NCLEX PN EXAM

s/s of cataracts

1. Painless, blurry vision 2. Dim surroundings 3. Reduced visual acuity 4. Glare sensitivity 5. Diplopia (Double vision) 6. floaters 7. increasing nearsightedness 8.complaints that colors are faded or appear yellowish or brownish 9. and difficulty with night vision

magnesium level

1.3-2.1

During the monitoring of a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings should the nurse interpret as acceptable responses? Select all that apply.

1.Symptom control during periods of emotional stress 2.Normal white blood cell, platelet, and neutrophil counts 3.Radiological findings that show nonprogression of joint degeneration 4.An increased range of motion in the affected joints 3 months into therapy

When performing cardiopulmonary resuscitation (CPR), the nurse should deliver how many breaths per minute to an adult client?

10

AST

10-40

The normal serum ammonia level

10-80

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the client?

100% oxygen via a tight-fitting non-rebreather face mask If inhalation injury is suspected, administration of 100% oxygen via a tight-fitting non-rebreather mask is prescribed until carboxyhemoglobin levels fall below 15%

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client?

100% oxygen via a tight-fitting, nonrebreather face mask If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined.

PT time

11-12.5 seconds

near or at term fetal heart rate

110 to 160 beats per minute

Hemoglobin female

12-16

Hemoglobin male

13.5-17.5

The client is taking phenytoin (Dilantin) for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result?

15 mcg/mL

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

15 min, which is the most likely time that a transfusion reaction will occur.

Platelet count

150-450

Phosphate

2.5-4.5

bicarbonate level

22-29

PTT time (heparin therapy/coagulation disorders)

25-35 seconds

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?

26 cm During the second and third trimesters (18-30 weeks' gestation), the fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 cm. In addition, at this point in the pregnancy, in a 4 week period, the fundal height should increase approximately 4 cm. At 14 to 16 weeks' gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and at term, the fundus is at the xiphoid process.

The nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first?

3 the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are normally always present here.

phosphorus level

3-4.5

Potassium levels

3.5-5

PaCO2 normal range

35-45

female hematocrit

37-47%

RBC count

4-6 million

Theraputic serum level of magnesium is

4-7 mg/dL

A normal blood glucose level for newborn infants

40-60

male hematocrit

42-52%

The nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is appropriate?

48 hours after using the antibiotic ointment

The nurse has a prescription to give a client albuterol (two puffs) and beclomethasone dipropionate (two puffs) by metered-dose inhaler. How much time should the nurse place between administering the albuterol and then the beclomethasone dipropionate?

5 minutes (bronchodilator first and gives time to open airway for glucocorticoid.)

BUN level

6-20

PTT (partial thromboplastin time)

60-70 seconds

segmented neutrophils (segs)

60-70%

PH levels

7.35-7.45

normal FASTING blood glucose

70-100

how often should the IV site dressing be changed

72 to 96 hours based on the Center for Disease Control guidelines. With an insertion date of 2/9, the due date for change should be 2/12.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior, the nurse should suspect the client is how far dilated?

8 to 10 cm During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear

Calcium

8-10

PaO2 normal range

80-100

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother?

9 months

chloride level

98-107

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse should prepare for which diagnostic study that can confirm this diagnosis?

A bone marrow biopsy

The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?

A change in the uterine contour Signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape.

hemolytic-uremic syndrome (HUS) in child interventions

A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be prescribed fluid restrictions. The treatment also involves providing adequate nutrition, preventing infection and anticipating CNS involvement, administer blood products as necessary

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding?

A decrease in oozing from puncture sites and gums Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes.

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?

A diet that is high in fluids and fiber to decrease constipation Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system.

The nurse is monitoring a client receiving glipizide. Which outcome indicates an ineffective response from the medication?

A glycosylated hemoglobin level of 12% Glipizide is an oral hypoglycemic agent administered to decrease the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in both polyuria and polyphagia would indicate a therapeutic response. Laboratory values are also used to monitor a client's response to treatment. A fasting blood glucose level of 100 mg/dL (5.7 mmol/L) is within normal limits. However, glycosylated hemoglobin of 12% indicates poor glycemic control.

The results are documented as a reactive nonstress test.

A negative test A reactive nonstress test (normal/negative) indicates a healthy fetus. A nonreactive nonstress test is an abnormal test and requires further follow-up. A suspicious test result also requires further follow-up. An unsatisfactory test cannot be interpreted because of the poor quality of the fetal heart rate findings.

Phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. Which should the nurse reinforce to the client?

A reddish-orange discoloration of the urine may occur. The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

The client with diagnosed acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition?

A result of another infection caused by the leukopenic effects of the medication. Frequent side/adverse effects of this medication include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection.

Goodell's sign

A softening of the cervix During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination. Goodell's sign does not indicate the presence of fetal movement.

Al-Anon

A support group designed for families living with an alcoholic.

myringotomy

A surgical incision into the tympanic membrane to provide drainage of the purulent middle ear fluid; may be done by a laser assisted procedure.

The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?

"I do not feel any urges yet to empty my bladder." The fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body begins to readjust and relax. An epidural may lead to loss of bladder sensation and resulting rapid bladder filling.

The nurse determines a 5-year-old child is in the expected Erikson's psychosocial stage if the child makes which comment?

"I like drawing my mommy pictures with my finger paints." A 5-year-old child would be expected to be experiencing Erikson's psychosocial stage of initiative versus guilt (late childhood, 3 to 6 years). A child in this stage enjoys exploring and making art. During Erikson's stage of industry vs. inferiority, which occurs during school age (6 to 12 years), a child spends a great deal of time in school and with friends. Hanging around at the mall describes behaviors that correspond with the stage that occurs during adolescence, identity vs. role confusion. Episodes of negativism best describes Erikson's stage of shame vs. doubt, which occurs during toddlerhood (early childhood, 18 months to 3 years).

Fluoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement by the client indicates an understanding about the administration of this medication?

"I should take the medication in the morning when I first arise." Fluoxetine is a selective serotonin reuptake inhibitor (SSRI). It is administered in the early morning without consideration to meals.

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?

"I will tell the nurse at the hospital that I had an Rh shot during pregnancy." As described in the question, it is accepted practice to administer Rho(D) immune globulin to an Rh-negative woman at 28 weeks' gestation, with a second injection within 72 hours of delivery. This prevents sensitization, which could jeopardize a future pregnancy. For subsequent pregnancies or abortions, the injections must be repeated, because the immunity is passive.

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of the clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K because the bowel does not have the bacteria necessary for synthesizing this fat-soluble vitamin.

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose?

"The medication causes the pupil to constrict and will lower the pressure in the eye."

contraction stress test

"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." A contraction stress test assesses placental oxygenation and function and determines the fetus's ability to tolerate labor, as well as its well-being. The test is performed if the nonstress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40 seconds or more during a 10-minute period have occurred. Frequent maternal blood pressure readings are performed and the client is monitored closely while increasing doses of oxytocin are given.

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?

"We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase.

A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse should make which appropriate response to the client?

"Weakness and fatigue commonly occur and will diminish with continued medication use." The client should be instructed that symptoms such as drowsiness, weakness, and fatigue are more intense in the early phase of therapy and diminish with continued medication use. The client should be instructed never to withdraw or stop the medication abruptly because abrupt withdrawal can cause visual hallucinations, paranoid ideation, and seizures. It is best for the nurse to inform the client that these symptoms will subside and encourage the client to continue the use of the medication.

The nurse is assisting with data collection for a parent and son during a well-child visit. The nurse determines the child is in the phallic stage of Sigmund Freud's theory of personality development if the parent makes which comment?

"Yesterday my son asked me why he looked different from his sister." Freud's phallic stage of development includes the recognition of differences between the sexes. Accomplishing toilet training occurs during the Freud's anal stage. Development of pubic hair is characteristic of the genital stage. Freud's latency stage is characterized by same sex friendships and making comments about the other sex.

questions to ask before aversion therapy

(1) Is the therapy in the best interest of society? (2) Does it violate the client's rights? (3) Is it in the best interest of the client?

early sign/symptom of lithium toxicity

(GI) disturbances, such as nausea, vomiting, and diarrhea

decerebrate posturing

(extension) posturing is characterized by the rigid extension and pronation of the arms and legs. a sign of dysfunction at the level of the midbrain.

decorticate posturing

(flexion) posturing: adduction of the arms at the shoulders; arms are flexed on the chest with the wrists flexed and the hands fisted, and the lower extremities are extended and adducted; seen with severe dysfunction of the cerebral cortex.

s/s epididymitis

**Inflammation of the tube at the back of the testicle that stores and carries sperm. Fever, nausea and vomiting, and painful scrotal edema

a pregnant client is receiving magnesium sulfate therapy for Preeclampsia. Signs of Magnesium toxicity are..

**respirations 10breaths/min **urine output of 20mL/hr Rationale: CNS depressant: respiratory depressant, loss of deep tendon reflexes, sudden decline in fetal heart rate, maternal heart rate and blood pressure.

Hypercalcemia causes

*Excessive intake of calcium supplements, milk, and antacid products that contain calcium* *Excessive intake of vitamin D* *Increased bone resorption or destruction from conditions such as bone tumors, fractures, osteoporosis,* and immobility *Decreased excretion of calcium* Renal disease Use of *thiazide diuretics* Hyperparathyroidism *Use of lithium* *Use of glucocorticoids* *Adrenal insufficiency*

hypercalcemia s/s

*Increased heart rate and blood pressure* *Bounding pulse* Bradycardia (late stage) *Shortened QT interval and widened T wave* Muscle weakness (hypotonicity) Diminished deep tendon reflexes *Nausea and vomiting* *Constipation* *Abdominal distention* Confusion, lethargy, and *coma*

hyperphosphatemia s/s

*Neuromuscular irritability* Muscle weakness Hyperactive reflexes Tetany Positive Chvostek's or Trousseau's sign

Nalbuphine (Nubain)

*class*: opioid agonists/analgesics *Indication*: pain, analgesia during labor, sedation before surgery, supplement to balance anesthesia *Action*: alters perception and response to pain, causes CNS depression *Nursing Considerations*: - use caution with head trauma - can cause dizziness, headache, nausea, vomiting, respiratory depression - do not use with MAOIs - assess pain - asses hemodynamic parameters - may elevate pancreatic enzymes - *narcan (naloxone)* is the antidote

s/s Hodgkins

- NIGHT SWEATS - painless enlargement of lymph nodes - anemia - fatigue & weakness -weight loss - skin rashes - itching

Cardiac changes with hypokalemia

- Slight prolonged PR interval - Peaked P wave - ST depression - Shallow/inverted T wave - U wave

Myasthenia Gravis Treatment

- supportive, anticholinesterase drugs, corticosteroids - no known cure

The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.

-"Fertilization occurs in the outer third of the fallopian tube." -"Only 1 sperm will penetrate the ovum to produce fertilization." -"Implantation occurs in the anterior or posterior fundal region of the uterus." -"The ovary produces hormones to maintain the pregnancy before placental development."

pregnancy and function of progesterone

-"It maintains the uterine lining for implantation." -"It relaxes all smooth muscle, including the uterus."

Kohlberg's theory

-"Moral development progresses in relation to cognitive development." -"A person's ability to make moral judgments develops over a period of time." -"It provides a framework for understanding how individuals determine a moral code to guide his or her behavior."

Busulfan (mechanism, use, toxicity)

-Alkylating medication (leukemia) -causes Hyperuricemia

Cisplatin

-Alkylating medications are cell cycle phase nonspecific and affect the synthesis of DNA by causing its cross-linking to inhibit cell reproduction. -Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. --Amifostine may be administered before cisplatin to reduce the potential for renal toxicity.

Asparaginase (Elspar)

-Antineoplastic -Interrupts DNA in leukemia cells -Can cause N/V, hypersensitivity reaction, alopecia, liver and pancreas toxicity, renal toxicity

Tamoxifen (Nolvadex)

-Breast cancer medication -Hormonal agent -Stops growth of estrogen-dependent breast cancer cells -Can cause endometrial cancer, hypercalcemia, N/V, PE, hot flushes, vaginal discharge or bleeding -Increase Ca and vit D intake

Hirschsprung's disease peds

-Chronic constipation, beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul smelling -Bowel obstruction, especially in the neonatal period, abdominal pain and distention, and failure to thrive are also signs and symptoms.

which medications are H2-receptor antagonists?

-Cimetidine -Ranitidine -Famotidine -Nizatidine -H2-receptor antagonists suppress secretion of gastric acid, alleviate symptoms of heartburn, and assist with preventing complications of peptic ulcer disease. These medications also suppress gastric acid secretions and are used in active ulcer disease, erosive esophagitis, and pathological hypersecretory conditions.

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply.

-Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. -Change diaper every 4 hours or more often to inspect the penis for drainage or infection. -Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.

The advantages of using spinal anesthesia for delivery of a fetus include which reasons? Select all that apply.

-Ease of administration -Absence of fetal hypoxia -Immediate onset of anesthesia

Proton pump inhibitors (heartburn)

-Esomeprazole -Lansoprazole -Omeprazole -Pantoprazole -Rabeprazole

Bell's palsy s/s

-Excessive tearing -Inability to furrow brow -A lag in closing the bottom eyelid

signs and symptoms of a neuroblastoma found on the adrenal gland

-Firm, nontender, irregular mass in the abdomen -Urinary frequency or retention from compression on the bladder

Graves disease treatment

-Goal: inhibit production of thyroid hormones and block effect on the body -Radioactive iodine therapy: destroys overactive thyroid cells over time -Propylthiouracil, methimazole -Betablockers -Subtotal or full thyroidectomy (risk of damaging vocal cords and parathyroid glands)

A nursing student enrolled in a physical assessment course is asked to describe the probable signs of pregnancy. The student displays correct understanding if the student lists which signs? Select all that apply.

-Hegar's -Chadwick's -McDonald's Hegar's sign is softening of the lower uterine segment. This allows the body of the uterus to flex against the cervix, which is termed McDonald's sign. Chadwick's sign is a purple or blue discoloration of the cervix, vagina, and vulva caused by increased vascular congestion.

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.

-Lubricate the enema tube and insert it approximately 4 inches -Clamp the tubing if the client expresses discomfort during the procedure -Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C) -Left SIMS position -hung about 12 to 18 inches above the client's anus

A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse should implement which interventions? Select all that apply.

-Observing perineal pad drainage -Observing the abdominal dressing -Rolling the client to one side to view bedding -monitoring output from the Jackson-Pratt drain

Beractant (Survanta)

-Prevention or treatment of RDS in newborns -given via intratracheal

Repaglinide (Prandin)

-Results in insulin release from pancreas -rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. -Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times.

The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.

-Small parts are located on the left side of the uterus. -Small parts are located on the right side of the uterus. -A soft, irregular non-ballottable shape is located just above the symphysis pubis.

Misoprostol used for

-The client who frequently uses nonsteroidal antiinflammatory drugs (NSAIDs) is prone to gastric mucosal injury. -Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication, but it is not an intended effect.

The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of a plaster cast. Which statement should the nurse include in the instructions? Select all that apply.

-The foot should be kept elevated for the first 24 to 48 hours. -Reposition the infant every 2 to 4 hours until cast is thoroughly dried -The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape -laster casts will set within 10 to 15 minutes, but will not fully dry for 24 to 48 hours so they should not be handled until after that time as indentations can be left.

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.

-Use eggs as a source for protein. -Avoid eating lunch meats and bolognas. -Eat salads with cabbage and lettuce and avoid spinach.

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections?

-Use indwelling urinary catheters judiciously. -Remove indwelling catheters when no longer needed. -Use strict aseptic technique when inserting all urinary catheters.

Vincristine (Oncovin)

-a vinca alkaloid antineoplastic (miotic inhibitor) medication that has an adverse effect, specifically peripheral neuropathy. -constipation -hair loss

Isoniazid (INH)

-anti TB - take daily for 6-12 months and most likely with other meds too -worked if 3 neg. sputum cultures, no temp. - Liver toxicity (hepato) check liver fxn - Don't take with alcohol (liver fxn remember?) - Take on empty stomach

Silver sulfadiazine (Silvadene) side sffects

-antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied. - Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis.

ethambutol

-antibiotic to treat TB -causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green

Baclofen

-antispasticity agentsskeletal muscle relaxants (centrally acting) -Adverse: SEIZURES, do not give w/ seizure disorder

Cimetidine (Tagamet)

-for gastric ulcers/GERD -histamine 2 (H2)-receptor antagonist. Older clients are especially susceptible to the central nervous system side effects of cimetidine. The most frequent of these is confusion. Less common central nervous system side effects include headache, dizziness, drowsiness, and hallucinations.

levothyroxine sodium

-for hypothyroidism -may cause nausea/decreased appetite, abdominal cramps/diarrhea, weight loss, nervousness/tremors, insomnia, sweating, heat intolerance, tachycardia/dysrhythmias/palpations/chest pain, hypertension, headache

Sucralfate (Carafate)

-gastric protectant. - The medication should be scheduled for administration 1 hour before meals and at bedtime. The medication is timed to allow it to form a protective coating over the ulcer before food intake stimulates gastric acid production and mechanical irritation

nephrotic syndrome (nephrosis) pediatric

-group of conditions in which excessive amounts of protein are lost through the urine. -A diet that is normal in protein with a sodium restriction is normally prescribed for a child with nephrotic syndrome. Parents or other family members should be encouraged to be present at mealtimes with a hospitalized child.

the nurse is monitoring a patient receiving Oxytocin, the nurse knows to immediately discontinue infusion when..

-late decelerations of fetal heart rate -uterine hyperstimulation

Metphormin

-oral hypoglycemic given in combination with repaglinide -works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. -Muscle pain may occur as an adverse effect from metformin, but it also might signify a more serious condition that warrants PHCP notification, not the use of acetaminophen.

therapeutic serum level of lithium

0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L). A level of 3 mEq/L indicates toxicity.

therapeutic serum digoxin level

0.8 to 2.0 ng/mL

INR

0.81-1.2 (2-3 for warfarin therapy, 3-4.5 for high dose warfarin)

Bicarbonate (HCO3)

ABG 21-27 -main form of CO2 in body, measurement of metabolic component of the acid-base balance

Partial pressure of CO2 (PaCO2)

ABG 35-45 -measures amount of carbon dioxide gas in blood

pH level

ABG 7.35-7.45 Measure of the balance of acids & bases in blood

Partial pressure of O2 (PaO2)

ABG 80-100 -measures amount of blood gas in the blood

Leukopenia

Abnormally low white blood cell count

A client is taking lansoprazole for the chronic management of Zollinger-Ellison syndrome. If prescribed, which medication would be appropriate for the client if needed for a headache?

Acetaminophen Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) such as naprosen and ibuprofen. Acetaminophen would likely be prescribed for headache for this client because it would not be irritating to the stomach.

antidote for acetaminophen

Acetylcysteine

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid Aspirin is contraindicated for gastrointestinal bleeding and is potentially ototoxic. The client should be advised to notify the prescribing PHCP so that the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead.

Isotretinoin

Acne treatment- check triglyceride level before treatment; discontinue Vitamin A supplements.

Theraputic action of Dantrolene sodium

Acts directly on the skeletal muscle to relieve spasticity

Hypokalemia Tx

Admin K+ supplements PO or IV; PO K+ have unpleasant taste and irritate GI tract = don't give on empty stomach, dilute; NEVER give IV bolus; Assess renal fx before admin; Enc foods high in K+

The nurse is assigned to assist in caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). Which is the priority nursing action for this client who is in the acute phase?

Administer intravenous (IV) regular insulin.

client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate?

Aluminum intoxication Aluminum intoxication may occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum.

agoraphobia

An abnormal fear of open or public places (leaving the house)

The client with myasthenia gravis becomes increasingly weak. The primary health care provider (PHCP) prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis?

An edrophonium injection makes the client experiencing cholinergic crisis temporarily worse. This is known as a negative test. An improvement of weakness would occur if the client were experiencing myasthenia gravis.

command hallucinations

An individual hearing voices that direct the person to take action.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An unlicensed assistive personnel who has never had chickenpox Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox.

A mother of a 5-year-old child tells the nurse that the child scolds the floor or table if the child hurts herself on the object. The nurse identifies the child as displaying signs of which stage of Piaget's theory of cognitive development?

Animism Animism means that all inanimate objects are given living meaning. Object permanence, the realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. Egocentric speech occurs when the child talks just for fun and cannot see another's point of view. Global organization means that if any part of an object or situation changes, the whole thing has changed. Egocentric speech and global organization occur during the preoperational stage.

Betamethasone (Celestone)

Antenatal steroids. Stimulate production of surfactant in fetus between 24 and 34 weeks gestation. Promotes fetal lung maturity in preterm labor when delivery is likely. Side effects: fluid retention and elevated BP. Interventions: administer 2 doses (usually IM) 24 hours apart (repeat doses not recommended). Provide emotional support to family.

isosorbide mononitrate (Imdur)

Antianginal Side effects: headache, orthostatic hypotension, dizziness, weakness, faintness, nausea/vomiting, flushing or pallor, dry mouth, reflex tachycardia.

Etanercept (Enbrel) side effects

Antiarthritic med for rheumatoid arthritis. injection site inflammation/pain, ecchymosis/edema, bone marrow suppression/ infection, fatigue, headache, nausea, vomiting, flu-like symptoms, allergic response.

The nurse is caring for a client with Paget's disease. The nurse knows that when serum calcium levels are lowered, what hormone secretion increases to release calcium to the blood?

Antidiuretic hormone (ADH)

Foscarnet (Foscavir)

Antiviral Foscarnet is toxic to the kidneys. Serum creatinine is monitored before therapy, two to three times per week during induction therapy and at least weekly during maintenance therapy. Foscarnet may also cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus these levels are also measured with the same frequency.

A pregnant client has just been admitted to the hospital with severe preeclampsia. The nurse knows it is important to monitor for additional complications at this time. Which assessment should be part of the plan of care?

Any bleeding, such as in the gums, petechiae, and purpura Bleeding is an early sign of disseminated intravascular coagulation (DIC), a complication of preeclampsia, and should be reported.

The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care for the client? Select all that apply.

Applying prescribed topical antibiotic, Administering prescribed corticosteroid, Applying Domeboro solution to the affected skin Pemphigus is a chronic autoimmune condition in which bullae (blisters) develop on the face, back, chest, groin, and umbilicus. The blisters rupture easily, releasing a foul-smelling drainage. Potassium permanganate baths, Domeboro solution, and oatmeal products with oil may be prescribed to soothe the affected areas, reduce odor, and decrease the risk of infection. Treatments may include corticosteroids, other immunosuppressants, and oral or topical antibiotics.

steal syndrome

Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia

Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly?

Asks the client to block one ear at a time In a voice test, the nurse, while facing the client, stands 1 to 2 feet away and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately.

A client is admitted to the emergency department with a diagnosis of acute myocardial infarction (MI). Which prescriptions should the nurse anticipate implementing? Select all that apply.

Aspirin,Oxygen ,Morphine,Nitroglycerin As soon as a patient with an acute MI is brought to the emergency department, measures are taken to relieve pain, decrease ischemia, and prevent further circulatory collapse and shock. The MONA (morphine, oxygen, nitrates, aspirin) regimen is initiated.

The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium.

Aspirin-containing products should be avoided while taking this medication. Alcohol consumption should be avoided by a client taking warfarin sodium. Taking prescribed medication at the same time each day increases client compliance. The Medic-Alert bracelet provides health care personnel with emergency information.

unilateral hip dysplasia

Asymmetry of the gluteal folds when the infant is placed prone would be a finding in hip dysplasia in infants beyond the newborn period

Antimyasthenic medication (ex: pyridostigmine) antidote for cholinergic crisis

Atropine sulfate

Pilocarpine hydrochloride reversal med (glaucoma med)

Atropine sulfate Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizure. Atropine sulfate must be available in the event of systemic toxicity

A client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?

Atropine sulfate The antidote for cholinergic crisis is atropine sulfate

serious adverse reaction to propranolol

Audible expiratory wheezes may indicate a serious adverse reaction: bronchospasm.

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered?

Autonomy vs. shame and doubt Negative feelings of doubt and shame arise when individuals are made to feel self-conscious and shame. The positive outcomes of mastering this developmental stage are self-control and willpower

Common Potassium Food Sources

Avocado, Bananas, cantaloupe, carrots, fish, mushrooms, oranges, pork, beef, veal, potatoes, raisins, spinach , strawberries, tomatoes.

The nurse is reinforcing medication discharge instructions for a client who has just begun taking isocarboxazid for depression and knows that the client needs further teaching after stating that which foods are safe to eat? Select all that apply.

Avocado,Bologna The client who is taking isocarboxazid needs further teaching after stating that avocado and bologna are safe to eat. Foods that are restricted for clients who take monoamine oxidase inhibitors (MAOIs) are foods that contain tyramine and include avocados; figs; fermented, smoked, and organ meats; dried and cured fish and most cheeses; foods with yeast; imported beers and Chianti wines; and some soups that contain protein extract.

Saquinavir is prescribed for the client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse should reinforce medication instructions about which health care measure to the client?

Avoid sun exposure. Saquinavir is an antiretroviral (protease inhibitor) used with other antiretroviral medications to manage HIV infection. Saquinavir is administered with meals and is best absorbed if the client consumes high-calorie, high-fat meals. Saquinavir can cause photosensitivity, and the nurse should instruct the client to avoid sun exposure.

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?

B12 Deterioration and atrophy of the lining of the stomach lead to the loss of function of the parietal cells. When the acid secretion decreases, the source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia.

Sodium (Na)

BMP -135-145 -electrolyte vital to normal body function including nerve & muscle function. -Helps regulate amount of fluid in body

Potassium (K+)

BMP -3.5-5.0 -regulates activity of muscles, maintains normal heart electrical rhythm & normal electrical signals in nervous system.

Chloride (Cl)

BMP -95-105 -electrolyte to help regulate fluid in the body & maintain acid-base balance -increase = dehydration/ respiratory alkalosis

Creatinine (Cr)

BMP 0.6-1.2 -waste product produced in muscles, filtered out of blood by kidneys so blood levels are a good indication of how kidneys are working

Bicarbonate (HCO3)

BMP 22-28 -helps maintain body's acid-base balance (PH)

Blood Urea Nitrogen (BUN)

BMP 7-18 -determines ow well kidneys are working. Urea Nitrogen is a waste product thats created in liver when body breaks down proteins

Glucose (Glc)

BMP 70-115 -energy source for the body, steady supply must be available for use, relatively constant level of glucose must be maintained in blood.

The nurse employed in a well-baby clinic is collecting data on the language and communication developmental milestones of a 4-month-old infant. Based on the age of the infant, the nurse expects to note which highest level of developmental milestones?

Babbling sounds Babbling sounds are common between the ages of 3 and 4 months. Additionally, during this age, crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months.

The nurse is monitoring a client receiving baclofen for side effects related to the medication. Which should indicate that the client is experiencing a side effect?

Baclofen is a central nervous system (CNS) depressant and frequently causes drowsiness, dizziness, weakness, and fatigue. It can also cause nausea, constipation, and urinary retention.

probable signs of pregnancy

Ballottement, Chadwick's sign, Uterine enlargement, Braxton Hicks contractions probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy); Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's fingers on palpation); Braxton Hicks contractions; and a positive pregnancy test that measures for human chorionic gonadotropin.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?

Baseline fetal heart rate

miotic agents used to treat glaucoma

Betaxolol Pilocarpine Pilocarpine hydrochloride

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron in which way?

Between meals iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the absorption of iron by the body.

The nurse is caring for a postrenal transplantation client with prescription for cyclosporine (immunosuppressant) . If the nurse notes an increase in one of the client's vital signs and the client is complaining of a headache, which vital sign is most likely increased?

Blood Pressure. Hypertension can occur in a client taking cyclosporine, and because this client is also complaining of a headache, the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism

Which finding would indicate that a child had a tonic-clonic seizure during the night?

Blood on the pillow he complications associated with seizures include airway compromise, extremity and teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on the tongue.

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication?

Blood urea nitrogen level of 25 mg/dL Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L). Anormal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL (4 to 6 mmol/L).

The nurse who is administering bethanechol chloride is monitoring for acute toxicity associated with the medication. The nurse should check the client for which sign of toxicity?

Bradycardia Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

s/s placenta previa

Bright red vaginal bleeding Soft, relaxed, nontender uterus

Platelet count

CBC 150,000-400,000 -when injury to blood vessel/tissue, platelets help stop bleeding by *adhering to injury site * clump together (aggregate) * release chemical compounds that stimulate further aggregation

WBC count

CBC 4.5-11 x10 -help protect against infection, has a play in inflammation, and allergic reactions. Increase= inflammation/ infection

Hemoglobin (male and female)

CBC Male: 14-18 g/dL Female: 12-16 g/dL -enables RBC to bind to oxygen in the lungs & carry to tissues & organs. -Helps transport small portion of carbon dioxide from tissues to lungs where it is exhaled.

cerebral palsy is best described by which statement?

Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?

Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output in hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 mL/kg/hour to 2 mL/kg/hour, potassium chloride should not be administered.

H2 Antagonists (tidine)

Cimetidine, Ranitidine, Famotidine, Nizatidine

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first?

Clear and maintain an open airway. serious condition where high blood pressure results in seizures during pregnancy. Seizures are periods of disturbed brain activity that can cause episodes of staring, decreased alertness, and convulsions.

Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.

Client who has been vomiting for 2 days Client receiving oral furosemide 40 mg daily Metabolic alkalosis is caused by any condition that creates the acid-base imbalance through either an increase in bases or a deficit of acids

The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

Client with pancreatitis Malnourished client Client with diabetes mellitus Client with status epilepticus Client with severe prolonged diarrhea

The nurse assists the nurse-midwife in examining the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation minus (-) 2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which activity for the client?

Complete bed rest Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk.

zidovudine to treat HIV/AIDS, the nurse should monitor which laboratory result during treatment with this medication?

Complete blood count side/adverse effect of therapy with zidovudine is leukopenia and anemia. The nurse monitors the complete blood count results for these changes.

Epispadias and Hypospadias

Congenital defects that involve the abnormal placement of the urethral opening of the penis; these anatomical defects can lead to the easy entry of bacteria into the urine. Surgical intervention is performed between 16 and 18 months of age.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority?

Connecting the resuscitation bag to the oxygen outlet The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?

Connects the umbilical vein to the inferior vena cava

The android pelvic shape

Convergent sidewalls, Narrow interspinous diameter, heart-shaped and narrow and is an unfavorable shape for a vaginal birth.

infiltrated IV s/s

Cool to touch, Swelling at the site, May not have a blood return

Dexamethasone (Decadron)

Corticosteroid to accelerate fetal lung maturity

The nurse is collecting data from an older adult client. Which indicates a potential complication associated with the skin of this client?

Crusting The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin indicates a potential complication.

Cushing's syndrome. Which statement by the student indicates an accurate understanding of this disorder?

Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones.

fluid volume deficit

DEHYDRATION: fluid intake is not sufficeint to meet the fluid needs of the body -increased specific gravity & hematocrit

The licensed practical nurse (LPN) is assisting a school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the most likely day for ovulation in a 30-day menstrual cycle is which day?

Day 16 The normal duration of the menstrual cycle is about 28 days. However, in a longer menstrual cycle, ovulation typically occurs 14 days before day 1 of the next cycle. Thirty days minus 14 days would be day 16.

An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity?

Decreased lean body mass and glomerular filtration rate

Hypernatremia cause

Decreased water intake, fever, excessive perspiration, dehydration, hyperventilation, watery diarrhea, enteral & parenteral nutrition deplete the cells of water, diabetes insipidus, Cushing's syndrome, impaired kidney function, use of corticosteroids, excessive administration of sodium bicarb

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication?

Dementia Donepezil hydrochloride is a cholinergic agent used in the treatment of mild to moderate dementia of the Alzheimer's type. It enhances cholinergic functions by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease.

Desmopressin acetate (DDAVP)

Desmopressin promotes renal conservation of water. The hormone carries out this action by acting on the collecting ducts of the kidney to increase their permeability to water, which results in increased water reabsorption. The therapeutic effect of this medication would be manifested by a decreased urine output.

A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which?

Detached retina Clients with a history of cataract surgery, myopia, trauma, or a family history of retinal conditions are at greater risk for developing a detached retina. Signs and symptoms include sudden onset of flashing lights or floaters. The client may also have loss of peripheral vision or a sudden shadow in the field of vision.

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record should the nurse identify as a risk factor for this diagnosis?

Diabetes mellitus Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.

interventions for metabolic acidosis.

Dialysis and insulin administration dialysis, sodium bicarbonate, treat underlying cause, treat hyperkalemia, IV FLUIDS ONLY, NO PO (due to n/v)

Hypocalcemia cause

Dietary deficiency, laxative abuse, diarrhea, pancreatitis, malabsorption

Disulfiram (Antabuse)

Disulfiram is used as an adjunct treatment for selected clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important data are to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.

A 4-year-old child has been brought to the emergency department after the grandparents found him with an open bottle of chewable, orange-flavored 81-mg aspirin tablets. In order to determine whether the child is experiencing a toxic effect, which question should the nurse ask the child?

Do you hear a sound like a bell ringing in your ears? Ringing in the ears is a common sign of salicylate toxicity, and it is appropriate to ask a 4-year-old whether they hear an unusual sound.

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take?

Document the findings. After a myringotomy with the insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding or bleeding that occurs after 3 days should be reported.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure?

Dorsiflex the client's foot while extending the knee. Leg cramps often occur when the pregnant woman stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping.

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?

Drink decaffeinated coffee and tea. Caffeine, like spices, may cause heartburn and needs to be avoided. Spices tend to trigger heartburn.

metabolic acidosis s/s

Drowsiness Confusion Headache Coma ↓BP Dysrhythmias (R/T Hyperkalemia) Warm, flushed skin Nausea/Vomiting/Diarrhea/Abdominal pain Deep, rapid respirations

respiratory acidosis s/s

Drowsiness Disorientation Dizziness Headache Coma ↓BP V-Fib Hyperkalemia Rapid/Irregular HR Warm, flushed skin Seizures Hypoventilation Hypoxia Cyanosis

metabolic alkalosis s/s

Drowsiness Diziness Nervousness Confusion ↑HR dysrhythmias r/t hypokalemia Anorexia/Nausea/Vomiting Tremors Hypertonic muscles Muscle cramps/Tetany/Tingling in extremeties/Seizures Hypoventilation

proton pump inhibitors (prazole)

Drugs: Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, Rabeprazole MOA: Irreversibly inhibit H+/K+ ATPase in stomach parietal cells Clinical Use: Peptic ulcer disease, gastritis, esophageal reflux, ZOLLINGER-ELLISON SYNDROME Adverse Effects: 1. ↑ Risk of C. difficile infection 2. Pneumonia 3. ↓ Serum Mg2+ with long-term use common side effects: headache, diarrhea, abdominal pain, nausea

During the emergent phase after a major burn injury, which abnormalities should the nurse expect to note?

During the emergent phase of a burn injury, the client's hemoglobin and hematocrit will be elevated because of fluid loss. Sodium will be decreased because of trapping in edema fluid and loss through plasma leakage. Potassium will be increased because of disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis, and albumin will be low because of loss through the wound and increased capillary permeability.

carbidopa/levodopa (Sinemet) Side effects

Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as the "on-off phenomenon") are frequent side effects of the medication.

pt is a lacto-vegetarian, which food should be removed from tray?

Eggs eat milk, cheese, dairy food but avoid meat, fish, poultry and eggs

The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function?

Elevated serum creatinine level, Decreased red blood cell (RBC) count, Elevated blood urea nitrogen (BUN) level

A client is in the first stage of labor. Which nursing actions are implemented in the first stage of labor? Select all that apply.

Encourage frequent urination., Continue maternal and fetal assessments., Review breathing and relaxation techniques. Failure to empty the urinary bladder can lead to rupture of the urinary bladder, or it can prevent effective contractions, thereby restricting the progress of labor. Maternal and fetal assessments are critical to determine the progress of labor and the safety of the mother and fetus. Breathing and relaxation techniques are reviewed during the latent phase and encouraged during the active phase. The client should be allowed lollipops to hold and suck on between contractions for carbohydrate and fluid intake. The client may take showers.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids. When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids.

A client receiving a blood transfusion begins to exhibit flushing, stridor, and a drop in blood pressure. The nurse should obtain which medication from the emergency cart to have ready for use as prescribed?

Epinephrine the symptoms exhibited by the client are compatible with an allergic reaction to the transfusion. Other common symptoms of allergic reaction are nausea and vomiting, diarrhea, and loss of consciousness. The nurse prepares to administer epinephrine and corticosteroid medications as prescribed.

The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which class of medications?

Episodes of urinary retention can be triggered by certain medications such as decongestants, anticholinergics, and antidepressants. Retention also can be precipitated by other factors such as alcoholic beverages, infection, bed rest, and becoming chilled.

The maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which hormones identified by the student indicate an understanding of the hormones produced by this endocrine gland

Estrogen, Progesterone

The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What should the nurse tell the client about the purpose of the test?

Examines visual fields or peripheral vision The confrontational method of eye testing is used to examine visual fields or peripheral vision. Tonometry is used to check for glaucoma. An Ishihara chart is used to check color vision. A flashlight is used to test pupillary response to light.

situational crisis

External sources such as a job change, motor vehicle crash, death of a loved one, or severe illness provoke situational crises.

Romberg's sign

Falling to one side when standing with feet together and eyes closed, indicating abnormal cerebellar function or inner ear dysfunction

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely?

Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid for 6 to 12 months. The client is usually not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis.

ACE inhibitors adverse effects

Fatigue Dizziness Headache Mood changes Impaired taste Possible hyperkalemia Dry, nonproductive cough, which reverses when therapy is stopped Angioedema: rare but potentially fatal Note: First-dose hypotensive effect may occur

Hypokalemia S/S

Fatigue, Anorexia, N/V, Muscle weakness, Decreased GI motility, Dysrhythmias, Paresthesia, Peaked P waves,Flat T waves, depressed ST segment and U waves on ECG

Rifampin (Rifadin)

First line medication for Tuberculosis. Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a PHCP. The medication should be administered on an empty stomach unless it causes GI upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes red-orange discoloration of body secretions and will permanently stain soft contact lenses.

Kaposi's sarcoma

Form of skin cancer frequently seen in pts with compromised immune systems (AIDS, kidney transplant, A client receiving antineoplastic medications

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client?

G = 2, T = 1, P = 0, A = 0, L = 1 GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/miscarriages (number of abortions/miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.

The client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse should monitor which parameter closely while the client is taking this medication?

Gait Stavudine is an antiretroviral used to manage HIV infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the client's gait closely and ask the client about paresthesia.

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication?

Gastrointestinal dysfunctions The most common adverse effects related to fluoxetine include CNS and GI system dysfunction. This medication affects the GI system by causing nausea and vomiting, cramping, and diarrhea.

Griseofulvin

Give with meals-- especially high fat meals (anti-fungal)

Betamethasone (Celestone)

Glucocorticoid administered IM in 2 injections 24 hr apart, given to stimulate fetal lung maturity if early delivery (28-32 weeks) is anticipated and to prevent respiratory distress. Can cause pulmonary edema (crackles, chest pain, SOB)

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client?

Gravida II, para I Gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity is a term that means the number of births after 20 weeks' gestation; it does not reflect the number of fetuses or infants.

pt having trouble with blood clotting, which food item should the client eat?

Green & leafy veggies high in vitamin K, which acts as catalyst for facilitating blood clotting factors.

Asian American health risks

HTN, heart disease, cancer, lactose intolerance, Thalassemia

Hispanic and Latino health risks

HTN, heart disease, diabetes mellitus, obesity, lactose intolerance, parasites from unsanitary conditions

Amikacin is prescribed for a client with a diagnosed bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs?

Hearing loss Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the PHCP immediately.

A client with chronic kidney disease is receiving epoetin alfa (Hematopoietic Growth Factors) . Which laboratory result would indicate a therapeutic effect of the medication?

Hematocrit of 33% Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% , Female: 37% to 47% Therapeutic effect is seen when the hematocrit reaches between 30% and 33% . The normal platelet count is 150,000 to 400,000 mm. The normal blood urea nitrogen level is 10 to 20 mg/dL . The normal white blood cell count is 5000 to 10,000 mm3

hemophilia A

Hemophilia A results from deficiency of factor VIII the term hemophilia refers to a group of bleeding disorders. The identification of the specific factor deficiencies allows for definitive treatment with replacement agents

A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which finding should the nurse note as being consistent with this diagnosis?

High serum glucose level and low serum bicarbonate level In DKA the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood and urine. The arterial pH is low (less than 7.35.) The plasma bicarbonate is also low. The client would exhibit polyuria and Kussmaul's respirations.

The nurse is collecting medication information from a client, and the client states that she is taking garlic as an herbal supplement. The nurse understands that the client is most likely treating which condition?

Hyperlipidemia Garlic is an herbal supplement that is used to treat hyperlipidemia and hypertension. An herbal supplement that may be used to treat eczema is evening primrose. Insomnia has been treated with both valerian root and chamomile. Migraines have been treated with feverfew.

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place?

Hypertension Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?

Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma

potential complication of parathyroidectomy

Hypocalcemia because the parathyroid regulates calcium in blood

The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching?

I need to give frequent, small, nutritious meals if my child starts to vomit The vomiting that occurs in Reye's syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small, frequent meals will not affect the amount of vomiting, and the PHCP is notified if vomiting occurs.

infliximab (Chron's disease)

Immunomodulator; reduces the degree of inflammation in the colon, thereby reducing the diarrhea

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply.

In the first trimester of pregnancy the pulse increases 10 to 15 beats per minute, the blood volume increases 40% to 50%, the cardiac output increases 30% to 50%, and red blood cell mass increases 17%. Blood pressure decreases in the first half of pregnancy, returning to baseline in the second half. The white blood cell count increases in the second and third trimesters.

Cyclophosphamide instruction

Increase fluid intake to 2000 to 3000 mL daily. Hemorrhagic cystitis is a toxic effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal (GI) upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client should not be told to increase potassium intake.

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value should the nurse note as a result of the massive cell destruction that occurred from the chemotherapy?

Increased uric acid level Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in a massive cell kill, releasing uric acid into the blood. Although anemia, decreased platelets, and decreased leukocytes also may be noted, an increased uric acid level is related specifically to cell destruction. Massive cell destruction may result in high levels of potassium, not hypokalemia.

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy?

Increased uric acid level Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and lymphomas, because the therapy results in massive cell destruction and the release of uric acid.

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

Increasing temperature, increase BP decreasing pulse, decreasing respirations,

The nurse is reinforcing instructions to a client newly diagnosed with diabetes mellitus regarding insulin administration. The primary health care provider has prescribed a mixture of NPH and regular insulin. The nurse should stress that which is the first step?

Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. initial step in preparing an injection of insulin that is a mixture of NPH and regular is to inject air into the NPH bottle equal to the amount of insulin prescribed. The client is instructed to next inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin should then be withdrawn followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer-acting form.

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

Insert the suppository 1 to 2 cm into the rectum. child should be positioned on the left side with the right leg flexed.

The nurse is preparing to perform an abdominal examination. Which step should be taken first?

Inspection The sequence of maneuvers is inspect, auscultate, percuss, and palpate.

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which should the nurse clarify?

Irrigating the NG tube a Billroth II resection, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the NG tube is critical for preventing the retention of gastric secretions. The nurse, however, should never irrigate or reposition the NG tube after gastric surgery unless specifically prescribed by the PHCP. In this situation, the nurse should clarify the prescription.

pt taking isoniazid should report what S/S?

Isoniazid is hepatotoxic, and therefore the client is taught to report signs/symptoms of hepatitis immediately (which include yellow skin and sclera). For the same reason, alcohol should be avoided during therapy. The client should avoid intake of Swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or light-headedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine during the course of isoniazid therapy.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse ensures that which baseline study has been completed?

Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is greater than age 50 or abuses alcohol.

purpose of estrogen

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

A nursing consideration in rubeola (measles)

Keep the child in a room with dim lights. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action?

Keep the client in a side-lying position. Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. Priority care of this client includes the promotion of fetal oxygenation. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression

The nurse is caring for a client who had a small bowel resection the previous day and has continuous gastric suction attached to the nasogastric tube. Which intravenous solution should the nurse anticipate to be prescribed for the client?

Lactated Ringer's solution Electrolyte solutions such as lactated Ringer's are used to replace fluid from gastrointestinal (GI) tract losses. Albumin is used for shock and protein replacement; 5% dextrose in water contains only glucose and no electrolytes to replace gastrointestinal losses. Normal saline contains no glucose, and glucose is essential for calories when a client takes nothing by mouth (NPO).

Which findings indicate to the nurse that placental separation has occurred?

Lengthening of umbilical cord, Sudden trickle or spurt of blood, Fetal membranes are seen at the introitus

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?

Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle. The position described in option 4 will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities.

Rapid acting insulin

Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra)

Aspartate aminotransferase (AST)

Liver 10-40 units enzyme found mostly in liver, heart, & less in kidneys/muscles. -when liver/muscle cells injured, they release AST into blood

Alanine aminotransferase (ALT)

Liver 10-50 units -enzyme found mostly in liver & kidney (some in heart and muscles) -when liver is damaged, ALT is released into blood

Albumin (Alb)

Liver 3.5-5.6 -keeps fluid from leaking out of blood vessels, nourishes tissues, & transports hormones, vitamins, drugs & substances like Ca throughout the body. Decrease= severe liver disease, kidney disease

Alkaline phosphatase (ALP)

Liver 40-140 -enzyme found in tissues, highest present in cells that comprise bone & Liver - Helps digest fat in diet -Increase= liver disease or bone disorder

Calcitonin

Lowers blood calcium levels

Which finding is characteristic of chicken pox?

Macular rash on the trunk and scalp

The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions?

Maintain a high fluid intake. Each dose of sulfadiazine should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfadiazine cause urine to turn dark brown or red. This does not indicate the need to notify the PHCP.

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care?

Maintaining standard precautions at all times while caring for the neonate The neonate born to a mother who is HIV-positive must be cared for with strict attention to standard precautions. This prevents the transmission of the infection from the neonate, if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate.

The nurse is caring for a prenatal client who is at risk for placental abruption. Which risk factor documented in the client's record supports this risk factor?

Maternal hypertension t is possible that placental abruption can result from maternal hypertension, which causes degenerative changes in the small arteries that supply intervillous spaces. This results in thrombosis, causing a retroplacental hematoma and leading to placental separation.

Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy?

Maximize the child's assets and minimize the limitations.

he client is receiving meperidine hydrochloride for pain. Which signs/symptoms are side and adverse effects of this medication?

Meperidine hydrochloride is an opioid analgesic. Side and adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

Metabolic acidosis

A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?

Metabolic acidosis Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel, which leads to the formation of ketones. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis.

Medications used to manage postpartum hemorrhage (Ergot Alkaloids)

Methylergonovine, Oxytocin, Prostoglandin F=Carboprost Tromethamine

16 week fundus location

Midway between the symphysis pubis and the umbilicus

Prostaglandins

Misoprostol, Dinoprostone ; Ripen the cervix making it softer and causing it to dilate and efface

The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen. How should the nurse administer the medication?

Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw. Because acetylcysteine has a pervasive odor of rotten eggs, it must be disguised in a flavored ice drink. It is consumed preferably through a straw to minimize contact with the mouth.

clinical indication of circulatory overload?

Moist, productive cough Chest or lumbar pain, cyanosis, dyspnea, moist productive cough, crackles in the lung bases, distended neck veins, and an increase in blood pressure are clinical indications of circulatory overload caused by excessive infusion amounts or too rapid an infusion rate.

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply.

Monitor liver function studies. Instruct the client to avoid alcohol. Instruct the client to avoid exposure to the sun. Ketoconazole is an antifungal medication. It is administered with food (not on an empty stomach), and antacids are avoided for 2 hours after taking the medication to ensure absorption. The medication is hepatotoxic, and the nurse monitors liver function studies. The client is instructed to avoid exposure to the sun because the medication increases photosensitivity. The client is also instructed to avoid alcohol.

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.

Monitor the skin temperature closely. Reposition the newborn every 2 hours. Cover the newborn's eyes with shields or patches. Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment (e.g., eye damage, dehydration, sensory deprivation) can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.

Betaxolol hydrochloride eye drops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication?

Monitoring blood pressure Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia

Myringotomy

Myringotomy is a surgical procedure that allows fluid to drain from the middle ear. Bed rest is not required, but activity may be restricted

Nevirapine (Viramune)

NNRTI (HIV AIDS) nonnucleoside reverse transcriptase inhibitor that is used to treat HIV infection. It is used in combination with other antiretroviral medications to treat HIV. Adverse effects include rash, Stevens-Johnson syndrome, hepatitis, and increased transaminase levels.

The nurse is assisting in caring for a client who is receiving morphine sulfate by continuous intravenous infusion. The nurse ensures that which medication is readily available if a morphine overdose occurs?

Nalmefene Nalmefene is a long-acting antagonist that is used to treat opioid overdose. Naloxone is also used to treat opioid overdose.

A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should check the client for which sign/symptom?

Naloxone hydrochloride is an antidote to opioids and may also be given to the postoperative client to treat respiratory depression. When given to the postoperative client for respiratory depression, it may also reverse the effects of analgesics. Therefore, the nurse must check the client for a sudden increase in the level of pain experienced.

A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness?

No rapid heartbeats or anxiety Buspirone hydrochloride is most often indicated for the treatment of anxiety and aggression.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse should make which determination about the client's neurovascular status?

Normal, caused by increased blood flow through the leg

A client tells the nurse about deciding to refuse external cardiac massage. Which should be the most appropriate initial nursing action?

Notify the primary health care provider of the client's request. do not resuscitate" (DNR) prescription from the PHCP must be present.

fluid volume excess

OVERHYDRATION: fluid intake or fluid retention exceeds fluid needs of the body -decreased hematocrit

cryptorchidism pediatrics

Occurs when one or both testes fail descend through the inguinal canal and into the scrotal sac.

Insulin glargine is prescribed for a client with diabetes mellitus. The nurse tells the client that which is the best time to take the insulin?

Once daily at the same time each day a long-acting recombinant DNA human insulin used to treat type 1 and type 2 diabetes mellitus. It has 24-hour duration of action and is administered once a day at the same time each day.

teaching plan for the client receiving an antineoplastic medication.

Oral hygiene is important and clients should inspect their mouths daily, rinse after meals, and use a soft toothbrush. The client should check with the PHCP before receiving any immunizations. The client should notify the PHCP for a low grade temperature such as 99.5° F (39.7° C) and a sore throat.

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process?

Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high

Humalin NPH hypoglycemic time?

PEAK 6-14 hours

phenylketonuria (PKU)

PKU results in central nervous system (CNS) damage. Treatment includes dietary restriction of phenylalanine intake (not sodium). PKU is a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood

sickle cell crisis precipitating factors

Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage a fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder?

Pao2 49 mm Hg, Paco2 52 mm Hg Respiratory failure is described as a Pao2 of 50 mm Hg or less, and a Paco2 of 50 mm Hg or greater in a client with no history of respiratory disease.

TX for scabies

Permethrin (scabicide) apply to cool, dry skin at least 30 min after bathing, which needs to be left on the skin for 8 to 14 hours, then washed off.

permethrin 1% to the parents of a child who has been diagnosed with pediculosis capitis.(lice)

Permethrin 1% is an over-the-counter, antilice product that kills lice and eggs with one application and that has residual activity for 10 days. It is applied to dried hair after shampooing and left for 5 to 10 minutes before it is rinsed (not shampooed) out. The hair should not be shampooed for 24 hours after the treatment.

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed?

Petechiae, oozing from injection sites, and hematuria DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.

A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? Select all that apply.

Phenelzine sulfate is a monoamine oxidase inhibitor. The client should avoid consuming foods that are high in tyramine. Eating these foods could trigger a potentially fatal hypertensive crisis. Some foods to avoid include yogurt, aged cheeses, smoked or processed meats, red wines, and fruits such as avocados, raisins, and figs.

Phenytoin (Dilantin)

Phenytoin is an anticonvulsant. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits.

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first?

Place the child in a knee-chest position.

The nurse is preparing for the intershift report when a nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a client experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first?

Place the client in modified Trendelenburg's position The client is exhibiting signs of shock and requires emergency intervention. Placing the client in the modified Trendelenburg's position increases blood return from the legs, which increases venous return and subsequently the blood pressure.

A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. Which action should the nurse take first?

Place the client on the left side with the head lowered. Lying on the left side may prevent air from flowing into the pulmonary veins. Placing the head lower than the body increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration.

The nurse is reviewing the health care record of a client with a new onset of pleurisy. The nurse notes documentation that the client does not have a pleural friction rub that was auscultated the previous day. How should this finding be interpreted?

Pleural fluid has accumulated in the inflamed area.

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions for the administration of the medication. Which instruction should the nurse reinforce?

Precautions need to be taken with the administration of alendronate to prevent gastrointestinal side/adverse effects (especially esophageal irritation) and to increase absorption of the medication. The medication needs to be taken with a full glass of water after rising in the morning. The client should not eat or drink anything for 30 minutes following administration and should not lie down after taking the medication.

pt on glyburide/metformin , which medication contributes to hyperglycemia?

Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client?

Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae. The preventive treatment of gonorrhea is required by law

what progesterone does for pregnancy

Progesterone maintains the uterine lining for implantation.

After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?

Prone The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage.

toxicity reversal agent for heparin

Protamine sulfate

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?

Protruding and swollen in which bowel protrudes through the stoma, with an elongated and swollen appearance.

purpose of the placenta

Provides an exchange of nutrients and waste products between the mother and the fetus

for a child who has Reye's syndrome. Which is the priority nursing intervention?

Providing a quiet atmosphere with dimmed lights he major elements of care for a child who has Reye's syndrome are to maintain effective cerebral perfusion and to control intracranial pressure. Decreasing stimuli in the environment should decrease the stress on the cerebral tissue and the neuron responses. Cerebral edema is a progressive part of this disease process.

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?

Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity

Laboratory studies are performed on a child suspected of iron deficiency anemia. The nurse reviews the laboratory results, knowing that which finding indicates this type of anemia?

RBCs that are microcytic and hypochromic The results of a complete blood cell count in children with iron deficiency anemia will show low hemoglobin levels and microcytic and hypochromic RBCs. The reticulocyte count is usually normal or slightly elevated.

The nurse assists with creating a plan of care for a client with hyperparathyroidism receiving calcitonin-human. Which outcome has the highest priority regarding this medication?

Reaching normal serum calcium levels Hypercalcemia can occur in clients with hyperparathyroidism, and calcitonin is used to lower plasma calcium levels. The highest-priority outcome in this client situation would be a reduction in serum calcium level.

A client has been on total parenteral nutrition for 8 weeks. The primary health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response should be to explain that the primary health care provider is concerned about which phenomenon?

Rebound hypoglycemia Clients receiving total parenteral nutrition are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before discontinuing the parenteral nutrition, the body must adjust to the lowered glucose levels. If the total parenteral nutrition were suddenly withdrawn, the client would probably have rebound hypoglycemia.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?

Red The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish-brown and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14

The nurse is assisting in caring for a client admitted to the emergency department with diabetic ketoacidosis. The nurse anticipates that the primary health care provider will prescribe which type of insulin for intravenous administration to treat this disorder?

Regular Regular insulin is a short-acting insulin and can be administered by the intravenous route.

Short acting insulin

Regular (Humulin R, Novolin R)

Magnesium (Mg)

Renal 1.5-2.5 -vital for energy production, muscle contraction, nerve function & maintenance of strong bones

Calcium (Ca+)

Renal 8.5-10.5 -essential for signaling/ proper function of muscles, nerves, and heart. -blood clotting & crucial for formation, density, &maintenance of bones and teeth.

Kussmauls respirations

Respirations that are regular but abnormally deep and increased in rate

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?

Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of breathing.

mumps is which type of communicable disease?

Respiratory disease caused by a virus involving the parotid gland Mumps is caused by a paramyxovirus that causes swelling from the parotid gland, causing jaw and ear pain. It is transmitted via direct contact or droplets spread from an infected person, salive from infected saliva, and possibly by contact with urine. Airborne and contact precautions are indicated during the period of communicability.

anorexia nervosa patients handle their anxiety by

Rules and rituals help the clients manage their anxiety.

pediatric digoxin administration

Safety in dosing is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats per minute in an infant, the nurse should withhold the dose and notify the registered nurse and primary health care provider.

A client arrives at the health care clinic and tells the nurse that they have been doubling their daily dosage of bupropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem?

Seizure activity Bupropion is an atypical antidepressant and does not cause significant orthostatic blood pressure changes. Seizure activity is common in dosages greater than 450 mg daily. Bupropion frequently causes a drop in body weight. Insomnia is a side effect, but seizure activity causes a greater client risk.

In the well-child clinic, the nurse observes an infant, age 10 months, playing with toys, bringing them to his mouth, and passing the toys from one hand to the next. The nurse determines the child is in which Jean Piaget's first developmental stage?

Sensorimotor Jean Piaget's first stage of cognitive development is the sensorimotor stage (birth to 2 years). The preoperational stage is the second stage (2 to 7 years of age). The concrete operational stage is the third stage (7 to 11 years of age). The formal operational stage is the fourth stage (11 years of age to adulthood).

The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted?

Serum amylase Didanosine can cause pancreatitis. A serum amylase level that is increased 1.5 to 2 times the normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure.

platypelloid pelvic shape

Shallow depth, Wide suprapubic arch, Compatible with vaginal delivery, Flattened anteroposteriorly, and wide transversely

African American Health risks

Sickle cell anemia, HTN, heart disease, cancer, lactose intolerance, diabetes mellitus, obesity, insufficient intake of vitamins and minerals

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?

Side-lying Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her side.

The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints?

Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints

risks associated with laryngeal cancer

Smoking cigarettes or cigars Drinking alcohol, especially daily Working in a dusty environment Persistent exposure to chemicals in the air Following a diet low in protein and vitamins

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy?

Sore throat Clients taking trimethoprim-sulfamethoxazole should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the PHCP if these symptoms occur. The other options do not require PHCP notification.

Nägele's rule

Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. (Ex: the first day of the LMP was October 20, 2019. When you subtract 3 months, you get July 20, 2019. If you add 7 days, you get July 27, 2019. Add 1 year to this, and you get the estimated date of birth: July 27, 2020.)

The nurse instructs the unlicensed assistive personnel (UAP) assigned to care for an older adult client to place an extra blanket in the client's room. The nurse provides this instruction because the older adult is less able to regulate hot and cold body changes as a result of alterations in the activity of which gland?

Sweat glands Functions of the skin include protection, sensory reception, homeostasis, and temperature regulation. The skin helps regulate the body temperature in two ways, by dilation and constriction of blood vessels and by the activity of the sweat glands. As aging progresses, alterations in sweat gland activity make the glands less effective in temperature regulation, so the aging person is less able to regulate hot and cold body changes. The parotid glands are responsible for the drainage of saliva, which plays an important role in digestion. The pineal gland is a major site of melatonin biosynthesis. The thymus gland plays an immunological role throughout life.

The nurse is assisting in caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide level reveals a level of 45%. Based on this level, the nurse should anticipate which sign in the client?

Tachycardia Carbon monoxide levels between 5% and 10% result in impaired visual acuity, levels of 11% to 20% result in flushing and headache, and levels of 21% to 30% result in nausea and impaired dexterity. Levels of 31% to 40% result in vomiting, dizziness, and syncope; levels of 41% to 50% result in tachypnea and tachycardia; and levels greater than 50% result in coma and death.

values to watch with Tamoxifen

Tamoxifen may increase calcium, cholesterol, and triglyceride levels.

amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?

The bladder must be full during the examination. Before 20 weeks' gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks' gestation, the bladder should be emptied to minimize the chance of puncturing the placenta or fetus.

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?

The bright red bleeding is abnormal and should be reported. Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet. Vision that is 20/20 is normal; that is, the client can read from 20 feet what a person with normal vision can read from 20 feet. A client with a visual acuity of 20/60 can only read at a distance of 20 feet what a person with normal vision can read at 60 feet.

The nurse reviewing health care records of patients. the nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction potassium rich GI fluids are lost through GI suction

Autonomic Dysreflexia S/S

The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

Autonomic dysreflexia

The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden, severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone Hyponatremia is a serum sodium level less than 135 mEq/L (135 mmol/L). Hyponatremia can occur secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

The nurse is employed in a newborn nursery. The nurse is reviewing all medications prescribed for newborns to prevent toxicity due to which causes? Select all that apply.

The liver is immature, The kidneys are less able to excrete medications The increased medication sensitivity of neonates and infants is largely a result of the immature state of five pharmacokinetic processes. These include medication absorption, renal medication excretion, hepatic medication metabolism, protein binding of medication, and exclusion of medication from the central nervous system by the blood-brain barrier.

The primary health care provider has written a prescription for ranitidine, for a client with gastrointestinal reflux disease. The nurse is explaining how this medication works to treat this disease. Which explanation should the nurse give?

The medication suppresses acid secretion by blocking H2 receptors.

The nurse is reviewing charts, which patient is LEAST likely at risk for third spacing?

The patient with diabetes mellitus

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means.

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

Intussuseption perforation s/s:

The signs of perforation and shock are evidenced by fever, an increased heart rate, a change in the level of consciousness or blood pressure, and respiratory distress and need to be reported immediately.

Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide is a potassium-excreting diuretic.

They are weak diuretics that are used in combination with potassium-excreting diuretics. This combination is useful when medication and dietary supplement of potassium is not appropriate.

Hydromorphone hydrochloride (Dilaudid)

This medication is used to help relieve moderate to severe pain. It is a hydrogenated ketone of morphine that belongs to a class of drugs known as narcotic (opiate) analgesics.

Cholestyramine

This medication should only be taken with water bile acid sequestrant used to lower the cholesterol level, and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption.

Thyroxine during pregnancy

Thyroxine increases during pregnancy to stimulate basal metabolic rate. It may also function to assist in the neural development of the fetus.

problem caused from Vegan diet only

Tingling in hands and feet Megaloblastic anemia and neurological manifestations occur from Vitamin B12 deficiency

furosemide adverse side effects

Tinnitus Hypotension Hypokalemia

A client with Crohn's disease has a prescription to begin taking antispasmodic medication. The nurse should schedule the medication so that each dose is taken at which time?

To be effective in decreasing bowel motility, antispasmodic medications should be administered 30 minutes before mealtime

Cyclopentolate eye drops

To dilate the pupil of the operative eye rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

Oxybutynin chloride ( Anticholinergics-Antispasmodics) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?

Toxicity (overdose) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdose.

The nurse reviews a patient with potassium level of 5.5, the nurse understands that a potassium value at this level would be noted with which condition?

Traumatic burn found in massive cell destruction (trauma, burns, sepsis or metabolic/ resp acidosis)

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first?

Turn the client onto her side. With a pregnant client who is in shock, the nurse should want to increase perfusion to the placenta to minimize fetal distress. A simple way to do this that requires no equipment is to turn the mother on her side. This increases blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels.

hypomagnesemia s/s

Twitching Paresthesias Hyperactive reflexes *Irritability* Confusion Positive Chvostek's or Trousseau's sign Shallow respirations Tetany Seizures Tachycardia *Tall T waves* and depressed ST segment

The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement?

Two thirds the distance between the antecubital fossa and the shoulder The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values and those that are too large will cause inaccurate low values. The cuff should cover two thirds the distance between the antecubital fossa and the shoulder.

fetal circulation consists of which components?

Two umbilical arteries and one umbilical vein

Hypospadias

Urethral opening is located below the glans penis (bottom) along the ventral surface.

Epispadias

Urethral opening is located on the dorsal surface (top) of the penis, often occurs with exstrophy of the bladder

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication?

Urinary strictures Bethanechol chloride (Cholinergic) can be harmful to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions.

Valerian

Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness.

A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which vitamin or mineral?

Vitamin B12 Pernicious anemia is caused by a deficiency of the intrinsic factor, which results in the inability to absorb vitamin B12 in the intestine. Treatment consists of weekly at first and then monthly injections of vitamin B12.

patient on ibuprofen, the nurse realizes that consulting RN is necessary because the pt is also taking what meds..

Warfarin, Glimepiride, Alodipine NSAIDS should not be combined with anticoagulants (Warfarin), hypoglycemia can occur as an adverse effect (Glimepiride), Toxicity can result if NSAIDS are combined with calcium channel blocker (Alodipine)

Glimepiride is prescribed for a client with diabetes mellitus. The nurse reinforces instructions for the client and tells the client to avoid which while taking this medication?

When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication.

A hospitalized client is taking clozapine for the treatment of a schizophrenic disorder. Which laboratory study prescribed for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication?

White blood cell count Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be checked before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever.

Carbamazepine (Tegretol) adverse side effects

White blood cell count, 3000 mm3 (low) appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbance, thrombophlebitis, dysrhythmia, and dermatological effects.

Pheochromocytoma

a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine

Dimercaprol

a chelating agent that is administered to remove lead from the circulating blood and from some tissues and organs for excretion in the urine.

Myasthenia Gravis

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles

The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication?

a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia.

Enuresis pediatric

a condition in which the child is unable to control bladder function, even though the child has reached an age at which control of voiding is expected ( by age 5 for most) or the child has successfully completed a bladder control program. Unable to sense a full bladder.

early deceleration of the fetal heart rate (FHR)

a gradual decrease in and return to baseline FHR in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary.

pediatric glomerulonephritis

a group of kidney disorders characterized by inflammatory injuries in the glomerulus, most of which are caused by an immunological reaction

nephrotic syndrome pediatrics

a kidney disorder characterized by massive proteinuria, hypoalbuminemia (hypoproteinemia), and edema. goal is to reduce excretion of urinary protein, reduce edema, prevent infection.

late signs of ICP

a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

ventriculoperitoneal shunt

a tube used to drain fluid from brain ventricles into the abdominal cavity

Buck's skin traction

a type of skin traction used in fractures of the femur and in hip and knee contractures. It pulls the hip and leg into extension.

Heparin drip lab

aPTT will assess the therapeutic effect of heparin sodium. The normal aPTT is 30 to 40 sec. To maintain a therapeutic level, the aPTT should be 1.5 to 2.5 times the normal value.

typical sign of ovarian cancer

abd distension/ fullness leading cause of death from gynecological cancers and occurs in women older than 50 years. Less common are vague symptoms of urinary frequency and urgency, and GI symptoms such as a change in bowel habits.

scarlet fever s/s

abrupt high fever, flushed cheeks, vomiting, headache, enlarged lymph nodes in the neck, malaise, and abdominal pain. red, fine, paperlike rash develops in the axilla, groin, and neck and spreads to cover the entire body except the face. the rash blanches with pressure except in areas of deep creases and folds of joints.

areflexia

absence of reflexes

Salicylic acid toxicity

absorbed through skin, (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances.

azelaic acid

acne treatment; can cause itching, burning, redness, stinging to skin. Hypopigmentation to dark skinned people.

The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction?

acute hemolytic reaction to the transfusion

Native American health risks

alcohol abuse, obesity, heart disease, TB, arthritis, lactose intolerance, gallbladder disease.

full liquid diet

all clear liquids AND plain ice cream, sherbet, breakfast drinks, milk, pudding, custard, strained soups, refined cooked cereal, fruit juice, strained veggie juice

aversion therapy

also known as aversion conditioning or negative reinforcement, is a technique used to change behavior. In this therapy, a stimulus attractive to the client is paired with an unpleasant event in hopes of associating the stimulus with negative properties.

conversion disorder

alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind.

Rye's syndrome

an acute encephalopathy that follows a viral illness. It is characterized pathologically by cerebral edema and fatty changes in the liver; a definitive diagnosis is made by liver biopsy.

Graves disease

an autoimmune disorder that is caused by hyperthyroidism and is characterized by goiter and/or exophthalmos

juvenile idiopathic arthritis

an autoimmune, inflammatory disease affecting the joints and other tissues, such as the articular cartilage, which occurs most often in girls. Tx is supportive (no cure) preserving joint function, controlling inflammation, minimizing deformity, reducing effect on child developmentally.

Methylergonovine (Methergine)

an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure.

Guaifenesin (Mucinex)

an expectorant. It should be taken with a full glass of water to decrease the viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication may occasionally cause dizziness, headache, or drowsiness. The client should contact the PHCP if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

catatonic stupor

an immobile, expressionless, coma-like state associated with schizophrenia

Placenta previa

an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus, who is at risk for severe hypoxia.

Exenatide

an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence, the nurse should hold the medication and question the PHCP regarding this prescription. -The medication is administered within 60 minutes before the morning and evening meal. -The client is monitored for gastrointestinal (GI) side effects after administration of the medication.

The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body?

an ultrasonography, computed tomography scan (CT), or magnetic resonance imaging can determine its location. The missing testis may be found at any point along the process vaginalis, may be located in the abdomen, or may follow an aberrant course and come to lie in the inguinal area, base of the penis, or perineum.

Sucralfate (GI)

anti ulcer agent- creates protective barrier, take on empty stomach, causes constipation, may impede absorption of warfarin, phenytoin, theophylline, digoxin, and some antibiotics. administer at least 2 hours apart from these meds.

Loperamide Hydrochloride (Imodium)

antidiarrheal agent. It is used to manage acute and also chronic diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be used to reduce the volume of drainage from an ileostomy

Brompheniramine side effects (Dynatapp)

antihistamine, and frequent side effects are drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating

Bleomycin (Blenoxane)

antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. During pulmonary fibrosis, the lung tissue becomes very scarred and hard. Pulmonary fibrosis is not reversible and the client is continuously short of breath. Pulmonary function studies and chest x-ray, along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity

Megestrol acetate

antineoplastic medication, appetite stimulant, used in caution with patients with thrombophlebitis

Pemphigus

autoimmune disease that causes blistering of the epidermis

Beta Thalassemia

autosomal recessive disorder. This disorder is found primarily in individuals of Mediterranean descent. The disease also has been reported in Asian and African populations

potassium foods

avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, pork, beef, veal, potatoes, raisins, spinach, strawberries, tomateos

magnesium foods

avocados, canned white tuna, cauliflower, cooked rolled oats, green & leafy veggies, milk, peanutbutter, peas, pork, beef, chicken, potatoes, yogurt,

common magnesium foods

avocados, canned white tuna, cauliflower, oatmeal, green leafy vegetables (spinach/broccoli), milk, wheat bran, peanut butter, almonds, peas, pork, beef, chicken, soybeans, potatoes, raisins, yogurt

Theraputic PTT

between 1.5-2.5 times normal, value should not be less than 40 or greater than 87.5 seconds

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate?

bleeding If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria should also indicate bleeding.

iron foods

breads and cereal, dark green veggies, dried fruits, egg yolk, legumes, liver, meats

osteogenesis imperfecta

brittle bone disease, genetic disease resulting in impaired synthesis of collagen by osteoblasts

Acetylcysteine (Mucomyst)

can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. The nurse administering this medication as a mucolytic should have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions.

transfusion reaction

can include a backache among other signs such as chills, itching, or rash

Trousseau's sign

can indicate Hypocalcemia. Place BP cuff on arm, inflate to pressure, greater than systolic BP, hold in place for 3 min. Will induce spasm in hand and forearm if hypocalcemia present.

Rh incompatibility

can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

Indicators that fluid volume deficit is resolving in child

capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production

Anthrax

caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. Antibiotics are administered.

patent ductus arteriosus (PDA) pediatrics

caused by a failure of the ductus to close within the first weeks of life. The infant may be asymptomatic or show signs of heart failure. The defect may be closed during cardiac catheterization or may require surgery. A characteristic machine-like murmur is present with PDA.

TUR syndrome (pt with BPH & a TURP)

caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

Pertussis

caused by the bacteria Bordetella pertussis and treatment requires antimicrobial therapy. Symptoms of pertussis consist of a respiratory infection followed by increased severity of cough with a loud whooping on inspiration. The child may experience respiratory distress, and the parents should be instructed on reducing environmental factors that cause coughing spasms, such as dust, smoke, and sudden changes in temperature.

rheumatic fever

characteristically presents 2 to 6 weeks after an untreated or partially treated group A ß-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child has had a sore throat or an unexplained fever within the past 2 months.

infectious mononucleosis (mono)

characterized by fever, a sore throat, and enlarged lymph nodes, caused by the epstein-barr virus. educate parents to Notify the pediatrician if the child develops abdominal (especially LUQ) or left shoulder pain (this could be signs of splenic rupture)

caloric test

checks CN 8 function, Water that is warmer or cooler than body temperature is infused into the ear. A normal response is demonstrated by the onset of vertigo (spinning sensation) and nystagmus (involuntary eye movements) within 20 to 30 seconds.

Calcium foods

cheese, collard greens, milk and soy milk, Rhubarb, sardines, tofu, yogurt

Vincristine (chemo)

chemotherapeutic medication that has the adverse effect of damaging the peripheral nerves. This results in numbness in the extremities

air embolism s/s

chest pain, coughing, hypotension, cyanosis, and hypoxia. In addition, if the client does have an air embolism, auscultation over the right ventricle may reveal a churning "windmill" sound.

signs and symptoms of air embolism

chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also should hear a loud churning sound over the pericardium on auscultation of the chest

systemic lupus erythematosus (SLE)

chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs

child with cystic fibrosis (CF)

chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait and can affect both males and females.

glucose tolerance test (OGTT)

client should have fasted for 10 to 12 hours. After a fasting blood sample is obtained, the client consumes a 75-g or 100-g glucose load in 5 minutes. Blood is drawn every 30 minutes for 2 or 3 hours, depending on the glucose load. During the test, the client may not eat, drink, or smoke.

hypophosphatemia s/s

confusion, seizure, weakness, decreased deep tendon reflexes, shallow respiration, increased bleeding tendency, immunosuppression, bone pain

Bladder exstrophy pediatric

congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall.

hypospadias

congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?

contact and airborne

Findings associated with fluid volume excess

cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

FAS (fetal alcohol syndrome) s/s

craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress.

s/s RDS (respiratory distress syndrome) in newborn

cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts.

phosphorus foods

dairy products, fish, organ meats, nuts, beef, pork, chicken, whole grain breads and cereal

pancytopenia

decrease in all blood cells types: red, white, and platelets high risk for infection because of significantly low immunity. The client should not eat fresh fruits and vegetables because they are at a potential for ingesting bacteria. All foods should be cooked thoroughly. The client should wear a mask when outside of the room to avoid potential infection spread from persons in the hallways

hypophosphatemia cause

decreased nutritional intake of phosphorus and malnutrition, magnesium/aluminum based antacids, kidney failure, hyperparathyroidism, malignancy, hyercalcemia, alcohol withdrawal, diabetic ketoacidosis, respiratoty alkalosis

BUN test

determines how well kidneys are working. Urea Nitrogen is a waste product that's created in the liver when the body breaks down proteins. Increased if liver or kidneys are damaged Diagnosis....liver damage, malnutrition, poor circulation, dehydration, urinary tract obstruction, cong HF, GI bleed Antibiotics and diuretics may increase BUN levels

mydriatic medications

dilation of the pupil

Hirschsprung's disease (congenital megacolon)

disease occurs as the result of an absence of ganglion cells in the rectum and other areas of affected intestine.

cerebral palsy

disorder characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system

drawing up Regular insulin and NPH use "RN"

draw regular insulin into the insulin syringe first, then draw the NPH insulin

hypernatremia s/s

dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temp, oliguria, muscle twitching, fatigue, confusion, seizure

s/s hypothyroidism

dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesia; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter.

pulmonary embolism s/s

dyspnea, tachypnea, tachycardia, a congested cough , hemoptysis, pleuritic chest pain, and a feeling of impending doom.

Zinc foods

eggs, green & leafy veggies, meats, protein rich foods

Emergency nursing actions to take for a child sustaining an extremity fracture

elevating the injured extremity, checking the extent of the injury including pain level, immobilizing the affected extremity, applying cold packs to the injured area, and monitoring the neurovascular status of the extremity.

Tx of phlebitis

emove the IV at the phlebitic site and apply warm moist compresses to the area to speed resolution of the inflammation. Because phlebitis has occurred, the nurse also notifies the PHCP about the IV complication. The nurse should restart the IV in a vein other than the one that has developed phlebitis. Finally, the nurse documents the occurrence, actions taken, and the client's response.

Ortolani maneuver (hip dysplasia)

examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum

hyperphosphatemia cause

excessive dietary intake of phosphorus, overuse of phosphorus containing laxtives or enemas, vitamin D intoxication, hypoparathyroidism, renal insufficiency, chemo

aortic stenosis (obstruction of blood flow) s/s children

exercise intolerance, chest pain, dizziness when standing too long.

Pulmonary edema s/s

extreme breathlessness, dyspnea, air hunger, and production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles.

Myxedema coma

extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multi-organ failure

Ethambutol (Myambutol)

first line medication for tuberculosis causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client is also taught to take the medication with food if GI upset occurs

isoniazid

first line medication for tuberculosis. causes peripheral neuritis

high phosphate foods

fish, chicken, eggs, milk products, vegetables, whole grains, and carbonated beverages

Transfusion reaction s/s

flushed, dyspneic, and complaining of generalized itching

Magnesium sulfate adverse effects

flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

PT and INR assess..

for the therapeutic effect of warfarin sodium.

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)?

frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level, and oral lesions and notifying the primary health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with their tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution made up of a 10:1 ratio of water to bleach.

Diabetic ketoacidotic coma

fruity breath odor; dry, cracked mucous membranes; hypotension; and rapid, deep breathing.

36 week fundus location

fundus reaches its highest level at the xiphoid process.

Histoplasmosis

fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. There may be an enlargement of the client's lymph nodes, liver, and spleen as well.

digoxin toxicity s/s

gastrointestinal signs, bradycardia, visual disturbances, and hypokalemia.

phenylketonuria (PKU)

genetic disorder that results in central nervous system (CNS) damage from toxic levels of phenylalanine in the blood, not the gastrointestinal system. PKU is an autosomal-recessive disorder and treatment includes the dietary restriction of phenylalanine intake. All 50 states require screening newborns for PKU.

Long acting insulin

glargine (Lantus) detemir (Levemir)

initial first aid at the site of a snakebite

having the victim lie down, removing constrictive items such as clothing or rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart.

Signs of glomerulonephritis pediatric

headache, abdominal or flank pain, gross hematuria resulting in dark, smoky, cola-colored or red-brown urine and periorbital edema or facial edema. Clients are hypertensive and have decreased urine output. BUN levels may be elevated.

presbycusis

hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.

metabolic alkalosis

high pH, high HCO3

respiratory alkalosis

high pH, low CO2

Nizatidine

histamine H2-receptor blocker, is frequently used in the management of peptic ulcer disease. Histamine H2-receptor blockers decrease the secretion of gastric acid

signs of preeclampsia

hypertension and proteinuria

ventricular dysrhythmias and lab results would show

hypokalemia

Signs and symptoms of decreased cardiac output

hypotension, altered mental status, weak peripheral pulses, and decreased urinary output.

hypermagnesemis s/s

hypotension, weak pulse, sweating and flushing, respiratory depression, loss of deep tendon reflexes, prolonged PR interval and widened QRS complex

hydrocephalus pediatric

imbalance of Cerebral Spinal Fluid absorption and production may be caused by a malformation, tumor, hemorrhage, an infection, or trauma. Results in head enlargement and increased ICP

clinical signs of impending or approaching death

inability to swallow; pitting edema; decreased gastrointestinal and urinary tract activity; bowel and bladder incontinence; loss of motion, sensation, and reflexes; cold or clammy skin; cyanosis; lowered blood pressure; noisy or irregular respiration; and Cheyne-Stokes respirations.

Hyponatremia causes

inadequate sodium intake, GI suction, excessive intake of water, GI tube irrigation with plain water, diuretics, increased sweating, draining skin lesions, burns, nausea and vomiting, diabetic ketoacidosis, syndrome of inappropriate antidiuretic hormone secretion, rentention of fluid, such as kidney or heart failure.

Causes of a fluid volume deficit

include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and ileostomy. A client with cirrhosis, heart failure (HF), or decreased kidney function

treatment plan for children with attention deficit hyperactivity disorder

includes stimulant medications that may have the adverse effect of appetite suppression and weight loss, not overeating. Treatment for these children includes behavioral therapy, maintaining a consistent environment, and appropriate classroom placement. Regular medication administration and regular follow-up visits are also important instructions for the parents.

s/s fluid volume deficit

increased respiration and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness.

epididymitis

inflammation of the epididymis that is frequently caused by the spread of infection from the urethra or the bladder. Tx:rest, elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics.

agoraphobia

intense, excessive anxiety or fear about being in places or situations from which escape might be difficult or embarrassing or in which help might not be available. being on a bridge, riding in an elevator, being alone at home, and travelling in an airplane. Other behaviors related to agoraphobia include being alone outside and travelling in a car or bus

NPH

intermediate acting insulin

s/s juvenile idiopathic arthritis (JIA)

intermittent joint pain that lasts longer than 6 weeks and painful, stiff, and swollen joints that are warm to the touch, with limited range of motion. The child will complain of morning stiffness and may protect the affected joint or refuse to walk. Systemic symptoms include malaise, fatigue and lethargy, anorexia, weight loss, and growth problems. A history of a late afternoon fever with temperature spiking up to 105° F will also be part of the signs and symptoms.

s/s incarcerated hernia

irritability, tenderness at the site of the hernia, anorexia, abdominal distension, and difficulty defecating. The parents should be instructed to contact the PHCP immediately if an incarcerated hernia is suspected. These signs may lead to a complete intestinal obstruction and gangrene.

The five client basic principles of bioethics

justice, fidelity, autonomy, veracity, and beneficence

Butorphanol tartrate (Stadol)

labor opioid analgesic

Respiratory Alkalosis S/S

lethargy lightheadedness confusion tachycardia dysrhythmias related to hypokalemia nausea vomiting epigastric pain numbness and tingling of the extremities hyperventilation (tachypnea)

The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium. Which laboratory test(s) would identify an adverse effect associated with the administration of this medication?

liver function tests Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage

respiratory acidosis

low pH, high CO2

metabolic acidosis

low pH, low HCO3

Hypomagnesemia cause

malnutrition, diarrhea, celiac disease, chrons disease, alcoholism, prolonged GI suctioning, acute pancreatitis, diabetic ketoacidosis, exlampsia, chemo, sepsis

Nephrotic syndrome pediatrics s/s

massive proteinuria, hypoalbuminemia, periorbital and facial edema, ascites, elevated serum lipids, and anorexia. The urine volume is decreased and the urine is dark and frothy in appearance. The child with this condition gains weight.

Signs and symptoms of mastoiditis

mastoid swelling (directly behind the ear) and soreness, headache, malaise, and an elevated white blood cell (WBC) count.

Rifabutin

may be prescribed for a client with active MAC disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, GI disturbances, neutropenia (low neutrophil count), red-orange body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome.

Food sources of riboflavin

milk, lean meats, fish, and grains

Riboflavin food

milk, lean meats, fish, grains.

Impetigo

most common during the hot and humid summer months. It begins in an area of broken skin, such as an insect bite. It may be caused by Staphylococcus aureus, group A β-hemolytic streptococci, or a combination of these bacteria. It is extremely contagious. Lesions are most often located around the mouth and nose, but they may be present on the extremities.

Levothyroxine

most common thyroid replacement

gynecoid pelvis

most favorable pelvis for successful labor Round shape Diagonal conjugate measures 12.5 cm to 13 cm Blunt, somewhat widely separated ischial spines

potassium of 5.4, what findings on ECG?

narrow, peaked T waves cardiac changes include a whide flat P wave, prolonged PR interval, widened QRS complex

pyloric stenosis

narrowing of the opening of the stomach to the duodenum

Early signs of theophylline toxicity (asthma)

nausea, vomiting, tachycardia, headache, and irritability. Seizures indicate a toxicity level greater than 30 mcg/mL. A normal theophylline level is 10 to 20 mcg/mL.

first trimester fetal heart rate

normally 160 to 170 beats per minute

pulmonary edema interventions

notify RN, Administering oxygen, Inserting a Foley catheter, Administering furosemide , Administering morphine sulfate intravenously

Urethritis in the male client

often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays.

DKA s/s

only in insulin dependent diabetics BGL 400-900 dehydrated (4-6L lost) No circulating insulin +acidosis b/c body breaks down fat into ketones Kussmaul (inc rate depth to blow off c02)

Rapid actin insulin onset, peak, duration

onset: 15 min peak: 1hr duration: 3 hrs "15 minutes feels like an hour during 3 rapid responses.

Intermediate acting insulin onset, peak, duration (NPH)

onset: 2 hrs peak: 8 hrs duration: 16 hrs "Nurses play hero 2 "8" 16 year olds.

Long acting insulin onset, peak, duration

onset: 2 hrs peak: none duration: 24 hrs "the 2 long nursing shifts never peaked, but lasted 24 hrs.

Short acting onset, peak, duration

onset: 30 min peak: 2 hrs duration: 8 hrs "short staffed nurses went from 30 pts "2" 8 pts."

acute pancreatitis meds

opiates for pain, anticholinergics, and antacid

Meperdine Hydrochloride (Demerol)

opioid analgesics given during labor

Metformin

oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin

Mannitol

osmotic diuretic , It is used to reduce intracranial pressure in the client with head trauma.

Hypermagnesemia cause

overuse of antacids or laxatives that contain magnesium, renal insufficiency and kidney failure, tx of preeclampsia with magnesium

Pancrelipase (Creon)

pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status.

Autologous blood donation

patient donates own blood to prevent possible complications of receiving banked blood

escharotomies

performed to alleviate the compartment syndrome that can occur when edema forms under nondistendible eschar in a circumferential burn. Bleeding is considered a complication.

The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. The nurse assesses which factors that can put this client at risk for amputation? Select all that apply.

peripheral neuropathy, limited joint mobility, bony deformity, peripheral vascular disease, and a history of skin ulcers or previous amputation.

Abruptio placentae

premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible.

The ovarian cycle consists of three phases:

preovulatory, ovulatory, and luteal

s/s child in sickle cell crisis

present with one or more swollen joints that are extremely painful (pain rated well above a 5 on a scale of 1 to 10), fever, and low oxygen levels. The heart rate would be increased because of the pain and the lack of normal red blood cells.

Misoprostol (GI)

prevention of gastric ulcers, take with meal, causes diarrhea & abdominal pain

Oxytocin

produced by the posterior pituitary, stimulates the uterus to produce contractions during and after birth, Oxytocin is used primarily for labor induction and augmentation

Left-sided heart failure

produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

myexedema coma

progresses from hypothyroidism and shows decreases in mental status

pyloric stenosis s/s

projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output, peritaltic waves during & after feedings, olive shaped mass in RUQ

Phytonadione (Vitamin K)

prophylactic Vitamin K for neonates; treatment of hemorrhagic disease of newborn

foods for wound healing

protein and vitamin C chicken breast, milk, broccoli, and strawberries

Omeprazole (Prilosec)

proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called "heartburn" by clients.

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the primary health care provider diagnoses a pulmonary embolism. Which interventions apply to the care of this client? Select all that apply.

pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bed rest, with the head of the bed slightly elevated, An IV line also will be required, and vital signs must be monitored. Heparin therapy started

hyponatremia s/s

rapid, thready pulse, postural blood pressure change, weakness, abdominal cramping, poor skin turgor, muscle twitching and seizure, apprehension, confusion

Repaglinide

rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion that should be taken before meals and that should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide, and the client should always be prepared by carrying a simple sugar with her or him at all times.

s/s hyponatremia

rapid/thready pulse, postural BP changes, weakness, abdominal cramping, poor skin turgor, muscle twitching/ seizure, apprehension, confusion

Pastia's sign

rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints.

foods that are naturally high in iron

red meat, liver, other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots

mittelschmerz

refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days.

Presbycusis hearing loss

refers to the age-related, irreversible, degenerative changes of the inner ear that lead to decreased hearing acuity. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched tones of voice are more easily heard and interpreted by the older client.

Proven negligence

requires a duty, a breach of duty, the breach of duty must cause the injury, and damages or injury must be experienced.

meperidine hydrochloride side effects (opioid)

respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention.

sensorineural hearing loss

result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

conductive hearing loss

result of a physical obstruction to the transmission of sound waves. Acute otitis media with effusion, a fluid buildup in the middle ear, can block the transmission of sound waves.

Phlebitis

results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site.

The nurse is caring for a client who is a victim of a major burn injury. Which are the names of the primary phases of burn care assessment? Select all that apply.

resuscitative or emergency phase begins at the time of the injury and continues for about 48 hours. With the onset of diuresis approximately 48 to 72 hours after the injury, the acute phase begins and continues until wound closure occurs. The second phase can last for weeks to months. The goals of the third phase (rehabilitative) are to minimize scarring and contractures, to restore the client's ability to function in society, and to return to an established family role and vocation.

immunizations administered to healthy 2-month-old infants with no allergies include..

rotavirus, hepatitis B, pneumococcal, inactivated poliovirus, DTaP (diphtheria, tetanus, pertussis), and Haemophilus influenzae type b.

Cycloserine (Seromycin)

second line TB medication an antitubercular medication that requires weekly serum drug level determinations to monitor for the potential of neurotoxicity. Serum drug levels lower than 30 mcg/mL reduce the incidence of neurotoxicity. The medication must be taken after meals to prevent GI irritation. The client must be instructed to notify the PHCP if a skin rash or signs of CNS toxicity are noted. Alcohol must be avoided because it increases the risk of seizure activity.

intussusception s/s

severe abdominal pain causes child to draw knees to chest, vomiting of gastric contents, bile stained fecal emesis, jelly-like stools w/ blood and mucus, hypo/hyperactive bowel sounds, tender & distended abd, possibly palpable sausage shaped mass in upper R quad.

ventriculoperitoneal shunt post op care

should be flat in bed to avoid the rapid reduction of intracranial fluid. Observe for increased ICP, if it occurs elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt. Position the infant on the inoperative side to prevent pressure on the shunt valve. Monitor for signs of infection and check dressings for drainage. A high shrill cry in an infant can be a sign of increased ICP.

diet for child with hepatitis

should consume a well-balanced, low-fat diet to allow the liver to rest.

Cyclobenzaprine

skeletal muscle relaxants (centrally acting)

Oxytocin

stimulates smooth muscle of the uterus and increases the force, frequency, and duration of uterine contractions. -Promotes milk let down

Famotidine & Nizatidine

suppress secretion of gastric acid, side effects uncommon , do not have to take with food

Ranitidine

suppress secretion of gastric acid, side effects uncommon, do not have to take with food

Cimetidine

suppress secretion of gastric acid, when taken with food slows absorption, wait 1 hour after antacids, may cause mental confusion, agitation, disorientation, reduce dose for renal pts or if taking warfarin, sodium, phenytoin, theophylline, or lidocaine

orchiopexy

surgical fixation of an undescended testis in the scrotum

Right-sided heart failure

systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain

Assessment findings with cardiac tamponade

tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure, accompanied by pulsus paradoxus (a drop in inspiratory blood pressure by greater than 10 mm Hg).

hypocalcemia s/s

tachycardia, hypotension, paresthesia, twitching, cramps, tetany, positive Chvosteks or Trousseaus sign, diarrhea, hyperactive bowel sounds, prolonged QT interval

Pediatrics early s/s pf heart failure

tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress.

Signs/symptoms of respiratory alkalosis

tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia.

Chevostek's sign

tapping the face, observe for contraction on same side, Hypocalcemia is present with twitch on same side of face

intussusception

telescoping of the intestines

Signs of placental abruption

tender, rigid abdomen; pain; severe, dark red vaginal bleeding; maternal shock (hypotension); and fetal distress.

s/s testicular cancer

testicular swelling without pain, heaviness in scrotum, back pain may indicate spreading.

third spacing

the accumulation and sequestration of trapped extracellular fluid in an actual or potential body space as a result of disease or injury

delusions of persecution

the belief that people are out to get you

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply.

the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.

Pt taking Isosorbide mononitrate (imdur) develops chronic headache, nurse should instruct patient to..

the client should be instructed to take the medication with food or meals. It is not necessary to contact the PHCP unless the headaches persist with therapy.

20 week fundus location

the fundus is located at the umbilicus

infiltrated IV

the site is cool, pale, and swollen and that the IV has stopped running. -one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop.

12 week fundus location

the uterus extends out of the maternal pelvis and can be palpated above the symphysis pubis

Tricuspid Atresia

there is no communication from the right atrium to the right ventricle.

hemolytic-uremic syndrome (HUS) in child

thought to be associated with bacterial toxins, chemicals, and viruses that cause acute kidney injury in children. 6 months-5 years old.

Extravasation

tissue injury that occurs from leakage of medication into surrounding skin and subcutaneous tissue; it can also cause tissue necrosis.

initial treatment goal when atrial fibrillation suddenly occurs

to control the rate of impulses with the administration of a calcium channel blocker or a beta blocker

Daunorubicin (anti tumor antibiotic for non-Hodgkins)

toxicity: cardiotoxicity, cardiomyopathy, ECG changes, pulmonary toxicity.

oral Griseofulvin

treatment for tinea capitis, give with milk

Hypokalemia causes

use of potassium losing diuretics, diarrhea, vomiting, low potassium intake, excessive gastric suction, Cushing's syndrome, chronic use of corticosteroids or laxatives, kidney disease, parenteral nutrition, uncontrolled diabetes, alkalosis

Sengstaken-Blakemore tube

used for tx of esophageal varices, purpose is to hold pressure on bleeding varices, keep scissors at bedside.Sudden rupture of the esophageal balloon can cause airway obstruction, aspiration, and/or asphyxiation. The tube should be cut and removed to prevent airway obstruction.

characteristics of scabies

usually appears as burrows or fine, grayish-red lines, It is transmitted by close personal contact with an infected person, and it is endemic among schoolchildren and institutionalized populations. Household members and contacts of the infected child need to be treated at the same time that the child is being treated.

Triple therapy for Helicobacter pylori infection

usually includes two antibacterial drugs and a proton pump inhibitor. Clarithromycin and amoxicillin are antibacterials. Esomeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production.

signs and symptoms of abruptio placentae

vaginal bleeding, abdominal pain, uterine tenderness, and contractions. Mild to severe uterine hypertonicity is present. Pain is mild to severe and either localized over one region of the uterus or is diffuse over the uterus, with a boardlike abdomen.

s/s dumping syndrome

vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down, cramping, diarrhea,

Interventions for respiratory alkalosis

voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed.

interventions for respiratory alkalosis

voluntary holding of breath, or slowed breathing and the rebreathing of exhaled CO2 by methods such as using paper bag or a rebreathing mask.

hemolytic-uremic syndrome (HUS) in child s/s

vomiting, irritability, lethargy, marked pallor, hemorrhagic manifestations: bruising, petechiae, jaundice, bloody diarrhea., oliguria, anuria, CNS involvement: seizures, stupor, and coma

clear liquids

water, bouillon, clear broth, carbonated drinks, jello, hard candy, lemonade, ice pops, coffee/tea

manifestations of opioid withdrawal

yawning, irritability, diaphoresis, cramps, diarrhea

Mafenide acetate (Sulfamylon)

› Used on wounds exposed to air › Used as a solution for occlusive dressings to keep the dressing moist › Penetrates eschar and goes into underlying tissues › Effective with electrical and infected wounds › Biostatic against gram-negative and gram-positive bacteria › Painful to apply and remove › May cause metabolic acidosis or hyperpnea › Inhibits wound healing › Hypersensitivity may develop