Nclex Study Rationale
s/s w/ bacterial pneumonia
- Dyspnea, cough fever, chills, dyspnea, tachypnea - pleuritic chest pain, consolidation
Normal WBC range is?
-4,500-10,000 mcL
IV admin of phenytoin should not exceed what rate?
-50 mg/min E.g if 100mg, needs to be admin in 2 min
During a vaginal exam the nurse feels soft, squishy tissue instead of head. What conclusion is made with this assessment?
-Breech presentation (feeling buttock of fetus) -If felt edema of cervix=thickened edge of cervix -If felt closed cervix=not able to feel presenting part, unable to assess any fetal presentation -Bulging membrane= taunt/not soft and squishy
Manifestations of Preeclampsia (4)?
-Calf muscle -irritability -Facial edema -Blurry vision -Epigastric pain
What medication should we be concerned about with a Hyperthyroid/ Hypothyroid PT?
-If the PT is taking Amiodarone -Amiodarone is an antiarrhythmic that has S.E that affect HYPO or HYPER thyroid b/c of iodine content
Define Glomerulonephritis:
-Inflammatory reaction in glomerulus -big holes = leak protein
S/S of renal failure (6)
-Malaise -N/V - H/A - decrease UO -Anorexia - Wt. gain
Positive s/s of Pregnancy
-Presence of fetus -FHT, X-ray, ultrasound
What is decontamination?
-Process were clothing is removed /wash off hazardous matter. -Don't rush to treat critical illness before decontamination process
What are interventions to lessen acid reflux with GERD pt?(4)
-Provide small, frequent meals -Avoid carbonated beverages -Admin omeprazole as prescribed -Assist with smoking cessation
If Pt has pain that is disproportionate to the injury (fracture), and becomes severe, and/or not relieved by elevation, cold packs, pain meds. What could this indicate?
-compartment syndrome. -Failure to detect could lead to neurovascular damage and possible amputation
What is Intra - renal failure? Examples?
-damage inside Kidneys e. g Glomerulonephritis / Nephrotic, Malignant HTN, DM
What is the procedure of removing interrupted sutures from PT Surgical wound?
1) Moisten dried cast w/ sterile 0.9% sodium chloride solution 2) clean suture line w/ antimicrobial solution 3) gently grasp knot w/ forceps & raise a slightly 4) Place the curved tip of suture scissors directly under the knot 5) gently out suture 6) Pull Suture out w/ forceps 7) Make certain all suture material is removed 8) Put suture on clean gauze 9) Apply Sterile wound Strips 10) Document dare, time, and # of sutures removed
The nurse is making rounds on the psych floor, who does she see first? 1) PT w/ Hallucinations 2) PT W/ depression 3) PT w panic attacks 4) PT w/ Somatoform
1) PT w/ Hallucinations -PT having hallucinations because (may be hearing voices/ harmful) -# 2 (risk for Suicide w/meds), #3 (Pt usually seeks out nurse when needed, #4 (Physical pain with psy causes).
A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. -Remove the client from the room. -Activate the fire alarm. -Obtain the fire extinguisher. -Extinguish the fire. -Close the door to the client's room.
1)Remove the client from the room. 2)Activate the fire alarm. 3)Close the door to the client's room. 4)Obtain the fire extinguisher. 5)Extinguish the fire.`
A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? 1. Are you feeling afraid now? 2. I am here with you. 3. Let's discuss something else. 4. You know that is not true.
1. Are you feeling afraid now? 2. Incorrect: The nurse is offering self. This does not respond to the underlying message in the client's statement that indicates fear and false information.
What s/s should the nurse assess for the presence of in a client diagnosed with valvular heart disease? STA 1. Orthopnea 2. Paroxysmal nocturnal dyspnea 3. petechiae on the trunk 4. increasing CVP with decreasing BP 5. Pericardial friction rub 6. Widening pulse pressure
1. Orthopnea 2. Paroxysmal nocturnal dyspnea - orthopnea is a condition where the PT must sit or stand to breathe comfortably. - Paroxysmal nocturnal dyspnea occurs when the PT is reclining, it is sudden respiratory distress.
A clinic nurse is conducting a health assessment with a patient. The patient states that she was researching her symptoms and thinks she might have gastroesophageal reflux disease (GERD). Which of the following symptoms reported by the patient would be consistent with this diagnosis? Select all that apply: 1. Painful swallowing 2. Pharyngitis 3. Weight loss 4. Dyspepsia 5. Portal hypertension
1. Painful swallowing 2. Pharyngitis 4. Dyspepsia
The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? 1. Progesterone 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG)
1. Progesterone
A new nurse is observing a nurse conduct an initial assessment of a 4 yr old PT with epiglottitis. The nurse attempts to examine the Pt's throat. Which of the following actions should the new nurse do first? 1. Tell the nurse to not attempt to throat inspection 2. Run and grab emergency airway equipment 3. Continue to observe the nurse perform the assessment 4. Fill out an incident report regarding the nurse's actions.
1. Tell the nurse to not attempt to throat inspection - examination of the throat with a tongue depressor is contraindicated until experienced personnel and equipment are available to proceed with immediate intubation or tracheostomy if the exam precipitates further or complete obstruction
Water heater should be set no higher than?
120°F
At what age is it a concern if the infant can't build at least 4 block tower
2 yrs
Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? 1. Take a stool softener. 2. Increase intake of fruit in the diet. 3. Monitor elimination habits for the next week. 4. Rest after each meal.
2. Increase intake of fruit in the diet. -Increased fiber intake may help to establish regular elimination habits.
What is the best indicator of fluid loss or gain?
Acute weight loss
A pt with MI has developed crackles in bilat lung base. What do you do first?
Admin furosemide 20mg IVP (pt developing pulm edema/HF, need to diurese to remove excess fluid)
What is Phenytoin?
An anticonvulsant
When the Pt is on Hemodialysis, what class of medication are they usually on?
Anticoagulant (Warfarin )
Assessment to reflect Changes in CVP reading? What to kind of problem are we thinking about with CVP changes
Fluid problem (FVD or FVE) Heart Sounds (elevate CVP = FVE=S3 Sound) Skin turgor (skin affected in FVD) - Urinary output (FVE- increase output, FVD decrease output)
What is s/s of Respiratory Alkalosis?
HYPERventilation, tachypnea
Sickle cell anemia Diet?
High calorie, high Protein
What is the diet of a preeclampsia mother?
High protein, calcium rich (ex: grilled cheese w/ tomatoes, chicken sandwich on wheat) Veggies that help control BP (broccoli, bell peppers, squash)
Why do we never discontinue TPN suddenly?
Hypoglycemia
In Primary Hypothyroidism what are TSH and T4 level.
Increase TSH, decrease T4
What to know about the use of Thiazolidinediones?
-may reduce the plasma concentration of contraceptives -Post menopausal women may resume ovulation -may lead to wt. gain, exacerbate CHF -therapeutic effect may not be reached until 8-12 wks
The nurse is caring for PT w/ pneumococcal pneumonia. Which observation would indicate a therapeutic response?
-moderate amounts of thin, white sputum -Crackles clearing w/ cough
How much blood should be removed at a time with CCRT? When is this performed?
-never more than 80 mL -On PT w/ fragile cardiovascular status/ AKI
What is Phenelzine?
-non Selective (MAOI). -antidepressant
Where is Vancomycin resistant enterococci (VRE) found in Pt's?
-normally lives in healthy intestines, but in an immunocompromised PT, it can be found in other locations including Urinary tract, intestines, blood or wounds
Chronic venous insufficiency s/s? pain? pulses? skin?
-pain with walking - pulses are generally normal and - color is generally normal with exception of brown pigmentation
Interventions to initiate bowel management in spinal injuries below T12 (3)
-rectal stimulant in the form of a suppository or a small volume enema, - digital rectal stimulation or manual evacuation - daily consumption of 20-30g of fiber
Define the side effect of Akathisia? What is this a possible S.E of?
-reports of restlessness, Inability to sit still nervous energy -possible S.E of antipsychotic meds
What is DIC?
- Clotting problem - Clot excessively in early stages of disease. When the clotting factor gets used up, PT starts bleeding excessively. **Look so s/s of bleeding!!!** (e.g: bleeding from multiple locations, blood clots, decrease blood pressure, easy bruising, rectal or vaginal bleeding petechiae)
Presumptive s/s of Pregnancy
-Suggest pregnancy -N/V, Amenorrhea, Fatigue, frequent urination
What is the ANC test? Normal levels?
-Test total neutrophil count (important w/cancer) -2,500 - 8,000 cells/mm =
What is the med Sertraline? What can suddenly withdraw do?
-a SSRI used for depression - sudden withdrawal may cause flu symptoms or thought disturbances.
Cannabis education? (5)
-causes tachycardia -produces greater amount of tar than Tobacco -contains more carcinogens than Tobacco -Ingestion can cause orthostatic hypotension -Increase nsk for heart disease
Define Tardive dyskinesia
-involuntary tongue movements, chewing, movements of mouth, lip smacking -irreversible
S/S of meningeal irritation
(+) kernig's sign - thigh is bent at hip and knee 90 degree, attempts to extend knee = painful resistance (+) Baudzinski's sign - involuntary lifting legs when the neck is passively flexed (lifted off exam surface) - Photophobia - Severe H/A Nuchal rigidity (stiff neck)
What does the meds of PPI end in? examples?
- "Prazole" (e.g omeprazole, Pantoprazole)
Calcium gluconate rate for IVP is?
- 1.5 - 2mL/min - rapid injection causes vasodilation, decreases BP, bradycardia, cardiac arrhythmias, and cardiac arrest.
For daily Wts, how many mL does 1kg =?
- 1000 mL of fluid
When is the 1st dose of Hib vaccine given?
- 2 months
What is sodium polystyrene? What lab value do we look at for effectiveness? What are two important S.E's?
-Reduce serum K+ level (look at K+ levels for effectiveness) -S.E Hypomagnesemia and Hypocalcemia
Hypothyroid client tend to have?
-CAD = increase nsk for MI - women experiences epigastric pain (Chest fullness) as a sign of MI
Order of Care by nurse of newborn at birth? Bulb suction excessive mucus Place ID bands on newborn and mom Admin erythromycin drops Assess newborn airway and breathing Assess newborn HR
1. Assess newborn airway breathing 2. Bulb Suchon excessive mucus 3. Assess newborn HR 4. Place ID bands on newborn mom 5. Admin Erythromycin drops
Define Akinesia
Lack of movement
What side do you lay on when trying to keep food in your stomach after gastrectomy/ dumping syndrome?
Lay on left side
Place Stethoscope for heart sounds of the Pulmonic valve?
Left 2nd intercostal space
Place Stethoscope for heart sounds of the Mitral valve?
Left 5th intercostal space medial to midclavicular line
What is the best position for pregnant women to receive epidural?
Left lateral position (placenta well perfused. Less likely to experience hypotension)
What do we wanna do with acute renal failure Pt's regarding fluid?
Limit fluid intake
Place Stethoscope for heart sounds of Tricuspid valve?
Lower left sternal 4th intercostal space
A client at 31 weeks gestation is being seen by the HCP for reports of generalized illness. when assessing the client, the nurse would immediately report what symptom to the HCP? 1. Right upper quadrant pain 2. N/V 3. Severe H/A 4. blurred vision
1. Right upper quadrant pain The symptoms being reported indicates hemolysis of blood cells, elevated liver enzymes and low platelet count (HELLP) syndrome, a LIFE THREATENING liver disorder related to preeclampsia. Occurring generally in the 3rd trimester, or even right after birth, the exact cause is unknown. the only tx is to deliver the fetus.
What is frothy sputum a sign of?
Pulmonary edema or pulmonary embolus
At what age is it a concern if the infant not bringing hands to mouth
2 months
What is the range of magnesium?
1.3 - 2.1 mEq
NPH Long acting onset?
1.5 hrs
What is the normal range for INR when ON anticoagulant therapy?
2-3 (when pt is on warfarin, the INR should increase to a therapeutic target range)
Regular acting peak?
2-3 hr
A pt diagnosed with ADHD 1 week ago can't sleep on Methylphenidate. What is the best response for the nurse to take?
To prevent insomnia, give your child the last daily dose at least 6 hrs before bedtime
What is the purpose of methotrexate with ectopic pregnancy?
To stop the growth of the embryo in the fallopian tube. The embryo is reabsorbed and the fallopian tube can be saved.
Pt with PCP is usually prescribed what medications?
Trimethoprim combo with sulfamethoxazole Dapsone Pentamidine nebulizer TX Atovaquone Corticosteroids (when PCP is severe and PT has low 02)
At what age is it a concern if the infant can build 9-10 block tower
3 yrs.
what type of medication is Interleukin Therapy
immune modulating treatment
After the age of 50 women what should women have done yearly?
mammogram
Lantus Long acting onset?
onset 2-4 hrs
Pericardial friction rub is a sign of?
pericarditis
What is Loop Electrosurgical Excision (LEEP)
physical removal of warts from cervix. This is contraindicated in pregnancy due to the risk of infection within the cervix. This creates greater problems for mother and her fetus.
What is Fluoxetine?
A SSRI
What kind of line is needed for TPN?
- Central line or PICC
PT W/ Lupus taking Hydroxychloroquine sulfate (Plaquenll)
- DMARD, Originally developed to treat / prevent maiana. Med reduces swelling and joint pain, and decreased skin problems. Few Side effects -Serious S.E = retinal toxicity! → **see opthalmologist every 6-12 months **
PT being discharge Post radial percutaneous (PTCA) w/ Stent insertion what instructions should nurse give about reducing risk of complications?
- Drink aheast 8 glasses of water / day (flush Contrast) - Wear loose sleeves (No constriction to Surgical Site) - Take Short walks around house (prevent blood clots)
Dyspepsia is?
- Heartburn
What thyroid medication do we not give with "Chest fullness"
- Levothyroxine increase workload of heart
What are early signs of Alzheimer's Disease?
- Mild disorientation (memory loss of both recent and remote memory) - Difficulty with words and numbers (difficulty finding right word)
To reduce risk of developing a complica non following balloon angioplasty, the nurse should implement which measures? STA
- Monitor cardiac rhythm /chest pain (s/s of reocclusion) - Measure UO hourly (decrease UO = decreased renal perfusion= decrease CO) - Prevent flex of affected leg / avoid lift buttocks -Assess Insertion site q15 min, in 1hour, then 30 min for 1 hr then 4hrs.
Nurse responsibilities w/ blood transfusion?
- Perform Hand Hygiene, Clean gloves, Asepsis - blood products should be admin w/NS - Admin w/ Y-tube filtered blood admin set - infusion should begin a slow rate of 2mL/min - first 15 min, infuse a 2 ml/min to monitor for any complications - remain w/PT first 15-30 min of transfusion - monitor VS every 30 min - Blood should be infused for no more than 4 hrs.
S/S of postpartum hemorrhage (4)
- Perineal pad Saturation in 10 min - Constant trickling of bright red blood - Oliguria (sign of FVD) - boggy fundus (uterine atony)
Manifestations of active TB
- Wt. loss - night sweats - fatigue - hoarseness in voice - cough that lasts > 2 weeks - pleural pain - dyspnea
What is Pre-renal failure? How will VS look?
- blood can't get to the kidneys - eg a BP, V HR, Hypovolemic, shook
What color tag would a pt with 2nd and 3rd degree burns over 70% of the body have?
-Black tag -2nd and 3rd degree burns over 60% of the body put pt in black because injuries are extensive and chances of survival are unlikely. -Pt should be separated but provided comfort care when possible
Three hours after delivery of a client's newborn, the nurse assesses for bladder distention. What signs would the nurse note if the client's bladder is distended?STA 1. Fundus 3 cm above umbilicus 2. Excessive lochia 3. Voids 200 mL every 2 hours 4. Fundus in abdominal midline 5. Tenderness above symphysis pubis
1. Fundus 3 cm above umbilicus 2. Excessive lochia 5. Tenderness above symphysis pubis
What is the correct order of Performing curf pressure in the endotracheal tube? - Suction secretions - Place Stethoscope in the Sternal notch on the trachea and listen for air leak at inspiration. - Manometers may also be used to monitor cuff pressure. -Remove equipment and reposition PT -If no leak, auscultated remove all air & Re-inflate as presanded -If a leak is auscultated, slowly add air until minimal leak -Hand Hygiene and apply clean gloves /face Shield -connect syringe to balloon port
1. Hand Hygiene and apply clean gloves /face Shield 2. Suction secretions 3.connect syringe to balloon port 4. Place Stethoscope in Sternal notch on trachea listen for air leak at inspiration. 5. If no leak, auscultated remove all air & Re-inflate as presanded 6. If a leak is auscultated, slowly add air until minimal leak 7. Remove equipment and reposition PT 8. Manometers may also be used to monitor to cuff pressure.
A patient with suspected heroin abuse comes to the clinic for an assessment. Which of the following questions must be asked as part of the CAGE screening questionnaire? STA 1. Have you ever felt the need to cut down on your heroin use? 2. What coping mechanisms have helped you with your addiction? 3. Have you ever felt guilty about using heroin ? 4. When did you first use heroin? 5. Have you ever been annoyed at criticism of your heroin use?
1. Have you ever felt the need to cut down on your heroin use? 3. Have you ever felt guilty about using heroin ? 5. Have you ever been annoyed at criticism of your heroin use? C- Have you every felt ought to cut down on your drinking/ drug use? A- Have you ever been annoyed at criticism of your drinking/ drug use? G- Have you ever felt guilty about your drinking/drug use? E- Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover (eye opener)?
A nurse is assessing a Pt who has a positive potassium hydroxide (KOH) test. Which of the following statement by the Pt about their care plan REQUIRE further teaching? 1. I will take a break from all strenuous exercise 2. I will use a new washcloth everyday 3. I will not allow my children to sleep in bed with me at night 4. I will make sure to wear breathable cotton socks
1. I will take a break from all strenuous exercise - inappropriate to include in care plan and require further teaching since fungal infections do not require ceasing all physical activity. Rather meticulous attention to cleanliness and reducing environments where fungus can proliferate, like warm moist environments. After physical exercise a client should ensure they wash and dry themselves well and wear appropriate clothing and footwear.
A percutaneous nephrostomy was performed to alleviate an obstruction in the renal pelvis and a nephrostomy tube was placed. Which of the following are appropriate actions by the nurse in caring for a patient with a nephrostomy tube? Select all that apply: 1. Monitor urine output, color and consistency 2. Label all drainage tubes 3. Flush the tube firmly with normal saline to dislodge any clots 4. Anchor the tube securely to prevent migration urinary catheter 5. Clamp the tube regularly to promote drainage via the urinary catheter.
1. Monitor urine output, color and consistency 2. Label all drainage tubes 4. Anchor the tube securely to prevent migration urinary catheter (Option #1) The nurse should ensure that urine output is adequate, as obstruction could cause hydronephrosis. The urine may appear bright red after a renal/urinary procedure but cloudy urine indicates infection. (Option #2) All drainage tubes should be labeled to prevent confusion. (Option #4) Tubes should be anchored to prevent migration or discomfort. (Option #3) The tube should not be flushed unless indicated by the HCP and it should be done gently to prevent trauma and bleeding. (Option #5) Clamping the tube could cause hydronephrosis.
Which of the following can be used as a treatment for delirium? Select one: 1. Olanzapine (Zyprexa) 2. Donepezil (Aricept) 3. Memantine (Namenda) 4. Galantamine (Razadyne)
1. Olanzapine (Zprexa) (option #1) This is correct as it is an antipsychotic (options #2,3,4): All options are cholinesterase inhibitors, which typically is used for treatment for dementia.
The nurse is caring for a patient who has just been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) and is complaining of thirst. During the shift report, it was mentioned that the patient had a seizure the night before. Which of the following are important interventions for the acute management of SIADH? Select all that apply. 1. Provide frequent oral care to decrease thirst-related discomfort 2. Position the head of the bed at 45 degrees 3. Initiate seizure precautions 4. Initiate fluid restrictions 5. Obtain daily weights
1. Provide frequent oral care to decrease thirst-related discomfort 3. Initiate seizure precautions 4. Initiate fluid restrictions 5. Obtain daily weights Interventions that are used in the management of SIADH include: • fluid restriction of 800-1000 mL/day position the head of the bed flat to promote venous return • frequent turning and positioning to prevent skin breakdown • initiate seizure precautions dietary sodium and potassium to maintain electrolyte levels • diuretics (e.g. furosemide) may be used if the sodium level is above 125 mEq/L (125 mmol/L) (Option #2) The head of the bed should not be elevated as it can inhibit blood return.
A public health nurse is conducting a home visit with a pregnant client at their first trimester. The client is complaining of N/V that only affects her in the morning and interferes with her morning routine, constantly making her late for work. What interventions can the nurse suggest to help relieve these symptoms STA? 1. Saltines 2. Brush teeth immediately after waking 3. Avoid fried and spicy foods 4. Avoid small frequent low fat meals 5. acupuncture
1. Saltines 3. Avoid fried and spicy foods 4. Avoid small frequent low fat meals 5. acupuncture
The nurse is caring for a patient on continuous cardiac monitoring and notices that the leads have fallen off. The nurse prepares to apply new leads, but the patient's skin is very oily. Which of the following actions should the nurse take before reapplying the leads? 1. Wipe skin with ETOH 2. Wipe with moist towel 3. Wipe skin with paper towel 4. Tell the patient you will put the pads back on after their next shower
1. Wipe skin with ETOH Wiping with a moist towel will leave the area wet, and wiping with a paper towel may not remove the oil.
A public health nurse is evaluating the use of stress management techniques of a PT with an acute exacerbation of genital herpes. Which of the following triggers should be AVOIDED to reduce the occurence of reinfection? 1. intense physical exercise 2. Working overtime for 3 continuous weeks 3. wearing 100% cotton underwear 4. drinking hot beverages
2. Working overtime for 3 continuous weeks - overworking for 3 straight weeks is causes for increase stress and exhaustion. Stress in small amounts is known to be good for immune system, however, continuous stress and exhaustion are not and will increase the chance of reinfection. - stress exhaustion, pregnancy, menstruation and tight clothing are all triggers for reinfection of genital herpes 1- intense physical exercise is not a trigger 3- wearing 100% cotton underwear is GOOD for genital bacterial infections (yeast, UTI, etc) 4 - drinking hot beverages is not a trigger for reinfection
Average Adult Fluid intake is?
2200-2700ml/day
A nurse is teaching a patient with an immunodeficiency disorder about preventing infection after discharge. Which of the following statements by the patient indicates the need for further teaching? 1. "I will avoid eating salads." 2. "I will wash my hands with antimicrobial soap." 3. "I am able to travel anywhere." 4. "I will avoid large crowds"
3. "I am able to travel anywhere."
The nurse is supervising a patient self admin of beclomethasone nasal spray for her sinusitis. which of the following actions by the PT require intervention by the nurse? 1. the PT occludes the other nostril with a finger before spraying 2. the patients sprays the med into their nose while inhaling 3. The patient breathes through mouth after the drug is admin 4. the patient tilts head back as he sprays medication.
4. the patient tilts head back as he sprays medication. - incorrect position for admin nasal sprays. The patient should be a sitting position with their head upright as the position allows the spray to reach the nasal passages.
At what age is it a concern if the infant not being able to roll over either direction
6 months
Normal range of BUN level?
8 mg - 20 mg/dL
What should a nurse triage first for a PT with a cast stating "my right leg is killing me and nothing I do will stop it."
A pt who has a cast with unrelieved severe pain indicates compartment syndrome and requires immediate action. This pt is at greatest risk for harm b/c untreated can cause irreversible nerve and muscle damage. Can lead to amputation
what conditions is Diltiazem hydrochloride used for?
A-fib, and A-flutter
What are Hep C tx meds?(2)
Alpha-interferon Ribavirin
What are adverse effects of Phenytoin?
Aplastic anemia (blood disorder) where not enough new blood cells are produced in the bone marrow
What is Pernicious Anemia?
Autoimmune lack of intrinsic factor, poor B12 absorption
What conditions is digoxin used for? when do we not give this?
CHF, A-fib, A-flutter Do not give to PT with HR under 60 bpm.
What is standard of care for children with ADHD?
CNS Stimulants along with family and behavioral therapy
What are some Foods high in B12?
Calf/beef liver Feta Cheese Shrimp Tuna
What is Retinol Acne meds contraindicated in?
Eczema, exposure to sun / UV rays, sunburn, child under 12, Pregnant
How do you know a walker is the correct height?
Elbows are at 30 degrees
What is the best indicator to measure kidney function?
Estimated Glomerular filtration rate (EGFR)
What PPE do you wear to drain large abd abscess?
Face shield Mask Gown Reg exam gloves
PT w/ crohn's diseases at risk for developing?
Fistula, and an abscess can result from fistula. (Look for s/s of fever or infection)
Pesticide exposure S/S ?
H/A, dizziness, muscle twitching
Widening pulse pressure can be a sign of?
ICP
When is the rotavirus vaccine given?
In infancy Most common cause of diarrhea disease
Acute renal failure s/s regarding electrolytes/ labs?
Increase BUN, Hyperkalemia. Hyponatremia
A patient has a 3 way indwelling catheter with continuous irrigation. The urine in the indwelling catheter bag is dark red. Which action should the nurse take first?
Increase the flow rate of irrigation solution until urine is light pink (continuous bladder irrigation is used following surgery to ensure that the bladder remains clear of blood clots. The nurse will increase the irrigation rate until light pink)
What is the leading cause of death in AKI?
Infection
What is Crohn's Disease?
Inflammation and erosion of ileum (small intestines) but can be found anywhere in the small or large intestine.
Define intentional tort?
It occurs when a person intends to perform an action that causes harm to another. Performing an invasive procedure w/o consent is considered battery b/c the PT is not given consent for the procedure. Threatening to withhold a med is internally, threatening to harm the Pt by not administering the medication
A reproductive nurse is discussing Tx options with a pregnant women diagnosed with Condylomata Acumiata (HPV). Which of the following is an INAPPROPRIATE Tx option for pregnant women? 1. Cryotherapy 2. Electrosurgery 3. Trichloroacetic Acid (TCA) 4. Loops electrosurgical excision (LEEP)
LEEP May cause infection within the cervix.
Pt has stage 4 pressure pressure ulcer dressing change. When leaving the room what should the nurse do?
Make sure when leaving room empty garbage bins. Nurse responsibility to dispose of biohazardous waste Pressure ulcer dressings may have infection and blood on it which makes it biohazardous, so should be removed from room
What is recommended annually for a group of females ages 45-54?
Mammography and influenza vaccine (colonoscopy done at age 50, every 10 years until 75 years)
What Mumps a common cause of?
Meningitis and acquire deafness
What vaccines are recommended for college students? (3)
Meningococcal Seasonal influence HPV
What type of drug is theophylline or aminophylline? What do they do? what are they used for?
Methylxanthines = used for long term asthma tx only when patients do not respond to corticosteroids or Beta 2 agonists. They are CNS stimulants that produce bronchodilation by relaxing the bronchial smooth muscles.
When Pt is taking IV Erythromycin what do we monitor?
Monitor for Prolonged QT interval.
Example of Three point gait ?
Move both crutches forward w/o bearing wt. On affected leg, then move the unaffected leg forward.
Levofloxacin (antibiotic) contradicted in a Pt that has what condition?
Myasthenia Gravis (may cause the condition to worsen M. Gravis breaks down the communication between muscles and nerves = muscle weakness)
Do we use any access for dialysis for IV/ blood draws /give meds?
NO (NO BP, no needle sticks, No constriction (watch , purse, etc)
Can a LPN give IV pain meds?
NO!!!! They can change colostomy bag, admin antibiotics IVPB, monitor urinary retention, and remove wound sutures
Can UAP collect UA from indwelling cath tubing?
NO/CANNOT
Can needles be recapped?
Needs should never be recapped
Intervention with Bryant traction include?
Neurovascular Checks q 2 hrs elimination Safety immobility issues nutrition
Is herpes simplex type I through the birth canal?
No
What is nonmaleficence?
No harm to the client
How to go upstairs with crutches?
Nonoperative leg goes up first with crutches (wear 2in below axilla
Define a clean needle stick?
Not contaminated yet
2 days after chest tube insertion, see constant bubbling in the water chamber, what action should the nurse take?
Notify PCP (water seal chamber is the middle of 3 Chambers and helps to create a 1 way flow of drainage and air from client to CDU. Water Seal chambers should bubble intermittently when PT coughs, sneezes, or breathes, creating a fluctuation of water, CONSTANT bubbling = air leak somewhere in system.) Nurse can't fix independently = call HCP
What's an indication of effective CPR on adults?
Palpable femoral pulse w/ compression
What is succinylcholine -chloride?
Paralytic to relax muscles to prevent Severe muscle contraction during seizures,
What is rebound tenderness ?
Peritoneal inflammation
Mantoux skin test - Induration of 15mm or greater in normal/ in normal/mild impaired Immunity Pts?
Positive
Asparare, Novolog onset?
Rapid acting
What is neuroleptic malignant syndrome?
Rare, but fatal complication of Neuroleptic drug s/s: hyperpyrexia (up to 107 degrees Fahrenheit), tachycardia, tachypnea, fluctuations in BP, coma
What color tag would a pt with traumatic amputation to lower left leg have?
Red tag (immediate care) Injuries are life threatening but survivable with min intervention
ACE inhibitors are contraindicated in what condition?
Renal arterial stenosis
Place Stethoscope for heart sounds of Aortic valve?
Right 2nd intercostal space
What side do you place a patient on after liver biopsy?
Right side (live is on right side, so can put pressure on side)
What sounds do you hear at Erb's point?
S1 and S2 sounds
After a fracture, loss of blood, into soft tissues surrounding the fracture can most likely cause what?
Shock when fracture occurs, the end of the bones can sever major arteries causing loss of blood into surrounding tissue
After PT has a TURP how should the irrigation be if the urine is clear?
Slow
Define Bradykinesia
Slowed movements
Define presbyopia
Starts in 40's, lens become less flexible
S/S that are seen in both open & tension pneumothorax
Subcutaneous emphysema, SOB, Tachypnea
What equipment will you have with gastric lavage (vomiting)?
Suction equipment
What is s/s of Metabolic Acidosis?
Tachypnea, Kussmaul's Resp (DKA)
What is "Bryant" traction used for?
Tension to keep end of femur in hip socket
When is the 1st dose of Hep B vaccine given?
birth - 2 months
Action of ACE inhibitors?
block aldosterone secretion (retain H20 + Nat)
What type of medication is Pamidronate
bone resorption inhibitor that contributes to lowering calcium levels
hallmark sign for cardiac tamponade
increasing CVP with decreasing BP
What does the U wave represent on the ECG?
slow repolarization of Purkinje fibers, or potassium imbalances
Types of play during early childhood/ toddler (1--3 years)
the child can engage in parallel play (playing alongside rather than with, other children). The child is developing major gross motor skills and therefore enjoys engagement in tactile place, as well as locomotive play. `
What is very important to monitor in theophylline or aminophylline? therapeutic range?
theophylline serum level (high potential for toxicity) 10-20 ug/mL.
when is Interleukin Therapy used
used to stimulate the immune system to fight disease
How long to wait between puffs when using an albuterol inhaler?
wait 1 min between a 2 puff use in inhaler
How long after C-section can a mother drive?
wait 3 weeks after c-section
when PT has skin graft, what's one intervention you can do to have good articulation
warm up room
pharmacological interventions from PMS include? when do we consider these?
when symptoms persist or interfere with daily functioning - SSRIS - Estrogen/ Progesterone - Diuretics - Vit B6 - pain meds
250 mL DSW IV over 2.5. How many gtt/min will the Wrate be at? Exhibit = 18gtt/mL .
~ 250mL /2.5hr x 159gtt / 1 mL x 1 hr/60 min ~250/2.5 X 15/1vX 1/60 → = 3750/150 = 25 gtts/min
Manifestations of an overdose of levothyroxine are those of hyperthyroidism, which includes? (5)
- palpitations, dysrhythmias - anxiety, insomnia -WT. loss - heat intolerance - osteoporosis
How do you decrease edema in Cellulitis?
-warm, moist compresses to stimulate circulation -DON'T use ice packs
Normal range of creatinine
0.6mg/dL -1.3 mg/dL
Eye care for unconscious patients?
- Administer moist compress to cover eyes every 2 hrs -Use a new cotton ball for each cleansing wipe -Instill artificial tears into the lower eyelids -Protect the eyes w/ protective eye shield -Monitor eyes for redness and exudate
Precautions when taking Sucralfate? (4)
- Avoid anti-acids 1hr before and 1hr after med (absorbs better in acidic state) - Take on empty stomach (stomach is more acidic empty) - constipation is S.E (increase fluids, But 1000mL lb 24hr NOT enough) - Don't crush or chew
When taking Fluoxetine, what should PT remember in their diet?
- Avoid tyramine containing foods (can lead to HTN crisis)
- Prior to giving Lithium med, make sure which electrolyte test are done?
- BUN (shows function of Kidneys ) - TSH (check how thyroid is working). - ECG (Show arrhythmia/rhythm problems of heart)
Carbon dioxide extinguisher
- Best for electrical fires or flammable liquid - like paints b/ prevent CO2 conduction. Class B appropriate for garage, car/ truck or tanker fires, Not class A blazes
What assessment date would a nurse expect w/ acute IBD?
- Bloody stools with mucus (damage to intestinal lining) - Pallor (PT tend to be iron deficient=anemia=pallor) - Anorectal excoriation (from severe/lots of diarrhea) - Urine output below 30mL/hr (because dehydration)
What is s/s of Pneumothorax? (potential complication of all central venous devices)
- Chest pain - Dyspnea - Shoulder or neck pain -Palpitations -Lightheadedness -Hypotension -Cyanosis - Unequal breath sounds
What is an audiometric test?
- Determines the degree and type of hearing loss - Produces pure tones at varying intensities to which the patient responds - Have the patient cover one ear and place ticking watch by uncovered ear; ask what the patient hears (watch has higher pitch than voice
Assessment finding that would Alert Nurse of Open pneumothorax change to tension pneumothorax
- Distended neck veins ( pressure building up in Chest causing pressure on the right side of ♡ = bad!! Decrease in venous return, can lead to cardiovascular collapse, or obstruct blood flow =Hypotension) -Hypotension -Distant & Sounds
What to know about clonazepam?
- Don't stop abruptly. - can cause seizures, confusion, delirium - can cause Rash / Alopecia , hirsutism (growth of hair)
How should a PT w/ ALS feet be positioned?
- Dorsiflexion - prevent Plantar flexion contractures
S/S OF Hodgkin's lymphoma
- Drenching night sweats (main symptom is not regulating temp. Body switches from fever and chills to excessive Sweating (worst w night). Overactive immune system trying to get rid of toxins). - Small, red, itchy bumps (As lymphoma cells grow. they secrete aChemical that causes itchiness/ irritant to body) -Enlarged Spleen (part of lymph system, can be enlarged from toxins and attempts to filter them).
- A roommate hears another roommate's lab report of HIV (+) and asks for a separate room. What order does the nurse complete the task?
- Educate roommate about transmission of HIV/Aids - Notify nurse manager of breach in confidentiality -Transfer PT ASAP -encourage PT to verbalize feeling about Situation - Constant Social Services to address PT future needs
PT diagnosed with ALS. Which nursing intervention would the nurse implement?
- Explore diversional activities (reduce frustration and depression of being immoble) - Perform range of motion exercise - Maintain the feet in dorsiflexion position (prevent plantar-flexion contractures) - Assess pressure points for skin changes
What are s/s of Phenytoin?
- Fatigue - dyspnea on exertion - Skin rashes - Pale conjunctiva
-S/S of TB
- Fatigue -Hemoptysis (cough up blood) - Diaphoresis during sleep - Anorexia (loss of Appetite)
What are some Educate tips for Home fire Safety?
- Fire extinguisher on every floor of home. - Keep matches / lighters locked away -install carbon monoxide monitors /check monthly - Have planned route of exit/ place to meet - Make sure real or fake christmas trees are turned off overnight
Asterixis is?
- Flapping tremor of the hand - Handwriting changes in Hepatic coma
What is the Rubella vaccine given for?
- Given to protect unborn baby from birth defects - Rubella can lead to mild rash (on face) / low grade fever
PT receives Nadolol, what PT data should the nurse use to hold me?
- HR less than 60 bpm / BP less than 90/60 (if unknown BP baseline) Beta blocker, Prescribe to lower Bp. Can further lower HR.
A patient receiving PPI, has bolus enteral feeding. Nurse checks PH aspirated gastric fluid to determine feed tube placement. PH read 6. What is the nurse's next action?
- Inspect the aspirated amount for color and consistency - Inspect color and consistency to determine correct placement - Normal stomach PH is 1-4 - A patient who is receiving PPI cna have a PH as high as 6 (b/c med is trying to make stomach acidic) - Small intestines can also have PH at or above 6 PH of 6 does confirm placement - Gastric contents are cloudy, green, tan or off white, bloody or brown
What is Inflammatory Bowel Disease (IBD)?
- Involves chronic inflam. of all/part of digestive tract (e.g: ulcerative colitis, Crohn's disease) - s/s: severe diarrhea and bloody stools -Abd pain w/ cramping -Fatigue -Decrease appetite/weight loss
There is a patient with bowel obstruction in transverse colon. What sounds would you expect to hear in abdominal quadrants?
- Peristalsis should increase in ascending colon (RLQ) in attempt to clear blockage resulting in hyperache BS. There will be little or no peristalsis distal to the obstruction (LLQ)= decrease of absent BS
What are late signs of AD?
- Poor personal hygiene - agitation/behavior changes - Visual agnosia (not recognize objects, people, sound, shape) - Dysgraphia (difficulty communicating by writing)
What does aspirin overdose stimulate?
- Resp center and causes increase in resp rate and depth. - This causes resp alkalosis by blowing off CO2 and causing the PH to increase. Losing CO2 (acid) make PT more alkalotic= PH is increase, PACO2 decrease, norm HCO3 - e.g: PH 7.9 (7.35-7.45), PACO2 30 (35-45), HCO3 25 (22-26)
Which herbal supplements are contraindicated with pregnancy? (7)
- Saw Palmetto - goji - goldenseal - black cohosh /blue cohosh - dong quai -Pennyroyal - ephedra
By 18 months, toddler should be able to
- Say Shake head "no" point to show what they want / they want someone they want -Points to one body part, can identify Ordinary things ( e.g phone, brush, Spoon ) - Show interest in doll or stuffed animals, - scribble on own - Drinks from cup - follow 1-step command leg sit down) - ability to walk alone, pull toy while walking (stairs = 2 yrs) - help undress self, eat w/ spoon
S/S of PT w/ Severe dehydration from Vomiting
- Specific gravity greater than 1.030 ( range 1.002 -1.030. # goes up when concentrated, down with diluted) -Dry mouth (related to severe dehydration / fluid loss) -Tachypnea (decrease blood volume as hypoxia, resp in attempt to improve hypoxia -Postural hypotension (low BP, bic fluid volume deficit) - Tachycardia (trying to pump little blood volume to vital organs)
PT has Aspirin Poisoning & is lethargic, excessive Sweating, hyperventilation, and hyperthermic. interventions nurses should do which interventions?
- Sponge bath - IV fluids - Pad side rails - NG tube - obtain blood gas ( PT has hyperthermia. Decrease temp by external cool down e. Tepid water Sponge bath. Dehydration occurs early in aspirin poisoning due to vomit & hyperventilation = IV fluids Gastric Lavage and activated charcoal PRN to deactivate Aspirin = NG tube Child is a risk for Seizures = Pad Side rails. Obtain blood gas results blc care based on metabolic acidosis = most concern) .
N/V method of control includes?
- Sports drinks and broths can help w/ hydration. - Juices and soft drinks should be avoided. - Smells from foods cooking can lead to N/V - Bland food in Small portions may be tolerated vs fried foods. - Avoid milk products.
When ROM is green what does that mean?
- Stained fetal passage of meconium - Think prepare equipment for immediate suction of newborn
What are the s/s of Bell's Palsy?
- Sudden weakness/paralysis on one side of face (droop) - Drooling - Eye problems (excessive tearing or dry eye) - Loss of ability to taste -Pain in or behind ear -Numbness in affected side of face -Increase sensitivity to sound -(Bell's Palsy is sudden, comes on usually overnight. Paralysis of muscles on one side of face. Can get better on own.
S/S Of cannula displacement at arterial line insertion
- Swelling -fluidleakage -Blanching /pain / discomfort - Poor arterial waveform
Health promotion interventions w/PT w/ cirrhosis? (5)
- Use Shower chair w/hygiene (help save energy) -Stop any activity causing dizziness (SOB, Fatigue, weakness) - calculate Nat intake (FVE) (Want low Na+ intake ) - Proper Hand Hygiene - Stop alcohol completely
Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing?
- Warm cleansing solution to body temp. (body temp enhances healing process/circulation) - Clean wound when there is drainage present (drainage could become infected) - Use sterile forceps when cleaning the wound (don't increase risk for infection. Need moisture environment)
Equipment needs for Hospice care for terminal hepatic encephalopathy
- alternating pressure mattress Hospital bed (to elevate HOB 30, ease Resp, decrease Work of breathing) - Oxygen (will be hypoxemia) - suction
What is Protamine Sulfate? What to check for?
- antidote for enoxaparin - Check if PT hgb/hct/ platelet is low - check for s/s of bleeding
What is Chlorpromazine? What to remember when taking this drug?
- antipsychotic med used to control psychotic or hyperactive behaviors (ADHD)/ Schizophrenia. - If followed correctly behaviors can be minimized. - Can cause sensitive skin, Susceptible to sunburn even on cloudy days.
What can't the LPN do regarding cervical checks?
- can't measure cervical dilation/check fundal Ht and FHR (invasive measure assessment, not in scope)
PT in anaphylactic shock, get epinephrine. How to know if a drug is working?
- increased HR, increased Resp rate. Dilated pupils, inhibit sex - Dilated bronchioles, inhibit digestion, Relaxes bladder
What is a Mediterranean type of diet? Examples?
- low fat diet - emphasizes Vegetables, fruits, and whole grains, low dairy products (poultry, fish, legumes, nuts.) - limit intake of sweets and red meats - grilled eggplant, purple grape juice, cashews, - skim milk, salmon
What kind of diet will a PT w/ Diverticulitis have?
- low residue / low fiber diet e.g cooked pasta meatballs, canned fruits, and garlic bread
Clinical manifestations of AKI include?
- oliguria (urinary output less than 13.5 oz/day or 400mL/day). - hypovolemia - metabolic acidosis (kidney cannot eliminate acid products) - electrolyte imbalances (NA+ and K+) - Waste product accumulation -neuro disorders (due to waste product build up in the brain)
S.E of Methylergonovine?
- palpitations - hyper and hypotension - Acute MI, transfer chest pain - arterial Spasms (coronary and peripheral) - bradycardia - Tachycardia
S/S of Wernicke's encephalopathy?
- paralysis, ocular muscles, Incoherent Speech, impaired reasoning ability, disorient to time and place, impaired recent mem, dielus, hallanations
what does the left hemisphere of the brain control. What problem will you have is this side of the brain has a stroke?
- right side of the body - language skills - expression - comprehension of written and spoken words - aphasia can occur w/ stroke - most clients with left brain damage are aware of their deficits which leads to depression and anxiety.
PT has s/s of nausea, numbness, prolonged muscle spasms, muscle twitching, and hand tremor. Current med is furosemide 40mg. What acid/base imbalance does a nurse anticipate for PT?
- s/s mentioned above= hypokalemia - Metabolic problems occur with hypokalemia - Hypokalemia causes alkalosis, causes rise in bicarb reabsorption= metabolic alkalosis
Drainage after Post cholecystectomy that would be alarming should be green (bile), Blood Problem
- should be green (bile), Blood or red = Problem
Define Anasarca, what is it seen in?
- total body edema (seen in nephrotic Syndrome)
- PT taking MAOIS (for depression) can't consume foods high in?
- tyramine (can cause a severe increase in BP)
Dry Chemical/ Powders extinguishers
- used for mixed material fires electrical - Not recommend for small, enclose Spaces, danger of inhaling dry chemical
Patient care plan as a result of positive KOH test include? (7)
- using clean towels and washcloths daily - frequent mouth care -avoiding sharing bedding or items which have contact with the affected area - carefully drying and inspecting skin, especially skin folds - wearing clean cotton undergarments and socks - ensuring footwear is clean an dry - using talcum powder or OTC powders that can keep skin dry
Risk factors for Otitis media?
- usually follows or w/ upper resp infect / common cold. - contact w/ siblings - Day care attendance - season of the year - Under age of 5 (Eustachian tube shorter, narrower, more vulnerable for blockage)
PT has Appendicitis, during hx and Physical which statements have the nurse suspect marijuana use? STA
-"My eyes have been bloodshot lately" (classic sign) -I sometimes feel off balance" -"I don't have the desire to do things I used to do" -"My heart seems to beat fast a lot of the time" -THC affects neuron receptors in the brain w/ affect Coordination. Can cause heart to beat faster
Some antiemetics can be very ___ ? example?
-(Promethazine), very sedating -Decrease resp drive and increase CO2 retention
Define Erikson's developmental stages - Industry vs. inferiority
-16-12yrs -attempt to achieve a sense of self confidence by learning, competing, performing successfully and receiving recognition from significant others, peers, acquaintances.
Define Erikson's developmental stages of intimacy vs. Isolation
-20-39 yrs -form an intense, lastinging relationship or a commitment to another person. If no intimate relationship
Example of how to find out weight loss percentage in a newborn. Birth wt 2600g, current wt. 2300g
-2600-2300 = 300 -300/2600 =0.11% greater than 10% wt loss of birth Wt = further Assessment
When is the 2nd dose of- Hib vaccine given?
-4 months
Define Erikson's developmental stage Generativity vs. Stagnation
-40-64yrs -to achieve life goals established for oneself while also Considering the welfare of future generations. Period to contribute to society (have kids, etc.)
Define Erikson's developmental stage of Ego integrity Vs. Despair
-65 yrs and older -an individual reviews one's life and derives meaning from both positive and negative events if an individual considers life accomplishments positive = integrity.
What are contradictions in the MMR vaccine?
-A known allergy to gelatin (MMR is grown using chicken embryo and manufactured by use of gelatin) -Antibiotic to neomycin
When preventing venous stasis ulcer formation. What topical corticosteroids should the patient avoid?
-AVOID lanolin, calamine (dry the skin) -topical antibiotic ointment : neomycin, benzocaine (numbing med)
How should Ciprofloxacin be admin? What might it cause? What are the Pt in increased risk for?
-Admin w/ Iv pump over 60 min (slow infusion, minimize discomfort) -May cause dizziness -Associated with increased risk for tendonitis, tendon rupture
If there is no wheal in mantoux TB test of at least 6mm in diameter after solution is injected, what should you do next?
-Administer the test again. -Admin in another area about 5-6cm from original injection site
What Is Nephrotic Syndrome?
-Also losing protein like in Glomerulonephritis but A LOT OF protein is being loss -Pt is very edematous! Causes are idiopathic
What is Metronidazole? What is it used for? What can interact with it?
-An antibiotic used for tx of vaginal infections. - ETOH can interact w/ and severe N/V as well as cramping and flushed appearance.
What is Phenytoin and what is it used for? What do we need to do every shift?
-Anticonvulsant, used for grand mal seizures -need to perform oral hygiene every shift b/c cf gingival hyperplasia (overgrowth of gum tissue around the teeth) , side effect.
Breastfeeding education? (3)
-Apply warm Compress to breast before feed (help let down reflex) -Massage breast during feeding - Hand Hygiene b4 feed
What are preconception health points for women trying to get pregnant?
-Attain healthy wt. -Make sure immunizations are up to date -Avoid drinking ETOH -Learn from HX -Maintain folic acid intake 400mcg/day
The nurse is coming for a PT w/ renal failure. The PT has 24 hr intake of 2500 mL and 24 hr UO of 200mL. What priority nursing action?
-Auscultate breath Sounds - The nurse is worried about FVE. #1 concern in FVE IS HF! w/ resultant pulmonary edema. In FVE, the heart is stressed so much it begins to fail. Co decreases, which decreases forward flow out of the heart. Which causes back flow from left ventricle into lungs. Therefore best Assess for HF = lung assessment.
What is APD dialysis? What is their diet?
-Connects to a cycler at night, disconnected in Am -Diet = increase fiber and Protein/losing in dialysis
Precautions when taking Setraline?
-DO NOT STOP Abruptly - monitor liver function - Should NOT be given w/MAO inhibitors both increase levels of serotonin in the brain . Dont Double dose
A home health nurse is preparing to perform venipuncture. Pt begins to experience palpitations, trembling, nausea, SOB, sense of losing control. What is the FIRST nursing action?
-Decrease stimuli in room (decrease pt anxiety) -Can't teach deep breathing until panic attack is over
What is sildenafil/alpha-adrenergic?
-Dilate small muscles, combo of both meds can cause hypotensive event -Sildenafil usually taken PRN 30min-1hr before sex -Don't take more than once daily -Side effects: flushing H/A and dyspepsia
Probable S/S of Pregnancy
-Documented by examiner - Increase temp, breast tender, swelling linea nigra, abdominal enlargement, soft cervix, ballot of uterus
How does a pt take Aripiprazole discmelt?
-Don't swallow, allow to dissolve in mouth -Can be taken with or without food -Skip the missed dose if it's almost time for the next scheduled dose. Do NOT take extra med to make up for missed dose
Precautions when taking Dabigatran?
-Don't take w/clopidogrel (7 bleeding risk) -Decrease the risk for Stroke associated w/A-fib (Not associated with a cardiac valve problem) -Take with food (decrease gastric side effects such as dyspepsia and gastritis) -Don't store in weekly pill organizers (Should be used within 30 days, sensitive to moisture)
Rho (D) immune globulin would be indicated w/ which Rh- PT?
-Elective abortion a 6 wks gestation -involved in major car accident -Requires amniocentesis -DX ectopic preg -48 hr post delivery of Rh (t) baby. All could have some bleeding & develop antibodies against Rob (+) fetus. can give a 28 wks
What are the s/s of Hep A?
-Fever, malaise, loss of appetite, diarrhea, nausea -Abdominal discomfort, dark urine, jaundice -Spread through food or water contaminant w/ feces
Foods Pt can eat w/ ulcerative colitis include?
-Fish -Scrambled eggs -Avoid Dried beans and apples (too much fiber) -Avoid dairy
What is PEG Tube Care?
-Flush feeding tube with 30 ML of warm tap water every 4hrs -Maintain HOB at 30 degree elevation
What are indications in assessment of premature infants? (3)
-Folded Pinna of ear springs back slowly Full term = spring back firmly & quickly - Lanugo on shoulders and chest Covers shoulders and chest prematurity -Vernix covering axilla, back and buttocks
When should a pregnant woman know when it's time to go to the hospital for delivery?
-Go to hospital ASAP when water breaks, or when contractions are 5 min apart for 1 hr of its first pregnancy -multipara - go to hospital when contractions are reg, 10min apart for 1 hr
What color tag should a pt with a fracture of humerus have?
-Green tag (minimal category) -Injuries are minor and tx can be delayed hour-days
What is Captopril taken for?
-HTN -should not be taken when trying to get Pregnant
When removing PPE what is the order of removal?
-Hand Hygiene is performed before removing face Shield or goggles, Shoe covers are removed w/ gloved hands.
Strep is untreated affects the which two organs?
-Heart and Kidneys -Affect Heart Valves: prevent backflow * damage of valves = BackFlow (S/S of HF)
Lab values of tumor lysis syndrome? (4)
-Hyperkalemia - Hyperuricemia -Hypocalcemia - Hyperphosphatemia - When Cells are destroyed or lyse from chemo, there is a release of k+ and phosphates from cells. = Hyperkalemia and Hyperphosphatemia. Phosphorus has an inverse relationship. w/ calcium = Hypocalcemia. Purines are also released during cell destruction which turns the uric acid = Hyperuricemia
Calcium gluconate can be used for?
-Hyperkalemia -reverse effects of hypermagnesemia monitor for hypophosphatemia
What are the drug effects/side effects of benzodiazepines?
-I should not drive my car until i see how the med affects me -Reaction time will be slowed/may affect general alertness -Usually prescribed for short periods of time -Risk for dependence, frequently abused (pt can develop tolerance/dependence on drugs)
What is the proper method of relaxation deep breathing exercises?
-Inhale slowly and deeply through the nose allowing ABD to expand (chest should be moving only slightly) -Sit or lie down in comfortable position with back straight (facilitates breathing deeply into the lungs) -Hold breath after inhaling (assist the pt to control breathing pattern)
What is advanced care directive?
-Legal document -Prepared by competent individual that specifies tx -If patient is incapacitated/unable to make informed healthcare decisions in the future, the person signing must understand and agree to the document
Maior complication of Nephrotic Syndrome?
-Loss of protein - common rule is to decrease Protein w/ Kidney problems,EXCEPT Nephrotic syndrome.
When examining testes, which finding indicates further investigation?
-Lump size piece of rice -Most common symptom of testicular cancer is painless enlargement of one testis and appearance of palpable small hard lump on front or side of testicle
May take up to 9-10 months to re-establish normal ovulation/ menstruation. Injectable prevents ovulation for 14 wks, schedule injections every 12 weeks when on?
-Medroxyprogesterone
An example of the correct snack Selection for PT on chemo?
-Milkshake and instant breakfast packet -PT w/ cancer experiences a combo of increased energy expenditure but the nutrition intake is decreased. Cold drinks / Shakes may be Soothing especially w/ no desire to eat Solid Food/ mouth pain. Shakes contain more calories, instant breakfast contain more protein.
In a dressing change what strips can be less irritating to the skin?
-Montgomery Strips. Allows the dressing to be held in place w/o tape.
How many calories does a breastfeeding mother need daily?
-Mother needs 500 extra kcal/day when breastfeeding -Average women will secrete 425-700kcal in breast milk
Interventions/ assessments when handling TPN? (6)
-Need to assess electrolytes everyday (TPN formula Changes per day) -Only be hung for 24hrs, w/ Pump -Change tubing w/ each bag hung -Home Care is hand hygiene = infection #l complicanon -Check central line placement w/ x-ray -usually put PT in trendelenburg to distend veins (upside down all straight \
What should nurse document after insert indwelling cath? (5)
-Perineal skin assess (prior to insertion) -Patient teaching -Color of urine -Date and time of insertion -Type of cath inserted
How to maintain skin integrity in bedrest pt?(5)
-Place pt on therapeutic mattress (reduce press ulcers) -Assess skin every 2 hours -Assess skin using braden scale -Place pillow between knees when lying on side -Keep incontinent pt clean and dry
What assignment could the charge assign to LPN in L&D/postpartum?
-Primipara needing assistance with breast feeding -Primipara who is 2 days post op c-section (pt's who are stable within scope of LPN practice -LPN CAN'T give IV narcotics (PCA pump)
Which finding would indicate a pt with addison's disease has received too much glucocorticoid replacement?
-Rapid weight gain (excessive drug therapy with glucocorticoid will cause rapid wt gain, round face, and fluid retention) -Increased cholesterol (cholesterol and triglyceride in the blood are also increased by glucocorticoids. Long term use of high steroid doses can lead to symptoms such as thin skin, easy bruising, changes in shape/location of body fat, increase acne or facial hair, menstrual prob, impotence, loss of interest in sex
PT w/ glomerulonephritis. In hx and Physical, what would be the priority assessment the nurse should include when asking caregiver ichid?
-Recent sore throat - Strep bacterial infection can cause the filtering units of the Kidney (glomeruli) to become inflamed and results in a decreased ability of the kidney to filter Urine. May develop 1-2 wks after untreated throat infection or 3-4 wks after skin infection.
What age is the HPV vaccine given in mates & females?
-Recommend in preleen boys and girls (age ll or 12) -Women can get a vaccine until they are 26 yrs. -Men to 21 -Recommend in any male had sex w/other male til 26 yrs and for immunocompromised til 26.
What color tag should a pt with BP of 90/40, lethargic have?
-Red tag (immediate) -Signs of shock
If a Pt with chronic renal failure, has anemia and is getting a synthetic erythropoietin to prevent anemia. And Pt Reports swelling of feet & ankles. What does the nurse do?
-Report to HCP b/c possible cardiovascular prob. -PT taking Erythropoietin is at risk for MI/cots.
What are S/S of Transplantation rejection in PT w/ heart transplant.
-SOB, Fatigue - New onset of bradycardia - Fluid retention - Hypotension - Abd distend - A-fib or flutter
Assessment findings of a Suspected fractured hip
-Severe pain in hip and groin (main sign) - Inability to bear weight on affected leg → External rotation (Knee & foot turns outward) - Bruising & swelling around hip
What is the importance of taking meds for myasthenia gravis?
-Should be taken on time/teach to set alarm for med time -Taken too early=weakness -Too late=extreme weakness/possible paralysis
S/S of Pernicious Anemia?
-Smooth tongue, red in color not pink -Neuro problems burning in feet, slow reflexes, disoriented -Light headed -dyspnea on exertion -Fatigue -Breathlessness
What is the most therapeutic intervention for a schizophrenic pt who is uncomfortable with other clients?
-Spend time in brief 1:1 interactions with nurse -Keep conversation reality base/provide interaction with someone. pt with schizophrenia can be very withdrawn
What is a whisper test?
-Stand 12-24in from the patient -Speak in low whisper -Ask patient to repeat the number of words whispered -All 4 tests (above) for gross hearing acuity.
What do you do if someone calls with a BOMB threat?
-Stay on phone as long as possible and try to obtain info, while being alert for voice characteristics /background noises -While caller on line motion for another nurse to call bomb threat
Pt has pernicious anemia. What kind of injections will they need and how long?
-Vitamin B12 injection, for a lifetime
What precautions do you take when caring for TB pt?
-Wear a particulate respirator (fits snug to face) -Initiate airborne precautions (pt needs to be on acid-fast-bacilli isolation precautions, NOT reverse isolation. Airborne precautions include neg press room with min of 6 air exchanges per hour. Ultraviolet lamps and air filters)
Can PT W/ Hep A donate blood?
-Yes if fully recovered
Some interventions for kidney PT with excessive thirst?
-chew gum / suck on hard candy (Increase salivation ) -Freeze fluids to allow longer consumption times (frozen lemonade) -Add lemon juice to water to make of more refreshing -Gargle cold, refrigerated mouthwash -Use small glasses instead of large ones -Keep lips moist w/ lip balm a petroleum jelly
What is St. John Wort? What is it used for? What should it not be used in combo with?
-herbal supplement used in te for mild depression. -Should NOT be used in combo W/ SSRI due to risk of serotonin Syndrome, which is fatal.
Some complications of Hyperparathyroidism? (Hypercalcemia) (3)
-kidney stones - osteoporosis (increase PTH pulls calcium from bones, into the blood) -constipation
If a Pt with chronic renal failure, has anemia and is getting a synthetic erythropoietin to prevent anemia. If Hgb is above g/dL. What should the nurse do?
-let HCP know b/c no longer needs tx for anemia. -Hgb of 10 still indicates need
What are Adverse effects of succinylcholine -chloride?
-malignant hyperthermia -Apnea (paralysis of face muscles) -Arrhythmia -tetany, spasms or Shiffress of Jaw -Hyperkalemia (b/c muscle relaxer, prolong muscle depolarization, muscle may release large amount of Kt in blood)
What were three examples of a clean needle stick?
-remove needle from Syringe -place suture needle into self locking forceps -Prior to insert of IV, PT moves, needle sticks RN
What can Fluoxetine cause?
-sudden drop of BP -routine liver labs
Define AKI (Acute Kidney Injury)?
-sudden episode of renal damage
When prescribed any med w/ sucralfate, the PT should avoid what?
-taking the med at the same time w/ sucralfate. -Sucralfate can make it harder for the body to absorb b/c it's forming a coating or barrier on the stomach lining. -Therefore, the PT should wait 30 min to take sucralfate
What might the HCP prescribe to prevent venous stasis ulcer formation?
-topical corticosteroids -prevention of scratching and skin break down.
What is Post-renal failure? examples ?
-urine can't get out of the kidneys -e.g enlarge Prostate, Kidney stone. Tumors, Ureteral obstruction
What is the normal range for INR when NOT on anticoagulant therapy?
0.8-1.2
PT is showing S/S of Flu-like symptoms, Sore throat, mild fever, fatigue, muscle aches (last fewer of hours or days), mild chest discomfort, SOB, N/v, coughing blood, Painful swallow. What are they showing s/s of?
Anthrax poisoning
used for behavioral problems such as agitation, physical aggression, and disinhibition in Alzheimer's Disease?
Antipsychotics and Benzodiazepines
What is a clear liquid diet? What are some examples?
Anything you can see through when in liquid state (ex: lemon juice, sprite, banana popsicle)
Define ethnocentrism
Belief one's own culture and traditions are better than those of another
What are two gas producing foods that are cause abdominal distention and flatulence?
Broccoli and cabbage
when are tall peaked T waves seen on ECg? Which electrolyte imbalance?
hyperkalemia
At what age is it a concern if an infant not being able to hold head steady
- 4 months
When is the 3rd dose of Hib vaccine given?
- 6 months
When is the influenza vaccine given?
- 6 months and older
Clotting Studies Normal values (APTT, PT, INR) ?
- APTT: 30 - 40 sec - PT: 110-125 sec - INR: 8.0-11
What are adverse reactions of an SSRI?
-Fever shivering, -Agitation, increased HR
What are the steps of an enema?
1) Explain all procedures to the patient 2) Assist patient to side lying position 3) Add warm water to enema bag (warm prevents cramping/discomfort) 4) Raise enema bag 18-20in 5) Insert lubricated tip into rectum (aim tip of the nozzle toward the umbilicus)
The nurse is beginning their day shift on the acute medical unit and is assigned the following 4 PT's. Which patient should the nurse assess first? 1. A 35 year old female currently receiving her first dose of vancomycin IV for the treatment of C-diff 2. A 14 y.o male due for a dose of oral acyclovir for the TX of acute viral infection 3. A 24 y.o male due for his dose of topical fluconazole 4. A 80 y.o female who is receiving interleukin treatment for multiple myeloma
1. A 35 year old female currently receiving her first dose of vancomycin IV for the treatment of C-diff - since this patient has recently begun her first dose of vancomycin, she require the most immediate assessment. The risk for red man syndrome is highest at this time, and thus screening to ensure that no manifestation are present is the best practice for the admin of this drug.
What side effects would the nurse expect to find in a client who has received too much levothyroxine?STA 1. Angina 2. Bradycardia 3. Hypotension 4. Heat intolerance 5. Tremors
1. Angina 4. Heat intolerance 5. Tremors Levothyroxine is the replacement hormone for clients with hypothyroidism, so if too much is given, they would exhibit symptoms just like someone with hyperthyroidism. These clients also tend to have coronary artery disease (CAD), which is why angina is a significant side effect. -Tachycardia and hypertension is also expected
What can an increased BUN cause?
impaired thoughts, H/A, /V. Fatigue
When is Fluconazole often used
in topical form for the treatment of an integumentary fungal infection
Heat Stroke s/s
increased sweating, tachypnea, temp greater than 105.8 F.
The nurse is utilizing Bowen's family systems theory to analyze a family's functioning. Which of the following is true with regards to this model? Select one: 1. A high-differentiation individual will seek a high-differentiation partner 2. A high-differentiation individual will seek a low-differentiation partner 3. An open family system is comprised of members of varying differentiation levels 4. A closed family system is made up of high-differentiation individuals
1. A high-differentiation individual will seek a high differentiation partner. Bowen's Family Systems Theory: describes concepts of family functioning, asserting that a person is able to change their behaviors based on an awareness of factors impacting family behavior patterns. This can lead to an intentional desire to make changes and a refusal to function as family members did or do. Differentiation: the degree to which the self is defined in terms of values and beliefs- the ability to remain emotionally level in conflict situations and express personal principles (i.e.: a decrease in emotional reactivity results in higher differentiation). This is projected across family members. -A spiral effect occurs, differentiation of family members continues through generations People tend to seek partners of similar differentiation levels - An open family system is made up high-differentiation individuals - A closed family system is made up of low-differentiation individuals -Understanding family function and dynamics allows patients to break the cycle. This is the basis of family therapy. Family systems theory can be used in the assessment, planning, implementation, and evaluation of family therapy. The nurse should consider several family care models when caring for a potentially dysfunctional family. RATIONALE: Correct answer (Option #1) Highly differentiated individuals (typically lower in emotional reactivity) typically seek similar partners. Therefore, functional family patterns repeat themselves throughout generations. Incorrect answers (Option #2) This is not typically the case, and due to this factor family dysfunction may arise (with two low-differentiation individuals). (Option #3) An open family system is composed of high-differentiation individuals, and therefore, is less likely to become dysfunctional. (Option #4) A closed family system consists of low-differentiation individuals.
The nurse is caring for a patient who was just admitted following an acute MI. The hospital's cardiac catheterization lab was closed, so thrombolytic therapy was implemented in the patient's plan of care. The nurse is monitoring the patient for complications. All of the following are priority actions that the nurse should take to monitor for complications of therapy except: Select one: 1. Asking if the patient has a headache 2. Monitoring clotting studies 3. Testing stool for occult blood 4. Double checking IV sites
1. Asking if the patient has a headache Thrombolytics are used in the care of patients with MI to break down the clot and improve blood flow to the affected area. The most common complication with the use of thrombolytics is bleeding. The nurse should monitor the patient for signs of bleeding by checking IV sites for bleeding and patency, monitoring clotting studies, and testing stool, urine, and emesis for occult blood. During and after thrombolytic therapy, it is important for the nurse to report any signs of bleeding to the physician or rapid response team. RATIONALE: Correct Answer: (Option #1) Asking the patient about whether or not they are experiencing a headache is not a priority action to monitor for bleeding. Incorrect Answers: (Options #2, 3 & 4) All of these actions can indicate whether or not the patient is at risk for bleeding.
The UAP has just taken a set of VS from a PT with a hx of chronic stable angina. The PT was arguing with a family member prior to the assessment. The UAP reports that the client seemed SOB, and is experiencing chest pain. Upon hearing this, what action should the RN take? 1. Assess the patient 2. Tell UAP to bring the PT nitro 3. Bring the Patient nitro and an analgesic 4. Ask LPN to bring aspirin to the PT
1. Assess the patient should assess the PT and confirm the findings reported by UAP.
How to calculate BMI?
kg/m^2
A nursing student is researching complementary and alternative therapies (CAT). Which of the following are considered mind-body interventions? Select all that apply: 1. Biofeedback 2. Massage therapy 3. Therapeutic touch 4. Guided imagery 5. Music therapy 6. Chamomile tea
1. Biofeedback 4. Guided imagery 5. Music therapy
The homecare nurse is visiting a client to assess the response to new medications ordered for benign prostatic hyperplasia (BPH). What symptoms reported by the client would indicate to the nurse the medications are not working? STA 1. Bladder pain 2. Fever with chills 3. Urinary frequency 4. Terminal dribbling 5. Nighttime sweats
1. Bladder pain 3. Urinary frequency 4. Terminal dribbling 1, 3 and 4. CORRECT: Symptoms of benign prostatic hyperplasia are very similar to those of a urinary tract infection. As the prostate enlarges and presses against the bladder wall, it becomes more difficult for a client to start and maintain a stream of urine, or even to completely empty the bladder. Medications prescribed for this disorder are meant to shrink the prostate, allowing urine to flow easily when voiding. When the medications are ineffective, the client again experiences the original symptoms such as bladder pain, urinary frequency and a tendency to continue 'dribbling' urine after the bladder is emptied. The client may then need a different medication or a change in the dose currently prescribed.
The nurse is caring for a patient who has been recently diagnosed with atrial fibrillation. The patient asks the Incorrect nurse about possible treatment options. Which of the following interventions may be considered for this patient? Select all that apply. 1. Cardioversion 2. Spironolactone 3. Amiodarone 4. Rivaroxaban 5. Pericardiectomy
1. Cardioversion 3. Amiodarone 4. Rivaroxaban
Which task would be appropriate for the charge nurse to assign to a LPN/VN? STA 1. Collect data on a new client admit. 2. Administer morphine IVP to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
1. Collect data on a new client admit. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client.
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? STA 1. Color Changes 2. Drainage 3. Odor 4. Fever 5. Bleeding 6. Increased Pain
1. Color Changes 2. Drainage 3. Odor 4. Fever 6. Increased Pain
If PT expires of injuries within 24 hours of being admitted. Coroner must investigate. The nurse must?
leave all invasive lines and tubes. Never wash the body of evidence (can empty poley bag)
How can we prevent Stress Incontinence?
limit caffeine, maintain healthy wt, Avoid Acidic Food
what is trichloroacetic Acid (TCA)
liquid that burns/ eels away warts
The nurse is admitting a new client to the pediatric medical unit. The patient is displaying the following symptoms : irritability, mild edema, lethargy, and mild skin depigmentation. The patient has a recent hx of a GI bacterial infection. In the development of comprehensive care plan for this client, which of the following interprofessional should the nurse seek for immediate consultation? 1. Dietitian 2. Social worker 3. Physiotherapy 4. Chaplain
1. Dietitian - The patient is displaying early signs of acute PEM. A dietitian is a key partner in the care of the patient with PEM. PEM is a severe childhood malnutrition that can be divided into two subcategories: 1. Kwashiorkor: deficiency of protein with an adequate supply of calories 2. Marasmus: general malnutrition of both calories and protein
What is Salmeterol used for?
maintenance medication. It can prevent asthma attacks and exercise induced bronchospasm. It acts as a bronchodilator. It works by relaxing muscles in the airways to improve breathing.
What is Hct normal level ?
male level 42-52% Female 37-47%
The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective?STA 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia
1. Decreased anxiety 2. Relief of chest pain 4. Lowered blood pressure 1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety.
A nurse is performing ostomy care for a patient with a history of Crohn's disease who has undergone a bowel resection. Place the following interventions in order of priority. - Assess the site for a moist and pink appearance - Clean the stoma with mild soap and water -Attach the drainage bag to the stoma -Apply adhesive to the area surrounding the stoma -Evaluate the drainage and characteristics
1. Evaluate the drainage and characteristics 2. Assess the site for a moist and pink appearance 3. Clean the stoma with mild soap and water 4. Apply adhesive to the area surrounding the stoma 5. Attach the drainage bag to the stoma
Which of the following lifestyle modification should be suggested to a pt dx with HTN? 1. Exercise 2. Low K+ diet 3. Low NA+ diet 4. Smoking cessation 5. Diabetic diet
1. Exercise 3. Low NA+ diet 4. Smoking cessation Risk factors for HTN include age, sex, race, fam hx, stress, obesity, high sodium intake, and smoking.
A 2-year-old child accidentally ingested a toxic amount of Acetaminophen. Place in order the stages of the expected clinical manifestations. - Improvement of symptoms -Multiple organ failure - Nausea, vomiting, sweating, pallor - Pain in right upper quadrant, jaundice, confusion, stupor, coagulation abnormalities
1. Nausea, vomiting, sweating, pallor 2. Improvement of symptoms 3.Pain in right upper quadrant, jaundice, confusion, stupor, coagulation abnormalities 4. Multiple organ failure The clinical manifestations of an acetaminophen overdose occur in 4 stages. Stage 1 (0-24 hours) • Nausea • Vomiting • Sweating • Pallor Stage 2 (24-72 hours) • The patient improves • May have right upper quadrant abdominal pain Stage 3 (72-96 hours) • Pain in right upper quadrant • Jaundice Vomiting Confusion Stupor Coagulation abnormalities Sometimes: renal failure, pancreatitis Stage 4 (5 days +) Resolution of hepatotoxicity or progression to multiple organ Failures May be fatal
A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that further treatment is required? STA 1. Sacral edema 2. Orthopnea 3. Shiny skin 4. S3 heart sound 5. Heart rate 88/min 6. CVP 8mmHg
1. Sacral edema 2. Orthopnea 3. Shiny skin 4. S3 heart sound 6. CVP 8mmHg Option 1: True. When a client has been on bed rest for a while the nurse will see sacral rather than ankle edema. Edema is seen with fluid volume excess. When the client has too much fluid in the vascular space it will eventually start to leak out into the tissue causing 3rd spacing. Option 2: True. Orthopnea is an abnormal condition in which the person must sit up or stand to breathe comfortably. This would indicate FVE. When the hear is weak it cannot pump well, so fluid backs up into the lungs. Option 3: True. Edematous skin is extremely stretched to where it appears shiny. Option 4: True. A S3 heart sound is often an indication of heart failure. The third heart sound (S3), also known as the "ventricular gallop", occurs just after S2 when the mitral valve opens allowing passive filling of the left ventricle. The S3 sound is actually produced by the large amount of blood striking a very compliant left ventricle. A S3 can be an important sign of systolic heart failure. Option 5: False. A heart rate of 88/min is normal sinus rhythm. With FVE, expect to see tachycardia. option 6: True. Normal CVP is 2-6 mmHg. This client's CVP of 8 mmHg is high indicating FVE.
Steps in order if PT w/NG tube vomits -suction as needed -admin an antiemetic if prescribed -stop feeding -place PT in side lying position
1. Stop the feeding 2. Place PT in side lying position 3. Suction as needed 4. Admin an antiemetic if prescribed is
The nurse is preparing a PT to undergo a platelet transfusion. Which of the following identifiers are appropriate for verification of the Patient identity prior to admin of this product?STA 1. patient name 2. patient room number 3. confirmation from another nurse 4. patient birthday 5. patient ID number 6. patient age
1. patient name 4. patient birthday 5. patient ID number
Steps for Peritoneal dialysis
1.warm dialysate (want to dilate vessels / more comfortable) 2.Access Tenckhoff Catheter (Like IV site, look for s/s of infection. Assess patency. Look at site) 3.begin dwell time 4.Complete exchange (by removing effluent by gravity drainage) 5. Assess effluent (Assess for color, clarity, amount, just like urine cloudy = infection )
The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? 1. My weight may decrease while taking this drug. 2. I may expect increased sweating while taking this drug. 3. I may actually feel more depressed while taking this medication. 4. I should feel better within a couple of days after beginning the medication.
2. I may expect increased sweating while taking this drug. -The drug causes temperature dysregulation, with increased sweating in some clients.
Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis? STA 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hyperkalemia
1., 2., 4. & 5. Correct: The client will have fatigue from anemia and anorexia from toxins. Fluid volume excess leads to swollen extremities. Hyperkalemia can be caused by reduced renal excretion or excessive intake. 3. Incorrect: The client may have an uremic frost not dark skin pigmentation.
Which food items, if chosen by a client diagnosed with diverticulosis, would indicate to the nurse that the client understands the prescribed diet? 1. Avocados 2. Acorn squash 3. Applesauce 4. Lima beans 5. Raspberries 6. Cottage cheese
1., 2., 4., & 5. Correct: High fiber foods include raw fruits, legumes, vegetables, whole breads, and cereals. Avocados have 10.5 grams of fiber per cup. Acorn squash has 9 grams of fiber per cup. Lima beans 13.2 grams of fiber per cup. Raspberries have 8 grams of fiber per cup. 3. Incorrect: Raw fruits have more fiber than cooked or processed fruits. A raw apple would provide more fiber than applesauce. 6. Incorrect: Milk and foods made from milk: such as yogurt, pudding, ice cream, cheeses, cottage cheese and sour cream are low fiber.
Which clinical manifestations would validate to the nurse that a client has developed an electrolyte imbalance due to malabsorption from celiac disease?STA 1. Numbness 2. Muscle cramps 3. Negative Trousseau 4. Irritable 5. Muscle spasticity 6. Hyperreactivity to sensory stimuli
1., 2., 4., 5., & 6. Correct: Low magnesium is typically due to decreased absorption of magnesium in the gut or increased excretion of magnesium in the urine. Conditions that increase the risk of magnesium deficiency include gastrointestinal (GI) diseases, such as Celiac disease, advanced age, type 2 diabetes, use of loop diuretics, and alcohol dependence. Early signs of low magnesium include nausea, vomiting, weakness, and decreased appetite. As magnesium deficiency worsens, symptoms may include numbness, tingling, muscle cramps, seizures, muscle spasticity, personality changes, dysrhythmias, tremors, hyperactive deep-tendon reflexes, hyperreactivity to sensory stimuli, positive Chvostek and Trousseau signs, tetany, and nystagmus. 3. Incorrect: The client with a low magnesium level will have a positive Trousseau sign
A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? STA 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre op Diazepam 10.0 mg given po. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.
1., 3, & 5.
What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis? 1. Effusion to knees. 2. Weight loss of 1 kg in 2 weeks. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.
1., 3., 4., & 5. Correct: As rheumatoid arthritis worsens, the joints become progressively inflamed and very painful. On palpation, these joints feel soft and look puffy because of synovitis and effusions, especially in the knees. Swan-neck deformity is a bending in (flexion) of the base of the finger, a straightening out (extension) of the middle joint, and a bending in (flexion) of the outermost joint. Peripheral neuropathy occurs in later stages of the disease due to vasculitis. Subcutaneous nodules or rheumatoid nodules are firm bumps of tissue most commonly form around pressure points, such as the elbows. 2. Incorrect: A 1 kg weight loss over 2 weeks would more likely occur in the early stages of the disease. As the disease progresses, there is moderate to severe weight loss and accompanying anemia.
The nurse is caring for a client in the emergency department who presents with hematemesis. What information is most important for the nurse to obtain during the initial assessment? STA. 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness
1., 4., & 5. Correct: A set of vital signs and assessment for hypovolemic shock take priority for this client. S/S of shock include thready, rapid pulse, decreased LOC, shortness of breath, cold and clammy skin, and decreased urinary output. 2. Incorrect: History of prior bleeding episodes is important but does not address the immediate problem. 3. Incorrect: Medication history is important, but the nurse must first determine whether or not the client is in shock.
What is the Hgb normal male range?
14-15 g/dL
What is normal BP for a 65-70yr old?
140/90 or less
You are preparing to teach an obesity support group about strategies and guidelines for dietary modifications to achieve weight loss goals. Which of the following are correct understandings of dietary planning principles for patients with obesity? Select all that apply. 1. Limiting consumption of grains and other carbohydrates is an effective means of weight loss 2. 3500 calories is equivalent to approximately one pound of weight lost 3. The patients should set goals to lose 5-6 pounds per week x 4. 'Cheat days' are an effective reward for good eating habits throughout the week x 5. The patient should plan to eat regular meals in small servings 6. All patients should utilize the help of a commercial weight loss program
2. 3500 calories is equivalent to approximately one pound of weight lost 5. The patient should plan to eat regular meals in small servings General principles of nutritional therapy for patients with obesity include: 3500 calories typically is equivalent to one pound of weight ost Dieting, such as fad diets, are typically unbalanced and are Not effective or sustainable means of losing weight. Use of these diets will result in deficiency of one or more nutrients Regular meals should be eaten in small servings, and typically should contain lower amounts of fat and calories, and contain adequate amounts of vitamins, minerals, and fiber Realistic and healthy weight loss goals (such as 1-2 pounds per week) are important to discuss with the patient. Research has shown that overweight people are stimulated by external factors to consume food. Behavior modification focuses on examining the lifestyle of patients and creating strategies to control food cues. Weight loss programs are often expensive and may not be accessible for a low-income patient.
The nurse is providing counseling to a patient with premenstrual syndrome (PMs). The PT has been experiencing abdominal pain and migraine h/a which she rates as 7 out of 10 on the pain scale. The nurse is working with the patient to develop strategies for non pharmacological pain management. Which of the following interventions would NOT be appropriate for the nurse to recommend? 1. Avoid excessive caffeine intake 2. Avoid exercising more than twice a week 3. Collaborate with a dietitian to implement dietary changes 4. Develop strategies for managing stress
2. Avoid exercising more than twice a week - exercising IS a form of nonpharmacological pain management. Should not be avoided. - non pharmacological measures include: - stress management - diet changes - exercise - avoid caffeine -counseling and education
Activities to Alert Nurse of PT on Chemo of Higher Risk of infection.
mani/ pedi a 2 wks (Avoid fake nails / salon's Spa) -60 to local water park - ( accident water ingestion increase risk of infection) -goes barefoot at home (risk of cuts, scapes = injury/ infection) - cats in house, clean litter box 1x per week ( risk for pathogen exposure, if approve by pcp use gloves, mask and hand wash)
What is acute epiglottitis?
medical emergency. A serious obstructive inflammatory process that occurs in children between 2 and 5 years of age but occur from infancy to childhood.
Types of play during preschool (3-6 years)?
the child is able to engage in associate play (playing with others), imitative, and dramatic play and imagination games. They also begin to refining gross motor skills such as running or jumping.
A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? STA 1. MMR (measles, mumps, rubella) 2. DTaP (diphtheria, tetanus, pertussis) 3. VAR (varicella) 4. HiB (haemophilus influenza) 5. OPV (oral polio virus)
2. DTaP (diphtheria, tetanus, pertussis) 4. HiB (haemophilus influenza) 2 & 4. Correct: Children with AIDS are immunocompromised because of the HIV virus. Vaccines are crucial to provide protection against common childhood diseases. However, only vaccines which contain synthetic or inactivated viral components are acceptable for children with active AIDS. Diphtheria, tetanus, pertussis is inactive and is provided in multiple doses, starting at 2 months of age, with a booster at age 6. Haemophilus influenza is critically important since this flu virus can lead to meningitis, pneumonia or epiglottitis. This vaccine is also administered in multiple injections over a period of months, starting at 2 months, and then yearly throughout life. 1. Incorrect: The combination vaccine of measles, mumps, and rubella contains a live virus. 3. Incorrect: Varicella is a live vaccine administered to protect children from chickenpox and the potential for shingles later in life. 5. Incorrect: Oral polio vaccine contains the live polio virus and could be deadly to those with an immunocompromised system. The correct form of polio vaccine for AIDS clients is called IPV, or inactivated polio vaccine, and is given by injection.
A nurse is teaching a 12 yr old patient with DM and their parents about the use of a portable insulin pump. Which of the following statements made by the patient demonstrates a need for further teaching? 1. The site for the pump should be changed every 2-3 days 2. I will cover the inflamed site with a transparent dressing 3. The site is rotated at the first sign of inflammation 4. I will clean the site thoroughly before inserting the needle
2. I will cover the inflamed site with a transparent dressing The site should be cleaned thoroughly before the inserted and then covered with a transparent dressing. The site is changed at the first sign of inflammation. 1. the site is changed and rotated every 48 to 72 hours 3. The site is changed and rotated at the first sign of inflammation 4. the site should be cleaned thoroughly before the needle is inserted **The major problem with the use of an insulin pump is the inflammation from irritation or infection at the insertion site**
The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container
2. In a chemotherapy sharps container
The nurse is consoling two parents of a child who was recently diagnosed with a brain tumor. The parents express guilt for mistaking the child's symptoms of h/a and visual difficulties as acting out behaviors. Which of the following response by the nurse is the MOST appropriate? 1. You should have reported those symptoms sooner 2. It is normal to feel guilty for misinterpreting those symptoms 3. The surgeons will do their best to remove the tumor 4. You shouldnt feel guilty since most parents would make the same mistake
2. It is normal to feel guilty for misinterpreting those symptoms - validating and emphasizing that feeling of guilt are normal in this period of therapeutic communication. The nurse is conveying empathy for the parent's reaction to their child's symptoms.
A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? 1. Yes, I believe that God will heal you. 2. Many people of faith believe that one way God works to heal is through medication. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the medication?
2. Many people of faith believe that one way God works to heal is through medication. -This allows the client to keep the belief that God will heal but will do it through the medication. This promotes compliance with the prescribed medication regimen.
A 90-year-old male is visited by a community nurse in his home. The client asks how he can protect himself from getting sick. Which of the following health promotion activities is most effective in pneumonia prevention? 1. Obtaining the influenza vaccine annually 2. Obtaining the pneumococcal pneumonia vaccine 3. Maintaining a physically active lifestyle 4. Ensuring adequate fluid intake x
2. Obtaining the pneumococcal pneumonia vaccine -Obtaining an annual influenza immunization and a pneumococcal pneumonia vaccination are effective preventive measures for pneumonia.
the nurse is providing teaching to nursing students about underlying physiology Parkinson's disease. Which of the following statements should the nurse include? 1. Parkinson's disease is a result of too much dopamine within the brain 2. Parkinson's disease is a result of not enough dopamine within the brain 3. Parkinson's disease is a result of not enough acetylcholine within the brain 4. Parkinson's disease is a result of too much serotonin within the brain
2. Parkinson's disease is a result of not enough dopamine within the brain - Parkinson's disease is the result of not enough dopamine which causes the acetylcholine response to go unopposed; thus causing rigidity, instability and slowed movements.
A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? 1. Send the client to the waiting room. 2. Place the client in a negative pressure room. 3. Put a surgical mask on the client. 4. Initiate contact precautions.
2. Place the client in a negative pressure room. The client may have smallpox, which is very contagious. Smallpox can also be used as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure.
The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth? 1. Dilated pupils after 1 minute of CPR 2. Presence of a carotid pulse with each compression 3. Cardiac rhythm on the monitor 4. Rise and fall of client's chest with ventilations
2. Presence of a carotid pulse with each compression -If chest compressions are being given with enough force and depth, a pulse will be felt with each compression.
The nurse is providing instruction to a PT with hypophysectomy about ways o reduce the risk of increase ICP. Which of the following activities should the nurse include in this list? 1. Fluid restriction of 1500 mL per day 2. Take stool softeners and laxatives 3. Bend at the waist with the head up when picking up objects off the floor 4. Perform deep breathing exercises
2. Take stool softeners and laxatives - the nurse should instruct the PT to do the following activities to prevent a rise in ICP: - avoid bending at the waist to pick things up, instead bed with knees and lower torso - drink a lot of fluids and eat high fiber diet - take laxatives or stool softeners
A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence? 1. Ecchymosis of incision 2. Tenderness over the kidney 3. Frequent polyuria 4. Subnormal temperature
2. Tenderness over the kidney Tenderness over the kidney indicates a problem with the kidney, and the primary healthcare provider should be notified immediately. Other s/s of an acute rejection are fever, increased BUN/CR, weight gain, decreased urine output, and increased BP.
The nursing students asks her supervising nurse why theophylline is not the drug of choice for long term asthma management. which of the following responses by the nurse is best? 1. Inhaled corticosteroids are more effective in long term management of asthma 2. Theophylline has a high potential for toxicity 3. Theophylline produces more undesirable side effects than other asthma meds 4. Theophylline is ineffective for treating acute asthma attacks
2. Theophylline has a high potential for toxicity - high potential for toxicity requires careful monitoring of serum levels.
which of the following interventions is used to manage the fluid and electrolyte imbalances associated with viral meningitis? 1. limit sodium intake 2. decrease fluid intake 3. admin lactated ringer's 4. admin amoxicillin
2. decrease fluid intake - decreasing fluid intake reduces the dilution of serum sodium and also prevents the patient from retaining more water. - SIADH secondary to meningitis should be managed by decreasing fluid intake and administering hypertonic fluids as well as loop diuretics
A client is admitted with a stroke on the right side of the brain. What clinical manifestation does the nurse expect to find when assessing this client? STA 1. right side hemiplegia 2. impaired judgement 3. depression 4. impaired language comprehension 5. impulsiveness 6. impaired speech
2. impaired judgement 5. impulsiveness - s/s are different depending on where the stroke damage is located. Patient with damage to the right side of the brain tends to deny or minimize their problems. The clients with right brain stroke tends to be impulsive and move quickly. Whereas the PT with left brain stroke are more likely to have memory problems related to language and are cautious in making judgments.
A female PT with paranoid schizophrenia has been hospitalized during an acute psychotic episode. She refuses to eat and has lost 20 lbs since she was admitted. What is the MOST appropriate nursing intervention? 1. supervise the patient's meals 2. offer canned or packaged foods 3. Taste the food to demonstrate that is has not been poisoned 4. Request an order for NG feeding.
2. offer canned or packaged foods - prevent further wt loss and malnutrition. Communicating with the patient to determine which foods she is comfortable with eating is an important part of dietary planning. - The nurse must attend to the PT's physical needs as well as psychological needs. Therapeutic communication and an understanding of the patient's condition can help the nurse and health care team develop client specific care plans.
A nurse is caring for a 2 yo pediatric Pt and is developing a care plan for the PT during their time in the hospital. Based on your knowledge of the child growth and development, which of the following forms of play would not be expected of the child at this stage? 1. Parallel play 2. Locomotive play 3. Associative play 4. Tactile play
3. Associative play - not appropriate type of play for a 2 yr old. Requires psychosocial development of a more mature child. The toddler is likely unable to play with others but can play alongside others.
Which client should the nurse, working the Emergency Department (ED), see first? 1. Client diagnosed with Chronic Obstructive Pulmonary Disease (COPD) who has a non-productive cough. 2. Client who is a diabetic and has an infected sore on the foot. 3. Client with adrenal insufficiency who feels weak. 4. Client with a fracture of the forearm that has been placed in a splint.
3. Client with adrenal insufficiency who feels weak. Correct: Adrenal insufficiency with weakness think SHOCK first. This is a client that does not have enough of all their steroids, including glucocorticoids, mineralocorticoids or sex hormones. The most pertinent of these is aldosterone, which causes loss of sodium and water, and leads to shock (fluid volume deficit). Since the client is feeling weak, this is a clear sign of fluid volume deficit (FVD) and potentially for shock.
Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? Select one 1. Hemoglobin of 11 g/dL (110 g/L) (6.8266 mmol/L) 2. White Blood Cell count of 22,000 mm3 3. Hematocrit of 18% 4. Serum glucose of 80 mg/dL (4.44 mmol/L)
3. Correct: A hematocrit in postpartum women can drop as low as 20% (0.2) and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of 18% and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope. 1. Incorrect: A hemoglobin of 11 g/dl (110 g/L) (6.8266 mmol/L) is considered to be normal for pregnancy and postpartum. 2. Incorrect: It is not unusual for a postpartum woman to have a WBC up to 25,000 mm3 without infection because of the healing process of the reproductive system. 4. Incorrect: Serum glucose of 80 m/dL (4.44 mmol/L) is within the normal range of glycemic control.
A community health nurse is teaching a class on eating disorders at the local community center. Which of the following statements indicate a need for FURTHER teaching? 1. Foods should only be available during scheduled meal time 2. Weight should be taken daily and physical activity should be limited. 3. Food should be given as positive reinforcement for good behavior 4. trips to the bathroom should be supervised after meals and snacks
3. Food should be given as positive reinforcement for good behavior - a person with an eating disorder may equate food with lose and this could encourage binge eating
A nurse is reviewing the medication admin record of a patient with hyperparathyroidism. Which of the following meds would the nurse find the most concerning? 1. Pamidronate 2. Calcitonin 3. Hydrochlorothiazide 4. Mithramycin
3. Hydrochlorothiazide - thiazide diuretics are contraindicated for patients with hyperparathyroidism because they decrease renal excretion of calcium, leading to hypercalcemia. - Bisphosphonates, corticosteroids, and calcimimetics are medication classes that work to decrease serum calcium levels. Thiazide diuretics are contraindicated for hyperparathyroidism PT's because they promote calcium retention
When caring for young adult clients, which developmental tasks would the nurse expect to see?STA 1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. 5. Developing sense of fulfillment by volunteering in the community.
3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. -In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust.
When completing a focused assessment for a patient with suspected increased intracranial pressure (IICP), what is the nurse's priority prior to beginning? 1. Strict hand hygiene 2. Ensuring patient is awake and rousable throughout assessment 3. Ensuring head and neck position maintain in a midline position 4. Application of antiembolism stockings
3. Ensuring head and neck position maintain in a midline position
An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has? 1. Hypocalcemia 2. Hypermagnesemia 3. Hypokalemia 4. Metabolic alkalosis 5. Respiratory acidosis
3. Hypokalemia 4. Metabolic alkalosis Clients who vomit lose acid; therefore, they will have metabolic alkalosis. A client who is not eating and is vomiting will also lose potassium. Potassium is the electrolyte most significantly lost from the upper GI tract.`
A nurse is caring for a patient with SARS who has been on airborne precautions for the past four days. During the morning assessment, the patient stated. "This is all my fault that I got SARS, now I am on isolation which is what I deserve" Which of the following actions of the nurse does NOT minimize the psychological effect of isolation? 1. Educate the PT about the purpose of isolation before initiating isolation measures 2. Manage time to play a quick card game with the patient 3. Provide care quickly to limit exposure to the virus 4. Give the patient a tepid sponge bath to maintain hygiene.
3. Provide care quickly to limit exposure to the virus - if the nurse hurries through care or shows a lack of interest, the patient will feel rejected and even more isolation. The nurse must act to minimize feelings of psychological and physical isolation because the pt's emotional state can interfere with his or her recovery. SO quickly rushing through care will NOT minimize psychological effect of isolation it will make it worst
The nurse is reviewing ECG strips from several patients and notices that two of the ECGs depict U waves following the T waves. The nurse recognizes that the occurrence of U waves represents which of the following? Select one: 1. Ventricular repolarization 2. Atrial depolarization 3. Purkinje fibre repolarization 4. Impulse travel through the AV node
3. Purkinje fibre repolarization A U Wave, which may be present on a normal ECG, represents the slow repolarization of Purkinje fibers.
A patient who overdosed on aspirin has come to the emergency department. During acute management of this patient, which of the following should the nurse monitor within Correct the first 12 hours after ingestion? Select one: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory alkalosis 4. Respiratory acidosis
3. Respiratory alkalosis During an ASA overdose, hyperventilation in the early stages results in respiratory alkalosis and can last for as long as 12 hours. The next stages that begin within 24 hours after ingestion result in dehydration and metabolic acidosis.
A 35-year old female patient is suspected to have acute otitis media and is scheduled for otoscopy. Which of the following results regarding the tympanic membrane indicate the presence of otitis media? Select one: 1. The tympanic membrane is translucent and exhibits single perforations 2. The tympanic membrane is pearl-gray and exhibits increased mobility 3. The tympanic membrane is retracted and exhibits decreased mobility 4. The tympanic membrane is flat and exhibits increased mobility
3. The tympanic membrane is retracted and exhibits decreased mobility -Patients with suspected otitis media are scheduled for otoscopy to assess the characteristics of the tympanic membrane. The tympanic membrane is typically pearl-gray, translucent, and flat with single perforations. If it exhibits decreased mobility, retraction, bulging, and redness, it is likely that otitis media is present. Correct Answer: Decreased mobility and visible retraction are common signs of serous otitis media (Option #3). Incorrect Answers: Normally, the tympanic membrane is translucent, pearl-gray, and flat. Therefore, these results do not indicate otitis media (Option #1, 2, 4)
A nurse is conducting a follow up appointment with a pregnant patient who has DM. The patient asks the nurse about insulin use during pregnancy. Which of the following does the nurse include in the teaching? STA 1. Insulin crosses the placenta 2. insulin doses should be decreased in third trimester 3. insulin doses should be increase in the second trimester 4. insulin doses decrease after delivery of the placenta 5. Maternal glucose crosses the placenta
3. insulin doses should be increase in the second trimester 4. insulin doses decrease after delivery of the placenta 5. Maternal glucose crosses the placenta Insulin doses need to change over the course of pregnancy due to the demands pregnancy puts on carbohydrate metabolism. The nurse should explain that maternal glucose passes through the placenta but insulin does not. The fetus creates its own insulin but pulls glucose from the mothers. Therefore, the insulin taken during the first trimester needs to be decreased. During the second and third trimesters, the placenta hormones causes the mother to have an insulin resistant state, which in turn requires increased doses of insulin After delivery of the placenta, the patient will have a sudden decrease in placental hormones and will then need a decrease in insulin.
Which of the following are clinical manifestations of absence seizures? Select all that apply: 1.Preictal aura 2.Muscle rigidity 3.Preictal hyperventilation 4.Blank-staring 5.Automatisms
3.Preictal hyperventilation 4.Blank-staring 5. Automatisms Options #3, #4, #5: are all clinical manifestations of absence seizures. Nurses must move the patient onto the floor and into a side lying position until consciousness is reestablished. Option #1: Preictal aura occurs in simple partial seizures and are not found in absence seizures. Option #2: Muscle rigidity is found in tonic or tonic-clonic seizures and is not found in absence seizures. TAKEAWAY: Absence seizures are manifested by preictal hyperventilation and flashing lights, brief LOC, blank-staring and automatisms.
How much fiber should an older adult consume? How much water should they consume?
35-50 gr of fiber Drink 2L of H20
At what age is it a concern if the infant is not able to push down feet when placed on hard surfaces?
4 months
When is the 2nd dose of Diphtheria vaccine given?
4 months
At what age is it a concern if the infant is not able to to build 10 blocks tower
4 yrs
A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan? 1. Moist, shiny, soft hair 2. Resting heart rate of 120 3. Adheres to the prescribed low-sodium diet 4. An absence of corneal irritation
4. An absence of corneal irritation Graves' disease is hyperthyroidism and can lead to exophthalmos. Exophthalmos is defined as abnormal protrusion of the eyes. These clients tend to have dry, irritated eyes. Absence of corneal irritation indicates that the client is following the plan of care, which includes eye drops or ointment to protect the exposed cornea.
The nurse is caring for a patient and her large family of six. It is a busy day on the unit and the nurse is assigned an unlicensed assistive personnel (UAP) to work for the day. The family is very concerned about the patient. Which of following tasks is appropriate for the nurse to delegate to the UAP in the care of the patient and family? 1. Provide the family with information about the patient's condition. 2. Teach family members how to assist patients with activities of daily living 3. Take the patient's vital signs while explaining to the family members what each vital sign indicates 4. Communicate observed information about family dynamics to the Registered Nurse
4. Communicate observed information about family dynamics to the Registered Nurse -The RN may not delegate any task requiring nursing knowledge, including patient teaching, to a UAP. The family may be cared for as a unit and require specific communication, education, and care.
A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? 1. Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Pre-term labor client with twins at 28 weeks gestation.
4. Correct: Both clients are presenting with the possibility of preterm deliveries. The room should be kept quiet to decrease stimulation of the clients. Also, the client with preeclampsia should not be stimulated which could increase her blood pressure. 1. Incorrect: The client will require frequent postpartum assessments and nursing care. The client will likely have a great deal of activity in her room and this would be potentially harmful to the newly admitted client. 2. Incorrect: This client will have a increase of activities in her room as the preterm labor progresses. There is also the potential of an emergency delivery. 3. Incorrect: The client is admitted with placenta previa. Emergency deliveries may occur if the client becomes hypovolemic or there are signs of fetal compromise.
The nurse is completing a focused assessment on a client post coronary artery bypass surgery (CABG). What finding warrants immediate attention by the nurse? 1. Central venous pressure (CVP) 6 mmHg 2. Mediastinal chest tube drainage of 70 mL in 1 hour 3. Incisional pain rated 9/10 4. Pulsus paradoxus
4. Correct: Pulsus paradoxus is an indicator of cardiac tamponade. This is a severe complication after open heart surgery and is a medical emergency. The primary healthcare provider will need to be notified
The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? 1. Endotracheal tube (ET) 2. Head tilt-chin lift maneuver 3. Oropharyngeal airway 4. Jaw thrust maneuver
4. Jaw thrust maneuver This is a trauma client that could possibly have a C-spine injury. The jaw thrust maneuver will open the client's airway without manipulating the client's C-spine. 1. Incorrect: The endotracheal (ET) tube is a device for maintaining an open airway, not for opening it. 2. Incorrect: This is a trauma client who may have a C-spine injury. The head tilt-chin lift maneuver would manipulate the client's C-spine therefore is not used with this client to open the client's airway. 3. Incorrect: The oral airway is a device for maintaining an open airway, not for opening it.
The nurse is caring for a first time mother of a newborn baby on the maternity unit. The mother is of Mexican descent and expresses to the nurse that she will not be breastfeeding until after she returns home, as the initial colostrum she has produced is bad for the baby. Which of the following interventions is most appropriate in the care of this mother and her newborn? 1. inform the mother that the healthcare team must observe one successful breastfeeding prior to d/c 2. agree with the mother regarding the negative effects of colostrum and allow her to follow this practice 3. have a lactation consultant communicate with the mother as the nurse's knowledge does not extend to the area 4. Explain to the mother the laxative and nutritive properties of colostrum
4. Explain to the mother the laxative and nutritive properties of colostrum - the nurse can respectfully provide the mother with education regarding the proven benefits of colostrum. The mother can use this information to make an informed decision about her infant's care. The nurse should respect the mother's decision and continue to provide care in an non judgemental and unbiased way.
A nurse is teaching an 8 year-old child with type 1 diabetes and their parents about insulin. Which of the following should the nurse not included in this teaching session? Select one: 1. Treatment method and insulin prescribed 2. Discard opened insulin vials after 1 month of being opened 3. Characteristics of the various types of insulins 4. Not to mix different insulin types as this can cause reactions
4. Not to mix different insulin types as this can cause reactions (Option #4) Some types of insulin can be mixed together; families need to know the proper mixing and dilution of insulins and how to substitute another type when their usual brand is not available. Incorrect answers (Option #1) Families need to understand the treatment method and the insulin prescribed. (Option #2) Insulin bottles that have been "opened" should be stored at room temperature or refrigerated for up to 28 to 30 days. After 1 month, these vials should be discarded. (Option #3) Families need to know the characteristics of the various types of insulins.
A client with hx of CHF has been admitted with digoxin toxicity. After reviewing the initial lab results the nurse knows the abnormal findings MOST likely contributed to the digoxin toxicity? 1. sodium 2. Calcium 3. Albumin 4. Potassium 5. Magnesium
4. Potassium 5. Magnesium - Hypokalemia and hypomagnesemia both can increase the client's potential to develop digoxin toxicity. Digoxin and potassium both bing at the same location on the ATPase pump. When potassium levels are low, more digoxin will attach to the sites, leading to toxicity. Low magnesium levels sensitize the cardiovascular system to the toxic effects of digoxin.
The nurse is developing a care plan for a PT with cancer, who is receiving hospice care at home. Which of the following interventions would be the most appropriate for the managing the client's chronic cancer pain? 1. PRovide pain med whenever the client rates the pain greater than 5 out of 10 2. Sedate the client with tranquilizers during reports of severe pain 3. admin analgesics when VS indicate increase pain severity 4. Provide prescribed analgesics used an around the clock schedule to prevent recurrent pain
4. Provide prescribed analgesics used an around the clock schedule to prevent recurrent pain - help to prevent breakthrough pain. more effective than admin when needed
The night nurse is caring for a PT with PTSD and finds him crying on the floor, repeatedly saying, "I didn't mean to kill all those people". After examining the PT and assisting him safely back to bed, which of the following actions should the nurse do first? 1. Notify the nurse manager 2. File an incident report on the fall 3. Raise all the bed rails up to prevent the PT's from falling from his bed again 4. Put the bed alarm back on.
4. Put the bed alarm back on. - promotes the immediate safety of the PT
The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene? 1. TPN has been hanging for 12 hours 2. Central venous catheter's dressing is clean and dry 3. TPN fluid is room temperature when beginning administration 4. TPN appears oily in consistency
4. TPN appears oily in consistency Correct: Do not use TPN if it looks curdled, oily, or has particles in it. This is an indication that something is wrong with the solution and could harm the client if given. 1. Incorrect: This TPN does not need to be replaced at 12 hours. It can infuse for 24 hours. 2. Incorrect: This is a description of an occlusive clean dressing at the insertion site. This description would not require intervention. 3. Incorrect: TPN should be at room temperature when beginning administration. Solutions that is too cold could cause vasoconstriction and undue harm to the client.
Which client diagnosis would require the nurse to initiate droplet precaution? 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Whooping cough
4. Whooping Cough 1&3 - contact 2- airborne
A charge nurse is working in a busy post op unit making shift assignments. Which of the following is an appropriate assignment for an LPN? 1. a newly admit PT who had abdominal surgery that morning 2. a patient with a mastectomy needing d/c instructions 3. a patient who had an appendectomy requesting assistance with a bed bath 4. a patient with urinary retention with an order for straight cath
4. a patient with urinary retention with an order for straight cath 1 and 2 are assignments for the RN. 3, the UAP can complete
What is the size of an infant needle length for a MMR vaccine?
5/8"
What is the size of a needle needed for Children 12 months or older?
5/8" - 3/4"
A homebound PT has uncontrollable DM and open wound. The home health nurse is concerned about PT condition/possible need for referral. What intervention do you initiate?
Ask provider to prescribe dm educator consult (education needs should be met before referral; made by HH nurse)
What is Terbinafine hydrochloride cream used to treat?
Athlete's foot/fungal infections to feets
Examples of foods high in tyramine?
Avocado, smoked ham Wine, Ales, chianti, sherry Sausage, salami, bologna Beer, blue cheese
What to avoid w/ Sickle cell anemia?
Avoid high altitudes
What can Phenobarbital and Loratadine cause?
CNS depression drug to drug interaction between anti seizure med and antihistamines.
OUT of BUN and creatinine what is the best indicator of kidney function?
Creatinine
Define a Cluster H/A
Ipsilateral nasal congestion & rhinorrhea
What is the action of fluoxetine?
Increase level of serotonin in the brain (can also increase level of norepinephrine in brain
Elderly bed-bound PT receiving G-tube feedings a home, In ED for behavioral changes & hallucinations. Nursing Priority?
Initiate Seizure precautions (G- tube makes Pt dehydrated so if already has neuro changes, seizure may be next)
Place a Stethoscope for the heart sounds of Erb's point?
Left 3rd intercostal space
What is Akinesia?
Muscle weakness
Define apraxia
Pt can't perform purposeful movement
What is an example of hospital associated infection?
Pt with c-diff while receiving IV antibiotics (IV cath increase risk of HAI)
Peak of Rapid acting insulin
Peak in 30 min
What is proper cone technique?
Place on stronger side of body, forward 6-10in, while the patient advances weak leg at the same time
Mantoux skin test Residents employee of high risk setting (e.g nursing home) with induration of 10m or more is?
Positive
Mantoux skin test, HIV PT induration of 5m or greater = ?
Positive
What is the credé method?
Pressing down over the bladder w/ hands, increases bladder pressure, and stimulates relaxation of sphincter to allow voiding.
What is Addison's Disease?
Prob w. Aldosterone (mineralocorticoid, not enough steroids) Retains H2O and NA+, lose K+
What is another name for kidney stones?
Renal lithiasis
Define a tension H/A
bilateral, pressing /Heightening pain
what is an endoscopic retrograde cholangiopancreatography (ERCP)?
diagnostic test to examine the duodenum, the papilla of Vater, the bile ducts, the gallbladder and the pancreatic duct. The produce is performed using a duodenoscope that can be directed and moved around the bends of the stomach and duodenum. Inserted through the mouth , through the back of the throat, down the esophagus, through the stomach and into the duodenum.
What is Menierre's disease
dilation of endolymphatic system by overproduction or decrease re-absorption of endolymphatic fluid
Lacto-ovo vegetarian diet means?
does not include meat, but does contain eggs and dairy.
what is manifested by Meniere's disease
ear fullness tinnitus h/a vertigo nystagmus N/V hearing loss
Define Dystonia?
upward gaze of the eyes
A patient is often physically startled when spoken to and reports feeling very anxious. The patient says, "It's as though something bad is always going to happen to me." In what order from first to last should the following nursing actions occur? Ordered Response - Approach calmly - Reduce environmental stimuli - Discuss the patient's feelings in more depth - Teach problem solving activities - Instruct the patient to deep breathe for two minutes
(1) The nurse should first eliminate or remove the anxiety-producing activity or stressor that has contributed to the patient's distress to prevent further agitation. (2) The nurse should then approach in a calm manner to prevent startling the patient. (3) Coaching the patient through deep-breathing exercises promotes relaxation. (4) Afterwards, the nurse can explore the patient's feelings and perceptions in more depth to identify potential triggers and underlying issues. (5) Lastly, the nurse can work with the patient to develop problem-solving strategies to handle the triggers and anxieties more effectively and appropriately should the patient experience another episode.
PT w/ brain injury Keep trying to get out of bed, interventions ?
- ASK a familiar person to stay W/PT (Calming effect, can I directly mentior PT) - Apply position Change alarm (result in quicker response by Start) - Move of close to nurse station (abie visvai /monster PT closer
What is the glomerulus?
- Kidney filter
some non-pharmacological interventions that can be taught to patients with symptoms of morning sickness? (6)
- dry carbohydrates such as saltine crackers and toast - avoid brushing teeth immediately after waking - eat small, frequent low fat meals during the day - drink liquids between meals - avoid fried and spicy food - asking the HCP about herbal remedies and acupuncture
Define Hypoalbuminemic? What problems may occur?
- low albumin in the blood - Problems w/ Protein loss - blood clots - High cholesterol & triglycerides
How often is CAPD peritoneal dialysis done? What kind of patient conditions are not eligible for this type of dialysis? What symptoms could the patient experience after dialysis?
-4 times a day, 7 days a week -PT with disc disease, arthritis, colostomy. -PT may have pressure or back pain
Pt with major depression spends all day in bed. What is the appropriate nursing action?
-Frequently initiate contact with pt -Be accepting of and spend time with pt. The pt may exhibit pessimism and negativism. Nurse should focus on strengths and accomplishments and minimize failures. -Nurse should round on pt in irregular intervals so pt doesn't know when nurse is coming (then attempt suicide) -Nurse should seek out pt (they're not likely to come look for you)
When giving isoniazid therapy for TB PT. What do we give with it?
-Give w/ bundokine (supplement nutritional agent) to prevent peripheral neuropathy. -Isoniazid interferes w/ Vitamin B6 (pyridoxine) metabolism by inhibiting the formation of the active form of Vit B6.
What is Timolol used for? When is it contradicted?
-Glaucoma -Contraindicated in Pt with asthma or COPD. -b/c systemic absorption can increase airway resistance and bronchospasm. -*Hold med if PT has asthma/COPD*
What might HCP order to assess generalized malnutrition?
-Prealbumin -Prealbumin decreased quickly when nutrition is not adequate.
DIC teaching of hiatal hernia
-eat 6 small meals a day (decrease heartburn) -Sit up for 1 hr after eating -Avoid eating grapefruit (too acidic) -Place blocks under bed (keep stomach down, reduce symptoms in sleep) -Avoid lifting heavy Objects (prevent straining) -may be prescribed laxatives (prevent straining)
S/S of Neuroleptic Malignant Syndrome (NMS)
-fever -altered mental state -muscle rigidity - Autonomic dysfunction
If Pt has Kidney injuries or disease what kind of restrictions are they put on?
-fluid restriction, -so the PT might have excessive thirst
How is MMR vaccine given?
-given Sub Q -use 23-26 gauge needle
What is Donepezil used for? Rare serious S.E? When should it be given?
-help decrease symptoms of dementia in Clients w/ Alzheimers -rare serious SE - black Stools, vomit coffee grounds, severe stomach abdominal pain. -should be given in the evening, just b4 bedtime.
What is a normal TSH range?
0.4 - 4.2
What are the interventions for oral feeding of a stroke patient?
1) High fowler's position (60-90 degrees) 2) Mouth care prior to feeding 3) Flex head forward for eating 4) Use crushed ice as stimulant for swallowing 5) Offer thickened liquids to drink Steps 2-5 are to stimulate sensory awareness, salivation, and decrease risk of aspiration
A pt with pancreatitis becomes increasingly restress, confused, and pulls out NG tube and IV catheter. HR-128min, BP-96/62, O2-90%, skin is cool and clammy to touch. What actions should the nurse take?
1) Initiate oxygen (pt is hypoxic) 2) Insert IV line (fluids to increase volume, improve bp/port for meds) 3) Check blood sugar (pancreatitis=possible insulin prob) 4) Insert NG tube (keep pt empty/dry. Prevent aspiration w/ vomit) 5) Recheck vital sign (evaluate nursing actions)
6 month PT admit w/ meningococcal meningitis. Order to implement Orders?
1) Place PT on droplet precaution (Safety first, highly contagious) 2) Start IV of D5% NS a 25mL/hr . 3) Draw blood cultures q8h/ 3x (decrease needle sticks, site may be used to admin Sedation for lumbar puncture) 4) Prepare for lumbar puncture 5) Admin Ceftriaxone 250 mg IV, TID.
In the event of a needlestick injury what steps should the nurse take? And in what order? -attend occupational health clinic to obtain post exposure -complete incident report, notify nurse manager -First, rinse affected area w/ running water
1) rinse affected area w/ running water and 2) Attend Occupational health clinic to obtain post exposure 3) compiere incident report, notify nurse manager
What is the order of NG-tube placement?
1)Elevate HOB to fowler's position 2)Measure distal NF tube from nose to ear to xiphoid process 3)Lubricate 2-3in of distal nf tube 4) Insert ng tube into unobstructed naris 5) Advance NG tube upward and backward until meet resistance 6) Rotate catheter and advance into nasopharynx 7)Have pt swallow ice as NG tube advances to stomach 8) Secure NG tube
The nurse is speaking to parents of a newborn diagnosed with phenylketonuria (PKU) prior to their discharge home. Which of the following statements is appropriate to include in the health teaching of these parents? Select all that apply: 1. "All natural proteins contain phenylalanine" 2. "Your child's diet will have 20-30 mg/kg of phenylalanine per day" 3. "You can gradually begin to introduce protein rich foods to your child until they are safe to consume them normally" 4. "Artificial sweeteners such as aspartame are a suitable alternative to provide, instead of natural sugars" 5. "This is a genetic disorder, and your future children are likely to also have phenylketonuria"
1. "All natural proteins contain phenylalanine" 2. "Your child's diet will have 20-30 mg/kg of phenylalanine per day 5. "This is a genetic disorder, and your future children are likely to also have phenylketonuria" PKU is a metabolic defect inherited as an autosomal recessive trait in which the patient has a deficiency or absence of the enzyme needed to metabolize phenylalanine (an essential amino acid), resulting in an accumulation of phenylalanine in the bloodstream and an absence of tyrosine. It is a genetic disorder for which there is no cure-treatment involving a lifelong commitment to strict dietary management of phenylalanine intake. Collaboration with a dietitian is essential for the patient and family with PKU. Option #1 : the parents should be aware that all protein sources, including meats, poultry, dairy and soy contain phenylalanine. Many foods contain low levels of phenylalanine and should also be carefully monitored. Specialized formulas are available that are free from phenylalanine. Option #2: maintaining a specific phenylalanine level will allow for growth that is required of the protein, without increasing serum levels to dangerous levels. This lab value should, therefore be frequently monitored. Option #5: Parents who have children with PKU are likely to have another child with PKU. Counseling regarding this genetic influence is indicated. Option #3: this is incorrect. Lifelong dietary management is indicated in PKU, and the patient will not be able to consume a full protein diet at any point. This condition is permanent. Option #4: Aspartame and other sweeteners contain phenylalanine and should be avoided in a patient with PKU.
Which of the following patients will be put on airborne precautions? Select all that apply: 1. A 4-year old with varicella 2. A 45-year old with HIV 3. A 16-year old with measles 4. A 24-year old with influenza A 5. A 1-year old with pertussis
1. A 4-year old with varicella 3. A 16-year old with measles Correct answer (Option #1,3): These illnesses require airborne precautions as they are transmissible through tiny droplets that can be caused by coughing and sneezing, where they remain for a period of time. Incorrect answer (Option #2) This patient requires standard precautions as HIV is only infectious through blood, mucous membranes, non-intact skin and other bodily fluids. (Option #4) This patient requires droplet precautions due to influenza A's transmissibility through droplets from coughing and sneezing. (Option #5) This patient requires droplet precautions due to pertussis transmissibility through droplets from coughing and sneezing
The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected? 1. Abrupt onset of dyspnea, fever. 2. Small papule on skin resembling an insect bite. 3. Pustular vesicles on skin. 4. Fatigue.
1. Abrupt onset of dyspnea, fever.
A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? Exhibit: Hgb-15g/dl Hct- 42% Platelets - 110,000/mm3 aPTT -110 seconds INR - 1.2 1. Administer protamine sulfate 50 mg over 10 minutes. 2. Type and cross match for 2 units PRBCs 3. Increase enoxaparin dose to increase INR 4. Give the scheduled dose of enoxaparin
1. Administer protamine sulfate 50 mg over 10 minutes. 1. Correct: Protamine sulfate is given for heparin overdose. It is a heparin antagonist. Overdose is seen with a aPTT of 110 seconds. Depending on therapeutic intent, a client's aPTT levels should be between 60-80 seconds. (Normal aPTT for a client not on an anticoagulant is 25-35 seconds). 2. Incorrect: RBC, Hgb, Hct are normal. Blood transfusion is not indicated. 3. Incorrect: PT is not used to measure the therapeutic effect of enoxaparin, but rather aPTT. PT and INR are used for warfarin.4. Incorrect: aPTT is too long at 110 seconds. Therapeutic level is 60-80 seconds.
A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? 1. Administer the digoxin. 2. Hold the digoxin. 3. Notify the primary healthcare provider. 4. Repeat the digoxin level.
1. Administer the digoxin. 1. Correct: This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL.
The nurse is providing patient education to a 40year old woman who has a strong family history of heart disease. Which of the following is the most significant risk factor for women for the development of coronary artery disease? Select one: 1. Age 2. Genetics 3. Smoking 4. Obesity RATIONALE: The most significant risk factor for developing coronary artery disease in women is age (Option #1). Women are typically older than men when they develop coronary artery disease and are also more likely to die during hospitalization.
1. Age
A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate? STA 1. Apply splint nightly to affected extremities. 2. Approach client from the right side. 3. Provide full range of motion once a shift. 4. Elevate left extremities on a pillow. 5. Place pillow in the right axilla. 6. Wrap affected hand into a fist.
1. Apply splint nightly to affected extremities. 5. Place pillow in the right axilla. 1., & 5. Correct: With a left-sided stroke, the right side of the body is affected. Applying a splint at night to the affected extremity will prevent flexion of that extremity. Prolonged flexion leads to contractures. Prevent adduction of the affected shoulder with a pillow placed in the axilla. 2. Incorrect: Vision is controlled by the left side of the brain. Vision on the right side of both eyes may have decreased (hemianopia) due to this left-sided stroke, so approach the client from the left side. 3. Provide full range of motion four or five times a day to maintain joint mobility. 4. Incorrect: Remember, left-sided cerebrovascular accident = right sided paralysis. The right extremities, which are affected by the left-sided stroke should be elevate on a pillow to prevent dependent edema. 6. Incorrect: The fingers should be positioned so that they are minimally flexed. This will prevent a contracture of the hand. Flexing the fingers into a fist will cause them to contract.
A nurse is caring for a patient who has developed sinus bradycardia. Which of the following meds should the nurse anticipate the physician prescribing? 1. Atropine sulfate 2. Digoxin 3. Diltiazem hydrochloride 4. Adenosine
1. Atropine sulfate
The nurse is preparing to administer beclomethasone to a patient with chronic asthma. Before administering the medication, which of the following statements should the nurse use as a part of the patient education? Select all that apply: 1. Beclomethasone is used for its anti-inflammatory effects 2. Beclomethasone is used for preventative therapy to reduce the frequency and severity of asthma attacks 3. Beclomethasone suppresses the effects of leukotrienes, which is a group of inflammatory mediators x 4. Beclomethasone affects sympathetic receptors in the respiratory tract 5. Beclomethasone is administered for patients experiencing an acute asthma attack
1. Beclomethasone is used for its anti-inflammatory effects 2. Beclomethasone is used for preventative therapy to reduce the frequency and severity of asthma attacks Beclomethasone is a corticosteroid used for long-term management of chronic asthma. Beclomethasone has an antiinflammatory effect, which reduces inflammation of the airways and decreases the recurrence of asthma attacks. All inhaled corticosteroids, including beclomethasone, are used for long term management and should not be used as a rescue inhaler for an asthma attack. Side effects of this medication include: • Hoarseness • Dry mouth Changes in taste • Oropharyngeal candidiasis Beclomethasone can also mask signs of infections and is contraindicated if an infection is present (Option #1) Beclomethasone is a corticosteroid. Thus, it is used for its anti-inflammatory effects for patients with chronic asthma. (Option #2) Beclomethasone is used for preventative therapy. This medication is not a bronchodilator and is not used for patients experiencing asthma attacks in progress (Option #3) Beclomethasone is a corticosteroid, not a leukotriene modifier. (Option #4) Beclomethasone is a corticosteroid, not an adrenergic stimulant.
Which of the following are nonpharmacological comfort interventions for pneumonia? Select all that apply: 1. Chest physiotherapy 2. Gingko 3. Garlic 4. Repositioning 5. Oxygen administration
1. Chest physiotherapy 4.Repositioning Interventions of pneumonia include administering oxygen, encouraging coughing as well as deep breathing, encouraging fluids, and providing a high calorie, high protein diet with small frequent meals. Chest physiotherapy, repositioning, and herbs such as Echinacea are widely used to alleviate symptoms associated with pneumonia. RATIONALE: Correct Answers (Options #1, 4) Chest physiotherapy and repositioning are effective nonpharmacological interventions for patients with pneumonia. Incorrect Answers (Options #2, 3) Gingko and garlic are not known to have any effect on symptoms of pneumonia. (Option #5) Oxygen administration is considered a pharmacological intervention.
Which symptoms should the nurse anticipate when caring for a client with acute cholecystitis?STA 1. Chills 2. Fever 3. Nausea and vomiting 4. Increased appetite 5. Rigidity of upper right abdomen
1. Chills 2. Fever 3. Nausea and vomiting 5. Rigidity of upper right abdomen 1., 2., 3. & 5. Correct: Many clients with acute cholecystitis present with acute onset of right upper quadrant pain associated with nausea and vomiting. Epigastric pain may also be present as well as fever, chills, and anorexia. A physical examination often reveals rigidity of the upper right abdomen that may radiate to midsternal area or right shoulder. Rebound and guarding are present in some cases. 4. Incorrect: The client with cholecystitis will have nausea and vomiting which usually results in a decreased appetite.
Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Multigravida at term who is dilated to six centimeters and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being.
1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. 2. Incorrect: Contractions are not close enough for this client to be an emergent situation. Also, since this is a multigravida client and not fully dilated yet, she is not a high risk client. 3. Incorrect: This client is in the active phase of labor, but there is much work to be done before she is fully dilated and engaged for delivery. 4. Incorrect: This client is not in labor and is a non-emergent client, particularly compared to client #1.
You are an RN working in collaboration with an otolaryngologist, a pharmacist, and a general surgeon. As a healthcare team, you are deciphering the order in which treatment is given for patients with Ménière's Syndrome. Place in order from first treatment/intervention given to last. -Low-sodium diet -Diuretic therapy -Labyrinthectomy -Creating a quiet, dark environment, ensuring side rails are up and bed is in lowest position -Endolymphatic sac surgery -Vestibular Nerve Resection
1. Creating a quiet, dark environment, ensuring side rails are up and bed is in lowest position 2. Low-sodium diet 3. Diuretic therapy 4. Endolymphatic sac surgery 5. Vestibular nerve resection 6. Labyrinthectomy
Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? STA 1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae
1. Ecchymosis 2. Bleeding gums 3. Palpable spleen 5. Petechiae 1., 2., 3., & 5. Correct: The word thrombocytopenia means low platelets. Any client with low platelets is at risk for bleeding, which is indicated by ecchymosis (bruising), bleeding gums, and petechiae (red to purple dots on the skin, 1-3 mm in size). Spleen and liver are often slightly palpable. 4. Incorrect: Pain is not associated with ITP unless there are other associated problems. However, the stem of the question gave no indication that other problems exist.
A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? 1. Firm, nodular liver 2. Ascites 3. Increased serum albumin levels 4. Increased ALT and AST levels 5. Lowered ammonia levels 6. Bleeding from the GI tract
1. Firm, nodular liver 2. Ascites 4. Increased ALT and AST levels 6. Bleeding from the GI tract With cirrhosis, the liver can become very large in size and feels very firm and nodular upon palpation. Third spacing of fluids out of the vascular space (ascites) occurs due to lowered albumin levels. The client is often in a nutritional deficit which contributes to the lowered albumin level. Also, the liver is sick and unable to synthesize albumin. The liver enzymes ALT and AST will be elevated with liver problems such as cirrhosis. Increased pressure in the liver (portal hypertension) causes a backward pressure throughout the GI tract. Esophageal varices may form as a result of this pressure. If variceal rupture occurs, GI bleeding will be noted. In addition, liver diseases, such as cirrhosis, are the common causes of blood clotting problems because the liver is unable to produce the needed clotting factors.
A client returns to the clinic two days after recieving tx for diarrhea caused by a Campylobacter jejuni infection. The client reports a tingling sensation that began in the toes yesterday, and has spread to the feet and legs today. The nurse notes muscle weakness in the legs and the client is having difficulty walking steadily. Based on this data what does the nurse suspect is wrong with the PT? 1. GBS 2. Multiple sclerosis 3. Myasthenia Gravis 4. systemic Lupus erythematosus
1. GBS The clues in the stem are diarrhea from Campylobacter jejuni, tingling sensation that began in the toes, spread to the feet and legs today, weakness in the legs and difficulty walking steadily. these are s/s that point to GBS. - CAMPYLOBACTER ONE OF THE MOST COMMON BACTERIAL CAUSE OF DIARRHEA, IS THE ALSO THE MOST COMMON RISK FACTOR FOR GBS. - First s/s of GBS is tingling sensation in toes, feet and legs.
You are preparing to admin a regular dose of levothyroxine (Synthroid) to your PT, a female age 39, on an inpatient medical unit. Which of the VS that you obtain would cause you to hold levothyroxine? 1. HR 2. BP 3. RR 4. Temp
1. HR - elevated levels of thyroid hormone will contribute to tachycardia. Admn another dose of levothyroxine would further increase HR, could result in adverse cardiovascular effects, including palpitations and dysrhythmias. The use of the drug should be re-evaluated before another dose is admin and VS should continue to be carefully monitored. 2- expected lower than normal BP in hypothyroidism
A 2 month old infant is experiencing nonbilious projectile vomiting after feeding. Based on the clinical finding, what does the nurse suspect as their MOST LIKELY diagnosis? 1. Hypertrophic pyloric stenosis 2. Celiac disease 3. omphalocele 4. Intussusception
1. Hypertrophic pyloric stenosis - food and fluids are unable to pass through the obstruction and back flows as projectile vomit. The vomit would be non-bilious as the fluid has not yet reached the small intestines.
The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement? 1. I will wear long sleeves and a hat when I go for my afternoon walks. 2. I will limit my alcohol intake to one glass of red wine with supper. 3. I need to limit my fluid intake in order to avoid fluid retention. 4. I need to maintain a high calorie diet and eat 6-8 small meals a day.
1. I will wear long sleeves and a hat when I go for my afternoon walks. 1. Correct: When taking tricyclic antidepressants such as amitriptyline, the skin may be sensitive to sunburn. Use sunscreens, wear protective clothing and sunglasses. 2. Incorrect: Alcohol should be avoided while taking antidepressant medications. These drugs potentiate the effects of each other. 3. Incorrect: An increase in fluid intake (unless contraindicated) is recommended along with foods high in fiber and exercise to avoid constipation. 4. Incorrect: Weight gain is common. Provide instructions for reduced calorie diet. Encourage increased level of activity if appropriate.
What nursing interventions should the nurse initiate in a client who experiences sundowning? STA 1. Limit naps. 2. Encourage TV watching in the evening. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 5. Leave the lights on at night. 6. Maintain a routine.
1. Limit naps. 3. Create a calm, quiet environment. 4. Open window blinds during the day. 6. Maintain a routine. 1., 3., 4., & 6. Correct: Sundowning occurs when the client becomes more confused and agitated in the late afternoon or evening. Behaviors commonly seen include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Limit naps because too much daytime napping may interfere with sleeping at night. Light therapy may reduce agitation and confusion so open the blinds. Caregivers should remain calm and avoid confrontation. Routine helps the client feel secure. 2. Incorrect: Watching television for this client may lead to restlessness, agitation, and confusion. Calming and more restful activities are better for the evening. 5. Incorrect: Lights should be on during the day but turned off at night (except for low lighting or nightlights so the client can see).
The charge nurse working on the cardiac inpatient unit is completing patient assignments for a RN, LPN and UAP. Which Is the following the most appropriate to assign to the registered nurse (RN) on staff? Select all that apply: 1. Patient who experienced a myocardial infarction (MI) whose INR is 4.5 2. Patient with endocarditis experiencing fatigue 3. Patient with symptoms of heart failure who is experiencing shortness of breath (SOB) 4. Patient with pericarditis who reports coughing up frothy, pink sputum. 5. Patient with mitral valve stenosis who is complaining of fatigue.
1. Patient who experienced a myocardial infarction (MI) whose INR is 4.5 4. Patient with pericarditis who reports coughing up frothy, pink sputum. (Option #1) The therapeutic range for INR is 2.5 - 3.5 for patients post MI. An INR higher than 3.5 indicates an increased risk of bleeding. This patient is unstable and requires the care of a registered nurse. (Option #4) Pink, frothy sputum is a sign of pulmonary edema and pulmonary congestion. This is a complication which needs to be assessed by the registered nurse and followed up with by the healthcare team immediately. (Option #2) Fatigue is an expected manifestation of endocarditis. If this patient is otherwise stable, it is not the priority to assign them to an RN. (Option #3) SOB is an expected manifestation of heart failure. Patients with expected manifestations do not need to be assigned to the RN. (Option#5) Fatigue is an expected manifestation of mitral valve stenosis. Stable patients with expected findings do not require an RN assignment.
Which nurse is providing cost effective care to a client? STA 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves
1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost-effective. Two additional preventive interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low dose aspirin.
Appropriate use of 4 wheel walker. Put the steps in order. -step forward with weak leg first -advance the stronger leg in front of weaker leg - walk slowly and maintain good posture -push or lift the walker a few inches or cm in front - ensure all four wheels make contact with floor before taking steps
1. Push or lift the walker a few inches or cm in front 2. Ensure all four wheels make contact w/ flour by taking Steps *3. Step forward w/ weak leg first. 4. Advance the stronger leg in front of weaker leg * 5. Walk slowly and maintain good posture.
The nurse is caring for a patient with an endotracheal tube. In the middle of the night the nurse hears the ventilator alarm and the patient is yelling. The nurse enters the room and finds the patient in respiratory distress. Which actions should the nurse immediately take next? Select all that apply. 1. Stay with the patient and call for help 2. Attempt to re-inflate the endotracheal tube cuff 3. Apply a bag-valve mask and oxygen 4. Prepare the patient for reintubation 5. Attempt to reinsert the dislodged tube
1. Stay with the patient and call for help 3. Apply a bag-valve mask and oxygen 4. Prepare the patient for reintubation If accidental extubation occurs, the nurse should take the following interventions: • remain with the patient and call for help • maintain and support ventilation •use a bag-valve mask and oxygen as required • prepare for re-intubation
Which of the following situations indicates the potential for a non therapeutic relationship? Select all that apply: 1. The client loans the nurse money and is promptly repaid 2. The nurse and patient enjoy joking about the other 3. The nurse reminds the patient of her granddaughter 4. The nurse finds her/himself thinking about the client when away from work 5. The patient and nurse have gotten to know each other and enjoy the time they spend together 6. The patient's family brings a treat for the nurses on the unit to share
1. The client loans the nurse money and is promptly repaid 2. The nurse and patient enjoy joking about the other 4. The nurse finds her/himself thinking about the client when away from work (Option #3) Nurses can often remind clients of others, and this doesn't necessarily pose a problem in the maintenance of a therapeutic relationship as long as the nurse is clear about her/his professional role (Option #5) Enjoying time together can be a healthy part of a professional relationship (Option #6) Recognition of the nurses on the unit as a group
Which of the following practices should be performed on an 8 year-old child in regards to basic life support (BLS)? Select one: 1. Use the head-tilt and chin-lift, assess pulse in the carotid artery, and ensure compression rate is about 100/min 2. Use the jaw-thrust maneuver, assess pulse in the carotid artery, and ensure compression rate is about 80/min x 3. Assess the patient using the carotid artery, ensure compression depth is 1 inch, and notify the health care provider 4. Assess the patient for consciousness, use chest thrusts for foreign body obstruction, and administer one breath every 10 seconds
1. Use the head-tilt and chin-lift, assess pulse in the carotid artery, and ensure compression rate is about 100/min (Option #1) Using the head-tilt and chin-lift, assessing pulse in the carotid artery, and ensuring the compression rate is 100/min are appropriate practices for a child. Incorrect answers (Option #2) The jaw-thrust maneuver is necessary when patients exhibit signs of trauma or injury. The rate of compression is 100/min not 80/min. (Option #3) The compression depth should be 2 inches. (Option #4) instead of chest thrusts, back slaps and abdominal thrusts are performed on children over 1 year of age with foreign body airway obstruction. Additionally breaths should be given every 3-5 seconds.
The nurse is providing education to the parents about a newborn infant prior to d/c. The nurse and young parents are discussing bathing and care of the umbilical cord. Which of the following statements made by the parent's indicate a CORRECT understanding of the teaching?STA 1. We can expect the umbilical cord stump to fall off after 10 days. 2. Sponge bathing is preferable to tube bathing in the prevention of newborn heat loss 3. we will use mild soap and thoroughly dry our baby after bathing 4. we can expect the umbilical cord to be red and edematous at the base during the first couple of days of life 5. out baby should be bathed at least one per day.
1. We can expect the umbilical cord stump to fall off after 10 days. 3. we will use mild soap and thoroughly dry our baby after bathing
Correct order of admin Phenytoin 100mg VP. -Aspirate for blood -admin Phenytoin -clean access port -Flush w/ NS, then w/ heparin -connect 10 mL of NS to access port -NG push pause method
1. cleanse access port 2. Connect 10mL of NS to access port 3. Aspirate for blood 4. Ng push pause method (Used method to flush/ clear the Cath of blood or drugs by creating a turbulent how from pause & push) 5. Admin Phenytoin 6. Flush w/NS, then w/ heparin (heparin generally used to fill lumen of central line between use to prevent thrombus)
A nurse is assigned to a patient diagnosed with borderline personality disorder. He consistently breaks unit rules and displays manipulative actions. It is most appropriate for the nurse to do which of the following? 1. confront the patient's action and set limits on activities 2. ignore the patient's actions and allow him to express his feelings 3. set realistic goals with the patient to reduce his anxiety 4. refer the patient to the HCP to prescribe a higher dose of pain mends?
1. confront the patient's action and set limits on activities Pt's with borderline personality disorder are often hostile, anxious and unstable. And oftentimes display manipulative actions. manipulative actions must be addressed by confronting them and setting limits.
The RN is caring for a Pt with a new colostomy and is working with an LPN and UAP. Which of the following task are the MOST appropriate for the RN to delegate to the LPN? 1. monitor skin around the ostomy 2. empty the ostomy bag and measure the contents 3. selection of the appropriate pouch system for the PT 4. Determine the PT's baseline bowel sounds 5. Assess and document appearance of stoma
1. monitor skin around the ostomy 2- can be delegated to UAP 3,4, 5 - RN responsibilities
A lient who needs to have a stool specimen for an occult blood test is instructed by the nurse to avoid which substances two hours prior to testing? STA 1. Liver 2. Tomato 3. Ibuprofen 4. Sardines 5. Ascorbic acid
1., 3., 4., 5. Correct: The following foods can cause a false-positive reading: red meats, liver, turnips, broccoli, cauliflower, melons, salmon, sardines, and horseradish. Medications altering the test include aspirin, ibuprofen, ascorbic acid, indomethacin, colchicines, corticosteroids, cancer chemotherapeutic agents, and anticoagulants. Ingestion of vitamin rich foods can cause a false negative result. 2. Incorrect: A tomato is not on the food list for false-positive reading and do not have to be avoided.
peak of immediate insulin
2-4 hours
Normal CVP range?
2-6 minHg
What is CVP normal range?
2-6 mm Hg
The son of a client diagnosed with Alzheimer's Disease who is listed as a person who has access to the client's health information asks the nurse why his father has been prescribed donepezil. What response should the nurse make? 1. "Depression is often treated with this medication." 2. "This medication is used to treat confusion." 3. "Behavioral problems are diminished when the client receives this medication." 4. "This medication will address sleep disturbances."
2. "This medication is used to treat confusion."
An infant with developmental dysplasia of the hip (DDH) is brought into the clinic. A nurse has provided Incorrect the parent with teaching about the Pavlik harness. Which of the following statements made by the parent demonstrates the need for additional teaching? 1. "I will check for red areas and gently massage the areas under the straps three times a day" 2. "To keep skin smooth under the straps I will apply lotion twice a day" 3. "The Pavlik harness secures the hip joint in a safe position" 4. "I should adjust the harness every one to two weeks" 5. "I will remove the harness during the night so my baby can sleep comfortably"
2. "To keep skin smooth under the straps I will apply lotion twice a day" 4. "I should adjust the harness every one to two weeks" 5. "I will remove the harness during the night so my baby can sleep comfortably" Lotions and powders should be avoided as they can build up and irritate the skin Parents should be instructed not to adjust the harness. Straps should be checked by the provider in the beginning of therapy and every one to two weeks for adjustments. Removal of the harness is determined individually based on the provider's recommendations Proper skin care includes checking frequently for red areas and gently massaging the skin to stimulate circulation The pavlik harness maintains the hip joint by dynamic splinting in a safe position and the proximal femur centered in the acetabulum in an attitude of flexion.
A client has been admitted for observation after having a minor automobile accident. During the admission history, the client admits to being an alcoholic. Two hours after admission the nurse notes the client's cardiac rhythm displayed on the telemetry monitor. The client reports shortness of breath, chest discomfort, and nausea. What initial action should the nurse take? Select one The patient is showing Torsades de point 1. Cardiovert at 200 joules. 2. Administer magnesium 1 gm IVP over 30 seconds. 3. Begin cardiopulmonary resuscitation (CPR). 4. Obtain a 12 lead ECG.
2. Admin mag 1gm IVP over 30 sec Torsades de pointes is associated with a prolonged QT interval. Torsades usually terminates spontaneously but frequently recurs and may degenerate into ventricular fibrillation. The hallmark of this rhythm is the upward and downward deflection of the QRS complexes around the baseline. The term Torsades de Pointes means "twisting about the points." Look at the clues in the stem: automobile accident, alcoholic, shortness of breath, chest discomfort, and nausea, Torsades de pointes. Alcoholics tend to develop hypomagnesemia, a common cause of Torsades. Magnesium is the drug of choice for suppressing Torsades and terminating the arrhythmia. Magnesium achieves this by decreasing the influx of calcium, thus lowering the amplitude of early after depolarizations. Magnesium can be given at 1-2 g IV initially in 30-60 seconds, which then can be repeated in 5-15 minutes. Alternatively, a continuous infusion can be started at a rate of 3-10 mg/min. Magnesium is effective even in clients with normal magnesium levels. Because of the danger of hypermagnesemia (depression of neuromuscular function), the client requires close monitoring.
A nurse is preparing an IV dose of phenytoin (Dilantin) for a patient with generalized tonic-clonic seizures. The nurse must notify the health care provider if what is noted in the patient's health history? 1. Alcohol-free for-3 years 2. Amiodarone 3. Head trauma 4. Oral contraceptives
2. Amiodarone Calcium channel blockers are one of the many drugs that will increase serum phenytoin levels. They are life threatening but must be monitored closely in patients taking phenytoin (Dlantin).
A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? 1. Prolonged bleeding time 2. Elevated reticulocyte count 3. Decreased platelet count 4. Elevated bands
2. Correct: Elevated reticulocyte count indicates increased production of RBCs. If a client is chronically losing blood, the body's response is to increase RBC production, so the retic count would increase.
Which of the following interventions is used to manage the fluid and electrolyte imbalances associated with viral meningitis? Select one: 1. Limit sodium intake 2. Decrease fluid intake 3. Administer Ringer's Lactate 4. Administer amoxicillin
2. Decrease fluid intake Meningitis causes a wide variety of complications which include shock, hydrocephalus, and Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Due to stimulation of the hypothalamic center, an increased amount of ADH is secreted, which results in water retention and ultimately, dilution of serum sodium. Consequently, hyponatremia occurs. This fluid and electrolyte imbalance is managed by limiting fluid intake and administering loop diuretics as well as hypertonic fluids. Decreasing fluid intake reduces the dilution of serum sodium and also prevents the patient from retaining more water (Option #2).
The charge nurse working in a respiratory unit is making shift assignments. Which of the following tasks is best delegated to an experienced registered nurse? STA 1. Provide oral care to a patient with a tracheostomy 2. Develop a plan to avoid aspiration in a PT with a trache 3. perform trach dressing using sterile technique 4. replace the tracheostomy after accident disologement 5. educate the patient's caregiver about home tracheostomy care
2. Develop a plan to avoid aspiration in a PT with a trache 4. replace the tracheostomy after accident disologement (emergency intervention, the unstable patient require an RN attention? 5. educate the patient's caregiver about home tracheostomy care 1- can be delegated to UAP 3- Dressing can be performed by LPN
A patient is admitted to the ER with s/s of agitation, asterixis and slurred speech. Which of the following meds should the nurse admin to address these s/s? 1. Folic acid 2. Lactulose 3. Spironolactone 3. Propranolol
2. Lactulose (Laxative) s/s point towards hepatic encephalopathy. Which results from impaired ammonia metabolism and excretion. Treatment includes antibiotics, like metronidazole, and laxatives like lactulose. Lactulose increases the acidity of the GI tract, which helps convert ammonia into a form that can be easily excreted.
When assessing a newborn following a breech delivery, what physical findings should the nurse report to the primary healthcare provider as positive indications of congenital hip dysplasia (CHD)? STA 1. Symmetrical gluteal folds. 2. Limited abduction of one leg. 3. Pain with the Barlow maneuver. 4. Presence of an Ortolani click. 5. Confirmed stepping reflex.
2. Limited abduction of one leg. 4. Presence of an Ortolani click. 2 & 4. Correct: When assessing a newborn, the nurse must determine which findings are normally expected at birth versus abnormal findings that should be reported to the primary healthcare provider. Two expected findings suggestive of congenital hip dysplasia (CHD) include limited abduction of one leg and the presence of an Ortolani click when the affected hip is placed into the "frog-leg" position. 1. Incorrect: Symmetrical gluteal folds are an expected, normal finding when the newborn is placed in the prone position. In an infant with suspected CHD, gluteal folds are notably asymmetrical. 3. Incorrect: During evaluation for congenital hip dysplasia, there is no pain during any assessment procedures. The Barlow procedure, in which one leg is adducted across the body, is currently used, in addition to other examination techniques, to determine any abnormalities with hip/socket placement. 5. Incorrect: The stepping reflex is part of the neurologic evaluation and is a normal finding at birth. When held upright with the soles of the feet lightly touching the table, the infant appears to lift alternate feet as if walking. This reflex disappears in about 2 to 3 months, but will return when the child begins learning to walk.
Which signs/symptoms should the nurse assess for when caring for a client diagnosed with bulimia nervosa? STA 1. Increased thirst 2. Muscle cramps 3. Blurred vision 4. Tingling of lips 5. Constipation
2. Muscle cramps 4. Tingling of lips 5. Constipation 2., 4., 5. Correct: The typical abnormalities associated with bulimia are hypokalemia and metabolic alkalosis because of the binging and purging process. This leads to muscle cramps, weakness, fatigue, constipation, and arrhythmias are all symptoms of this electrolyte and acid-base imbalance. Hypokalemia leads to metabolic alkalosis 1. Incorrect: Increased thirst is a sign of hyperglycemia and would not be the concern with someone that is purging. This client would be more likely to be hypoglycemic instead 3. Incorrect: Blurred vision is a sign of hyperglycemia because of the effect of too much glucose in the small vessels of the eye. Microvascular damage is one of the biggest concerns with hyperglycemia; the bulimic client would be hypoglycemic.
The nurse reviews documentation of newly admitted PT. Which of the following symptoms would most likely indicate to the nurse that the patent has acute kidney injury? (AKI) 1. Dysuria 2. Oliguira 2. Hematuria 4. Anuria
2. Oliguria - most common initial manifestation of AKI because kidney's are unable to effectively filter waste products and produce urine in the body. Dysuria = painful of difficult urination not associated with AKI Hematuria = presence of blood in urine not associated with AKI Anuria = inability of the kidneys to produce urine and is rarely an initial symptom of AKI
A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what measures will the nurse include in the client's initial plan of care? STA 1. Approach the client from his left side. 2. Place the client's meal on the right side of the over bed table. 3. Request a consult for an ophthalmologist. 4. Stand directly in front of the client when addressing. 5. Have client look at the left side of the body.
2. Place the client's meal on the right side of the over bed table 5. Have client look at the left side of the body. 2. & 5. Correct: Homonymous hemianopia is blindness in half of the visual field. The client has lost half of the visual field in the left side of both eyes. To avoid startling the client who has lost vision in half of their visual field and so the client can better view the food, the nurse should approach the client from the right side. Neglect of the left side can occur because the left side is out of the visual field. Encourage the client to intentionally look at the left side of the body to avoid neglect. 1. Incorrect: Approaching the client from the left side is inappropriate. The client cannot see in the left half of the visual field and could be startled. 3. Incorrect: An ophthalmologist cannot fix this problem. The problem is due to damage in the central nervous system, not in the eyes. 4. Incorrect: Standing in front of the client does not address the client's visual field deficit. This would give the client an altered view of the nurse since the left half of the visual field is affected.
A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
2. Respiratory alkalosis This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal.
A nurse is conducting a comprehensive health assessment for 7 year old child and obtains the findings displayed in the exhibit. which findings are NOT consistent with normal growth and development and may require follow- up? STA 1. The child has lost 3 teeth so far 2. The child is 49.2 in (125 cm) tall and weigh 34 kg (75 lbs) 3. The child can count to as high as 5 4. The child spends a lot of time alone and does not require a lot of companionship 5. when reading, the child skip words such as "it", "the" and "he" 6. the child's heart rate is abnormal 7. the child's Respiratory movement is abnormal
2. The child is 49.2 in (125 cm) tall and weigh 34 kg (75 lbs) 3. The child can count to as high as 5 6. the child's heart rate is abnormal - Normal findings for a 7.0 HR: 70-110bpm Temp: 97.7 - 100 RR 12-20 bpm O2: 95-100% HT : 44-51 inches (112-130cm) WT: 39-66.5 lbs (17-30kg) - Can repeat 3 numbers backward -Has concept of time -Mechanical reading, may not stop at the end of a sentence of skip words -Can brush or comb hair without help -Spends a lot of time alone, does not require a lot of companionship -prefers playing with the same gender.
A nurse working in a pediatric cardiology inpatient unit is assigned a student for the day to help care for a patient, a 15 year-old boy who is two days post operative from open-heart surgery and has a chest tube. The nurse intervenes when the student is performing which of the following actions in the care of this patient? Select all that apply: 1. The student palpates the chest tube site for the presence of subcutaneous air 2. The student teaches the patient the importance of remaining on bed rest while the chest tube is in place 3. The student uses aseptic technique to change the drainage system when the collection chamber is almost full 4. The student maintains the water seal level at 2 cm 5. The student assesses that the dressing is dry and clean and the sutures are intact at the insertion site
2. The student teaches the patient the importance of remaining on bed rest while the chest tube is in place 3. The student uses aseptic technique to change the drainage system when the collection chamber is almost full (Option #2) The patient with a chest tube and any patient following cardiac surgery should be encouraged to ambulate safely as soon as possible. Ambulation will help to prevent post-surgical complications such as pneumonia and deep vein thrombosis, as well as prevent pulmonary complications associated with fluid build up or stasis. The nurse should teach the student to assess the patient's ability to ambulate and assist them with ambulation while maintaining chest tube safety. (Option #3) The nurse should intervene if the student is using aseptic technique to change the drainage, as sterile technique must be used for this procedure. Failure to implement sterile technique could precipitate infection. (Option #1) This is an appropriate aspect of site assessment that will help the student and nurse to gather information about the tube's placement and effectiveness, as well as prevent complications that may arise from subcutaneous air collection. (Option #4) Water seal level should be maintained at 2cm, if the water column is too high, air flow from the chest may be impeded and oxygenation may be. (Option #5): This is an appropriate assessment that will allow the student and nurse to detect potential complications such as leakage of infection at the insertion site.
Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus? STA 1. White blood cells of 9,500 mm3 (9.5 x 10^9/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 5. Glucose of 100 mg/dL (5.6 mmol/L)
2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 2, 3 and 4. CORRECT: Diabetes insipidus results when the body is deficient in anti-diuretic hormone (ADH), resulting in a fluid volume deficit and shock. Blood becomes concentrated and urine dilute because of extreme loss of water. Specific gravity is very low, as evidenced by a lab result of 1.004. However, serum levels of sodium (149 mEq/L (149 mmol/L)) and hemoglobin (20 g/dL (200 g/L)) are high due to concentration. 1. INCORRECT: Normal white blood cell count is 5,000 to 10,000 mm3 (5-10 x 10^9/L). This WBC result is normal and does not require action by the nurse. 5. INCORRECT: Diabetes insipidus is not related to the disease diabetes mellitus. The blood glucose level in this question is normal.
What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism?STA 1. hypochloremia 2. hypokalemia 3. hypophosphatemia 4. hypomagnesemia 5. hypocalcemia
2. hypokalemia 3.hypophosphatemia 4. hypomagnesemia 5. hypocalcemia The number one way of getting rid of potassium is through the kidneys. Alcohol makes you Diuresis. Acute hypophosphatemia is seen in up to 50% of Pt over the first 2-3 days after they are hospitalized for alcohol overuse. Hypophosphatemia is manifested as rhabdomyolysis (muscle breakdown) and weakness of the skeletal muscles. Magnesium deficiency occurs due to that increase in diuresis as well. Hypomagnesemia is often accompanied by hypocalcemia, or lowered calcium levels , which may be aggravated by deficiency of Vit D.
The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? 1. Cottage cheese 2. Salami 3. Baked chicken 4. Potatoes
2.Salami The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis.
The nurse is caring for a PT who is undergoing chemotherapy for prostate cancer. When the session is finished, the nurse conducts an assessment to monitor for side effects. Which of the following symptoms best indicates that the patient is experiencing anemia? 1. bradycardia 2.cold intolerance 3. nausea 4. elevated temp
2.cold intolerance - diminished o2 supply to the peripheral circulation. - signs of anemia after chemo include cold intolerance, pale skin, fatigue, SOB, cyanosis, tachycardia
During an initial exam, a patient asks the nurse the reason for undergoing a computed tomography (CT) scan to check for lung cancer. Which of the following responses is the best with regards to the purpose of the CT scan? 1. "CT scans are superior to magnetic resonance imaging (MRI) for evaluating metastasis." 2. "CT scans are noninvasive and readily available." 3. "CT scans detect differences in tissue densities and lymph node involvement." 4. "CT scans differentiate between a malignant and a benign tumor."
3. "CT scans detect differences in tissue densities and lymph node involvement."
A 25 y.o female patient is recovering from T12 spinal cord injury. The nurse explains that a bowel management program must be initiated immediately to prevent bowel retention and mage reflex emptying. Which of the following interventions are included in bowel management STA 1. Massage the abdomen firmly to stimulate peristalsis 2. Admin of PPI 3. Digital rectal stimulation 4. Consumption of 20-30 grams of fiber daily 5. Use of rectal suppository to stimulate defecation
3. Digital rectal stimulation 4. Consumption of 20-30 grams of fiber daily 5. Use of rectal suppository to stimulate defecation Damage or trauma to the spinal cord can cause temporary or permanent loss of motor function, sensation, reflexes, bladder and bowel control. In spinal injuries below T12, the bowel is areflexic during spinal shock. Meaning the bowel that the bowel will not empty voluntarily or involuntarily and can cause bowel distension. Initiating a bowel management program is important for managing both paralytic ileus and reflex emptying.
The student nurse is researching pain in culturally diverse clients. Which statement is inaccurate and requires clarification? 1. Clients from both Chinese and Middle-Eastern backgrounds may apply suction to manage pain 2. The physiology and rate of metabolism of pain medication varies between individuals of different ethnicities 3. Ethnicity determines a client's subjective experience of pain 4. Pain may be expressed verbally, physically or not expressed at all.
3. Ethnicity determines a client's subjective experience of pain - It is important to appreciate that while perception and expression of pain is affected by ethnicity, it is not the sole determining factor. Ethnicity or heritage is only one among many aspects of their individual personality and experience, and so thorough individual assessment is crucial.
Which s/s will the nurse include when teaching a client about indicator of recurrent nephrotic syndrome? STA 1. Dysuria 2. Hematuria 3. Foamy urine 4. Periorbital edema 5. Wt. loss
3. Foamy urine 4. Periorbital edema = foamy urine , which may be caused by excess protein in the urine, is seen with nephrotic syndrome. Swelling edema particularly around the eyes (periorbital) and in the ankles and feet is a symptom.
What should the nurse include when teaching a client in renal failure about peritoneal dialysis? STA 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used.
3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 6. A sweet taste may be experienced when peritoneal dialysis is used. 3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste.
You are caring for a 6-year-old boy with cerebral palsy. You conduct a morning physical assessment and obtain the findings in the exhibit. Based on these findings, which of the following medications should be immediately evaluated for alterations in therapeutic level? Select one: 1. Acetaminophen 2. Pantoprazole 3. Gabapentin 4. Ibuprofen
3. Gabapentin -Gabapentin (Neurontin) is an antiepileptic agent used for children with cerebral palsy, specifically those with muscle spasticity or seizures. -The side effects of gabapentin include: sedation, drowsiness, headache, tremor, nausea, vomiting, memory difficulty, and difficulty concentrating. Adverse effects can include respiratory depression, paresthesia, and debilitating and disfiguring rash.
a nurse is caring for a 27 year old female PT with multiple sclerosis who has recently started taking beta-interferon. The nurse is aware that this drug has several adverse effects, but she is MOST concerned when the patient reports? 1. I got a really bad sunburn when I was outside yesterday 2. It's red and sore at the injection sites 3. I have started working on my will 4. I have been having fever, chills and a runny nose
3. I have started working on my will - think of S.E of suicidal ideation 1 - photosensitivity is an adverse effect of beta interferon so patient should be taught to apply sunscreen and wear protective clothing outside 2- redness and soreness at injection site is an expected finding 4- flu like symptoms are common when beta interferon therapy is first initiated. The PT may take acetaminophen or NSAID.
The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
3. Metabolic acidosis -A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. Hyperventilation occurs due to excess ketones in the body causing metabolic acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing. The hyperventilation occurs to reduce the arterial pCO2 level.
The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 3. Read about formalin on the Material Safety Data Sheet (MSDS). 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin.
3. Read about formalin on the Material Safety Data Sheet (MSDS). 3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of information. Calling another department does not ensure that the nurse will get as comprehensive information as the MSDS provides 2. Incorrect: The drug handbook is for medication, not handling of hazardous material. 4. Incorrect: The nurse can place the biopsy into a container with formalin and is within the scope of practice for the nurse.
The nurse instructs and demonstrates to an asthmatic patient how to use a dry powder inhaler. When the nurse asks the patient to perform a return demonstration to evaluate the teaching, which of the following actions by the patient indicate that the nurse's teaching was effective? Select all that apply: 1. The patient shakes the inhaler before use 2. The patient reaches for the spacer 3. The patient breathes out before using the inhaler 4. The patient breathes in deeply and slowly after closing his lips tightly around the mouthpiece 5. The patient holds his breath for 10 seconds after inhalation
3. The patient breathes out before using the inhaler 5. The patient holds his breath for 10 seconds after inhalation Instructions for DPI use are: 1. Remove mouthpiece cap or open the device according to instructions 2. Load the dose into the inhaler 3. Do not shake the medicine 4. Tilt head back slightly and breathe out forcefully to remove as much air out of the lung as possible. Do not breathe into the inhaler to avoid affecting the dose 5. Seal lips tightly around the mouthpiece 6. Breathe in deeply and quickly to ensure that the medicine moves deep into the lungs 7. Hold breath for 10 seconds 8. Note the number of doses remaining; it should be lowered 1 dose 9. Keep DPI in a dry place
The nurse is teaching a PT newly dx with asthma about pursed lip breathing. Which of the following patient response require FURTHER education by the nurse? 1. I should use PLB when engaging in activities that cause me to be SOB. 2. I should breathe out longer than when I breathe in 3. The purpose of PLB is to reduce wheezing and crackles associated with asthma 4. I should not puff my cheeks when i am exhaling.
3. The purpose of PLB is to reduce wheezing and crackles associated with asthma The purpose of PLB is to slow the rate of exhalation and maintain an open airway, which prevents air trapping.
The family of a patient overhears the physician discussing the poor prognosis of their family member to the nurse. The family asks the nurse to keep this information from the patient as it may cause more harm than good. Which two ethical principles in this ethical dilemma are conflicting? Select one: 1. Veracity and fidelity 2. Veracity and beneficence 3. Veracity and nonmaleficence 4. Veracity and autonomy`
3. Veracity and nonmaleficence
The nurse is caring for a PT who is deciding whether he will pursue peritoneal dialysis to manage his condition at home. When the client alerts the nurse that he has decided to pursue the procedure, which of the following response by the nurse is the MOST appropriate? 1. I am proud of you for making that decision 2. everything will be alright now that you have decided to do this 3. What led to your decision 4. I agree with the decision
3. What led to your decision - use of therapeutic communication 1- inappropriate statement 2- false reassurance 4- non therapeutic
You are caring for a patient with chlamydia infection. The patient is taking a tetracycline QID for treatment of the infection. As you are conducting a comprehensive health assessment, which of the following components of the patient's diet would require intervention and education? Select one: 1. Bananas 2. St. John's Wort 3. Yogurt 4. Orange juice
3. Yogurt -Dairy products, antacids, and magnesium-containing drugs may affect the absorption of tetracyclines. The patient should be educated on food-drug and drug-drug interactions to maximize treatment efficacy.
The nurse is providing care to a client who had an endoscopic retrograde cholangiopancreatogram (ERCP) two hours ago. Which finding would indicate a possible complication? 1. occasional cough 2. sore throat reported 3. abd pain rated 8/10 4. drowsy
3. abd pain rated 8/10 - possible complication of the procedure
A PT arrives with exposure to caustic/corrosive industrial chemicals. What is the nurses' best FIRST action? 1. Begin IV fluids per the parkland formula 2. Identify toxic agent 3. Assess the Patient's physiological response 4. Complete decontamination process
4. Complete decontamination process - Decontamination is an important first step to ensuring the safety of those providing care. It is a process where clothis is removed and typically patient's wash off hazardous material with water.
The hospital admin is evaluating the success of an emergency disaster drill. The drill is intended to train and prepare staff for a mass casualty event. For the drill to be considered successful, which group would the admin need to see protected first? 1. admit patient and hospital visitors 2.critically ill patients 3. Red tagged PT's who are seriously ill but have good potential for survival 4. Hospital staff
4. Hospital staff - one of the first stages in disaster management is providing the safety and security of those responding. Health care workers who spread infection or contamination are hurting their patient and will render themselves unable to deliver care. `
What instruction is most important to include when teaching a child how to self administer a combined dose of isophane suspension and regular insulin subcutaneously? 1. Alternate the injection sites from one body area to another with each dose. 2. Draw up the isophane suspension insulin first and then regular insulin into the same insulin syringe. 3. Massage the injection site after the medication is injected. 4. Insulin syringes should be stored at room temperature.
4. Insulin syringes should be stored at room temperature. 4. Correct: Insulin syringes and needles should be stored at room temperature. The potential benefits or risks of refrigerating the syringe are unknown.
You are assessing a 7-year-old pediatric patient with a stage 1 pressure ulcer. You ask the patient if you can assess the "spot" on her back when she states "not while the Jinn is in the room". As a culturally competent nurse you recognize that having a Jinn is a part of what culture/religion? Select one: 1. Judaism 2. Greek culture 3. Christianity 4. Islam
4. Islam Islam is the correct religion that believes Jinn's are an entity within this world and have power, whether good or bad
A nurse is responding to a patient with active tuberculosis who is coughing up blood. Which of the following personal protective equipment (PPE) should the nurse put on before entering the patient's room? Select one: 1. N-95 mask and gloves 2. N-95 mask, face shield and gloves 3. Surgical mask, gown, gloves and goggles 4. N-95 mask, gown, gloves and goggles
4. N-95 mask, gown, gloves and goggles -since the patient is coughing up respiratory fluids, the nurse should wear goggles, gloves, and a gown in addition to the N-95 mask.
What foods should the nurse inform the client to avoid for three days prior to guaiac test? STA 1. Chicken 2. Carrots 3. Apples 4. Raw broccoli 5. Steak 6. Turnip greens
4. Raw broccoli 5. Steak 6. Turnip greens - Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloup, radish and horseradish. All of these could cause a false positive reading for the guaiac test.
A nurse is caring for a PT diagnosed with Meniere's disease that had a severe attack earlier that day. The dietary aid brings the lunch tray. The nurse's knowledgeable about nutritional concerns associated with Meniere's disease when she indicates that which lunch tray is INAPPROPRIATE for the PT? 1. Roasted turkey on white bread and OJ and vanilla yogurt 2. Vegetable salad with vinegar dressing and chicken slices 3. Lasagna with coleslaw salad 4. Roast beef on a pita bun with caffeinated tea and apple slices
4. Roast beef on a pita bun with caffeinated tea and apple slices Should not have salt, caffeine, nicotine or ETOH
The nurse is admitting a patient who has recently experienced an angina attack for the first time. The health care provider (HCP) completed an angiogram to detect the cause of the attack and has prescribed nitroglycerin and several other medications. While looking at the updated medication reconciliation form, which of the following medications is she most concerned about? Select one: 1. Warfarin 2. Metoprolol 3. Ramipril 4. Sildenafil
4. Sildenafil (Option #4) Nitroglycerin and sildenafil should not be taken together. Sildenafil is a phosphodiesterase-5 inhibitor which can interact with nitroglycerin to cause life-threatening hypotension and cardiovascular collapse. The health care provider should be notified of this to prevent complications. (Option #1) Warfarin is an anticoagulant that prevents clotting by inhibiting the synthesis of coagulation factors. (Option #2) Metoprolol is a beta blocker that helps to control heart rate and blood pressure. It decreases the demand for oxygen, and can reduce or prevent symptoms of angina. (Option #3) Ramipril is an ACE inhibitor and reduces
These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first? 1. The client whose blood pressure is 40 palpable, heart rate 30, and respirations 6. 2. The comatose client with fixed and dilated pupils. 3. The unresponsive client with an open head fracture and visible white matter. 4. The client with a sucking chest wound and tension pneumothorax.
4. The client with a sucking chest wound and tension pneumothorax. 4. Correct: This client would be tagged red and would be immediate. This is a life threatening injury that can be helped, if done so quickly. 1. Incorrect: In a disaster this client would be tagged black- expectant: injuries that are extensive and chances of survival are unlikely even with definitive care. 2. Incorrect: In a disaster this client would be tagged black- expectant: injuries that are extensive and chances of survival are unlikely even with definitive care. 3. Incorrect: In a disaster this client would be tagged black- expectant: injuries that are extensive and chances of survival are unlikely even with definitive care
The nurse is caring for a patient who is about to start TX for active TB. The patient states " I can't believe my family and friends can't visit me for a whole 5 months!" Which of the following responses by the nurse is the most appropriate? 1. I understand. Everyone going through this treatment feels the same way 2. The standard tx regimen actually last 6-12 months 3. Why do you feel this way? 4. The risk of transmission will be greatly reduced after 3 weeks into the treatment.
4. The risk of transmission will be greatly reduced after 3 weeks into the treatment. - After positive sputum smear tests, PT's are infectious for the first 2 weeks after the initiation of tx. The full duration of Tx is usually 6-23 months, the primary method used to cure TB is drug therapy. - Giving accurate and factual info about the tx is an important form of therapeutic communication. In this case, the nurse, should inform the Pt that the risk of transmission will be greatly reduced after 3 weeks of treatment and will not need to be isolated for 5 months. 2- is factual information but it does not address the patient's concern 1- minimizes the patients concern 3- asking why questions implies criticism and makes patient feel the need to justify
How do you admin Thiamine given to a pt with chronic alcoholism?
50-100mg IV or IM is indicated twice a day for pts with chronic alcoholism. Given to alleviate dehydration, prevent delirium and precaution tx for vir. B complex deficiency. Given for days followed by 10-20mg once a day until therapeutic response observed.
A patient has an order for inhaled theophylline for 0900. Due to a last-minute admission, the inhaler was not administered until 1030. Prior to administration, the nurse asks the patient to confirm their first and last name. Two puffs of theophylline were given as per order. The nurse later documents that theophylline was administered as per order and moves on to her next patient. Which rights of medication administration did the nurse violate? Select all that apply: 1. Right patient 2. Right medication 3. Right dose 4. Right documentation 5. Right time
6. Right patient 4. Right documentation 5. Right time (Option #1) Although the medication was given to the right patient the nurse failed to properly identify the patient. Two patient identifiers should be used at all times to ensure that the medication is being administered correctly. Asking for a patient's first and last name is only one identifier and so this right was violated. (Option #4) The dose was administered late but the nurse documented it as administered per order, right documentation was violated. (Option #5) Most facilities have a one hour window of medication administration. Theophylline was administered beyond that one hour window and is considered late. Incorrect Answers: (Option #2) Theophylline was administered as per order. (Option #3) Two puffs were administered as per order.
When to treat blood sugar, what range makes it a Hypoglycemia range?
70-80 glucose
What is the range of calcium?
9.0-10.5 mg/dL
Normal range of Estimated Glomerular filtration rate (EGFR)?
90-120 ml/min
A PT with Herpes varicella Zoster will probably be prescribed?
Acyclovir ( anti-viral)
Acronym to remember for stethoscope placement for heart sounds?
All People Enjoy time Magazine Aortic, Pulmonic, Erb's, Tricuspid, Mitral
What is a full liquid diet? What are some examples?
All clear liquids w/ thin (ex:hot cereal, strained cream soups, juices, milkshakes, custard/pudding)
Correct order of steps to perform Allen's test. Why is this test performed? - Release pressure from ulnar artery while keeping the radial artery compressed -assess return of color -apply pressure to the ulnar and radial arteries simultaneously -ask the patient to make a first several times until palm is blanched - explain the procedure
Allen's test confirms the existence of collateral circulation in the hand to prevent ischemia when either the radial or ulnar artery is occluded. 1. explain procedure 2. apply pressure to the ulnar and radial arteries simultaneously 3. ask the patient to make a fist several times palm is blanched 4.release pressure from the ulnar artery while keeping the radial artery compressed 5. assess return of color
Define anomia
Can't name objects, early signs of Alzheimers
What do we check immediately after ROM?
Check Fetal heart rate
How can genital herpes type II be transmitted?
Childbirth
What is an example of Blood borne needle Stick?
Clean needle Stick through blood soiled gloves
What is Clonidine used for?
Clonidine is used to suppress opiate withdrawal symptoms. Serves effectively as a bridge to enable pt to stay opiate free long enough to facilitate termination of methadone maintenance
What is a Rinne Test?
Compares air to bone conduction
What is Thiazolidinediones used for?
DM type 2.
In Secondary Hypothyroidism what are TSH and T4 levels.
Decrease or close to normal TSH and decreased T4
What medication may be prescribed for sickle cell anemia and for what?
Deferasirox helps prevent liver damage from iron deposits
What are two Early signs of Lithium toxicity?
Diarrhea and vomiting,
Why is disulfiram given to selected chronic alcohol pts?
Disulfiram aids in the management of selected chronic alcohol pts who remain in a state of enforced sobriety so that supportive and psychotherapeutic tx
What kind of med is Donezepril?
Donepezil is a cholinesterase inhibitor. It improves the function of nerve cells in the brain. It works by preventing the breakdown of acetylcholine. People with dementia usually have lower levels of this chemical, which is important for the processes of memory, thinking, and reasoning. Donepezil is used to treat mild to moderate dementia caused by Alzheimer's disease.
Common drugs often used to treated TB are? (3) What is the major side effect/ what do you do to monitor it?
Isoniazid Rifampin Pyrazinamide S.E are hepatotoxicity and liver function test are done to monitor the potential outcome
Why is RhoGAM given?
To destroy fetal cells that got into the mother's blood so antibodies are not formed
What should be done if we are not sure if all the fluid came out in Peritoneal dialysis?
Turn PT side to side or reposition
When do children no longer need booster seats?
Typically when 4'9 and age 8-12 BUT depends on weight and height limits
What is Ulcerative Colitis?
Ulcerative inflammatory bowel disease just in large intestines.
What is an oculogyric crisis?
Uncontrolled rolling back of the eyes and may appear apart of dystonia inoculant muscular movement of face, arms, legs, and neck) S.E of thioridazine
Memantine is a medication used for? And what can it cause? How can it be given?
Used to treat for Alzeheimers (moderate - Severe) can cause dizziness can be Sprinkled on applesauce. Can take w/ or w/o food
Types of play during infancy (birth to 12 months)?
able to engage in sensorimotor stimulation by 6 months, and enjoys games such as peek a boo and pat a cake. Body parts are an object of play.
common side effects of Diltiazem hydrochloride
bradycardia and hypotension
What type of medication is Mithramycin
calcium chelator used to lower serum calcium levels
while taking warfarin, what dietary food item do we limit?
green leafy vegetables contains vitamin K
define beneficence
guide difficult decisions concerning whether the benefits of a treatment may be challenged
Zolpidem is used for what in Alzheimer's disease?
help with sleep disturbance
What is medical term for morning sickness
hyperemesis gravidarum
When you see DKA, what acid base imbalance do you think of?
metabolic Acidosis
Define autonomy?
refers to the freedom to make decisions for oneself. This principle requires nurses to respect patients' rights to make their own choices about treatment if deemed competent beneficence demands that good actions be done for the benefit of others.
left total pneumonectomy means? Do you need any tubes after the procedure is completed?
remove the entire left lung. No Tubes are needed. Fluid & air must accumulate in thoaic space to prevent mediastinal shift to the left.
define veracity
requires nurses and other health care professionals to be truthful as the truth is fundamental to building a trusting relationship
define nonmaleficence
requires the avoidance of harm, either deliberately or unintentionally. This principle requires nurses to protect individuals who are unable to protect themselves from danger
At what rate is blood being removed, cleansed and returned with hemodialysis?
returned at 300-800 mL/min
w/ corticoid inhaler what interventions do you want to do for mouth care?
rinse mouth /Brush teeth after every use
If a PT makes the statement of "I just can't take this loneliness anymore" what are they at risk for?
risk for suicide / Self harm
The nurse provides discharge education to a patient with peptic ulcer disease. What lifestyle considerations should the nurse make the patient aware of before leaving the hospital? Select all that apply 1. Avoid foods that cause discomfort 2. Avoid alcohol intake 3. Have three meals per day 4. Smoking cessation 5. A bland diet may help with symptom relief
(Options #1, 2, 4 & 5) All of these considerations can be helpful in the management of peptic ulcer disease/gastritis. (Option #3) Three meals per day is typically not preferred over smaller, more frequent meals in the management of peptic ulcer disease/gastritis.
Can a nurse admin Propofol?
Now outside nurse scope of practice need nurse anaesthetist/ anesthesiologist
Precautions appropriate for PT w/shingles
Private room, Neg pressure airflow, Resp mask
What is Cheyn-strokes Resp?
Progressively deeper and sometimes fast resp followed by apnea periods
When does Pseudoparkinsonism appear following initiation of antipsychotic med?
Pseudoparkinsonism may appear 1-5 days following initiation of antipsychotic med. Occurs most often in women, the elderly, and dehydrated clients s/s include: tremor, shuffling gait, drooling, rigidity
adverse effects of theophylline or aminophylline? What are they chemically related to?
chemically related to caffeine and can produce tremors, insomnia and nervousness. If admin in large doses or used for a long period can cause convulsions.
What is vincristine?
chemotherapy drug
What is the fastest way to get aspirin into circulatory system?
chewing
What to think of with Asymmetrical Chest expand
collapsed lung from premom or hemothorax
With Night sweats think?
common in tuberculosis
If an asthma PT has a reading of 80%-100% peak expiratory flow meter as personal best value? What does this mean?
continue long term inhaler med. PT is doing well and can do usual activities.
What does the ST segment represent on the ECG?
early ventricular slow repolarization
A nurse is providing discharge teaching for a patient admitted for acute decompensated heart failure. Which statements made by the patient indicate good understanding? Select all that apply: 1. "I will learn relaxation techniques to help me combat stressful situations." 2. "I will avoid the use of ibuprofen for pain." 3. "I will take furosemide at night." 4. "I will read food labels at grocery stores so I can avoid purchasing foods that are high in sodium." 5. "I will make sure I take all my blood pressure pills."
1. "I will learn relaxation techniques to help me combat stressful situations." 2. "I will avoid the use of ibuprofen for pain." 4. "I will read food labels at grocery stores so I can avoid purchasing foods that are high in sodium." 5. "I will make sure I take all my blood pressure pills." (Option #1) Relaxation techniques would be helpful in this case because management of stress is crucial in preventing exacerbations. (Option #2) Ibuprofen is an NSAID and should not be the drug of choice for pain management for this patient. NSAIDs are contraindicated in individuals with heart failure as they lead to fluid retention. (Option #4) The patient should be encouraged to purchase foods with low in sodium. Sodium can cause fluid retention which can worsen heart failure. (Option #5) Adherence to blood pressure medications will help to decrease blood pressure, therefore decreasing workload on the heart. Incorrect Answer: (Option #3) Although furosemide is indicated in individuals with heart failure, the timing would not exacerbate heart failure. TAKEAWAY: To prevent exacerbation, avoid all factors that increase the workload of the failing heart.
Which client should the charge nurse assign to a new RN? 1. Child needing pre-operative medication prior to reduction of a fracture. 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago.
1. Child needing pre-operative medication prior to reduction of a fracture. 1. Correct: This is the least complicated client that could be given to a new, inexperienced nurse. Even though he client has a fracture, the focus is on giving pain medication prior to a major procedure. 2. Incorrect: This client could have internal bleeding and other complications not diagnosed. This is not the best client to give to the new nurse. 3. Incorrect: This is a more complex client and is least likely to be assigned to a new nurse because of the increased need for pain medications, like narcotics, and use of a technological device. Sickle cell pain episodes will vary in it's intensity and frequency. 4. Incorrect: This is a complex client and should not be given to the new nurse. This client is a new admit at risk for respiratory distress and potential infections due to the chronic long term effects of cystic fibrosis.
How can the condition of PEM manifest? whats the s/s?
edema, lethargy, depigmentation and irritability. Early detection and nutritional tx may reduce the risk of further PEM complications.
The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? 1. Dramatic decrease in pain after beginning medications. 2. Severe abdominal pain following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash.
1. Dramatic decrease in pain after beginning medications. 1. Correct. The client usually experiences dramatic improvement within 24 hours after beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of NSAIDs, in fact, most NSAIDs are also antipyretics and would prevent fever.
petechiae on the trunk is a sign of?
endocarditis
manifestations of red man syndrome
erythematous rash flushing tachycardia hypotension
define justice
fairness and obliges nurses and other health-care professionals to treat every person equally regardless of gender, sexual orientation, religion, ethnicity, disease or social standing
S/S of Pneumocystis Camli pneumonia in
fever (low grade if Pt has HIV, high temp w/ no HIV) - Dry cough or wheeze -SOB, dyspnea on exertion - Fatigue - Pleuritic pain on inspiration - most likely to get PCP w/ CD 4 count less than 200
S/S of Bacteremia?
fever, hypothermia, tachycardia, tachypnea inadequate blood flow to internal organs
PT w/ hypothyroidism Should increase what in their diet?
fiber (Constipation w/ GI motility)
What is cyrotherapy
freezing of warts and their surrounding tissue
A mother who just has given birth an hour ago states she is concerned as her newborn presents with an awkwardly shaped foot. The nurse provides the parents with education on the s/s of congenital clubfoot. Which of the following is NOT a sign of clubfoot? 1. asymmetric thigh folds 2. midfoot supination 3. calf atrophy 4. transverse plantar crease
1. asymmetric thigh fold - sign of dysplasia of the hip congenital club foot is a complex deformity that includes: - forefoot adduction -midfoot supination -hindfoot varus -ankle equinus The affected food is usually smaller and shorter with an empty heel pad and transverse plantar crease. the deformity is unilateral , the affected limb may be short and calf atrophy is present.
A nurse is conducting a neuro assessment on a 40 y.o PT. Using a reflex hammer, the nurse strokes the sole of the PT's foot in an upside J shape. Which of the following responses would the nurse label as normal reaction? 1. plantar flexion of the toes and inversion of the foot 2. dorsiflexion of the toes and inversion of the foot 3. plantar flexion of the big toe and fanning of all toes 4. Dorsiflexion flexion of the big toe and fanning of all toes
1. plantar flexion of the toes and inversion of the foot The normal response is plantar flexion of the toes and inversion and flexion of the forefoot.
The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate? STA 1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 4. Place a trochanter roll at the hip. 5. Perform passive range of motion exercises once daily. 6. Monitor for pain by assessing Homan's sign.
1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint. 1., 2., & 3. Correct: Assessment for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. Incorrect: A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Incorrect: Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Incorrect: Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure.
The nurse is caring for a patient with an electrolyte imbalance due to acute renal injury. The patient's ECG displays the Tall, peaked T-waves, Prolonged PR intervals, Flattened P wave, Wide QRS complex, Ventricular fibrillation, Ventricular standstill. The patient is becoming increasingly irritable, and the nurse observes bradycardia and hypotension. Which of the following abnormal laboratory values does the nurse expect to see when the serum electrolyte values are obtained? Select one: 1. Potassium 5.5 mmol/L (5.5 mEq/L) 2. Calcium 1.5 mmol/L (1.5 mEq/L) 3. Potassium 3.0 mmol/L (3.0 mEq/L) 4. Calcium 3.0 mmol/L (3.0 mEq/L)
1. Potassium 5.5 mmol/L (5.5 mEq/L) (Option #1) This laboratory value indicates hyperkalemia (serum potassium greater than 5.0 mmol/L (5.0 mEq/L)). The ECG pictured shows peaked T waves, which is characteristic of the condition. Furthermore, the patient is experiencing physical manifestations of hyperkalemia including irritability, bradycardia, and hypotension. It is important for the nurse to recognize and promptly intervene in the case of this life threatening imbalance. (Option #2) This laboratory value indicates hypocalcemia. Although ventricular dysrhythmia is a potential complication of this condition, the specific ECG changes and clinical manifestations are more suggestive of hyperkalemia, and the nurse should anticipate that this is the prominent imbalance. (Option #3) This laboratory value indicates hypokalemia. ECG changes in this condition include flattening of T-waves, ST segment depression, and a present U wave. These characteristics are not seen in this patient's ECG, and therefore this condition is not likely indicated. (Option #4) This laboratory value indicates hypercalcemia. Although cardiac changes and cardiac arrest are potential complications of this condition, the specific ECG changes and clinical manifestations are more suggestive of hyperkalemia, and the nurse should anticipate this imbalance.
What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? 1. Suggest client eat several small meals a day, with the largest at breakfast. 2. Recommend eating meals in a semi-recumbent position. 3. Administer metoclopramide 1 hour after meals. 4. Avoid fruit juices and carbonated beverages.
1. Suggest client eat several small meals a day, with the largest at breakfast. 1. Correct: Large meals are difficult to manage when the client is anorexic and has loss of appetite, as is usually the case with Hepatitis B. Anorexia may also worsen during the day, making intake of food difficult later in the day. 2. Incorrect: Recommend eating in upright position to reduce sensation of abdominal fullness and therefore enhance intake. 3. Incorrect: Antiemetics, such as metoclopramide, should be given ½ hour before meals, to reduce nausea, and increase food tolerance. 4. Incorrect: Encourage intake of fruit juices, carbonated beverages, and hard candy throughout the day to supply client with extra calories. These may be easier to digest/tolerate than other foods.
A patient is newly admitted to the cardiac unit with heart failure. The initial assessment reveals that the patient is a 50year-old African American female with a Body Mass Index of 20.5. The patient has poorly managed diabetes. She is asthmatic and reports that "it has been a year" since she's her puffer. The patient is also on daily blood pressure medications that she takes when she feels the need to. Which of the following findings increase the risk of heart failure? Select all that apply: 1. The patient is not adhering to her blood pressure medications. 2. The patient is diabetic. 3. The patient has a BMI of 20.5. 4. The patient is asthmatic. 5. The patient is African American.
1. The patient is not adhering to her blood pressure medications. 2. The patient is diabetic. 5. The patient is African American. (Option #1) Uncontrolled hypertension/sustained high pressure is the most common cause of heart failure. (Option #2) Diabetes is a risk factor of heart failure. (Option #5) Heart failure is more prevalent in individuals of African American descent. (Option #4) Asthma is not a risk factor of heart failure. (Option #3) A BMI of 20.5 is considered healthy. A BMI greater than 30 is considered obese and obesity is a risk factor of heart failure.
A new graduate nurse is working with a RN to provide care for a female PT with type 1 DM who was recently diagnosed with Graves disease. which of the following statements by the new grad nurse to the client requires intervention by the RN? 1. The red, swollen, skin on your shins is likely due to an allergic reaction to the med you were previously taking 2. Graves disease is most common cause of hyperthyroidism, which may explain your increase appetite 3. the fact that you are female, and have type 1 DM put you at high risk of developing hyperthyroidism 4. As mentioned by your Dr, your lab tests indicate a decrease level of thyroid stimulating hormone.
1. The red, swollen, skin on your shins is likely due to an allergic reaction to the med you were previously taking - Does not demonstrate clear understanding of the manifestations of hyperthyroidism. The red, swollen skin on the pt's legs are likely Grave's dermopathy, not an allergic reaction 2- Grave's disease is the most common cause of hyperthyroidism. 3- female gender and hx of autoimmune conditions are risk factors for hyperthyroidism 4- decrease thyroid hormone level is seen in PT's with hyperthyroidism due to the feedback mechanisms in the body. High thyroid hormone level stimulate the anterior pituitary gland to decrease the release of thyroid stimulating hormone
The nurse is providing d/c instructions to a child newly dx with asthma and his parents about avoiding environmental triggers in the home setting. Which of the following interventions should the nurse include in the discussion? STA 1. Wear a mask to retain humidity and avoid inhaling cold and dry air 2. use aromatherapy scents as complementary therapy for lung relaxation 3. Wash begging weekly in cold water to get rid of dust mites 4. Replace carpeted floors with wooden floors in the child's room for dust management. 5. Utilize pursed lip breathing for episodes of dyspnea and restlessness
1. Wear a mask to retain humidity and avoid inhaling cold and dry air 4. Replace carpeted floors with wooden floors in the child's room for dust management. 5. Utilize pursed lip breathing for episodes of dyspnea and restlessness -wearing a mask during exercise or cold outdoor temps helps to retain humidity and inhalation of warm air into the lungs. Breathing in cold and dry air can cause narrowed airways, triggering symptoms. -carpeted floors can harbor dust and other irritating agents. Wooden floors are recommended for households with asthma patients to reduce the amount of potential triggers. - pursed lip breathing keeps the airway open and promotes elimination of Carbon dioxide for maximal respiratory effort. This method also slows the pace of breathing and makes each breath more effective. - aromatherapy scents can be irritating to asthmatic PTs - bedding should be washed weekly in HOT water
A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational points should the nurse include? STA 1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%. 4. Have estimated glomerular filtration rate measured every five years. 5. Increase protein intake to 30% of total calories eaten per day.
1., 2. & 3. Correct: NSAIDs can damage the kidneys with chronic use. Risk factors for diabetic related renal complications include hypertension and hyperglycemia; therefore, management of blood pressure and blood glucose is necessary. The ADA treatment goal for HgbA1c is < 7%. 4. Incorrect: The estimated glomerular filtration rate (eGFR) should be assessed at least yearly if not more frequently. 5. Incorrect: A diabetic client's diet should consist of no more than 15-20% caloric intake of protein because protein makes the kidneys work harder.
A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance?STA 1. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses' reasons for not using pain level scale. 6. Disciplines offenses through unpaid time off.
1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill before, but have not practiced the skill on a regular basis, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Counseling the nurses when pain level scale is not utilized may improve understanding and performance. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance. 6. Incorrect: Quality improvement looks at improving processes and does not use intimidation and punishment to improve quality care.
How to measure the correct size of oropharyngeal airway for PT?
measure from earlobe to corner of mouth
If the Surgeon delays Surgery for another 20 min. What do you do as a nurse?
monitor the sterile field while awaiting a surgeon (keep sterile field in site)
what is Acyclovir used for
most often used to treat herpes virus.
IV glucose and insulin do together? What electrolyte imbalance do we think of?
move out of blood into cell (THINK Hyperkalemia)
What is beta interferon used for
multiple sclerosis
What type of precautions should a PT with VRE be put on?
needs to be placed on contact Isolation for Entire hospital stay or until (3) negative cultures of area, 11 week apart.
Dabigatran is used for?
new onset of A-fb
How does a PT with Major / Severe depression eat/ sleep?
no appetite / weight loss, insomnia
What is Anaphylactoid syndrome?
occurs when debris such as amniotic fluid and fetal cells enter maternal circulation.
regular acting onset?
onset 30 min (clear) *Remember clear before cloudy*
How to safely sit in a chair from a stand position with a patient with crutches? Flex the knee of unaffected side Grab the arm of the chair w/ unaffected side's hand Lower into the chair w/ affected leg straight out Move crutches to affected side Backing up to the chair Placing unaffected leg against chair
1.Backing up the chair 2.Placing unaffected leg against chair 3.Move crutches to affected side 4.Grab the arm of chair w/ affected side's hand 5.Flex the knee of unaffected 6.Lower into the chair w/ affected leg straight out
A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? 1. Depersonalization 2. Echopraxia 3. Neologism 4. Concrete thinking
1.Depersonalization 1.Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance). 2. Incorrect: The client who exhibits echopraxia may purposelessly imitate movements made by others. 3. Incorrect: Neologism is the invention of new words by a psychotic client. 4. Incorrect: Concrete thinking, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development.
A newborn is born with a congenital defect. Which of the following conditions will most likely require surgery within 24 hours after birth? Select one: 1. Gastroschisis 2. Cleft palate 3. Umbilical hernia 4. Imperforate anus
1.Gastroschisis Gastroschisis is a congenital abdominal wall defect. The intestines herniate through the abdomen, lateral to the umbilicus. Surgery to repair gastroschisis should be performed within 24 hours after birth in order to prevent life-threatening complications. (Option #2) Cleft palate surgery is delayed for 6-12 months to allow for skeletal growth of the mid-face. Immediate surgery is not indicated. (Option #3) Umbilical hernias often reduce spontaneously. Surgery is performed on an elective basis after 3-5 years of age. (Option #4) Surgery for an imperforate anus is performed 24+ hours after birth. This is recommended so the team can properly evaluate for the presence of a fistula and other possible abnormalities.
1000 mL of D5 ½ NS, infusing at 25gtts/min. DF is 60 gtts/mL. What is the infusion time in hours?
1000 x 60 = 25 total fluid x DF = infusion time x time in min 60,000/25 = 25X/25 X=2400min/60min X=40 hours
What is a normal fetal HR range?
110-160
When is the 1st dose of Diphtheria vaccine?
2 months
An emergency nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? Select one: 1. A 45-year-old male patient diagnosed with Diabetes Mellitus (DM) with a fasting blood glucose level of 5.4 2. A 30-year-old male patient who was involved in a motor vehicle collision has a temperature of 38°C (100.4°F), high urine output and reports fatigue 3. A 10-year-old child with flu-like symptoms and a headache rated 7/10 4. A 22-year-old female patient who has a laceration to her right leg reports pain as 5/10q
2. A 30-year-old male patient who was involved in a motor vehicle collision has a temperature of 38°C (100.4°F), high urine output and reports fatigue (Option #2) This patient is at risk for temperature fluctuations, hormone imbalance and fluid deficit. The patient is unstable and requires further assessment (Option #1) The patient's blood glucose level is within normal range. The patient is stable and not a priority (Option #3) The headache of this patient may be concerning. However, the patient is stable and is not a priority (Option #1) The patient has no other symptoms and is stable. Therefore, this patient is not a priority
Chronic arterial insufficiency s/s? pain? pulse? extremities?
pain with walking that is relieved by rest. The pain is intermittent claudication. The pulses are decreased or may be absent and the extremities are cool to touch. - other s/s: paleness of extremity when elevated or possible redness when lowered. loss of hair on affected extremity, and thick nails.
A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? 1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4. Side lying position in the operating room generated pressure damage.
2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If the CO2 irritates the phrenic nerve, it radiates to the shoulder
Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? 1. Client admitted with possible tuberculosis (TB) awaiting skin test results. 2. Client diagnosed with seizure disorder. 3. Client with a new pacemaker scheduled to be discharged in the morning. 4. Client with a history of mild heart failure prescribed one unit of packed red blood cells for anemia.
2. Client diagnosed with seizure disorder. OB nurses would have the appropriate knowledge needed to care for a client with a seizure disorders, because they care for clients who have eclampsia (seizures).
The nurse is caring for a PT who had an open reduction w/ internal fixation of a fractured femur. A neurovascular assessment is ordered Q4hr. Which of the following actions are part of this assessment? STA 1. Pulse OX 2. Color and temp of extremities 3. Cap refill 4. Dorsiflexion and plantar flexion 5. Palpating the dorsal surface
2. Color and temp of extremities 3. Cap refill 4. Dorsiflexion and plantar flexion 5. Palpating the dorsal surface 2&3 - assessing the color and temp of the extremities and cap refill allows the nurse to determine whether the patient's perfusion is adequate. 4- Dorsiflexion, test the peroneal nerve and plantar flexion (test the tibial nerve) allows the nurse the determine whether the Pt's motor function is affected 5- Palpating the dorsal surface tests the PT's peripheral pulse and sensation.
What is Adenosine used for?
paroxysmal supraventricular tachycardia, and short period of asystole may be common after admin.
adverse effect of beta interferon
photosensitivity suicidal ideation flu like symptoms hepatotoxicity teratogenicity - Teach patient to rotate injection sites and to identify and report S.E
What is multiple sclerosis
progressive degenerative disease of the CNS, characterized by demyelination of the neurons of the brain and spinal cord and the presence of sclerotic plaques. IT causes weakness, muscle spasms, decreased sensation, pain as well as cognitive and emotional problems. NO cure.
If IV is infusing @ 200 mL/hr, What does that mean?
rapid infusion, Assess lung (FVE)
Education during meal time w/ middle stage Alzheimer
serve in quiet environment (limit distraction / Stimuli) - Sene finger foods (too many foods at once may be overwhelming ) - Serve 1 dish @ a time - Don't worry about mess
What is Wernicke's encephalopathy?
severe form of thiamine def in Alcoholics
How should TPN be admin temp wise?
should be refrigerated until use then warm (by sitting out)
How is Paroxysmal A-fib typically resolved?
spontaneously
what is a hypophysectomy
surgery to remove the tumor and pituitary gland due to hyperpituitarism which is causing hormone overproduction
How can a nurse encourage a PT in a skilled nursing unit to eat?
take PT to dining room for all meals
Types of play during school ae (6-12 yrs)
the child enjoys play with rules and competition. They beg into learn to play as a team and can engage in skillful play.
A client arrives at the emergency department with a pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, what intervention should the nurse initiate? 1. Ausculate the lung sounds. 2. Document the finding. 3. Notify the primary healthcare provider. 4. Place the client on oxygen.
2. Document the finding. - normal with respiratory effort
What should the nurse teach the client following a right knee arthroscopy? STA 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.
2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering. - continuous icing can cause tissue damage
The nurse is assessing the lab results for a PT who has been on furosemide for several days. The patient's K+ level is 2.9 mEq/L. Which of the following would the nurse expect to see on the PT's ECG strip? STA 1. Tall, peaked T waves 2. Flattened T waves 3. Inverted P waves 4. Presence of U waves 5. ST depression
2. Flattened T waves 4. Presence of U waves 5. ST depression
A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? STA 1. Directly observe the client at least every 4 hours. 2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. 5. Discourage client's expression of negative feelings.
2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. 2., 3. & 4. Correct: Anxiety rises in stimulating environments. Individuals may be perceived as threatened by a fearful and agitated client. Removing dangerous objects will prevent the confused and agitated client from using them to harm self or others. Anxiety is contagious and can be transmitted from staff to client. 1. Incorrect: The client should be observed closely and frequently to ensure safety for self and others. Every 4 hours is not frequent enough and doesn't ensure the client's safety. 5. Incorrect: Accepting expression of negative feelings is therapeutic and helps the client learn more effective ways of dealing with anger, anxiety or aggression.
The nurse is conducting a health history interview with a patient newly diagnosed with asthma. When the patient lists the medication he is currently taking, which of the following drugs would the nurse find concerning? Select all that apply: 1. Atorvastatin 2. Ramipril 3. Timolol 4. Naproxen 5. Pantoprazole
2. Ramipril 3. Timolol 4. Naproxen Triggers of asthma exacerbation can come from sensitivity to specific drugs and should be avoided. It is important to educate patients about the importance of avoiding these following medications to avoid further complications: • Aspirin • Nonsteroidal anti-inflammatory drugs (NSAIDs) • Angiotensin-converting enzyme (ACE) inhibitors • Beta blockers RATIONALE: Correct Answers: (Option #2) Ramipril is an ACE inhibitor. Patients taking this medication often report coughing, which exacerbates asthma symptoms and irritates the lungs. (Option #3) Timolol is a beta blocker. These medications can cause bronchospasm and should be administered carefully for patients with asthma. (Option #4) Naproxen is an NSAID medication. Many asthmatic patients have sensitivity to aspirin and NSAID drugs, causing the body to produce leukotrienes. Leukotrienes then cause the muscles surrounding the bronchial tubes to contract, resulting in wheezing and dyspnea. Incorrect Answers: (Option #1) Atorvastatin is not a concerning medication for asthmatic patients. (Option #5) Pantoprazole is not a concerning medication for asthmatic patients. TAKEAWAY: Administration of NSAIDs, ACE inhibitors and beta blockers can exacerbate and trigger symptoms of asthma.
The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? STA 1. Shaving the hair with a razor. 2. Removing the hair with clippers. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor.
2. Removing the hair with clippers. 4. Using a depilatory cream. 2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery.`
The nurse is caring for a patient with a history of dilated cardiomyopathy who had a heart transplant 12 hours ago. The nurse is performing an assessment on the patient and decides to alert the healthcare provider immediately. Which of the following signs and symptoms may have caused the nurse to be concerned about transplant rejection? Select all that apply: 1. Increased ejection fraction 2. Shortness of breath 3. Atrial flutter 4. Hypertension 5. Abdominal bloating
2. Shortness of breath 3. Atrial flutter 5. Abdominal bloating Manifestations of transplant rejection include • Shortness of breath • Fatigue • Fluid retention • Abdominal bloating • New onset bradycardia • Hypotension • Atrial fibrillation or flutter The nurse should be mindful of standard precautions and aseptic technique at all times, as an infection is a major cause of death for transplant patients. RATIONALE: Correct Answers: (Options #2, 3 & 5) Shortness of breath, atrial flutter, and abdominal bloating are all manifestations of transplant rejection. Incorrect Answers: (Options #1 & 4) Decreased (not increased) ejection fraction and hypotension (not hypertension) are signs of transplant rejection. TAKEAWAY: Cardiomyopathies are diseases that affect the structure or function of the cardiac muscle. They can be primary and idiopathic with no other structures involved, or secondary to another disease process. Surgical management via heart transplant is typically indicated in the management of dilated cardiomyopathy. It is important to monitor for signs and symptoms of transplant rejection following the procedure.
A patient with hypoparathyroidism asks the nurse why her prescription includes vitamin D in addition to calcium gluconate. Which of the following responses by the nurse provides the best rationale? Select one: 1. Vitamin D and calcium gluconate produce a synergistic effect on bone resorption activity 2. Vitamin D promotes calcium absorption in the gastrointestinal (GI) tract 3. Hypoparathyroidism causes vitamin D deficiency 4. Vitamin D levels can be maintained through regular sun exposure
2. Vitamin D promotes calcium absorption in the gastrointestinal (GI) tract
A new graduate nurse is working with a registered nurse (RN) to care for a patient who has asked to see their ECG strip. The patient is confused about how the pattern is interpreted and asks for some clarification. Which of the following statements made by the new graduate nurse requires intervention from the registered nurse? Select all that apply: 1. The ECG is a graphical representation of the heart's electrical impulses 2. Voltage is measured on the horizontal axis 3. Time is measured on the vertical axis 4. Waveforms represent the depolarization and repolarization of the heart 5. 5 lead ECGs are the standard
2. Voltage is measured on the horizontal axis 3. Time is measured on the vertical axis 5. 5 lead ECGs are the standard An electrocardiogram is a graphical representation of the electrical impulses of the heart. The electrocardiograph uses the electrical impulses to create waveforms, which are depicted on the ECG strip. Time is measured on the horizontal axis in seconds, and voltage is measured on the vertical axis in millivolts. Electrode placement allows for different views of the activity of the heart. 12-Lead ECGs are the standard and include six limb leads and six precordial leads.
What does the QRS duration represent on the ECG?
time for depolarization of both ventricles
What does the QT interval represent on the ECG?
time for ventricular depolarization and repolarization
A nurse has been educating a client newly diagnosed with diabetes, about proper foot care. The nurse knows teaching will need to be reinforced again when the client makes what statement? STA 1. "I should cut my toenails with nail clippers." 2. "Drying both feet thoroughly is important." 3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes.
3. "I should never use nail polish on my toes." 4. "Weekly foot inspection must include the soles of the feet." 5. "I need larger shoes that don't pinch my toes. The nurse is evaluating the client for an understanding of proper diabetic foot care; therefore, an incorrect statement would require further instruction. There is no reason a client with diabetes could not use nail polish on toenails. Inspection of both feet, including the soles of the feet, must be done daily and not weekly. Most importantly, properly fitted shoes are crucial to prevent complications that might result in a blister or eventually an amputation.
What does the PR interval represent on the ECG?
time of atrial depolarization and impulse slowing at the AV node
Which of the following statements about autoimmune disorders are CORRECT? Select all that apply: 1. Activated natural killer cells release inflammatory mediators and cause the inflammation seen in autoimmune disorders 02. The clinical manifestations of autoimmune diseases are primarily driven by cell-mediated immunity 3. Autoimmune diseases occur when self recognition by the immune system is impaired 4. Autoimmune diseases are often characterized by exacerbations and remissions 5. Genetic predisposition is a major factor in the development of autoimmune diseases
3. Autoimmune diseases occur when self recognition by the immune system is impaired 4. Autoimmune diseases are often characterized by exacerbations and remissions 5. Genetic predisposition is a major factor in the development of autoimmune diseases RATIONALE: Correct Answer(s): (Option #3) Autoimmune diseases occur when self-recognition by the immune system is impaired. (Option #4) Autoimmune diseases are often characterized by exacerbations and remissions. (Option #5) Genetic predisposition is a major factor in the development of autoimmune diseases. Incorrect Answer(s): (Option #1) Natural killer cells target and destroy tumor cells and virus infected cells by releasing perforin and granzyme. They are not involved in autoimmunity. (Ontion #2) The clinical manifestations of autoimmune disease are primary drive by the humoral immunity, which is responsible for antigen recognition and antibody production. CEll mediated immunity involves cytotoxic T cell activation without antibodies
When is a potassium hydroxide (KOH) test used
to diagnosis fungal infections such as ringworm, candida albican.
What is Lithium given for?
to treat bipolar/manic disorder but can cause adverse afteers to other body systems Essential to Check, renal, thyroid, and cardiac Function.
where are toes pointed with dorsi flexion
towards the ceiling
Where are toes pointed with plantar flexion
towards the ground
How is Persistent A-fib resolved?
typically terminated through meds or cardioversion.
Define a migraine HA
unilateral pulsating pain
"Foam extinguishers"
used for both class "A" and "B"fires -most appropriate for flammable liquids
" Water only Fire extinguisher"
used for class "A"fires. include solid combustibles such as wood, paper,
What is electrosurgery
uses high frequency heat to cut tissue
What is "red man' syndrome and with this medication do you see this with?
vancomycin - an acute hypersensitivity reaction to vancomycin admin, usually associated with the first dose of the drug. It is seen within 4-6 minutes of the start of the dose or after completion. This is LIFE THREATENING
What does the QRS Complex represent on the ECG?
ventricular depolarization
What does the T wave represent on the ECG?
ventricular repolarization
A nurse, working in a walk-in clinic, is taking a client's health history. The client mentions that since they started taking methimazole, they have been developing small rashes that go away on their own. Which of the following conditions does the nurse suspect the client has? Select one: 1. Addison's disease 2. Cushing's disease 3. Hyperthyroidism 4. Hypothyroidism
3. Hyperthyroidism Hyperthyroidism is an endocrine disorder characterized by an overactive thyroid gland and hypersecretion of thyroid hormones. Antithyroid medications inhibit thyroid hormone production and are the first line of therapy for hyperthyroidism. Methimazole and propylthiouracil (PTU) are antithyroid medications that are commonly used in the management of hyperthyroidism. Methimazole works by blocking thyroid hormone production. It is safe to administer methimazole to children but it is contraindicated in those who are pregnant. RATIONALE: Correct answer (Option #3) Methimazole is used to treat hyperthyroidism. I ncorrect answers (Options #1 & 2) Cushing's disease and Addison's disease are related to adrenal function and would not be consistent with the use of methimazole. (Option #4) Methimazole would not be administered for hypothyroidism as it lowers the levels of thyroid hormone. In hypothyroidism, thyroid hormone levels are already lower than normal. Hypothyroidism would be treated with a thyroid hormone replacement.
The nurse is preparing to perform hemodialysis for a patient with chronic kidney disease (CKD). Which of the following patient findings is the most concerning? 1. Pale and yellow skin tone 2. An estimated glomerular filtration rate of 14 mL/min 3. Inability to palpate a thrill 4. A hemoglobin of 100 g/L (10 g/dL)
3. Inability to palpate a thrill Before performing hemodialysis, the nurse must assess the patency of the fistula by palpating a thrill and auscultating a bruit. If these signs are absent, notify the HCP.
The nurse has just received a change of shift report from another nurse who was caring for a patient who is stable after experiencing cardiogenic shock. She is reviewing medications that are typically used in cardiogenic shock, and recognizes that all of the following are vasodilators except: Select one: 1. Nitroprusside 2. Nitroglycerin 3. Norepinephrine 4. Amrinone
3. Norepinephrine Cardiogenic shock occurs when cardiac output is unable to be maintained due to an impairment in the heart's ability to pump blood. It can be a result of any condition that affects systolic or diastolic function, such as tamponade, myocardial infarction, or restrictive pericarditis. Vasodilators act on smooth muscle to widen the walls of the blood vessels. In cardiogenic shock, vasodilators can be used to decrease the oxygen demands on the heart by decreasing peripheral vascular resistance. This allows for blood to flow out of the heart more effectively, and therefore increases cardiac output. Vasodilators are predominantly used in the treatment of cardiogenic shock. Norepinephrine is an adrenergic drug that stimulates alpha and beta receptors to cause vasoconstriction. In cardiogenic shock, vasoconstriction would increase peripheral vascular resistance, worsening the condition.
A nurse is providing care for a PT with acute Guillain- Barre Syndrome (GBS), who is experiencing paralysis of the lower extremities. The PT expresses that they feel "useless" and "Worthless" because they cannot walk anymore. Which is the MOST appropriate response by the nurse? 1. Lucky for you, this is not a permanent disorder 2. There is no need to worry, there are plenty of activities that you can do while you are paralyzed 3. Tell more more about why you are feeling this way 4. I will refer you to the social work so you can talk to someone about your concerns.
3. Tell more more about why you are feeling this way -Most therapeutic response. Encourages the patient to verbalize their feelings
The nurse is assessing a patient who had an amputation for d/c. Which of the following patient parameters should the nurse observe during the assessment?STA 1. The patient is no longer NPO status since this morning 2. The patient verbalizes depressed feeling overlost body part 3. The patient has voided in the past 8 hours 4. The patient ambulates within halls 5. The patient has minimal and manageable pain
3. The patient has voided in the past 8 hours 4. The patient ambulates within halls 5. The patient has minimal and manageable pain - The patient must demonstrate the ability to care for themselves in the home setting before d/c. These skills would include the ability to swallow, ambulate, void and manage minimal pain from the surgery. 1- removing patient off of NPO status requires further assessments of the Pt's ability to digest and eliminate bowel contents 2- Verbalization of depressed feeling would prompt the nurse to inquire whether the PT is developing a depressive disorder. Which suggest a possible complications
The nurse is caring for a patient in the emergency department after being brought in by the family for sudden right-sided weakness 1 hour ago. CT and MRI scans rule out hemorrhage and the patient is diagnosed as having an ischemic stroke. Which of the following therapies does the nurse anticipate for the patient at this time? 1. Nimodipine 60 mg PO q4h 2. Heparin 250 units/kg SC 912hr 3. Tissue plasminogen activator (TPA) 0.9 mg/kg IV 4. Clopidogrel 75 mg PO q1d
3. Tissue plasminogen activator (TPA) 0.9 mg/kg IV TPA is the most appropriate at this time as it can dissolve clots within 3 hours of onset of a stroke. Nimodipine is a calcium channel blocker used to relax the blood vessels in subarachnoid hemorrhage. Hemorrhagic stroke is ruled out for the patient. Heparin and Clopidogrel are anticoagulants which are used for preventative measures and cannot dissolve clots.
Diet Full A thickness bums =
vitamin C and Protein (oranges and Chicken)
A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? 1. Inspect the catheter tubing for obstruction. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.
4. Correct: The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent further bladder distention. Bladder distention is one of the main causes of hemorrhage in the fresh post op period. 1. Incorrect: The next action is to check the external system for kinks or obstruction to assess if this is the cause of the decreased urine output. Obstruction of the catheter tubing can also cause bladder distention. 2. Incorrect: After the external system is checked for kinks or obstruction, and the client's urine output doesn't change, then the catheter is irrigated with 30 to 50 mL of normal saline using a large piston syringe. However, irrigating a new post-op client is not the safest or first action for the nurse. 3. Incorrect: Of the options listed here, this is the last intervention. If the obstruction is not resolved after irrigating the system, the primary healthcare provider must be notified.
What electrolyte imbalance should the nurse monitor for a client diagnosed with HHS? 1. hypocalcemia 2. hypermagnesemia 3. Hyperkalemia 4. Hyponatremia
4. Hyponatremia - Hyperglycemia can cause dilutional hyponatremia, so Normal saline administered to replace both fluid and sodium lost through increase UO.
A nurse is caring for a PT with a hx of dysrhythmias. The nurse checks the telemetry monitor and notices that the patient is in ventricular asystole. Which of the following is NOT a priority action for the nurse? 1. begin CPR 2. recheck ECG 3. Call for assistance 4. Initiate cardioversion
4. Initiate cardioversion Priority interventions by an RN include: - call for assistance -begin CPR - recheck ECG - DO NOT SHOCK ASYSTOLE
The ER nurse is assessing a client reporting severe abdominal pain for several hours prior to arrival at the hospital. Assessment findings include slight mottling of the lower extremities and pulsating mass near the umbilicus. Which actions should the nurse implement immediately? STA 1. position client on left side 2. apply warm blankets to legs 3. admin IM pain meds 4. alert the operating room staff 5. notify HCP 6. palpate mass to determine size
4. alert the operating room staff 5. notify HCP The client symptoms indicate the prescence of an aortic abdominal aneurysm that may be dissecting (rupturing) at this time). This is LIFE THREATENING EMERGENCY and the client will need urgent surgery to survive.
The nurse is teaching a class the difference between active and latent TB, Which of the following s/s should the nurse include as associated with a latent TB infection? 1. chest pain 2. fever and chills 3. may spread bacteria to others 4. Positive mantoux skin test indicating TB infection 5. Normal chest x-ray
4. positive mantoux skin test 5. normal chest x-ray - Pt's with latent TB infection will be asymptomatic with normal chest X-ray despite a positive skin reaction to TB. - Those with active TB are able to spread the bacteria to others and will have abnormal chest X-ray results with positive sputum smear.
peak of long acting insulin?
6 hours
What is Sulfonylureas?
Oral hypoglycemic
How does a PT with mild depression eat/ sleep?
Overeating sleep too much
1 year old PT w/ congenital heart defect is having difficulty breathing. How should you position the PT?
Place PT in reverse Trendelenburg (decrease work of breathing)
The medication discmelt can cause s/s of hyperglycemia as an adverse reaction. What are the s/s?
Polydipsia, polyphasia, polyuria
Mantoux skin test Immigrants (less than 5yrs/) or children less than 4yrs old with induration of 10m or greater =
Positive
What is Bacteremia ?
Presence of bacteria in bloodstream
How should blood be admin?
Through a large bore IV needle such as 18 no smaller than 20 (smaller will cause PRBC's to lyse
Why are a combo of Pyrazinamide and Isoniazid is used in a TB pt?
To decrease bacterial resistance
What is a Weber Test?
Uses tuning fork to assess bone conduction
What is s/s of Metabolic Alkalosis?
Vomiting
What type of solution do you NOT lubricate an NG tube with?
Water solution Petroleum gel
What is Subcutaneous emphysema?
When air gets under the skin after chest tube or tracheostomy
When do you empty JP drain?
When ⅔ full
A patient with a history of rheumatic fever needs to be premedicated with what?
With antibiotics prior to any surgical/dental procedure to prevent recurrence
define fidelity
a promise that an individual will fulfill all commitments made to oneself or others and requires loyalty
What is Methylergonovine?
affects Smooth muscle of a woman's uterus and improves muscle tone and strength. Used after child birth to help deliver placenta.
What time of drug is beta interferon
anti-inflammatory and immunomodulatory effects.
What type of medication is vancomycin
antibiotic
What kind of medication if Fluconazole
antifungal
What type of medication is Acyclovir
antiviral
If an asthma PT has a reading of 60-79% peak expiratory flow meter as personal best value. What does that mean?
asthma is getting worse. Take PRN med which should be short-acting bronchodilator
What does the P wave represent on the ECG?
atrial depolarization
Where do you to place D-fib electrodes on v-fib PT?
below right clavicle to the right of the sternum and just below the left nipple.
Two hours after gastrectomy PT bas pink tinged drainage from NG tube, the tube appears occluded. Nurse's initial action?
call HCP (don't tamper w fresh Surgery tubes)
Types of play during adolescent (12-19 yrs)
can engage in increasingly complex activities due to advance cognitive and physical skill. Activities are focused on spending time with peers.
Define iatrogenic?
caused by medical tx
