Readiness Test Review, QBanks Review #1, Review Up to Question Trainer #7
Pertussis requires which precautions?
"Whooping cough" Droplet
Thiazolidinediones (TZD) --Nomenclature --Effect on body --Adverse effects --Usage tips
-zone (pioglitazone) ----------------------------------------------- 1. Increase insulin sensitivity 2. Reduce glucose release by liver ----------------------------------------------- 1. Swelling (water retention) 2. Weight gain 3. Infection 4. Headaceh 5. Liver failure INCREASE RISK OF BLADDER CANCER (pioglitazone) AND MI (rosiglitzone) ----------------------------------------------- Can be taken with or without food, but are taken at same time during day Require liver studies test
Sodium glucose co-transporter 2 inhibitors (SGLT2) --Nomenclature --Effect --Adverse effects
-flozins (thin urine - "flow") ----------------------------------------------- Block reabsorption of glucose, so it is urinated out ----------------------------------------------- 1. Urinary infections (think - you have sugary urine) 2. Joint pain 3. Nausea
The nurse cares for the client 4 hours after admission to the neuroscience unit due to a closed-head injury. Which is the most important action for the nurse to take? 1.Assess pupil shape and reactivity. 2.Take the client's rectal temperature. 3.Assess blood pressure and apical heart rate. 4.Observe the client's oxygen saturation level.
1 (you said 4)
The adult grandchild of a client diagnosed with Parkinson disease tells the nurse about proposed gift ideas for the grandparent's birthday in 2 weeks. The grandchild asks the nurse which idea is best. Which option is the best gift for the nurse to recommend? 1.Perfume and makeup. 2.Hearing aid with batteries. 3.Warming tray for food. 4.Quilt and soft pillow.
1 -> no physiological benefit 2 -> Parkinson's doesn't cause hearing loss 3 -> TRUE, because of imparied motor skills, eating food may take a while; this keeps it warm 4 -> shouldn't have pillow when laying down (neutral alignment)
The nurse provides care for a client diagnosed with atherosclerosis. Which client statements about clopidogrel require follow-up by the nurse? (Select all that apply.) 1."This medication may cause my blood pressure to be low. " 2."I play racquetball three times each week for exercise. " 3."I need to go back to the health care provider next year. " 4."I take my medications at the same time each day. " 5."I take this medication so I don 't have a stroke. " 6."I will notify my health care provider if I notice bruises. "
1, 2, 3 1 -> causes HTN, not low BP 2 -> risk of bleeding, avoid risky exercises 3 -> need more regular checkups 4, 5 6 are good
The client has an order for hydrochlorothiazide 50 mg qd. The nurse knows that further teaching is needed if the client makes which statement? Select all that apply. 1."I should not operate heavy machinery." 2."I should drink five glasses of liquid per day." 3."This medication will cause my urine to turn orange." 4."I should eat dried apricots each day." 5."I should take this medication on an empty stomach
1, 2, 3, 5 1 -> diuretics don't cause drowsiness, so this isn't relevant 2 -> no fluid restrictions stated; if anything, you want to encourage fluids to an extent to avoid dehydration 3 -> diuretics don't cause urine changes 4 -> GOOD, apricots contain potassiu 5 -> take with food; causes GI upset
The health care provider writes an order for piperacillin 3 g IV q6h for the adult client. Before administering this drug, the nurse should take which action appropriate to this medication? Select all that apply. 1.Check for known allergies to medications. 2.Obtain specimen for culture and sensitivity 3.Administer dexamethasone sodium phosphate 2 mg IV stat. 4.Obtain client's current creatinine clearance results. 5.Ensure that the client's respiratory rate is over 12. 6.Check the client's blood pressure both sitting and standing
1, 2, 4
The nurse administers intravenous dopamine to a client. Which parameter will the nurse monitor to evaluate the response to this medication? 1.Heart rhythm. 2.Central venous pressure. 3.Vital signs. 4.Daily weights.
3 (you said 2)
The client is admitted to the hospital with dry mucous membranes and decreased skin turgor. The client's vital signs are BP 120/70, temperature 101°F (38.3°C), pulse 88, respirations 14. Laboratory tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the health care provider to order which IV fluids? 1.D5NS. 2.0.45% NaCl. 3.0.9% NaCl. 4.Lactated Ringer's.
2 You said 3; notice that they are in a dehydrated state If dehydrated, hypo is better than iso
The nurse observes late decelerations of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. Which actions should the nurse take? Select all that apply. 1.Change the fluids to Ringers lactate. 2.Discontinue the oxytocin infusion. 3.Assist client to bathroom and measure urine. 4.Turn client to the left side. 5.Apply oxygen at 8 L/min by mask. 6.Increase the primary IV infusion flow rate.
2, 4, 5, 6 You said 1; it doesn't make a difference ♂️
How long do antidepressants take?
A long time (weeks for effect, months for full effect)
Meconium ileus
Bowel obstruction in intestines of newborns --Is a result of cystic fibrosis
Depressed fracture
Broken portion of bone is pushed inward (think piece of your skull inside brain)
Circumoral cyanosis
Bluish coloration around mouth Is an INDICATION of hypoxia in newborn
Chadwick's sign
Bluish coloration of cervix Is a PROBABLE indicator ofp regnancy
How do you move a fracture patient?
If they can help -> use trapeze bar If they can't -> log roll
Glucocorticoids --Effects (3) --Adverse effects
Immunosuppression, anti-inflammation, replace missing adrenal hormones ------------------------------------------- IMPAIRED IMMUNE/INFLAMMATORY RESPONSE: 1. Increased risk of infection 2. Delayed wound healing CUSHING'S SYMPTOMS 1. Hyperglycemia 2. Osteoperosis (low calcium) 3. Low potassium 3. Psychoses/depression 4. Buffalo hump 5. Weight gain 6. Petechiae/thin skin OTHER 1. Edema 2. Risk of ulcers/gastric hemorrhaging 3. Stunted growth in children
Lumbar Puncture --What is it? --Pre-test placement --Post-procedure care
Inserting needle into subarachnoid space 1. Have patient at edge of bed in lateral recumbent fetal position (basically just sitting on side of bed with head in lap) 2. Explain they may have some discomfort at or below level of needle during insertion 1. Neuro assessments 2. Put flat in bed for a couple hours 3. Promote fluids (to remove dye) 4. Pain meds for headache 5. Apply sterile dressing and look for drainage
When caring for a droplet precaution patient, where should the mask be discarded
Inside the room
Normal BNP
Less than 100
A patient has an abscess draining with no dressing on it; what precautions are needed?
Contac5`
C. dif requires which precautions?
Contact
Hepatitis A requires which precuations?
Contact
MRSA and Cdif have what precautions?
Contact
MRSA requires which precautions?
Contact
Patients with lice require what precautions?
Contact
Pediculosis requires which precautions?
Contact
School-aged play pattern (which age)
Cooperative play -> organized rules and leaders Age 6-12
Hypercalcemia S/S
DEPRESSED 1. Fatigue/weakness 2. Constipation 3. Mental status changes 4. Bradycardia 4. Kidney stones 5. Wide, depressed T waves 6. Short QT interval
A mother is breastfeeding. What measures do you promote?
DO 1. Promote heat (increases milk excretion) 2. Massage
When breastfeeding, what do you do and not do?
DO 1. Put cold compresses 2. Wear well-fitting bra 3. Rinse with water DO NOT 1. Do warm water 2. Use lotions 3. Massage breast 4. Use soap
Main focus of epiglottitis in children
DO NOT GIVE STRESS UNTIL AIRWAY IS SECURED WITH ET TUBE 1. Do not examine area 2. Keep patient calm (parents close) 3. No procedures Keep on droplet precautions for 24 horus for antibiotics
The chest drainage tube becomes detatched from the 3-chamber apparatus. What do you do and NOT do?
DO immediately place the chest tube in sterile water to prevent backflow of air Do NOT just reattach it (needs to be sterile - get another machine)
Nephrotic syndrome --What is the most severe complications you should look out for?
Damage to glomeruli leading to frothy urine (extreme protein loss in urine) F/E imbalance and thrombus formation risk
Crossing legs causes what circulation change? Who should avoid it?
Decreases blood flow to legs/feet Should not be done by diabetics
Bilirubin; how is it impacted by liver disease?
Defective dead RBCs Are increased, since liver can't filter them out
You are about to cap a trach tube. What is singlehandedly the most important thing to do?
Deflate the cuff --Since the opening is being closed via capping, if you don't deflate, they physically won't be able to breathe
amyotrophic lateral sclerosis (ALS)
Degeneration of motor nerves over time leading to loss of voluntary muscle control Starts as muscle weakness in arms/legs Progresses to inability to do mouth functions --Can't speak --Can't swallow --Can't breathe without help Eventually is completely paralyzed
Diptheria requires which precautions?
Depends on type If skin/cutaneous -> contact If oral/pharyngeal -> droplet
What compound leads to gout?
Excessive purines Found in alcohol + meats
(T/F) Pregnant women can receive vaccines
FALSE; risk of fetal complications
(T/F) Administering IV medications is a good idea for LPNS
False; IV medications have a rapid effect, and therefore require rapid assessment of their effects
How to calculate expected birth date
Find start date of last menstrual period Take date Add 9 months and 1 week (aka 37 weeks)
Low-residue vs high residue diet
HIGH residue --Contains high-fiber foods --Common when stools are encouraged and need to be bulked up --Constipation, large bowel issues LOW residue --Contains low-fiber foods (no whole wheat, bran, corn, etc) --Done to reduce intestinal activity --I.e. ulcers, lower bowel surgery
When inserting a pacemaker, which finding indicates there has been an error, and the pacemaker is now defective?
HR falls below what was set in the pacemaker Being above is fine
Patients with renal failure have what calcium levels? Why?
HYPO-calcemia Because of elevated phosphate
What kind of mouth problems do Parkinson's patients have?
Have slurred speech + difficulty eating r/t impaired fine motor functions
Jaundice in the newborn indicates what?
Hemolytic disease of the newborn Is NOT normal, and requires treatment
What kind of diet is ulcerative colitis/Crohns put on
High protein/calories (absorption is impaired, so you need it) Lower fiber (increased motility exacerbates it) May also need vitamin supplementation
How often is blood glucose checked with DKA and HHNK?
Hourly
Changes associated with acidosis state
Hypocalcemia --More acidity = calcium has greater affinity to albumin Leads to HYPER-reflexes
What are the side effects of epidural anesthesia?
Hypotension
Chickenpox/shingles need to be put on airborne precautions only ___
If it is not localized (the "shingles" are not localized to 1 area, but have spread)
PT clot
Normal while on heparin -> 25-35
How do you pull the ear to assess it?
Pull up and back if above age 3 Pull down and back if younger than that
Aspart
Rapid-acting insulin
sulfamethoxazole-trimethoprim common side effect
Rash/itchiness
What should be done again 1 hour before surgery?
Recheck the consent form
S/S of hypernatremia
S/S associated with dehydration 1. Dry, sticky membranes 2. Low urine 3. Firm tissues 4. Rapid HR 5. Weakness OTHER 6. Flushed skin 7. Coma
A woman with a diagnosis of Alzheimer's disease is admitted to the hospital for treatment of an upper respiratory tract infection. On admission, she is incontinent of urine. When assigning the client to a room on the nursing unit, which location would be best? 1.A semi-private room near the nurse's station. 2.A private room near the nurse's station. 3.A private room away from the nurse's station. 4.A semi-private room away from the nurse's station.
So Alzheimers, so they need to be near nurses station Put in semi-private room for stimulation The upper respiratory infection sounds concerning, but it doesn't necessarily mean they are put in private room (those are overtly for airborne/neutropenic patients)
Play type for infant (which age)
Solitary play (on their own) Birth - 1 year
Huff cough
Special form of cough which stimulates a coughing reflex --Is good for clearing lung secretions
Lyme disease precautions
Standard
Hydrocolloid dressing usage?
Used for shallow to moderate ulcerations
When is thumb-sucking prevalent in children?
Usually present until around 2 y.o. Is NORMAL, do not attempt to stop it Usually happens when kid is agitated or hungry
What kind of stool do cystic fibrosis people have
Very greasy with a foul odor
What kind of sweat do cystic fibrosis patients have?
Very sodium-heavy (at risk of hyponatremia0
What kinds of S/S does lung cancer have?
Very vague ones which often appear late
Aspirin poisoning treatment
Vitamin K + IV sodium bicarbonate
What is the best way to assess for fluid volume deficit?
Weigh them
Normal weight changes in first year of life
Weight doubles by 4 months old Triples by 1 year old
What is the MOST important implementation to prevent further bone breakdown in an osteoperosis patient?
Weight-bearing exercises Yes, it even trumps eating calcium
Brainstem
the oldest part and central core of the brain, beginning where the spinal cord swells as it enters the skull; the brainstem is responsible for automatic survival functions
When should toilet training start in a kid?
~21 months; at this point they have sphincter control
Aortic valve location
*Right sternal border at the 2nd intercostal space*. Best auscultated with the patient seated, leaning forward, and exhaling
The nurse cares for the client recovering from abdominal surgery. During ambulation, the client reports a dull ache in the left leg. Which action does the nurse take first? 1.Places the client on bedrest with extremity elevated. 2.Places a pillow under the client's knee. 3.Encourages client to ambulate more frequently. 4.Obtains thigh-high compression stockings.
1 2 -> the distance from lower leg to knee is now uphill, dissuading return 3 -> FALSE, can dislodge clot 4 -> TED hose are preventative measure, not a treatment
The nurse cares for the 4-year-old child diagnosed with a closed head injury. The nurse is reassured by which observation? 1.The child is able to state their name when asked who they are. 2.The child reaches for a stuffed animal brought from home. 3.The child maintains themself in opisthotonos. 4.The child withdraws from mildly painful stimuli.
1 2 is tempting, but remember; even the intercranial bleed guy still had the ability to grab things
The nurse reviews care needs for assigned clients. Which client will the nurse assess first? 1.Client who had a vaginal hysterectomy 2 days ago and is reporting that the right calf is warm to touch. 2.Client who received a dose of prescribed warfarin while receiving a heparin infusion. 3.Client with chronic obstructive pulmonary disease who is using pursed-lip breathing. 4.Client who had an abdominal aortic aneurysm repaired 10 hours ago and has bronchial breath sounds over the trachea.
1 4 -> bronchial sounds over trachea is normal For 1, a warm calf indicates thrombi formation, which can be life-threatening
A nurse assesses a patient getting TPN. Which is most concerning? 1. Urine output 150 mL/hr 2. Temperature of 100 F 3. Albumin is 3.2 4. Crackles heard in lungs which clear upon coughing
1 4 is tempting, but it's not an immediate issue Urine output is bad; remember they are getting TPN. It says nothing about IV fluids, so they're at risk for dehydration
The nurse provides care for a client diagnosed with diabetes mellitus who is hospitalized with acute pyelonephritis. Which collaborative problem is a priority for the team to address? 1.Urosepsis. 2.Hydronephrosis. 3.Hyperglycemia. 4.Flank pain.
1 Note that they were hospitalized for an infection (and of the kidneys no less) -> what is the main concern of infections?
Proton Pump Inhibitors --Nomenclature; give an example --Usage
-prazole Omeprazole ------------------------------------------- Reduce secretion of stomach acid Used to prevent ulcers
Tricyclic antidepressant nomenclature
-ptyline
Aminoglycoside nomenclature; what is a notable side effect?
-ycin or -icin Cause ototoxicity
Antipsychotic nomenclature
-zine Exceptions: 1. Haloperidol 2. Risperidone (and other -dones) 3. Quetiapine 4. Clozapine/olanzapine
The parents of the newborn diagnosed with a myelomeningocele have been grieving the loss of their perfect child. After three days of grieving, the progress in their emotional status is indicated to the nurse by which comment? 1."When will it be safe for us to hold our baby?" 2."We would rather that you feed our baby." 3."What did we do to cause this problem?" 4."When do you anticipate our baby going home?"
1 (you said 3) Myelomeningocele = bulging on back due to spinal fluid/spinal cord jutting out Will lead to paralysis #3 is wrong, it's taking blame for the issue (guilt) #1 is good
The nurse admits an older adult client to the unit. The client demonstrates decreased ability to problem-solve, psychomotor deficits, and social isolation. Which nursing action is most appropriate? 1.Prepare a schedule of activities and monitor the client's participation in the activities. 2.Encourage the client to choose the client's own activities. 3.Allow the client time to get acclimated to the milieu before scheduling activities. 4.Allow the client to rest quietly to restore energy level.
1 (you said 3) The symptoms indicate dementia - these patients need structured routines or they get distressed
The nurse provides care for a client diagnosed with diabetic ketoacidosis (DKA). Which intervention does the nurse expect the health care provider to prescribe? (Select all that apply.) 1.Short acting intravenous (IV) insulin. 2.Isotonic intravenous (IV) fluids. 3.Total parenteral nutrition (TPN). 4.Hourly intake and output. 5.Finger blood glucose every four hours.
1, 2, 4 You said 5 before; notice that it's every 4 hours (too long)
The nurse administers carisoprodol to the incorrect client. Which strategy should the nurse use to reduce the risk of malpractice litigation? (Select all that apply.) 1.Ask the charge nurse to reassign the client to a different nurse. 2.Notify the health care provider of the medication error immediately. 3.Report the incident to the manager for appropriate follow-up with the client. 4.Print a copy of the incident report to keep in the nurse's personal records. 5.Explain to the client that the nurse has a heavier assignment than normal.
2, 3 You said 4, but remember that violates HIPPA
The nurse cares for the client with a radium implant. It is important for the nurse to take which action? Select all that apply. 1.Evaluate the position of the applicator every two hours. 2.Place the client on a low-residue diet to decrease bowel movements. 3.Encourage the use of the bedside commode. 4.Decrease fluid intake to decrease radiation in the bladder. 5.Encourage the client to conserve their energy. 6.Encourage the client to take their anti-nausea medication.
2, 5,6
A parent asks the nurse about the best time to begin toilet training a 22-month-old child. Which nursing response is most appropriate? 1."When your child turns 2 years old." 2."When your child expresses interest in toilet training." 3."When you are ready to begin toilet training." 4."When your child turns 3 years old."
2, when they express interest
At what rate should a blood pressure cuff be deflated --Stupid, I know
2-3 mmHg/second
Normal CVP pressure
2-8
One afternoon in the hospital day room, the nurse overhears a woman with chronic schizophrenia say to another other client, "I hate you, get away from me or I'll kill you." Which response, if made by the nurse, is MOST appropriate? 1."I will not let that client hurt you." 2."There is no reason for you to be angry with that client." 3."You seem to be frightened by that client." 4."You don't really want to kill that client."
3 (you said 1) #1 is technically false reassurance, you can't guarantee that they won't be hurt
The nurse provides care to a client with a tracheostomy who is receiving oxygen. Which action is considered negligence by the nurse? 1.Wears goggles when changing the tracheostomy dressing. 2.Applies cream on the feet and legs after a bath. 3.Sprinkles powder on the chest after a bath. 4.Places a pre-cut gauze dressing around the tracheostomy.
3 The powder can go down trach tube; not a good look
The nurse provides care to a client at risk for hypercalcemia. Which action is most appropriate for the nurse to take? 1.Encourage strict bed rest. 2.Limit dietary fiber. 3.Encourage oral fluids. 4.Hold prescribed zoledronate.
3 Weight-bearing exercises help to alleviate it The patient is constipated; fiber helps Fluids also help with constipation
The client who had an appendectomy four days ago reports severe abdominal pain. During the initial assessment they state, "I have had two almost-black stools today." Which nursing action is most important? 1.Start an IV with D5W at 125 ml/hour. 2.Insert a nasogastric tube. 3.Notify the health care provider. 4.Obtain a stool specimen.
3 (you said 1) Think - if I could only do 1 thing... Starting an IV does not fix the bleed
The nurse cares for the client in the outpatient clinic. The client is seen for treatment of hypertension. The client expresses concern to the nurse that the spouse has been unemployed for more than six months. The client is afraid that soon they will be unable to pay their rent. Which response by the nurse is BEST? 1."These things always have a way of working themselves out." 2."It's important for your health that you not worry too much." 3."You're worried that you won't be able to pay the rent?" 4."A social worker might be able to help you with this problem."
3 (you said 4) 4 is passing the buck, and doesn't address emotional distress
The nurse instructs a client with urinary frequency and burning and a temperature of 102°F (38.8°C) to collect a urine specimen for culture and sensitivity. Which statement by the client demonstrates to the nurse teaching is successful? 1."I will call the lab before I collect my urine." 2."I will drink several glasses of water before I collect my urine." 3."I will collect the specimen using an aseptic technique." 4."I will discard my first voiding in the morning."
3 (you said 4) First void in the morning isn't necessary, just empty bladder a little before giving urinary specimen (stasis of urine)
Based on the nurse's knowledge of the goal of diuretic therapy for the client with heart failure, which assessment BEST indicates that the client's condition is improving? 1.The client's weight has decreased 2 pounds. 2.The client's systolic blood pressure has decreased. 3.The client has fewer crackles heard during auscultation. 4.The client's urinary output has increased.
3 (you said 4) Note that the question is the indicator that "their condition is improving", that "the diuretic is taking effect", otherwise it would be #4 Even if urine is increased, that is not specific to their condition complications (pulmonary edema) in the way #3 is
The nurse cares for the client with a nasogastric tube in place after extensive abdominal surgery. The client reports nausea. The nurse notes the client's abdomen is distended and there are no bowel sounds. Which action does the nurse take first? 1.Administers the PRN pain medication and an antiemetic. 2.Irrigates the nasogastric tube with normal saline. 3.Determines if the nasogastric tube is patent and draining. 4.Checks the placement of the nasogastric tube by auscultation.
3 (you said 4) Notice that they didn't say they had dyspnea
A nurse is performing triage in the emergency department. Which client should the nurse see first? 1.A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C). 2.A client reporting a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C). 3.A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C). 4.A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F (37.4° C).
3 (you said 4) Obviously facial burns, risk of airway obstruction #4 is tempting, but think: is this an expected finding?
The public health nurse assesses a client reporting a persistent cough with blood-tinged sputum and night sweats. Which action does the nurse take first? 1.Assess the client's oxygen saturation.2.Place oxygen per nasal cannula on the client.3.Assist the client in putting on a mask.4.Assess the client's lung sounds.
3 (you said 4) Prevention of spread of disease takes precedence; you have enough data to suspect TB
A nurse is presented with a group of clients in the emergency room. The nurse knows that which client needs immediate attention? 1.A child who is bleeding from a facial injury. 2.A middle-aged client with midsternal chest pain. 3.A middle-aged client in respiratory distress. 4.An infant who has been vomiting for 8 hours.
3 (you said 4) Which ones are ABCs? Only 2 and 3, eliminate 1 and 4 3 is an airway problem, which trumps circulatory problems
Cushing's triad
3 classic signs of increased ICP 1. Slow HR 2. HTN 3. Slow breathing
Hepatitis B vaccine schedule
3 doses 1 -> AT BIRTH (the only one received at birth) 2 -> 1 month 3 -> 6 months
What is the time restriction on visitors for radiation patients?
3 hours
It usually takes how long for TB to go away? Describe how clearance is checked
3 months Have patient take 3 separate cultures in a row that are negative for TB
A kid __ y.o. can draw a circle
3 years
A kid __ y.o. can undress without help; when can they dress without help?
3 years; 5 years old
The nurse cares for the 8-month-old client. Which observation tells the nurse the client is in pain? Select all that apply. 1.Decreased pulse rate. 2.Increased fluid intake. 3.Decreased respiratory rate. 4.Rubbing a body part and crying. 5.Eyes closed tightly. 6.Pushes away painful nurses hands.
3, 4 You said 6 too; would an 8 month old be strong enough to do this?
Which hepatitis types have vaccines?
A + B
When making nursing diagnosis, "Risk for" diagnoses are always ___
A lower priority than present diagnoses A problem that already exists is always a bigger issue than a hypothetical problem
The nurse prepares to administer medication via IV push into an established IV line. Which action does the nurse take? 1.Select the port farthest from the insertion site. 2.Ensure that the tubing above the injection port is patent. 3.Time the medication administration with a watch. 4.Explain the procedure to the client after completion.
A major concern of IV push with a running IV med is that the IV push med can be diluted out THEREFORE, take measures to keep the medication concentrated 1 -> furthest away from insertion promotes dilution 2 -> you'll be kinking the tubing to prevent dilution, so not important 3 -> GOOD 4 -> should be done before
Antacids are best taken when?
AFTER meals --Think -> that's when the stomach acid (which you need to neutralize) is being secreted the most Do it before, and there isn't as much
Describe how to care for each of the following in newborn --Airway --Thermoregulation --Nutrition --Drugs --
AIRWAY --Suction using bulb syringe Thermoregulation --Skin to skin contact --Cover up and avoid cold air --Avoid bathing unless temperature is high + stable Nutrition --Breastfeed if possible; otherwise formula --Feed every 2-3 hours Drugs --Erythromycin eye drops --Hep B vaccine --Vitamin K injection
The nurse counsels a client diagnosed with glaucoma. Which client statement demonstrates to the nurse that teaching is successful? 1."Because of glaucoma, the correction in my eyeglasses needs to be changed. " 2."I will schedule appointments with my physician early in the morning. " 3."I 'm glad that surgery can reverse the damage caused by the glaucoma. " 4."I will be happy when I don 't have to use the eye drops anymore. "
2 Glaucoma causes visual damage due to increased pressure against the optic nerve, so 1 -> eyeglasses won't fix damage to optic nerve 3 -> damage is permanent 4 -> this is a chronic condition, so eyedrops need to be taken 2 -> ICP is highest in the morning, so results will be most accurate
The nurse provides care for a client in the final stage of chronic kidney disease. The client's serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client? 1.Activity intolerance. 2.Risk for injury. 3.Imbalanced nutrition. 4.Failure to thrive.
2 Has low calcium (9-10.5) and high phosphate (3-4.5) Will potentially cause breakdown and loss of bone
The nurse cares for the child after a tonsillectomy. The nurse is MOST concerned if which finding is observed? 1.Heart rate of 88 beats per minute. 2.Expectorating bright red secretions. 3.Thirty milliliters of dark brown secretions. 4.Infrequent swallowing.
2 Indicates excessive bleeding, which can impair airway (You said 4) - patient probably won't be swallowing much anyway due to discomfort
The nurse cares for the client after an ileostomy. The nurse is most concerned if which observation is made? 1.The ileostomy functions without daily irrigations. 2.The stoma appears to be tight, and there is a decreased amount of stool. 3.A small amount of mucus is seen around the anal area. 4.There is a weight gain of 5 lb over a 3-week period of time.
2 Indicates some obstruction
A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following? 1.Prepare to administer IV Pitocin to the client. 2.A reduction in the amount of pain medication administered. 3.Check the client's blood pressure every 5 minutes. 4.Prepare an isolette for the infant.
2 They have multiple sclerosis, so they don't need as much pain medication That, and pain meds can cause decreased respirations (which impacts baby), so they should be avoided if applicable
The nurse cares for the client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate 22 per minute. Which order should the nurse question? 1.0.9% sodium chloride water infusion at 150 mL/hour. 2.Epinephrine 1 mg bolus intravenously. 3.Monitor urinary output hourly for 24 hours. 4.50 mL 25% albumin (human) 50 mL intravenously.
2 Think - you haven't given fluids less, so a bolus will cause vasoconstriction to extremities, killing them faster Will also spike HR/respiratory rate, so not great
The nurse provides care for a client diagnosed with advanced-stage dementia. The client walks to the nursing station and states, "I don't want to be here. I am going to leave." Which action by the nurse is best? 1.Assess the client's orientation to person, place, and time. 2.Assign a sitter to remain with the client. 3.Notify hospital security. 4.Request a STAT psychiatric consult.
2 You said 1, but notice that you already know they're going to have poor A+O; constantly asking them will just annoy them and exacerbate hte issue
The nurse prepares the client for a herniorrhaphy. It is most important for the nurse to take which action 1 hour before surgery? 1.Administer an enema. 2.Confirm the consent form has been signed. 3.Perform a preoperative shave and scrub. 4.Evaluate for food or medication allergies.
2 You said 4; that should have been done long before that (and it gives no indication that you are re-checking)
Rotavirus vaccination schedule
2 doses 1 at 2 months 2nd at 4 months
What kind of mobility should a patient diagnosed with a DVT have? Why? --What are potential pitfalls?
Bedrest until anticoags can be started --You don't want the clot to dislodge, which movement can cause --TED hose are used to PREVENT DVTs, not treat them
For patients with radium implants, they have what mobility? Why?
Bedrest; to keep it from dislodging
Your client is receiving famotidine; when should they take it?
Before meals + before bedtime It is a H2RA -> taken before meals, it will reduce stomach acid excess r/t food stimulation At night, it can prevent heartburn
The diaper should be above/below cord
Below (prevent infection)
What positioning decreases abdominal muscle strain in the event of dehiscence?
Bent knees
Chlordiazepoxide
Benzodiazepine
Chlordiazepoxide
Benzodizepine --:Watch out for excess drowsiness/slurred speech (excess dosage)
What medication is given prior to cardioversion?
Benzos (not pain meds)
A patient taking a lot of meds has wheezing. Which common med would you take them off of if they're on it?
Beta blockers Cause bronchospasms
Cholestyramine; usage tips?
Bile acid sequestarant --Used to lower LDL Interferes with the absorption of some drugs; should be taken AFTER other meds Take with food
Meconium; is it normal?
Black, sticky first stool of infant The black and sticky qualities are normal
Why is bladder distention a major concerning sign for a post-neuro procedure?
Bladder emptying has some degree of neuro control Bladder distention = nerve damage
The nurse provides care for a client after a renal biopsy. The client reports pain at the biopsy site that radiates to the front of the abdomen. Which complication does the nurse suspect the client is developing?
Bleeding Kidney heavily vascularized, high risk of bleed Pain in abdomen because of blood pooling, putting pressure on intestines
Postoperatively, what is the most critical concern we are worried about?
Blood pressure alterations AKA - SHOCK Fluid/electrolyte imbalances are not the same thing
COPD patients should not receive what common med?
Bronchodilators
How should irrigated fluid during wound care drain?
By gravity Do NOT use a syringe to remove it
Salmonella has what precautions
CONTACT Think of the gloves at your job
CPAP vs PEEP vs BiPAP
CPAP -> used without ventilator; patient can breathe on own PEEP -> used with ventilator BiPAP -> used without ventilator; air is given when patient inhales and exhales
Almonds are high in __
Calcium
Normal calcium/phosphate levels
Calcium -> 9-10.5 Phosphate -> 3-4.5
Treatment agent for excess magnsium
Calcium gluconate
For benzos, are there any restrictions on what they can be taken with?
Can't be taken with alcohol Can't be taken with other depressant meds Otherwise take it with food, water, whatever they want
What nutrient should be limited during respiratory failure?
Carbohydrates Their rapid metabolism promotes production of extra CO2
A patient is incredibly cold (90 F); what is the most immediate concern you have for the patient? --After that main priority, what are you worried about?
Cardiac dysrhythmias Hypothermia can lead to ventricular fibrillation
What is a side effect of taking lithium that requires a dietary change?
Causes fluid deficiencies Encourage intake of fluids with adequate sodium Avoid natural diuretics (i.e. coffee)
(Hot/cold) compresses should be applied to the breast to help with soreness; why?
Cold The discomfort is caused (partly) by elevated blood circulation to the area (think inflammation r/t feeding); applying warm compresses will just make it worse
A client in a long leg cast just took pain medication, but it did not relieve their pain. What do you expect?
Compartment syndrome (pain unrelieved by pain meds)
Neonatal Abstinence Syndrome (NAS); S/S
Condition where baby goes through drug withdrawal at birth r/t maternal drug use 1. High-pitched cry 2. Rapid HR 3. Hyperreflexes/seizures 3. Vomiting/diarrhea
RSV requires which precautions?
Contact
Rotavirus requires which precautions?
Contact
Scabies requires which precuations?
Contact
Impetigo requires which precautions? What is its major symptom?
Contact Honey crust scabs
A client with a history of hypertension experiences a subarachnoid hemorrhage, head laceration, and ulnar fracture from a motor vehicle crash. Which finding indicates to the nurse that the client's condition is deteriorating? (Select all that apply.) 1.Urine output 5000 mL in 24 hours. 2.Pink drainage on laceration dressing. 3.Radial and apical pulse 120 beats per minute. 4.Diminished pupillary response. 5.Glasgow Coma Scale score of 15.
Correct answers: 1 (diabetes insipidus potential) 3 (indicates hemorrhage) 4 (indicates elevated ICP) Pink drainage is expected; CSF (clear) drainage would be bad Glasglow is fine; 8 or below is concerning YOU DIDN'T SAY 3 BECAUSE OF CUSHING'S TRIAD, BUT HEMORRHAGE IS STILL IMPORTANT
You notice that fetal HR is rapidly climbing during administration of oxytocin; what do you do?
D/C it
5 common causes of AMS
DELIRIUM D -> drug (i.e. alcohol) E -> electrolyte/glucose imbalance L -> lacking drugs (drug withdrawal) I -> infection R -> reduction in senses (can't hear, see, etc) I -> intracranial issues/pressure U -> urine retention M -> myocardial problems (infarction, dysrhythmia)
Gastric vs duodenal ulcers --Age --Sex --Secretions amount --Pain and when it occurs; what makes it better? --Does vomiting occur? --Does bleeding occur? --Is cancer possible?
DUODENAL Age -> 30-60 y.o. Sex -> more common in males Secretion amount -> EXCESS Pain -> 2-3 hours after meals and during nighttimes/sleep; food makes it feel BETTER Vomiting -> not common Bleeding -> not common Cancer -> not common GASTRIC Age -> 50 or older Sex -> equal among sexes Secretions -> normal or low Pain -> 30 minutes-1 hour after meal or when not eating; eating DOES NOT help, vomiting does Vomiting -> frequent Bleeding -> frequent Cancer -> common
Describe the change in lochia post-birth, and the time frame
Day 1-3 -> rubra (red, bloody) Day 4-9 -> serosa (pinkish/brownish) Day 10+ -> alba (white/yellow)
What is a major side effect of pronestyl?
Decreased BP
How is blood affected by SSRIs?
Decreased platelets; higher risk of bleeding
Upon receiving treatment, what other disease state do Addison disease patients have to watch out for?
Diabetes r/t administration of glucocorticoids
Interferon gamma release assay
Diagnostic test used to detect LATENT TB (not active)
Oblique fracture
Diagonal fracture
Aphasia
Difficulty or inability to speak
Diptheria is ____ precautions, rubella is ___ precautions
Diptheria -> contact Rubella -> droplet
DtAP vaccine schedule (which diseases?)
Diptheria, pertussis, tetanus 5 doses 1st at 2 months old 2nd at 4 months 3rd at 6 months old 4th at 15-18 months 5th at 4-6 y.o.
IPV
Inactivated polio vaccine NOTICE -> AIDS patients are allowed to have this (just can't have live vaccines)
You mix 2 medications together and notice their coloration changes; what does this indicate?
Incompatibility
Define each of the following for medications --Incompatibility --Additive effect --Synergistic effect
Incompatibility -> meds that shouldn't be mixed together are; indicated by color change Additive effect -> meds which do similar/the same thing are combined Synergistic effect -> the combination of 2 meds has a greater effect than when given individually (think bronchodilators + steroids)
What is the most concerning finding in an asthmatic patient that indicates deterioration?
Increase in pulse outside of normal limits
What is a major indication that a cystic fibrosis patient has had an exacerbation?
Increase in sputum (especially if yellow colored and foul-smelling) Indicates pneumonia
Ectopic pregnancy --What is it? --Subjective/objective S/S --How serious is it? What is the main concern? --Treatment
Egg is implanted somewhere other than the uterus (usually fallopian tube) -------------------------------------------------------------- 1. Abdominal pain with some shoulder pain 2. Rigid abdomen (from blood) 3. Low H&H 4. Bleeding from vagina present -------------------------------------------------------------- LIFE-THREATENING --Main concern is blood loss -------------------------------------------------------------- Emergency surgery to remove the egg Monitor/prevent shock before and after
What kind of weight would you encourage RA patients to have?
Encourage a healthy body weight/weight reduction Less weight = less pressure on the joints
What do you do if incomplete airway blockage by object?
Encourage coughing
The nurse cares for the client immediately after an ileostomy procedure. Which is the best INITIAL action for the nurse to take during client teaching? 1.Schedule the teaching demonstrations during family visits.2.Encourage the client to discuss any concerns and to ask questions.3.Show a video demonstrating ileostomy care.4.Perform care for the ileostomy until the client is able to do it herself.
Encourage discussion of concerns
What should be done prior to doing an ultrasound of uterus?
Encourage patient to drink fludis without urinating An enlarged bladder pushes the uterus forwards, which makes it easier to see
What should client do while NG tube is inserted?
Encourage swallowing
During preeclampsia, what S/S indicates that a impending seizure is present?
Epigastric pain
What is a major side effect to be concerned about with TB/hepatitis antibiotics drug regimen? Which drug specifically?
Ethambutol Causes optic nerve damage, which manifests as color blindness
What kind of mood do cocaine patients have while on it
Euphoria
How often do you change NG feeding tubes?
Every 1-2 days
Antibiotics are avoided in patients with what disease?
Extreme renal damage (can't remove it)
(T/F) Bruising is a sign of infection
FALSE
(T/F) Dialysis is required to be continued post renal transplant
FALSE
(T/F) Herbal medications should be taken during pregnancy
FALSE
(T/F) Pets like dogs can transmit the flu
FALSE
(T/F) Tremors are found with increased ICP
FALSE
(T/F) A dementia patient should have flexibility in their schedule to account for confusion
FALSE --Dementia patients are easily confused. You want consistent schedules
(T/F) Aspirin, naproxen and ibuprofen are safe to take in alcohol-drinking patients
FALSE Alcohol causes GI upset, which increases bleeding risk While taking these, don't have alcohol
(T/F) When breastfeeding, the baby should also be given the option of formula
FALSE Baby may be confused and refuse breast milk
(True/false) Family members call the psych nurse directly to talk about patient
FALSE Generally they are given a specific number to call
(T/F) Tomatoes contain a large amount of calcium; what does?
FALSE Green leafy vegetables
(T/F) A stroke patient should have peanut butter
FALSE Think about all the times the peanut butter got stuck in your mouth; do you want a patient with dysphagia eating that?
(T/F) Staph aureus alwys requires contact precautions
FALSE Unless it is specifically listed as antibiotic resistant, it is standard precautions
(T/F) Visitors with a flu or other infection can visit immunosuppressed people if they wear a mask
FALSE, should not visit at all
(T/F) Should live vaccines be given to a patient during pregnancy?
FALSE: can hurt baby (give immediately after delivery instead)
(T/F) A UC/Crohn's disease should have laxatives, enemas and other pro-poop treatments
FALSE: diarrhea is already a problem
(T/F) TB has a nonproductive cough
FALSE: has sputum
(T/F) Enteric-coated medications can be given via NG tube
FALSE: it has to be crushed
(T/F) Pillows below the knee and knee gatches are appropriate
FALSE; if patient is in bed, elevating the knee reducing heart return, which promotes the production of VTE Should keep feet level (or elevated)
(T/F) Telling a patient's spouse about their medical condition without permission does not violate HIPPA
FALSE; it does
(T/F) Breathing exercises done during birth will speed up labor
FALSE; it helps with anxiety/pain, but does not speed it up
(T/F) A unique informed consent is required for a chest x-ray
FALSE; it is covered under the general consent (along with other hospital treatments like bladder scans) Only more invasive techniques (i.e. bronchoscopy) require a consent form
(T/F) A mother cannot breastfeed if they have a flu-like infetion
FALSE; just wear a mask
(T/F) Rheumatoid arthritis joints should be massged What should be done instead?
FALSE; leads to further pain and inflammation Do ROM exercises and apply heat
(T/F) Massaging the breasts for breastfeeding is a good idea
FALSE; may cause irritation/tenderness
(T/F) A patient has a DVT in their lower leg; you should elevate their knee
FALSE; now the distance from the lower leg to the knee is uphill, which prevents venous return and promotes clot formation
(T/F) Caregivers from home are allowed to care for radiation patients
FALSE; nurse does care
(T/F) Manic patients are required to be isolated
FALSE; only if they are causing threat of danger to others Isolating them will only make them more anxious; let them walk around the unit
(T/F) Weighing oneself is an effective measurement for both dehydration and overhydration
FALSE; only overhydration
(T/F) Client with chronic constipation should take laxatives
FALSE; only taken as a last resort; fix the underlying problem
Side effect of gabapentin
Fatigue + tremors
If a psych patient is in the seclusion room and lunchtime comes, what do you do?
Feed them in the room
Fetal macrosomia; risk factors?
Fetus is abnormally large for gestational age (9 lbs usually benchmark at birth) Mother has: 1. Diabetes 2. Obesity
How does cardiac output change during pregnancy? What can be done to deal with this?
Fetus puts pressure on vena cava, which impairs output Can be reduced by not sleeping supine, but instead on side
Which nursing action is MOST appropriate when an infant is admitted for fever, poor feeding, irritability, and a bulging fontanel? 1.Perform neurological checks every four hours. 2.Place the client on droplet precautions. 3.Monitor the client's urine output closely. 4.Encourage fluid intake.
Fever + bulging fontanel = meningitis Place on droplet precautions to prevent spread of disease
You notice that the previous nurse's documentation is incomplete; what do you do?
File an incident report
When is BiPAP given?
Given for people who are hypoventilating (i.e. sleep obstruction)
Otosclerosis; what is its progression?
Hardening of bony tissue of middle ear Occurs over a long period of time gradually
Notable side effect of spironolactone
Has progesterone-like effects MALES --Gynecomastia --Impotence FEMALE --Hirsutism (male-like hair growth on face) --Altered period
A kid is brought to the ER with their 18 y.o. brother. The parents can't be reached. What do you do?
Have the brother sign the consent (adult siblings can do it if parents not available)
Describe the 3 ways neuromuscular development develops
Head to toe Trunk to extremities Gross to fine
What is a major indicator that epoetin alfa needs to be scaled back?
Hematocrit increases by more than 4 in 2 weeks Also can D/C if hemoglobin is 12+
Describe the blood tests done for each of the following --Heparin --Warfarin --Enoxaparin
Heparin -> check PT Warfarin -> check INR Enoxaparin and other LMWH do not require frequent blood tests, nor do argatroban and the like
What is transcutaneous electrical nerve stimulation used for?
Herniated disks mostly
Hypocalcemia S/S
Hyperreflexes 1. Trousseau's 2. Chvostek 3. Seizures 4. Diarrhea 5. Paresthesias around extremities/mouth 6. Increased QT interval
What is a major complication of prolonged nebulizer use, and why?
Hypervolemia and fluid in lungs Think -> nebulizers contain water mist, so doing it too much...
Dextrose solutions are (hypo/iso/hyper) tonic
Hypo They start iso, but once the glucose is absorbed they are hypo
S/S of hypo vs hypercalcemia
Hypo --Positive Chvostek/Trousseau sign --Tetany --Muscle cramping Hyper --Elevated urine --Constipation --Weakness --Nausea
As magensium falls, what is the patient also at risk for?
Hypocalcemia
The nurse provides care to a client who is prescribed oxycodone for pain every 6 hours. The nurse notes that the client's serum potassium level is 2.4 mEq/L (2.4 mmol/L). Which finding indicates to the nurse that the client is experiencing an adverse reaction to the prescribed oxycodone? 1.Loose bowel movements. 2.Severe frontal headache. 3.Absent bowel sounds. 4.Itchiness in extremities.
Hypokalemia causes constipation Opioids cause constipation Double them and what are you worried about? 3
Erikson Stages
INFANT (birth - 1 y.o.) Trust vs mistrust TODDLER (1-3) Autonomy vs shame/doubt PRESCHOOL (3-6) Initiative vs guilt SCHOOL (pre-adolescent; 6-12) Industry vs inferiority ADOLESCENT (12-20) Identity vs role confusion YOUNG ADULT (20-40) Intimacy vs isolation MIDDLE-AGED (40-65) Generatively vs stagnation OLDER ADULT (65+) Integrity vs despair
S/S of multiple sclerosis
INITIAL Impaired muscle ability --Weakness/fatigue --Falling down a lot --Spasms LATER --Full blown paralysis --Bladder dysfunction --Bowel dysfunction --Diminished sensation (risk with cold/hot) LATE --Difficulty speaking --Difficulty swallowing/eating --Pneumonia r/t immobilization --Cognitive issues (short-term memory loss)
What should be placed on a mother post-episiotomy care? Why?
Ice packs Vasoconstricts, decreasing bleeding
What is the mechanism of action for anti-vomiting medications? --Give some examples --What would this lead them to be contraindicated in then?
Increase the motility of the GI tract (get it away from the mouth) ------------------------------------------- 1. Ondansetron 2. Metoclopraide 3. Promethazine ------------------------------------------- Do NOT give to patients with ulcerations A major focus of treatment is to SLOW DOWN motility (hence why caffeine isn't allowed)
What is the major symptom which indicates that levothyroxine is having an effect?
Increased urine output
Describe how each of the following respond to death --Infant --Preschool --School-age --Adoelscent
Infant --No understanding, but respond to caretaker emotions Preschool --May blame themselves for death --Think in concrete terms -> don't see death as permanent School-aged --Can understand death is permanent --Still may blame themselves Adolescent --Understand death like adults, but may have difficulty expressing emotions
Lofenalac
Infant formula for PKU babies Has phenylalanine removed
What is often a precipitating factor of DKA and HHNK?
Infection
COPD patients are at high risk of what other complication? What preemptive measure should be done?
Infections Get immunizations at highest dose (and early)
Elderly confusion phrase
If I'm not pee, check my pee especially in the elderly UTIs
How should corticosteroids be administered?
If PO, give with food (not after meals, WITH the food) Do NOT give with juice
Internal radiotherapy implants --Give an example --Tips for care specific to this
If it says "implant" and not liquid, it's this (radium) ------------------------------------------- 1. Keep a lead container/forceps in the room in case it dislodges (you won't be the one picking it up though) 2. Bed linens/dressings stay in room 3. PATIENT IS ON BEDREST 4. Bodily fluids are NOT considered radioactive 5. Low-fiber diet (want to avoid bowel movements, which can dislodge implant)
A patient misses a pill on their oral contraceptive; what do they do?
If they only missed 1 pill, take the 1 they missed immediately and go back on schedule If they missed 2 or more, stop taking them and only use barriers (i.e. condoms) until their current menstrual cycle is over
A patient has low calcium levels; what is the priority action?
Initiate seizure precautions (hyperreflexes)
Describe relationship between calcium and magnesium
Injecting calcium will treat excess magnesium, since it promotes binding
Isophane
Intermediate-acting insulin
Which forms of insulin are expected to be cloudy?
Isophane
What side does the nurse stand on in a cane patient?
Slightly behind patient on strong side
A patient just got hit in the temple with a baseball. What is an early concerning symptom you should be on the lookout for?
Slurred speech/AMS Is an early sign of increased ICP N/V, pupil changes, etc are all later signs
What kinds of food practices should a patient have? --What foods should be avoided
Small, frequent meals Soft foods High calorie, protein, vitamin/mineral foods Low fiber (too much = more diarrhea) --------------------------------------------- Foods that produce gas Nuts/seeds High fiber foods Caffine/carbonated beverages Smoking/alcohol
Cred é maneuver
Special manuever to promote bladder control in those who are incontinent By manually apply pressure, control of bladder can be reattained
What is the only way to confirm active tuberculosis? What is a potential misstep?
Sputum cultur Interferon gamma release assay (detects latent TB, not active)
A patient presents with suspected tuberculosis. Which of the following is used to confirm active tuberculosis? 1. CXR 2. ABGs 3. Interferon gamma release assay 4. SPutum culture 5. Bronchoscopy 6. Pulmonary function test
Sputum culture ONLY CXR -> nondefinitive, could be something else (i.e. pneumonia) ABG -> nondefinitive
Cytomegalovirus (CMV) is what kind of precautions?
Standard
What lipid-lowering drug can't be taken during pregnancy?
Statins
A child is admitted to the hospital with a diagnosis of status asthmaticus. The nurse is most concerned if which is observed? 1.SaO2 91%. 2.Expiratory wheezing. 3.Intercostal retractions. 4.Arterial pH 7.25.
Status asthmaticus = asthma exacerbation What would be normal findings that don't necessarily indicate they are dying? 1. Normal ABGs 2. Rapid breathing 3. Wheezing 4. Signs of respiratory distress (retractions) #4 is the only one which indicates a potential exacerbation (respiratory acidosis) which is life-threatening
Tonometer testing; who should get it?
Itraocular pressure testing Should be done with people who have glaucomas routinely
In what order would you do the following assessments on an infant? --Palpate and percuss abdomen --Record respiratory/heart rates --Elicit MOro reflex --Examine eyes, ears and mouth --Auscultate heart and lungs
Least to most invasive (You thought eyes, ears and mouth were more invasive than Moro - Moro comes last) 1. Record respiratory/heart rates 2. Auscultate heart and lungs 3. Palpate and percuss abdomen 4 .Examine eyes, ears and mouth 5. Elicit Moro reflex
In general, if there is a problem with oxygenation to the baby, the mother is placed in what position? Why?
Left side Reduces pressure on uterus (which remember is on the left side); more blood/oxygen
Bow leg
Legs bend outward at knees when walking Normal for toddler r/t development of back muscles not fully being complete; should disappear by 2 y.o.
Normal C-reactive protein levels
Less than 1
Normal erythrocyte sedimentation rate
Less than 15 for men, less than 20 for women
Sucralfate; usage details
Medication which covers the surface of the intestinal tract, protecting it from duodenal ulcers Do not take with antacids or H2 blockers Take it separate from other meds (2 hours before or after); since it affects the GI wall, it impacts absorption of the other meds
What is a common cause of painful intercourse in middle aged women?
Menopause
Cognitive viewpoint of depression
Mental disease (like depression) occurs from errors in thought or language --I.e. encourage positive language
Interactions with metformin and antibiotics
Metformin levels are INCREASED as a result of taking anitbiotics; watch out!
Distended white sebaceous glands over the cheeks and nose.
Milia; normal finding in newborns
Leukorrhea; is it normal
Milky-white discharge from vagina Is normal during 1st trimester (you are concerned if foul-smelling or green/yellow)
Irregular area of blue-gray pigmentation over the sacrum.
Mongolian spots; normal in newborns
When does the posterior fontanelle close?
Month 3
When should testicular self-exam be done? How often?
Monthly Do it in the shower or after showering
HHNK --Blood glucose level --What age range? --What type of diabetes? --S/S --What does NOT occur? --Treatment
More than 800 ------------------------------------------- More common in older adults ( >50) ------------------------------------------- Happens in Type 2 ONLY ------------------------------------------- 1. Hypotension (excess urine) 2. S/S of dehydration 3. Rapid HR 4. AMS ------------------------------------------- Does NOT have ketones in blood/urine Is NOT acidotic ------------------------------------------- 1. Fluids (iso or 0.45%) 2. Insulin 3. Potassium (for insulin) 4. Treat cause
Describe when the following reflexes should disappear --Moro --Babinski --Tonic neck --Stepping
Moro -> 3-4 momths Babinski -> 1 year old Tonic neck -> 3-4 months Stepping -> 4-5 months
You notice an elderly person has difficulty understanding you and you expect hearing impairments. What is the most common cause, and what do you do?
Most common cause is earwax buildup Remove earwax
Drugs given for Crohns and UC
Mostly drugs that reduce immune response and inflammation 1. Immunomodulators/suppressants 2. Steroids Do NOT give drugs that increase GI motility (i.e. anti-emetics, laxatives)
cyclobenzaprine hydrochloride
Muscle Relaxant
Fluoxetine and other SSRIs have what GI side effect?
N/V/D Also increase risk of GI bleeding, so should not be taken if patient has ulcers
Following a stroke, a patient should NEVER be placed in what tempting poistion?
NEVER in high fowlers (elevates ICP)
Salem sump --What are the 2 openings? --What do you do if the air hole becomes obstructed?
NG tube used to decompress stomach 2 openings -> air opening (to create vacuum) and opening for stomach contents If air obstructed -> inject air into it
A mother plans to breastfeed, but no milk is coming out yet. Should she give formula?
NO Give clostrium (nutrient-rich secretions) that are coming out before breast milk
(!!) Tip - for psychosocial, should you ever ask Yes/No quesetions?
NO, unless suicide (or other life-threatening)
Corticosteroids when stopped should _ _
NOT be stopped abruptly (will cause Addisonian crisis)
Sulindac
NSAID
Naproxen drug class
NSAID (similar to aspirin)
Hepatic encephalopathy
Neurological problems r/t liver cirrhosis since ammonia builds up
Post-transplant patients are put on what kinds of precautions?
Neutropenic/protective isolation
What kinds of precautions are needed in the home for TB patient
No airborne precautions needed; however: 1. People in house need to be tested 2. Cover mouth (duh) 3. Wear mask when in crowds; avoid crowds in general if you can
What is a good indicator that insomniacs are getting enough sleep?
No longer nap during the day
Should parents rock their newborns to sleep?
No; it's good in theory, but the problem is it causes the baby to become dependent on the rocking to be able to go to sleep
In the summer, you notice an elderly patient wearing long sleeves. Are you concerned?
No; remember older people have less fat, and are less tolerant to cold --You SHOULD be concerned if they wear stockings/pantyhose; it will cut off leg circulation
Describe the PTT threshold for heparin
Normal range - 20-39 PT is expected to increase by 1.5-2 in response to therapy 39*2 = 78 If above 78, you should hold med
How should the patient breathe during suctioning?
Normally
The nurse teaches the client about skin care during radiation therapy. The nurse includes which teaching point? (Select all that apply.) 1.Use lukewarm water and gentle soap to bathe. 2.Rub the affected skin with lotion as needed. 3.Wear loose-fitting clothing made from natural fibers. 4.Shave the area using non-alcohol-based products. 5.Wear sunblock when engaging in outdoor activities.
Note - the affected area is very SENSITIVE 1, 3, 5 Hot water irritates skin and fragrant soaps Friction irritates skin (don't rub) Artificial fibers cause skin damage/irritation Shaving causes skin damage Sunblock protects skin
Levothyroxine should be taken with what?
Nothing In morning on empty stomach
The nurse provides care to a school-age child suspected of being sexually abused. Which assessment data best supports this suspicion? 1.Difficulty walking. 2.Bald spots on scalp. 3.Fear of parents. 4.Welts on buttocks.
Notice it says SEXUAL abuse 1 All the others are more physical abuse
How are blood-tinged bandages disposed of?
Now this is surprising Dressings are biohazard Bandages can retain blood well enough that they only go in biohazard if they are saturated
For a patient with a radium implant, what kind of diet are they on?
Nutritious, but low fiber Bowel movements can detatch the implant
How do you position a patient post liver biopsy?
On RIGHT side
Sucralflate should be taken how?
On empty stomach BEFORE other meds
The RN cares for the client just admitted after sustaining a second-degree thermal injury to the right arm. Which observation is MOST important to report to the health care provider? 1. Pain around the periphery of the injury. 2.Gastric pH less than 5.0. 3.Increased edema of the right arm. 4.An elevated hematocrit.
On initial assessment, which of these is NOT expected? 1 -> expected 3 - > expected 4 -> expected (yes, it's confusing. You put this one initially r/t fluid loss) 2 is the most concerning due to risk of curling ulcer formation
How should an infant be placed in a crib?
On their back (risk of SIDS)
How often should ostomy bags be changed?
Once a week
When is a tuberculosis patient discharged? Under what conditions?
Once they initiate antibiotics They must continue taking them at home until they have 3 positive sputum cultures
How does herpes zoster present?
One-sided pain and redness along the face and dermatomes of the body (hence the name "shingles) which lasts for a couple months Will eventually form crusts
When self-catheterizing, what do you use to clean? Why?
Only soap and water DO NOT use alcohol, will cause irritation and dry out the area
Keloid
Overgrown scar tissue
What is the expected lab result of administering heparin?
PTT increase by factor of 1.5
A patient taking disulfuriam has a furniture-making hobby. Why is this concerning?
Paints and other supplies contain trace amounts of alcohol
When administering oxytocin, what must you regularly assess? How does this relate to its effect?
Palpate the uterus REMEMBER the purpose of oxytocin is to contract the uterus You need to verify it is having that effect
During the end of the first stage of labor, what kind of thing should the patient be doing?
Pant breathing (rapid shallow)
What is the MOST concerning side effect of isonazid?
Paresthesias
Major symptom which indicates fluoroquinolone should be stopped
Paresthesias + tendon pain (can rupture Achilles tendon)
What kind of weight-bearing exercises should gout patients do?
Partial Should not be immobilized -> that makes it worse ROM exercises also make it worse
Pathological vs physiological jaundice
Pathological -> mother is destroying Rh-positive baby blood Physiological -> baby liver can't effectively clear bilirubin
Pressure-controlled variation
Patient is put on sedation, and a set constant pressure is given (patient doesn't breathe on own)
Bismuth salicylate --Alternative name --Usage --Side effects --Tips for administration
Pepto-Bismol -------------------------------------------------------------- Anti-diarrhea med -------------------------------------------------------------- 1. Darkening stool/urine 2. Constipation -------------------------------------------------------------- 1. It prevents absorption of PO meds, so take it on its own 2. Take until diarrhea is controlled 3. Encourage fluids 4. This is a salicylate drug, so look out if they're already taking aspirin
The nurse provides care for a client diagnosed with a stroke located in the left hemisphere. Which characteristics of the client would the nurse expect to most influence the emotional response to this situation? 1.The client 's ability to understand the illness and treatment. 2.The client 's perception of the care received during the illness. 3.The client 's personality and general health prior to the stroke. 4.The client's prognosis based on the type of lesion from the stroke. View Explanation
Personality coping skills most important #3 A person with bad coping skills can have good #1 and #2, but it doesn't matter
What is put on the penis post-circumcision which may trip you up?
Petroleum jelly Is a potential slip-up since you don't put it on umbilical cord HOWEVER, in circumcision, will prevent adherence to diaper
How does tolerance for pain change with age?
Pt. becomes less tolerant as they get older (compensatory mechanisms fail)
How should oral medication be administered to a young child?
Put in a nipple and have infant suck
How are linens filled with urine/feces disposed of?
Put in plastic bag NOT biohazard
You are thinking about putting patients in rooms together with infections; how do you do it?
Put similar infections together Droplet with droplet, etc
How do you care for a patient with latex allergy?
Put them in a private room if you can (latex can stay in air) Otherwise if placed with another patient, implement no latex for BOTH of them
What order to you put on/take off PPE?
Putting on: 1. Gown 2. Mask/eyewear 3. Gloves Taking off 1. Gloves 2. Gown 3. Mask
What are S/S indicative that a spontaneous abortion has occurred?
Red spotted (scarce) bleeding from vagina and mild cramping The more serious the pain, the more serious the condition (with the worst being ectopic pregnacy)
Extrusion reflex --When does it go away?
Reflex where young infant will involuntary stick tongue out if object is placed in mouth --Is an attempt to prevent aspiration (hence the name "extrusion") Goes away at 3-4 months
What are lab indications that chemo should not be given?
Remember -> lowers, platelets and WBCs Therefore, avoid giving if they already have low platelets/WBCs (let them recover) ALSO, avoid if kidney issues (high BUN/creat) r/t excretion issues 1. Low WBC 2. Low platelet 3. High kidney labs
The nurse knows that which assessment is BEST to indicate relief from abdominal pain for a child who received morphine 1 hour ago? 1.The child states that pain has gone away. 2.The child's heart rate has changed from 80 to 95. 3.The child sleeps except when receiving nursing care. 4.Results from the incentive spirometer have improved.
Remember -> this is a kid, and they dislike pills/pain shots You said 1 -> can't they lie in order to avoid another shot? 2 -> indicates worsening 3 -> indicates too much medication 4 -> is good
The nurse in the newborn nursery receives report from the previous shift. In which order should the nurse see the infants? Place the answers in order of priority. All options must be used. 1. Sleeping 1 y.o. with bulging fontanel 2. Infant with 65 BPM respiratory rate 3. Infant with 185 HR 4.5 hour old infant with acrocyanosis
Remember ABCs trump other things (you put fontanel first) #2 #3 #1 #4
Somogyi's effect
S -> sleep Drop in blood glucose while sleeping in the night The blood sugar increases as a result of release in hormones However, in diabetes, the blood glucose will remain elevated throughout the night, leading to headache, nightmares and sweating How to treat -> check blood glucose at 2-3 am, adjust insulin, eat a bedtime snack
Alginate dressing usage
Used for woudns which have large amounts of drainage (i.e. infected wounds)
The nurse provides dietary teaching to a client with an acute kidney injury. Which menu selection made by the client indicates to the nurse that teaching is effective? 1.Potatoes. 2.Raisins 3.Pasta. 4.Bananas.
What is a MAJOR issue with kidney injuries in general? Risk of elevated potassium All of the foods contain high potassium except for pasta 3
The nurse reviews room assignments for 4 clients admitted to the unit. The nurse should question which room assignment? 1.A child with chickenpox placed in a private room at the end of the hall. 2.A child with meningitis placed in a private room across from the nurses' station. 3.A client with cellulitis of the right leg placed in a semi-private room with a client diagnosed with type 1 diabetes. 4.A client with essential hypertension placed in a semi-private room with a client who has pancreatitis.
You narrowed it down to 3 and 4 (infected patient with non-infected) Diabetics are more susceptible to infections; HTN patients are not #3 is therefore the worst
Pyloric stenosis -What is it? -Who gets it? -Symptoms
Thickening/narrowing of passageway between stomach and small intestine Common in infants Infant is constantly feeding; always seems hungry and fussy (not enough food reaches intestines to be digested)
S/S of hyponatremia
Think S/S of excess fluid "Cerebral edema" 1. Headache 2. Lethargy 3. Muscle twitches/convulsions 4. Anxiety/apprehension OTHER 1. Diarrhea (too much water)
Sengstaken-Blakemore tube; what is a potential respiratory complication
Tube designed to hold pressure via a balloon on the esophagus Supposed to stop esoaphageal varices May slide up and block airway, in which cause CUT BALLOON and PULL OUT
fluorescein angiography
intravenous injection of fluorescein (a dye) followed by serial photographs of the retina through dilated pupils Used to determine shape/circulation of retina Not to be confused with tonometry, which measures intraocular pressure
Naltrexone; usage?
Opioid antagonist Is given when a patient is kicking the habit to reduce craving for it
Watch video on renal calculi
...
Impacted fracture
2 ends of bone are forced into each toher
What is a normal fluid intake amount?
2-3 Liters/day
Normal newborn head circumference
32-36
A kid __ y.o. can brush their teeth
4 years
At what age can a child only say "dada" or "mama"?
8 months
A kids has enough fine motors skills to handwrite at what age?
8 years
What types of hepatitis are spread via sex?
B and D only
(T/F) A droplet precaution patient uses disposable utensils and plates
FALSE
You notice that a patient has a high BUN but otherwise their labs are fine; what dietary change can be done to fix this?
Restrict proteins
Regular insulin
Short-acting insulin Only one given IV
(T/F) Opioids are contraindicated post eye surgery
TRUE; cause constipation (straining = more eye pressure)
An egg allergy is important when?
The flu vaccine is contraindicated if they hav eit
The nurse cares for clients in the pediatric clinic. The nurse would be most concerned if which was observed? 1.A 3-month-old infant's back is rounded. 2.A 4-year-old has a blood pressure of 90/60. 3.A 5-year-old has a pulse of 88. 4.The hem of the skirt on a 10-year-old is longer on one side than the other.
#4 indicates scoliosis #3 is normal (80-120 #2 is normal #1 is normal
Solfonylureas --Nomenclature --Effect --Adverse side effects --Usage tips
-Glip or gly- (glipizide) ----------------------------------------------- Stimulates the pancreas to release insulin ----------------------------------------------- 1. GI upset 2. Weight gain 3. Skin reactions (rash) ----------------------------------------------- Take before meals Do NOT take before bedtime
DDP-4 inhibitors --Nomenclature --Effect
-Gliptins ----------------------------------------------- Intensify the effects of intestinal hormones which control blood sugar ----------------------------------------------- 1. Pancreatitis 2. heart failure 3. Headache 4. Pharynx inflammation
Which of the following assessments does the nurse expect to make regarding the developmental stage of a 40-year-old male?
"Midlife crisis" Measures accomplishments against goals
A client returns to the unit following a thyroidectomy. Which assessment finding requires an intervention by the nurse? 1.The client makes noises when breathing.2.The client reports pain at the surgical site.3.The client asks for liquids to drink.4.The client is sleepy from anesthesia.
#1 1. Bad, indicates bleeding at site 2. Expected finding 3. Patient is NPO, but pt is expected to ask for fluids, not priority 4. Expected finding
The nurse cares for the client in active labor. The client's membranes rupture spontaneously at 6 centimeters of dilation. Which action should the nurse take FIRST? 1.Check the fetal monitor.2.Place the client on her right side.3.Auscultate fetal heart rate.4.Check the client's heart rate and blood pressure.
#3 (not #1) Assess the pt. not the equipment
Antifungal nomenclature
--azole Fluconazole Metronidazole
Lithium levels
0.5-1.5
Normal digoxin levels
0.5-2
Digoxin levels
0.5-2.0
Lithium therapeutic range --Normal side effects (non-toxicity) --Toxicity side effects --What do you look out for?
0.6-1.2 Normal side effects 1. Fine tremors 2. More urine Toxicity symptoms 1. Diarrhea (BIG ONE) 2. Extreme tremors 3. Metallic taste in mouth Give fluids if toxic Remember that sodium loss will make lithium toxicity more likely
INR
0.8-1.1 if not on warfarin If on warfarin, therapeutic range is 2-3
The nurse assists the parent to provide appropriate foods for the 3-year-old. Which action has the highest priority? 1.Provide the child with finger foods. 2.Allow the child to eat only favorite foods. 3.Encourage a diet higher in protein than in other nutrients. 4.Limit the number of snacks during the day.
1
The nurse makes client assignments on a medical surgical unit. The staff includes one nurse, one nurse pulled from the pediatric unit, an LPN/LVN, and a nursing assistive personnel (NAP). Which client is assigned to the nurse from the pediatric unit? 1.The client 1 day postoperative after an appendectomy. 2.The client who had a detached retina surgically repaired 4 hours ago. 3.The client with a Sengstaken-Blakemore tube in place. 4.The client 2 days postoperative after a laminectomy with spinal fusion.
1 ALl the other patients are unstable and/or require teaching
An extremely agitated client receives haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. It is MOST important for the nurse to take which of the following actions? 1.Monitor blood pressure every 30 minutes. 2.Remain at the client's side to provide reassurance. 3.Tell the client the name of the medication and its effects. 4.Assess for anticholinergic effects of the medication.
1 Antipsychotics (including haloperidol) cause orthostatic hypotension and drop in BP; should be assessed
The nurse plans to delegate a simple dressing change to nursing assistive personnel (NAP). The nurse checks with the charge nurse before delegating the task. Which right of delegation does the nurse follow in this situation? 1.Right task. 2.Right circumstance. 3.Right person. 4.Right direction.
1 Checking to see if the task can be delegated
While doing a physical examination of a 1-year-old child, which assessment should be completed by the nurse LAST? 1.Examine infant's ears. 2.Auscultate the breath sounds. 3.Auscultate the apical heart rate. 4.Evaluate motor functions.
1 Examining ears involved putting in uncomfortable devices; do uncomfortable tasks last
The nurse reviews the blood-test results of four adult clients. Which result indicates to the nurse that the client has a high risk of falling? 1.Blood urea nitrogen (BUN) of 28 mg/dL (10 mmol/L).2.Serum sodium (Na) of 140 mEq/L (140 mmol/L) and potassium (K) of 4.2 mEq/L (4.2 mmol/L).3.Erythrocyte sedimentation rate (ESR) of 30 mm/hr (30 mm/hr).4.Serum calcium (Ca) of 9 mg/dL (2.25 mmol/L) and magnesium (Mg) of 1.8 mEq/L (0.9 mmol/L).
1 High BUN = dehydration Dehydration = ortho hypo
The client tested positive for the tuberculosis antibody and was placed on isoniazid 4 weeks ago. The nurse is most concerned if which observation is made? 1.Fatigue and dark urine. 2.Malaise and glucosuria. 3.Proteinuria and lethargy. 4.Diluted urine and epigastric distress.
1 Indicates liver problems; the drug is metabolized by liver
The nurse provides care for a client who was in a car accident as the result of falling asleep at the wheel. The client reports only being able to sleep 3 to 4 hours a night over the past month, due to stress. The client reports waking up frequently during the night. Which outcome is most appropriate for the nurse to include in the client's plan of care? 1.Client will verbalize a plan to implement a sleep promoting program within the next week. 2.Client will fall asleep with less difficulty over the next 2 weeks. 3.Client will achieve a more normal sleep pattern within 2 to 4 weeks. 4.Client will achieve an improved sense of adequate sleep over the next 4 weeks.
1 Note that 2-4 don't have measurable outcomes
During preadmission planning for a client scheduled for a renal transplant, the client should be educated by the nurse regarding which of the following? 1.Remind family and friends that there is restricted visiting for at least 72 hours postoperatively. 2.Arrange all live plants received postoperatively in one section of the room. 3.Continue intermittent peritoneal dialysis for 3 months following surgery. 4.Limit consumption of sodium-free liquids for 1 year postoperatively.
1 Patient is put on neutropenic precautions
he nurse instructs the prenatal client about the importance of prenatal vitamins. It is MOST important for the nurse to include which instruction? 1."Take prenatal vitamins with orange juice at bedtime." 2."Take the prenatal vitamins at breakfast with coffee." 3."Take the prenatal vitamins with milk at lunch." 4."Take the prenatal vitamins with water at dinner."
1 Prenatal vitamins contain iron Orange juice promotes absorption of iron Taking them at night also reduces the change of nausea
Which of the following assessment findings indicates to the nurse the need for more sedation for a client withdrawing from alcohol dependence? 1.Steadily increasing vital signs. 2.Mild tremors and irritability. 3.Decreased respirations and disorientation. 4.Stomach distress and inability to sleep.
1 Remember - delirium tremens is a MASSIVE increase in HR/BP which is potentially fatal All the other symptoms are expected and mild
The nurse provides care to a client requiring a sterile dressing change. Which action will the nurse take when preparing the sterile field? 1.Place sterile items within 2.5 cm (1 in.) of the edge of the sterile field. 2.Hold the bottle of sterile solution with the label facing down. 3.Wear sterile gloves when opening sterile gauze. 4.Reach over the sterile pack to open the edges.
1 Remember -> the edges of packaging (1 inch) is considered non-sterile, so touching the gauze will contaminate your gloves
An adolescent is admitted for insertion of a Harrington rod due to scoliosis. In preparation for the immediate postoperative care, the nurse should include which information in the teaching plan for this client? 1.Take 10 deep breaths every 2 hours. 2.Get on the bedpan by lifting the hips. 3.Soft diet as tolerated. 4.Elevate legs 10 times every 4 hours.
1 Remember, this is POSTOPERATIVE for a major surgery 2 -> wrong, will have a catheter 3 -> wrong, probably on clear liquids for a while/NPO 4 -> do you really want to be moving around a back surgery patient like that?
The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care to protect the safety of staff? 1.Standard precautions. 2.Testing for HIV. 3.Transfer to an acute care nursery facility. 4.Place the infant in isolation.
1 Risk of blood-based infection
The nurse prepares the older client for discharge after treatment for dehydration. Which client statement indicates the nurse needs to provide further teaching? 1."I should weigh myself daily." 2."I should drink fluids throughout the day." 3."I can use a measuring cup to find out how much I drink during the day." 4."I should let my health care provider know if I get dizzy when I change positions."
1 Weighing yourself only indicates water retention, it cannot be used for dehdyration
The nurse notes that at 2200, a client is scheduled to receive 10 units of insulin glargine. The client also has a "now" prescription of 7 units of regular insulin. Which approach will the nurse use to administer these medications? 1.Prepare two separate injections. 2.Administer the regular insulin first. 3.Mix the medications in one syringe. 4.Administer the insulin glargine first.
1 Yes, it's confusing Just note in the orders it doesn't explicitly say you should give either of them first
A client recovering from total hip replacement surgery reports increased pain with movement. Which nursing diagnosis is the most appropriate for this client? 1.Acute pain. 2.Ineffective coping. 3.Risk for injury. 4.Activity intolerance.
1 You said 4 before; note that is says nowhere that he is unable to perform tasks
The triage nurse receives 4 phone messages. In which order does the nurse return the phone calls? (Please arrange in order. All options must be used.) 1. Multipara client at 6 weeks' gestation reports colicky abdominal pain and shoulder tip pain 2. Multigravida client at 6 weeks' gestation reports red vaginal bleeding, moderate cramping 3. Primipara client at 7 weeks gestation reports increase in milky white vaginal secrtions 4. Primigravida client at 5 weeks gestation has light vaginal spotting, mild cramping
1 2 4 3 REMEMBER -> spontaneous abortions involve cramping/pain and vaginal bleeding (the worse the symptoms, the worse the condition) 1 -> shoulder pain = ectopic pregnancy, LIFE THREATENING 2 - > note that it says moderate (not mild) pain, so it's more serious 4 -> mild pain 3 - > milky secretions are fine during first trimester
he client is admitted with these symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client receives 80 mg of furosemide. Which nursing observation is most important to report to the next shift? 1.Reports of nausea and vomiting. 2.Urine output of 200 mL in two hours. 3.Quiet and withdrawn behavior after lunch. 4.Blood pressure changes from 160/90 to 150/90.
2 Furosemide is a diuretic, you should track its effect (urination) The urination level indicates it's effective
The nurse provides care for a newborn who is recovering from necrotizing enterocolitis (NEC). Which intervention does the nurse include in the newborn's plan of care? 1.Feed the newborn fresh breast milk. 2.Use droplet transmission precautions. 3.Assess rectal temperature frequently. 4.Place the newborn in a prone position.
1 Remember -> breast milk has antibodies in it which can help fight the infection Standard precautions Rectal temp can cause perforation Why prone? It puts pressure on abdomen
The nurse is called to a neighbor's house during a snowstorm. The neighbor states she is in her 40th week of gestation with her second baby, and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. Which statement most concerns the nurse? 1.The woman asks for help to go to the bathroom. 2.The woman's contractions become stronger. 3.The woman's contractions are more frequent. 4.The woman becomes flushed and diaphoretic.
1 (you said 2) ONE INDICATES MOTHER IS GOING INTO TRANSITION PHASE, which is the last phase of stage 1 Baby is most likely coming soon, so they need help #2 and #3 seem promising, but they are unreliable metrics
The nurse provides care to a client 4 weeks after a kidney transplant. Which client statements require immediate follow-up by the nurse? (Select all that apply.) 1."I take an antacid after meals, which helps with my indigestion." 2."My family was disappointed when I told them I would stay home from vacation this year." 3."I found that a little wine in the evening helps me sleep better." 4."My feet were so itchy until my adult child told me to start using lotion twice a day." 5."I worry that my new kidney will quit working." 6."I saw that my blood pressure was up a little. I think I get nervous when I come to the office."
1 -> indigestion is a complication of transplants r/t glucocorticoid use; needs follow-up 2 -> good practice, reduces infection risk 3 -> should not drink wine 4 -> itchiness is concerning; potential symptom of graft rejection 5 -> normal psychosocial finding 6 -> HTN is an adverse response
The nurse teaches the client who had an above-knee amputation (AKA) 2 days ago about how to care for the residual limb. Which statement, if made by the client, indicates to the nurse that the teaching is effective? 1."I shall apply cream to the residual limb to soften the skin." 2."I should rewrap my residual limb with elastic bandages 3 times a day." 3."I will not be able to sleep on my stomach from now on."4 ."I will no longer be able to sit in straight back chairs at home."
1 -> wrong, increases risk of infection (substrate), and prevents the skin to become toughened 2 -> TRUE 3 -> FALSE, you actually encourage prone position 4 -> FALSE, they can sit in the chair, tehy just need to limit the time spent
When are ACE inhibitors taken relative to meals
1 hour before or 2 hours after NOT with meals
The nurse performs discharge teaching for the client diagnosed with multiple sclerosis. It is MOST important for the nurse to include which instruction? Select all that apply. 1.Ambulate as tolerated every day. 2.Avoid overexposure to heat or cold. 3.Perform stretching and strengthening exercises. 4.Participate in social activities. 5.Use cold packs on joints.
1, 2, 3, 4 Think -> they have poor coordination, poor sensation, and risk of immobility/loss of mobility 1, 3 -> promote retention of strength 2 -> prevents sensation issues 4 -> prevents social isolation 5 should NOT be done, because they can hurt themselves
The nurse assists a graduate nurse with the care of a client whose blood glucose is 525 mg/dL (29.14 mmol/L), pH is 7.1, and serum bicarbonate level is 14 mEq/L (14 mmol/L) and has ketonuria. The nurse intervenes if the graduate nurse makes which statement? (Select all that apply.) 1."I should add 5% dextrose to the IV fluids when the client's blood glucose drops below 100 mg/dL (5.55 mmol/L)." 2."The client's potassium level will increase as the blood glucose decreases." 3."The client's laboratory results are characteristic of hyperglycemic hyperosmolar syndrome (HHS)." 4."The client requires a STAT electrocardiogram (ECG)." 5."I should check the client's blood glucose every 2 hours."
1, 2, 3, 5 1 -> start giving dextrose once it hits 250 to prevent rebound hypoglycemia 2 -> it will decrease, not increase 3- > ketonuria (and glucose less than 600) indicate it isn't HHNK 5 -> should be checked hourly
While performing abdominal thrusts to remove a foreign body, the client becomes unconscious. Which action is appropriate for the nurse to implement at this time? (Select all that apply.) 1.Begin chest compressions. 2.Look in the client's mouth for a foreign body. 3.Insert an oropharyngeal airway. 4.Open the client's airway using a head-tilt, chin-lift maneuver. 5.Activate the emergency response system.
1, 2, 4, 5 So they're already not able to breathe, unconscious = start CPR Start CPR Look for foreign body Apply breaths using mask and chin lift Call for help Do not put in airway because it will force the food object further down
The nurse teaches the parents of a newborn how to care for a circumcised penis. Which instruction does the nurse include? (Select all that apply.) 1."Wash the circumcised area by squeezing warm water over it." 2."Avoid wipes that contain alcohol." 3."Gently remove yellow crust from the penis daily." 4."Fasten the diaper snugly to prevent bleeding." 5."Report any redness, bleeding, or drainage."
1, 2, 5
The nurse provides care for a client diagnosed with right-sided heart failure. The nurse expects which assessment findings? (Select all that apply.) 1.Dependent edema. 2.Distended jugular veins. 3.Urinating less frequently. 4.Third heart sound (S 3). 5.Intermittent weight gain. 6.Dry, nonproductive cough.
1, 2, 5 3 -> expect them to urinate MORE (fluid overload) 4 -> 3rd heart sound is due to an enlarged left ventricle, so right sided wouldn't have it (at least not initially) 5 -> weight gain due to fluid retention
During a non-stress test (NST), the nurse observes this tracing: (slow fetal HR). What do you do? 1.Reposition the client on her right side. 2.Notify the health care provider for further evaluation. 3.Document these results in the nurse's notes. 4.Stop the oxytocin immediately. 5.Provide oxygen by non-rebreather mask. 6.Start an IV normal saline.s
1, 2, 5, 6 This is kind of a shit question, but let's go over it 1 -> left is preferred, but right still helps 2 -> good 3 -> should be done LATER, not immediate response 4 -> this is a non-stress test; oxytocin isn't being given 5 -> good 6 -> good
The nurse presents a class on herbal medications at a community health care seminar. Which statement should be included in the class? Select all that apply 1.(1.) The potency of herbal preparations varies between manufacturers. 2.(2.) The FDA tests and regulates herbal preparations. 3.(3.) Herbal preparations are classified as dietary supplements. 4.(4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure. 5.(5.) Herbal preparations are used in the treatment of immune system dysfunction.
1, 3, 4
A wound located on the foot of a client with type 2 diabetes mellitus (DM) is healing. The nurse teaches the client about the prevention of future foot wounds. Which client statement indicates the teaching is effective? (Select all that apply.) 1."I should not cross my legs." 2."I should wear shoes only when I go outside." 3."I should apply lotion between my toes after a shower." 4."I should inspect the inside of my shoes before I put them on." 5."I should use a mirror to examine the bottom of my feet every day."
1, 4, 5
The nurse instructs a client being discharged about home oxygen therapy. Which client statement indicates that further teaching is needed? (Select all that apply.) 1."I know I can turn up the rate of oxygen flow if I get short of breath." 2."I have a fire extinguisher and smoke detector in my home." 3."My family has posted several signs that say 'Oxygen is in use'." 4."My family members who smoke promise not to smoke in my room." 5."We have a gas fireplace so I won't be breathing smoke from burning logs."
1, 4, 5 1 -> the person should get oxygen based upon what the doctor prescribed, as it is a medication Increasing it too much can cause secondary complications (i.e. retinopathy) 4. Smoking should not be allowed ANYWHERE in the house 5. Fireplaces/heaters are a fire hazard
S/S of late-stage lithium toxicity
1. Coarse (not fine) hand tremors 2. Mental confusion 3. Poor coordination 4. Persisting GI upset
A client with a history of diabetes mellitus (DM) and asthma takes high-dose corticosteroids. Which dermatologic complications will the nurse assess in this client? (Select all that apply.) 1.Delayed wound healing. 2.Skin pigmentation changes. 3.Alopecia. 4.Erythematous plaques on legs. 5.Decreased subcutaneous fat over extremities.
1, 4, 5 Remember -> glucocorticoids promote CATABOLISM --Leads to thin extremities with very fragile skin and poor blood circulation 1, 4, 5 all indicate that 2 would be an Addison's issue, not Cushings
The nurse educator teaches a group of staff nurses about measures to prevent the transmission of healthcare-associated infections when providing care for clients. Which intervention does the nurse educator include in the teaching? (Select all that apply.) 1.Clean stethoscopes between clients. 2.Empty bedpans as soon as possible. 3.Limit fresh flowers in client rooms. 4.Use personal protective equipment (PPE) 5.Perform handwashing and alcohol-based sanitizing.
1, 4, 5 Yes, I know 2 sounds like a good idea, but it doesn't have a direct connection
The nurse plans to discharge a client who has recovered from an acute asthma episode. Medications include a prescribed corticosteroid to be taken twice a day. Which teaching instruction does the nurse include in the client's discharge plan? (Select all that apply.) 1.Client should use a spacer with all inhalers. 2.Client and family should smoke outside of the home. 3.Client can take the corticosteroid as needed once symptom-free. 4.Client should use the peak flow meter as ordered. 5.Client's home should be kept dust free and dry.
1, 4, 5 You said 2, but they should STOP smoking, not just limit it
The client is seen in the health care provider's office for follow-up after treatment for calcium urinary tract calculi. The nurse discusses methods to prevent a recurrence of the problem. Which instructions by the nurse are beneficial? Select all that apply. 1."Drink at least 3,000 mL of fluid a day." 2."Increase the amount of milk in your diet." 3."Increase the amount of whole grains that you eat." 4."You should eat a diet low in sodium." 5."Increase your fluids in warm or hot environments." 6."Limit your intake of coffee."
1, 4, 5, 6 1 -> fluids help flush out potential stones before they develop 2 -> has no impact 3 -> has no impact (not GI) 4 -> high sodium promotes excretion of calcium; also causes hTN 5 -> dehydration may happen 6 -> natural diuretics; dehydration may happen
The nurse prepares the client for a skin biopsy. Which client statement should the nurse report to the health care provider? Select all that apply. 1."I've been taking aspirin for my sore knees." 2."Using lotion has helped my dry skin." 3."I have a tanning appointment tomorrow." 4."I had a big breakfast this morning." 5."I have changed my mind about having this done."
1, 5 (You said 2, 3, 4, 5) 1 -> you're scrapping off part of their skin; don't you think you want to know if they'll bleed more? 2 -> yes, confusing (I know), but apparently lotion won't affect test results 3+4 don't affect results/procedure
The nurse prepares to discharge the infant home with the parents. Which statement, if made by the mother to the nurse, indicates a need for further teaching about newborn care? Select all that apply. 1."I will notify my health care provider about absence of breathing for 10 seconds." 2."I will notify my health care provider about more than one episode of projectile vomiting." 3."I will notify my health care provider if my baby's temperature is greater than 101°F (38.3°C)." 4."I will rock and cuddle my infant frequently to promote a sense of trust." 5."I will put my baby in the sun if I notice the baby's eyes are yellow." 6."I will call my health care provider if my baby has yellow stool."
1, 5, 6 1 -> apnea is normal in newborn, provided it lasts less than 15 seconds 5 -> indicates liver damage; should see doctor 6 -> yellow stool is normal
The child admitted with failure to thrive has just had a positive sweat test. The nurse anticipates which changes in the child's plan of care? Select all that apply. 1.Administration of replacement enzymes. 2.Immediate arterial blood gas. 3.A salt-restricted diet. 4.Limited activity with physical therapy. 5.Social service referral. 6.An unrestricted fat diet.
1, 5, 6 They have cystic fibrosis 1 -> need enzymes to replace those pancreas can't make You said 2 -> does anything in the question state they are having breathing problems rn? It's more of a long-term issue 4 -> physical activity helps preserve function 5 -> needed for home care changes 6 -> they can't process fat effectively; if you give too much, their stool will be atrocious
Furosemide IV push should be given over what duration?
1-2 minutes
Normal cap refill
1-3
Digoxin toxicity s/s
1. " Yellow haloes" in vision and other visual impairments 2. Confusion 3. Fatigue/weakness 4. N/V + abdominal pain
SSRI adverse effects
1. Weight gain 2. Difficulty sleeping 3. Sexual dysfunction 4. LOTS of sweating 5. Agitation/irritability 6. Dry mouth 7. Flu-like symptoms (headache, upset stomach, nausea)
S/S of aspirin overdose
1. AMS 2. Tinnitus 3. GI bleed 4. Sweating 5. Dizziness/headache 6. Increase in temperature 7. Rapid breathing (leading to alkalosis)
S/S of fetal alcohol syndrome
1. Abnormally small head (microcephaly) 2. Facial abnormalities 3. Small height/weight 4. Learning disabilities
Extrapyramidal symptoms --What are the 4? --Treatment
1. Akathisia (can't sit still) 2. Dystonia (abnormal flexion/muscle spasms) 3. Pseudoparkinsonism 4. Tardive dyskinesia ---------------------------- Monitor for them; if present: 1. Change drug 2. Give meds to treat Parkinson effects (benztropine) 3. Administer benadryl If it progresses to tardive dyskinesia, it can't be reversed
GI/duodenal ulcer --Medicatiosn given
1. Antacids (aluminum/magnesium hydroxide) 2. H2RA (-dine) 3. PPIs (-prazoles) 4. Sucralfate 5. Anticholinergics
Tricyclic antidepressants side effects
1. Anticholinergic (can't see, can't pee...) 2. Sexual dysfunction 3. Increase in appetite 4. Drowsiness Heart/nerve damage which can be lethal in overdose
What are diagnostic findings which indicate a woman MAY (but not definitively is) pregnant
1. Enlarger uterus 2. Contractions 3. Positive pregnancy tests 4. Hegar's sign 5. Chadwick's sign
External radiotherapy for cancer --Tips for care
1. Avoid putting substances on skin unless prescribed (i.e. creams, lotion, deodorant, perfume) 2. Avoid extreme hot or cold --Clean with lukewarm water --Avoid sunlight or cold 3. Assess skin regularly 4. Wear cotton (breathable clothing)
Following a gastric surgery, what teaching measures should be taken to avoid Dumping syndrome?
1. Avoid taking fluids with meals 2. Sit/lay down after eating (slows down metabolism) 3. Reduce intake of carbohydrates
Following stomach surgery, what vitamin supplementation do you give?
1. B12 (think intrinsic factor) 2. Iron
Which treatments are given for alcohol withdrawal?
1. Benzos 2. Anti-seizure eds/precautions If malnourished: 1. Vitamin B12 (thiamine) 2. IV glucose
PCP intoxication --S/S --Treatment --Major safety concern
1. Blank stare 2. Muscle rigidity 3. Difficulty moving 4. Vertical/horizontal darting of eyes Mostly supportive 1. Monitor VS 2. May need sedation MAJOR CONCERN -> patient will be aggressive, so look out
What are some early symptoms (1-2 days) after a fracture?
1. Bleeding at site 2. Fat embolism -> (piece of fat breaks off and blocks respiratory function -> S/S dyspnea) 3. Infection 4. Compartment syndrome 5. Blisters
Which 3 measure are the BEST indicators of fluid replacement effectiveness during shock?
1. CVP 2. Blood pressure 3. Urine output
What vitamins/minerals are vegans often deficient in?
1. Calcium (no dairy products) 2. Vitamin B12 --NOT other vitamin Bs (i.e. B1) 3. Iron 4. Vitamin D 5. Protein 6. Zinc
Drowning care for child on-site
1. Call for help 2. Remove from water 3. Remove clothing and wrap in blanket 4. Start breaths immediately after removing from water; start chest compressions when flat surface is available
Medications administered in which forms should not be given to ileostomy patients?
1. Capsule 2. Enteric-coated These have delayed absorption, which means they may be passed before they ever get released
What are some S/S indicating onset of labor in a pregnant woman?
1. Cervix softens 2. Mucus plug is expelled 3. Uterine contractions are felt (are usually soft and regular, but not necessarily) 4. Effacement + dilation begin 5. Amniotic sac ruptures 6. Blood present from vagina
Buck traction care
1. Check extremity 2. Maintain traction weights 3. Give anticoag prophylactically (are on bedrest) 4. Give pain meds as needed 5. Reposition/turn patient every 2 hours 6. Take off boot and check skin regularly
The nurse provides care to a client diagnosed with acute renal failure secondary to severe kidney infection. During the oliguric phase, which assessment finding does the nurse expect to observe? (Select all that apply. ) 1.Urine specific gravity is 1.039.2.Azotemia.3.Pruritus.4.Nausea.5.Serum potassium (K+) is 6 mEq/L (6 mmol/L).
1. FALSE (think - since the body retains electrolytes and byproducts, the urine will mostly be water) 2. TRUE (azotemia = buildup of metabolic byproducts like uric acid) 3. TRUE (itchiness is due to buildup of metabolic byproducts) 4. TRUE (du to buildup of metabolic byproducts) 5. TRUE (side effect of byproducts) 6. TRUE
What are definitive determinants that a person is pregnant?
1. Fetal HR 2. Fetal movement is palpated 3. Ultrasound
In-hospital treatment for drowned kids
1. Immediate resuscitation 2. Establish airway 3. Check neuro assessment regularly 4. 100% oxygen 5. Check body values: --ABG --Glucose/electrolytes --Pulse ox --Temperature --Cardiac status
What measures can be taken to promote uterine contraction?
1. Massage uterus 2. Inject oxytocin 3. Have infant breastfeed (releases natural oxytocin) 4. Have mother clear out bladder (full bladder relaxes uterus)
Neurogenic shock S/S; what causes it
1. Drop in BP 2. Rapid breathing 3. Rapid HR 4. Warm, flushed skin Caused by damage to nerves innervating the heart (think spinal injury)
SIde effect of antipsychotics
1. EPS 2. Neuroleptic malignant syndrome 3. Ortho hypo 4. Photosensitivity 5. Anticholinergic effects
What should a pregnant client do to reduce morning sickness?
1. Eat a small dry carb snack (saltines, pretzels, etc) 2. Encourage carbonated beverages (remember - alkaline) 3. Eat small meals throughout day, not large meals 4.
What kinds of abnormal labs do Crohn's/UC patients have?
1. Elevated C-reactive and erythrocyte sedimentation (inflammatory response present) 2. Decreased hemoglobin 3. Elevated hematocrit (dehydration) 4. Low folic acid + B12 (inflamed intestines can't absorb as well)
What signs indicate cardiovascular dysfunction in newborns? (3)
1. Cyanosis at some points 2. Have to stop eating to breathe 3. Clubbing of fingers
Major S/S of hepatitis
1. Dark urine 2. Clay-colored stool 3. Jaundice
Opioid side effects
1. Decreased respirations 2. Low HR/BP 3. N/V 4. Constipation 5. Delirium 6. Pinpoint pupils (overdose)
How should the umbilical cord be cared for?
1. Detaches on its own within 2 weeks 2. Keep area clean 3. Only use soap and water without bath; don't use alcohol or jellies 4. Do not give baths until it falls off 5. Keep cord dry + open to air
S/S of Crohn's disease
1. Diarrhea 2. Abdominal pain 3. Bloody stools (UC) or loose stools (Crohn's) 4. Constant need to poop 5. Decreased appetitie/weight loss 6. Fatigue 7. Elevated temperature Cobblestone-like intestines r/t inflammation
Viral diseases which require droplet
1. Influenza 2. Mumps 3. Rhinovirus 4. Rubella
When ambulating with the walker, describe the sequence
1. Move walker forward 2. Move weak leg 3. Move strong leg
S/S of intestinal obstruction
1. N/V 2. Abdominal pain 3. Hyperactive bowel sounds ABOVE the obstruction, but diminished below it 4. No poop Diarrhea is NOT a sign Bloody stool (melena or otherwise) is NOT a sign
Levodopa --Side effects --Usage details
1. N/V (and anorexia related to those) 2. Ortho hypotension 3. Mental changes 4. Twitching 5. Cardiac dysrhythmias 1. Give with food 2. Give in morning 3. Precautions against postural hypotension 4. Avoid large intake of vitamin B6; it reverses the effects
Airborne precautions
1. N95 mask 2. Negative pressure room 3. Are in the room by themselves 4. Patient must wear mask when they leave
Treatment of intestinal obstruction
1. NPO to prevent further obstruction 2. Decompress abdomen (Salem sump) 3. Mouth care (due to NPO - prevent breakdown) 4. Fluid replacement
What are S/S in a woman which MAY (but not definitively) indicate they are pregnant?
1. No period 2. Morning sickness 3. Breasts are sensitive 4. Fatigue 5. Increased need to pee 6. "Quickening" (feeling fetal movement)
Kosher diet
1. No shellfish 2. Meat and dairy products are not served together 3. No pork
GI/dudenal ulcers --Lifestyles changes
1. No smoking/alcohol 2. Avoid stress
In what order does the nurse call people if they suspect child/elder abuse?
1. Nurse supervisor/charge nurse 2. HCP 3. Local law enforcement
A client receives a diagnosis of bleeding duodenal ulcer. The nurse is concerned if the client reports taking which medication? (Select all that apply.) 1.Omeprazole 20 mg PO. 2.Metoclopramide 15 mg PO. 3.Sucralfate 1 g PO. 4.Famotidine 20 mg PO. 5.Naproxen 250 mg PO. `6.Fluoxetine 20 mg PO.
1. Omeprazole -> is a PPI (-prazole); is indicated 2. Metoclopramide -> is an anti-vomiting drug, increases GI motility, so is contraindicated 3. Famotidine -> is a H2RA (-dine), so is indicated 4. Sucralfate -> antiulcer medication, is indicated 5. Naproxen -> salicylate NSAID, increases GI bleeding, contraindicated 6. Fluoxetine -> SSRI, have side effect of GI bleed, not indicated 2, 5, 6
Describe the tuberculin skin test process --What's the process/time frame? --What sizes are concerning? --What problem can occur?
1. PPD (protein derivative - aka TB antigen) is injected into forearm subdermally 2. Patient leaves for 2-3 days 3. Patient comes back, and the area is checked for rash -------------------------------------------------------------- 5 MM If in immunosuppressed state OR has data that supports current TB risk (TB-like fibrosis in CXR, previous TB exposure) 10 MM If immigrant, young child, IV drug abuser, around people at high risk of having it, or in high-risk setting (i.e. heavily trafficked areas, lab personnel) 15 MM Everyone else -------------------------------------------------------------- PROBLEMS Can be false negative if they had TB a long time ago (body isn't as reactive) Can be false positive if they have BCG vaccine
List common findings of a sickle cell patient; what is the main thing you are looking out for?
1. Pain 2. Cyanosis of tongue 3. Jaundice 4. Slow capillary refill You are mainly looking for things that indicate inadequate perfusion to life-critical organs (i.e. chest pain, slurred speech)
What are S/S of organ transplant rejection?
1. Pain over the organ 2. Infection-like symptoms --Fever --Rapid HR --N/V/D --Chills 3.
Drugs given for cystic fibrosis
1. Pancrealipase (pancreatic enzymes -> look out, don't put in hot food - denaturation) 2. Vitamin supplements 3. Bronchodilators/anti-inflammatories/mucolytics 4. Antibiotics
What symptoms would you expect naloxone to induce in a patient?
1. Reversal of opioid overdose effects --Tachycardia --Increase in respirations --Is now conscious --Normal pupils 2. Symptoms of opioid withdrawal --N/V --Tachy --Agitation --Muscle cramps
What disease history is associated with valvular defects?
1. Rheumatic fever in the past 2. Dental procedure infections
What specific values does the Swan-Ganz catheter measure?
1. Right ventricle pressure 2. Pulmonary artery pressure 3. Wedge pressure Left ventricular pressure can be inferred from pulmonary pressure
5 vaccines are given at 2 and 4 months; which are they?
1. Rotavirus 2. dTAP 3. Pneumococcal 4. Polio 5. Hemophilius influenzae
Which diseases are DROPLET
1. Rubella 2. Influenza 3. Mumps 4. Meningococcal meningitis 5. Pertussis
What are the 3 things which non-emancipated minors can do without parental consent?
1. STD junk 2. Drug abuse treatment 3. Outpatient/temporary mental health stuff (Darren)
Drugs given for COPD
1. Short/long acting beta agonists 2. Steroids 3. Anticholinergics 4. Antibiotics (for infection - can exacerbate symptoms)
Describe the proper procedure for administering a soapsuds enema
1. Slightly heat the mixture above body temp (~105 F) 2. Place tube 3 inches into rectum 3. Have patients in Sims position 4. Hold 12-18 inches above rectum; DO NOT HOLD HIGHER THAN THiS (travels in too quickly)
S/S of fetal alcohol syndrome
1. Small head (microcephaly) 2. Small for their age 3. Flaccid muscle tone 4. Thin upper lip
What substances should be avoided when breastfeeding?
1. Smoking 2. Alcohol 3. Excess caffeine Also presumably illicit drugs
Risk factors for pneumonia
1. Things that increase risk of foreign object --ET tube --Dysphagia --Low LOC 2. Poor immune system --Old age --Immunosuppression 3. Smoking 4. Alcohol 5. Diabetes
Which diseases require airborne precautions?
1. Tuberculosis 2. Smallpox 3. Shingles (herpes zoster) 4. Chickenpox (varicella) 5. Measles (rubella)
What substances are considered biohazards?
1. Used syringes 2. Used tubing 3. Blood transfusions 4. Body samples (urine, blood, feces) This also includes linens and other objects which have been contaminated with these substances (i.e. sheets with feces)
Treatment of postpartum hemorrhage
1. Uterine massage 2. Give oxytocin (contracts uterus) 3. Oxygen + fluids + blood If all else fails, cut out the uterus if it won't stop bleeding
Glasglow
1. Verbal responsiveness --Oriented --Confused --Inappropriate --Incomprehensible --None 2. Motor response to stimuli --Can obey commands --Localized response to pain (i.e. bats away hand) --Generalized withdrawal in response to pain --Flexion in response to pain --Extension in response to pain --No response 3. Eye opening ability --Spontaneously --To speech --To pain --None (spontaneously, to speech, to pain, none)
List the steps done for a urine specimen collection
1. Wash hands 2. Clean urinary meatus in to out 3. Void a little bit 4. Void into container using aseptic technique, taking care not to touch the sides
What are the 3 keystone signs of increased ICP?
1. Widened pulse pressure (difference between systolic and diastolic is wider) 2. Slow HR 3. Slow respirations
Sick day care for diabetic patiens
1. Your glucose day levels may increase, so dosage may be adjusted 2. Check glucose every 3-4 hours and adjust as needed 3. Check urine ketones 4. If you can't eat normal foods, substitute with gelatin and other foods 6-8 per day and substitute with drinks 5. Continue taking insulin
The nurse cares for the client receiving parenteral nutrition. Lab values are glucose 72 mg/dL (4 mmol/L), chloride 98 mEq/L (98 mmol/L), sodium 138 mEq/L, potassium 3.0 mEq/L (3.0 mmol/L). Which nursing action is most appropriate? 1.Discontinue the PN administration. 2.Notify the health care provider. 3.Administer IV glucose. 4.Check the client's vital signs.
2 (you said 4) Think -> does the doctor need extra info to make a decision about what to do in this situation? Probably not
A client diagnosed with schizophrenia hears voices and tells the nurse that the building is going to explode. Which action will the nurse take first? 1.Escort the client to a quiet room. 2.Engage the client to focus on the nurse. 3.Provide an emergency dose of medication. 4.Call for help since the client is going to run.
2 1 is tempting, but the person will likely not follow it unless you get them to focus on you
Describe each of the following in terms of year milestones --Mobility of child --Tower building --Vocabulary
18 months old 1. Scribbles 2. Can climb stairs 3. Can build 3-block tower 4. Has 10-word vocabulary 2 years 1. Jumps/hops 2. Builds 5-6 block tower 3. Has 300-word vocabulary 30 months (2.5 years) 1. Can stand on tiptoes 2. Can stand on 1 foot 3. Can build 7-8 block tower
Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge? 1.The client shaves and brushes his teeth. 2.The client transfers himself into and out of his wheelchair. 3.The client maneuvers the wheelchair without difficulty. 4.The client prepares well-balanced meals.
2 3 is easier, so not a good indicator 4 is vague; it may or may not require them to get out of the wheelchair
What specificaly does urine specific gravity mean?
1.01-1.03 is range Less than 1.01 -> incredibly dilute urine More than 1.03 -> incredibly concentrated urine Think gravity -> the solutes are "heavier"
What is normal urine specific gravity?
1.010-1.030
Urine specific gravity
1.010-1.030 Less than 1.010 -> dilute urine More than 1.030 -> concentrated urine
Normal mangesium levels
1.3-2.1
Healthy BMI
18.5-24.5
Poliovirus vaccine scheulde
1st dose -> 2 months 2nd dose -> 4 momths 3rd dose - somewhere between 6-18 months 4th dose -> 4-6 years
Haemophilus influenzae immunization schedule
1st dose -> 2 months 2nd dose -> 4 months 3rd dose -> 12/15 months
Pneumococcal pneumonia vaccine schedule
1st dose -> 2 months 2nd dose -> 4 months 3rd dose -> 6 months 4th dose -> 14-15 months
A client has hemodynamic monitoring using a Swan-Ganz catheter. The nurse is aware this type of monitoring will provide which information? 1.The circulatory volume in the coronary arteries. 2.The pressure in the ventricles. 3.The adequacy of pulmonary circulation. 4.The adequacy of carbon dioxide exchange.
2
The client diagnosed with schizophrenia has become increasingly withdrawn to the point of mutism. It is most important for the nurse to take which action? 1.Ignore the client until the client is ready to respond. 2.Sit with the client for brief periods of time. 3.Read to the client in a quiet area of the unit. 4.Encourage the client to play dominoes with the group.
2
The elderly client has a depressed affect. Which nursing action is most appropriate to help the client complete activities of daily living? 1.Medicate the client before the activities begin. 2.Develop a written schedule of activities, allowing extra time. 3.Assist the client with grooming activities so it doesn't take as long. 4.Provide frequent forceful direction to keep the client focused.
2
The client recently admitted to labor and delivery states that she is having severe discomfort with contractions. The nursing assessment reveals that the client is 3 cm dilated. The nurse assists the client through guided imagery. Ten minutes later the client is more agitated. The nurse should take which action? 1.Reteach the exercise. 2.Reposition the client. 3.Turn on the television. 4.Ambulate the client.
2 Ambulating will make pain worse (Cramps) Turning on the television is good, but not the best
The nurse notes that a client's heart rate decreases from 55 to 45 beats/min. Which action does the nurse take first? 1.Notify the health care provider (HCP). 2.Determine if the client is lightheaded. 3.Administer 0.5 mg of intravenous (IV) atropine. 4.Prepare for transcutaneous pacing.
2 Ask yourself 'before you call doctor, would the assessments listed be something they would ask for?" Knowing if the patient is symptomatic is important
The client receives digoxin 0.25 mg PO qd and furosemide 40 mg PO bid. The client calls the health care provider (HCP) reporting mild diarrhea. The HCP prescribes bismuth subsalicylate 60 mg after each bowel movement for two days and instructs the client to call back if symptoms don't subside. The client asks the office nurse if there should be any changes to the medication schedule. The nurse should instruct the client to take which action? 1.Continue the medication schedule. 2.Wait 1 hour before taking the scheduled medications if the bismuth subsalicylate is taken. 3.Hold the scheduled medications until the diarrhea subsides. 4.Take the digoxin but hold the furosemide if the client takes the bismuth subsalicylate.
2 Bismuth (Pepto-Bismol) impedes absorption of PO meds, so it needs to be taken separately 3 -> why would you hold an anti-diarrhea med?
An older adult client diagnosed with alcoholism receives chlordiazepoxide for 2 days for symptom management. The client says to the nurse, "Get those bugs off of me! " Which action does the nurse take? 1.Stop the chlordiazepoxide.2.Assess the client for tachycardia and tremors. 3.Document an allergy to chlordiazepoxide in the client's health record.4.Notify the health care provider that the client is experiencing delirium.
2 Note - hallucinations are a normal symptom of alcohol withdrawal If anything, the patient needs MORE chlordiazepoxide (is a benzo) Look for #2; sign of worsening withdrawal
The visiting nurse notes that a client diagnosed with asthma is in the "red zone" of the peak flow meter system. Which action does the nurse take first? 1.Take a detailed medical history. 2.Call the health care provider. 3.Do a medication reconciliation. 4.Repeat the peak flow meter test.
2 Note -> in the real world, 4 would probably be accurate However, assume all readings are accurate unless otherwise specified
The nurse provides care for a 9-month-old infant who weighs 9 pounds. The infant was taken from the parent's home for neglect. The infant cannot roll over or sit up independently. Which nursing diagnosis does the nurse assign as highest priority? 1.Injury related to physical abuse. 2.Imbalanced nutrition; less than body requirements. 3.Risk for violence. 4.Impaired growth and development.
2 Note that you put 4 first; however, nutritional imbalances will kill them FIRST (development is more long-term)
A client treated for a lung tumor has low urine output and signs suggesting hypernatremia; what do you do? 1. Begin 0.45% NaCL at 75 mL/hr 2. Obtain urine for urinalysis 3. Contact doctor 4. Encourage PO fluids
2 REMEMBER -> diabetes insipidus is a thing You need to check for that
The nurse cares for the young adult client. The client is scheduled for the first debridement of a deep partial thickness burn of the left arm. It is MOST important for the nurse to take which action? 1.Assemble all necessary supplies and medications. 2.Plan adequate time for the dressing change and provide emotional support. 3.Prepare the client and family for the pain the client will experience during and after the procedure. 4.Limit visitation prior to the procedure to reduce stress.
2 (you said 3) 3 is good, but 2 covers more bases PHYSICAL -> have enough time for actual procedure PSYCHOSOCIAL -> provide emotional support 3 is only psychosocial
While working at a local food processing plant, a flying object penetrates an employee's right eye. The employee is admitted to an emergency department. After administering pain medication, which question is most important for the nurse to ask? 1."Does the company provide worker's compensation?" 2."Do you wear glasses?" 3."Did you have visual problems before the injury?" 4."Are you afraid?"
2 (you said 3) Glasses could have shattered on impact, putting glass into the eye
The nurse determines teaching is effective if the parents of the 4-year-old child diagnosed with sickle cell anemia makes which statement? Select all that apply. 1."When my daughter reports pain, I use cold compresses." 2."I try to keep my daughter away from people with infections." 3."I sometimes have to give my daughter some of her morphine for pain." 4."I encourage my daughter to drink a lot of water." 5."I love to watch my daughter play hard through a whole soccer game."
2, 3, 4 HOP to it (hydration, oxygen, pain meds) Not 1 because cold = vasoconstriction Not 5 because they shouldn't be playing an entire game
The nurse prepares to document care given to clients. Which areas will the nurse include in complete and accurate documentation? (Select all that apply.) 1.Subjective nursing observations. 2.Client symptoms and response to treatments. 3.Nursing care given. 4.Explanation of a medication error. 5.Medications and treatments.
2, 3, 5 Must be OBJECTIVE information (no opinions) Medication errors and other errors would be filed in incident reports, not in the main documentation
A client diagnosed with peptic ulcer disease asks if an over-the-counter antacid can be taken instead of esomeprazole because of the cost. Which responses by the nurse are appropriate? (Select all that apply.) 1."Try the antacids for a few days. If you start to feel worse, call your health care provider." 2."I will call your pharmacy and find out the cost." 3."Esomeprazole helps reduce stomach acid, and you will need to take it for several weeks to achieve healing." 4."Increase your intake of caffeinated liquids to promote healing of the ulcer." 5."Here is information about smoking cessation classes available in your area." 6."Notify your health care provider if you have stools that are black and tarry."
2, 3, 5, 6 1 -> antacids are not the drug of choice, PPIs/H2RAs are 2 -> good, patient advocate 3 -> accurate 4 -> FALSE, shoudl avoid caffeine (increases GI motility, aggravates ulcer) 5 -> good, smoking is risk factor 6 -> good, indicates bleeding
The nurse provides care to an adult client who sustained a T3 spinal cord injury 2 days ago. The nurse suspects a developing emergency based on which assessment finding? (Select all that apply.) 1.Respiratory rate of 18 breaths/min. 2.Warm, dry, flushed skin. 3.Absence of sensation in lower extremities. 4.Blood pressure of 88/42 mm Hg. 5.Heart rate of 88 beats/min.
2, 4 1 -> WNL 2 -> can be indicative of neurogenic shock (in general, skin shouldn't be flushed) 3 -> is a normal finding for a spinal injury 4 -> below normal limits 5 -> WNL
When assessing an older adult client who is diagnosed with dehydration, the nurse expects to observe which clinical manifestations? (Select all that apply.) 1.Weight gain. 2.Tachycardia. 3.Moist mucous membranes. 4.Cold hands or feet. 5.Flattened neck veins.
2, 4, 5 You didn't include 4 initially; vasoconstriction to preserve major organs causes this
A client diagnosed with a necrotizing spider bite is to perform dressing changes at home. The nurse determines which statement, if made by the client, indicates a correct understanding of aseptic technique? Select all that apply. 1."I need to buy sterile gloves to redress this wound." 2."I should wash my hands before redressing my wound." 3."I should keep the wound covered at all times." 4."I should only use whatever my health care provider orders for the dressing change." 5."I should make sure someone looks at my wound every dressing change." 6."I will throw the dressing away in the kitchen garbage wrapped in my glove."
2, 4, 5, 6 You said 1, 2, 4, 6 Sterile gloves are not given for home care. For wound care too after the 1st initial cleaning in-hospital 5 is just generally a good idea
The nurse instructs a group of high school parents at a local health fair. Which statements by the parents during the discussion period require follow up by the nurse? (Select all that apply.) 1."My teenager is very independent and doesn't need constant supervision after school." 2."My teenager can be impulsive at times, but is improving on problem solving skills." 3."Although I've made some mistakes in my life, I feel that I am a good role model for my teenager." 4."My child is moody and requires some guidance when frustrated with homework." 5."It is important to consistently tell my teenager what to do every day."
2, 5 (you said 5 only) Impulsiveness indicates potential for risky behavior so it should be discussed
Isolation precautions can be stopped when usually?
24 hours after antibiotics are started
After caring for a client, the nurse needs to dispose of which item in the biohazard bin? 1.Linen soiled with urine. 2.Blood-tinged adhesive bandage. 3.Canister of gastric secretions. 4.An empty indwelling catheter bag.
3 1 -> put in plastic bag 2 -> normal trash; bandage isn't saturated, and can hold onto blood (dressings/gauze goes in biohazard though) 3 goes in; high risk of escape of luids 4 -> normal trash, is contained inside tubing
The client is transferred to the neurology unit after developing right-sided paralysis and aphasia. The nurse includes which intervention in the client's plan of care? 1.Encourage client to shake head in response to questions. 2.Speak in a loud voice during interactions. 3.Speak using phrases and short sentences. 4.Encourage the use of radio to stimulate the client.
3 1 is tempting, but 3 preserves some recognition function if there is any
The nurse provides care for a client who reports fatigue, has dry skin, and a poorly healing wound. Which health problem will the nurse consider the client to be experiencing? 1.Anemia. 2.Malnutrition. 3.Activity intolerance. 4.Peripheral vascular disease.
2. Malnutrition Note that a patient with anemia would NOT have dry skin or poor wound healing
After a client completed 6 months of multidisciplinary treatment for anorexia nervosa, the nurse evaluates whether the client has met the goal of balanced nutrition sufficient to meet metabolic demands. Which is the best indicator that the goal has been met? 1.The client no longer sees herself as fat or overweight. 2.The client eats balanced meals without obsessive behaviors. 3.The client's menstrual period has returned and is regular. 4.The client's ideal body weight has been attained.
3 2 -> may not have enough nutrients, just indicates they're on the path to it 4 -> can be adequate body weight, but not have appropriate nutrients for metabolic needs
The nurse provides care for a client taking warfarin for a mechanical prosthetic heart valve. The client has an international normalized ratio (INR) of 3.1. Which is the correct interpretation by the nurse of this finding? 1.The next dose of warfarin needs to be stopped. 2.The result indicates a sign of warfarin toxicity. 3.The client's treatment goal has been achieved. 4.The client may require a plasma transfusion.
3 2.5 - 3.5 is ideal range
What is the ideal INR when taking warfarin? --What do low/high values mean?
2.5 - 3.5 Below 2.5 -> clots too easily; increase warfarin Above 3.5 -> bleeds too easily; lower warfarin and maybe give infusion
At what age is the height of the fundus in a pregnant woman expected to be at the level of the umbilicus?
20 weeks
At what age is a child physiologically able to control toilet functions?
22 months, or ~ 2 years
The nurse cares for the client diagnosed with schizophrenia. Which statement is most descriptive of the affect of this client? 1.Answers all questions with one word. 2.Laughs while talking about being raped. 3.Exhibits no energy or interest in tasks. 4.Cries while talking about a parent's death.
2; inappropriate affect
Normal child BP
2x age + 80 / 50-80`
A client is brought to the mental health center reporting severe headaches, insomnia, and poor appetite. Each time a question is asked, the client provides a lengthy, detailed description of events. Which is the most important action for the nurse to take? 1.Remind the client of the time. 2.Tell the client that people are there to take care of her. 3.Sit and listen to the client. 4.Ask the client to be brief.
3
A young Hispanic client who speaks little English is admitted to a medical-surgical unit with an increased temperature. Prior to the nurse performing a physical assessment, which nursing action is the MOST appropriate? 1.Attempt to prepare the client with hand signals. 2.Show the client pictures of the physical exam process. 3.Contact an employee who speaks Spanish to translate. 4.Speak slowly to explain the physical assessment.
3
The client who is terminal is on a unit with limited visiting hours that restrict children younger than 12 years of age from visiting. Which nursing action has the highest priority? 1.Explain the visiting hours to the client's family. 2.Propose a policy change to the medical and nursing staff. 3.Allow flexibility with family members' visitation. 4.Encourage the family to call the unit between visiting hours.
3
The clinic nurse is giving instructions to the family of a school-aged child diagnosed two weeks ago with hepatitis A. The family asks if the child can return to school. Which response by the nurse is BEST? 1."You must isolate your child at home for two more weeks." 2."Why don't you speak with the health care provider about this matter?" 3."Your child may return to school this week." 4."Your child may return to school in two weeks but cannot participate in sports."
3
The RN obtains a urinalysis from the client reporting dysuria, urinary frequency, and discomfort in the suprapubic area. After evaluating the results, the nurse should order a repeat urinalysis based on which finding? 1.Negative glucose. 2.RBCs present. 3.No WBCs or RBCs reported. 4.Specific gravity 1.018.
3 Based upon the symptoms, what do you expect -> UTI You order an extra test if the initial one does NOT match what you expect (to play it safe) You said 2 initially; that's an expected infection finding Correct answer -> 3
he primipara attends a class for women who plan to breast feed. To prepare for breast feeding, the nurse encourages the women to perform which implementation? 1.Apply moisturizer to the breasts every day after bathing. 2.Nurse the infant every 4 to 5 hours after delivery. 3.Wash the breasts with warm water only. 4.Massage the breasts to increase circulation twice daily.
3 Creams/massages cause breast tenderness Infant should be nursed when hungry
The nurse provides care for a client diagnosed with lymphoma. The client has a large tumor. Which intervention by the nurse is most important in preventing tumor lysis syndrome? 1.Record vital signs every 2 to 4 hours. 2.Send a urinalysis test every 6 hours. 3.Administer a high rate of intravenous fluid. 4.Ask the client to report decreased urine output.
3 Note the word "PREVENT" Assessment techniques alone won't prevent it, just let you catch it early 3 is the only intervention
The nurse instructs a client receiving naproxen 250 mg enteric-coated tablets PO bid. Which response, if made by the client, indicates that the nurse's instruction about the medication is effective? 1."I have a glass of wine with dinner." 2."I should avoid milk and dairy products when I take this pill." 3."I should call my health care provider if my stools turn very dark." 4."I don't like to take pills, so I will crush the pill and add it to some applesauce." Strategy: "Teaching is effective" indicates you are looking for a true statement.
3 Dark stools = GI bleed
The health care provider prescribes cimetidine 300 mg PO qid for the client. The nurse instructs the client about the medication. Which client statement indicates further teaching is needed? 1."I'll take this pill with meals and before bed." 2."I may experience mild diarrhea for a while." 3."My stools may change color while I'm on this medication." 4."I should call my health care provider if I get an acne-like rash."
3 Diarrhea is normal (you disrupted stomach acidity - what did you expect?)
The nurse receives a prescription to start an IV dopamine infusion for a client with hypotension. Which action does the nurse take next? 1.Verify that the client has a "full code" status documented. 2.Ensure the client has a gauge 18 peripheral IV line. 3.Check to see if the client received volume replacement. 4.Attach the client to an oxygen saturation monitor.
3 Dopamine doesn't require a code; it isn't currently a code Dopamine is given via a central line (to prevent infiltration) Since dopamine causes HTN, you want to make sure there is enough blood, otherwise extremities are double screwed
The nurse determines which client is at highest risk of developing colorectal cancer? 1.An adult client who teaches high school and has a history of endometrial cancer. 2.An adult client who owns a restaurant and has a history of alcoholism. 3.An older adult client who is a cattle farmer diagnosed with Crohn disease. 4.An older adult client who is a bus driver and has a hiatal hernia and obesity.
3 General cancer risk factors: 1. Previous cancer (general) 2. Stress 3. Age 4. Obesity Risk factors specific to colorectal 1. History of Crohn's/UC 2. ALcoholism 3. Consumption of red meat 4. Family history (direct family)
The nurse instructs the client about digoxin, furosemide, spironolactone, and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1."I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2."I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3."I plan to use salt substitutes now that I have to limit my sodium intake." 4."I should read food and nonprescription medication labels to check the ingredients."
3 Would increase potassium Yes, they are on lasix, but spironolactone is potassium-sparing, so their K+ will potentially elevate
The nurse provides care for several assigned clients. Which situation requires an immediate follow-up by the nurse? 1.A client on mechanical ventilation has moisture in the ventilator tubing. 2.A client's blood glucose monitor shows a message noting there is insufficient amount of blood to complete the glucose level. 3.A client receiving a liter of intravenous fluid at 120 mL/hr has 460 mL remaining after 2 hours. 4.A client with a chest tube attached to suction has bubbling in the control chamber of the closed-drainage system.
3 You narrowed it down to 1 and 3 Moisture is a normal finding (yes, it get it impairs breathing); there is no indication they are in immediate risk of respiratory impairment 3 on the other hand has an immediate risk of fluid overload leading to cardiac failure
An adolescent student asks the school nurse what to do when a parent has a panic attack every time the parent attempts to leave the house. Which statement is the best response for the nurse to make? 1."Have your parent practice deep breathing and relaxation techniques before leaving the house." 2."Tell your parent that this behavior is disruptive to the whole family." 3."You are concerned for your parent, but more help is needed than you are able to provide." 4."Desensitize your parent by having them get into the car and quickly leave the area."
3 You said 1, but this is bad enough to warrant professional help (and not jsut a kid helping them)
The client with chronic pain due to cancer receives morphine 10 mg PO q4h PRN for pain without much relief. Which change in narcotic pain management is the most valid suggestion for the nurse to make to the health care provider? 1.Decrease medication to twice a day. 2.Decrease medication to every 6 h PRN. 3.Administer medication every 4 h around the clock. 4.Administer medication every 2 h PRN.
3 You said 4; every 2 hours is probably too dangerous
A client who is positive for human immunodeficiency virus (HIV) is to be discharged and will be taking zidovudine (AZT) at home. Which of the following actions by the nurse is BEST? 1.Review the importance of adhering to a 4-hour schedule. 2.Advise the client to buy a timed pill dispenser. 3.Write the schedule of when the medicine should be taken. 4.Encourage self-medication prior to discharge.
3 (gives them the clearest plan to follow and gives a visual reminder) You said 4
The nurse follows up a community education session by asking clients to describe ways to reduce their cancer risk. Which client statement requires clarification by the nurse? (Select all that apply.) 1."I will limit my exposure to second-hand smoke." 2."I will walk for 30 minutes, at least 5 days a week." 3."I should stop eating meat." 4."I will lose 20 pounds." 5."I should not go outside on very sunny days." 6."I will avoid being around persons consuming alcohol."
3, 4, 5, 6 3 -> don't need to stop, just limit 4 -> need to have healthy weight, not just lose an arbitrary amount 5 -> can go outside, just limit time
The nurse provides care for a client who reports difficulty breathing. Which assessment finding requires immediate action by the nurse? (Select all that apply.) 1.Non-productive cough. 2.Flushed skin appearance. 3.Use of accessory muscles. 4.Oxygen saturation of 78%. 5.A heart rate of 145/minute.
3,4, 5 Note that other problems can cause flushed skin and a non-productive cough (I.e. the patient has COPD - cough is normal) Flushed skin can be caused by other problems
A client undergoes admission from the recovery room with an intravenous fluid infusing at 100 mL/hour. There are 900 mL left in the bag. One hour later, the client has received 850 mL. The nurse is most concerned by which assessment finding? 1.A CVP reading of 8 mm Hg and bradycardia. 2.Tachycardia and hypotension. 3.Dyspnea and oliguria. 4.Rales and tachycardia.
4 1 -> normal findings, you would expect tachy, not brady 2 -> you would not expect hypotension with fluid overload 3-> why oliguria?
When performing a sterile dressing change, the nurse removes the saturated dressing, notes the wound is clean, applies a new dressing, and discards the used gloves. Which action does the nurse take next? 1.Put on sterile gloves. 2.Open the sterile gauze packaging. 3.Perform hand hygiene. 4.Date and initial the new dressing.
3. Perform hand hygiene Initialing the dressing is done LAST (You don't want to contaminate pen)
Normal albumin levels
3.5-5.5
aPTT
30-40 seconds
Normal newborn respirations; what other modifications are there (3)
30-60 Breathe with abdomen, not thoracic Also are obligate nasal breathers May have short apnea periods (are only concerning if longer than 15 seconds)
How many more calories should a pregnant mother eat?
300 more
The client with sudden onset of venous thromboembolism (VTE) is started on IV unfractionated heparin. Which order should the nurse question? 1.Warm, moist packs to the affected leg. 2.Elevate the foot of the bed 6 inches. 3.Complete bedrest for 5 days. 4.Elastic stockings on unaffected leg.
3; bedrest stays untl heparin is started, but not longer
A client developed diabetes insipidus following a craniotomy. The nurse provides discharge instructions for the client and spouse. Which statement, if made by the client, indicates to the nurse that further teaching is needed? 1."I should keep a daily record of my fluid intake and how much I go to the bathroom." 2."I should call my health care provider if I seem thirsty a lot and my urine specific gravity is less than 1.005." 3."I should weigh myself every day and drink less fluid if I gain more than 5 lb over a week." 4."I will need to take the nose spray medication for the rest of my life."
3; if they notice weight gain, they should call doctor Fluid changes should be regulated by meds, which doctors prescribe
The nurse observes care given to the client who vigorously follows several rituals daily, including frequent hand washing. The client's hands are now reddened and sensitive to touch. The nurse should intervene if which action is observed? 1.The staff administers special skin care to the client. 2.The staff gives positive reinforcement for nonritualistic behavior. 3.The staff limits the amount of time the client may use to wash hands. 4.The staff protects the client from ridicule by other clients on the unit.
3; rituals should not be forcefully limited Just restricted slowly over time
The nurse determines which diversional activity is most appropriate for a 10-year-old client recovering from a sickle cell crisis? 1.Walking in the hall 20 minutes twice a day. 2.Watching the cartoon channel all day. 3.Collecting pictures from magazines. 4.Putting together large-pieced wooden puzzles.
3; school-aged children lik collecting things You said 4; that's listed as a preschool activity
Where is Erb's point located?
3rd intercostal space, left sternal border
An elderly client is oriented during the day but becomes disoriented during the evening. Which nursing action is MOST appropriate? 1.Place a large clock where the client can see it. 2.Place a vest restraint on the client during the evening. 3.Encourage the client to take a nap during the afternoon. 4.Install nightlights in client's room and bathroom.
4
The nurse provides care to a client who requires wound care. When collecting a wound drainage specimen for culture, the nurse implements which step? 1.Administer a single dose of antibiotic medication 30 minutes before obtaining the specimen. 2.Remove the crusts or scabs with sterile forceps and then culture the site beneath. 3.Swab the area in which the largest collection of drainage is present. 4.Irrigate the wound with sterile water prior to obtaining the specimen.
4 1 -> wrong; disrupts flora in the area 2 -> causes unnecessary discomfort and disrupts wound bed; debridement is not done during specimen collection 3 -> the area with greatest drainage is older, which means it probably has extra bacteria mixed in 4 -> GOOD; removes extraneous bacteria and collects microbe at site of infection
The nurse receives reports on several clients. Which client will the nurse assess first? 1.9-month-old client with a barking cough, not eating or drinking, with an oxygen saturation of 92% on room air. 2.14-month-old client with an oral temperature of 1020 F, green nasal drainage, and is pulling at the ears. 3.6-month-old client with a harsh cough, mild audible wheezes, and retractions noted in the ribs. 4.2-year-old client with a sore throat, sitting upright, refusing to swallow, and drooling.
4 1 and 2 are fine (1 has normal O2 sat and no signs of immediate respiratory impairment, 2 has no issues immediately either) 3 is concerning, but 4 is the MOST concerning, since drooling is an aspiration risk and the symptoms indicate epiglottitis, which can cause airway loss
The nurse cares for the client diagnosed with Parkinson's. The nurse notes that the client is ambulating with short, accelerating steps. Which action is the most appropriate for the nurse to take? 1.Offer the client a wheelchair. 2.Provide the client a walker. 3.Suggest that the client wear comfortably fitting shoes. 4.Teach the client to walk with a broad-based gait.
4 2 is tempting, but you need to improve their walking style BEFORE doing this (walkers can slide forward if they fall)
The nurse cares for the client diagnosed with dementia in a long-term care facility. Which action by the nurse is best? 1.Encourage the client to verbalize feelings about being placed in a nursing home. 2.Ask the client what favorite pastimes and what types of activities the client used to participate in. 3.Orient the client to the present time and assist the client to be alert and oriented when the family comes to visit. 4.Direct conversation toward assisting the client to reminisce and talk about important past events in life.
4 3 is tempting, but remember that orientation won't last very long Reminiscing is more important, since those memories are more likely to stick around
A father brings his 15-month-old son to the well-baby clinic for a routine checkup. The father confides to the nurse that he is concerned that his son still crawls and does not walk. Which response, if made by the nurse to the father, is best? 1."I will refer you to a pediatric specialist if he doesn't start walking soon." 2."Have you noticed any signs of paralysis or weakness in your son?" 3."Try standing him on his feet several times a day." 4."Children frequently set their own pace for development."
4 Children all have different developmental speeds
The nursing manager observes a graduate nurse conduct a physical examination on a newly admitted client. Which action made by the graduate nurse requires an immediate intervention by the nursing manager? 1.The nurse uses the ball of the hand to palpate for tactile fremitus. 2.The nurse depresses the client's tongue slightly off center when using a tongue depressor to inspect the uvula. 3.The nurse uses a stethoscope to palpate the client's abdomen, with fingers moving over the edge of the diaphragm. 4.The nurse completes inspection of the client's thorax for cardiac assessment and then begins auscultation.
4 Forgot percussion and palpation
The client is being discharged with sublingual nitroglycerin. Which information should the nurse give to the client? 1.Take the medication 5 minutes after the pain has started. 2.Stop taking the medication if a stinging sensation is absent. 3.Take the medication on an empty stomach. 4.Avoid abrupt changes in posture.
4 Nitro lowers BP by vasodilating (that's the effect) Rapid posture changes leads to ortho hypo
The nurse provides care for an adolescent client experiencing a migraine headache. Which finding causes the nurse to be most concerned? 1.Blurred vision. 2.Nausea and vomiting. 3.Sound and light intolerance. 4.Urinary incontinence.
4 Note that 1-3 are normal expected findings of a migraine headache 4 is a developmental stepback, and can indicate potential for seizure
The charge nurse reviews the medical records of several clients. Which documentation from a staff nurse requires the charge nurse to follow-up? 1."Returned from radiology department following a chest X-ray. Requesting lunch, but remains nothing by mouth until seen by the health care provider as prescribed." 2."Late - entry. Ambulated from bed to doorway without assistance. No shortness of breath or diaphoresis noted. Vital signs remained within baseline after ambulating." 3."Intravenous catheter site in left antecubital space is red and warm to touch. Intravenous solution infusing slowly. Catheter removed intact. New catheter placed in right forearm." 4."Found client sitting on floor. All four side rails were in upright position. Client reports no pain. No abrasions or bleeding noted. Health care provider notified. Incident report completed."
4 Remember - incidence report findings are NOT listed in the main documentation
The nurse cares for the client being maintained on a ventilator. The client suddenly becomes distressed and agitated. Which is the most appropriate action for the nurse to take? 1.Obtain an order for a tranquilizer. 2.Restrain the client. 3.Check the last arterial blood gas result. 4.Assess the client's breathing pattern in relation to the ventilator.
4 The most common form of distress is "fighting" the ventilator, wherein the breathing pattern is desynchronized Assessing breathing pattern will let you knwo if this is occurring
During a paracentesis, 1500 mL of fluid is removed from the client. Which action should the nurse take IMMEDIATELY following the procedure? 1.Measure the client's abdominal girth. 2.Weigh the client. 3.Assess the client's level of pain. 4.Check the client's blood pressure.
4 They're leaking fluid (third spacing), so risk of hypovolemic shock Which factor will indicate they are dying the most? #4
The neonatal nurse instructs the family of a newborn about an apnea monitor. The nurse is MOST concerned if a family member makes which statement? 1."We will be able to leave our baby for brief periods of time." 2."We plan to sleep by our baby's crib." 3."We can remove the monitor during our baby's bath." 4."A family member will closely watch the monitor all the time."
4 Think about what it means; they think a person has to be staring at the monitor 24/7 (or at least during the day) The thing will beep if they stop breathing, so it that required?
The nurse is providing education to the client receiving phenelzine sulfate. The nurse determines teaching is effective if the client selects which dinner menu? 1.Chicken with teriyaki sauce and kimchi.2.Grilled cheddar cheese sandwich and tea.3.Pizza with pepperoni.4.Omelet with broccoli.
4 You got this 1 right, but 2 is tempting Remember that cheddar cheese is an aged cheese
The nurse arrives at work stating, "My throat hurts and I have a temperature of 99.5°F (38°C)." This nurse is one of two RNs scheduled to work the shift with no additional support staff. Which action by the healthy nurse is most appropriate? 1.Refuse to work with the nurse who has the sore throat. 2.Suggest that the nurse with the sore throat obtain a throat culture before accepting an assignment. 3.Tell the the nurse with the sore throat to go home. 4.Arrange for coverage for the nurse with the sore throat while a rapid strep test is obtained.
4 (You said 3) 3 would be good with adequate staffing, but you don't have it
How much polyethylene glycol has to be consumed?
4 L
The nurse cares for the client currently hospitalized with chronic kidney disease. The client has 3+ pitting edema of the lower extremities. Which nursing observation indicates a therapeutic response to therapy for the edema? Select all that apply. 1.Serum potassium 4.0 mEq/L (4.0 mmol/L). 2.Plasma glucose 140 mg/dL (7.8 mmol/L). 3.Increased specific gravity of the urine. 4.Weight loss of 5 lb over last two days. 5.Decrease in calf circumference by 2 cm.
4, 5 Which indicate that the EDEMA is improving? 1 (you put this) -> K+ has nothing to do with edema 2 is elevated, and has nothing to do with edema 3 -> you would expect decreased specific gravity (dilute urine r/t edema fluid being removed) 4+5 are good
The young adult comes to the outpatient clinic reporting vaginal itching. Which recommendation, if given to the client by the nurse, is appropriate? Select all that apply. 1."Supplement your diet with yogurt and dairy products." 2."Douche with an over-the-counter preparation." 3."Wash the area with soap and water several times a day." 4."Wear underwear that is lined with a cotton crotch." 5."Refrain from sexual intercourse for a week after starting treatment." 6."You should take your medication until is it all gone."
4, 5, 6 1 -> probiotics are reaching the GI tract, NOT the vagina; has no impact 2 -> douching in general is discouraged; disrupts vagina pH 3 -> causes dryness, which will make itching worse 4 -> TRUE; cotton wicks away moisture, and a damp crotch exacerbates the infection 5 -> TRUE; prevents exacerbations/transmission 6 -> TRUE, true for medications in general
The nurse suspects that a newly admitted client might be a victim of elder physical abuse. Which is the nurse's priority action? 1.Call the local police precinct. 2.Alert the hospital security staff. 3.Interview the client with the family. 4.Notify the health care provider.
4. Notify the HCP Note that there needs to be further evaluation to see if the elderly person is abused If nursing supervisor was an option, that would be the selection; the next in line is the doctor
Normal male hematocrit
42-52
The school-aged child informs the school nurse that the right knee "doesn't feel right." Which action should the nurse take first? 1.Instruct the child to extend the right leg. 2.Put both of the child's legs through range of motion. 3.Advise the child to soak the right knee in warm water. 4.Compare the appearance of the right knee with the left knee.
4; need to determine what "normal" is to find what the problem is Assessment finding -> will determine what kind of treatment
What things should you look for to determine if med order is missing something?
5 rights 1. Right patient (if applicable) 2. Med listed 3. Dosage listed 4. Frequency listed 5. Route listed
A client receiving 50 mL/hr of continuous bladder irrigation fluid has a total output of 500 mL over 8 hours. Which action does the nurse take? 1.Assess the catheter for kinks. 2.Notify the health care provider. 3.Manually irrigate the catheter for clots. 4.Reduce the rate of the bladder irrigation fluid.
50*8 = 400 500 mL More came out than was put in 1. Kinks would cause LESS to come out, not more 3. Clots would cause LESS to come out, not more 4. Nurses aren't allowed to change med dosages
Where is the bicuspid valve auscultated?
5th intercostal space, just to the left (Ik, confusing) or the sternum
A ___ y.o. can tie knots
6
What is the single BEST indicator of nutritional status in a patient taking parenteral nutrition?
Albumin levels; if it's normal, they're good You'd expect weight gain, but remember that fluid retention can cause that
Describe what each of the following spontaneous abortions are, and their defining symptom --ECTOPIC --THREATENED --INEVITABLE -_INCOMPLETE --COMPETE --MISSED --HABITUAL
ALL of them involve vaginal bleeding and some degree of cramping ECTOPIC --Severe abdominal pain which extends to shoulder --Egg has implanted somewhere other than uterus --LIFE-THREATENING THREATENED --Vaginal bleeding/moderate cramping --Cervix is NOT dilated --Decrease activity/avoid sex until 2 weeks after bleeding ends INEVITABLE --Cervix is dilated and cannot be closed --Bleeding and cramping INCOMPLETE --Reproductive parts stay inside --Same symptoms (bleeding, cramping), may persist for a while COMPLETE --Same as incomplete, but everything is gone MISSED --Fetus dies, but is not expelled --Cervix remains closed --Vaginal bleeding/cramping present --If retained for too long, risk of infection + DIC (GET IT OUT) HABITUAL --Have had 3 or more spontaneous abortions
An infant doubles weight by ___, and triples by
Double by 4 months, triples by 1 year
Carbonated soda is (acidic/alkaline)
Alkaline
Tomato juice is (acidic/alkaline)
Alkaline
You notice that the water in the water-seal chamber is no longer fluctuating. What do you expect, and what follow-up is there?
All of the air has been removed, and the lung is now no longer collapsed Do imaging (CXR) to verify
Rheumatoid arthritis --What is it? --Expected S?S --Medcations/treatments
Autoimmune attack of joints leading to pain, redness and inflammation ------------------------------------------- 1. Pain + swelling 2. Reduced movements 3. Nodules 4. Rash You do NOT expect contractures in joints; ROM should be done to prevent this ------------------------------------------- 1. Pain meds 2. Promote ROM exercise supplemented with rest 3. Warm compresses 4. Splints for jointss 5. Immunosuppressors
Guillain-Barré syndrome (GBS) --What is it? --Symptoms? --What should patients who have it look out for?
Autoimmune destruction of myelin sheath --Starts in legs and progresses upwards Try to be careful with vaccinations; infections exacerbate the disease
GI/duodenal ulcers --Modification to diet
Avoid foods which will cause excess secretion/excess mobility 1. 3 meals per day 2. No extremely hot/cold foods 3. No caffeine (coffee, soda, tea) 4. No alcohol 5. No dairy products (milk/ice cream)
Tips for preventing complications for abdominal aortic aneurysm
Avoid things that cause increase straing: 1. Constipation (Valsalva) 2. Avoid lifting heavy objects
(T/F) Meats contain poor amounts of calcium
True The one exception (if you consider it meat) is tofu
What do you encourage a patient with back pain NOT to do?
Avoid things that cause undue flexing/twisting of spine 1. Bending over to tie shoes 2. Standing on tippie toes 3. Crossing legs when sitting/standing Also encourage: 4. Broad leg support (stand with feet shoulder-length apart)
When should Hemovac drains be drained? What is done otherwise?
Drain when ~half full (maybe every 4-6 hours) Otherwise keep it sealed at all time to prevent contamination
Influenza requires which precautions?
Droplet
Mumps requires which precautions?
Droplet
Rhinovirus requires which precautions?
Droplet
Rubella has what precautions?
Droplet
Streptococcus requires which precaution (Group A)
Droplet
S/S of pancreatitis
Abdominal pain radiating to the back which is worse when sitting forward
Disseminated Intravascular Coagulation (DIC)
Abnormal clotting --Clots form, leading to no more platelets able to stop bleeding --S/S -> persistent bleeding from IVs, wounds, orifices (if extreme) --Commonly caused by infection (sepsis), is complication of pregnancy
Tracheoesophageal fistula
Abnormal connection between trachea and esophagus in newborns
Rales
Abnormal crackling sound made during inspiration Indicates the presence of fluid in the lungs
What phenytoin level is considered toxic?
Above 25
The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child?`
Airborne and contact --They are having chickenpox
(T/F) Tractions lead to increases in muscle spasms
True/False They shouldn't increase spasms; if they do, it's because there is too much weight, and you should be concerned
The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate? 1.A 38-year-old client with a diagnosis of systemic lupus erythematosus. 2.A 45-year-old client receiving daily external radiation therapy treatments for breast cancer. 3.A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg. 4.A 74-year-old client who has received intravenous antibiotics for 7 days.
Accepting a patient from another unit; which is the "safest" and which the unit has the capacity to care for (non-specialized 1 -> correct (no listed complications, SLE isn't infectious, stable client) 2 -> WRONG, radiation is specialized, maternity won't know it 3 -> WRONG, risk of infection 4 -> WRONG, risk of C. dif and infection
Curling's ulcer; what makes you suspect it?
Acute gastric ulcer associated with severe burns Suspect it if stomach pH is 1-5
(T/F) People with halo collars can take baths
True; cannot take showers though (don't get head/device wet)
Neuroleptic malignant syndrome --Symptoms? (6) --Treatment
Adverse effect to antipsychotics: 1. Rigid muscles 2. Fever/sweating 3. Autonomic failure --Dysrhythmias --BP fluctuations 4. Confusion 5. Seizures/coma ---------------------------- 1. Stop antipsychotics 2. Control temperature 3. Give fluids (to combat sweating/Bp changes) MEDICATIONS 1. Dantroline (muscle relaxant) 2. Bromocriptine
Play type for toddlers (which age)
Age 1-3 Parallel play (next to another person, but on their own)
Procedure for choking child --Age range?
Age 1-puberty 1. Put on back 2. 5 abdominal thrusts 3. Open mouth to look for object -> remove if visible, but DO NOT DO finger sweep 4. If unsuccessful and stops breathing/no pulse, begin CPR
Preschooler play pattern (which age)
Age 3-6 Associative play; no organized rules, just messing around
Chickenpox/shingles require which precautions?
Airborne
Measles require which precautions
Airborne
Rubella requires which precautions?
Airborne
Smallpox requires which precautiosn?
Airborne
What kind of precautions is measles?
Airborne
What is a side effect of angiotensin 2 receptor blockers? (-sartans?)
Angioedema
How often are influenza vaccines given?
Annually
Describe where to auscultate each of the following: --Aortic valve --Pulmonic valve --Erb's point --Tricuspid valve --Mitral valve
Aortic -> 2nd intercostal space to the RIGHT of sternum Pulmonic -> 2nd intercostal space to the LEFT of sternum Erb's point -> 3rd intercostal space, left of sternum Tricuspid -> 4th intercostal space, left of sternum Mitral -> 5th intercostal space, midclavicular line
Apgar
Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent)
A VTE patient has what kind of mobility; for how long
Are on bedrest, but ONLY until heparin is started
When should babies be introduced to solid foods? How?
At 6 months Feed them cereals via spoon (DO NOT PUT IN BOTTLE)
When are lipid-lowering medications typically given? Why?
At night; cholesterol metabolism/creation peaks at that time
What activity should you encourage the siblings of a kid with a chronic illness to do?
Be involved in the care
Isoniazid side effects
BIG ONE -> hepatitis Check out for jaundice
What kind of car safety do toddlers have?
Backseat in car seat which is backward-facing
Describe the interaction between antibiotics and warfarin/heparin
Bacteria in the gut naturally produce a lot of our vitamin K Antbiotics wipe them out (less vitamin K) THEREFORE Antibiotics + warfarin = increased risk of bleeding
Describe the appearance of each of the following: --Basal-cell carcinoma --Squamous cell carcinoma --Melanoma
Basal-cell --Waxy, pearl-colored bump Squamous cell --Firm lesion with visible crusting Melanoma --Irregularly shape lesion (may be red/blue colored)
S/S of opioid withdrawal
Basically think the opposite of morphine's effects 1. Rapid HR/breathing 2. N/V/D (as opposed to constipation) 3. High BP Elevated state: 4. Can't sleep 5. Elevated reflexes 6. Sweating 7. Muscle spasms 8. Yawning
Electric larynx
Battery powered device that is held against the side of the neck to speak
Dopamine and other vasopressors are preferentially put through what type of line? Why?
Central lines They have major necrosis effects if they infiltrate an IV line
You notice an IV dressing is loose; what do you do?
Change it out Do NOT tape it or reinforce it Taping it increases risk of infeciton
How does one diagnose UC/Crohn's
Check stool (bloody?) Colonoscopy Imaging (MRI/CT)
Suspicions of child abuse should be reported to the (social worker/child protection agency)
Child protection agency
The nurse delegates care of a client diagnosed with osteoporosis to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? 1."Monitor the urinary output." 2."Clean up clutter in the room." 3."Encourage the client to bathe independently." 4."Perform passive range-of-motion exercises."
Clean up clutter so they don't fall Weight-bearing exercises are most important of theses
Which breath sound indicates pulmonary edema?
Coarse rales
The nurse cares for the client who experienced a thermal injury 2 weeks ago. The nurse is most concerned if which vital sign is observed? 1.Increased heart rate and elevated blood pressure. 2.Temperature of 100.6° F (38.1° C) and decreased respiratory rate. 3.Increased heart rate and decreased respiratory rate. 4.Increased respiratory rate and decreased blood pressure.
D indicates sepsis 4
Lactulose
Laxative --Helps with liver disease because it traps ammonia, preventing encephalopathy
Multiple sclerosis --What is it? --S/S --Treatment --Nursing care goals
Disease state characterized by gradual loss of myelin sheath around nerves r/t autoimmune attack -------------------------------------------------------------- 1. Muscle weakness 2. Tingling in muscles 3. Fatigue Eventually results in: 1. Falling all the time 2. Visual problems in 1 eye 3. Bowel/bladder dysfunction (nervous control is impaired) -> think incontinence or constipation Eventually pneumonia r/t immobility - this usually kills them -------------------------------------------------------------- There is no cure, but drugs can slow it down 1. Cholinesterase inhibitors 2 Steroids/immunosuppressants 3. Anticonvulsants (for neuropathic pain - gabapentin) 4. Physical therapy 5. Plasmapheresis of antibodies attacking myelin sheath -------------------------------------------------------------- Teach how to avoid exacerbations 1. Enough rest 2. Good diet 3. Exercise 4. Avoid extreme temperatures 5. Avoid infections 6. Avoid excessive stress ONCE LATER ON: 1. ROM exercises 2. Assess respiratory function (can they cough?) 3. Give easier to digest foods 4. May have impaired communication -> speech therapist?
In general, if a patient is vomiting, how do their beds change?
Do NOT give oral meds Meds given IV
What skin color should NOT be massaged
Do NOT massage red areas (can cause pressure injury)
Machinery should not be operated for drugs that cause ___
Drowsiness (aka benzos)
Epoetin alfa --What is it? --S/E --Usage tips
Drug which mimics the effects of erythropoetin, promoting production of RBCs -------------------------------------------------------------- 1. Headache 2. Too many RBCs (elevated BP, risk of clotting) -------------------------------------------------------------- This is used to treat CHRONIC anemia, not ACUTE (do transfusions for that) Stop once Hgb is 12 or above to prevent risk of clotting
Review vaccination schedule
Dude pls
Describe what happens during liver cirrhosis
Due to alcohol abuse or other liver disease (i.e. hepatitis), liver becomes scarred and can no longer perform its job
When ordered for home use, when should TED hose be worn?
During the day and when not ambulating Do NOT wear them at night while sleeping
What is the most common complication post-MI that you should be worried about?
Dysrhythmias
The nurse explains the use of transcutaneous electrical nerve stimulation (TENS) to the client diagnosed with sciatica. Which action, if performed by the client, indicates to the nurse that further teaching is necessary? Select all that apply. 1.The client applies a conducting gel before applying the electrodes. 2.The client places the electrodes on the side of the body opposite from the painful area. 3.The client turns up the voltage until they feels a prickly "pins and needles" sensation. 4.The client adjusts the voltage based on the relief of pain she/he experiences. 5.The client turns up the voltage until mild twitching of the extremity begins. 6.The client turns on the unit before applying the electrodes.
First off, what is TENS? Electrical shock through a patient done for those with back pain (due to herniated disk) 1. Apply conducting gel over unbroken skin 2. Place electrodes on gel over painful area 3. Turn on the unit 4. Turn up voltage until pins and needles, then adjust until pain relief occurs 5. Do NOT turn it up so high that the muscle twitches; the pins and needles is the highest dosage
How do you position a patient post-breast removal?
Fowlers with affected arm elevated THINK You need to elevate arm above body to promote drainage of fluid from lymph pathways (which will be clogged) If you put them on their side, can they raise their arm vertically easily? Probably not
Basal skull fracture; what are the signs?
Fracture at the BASE of the skull Causes damage to ears + spinal cord 1. CSF draining from ear 2. Changes in hearing 3. Paralysis and other spinal cord issues
Stress fracture
Fracture of bone r/t overuse
Transverse fracture
Fracture that goes straight across the bone
Dupuytren contracture
Flexion contracture in fingers due to palm fascia overgrowing Common in Scandanavian people
Benzodiazepine reversal agent
Flumazenil
Postpartum diuresis; is it normal?
Following birth (~12 hours), large increases in the amount of urine produced by pregnant women Is a normal finding
Dumping Syndrome --What is it? --Measures to prevent it
Food passes from stomach way too fast --Common after stomach surgery ------------------------------------------- 1. Don't drink fluids close to or with meals 2. Eat sitting down (recumbent position) 3. Lie down after eating 4. Eat small, frequent meals 5. Avoid simple sugars
Aspirin has cross-sensitivity with which other drugs?
For all intents and purposes, all other NSAIDS besides tylenol
In what order is assessment done? What about for abdomen?
For non-abdomen 1. Inspect 2. Palpate 3. Percuss 4. Auscultate For abdomen 1. Inspect 2. Auscultate 3. Percuss 4. Palpate
Retinoblastoma; how do you assess for it, and in who?
Form of eye cancer more common in children Check for "red reflex" (when shining light in eye, it should be pure red, not another color)
In what direction should incisions be cleaned?
From incision to drain area Never drain area first
Dulalutide
GLP-1 agonist (incretin mimetic) (-tide)
A kid with a contact-based disease is playing with a toy; where should the toy go if they go to a procedure?
Keep it in the room; do NOT remove objects (can spread contamination)
The nurse cares for the client after a lumbar laminectomy. Which action by the nurse is most important? 1.Elevate the head of the bed 30° and then turn the client.2.Place a pillow between the client's legs and then turn the client.3.Have the client grasp the side rail on the opposite side of the bed and then assist the client to turn.4.Instruct the client to bend the knees and then assist the client to turn.
Keep spine straight and avoid twisting 1. Does not keep it straight 2. CORRECT, logrolling keeps it straight 3. Twists spine 4. Bends AND twists spine
When touching a drop of blood to a glucose strip, how should it be done? Why?
Like a raindrop (large drop of blood) Smearing will impact results
You notice during labor that a mother's BP swiftly declines, and there is no sign of bleeding; what is the likely cause, and what do oyu do?
Likely caused by pressure on vena cava (decreased blood return) Place on left side
The golden standard for liver cirrhosis diagnosis is __
Liver biopsy
Dark urine is a sign of
Liver dysfunction (it's a symptom of liver cirrhosis)
What is a major concern gout patients losing weight have to worry about?
Look out if they are fasting/eating low-calorie substances instead of meals (i.e. Slimfast and other drinks) Fasting leads to ketone release, which prevents uric acid breakdown Leads to gout exacerbations
The diaper of a circumcision patient is put on ___
Loosely
For infants with heart disorders (i.e. Tetralogy), what special accommodation should be given with feeding?
Make it easier on them Larger opening on nipple bottle Allow time for breaks Remember that eating is tiring, and they may not be able to handle it as easily
How might hte feet of a comatose patient bearranged?
May be placed against baseboard to prevent foot drop
Of the common immunizations, which one is a live virus which should not be given to the immunocompromised?
Measles, mumps, rubella
Prothrombin time
Measurement of how long it takes blood to clot (the larger it is, the longer) Normal is 11-16
Salmon is high in ___
Potassium
Puppets are appropriate for what age range? What about after that?
Preschool For school-aged children, you're better off using visual tools (i.e. drawings)
Playacting a nurse-and-client scenario. is an appropriate activity for what age raneg?
Preschool (age 3-6)
Blanching that persists and does not disappear is a warning sign for ___
Pressure ulcers
What kinds of limb activity do preterm babies vs full term babies have?
Preterm -> flaccid or extended Full term -> flexed
A client has abdominal surgery for colon cancer. The nurse cares for the client just returning to the post-surgical unit. It is best for the nurse to take which action? 1.Determine the stage of loss and grief. 2.Assess the quality and quantity of pain. 3.Instruct the client to cough and deep breathe. 4.Ask the client to lift the head off the pillow.
Priority question You said 3 However, note that they are coming back from surgery; if they are still sedated, will they be able to follow instructions? With that in mind, 4 is the correct answer
A patient is taking prophylactic antibiotics; what foods should be encouraged?
Probiotics to replace normal gut flora 1. Yogurt 2. Acidophilus milk
Bulge test
Procedure to determine presence of fluid behind the kneecap (patella) Have patient lay down supine and flat; displace the patella and see if there is fluid swelling
;The nurse provides care for the client diagnosed with left-sided heart failure. Which data documented by the nurse support the client's current diagnosis? (Select all that apply.) 1.The client leans over the bedside table and pauses often while speaking. 2.The client has pitting edema on bilateral lower extremities. 3.The client's lung sounds are positive for crackles bilaterally. 4.The client grimaces with palpation of the right upper abdominal quadrant. 5.The client's heart rate as 128 beats/min. 6.The client has distended neck veins.
REMEMBER Left = lung S/S Right = peripheral edema S/S 1 -> true (lung) 2 -> false (peripheral edema) 3 -> true (lung) 4 -> false (appendicitis) 5 -> true (generalized sign of heart failure) 6 -> false (peripheral edema)
Why are lotions generally discouraged in diabetic patients?
Retain moisture, which increases risk of infection
What is a major complication of oxygen use in preterm infants?
Retinopathy
2 main drugs given for TB
Rifampin Isonazid
Where is the brachial pulse auscultated?
Right behind the elbow (elbow armpit)
Post-surgically, what side are abdominal patients put on to encourage release of gas?
Right side (remember that stomach/intestines are left-side)
A fetus presents with a right sacrum anterior (RSA) in-utero. Where would you auscultate to hear the fetal heart tones
Right side, at or above level of umbilicus If sacrum presentation (aka breech) -> above level of umbilicus If occiput presentation (aka vertex) -> below level of umbilicus
Define each of the following rights of delegation 1. Right task 2. Right person 3. Right time/circumstances 4. Right information 5. Right supervision/evaluation
Right task -> the task is an appropriate one to delegate (i.e. isn't an admit, doesn't require teaching, etc) Right person -> the person is the correct job for the job to be within their jurisdiction (LPN/CNA, etc) Right time -> client is stable, and your workload justifies delegation Right information -> specific directions on the task to be performed (and what to expect/what to do if things go wrong) are communicated Right follow-up -> appropriate feedback/evaluation performed
Small circular patches on the top of the head indicate ___
Ringworm
When parents store guns/ammunition for child safety, they should do what?
SEPARATE THEM and keep them in locked boxes Do not put in same place
Dapagliflozin
SGLT2 inhibitors (-flozin)
What measure can be done to promote client safety in the household for blind people?
Set water heater to appropriate low temp (prevent burns)
Trigeminal neuralgia
Severe shooting pain r/t inflammation of cranial nerves Treated with pain meds but ALSO tricyclics/antiseizures (carbamazepine) Opioids alone won't help
Neuropathic pain is treated how? What symptoms does it have?
Shooting + burning pain Opioids AND tricyclics/antiseizure mesd
Short vs long-lasting beta agonists
Short -> albuterol Long -> salmeterol, formoterol
Contractions during labor should be how far apart? What does it indicate if htey aren't?
Should be 30 seconds apart If less than that, there is risk for hypoxic injury to the infant; discontinue oxytocin if they're taking it, left side lying, oxygen, fluids...
Who do you get information about cultural beliefs from?
The client, never the family
What is the ventilator mode used for weaning?
Synchronized intermittent mandatory ventilation (SIMV). Will give breaths relative to the breathing rate of the patient, and will give bonus air based on client needs Assist control is NOT the mode; it will always give the same volume of air (though the rate can change
Red light reflex
Test in newborns --Shine light in eyes -> should see red with no abnormalities (i.e. black spots, not visible, etc) POSITIVE RESULT --Normal retina; no issues NEGATIVE RESULT --Probable retinal cancer (retinoblastoma) -> call HCP IMMEDIATELY
Glipizide
Sulfonylurea (glip-)
Glyburide
Sulfonylurea (gly-_
When inserting a subclavian catheter, wht position should the patient be put in?
Supine Keep head low and turn it AWAY from the insertion are This dilates the blood vessels the most, and makes it the easiest to put the catheter in (head/neck isn't in the way)
A patient is undergoing a liver biopsy; what position would be preferred, and why? --How are they positioned afterwards?
Supine with arms up This allows for easiest access to the target spot (just below ribs) Afterwards, position on right side
What position is a pt put in if they have prolapsed cord?
Supine with foot of bed elevated Aka knee chest
You notice that a post-surgical patient is reporting dull pain in their leg --What do you suspect? --What do you do?
Suspect DVT Put them on bedrest until anticoagulants can be started
A patient has a central line and is exhibiting respiratory distress (cyanosis, SOB, pain); what do you suspect, and what do you do?
Suspect air pulmonary embolism Lower the bed and place on RIGHT side If you do high Fowlers, it encourages air emboli to form/travel to lugns
The nurse cares for the client admitted in the first trimester of pregnancy. The client experiences hyperemesis gravidarum. The client presents with decrease in weight, poor skin turgor, and a chloride deficiency. Which action should the nurse implement? Select all that apply. 1.Start an IV. 2.Complete an intake and output record every 4 hours. 3.Provide oral fluids every hour. 4.Perform a weight check every morning. 5.Administer oral antiemetic medications. 6.Place client on bed rest.
THINK -> they are vomiting, so oral meds aren't going to stay down 1 -> good 2 -> good 3 -> is oral, is pointless 4 -> weight change is only a good indicator of fluid retention; it is not reliable for fluid loss 5 -> is oral, is pointless 6 -> is dehydrated and at risk for falls; good idea
(T/F) Abnormal periods (i.e. skipping months) is normal during the first few years of adolescence
TRUE
(T/F) Anti-cancer drugs cause hearing damage
TRUE
You hear a whistling sound from a ventilator patient; what do you suspect?
The cuff isn't inflated enough
When administering a tracheostomy, you should NEVER suction what first? Why?
The mouth Think -> you just contaminated the catheter with mouth goop, which contains bacteria Do you really want to be putting that in their breathing hole?
Which diuretic has a marked impact on glucose levels? How?
Thiazide (HCTZ) Causes hyperglycemia (patient needs to take dietary measures)
A patient is receiving their first dose of a blood pressure med; why is this significant?
The patient is at higher risk for hypotensive complications on first dose (aren't "used to it") You should try and avoid adding other blood pressure meds if possible on top of it during this first dose
Post laryngectomy support of head
The suture line is on the neck; support the neck Put hands behind head and support neck from behind
You are assessing a patient taking fluticasone for their WBCs; what do you find?
Their WBC count is actually normal The immune response itself is impaired, not the cell counts
A patient has a yellow-brown coloration on their tongue; what does this indicate?
They are a smoker
A child constantly has gastroenteritis; what is the most concerning situation that may lead to this?
They are in a day care center where there are a lot of other kids (risk of infection)
When taping a NG tube, how do you do it?
They are not taped immediately (because peristalsis is needed to move it down to intestines) Once it is taped, it is taped to an immovable object
What is a major diagnostic finding of a scoliosis patient?
Thorax appears asymmetrical
What group of minors do not require parental consent?
Those in the military
What is the presentation of scabies?
Thread-like lines below the skin
Vaginal spotting and cramping during pregnancy indicate ___
Threatened abortion Have patient decrease activity
What is the balancing game with the cuff of the ventilator?
Tight enough to prevent aspirations Loose enough that it doesn't cause tracheal erosion/vocal cord damage
What is the purpose of administering meds using the Z-track method? For what type of injection?
To prevent irritation of surrounding fat + skin tissue by locking it in muscle IM
A patient is having spasms with a spasm; what does this indicate?
Too much weight
TRALI; how do you treat it?
Transfusion-associated lung injury Immune reaction in blood transfusion resulting from attacks against WBCs in the donor blood Reduce the occurrence by giving blood with reduced WBC count
Medications shouldn't be given during what stage of labor? Why?
Transition --Will cause depression in respiratory state of baby Hold off until you can pull that sucker out
How do you treat phantom pain?
Treat it as if it's normal pain (pain meds) Ambulation also reduces its severity
(T/F) CNAs can give enemas
True
(T/F) Yellow crusting after circumcision is normal and shouldn't be removed
True
Testicular torsion
Twisting of spermatic cord around blood flow to testes, causing potential loss of testicle S/S -> red swollen testicles and cord
How does the stool of UC vs Crohn's compare?
UC -> usually blood Crohn's -> not bloody, just loose
You notice that the umbilical cord is sticking out of the vagina; what is this called, and what do you do?
Umbilical prolapse 1. Put patient in knee-chest position 2. Wrap umbilical cord in sterile gauze to prevent drying out. Attempt to relieve pressure on cord. DO NOT ATTEMPT TO STICK IT BACK IN 3. Administer oxygen at highest rate possible (nonrebreather mask, not cannula) 4. Call doctor
How is breathing different in young children?
Until school-age, children breathe with ABDOMEN, not thoracic area
A sterile solution should be held with the label facing __
Up (palm the label)
How is a patient positioned during a peritoneal dialysis?
Usually supine with Semi-Fowlers to prevent fluid from pressing down on diaphragm too much
Hegar's sign
Uterine softening Is a PROBABLE (not definitive) indication of pregnancy
Which vaccinations are NOT given at 2 months?
Varicella Measles, mumps and rubella
What is a major side effect of nicotine replacement therapy medications? What does the patient need to look out for?
Vasoconstriction of blood vessels Ask about chest pain
Milrinone; what is it incompatible with?
Vasodilator used for treatment of heart failure Incompatible with Lasix
Spiral fracture
a fracture in which the bone has been twisted apart
Esophageal speech
a method of swallowing air, trapping it in the esophagus, and releasing it to create sound.
Propulsive gait
a stooped, rigid posture, with the head and neck bent forward; movement forward is by small, shuffling steps with involuntary acceleration; also known as festinating gait; common in Parkinson's disease
Psychodrama; what is it best used for?
a therapy in which clients act out personal conflicts and feelings in the presence of others who play supporting roles Best used for children/adolescents
aPTT
activated partial thromboplastin time Norma; 30-40
Which foods are high in magnesium?
green vegetables, nuts, bananas, oranges, peanut butter, and chocolate
Opisthotonic position
hyperextension of the head and neck to relieve discomfort r/t meningitis Is a sign indicating meningitis
After consuming polyethylene glycol, what is the patient allowed to consume?
Water only
A pregnant woman reports shoulder pain and abdominal pain; what do you suspect?
Ectopic pregnancy MEDICAL EMERGENCY -> risk of extreme blood loss
What kind of abortion requires IMMEDIATE evaluation at the clinic; what is its S/S
Ectopic pregnancy Unilateral dull abdominal pain
(T/F) An amputee is not allowed to sit in a straight-back chair
FALSE; they just need to limit the time (1 hour/day or less)
Theophylline; what are major contraindications?
Bronchodilator 1. Rapid HR (the drug increases it) 2. Cardiac dysrhythmias (see tachy) 3. Peptic ulcers (causes N/V) 4. Epilepsy
Aminophylline
Bronchodilator DO NOT TAKE WITH BETA BLOCKERS --Beta blockers will cause it to build up to toxic levels
Ipratropium bromide
Bronchodilator (anticholinergic)
Aminophylline
Bronchodilator - Decreases SOB *CANT MIX WITH ANYTHING*
What is given first, the bronchodilator or the steroid?
Bronchodilator first, then steroid
(T/F) When a patient with TB leaves the room, they wear a N95 mask
FALSE; they won't have time to have it properly fitted When leaving the room, they just wear a surgical mask People entering their room still wear N95 though
(T/F) You deflate the cuff of a trach tube whenever you do suctioning
FALSE; this increases risk of secretions going down
(T/F) People entering neutropenic precaution rooms have to wear masks
FALSE; wash hands (wear mask if they have infection)
(T/F) You should massage tumors
FALSE; will cause them to spread
(T/F) Powders should be used to protect patient skin and prevent woudns
FALSE; will dry and require pressure to remove, which will damage the skin
(T/F) You can catch shingles from someone else
FALSE; you can only catch chickenpox, not shingles (shingles is a dormant response)
The nurse applies the prescribed medication to an adult client diagnosed with scabies. Which body area should the nurse avoid when applying the scabicide?
Face/scalp Causes irritation to the face Should be applied from neck down
What is the MOST important consideration following a C-section?
Risk for fluid impairment Postpartum hemorrhage kills QUICKLY and READILY Infections are important too, but remember they show up later
The nurse observes a client sign a surgical consent form. The nurse signs the form as a witness. What does the nurse's signature on the surgical consent form indicate? 1.The client signed the form and the nurse witnessed it being done.2.The client signed the form without pressure or coercion.3.The client was awake, alert, and not taking narcotic medication.4.The client was fully informed and aware of all consequences
1
A 39-year-old man is admitted with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS). His lab results are hemoglobin 9.3 g/dL, hematocrit 25%, platelets 50,000/mm3, white cell count 1,500/mm3. Which order will the nurse implement FIRST? 1."Infuse 2 units of packed red cells." 2."High-protein, high-carbohydrate diet as tolerated." 3."Administer 2 units platelets." 4."Place the client on neutropenic precautions."
#4 (you said #1) Which can be done the fastest to have the greatest degree of safety?
A client with an 8-year history of ulcerative colitis is admitted to the hospital with severe abdominal cramping and diarrhea. The client has experienced 18 to 20 stools a day for the last 4 days. The nurse is most concerned by which finding? 1.The client's diastolic blood pressure decreases 20 mm when the client rises to a standing position. 2.The client's urinary specific gravity is 1.020. 3.The client has lost 3 pounds since her last admission. 4.The client appears pale and thin.
#1 (ABCs)
The home care nurse visits the client who had a traditional cholecystectomy 10 days ago. The client returned to the healthcare provider to have the T-tube removed 2 days ago. It is most important for the nurse to take which action? 1.Observe the color of the client's urine and stool. 2.Ask the client to describe the quality and quantity of pain she is experiencing. 3.Instruct the client to avoid fatty foods for 6 weeks. 4.Listen to bowel sounds.
#1 (you said 4) Bowel sounds are nonspecific, and aren't like measuring ABCs; no immediate risk of death #1 is specific to condition; expect clay-colored stool and dark urine which indicates the bile is draining properly
A nurse from the surgical floor is reassigned to the pediatric unit. Which assignment is most appropriate for this nurse? 1.A 5-month-old infant after a cast application on the left extremity due to club foot. 2.A 4-year-old boy with right abdominal swelling and a decreased appetite. 3.A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C). 4.A 10-year-old girl with newly diagnosed type 1 diabetes.
*Which patient is the most stable, and requires the least specialized care?* 1 -> CORRECT, most stable 2 -> WRONG (you chose this one), probably bowel obstruction which will require intensive efforts 3 -> WRONG, cystic fibrosis is specialized, and they are unstable 4 -> WRONG, requires teaching
The nurse provides care for a postoperative client. The nurse notes the client is restless. The client grabs at the incisional area. The nurse notes the client's blood pressure to be 146/96 mm Hg. Which action should the nurse take next? 1. Ask the client to rate the pain level. 2.Assess the incisional site. 3.Reposition the client. 4.Apply ice to the incisional site.
1
The nurse reviews the care needs for a group of postpartum clients. Which client does the nurse identify as being the most at risk for developing a hemorrhage? 1.Client with a distended bladder. 2.Client with an episiotomy.3.Client with engorged breasts.4.Client requesting assistance with fundal massage.
1 (bladder distention is a risk factor; the others aren't)
Fluoroquinolones --Nomenclature --Effect --Side effects
--floxacin -------------------------------------------------------------- Antibiotics
Glucagon-like peptide 1 agonists --Nomenclature --Effect --Adverse effects
--tide ----------------------------------------------- Mimic incretin intestinal hormones which manipulate blood sugar levels ----------------------------------------------- 1. N/V/D 2. Pancreatitis
Tetracyclines --Nomenclature; example? --Side effects --Usage details
-cycline (Doxycycline) 1. Staining of teeth 2. Photosensitivity 3. Risk of secondary infection r/t knocking out gut flora 4. Dysphagia/nausea 5. Inflammation of tongue 1. Do not take with meals 2. Iron, milk, antacids and other alkalines should be avoided with this (take them 3 hours apart) 3. Photosensitivty precautions 4. Look out for signs of infection 5. It prevents effects of contraceptives
The nurse teaches a client about prescribed vaginal suppositories for use at home. Which client statement indicates a need for further instructions? 1."I should insert the suppository about a half inch into my vagina." 2."I should plan to lie on my back with my hips elevated for 5 to 10 minutes after inserting the suppository." 3."I should wear a perineal pad if I have some of the melted medication come out." 4."If I reuse an applicator, I should wash it with soap and water before I use it again."
1 1/2 an inch, and it'll fall out 2 inches at least
A 24-year-old woman at 30 weeks' gestation is seen in the outpatient clinic for a routine visit. The nurse is MOST concerned if the client makes which statement? 1."During the day I seem to get hot flashes and chills." 2."I am having some trouble with constipation and hemorrhoids." 3."At the end of the day I have leg cramps." 4."When I put my hand on my abdomen, I can feel it tense and relax."
1 2 -> is normal (think; baby is pressing on GI tract) 3 -> is normal 4 -> is normal
The nurse delegates a task to an LPN/LVN. Which action will the nurse make that indicates delegation was appropriate? 1.The nurse follows up with the LPN/LVN to make sure the task was completed. 2.The nurse has the LPN/LVN to ask another LPN/ LVN for help if needed. 3.The nurse gives a brief explanation of the task the LPN/LVN is to do. 4.The nurse has the LPN/LVN complete a task the LPN/LVN has completed once.
1 3 is inaccurate, but the explanation is vague...I'll say it's because if you have to explicitly explain the task, they shouldn't be doing it?
The client comes to the local outpatient clinic reporting dizziness and palpitations. The physical exam and laboratory results are normal. The client reports the family-owned company is on the verge of bankruptcy. Which response, if made by the nurse to the client, is BEST? 1."When did you first notice these symptoms?" 2."Have you shared this information with anyone?" 3."Are you concerned about your financial difficulties?" 4."Would you like to discuss your situation with me?
1 Notice that all other options are yes/no questions
The nurse cares for a client with type 1 diabetes. The client receives nasal oxygen at 4 L/min. The student nurse reports that the client has pulled out the nasogastric tube and is picking at the bed covers. The client's BP is 150/90 and pulse is 90. Which of the following actions by the nurse is MOST appropriate? 1.Obtain a pulse oximetry reading. 2.Apply soft wrist restraints. 3.Reorient the client to person and place. 4.Determine the client's blood glucose level.
1 Notice that none of the data tells about oxygenation status The patient is exhibiting confused behavior (often caused by hypoxia)
Which technique is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain? 1.Remove the dressing layers one at a time. 2.Clean the wound with povidone solution and hydrogen peroxide. 3.Clean the drain area first. 4.If the dressing adheres to the wound, pull gently and firmly.
1 Risk of dislodging the catheter if you do multiple at a time (or do #4) #3 is tempting, but remember -> clean from incision to drain area, otherwise you're recontaminating
Malpractice requires which elements?
1. Breach of duty 2. Causation (the breach of duty caused the harm) 3. Harm AKA they HAVE to have suffered a negative consequence for malpractice to occur
The client on continuous mechanical ventilation desires to go home. In order to determine the client's ability for home care, the nurse should take which action? 1.Assess the ability of others in the home to be trained to provide appropriate care for the client. 2.Confer with the client's health care provider, and discuss the feasibility of the client's request. 3.Assess the number of people in the home and the adequacy of space to care for the client. 4.Examine the client's reasons for wanting to go home, and discuss the implications of home care.
1 (said 1) 1 is assessment; do you need to know it before you contact the HCP? YES; it's completely pointless to talk about sending them home if they don't have a plan when they get there
A staff member informs the nurse that the staff member's 6-year-old child has head lice. It is MOST important for the nurse to take which action? 1.Inspect the staff member's head for louse and nits. 2.Inform the staff member that he cannot care for clients until further notice. 3.Request that the staff member contact his health care provider. 4.Instruct the staff member about how to use Kwell.
1 (said 2) Notice that it says a family member has it. It doesn't necessarily mean they have it
The nurse enters the room of a client and finds that the tracheostomy tube inserted two days ago has been accidentally dislodged. The nurse should take which action? 1.Immediately replace the tracheostomy tube. 2.Suction the client's airway using sterile technique. 3.Provide oxygen at 8 L/minute per mask over the stoma. 4.Check for bilateral breath sounds immediately.
1 (said 3)
The nurse prepares to assign the client requiring a capillary blood glucose test to a newly hired nursing assistive personnel. Which action should the nurse take first? 1."Show me how you check a capillary glucose level." 2."How many of these glucose checks have you done in the past?" 3."Would you like for me to go with you when you do the glucose test?" 4."Was this procedure covered during your nursing class?"
1 (you said 2)
The nurse provides care to a client diagnosed with hydronephrosis secondary to renal calculi. After surgical removal of the calculi, post-obstructive diuresis occurs. Initial client assessment and monitoring include which nursing action? 1.Monitor daily serum electrolytes. 2.Assess urine output each shift. 3.Measure vital signs every hour. 4.Obtain weekly weight measurements.
1 (you said 2) 2 is important, but 1 can be life-threatening (risk of hypokalemia leading to cardiac issues)
A client is in the emergency department to rule out a cerebral vascular accident (CVA). The client suddenly develops a severe headache and loses consciousness. Which finding is a priority for the nurse to report to the health care provider? 1.A history of atrial fibrillation. 2.The client takes warfarin every day. 3.The blood glucose level is 200 mg/dL (11.1 mmol/L). 4.Lung sounds are diminished bilaterally at bases.
1 (you said 2) Fibrillation causes 2 risk factors (decreased cardiac output AND risk of emboli) Warfarin only causes increased risk of bleed
The nurse admits a young adult client suspected of having acute glomerulonephritis to the unit. Which question does the nurse ask first? 1."Have you had a sore throat within the last few weeks? " 2."Have you noticed a significant weight gain? " 3."Have you had a decreased appetite within the last few weeks? " 4."Have you noticed an increase in fatigue over the last few weeks? "
1 (you said 2) Glomerulonephritis may or may not be caused by an infectious agent; answer #1 narrows that down #2 is important, but is generally an expected symptom, so not as important
The husband of a woman at 39 weeks gestation calls the clinic nurse and states, "My wife's water just broke, and I think she's going to have the baby!" Which statement, if made by the nurse, is BEST? 1."Look at your wife's vaginal area and tell me what you see." 2."Time the contractions for 5 minutes." 3."Tell your wife to pant between contractions." 4."I will instruct you about how to deliver the baby."
1 (you said 2) Need to determine stage of labor Remember that not all women are the same; contractions may not be consistent, plus you have to wait a full 5 minutes before you do anything to help #1 is quick and easy (can you see the baby coming out? Cool, they're in stage 2)
Which action does the nurse take to utilize milieu therapy when providing care to clients in a psychiatric inpatient setting? 1.Provide a consistent set of activities and responsibilities for each client. 2.Ask the family to bring in items from home in order to recreate the home environment. 3.Use therapeutic communication with other staff members to foster community. 4.Set consistent limits on client behaviors.
1 (you said 2) Note that the home environment could be the thing causing the stress
The nurse works with a group of developmentally disabled adults. The nurse instructs the group members to ignore one client whenever that client interrupts others who are speaking. To evaluate the progress of this intervention, the nurse takes which action? 1.Counts the number of times the client stops interrupting. 2.Counts the number of times the client interrupts. 3.Counts the number of times the group ignores the client's interruptions. 4.Counts the number of tokens and earned privileges given for interruptions.
1 (you said 2) Remember - the focus is to reward POSITIVE behavior before punishing negative behavior 1 allows you to reward positive behavior 2 is used to promote punishment
The 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which action by the nurse is best? 1.Observe the child at mealtime. 2.Inquire about the child's eating patterns. 3.Weigh the baby each month. 4.Attempt to feed the baby for the mother.
1 (you said 2) Seeing it for yourself is more reliable
A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take FIRST? 1.Check the patency of the catheter. 2.Assess residual urine volume using bladder ultrasonography. 3.Assess the amount of drainage in the urinary drainage bag. 4.Decrease the tension on the catheter.
1 (you said 3)
The nurse answers the call light of a client reporting a severe headache 30 minutes after undergoing a lumbar puncture. Which action does the nurse take first? 1.Assess the puncture site. 2.Administer an analgesic as prescribed. 3.Assess the client's blood pressure. 4.Encourage the client to lie flat.
1 (you said 3) 3 is more generalized; when in doubt, choose the more focused assessment
The nurse provides care for a client who had a hypophysectomy. The nurse observes clear drainage coming from the client's nostril. Which action does the nurse take immediately? 1.Test the drainage for glucose. 2.Document the drainage. 3.Lower the head of the bed. 4.Obtain a culture of the drainage.
1 (you said 3) Clear fluid from the nose; is it necessarily CSF? (could be boogers) 1 -> CSF contains glucose, so this would definitively mark it as such 2 -> do nothing answer 3 -> increases ICP 4 -> not immediate
The client diagnosed with a severe thought disturbance has not been taking their medication and appears to be hallucinating more actively. The client reports that the medicine makes them drowsy during the day. Which action by the nurse is best? 1.Ask the health care provider to schedule the client's entire dose at bedtime. 2.Tell the client that they are getting sicker and must take the medicine. 3.Teach the client about the side effects of the medication. 4.Ask the family to talk to the client about this problem.
1 (you said 3) THINK -> patient is noncompliant and drowsy at a bad time How do you fix this? 1. Make it easier to take med (fewer times a day) 2. Make the drowsiness occur at a convenient time That's #1
A client contaminated with an unidentified hazardous material arrives by ambulance at a local hospital. Which action should the nurse take FIRST? 1.Determine the decontamination that occurred in the field. 2.Reassure the client that he will receive excellent care. 3.Identify the type of hazardous material. 4.Remove all the client's clothing.
1 (you said 3) Think of this as a precautions question -> PREVENT THE SPREAD OF CONTAMINATION IS #1 Determining spread of contamination should be done first so you know how isolated they need to be #3 is done later, usually by people other than nurses
The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which finding is the most important nursing implication regarding this anesthesia? 1.Adequately hydrate the client. 2.NPO client for at least 12 hours. 3.Assess the client for any allergies to iodine preparations. 4.Determine the specific gravity of the urine.
1 (you said 3) This isn't a dye, so 3 is wrong Remember -> spinal anesthesia (epidural and otherwise) both have the side effect of HYPOtension, so give fluids to combat that
An elderly client diagnosed with Alzheimer's disease frequently wanders down the halls of the extended care facility and displays restless agitation. The health care provider orders a vest restraint. When the nurse takes the restraint to the room, the client refuses to put it on. It is MOST important for the nurse to take which action? 1.Take the restraint away, and check the client frequently. 2.Notify the health care provider immediately that the client refused the restraint. 3.Ask a coworker to hold the client and gently apply the restraint. 4.Exchange the vest restraint for wrist restraints.
1 (you said 3) Yes, you have an order, but you should ALWAYS try alternative measures, even if an order is in. Nothing in the question states you've tried alternatives
The nurse cares for clients in the pediatric clinic. Which client should the nurse see first? 1.An 8-month-old infant who had 6 watery stools in the past 8 hours. 2.A 13-month-old infant who received the MMR immunization 8 days ago and has a temperature of 101° F (38.3° C). 3.A 2-year-old child who has swelling, pain, and tenderness of the upper arm after falling off a chair. 4.An 8-year-old discharged from the hospital 2 days ago for asthma.
1 (you said 4) Risk of dehydration for #1, which trumps mild immunization reaction (2) and arm injury (3); it'll kill them faster #4 is tempting (airway), but it was 2 days ago, so it's been resolved
The nurse teaches the client with a spinal cord injury how to perform self-catheterization at home. Which statement, if made by the client, indicates that teaching has been successful? 1."I will keep the catheter in a plastic bag." 2."I will catheterize myself every 2 hours." 3."I will wear sterile gloves." 4."I will wash the perineum with alcohol prior to catheterizing myself."
1 (you said 4) 1 -> good 2 -> FALSE, too often (do every 6-8 hours) 3 -> FALSE, use clean gloves 4 -> FALSE, alcohol will dry out area, use soap + water
A nursing team consists of an RN, an LPN/LVN, and a nursing assistive personnel. The nurse should assign which client to the LPN/LVN? 1.A 72-year-old client with diabetes requiring a dressing change for a stasis ulcer. 2.A 55-year-old client with terminal cancer being transferred to hospice home care. 3.A 42-year-old client with cancer of the bone reporting pain. 4.A 23-year-old client with a fracture of the right leg asking to use the urinal.
1 (you said 4) 1 -> stable patient with expected outcome; procedure is not uniform though 2 -> requires assessment/education 3- > require assessemnt 4 -> urinal assistance is so simple, a CNA can do it
The client diagnosed with AIDS is admitted to the medical unit reporting fatigue, a persistent dry cough, and dyspnea on exertion. Vital signs include BP 136/88, temperature 104°F (40°C), pulse 95, respirations 22. Which action by the nurse is best? 1.Administer a tepid sponge bath with the client in semi-Fowler's position. 2.Limit oral intake to a maximum of 2,000 ml of fluid per day. 3.Encourage the client to perform passive ROM four times a day. 4.Suction the client every four hours to maintain a patent airway.
1 (you said 4) 1 helps with the fever 4 is wrong because SUCTIONING IS ALWAYS PRN
The client is admitted to the hospital reporting diarrhea and vomiting for 3 days. The blood pressure is 90/60, apical heart rate 96, and respiratory rate 22 with shallow respirations. Laboratory results include Na+ 147 mEq/L, K+ 5.6 mEq/L, hematocrit 52%, hemoglobin 14 g/dL. The client is receiving 5% dextrose in 0.45% normal saline with K+ 20 mEq at 125 mL/hr. Prior to calling the healthcare provider, it is most important for the nurse to take which action? 1.Change IV fluids to 5% dextrose in 0.45% normal saline. 2.Increase IV flow rate to 150 mL/hour. 3.Check the hourly urine output. 4.Observe the client for muscle weakness.
1 (you said 4) 4 is a do nothing answer 1 is somewhat confliected, since you aren't allowed to change medication orders, but whatever
The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? 1."I have been sleeping 6 hours at night." 2."I have lost 2 lbs in the past week." 3."Lately, I have trouble watching television." 4."I have much less muscle tension now."
1 (you said 4) 6 hours is close-ish to normal sleep patterns 4 is wrong because muscle tension isn't a sign of depression, it's a sign of anxiety
The nurse cares for the client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate? 1.Inform the health care provider that the client is menstruating. 2.Send the urine collected prior to the onset of the client's menstruation to the lab. 3.Insert an indwelling bladder catheter during the remainder of the collection period. 4.Request a separate urine collection container from the laboratory to be used during the remainder of the urine collection period.
1 (you said 4) Obviously menstruation impacts the quality of the urine specimen 2 -> didn't occur for full 24 hours 3 -> invasive 4 -> tempting, but it doesn't say anywhere that you would inform the doctor of the change, and it would invalidate the test to some extent
The college student has a positive Mantoux test. The health center clinic nurse takes which action? 1.Refers the student to an appropriate center for further testing. 2.Restricts the student's activity until the parents can be notified. 3.Notifies the local Public Health Department. 4.Places the student in an isolation room in the college infirmary.
1 (you said 4) Remember - the test alone does NOT confirm TB (sputum cultures do) You need further testing, and are not allowed to isolate them until you do Plus there are false-positives
The nurse cares for the client diagnosed with venous thromboembolism (VTE) of the left leg. Which nursing goal is appropriate for the client? 1.Decrease inflammatory response in the affected extremity and prevent embolus formation. 2.Increase peripheral circulation and oxygenation of the affected extremity. 3.Prepare the client and family for anticipated vascular surgery on the affected extremity. 4.Prevent hypoxia associated with the development of a pulmonary embolus.
1 (you said 4) What is the most concerning outcome of VTE -> pulmonary emboli/stroke 4 is good for TREATING pulmonary emboli However, 1 is good for PREVENTING pulmonary emboli, which is a better outcome
The nurse observes a nursing assistive personnel (NAP) transfer a client with right-sided paralysis using a hydraulic lift. For which action will the nurse intervene? 1.Lowers the bed before the transfer is initiated. 2.Positions a canvas sling under the center of the body. 3.Folds client's arms over the chest. 4.Pumps the hydraulic handle using long, slow strokes.
1 (you said 4) Why would you lower the bed while you're trying to lift them? You'll destroy your back
The nurse cares for the client after a vaginal delivery. Which action should be implemented FIRST? 1.Check the client's lochial flow. 2.Palpate the client's fundus. 3.Monitor the client's pain. 4.Assess the client's level of consciousness.
1 (you said 4) Yes, Ik blood loss can cause LOC, but go to the source, not a resulting event
The clinic nurse obtains a throat culture from the client diagnosed with pharyngitis. It is MOST important for the nurse to take which action? 1.Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx. 2.Obtain a sputum container for the client to use. 3.Irrigate with warm saline, and then swab the pharynx. 4.Hyperextend the client's head and neck for the procedure.
1 (you said 4) You were confused because you didn't know if tonsils are part of swab; it is The neck should be upright; hyperextending makes it harder
The nurse stabilizes the client with severe multiple trauma injuries from a motor vehicle accident. Which action does the nurse take next? 1.Limits visiting hours to promote optimal rest. 2.Arranges for clergy to visit with the client and family as requested. 3.Arranges for a psychologist to visit with the family. 4.Arranges for the family to meet with a social worker to discuss financial aid.
1 -> WRONG, in general visiting hours should not be limited (unless infectious agent - think neutropenic OR radiation) 2 -> TRUE; addresses immediate concerns, and the family specifically requested it 3 -> WRONG -> is weaker than 3, since the family didn't specifically address it. Also, this isn't a mental health issue (a psychologist would therefore be more of a long-term trauma solution, not immediate) 4 -> WRONG; money isn't a priority immediately
The nurse instructs parents on ways to decrease the incidence of sudden infant death syndrome (SIDS). Which statements require the nurse to intervene? (Select all that apply.) 1."I position my baby on the back for sleep. " 2."My baby takes naps in the car seat. " 3."My baby sleeps covered with one blanket from chest to feet. " 4."My baby sleeps with one pillow under the head. " 5."My baby sleeps best on the sofa. "
1 -> good 2-5 are bad 2 -> should avoid sleeping in seat (can obstruct airway r/t slumping) 3 -> blanket is suffocation hazard 4 -> pillow is suffocation hazard 5 -> shouldn't sleep on soft surfaces
The nurse cares for the client after delivery of a 7 lb 10 oz baby boy. The client has decided to bottle-feed her infant. The nurse should encourage the client to take which action? Select all that apply. 1.Use acetaminophen po as directed. 2.Apply cool packs around the outside of each breast. 3.Massage the breasts. 4.Wear a well-supportive bra 24 hours a day. 5.Use the manual breast pump to relieve pressure. 6.Be patient, the milk will resolve in 5-7 days.
1 -> good, just avoid aspirin/ibuprofen/naproxen 2 -> cold is good, warm is bad 3 -> WRONG, massing causes irritation 4 -> true 5 -> FALSE, will cause the breast to continue for longer 6 -> true
The nurse performs a nutrition assessment on an adolescent female client. Which dietary recommendation does the nurse give to the client and parents? 1.High calcium. 2.Low iron. 3.High protein. 4.Low sodium.
1 -> high calcium In adolescents, bones are growing, so you need that You said (3) protein, but they only need adequate protein, not increased amounts
The nurse assigns rooms to clients admitted to the unit. The nurse wants to place clients as far away from the nurses' station as possible to promote rest and relaxation. Which client would be most appropriate for the nurse to place away from the nurses' station? 1. 84-year-old client diagnosed with Parkinson disease. 2. 73-year-old client diagnosed with congestive heart failure. 3. 58-year-old client who had a total abdominal hysterectomy. 4. 68-year-old client diagnosed with a cerebellar tumor.
1 and 4 are fall risks 2 is heart failure, and requires fluid balance checks regularly 3 is not a fall risk, and is more stable than 2
True labor is indicates if contractions occur for ___
1 hour or longer Also if pain is in lower back, rather than in abdomen/groin
When administering antipsychotic medications parenterally, which action should the nurse take FIRST? 1.Monitor the client's blood pressure while the client is sitting and standing before and after each dose is given. 2.Caution the client not to drink or operate machinery that requires mental alertness for safety until effect of medication is known. 3.Have an emergency cart available in case of an adverse reaction. 4.Reassure the client that side effects are only temporary.
1 is correct -> ortho hypo is a side effect 2 -> is sign of benzodiazepines, not antipsychotics 3 -> is a bit too late; shouldn't be done first
The charge nurse reviews care for the client with internal radiation. The charge nurse intervenes if which actions are noted? Select all that apply. 1.Visitors are limited to 5 hours per day with the client. 2.A male caregiver is assigned to all care. 3.Time in the room is limited for all care providers. 4.Lead-lined apron is worn for all care delivery. 5.Verbal exchanges with the client are made from the doorway. 6.Frequent rest periods are incorporated into client's care.
1, 2, 4 1 -> should be fewer (3 hours) 2- > the nurse (not caregivers) should be providing care 4 -> lead aprons are only needed if in the room for a prolonged period, not for short routine procedures (i.e. vital signs)
The nurse notes that a client diagnosed with Parkinson disease moves slowly, has difficulty dressing, and experiences bowel and urinary incontinence. Which intervention is appropriate for this client? (Select all that apply.) 1.Provide an elevated toilet seat. 2.Make modified clothing without buttons available. 3.Transfer to a skilled nursing facility. 4.Arrange for gait training. 5.Lower the dose of Parkinson medications.
1, 2, 4 YOu said 3 before, but there's no indicate that he can't perform ADL
The nurse teaches the client being discharged on risperidone. Which client statements indicate the teaching has been successful? Select all that apply. 1."I may gain weight when taking this medication." 2."I should avoid extreme temperatures." 3."I can take over-the-counter sedatives if I have trouble sleeping." 4."I can drink alcohol as long as I drink in moderation." 5."I will wear long sleeves when I am out in the sun." 6."I will change positions slowly."
1, 2, 5, 6 1 -> weight gain expected 2 -> thing neuroleptic malignant 3, 4 -> don't take alcohol or OTC without asking doctor 5 -> photosensitivty is expected 6 -> ortho hypo is expected
The health care provider prescribes a unit of packed red blood cells for a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.) 1.Ensure adequate infusion access is present before obtaining the blood from the blood bank. 2.Initiate the transfusion within 1 hour of removing the blood from the blood bank refrigerator. 3.Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood. 4.Monitor the client closely during the first 15 to 30 minutes of administration. 5.Ensure the administration time does not exceed 6 hours.
1, 3, 4 1 -> should always put an IV in first so blood doesn't expire if there are complications 2 -> should start within 30 minutes 3 -> 2 person verification is good 4 -> monitoring is good 5 -> should be given within 3-4 hours, not 6
The nurse provides care to a client who is believed to have developed tuberculosis. The nurse implements which steps when collecting the client's sputum specimen? (Select all that apply.) 1.Use a suction catheter to obtain the specimen if needed. 2.Ask the client to spit into the sputum container. 3.Offer oral care before collecting the sputum specimen. 4.Send the specimen to the laboratory immediately. 5.Collect the specimen in the evening or before bedtime.
1, 3, 4 2 -> WRONG, will be more saliva than sputum from the lungs; encourage coughing 3 -> confusing, but if you don't do oral care, the mouth microbes that grow may contaminate the sample 5 -> WRONG, should be taken in morning
The nurse provides care to a client with an internal radiation implant. Which intervention will the nurse include in the plan of care? (Select all that apply.) 1.Donning gloves when emptying the client's bedpan. 2.Placing the client in a semiprivate room at the end of the hallway. 3.Wearing a lead apron when providing direct care to the client. 4.Keeping all linens in the room until the implant is removed .5.Restricting all visitors, including family members.
1, 3, 4 2 -> a PRIVATE room is needed, not a semiprivate one 5 -> visitors are allowed to come in, but their time is limited
The nurse observes the unlicensed assistive personnel (UAP) providing care for a client diagnosed with disseminated herpes zoster (shingles). Which UAP action requires the nurse to intervene ? (Select all that apply.) 1.Ambulating the client to the nurses station. 2.Donning gloves, a gown, and N-95 mask prior to entering the client's room. 3.Refusing to enter the client's room due to a personal positive titer. 4.Performing hand hygiene upon entering the client's room. 5.Using the unit equipment to monitor the client's vital signs.
1, 3, 4, 5 1 -> need to stay in room (airborne) 3 -> if UAP is positive for chickenpox, they are immune, so no issues 4 -> handwashing done BEFORE entering room 5 -> isolation rooms have their own equipment to prevent contamination
The nurse teaches a class on suicide prevention to high school students. Which risk factor is accurate with regard to suicide in adolescent clients? (Select all that apply.) 1.Possessions that are given to friends. 2.A low grade point average. 3.Statements like, "I may not be around anymore." 4.Access to a gun at home. 5.Frequent thoughts of suicide.
1, 3, 4, 5 2 (surprisingly) is not correlated - think of coping mechanisms
Benzodiazepine side effects
1. Lowered cardio (low HR, low BP) 2. Lowered respiratory (lowered rate) 3. Ataxia (can't move) 4. Dizziness/blurred vision
An older client has an order for digoxin 0.25 mg PO daily. Which information would cause the nurse to withhold the medication and contact the health care provider? Select all that apply. 1.Apical pulse of 55 bpm. 2.Respirations of 16 per min. 3.Plasma digoxin level of 2.1 ng/mL(2.7 nmol/L) .4.Blood pressure of 122/62. 5.Apical rhythm has 20 skipped beats in 1 minute. 6.Temperature 100.5° F.
1, 3, 5 Yes, Ik it's strange that an anti-dysrhythmia medication causes dysrhythmias. What are you gonna do about it?
The nurse provides care to a client receiving thrombolytic therapy for a blood clot in the lower extremity. Which assessment findings indicate that treatment is effective? (Select all that apply.) 1.Dorsal pedal pulses +1 bilaterally. 2.Client reports numbness and tingling present in the foot. 3.Affected foot slightly pink. 4.Capillary refill 4 seconds. 5.Client reports feeling pinpricks on the great toe.
1, 3, 5 1 -> +1 indicates blood flow (+3 would be ideal, but whatever) 2 -> bad, numbness = poor blood flow 3 -> pink = good blood flow 4 -> should be less than 3 sec 5 -> is tempting, but pinpricks indicate there is sensation, which is good
A client has a cataract removed from the left eye. Which actions are important for the nurse to take in the immediate postoperative period? Select all that apply. 1.Position the client on the right side with the head slightly elevated. 2.Place the client on the left side to protect the eye. 3.Perform sensory neurological checks every two hours. 4.Maintain complete bedrest for the first 48 hours. 5.Assess client's level of consciousness. 6.Assess client knowledge of home care.
1, 3, 5 1 -> keep pressure off the eye by turning head on OTHER side 2 -> wrong, puts pressure on eye 3- > this is eye surgery, not neuro surgery. Not needed 4 -> FALSE; they still have 1 good eye, so they can still get around 5 -> TRUE; they just got off anesthesia, so check this 6 -> FALSE: notice that it says IMMEDIATE post-op period. Home care is more long-term (they're on anesthesia rn)
What diseases require contact precautions?
1. MRSA 2. C dif. 3. VRE 4. Rotavirus 5. Chickenpox/shingles (require both airborne and contact) 6. Hepatitis A (if handling poop)
The nurse prepares the client for ambulatory surgery. Which procedural information is important for the nurse to provide? (Select all that apply.) 1.The methods of pain control that will be used. 2.The odors and sensations that may be experienced. 3.Explanations of common monitoring equipment. 4.Any fluid and food restrictions that will be required. 5.Technique and practice of deep breathing and coughing.
1, 4, 5 2 is subjective -> people vary with their sensations, so it may be different 3 is extraneous information that doesn't need to be said unless they specifically ask
The nurse notes that a client has 3+ pitting edema of both feet and ankles. Which additional assessment does the nurse make before contacting the health care provider (HCP)? (Select all that apply.) 1.Pulse. 2.Weight. 3.Lung sounds. 4.Temperature. 5.Blood pressure.
1,2,3, 5 Note that all of these factors EXCEPT FOR temperature would be affected by fluid overload
When doing peritoneal dialysis, the fluid coming back isn't enough. What do you do in order? What do you NOT do?
1. Check for kinks 2. Have patient roll side to side Do NOT milk the catheter
Nursing care tasks for fractures
1. Check neurovascular status of extremity 2. Make sure weights are hanging off of ground 3. Make sure patient is properly aligned If skin traction, check skin integrity
Which diseases require BOTh contact and airborne precautions?
1. Chickenpox/shingles 2. Smallpox
List the steps done to suction a tracheostomy/laryngectomy tube
1. Choose correct equipment size 2. Hyperoxygenate the patient/have patient take a couple of deep breaths 3. Insert the catheter 4. Occlude the Y tube to apply suction 5. Pull out in twirling motion while applying intermittent suction 6. Suction the oropharyng (mouth - do it last to prevent contamination) 7. Have patient take some more deep breaths
S/E of iron supplements; how should it be taken?
1. Constipation 2. Nausea 3. Black stools 4. Staining of teeth/skin Take on an empty stomach with orange juice Do NOT take near bedtime (can be corrosive, so you want to monitor for that)
Side effects specific to tetracycline
1. Photosensitivity 2. Can decalcify bones, especially in children 3. Teeth staining
S/S of opioid overdose
1. Pinpoint pupils 2. Unconscious 3. Slow breathing
Carbamazepine usage
1. Prevent seizures 2. Neuropathic pain relief (In the case of neuropathic diseases like trigeminal neuralgia)
How to treat aspirin overdose
1. Promtoe vomiting/lavage 2. Give IV fluids and monitor electrolytes 3. Reduce temperature (at risk of hyperthermia) 4. Give vitamin K BUT ONLY IF BLEEDING PRESENT
Nursing care for radiation
1. Put in private room with warning sign 2. Wear dosimeter badge 3. Pregnant nurses do NOT provide care 4. Limit exposure to 30 minutes per shift 5. Limit visitors 6.
You notice there is redness and tenderness at an IV site and along the vein. What do you do? Who do you contact?
1. Remove IV 2. Apply WARM soaks 3. Elevate the limb to reduce swelling 4. If another IV is needed, put it proximal to the other one ONly contact the doctor if symptoms are severe or persist for long periods; otherwise a doctor isn't needed
List the steps taken to perform a moist-to-dry dressing change
1. Remove dressing 2. Clean and dry the skin around the wound AWAY from the wound to prevent contamination 3. Moisten gauze with solution 4. Apply gauze as a single layer 5. Cover with dressings
List the order these are done in for the surgical hand scrub 1. Remove jewelry 2. Turn on sink 3. Clean under nails with disposable pick
1. Remove jewelry 2. Turn on water 3. Clean under nails
Describe the electrolyte effects of loop and HCTZ diuretics
1. Sodium is lost 2. Water is lost 3. Potassium is lost LESSER KNOWN 4. Calcium is lost 5. Hydrogen ions is lost (leads to metabolic alkalosis)
Which foods are high in oxalate? Who should avoid these?
1. Spinach 2. Rhubarb 3. Black tea People with renal calculi (oxalate crystal build-up)
Drugs given for UC and Crohn's
1. Steroids (reduce inflammation) 2. Immunomodulators/immunosuppressats (-mab) 3. Antibiotics 4. Anti-diarrhea meds
Alendronate administration; what is it used for?
1. Take before meals and meds 2. Take with water (6-8 oz) 3. Stay upright afterwards Is a medication used for osteoperosis
Patients with low iron should be given what kind of foods?
1. High in iron (meats) 2. High in vitamin C (promotes absorption of iron)
What kind of diet does Crohn's/UC get?
1. High protein 2. High calorie 3. LOW FAT 4. Low fiber Also avoid irritating foods (i.e. spicy foods)
A chest tube falls out; how do you cover the opening?
Cover with tape dressing ON 3/4 SIDES (closing all 4 leads to tension pneumo)
Describe the steps of collecting a clean-catch urine specimen in a woman
1. Hold open labia lips 2. Clean area 3. Have patient urinate a small amount to clear out "stale" urine (which isn't indicative of the bladder) 4. Have patient urinate into specimen container 5. Removes specimen container and put into transfer package 6. Have patient clear out rest of bladder 5 and 6 are more technicalities; you just want to avoid overfilling the container
List the steps of tracheostomy care
1. Hyperoxygenate patient 2. Suction the trach tube for no longer than 10 seconds while withdrawing in whirling motion 3. Remove the old dressing 4. Open sterile kit. Apply sterile gloves 5. Remove inner cannula (clean or dispose) 6. Clean stoma site AWAY from insertion area 7. Change ties (keep old ones on until new ones are on) 8. Apply new dressing
What are common S/E of all anitbiotics
1. Diarrhea 2. Gi upset 3. N/V 4. Risk of C dif. 5. Leukopenia/thrombocytopenia 6. CNS effects (especially if kidney damage) Try to avoid giving them in the evening because of GI upset, and give with food (again for GI upset)
S/S of lithium toxicity
1. Diarrhea 2. Vomiting 3. Drowsiness/slurred speech 4. Lack of coordination (ataxia) 5. Muscle weakness
Which bacterial diseases require droplet
1. Diptheria 2. Pertussis (whooping cough) 3. Pneumonia 4. Streptococcus
What are 3 common types of meds held before surgery?
1. Diuretics (risk of shock) 2. Anticoags (risk of bleed) 3. Metformin/insulin medications (drug interactions)
Prior to an EEG brain scan, what should the patient do?
1. Do not use hair products or wash hair (makes it harder to stick on gels/electrodes) 2. Patient is not NPO (low glucose affects brain activity) 3. Avoid stimulants (caffeine, etc)
What are the 2 most common causes of hypercalcemia?
1. Hyperparathyroidism 2. Cancer
The parent of a toddler asks the pediatric clinic nurse, "Do you have any suggestions for what I can say to get my child to go to bed without a fuss?" Which suggestion by the nurse is best? 1.Ask your child, "Do you want to go to sleep now?" 2.Say to your toddler, "After we read this story, it will be time for sleep." 3.Say to your toddler, "It is time to go to sleep." 4.Ask your child, "Would you like to take your bear or elephant to bed with you?"
1. Encourage a consistent bedtime and bedtime ritual 2. Try to make bedtime an enjoyable experience 3. Do not give the toddler a choice 4. Try to have a "transition time" (i.e. doing another activity before bed routinely, like reading story) 1 -> gives a choice, bad 2 -> makes it fun, established a ritual, good 3 -> does not establish ritual 4 -> does not establish ritual/consistent bedtime
List all of the medications done for an anaphylactic reaction
1. Epinephrine 2. Benadryl 3. Albuterol 4. Steroid
What drugs are given to a baby at birth?
1. Erythromycin eye drops (to prevent eye infections 2. Vitamin K 3. Hepatitis B vaccine Vitamin K and hepatitis are given within 24 hours of birth
Side effects of antipsychotics (4)
1. Extrapyramidal symptoms 2. Neuroleptic malignant syndrome 3. Orthostatic hypotension 4. Photosensitivity
Major S/S of myasthenia gravis
1. Eye problems (ptosis, double vision) 2. Difficulty eating 3. Respiratory distress 4. Some muscle weakness FOCUSES OF CARE 1. (!) Prevent choking/airway issues 2. Eye care 3. Regular rest 4. Immunosuppressants (to avoid autoimmune destruction)
Long-acting insulins (3)
1. Glargine 2. Determir 3. Degludec
What order do you take PPE off?
1. Gloves 2. Goggles 3. Gown 4. Mask
What order do you put PPE on?
1. Gown 2. Mask 3. Goggles 4. Gloves
What are common indications that labor is starting?
1. Gush of water between legs (amniotic fluid) 2. Blood out of vagina 3. Back ache Note that fetal movement is NOT a sign - if anything, the fetus moves LESS
Alcohol withdrawal symptoms
1. Hallucinations 2. Tremors 3. Seizures 3. Anxiety 4. Inability to sleep 5. Anorexia
What do you tell patient to do/avoid doing after being moderately sedated?
1. Have someone help them out/stay with them for 24 hours 2. Avoid exercise, driving, important decisions for 24 hours 3. Be careful when standing up (hypotension) 4. Do not take medicines that cause drowsiness or alcohol 5. Drink fluids to encourage meds to leave body 6. Eat small meals to avoid N/V
Meningitis --S/S --Diagnostic signs --Infant symptoms --Treatment
1. Headache 2. Fever 3. Photosenstivity 4. Changes in consciousness 5. Seizures 6. Rigid neck 7. Petechial rash ------------------------------------------- KERNIG'S SIGN -> when you flex the hip 90 degrees, extending the knee is painful Brudzinski's -> flexign the neck will cause knee and thigh to flex too Opisthotonic position -> patient with hyperextend head and neck to relieve neck soreness ------------------------------------------- 1. Won't feed, N/V 2. Bulging fontanelles (elevated ICP) 3. High-pitched cry ------------------------------------------- 1. DROPLET PRECAUTIONS 2. IV antibiotics 3. Vaccination to prevent it 4. Reduce stimuli to prevent seizures 5. Fluid restrictions
Which things should be avoided when using a transdermal pouch?
1. Heat (causes rapid release) 2. Microwaves (can heat up the patch via leaked radiation)
Nurse care for liver disease
1. High calorie, high carb food with MODERATE (not high) protein + vitamin supplements 2. Check skin (is weakened) 3. Restrict fluids (risk of breathing issues) 4. STOP alcohol
Treatment of pancreatitis
1. IV fluids 2. NPO (do not want to excite GI tract, which promotes pancreatic activity/irritation) 3. Pain meds (again, to prevent GI motility) 4. Bedrest (to prevent GI motility) 5. Regular labs
What complications can occur while a fracture is healing?
1. Improper re-union or bone (fracture won't reunite, is delayed, is in abnormal place) 2. Regional pain syndrome -> extreme pain and autonomic issues (sweating and alternates between being very hot and cold skin) 3. Thromboembolisms
In what order do you assess the abdomen?
1. Inspect 2. Auscultate 3. Percuss 4. Palpate
A patient is recovering from an ocular procedure. What should you assess/encourage the patient not to do?
1. Is the client constipated? (pushing down increases eye pressure) 2. Is the client nauseous (N/V increases eye pressure)
S/E of drug regimen for TB
1. LIVER DAMAGE 2. OPTIC NERVE DAMAGE 3. PERIPHERAL NERVE DAMAGE (paresthesias) 4. GI distress
List drugs that cause ototoxicity
1. Lasix 2. Aminoglycosides (-micin) 3. Vancomycin 4. Chemotherapy meds
What are the 3 stages of the first stage of labor?
1. Latent 2. Active 3. Transition
Care after renal biopsy
1. Lie on affected site (apply pressure) 2. Have pressure dressing 3. Bedrest 4. Monitor for bleeding, altered VS Once they go home: 1. Avoid heavy lifting 2. No anticoagulants
Tuberculosis drugs (isonazid, rifampin, etc) --Side effects --Care tasks (2)
1. Liver toxicity 2. Peripheral neuropathy (numbness, paresthesias0 3. GI upset Avoid in patients with liver disease Give vitamin B to treat peripheral neuropathy
Which drugs cause ototoxicity?
1. Loop diuretics (Lasix) 2. Aminoglycosides (-ycin or -icin) 3. NSAIDs
The nurse notes that a client's T-tube has drained 425 mL of dark green thick fluid. Which action does the nurse take next? 1.Clamp the tube for the next 8 hours. 2.Document the amount on the output sheet. 3.Notify the health care provider immediately. 4.Irrigate the tube with 30 mL of normal saline.
2
The nurse prepares discharge instructions for a client with active tuberculosis who has been on a medication regimen for 14 days. Which statement by the client does the nurse recognize as the need for additional education? 1."My family members will have to take one of the medicines for a long time too." 2."I am so glad that I only have to take that one combination pill now." 3."I will not return to work until after I see my health care provider in 10 to 14 days." 4."I will continue to cough into a tissue, throw it away immediately, and wash my hands."
2 1 -> the family members take a prophylactic med 2 -> the patient is taking 4 different meds
The client is newly diagnosed with type 1 diabetes. The nurse instructs the client to take which action if symptoms of hypoglycemia occur? 1.Eat a candy bar then check the blood glucose. 2.Drink 1/2 cup fruit juice followed by peanut butter crackers. 3.Inject 10 units of regular insulin. 4.Inject glucagon followed by a protein snack.
2 1 is tempting, but it won't stabilize their BP long-term
A family with visible colds comes in. What do you do FIRST? 1.Inform family members to stay home if coughing. 2.Instruct those who are coughing to sit at least 3 feet way from others. 3.Post an alert at the entrance to the facility. 4.Provide tissues to the family members.
2 2 is part of droplet precautions (you would also give masks if you could)
The nurse admits several clients during the day shift. Which room assignment is most appropriate for the nurse to make? 1.Assign the client who is returning from an appendectomy to a room with a client who had an incision and drainage of a leg wound earlier today. 2.Assign the client who is returning from a total knee replacement to a room with a client diagnosed with pancreatitis. 3.Assign the client diagnosed with streptococcal pneumonia to a room with a client diagnosed with staphylococcal pneumonia. 4.Assign the client diagnosed with gastritis to a room with a client who is neutropenic.
2 1 -> you are putting a post-surgical patient with an open incision with a patient who (likely) has an infection with the drainage 3 -> don't put people with different infectious agents together 4 -> don't put immunocompromised person with infected person
The nurse prepares the client for a paracentesis. It is most important for the nurse to take which action? 1.Keep the client NPO 12 hours before the procedure. 2.Ask the client to void just before the procedure. 3.Initiate a bowel preparation program 24 hours before the procedure. 4.Place the client supine during the procedure.
2 1 -> NPO not necessary 2 -> prevents rupture of bladder (smaller target) 3 -> no bowel prep needed 4 -> HOB is elevated to promote drainage of fluid
The nurse prepares a client diagnosed with diabetes mellitus for a cardiac catheterization. Which lab result would cause the nurse to notify the health care provider (HCP)? 1.White blood cell (WBC) of 10,000/mm3 (10 × 109/L). 2.Creatinine clearance of 41 mL/min. 3.Fingerstick glucose of 222 mg/dL (12.32 mmol/L). 4.Glycated hemoglobin A1c of 7% (0.07 proportion of total hemoglobin).
2 1 -> WBC is normal (less than 11,000) 3 is expected, and doesn't prevent test 4 is expected Remember that cardiac catheterization uses contrast dye. If the kidneys don't work, where will it go?
The client diagnosed with lung cancer undergoes a pneumonectomy. In the immediate postoperative period, which assessment is MOST important? 1.Presence of breath sounds bilaterally. 2.Position of the trachea in the sternal notch. 3.Amount and consistency of sputum. 4.Increase in the pulse pressure.
2 1 -> bilateral lung sounds after a lung removal? 😏 2 -> deviation indicates pneumothorax, which is life-threatening 3 -> not as life threatening as 3
At 07:00, the nurse administers 10 mg glipizide to a 75-year-old client. At 11:00, the nurse notes that the client is drowsy, pale, and has cold, clammy skin. Which is the initial action the nurse will take? 1.Administer 1 mg glucagon subcutaneously. 2.Give the client 1 cup of fruit juice to drink. 3.Determine if the client ate breakfast. 4.Notify the healthcare provider.
2 (you said 1) Note that "drowsy" is not incapacitated enough to not be able to take in fluids
The nurse plans care for a neonate diagnosed with Tetralogy of Fallot. Which action does the nurse implement when providing care to this client? 1.Offer the newborn water every four hours. 2.Select a nipple with a larger hole for formula feeds. 3.Position the newborn on the stomach after bottle feeding. 4.Gradually increase the time between bottle feedings.
2 1 -> should be giving formula, not water. If giving water too, may overload baby circulatory system, which weakened heart can't handle 2- > GOOD, easier to feed, which means weaker heart can handle energetic needs required to feed 3 -> risk of aspiration 4 -> should be giving frequent feedings, not decreasing them. They also may not be eating as much as they should due to hypoxia
Normal magnesium levels
1.5-2.5
Albuterol adverse effects which may warrant taking them off
1.Changes in BP 2. Metabolic acidosis 3. Angina
What are the 4 requirements for malpractice?
1/2. Duty and breach of said duty 3. Causation (breach of duty is cause of injury) 4. Injury
At what age are meats introduced to infants?
10-12 months
A client with a serum potassium level of 2.4 mEq/L (2.4 mmol/L) is to receive 40 mEq of potassium chloride (KCl) intravenously. The available supply is 10 mEq KCl in 100 mL sodium chloride in each premixed bag. After hanging the first bag, the nurse sets the pump to infuse at how many milliliters per hour? (Do not round. Record your answer using a whole number.)
100 mL/hr over 4 hours Since you only have 100 mL bags, it can't go faster than that
When does lead poisoning screening in kids begin?
12 months
At what age can the fetal heart rate be present?
12 weeks
Normal newborn chest circumference
12-13
Normal newborn HR
120-140
What is the defibrillation energy level for a BIPHASIC model during a code?
120-200
Normal newborn head circumference
13-14
The nurse cares for the client admitted 4 days ago for treatment of alcohol dependence. The client has slurred speech, ataxia, and uncoordinated movements, and reports a headache. Which action does the nurse take first? 1.Observe the client for 8 hours to collect additional data. 2.Perform a complete physical assessment. 3.Collect a urine specimen for a drug screen. 4.Encourage the client to talk about whatever is causing distress.
2 3 is tempting, but could other things be causing this? Would having full assessment information be beneficial?
The nurse provides care for a client diagnosed with a duodenal ulcer. The client asks how a stomach infection can cause a duodenal ulcer. Which response by the nurse is best? 1."Bacteria in the duodenum deteriorate the area, causing an ulceration." 2."The bacteria enters the lining of the intestines and changes the protective layer." 3."There is no explanation for how this occurs in a vast majority of people." 4."Medication for the stomach infection causes the duodenal lining to break down."
2 Duodenal ulcers are caused by movement of H. pylori from the stomach to the duodenum
The nurse cares for the client admitted to the unit three days ago with deep partial thickness and full thickness burns over 30% of the body. It is most important for the nurse to report which observation to the next shift? 1.CVP reading of 12 cm water pressure. 2.General muscle weakness and lethargy. 3.Heart rate of 100 beats per minute. 4.Systolic blood pressure of 105.
2 Indicates hypokalemia; remember they have massive fluid loss, so they lose potassium
Four days after a client has an abdominal perineal resection, which sign is most important for the nurse to report to the health care provider? 1.Moderate amount of serosanguineous drainage on the abdominal dressing. 2.Nausea, vomiting, and increased abdominal distention. 3.Moderate amount of yellow-green nasogastric drainage and decreased urine output. 4.Urinary output via Foley catheter 120 ml over a 4-hour period.
2 These indicate that the bowels haven't started peristalsis again yet Risk of paralytic ileus Everything else is normal
During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection? 1.Wash the burn with an antiseptic soap and water. 2.Remove clothing, and wrap the victim in a clean sheet. 3.Leave the blisters intact and apply an ointment. 4.Take no action until the victim arrives in a burn unit.
2 Think back to class -> they cut off the clothing
The nurse administers sublingual nitroglycerin to the client reporting chest pain. Which observation is MOST important for the nurse to report to the next shift? 1.The client indicates the need to use the bathroom. 2.Blood pressure has decreased from 140/80 to 90/60. 3.Respiratory rate has increased from 16 to 24. 4.The client indicates that the chest pain has subsided.
2 What is a major adverse effect of nitro? Lowering BP too much You said 4, but that's an expected outcome, so no reporting is necessary
The nurse coordinates community placement for the client diagnosed with schizophrenia and alcoholism who is homeless. The nurse should take which action? 1.Collaborate with members of the client's family to explore placement options. 2.Collaborate with the health care team and the client to schedule a predischarge visit to a residential placement facility. 3.Visit the placement facility alone to make an independent decision about the facility, and report to the client and family. 4.Review with the client specific rules of the facility.
2 You said 1 -> the client themselves should be involved in the decision
A client's IV alarm sounds. A nurse states, "I'll get it! That alarm has been beeping all shift. Maybe it's broken." During client rounds, the charge nurse finds the IV pump alarm button covered with a heavy layer of tape. Which immediate action by the charge nurse is appropriate? 1.Report evidence of "alarm fatigue" among staff to the unit manager. 2.Replace the pump, label the current pump, and send it for repairs. 3.Fill out an incident report, citing the behavior that endangered a client. 4.Approach the nurse and discuss how to handle broken equipment.
2 You said 3, but that doesn't fix the issue
The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1.A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2.A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. 3.A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4.A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL.
2 You said 4 before Please note -> disorientation can indicate low oxygen (airway trumps glucose)
An adult client is admitted to an acute locked psychiatric unit one month prior to an election. The client requests the opportunity to vote in the upcoming election. Which response by the nurse is best? 1."You are not eligible to vote because you are a psychiatric client." 2."I'll make the appropriate arrangements for you to vote." 3."You may vote only if you are discharged by Election Day." 4."I'll contact the Election Board to see if you are registered to vote."
2 You said 4; that's beyond the nurse's workload They can vote via absentee ballot
A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is most appropriate? 1.Get Doppler studies to check the pulse. 2.Notify the healthcare provider. 3.Determine if the cast is dry. 4.Check the client's vital signs.
2 (you said 1) This is enough information to warrant a call, regardless of whether they don't have pulses Remember that pulselessness is a LATE sign
The home care nurse teaches the adult child of an older adult client about the parent's hydration status. Which statement from the adult child most concerns the nurse? 1."I should check my parent's mouth for dryness." 2."I should pinch a fold of skin on the back of my parent's hand." 3."I should check my parent's eyes for dryness." 4."I should make sure that my parent stands up slowly."
2 (you said 3) 1 -> dry mucous membranes 2 -> poor skin turgor; HOWEVER, remember that elderly skin naturally loses turgor over time (think wrinkles) 3 -> sunken eyes 4 -> prevent ortho hypo
When preparing discharge plans for a client being treated for syphilis, it is MOST important for the community health nurse to include which information? 1.Have sexual activity with one partner. 2.The practice of safe sex. 3.Information about health clinic. 4.Signs of a secondary infection.
2 (you said 4) Will prevent further spread of disease; they're being treated, and secondary infections will be much later down the line, so not immediate priority
Haloperidol 5 mg IM every 4 hours PRN is prescribed for the client. Which observation requires an IMMEDIATE intervention by the nurse? 1.Client reports dizziness; heart rate 58 beats per minute. 2.Client has tongue protrusion and muscle rigidity. 3.Client has a facial rash and periorbital edema. 4.Client reports sensitivity to light and blurred vision.
2 (EPS, obviously) You said 1; I don't really get it either, but it's only a mild brady I suppose
The nurse cares for a 24-year-old female client admitted to an outpatient treatment unit with a diagnosis of purging-type bulimia. It is most important for the nurse to take which action? 1.Encourage the client to verbalize feelings about eating disorders. 2.Sit with the client in silence as she discusses her daily life and eating habits. 3.Ask the family to describe the client's eating habits prior to admission. 4.Ask the client about any emotional distress she may be experiencing.
2 (more open ended and specific to client; talking about eating disorders in general is too broad)
The nurse enters the room and discovers that the client has slurred speech, right-sided paralysis, and unequal pupils. Which action should the nurse take first ? 1.Call the health care provider. 2.Assess the respiratory status. 3.Determine the level of consciousness. 4.Perform a complete neurological evaluation.
2 (respiratory trumps all)
A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic nurse that she was exposed to rubella 2 days ago. Which statement, if made by the nurse, is most appropriate? 1."You need to see the health care provider today, but come in after hours." 2."Come in this afternoon for your regularly scheduled appointment." 3."You will receive the rubella vaccine during your regularly scheduled appointment." 4."Please cancel today's appointment and reschedule for next month."
2 (you said 1) 1 sounds tempting, because of airborne precautions, but it's only been 2 days The incubation period takes a while
The clinic nurse assesses a client who presents with a documented history of a gastric ulcer. Current symptoms include nausea, vomiting, and diarrhea of 2 days' duration. Which client statement requires immediate intervention by the nurse? 1."I take aspirin for headaches and arthritis pain, and antacids for this ulcer of mine." 2."I have been drinking more fluids to keep from getting dehydrated, but I am urinating less than I thought I would." 3."On my last visit to the health care provider, I was told I may be developing cataracts." 4."I knew I was under a lot of stress at work, but I thought I was coping well."
2 (you said 1) 3 is a long-term issue 4 is psychosocial 1 is important (risk of additional bleeding), but notice I said RISK; they haven't necessarily started on the path to shock yet 2 indicates oliguria, which is an early sign of shock, ACTUAL problem (not just a risk)
The nurse provides teaching to a pregnant client about varicose vein prevention. Which client statement indicates that the client needs further teaching? 1."I cross my ankles." 2."I wear tight socks." 3."I elevate my legs." 4."I change positions hourly."
2 (you said 1) Avoid crossing legs at THIGHS (puts pressure on veins located in large portion of legs); ankles are fine 2 is wrong because tight socks apply a lot of pressure, which can cause damage to veins/promote blood retention
The nurse is caring for an elderly client receiving parenteral nutrition (PN) due to malnutrition. Which observation, if made by the nurse, indicates that the client is improving? 1.The client gains 8 lbs in one week. 2.The client's edema decreases. 3.The client's hemoglobin increases. 4.The client's output is greater than the intake.
2 (you said 1) Malnutrition leads to ascites r/t poor albumin; decrease in edema is a good thing #1 and #3 both indicate fluid retention, not improved nutritional status #1 is way too fast of a gain in weight
The industrial nurse supervises the health care needs at a local plant. It is announced on the news that a device has exploded in a heavily populated area away from the plant and that individuals near the site have become ill. Several hours later, workers at the plant come to the nurse and demand antibiotics to protect them against potential effects of the device. Which is the best response by the nurse? 1."I cannot administer medication without a prescription. " 2."Tell me about how you are feeling. " 3."The cause of the illness has not been identified. " 4."Do you have any allergies to medications? "
2 (you said 3) Notice that the device isn't necessarily a bomb; it can be a biohazard weapon By assessing, you can help determine what kind of impact it had; 3 is just turning them away
The health care provider prescribes acetaminophen 650 mg PO for a client with an allergy to codeine. The nurse administers acetaminophen with codeine PO. The nurse then notifies the health care provider and administers diphenhydramine 50 mg IM as prescribed. After informing the client of the error, which action is most important for the nurse to take? 1.Apologize to the client for administering the wrong medication. 2.Ask the client to remain in bed for 3-4 hours. 3.Explain to the client the symptoms of a reaction to codeine. 4.Clarify why the nurse administered the diphenhydramine.
2 (you said 3) Safety trumps education At high risk for falls + bleeds (benadryl + aspirin) Need to stay in bed
The nurse provides care for an adult client prescribed regular insulin before breakfast. The nurse notes the client is nauseated with a blood glucose level of 74 mg/dL (4.1 mmol/L). Which action does the nurse take? 1.Immediately gives the client orange juice to drink. 2.Administers the insulin on time. 3.Withholds the insulin, and notifies the health care provider. 4.Returns the breakfast tray to the kitchen.
2 (you said 3) Sick day insulin treatment Stress/illness causes hyperglycemia, you CANNOT hold the insulin, even if the patient cannot eat Instead, promote foods that are easy to eat (i.e. soft foods, liquids)
Prior to helping a client out of bed on the first day after an anterior cervical fusion, the nurse should take which action? 1.Remove the client's cervical collar. 2.Raise the head of the bed. 3.Position the client supine at the edge of the bed. 4.Ask the client to fold both arms across his chest.
2 (you said 3) Think about it; it's hard to rise straight up from supine on your own, especially with a cervical collar and after being in bed for a while Raising HOB makes it easier to get htem up 3 is bad because of risk of falling out of bed
The nurse enters the client's room and discovers the client is having difficulty breathing because the tracheostomy tube has become dislodged. Which is the INITIAL action the nurse should take? 1.Perform mouth-to-stoma breathing. 2.Extend the client's neck. 3.Place the client in high-Fowler's position. 4.Administer oxygen.
2 (you said 3) Think of this as the chin back movement used during CPR (opens up airway) Putting in high Fowlers won't do shit if their airway is obstructed
The client is diagnosed with metastatic cancer with a poor prognosis. Recently, the client reports increased pain, is less communicative, very irritable, and anorexic. Which nursing goal should be a priority at this time? 1.Encourage client to talk about the possibility of dying. 2.Provide pain assessment and effective pain management. 3.Manage nutrition and hydration. 4.Verify that the health care provider has discussed the prognosis with the family.
2 (you said 3) Yeah, I don't really get it either. Controlling the pain promotes adherence to diet plans?
The nurse answers the phone on the psychiatric unit. The caller identifies himself as the spouse of a client and inquires about the client's condition. Which response by the nurse is MOST appropriate? 1."I cannot deny or confirm any client's presence in this hospital." 2."Clients are not allowed access to this phone. Please call the number you were given." 3."I cannot give information over the phone. If you come in, we can discuss her condition." 4."I will have to ask her if she wishes for me to give out that information."
2 (you said 4)
The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action? 1.Leave the television on all day in the client's room. 2.Frequently inform the client of the room and bathroom location. 3.Provide the client with newspapers and magazines. 4.Assign a staff member to check on the client every 15 minutes.
2 (you said 4) 4 is unrealistic, and doesn't promote independent activity 2 provides for orientation, safety and stimulation
After the nurse assesses the assigned clients, which activity does the nurse delegate to the unlicensed assistive personnel (UAP)? 1.Complete tracheostomy care. 2.Provide oral suctioning using a Yankauer suction tube. 3.Change the appliance of a new colostomy. 4.Obtain a wound culture from a leg ulceration.
2 (you said 4) Do you want them messing with a new colostomy? The other 2 are sterile procedures Suctioning orally is non-sterile
The nurse cares for the client in the cardiac care unit who had cardiopulmonary arrest 2 hours ago and was successfully resuscitated by emergency personnel. As the nurse enters the room, the client develops ventricular fibrillation and is unresponsive to loud spoken voice. Which is the INITIAL action the nurse should take? 1.Ventilate the client with a manual resuscitator bag. 2.Defibrillate the client. 3.Administer sodium bicarbonate intravenously. 4.Begin chest compressions.
2 (you said 4) Notice that it never says that they have no pulse/breathing It only says unresponsive and abnormal heart rhythm
When caring for a client postpartum, the nurse provides education regarding proper perineal care. Which client statement indicates that additional teaching is needed? 1."I will wash my hands before and after I use the bathroom." 2."I will change my peri-pads when soiled." 3."I will remember to wipe my bottom from front to back." 4."I will soak my bottom in warm or cold water, whichever feels best."
2 (you said 4) Peri-pad being soiled means it is saturated with blood/fluids Do you want to wait until then? Leaving a semi-soiled peri-pad on can cause infections Change out the peripad every time they go to the bathroom
A woman delivers a 6-lb and 2-oz infant. The Apgar scores at 1 and 5 minutes are 8 and 9, respectively. Which action is MOST appropriate for the nurse to take? 1.Perform nasopharyngeal suctioning. 2.Document the Apgar score. 3.Administer O2 per mask. 4.Rub the infant's back.
2 (you said 4) Remember that rubbing the back is used for a LOW APGAR SCORE (promotes stimulation of baby activity), and not a normal procedure in this case
The nurse cares for the client reporting moderate pain. Which nursing action is MOST important to provide the client with effective pain relief? 1.Teach the client about the pain. 2.Establish a trusting relationship with the client. 3.Determine how various relaxation techniques affect the pain. 4.Provide alternative measures to relieve pain.
2 -> you need rapport for them to talk to you You said 3 -> notice that it says "determine", not "ask them". This means this is an evaluation.
The client develops right-sided heart failure. The nurse expects to observe which symptoms? 1.Increased respiration with exertion. 2.Peripheral edema and anorexia. 3.Polycythemia 4.Cough producing large amount of thick, yellow mucus. 5.Twitching of extremities. 6.Distended neck veins.
2 3, 6 Polycythemia because you are trying to compensate (more RBC to carry oxygen) You said #1 before; that is a normal finding
Proper fitting/usage of crutches
2 fingers fit between armpit and crutch top (prevents nerve damage) Arms should not be straight (flexed 20-30)
Lithium toxicity
2 or greater, tremors, metallic taste, severe diarrhea, number one intervention, give fluids, if sweating give electrolytes too
What is a favorable response to a nonstress test?
2 or more FHR accelerations which last 15 seconds and increase by 15 bpm in response to activity
The nurse provides care to a client with the following assessment data: nonproductive cough, fever, lung crackles, headache, and myalgia. Which nursing concerns are appropriate? (Select all that apply.) 1.Acute discomfort. 2.Potential for aspiration. 3.Inefficient gas exchange. 4.Ineffective breathing pattern. 5.Potential for infection.
2, 3, 4 (not 5, you said 5) 5 is wrong because there isn't a potential for infection, they already have one
The nurse prepares a client for a Holter monitor study. Which instructions will the nurse include when teaching the client about this study? (Select all that apply.) 1.Bathing and showering with the device on is permissible. 2.Trigger the event marker when pain or other symptoms occur. 3.Use a regular toothbrush instead of an electric toothbrush. 4.Keep a diary of activities, focusing on symptom occurrence. 5.Immediately report fast heart rate or difficulty breathing.
2, 3, 4, 5
The nurse instructs the client with newly diagnosed type 1 diabetes about proper foot care. Which statement, if made by the client to the nurse, indicates that further teaching is necessary? Select all that apply. 1."I should cut my toenails straight across." 2."I love to go barefoot." 3."I should inspect my feet once a week." 4."I should bathe my feet daily in warm water." 5."I can keep using my heating pad on my feet." 6."I am going to buy some warm socks."
2, 3, 5 1 -> cutting nails is good to avoid ingrown, but cut straight across (or may cut themselves) 3 -> should be DAILY 4 + 6 say WARM, so they won't burn
The nurse instructs a client recovering from a right above-the-knee amputation (AKA). Which information does the nurse include in the client's teaching plan? (Select all that apply.) 1.A prosthesis will be fitted in about 3 months. 2.Phantom limb pain is common after extremity amputation. 3.Maintain the prone position several times daily. 4.No exercise or ambulation is allowed for several weeks. 5.Anti-seizure medications may help with phantom limb pain.
2, 3, 5 1 -> wrong, fitted immediately 4 -> wrong, ambulation is started ASAP Antiseizure meds (i.e. carbamazepine) is used for neuropathic pain, like in phantom limb
The RN talks to the parents of a 6-month-old. They discuss ways to minimize the adverse effects of a DTaP immunization. Which actions are important for the RN to discuss? Select all that apply. 1.Give the child an alcohol bath for an elevated temperature. 2.Administer acetaminophen for discomfort. 3.Place a cool cloth on the injection site for 15 minutes. 4.Check the child's temperature every four hours for three days. 5.Wrap and comfort the child for signs of irritability. 6.Administer a salicylate medication for a fever.
2, 3, 5 Aspirin (and other salicylates) should NOT be given to pregnant women or children You initially said 4; notice that the question asks what things MINIMIZE SIDE EFFECTS Does an assessment do that, or just give you more info?
The nurse observes the student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which student nurse actions require an intervention by the nurse? Select all that apply. 1.The student nurse checks the pH of the contents aspirated from the NG tube. 2.The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube. 3.The student nurse uses a large-barreled syringe to aspirate for stomach contents. 4.The student nurse flushes the NG tube with 30 mL of air before aspirating fluid. 5.The student nurse places the end of the NG tube in a cup of water and watches for bubble formation.
2, 5 1 -> fine; standard procedure (should be 1-4) 2 -> UPPER abdomen is a bad idea; you may hear lungs (check lower) 3 -> large barrel is acceptable 4 -> good; makes it easier to aspirate fluid 5 -> BAD; not standard procedure
The nurse conducts preoperative teaching with the family of a client scheduled for a total laryngectomy. Which statement, if made by the family, indicates to the nurse a need for further teaching? Select all that apply. 1."We will need to learn other ways to communicate with each other." 2."My husband will require a feeding tube for several months." 3."My father will require a special kind of tube in his neck for his airway." 4."Dad may develop some difficulty with taste and smell after the surgery." 5."Dad is looking forward to learning how to laugh using tracheoesophageal puncture." 6."We will encourage Dad to cough and deep breathe after surgery."
2, 5 1 -> not able to talk initially; will need writing (later on will need esophageal speech or other methods) 2 -> WRONG, only need special foods for ~10 days, not months 3 -> true, tube put in to prevent neck muscle contractures 4 -> true 5 -> WRONG, laughing, singing, whistling aren't possible 6 -> true
The nurse performs teaching for the client being discharged on dexamethasone 0.75 mg PO daily. The nurse determines teaching is successful if the client makes which statement? Select all that apply. 1."I will take my medication with orange juice in the morning." 2."I will take my medication with breakfast." 3."I will take my medication three hours after eating." 4."I will take my medication before I eat breakfast." 5."I will avoiding any alcohol while taking this medication." 6."I will call the clinic if I experience muscle weakness."
2, 5, 6 PO is taken with food Alcohol should be avoided Muscle weakness can indicate adrenal insufficiency (Addison crisis)
The nurse cares for the client 4 hours after admission to the hospital for treatment of an anterior wall myocardial infarction. The client suddenly reports difficulty breathing and appears very anxious. Which action should the nurse take first? 1.Evaluate the client's cardiac rhythm. 2.Check for cyanosis of the hands and the toes. 3.Auscultate the client's posterior lung fields. 4.Listen to the apical heart rate.
3 4 is tempting, but remember ABCs
A preschool-age client experiences a sudden cardiac arrest. Which action will the nurse take when performing cardiopulmonary resuscitation (CPR)? 1.Deliver 12 breaths per minute. 2.Compress the sternum with both hands at a depth of 2 inches (4 to 5 cm). 3.Use the heel of one hand for sternal compressions. 4.Use two fingers for sternal compressions.
3 Give 20 bpm Use only 1 hand Using 2 fingers is for a baby
The nurse notices the elderly client has a dry, parched mouth and tongue. The nurse takes which action? 1.Brushes the client's teeth with a hard-bristled toothbrush before meals and at bedtime. 2.Uses glycerin swabs to give mouth care every 24 hours. 3.Rinses the client's mouth with room-temperature tap water before and after meals. 4.Uses a water pick, then rinses with commercial mouthwash every 8 hours to freshen the mouth.
3 Hard-bristled toothbrush is always the wrong answer (risk of gum damage0 2 is not often enough Mouthwash (aka alcohol) dries the mouth
The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider? 1.Cyanosis of the tongue. 2.Jaundiced skin. 3.Slurred speech. 4.Slow capillary refill.
3 Indicates stroke; everything else is normal
A client is scheduled for a cardiac catheterization at 0800. The client's laboratory work was completed five days ago, and the results include K+ 3.0 mEq/L (3.0 mmol/L), Na+ 148 mEq/L (148 mmol/L), glucose 178 mg/dL (9.9mmol/L). The client reports of muscle weakness and cramps. Which action by the nurse is BEST? 1.Administer the 0700 dose of spironolactone. 2.Encourage eating bananas for breakfast. 3.Obtain stat K+ level. 4.Call for 12-lead EKG.
3 Need to determine what direction the K+ issue is; the patient isn't exhibiting cardiac signs
The nursing assistive personnel comes to take the client by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck. Which observation, if made by the nurse, requires an intervention? 1.The client removes her dentures and gives them to her spouse. 2.The client's vital signs are BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C). 3.The client has a nitroglycerine patch on the right chest area. 4.The client has red nail polish on both fingers and toes.
3 Nitroglycerin contains aluminum, so it technically counts as a metallic object
The nurse is caring for a client with a shoulder injury. Which intervention will the nurse delegate to nursing assistive personnel (NAP)? 1.Perform a complete bed bath. 2.Direct the client to the shower. 3.Provide back care as part of a partial-care bath. 4.Set the client up for a self-care bath at the bedside.
3 Note that the client can still wash most of their bodies; they just need help with their arms and back Therefore, a partial bath is most appropriate
The nurse reviews prescriptions from a health care provider for a client's care. Which prescription will the nurse question before implementing? 1.Monitor intake and output. 2.Begin a 2 L/day fluid restriction. 3.Start heparin infusion by 0800 hours. 4.Continue intravenous fluids D5W at 150 mL/hour.
3 Notice it doesn't tell the dosage
The nurse examines the medical record of a client with type 1 diabetes mellitus (DM). Which health problem causes the nurse the most concern? 1.Depression. 2.Osteoarthritis. 3.Pneumonia. 4.Hypothyroidism.
3 Remember -> DKA is often caused by infection
The nurse receives a phone call from the mother of a 10-year old child taking methylphenidate (Ritalin) daily. The mother reports the child has lost 2 pounds in the last 2 weeks. Which is the MOST appropriate response by the nurse? 1."How much does your child exercise on a daily basis?" 2."Stop giving the Ritalin for several days to see if the appetite improves." 3."At what time do you give your child the Ritalin medication?" 4."What is your child's bedtime and when does he usually awaken?"
3 Ritalin (and amphetamines in general) suppress appetite, and thus should be given AFTER BREAKFAST
In planning anticipatory guidance for parents of a beginning school-aged child, it is MOST important for the nurse to include which of the following? 1.Teach the child to read and write. 2.Teach the child sex education at home. 3.Give the child responsibility around the house. 4.Expect stormy behavior.
3 School-aged is industry vs inferiority They want to feel competent
Lead toxicity treatment
Calcium disodium + dimercaprol
The nurse cares for the client diagnosed with bipolar disorder. The client will not stop swinging a mop to threaten other clients and staff. Which information is most important for the nurse to consider before administering a PRN IM dose of lorazepam? 1.The client is harmful to self. 2.The client is psychotic. 3.A less restrictive intervention failed. 4.The client is harmful to others.
3
The nurse provides care for a toddler who is a ward of the state. The toddler requires surgery. Who is authorized to give written, informed consent for the procedure? 1.Primary care health care provider.2.Nurse manager.3.Foster parent.4.Social worker who placed the child in the foster home.
3
The nurse uses a tape measure to ensure that a client receives the correct size of knee-high antiembolism stockings. Which measurement does the nurse use for these stockings? 1.Knee circumference. 2.Mid-thigh circumference. 3.Achilles tendon to the popliteal fold. 4.Bottom of the heel to the fold of buttocks.
3
Which finding indicates to the nurse that the client's Salem sump tube (nasogastric) is functioning effectively? 1.Fluctuation of the fluid level in the water seal chamber. 2.Active bubbling in the suction bottle. 3.The presence of a hissing sound from the blue lumen tube. 4.A pressure of 25 mm Hg in the esophageal balloon.
3 1 + 2 are from a chest tube 4 is from a ventilator tube 3 is the only one from a NG tube
Which plan is most appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization? 1.Show a videotape about cardiac catheterization, one specifically prepared for children. 2.Provide the child with a pamphlet about the procedure, and encourage the child to read it. 3.Draw a picture of a heart, and explain where the tube will go and what the health care provider will see. 4.Present a puppet show explaining the anatomy and physiology of the heart.
3 1 + 4 are tempting, but remember: 1 is more for adolescents 4 is more for preschoolers 10 is elementary school
The nurse cares for the client diagnosed with vasoocclusive crisis. The nurse instructs the client how to use patient-controlled analgesia (PCA). The nurse determines teaching is effective if the client makes which statement? 1."If I start feeling drowsy, I should notify the nurse." 2."This button will give me enough to kill the pain whenever I want it." 3."If I start itching, I need to call you." 4."This medicine will help me feel no pain."
3 1 -> normal side effect 2 -> it has a lockout period; it doesn't give it whenever they want 4 -> feel NO pain? I don't think so
During the first 24 hours after parenteral nutrition (PN) therapy is started, the nurse should take which action? 1.Monitor vital signs every two hours. 2.Determine urinalysis results. 3.Evaluate blood glucose levels. 4.Compare weight with the previous readings.
3 1 is too often 4 is a delayed response 3 is the most important; it's the entire point of the medication
Toilet training age + social indicators
Can physiologically control sphincter at 18 months SOCIAL INDICATORS 1. Diaper is dry when taking up (can control it while sleeping) 2. Infant is bothered by wearing wet diapers 3. Infant can dress/undress (good motor skills) 4. Infant can sit still for ~5 minutes 5. Infant has bowel movements at regular intervals (not random)
The nurse cares for the teenager in Buck's traction. It is most important for the nurse to take which action? 1.Check the pin sites for bleeding or infection. 2.Apply topical or antibiotic ointment as ordered. 3.Assess that the elastic bandages are not too loose or too tight. 4.Remove the bandages daily to lubricate the skin.
3 (you said 1) 3 is a circulation issue; if too tight, they can lose the limb 1 is wrong because Buck's traction is a skin traction. It doesn't have pins
A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her husband is coaching her during labor. During the transitional phase of labor, the client begins to scream and grab the side rails with each contraction. Which action, if taken by the nurse, is MOST effective? 1.Offer the client pain medication before her next contraction. 2.Assist the client to a side-lying position with her knees flexed and a pillow between her legs. 3.Establish eye contact with the client and breathe with her. 4.Suggest to the client that she watch television between contractions.
3 2 is tempting, but these are normal physiological responses that don't indicate fetal distress, and are not an immediate priority Besides, #3 gets her to pay attention to you; do you think she's going to turn to her side otherwise?
When is a low-grade fever response expected after an immunization?
24-48 hours later
A nonstress test is scheduled for a client at 34 weeks' gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1.Start an intravenous line for an oxytocin infusion. 2.Obtain a signed consent prior to the procedure. 3.Instruct client to push a button when she feels fetal movement. 4.Attach a spiral electrode to the fetal head.
3 What is the question asking? How do you prepare a patient for this specific procedure (nonstress test) What is a non-stress test? Noninvasive procedure where a fetal monitor is inserted externally and is used to assess fetal HR and movement Why not the other answers? 1. Oxytocin not given 2. This is noninvasive, so no consent needd 4. This is an invasive test; this isn't the same test
The spouse of a client diagnosed with a phobia is concerned by the client's sudden fear of elevators. The spouse asks the nurse what to do when the client becomes frightened. Which action does the nurse encourage the spouse to take first? 1.Ride the elevator with the client. 2.Encourage the client to get into the elevator .3.Allow the client to avoid the elevator. 4.Encourage the client to discuss the fear.
3 (not 4) Phobias don't respond well to discussion; they are not rational and require desensitization
The nurse provides care for a client in acute respiratory distress. The health care provider initiates mechanical ventilation. Which parameter is most important for the nurse to assess after initiation of mechanical ventilation? 1.The respiratory rate. 2.The heart rate. 3.The blood pressure. 4.The oxygen alarm on the ventilator.
3 (you said 1) 1 and 4 are preset by the machine, and won't change; what you are concerned about is the patient response 3 indicates that they are going into cardiogenic shock, which is most important
The nurse provides care for a client at 28 weeks' gestation. The nurse counsels the client about how to prepare her 2-year-old child for the new baby. Which statement made by the client indicates that further teaching is necessary? 1."I am going to wait another month to tell my child about the new baby." 2."I have given my child a baby doll, bottles, and diapers." 3."I am talking to my child about being a big sibling." 4."We are already getting my child used to sleeping in a bed rather than the crib."
3 (you said 1) 1 is a good idea since she may not display any outward signs the toddler would notice of pregnancy rn, leading to confusion 3 is bad because a 2 year old is too young to understand the concept of siblings
The nurse in the prenatal clinic monitors the condition of a pregnant client at 30 weeks' gestation who is diagnosed with gestational diabetes mellitus (GDM). Which test result most concerns the nurse? 1.Hemoglobin 11.5 mg/dL (115 g/L) and hematocrit 33% (0.33).2.Glycosylated hemoglobin (HbA 1c) 7%.3.Urine dipstick testing is positive for ketones.4.One-hour glucose tolerance test (GTT) result is 140 mg/dL (7.8 mmol/L).
3 (you said 1) 1 is a normal response; H&H drop during pregnancy due to increased plasma cells 3 indicates DKA
The nurse cares for the client after a craniotomy. The client's history reveals breast cancer with metastatic lesions to the brain, and the client has received chemotherapy for one month. Postoperatively, the nurse is MOST concerned if which finding is observed? 1.Urine is foul smelling, and the urine specific gravity is 1.035. 2.The client's 24-hour fluid intake is 3,000 ml. 3.The client's 24-hour urinary output is 4,000 ml. 4.The client has diarrhea and excoriation of the anal area.
3 (you said 1) 3 indicates diabetes insipidus 1 indicates either dehydration or infection DI is both a short-term (risk of dehyration) and long-term problem, so it has greater priority
The nurse cares for clients in a mental health center. The nurse observes the client, formerly homeless and malnourished, diagnosed with chronic schizophrenia putting food from lunch into a plastic bag. Which statement by the nurse is most appropriate? 1."We don't allow people to take food from the dining room." 2."What are you going to do with the food?" 3."We will be serving snacks and juice at 3 P.M." 4."Let's go watch a movie with the others."
3 (you said 1) Addresses the needs of patient (fear of lack of access to food), without being potentially confrontational and "judgemental"
The nurse cares for clients in a rehabilitation facility. The nursing team reports a client recovering from a hip fracture has repeatedly "transferred herself to the floor." Which action, if taken by the nurse, is best? 1.Place the call light within the client's reach. 2.Remove the footrests from the wheelchair. 3.Observe the client rise from a sitting to a standing position. 4.Place a Posey vest restraint on the client.
3 (you said 1) Notice it said nowhere that the patient was trying to get out of bed on their own, just that they fell #1 won't necessarily fix the problem #3 is a good assessment; before getting them out of bed, determine if they can stand
The nurse encounters a client diagnosed with psychosis coming out of the room nude. Which response by the nurse is best? 1."Come with me. You need to get dressed." 2."Why are you coming into the hallway undressed?" 3."Being naked in the hallway is inappropriate. Return to your room to get dressed." 4."Do I need to get a male nurse to help you get dressed?"
3 (you said 1) The problem with 1 is that it doesn't communicate that this is unacceptable behavior
The nurse in the emergency department (ED) is notified that multiple workers in a local plant have been exposed to radioactive materials and will be arriving shortly. Which action does the nurse take first? 1.Set up decontamination stations outside of the emergency department.2.Locate the nuclear exposure immediate reaction kit.3.Notify the Director of Nursing of the incident.4.Obtain official verification that the incident has occurred.
3 (you said 1) This is a major emergency that requires a broad hospital approach; get help
The nurse overhears a conversation in the cafeteria between two nurses regarding a client's home situation. Which action is the most appropriate? 1.Report the incident to the nurse manager. 2.Join the conversation with the nurses. 3.Suggest that the nurses continue their conversation in private. 4.Ignore the incident because the nurse is not involved.
3 (you said 1) Yes, this is a bad question, since it's asking you to be confrontational The rationale is that reporting it doesn't fix the immediate problem; asking them to stop does
Which intervention should be the priority during the nursing care of a 2-month-old infant after surgery? 1.Minimize stimuli for the infant. 2.Restrain all of the infant's extremities. 3.Encourage the parents to stroke the infant. 4.Demonstrate to the parents how they can assist with their infant's care.
3 (you said 1) Yes, you want them to rest, but 1 is a negative, since bonding doesn't occur
The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to compression fractures of the 5th and 6th cervical vertebrae. The client reports a sudden onset of sweating and has a flushed face and chest. Which action should the nurse take first? 1.Perform a digital rectal examination. 2.Check the color and temperature of the extremities. 3.Place the client in high-Fowler's position. 4.Administer hydralazine 20 mg intravenously.
3 (you said 1) You know from the info they're in auto dysreflexia; no further assessment needed High-Fowlers is the choice; normally high-Fowlers isn't good for risk of ICP, but notice that this is a SPINE injury, not a HEAD injury
During a health history, the teenage client tells the nurse, "I have no appetite, and I've lost 4 lb this week." It is most important for the nurse to take which action? 1.Notify the health care provider. 2.Weigh the client. 3.Continue with the interview. 4.Examine the abdomen.
3 (you said 2) Get all interview info first (you want more clarity on the situation of why they're like this, right?)
The nurse assesses the emotional support available to a client who is starving herself. Which question is MOST important for the nurse to ask in the assessment interview? 1."What do you consider your ideal weight to be?" 2."How does your eating pattern change when you are around other people?" 3."What happens at home when you express opinions that are different from those of your parents?" 4."What do you think about your present weight?"
3 (you said 2) NOTE - emotional support; that generally means friends and family 2 is too vague, and doesn't address how people respond to her
Which action should the nurse instruct the client to complete first to establish a normal urinary pattern? 1.Urinate every two hours. 2.Record each time the client urinates. 3.Keep a record of daily fluid intake. 4.Stay near a bathroom.
3 (you said 2) Encourage adequate fluids first
The nurse supervises care of clients on a postoperative surgical unit. Which finding requires an immediate intervention by the nurse? 1.The nursing assistive personnel (NAP) obtains vital signs on a client who had a bowel resection 24 hours ago. 2.The NAP assists a client who had an above-the-knee amputation apply an elastic bandage to the residual limb. 3.The NAP assists a client who had a stroke 3 days ago with feeding. 4.The NAP assists a client who had a laparoscopic cholecystectomy 6 hours ago ambulate.
3 (you said 4) 1 -> good, unchanging procedure, no TEA 2 -> good, appropriate, unchanging procedure with no TEA 3 -> BAD, you need to assess gag reflex 4 -> good, appropriate, unchanging procedure with no TEA
The home care nurse cares for the client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. Which response by the nurse is BEST? 1."Let's get your mother a walker." 2."Do you think it's time to put your mother in a nursing home?" 3."When does your mother fall?" 4."Does your mother seem to be more confused lately?"
3 (you said 4) 4 is too specific (yes/no) Ask a more generalized question to determine cause; it may not be hypoxia
The nurse provides care for a client after a thoracotomy. The client has a chest tube drainage system in place. Which observation most concerns the nurse? 1.The water in the suction control chamber bubbles constantly. 2.There is 700 mL of drainage in the collection chamber. 3.The level of the fluid in the water-seal chamber does not move. 4.There are air bubbles in the water-seal chamber when the client exhales.
3 (you said 4) Lack of tidaling indicates either no more air in the lung (which means chest tube can be D/Ced) or there is an obstruction in the tubing 4 is normal
The nurse provides care to a client diagnosed with chronic heart failure (HF) and an acute bacterial infection. The client's medications include furosemide 40 mg PO daily and aspirin 81 mg PO daily. Which new prescriptions cause the nurse to seek clarification from the health care provider? (Select all that apply.) 1.Potassium chloride (KCl) 40 mEq PO daily. 2.Enalapril 20 mg PO daily. 3.Vancomycin 3 g IV piggyback every 12 hours. 4.Digoxin 0.25 mg PO daily. 5.Clopidogrel 75 mg PO daily.
3, 4 The lasix causes decrease potassium, so digoxin toxicity is a higher risk Vancomycin causes ototoxicity, as does lasix; additive effect
The wound care nurse assesses a group of clients. The nurse determines that which client is receiving appropriate care? (Select all that apply.) 1.The client 1 day post-operative after an appendectomy with a hydrogel dressing over the surgical site. 2.The client with necrotic areas on both heels covered by sterile gauze and tape. 3.The client with a stage 3 pressure injury whose hydrocolloid dressing is changed weekly. 4.The client with a spinal cord injury who has a non-blanching reddened area covered by a foam dressing. 5.The client whose poorly healing leg wound is being treated with a negative-pressure wound vacuum system. 6.The client with an infected wound that is covered with an alginate dressing changed every 3 days.
3, 4, 5
The multipara client comes to the prenatal clinic during her fifth month of pregnancy. The client reports that her breasts are sensitive and sore. Which suggestion by the nurse is best? Select all that apply. 1."Apply warm compresses to your breasts, and take two aspirin as needed." 2."Massage your breasts with lotion in a downward motion." 3.Apply cool compresses to the sides of your breasts." 4."Take an herbal diuretic once a day." 5.Wear a well fitting supportive bra."
3, 5 Cool, not warm are applied to breasts Massaging makes it more irritated, lotion dries it out, making it worse Herbal diuretics (and OTC medications in general) should generally be avoided during pregnancy
The nurse prepares to discharge the client after an abdominal cholecystectomy. The client will go home with a T tube in place. Which statement, if made by the client to the nurse, indicates a need for further teaching? Select all that apply. 1."It will be great to finally get home, take a shower." 2.If the amount of drainage increases over the next several days, I should call my health care provider." 3."I can resume swimming laps three times a week." 4."I will check the skin around the tube once a day." 5."I will call my health care provider if I have green drainage." 6."I am glad I can lift whatever I want."
3, 5, 6 1 -> WRONG; person hygiene is good (a bath would be contraindicated) 2 -> you would expect the drainage to DECREASE; increased drainage indicates a problem 3 -> WRONG; will cause infection 4 -> true 5 -> WRONG; green drainage (bile) is expected 6 -> WRONG; should limit lifting to prevent excess pressure on incision site
The nurse prepares the client for a lumbar puncture. It is important that the nurse makes which statement? Select all that apply. 1."Don't worry because a general anesthetic will be used." 2."You can't drink fluids for eight hours before the test. 3."You will remain flat in bed for eight hours after the test." 4."A compression bandage will be in place for 10 hours after the test." 5."You may feel discomfort in your leg when the needle is inserted." 6."You can have analgesics after the procedure if you have a headache."
3, 5, 6 1 -> only local anesthesia used 2 -> no dietary restrictions 3 -> true 4 -> use a sterile dressing, not compression 5 -> true 6 -> true
The client reports chronic constipation to the nurse. The nurse in the health care clinic should advise the client to take which action? Select all that apply. 1.Reduce intake of highly seasoned foods and fats. 2.Drink 1,000 ml of fluids daily. 3.Increase intake of cereals, fresh fruits, and vegetables. 4.Ask the health care provider to prescribe bisacodyl 5 mg enteric-coated tablets daily. 5.Plan the day to be home around the usual time of defecation. 6.Establish daily exercise pattern.
3, 5, 6 1 -> seasoned foods aren't used for constipation, only hiatal hernias, Crohn's and UC 2 -> too little fluid 3 -> good, promotes fiber 4 -> laxatives should only be used as a last resort (risk of dependency) 5+6 -> good
Multiple myeloma; what imaging alteration is there?
Cancer involving overproduction of plasma cells in bone marrow, leading to destruction of bone marrow --A bone imaging study is not a good idea, since the marrow is destroyed; the test is unnecessary, and is invasive
A client returns to the room following an open cholecystectomy. It is most important for the nurse to obtain an answer to which question? 1."Have postoperative pain medications been prescribed?" 2."When will the surgeon remove the dressing?" 3."Have postoperative anti-emetic medications been prescribed?" 4."Was a drain placed during surgery?"
4 You said 1 4 is a physical problem (something you need to regularly assess) 1 is a psychosocial issue
The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act? 1."A client needs to complete an advance directive and identify a health care proxy to become an organ donor." 2."The health care provider is the person who requests organ donation from a client's family members." 3."The health care provider who signs the client's death certificate must supervise the removal of the client's donated organs." 4."Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated."
4
The nurse provides dietary teaching to the parents of a child with celiac disease. Which statement made by a parent indicates that teaching is effective? 1."My child's diet should include raw vegetables, fruits, and crackers." 2."My child's diet should be high in carbohydrates, high in calories, and high in proteins." 3."The only restriction in my child's diet should be breads and cereals." 4."My child's diet should be high in calories, high in protein, and restrict foods containing rye, oats, wheat, and barley."
4
The nurse cares for an elderly client following a right total hip replacement. The nurse's notes indicate that since the surgery, the client has become disoriented and confused at night. One evening as the nurse prepares the client for sleep, the client glances to his left and says, "Oh, you think so?" and starts to laugh. Which response by the nurse is the BEST? 1."Do you hear voices talking to you?" 2."Tell me why you are laughing so I can laugh too." 3."What is it that you find amusing?" 4."I notice you're laughing."
4 You said 1; it's a yes/no question
The nurse makes a follow-up visit to a client recently diagnosed with AIDS. Which activity, if performed by the client, indicates that the nurse's teaching has been effective? 1.The client uses a firm toothbrush once a day to brush teeth. 2.The client eats a large lunch at noon and a small dinner at 6 PM. 3.The client changes the litter in the cat's litter box every day. 4.The client takes docusate sodium 300 mg once a day.
4 1 -> causes mouth damage, can get infected 2 -> patient is nauseated/weak; large meals may not get finished 3 -> risks infection 4 -> preventing constipation helps with nausea and prevents infections
An 8-year-old boy falls off the swings at school and hits his head. He is examined by the health care provider at an urgent care center. The client is diagnosed with a minor head injury, and sent home. Which statement, if made by the mother to the nurse, requires further teaching by the nurse? 1."He should avoid blowing his nose or cleaning his ears for two days." 2."I should wake him every three hours tonight and tomorrow night to check him." 3."I can give him acetaminophen every four hours if he reports a headache." 4."He will be well enough to play in his soccer game tomorrow."
4 1 -> increases iCP; not a good idea 2 -> good to observe 3 -> tylenol is fine; avoid aspirin/ibuprofen/naproxen 4 is good
The nurse cares for the client with deep partial thickness and full thickness burns. The client receives morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention. Which action, if taken by the nurse, is BEST? 1.Recommend that the morphine dose be decreased. 2.Withhold the pain medication. 3.Administer the medication by another route. 4.Explore alternative pain management techniques.
4 You need to keep up with the pains meds - supplement with alternative methods
DKA --Blood glucose level --S/S --Urine changes --Major giveaway S/S --Treatments
300-800 ------------------------------------------- 1. Headache 2. Drowsiness 3. Weakness progressing to coma 4. Rapid HR 5. Low BP (r/t urination) 6. Hot, dry membranes 7. Acetone brath ------------------------------------------- 3 Ps (polydipsia, polyuria, polyphagia) Ketones are present in blood Acidosis is present ------------------------------------------- Kussmaul respirations ------------------------------------------- Correct fluid loss - major focus Replace insulin/potassium Check EKG (low potassium) and potassium levels Regular assessments
During the discharge planning session for a chronically ill infant, the nurse observes that the single mother nervously paces most of the time while bouncing the infant in her arms. Which suggestion by the nurse is best? 1."See your health care provider for a prescription for a mild tranquilizer." 2."Buy a commercially made 'baby bouncer' infant seat." 3."Enroll in a Volunteers of America parenting class." 4."Investigate hiring a live-in 'nanny.'"
3. Entroll in a Volunteers of America parenting class (You said #2) Think about it: the baby bouncing is just a symptom of the anxiety the mother is feeling about the chronic illness Do you want to treat just this one symptom? Or do you want to try and treat the underlying issue? The parenting class can help treat both the danger to the baby AND provide coping mechanisms/support groups for the mother
Normal female hematocrit
35-47
A college student reports a history of a motor vehicle accident six months ago. The client was minimally injured but a friend was killed. The client comes to Student Health Services reporting inability to study or sleep. The client also reports thinking they are "going crazy." Which action by the nurse is MOST important? 1.Perform a complete physical and social history. 2.Obtain a complete drug and alcohol history, including reports from a drug screen. 3 .Review the significant events of the last year. 4.Explore the client's coping methods over the crash and the friend's death.
4 You said 1; notice that it doesn't say psychological assessment
The client diagnosed with Addison's disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which statement about Addison's disease? 1.The client requires increased sodium intake to prevent hypotension. 2.A decrease in sodium intake may lead to seizures. 3.Steroid replacement causes rapid loss of sodium. 4.Sodium intake should be increased during periods of stress.
4 You said 2 Think about it -> they have pneumonia, so they're gonna be sweating, in an elevatd physio state, etc Sodium intake should be increased to account for that
The postoperative client returns to the assigned room from the surgical recovery area. The client is sleeping, and the nurse notes the client is disoriented when aroused. Which nursing action is best? 1.Place the call bell within the client's reach. 2.Stay with the client until the client is totally oriented. 3.Restrain all four extremities until the client is oriented. 4.Elevate the side rails until the client is fully awake.
4 You said 2 -> they are sleeping, so that isn't necessary 4 is right because it doesn't state all 4 side rails
The nurse provides care for a client diagnosed with hypovolemia. Which observation does the nurse identify as the desired response to fluid replacement? 1.Urine output 160 mL in 8 hours. 2.Hemoglobin 11 g/dL (110 g/L). 3.Arterial pH 7.34. 4.Central venous pressure (CVP) of 8 mm Hg.
4 You said 2; remember that low hemoglobin indicates potential fluid overload Normal CVP is 2-8, so that's WNL
The nurse leads an in-service education class on legal issues. The nurse identifies which of the following acts constitutes battery? 1.The nurse restrains an agitated, confused patient in the emergency room with a physician's order. 2.The nurse chases a patient who tries to run away while outside for a walk. 3.The nurse holds the arms of a manic patient who struck her while the nurse calls for assistance. 4.The nurse administers an injection to a schizophrenic patient who refuses to take the medication by mouth because he believes it is poison.
4 You said 3; restraining a patient that is hitting other people is NOT battery
The nurse provides care for a client diagnosed with an abruptio placenta. Which is the priority nursing diagnosis for this client? 1.Infection. 2.Fetal demise. 3.Altered tissue perfusion. 4.Fluid volume deficit.
4 (blood loss) You said 2, but think -> fluid deficit puts both the infant and mother in danger
The clinic nurse assesses an adult client who presents for a routine visit. Which finding concerns the nurse? 1.Weight of 142 lb (64 kg) and height of 5 feet, 7 inches.2.Extremities warm to the touch.3.Skin fails to tent when pinched and released.4.Hair thin, dull, and dry.
4 (yes, it is confusing) The hair indicates hypothyroidism
The client is to receive peritoneal dialysis through a catheter inserted through a trocar. Which nursing intervention is essential for the nurse to perform? 1.Maintain the client in a supine position during the procedure. 2.Weigh the client during the procedure and again 24 hours later. 3.Change the dwell time according to the client's tolerance during the procedure. 4.Check the client's BP and apical and radial pulses before the procedure.
4 (you said 1) 1 -> usually elevated to Semi-Fowler to prevent pressure on diaphragm/breathing issues 2 -> not essential immediately 3 -> should not be changed by nurse, is a med order 4 -> essential, gets baseline VS to determine adverse effects
The client on suicide precautions asks for a razor to shave her legs. When the nurse tells the client that she must remain with the client, the client responds, "Don't you trust me?" Which response by the nurse is best? 1."It is against hospital policy to allow clients on suicide precautions to have razors unsupervised." 2."I trust you, but your health care provider said a nurse has to watch you if you want to shave your legs." 3."Wouldn't you rather wait until you are feeling better before you try to shave your legs?" 4."You have been having thoughts about wanting to hurt yourself recently, so I'll stay with you."
4 (you said 1) Is more therapeutic while still enforcing that you need to stay with them - 1 sounds too sterile
When administering preoperative medication to a client, the nurse notices small insects crawling out of the closet where the client placed the suitcase. The client refuses to allow the nurse to inspect the suitcase. Which action by the nurse is best? 1.Notify security.2.Kill the insects.3.Inspect the client's suitcase.4.Double-bag the client's suitcase.
4 (you said 1) Security may be called, but prevention of contamination spread is most important rn
One day after a coronary artery bypass graft (CABG), the nurse discovers a client sitting in a chair. The client is cool and pale, and responds only to loud verbal stimuli. Which action does the nurse perform first? 1.Perform a cardiac assessment. 2.Review documentation for abnormal findings. 3.Administer oxygen per nasal cannula. 4.Transfer the client back to bed with assistance.
4 (you said 1) Sitting in chair = blood has to circulate against gravity Should get back in bed to promote better circulation
The nurse provides care for a client who just passed a renal calculus. The nurse sends the specimen to the laboratory. Which specimen analysis will assist the nurse to plan care? 1.Type of infection.2.Size and number of calculi.3.Antibodies.4.Composition of the calculus.
4 (you said 2) They can't find out the size (and especially #) from a lab; you find that out
The nurse questions the family of a client admitted with hyperglycemic hyperosmolar nonketotic syndrome (HHNK). Which information does the nurse expect to find in the client's history? 1.The client was diagnosed with type 1 diabetes four years ago. 2.The client has a history of 3+ ketones in the urine. 3.The client is 20 lb overweight and smokes a pack of cigarettes a day. 4.The client is 66 years old and takes propranolol 20 mg PO tid.
4 (you said 2) 1 -> is common in type 1 diabetes, not type 2 2 -> ketones aren't present (non-ketoic) 3 -> obesity/smoking not related; is due to illness usually or treatments 4 -> CORRECT - common in people over 50
A 7-year-old boy is brought to the emergency room by his mother following a fall from his bicycle. X-ray reveals healed fractures of the ribs. The child's mother states, "My son is such a careless child; he's always having accidents or fights with his brother." Which response by the nurse would be most appropriate? 1."When I document information about these injuries, it will be on your son's hospital record forever." 2."How would you describe your son's relationship with his brothers and sisters?" 3."What I see suggests that someone has been abusing your son." 4."I will need to talk to the nurse manager about this situation before you leave."
4 (you said 2) 2 is more psychosocial You need to report potential abuse (4)
The clinic nurse returns a phone call from a client diagnosed with type 1 diabetes. The client has been vomiting for 24 hours. It is MOST important for the nurse to instruct the client to take which action? 1.Take half of the regular insulin dose. 2.Attempt to maintain the regular diabetic diet. 3.Limit intake of sweets and sugar. 4.Drink liquids as often as possible.
4 (you said 2) 2 is pointless -> they'll just vomit the food up Since they're vomiting, they're at risk of dehydration; 4 is the choice
A client just had an abdominal aortic aneurysm repair. Vital signs are blood pressure 100/70 mm Hg, pulse 120 bpm, respirations 24 per minute, and urine output 75 mL during the past three hours. Which is the priority nursing action for this client? 1.Weigh the client. 2.Obtain an ECG. 3.Decrease the rate of the IV fluids, and start nasal oxygen. 4.Maintain bed rest, and evaluate for a decrease in CVP readings.
4 (you said 2) Alright, so you have a low BP. Can you diagnose using only 1 value for shock? FALSE; you need multiple to be 100% sure that's the cause, rather than something else ECG may be useful later, but you need to determine the cause before jumping to it (if I could only do 1 thing...). Plus this is due to low blood volume; ECG won't asesess for that
The nurse of a client in a long-term care facility talks with the client's spouse. The spouse reports seeing a red haze within visual fields for the past several days. Which response by the nurse is most appropriate? 1."Have you been getting enough sleep?"2."How long have you had this problem?"3."I am concerned about how this may affect your driving."4."Have you made an appointment with your ophthalmologist?"
4 (you said 2) Asking for the duration is good, but they already said it
The nurse provides care for clients at the local eye care center. Several clients who are 24 hours post-operative after intracapsular cataract extraction have left phone messages. Which message should the nurse return first? 1.A client asks if it is appropriate to take acetaminophen for discomfort in the operative eye. 2.A client reports feeling light-headed when assuming a standing position. 3.A client reports mild itching in the operative eye. 4.A client states that the eyelid is swollen and the client is having difficulty seeing with the affected eye.
4 (you said 2) Eye surgery involves anesthesia, so ortho hypo is expected for a while #4 however indicates an infection
A client admitted to the hospital has chest pain when taking deep breaths and peripheral edema. The health care provider (HCP) prescribed "digoxin 0.25 mg orally now. Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse, is best? 1.Do not administer the second dose of digoxin. 2.Call the HCP to clarify the client's digoxin prescription. 3.Administer half the prescribed second dose of digoxin. 4.Review the client's serum digoxin level.
4 (you said 2) It is routine to check digoxin levels before administration These are signs of heart failure; the chest pain threw you off a little
The nurse evaluates care for the client diagnosed with depression. The nurse is MOST concerned if which finding is observed? 1.The LPN/LVN reinforces the client deep breathing and relaxation techniques. 2.The staff allows the client to verbalize thoughts when they try to sleep. 3.The staff encourages the client to express feelings more clearly. 4.The LPN/LVN administers flurazepam hydrochloride 15 mg hs.
4 (you said 2) Medications should be a last resort 2 is fine because you're trying to get to the root of why they can't sleep by asking them to describe it; you thought it was wrong because it is disrupting normal sleep times
To best evaluate home compliance with metoclopramide for a 3-month-old, the nurse should take which action? 1.Observe the mother feeding the infant. 2.Ask the mother about the infant's retention of feedings. 3.Ask the mother how many wet diapers the baby has each day. 4.Weigh the baby, and compare to baseline weight.
4 (you said 2) Metoclopramide -> anti-vomiting medication RULE OF THUMB -> OBJECTIVE DATA IS ALWAYS MORE RELIABLE THAN SUBJECTIVE 4 is objective, 2 isn't
The nurse counsels the mother of a school-age client who is diagnosed with laryngitis secondary to pharyngitis. Which intervention is appropriate for the nurse to suggest to the mother? 1.Instruct the child to come close and whisper when something is needed. 2.Encourage the child to take frequent sips of warm or cold milk. 3.Encourage the child to sing favorite songs while taking a shower. 4.Give the child a paper and pencil to communicate.
4 (you said 2) Milk promotes production of mucus (just think of drinking milk while you have a cold - disgusting) 4 is good because it rests the throat
The psychiatric client admitted involuntarily asks the nurse to mail a letter to the President. The client states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which response by the nurse is best? 1.Accept the letter and place it in the client's medical record. 2.Read the client's letter and decide if it is appropriate to mail. 3.Call the client's health care provider and inform them of the letter. 4.Discourage the client from sending the letter, but mail it if client insists.
4 (you said 2) Patient has right to communication
The mother of a 4-year-old boy comes to the prenatal clinic to confirm her second pregnancy. During the initial visit, it is MOST important for the nurse to take which action? 1.Assess the client's feelings about pregnancy, labor, and delivery. 2.Obtain a history of the client's last labor and delivery. 3.Determine how the client's 4-year-old feels about the pregnancy. 4.Identify the client's general health needs.
4 (you said 2) Think -> if I can only get 1 piece of information/do 1 thing, what would it be? I think it's more important to know the problems the patient has NOW as opposed to what they had in the past
The nurse answers a call light for a client who reports pain at the intravenous (IV) access site. Upon assessment, the nurse notes the IV insertion site is pale, cool to the touch, and mildly swollen. It is most important for the nurse to take which action? 1.Slow the infusion rate and monitor the client's response. 2.Stop the infusion and notify the health care provider. 3.Remove the IV catheter and apply a pressure dressing. 4.Remove the IV catheter and place the client's arm on a pillow.
4 (you said 2) Try and prevent edema via putting in pillow Does not necessitate contacting doctor unless other symptoms appear (i.e. pain)
The home care nurse instructs the daughter of a client diagnosed with congestive heart failure. The daughter states her father is taking digoxin 0.25 mg and the healthcare provider just prescribed furosemide 40 mg. Which statement, if made by the daughter to the nurse, indicates teaching is successful? 1."I'm glad that Dad doesn't have to change his diet." 2."Dad is going to have to eat more cottage cheese and add some more salt to his diet." 3."Dad must increase his intake of cheese and yogurt." 4."I should encourage Dad to eat more fresh fruits and vegetables."
4 (you said 2) What do you need to eat for digoxin? Potassium Fruits/veggies contain potassium (think spinach) #2 is wrong; it contains sodium as the salt, not potassium #3 contains dairy products, so high calcium, but not potassium
A nurse driving home from work observes a car go off the road into a shallow embankment. Which client does the nurse advise the arriving paramedics to transport to the hospital first? 1.A crying infant restrained in a rear-facing child safety seat. 2.The restrained front seat passenger who has a laceration to the right side of his head. 3.The restrained rear seat adult passenger who has a deformity of the right forearm and who reports pain at the site. 4.The restrained driver who has faint discoloration around the umbilicus and reports abdominal pain.
4 (you said 2) You said 2 because of risk of elevated ICP; however notice that they only said laceration (don't read into question) 4 is right because of acute peritoneal bleed
The nurse performs health screening at a shelter for the homeless. Which observation most likely indicates the need for teaching about personal hygiene? 1.Fruity breath odor. 2.Foul-smelling stools. 3.Vaginal itching. 4.Red, swollen gums.
4 (you said 3)
A staff member working in the newborn nursery reports to the charge nurse, "Even though I do not feel bad, I have had loose stools for the last couple of days. Which response by the charge nurse is best? 1."Make sure you wash your hands after going to the bathroom." 2."Are you drinking plenty of fluids?" 3."Describe to me how you are feeling." 4."I'm going to reassign you to the orthopedics."
4 (you said 3) 3 is redundant; they already said how they feel 4 is good -> they have probable infection, so they shouldn't be working with newborns
The nurse provides care to a client who underwent a bone marrow biopsy. During the post-procedure period, the nurse implements which action? 1.Measure abdominal girth at the level of the umbilicus. 2.Assist the client to a right side-lying position. 3.Observe for changes in the client's cough and sputum. 4.Assess for bleeding and hematoma formation.
4 (you said 3) 3 is tempting, because of air emboli risk; however, sputum would not be a symptom 4 is true because you just stuck a needle in them idiot
The unlicensed assistive personnel (UAP) reports to work on the oncology unit with a cough, runny nose, and an elevated temperature. The UAP reports having no sick leave and being the breadwinner of the family. Which response does the nurse provide to the UAP? 1."Did you receive a flu shot?" 2."Can you work at the desk and help the unit secretary with the medical records?" 3."I will call one of the other units where clients are less vulnerable." 4."I am sorry, but you will have to go home." View Explanation
4 (you said 3) 3 is tempting, but in a hospital setting, there are immunocompromised patients on every unit
The nurse oversees care provided by an LPN/LVN and an unlicensed assistive personnel (UAP). Which task is best to delegate to the UAP? 1.Monitor a client during the first 15 minutes after the nurse begins a blood transfusion.2.Determine the patency of a chest tube drainage system for a client diagnosed with a pneumothorax.3.Teach a client newly diagnosed with type 1 diabetes mellitus how to fill out the menu.4.Implement bladder training measures for a client diagnosed with urinary incontinence. View Explanation
4 (you said 3) 3 is tempting, since the menu is a low-priority, but notice that the patient is diabetic; further help is needed
The client had a thoracotomy three hours ago. For the past two hours, there has been 100 ml/hour of bloody chest drainage. Which action should the nurse take first? 1.Increase the IV fluid rate. 2.Administer oxygen at 5 L/minute per oxygen mask. 3.Elevate the head of the bed. 4.Advise the health care provider (HCP) of the amount of drainage.
4 (you said 3) If you can only do 1 thing...
A client recovers from a cardiac catheterization that was performed using the brachial artery. Which action is the most important for the nurse to take? 1.Place a warm pack on the affected foot. 2.Measure vital signs every 2 hours. 3.Compare the quality of pulses on both legs. 4.Determine the presence of the radial pulse bilaterally.
4 (you said 3) Note it says BRACHIAL; where is that? (in the upper arm between bicep and tricep) Checking the legs doesn't do jack
A client diagnosed with a chronic idiopathic seizure disorder, controlled with antiseizure medication, will be married in five weeks. The client is concerned about having a seizure during the ceremony. Which is the best action for the nurse to implement? 1.Ask the health care provider to increase the client's medication dosage for the wedding day. 2.Ask a nurse to attend the wedding and assist as needed. 3.Teach the client how to perform relaxation exercises. 4.Tell the client to make a medication and seizure chart.
4 (you said 3) Note that it is described as IDIOPATHIC (unknown cause); 3 is good if it is stress-triggered, but you don't know yet
The nurse cares for the client with a long leg cast on the right leg. The nurse notes that the right foot is pale and cool to the touch, and the client continues to report pain even though an analgesic was administered 45 minutes ago. Which action should the nurse should take first? 1.Apply a heating pad to the client's right toes. 2.Repeat the dose of the analgesic stat. 3.Remove the cast immediately. 4.Notify the health care provider immediately.
4 (you said 3) Removal of the cast is not within the jurisdiction of the nurse; the HCP will likely remove it
The nurse cares for the client with a marked depression of T cells. The nurse should take which action? 1.Keep a linen hamper immediately outside the room. 2.Restrict eating utensils to spoons made of plastic. 3.Provide masks for anyone entering the room. 4.Remove any standing water left in containers or equipment.
4 -> risk of bacterial growth in water Surprisingly, people don't have to wear masks for neutropenic precautions, they just need to wash hands
The nurse cares for clients at the student health clinic. Which signs and symptoms should cause the nurse to suspect cocaine abuse in the college student? Select all that apply. 1.Frequent sneezing. 2.Paranoia. 3.Fatigue. 4.Reports of insomnia. 5.Rhinorrhea. 6.Tachycardia.
4, 5, 6 Remember - cocaine is a STIMULANT 1. (False - yes it's inconsistent) 2. FALSE (euphoria, not paranoia) 3. FALSE (elevated energy) 4. TRUE 5. TRUE 6. TRUE
The 76-year-old woman has a medical history that includes hypertension with cardiac involvement. A public health nurse visits this client regularly and on each visit records vital signs. Which finding should the nurse expect for this client? Select all that apply. 1.Pulse 110 2.Blood pressure 120/80. 3.Temperature 99.8°F (37.7°C) 4.Temperature 98.6°F (37°C) 5.Pulse 80 6.Blood pressure 150/85
4, 5, 6 (you said 1, 4, 6) 6 is a given -> that's the definition of HTN Elderly are generally colder if they have cardiac disorders because of diminished blood flow Pulse would be expected to be normal due to compensatory mechanisms; it doesn't say this is acute
Newborn normal BP
60-80 / 40-60
A patient previously at 3 cm dilated has been in labor for 4 hours. What is her current dilation?
7 cm You dilate at a rate of roughly ~1 cm per hour
At what age should stranger anxiety appear?
7 months
At what age can children sit up unsupported?
8 months
A kid has complete eye development at which age?
8 years
Normal PaO2
80-100
What is the standard suction strength used during trach care and other suctioning?
80-120
Normal creatinine clearance
85-135
A kid should be saying "dada" or "mama" by what age
9 months
When does the anterior fontanelle close?
9-18 months
The nurse provides teaching to a client scheduled for radiation therapy for cancer. Which client statements require intervention by the nurse? (Select all that apply.) 1."I will shower with a mild soap." 2."I won't use any lotion on the radiation area." 3."If my skin starts to ooze, I will clean it with saline." 4."I will not go swimming while I'm still getting radiation treatments." 5."I will keep the radiation area covered at all times." 6."I will only stay outside for short intervals when the sun is shining."
5, 6 1 -> normal, don't use lotions (dry skin, encourage bacterial growth) 2 -> see 1 3 -> good 4 -> should not go swimming (chlorine irritates skin, natural water can cause infection r/t bacteria in it) 5 -> FALSE, should wear loose clothing and not 100% of the time, or risk retaining radiation more than desired 6 -> DO NOT GO OUT IN THE SUN DURING TREATMENT
Levodopa --What is it? --For what disease? --How do you give it? --Side effects
Compound which the body can convert into dopamine ------------------------------------------ Parkinson's ------------------------------------------ Give with food ------------------------------------------ 1. Ortho hypo 2. Arrhythmias 3. Twitching 4. AMS 5. N/V (and anorexia)
How should a wound suction container be placed?
Always below the level of the patient to prevent backflow
Magnesium/aluminum hydroxide --What are they? --Usage --Adverse effects --Which drugs does it interact with?
Antacids ------------------------------------------- Reducing gastric pH 1. Ulcer treatment/prevention 2. Acid reflux into esophagus 3. Indigestion ------------------------------------------- 1. Altered GI (constipation/diarrhea) 2. Acid/ base changes 3. Excess acidity of stomach between doses ------------------------------------------- May interfere with absorption of antibiotics (mostly tetracyclines) Also reduces effectiveness of contraceptives/salicylates (aspirin)
Gemfibrozil
Anti lipid drug Fibric acid Causes liver damage -> assess labs
Disulfiram
Anti-alcoholic drug
Chlordiazepoxide; what is it used for?
Anti-anxiety medication --Is often used for alcohol withdrawal, since it is structurally similar
Phenytoin --What is it? --S/E --Nutitional focus
Anti-seizure med 1. GI upset (take with food) 2. Pink/red urine is normal 3. Drowsiness/dizziness Also impairs absorption of Vitamin D/folate; encourage foods high in this (milk for vitamin D, kale and other green leafies for folate)
Promethazine
Anti-vomiting drug Also used for motion sickness
Ondansetron
Anti-vomiting medication
Sucralfate; when should it be given? What should it NOT be given with?
Antialcoholic med (causes patient to vomit if they drink) Should be given on empty stomach Do not take with H2Ras/PPIs
Sulfasalazine; usage?
Antibiotic used to reduce inflammation in ulcerative colitis/Crohns
Trihexyphenidyl
Anticholinergic (think benzotropine) Used for Parkinson and dystonia
Benztropine
Anticholinergic medication given for Parkinson symptoms
Fondaparinux --What is it? --How does it work? --How does it vary from more commonly known variants in its class? What are the implications of this?
Anticoagulant Inhibits clotting factor Xa Does not have a specific coagulation test for monitoring (unlike heparin/warfarin) Therefore, to monitor you need to check general kidney function tests (creatinine), since it is excreted by the kidneys
Dopexin hydrochloride
Antidepressant
Metoclopramide; major side effect
Antiemetic Can cause EPS (i.e. tardive dyskinesia) Hold if they have involuntary finger movements
Fluconazole
Antifungal
Hydroxyzine hydrochloride
Antihistamine medication
What action is necessary for an amputee patient to promote effective fitting of a prosthetic?
Apply bandages; helps prevent swelling and "molds" the limb to the needed shape
What should be done a wound dressing sticks to the skin?
Apply sterile water (and/or alcohol swaps) to loosen it Do NOT just pull it off; will damage area
For solid radium implants, bodily fluids (are/aren't) conisdered contaminated; what is the opposite
Are considered Liquid implants make bodily fluids contaminated
Proper walker usage --How should arms to placed --Movement sequence --Getting into chair sequence
Arms should NOT be straight (flexed 20-30 degrees) Lift walker 6 inches in front Walk with bad leg Follow with good leg Grasp arm using bad side Shift weight to good leg Using bad side, lower into chair
For substance abuse patients, how often are opioid meds given following surgery?
Around the clock, due to high risk of withdrawal
When should antivirals be started?
As soon as symptoms appear
What pain medication should NOT be used during pregnancy?
Aspirin
A ventilator alarm goes off. In what order do yo uassess things?
Assess patient first, not equipment 1. Auscultate breaths 2. Check respiratory rate Then check equipment 1. Check for kinks/clumping Once everything is resolved, THEN you can turn off the alarm
Palpitations are caused by what blood pressure med?
Beta blockers
Compression fracture
Bone is crushed by other structures (think vertebrae crushed between 2 other vertebrae)
Comminuted Fracture
Bone is shattered into multiple pieces (at least 3)
Greenstick fracture
Bone isn't completely in half (think a crack)
What is obtained first in a baby, bowel or bladder control?
Bowel
What is an adverse effect of calcium channel blockers?
Bradycardia Hold it if they have low HR
When palpating the abdomen, how should the patient breathe? What is the exception?
Breath slowly in and out Palpate with one hand if they're in pain (too much pressure = more pain) They need to hold their breathe to palpate the liver
How does the female body adapt to the increased cardiac output during pregnancy
Breathing becomes deeper (but NOT faster) HR increases by 10-15 bpm Blood pressure does NOT increase (the vessels vasodilate to keep it consistent)
Theophylline
Bronchodilator
Axotemia
Buildup of uric acid and other byproducts Is a result of kidney damage
What is a major symptom of trigeminal neuralgia?
Burning shooting pain across the face Think about what the trigeminal nerve is involved in (tests) Facial sensation Movement in mastication (hold mouth closed against pressuer)
Diet for Addison's vs Cushings
CUSHING 1. Low sodium (elevated aldosterone) 2. High potassium 3. Low carbohydrate 4. Low calorie 5. High protein ADDISONS 1. High protein 2. High sodium 3. High carb 4. Low potassium
A patient is having an exacerbation of UC; what body system gets priority?
Cardiovascular (heart rate/rhythm) Remember, they are anemic r/t bloody stools and hypvolemia can occur
You suspectt a patient has an air embolism --What caused this? How do they present? --How do you position them
Caused by injection of air into IV line OR detatchment of IV tubing from IV site (especially central lines) -------------------------------------------------------------- Trendelenberg, left side-lying (traps air in right ventricle)
What is a MAJOR life-threatening side effect of estrogen replacement?
Causes increased coagulation Risk of DVT/pulmonary embolism
Licorice has what drug interaction
Causes loss of K+ Therefore, should be avoided in drugs where K+ loss is an issue --Furosemide --Digoxin
Chemotherapy has what GI effects; how do we help with this?
Causes stomatitis Do regular mouth care and avoid foods which exacerbate it (spicy + hot)
What is a major side effect of Ritalin and other amphetamines in terms of child growth/development? How do you combat it?
Causes suppression of appetite Give AFTER breakfast to prevent this
Rales
Crackles; wet crackling noise in lungs
The home health nurse visits a client diagnosed with dementia. The client lives with an adult child and family. The nurse identifies which stressor as most critical to the family? 1.The client is unwilling to eat with the family. 2.The client does not recognize family members. 3.The family is not aware of community resources available to them. 4.The client is continent.
Client does not recognize family members
Treatment of diverticular disease --Symptoms --Drugs/diet --Acute care
Cramping which is relieved when pooping or farting Fever/WBC elevated (If diverticulitis) Constipation/diarrhea alternate ---------------------------------------------------- 1. Laxatives 2. High-fiber diet 3. Avoid nuts/seeds/popcorn (foods that can get stuck in there) 4. Promote fluids ---------------------------------------------------- 1. Bedrest 2. NPO 3. NG tube food 4. Antibiotics 5. Surgical drainage of outpocketing if necessary
Esophageal atresia; what would lead you to suspect this?
Congenital condition in which esophagus has a dead end, instead of connecting to stomach -Excessive saliva -Choking/coughing/vomiting when eating -Sputum which is white (food coming back up)
Synchronized Intermittent Mandatory Ventilation (SIMV)
Control mode fo ventilator The machine will give a set number of breaths at a given volume If the patient attempts to breathe on their own, the machine will lay back and let them breathe -- NO EXTRA AIR GIVEN
(Cool/cold) cloths are used to treat pain
Cool
The toddler admitted with an elevated blood lead level is to be treated with intramuscular (IM) injections of calcium disodium edetate and dimercaprol. Which nursing action has the highest PRIORITY? 1.Keep a tongue blade at the bedside. 2.Encourage the child to participate in play therapy. 3.Apply cool soaks to the injection site. 4.Rotate the injection sites.
Correct is 4 You said 1; I'm not really sure why
What is the most effective measure a patient can do at home to determine if their fetus is alright in-utero?
Count number of fetal kicks
Strabismus; what is a major indicator?
Cross-eyed Have to close 1 eye to look at something
When disposing of a transdermal pouch, you should NOT do what with it? Why?
Cut it It will release some of the medication, which can then be absorbed by the skin
Acrocyanosis; how does it relate to newborns
Cyanosis on extremities Is normal for first 12-24 hours, afterwards is bad
Sitagliptin
DDP-4 inhibitor (-gliptin)
In a patient with a tube, you would expect the amount of secretions to ____ over time; what do you expect if the opposite happens
DECREASE over time IF it increases, suspect an obstruction/impaired healing
The nurse performs dietary teaching for the client diagnosed with asymptomatic diverticular disease. The nurse determines further teaching is required if the client makes which statement? 1."I'm glad that I can eat the tomatoes from my garden." 2."I eat baby carrots as a snack almost every day." 3."I mix several different kinds of lettuce for my evening salad." 4."I only eat whole-wheat bread for my lunch sandwich."
Diverticular disease patients should have lots of fiber, but avoid seedy foods Tomatoes contain seeds 1 is bad
When performing a urine glucose test, what urine should you not use?
Do NOT use the initial urine early in the morning from first void It has been staying in the bladder for hours, so it may have unreliable results
A patient misses their doses of birth control. What do they do?
Do a new form of birth control for the rest of the cycle, then restart Also check for pregnancy
What 2 things should NEVER be done with a traction? --How do you reposition patient if it's in the wrong spot?
Do not release it, do not pull on the weights Hold it steady and have patient lift themselves up in bed
When should tetracyclines be taken?
Do not take at night, because they cause esophageal irritation Take with food
What is a major change that is often present in patients with impaired hearing?
Do not trust strangers (cannot understand the explanations of what is going on)
Myelogram --What is it? --What is done BEFORE test --What is done AFTER test
Dye injected into spine to visualize it ------------------------------------------- 1. NPO 6 hours before test 2. Generic stuff (allergies, consent) ------------------------------------------- 1. Neuro checks 2. Bedrest with HOB elevated 3. Oral meds for headache 4. Encourage fluids to remove dye 5. Check for bladder distention
Intravenous Pyelogram --What is it? --Pre-procedure --What may patient experience DURING procedure? --Post-procedure care
Dye is injected and used to visualize via x-ray the urinary tract (kidneys, ureters and bladder) ---------------------------------------------------- 1. Bowel prep 2. NPO after midnight before procedure ---------------------------------------------------- Patient may have: 1. Burning sensation/flushed skin 2. Salty taste in mouth This would occur during injection of dye ---------------------------------------------------- Encourage fluids
Early vs late signs of liver cirrhosis
EARLY 1. Impaired ability to think 2. Difficulty sleeping at night 3. Changes in handwriting/mild tremors in hands LATE 1. Asterixis (flapping of hands) 2. Abnormal sleep patterns (think sleeping throughout the day)
You receive calls from the following 2 patients. Which do you call back first? 1. Person who had eye surgery and has constipation 2. Person who has foul-smelling urine and a Foley catheter.
EYE SURGERY PERSON Constipation promotes straining, which will increase pressure in eye and cause permanent damage Permanent damage trumps a potential infection, at least with no other noted complications
Describe what each of these mean --Early decelerations --Late deceleratins --Variable decelerations --Heightened/marked variability --Decreased variability
Early decels -> head compression, usually benign Late decelerations -> uteroplacental insufficiency; caused by oxytocin infusion and hypotension in mother (i.e. epidural) Variable decelerations -> caused by umbilical cord issues Marked variability -> more variability than usual; due to stimulants and hypoxia in infant Decreased variability -> variability is lessened (consistent HR); is caused by opioids
In what order do these occur? 1. Dilation 2. Effacement 3. Fetal descent (think station)
Effacement first Descent second Dilation third
Describe proper placement of a patient with below-knee amputation
Elevate limb for first 24 hours Put in prone position for first 24 hours Encourage flexion of quad/glut to prevent contractures
(T/F) Sterile supplies should be all be preemptively opened
FALSE; should only be opened as needed for a given procedure
(T/F) Aspirin, ibuprofen and naproxen should be taken without food
FALSE; take with food, milk or antacids to reduce GI upset
Colonoscopy screening details
Every 10 years starting at age 50
Describe when breast exams should be done
Every 3 years from age 20-40 Yearly from 40 onward
When are PAP smears done?
Every 3 years from age 21-29
Liver cirrhosis patients are at high risk for what blood issue? Why?
Excessive bleeding; portal HTN leads to backup of blood
(T/F) A gout patient should do passive ROM activities
FALSE; that makes it worse?
(T/F) A patient with a colostomy cannot swim
FALSE; the patient can return to all previous activities They don't even require a waterproof barrier once it fully heals. Go figure
(T/F) Following major surgery, the patient has BOTH bladder and bowel incontinence
FALSE; they generally have bladder incontinence, but not bowel
(T/F) When a patient returns home, some bloody drainage is normal
FALSE Generally, the patient won't be allowed to go home until it is serosanginous If it is sanginous or bloody, that's a problem
(T/F) For home care sterile techniques, the patient must wear sterile gloves
FALSE It's a good idea, but impractical, so they just wear non-sterile grloves
(T/F) You should milk the finger for a blood glucose test
FALSE Milking the finger causes the interstitial fluid to mix with the blood, impacting results
(T/F) Vitamin C is not encouraged for patients with wounds
FALSE Remember -> vitamin C helps with connective tissue repair/maintenance
(T/F) Itchiness during opioids is perfectly fine, and should not be addressed
FALSE: is an adverse effect, interventional measures should be taken
(T/F) CXR are definitive for TB
FALSE: only suggestive
(T/F) Aspirin should be given to children
FALSE: salicylates are not recommended Give tylenol instead
(T/F) Medications can be given through a TPN line
FALSE: the line is ONLY for TPN
(T/F) Patients with dialysis fistulas cannot get their arms wet
FALSE: they can
(T/F) Seasoned foods prevent constipation
FALSE; are generally avoided with hiatal hernias, Crohn's and ulcerative colitis
(T/F) Amputee patients are always placed on their back
FALSE; are placed prone part of the day to prevent over-flexion of the extremity
(T/F) The breasts of a breastfeeding mother should be washed with water and soap
FALSE; avoid soap; dries out the breast
(T/F) Immunosuppressed people should brush and floss teeth
FALSE; do not floss (risk of bleeding)
(T/F) Do wounds require sterile gloves?
FALSE; only the initial cleaning; every other cleaning and home care do not
(T/F) For patients with radiation, a lead apron is required to be worn at all times
FALSE; only wear if you are required to be in room for extended time (i.e. a procedure) For routine things like vital signs, it's not needed
(T/F) Bumper pads should be placed in newborn crips
FALSE; risk of aspiration
(T/F) CNAs are allowed to clean up plants in the room
FALSE; risk of cross-contamination from things on plants Let janitors clean it up
How do you measure for NG tube?
From tip of nose to earlobe, then to xiphoid process Tip of nose to earlobe is to reach esophagus To xiphoid process is to reach stomach
Describe the position of the fundus post-birth in a mother
For the first 6-12 hours, it is at the level of the belly button Starting on day 1 post-birth, the fundus will drop roughly 1 finger length per day below the belly button
Kaposi's sarcoma; what patient care should be done?
Form of skin cancer common in AIDs patients Manifests as purple-brown spots that spread throughout the skin (and eventually to organs) Wash them with soap and water daily to prevent infection
What is a major complication that can make removing a gastrostomy tube difficult? How do you prevent it?
Formation of adhesions onto the tube Once every day: 1. Rotate the tube 360 degrees 2. Pull it in and out slightly
You see a postpartum patient bleeding between legs; what is most important to assess, BP or fundus?
Fundus BP is too nonspecific; the fundus will tell you specifically if it's postpartum hemorrhage
Describe each of the following for gastric vs duodenal ulcers 1. Age 2. Sex 3. Risk factors 4. Stomach secretion rate 5. Pain, and when it occurs/what relieves it 6. Vomiting 7. Bleeding risk 8. Cancer risk
GASTRIC 1. 30-60 years (middle age) 2. More common in males 3. COPD, renal failure, smoking, alcohol, stress 4. Elevated secretions 5. Pain occurs 2-3 hours after eating and when sleeping; eating foods makes pain better 6. Low risk of vomiting 7. Bleeding not likely 8. Cancer rare DUODENAL 1. Above 50 (elderly) 2. Equal among sexes 3. Gastritis, alcohol/smoking, NSAIDS, stress 4. Normal or diminished secretion 5. Immediately after eating or when not eating; eating does NOT help, but vomiting does 6. Frequent vomiting 7. Bleeding common 8. Cancer occurs sometimes
Exenatide
GLP-1 agonist (incretin mimetic) (-tide)
After abdominal surgery, the client reports abdominal gas pain. It is most important for the nurse to take which action? Select all that apply. 1.Offer the client fresh fruits. 2.Ambulate the client frequently. 3.Teach the client how to splint the abdomen during activity. 4.Position the client on her right side. 5.Provide bisacodyl suppositories prn.
Gas retention indicates what? --Lack of peristalsis What do you do to fix that? 1 -> WRONG; they have no peristalsis, so they can't eat yet 2 -> CORRECT 3 -> doesn't fix the peristalsis issue; psychosocial 4 -> TRUE; stomach is on left side, puts pressure off it 5 -> TRUE
A patient receiving lispro and NPH is scheduled for surgery; what do you do with their insulin regimen the morning of the surgery?
Hold it
Describe proper usage of a cane
Hold on good side (opposite bad) When moving on flat ground: 1. Cane + bad leg first 2. Good leg second Do NOT hold with a straight arm (should be flexed)
Patients diagnosed with heart failure should have what prophylactic measure?
Get pneumonia/flu vaccinations, since infections increase cardiac workload, which can kill them
Fecal occult blood test screening details
Get yearly starting at age 50
How is adenosine administered?
Give as a rapid IV bolus (1-3 seconds), then IV flush it
Describe the CPR technique for a non-infant child
Give breaths for 20 bpm Use the heel of 1 hand and compress the sternum Compress 2 inches
A patient has just experienced a seizure, and has symptoms indicating they are about to have another one. What is the priority?
Give medication to prevent seizure --Benzodiazepines
What kind of fluid replacement is done with DKA?
Give normal saline until blood glucose is less than 250 At that point, change to dextrose solution to prevent rebound hypoglycemia
A 1 year old infant is scheduled to get a vaccine, but they have a low-grade fever and minor respiratory illness symptoms. What do you do? --What is the ONLY indication the vaccination should not be given?
Give the vaccine Minor fever/respiratory illness ins't enough; they need a more severe illness ONLY hold the vaccine if: 1. They are allergic 2. They are immunosuppressed 3. They are taking antiviral meds
A patient in a psych unit brags about binging alcohol and not having a job for 3 years. What is an appropriate task to give them?
Give them a job to do in the place (i.e. cafeteria)
Volume-guaranteed pressure option (ventilator)
Gives a preset volume AND pressure of air
Pressure-support ventilation
Gives a set pressure of air during inhalation Assist patient with breathing themselves
Budesonide
Glucocorticoid
In general, weight changes are good for measuring ___, but not ___
Good for measuring degree of fluid retention Not good for dehydration
In general, when going up stairs it is ___
Good leg first when going up Bad leg first when going down
A wound (Hemovac) drain is attached to what?
Gown/clothing
lecithin sphingomyelin
Greater than 2 = baby can produce surfactant Lower than 2 = baby has Down syndrome
List the transmission route and outcome for each of the following --Hepatitis A --Hepatitis B --Hepatitis C --Hepatitis D --Hepatitis E
HEPATITIS A 1. Fecal-oral route (travelling) 2. Common to those HEPATITIS B Routes: 1. IV drugs 2. Sex 3. Health care (IV infection)/hemodialysis 4. During birth HEPATITIS C Routes: 1. IV drugs 2. Health care (IVs/hemodialysis) 3. During birth HEPATITIS D See hep B (person has to be infected with hep B first) HEPATITIS E 1. Fecal-oral (going to 3rd world countries)
Adverse effects of corticosteroids
HID HAVOC CRUTCH H -> headache I -> insomnia D -> depression H -> hypertension A -> anxiety V -> vertigo O -> osteoporosis C -> confusion C -> cataracts R -> retention (of Na+ and water) U -> ulcters T -> tachycardia C -> cushings (weak skin, buffalo humpt) H -> hyperglycemia
A news reporter and camera person arrive on the nursing unit to videotape an interview of the client. When the nurse refuses their request, the reporter references his First Amendment rights. Which statement, if made by the nurse, is most appropriate? 1."Why do you want to talk with the client?" 2."I'll ask the client if he is ready to speak with you." 3."I will need to call the nurse manager about your request." 4."Does the client know that you are coming?"
HIPPA - remember that you can't confirm or deny the existence of the patient You said #2; this confirms existence of patient Do #3
How should a neuro patient be placed to prevent increases in ICP?
HOB elevated and supine (promotes drainage from head)
List the priorities, IN ORDER for a sickle cell crisis
HOP to it H -> hydration O -> oxygen P -> pain medications Therefore, hydration is most important
A patient is exhibiting a panic attack and is beginning to have combative behavior. You receive an order for PRN medications to calm them down. One of the medications is a benzodiazepine, and the other isn't. What is the other drug?
Haloperidol or fluphenazine Aka traditional antipsychotics
Pleural friction rub --What does it sound like? --What is it associated with?
Harsh rubbing noise Indicates inflammation of pleura
What is the most dangerous blood transfusion reaction? --Symptoms? --What do you do?
Hemolytic reaction -------------------------------------------------------------- 1. N/V 2. Back pain 3. Bloody urine -------------------------------------------------------------- 1. Stop blood 2. Assess blood volume status (BP) and kidney status (creatinine) 3. Send blood product/tubing to lab
What is a normal expected finding following a laryngectomy? What causes it? When is it concerning?
Hoarseness when speaking Caused by normal post-surgical edema in area Is normal if short-term; is concerning if it persists (nerve damage)
What are the S/S of heroin withdrawal?
Heroin is an opioid; what are opioid withdrawal symptoms? The opposite of the effects: 1. Rapid HR/breathing 2. High BP 3. Muscle pain 4. Dilated pupils 5. Diarrhea OTHER NOTABLE EFFECTS 1. Yawning 2. Runny nose 3. Fever
Which diseases require both airborne AND contact?
Herpes/shingles
When are RBCs indicated?
Hgb less than 8 for immunocompromised Hgb less than 7 for everyone else
In what position is a COPD/emphysema patient placed, Semi-Fowler or high Fowler?
High Fowler
Diet for liver cirrhosis
High calorie, high carb, low fat, MODERATE (not high) protein
What diet is a risk for colon cancer?
High fat
What is the appropriate diet for a spinal cord injury patient?
High-fiber Remember - autonomic damage may lead to diminished bowel motility
Wheezes
High-pitched continuous sounds (like whistling) Indicate impaired movement of air (common during exhalation in COPD, emphysema, asthma)
Stridor --What does it sound like? --What is it associated with?
High-pitched crowing noise with a constant pitch Indicates obstruction in trachea or larynx
What is an early sign of elevated ICP in an infant?
High-pitched cry
Colloid solutions are (hypo/iso/hyper) tonic
Hyper
Hyper vs hypocalcemia GI
Hyper -> constipation Hypo -> diarrhea
Changes associated with metabolic acidosis
Hyperkalemia Kussmaul respirations (to blow off CO2)
When does prosthesis fitting for an amputee begin?
Immediately (or upon healing of wound, which is usually pretty quickly)
When taking out an IV, the catheter tip is not attached when pulling it out; what do you do first?
Immediately apply a tourniquet to prevent embolisms from forming in heart/lungs
Medication air lock; for which route
In IM injections, drawing in a small amount of air after the medication before injecting Prevents the medication from leaking out to other ares
True contractions during true labor are felt ___
In the lower back
When should corticosteroids be taken? Why?
In the morning with food --Remember -> insomnia is a side effect
Describe the positioning of a amputee patient IMMEDIATELY after surgery and long-term
In first 24 hours -> ELEVATE LIMB Long-term -> do not elevate limb for long periods; promote prone position multiple times a day to prevent contractures
How do you dispose of urinary catheter supplies after use?
In garbage No need for biohazard bag
What is the normal reaction of a patient following a major body-altering surgery at the 1 month mark
In grieving stage
Cervix cerclage
In pregnant women, the artificial closing of the cervix with sutures temporarily if it will not stay closed long enough to allow for a pregnancy
When shoudl eye ICP measurements be done?
In the morning; ICP is highest then (head has been laid down, so more flow of fluid)
Bronchiolitis --What is it? Who gets it? --Causative agent --Nursing care
Infection of lower airways common in younger children RSV (virus) 1. CONTACT PRECAUTIONS 2. Put in private room 3. Put in tent with cool humidified oxygen 4. IV fluids 5. Control fever
Impetigo --What is it? --Treatment --What is a potential problem if not treated? What symptom does this have?
Infection resulting in red-colored rash which then becomes honey-colored and crusts over ---------------------------------------------------- 1. Take measures to prevent transmission (wash hands, avoid touching face) 2. Antibiotics 3. Loosen scabs with compresses and remove ---------------------------------------------------- If untreated, leads to glomerulonephritis (kidney damage) Major giveaway -> edema
Mononucleosis --Transmission --MAJOR sign/symptom
Infectious disease transmitted via saliva General flu-like symptoms, sore throat, ENLARGED LYMPH NODES
Toxic hepatitis
Inflammation of liver r/t exposure to a substance (is not caused by an infectious agent, and is not transmissible) Major cause -> tylenol/statin overuse Treatment -> remove cause (acetylcystein for tylenol), supportive care
Intermittent vs continuous bubbling in water seal
Intermittent -> is normal, associated with coughing Continuous -> is NOT normal, check for air leak
Metformin should be held if patient is doing a procedure that contains ___
Iodine (aka contrast medium)
Ferrous sulfate --What is it? --Side efects --Usage
Iron supplement ------------------------------------------- 1. Black stools (may be misinterpreted as blood) 2. Nausea 3. Constipation ------------------------------------------ 1. Take with orange juice 2. Do NOT take with milk or antacids 3. Drink through straw (stains teeth)
Describe what urine specific gravity is
Is a comparison of urine density to that of water (which is set at 1) Normal -> 1.01-1.03 If less than 1.01 -> you have more dilute urine If more than 1.03 -> you have more concentrated urine
How does bladder distention relate to postpartum hemorrhage?
Is a risk factor (displaces uterus, which impairs contraction) To promote contraction, have them empty bladder
Longitudinal fracture
Is along the long line of the bone
How does hemoglobin and hematocrit change during pregnancy?
Is expected to drop r/t increased amount of plasma cells
(!) What is the purpose of giving a pregnant woman terbutaline/albuterol in labor?
It delays birth, stalling for time if the kid is preterm (Think of it as the opposite of oxytocin)
Following a vasectomy, what should be done during sex?
Keep wearing condoms for ~6 weeks to prevent pregnancy from residual sperm
What is a major secondary disease complication of hyperparathyroidism? What are you looking for?
Kidney stones (because of elevated calcium) Bloody urine
What is the appropriate positioning of a child patient with Tetralogy of Fallot experiencing respiratory distress?
Knee-chest NOT HOB elevated
In child clients with a painful area, when should you assess that area?
LAST That way they will be cooperative
Describe what each of the following are for active vs latent TB --Can it be spread to others? --Do they have symptoms/feel sick? --CXR results --Interferon gamma results --Sputum culture results --Do they need to be isolated?
LATENT --Can't be spread --Don't feel sick --Normal CXR --Positive interferon results --Negative sputum --NO ISOLATION NEEDED ACTIVE --Can spread --Have symptoms --Infiltrates in CXR --Positive interferon results --Positive sputum --ISOLATION NEEDED
A left-sided stroke results in what impairments? How about a right-sided stroke?
LEFT SIDE 1. Right-sided weakness/paralysis 2. "Analytical" + speech impairments --Can't speak --Poor analytical thinking --Poor math skills RIGHT SIDE 1. Left-sided weakness/paralysis 2. "Emotional" impairments + orientation --Impulsive behavior --Disorientation (A+Os are off)
What is a normal cholesterol level?
LESS than 200 (200 itself is bad)
Define each of the following: 1. Lordosis 2. Kyphosis 3. Ankylosis 4. Scoliosis
Lordosis -> abnormal forward curvature of spine Kyphosis -> abnormal backward curvature of spine (think a hump) Ankylosis -> abnormal stiffness in joint Scoliosis -> S-shaped curvature of spine; usually presents itself during adolescence
Precipitous labor; why is it concerning?
Labor lasting less than 3 hours Is a HIGH risk for postpartum hemorrhage due to rapid stretching (and potentially tearing) of maternal tissues
Preferably, IM injections should be done in ____
Large muscles Deltoid not preferred unless immunizations Iron medications especially
Ewald tube
Large, orally inserted tube designed for rapid lavage of stomach contents SUCTION EQUIPMENT MUST BE THERE (risk of vomiting)
Children can transition away from booster seats once they are what?
Larger than 4 foot 9 --Make sure if they are in a booster seat that they have both lap AND shoulder seatbelt attachments
Cyanosis is an (early/late) sign of hypoxemia
Late
Knock-knee
Legs curved inward so that knees come together as person walks Normal in children aged 2-4
What is a common "soda" that does not contain a large amount of sodium?
Lemonade
A patient is exhibiting a heart block. An order for what medication should be questioned?
Lidocaine You don't want to knock out what ventricular activity you have, which lidocaine will do
When is a loop diuretic the drug of choice? When is a thiazide diuretic the drug of choice?
Loop -> EXTREME hypertension Thiazide -> mild to moderate
Early in pregnancy, where would you put a Doppler to check for fetal heart sounds?
Low (close to the vagina almost) Remember -> the fetus is small at this point
The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first? 1.Place the client on continuous pulse oximetry. 2.Monitor the client for changes in blood pressure. 3.Notify the health care provider. 4.Assist the client to use the incentive spirometer.
Low BP Rapid HR Rapid breathing What does this indicate? SHOCK 1. Do you need pulse ox to tell there is a problem? NO 2. This is effectively doing nothing 3. Correct 4. This is an emergent emergency condition -> spirometry will be helpful later
The presence of U waves indicates what electrolyte problem?
Low potassiu
Rhonci --What do they sound like? --What are they associated with?
Low-pitched rumbling noise Indicate secretions (or tumors)
Following low bowel surgery, what diet are you on?
Low-residue (to reduce intestinal activity)
How should a Crohn's patient be positioned?
Lying straight with legs flexed at knees If left straight, the abdominal muscles are flexed, which exacerbates pain
Tranylcypromine sulfate
MAOI
In what order are the medications given during a heart attack?
MONA #1 -> morphine #2 -> oxygen #3 -> nitroglycerin #4 -> aspirin
Signs of hypermagnesemia (6) --What should you do to prevent this? --What is the reversal agent?
Mag is a drag 1. Slow HR/breathing 2. Low BP 3. Weakness 4. Can lead to arrhythmias, leading to death 5. N/V 6. Cardiac arrest (if not treated) -------------------------------------------------------------- Monitor VS -------------------------------------------------------------- Calcium gluconate
Magaldrate
Magnesium-based antacid
Dantrolene
Muscle relaxant Used for neuroleptic malignant syndrome from antipsychotics
Moderate sedation vs general anesthesia --Status of patient --Breathing --Reversal agents
Moderate sedation --Patient can still respond to commands --ET tube not needed --Do not need to give reversal agents at the end General anesthesia --Patient is completely unconscious --ET tube needed --Reversal agents needed
Delirium tremens
More life-threatening version of alcohol withdrawal, involving: 1. N/V/D 2. Delusions 3. Seizures
There is a high pressure alarm on a ventilator; what do you expect?
Mucus plus, tubing kink?
Pyloric sphincter
Muscle between stomach and small intestines
What are NOT reliable indicators of infection in elderly? --Which factors ARE the most reliable?
NOT RELIABLE 1. Elevated temp 2. Elevated WBCs IS RELIABLE 1. Confusion 2. Rapid HR/breathing
A mother being treated for a leg emboli with heparin asks a question concerning changes in breastfeeding practices. What is an appropriate response?
NOTHING needs to be changed Heparin cannot be transmitted via breast milk
When ambulating a patient, the nurse stands on the (strong/weak) side, and the cane is held on the (strong/weak) side
NURSE -> stands on weak side Cane -> held on STRONG side
Describe how each of the following are cared for in UC and Crohn's --Nutrition --Fluids/electrolytes --Pain --Skin
NUTRITION 1. Weigh them daily 2. High nutrient intake (can be malnutrition) FLUID/ELECTROLYTE 1. Check for anemia (H/H) 2. Check for electrolyte impairments (can't absorb -> check values) 3. Check urinary output (sign of dehydration) 4. VS/mental status PAIN 1. Give pain meds SKIN INTEGRITY At risk of skin degradation/fissures due to constant poop; check for that
dipyridamole thallium
Name of medication used for heart chemical stress test Avoid caffeine before giving; it "tires out" the heart preemptively
Bromocriptine --Usage --Effect --Side effects --Usage details (when is it given?)
Neuroleptic malignant syndrome + Parkinsons ------------------------------------------ Promote dopamine activity ------------------------------------------ 1. Low BP/ortho hypo 2. Headache/dizziness 3. Nausea/abdominal cramps 4. Tinnitus ------------------------------------------ GIVE WITH MEALS Check cardiac function Check liver/renal function (else potential buildup)
Molding
Newborn head has bones which can overlap to make it easier to slide out Head may be abnormally shaped when it comes out; that's normal
When are long-acting insulins like glargine usually taken?
Night
A pregnant woman says she lies on her back to watch television. What do you say?
Not a good idea; have them lay on side (remember that vena cava becomes compressed)
An influx of clients arrives at an emergency department. The nurse is correct in triaging which clients as critical? (Select all that apply.) 1.The client with facial asymmetry and pulse 112 beats/min. 2.The client with chest pain and blood pressure 140/100 mm Hg. 3.The client with generalized weakness and dizziness and pulse 30 beats/min. 4.The client with copious amounts of diarrhea and blood pressure 118/72 mm Hg. 5.The client with an oxygen saturation of 79% on room air. 6.The client with confusion and blood glucose 42 mg/dL (2.33 mmol/L).
Notice - critical means they are expressing life-threatening S/S of their illness, and will immediately progress to death if not treated Patients who have not been diagnosed yet are not pronounced critical unless life-threatening 1 +2 are serious, but because they are emergent cases (diagnosis hasn't been made), they aren't critical 3, 5 and 6 display life-threatening symptoms already, so they're critical
The nurse cares for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It is MOST important for the nurse to take which action? 1.Utilize an organized team to place the client in seclusion. 2.Leave the client alone in his room to identify feelings of anger. 3.Redirect the client to a quiet activity to divert his attention and not disturb the other clients. 4.Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Notice it says it's escalating INTO aggressive behavior; the behavior hasn't started yet Try and talk them down
How do you do a breast exam?
Take 3 middle fingers Press breast against chest wall and feel for mass Repeat in circular motion
A patient with a halo vest arrives to your clinic alone. They say they did not take public transport. Why are you concerned?
They can't turn their head while the halo vest is on, so how can they drive effectively?
A nurse comes in to work with shingles. What instructions do you give?
They cannot care for patients Stay home until the shingles lesions crust over
"I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his bike." What concerns you about this statement
Only a bicycle helmet is needed All the other things are used for skateboard/rollerblade
As an agent, benztropine is used in neuroleptic malignant syndrome ___
Only to treat Pseudoparkinsonism symptoms Otherwise give dantrolene + bromocriptine
Intermediate-acting insulin onset, peak, duration
Onset -> 1-2 hours Peak -> 4-12 hours Duration -> 16 hours
Rapid-acting insulin onset, peak, duration
Onset -> 15-30 minutes Peak -> 1-3 hours Duration -> 3-5 hours
Long-acting insulin onset, peak duration
Onset -> 3-4 hours No peak Duration -> 24 hours
Short-acting insulin onset, peaking duration
Onset -> 30-60 minutes Peak -> 1-5 hours Duration -> 6-10 hours
Meperidine
Opioid
Butorphanol tartrate
Opioid analgesic --Need to observe respirations
Describe how breaft feeding and fertility relate
Oral contraceptives inhibit the nutrients of breast milk, so they shouldn't be taken together Breasfteeding will NOT prevent you from getting pregnant
Describe the acidity of each of the following: --Orange juice --Tomato juice --Milk --Apple juice --Carbonated beverages
Orange + tomato are acidic Milk is alkaline Apple is alkaline Carbonated beverages (surprisingly) are alkaline
During a kidney transplant, what signs would indicate rejection is occurring specific to that organ?
Organ isn't functioning 1. No urine 2. Fluid retention (edema/weight gain) Just think of a late-stage renal failure patient
Before an oral airway can be removed, what is the BEST indicator that you should proceed and take it out?
Patient is responsive They respond to the spoken voice, can follow commands, etc Note that the gag reflex returns BEFORE this; it isn't reliable
A chest tube tubing becomes disconnected; what do you do?
Place tube end in 2 cm of sterile water and notify provider
How is the intubation equipment cleaned following a ET tube insertion?
Placed in a bag and gas sterilized
What is a skin sign of allergic reaction?
Petechiae/hives
sevelamer
Phosphate binding agent Given to reduce phosphate levels
The nurse instructs a client on 100 mg losartan and 25 mg hydrochlorothiazide tablets to be taken once daily. Which statement requires an intervention by the nurse? 1."I will eat more fresh fruits while taking this medication." 2."I should call my health care provider if I develop swelling of my lips." 3."I can take this medication with or without food." 4."I understand that I may develop a dry cough while taking this medication."
Process of elimination 1 -> HCTZ causes loss of K+; fruits contain K+ 2 -> angioedema is a side effect of -sartans 3 -> true, can be taken with or without food 4 -> FALSE, a cough is exclusive to ACE inhibitors, not -sartans
When lifting a kid out of the water from drowning, you do so in what position?
Prone (to prevent spinal damage)
The nurse notes that a client requires protective isolation. Which additional client will the nurse safely pair with the client in protective isolation? 1.Client with a urinary tract infection. 2.Client with a stage 3 sacral pressure ulcer. 3.Client with unstable diabetes mellitus. 4.Client recovering from surgery for a perforated bowel.
Protective isolation = poor immune system Which of these has the lowest risk of developing an infection? 3
A chemo patient has no fever, but a productive cough. What do you do?
REMEMBER -> they have a diminished immune response, so they may not have fever Suspect an infection
You suspect a patient is in shock; what position do you put them in?
Raise the lower extremities Do NOT put in Trendelenberg (though it makes sense on initial inspection) -- this puts extra pressure on lungs
Epiglottitis is slow/rapid
Rapid
Acidosis leads to ___ breathing
Rapid (blow off CO2)
Lispro
Rapid acting insulin
Automatic insulin pumps used at home are only allowed for what type of insulin?
Rapid-acting Glargine and other long-acting are always given once daily, usually at night
Phenylketonuria (PKU) --What is it? --Treatment?
Recessive disorder in children leading to an inability to break down phenylalanine Eventually it will build up in the brain, causing mental disability Low-protein diet (phenylalanine is an amino acid) Lofenalac milk (is a substitute without the substance)
Metformin --Effect --Adverse effects --Safety tips in hospital --What should be avoided?
Reduces glucose release by liver (has no direct effect on insulin release by pancreas cells) ----------------------------------------------- 1. GI upset (nausea, diarrhea, abdominal discomfort) 2. Metallic taste in mouth 3. Lowered vitamin B12 if taken long-term 4. Lactic acidosis (if taken with contrast medium) ----------------------------------------------- Patients generally do not take these in hospital because stricter insulin control is needed; insulin is given instead HOLD THIS BEFORE SURGERIES/PROCEDURES ----------------------------------------------- Don't drink alcohol
The home care nurse is visiting an alert, oriented woman living with her daughter. The client is malnourished and has multiple bruises on her body, and the situation is reported to the appropriate authority. After counseling the client and daughter, the nurse notes the situation has not improved. The client decides to remain with her daughter. Which action, if taken by the nurse, is MOST appropriate? 1.Respect the client's decision to stay in her daughter's home. 2.Insist the client move in with her other child. 3.Begin guardianship procedures. 4.Place live-in help in the home.
Remember - you need the consent of the elderly person (they are an adult, and alert/oriented) 3/4 don't say you gave consent before doing them 1 is correct
Escharotomy --Why is it done? --What is used to determine if it is successful?
Removal of burn scar tissue Done to prevent tissue from putting pressure on underlying vessels, causing compartment syndrome Pedal pulses should be palpable
What are the surgical treatments for ulcerations?
Removal of stomach or portion of intestines Also vagotomy (remove portion of vagus nerve, since it stimulates HCl production)
What kind of breathing should a patient have while a suppository is put in?
Relax and breathe normally through mouth Holding breath causes them to tense, which makes it harder to put in
In general, what is the biggest safety hazard to remove for a patient entering MRI? What might trip you up?
Remove metallic objects Transdermal medications count as metallic objects (contain aluminum)
In general, when reporting to next shift on a drug, what do you report. What do you NOT report?
Report on adverse effects/responses to drug Do NOT report expected outcomes (i.e. do not report that nitroglycerin patient no longer has chest pain)
After taking an inhaled steroid, you should ___
Rinse mouth
A patient taking an inhaled corticosteroid should do what afterwards?
Rinse mouth afterwards (risk of thrush if they don't)
What temperature should Go-Lytly be consumed at?
Room temperature Too cold -> risk of hypothermia Too hot -> risk of damaging mouth/hyperthermia
Normal child HR
Roughly 80-120 (70-115 in later age) Lasts until age 11
Describe the appropriate age for each of hte following: --Running after a ball --Walking up/down stairs --Hopping/skipping --Tying shoelaces
Running after ball -> 2 years old Walking up/down stairs -> 2-4 years old Hopping/skipping -> 4-6 years old Tying shoelaces (fine motor movement) -> after age 6
A mother giving birth is in the first stage of labor What event causes them to be placed on bedrest, and why?
Rupture of amniotic sac (water down leg) Because the bag holding the baby/umbilical cord is compromised, there is a high risk of umbilical prolapse
List what each of the 4 heart sounds are, and what they mean?
S1 1. "Lub" 2. Contraction of ventricle, relaxation of atria 3. Normal S2 1. "Dub" 2. Contraction of atria, relaxation of ventricle 3. Normal S3 1. Sound AFTER S1/S2 (Lub-Dub-"Noise") 2. Indicates heart failure S4 1. Sound BEFORE S1 2. Indicates ventricular hypertrophy 3. Is normal in elderly
S/S of liver cirrhosis --Skin --Blood --Cardio --GI --Electrolytes --Reproductive --Neuro
SKIN 1. Jaundice 2. Spiderweb-like marks on skin 3. Petechiae/purpura (liver spots) BLOOD Decrease in all blood cells 1. Anemia 2. Thrombocytopenia 3. Leukopenia Bleeds easily Esophageal varices common CARDIO 1. Edema/ascites (think no albumin - can't hold fluid in blood) 2. Portal HTN GI 1. N/V 2. Abdominal pain 3. Anorexia ELECTROLYTES Decrease in everything 1. Low sodium 2. Low potassium 3. Low magnesium 4. Low albumin REPRODUCTIVE Abnormal findings for each gender 1. Gynecomastia 2. Impotence 3. Small testicles 4. Abnormal/absent period NEURO 1. Low B12, folic acid 2. Peripheral neuropathy
The nurse provides care for a child who ingested an unknown substance. The client is unconscious with a respiratory rate of 10 breaths/min, pulse oximeter reading is 88%, and the heart rate is 160 beats/min. The nurse determines which nursing diagnosis is the highest priority for this client? 1.Decreased cardiac output. 2.Ineffective breathing pattern. 3.Ineffective tissue perfusion. 4. Impaired cerebral tissue perfusion.
SLOW BREATHING Breathing trumps everything else; it will kill the fastest
What are each of the following pressure ulcer stages? --Stage 1 --Stage 2 --Stage 3 --Stage 4 --Suspected deep tissue injury --Unstageable
STAGE 1 --Redness on skin, but intact; does not blanch STAGE 2 --Shallow open ulcer with pink/red bed --Partial thickness STAGE 3 --Full thickness --Deep open ulcer --Fat may be visible, but muscles/tendons aren't STAGE 4 --Tendons/muscles are visible --Bone may also be visible Suspected Deep Tissue Injury --Purple or dark red area --May have blood blister Unstageable --Deep, full thickness wound; HOWEVER, the bottom is covered by eschar or slough, so you can't see what's there
Suction the client every four hours to maintain a patent airway. What is the problem with this?
SUCTIONING IS ALWAYS PRN This is too often too
Cocaine drug use --Which symptoms? --What are withdrawal symptoms?
SYMPTOMS - ELEVATION (is a stimulant) 1. High HR, BP, breathing rate 2. Anxiety, irritability 3. Can't sleep 4. N/V 5. Hyperactivity 6. Potentially seizures/coma 7. Hallucinations 8. Nasal septum damage (excess mucus in nose, nasal damage, etc) WITHDRAWAL - the opposite (depressed) 1. Apathetic 2. Sleeping all the time 3. Irritable 4. Depressed
Apgar score
Scale used to evaluate newborn 1 and 5 minutes after birth - each category is scored from 0-2 A -> appearance 2 -> red 1 -> cyanosis on extremities 0 -> full cyanosis P -> pulse 2 -> above 100 1 -> below 100 0 -> no pulse G -> grimace (reflexes) 2 -> responds quickly to stimuli 1 -> some response, but diminished 0 -> no response A -> activity 2 -> spontaneous movements 1 -> flexes arms and legs only 0 -> no movement R -> respirations 2 -> loud, vigorous cry 1 -> slow and irregular 0 -> silent; no breathing Baby should be above 6 If not above 6, is reassessed again 5 minutes later (10 minutes after birth) Score 7-10: no interventions, baby doing good just needs routine post-delivery care Score 4-6: some resuscitation assistance required. Oxygen, suction.... stimulate the baby, rub baby's back Score 0-3: need full resuscitation
What happens if you don't rotate insulin injection sites?
Scar tissue accumulates in area The insulin can't circulate as well from that type of tissue, as a result: Glucose levels go up
Math problems are an appropriate activity for what age range and above?
School-aged (6+)
What should be done with dialysate fluid prior to peritoneal dialysis, and why?
Should be warmed up Cold fluids cause pain (think muscle spasms)
What is a major assessment finding in the posture of a scoliosis child?
Shoulders are uneven
Hypertensive crisis
Side effect of MAOI r/t consuming foods with tyramine in them (cheese, wine, cured meats) EXTREME increase in BP (to 180/110)
Seretonin syndrome
Side effect of SSRIs/MAOIs (block seretonin 1. High HR 2. High BP 3. High temp (sweating/flushing) 4. Elevated reflexes (muscles rigid) 5. Dilated pupils
Kernig's sign
Sign of meningitis When hip is bent, extending the knee is painful
A woman at 6 weeks' gestation and who reports left lower quadrant abdominal pain and vaginal spotting.
Signs of ectopic pregnancy --LIFE-THREATENING, needs to be seen immediately "Spotting + abdominal pain" = ectopic
S/E of beta agonists (i.e. albuterol)
Similar to other alpha/beta activators, it causes sympathetic-esque response (fight or flight) 1. Tremors in muscle 2. Anxiety/agitation 3. Difficulty sleeping 4. Hyperactivity 5. Elevated BP
What kind of positioning should a paracentesis patient have?
Sit upright at the side of the bed (it's very similar to a epidural)
Nutrition of radiation treatment patient
Small frequent meals with high calories and protein If radium implant, low fiber (excess pooping can dislodge implant) Also avoid spicy or hot foods, can exacerbate stomatitis
Wound care is a (clean/sterile) procedure
Sterile
What are S/S of aspiring overdose?
Stomach distress (think bleeding) Ringing in the ears
A client in the ICU is given procainamide HCl (Pronestyl) slowly by IV push. The nurse should withhold the next dose if which of the following is observed? 1.Presence of premature ventricular contractions. 2.Occurrence of severe hypotension. 3.Recurring paroxysmal atrial tachycardia. 4.A sedimentation rate of 10.
THINK! Would an anti-dysrhythmia drug cause dysrhythmias? Probably not Eliminate 1+3 Sedimentation rate is normal (0-30) That leaves 2
(T/F) Carbonated beverages have high sodium
TRUE
(T/F) Contact precaution patients should be placed in private rooms
TRUE
(T/F) LPNs are allowed to perform wound measurements
TRUE
(T/F) Milk has high sodium
TRUE
Hydralazine should be taken with food (T/F)
TRUE
(T/F) The use of no-spill cups with nipples on them is discouraged
TRUE If you do this, the infant will never learn how to drink from a regular cup
(T/F) People in hospitals are allowed to vote; how?
TRUE Using absentee ballot
(T/F) Before feedings, NG tube feedings should be warmed
TRUE (cold foods cause intestinal cramps/spasms) However, do NOT raise it any higher than room temp
(T/F) LPNs are allowed to do routine insulin injections
TRUE (not an IV med)
(T/F) Edema in the legs is normal during pregnancy
TRUE; is due to increased pressure on veins r/t uterus
(T/F) For a clean catch, the urethral opening is cleaned first; what else is done
TRUE; is meant to be a sterile specimen Put into sterile cup
(T/F) Vaginal discharge is normal during pregnancy
TRUE; is only problematic if cloudy/foul smelling or bloody/abnormally colored
(T/F) Less swallowing is expected after a tonsillectomy
TRUE; is uncomfortable to swallow
Rosiglitazone
TZD for diabetes Increases risk of MI
Pioglitazone
TZD for diabetes Increases risk of bladder cancer
What is a contraindication for the dTAP vaccine in infants? What is done in response?
Temperature over 103 after administration Give a modified pediatric DT vaccine
Bell's palsy
Temporary paralysis of 1 side of the face r/t damage to facial nerve
The nurse working in a community hospital's emergency department provides care to a client with chest pain. Which level of care is the nurse providing?
Tertiary care The problem is there, you're treating it Primary -> preventative measures Secondary -> screening/diagnostic measures Tertiary -> actual treatments once it exists
Alpha-fetoprotein (AFP); what does it mean?
Test for neural defects/Down syndrome in fetuses Elevated -> neural tube defects Decreased -> Down syndrome
Alpha-fetoprotein
Test for neural tube defects High levels = neural tube defects
Brudzinski's Reflex
Test in children to determine the presence of meningitis --Flex their neck (lift neck up while laying down); if meningitis, neck stiffness should cause knees to bend as well
The nurse assesses a school-age child after the surgical removal of a brain tumor. Which sign indicates to the nurse that brainstem involvement occurred during the surgery? 1.Orthostatic hypotension. 2.Hearing loss. 3.Elevated temperature. 4.Swallowing difficulty.
The hypothalamus is considered part of the brainstem dummy Brainstem = control of automatic survival stuff (i.e. breathing, HR, temperature) If ICP was increased, you would expect INCREASED BP (Cushing's triad)
How is the positioning of a comatose patient different?
They are placed in a side-lying position with a flat bed (unlike other patients, who have an elevated bed) Remember -> there is nothing stopping saliva from running back, causing aspiration, so you need gravity to help you
What child observation indicates that they are physically ready for potty training; what do you wait for?
They can recognize when they just pooped/peed Wait until they express interest
During dehiscence of a wound, what bed placement does the patient have?
Think -> I want to prevent pressure being placed on wound site, causing further dehiscence 30 degrees and up will cause further strain; not a good idea 15 degrees is good Supine is good
The nurse teaches a client who is prescribed prednisone for systemic lupus erythematosus (SLE). Which information related to prednisone does the nurse include in the teaching plan? (Select all that apply.) 1.Report any symptoms of infection. 2.Do not discontinue medication abruptly. 3.Take medication at bedtime. 4.Report unusual weight gain. 5.Get vaccinated for influenza. 6.Avoid salt substitutes.
Think about the side effects of steroids (in terms of Cushings) Excess aldosterone 1. Fluid retention/weight gain 2. Potassium loss Excess cortisol 1. Osteoperosis 2. Immunosuppression (infections) 3. Hyperglycemia/weight gain 4. Buffalo hump --------------------------------------------------- 1 -> good 2 -> good, prevent Addisonian crisis 3 -> BAD; taken with food in the morning 4 -> GOOD; risk of fluid retention 5 -> BAD, causes immunosuppression 6 -> GOOD, causes hypokalemia
Babinski reflex --When does it go away?
Toes fan out when bottom of foot is brushed Goes away at 1 year old
The nurse provides care for a client diagnosed with ventricular tachycardia and angina. Which medication does the nurse administer first? 1.Nitroglycerin .2.Morphine sulfate. 3.Amiodarone. 4.Metoprolol.
Treat the underlying cause of the chest pain first (the v.tach) Amiodarone
Beta blockers should be taken with food (T/F)
True
BCG vaccine; why should you know it?
Tuberculosis vaccine (used in developing countries due to higher incidence) NOTE -> if they've taken this, they will test + for tuberculin skin test even if they don't have it
In a patient with a cleft lip repair, what do you do if the infant is having congestion/poor respiration?
Turn on the side Do NOT suction (it will irritate the suture line)
Digoxin --What is it used for? What does it do? --Therapeutic levels --Safety concerns --S/S of overdose; what do you give?
Used for heart failure/dysrhythmias Increasese heart contractile strength + slows HR down ----------------------------------------------- 0.5 -2 ----------------------------------------------- 1. Check digoxin levels regularly (more than 2 = bad) 2. Check K+ (hypokalemia increases toxicity risk) 3. Monitor renal function; avoid in patients with renal problems 4. Take apical pulse 2 minute before giving; hold if slow ----------------------------------------------- 1. Nausea/Vomiting 2. Loss of appetite Contact HCP Will give Digibind, the reversal agent
Assist Control (Ventilator)
Volume mode for ventilator Gives a set volume of air per mechanical breath (control) However, it will also provide air to the patient if they attempt to breathe on their own (assist) -- NOTICE YOU ARE GIVING EXTRA AIR
At what age can a kid walk? At what age can they walk with COORDINATED movements?
Walk age -> 1 year Coordinated age -> A year and a half (18 months) If you want to give them a walking toy to play with, wait until coordinated movements
What kind of air should be given for ventilator?
Warm, humidified air
What is the PRIORITY for preventing infections?
Wash hands
When leaving a droplet room, what do you do first, wash hands or remove mask?
Wash hands (think -> your hands are still dirty, do you want to be touching your face with droplets?)
The nurse conducts a class at a senior citizen center on the changes associated with aging. The nurse is MOST concerned if the client makes which statement? 1."I seem to get colds more often now than I did years ago." 2."I'm about an inch shorter now than I was when I was working." 3."I don't mind cooking, but eating doesn't appeal to me much anymore." 4."I've been sleeping with fewer blankets over me lately."
What are normal changes with aging? 1. Greater susceptibility to infection 2. Loss of height (bone changes) 3. Less of an appetitie 4. Feel colder (loss of fat, slower metabolism) 4 is the opposite of what you'd expect (they should have MORE blankets) It's possible they have an infection
A client with a newly casted lower leg reports to the nurse that the foot feels numb. Which action will the nurse take first? 1.Assess for pain. 2.Monitor the cast for dampness. 3.Measure the client's blood pressure. 4.Notify the health care provider.
What are you worried that they have? Compartment syndrome 5 Ps Pallor Paresthesias Pain Pallor Pulselessness (late) The blood pressure won't tell you anything you don't already know; #4
The nurse performs teaching on the client diagnosed with Bell's palsy. It is MOST important for the nurse to include which instruction? 1.Use artificial tears four times per day. 2.Wear sunglasses at all times. 3.Avoid sudden movements of the head. 4.Change the pillowcase daily.
What is Bells palsy? Temporary paralysis of 1 side of face r/t facial nerve damage 1 -> good, won't be able to blink (You said 3) -> this isn't really a specific issue; more of an ICP/ocular pressure issue
The client diagnosed with peripheral artery disease (PAD) talks with the nurse. The client reports leg pain frequently when walking. The nurse should advise the client to take which action? Select all that apply. 1.Lie down with feet elevated above the heart when experiencing pain. 2.Apply a heating pad to his legs for 15 minutes before walking. 3.Walk until pain begins, then rest, and then resume walking. 4.Perform stretching exercises 20 minutes before starting to walk. 5.Start a smoking cessation program. 6.Apply cool packs before walking.
What is PAD -> diminished blood flow to legs r/t narrowed blood vessels resulting in pain 1 -> will REDUCE the blood flow to the legs, actually making the problem worse 2 -> have diminished sensation r/t poor blood flow; likely to burn themselves 3 -> GOOD; exercise promotes circulation 4 -> won't stop pain (I dunno dude) 5 -> GOOD; smoking promotes vasoconstriction 6 -> cool packs promote vasoconstriction, which makes the problem worse
The nurse cares for the client with a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the client in respiratory distress. Which action does the nurse take first? 1.Notifies the health care provider immediately to remove the tube. 2.Elevates the head of the bed, and administers oxygen. 3.Cuts the balloon ports and removes the tube. 4.Calls a code and begins rescue breathing.
What is a Sengstaken-Blakemore tube? Tube with a balloon designed to hold pressure on esophagus to stop varices from bleeding If they're in respiratory distress, it's probably because the tube shifted up and blocked the airway You said 2; is that going to do anything if there's a balloon blocking the air pipe? 3 is correct
The nurse administers an immunization to an adult client. Which observations made after the injection cause the nurse to immediately intervene? (Select all that apply.) 1.The client is clearing the throat and coughing. 2.The client has nasal drainage and sneezing. 3.The client is anxious and exhibits rapid breathing. 4.The client is feverish and sweating profusely. 5.The client reports dizziness upon standing. 6.The client has a diffuse rash across the trunk.
What requires immediate response? Anaphylactic reaction S/S? 1. Airway constriction 2. Drop in BP (dizziness, difficulty talking) 1 -> airway problem, + 2 -> doesn't indicate airway constriction, just mucus formation 3 -> sign of dyspnea, + 4 -> not immediately life-threatening 5 -> sign of drop in BP, + 6 -> sign of less severe allergic reaction, not immediate problem 1, 3 and 5 all indicate IMMEDIATE life-threatening reaction All the others are more long-term, so they don't require immediate intervention
A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action? 1.Observe the color of the client's fingernail beds. 2.Assess the client's blood pressure in both arms. 3.Listen to the client's breath sounds. 4.Assess for intercostal retractions.
Which of these will give the most pertinent information the fastest? Answer is 3 4 is tempting, but it doesn't tell you anything you don't already know (they're in respiratory distress), whereas breath sounds can tell you if its due to fluid in lungs, bronchoconstriction, etc
When can sexual activity be resumed after a heart attack?
When patient can: 1. Walk up 2 flights of stairs 2. Walk 1 city block Without chest pain
When are bubbles in the water seal chamber expected?
When patient is exhaling, coughing or sneezing Should NOT be continuous (air leak)
A registered nurse from a surgical floor is reassigned to a medical unit. Which assignment is most appropriate for this nurse? 1.A client with type 1 diabetes mellitus scheduled for discharge at 2 P.M. 2.A client admitted 4 hours ago with a diagnosis of myocardial infarction. 3.A client with Alzheimer's disease who requires a tube feeding. 4.A client admitted yesterday with a diagnosis of left-sided cerebral vascular accident.
Which one is the most stable, and requires the least (1) evaluation, (2) assessment and (3) teaching? 1. Requires teaching, not a good idea 2. Just came in recently with a life-threatening disease, not stable and requires frequent assessment 3. Only have a chronic condition and a generalized procedure, most stable and most predictable outcome 4. CVA which occurred fairly recently, not stable and requires frequent assessment
The nurse visits the home of a family whose mother died 2 months ago in a motor vehicle accident. Which observation causes the nurse the most concern? 1.A 3-year-old explains that mother is sleeping at grandmother's house. 2.A 6-year-old experiences enuresis and temper tantrums. 3.A 9-year-old states that no one will play with him. 4.A 12-year-old spends time away from home with friends.
Which statement indicates poor death response in its respective age bracket? 1 -> normal, do not understand concept of death 2 -> normal behavior 3- > S/S of depression as a result of event 4 -> indicates positive coping #3 is most concerning
Interaction of carbamazepine during surgery
Will reduce the effect duration of anesthesia, so tell the anesthesiologist to increase dosage
How should oral steroids be taken? WHy?
With food Cause GI upset
NSAIDS should be taken __
With food, because they cause GI upset
At what time is metformin taken? Why?
With meals Causes GI upset, so want to reduce that
Vitamins containing iron should be taken when, and with what??
With orange juice (acidic compounds promotes absorption) and at night (to reduce nausea, since they'll be asleep)
Myelogram
X-ray record of the spinal cord after injection of contrast dye into the area Big difference -> the patient is forced on bedrest for 24 hours afterwards
(T/F) Breast enlargement is expected in adolescent males
YES Though it is temporary
If a child's parents are unavailable but their grandparents are and they are staying with them, can they sign consent forms?
Yes
The nurse knows that the client diagnosed with drug-induced Cushing's syndrome should FIRST be instructed about which of the following? 1.Compression fractures from increased calcium excretion. 2.Decreased resistance to stress. 3.The schedule for gradual withdrawal of the drug. 4.Changes in secondary sex characteristics.
Yes, this is tricky "You can only teach one thing. What will kill them" You said 1 The correct answer is 3 (rapidly stopping drug can lead to Addisonian crisis, which is life-threatening)
Do we treat latent TB?
Yes, to prevent it from converting to active TB
For a baby receiving phototherapy for jaundice: --Can you turn it off/take them out to breastfeed/do procedures? --What indicates the eyepatches aren't on correctly?
Yes, you can The area directly around the eyes and the eyes themselves are losing their yellow coloration (they should be covered)
You see a bulge in the baby's spine; are you concerned?
Yes; spina bifida/spinal cord defect suspected
Lecithin/sphingomyelin ratio
fRatio which determines if production of surfactant has begun, which is the final barrier before labor can be initiated Greater than 2 -> you're good to go, pop that sucker out
Managed care
healthcare system designed to reduce cost of healthcare through focus on PREVENTION of disease`
Flail chest; what respiratory finding do you see?
instability of the chest wall resulting from multiple rib fractures. Chest behaves in opposite manner (when inhaling it goes down, when exhaling it goes up)
Station (fetus)
where baby is related to ischial spines
Phenytoin should NOT be taken if ___
you are pregannt