in circulating level -then diuretic -then digoxin if HR is normal

semi-fowlers position

-semi-fowler position can place lungs in normal anatomical position and decrease work of breathing, may alleviate dyspnea

neuroleptic malignant syndrome

-serious complication of antipsychotic drugs -s/s: sudden high fever, rigidity, tachycardia, hypertension, decreased LOC -nurse: manage fluid balance, reduce client temperature, monitor for complications, DC antipsychotic medications and administer bromocriptine (counteracts NMS)

autonomic dysreflexia

-serious complication of spinal cord injuries at or above t6 -a noxious stimuli sets off responses resulting in increased BP s/s: flushed face, sweat, increased BP trt: hydralazine hydrochloride (rapid acting hypertensive)

self-determination act

-set of federal laws requiring health care facilities to provide written material to adult clients about their rights to make health care decisions

expected findings and when to be concerned with status asthmaticus

-severe and persistent asthma that does not respond to conventional therapy -expiratory wheezing is expected (absence of wheezing is when HCP would be concerned) -dusky fingertips (cyanosis) -intercostal retractions indicate the client is using accessory muscles to breathe, expected -oxygen saturation of 85% translates to PO2 < 60 mmHg on the hemoglobin curve which indicates hypoxemia (VERY CONCERNING)

acute dystonic reaction

-severe muscle contractions of head and neck -trt: diphenhydramine hydrochloride

neuroleptic malignant syndrome

-severe reaction to antipsychotic drugs as a result of dopamine blockade in hypothalamus -fatal in 10% of cases -trt: stop medication, transfer patient to medical unit, cool body and administer bromocriptine to treat muscle rigidity and dantrolene to decrease muscle spasms

specimen collection for forensic cases

-shot gun shells, bullets, etc. should be wrapped in gauze and kept in a cup/envelope -save gravel, soil, grass, twigs, or glass from the client or on the sheet -swabs and smears of vaginal, cervical, rectal, or penile secretions, should be air-dryed before placed in sterile bag -place clothes in paper not plastic bag

how soon should open heart surgery clients be ambulatory

-should be encouraged to be out of bed and ambulating ASAP -frequently as early as 1-2 days after surgery

nurse with loose stools working in newborn nursery

-should be reassigned to orthopedics -don't allow them to care for newborns, infants, or immunocompromised patients

best action for nurse with adult male client with total plasma cholesterol of 200 mg/dL

-should be under 200 mg/dL -requires a low fat diet -obtain a diet history first

position for patient following prosthetic hip implant

-side lying with affected hip in a position of abduction -avoid: flexion beyond 60 degrees, adduction, internal rotation

psoriasis

-silvery white patches on the scalp, elbows, knees, and scrotum

CABG normals post-procedure

-small amount of serosanguinous drainage is expected on the dressing -edema of graft site will increase slightly when patient is home due to increased activity (client should elevate) -increased temp and fatigue: post pericardiotomy syndrome (pleural pain, increased WBC, dysrhythmia) -minimal incisional pain for 6-12 weeks after

ringworm

-small circular patches on the top of the head

dressing for circumcision

-small gauze pad with petroleum jelly is applied to the circumcision site as a dressing -this prevents the wound from adhering to the dressing or diaper -dressing changes continue for 3 days after the procedure

roseola

-small pink bumps with a raised surface on the face, chest, and limbs

cushing syndrome

-sodium retention and hypernatremia -hypertension -hyperglycemia -hypokalemia -metabolic alkalosis

suggestions for AIDS patients

-soft toothbrush 3-4 times a day to avoid injury to oral mucosa -small frequent meals -dont handle pet poop -bowel programs like stool softeners and laxatives will reduce intestinal stasis and bacterial overgrowth

swan/ganz catheter

-soft, flexible catheter that is inserted through a vein into pulmonary artery -used to provide continuous measurements of pulmonary artery pressure -can exercise with device but patient should avoid activities that increase pressure on injection site

sigmoid colostomy

-some sigmoid colostomy patients can go without a collection bag by routinely irrigating -irrigating a sigmoid colostomy is not necessary more than once a day and sometimes every 2 or 3 days s

somogyi vs. dawn phenomenon

-somogyi: man-made, rebound hyperglycemia, rebound from low blood sugar (<70) to high blood sugar (>200) -counter hormones pull the blood sugar up -teach patient to take blood sugar at 0200-0300, have a snack at bedtime, and change insulin regimine -dawn: body response to counter-hormones -diabetic doesn't have enough insulin to keep normal glucose level -limit carbs at bedtime, try cheese and nuts instead -change insulin routine

agina

-squeezing or viselike pain -exertion, emotion, extremes in temperature increase pain -pain is relieved with rest -pain is relieved with nitroglycerin

what should be removed from room of client with t cell depression

-standing water in containers as this acts as a culture medium for bacterial growth -risk for infection

cause of impetigo

-staphylococcus and streptococcus -can lead to acute glomerulonephritis -sign of progression to glomerulonephritis: periorbital edema

good samaritan laws

-statutes that protect rescuers from being sued for giving emergency care -if the client develops complications resulting from the professionals actions, the professional is immune from liability as long as the professional acted without gross negligence

The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)

-stay with client -give lorazepam -provide privacy from other activities in the ED -write down important information

how to minimize phantom limb pain

-staying active can decrease episodes of and degree of phantom pain

inhaler for school age-child

-stays with nurse during the day

weber test

-stem of vibrating tuning fork held against patient forehead, and hearing is assessed in both ears -client is asked to say when sound is heart best normal: midline tone and sound is equal abnormal, conduction hearing loss: sound is louder in affected ear abnormal, sensorineural hearing loss; sound is louder in normal ear

paracentesis

-sterile surgical puncture to remove fluid from the abdomen -use: to diagnose a condition, to relieve pain, to relieve pressure or SOB d/t ascites or cirrhosis -client should empty bladder first and sit upright -normal to have red-tinge to outflow if client is menstruating, dialysate can pull blood from uterus

sleep apnea

-stop breathing during sleep leading to hypoxia can be obstructive or central trt: avoid alcohol and meds that make sleepy, weight loss, sleep on side not back, use nasal sprays or strips CPAP: nose and mouth covered, uses room air

risk for colon cancer

-stress -history of endometrial cancer -alcoholism -age -history of irritable bowel disease -red meat consumption -obesity

position for liver biopsy

-supine with arms raised above head

treatment for respiratory distress

-supplemental oxygen -assist with intubation/airway management -IV fluids -ephinephrine, antihistamines, corticosteroids, inhaled bronchodilatiors -vasopressor meds

effects of stress on the body

-suppresses immune system and places client at risk for cancer and infection -blood glucose levels rise in response to stress as cells become resistant to insulin

post transphenoidal hypophysectomy what is most important for nurse to monitor

-surgery is performed through nose -urine spec grav is MOST IMPORTANT -lack of ADH from pituitary gland may cause diabetes insipidus and diuresis with low spec grav

hydraulic lift for transferring patient

-suspend client briefly above the bed prior to moving away from it to provide reassurance and increase client feelings of security

clinical manifestations of dehydration

-tachycardia -cold hands and feet d/t vasoconstriction -flat neck veins -thirst -hypotension -lethargy

considerations with patient taking disulfiram

-take at night to minimize complications from sedative effects -any contact with alcohol even 7-15 mL of alcohol on wood paint would cause a reaction, patient needs to avoid substances containing alcohol like paint, wood stain products -longer a person takes disulfiram, the more sensitive to alcohol they will be

home care for patient with pacemaker

-take pulse daily for a full minute, at same time each day, document

intervention for client who wants to bottle feed infant

-tell woman to wear a well-fitting supportive bra to minimize discomfort during engorgement (even while sleeping) -minimize allowing warm water to contact breasts in shower -application of ice packs may reduce engorgement

s/s of heat stroke

-temperature of 105°F (40.6°C) or above with skin that is hot and dry -client's behavior may be bizarre, with confusion or delirium, or the client may be comatose

bell palsy

-temporary unilateral facial paralysis that results from malformation of the 7th cranial nerve (facial) -s/s: facial paralysis, inability to close affected eye, decreased corneal reflex, increased lacrimation, speech difficulty, loss of taste -trt: isometric facial exercise (blow and suck with straw), electrical stimulation, analgesics, steroid therapy, antiviral meds

positive trousseau sign

-tension and muscle spasm of the hand when BP cuff is applied to arm and inflated -due to decreased serum calcium

trendelenburg test

-test for varicose veins. -if they fill proximally = varicosity

fecal occult blood test (FOBT)

-test to detect occult blood in feces -taking vitamin C is contraindicated for 3 days prior to specimen -pink results: negative -blue results: positive -collect sample from two areas of specimen -occult blood is tested in client with anemia with no cause, test for colon cancer, reports of abdominal pain, changes in bowel movements, or unexplained weight loss

major sign of hypoparathyroidism

-tetany

sengstaken-blakemore Tube

-three-lumen tube used in treating esophageal bleeding -manages bleeding -decompresses and drains the stomach -keep scissors at bedside because if respiratory distress occurs, need to be able to cut balloon parts and remove the tube -also can be called a Minnesota Tube

behavior training with kids

-time out= 1 minute for year of age -delay timeout if childs behavior is loud/disruptive -use loud kitchen bell timer -once child has experienced consequences, do not dwell on situation again -cant distinguish between their point of view and others so teaching morals doesnt always work

upper GI fluoroscopy

-time sensitive, affects other tests because the barium used will interfere with other tests by interfering with x-rays and other tests that use iodine -should be performed last

proper breast self-exam

-to perform a proper breast self-examination, women need to first look in the mirror and note any changes in appearance of breasts and nipples -second, women examine their breasts with their arms raised above their heads, this allows them to see if the breasts move freely over the chest wall -third, women must lie down, placing a pillow under their shoulders along with their hands behind their heads, this position distributes breast tissue -finally, they should use the pads of their middle three fingers to palpate the breasts in a circular motion

what can cause a false high BP reading

-too short cuff (wide-low BP) -too quick repeats -brachial artery below heart -deflating too quickly

carbidopa/levidopa

-treats symptoms of parkinsons disease -can reduce tremor frequency/severity -reduce rigidness and bradykinesis -facilitates mobility and can be very thereapeutic

pseudoparkinsonism

-tremors, rigidity, shuffling gait -trt: anticholinergic agent

t-tube

-tube that may be inserted into the common bile duct during surgery when a common bile duct exploration is part of the surgical procedure -ensures patency of the duct until the edema produced by the trauma of exploring and probing the duct has subsided -also allows the excess bile to drain while the small intestine is adjusting to receiving a continuous flow of bile -client may shower if there is not a dressing covering it -drainage should decrease as healing occurs -client should avoid strenuous activity for up to 6 weeks, swimming and bath tubs are prohibited -incision should be checked for

intervention for client with end-stage metastatic breast cancer

-turn client q2h

volkman contracture

-type of compartment syndrome caused by obstruction of arterial bloodflow to hand and forearm -fingers cannot be straightened

spinal laminectomy

-type of procedure used with herniated disc, etc. -post operative pain is common -should not cause a deformity of incontinence

liver cirrhosis

-types include alcoholic, postnecrotic, biliary -assess: alcohol use, drug use, upper right quadrant pain, weight loss, weakness, anorexia, elevated BP, ascites, splenomegaly, abnormal bleeding -nurse: daily weights, calculate I&O, measure abdominal girth, assess neck vein distention, monitor coags and ammonia levels, place in high fowler and provide low-sodium, low-protein diet -trt: decrease fat, increase carbs, decrease sodium, increase B vitamins, increase calories, decrease fluids

what is important to assess when discharging elderly diabetic client

-understanding of disease -assess visual acuity and manual dexterity -assess ability to draw up and administer insulin

cast syndrome (superior mesenteric artery syndrome)

-unusual but serious and urgent complication seen with hip spica or body cast -cast pressures or intestinal gasses cause duodenum to be compressed between aorta and superior mesenteric artery s/s: distention, abdominal pain, n/v trt: cut a window in abdominal area of cast, bivalve the cast, insert NG tube to relieve pressure on intestine

sulfamethoxazole/trimethoprim

-urinary anti-infective -mild to moderate rash is common side effect

what should be monitored when client has spinal anesthesia in place

-urinary incontinence -hypotension -respiratory depression -nausea/vomiting

dexamethasone suppression test

-used for Cushing's syndrome (increased corticosteroid) -determines function of adrenal gland

gabapentin

-used for neuropathic pain -can cause drowsiness -usually 3 times a day unless extended release form -treats postherpatic (shingles) pain -anti-seizure med

buddy bandaging or buddy taping

-used with broken extremities -healthy extremity acts as a splint (keeping the injured extremity immobile) -used with sprains, dislocations, and fractures

acute stage of HIV

-usually appears 2-3 weeks after initial infection and lasts 1-2 weeks -within the acute phase, there is a decrease in CD+ or T cells

colon cancer

-usually begins as benign polyps that grow normal: hyperplastic polyps iffy: adenocarcinomas that grow slowly adenocarcinomas: malignant can spread to other organs trt: chemo, radiation

breastfeeding position with c-section patient

-usually football or clutch position, try different options

s/s of aging

-visual/hearing impairment -decreased sense of thirst -loss of taste/smell -difficulty communicating -confusion -loss of skin elasticity and wrinkling -decreased digestive enzymes -increased anteroposterior chest diameter -fat decreases on extremities and increases in abdomen -hair thinning -height shrinkage -bone density loss -decreased metabolism -memory changes -irregular heartbeat/hypertension -SOB -activity intolerance -increased total body fat but increased accumulation in abdomen (males) and thighs (females) -decreased gastric motility

chronic pain

-vitals remain within normal limits -skin is warm and dry -client does not display signs of pain (crying, etc) -client doesnt report pain unless asked

interventions for PAD before exercising to reduce leg pain

-walk until pain begins, then rest, then walk again -start a smoking cessation program

cushings s/s

-weak bones d/t chronic excess corticosteroids -weight gain -edema of lower extremities (may need potassium-sparing diuretics -risk for infection d/t lower resistance to stress and immune system suppression d/t corticosteroids -hypokalemia

important interventions for older client with left-sided weakness d/t stroke, histroy of hypertension and osteoporosis

-weight bearing exercise is a primary way to develop high-density bones, decrease bone resorption, and stimulate bone formation -may also help with maintaining mobility with left-sided weakness

brudzinski's reflex

-when flexing clients head and neck onto the chest, the client flexes hips and knees to indicate meningeal irritation

post MI when can patient resume sexual activity

-when they can walk one city block or climb two flights of stairs without having chest pain -maintain a supine position and not have intercourse after a heavy meal

ways to avoid UTI

-wipe front to back only -empty bladder every 3-4 hours -drink at least 6-8 glasses of water a day -avoid bubble baths

IV pyelogram

-xray with IV dye to visualize kidney, rate of excretion by illuminating ureters and bladder -cleansing enemas the night before to visualize the abdominal area

can you give flu and pneumococcal vaccine at same time

-yes

should pediatric client with low-grade fever and minor respiratory illness get a vaccine

-yes, give anyway on time even if (ear infection, mild diarrhea, cough/cold symptoms, fever less than 101)

nursing student with shingles on their trunk wants to care for patinets, what is best response from the nurse

-you cannot care for patients until your lesions have crusted

what to tell pre-school patient who does not want their dressing changed

-your mom is going to be here with you -offering them choices is good except for delaying or refusing necessary treatment

rate for rewarming patients

0.45 degrees F or 0.5 degrees C per hour

therapeutic level for lithium carbonate

0.6-1.2 mEq/L

interventions for client with MI symptoms

1) bed rest 2) supplemental oxygen 3) assess serum troponin level 4) monitor I + O 5) high-fowlers position 6) 12 lead ECG

nurse interventions immediately after birth

1) determine APGAR score 2) physical exam with lab results 3) clear secretions with bulb syringe 4) give eye trt and vitamin k 5) obtain blood for screening 6) perform hearing screen 7) skin to skin contact 8) bathe when baby has stable temperature 9) asses parental interactions 10) assist mom with feeding 11) teach newborn development

safe medication administration steps

1) double verify with the other nurse if necessary, give insulin 2) document after administration 3) use 2 client identifiers 4) prepare meds for 1 client at a time 5) verify if there are questions about the dose 6) read label 3x and verify with medication record

steps to take after medication error

1) evaluate effect of medication 2) notify HCP, patient, charge or nurse manager 3) complete incidence/occurance report -risk management finds out with report -attorney finds out if harm is done

bulb suction drain removal

1) release suction from bulb 2) remove sutures 3) instruct client to breathe deep and even 4) remove drain with continuous, smooth, motion 5) assess exit site for irritation and drainage

-wound separating after abdominal surgery

1) sterile saline towel or dressing cover 2) position client in place to relieve pressure (flex knees to abdomen) 3) avoid deep breathing/coughing

nalaxone (narcan)

1. It competes with opioid receptor sites to block effect of the narcotic 2. used to treat heroin and opioid overdoes 3. shorter half-life than the narcotic means the Narcan will wear off and narcotic will still be there and bind to receptors

max rate for potassium chloride via IV

10 mEq/hour

when should ostomy bags be changed

1x week whenever stoma is loose or leaking

warfarin therapy after a stroke

2-5 days

when should fundus reach umbilicus

20 weeks

if there are 8 QRS in 30 large squares on a 6 second strip, what is the heart rate

30 large squares = 6 seconds 8x10= 80 bpm

normal urine output/day

30 ml/hour or 720 ml/day

how long should clients remain in semi-fowler position post NG feeding

30-60 min

how long is vaginal edema present post delivery

6-10 weeks

normal serum amylase

60-100 somogyi u/dL -elevated with acute pancreatitis

ideal pressure for trach suction

80-120 mmHg

best suggestion for follow-up care to patient during drug and alcohol discharge

AA or self-help groups

anti-retroviral therapy

ART: helps controls AIDS, saves lives but has drawbacks -negative metabolic effects like hypertriglyceridemia, dyslipidemia, insulin resistance, and increased MI risk -get lipid profile checked

AST/ALT

AST: aspartate aminotransferase assesses liver function normal: 10-30 microliters

A pregnant client comes into the prenatal clinic accompanied by her spouse. The spouse states they were in a car accident and his wife's abdomen hit the steering wheel. The nurse observes the woman wringing her hands and not making eye contact. The client's record shows two recently missed prenatal appointments. Which action does the nurse take?

Accompany the client into the restroom to obtain a urine sample -get woman away from her abuser by claiming the need to accompany her to obtain a sample

The nurse prepares a toddler-age client for placement of tympanostomy tubes. Which action is most important for the nurse to take?

Allow the client to play with a toy stethoscope before auscultation -decreases fear of unfamiliarity -explain procedure by saying what toddler will see, taste, hear, feel

Adrenoleukodystrophy

An inherited disorder in which certain fatty acids accumulate and thereby cause seizures, nervous system degeneration and death in childhood onset: 4-10 years old duration: 1-10 years give Lorenzo's oil treatments

The nurse enters the room and discovers that the client has slurred speech, right-sided paralysis, and unequal pupils. Which action should the nurse take first?

Assess the respiratory status

use of b vitamins

B1: thiamine: give to clients with alcoholism to decrease alcohol related changes like wernicks encephalopathy and korsakoff syndrome B6: pyridoxine: give to client with Tb to prevent neuropathy, dizziness, and ataxia B9: folic acid: give to pregnant client to prevent neural tube defects, give to all women capable of becoming pregnant B12: give B12 for anemia or neuro issues

older adult with knee-high nylon stockings

BAD -constrict circulation to extremities, promote venous stasis and cause thrombi and emboli -encourage compression or simple cotton socks

anorexia nervosa

BMI 17.5 or lower avoid discussing food, especially while client is eating and require consumption of food within a limited time insert feedings via NG tube if prescribed

"CAUTION" warning signs of cancer

Change in bowel or bladder habits A sore that does not heal Unusual bleeding/discharge Thickening or difficulty swallowing Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough/hoarseness

what should be included in change-of-shift report

Changes in condition, new medications, complications, diagnostic procedures, treatments (lasix for crackles, etc.) -in documented report: admitting diagnosis and changes in relevant history, clients emotional response to the condition, current IV and flow rate, use of and response to all PRN medications

rules for radiation cancer therapy

DO: shower with mild soap, apply absorbent dressing to drainage, allow air to circulate over area, avoid sun exposure and dont put sunscreen on until after treatment DONT: apply lotion to radiation site, swim in pools, lakes, etc.

tetrology of fallot

DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Goals: ensure adequate oxygenation, preserving cardiac function, maintaining fluid volume balance, promoting adequate nutrition, maintaining balance between physical activity and rest, and providing parental education. NURSE: small, frequent feedings every 2 hours with a soft nipple designed for premature neonates or one with hole large enough to allow easy flow of breastmilk or formula will help with energy conservation. trt: requires surgical correction.

The Joint Comission (TJC) do not use list

Daily (Q.D., QD, q.d, qd) Every other day (Q.O.D., QOD, qod, q.o.d) Lack of leading zero (.Xmg) Use of trailing zero (X.O mg)

early side effects of lithium toxicity

EARLY -nausea and vomiting -slurred speech -muscle weakness LATE -coarse hand tremor -persistent GI upset -mental confusion -poor coordination -defective, uncoordinated movements

what does black tarry stool with GI bleeding indicate

GI bleed

which meds should be held/not held for administration until after dialysis has finished

HELD: -antihypertensives (blood pressure decreases when dialysate is removed) -ACE inhibitors are held until after dialysis as BP drops after dialysate is removed -antimicrobials are removed with the dialysate and should be given after dialysis is complete NOT HELD: -pain medications -insulin

herpes simplex

HSV1: oral HSV2: genital trt: clean lesions BID with diluted povidine-iodine solution and leave open to air

moro reflex

Infant reflex where a baby will startle in response to a loud sound or sudden movement -disappears at 4 months of age

nursing interventions for clients with headache, hypertension, and ride-sided weakness

NPO CBC CT scan Lumbar puncture IV fluids

continuous bladder irrigation

Prevents formation of clots that can lead to obstruction and spasm -use in port operative TURP patients -keeps urine flowing

nurse response to fire in hospital

Rescue Alarm Contain Extinguish

The parent of a toddler asks the pediatric clinic nurse, "Do you have any suggestions for what I can say to get my child to go to bed without a fuss?" Which suggestion by the nurse is best?

Say to your toddler, "After we read this story, it will be time for sleep." -sets clear and reasonable limits and allows time for adjustments -having a clear routine builds trust when the parent follows through and pairing it with a calming routine like reading a story is good

transfusion-related acute lung injury

arises within 6 hours of transfusion -s/s: fever, chills, hypotension, tachypnea, frothy sputum, dyspnea, hypoxia, respiratory failure

SMART goals

Specific Measurable Achievable Results Focused Time bound

A client receiving an IV infusion of heparin has an activated partial thromboplastin time (aPTT) that is greater than 150 seconds. Which is the priority action by the nurse?

Stop heparin and report to HCP

hypophysectomy

Surgical removal of the pituitary gland. Post Op: Monitor dressing for CSF. (CSF has glucose so drainage checked by a BS test with a glucose strip) Determine if CSF if halo ring sign shows and turns yellow circle on cotton swab Use stool softeners and antitussives to prevent straining, assess vision, risk of hematoma formation

ovulation

The time where the temperature drops and then rises is the period of highest fertility.

how to calculate ANC

WBC X (%neutrophils + %bands)/ 100 risk levels -mild: less than 1000 to 1500 -moderate: less than 500 to 1000 -severe: less than 599 cells/micro liter

stenosed stoma

appears narrow and flat

if nurse receives call of 50 victims coming to hospital who does the nurse call

contact supervisor and follow the chain of command -supervisor will activate disaster plan

wheezes

continuous high-pitched whistling or musical sound primarily during expiration, but sometimes with inspiration as well

rheumatoid arthritis

a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked -need a lot of rest -use joints often to decrease pain -slide objects, don't lift goal of treatment: reduce or eliminate pain trt: surgery, medicine, diets, vitamins, consistent exercise, active is better than passive

ulcerative colitis

a chronic condition of unknown cause in which repeated episodes of inflammation in the rectum and large intestine cause ulcers and irritation -trt: bowel rest, low residue diet example of good diet: canned, cooked, seedless fruits and vegetables, refined grains, dairy bad foods: beans, legumes, whole grains, raw fruits/veggies

stepping reflex

a neonatal reflex in which an infant lifts first one leg and then the other in a coordinated pattern like walking -gone at 5 months of age

fluorescein angiography

a radiographic study of the blood vessels in the retina of the eye following the intravenous injection of a fluorescein dye as a contrast medium -vessels examined after eyes are dilated -avoid sunlight right after exam -can cause a temporary stain to the skin

acute respiratory distress syndrome

a sudden and progressive form of acute respiratory failure in which the alveolar-capillary interface becomes damaged and more permeable to intravascular fluid -risks: aspiration of gastric contents, viral/bacterial pneumonia, sepsis, severe massive trauma -s/s: dyspnea, tachypnea, tachycardia, cough, restlessness, diaphoresis, crackles -x-ray often reveals a whiteout or white lung because infiltrates are spread throughout the lung with few air spaces -trt: prepare for tracheal intubation

cross-reactive foods with latex

apple, apricot, avocado, banana, carrot, celery, cherry, chesnut, fig, grape, kiwi, melon, nectarine, passion fruit, papaya, peach, pear, pineapple, plum, potato, tomato

what can UAP do with restraints

application and removal of ordered restraints

voting rights for psych patients

absentee ballot

lymphedema

accumulation of lympm (pale yellow interstitial fluid) in soft tissue cause: develops d/t an overproduction of lymph fluid or interference with lymph absorption risk: if not treated, can lead to cellulitis (evidence by warmth, redness, and pain), may occur as complication of mastectomy and lumpectomy

priority for sickle cell crisis

adequate hydration

bilrubin levels

adult normal: 0.3-10 mg/dL newborn normal: under 5/2 mg/dL phototherapy: above 15 mg/dL

when helping a patient out of bed post hip replacement what side should nurse be on

affected side

highest risk for lung cancer

african americans

when should nurse be able to palpate fetal movement

after 18 weeks

when should aluminum hydrochloride be taken

after meals

prostate cancer risks

age (men over 50); African Americans; occupation and environment (exposure to carcinogens found in urban areas and in occupations such as fertilizer, rubber, and textile industries, as well as in places w/ heavy metals such as cadmium; cadmium used in low-friction, fatigue-resistant alloys, in nickel-cadmium batteries, and in rustproof electroplating)

albuterol vs. beclamethasone

albuterol: rapid acting bronchodilator used to treat acute asthma attacks beclomethasone: anti-inflammatory agent used chronically to prevent asthma attacks by reducing inflammation in airways

conditions common with hypophosphatemia

alcoholism, starvation, anorexia, bulimia, bone tumor, celiac disease, crohn disease risk for bone fractures

cheyne-stokes

alternating periods of slow, irregular breathing and rapid, shallow breathing

holter monitoring

ambulatory ecg monitor worn over 24-48 hours -client is encouraged to maintain normal activity -start recording when symptoms develop -immediately report symptoms of weakness, etc to HCP -keep a diary of daily activities -avoid electrical devices (razors, shavers, electrical toothbrushes) -no bath or shower, only sponge bath

aluminum hydroxide

antacid taken after meals to neutralize gastic acid

lidocaine hydrochloride

antiarrhythmic, local anesthetic drug of choice for PVC occurring frequently, excess of 6-10 per minute, coupled PVC's or v-tach

what does apgar assess

appearance, pulse, grimace, activity, respiration

fern and nitrazine paper tests

assess presence of leaking amniotic fluid fern paper test: positive when ferning pattern of dried amniotic fluid is visualized under a microscope nitrazine test: positive when pH strip turns blue indicating pH is between 7.0-7.5

priority with bucks traction

assess the client to make sure circulation is not compromised -assess that elastic bandages are not too tight

serotonin syndrome

associated with medications that increase serotonin like SSRI's s/s: agitation, confusion, muscle twitching, headache, diarrhea, high fever, seizures

situational leadership style

assumes a combination of leadership styles and changes depending on the needs of the group

when should nurse be able to hear fetal heart rate

at 10-12 weeks gestation

legionella

bacteria found in warm, stagnant water (hot water tanks, decorative fountains, hot tubs) s/s: fever, body aches, cough -causes pneumonia risk factors: advanced age (50+), end stage kidney disease, immunosuppression, diabetes, smoking, pulmonary disease

mastoiditis expected finding during otoscopic exam

bacterial infection of mastoid bone (small bone sitting behind ear canal that affects ear structures) s/s: red, dull, thick membrane, edematous, inflammed trt: antibiotics

how often should tube feed bag/tubing be changed

bag every 24 hours, tubing every 24 hours -monitor daily weights -if PN is not available, give D10W or D20W -if PN bag has insulin included, keep finger-stick next to bed

adhesion

band of scar tissue that forms between organs after a surgical procedure s/s: similar to intestinal obstruction

barium enema

barium must be retained in the rectum for the test to be effective, uses barium contrast medium to identify the structures can diagnose a change in the colon must use deep breathing to prevent defecation increase fluid intake after test to promote barium passage

parent of newborn cant visit d/t restricted visitor hours/work conflict, what is best response by the nurse

be patient and family advocate, adjust visiting hours to meet new parent's needs

initial DVT treatment

bed rest elevate affected leg

what is a safety intervention for a confused client

bedrails up

when should blood cultures be drawn

before antibiotics are given and close to febrile episode -always draw blood from two different venipuncture sites to rule out contaminants

when are compression stockings applied

before the client gets up out of bed

husband of psych patient calls and wants patient information

best response is please call the number you were given

therapeutic communication

between client and nurse setting: private, quiet, confidential, safe content: encourages patient to express thoughts, beliefs, feelings, anxieties, fears, problems goal: promote growth and change

priority largest safety concern in school-aged children

bicycle and sports-related injuries and proper nutrition

how to measure residual urine volume

bladder scanner

what does pain at the biopsy sight radiating to front of abdomen post renal biopsy indicate

bleeding

major side effect of heparin therapy

bleeding -decreased LOC indicates intracranial bleeding and represents a serious immediate concern

what to look for after bone marrow biopsy

bleeding and hematoma formation at procedure site

what should be closely monitored with PN or hyperalimentation

blood glucose levels

what finding after MVC would indicate a basal skull fracture

bloody or clear drainage from the auditory canal indicates CSF leak and indicates basal skull fracture

prolapsed stoma

bowel protrudes through stoma

genu varum

bowleg -normal for toddler -caused by lateral bowing of tibia and lasts until all leg/back muscles are developed, usually around 2 years of age

who has softer stool, breast or bottle-fed infants?

breastfed

acute glomerulonephritis

complex immune system disease that occurs 10 days after a skin or throat infection (strep) s/s: fever, chills, hematuria, dyspnea, weight gain, edema, hypertension, headache, decreased LOC, confusion, abdominal or flank pain trt: antibiotics, corticosteroids

refeeding syndome

complication of PN nutrition with rapid drop in potassium, magnesium, and phosphate serum levels

what are common feelings after a seizure

confusion and sleepiness

s/s of detached retina

bright flashes of light dark portion in visual field

foods to avoid for patient with AIDS and cytomegalovirus

caffeine, roughage, dairy

what is the main cause of insufficient dialysate flow

constipation -stool softener and high fiber diet are recommended

if family of patient says previous nurse already gave insulin, what is the best response by the current nurse?

contact nurse from previous shift to confirm

medication to replace calcium

calcium gluconate

first step when finding client with heart failure and diabetes type 1 unresponsive

call for help, then check breathing, then check for pulse

pulmonary rehabilitation

can be inpatient or outpatient goal: decrease the oxygen needs of the patient examples: exercise training, focus on muscles used for ambulation, smoking cessation, nutritional counseling, education benefits: decrease hospitalizations, improved dyspnea, decrease fatigue, assist with emotions

apnea monitor

can be removed during bathtime

what can fainting/syncope indicate

can be the result of an irregular cardiac rhythm or rate change need to evaluate soon

reglan/metoclopramide

can cause tardive dyskinesia if used long term

long term effects of chemo

cardiac toxicity cataracts arthralgias endocrine alterations renal insufficiency hepatitis osteoporosis secondary malignancies: leukemia, angiosarcoma, skin cancer

where is pulse measured during CPR

carotid pulse assess character of pulse peripherally also during CPR

active exercise

carried out by the client without help from the nursing staff increases muscle strength and increases joint flexibility

peptic ulcer disease

cause: erosion of the GI mucosa by HCl and pepsin s/: dull, gnawing pain or burning trt: antibiotics, proton pump inhibitors, h2 blockers diet: no alcohol or smoking, no milk or cream, no aspirin, no meat extracts, no caffiene, no coffee

late decelerations

cause: uteroplacental insufficiency or maternal supine hypotensive syndrome goal: increase fetal oxygenation intervention: place woman on left side, apply O2 rebreather mask

before administering anything via NG tube, what does the nurse do

check NG tube placement

nursing action before giving piperacillin

check for allergies obtain culture/sensitivity obtain creatinine clearance

fist action after vaginal delivery

check lochial flow

flail chest

chest on affected side is pulled in during inspiration and out during expiration

medication to help with alcohol withdrawal

chlordiazepoxide -pharmacologically similar to alcohol, used as a substitute for alcohol in decreasing doses to comfortably and safely withdraw a client from alcohol dependence

pheocromocytoma

class sign: hypertension A pheochromocytoma is a rare, usually noncancerous (benign) tumor that develops in an adrenal gland. Usually, this type of tumor affects one of your two adrenal glands, but it can affect both.

ranitidine

class: antacid use: treats and prevents heartburn, GERD, stomach ulcers take: 1x day

what goal is most important when discharging client with bulimia

client will identify symptoms of electrolyte imbalance

suitable roommates for post-op client

clients considered clean should not be placed with contaminated clients

what will have the greatest impact on a patients emotional response to suffering from a stroke

clients personality and health prior to the stroke

live vaccine with cancer

clients undergoing chemotherapy are immunocompromised and should not receive any live vaccines

breath sounds for pulmonary edema with myocardial infarction

coarse rales

adult cancer screening schedule

colonoscopy: every 10 years after age 50 fecal occult blood test: every year after age 50 pap test: women 21-29 need every 3 years breast exam: women between 20-40 need it every 3 years and then every year after that

most important characteristic of wound drainage

color: indicates status of wound dark green/yellow: not improving pale yellow serous: infection

sympothermal methods of birth control

combines cervical mucous evaluation and basal body temperature evaluation any time two methods can be used instead of one, there is a better chance for success

renal oaxalate calculi

common type of kidney stone -need low- oxalate diet -low-calcium increases risk for oxalate renal calculi -avoid high oxalate diet diet: decrease dark roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, beans, chocolate cocoa, tea increase fluid intake

ACHES of birth control

dangerous side effects Abdominal pain (severe) Chest pain Headaches (severe) Eye disorders Severe leg pain/lower leg swelling

ischemic stoma

dark and blue

osteoporosis

decreased bone density, increased risk of fractures risk factors: estrogen deficiency, older age, female caucasian or asian, lack of sunlight, smoking, taking anticonvulsant medications trt: increase calcium intake (1000-1500 mg/day), and vitamin d

western blot test

determines if the patient has HIV antibodies

intake

difference between inflow and outflow

hantavirus pulmonary syndrome

disorder caused by a rodent who carries the virus results in severe cardiopulmonary illness s/s: fever, muscle aches, n/v, sob complications: thrombocytopenia, hemoconcentration, cardiopulmonary compromise

active assistive exercise

distal part of the limb is supported by the nurse when the client actively takes the joint through range of motion

oral contraceptives and breast feeding

do not take together- suppresses breast milk production

response to "i'm going to shoot myself"

do you have access to a gun? -okay to ask a yes or no question in this situation

xerostania

dry mouth

when will ballotement be felt

during the 4th to 5th month

early symptoms of ALS

dysphagia, fatigue while talking, tongue atrophy, weakness of hands and arms

what indicates acute respiratory distress in asthma patients

dyspnea, wheezing, cough, chest tightness, decreased airflow upon auscultation, decreased pulse ox, absent breath sounds

what does cloudy or opaque dialysate indicate

earliest sign of peritonitis -major complication of peritoneal dialysis -normal outflow should be clear a light yellow

carcinoma in-situ

earliest stage of cancer non-invasive doesn't normally develop into tumor except for colon polyps (early stage of colorectal cancer)

early and late hypoxemia signs

early: restlessness, increased HR, irritable, nasal flaring late: cyanosis, circumoral cyanosis

who gives consent if parents are divorced with joint custody

either parent can

gout

elevated levels of uric acid that results in crystal deposits in joints and surrounding tissue causing pain risk factors: obesity, alcohol consumption, diuretics, beta blockers, ACE inhibitors, hormonal changes, immuno-suppresive agents, foods high in purine (red meat and shellfish) s/s: swollen, red, acutely painful great toe joint trt: partial weight bearing with ambulation, use walker, avoid purines in the diet (organ and glandular meats such as liver, kidneys, sweetbreads, avoid beer, distilled liquor, high fructose corn syrup, increased water intake)

pre-operative teaching

ensure basic needs are met (food, fluid, elimination, rest) teach about pain provide quiet environment give meds for pain/anxiety

rinne test

hearing test using a tuning fork; checks for differences in bone conduction and air conduction -stem of vibrating tuning fork is held against mastoid bone until client indicates that sound is no longer heard -client should hear the sound again when tuning fork is moved from mastoid bone to front of auditory canal because air conducts better than bone

diet for hep b

high carb, low fat

diet for patient with cystic fibrosis

high protein, high calorie

diet for addisons disease

high protein, high carbs, normal sodium avoid stress and strenuous exercise

type of exercise preferred for older adults

high-intensity resistance training, walking, social activity

stridor

high-pitched inspiratory, continuous crowing sound over upper airway

s/s of alc withdrawal

hyperalertness, easily startled, anorexia, increased pulse, anxiety, tremors, insomnia, hallucinations

virchows triad

hypercoagulability, endothelial damage, venous stasis

complication from excessive respiratory treatments

hypervolemia

effect of calcium on cardiac monitor

hypocalcemia: prolonged QT or ST segment, Torsades de pointe is also common and with hypocalcemia and is a lethal ventricular arythmia hypercalcemia: short QT interval, short ST segment

age-related changes in electrolyte status

hyponatremia -increased water retention in the kidneys

what flu vaccine do people with chronic illness get

if over 6 months old, quadrivalent influenza vaccine

how to examine a childs ear

if under three years old: pull pinna down and back to straighten ear canal if above three years old: pull pinna up and back

how to know if patient discharged with cardiomyopathy has done too much

if you feel fatigued

big concern for nurse when providing home care for a pediatric client

immunizations are not up to date

ectopic pregnancy

implantation of the fertilized egg in any site other than the normal uterine location s/s: unilateral, dull abdominal pain

what is the purpose of turn, cough, and deep breathe post surgery

improve and maintain good gas exchange, especially the removal of CO2 to prevent respiratory acidosis

sign of increased pain relief in child

improved incentive spirometer use

akasthesia

inability to remain still

indication that adrenal crisis is improving

increased BP

what is an early sign of hypoxemia that a child may show with epiglottitis

increased HR and restlessness

desired response to heparin therapy

increased aPTT time

issue with smoking while wearing nicotine patch

increases the risk of myocardial infarction

granular casts in urine

indicate kidney disease

boggy uterus deviated to the right

indicates full bladder

elevated serum anti-streptolysin ASO titer

indicates glomerulonephritis

negative (absent) red light reflex in 2 day old neonate

indicates severe neurological deficit, possibly caused by increased ICP -screens for retinoblastoma -lack of red reflex is known as "cat's eye" -if detected later in life, use hematopoietic stem cell transplant, chemotherapy, or radiation to trt

intervention for late decelerations

indicates uteroplacental insufficiency 1) stop of decrease oxytocin infusion 2) turn to lateral side 3) give 8-10 L O2 by nonrebreather mask 4) IV fluid bolus

cd4+ count

indicates whether an infectious process is occurring

subcutaneous emphysema

indication of pneumothorax s/s: crackling under skin around chest trt: observe for respiratory distress

urine nitrates

indications of UTI

nitrates in urine

infection by e.coli

tuberculosis

infectious disease transmitted by droplet infection via airborne route -s/s: dry persistent cough with night sweats -meds: isonizad, rifampin, ethambutol (taken to prevent resistant strains, take all 3 for 8 weeks, after 8 weeks isonizad and rifampin are taken for 4-8 months -non-infectious after 2-3 weeks of meds or 3 negative sputum cultures -vitamin B6 (pyridoxine) with isonizad to decrease peripheral neuropathy

pyelonephritis

inflammation of the renal pelvis and the kidney caused by bacterial infection s/s: fever, chills, malaise, flank pain, urinary frequency, dysuria, CVA tenderness risk factors: UTI, pregnancy, tumor, urinary obstruction trt: antibiotics, analgesias, encourage fluids 3000 ml/day

gastroenteritis

inflammation of the stomach and intestines -commonly contracted in environments with an increased number of children who promote infection such as a daycare

malpractice

injury, causation, duty, breach of duty -when a nurse fails to act as a competent nurse normally would act in the same situation and client injury results ex: carelessness, delivery of sub-standard care, failure to adhere to standards of care

chronic kidney disease

irreversible loss of kidney function with decrease in GFR to 10 mL/min diet: low protein, high carb, limit sodium, potassium, and phosphorus s/s: fluid overload, hypertension, malaise, uremia, electrolyte changes, uremia, metabolic acidosis, anemia, muscle cramps, confusion, bone disorders

quadricept setting

isometric exercise performed by patient in cast, affected leg needs the most strengthening

what exercises are contraindicated in hypertension patients

isometric like weight lifting due to potential vasovagal response -aerobic exercise is encouraged to benefit vascular system and decrease BP readings over time

pruitus

itching

how to open airway if cervical spine injury is expected

jaw thrust without head extension

nursing interventions for client with acute confusion and delirium

keep their room clean and organized to avoid safety risks

largest concern during pregnancy when diagnosed with gestational diabetes

ketones found in urine may lead to ketoacidosis which is a major factor contributing to intrauterine death

genus valgum

knock-knee normal for 2-7 years old

ewald tube

large, orogastric tube designed for rapid lavage; insertion often causes gagging & vomiting; suction equipment must be immediately available to reduce the risk of aspiration

babinksi reflex

last to disappear, usually leaves around 12 months

plubism

lead toxicity watch for increased ICP and decreased hemoglobin

cloudy insulin

lente, protamine zinc, isophane -do not shake insulin (instead rotate vial between hands for 1 minute) -do not refrigerate insulin

nurse response if family wants update during surgery

let me go get an update, i will be right back -can provide a basic update

bucks traction

limb is in a straight position widely used turn client to the unaffected side every 2 hours

laissez-faire leadership style

little direction is provided to the group, many people feel confused or frustrated with this type of leadership, nurse is responsible for responding to any concerns the UAP has

diet for CKD patient

low-protein, limit sodium, potassium, and phosphorus

where should legs be for client in wheelchair with halo traction

lowered, risk for wheelchair tipping backwards

myelogram

lumbar puncture with injection of contrast medium -allows xray visualization of vertebral canal

chief complaint

main reason for the patients visit, should be given in clients own words

post hip replacement position

maintain leg in position of abduction for 2-3 months -avoid outward rotation -limit flexion to 60 degrees for 6-7 days and then 90 degrees for 2-3 months

predisposing factors to suicide

males over 50 ages 15-19 poor social attachments previous suicide attempts

most common causes of hypercalcemia

malignancies and hyperparathyroidism -normal serum calciumL 8.6-10.2

democratic leadership style

manager asks group to participate in decisions

salt-substitutes

many are potassium based and may lead to hyperkalemia

why should pregnant client with persistent or severe abdominal pain be assessed first

may indicate ectopic pregnancy (if early in preg), worsening preeclampsia, or abruptio placentae

spermatic cord torsion

medical emergency, requires immediate surgical repair most common cause of testicular loss in males d/t hypoxic injury to the testicle s/s: very painful, enlarged and red scrotum, nurse palpates a thickened and swollen spermatic cord

parkland formula

method of calculating fluid repletion in burn patients 4x patients weight in kg x % burned = ml to give

INR

monitors warfarin therapy -therapeutic 2-3 ->4 = C(ritical) -hold all warfarin assess for bleeding prepare to give vit. K call doctor

best time of day to interact with adjustment disorder patient who is depressed

morning, when the client has the most energy

iron deficiency anemia

most common type of anemia causes: chronic blood loss, removal of duodenum, inadequate iron intake, impaired iron absorption, slow bleeding (gastric ulcer, colon cancer) risk factors: low birth weight, premature infants, frequent blood donation, vegetarians, women with heavy menses s/s: weakness, extreme fatigue, pale skin, poor appetite, cold hands/feet, brittle nails, chest pain, tachycardia, SOB, tongue inflammation, craving for non-nutritive substances like ice

s/s of scoliosis

most noticeable during growth spurt in pre-adolescence -s/s: arms of a 14-year old appear different in length and there is a slight limp during ambulation

s/s of lower intestinal obstruction

n/v abdominal distention

s/s of overdose of thyroid replacement hormone

nervousness difficulty sleeping

breastfeeding

newborn should be relaxed after feeds moms breast is soft after feeds should feed every 3 hours baby should have 6-8 wet diapers a day audible swallowing should be heard when feeding

yes or no, analgesics during transition phase of labor

no

how should breasts be cleansed

no creams wash with warm water and no soap

mouth care

no glycerin swabs or mouthwash soft-bristled toothbrushes, hydrogen peroxide and NS, petroleum jelly for lips

best indication of pain relief

non-verbal -"client appears to be physically relaxed"

lithium side effects and toxicity

normal SE: -increased urine output, client should be encouraged to drink 12 glasses of water daily -fine hand tremor (lithium tremor), should be reported to HCP signs of toxicity: diarrhea, loose stools, oversedation, ataxia, slurred speech, muscle weakness/twitching nurse should withhold next dose

normal ammonia level

normal ammonia level: 15-45 mcg/dL

hypomagensium

normal range: 1.5-2.5 s/s: prolonged QT interval, risk for seizures ( keep Benzo's around, increase intake of bananas and oranges, positive chovstek's because hypocalcemia comes with hypomagnesium

result of low albumin

normal: 3.5-5.5 albumin deficit: decreases oncotic pressure and fluids shift from vascular area to tissue causing edema

bone scan

nuclear medicine scan using radioactive dye to visualize bones; especially useful for finding stress fractures and bone cancer -given IV -client should drink lots of fluids to decrease the effects of dye on the kidneys

autocratic leadership style

nurse manager makes all decisions and does not ask for input

passive exercise

nurse performs the exercise without help from client

who should assist women to bathroom first time after delivery

nurse, NOT uap

s/s anorexia

obsessive with what/how much/and when they eat can be as little as 200 cal/day always thinking about food/exercise may binge-eat physical s/s: amenorrhea, hypotension, constipation, muscle weakness, fatigue, intolerance, bradycardia

highest priority when patient in labor gets epidural

obtain the blood pressure (adverse effect= hypotension)

gynecomastia

occurs in 50% of adolescent boys may be unilateral or bilateral usually lasts 1 year before resolution s/s: unilateral breast enlargement

how to palpate fundus

one hand on abdomen over fundus, press gently with fingertips

stool of breastfed infant

orange-yellow, soft and small with even consistency should have up to 6 stools a day number of stools decreases with age color changes with introduction of solid foods

interventions for COPD

oxygen therapy, nebulizer, medical ID bracelet

acceptable pH for NG tube placement

pH of 0-4

5 p's to check neurovascular status before cast application

pain pallor paralysis paresthesia pulselessness

intermittent claudication

pain in the leg muscles that occurs during exercise and is relieved by rest

where to assess for cyanosis in dark-skinned client

palms of hands will be blue or ashen gray -if central cyanosis, pt will have blue/gray membrane and conjunctiva

normal pa02

partial pressure of oxygen in arterial blood -75-100 mmHg if at higher altitude, higher is normal

way to improve bladder control post prostatectomy

perform pelvic muscle exercises

how to get sputum sample for TB

pharyngeal suction offer oral care before send specimen immediately

what should we monitor for post-hemorrhoidectomy

urinary retention -occurs because proximity of bladder to surgical site -may cause hemorrhage if untreated due to pressure and stress on suture line

PKU test

phenylketonuria - done to check whether a newborn baby has the enzyme needed to use phenylalanine in his or her body. Phenylalanine is an amino acid that is needed for normal growth and development. "Guthrie blood test" -heel stick -if collected before 24 hours old, check again by 2 weeks old -only one blood sample needed -if positive, give Lofenalac formula (low phenylalanine but has vitamins and minerals)

client with withdrawal delirium

place client in quiet, well-lit room stay with client if possible to interpret the environment

intervention for bells palsy

place food on unaffected side of mouth use artifical tears to prevent dryness protect face from cold and drafts may tape eye closed at night or use eye patch

steps for bathing newborn the first time

place infant on warn suface cleans eyes clean face with warm water only clean body with warm water and mild soap wrap in towel/blanket shampoo hair/head

easy way to administer oral meds to an infant

place meds in an empty nipple and allow client to suck

where should clients with Tb dispose of their tissues

plastic bag or container

early stage chronic kidney disease s/s

polyuria -kidney is unable to concentrate urine

s/s of hypercalcemia

polyuria weakness nausea

expected urination after labor

postpartum diuresis is caused by -decreased serum estrogen, elimination of increased venous pressure, loss of remaining pregnancy-induced increases in blood volume -urine output of 3000 mL or more each day during the first 2-3 day is expected

what med should never be given IV push

potassium or vancomycin

medications for c-section vs general surgery

pre-op medications before c-section contain lower amounts of narcotics than before general surgery

examples of pre, intra, and post renal injuries

pre: decreased cardiac output, hypovolemia intra: acute tubular necrosis, glomerular injury post: ureteral obstruction

PQRST for MI

precipitating factors, quality of pain, radiation, severity of pain, timing of onset

abruptio placenta

premature separation of the placenta from the wall of the uterus s/s: painful vaginal bleeding, tender abdomen, painful, tense, possible fetal distress, prepare for immediate delivery

what needs to be in container for 24 hour urine specimen

preservative, like ice

what causes varicosities of vulva, rectum, and legs during pregnancy

pressure of enlarging uterus normal

Hib vaccine

prevents Hib disease which causes meningitis, brain damage, and deafness, also prevents epiglottitis

syphillis

primary syphilis: a chancre develops within 2-6 weeks secondary syphilis: skin rash, mucocutaneous lesions, and lymphadenopathy tertiary syphilis: cardiac symptoms, gummatous lesions, tabes dorsalis, general paresis -appears at the point of entry and starts as a small papule that develops into a painless ulcer -screen with VDRL blood test and is reactive 2-6 weeks after the primary infection -treated with abx (IV penicillin)

omnibus budget reconciliation act

pro ides clients with the right to be free from physical and chemical restraints imposed for the purpose of discipline or convenience

rupture of membranes

procedure performed by health care providers to hasten labor progression -most serious complication is a prolapsed cord -nurse must place client in supine position, press against fetal presenting part to relieve pressure from cord, place patient in trendelenburg or knee-chest position

primigravida labor

process: effacement, descent, dilation normal dilation: 1-1.2 cm/hour

symptoms of pyloric stenosis

projectile vomiting and a palpable olive-shaped mass in the right upper quadrant s/s: lethargic, dehydrated, malnoursihed, emesis with milk or formula

first sign of disseminated intravascular coagulation

prolonged oozing from sites of minor trauma

inguinal hernia

protrusion of a small loop of bowel into the scrotum refer to HCP s/s: scrotum appears swollen, nurse unable to insert a finger above the mass

good fluids for flaccid bladder

prune juice cranberry juice blueberry juice these will increase the acidity of urine and decrease the risk of UTI/calculus formation

who needs 1:1 supervision

pt verbalizing intent to harm self unwilling to sign no suicide contract poor impulse control pt who have already attempted suicide with a lethal method (gun, hanging)

normal A1c levels

range from 4% to 6% target range for patients with diabetes: less than 7%

cystine stones

rare and occur in clients with a genetic defect that results in decreased renal absorption of amino acid cysteine

potassium chloride infusion

rate of IV infusion should be no faster than 10 mEq/hr or 20-30 mEq/hr in highly specialized settings

miller-abbot tube

reaches into small intestine, provides decompression and can treat paralytic ileus

what can cause false negative Tb skin test

recent admission of live virus vaccine corticosteroid meds AIDS patients

early symptoms of alzheimers

recent memory loss change in motor activity, pacing, continuously wandering, agitation

erythma migrans

red, flat lesion associated with early lyme disease looks like a bullseye

phenazopyridine

urinary tract analgesic -if yellowish discoloration of the skin or sclera develops, contact HCP as this is a sign that the drug is accumulating in the body and causing renal impairment

mastitis

reddened, inflamed, painful breast with exudate form the nipple risk for developing mastitis: poor hygiene, ductal abnormalities, nipple cracks, fissures, fatigue, tight clothing, missing a feed, failure to empty breast trt: antibiotics, massage breast, warm packs, manual milk expression, switch between head and cold packs

intervention for phlebitis

remove IV catheter apply warm, moist compress to affected area

emergency treatment for partial thickness burn

remove clothing cover victim with clean sheet

tarasoff act

requires the reporting of threatened suicide or harm to others

what lab result is increased in sickle cell disease

reticulocyte count (immature RBC) -lifespan of RBC is shortened

how to hydrate elderly clients mouths

rinse mouth with room temperature tap water before and after meals

s/s of latex allergy

runny nose, conjunctivitis, angioedema, bronchospasm, shock

ICP

s/s: headache, change in LOC, emesis without nausea, irritability, sluggish or unequal pupil response, seizures, weakness, slow or slurred speech, diabetes insipidus DI: head trauma causes the urine output to increase and the specific gravity to go down, urine osmolarity goes down

hemolytic reaction

s/s: nausea, vomiting, back pain, hypotension, increased pulse, decreased urine output, hematuria nurse: get urine specimen, start IV NS, stop blood, oxygen, benadryl, manage airway, DC infusion, draw blood sample for plasma, hemoglobin culture and retyping

neuroleptic malignant syndrome

s/s: pallor, tachycardia, hypertension, hypotension, diaphoresis, fever, convulsions, loss of bladder control, respiratory distress -a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction.

guillaine barre

s/s: respiratory failure, flaccid paralysis, urinary retention

pneumothorax

s/s: sucking sound with respirations and tracheal deviation to uninjured side trt: place a sterile dressing loosely over the wound to allow for air to escape but not re-entry

toxic shock syndrome

s/s: temp above 102, vomiting, diarrhea risks: super absorbant tampons can increase vaginal dryness and predispose vaginal walls to damage, avoid products with deodorant, change tampon every four hours, use pads at night

MS symptoms

s/s: urinary retention, ataxic movements, short term memory loss intervention: ambulate as tolerated, avoid overexposure to heat/cold, perform stretching and other exercises, participate in social activities

varicocele

scrotal mass d/t enlarged veins of the spermatic cord can cause male infertility s/s: scrotum aches after exercise, nurse palpates a worm-like mass above testes trt: may require scrotal suppoer

purpose of cuff on trach tube

seals trachea to prevent aspiration

segs vs. bands

segs: mature neutrophils bands: immature neutrophils ANC less than 1500 cells/microliter is neutropenia

adverse reaction to hypothermia

seizures

SMGB

self-monitoring of blood glucose -dangle hand before sticking finger -stick the finger on the side to avoid maximum discomfort -blood should drop like a raindrop onto the slip -do not milk finger as this will cause interstitial fluid to go into the blood sample

patient positioning post craniotomy

semi-fowler head midline minimal flexion

presbycussis

sensorineural age-related hearing loss s/s: high pitches are harder to hear

contracture with rheumatoid arthritis

serious concern that must be treated quickly to avoid further damage

scabies

several wavy or straight thread-like lines beneath the skin -caused by the female mite that burrows beneath the skin to lay eggs

hyperemesis gravidarum

severe nausea and vomiting in pregnancy that can cause severe dehydration in the mother and fetus

herpes zoster

shingles`

appearance of fractured hip

shortened, adducted, and externally rotated

intermittent low back pain during pregnancy

sign of labor

example of negligence

signs off medications for the entire shift for multiple clients

nursing interventions for schizophrenic client who is withdrawn to the point of mutism

sit with client for brief periods of time

paget disease

skeletal disease affecting elderly people that causes chronic inflammation of bones, resulting in thickening and softening of bones and bowing of long bones; also called osteitis deformans, abnormal bone remodeling -increased serum alkaline phosphatase, causes pathological fractures s/s: bone pain, fatigue, waddling gait, enlarged skull causes headaches, dementia, visual deficits, loss of hearing, client may report getting shorter and head getting bigger

sonorous/stertor respirations

snoring sound resulting from partial obstruction of upper airway

lead poisoning

sources: hot water in lead pipes, artists paint, homes prior to 1950 and exterior of homes 1950-1978, lead is absorbed on empty stomach so keep fed affects: neurodevelopment, school performance s/s: learning changes, difficulty concentrating, fatigue, headache, paralysis, tremors, n/v, abdominal pain, constipation, lead inhibits hemoglobin formation

nursing care with increased ICP patient

space it out, dont want to cause too much stress/disturbance at once

MRSA

spread by direct contact and invades clients with existing portal of entry example: indwelling catheter, vascular port, cancer therapy, decreases t cells)

where does nurse stand when teaching the client how to use a cane

stand slightly behind the client on the strong side

epoetin alfa

stimulates RBC production

intervention for blood transfusion reaction

stop transfusion infuse NS (in case of needing IV access for meds and to avoid clotting line notify HCP collect urine sample return blood to blood bank

what can be used to clear resistance in the subclavian vein

streptokinase, need HCP order

what can elevated progesterone levels during pregnancy cause

stuffiness, nosebleeds (epistaxis), and voice changes this is normal

common concern for adolescents

suicide prevention

retracted stoma

sunken and inverted

levothyroxine

synthetic hormone replacing only t4 -replaces clients lack of endogenous hormone

best intervention for phobic disorders

systematic desensitization

systolic vs. diastolic HF

systolic: insufficient force of contraction diastolic: inadequate filling

CD4 count

t cells these are attacked with AIDS and as CD4 count drops, immunosuppression is seen and opportunistic infections take over (candidiasis, pneumocystis, pneumonia, cytomegalovirus

most reliable signs of infection in older adults

tachypnea, confusion, tachycardia

parental care for infant post surgery

tactile stimulation, stroking the infant, etc is encouraged

tracheal shift from midline

tension Pneumothorax, hemothorax, significant atelectasis

biophysical profile

test that assess five variables; fetal breathing, fetal movement, fetal tone, amniotic fluid volume, and fetal reaction -failure of stress test indicates you need the biophysical profile -scores 0-10; 2 points for normal, 0 for abnormal -low score = increased rate of infant mortality; possible emergent c-section -high score = continued monitoring

radioactive iodine -123

test to destroy overactive thyroid cells present in thyroid cancer

adult immunizations

tetanus booster: every 10 years influenza: every year pneumococcal: high risk groups younger than 65 and others 65 years and above need every 5 years

placenta previa

the abnormal implantation of the placenta in the lower portion of the uterus -painless vaginal bleeding

what does a negative nitrogen balance indicate

tissue destruction

evisceration

tissues or organs protruding outside the body through the surgical incision

how slowly should blood pressure cuff be released for client with previous BP reading of 138/76

to ensure diastolic has been determined, the cuff should be released slowly until the mid 60's mmHg, since the cuff should be deflated at a rate of 2-3 mm per second, a range of 90 mmHg would require 30-45 seconds inflate to a pressure of 30 mmHg above the level at which the radial pulse is no longer palpable

symptoms of alcohol related problems

tremors, increased body temp, nocturnal leg cramps, pain

feeding with new trach placement

tube feeding initially then will eat normally when the area has healed

endotracheal tube

tube inserted in nose or mouth and through trachea to mechanically oxygenate the lungs condensation: good sign complications: food in tube/airway, pilot balloon not filling indicates a leak

teratoma

tumor composed of tissue not normally found at the site the tumor is located -CNS teratoma causes increased ICP

best intervention to protect client skin

turn q2h to prevent skin breakdown

tonic neck reflex

turning the head to one side, extending the arm and leg on that side, and flexing the limbs on the opposite side -gone at 4 months of age

resistive exercise

type of active exercise carried out independently by the client client works against resistance to increase muscle power

rheumatic fever onset

typically begins 1-6 weeks after having pharyngitis or strep throat -priority to determine if client had these symptoms

Curling's ulcer

ulceration of gastric or duodenal tissue as a result of burn or trauma usually with gastric pH of 1-5

test to determine size and composition of thyroid gland

ultrasoundography

patients unable to leave AMA

under influence of substance parents with child requiring life-saving measures homicidal/suicidal psychotic, delusional, demented

signs of developmental hip dysplasia

unequal knee height uneven gluteal thigh folds

how to use can when going up and down stairs

up: (up with the good) down: (down with the bad)

pavlik harness

used for developmental hip dysplasia or hip dislocation kept on continuously to hold ball in socket keep skin clean and dry parents do no adjust, usually is adjusted weekly by HCP do: place shirt under chest strap, check skin under strap, place knee socks to protect legs, place diaper under straps dont: swaddle legs together

contraction stress test

uses oxytocin to evaluate respiratory function of the placenta

most serious complication post MI

ventricular dysrhythmias -most common cause of death related to MI -more likely to happen when right coronary artery is involved as this artery supplies blood to coronary pacemaker cells

common complication with nephrotic syndrome

venus thrombosis

kussmaul respirations

very deep and rapid respirations

vitamin roles

vitamin A: night vision vitamin B: wound healing/iron absorption vitamin D: stimulates calcium absorption from GI tract vitamin K: essential for blood clotting

immediate action for nurse post-needlestick

wash area with soap and water to flush the site of all pathogens

common concerns for toddlers and pre-school aged children

water safety and burn prevention

s/s of narcotic withdrawal

watery eyes, cramps, tremors

transdermal patches

wear clean gloves when removing/applying cleanse skin beneath with only water avoid head application fold patch in half with sticky sides touching

best indicator of fluid retention with pediatric client

weight gain -nurse should obtain daily weights

when is client able to live alone and provide self care

when client can perform ADL's (bathe/dress, self-feed, toilet)

when can parents transfer from booster to regular car seats

when the child is taller than 4 ft. 9 inches and seat belt fits snugly around lap and chest

low-residue diet for diarrhea

white bread waffles refined cereals are all good options

bone scan with multiple myeloma

will create false-negative results -this should be avoided as it is an exposure to potential harm without benefit

what should geriatric clients be encouraged to discuss

with dementia we want them to discuss their past life as they have recent memory loss and it is good to refer to their past

what should nurse do if client begins to cough and gasp during insertion of feeding tube

withdraw the tube allowing time to rest for reinsertion

when must charcoal be given to absorb salicylates

within 2 hours

what do you want client to avoid during 24 urine spec for creatinine clearance

working out in the gym -creatinine is a waste product of muscle breakdown

glascow coma score

worst (3) to best (15) -eye opening (spontaneous, to speech, to pain, none) -verbal response (oriented, confused, inappropriate words, sounds, none) -motor response (obeys, localizes pain, withdraws from pain, flexion with pain, extension with pain, none)

libel

writing falsely about another person

hysterosalpingogram

x-ray of the uterus and fallopian tubes with contrast

exercise when leg is in full casts

yes: quadricep setting (flexing and contraction of quad, isometric exercise), strengthening exercise of upper limbs no: passive ROM of affected limb, active ROM of unaffected limb, no passive ROM exercise of upper limbs

what should client consume to decrease changes in intestinal flora d/t antibiotics

yogurt or acidophilus milk