Review Up to Question Trainer #7
Chadwick's sign
Bluish coloration of cervix Is a PROBABLE indicator ofp regnancy
Compression fracture
Bone is crushed by other structures (think vertebrae crushed between 2 other vertebrae)
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
Pertussis requires which precautions?
"Whooping cough" Droplet
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
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
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
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
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
Watch video on renal calculi
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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 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
Greenstick fracture
Bone isn't completely in half (think a crack)
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
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
Healthy BMI
18.5-24.5
Normal newborn head circumference
32-36
Normal female hematocrit
35-47
Which hepatitis types have vaccines?
A + B
How long do antidepressants take?
A long time (weeks for effect, months for full effect)
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
(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
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
S/S of pancreatitis
Abdominal pain radiating to the back which is worse when sitting forward
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
Curling's ulcer; what makes you suspect it?
Acute gastric ulcer associated with severe burns Suspect it if stomach pH is 1-5
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
How often are influenza vaccines given?
Annually
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
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
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
Hydroxyzine hydrochloride
Antihistamine medication
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
What pain medication should NOT be used during pregnancy?
Aspirin
What types of hepatitis are spread via sex?
B and D only
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
What kind of car safety do toddlers have?
Backseat in car seat which is backward-facing
Circumoral cyanosis
Bluish coloration around mouth Is an INDICATION of hypoxia in newborn
What activity should you encourage the siblings of a kid with a chronic illness to do?
Be involved in the care
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)
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
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
Postoperatively, what is the most critical concern we are worried about?
Blood pressure alterations AKA - SHOCK Fluid/electrolyte imbalances are not the same thing
Meconium ileus
Bowel obstruction in intestines of newborns --Is a result of cystic fibrosis
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
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
Lead toxicity treatment
Calcium disodium + dimercaprol
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
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
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
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)
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
(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
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)
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
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)
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
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
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
School-aged play pattern (which age)
Cooperative play -> organized rules and leaders Age 6-12
What is a major secondary disease complication of hyperparathyroidism? What are you looking for?
Kidney stones (because of elevated calcium) Bloody urine
Strabismus; what is a major indicator?
Cross-eyed Have to close 1 eye to look at something
(T/F) Sterile supplies should be all be preemptively opened
FALSE; should only be opened as needed for a given procedure
There is a high pressure alarm on a ventilator; what do you expect?
Mucus plus, tubing kink?
cyclobenzaprine hydrochloride
Muscle Relaxant
Pyloric sphincter
Muscle between stomach and small intestines
You notice that fetal HR is rapidly climbing during administration of oxytocin; what do you do?
D/C it
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
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)
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)
What is a major side effect of pronestyl?
Decreased BP
How is blood affected by SSRIs?
Decreased platelets; higher risk of bleeding
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
(T/F) Enteric-coated medications can be given via NG tube
FALSE: it has to be crushed
(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) Seasoned foods prevent constipation
FALSE; are generally avoided with hiatal hernias, Crohn's and ulcerative colitis
Diptheria requires which precautions?
Depends on type If skin/cutaneous -> contact If oral/pharyngeal -> droplet
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.
(T/F) The breasts of a breastfeeding mother should be washed with water and soap
FALSE; avoid soap; dries out the breast
(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)
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
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)
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
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)
Influenza requires which precautions?
Droplet
During preeclampsia, what S/S indicates that a impending seizure is present?
Epigastric pain
What kind of mood do cocaine patients have while on it
Euphoria
How often do you change NG feeding tubes?
Every 1-2 days
Liver cirrhosis patients are at high risk for what blood issue? Why?
Excessive bleeding; portal HTN leads to backup of blood
What compound leads to gout?
Excessive purines Found in alcohol + meats
(T/F) A droplet precaution patient uses disposable utensils and plates
FALSE
(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
Fetal macrosomia; risk factors?
Fetus is abnormally large for gestational age (9 lbs usually benchmark at birth) Mother has: 1. Diabetes 2. Obesity
In what direction should incisions be cleaned?
From incision to drain area Never drain area first
You notice that the previous nurse's documentation is incomplete; what do you do?
File an incident report
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
Benzodiazepine reversal agent
Flumazenil
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
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)
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
In general, when going up stairs it is ___
Good leg first when going up Bad leg first when going down
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
Dulalutide
GLP-1 agonist (incretin mimetic) (-tide)
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
Patients diagnosed with heart failure should have what prophylactic measure?
Get pneumonia/flu vaccinations, since infections increase cardiac workload, which can kill them
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
When is BiPAP given?
Given for people who are hypoventilating (i.e. sleep obstruction)
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
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
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
Which diseases require both airborne AND contact?
Herpes/shingles
Describe the 3 ways neuromuscular development develops
Head to toe Trunk to extremities Gross to fine
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 transcutaneous electrical nerve stimulation used for?
Herniated disks mostly
Diet for liver cirrhosis
High calorie, high carb, low fat, MODERATE (not high) protein
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)
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)
Hypocalcemia S/S
Hyperreflexes 1. Trousseau's 2. Chvostek 3. Seizures 4. Diarrhea 5. Paresthesias around extremities/mouth 6. Increased QT interval
Dextrose solutions are (hypo/iso/hyper) tonic
Hypo They start iso, but once the glucose is absorbed they are hypo
Changes associated with acidosis state
Hypocalcemia --More acidity = calcium has greater affinity to albumin Leads to HYPER-reflexes
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
What are the side effects of epidural anesthesia?
Hypotension
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
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
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
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)
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)
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
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 should corticosteroids be taken? Why?
In the morning with food --Remember -> insomnia is a side effect
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
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
A patient has low calcium levels; what is the priority action?
Initiate seizure precautions (hyperreflexes)
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
Isophane
Intermediate-acting insulin
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
What is a normal cholesterol level?
LESS than 200 (200 itself is bad)
Ewald tube
Large, orally inserted tube designed for rapid lavage of stomach contents SUCTION EQUIPMENT MUST BE THERE (risk of vomiting)
Cyanosis is an (early/late) sign of hypoxemia
Late
Lactulose
Laxative --Helps with liver disease because it traps ammonia, preventing encephalopathy
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
Normal C-reactive protein levels
Less than 1
Normal BNP
Less than 100
Normal erythrocyte sedimentation rate
Less than 15 for men, less than 20 for women
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 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
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
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
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
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)
Tranylcypromine sulfate
MAOI
In what order are the medications given during a heart attack?
MONA #1 -> morphine #2 -> oxygen #3 -> nitroglycerin #4 -> aspirin
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
Leukorrhea; is it normal
Milky-white discharge from vagina Is normal during 1st trimester (you are concerned if foul-smelling or green/yellow)
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
When does the posterior fontanelle close?
Month 3
Delirium tremens
More life-threatening version of alcohol withdrawal, involving: 1. N/V/D 2. Delusions 3. Seizures
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
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
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
(!!) 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)
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
Sulindac
NSAID
Naproxen drug class
NSAID (similar to aspirin)
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
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)
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
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
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
Meperidine
Opioid
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
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
sevelamer
Phosphate binding agent Given to reduce phosphate levels
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
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)
Blanching that persists and does not disappear is a warning sign for ___
Pressure ulcers
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
When lifting a kid out of the water from drowning, you do so in what position?
Prone (to prevent spinal damage)
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
How should oral medication be administered to a young child?
Put in a nipple and have infant suck
You are thinking about putting patients in rooms together with infections; how do you do it?
Put similar infections together Droplet with droplet, etc
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
Epiglottitis is slow/rapid
Rapid
Acidosis leads to ___ breathing
Rapid (blow off CO2)
Lispro
Rapid acting insulin
Aspart
Rapid-acting insulin
What should be done again 1 hour before surgery?
Recheck the consent form
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)
Regular insulin
Short-acting insulin Only one given IV
How does the stool of UC vs Crohn's compare?
UC -> usually blood Crohn's -> not bloody, just loose
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
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
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
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)
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)
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
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
Post-surgically, what side are abdominal patients put on to encourage release of gas?
Right side (remember that stomach/intestines are left-side)
After taking an inhaled steroid, you should ___
Rinse mouth
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
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
What should be done with dialysate fluid prior to peritoneal dialysis, and why?
Should be warmed up Cold fluids cause pain (think muscle spasms)
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
What kind of positioning should a paracentesis patient have?
Sit upright at the side of the bed (it's very similar to a epidural)
What side does the nurse stand on in a cane patient?
Slightly behind patient on strong side
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
Play type for infant (which age)
Solitary play (on their own) Birth - 1 year
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
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
Who do you get information about cultural beliefs from?
The client, never the family
You hear a whistling sound from a ventilator patient; what do you suspect?
The cuff isn't inflated enough
A patient has a yellow-brown coloration on their tongue; what does this indicate?
They are a smoker
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
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
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
What kind of air should be given for ventilator?
Warm, humidified air
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?)
After consuming polyethylene glycol, what is the patient allowed to consume?
Water only
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
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
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
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)
Spiral fracture
a fracture in which the bone has been twisted apart
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
Opisthotonic position
hyperextension of the head and neck to relieve discomfort r/t meningitis Is a sign indicating meningitis
(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) 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) Itchiness during opioids is perfectly fine, and should not be addressed
FALSE: is an adverse effect, interventional measures should be taken
(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) 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) 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
(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) Aspirin, ibuprofen and naproxen should be taken without food
FALSE; take with food, milk or antacids to reduce GI upset
(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) 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) 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
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
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
(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
If a psych patient is in the seclusion room and lunchtime comes, what do you do?
Feed them in the room
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
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)
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
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 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 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 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?
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 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
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 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
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?
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)
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?
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
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
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 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 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
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 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
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
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 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 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 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 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
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 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 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
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
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 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 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 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 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 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
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
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
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
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 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 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
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?
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)
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
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
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
Furosemide IV push should be given over what duration?
1-2 minutes
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?
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
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 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
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)
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
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
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
How much polyethylene glycol has to be consumed?
4 L
A kid __ y.o. can brush their teeth
4 years
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)
Which treatments are given for alcohol withdrawal?
1. Benzos 2. Anti-seizure eds/precautions If malnourished: 1. Vitamin B12 (thiamine) 2. IV glucose
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
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
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
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
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
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
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 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
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 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
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
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)
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)
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
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 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
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
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
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
SIde effect of antipsychotics
1. EPS 2. Neuroleptic malignant syndrome 3. Ortho hypo 4. Photosensitivity 5. Anticholinergic effects
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 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
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
What are definitive determinants that a person is pregnant?
1. Fetal HR 2. Fetal movement is palpated 3. Ultrasound
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
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
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
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
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
Viral diseases which require droplet
1. Influenza 2. Mumps 3. Rhinovirus 4. Rubella
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)
Which drugs cause ototoxicity?
1. Loop diuretics (Lasix) 2. Aminoglycosides (-ycin or -icin) 3. NSAIDs
Benzodiazepine side effects
1. Lowered cardio (low HR, low BP) 2. Lowered respiratory (lowered rate) 3. Ataxia (can't move) 4. Dizziness/blurred vision
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)
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)
When ambulating with the walker, describe the sequence
1. Move walker forward 2. Move weak leg 3. Move strong leg
Airborne precautions
1. N95 mask 2. Negative pressure room 3. Are in the room by themselves 4. Patient must wear mask when they leave
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)
GI/dudenal ulcers --Lifestyles changes
1. No smoking/alcohol 2. Avoid stress
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
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)
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
S/S of opioid overdose
1. Pinpoint pupils 2. Unconscious 3. Slow breathing
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.
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
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
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
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
Which diseases require airborne precautions?
1. Tuberculosis 2. Smallpox 3. Shingles (herpes zoster) 4. Chickenpox (varicella) 5. Measles (rubella)
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
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)
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 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
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
When does lead poisoning screening in kids begin?
12 months
At what age can the fetal heart rate be present?
12 weeks
Normal newborn HR
120-140
What is the defibrillation energy level for a BIPHASIC model during a code?
120-200
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
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
Normal mangesium levels
1.3-2.1
Normal magnesium levels
1.5-2.5
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?
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
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 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 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
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
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
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
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
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 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)
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
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 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 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
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
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
Rotavirus vaccination schedule
2 doses 1 at 2 months 2nd at 4 months
Impacted fracture
2 ends of bone are forced into each toher
Proper fitting/usage of crutches
2 fingers fit between armpit and crutch top (prevents nerve damage) Arms should not be straight (flexed 20-30)
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 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 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 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 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 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 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 ♂️
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 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 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
What is a normal fluid intake amount?
2-3 Liters/day
Normal CVP pressure
2-8
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
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
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
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
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 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 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
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
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 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
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
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 a child physiologically able to control toilet functions?
22 months, or ~ 2 years
Isolation precautions can be stopped when usually?
24 hours after antibiotics are started
When is a low-grade fever response expected after an immunization?
24-48 hours later
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
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 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
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 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
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 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 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 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
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
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 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 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
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?
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
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
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 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
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?
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 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 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 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 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
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
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)
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
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
Normal albumin levels
3.5-5.5
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
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
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 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 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 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
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 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
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 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
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.
4 (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
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
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 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 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 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 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...
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 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
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
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
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
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
Otosclerosis; what is its progression?
Hardening of bony tissue of middle ear Occurs over a long period of time gradually
Pleural friction rub --What does it sound like? --What is it associated with?
Harsh rubbing noise Indicates inflammation of pleura
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)
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
What is the appropriate diet for a spinal cord injury patient?
High-fiber Remember - autonomic damage may lead to diminished bowel motility
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
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
What is an early sign of elevated ICP in an infant?
High-pitched cry
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
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
A ___ y.o. can tie knots
6
Newborn normal BP
60-80 / 40-60
At what age should stranger anxiety appear?
7 months
At what age can a child only say "dada" or "mama"?
8 months
At what age can children sit up unsupported?
8 months
A kid has complete eye development at which age?
8 years
A kids has enough fine motors skills to handwrite at what age?
8 years
Normal PaO2
80-100
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
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
Butorphanol tartrate
Opioid analgesic --Need to observe respirations
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
Naltrexone; usage?
Opioid antagonist Is given when a patient is kicking the habit to reduce craving for it
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
What is the expected lab result of administering heparin?
PTT increase by factor of 1.5
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
Depressed fracture
Broken portion of bone is pushed inward (think piece of your skull inside brain)
Aminophylline
Bronchodilator - Decreases SOB *CANT MIX WITH ANYTHING*
What is given first, the bronchodilator or the steroid?
Bronchodilator first, then steroid
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)
How should irrigated fluid during wound care drain?
By gravity Do NOT use a syringe to remove it
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
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
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
How should a wound suction container be placed?
Always below the level of the patient to prevent backflow
For solid radium implants, bodily fluids (are/aren't) conisdered contaminated; what is the opposite
Are considered Liquid implants make bodily fluids contaminated
A VTE patient has what kind of mobility; for how long
Are on bedrest, but ONLY until heparin is started
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
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
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)
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
Comminuted Fracture
Bone is shattered into multiple pieces (at least 3)
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)
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
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)
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
Acrocyanosis; how does it relate to newborns
Cyanosis on extremities Is normal for first 12-24 hours, afterwards is bad
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
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
A pregnant woman reports shoulder pain and abdominal pain; what do you suspect?
Ectopic pregnancy MEDICAL EMERGENCY -> risk of extreme blood loss
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
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
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?
An infant doubles weight by ___, and triples by
Double by 4 months, triples by 1 year
Mumps requires which precautions?
Droplet
Rhinovirus requires which precautions?
Droplet
Rubella has what precautions?
Droplet
Streptococcus requires which precaution (Group A)
Droplet
Machinery should not be operated for drugs that cause ___
Drowsiness (aka benzos)
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
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
What is the most common complication post-MI that you should be worried about?
Dysrhythmias
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)
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
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
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
(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
(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) 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
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
Stress fracture
Fracture of bone r/t overuse
Transverse fracture
Fracture that goes straight across the bone
Budesonide
Glucocorticoid
In general, weight changes are good for measuring ___, but not ___
Good for measuring degree of fluid retention Not good for dehydration
How should a neuro patient be placed to prevent increases in ICP?
HOB elevated and supine (promotes drainage from head)
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
Lofenalac
Infant formula for PKU babies Has phenylalanine removed
What is often a precipitating factor of DKA and HHNK?
Infection
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
COPD patients are at high risk of what other complication? What preemptive measure should be done?
Infections Get immunizations at highest dose (and early)
Mononucleosis --Transmission --MAJOR sign/symptom
Infectious disease transmitted via saliva General flu-like symptoms, sore throat, ENLARGED LYMPH NODES
Intermittent vs continuous bubbling in water seal
Intermittent -> is normal, associated with coughing Continuous -> is NOT normal, check for air leak
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)
Longitudinal fracture
Is along the long line of the bone
(!) 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)
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)
Dark urine is a sign of
Liver dysfunction (it's a symptom of liver cirrhosis)
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
Dantrolene
Muscle relaxant Used for neuroleptic malignant syndrome from antipsychotics
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
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
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
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 should an infant be placed in a crib?
On their back (risk of SIDS)
How often should ostomy bags be changed?
Once a week
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
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
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 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
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) Contact precaution patients should be placed in private rooms
TRUE
(T/F) People in hospitals are allowed to vote; how?
TRUE Using absentee ballot
(T/F) Edema in the legs is normal during pregnancy
TRUE; is due to increased pressure on veins r/t uterus
(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
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
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)
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
A patient taking an inhaled corticosteroid should do what afterwards?
Rinse mouth afterwards (risk of thrush if they don't)
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
What temperature should Go-Lytly be consumed at?
Room temperature Too cold -> risk of hypothermia Too hot -> risk of damaging mouth/hyperthermia
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)
Normal child HR
Roughly 80-120 (70-115 in later age) Lasts until age 11
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
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
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
Dapagliflozin
SGLT2 inhibitors (-flozin)
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
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
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
Huff cough
Special form of cough which stimulates a coughing reflex --Is good for clearing lung secretions
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
Wound care is a (clean/sterile) procedure
Sterile
What are S/S of aspiring overdose?
Stomach distress (think bleeding) Ringing in the ears
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
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
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
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
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?
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)
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
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
Which diuretic has a marked impact on glucose levels? How?
Thiazide (HCTZ) Causes hyperglycemia (patient needs to take dietary measures)
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)
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
A patient is having spasms with a spasm; what does this indicate?
Too much weight
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) Yellow crusting after circumcision is normal and shouldn't be removed
True
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
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)
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)
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
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
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 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 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
Do we treat latent TB?
Yes, to prevent it from converting to active TB
You see a bulge in the baby's spine; are you concerned?
Yes; spina bifida/spinal cord defect suspected
Esophageal speech
a method of swallowing air, trapping it in the esophagus, and releasing it to create sound.
Managed care
healthcare system designed to reduce cost of healthcare through focus on PREVENTION of disease`
Station (fetus)
where baby is related to ischial spines
Phenytoin should NOT be taken if ___
you are pregannt
When should toilet training start in a kid?
~21 months; at this point they have sphincter control