RN Comprehensive Predictor Nursing -Study Guide
BUN/Creatinine normal values
(for kidney function) 7-20/0.8-1.4
Cranial nerve XI
(hot spot) shoulder
After infratentorial surgery
(incision at the nape of neck) position pt flat and lateral on either side.
A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity?
* Verapamil (Calan)
Lab values (Per ATI)
*BUN*: 10-20 *Cr*: 0.6-1.2 *Creatinine Clearance*: 80-139 *Na*: 135-145 *K*: 3.5-5 *Ca*: 9-11 *Cl*: 98-106 *Mg*: 1.3-2.1 *Albumin*: 3.5-5 (slow changes in protein) *Prealbumin*: 23-43 (better indication of malnutrition - for acute changes in protein) *Urine Specific Gravity*: 1.010-1.025 *Fasting Glucose*: <110 *Oral glucose tolerance test*: <140 *HbA1c*: <5%; pre-diabetes: 5.7-6.4%; DM: >6.5% *ICP*: 10-15 mm Hg *pH*: 7.35-7.45 *O2*: 95-100% *PaCO2*: 35-45 mm Hg *HCO3*: 22-26 *CO*: 4-7 L/min *D-dimer*: 0.43-2.33 mcg/mL (elevated = clot formation occurred--> pulmonary embolism occurred) *CK-MB*: 0% (30-170 units/L); elevated 4-6 hrs; lasts 3 days *Troponin I*: <0.03 ng/L; elevated @ 3hrs; lasts 7-10 days *Troponin T*: <0.2 ng/L; elevated @3-5hrs; lasts 14-21 days *Cholesterol*: <200 mg/L *HDL*: 35-80 (female): 35-65 (male) -- High Desirable *LDL*: >130 mg/dL -- Low Desirable (up to 70% of total cholesterol) *Triglycerides*: 40-160 (males); 35-135 (females); 55-220 (older adults) -- Evaluates Atherosclerosis *RBC*: 4.2-5.4 (female); 4.7-6.1 (male) *WBC*: 5,000-10,000 *Platelets*: 150,000-400,000 *Hgb*: 12-16 (females); 14-18 (males) *Hct*: 37-47 (females); 42-52 (males) (3x Hgb) *PT*: 11-12.5 -- See clotting & vit. K *aPTT*: 30-40 seconds -- Monitor for Heparin; increased if DIC, liver disease *INR*: 2-3 on warfarin (checked with PT)
What is the proper nutrition during pregnancy
- Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida - green leafy vegetables and brown rice
The nurse should consider the hierarchy of human needs when prioritizing interventions, which are?
- Physiological needs first (oxygen, shelter, food) - Safety & security needs (physical safety) - Love and belonging - Self esteem - Self actualization
What are some things to teach about home safety with elderly patients?
- Removing items that could cause the client to trip, such as throw rugs and loose carpets - Placing electrical cords and extension cords that against a wall behind furniture - Making sure that steps and sidewalks are in good repair - Placing grab bars near the toilet and in the tub or shower and installing a stool riser - Using a non-skid mat in the tub or shower - Placing a shower chair in the shower - Ensuring that lighting is adequate both inside and outside of the home
Evaluating proper placement of NG tube
- aspirate gastric contents and test pH (4 or less) - X-ray - note: injecting air into tube to listen over abdomen is NOT an acceptable practice
What values would a nurse possess to be a client advocate?
- caring - autonomy - respect - empowerment
S/S of hypomagnesaemia
- hyperactive DTRs - muscle tetany - positive Chvostek's and Trousseau's signs - hypoactive bowel sounds - paralytic ileus
S/S of hypernatremia
- hyperthermia - tachycardia - rapid thready pulse - orthostatic hypotension - restlessness - irritability - muscle twitching - reduced to absent DTRs - hyperactive bowel sounds
S/S of dehydration
- hyperthermia - tachycardia - thready pulse - hypotension - orthostatic hypotension - decreased CVP - tachypnea - dizziness - cool clammy skin - diaphoresis - sunken eyeballs
S/S of hypokalemia
- hyperthermia - weak irregular pulse - hypotension - restlessness - irritability - weakness with ascending flaccid paralysis - N/V - diarrhea - hyperactive bowel sounds
S/S of hyponatremia
- hypothermia - tachycardia - rapid thready pulse - hypotension - orthostatic hypotension - headache - confusion - decreased deep tendon reflexes - hyperactive bowel sounds
What do you do when a client has a seizure
- lower to bed/floor - protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement
S/S of hypocalcemia
- muscle twitches/tetany - hyperactive DTRs - positive Chvostek's sign (tapping on the facial nerve triggering facial twitching) - positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation) - seizures
S/S of hypothryoidism
- persistent lethargy - feeling cold - puffiness of the face - loss of body hair
What type of infectious diseases are required to be reported to the health department?
- severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA)
S/S of hypoglycemia
- shakiness - diaphoresis - anxiety - nervousness - chills - nausea - headache - weakness - confusion
S/S of overhydration
- tachycardia - bounding pulse - HTN - tachypnea - increased CVP - confusion - muscle weakness - weight gain - ascites - dyspnea - crackles
Pacreatitis
-- Upper left quadrant pain (abdominal pain) Priority Finding: *Absent bowel sounds* (indicative of paralytic ileus. *Expected findings:* (H) amylase + (H) Lipase Liver enzymes elevated Glucose may be elevated - (L) insulin N/V, jaundice, (H) WBC
Diabetes Type I and traveling
--Change shoes often to decrease risk of blisters and sores. --Limit physical activity if blood glucose <65 mg/dL --carry insulin in insulated tote bag to protect against temperature changes --Drink water every 2 hrs to reduce risk of dehydration
Digoxin
--Don't miss a dose --Antiacids reduce absorption --Adverse Effect = N/V --Check pulse rate before each dose
Pregnancy Lab tests
--Group B Strep (GBS) @ 35-37 wks --3-hr glucose tolerance @ 28 wks --Rubella Titer @ initial consult
Above the knee amputation and temporary prosthesis
--Have firm mattress (avoid soft mattress) --Wear compression bandage at all times --Keep residual limb in extension
Inflammation markers
--Increase Erythrocyte Sedimentation Rate (ESR) --Increase WBC --Decreased Serum complement level --Increased Globulin level
Contraction Stress Test (CST). Description, Purpose, normal range.
-Brush palm across nipple for 2-3min to release natural oxytocin that produce contractions. -Determine how fetus will tolerate stress of labor. -3 contractions, 10 min period, duration 40-60 secs.
Cystic Fibrosis (Respiratory Disorder) -Diagnostic Test -Possible Medication Administration
-DNA mutant gene identification. -Open capsule sprinkle on food (Enzyme: Pancrease).
Arthroplasty pt education -How to avoid contractures, dislocations; prevent DVT's. -Non-pharmalogical treatment
-Do not bend at waist. -Use abductor pillow in between legs. -Perform Continuous Passive Motion -Ice pack
Position for suppository or enema administration.
-Sim's/left lateral/Rt. knee to chest
Type Stomas: Appearance -Single -Loop -Divided -Double-Barrel
-Single (one stoma); brought through onto anterior abd wall. -Loop (two openings); proximal (active) and distal (inactive). -Divided (two separate stomas); proximal (digestive) and distal (secretes mucus). -Double-Barrel (distal and proximal sutured together are both brought up onto abd wall).
Moro Reflex (one of many reflexes present at birth)
-Startled (arms out sideways, palms up, thumb flexed). Ex: strike surface next to newborn.
How to calculate due date: LMP 8/2/15
-subtract 8-3=5 -add 7 + 2= 9 May 9, 2016
Normal creatinine levels
0.6 - 1.35
creatinine
0.7-14
therapeutic lithium level
0.8 - 1.1
what are normal creatinine levels? what are normal BUN levels?
0.8-1.4 mg/dL 8-25 mg/dL
INR
0.9 - 1.2
due date
0711
A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy set-up. 4. Suction equipment.
1
The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient 1. with his neck in a midline position and the head of the bed elevated 30°. 2. side-lying with his head extended and the bed flat. 3. in high Fowler's position with his head maintained in a neutral position. 4. in semi-Fowler's position with his head turned to the side.
1
The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization.
1
The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.
1
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is 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
Combination Oral Contraceptives Contradictions
1. Are smokers and over the age of 35. 2. Have a history of thrombophlebitis and cardiovascular events. 3. Have a family history or risk factors for breast cancer. 4. Are experiencing abnormal vaginal bleeding. 5. Use cautiously in clients who have hypertension, diabetes mellitus, gall bladder disease, uterine leiomyoma, seizures, and migraine headaches
Anorexia Abnormal Lab Values
1. Hypokalemia 2. Serum Albumin less than 3.5 (malnutrition) 3. Anemia and leukopenia with lymphocytosis 4. Possible impaired liver function, shown by increased enzyme levels 5. Possible elevated cholesterol 6. Abnormal thyroid function tests. 7. Elevated carotene levels, which cause skin to appear yellow. 8. Decreased bone density 9. Abnormal blood glucose level 10. ECG changes
a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include
1. change position slowly to minimize dizziness 2. chewing sugarless gum to prevent dry mouth
When should a trough level be scheduled for a once daily dosing of Gentamycin?
1hr prior to next dose
equation for calculating due date
1st day of last period + 1yr - 3 months + 7d = due date
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? 1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation.
2
A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils.
2
COPD patients and O2
2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less
latent phase
2cm dilated talkative
. If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe 1. increasing respiratory difficulty seen with exertion. 2. cough productive of a large amount of thick, yellow mucus. 3. peripheral edema and anorexia. 4. twitching of extremities.
3
A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication."
3
A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter.
3
A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via facemask or nasal prongs. 3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside.
3
A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness. 2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure.
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
A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0mg/dL. 4. The patient's hemoglobin is 8.5g/dL.
3
A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. reestablishes a trusting relationship with his/her other parent. 3. verbalizes that s/he is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse.
3
A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares." 2. "I have a headache and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am and I don't know where I live."
4
Addison's Disease
Adrenal Gland Hypofunction; inadequate production of glucocorticoids. Acute adrenal insufficiency can be a life-threatening event- severe fluid and electrolyte imbalances. Sodium levels will fall, potassium levels will increase. Rapid infusion of IV fluids (NS), high dose corticosteroids (Solu-Cortef)- are started as soon as venous access is established. So Hyponatremic, Hyperkalemic, Hypoglycemic
Nurse is giving a client with a left leg cast crutch-walking instructions using the tree-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action?
Advance the crutches along with the left leg, and then advance the right leg
Client in labor and reports back pain with right occiput posterior position
Apply sacral counterpressure
Calculate Nagele's rule for the first day of LMP of July 12, 2012. Subject: Maternity
April 19, 2013
AP delegation:
Arranging the lunch tray for a client with a hip fracture
Otitis Media
Ask about smoking- allergies to common irritants; not contagious. Otitis Externa could could from water exposure.
Nursing Care for Boggy Uterus
Ask pt to void; if still boggy massage top of fundus with fingers and reassess every 15 mins.
Limited knowledge re: chest tubes; Charge Nurses Action:
Ask the nurse about her knowledge
Verify NG tube placement:
Aspirate contents from tube and test pH content
a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoid
Aspirin
CVA; Prior to transferring:
Assess the clients functional limitations
Early Decels:
Associated with the progression of labor and are benign; Continue to Observe if seen
When does Discharge planning begin?
At Admission
Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant hand
B
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning
B C D
A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances
B C E
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home.
B C E
nutrients for healthy nervous system
B complex vitamins (thiamine, niacin, B6 & B12, Ca, and Na
Hydatidiaform Mole
Called gestational trophoblastic disease. The trophoblastic cells become fluid filled and the embryo fails to grow fetal loss usually occurs a 16 weeks and rarely is fetus carried to term
What is the function of the pancreas?
Carbohydrate/fat/protein metabolism.
Cholinergic Crisis
Caused by excessive medication ---stop giving Tensilon...will make it worse.
Hypothyroidism
Causes constipation (due to decreased metabolism)
Pt has Catheter and Incision:
Change gloves between wound care and cath care
89% oxygen postoperative: what to do...
Change oxygen to another finger
What to do before bolus feeding or administration of medication
Check for residuals (60 mL syringe)
MAOI's/Nardil, avoid what?
Cheese!
Epinephrine; A/E:
Chest pain
The nurse caring for a child in Buck's skin traction will keep the:
Child pulled up in bed
What do the nurse need to keep in mind about the client when being their advocate?
Client's religion & culture
Ovarian Cancer; Pt Education
Clinical manifestations are vague in the early stages
Two different Eye Drops; Pt Education:
Close eyes for 1 minute following administration of each eye medication; wait 10-15 minutes between each medication to prevent dilution of the med
Disposing of insulin syringes at home
Coffee container on a high shelf
Newborn complications
Cold stress - leads to hypoxia, acidosis, and hypoglycemia (due to use of energy to establish respirations and maintain body heat) Tx: Cold: warm slowly across 2-4 hrs; Hypoglycemia: breastfeed or formula feed. Hypoxia: Oxygen
Opiates (Heroin, fentanyl)
Constricted pupils, decreased respirations, decreased BP, initial euphoria followed by dysphoria
Respiratory Syncytial Virus Transmission Precautions
Contact Precautions PPE: Gloves, Gown (mask and goggles as needed) Private Room Gloves and gown by visitors Disposal of infectious dressing material into nonporous bag Dedicated equipment to room or disinfect Droplet Precautions PPE: Mask when 3 feet of the client Private room Keep door closed In Baby: Maintain normal body temperature
RN Suspects Abuse; RN's legal responsibility:
Contact proper legal authority
Nursing Care for Mastitis
Continue breastfeeding and take antibiotics as prescribed.
What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given?
Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis)
Following esophagogastroduodenoscopy (EGD); Report:
Cool, clammy skin
S/S Hypoglycemia
Cool, clammy skin
What is most likely to happen during variable deceleration?
Cord compression
Varicella contraindication
Corticosteroids
X-ray of Femur; RN to:
Cover pelvic area with a lead shield
What is the nursing action for dehiscence
Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's .
Detached retina
Curtain pulled over the visual area with occasional flashes of light. Medical emergency Manifestations: sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field.
Prednisone toxicity
Cushings (buffalo hump, moon face, high blood sugar, HTN)
Fractured Ankle; Report:
Cyanotic Nail Beds
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting
D
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant
D
A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? a) assess for bladder distention after 6 hr b) encourage the client to use a bed pan in the supine position c) restrict the clients intake of oral fluids d) pour warm water over the clients perineum
D
A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbet
D
A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficience
D
A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmalificence
D
An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24 hr postop to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift C. providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump
D
includes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collaboration is necessary
Democratic
What is the function of the testes?
Development secondary sex characteristics.
Digoxin Toxicity
Diarrhea, Nausea and Muscle Weakness 0.8-2.0
Cocaine/Amphetamines
Dilated pupils, tachycardia, elevated BP, impaired judgement, grandiosity, paranoia with delusions
Varicella/ Chickenpox
Direct contact and airborne precautions. 2-3 week incubation. Contagious until all lesions have scabbed. Pregnant women should not be in contact.
Disseminated herpes zoster localized herpes zoster
Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered!
What kind of medications are indicated for abstinence maintenance of alcohol?
Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)
LLQ
Diverticulitis
Med Error Documentation
Do not document in MAR if IV med was given orally
What should be avoided during pregnancy
Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby
St. John's Wort
Do not take with Zoloft
Warfarin
Do not take with acetaminophen report dark stools
What is wrong with the script? gentamicin 50 mg po every 4 hours #30
Drug name: Gentamicin (capital G)
Opioids (relief and sedation)
Duragesic, Dilaudud, Morphine, Demerol, Codeine, oxycodone
What therapy will be useful for patients with bipolar?
Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior.
Anorexia Nervosa
Electrolytes increasing: Sodium, Potassium, Chloride, BUN, Liver function, Cholesterol.
Reconstructive
Emotional/cognitive restructuring takes place.
Gestalt therapy
Emphasis is on "here and now".
Asthma:
Encourage children to stay active Avoid extreme temp changes, get the flu vaccine, use peek flow meter at the same time daily
Hepatitis A
Ends in a vowel, comes from the bowel
Venturi Mask
Ensure reservoir bag 2/3 full during inspiration and expiration.
ICP and Shock
ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp
Rifampin, isoniazid, phenytoin, what's up?
INH/Isoniazid increases phenytoin toxicity, meaning ataxia and hallucinations may present; decrease phenytoin dosage; hepatotoxicity possible with rifampin
Incident Report:
IV pump delivers inadequate dose of meds
never give K+ in
IV push
COPD patients considerations
If hypoxic, deliver O2 to 90%. --sit up in orthopneic position, with arms resting over bed table to facilitate breathing.
What does a newborns poop look like
If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency
Best time to perform bladder scan.
Immediate after void
Methotrexate
Immunosuppressant --Monitor signs of infection such as fever
Left CVA
Impaired speech and comprehension Slow and depressed
High Pressure alarm
Indicates an increase in resistance each time the ventilator administers a breath to the client. Excessive airway secretions, decreased lung compliance (COPD), client is coughing or attempting to talk.
Chest Tubes
Keep collection chamber below lungs
Surgical aseptic technique:
Keep sterile objects in the line of vision, hands above waist, 1" border of sterile drape
Meningitis--check for
Kernig's/ brudinski's signs
Moving pt up in bed:
Lower side rails, bed in high position, as pt to flex knees and push if possible, DO NOT GRAB UNDER ARMS
potential food and med interaction
MAOI wants cheeseburger
Contact Precautions
MRS WEE) Multidrug resistant organism, respiratory infection, skin infection (varicella, diphteria, shingle, impetigo, scabies), wound infection, enteric infection (c-diff), eye infection Protect visitors and caregivers against direct client/ environmental contact infections(respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multi-resistant organisms). Contact precautions require: - A private room or a room with other clients with the same infection - Gloves and gowns worn by the caregivers and visitors. - Disposal fo infectious dressing material into a single, nonporous bag without touching the outside of the bag.
Contact precaution
MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves
Airborne precautions
MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB
Hyperkalemia
MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes
What is the key finding for Rocky Mountain Spotted Fever?
Maculopapular rash on ankles/wrists.
Crutches:
Make sure rubber tips are secure
Where should the cath bag be placed when urinary catheterization
Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux.
Neologisms
Makes up and uses words that have no meaning except to the speaker
12 yr old bacterial meningitis which finding indicates client is experiencing increased intracranial pressure (ICP)
Memory Loss
Indication of Increased ICP:
Memory Loss
Right CVA
Minimizes problems Short attention span Impaired judgement and time Impulsive
Multiple Sclerosis Patient
Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug) * Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone) * Vomiting = causes dehydration * Hair Loss = emotional distress * Amenorrhea = emotional distress
Atorvastatin (statins medications)
Monitor CK (due to muscle breakdown)
Pregnant woman, water breaks
Monitor Fetal HR
Musculoskeletal congenital disorders
Monitor skin for breakdown areas and prevent pressure sores.
Cushing's Disease
Moon Face is expected; HTN
What are the values and beliefs that guide behavior and decision making?
Morals
Which is a presumptive sign of pregnancy? A) More frequent urination B) Goodell sign (cervix) C) Chadwick sign D) Fetal movement palpable Subject: Maternity
More frequent urination.
Ventricular septal defect vSD
Most common congenital heart defect irritability and restlessness our clinical manifestations
Fluid Balance
Most sensitive indicator is daily weights. Especially critical in children under 2 y/o- greater body weight of fluid
Understanding Rh. Administration of antibody and time.
Mother Rh negative. Fetus Rh positive. Rhogam at 28 weeks, then 72 hrs after birth.
Guaifenesin
Mucolytic medication. removes thick mucus secretions from COPD patients w/ SOB, cough, and fatigue.
Munchausen syndrome vs munchausen by proxy
Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child
Weighted NI (naso intestinal tubes)
Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris
Addesonian crisis
N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP
3-4 cups of milk a day for a child?
NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA
can you give an antibiotic in a TPN infusion line? what can you add to a TPN infusion line?
NO! Nothing!
steps to take when child is hypoglycemic
OJ, wait 15 min, recheck glucose, give crackers & cheese
Blood transfussions
OK to use 0.9% sodium chloride. --5% dextrose & Ringer's lactate will cause clots --0.45% cannot use because it's hypotonic Adverse reaction: Low back pain. Stop transfusion immediately.
Dialysis Disequilibrium Syndrome (DDS)
Occurs in patients new to dialysis- rapid removal of solutes and changes in blood pH levels. S/S: HA, nausea, disorientation, restlessness, blurred vision, and asterixis.
Infertility Clinic
Offer support group info
RN to see 1st:
Older client confused and trying to pull IV
Candidiasis
Opportunistic infection Affects oral cavity of infants, diabetics, or other clients with immature or compromised immune systems. Often the initial opportunistic infection noted in an HIV + child who is developing AIDS
Symptom that is indicative of Fluid Volume Deficit:
Orthostatic hypotension
Have infection rates decreased following a policy revision?
Outcome
Patient is having a hysterectomy and states, "I can possibly plan a pregnancy". What needs to be reinforced?
Outcome
Assessment: Following Vaginal Delivery; Heacy lochia and a boggy fundus. Med to administer:
Oxytocin
Fire extinguisher
PASS
patient up & walking, pain 8, need what type of pain management?
PCA pump, prn morphine
FHR monitoring for:
PROM, decreased fetal movement, pt with gestational HTN
McBurney's point
Pain in RLQ with appendicitis
Murphy's sign
Pain with palplation of gall bladder (seen with cholecystitis)
Causes of Prolonged QT
Parathyroid function, chronic renal disease, massive blood transfusions, and diarrhea
What is 'parity' mean in GP?
Parity, or "para" indicates the number of >20-week births (including viable and non-viable; i.e., stillbirths). Pregnancies consisting of multiples, such as twins or triplets, count as one birth.
What is the key finding for Mumps?
Parotid gland swelling.
What is the key finding for Pertussis?
Paroxysmal coughing episodes.
Stg II pressure ulcer:
Partial-thickness skin loss
Amniocentesis
Performed at 14-16 weeks assess fetal lung maturity and well being Rh-negative mothers get Rhogam Complications are bleeding, contractions, signs and symptoms of infection
What is the key finding for Rubella?
Petechial spots on soft palate.
NS w/ new script for cefazolin (over 30 min):
Piggy back cefazolin into the NS.
Non-tunneled percutaneous central venous catheter
Place client in trendelenburg position to provide easier access to vessels & decrease risk of air embolus
Prevent breast engorgement:
Place ice packs on the breasts for 15 min 3-4 times daily
Cane
Place on unaffected side of the body. 6-12" in front of the body prior to stepping forward Step forward with affected leg 1st.
Fetal bradycardia, late deceleration of the FHR, decrease or loss of FHR variability, and variable deceleration of FHR
Place the client in a side-lying position. For late or variable - can also DC the oxytocin.
RN to see 1st:
Post op with abd distention and no bowel sounds
Position of the baby by fetal heart sounds
Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis.
Radiation Exposure Med
Potassium Iodide (Pima) Blocks the thyroid gland's uptake of radioactive iodine and thus could reduce the risk of thyroid CAs
Refeeding Syndrome
Potassium, magnesium, and phosphate move intracellularly during enteral nutrition, electrolyte disturbances can result. Patients who are severely malnourished are at high risk for refeeding syndrome and require careful management of fluid and electrolytes when tube-fed. For patients who are severely ill or malnourished, provide feedings at 50% of estimated requirements and increase gradually over 24 to 48 hours if careful monitoring does not suggest clinical or biochemical abnormalities. Circulatory collapse that occurs when a client's completely compromised cardiac system is overwhelmed by a replenished vascular system after normal fluid intake resumes.
If client decides to leave the facility without a discharge order, the nurse notifies the provider and discusses with the client __________
Potential risks associated with leaving
Preload/Afterload
Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.
Vaginal Flush Complications
Preterm Labor: Ruptured membranes, signs of infection
Immunizations
Primary Prevention
Burns
Priorities: --Resuscitation Phase (first 48 hrs): Fluid balance & maintain Electrolyte balance. --Acute phase (36-48 hrs): Have adequate nutrition to maintain weight, including increased caloric intake. --Rehabilitative phase: encourage use of affected extremity to maintain maximal limb function.
What is the function of the ovaries?
Progesterone/estrogen production.
Age appropriate toys for a 2 -year old
Puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. Allow for manipulation and exploration and meet the child's developmental and diversional activity needs. Want interactive. No dolls bc of choking hazard (better for Preschooler or school-aged child)
chronic emphysema ABG?
RESP, acid (low ph, low co2)
Sprain or Strain
RICE Rest Ice Compress Elevate
Narcotic:
RN to waste remainder of Med w/ another RN
Brachytherapy (Radiation)
Radiation source is within the client who emits radiation and is a hazard to those around for a period of time.
What can prevent MI, stroke, or death in high-risk patients
Ramipril
PTSD; Effective Tx response:
Recognizes the personal effects of the traumatic experience
Lactose Intolerant
Recommend collard greens; contain lactose-free calcium.
codes for pt care
Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival
What is the best recommendation for a newly diagnosed diabetic 2 patients that lives independently?
Refer to support group
Supportive therapy
Reinforcement of client's existing coping mechanisms.
Metformin most common side effect
Renal (kidney) failure
Interdisciplinary Care Conference:
Reoccurring hospitalizations
Desensitization therapy
Repeated exposure to stimulus which gradually reduces intense reaction.
Echopraxia
Repeating what someone else is saying
Warfarin
Report changes in stool color (may indicate GI bleed)
mild preeclampsia
Report swelling of hands/feet, rest in a side-lying position, report decreased urinary output, and perform daily fetal kick count
In Case of Fire
Rescue Pull Alarm Aim Contain Squeeze Extinguish Sweep
Seizure Precautions
Rescue equipment at bedside Establish IV Site Position seizing pt to ground, stay with them Protect Head If in bed, pad side-rails Side lie with head flexed and slightly forward Loosen restrictive clothing Document time, behavior, aura, etc. Report seizure to the provider
CF chief concern?
Respiratory problems
Flumazenil
Reversal agent for Benzodiazepine Toxicity
Narcan & Naloxone
Reversal agent for Opioid toxicity
Atropine
Reversal agent for inhibitor overdose
Neostigmine
Reversal agent for neuromuscular blocker overdose
Non Dairy calcium
Rhubarb sardines collard greens
Clang Association
Rhyming words or words that all start with the same letter; "Big Bad Box Bouncing Back"
JVD. What side of heart?
Right
Inappropriate prescription:
Rn to tell charge nurse
What is the key finding for Roseola?
Rose-pink macules that blanche on pressure.
What types of airborne diseases require a negative pressure room and N-95 fitted masks?
Rubeola, Vericella and Tuberculosis
Hypernatremia
S (Skin flushed) A (agitation) L (low grade fever ) T (thirst)
Air or Pulmonary Embolism
S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.)
Autonomic Dysreflexia/Hyperreflexia
S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!
Cranial nerves
S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More
Equation for calculating pulse pressure
SBD-DBP = PP
Sickle cell complication
SOB
Post-Op Cholecystectomy
Sanguineous drainage 2 hours post op is expected finding.
Left-sided heart failure
Sign: Oliguria during the day from decreased blood flow to kidneys
Delirium (occurs quickly)
Simple orientation and low stimuli environment
What is the key finding for fifth disease?
Slapped face rash appearance.
Foods that contain tyramine; Avoid w/ MAOI's:
Smoked meat, cheeses and ripe avacados
Newborn Car Seat Safety
Snug harness across axillary. Not across abdomen or neck.
What is the function of the Adrenal gland?
Sodium/electrolyte balance/SNS response.
Dehydration (Therapeutic Lab Values):
Sodium: 136-145mEq/L Urine Specific Gravity:
Infectious Mononucleosis
Spread? saliva Transmission Precautions? Standard Contact Incubation Time? 4-6 Weeks S/S: fever, soar throat, swollen lymph glands, increased WBC, atypical lymphocytes, splenomegaly, enlarged liver Complication: ruptured spleen
Trach Suctioning
Suction pass: 10-15 sec Preoxygenate: 30 sec to 30 min 100% O2 Pressure: 80-120 mmHg Suction up to 3 times
Mastitis
Sudden onset of fever, chills, body aches, and unilateral breast pain with tenderness
Blocking
Suddenly stops speaking for no reason
Left Sided Heart Failure Sx
Symptoms Weakness, fatigue, anxiety, depression, dyspnea, shallow respirations up to 32-40 min, Paroxysymal Nocturnal Dyspnea, Orthopnea (SOB in recumbent position, dry hacking cough, nocturia, frothy pink tinged sputum (advanced pulmonary edema)
Right sided Heart failure Sx
Symtpoms fatigue, anxiety depression, dependent bilateral edema, right upper quadrant pain, anorexia and GI bloating, nausea
Ergotamine sublingual for migraine headaches
Take one table at onset of migraine. Up to 3 tablets/day
INH can cause peripheral neuritis
Take vitamin B6 to prevent. Hepatotoxic
Skin infection
VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies
Periodic FHR Changes
Variable Cord Compression Move client Early Head Compression Identify progress Acceleration Other (Okay) No action needed Late Placental Insufficiency Execute action fast
infants IM site
Vastus lateralis
Toddler 18 months+ IM site
Ventrogluteal
17 year old having an emergency surgery. What type of consent is best to intervene?
Verbal
Blood Transfusion:
Verify the pt and blood product with another RN
What is the key finding for Varicella?
Vesicles.
Sildenafil
Viagra Monitor when taking Isosorbide Mononitrate
Care at Birth
Vital signs should be checked on admission/birth and every 30 min x 2, every 1 hr x 2, and then every 8 hr. Weight should be checked daily at the same time, using the same scale. Inspect the newborn's umbilical cord. Observe for any bleeding from the cord, and ensure that the cord is clamped securely to prevent hemorrhage. In the first 6 to 8 hr of life as body systems stabilize and pass through periods of adjustment, observe for periods of reactivity. First period of reactivity - The newborn is alert, exhibits exploring activity, makes sucking sounds, and has a rapid heart rate and respiratory rate. Heart rate may be as high as 160 to 180/min, but will stabilize at a baseline of 100 to 120/min during a period that lasts 15 to 30 min after birth. Period of relative inactivity - The newborn will become quiet and begin to rest and sleep. The heart rate and respirations will decrease, and this period will last from 30 min to 2 hr after birth. Second period of reactivity - The newborn reawakens, becomes responsive again, and often gags and chokes on mucus that has accumulated in his mouth. This period usually occurs 2 to 8 hr after birth and may last 10 min to several hours.
Gastrectomy Medications Needed
Vitamin B12 is absorbed in the stomach and must be supplemented with regular injections by patients who underwent a total gastrectomy. Absorption may be impaired in those who still have part of their stomach, so it is necessary to have B12 levels checked periodically. Supplementation with folate, iron, and calcium may also be necessary to correct deficiencies caused by the surgery.
gtt
Volume/time * gtt = gtt 1 min 100ml/20min * 10gtt 50 gtt 1 min If given hours multiply by 60
Signs for meningococcemia
Vomiting, febrile, petechial rash (unstable)
Which is a probable sign of pregnancy? A) Darkened areolas B) Fetal movement felt at 20 weeks C) Von Fernwald sign D) Hearing FHT (Fetal Heart Tones) Subject: Maternity
Von Fernwald sign
cardioversion indication
Vtach
Lymphocytic leukemia; Labs to report:
WBC 1,000
Prednisone inhaler
Wait 20-30 seconds between puffs Exhale with pursed lips Rinse mouth afterwards (to decrease chance of infection) hold breath for 10 seconds
dry, shiny red skin over the clients neck and clavicular area; RN education regarding skin care:
Wash with mild soap and water
Valproic Acid
Watch for Jaundice- liver damage.
Aminoglycosides or Minocycline (Minocin)
Watch for ototoxicity; think mycin- Gentamicin
Doxycycline (Vibramycin)
Watch for photosensitivity Tetracycline ABX GI Distress: A/N/V/D
Newborn Water and Room Temp
Water: 120F or lower Room: 97.9-99 F
S/S Hypovolemia
Weak pulse, hypoTN, decreased CVP, decreased CO, elevated BUN and serum osmolality, increased urine sp gravity and osmolality, decreased UOP, hematocrit elevated
Cipro Teaching
Wear large-brim hat and long sleeves (phototoxicity), limit intake of coffee, tea or colas, do not take with milk or other products, do not take with an antacid.
Which of these statements, if made by a client who is taking a diuretic, should a nurse recognize as indicative of the need for additional instructions? a. "I take all of my medications at bedtime so I don't forget them." b. "I eat one or two bananas every day." c. "I weigh myself every day in the morning." d. "I will call my doctor if I have muscle weakness."
a. "I take all of my medications at bedtime so I don't forget them."
Which of these instructions should a nurse give to a client when collecting a sputum specimen? a. "Take a deep breath, then cough and spit into this container." b. "Gargle with antiseptic mouthwash before you spit into this container. c. "Spit whatever sputum you have in your mouth into this container." d. "Drink some fluids to loosen your secretions and the spit into this container."
a. "Take a deep breath, then cough and spit into this container."
What are the contraindications for Mag sulfate?
active vagninal bleeding, dilation of cervix is > 6cm, chorioamnionitis, > 34 wks gestation, acute fetal distress, severe pregnancy induced HTN or eclampsia
Buck's Traction; AP can NOT
adjust the pt's hanging weights
RN intervention; toddler tonsillectomy:
administer pain meds on a regular schedule 1st day post op
IV technique
advance catheter
MMR and varicella immunizaions
after 15 months!
what to tell woman if trying to get pregnant
after stops, may take awhile
complications of chest tube insertion
air leaks - monitor the water seal chamber for continuous bubbling (air leak); tension pneumothorax - sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstructing can cause this
Complications of chest tube insertion
air leaks - monitor the water seal chamber for continuous bubbling (air leak); tension pneumothorax - sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause this Tidaling in water seal chamber is normal!
complications of chest tube insertion
air leaks - monitor the water seal chamber for continuous bubbling; tension pneumothorax - sucking chest wounds, prolonged clamping of the tube; kinks in the tubing, or obstruction may cause this
nutrition and oral hydration to report
albumin 3.5-5
before an IV urography procedure the nurse should check if patient is
allergic to iodine & check creatinine levels b/c dye can cause renal failure
what to ask before MMR
allergy to eggs or neomycin
what should the nurse check before an IV urography procedure
allergy to iodine and check creatinine levels because dye can cause renal failure
infant with CP getting enteral feeding, intervene when
allowing to run for 8 min
16 weeks pregnant
alpha protein
Hypnosis purpose
alter perception of pain
clozapine, Clozaril
antipsychotic anticholinergic
report what after a craniotomy?
aphasia, because this means increased ICP r/t increased bleeding, which is the highest risk. keep HOB at 30
late s/s of cold stress in infants
apneic episodes, bradycardia, acrocyanosis, decreased activity
Latex allergies
assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches
high pressure alarm, do what?
assess for kinkds, client bitingg, excess secretions (suction), pulmonary edema, etc. Notify provider
At what age does bone loss begin with osteoporotis what are normal Calcium levels?
at age 35 (women) 8.6-10 mg/dL
Which of these statements, if made by a nurse, is non-therapeutic because it disregards a client's feelings and concerns? a. "You appear anxious and tense." b. "Everything will be okay." c. "I notice you're biting your nails." d. "I'm not sure I understand what you're saying."
b. "Everything will be okay."
Which of these statements, if made by a client who has chronic obstructive pulmonary disease, indicates improvement? a. "I hope to attend my grandson's graduation next month." b. "I can now walk one more block than I could last month." c. "I take several quick breaths when I begin to cough." d. "I do my breathing exercises in the evening after I eat dinner."
b. "I can now walk one more block than I could last month."
Which of these statements, if made by a client who had a total hip replacement, would indicate a correct understanding of the postoperative instructions? a. "I will stoop carefully to pick up items from the floor." b. "I will use a raised toilet seat in the bathroom." c. "I will bend forward when tying my shoes." d. "I will put my leg through the full range of motion each day."
b. "I will use a raised toilet seat in the bathroom."
Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation? a. "Please bathe the client in room 12, and then bring the client to the dining room for breakfast by 9 A.M." b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort." c. "Please measure the intake and output for the client's in rooms 8. 9. and 10, and record each on the intake/output sheets by 2 P.M." d. "Please toilet the clients in rooms 11, 12, and 13 mid-morning and after lunch."
b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort."
A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A client who is eight-hours postoperative after a hip replacement. b. A client who is drowsy after falling out a third story window. c. A client who is four hours post-colonoscopy and polyp removal. d. A client who is dysphasic after a transient ischemic attack.
b. A client who is drowsy after falling out a third story window.
A child is brought to the clinical for serum lead screening because of ingestion of lead-based paint. Which of these manifestations, if present in the child, would indicate early signs of lead toxicity? a. Convulsive seizures. b. Behavior changes. c. Bleeding tendencies. d. Low-grade fever.
b. Behavior changes.
Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance? a. Absence of wheezing throughout the lung fields. b. Clear lung sounds on auscultation. c. Pulse oximetry level of 80%. d. Frequent coughing throughout the day.
b. Clear lung sounds on auscultation.
Which of these changes in the assessment data of a child who has congestive heart failure should a nurse recognize as indicative of a therapeutic response to prescribed medication therapy? a. Increased weight. b. Increased urine output. c. Increased respiratory rate. d. Increased heart size.
b. Increased urine output.
Which of these actions should a nurse include to enhance the effectiveness of client teaching sessions? a. Include all content in one session so as not to overwhelm the client. b. Initially demonstrate and explain the procedure to the client. c. Avoid repetition of content. d. Include all clients on the unit in the sessions.
b. Initially demonstrate and explain the procedure to the client.
Which of the following manifestations should a nurse recognize as suggestive of right-sided heart failure? a. Cool extremities and frothy sputum. b. Jugular vein distention and pedal edema. c. Orthopnea and frequent cough at night. d. Weight loss and lower calf pains.
b. Jugular vein distention and pedal edema.
When auscultating the lungs of a woman who is admitted for severe pregnancy-induced hypertension, a nurse notes the presence of crackles and moist respirations. These assessment findings most likely indicate which of these complications? a. A convulsion is imminent. b. Pulmonary edema has developed. c. Bilateral lobar pneumonia is present. d. Respiratory failure is evident.
b. Pulmonary edema has developed.
Which of these rationales explains the purpose of nasogastric tube with suction for a client who had abdominal surgery? a. Prevention of gastric decompression. b. Removal of secretions from the stomach. c. Provision of postoperative nutrition. d. Promotion of abdominal distention.
b. Removal of secretions from the stomach.
A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up first? a. Heart rate, 60/minute and regular. b. Respiration, 30/minute and deep. c. Temperature, 97.1 °F (36.2 °C) d. Blood pressure, 136/86 mm Hg
b. Respiration, 30/minute and deep.
perform amniocentesis
before 20 weeks to check for cardiac and pulmonary abnormalities
pathological jaundice occurs: physiological jaundice occurs:
before 24 hours (lasts 7 days) after 24 hours
Hypervolemia
bounding, JVD, edema, confusion, increase everything
IVP requires
bowel prep so bladder can be visualized
Indications to withhold Propranolol (inderal) Beta Blocker
bradycardia, SOB, edema, fatigue, AV block, Pt has asthma
when phenylaline increases
brain problems occur
antiplatelet drug hypersensitivity
bronchospasm
Addison's
bronze like skin pigmentation
chest tube
bubbling continuous
Chest tube complications
bubbling in water seal
Lymes disease
bullseye rash
sle (systemic lupus)
butterfly rash
A woman is treated in the emergency room for a broken arm and multiple facial bruises caused by her spouse. Which of these statements, if made by a nurse, is therapeutic? a. "You should leave this relationship now or you will be sorry." b. "Are you aware that women who remain in abusive relationships eventually are killed?" c. "This type of abuse typically recurs after a period of remorse by the abuser." d. "Can you think of what you did to cause this abuse?"
c. "This type of abuse typically recurs after a period of remorse by the abuser."
When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is: a. at least 15 pounds. b. 15 to 20 pounds. c. 25 to 35 pounds. d. at least 45 pounds.
c. 25 to 35 pounds.
A nurse takes the weight of a normal 2-year-old child who comes in to the pediatric clinic for a well-child visit. If the child weighted 7 lbs, 2 oz. at birth, how much should the nurse expect the child to weight at this visit? a. 14 lbs, 2 oz. b. 18 lbs, 6 oz. c. 28 lbs, 8 oz. d. 45 lbs, 10 oz.
c. 28 lbs, 8 oz.
Which of these measures should a nurse include when planning care for an 88-year-old client who is admitted to the hospital with pneumonia? a. Restricting visitors to the client's immediate family members. b. Limiting the client care activities to no more than five minutes each. c. Allowing the client to perform self-care as tolerated. d. Providing the client with a non-stimulating environment.
c. Allowing the client to perform self-care as tolerated.
All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown? a. An 82-year-old client who bathes once a week. b. An 83-year-old client who applies powder after drying the skin. c. An 84-year-old client who has been NPO for four days. d. An 85-year-old client who has coronary artery disease.
c. An 84-year-old client who has been NPO for four days.
Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring? a. Gatch the knee of the bed. b. Administer anticoagulants preoperatively. c. Apply sequential compression devices. d. Maintain the legs in a dependent position.
c. Apply sequential compression devices.
A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks. To determine if the desired effects of the Pancrease are achieved, a nurse should consider which of these questions? a. Is the child's blood sugar level within normal limits? b. Has the child's appetite improved with the medications? c. Are the child's stools of normal consistency? d. Does the child report increased belching and flatus?
c. Are the child's stools of normal consistency?
A client is eight hours postoperative after a transurethral resection of the prostate (TURP). Which of these observations, if noted by a nurse, indicates a complication? a. Hourly urine output of 90 mL. b. Reports of bladder spasms. c. BP 92/60 mm Hg, pulse rate 118/minute. d. Pink-tinged urine output.
c. BP 92/60 mm Hg, pulse rate 118/minute.
Which of these nursing measures is appropriate for a client who has recurrent renal calculi? a. Weighing the client daily before breakfast. b. Measuring the blood pressure every four hours. c. Encouraging a daily intake of three liters of fluids. d. Testing the urine for protein each shift.
c. Encouraging a daily intake of three liters of fluids.
Which of these measures should an emergency room nurse include when speaking with a family experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)? a. Explaining to the parents how SIDS could have been predicted. b. Discouraging the parents from viewing the infant's body. c. Encouraging the parents to take the opportunity to say goodbye. d. Interviewing the parents in-depth about the circumstances of the infants death.
c. Encouraging the parents to take the opportunity to say goodbye.
Which of these techniques should a nurse plan to use with a client who is delusional? a. Explore the delusion so the client will know it is false. b. Explain clearly why the client's belief is incorrect. c. Focus on reality-based topics. d. Avoid speaking with the client when he/she is delusional.
c. Focus on reality-based topics.
Which of these assessments is the priority for a client who is admitted with recurrent depression? a. Previous episodes of depression. b. Compliance with prescribed medications. c. Presence of a suicide plan. d. Problems with communication.
c. Presence of a suicide plan.
Which of these factors should a nurse consider when delegating tasks to unlicensed assistive personnel (UAP)? a. The UAP's relationship with clients. b. The UAP's willingness to perform tasks. c. The UAP's previous experiences on the unit. d. The UAP's duration of employment on the unit.
c. The UAP's previous experiences on the unit.
A nurse is monitoring a client who had a cystoscopy six hours ago. The nurse should inform the physician of which these manifestations? a. The client has pink-tinged urine. b. The client reports burning on urination. c. The client's white blood cell count is 15,000 mm3. d. The client appears drowsy.
c. The client's white blood cell count is 15,000 mm3.
A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A nurse should interpret this to mean that the client has: a. had a period of sustained hyperglycemia. b. been non-compliant with home management. c. been in relatively good diabetic control. d. eaten a high carbohydrate snack just prior to testing.
c. been in relatively good diabetic control.
Complication of pericarditis
cardiac tamponade (hypoTN, muffled heart sounds, JVD, paradoxical pulse)
complications of pericarditis
cardiac tamponade (hypotension, muffled heart sounds, JVD, pardoxical pulse)
pt not going to have surgery
clarify, notify, AMA, Document
Adverse effects of ferrous sulfate
constipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth.
resspiratory synictal virus
contact
rsv
contact
Care for Pt who has clostridium difficile
contact precautions, encourage increased fluid intake, antiemetics, antimicrobial therapy
appropriate action for early decelerations
continue observing the fetal heart rate
use of three way indwelling catheter
continuous bladder irrigation prostate issues
esophagogastroduodenoscopy (EGD) findings to report
cool, clammy skin
post EGD, what to watch for?
cool/clammy skin, sign of perforation
variable decelerations = what? intervention?
cord compression! prep for emergency c-section or inducing labor. also can change position, d/c oxytocin, o2 8-10L/min per mask, perform/assist with vaginal exam, assist with amnioinfusion if ordered
adverse reaction propanolol
coughing at night
cognitive therapy
counseling
Sucking stab wound
cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo!
MI
crushing stabbing chest pain unrelieved by nitro
angina
crushing, stabbing chest pain relieved by nitro
proper use of crutches: going down the stairs
crutches and affected leg down, followed by unaffected leg
Colostomy care
cut the bag
when on nitroprusside monitor:
cyanide. normal value should be 1.
Which of these recommendations should a nurse make when teaching a client who is to start taking oral prednisone (Deltasone)? a. "Take this medicine at bedtime, on an empty stomach." b. "Take this medicine with a hot beverage in the evening." c. "Take this medicine in the morning, one hour before breakfast." d. "Take this medicine in the morning with food or milk."
d. "Take this medicine in the morning with food or milk."
A client who has a breast tumor says to a nurse, "I am so anxious. Why did I have to get sick now?" Which of these responses, if made by the nurse, is therapeutic? a. "You will need to find someone to talk over your fears on a regular basis." b. "What do you think is making you feel so anxious now?" c. "Are you aware that there are newer, more effective treatments for breast cancer?" d. "Tell me more about your concerns."
d. "Tell me more about your concerns."
if anemic, increase or decrease milk and give iron or no?
decrease milk as it interferes with iron absorption, and they need iron; give iron!
Renal failure
decrease protein, K, Na, increase carbs, strict I&O
Nursing interventions for Pt who is manic
decrease stimulation, frequent rest periods, observe for escalating behavior, provide outlets for physical activity, provide portable nutritious food, use a calm, matter-of-fact approach, give concise explanations
expected physiological changes of aging
decreased EVERYTHING (skin turgor, wt, chest wall movement, senses, ht, subQ fat)
nutritional needs for patient with hepatic encephalopathy
decreased protein, increased ammonia lvl
Valium, monitor for what?
decreased respirations
old ppl
decreased taste sensation
Benefits of applying ice to extremity
decreases inflammation, bleeding, fever, swelling, muscle spasms and pain
IM site for children
deltoid and gluteus maximus
What are the five stages of grief
denial anger bargaining depression acceptance
failure to thrive
develop a structured routine
Hirschprung's
diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools
AWS
diazepam lorezepam tegretol catapress
Interventions for chronic renal failure
diet high in carbs and mod. fat, control protein intake, restrict Na, K, Ph, and Mg
short cord
discontinue pictocin
Domestic Violence:
discuss escape plan
stem falls of when dry
do nothing
Priority for patient in seclusion
document
FHR pattern shows variability with accelerations; RN to:
document and continue to monitor
Patient can't sleep
don't drink caffeine before bed
asthma & beta blockers
don't give lol's/beta blockers to asthma patient's
Beta blocker teaching
don't stop abruptly; avoid in asthma; take with food
Teaching for Atorvastatin (Lipitor)
don't take with grapefruit juice, take in evening
whats up with central lines and pushing meds with resistance ?
dont do it! may be dislodging a thrombosis
ateriovenous fistula fact
dont measure bp on this side
mom engorged, don't do what?
dont self express milk; ice packs, support bra all ok
gardening
double glove
birth weight
doubles by 6 months triples by 1 year
iron replacement
drink oj
meningitis appropriate actions
droplet mask until 24 hrs after with antibiotics or if culture comes back negative
Appropriate actions for bacterial meningitis
droplet precautions, decrease environmental stimuli, maintain best rest w/ HOB at 30, seizure precautions, replace fluid and electrolytes
TKA 1 day post op; report:
drsg saturated w/ sanguineous drainage
Basophils reliease histamine
during an allergic response
involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist for an extended period of time
dysfunctional grief
Gastric surgery
eat 3 meals
propofol allergy
eggs, egg products, soy
Head Injury
elevate HOB 30 degrees to decrease ICP
Buck's Traction (skin)
elevate foot of bed for counter traction
AKA (above knee amputation)
elevate for first 24 hours on pillow. position prone daily to maintain hip extension.
Lab Results of an MI
elevated troponin, CK-mb enzymes, elevated LDH
Prior to amniocentesis
empty bladder
wilm's tumor
encapsulated above kidneys...causes flank pain
oral glucose tolerance test
fasting blood glucose level drawn at start then pt consumes a specified amount of glucose; blood glucose levels drawn every 30 m for 2 hrs, instruct client to consume balanced diet for 3d prior then fast 10-12 hr
Oral glucose tolerance test
fasting blood glucose level drawn at start then pt consumes a specified amount of glucose; blood glucose levels drawn every 30min for 2hours; instruct client to consume balanced diet for 3 days prior to test, then fast for 10 to 12 hours
Hyper-parathyroid
fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet
russell traction
femur or lower leg
lumbar puncture
fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache.
mononucloesis
fever sore throat swollen lymph nodes increased WBC atypical lymphocytes spleanomegaly enlarged liver
pneumonia
fever and chills are usually present. For the elderly confusion is often present.
s/s of infections mono
fever, sore throat, swollen lymph glands, increased WBC, atypical lymphocytes, splenomegaly, enlarged liver
S/S of infectious mononucleosis
fever, sore throat, swollen lymph glands, increased WBCs, atypical lymphocytes, splenomegaly, enlarged liver
priority infection for amniotomy
fever/infection
crohns disease decrease what in diet?
fiber
What are the S/S of lithium toxicity? (depakote for bipolar disorder)
fine hand tremors, mild GI upset, slurred speech and muscle weakness
when a pt comes in and is in active labor
first action of nurse is to listen to fetal heart tones/rate
pancreatitis
first pain relief, second cough and deep breathe
laboring mom's water breaks?
first thing--worry about prolapsed cord!
Foods that can cause odor for ostomy
fish, eggs, asparagus, garlic, beans, and dark green leafy veggies
Dehydration improving baby
flat fontanelle
Pt with heat stroke
flat with legs elevated
Negative symptoms of schizophrenia
flat, blunt affect; algoia (poverty of thought/speech); avolition (lack of motivation); anhedonia (lack of pleasure/joy); anergia (lack of energy)
bend at waist to pick up, or tuck pelvis and flex abs?
flex & tuck, never bend at waist!
what is histrionic personality disorder?
flirty & seductive
retinal detachment
floaters and flashes of light. curtain vision
Myelosuppression
flu shot
best to orient what? what not?
follow nurse, not skills checklist
BKA (below knee amputation)
foot of bed elevated for first 24 hours. position prone to provide hip extension.
nurse difficulty staffing weekend shifts. which actions should nurse manager take first to successfully implement staffing changes
form a staff task force to investigate current staffing issues
Insulins not to mix
garglarine and determis
Staff nurse documents dressing change but doesn't do it:
gather info about it
nurses documents dressing change that was not performed what should charge nurse do first?
gather more info about staff nurse's actions ASSESSSSS
Pt teaching for external radiation therapy
gently wash skin over the irradiated area w/ mild soap and water, DON'T remove radiation tattoos, DON'T apply powders or lotions, wear soft clothing over irradiated area, avoid tight clothing, DON'T expose area to sun or heat
pt teaching for external radiation therapy
gently wash skin over the irradiated area w/ mild soap/water, DONT remove radiation tattoos, DONT apply powders or lotions, wear soft clothing over irradiated area, avoid tight clothing, DON'T expose area to sun or heat
Postural drainage
give albuterol, trendelenberg; 1 hour before meals or 2 hours after
tpn monitoring
glucose q. 4 hrs
Organize workload
goals for the day
up stairs with crutches? down stairs with crutches?
good leg first followed by crutches(good girls go to heaven) crutches with the injured leg followed by the good leg.
crutches
good side
what can a 3 month old eat? carrots, grapes, graham crackers or popcorn
graham crackers
Statin
grapefruit
Food label
greatest weight listed first
Newborn Assessment; Report:
grunting, tachypnea, nasal flaring
assessing newborn immediate intervention
grunting, tachypnea, nasal flaring
adverse effect of fluoxetine
h/a...also urinary freq, hypotension
Positive symptoms of schizophrenia
hallucinations, delusions, alterations in speech, bizarre behavior
Trousseau's sign
hand/finger spasms with sustained blood pressure cuff inflation
if you run out of TPN, do what?
hang dextrose
Positive TB
hard raised bump
Spanish speaking patient:
have an official interpreter provide translation
RSV
have own stethoscope in room
increased ICP intervenstions
head 30 degrees avoid flexion sneezing coughing minimize suction body in alignment
burns rule of Nines
head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1%
early decel
head compression
early deceleration
head compression
Newborn reflex shown on day 1
hear voice
Nursing interventions for domestic partner abuse
help Pt develop a safety plan, identify behaviors and situations that might trigger violence and provide information regarding safe places to live; encourage participation in support groups
TB drugs are
hepatotoxic!
After a blood transfusion, will you look at hub, hct, BP or HR for changes?
hgb!!! 1-2 pt increase per unit of blood
What do bananas, avocado and spinach have in common? If patient on what med, these are good foods?
high K+, so good for hypokalemic patients; if patients on thiazide diuretics (Diuril, enduron), may be HYPOKalemic, so give these!
Nutritional needs for Hepatic Encephalopathy
high carb, high cal, low to mod fat, and low to mod protein; small, frequent meals; supplement w/ vitamins (B complex), folic acid, and iron
small pox
high fever fatigue severe headache rash center out pus lesions chills vomitting delirium
clinical manifestations of smallpox
high fever, fatigue, sever headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding
tuna good for what? bad for what?
high in protein and potassium; so watch out
Dumping syndrome
high protein and fat; avoid milk, sweets, and sugar; small, frequent meals
heat/cold
hot for chronic pain; cold for accute pain (sprain etc)
contra isorbide monitrate
hypersensitive to nitrates head injury carefull liver renal
increased ICP
hypertension, bradypnea,, bradycarday (cushing's triad)
S/S of thyroid storm
hyperthermia, HTN, delirium, vomiting, abdominal pain, hyperglycemia, tachydysrhythmias
s/s hypernatremia
hyperthermia, tachycardia, rapid thready pulse, ortho hypo, restlessness, irritability, muscle twitching, reduced to absent DTR's, hyperactive bowel sounds
S/S of hypernatremia
hyperthermia, tachycardia, rapid thready pulse, ortho hypo, restlessness, irritability, muscle twitching, reduced to absent DTRs, hyperactive bowel sounds
S/S of dehydration
hyperthermia, tachycardia, thready pulse, hypoTN, orthostatic hypotension, decreased CVP, tachypnea, dizziness, cool clammy skin, diaphoresis, sunken eyeballs
s/s dehydration
hyperthermia, tachycardia, thready pulse, hypoTN, orthostatic hypotension, decreased CVP, tachypnea, dizziness, cool/clammy skin, diaphoresis, sunken eyeballs
s/s hypokalemia
hyperthermia, weak irregular pulse, hypotn, resp distress, muscle cramping, pvc's, bradycardia, decreased mobility
S/S of hypokalemia
hyperthermia, weak irregular pusle, hypoTN, resp. distress, muscle cramping, hypoactive DTRs, PVCs, bradycardia, decreased motility
s/s hyponatremia
hypothermia, tachycardia, rapid thready pulse, hypoTN, ortho hypo, headache, confusion, decreased DTR's, hyperactive bowel sounds
S/S of hyponatremia
hypothermia, tachycardia, rapid thready pulse, hypoTN, ortho hypo, headache, confusion, decreased DTRs, hyperactive bowel sounds
with oxygen toxicity, will you see hypo or hyperventilation?
hypoventilation and bradypnea
Cardinal sign of ARDS
hypoxemia
a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching
i should decrease the amount of calcium in my diet while taking the medication
a woman comes in to you and says she is on contraception and wants to get pregnant. waht is she at risk for?
if IUD, then ectopic pregnancy.
Spinal shock occurs
immediately after injury
DKA is rare
in DM II (there is enough insulin to prevent fat breakdown)
Edema is located
in the interstitial space, not the cardiovascular space (outside of the circulatory system)
Chest tubes are placed
in the pleural space
iv pump
incident report
Combination contraceptives
increase BP
COPD
increase calories and protein
Glucocorticoid
increase dose in DM; take with meals; avoid NSAIDs; Addison's crisis if stopped abruptly
Dumping syndrome
increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink
DASH diet
increase fruit, vegetables, and low fat dairy; k, mg, ca
hot spot
increased drainage warm to touch odor immobility SOB skin breakdown constipation
the first sign of ARDS
increased respirations! followed by dyspnea and tachypnea
Thyroid storm
increased temp, pulse and HTN
Hypovolemia
increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030
Hypernatremia
increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution.
Digitalis
increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion
how does dopamine work, by vasodilating or increasing cardiac output?
increasing cardiac output
Toddlers need to express
independence!
thyroid med side effects
insomnia. body metabolism increases
total hip going home teaching
install raised toilet seat
nurse assisting with thoracentesis for a client who has pleurisy nurse should plan to do what
instruct the client to avoid deep breathing during procedure
first thing for implementing staff changes?
investigate staffing issues with task force
appropriate action for client who will need physical therapy
involve client in selection of pt provider
What causes constipation
iron
ventriculoperitoneal shunt post op for infant with hydrocephalus report what to provider
irritability when being held
Heroin withdrawal neonate
irritable, poor sucking
normal PCWC (pulmonary capillary wedge pressure)
is 8-13 readings 18-20 are considered high
Defamation
is a false communication or careless disregard for the truth that causes damage to someone's reputation. in writing(Libel) or Verbally(Slander)
orange tag in psych
is emergent psych
MMR
is given SQ not IM
When pt is in distress....medication administration
is rarely a good choice
Total Gastrectomy
is total removal of the stomach; long term complication include dumping syndrome- undigested food rapidly enters the duodenum or jejunum usually 5-30 minutes after eating, epigastric pain with cramping, loud hyperactive bowel sounds- managed primarily with smaller and more frequent meals- no liquids with meals- increase in protein and fats- reduce carbs; Anemia may also be problem after gastric surgery due to decreased iron absorption; intrinsic factor is also lost so B12 cant be absorbed; folic acid deficiency, poor absorption of nutrients
woman is post pelvic surgery and asks why she has a foley catheter inserted, what is your response?
it avoids stress on the incision site/bladder
iv pump incident report
iv pump malfunction
Valproic acid for seizure control; A/E to report:
jaundice (liver damage)
Nutrition for increased ICP
keep HOB at 30 degrees, avoid extreme flexion, extension or rotation of the head and maintain in midline neutral position keep body aligned, avoid hip flexion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid coughing or blowing nose
nursing interventions for increased ICP
keep HOB at 30, avoid extreme flextion, extension or rotation of the head & maintain in midline neutral position; keep body aligned to avoid hip flextion/extentio, minimize endotracheal suctioning; instruct pt to avoid coughing or blowing nose
ICP
keep HOB midline
stump
keep dry
Metformin contraindication
kidney disease, severe infection, shock, hypoxic conditions
Who Cannot Give Consent
kids less than 18 intoxicated- blood alcohol level of .08 client with a dose of morphine
buck's traction
knee immobility; dont adjust weights
measles
koplick's spots
DKA
kussmal's breathing (deep rapid)
antisocial personality disorder
lack of remorse
autism ati
lack of responsiveness
Mastectomy
lay of affected side to promote drainage, support arm on pillow, HOB 30
positioning for pneumonia
lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!)
gastric lavage
lay patient on left side, instill 2-300 ml sterile water
Nursing Interventions during late or variable deceleration
left lateral position, oxygen, c-section
Change-of-shift report:
level of assistance needed from bed o wheelchair
Radiation implant
limit visitors to 30 minutes
Bariatric surgeries Dietary planning
limited to liquids or pureed foods for first 6wks, meal size shouldn't exceed 1c, vit & min supplements
Psych med
lip smacking
contraindications of statin medications
lipitor hepatitis
infant has scaly spots, erythemic papillae, and something on lips. Report which to physician/
lips
valproic acid
liver failure, jaundice
pain with diverticulitis
located in LLQ
appendicitis pain
located in RLQ
prednisone 10 months ok? watch for what?
long term not recommended, never change dosage, watch for osteoporosis, avoid large crowds due to increased risk for infection;
cancer treatment for radiation
loose clothing wash mild soap + water, protect from sun
long term effect of corticosteroids
losing hair on legs
What are s/s of Mag sulfate toxicity? What is the antidote for Mag Sulfate?
loss of Deep Tendon Reflexes, urinary output < 30ml/hr, resp depression, pulmonary edema, and/or chest pain Calcium Gluconate to fix!
What are the signs and symptoms of fluid volume deficit
loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension.
ptsd assessment
lost of interest withdrawal things they enjoy
Baby from mom w/ gestational diabetes at risk for
low Ca & Mg & glycemia. high bili
dehydration = what v/s
low bp, high hr, metabolic acidosis (low ph, high bicarb), postural hypotension, h&h, BUN, elevated
PTB
low grade afternoon fever
after Thyroidectomy
low or semi-fowler's position, support head, neck and shoulders.
diet for glomerulonephritis?
low sodium, water restriction
calcium gluconate antidote
mag
Hand Rolls:
maintains a functional position
hand roll in each hand
maintains functional position
montelukast
maintanence, not rescue inhaler
do you report chlamydia, do you need consent, etc?
mandated reporting to CDC, without verbal or written consent
Malfunctioning IV machine
mark as defected and get new one
impaired vision:
mark steps with colorful tape
Nursing Interventions for Boggy Uterus Postpartum
massage first then administer oxytocin
Nutrition of boggy uterus postpartum
massage first then administer oxytocin
nursing interventions for boggy uterus
massage the fundus then administer oxytocin
Iatragenic
means it was caused by treatment, procedure or medication
DKA patient drops glucose from 450-250; do what? measure glucose, temp, what and how often?
measure glucose & potassium hourly, provide IV glucose at 250 to prevent hypoglycemia
early sign of cystic fibrosis
meconium in ileus at birth
community mental health clinic which group is appropriate for nurse to lead?
medication education group
expected findings of schizo?
memory deficit, difficulty concentrating, disordered thinking, poor problem solving and decision-making
If Pt develops reflex tachycardia from taking Imdur give what?
metoprolol (Lopressor)
Extreme focus
mild anxiety
kosher
milk and meat seperate
alk ash diet
milk, veggies, rhubarb, salmon
Normal stoma findings
moist shiny/pink; mild soap and water, then dry gently and completely, apply paste if used, apply barrier pastes to creases
nursing interventions for patient who has HSV-2
monitor fetal well being, fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible c-section of lesions present during labor
Nutrition for pt who has HSV-2
monitor fetal well-being, fetal consequences - include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible C-section of lesions present during labor
Nursing Interventions for Pt who has HSV-2
monitor fetal well-being, fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible c section if lesions present during labor
Complications following a hypophysectomy
monitor for bleeding and nasal drainage for possible CSF leak (assess drainage for glucose of halo sign); assess neurological condition every hour for first 24 hours and every 4 hours after
Complications following a hypophysectomy (removal of pituitary gland)
monitor for bleeding and nasal drainage for possible CSF leak (assess drainage for glucose or halo sign); assess neurological condition every hour for first 24h and every 4h after
complications following hypophysectomy (removal of pituitary gland)
monitor for bleeding and nasal drainage for possible csf leak, assess neurological condition every hour for first 24 h and every 4h after;
hypermagnesiumemia
monitor for cardiac dysrhythmias
risk for diabetes inspidus
monitor for polyuria
cancer treatment
monitor platelets
Nursing intrvetions for Pt receiving TPN
monitor serum and urine glucose, monitor for "cracking" of solution, use sterile technique when changing central line, bag and tubing should be changed q24h
cushings disease, 2 things
moon face and increased cortisol
Cushing's
moon face, buffalo hump
bowel obstruction
more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids)
multiple sclerosis
motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia
manifestations cold stress
mottled skin apneic temp lower 97.7 respiration increased HR increased acrocynanosis decreased activity
o2 sat
move q. 4 hrs
3 days post op aka
move to prone position q 4 hr to prevent flexion contracture, don't elevate for 48 hr, wrap limb distal to promimal to prevent restriction of blood flow
S/S of hypocalcemia
muscle twitches/tetany, hyperactive DTRs, positive Chvostek's sign (tapping on the facial nerve triggering facial twitching), positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation), seizures
Strabismus
muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. Will result in central blindness if not treated by 6 y/o. Patch the eye.
hypokalemia
muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery)
Hypercalcemia
muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency!
Liver biopsy (prior)
must have lab results for prothrombin time
multiple sclerosis
myelin sheath destruction. disruptions in nerve impulse conduction
Alcohol withdrawal expected finding
n&v, tachycardia, diaphoresis, tremors, seizures
Opioid agonist
naloxone (Narcan)
Cheese is not good with what? Cheese is good for what and why?
nardil/maoi! good for hyponatremia because high in sodium, high in protein
digoxin toxicity
nausea!!! diarrhea
dumping syndrome S&S
nausea, distension, cramping pains, diarrhea within 15 minutes after eating
Hyponatremia
nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids
patient has l1-l2 paralysis, lives with spouse, bathroom & bedroom on 2nd floor. Needs PT, respite, speech therapy and what?
needs occupational and physical therapy, but social services is number one for help with home adapation
Clozapine (Clozaril) Chlorpromazine (Neg and Pos s/s Schizophrenia) S/E What to do?
neg and pos s/s of schizophrenia, relief of psychotic symptoms DRINK FLUIDS AVOID SUNLIGHT New onset diabetes/loss of glucose control (report s/s of increased thirst, urination, appetite), wt gain, hypercholesterolemia, orthostatic hypotension, anticholinergic effects, symptoms of agitation, dizziness, sedation, and sleep disruption, mild EPS such as tremor, risk for dyslipidemia, risk for fatal agranulocytosis (baseline & wkly monitor of WBC, notify of S/S of infection) Stop med for signs of neuroleptic malignant syndrome
Cholecystitis diet
no cheese! low fat, low cholesterol (<200), if AST & lipase, any type of bilirubin, WBC, amylase, LDH, are elevate = bad
TPN, slow down infusion before endingg, d/c until new bag ready?
no, dont d/c or change rate, don't change flow rate!
can clients family change dressing daily? tie tubing to neck?
no, every 8 hours? yes, square knot with 1-2 finger width
pediatric patient dehydrated, after initial oral rehydration, give water, juice or ginger ale?
none!
S3 sound
normal in CHF. Not normal in MI
thrombocytopenia instruct nurse to avoid what
nose blowing
thrombocytopenia; avoid:
nose blowing; increases the risk of bleeding and hemorrhaging
Hyperthermia
not blanket or ice
Thoracentesis causes pneumothorax expected finding
not friction rub; tracheal deviation
Unstable Angina
not relieved by nitro
aPTT 30 and platelets 200, what's wrong?
nothing
ice
num antiinflammatory
infant has substernal heaves, expect what?
o2, suction, survanta for surfactant, vent support
diet dysphagia
oatmeal
R sided Heart Failure
occurs when the right ventricle fails to contract effectively. right sided heart failure causes a backup of blood into the right atrium and venous circulation. Venous congestion in the systemic circulation results in jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal tract, and peripheral edema. Right sided heart failure may result from an acute condition sich as right ventricle infarction or pulmonary embolism. Cor Pulmonale (right ventricular dilation and hypertrophy caused by pulmonary disease) can also cause right sided HF. Thr primary cause of heart failure is left sided heart failure. In this situation, left sided heart failure results in pulmonary congestionand increased pressure in the blood vessels of the lung (pulmonary hypertension). Eventually, chronic pulmonary hypertension (increased right ventricular afterload) results in right sided hypertrophy and HF.
reaction formation
ocer compensation or demnostrating the opposite behacior of what is felt
bacterial vaginosis
odor discharge dysuria
Sibling bonding
offer gift each time sibling gets one
Bulimia Therapeutic Nursing Care
offer small and frequent meals
intraosseous infusion
often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist.
client to see first?
older client who is confused and attempting to pull on IV
Dehydration
oliguria
findings w/ severe preeclampsia
oliguria, proteinuria, blurred vision, facial edema
pyloric stenosis
olive like mass
During internal radiation
on bed rest while implant in place
prone to urinary calculi, include in diet...
oranges
dementia
orient with calendar
a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this client
orthostatic hypotension
Change of shift report
orthostatic hypotension by nurses station
urine output 15 ml/hr what additional assessment data is indicative of fluid volume deficit
orthostatic hypotension! inc bun, tachy,
Long term use of proton pump inhibitors
osteoporosis
gentamicin
otoxicity (tinnitus, HA, hearing loss, nausea, dizziness, vertigo) nephrotoxicity hypersensitivity- rash, pruritus
Intervene
pacing around wife
PAD
pain/cramping when walking, calf muscle atrophy, shiny cool extremities; elevate legs
glaucoma
painful vision loss. tunnel vision. halo
Bladder CA
painless hematuria
prevent heat loss in infant via conduction
paper on scale
what can grant informed consent?
parent of minor, spouse or closest relative granted power of attorney, court-ordered rep, legal guardian
tracheostomy tube suctioning:
pass the catheter no more than three consecutive times
Battery
performing procedure without consent
Cleft palate repair
periodic restraints
hip arthroplasty, what to watch out for?
peripheral pulses! cool & weak, 1+ peripheral pulses, sign to call provider
Glaucoma patients lose
peripheral vision.
quad cane
place of unaffected side of body place it 6-12 in in front of the body before walking steps forward with affected leg first bring the unaffected leg as well, bringing the foot past the cane
first trimester routine prenatal exam when checking if fetal heart can be detected nurse should
place scope midline just above the symphysis pubis and apply firm pressure
FHR detection:
place the scope midline just above the symphysis pubis and apply firm pressure
complications of mechanical ventilation
pneumothorax, ulcers
post spelectomy
pneumovax 23 is administered to prevent pneumococcal sepsis
Diabetes insipidus
polyuria
DM
polyuria, polydipsia,polyphagia
Cleft Lip
position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.
After Myringotomy
position on the side of AFFECTED ear, allows drainage.
Thoracentesis:
position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing
after receiving report assess who first?
post op client with abdominal distention and no bowel sounds because of paralytic ileus
Fasting blood glucose
post pone admin of antidiabetic med until after levels are drawn; ensure pt has fasted for 8hr prior to blood draw
fasting blood glucose
post pone admin of antidiabetic med until after levels are drawns, ensure patient has fasted for 8 hours prior to blood drawn
alternate communication methods
postop laryngectomy pt use a pad and pencil to write requests
Fasting blood glucose
postpone administration of anti-diabetic medication until after blood glucose levels are drawn; ensure patient has fasted for 8 hours prior to blood draw
advance directives
power of attorney
Anorexia
prealbumin 10
Contraindications to MMR Immunization
pregnancy, allergy to gelatin and neomycin, hx of thrombocytopenia, immunosuppression, recent blood transfusion; common cold NOT a contraindication
singulair
prevent exercise-induced bronchospasm, and for long-term use; take ONCE DAILY AT BED TIME
Airborne precautions protective equip
private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB
Koplick's spots
prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth
phototherapy child
protect eyes
Give RhoGAM in second pregnancy
protect future pregnancy
gastric bypass
protein first
Preeclampsia
proteinuria
downs syndrome
protruding tongue
nurse manager changing scheduling
provide info about sched issues to staff
Nursing interventions for Pt with PTSD
provide safety and comfort, remain w/ Pt through episode, give reassurance, group/family therapy is best, assist client to eval. coping mechanisms that work, assist Pt in determining triggers
use of restraints
provider must rewrite order every 24h, Toileting and ROM exercises and assessment of neurovascular and neurosensory status q2h, tie to bed frame (loose knots that are easily removed)
diptheria
pseudo membrane formation
sealed radiation implant
pt in private room, nurse should wear dosimeter film badge, visitors limited to 30m visits and maintain distance of 6ft, visitors who are pregnant or under 16yrs. should not contact Pt, lead container in room, instruct pt to call nurse for assistance with elimination
After lumbar puncture and oil based myelogram
pt is flat SUPINE (prevent headache and leaking of CSF)
administration of enema
pt should be left side lying (Sim's) with knee flexed.
After Cateract surgery
pt sleep on UNAFFECTED side with a night shield for 1-4 weeks
WBC left shift
pt with pyelo. neutrophils kick in to fight infections
brachial pulse
pulse area on an infant
pericardidtis
pulses paradoxes
cardiac tamponade
pulsus paradoxus
a patient is experiencing umbilical cord prolapse - intervention?
put hand up vagina and hold it there
when drawing an ABG
put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2
agitated and confused pt with head injury pulling iv
put on mittens and watch
wound has dehisced, do what?
put saline soaked sterile gauze over
pancreatitis pts
put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids
bipolar disorders for manic
quiet area, not isolated give finger food
pt had cva 6 yrs ago, decrease ICP how?
quiet environment, HOB no more than 30 degrees
Cushing's triad
r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)
Cushings ulcers
r/t brain injury
Confused patient
raise 1 side rail
Expected finding of small pox
rash in mouth
pernicious anemia
red beefy tongue
patients with hallucinations patients with delusions
redirect them distract them
BPH
reduced size and force of urine
Swallow problem
refer to speech therapist
Client's family asks you to pray with them. Response?
refer to spiritual services
Nursing interventions for dementia
reinforce reality, orientation to Person Place Time, encourage reminiscence about happy times, talk about familiar things, minimize need for decision making and abstract thinking to avoid frustration
Does does Magnesium Sulfate do?
relaxes smooth muscle of the uterus and inhibits uterine activity by suppressing contractions
Uses for methadone (Dolophine)
relief of mod to severe pain; sedation; reduction of bowel motility
infant with apnea monitoring
remove leads, ensure alarm can be heard, avoid cosleeping
cleft palate
remove restraints
Peritoneal dialysis
report cloudy; monitor glucose; warm solution before
reportable diseases
report lyme disease
epinephrine adverse effects
report of chest pain!
impaired nurse, do what?
report to charge nurse
Lyme disease
report to health department
Fluoxetine (Prozac)
report tremors, agitation, confusion, anxiety, hallucinations=serotonin syndrome (risk in the first 2-72 hrs after given first time); client will stop the meds; weight gain/diabetes/ hyperglicemia
umbilical cord compression
reposition side to side or knee-chest
What do you hear when you palpate abdomen
resonance
what acid-base imbalances w/ a pt with chronic emphysema most likely have?
resp. acidosis and compensatory metabolic alkalosis
What acid-base imbalance with a pt with chronic emphysema most likely have?
respiratory acidosis and compensatory metabolic alkalosis
what acid base imalance w/ a pt with chronic emphysema most likely have
respiratory acidosis; compensatory metaboli alkalosis
Pericarditis commonly follows a
respiratory infection
2 years of age, presentation of arms longer than torso, or round & soft abdomen
round & soft abdomen, NOT arms longer than torso
complications of infections mono
ruptured spleen
tranmission precautions for infectious mononucleosis
ruptured spleen
pneumonia
rusty sputum; when percuss-will hear dull sounds
how is infectious mononucleosis spread?
saliva
equation for calculating a pulse pressure
sbp - dbp = pp
Varicella
scabs okay
Pernicious anemia
schilling's test
Osteoporosis; risk factors:
sedentary lifestyle
Nursing interventions for alcohol withdrawal syndrome
self-assess ones own feelings regarding abuses; use open-ended questions, close/one-on-one observation; low-stimulation enviro, encourage attendance of self-help groups
children 5 and up
should have an explanation of what will happen a week before surgery
asthma kid
should participate in sports, inhaler prior to sports, stay inside when cold, use peak flow meter every day same time, annual influenta vaccine important
Informed consent
signed willingly
Thoracentesis position
sitting position, arms raised and resting overbed table.
dunlap traction
skeletal or skin
interventions with kid with gastroenteritis
skin barrier 241 comp
s/s hyperkalemia
slow/irregular pulse, hypotn, restlessness, irritability, weakness with ascending flaccid paralysis, n/v/d, hyperactive bowel sounds
Myxedema/ hypothyroidism
slowed physical and mental function, sensitivity to cold, dry skin and hair.
s/s of early lithium toxicity
slurred speech, nvd, thirst, polyuria, muscle weakness
PRBC need further teaching
start IV on other arm
Doxazosin teaching
stay with patient orthostatic hypotension
malaria
stepladder like fever--with chills
Delegate to LPN
sterile dressing
Complication of conscious sedation with RR 6
stop infusion or give something
Collecting urine culture on baby
straight cath
kawasaki syndrome
strawberry tongue
have client do what with anthrax?
strip down
TPN given in
subclavian line
Administration of Enoxaparin (Lovenox) Anticoagulant
subq q12h for 2-8d; use 20-22G needle to draw up; 25-26G needle to admin; admin in abdomen at least 2" away from umbilicus; apply pressure for 1-2m after injection; DON'T RUB
seizure precautions
suction nearby
first sign of PE
sudden chest pain followed by dyspnea and tachypnea
Leukotrien Modifiers Montelukast (Singulair)
suppress inflammation, bronchoconstriction, airway edema, and mucus production long-term therapy for asthma and to prevent exercise-induced bronchospasm Take once daily at bedtime
bethamethasone (celestone)
surfactant. premature babies
Describe pre-albumin
this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks)
When taking MAOI's, limit your consumption of
thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar...
No phenylalanine
to a kid with PKU. No meat, dairy or aspartame
never give potassium
to a pt who has low urine output!
Rh mothers receive Rhogam
to protect next baby
band w/ bead that applies pressure to the P6 meridian on her wrist:
to relieve nausea
med admin what is risk
too frequently
ausculating heart valve
top left
How to measure Fundal Height
top of symphysis pubis to top of fundus
methergine risk? what does it do?
treats postpartum hemorrhage by inducing uterine contractions; reducing hemorrhage; HYPERTENSION is a risk, so check bp prior to administration, watch for n/v, headache
True Labor vs False Labor Abdominal Discomfort
true: low back and abdominal false: abd and groin
frequent variable decels
turn on left side first
chlorpromazine:
tx: hallucinations Ed: Sip water frequently and minimize exposure to the sun
position crutches on affected or unaffected side when sitting or rising from chair?
unaffected side 2-3 finger widths Crutches no weight bearing Tripod position weight on UNAFFECTED side. advance both crutches and affected extremity move unaffected forward (beyond crutches) advance both crutches then affected extremety continue sequence (steps equal length) Crutches with weight bearing move crutches forward about 1 step length move AFFECTED leg forward level with crutches move unaffected leg forward continue sequence (steps equal length)
cryptorchidism
undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence
Assessment; 18hr post of C-Section during breastfeeding:
unilateral tenderness of the LLE; potential DVT
IV urography
used to detect obstruction, assess for a parenchyma mass, and assess size of kidney
IV Urography Procedure
used to detect obstruction, assess for a parenchymal mass, and assess size of kidney Before procedure check allergy to iodine and check creatinine levels because dye can cause renal failure.
IV urography
used to detect obstruction; assess for a parenchymall mass, and assess size of kidney
Nephrotic syndrome
vitamin K
appropriate post-op care for diabetes/
vitamin c
Warfarin
vitamin k for toxicity; INR 2-3; PT 11-12.5
child to see first
waiting appendectomy has sudden relief of pain
24 month old
walk up steps
Promote circulation following an episiotomy:
warm sitz baths
Difficulty voiding
warm water
blood glucose monitoring what to do first
wash patients hands to stimulate blood flow & decrease infection
ventriculoperitoneal shunt
watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees
HSV2 and pregnant
watch for active lesions
Tamoxifen
watch for visual changes--indicates toxicity
TB patient precautions
wear N95 mask, neg pressure room,
osteoporosis
weight bearing
treatment for chlamydia, both mom & baby? timing for baby?
zithromax, amoxicillin and erthromycin for both mom & baby; immmmmmmediately following delivery
Bladder retraining for the treatment of urge incontinence:
• Use timed voidings to increase intervals between voidings/decrease voiding frequency. • Perform pelvic floor (Kegel) exercises. • Perform relaxation techniques. • Offer undergarments while the client is retraining. • Teach the client not to ignore the urge to void. • Provide positive reinforcement as client maintains continence. • Eliminate or decrease caffeine drinks. • Take diuretics in the morning.
"I don't know what to do without my wife. Life is just not worth living."
"You seem to be having a difficult time right now."
Addison's disease: Cushing's syndrome:
"add" hormone have extra "cushion" of hormone
Detached Retina
"feels like a *curtain* is pulled over my eye"
expect what during latent phase of labor?
(0-3, 5-30, 30-45) 0-3 cm, contractions mild and moderate, 5-30 min apart/30-45 seconds
Malnourished COPD patients
(1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup
Intervention for sprain
(PRINCE) Protect, Rest, Ice, NSAIDs, Compress, Elevate
ALS
(amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems
WBC normal values
(for infection) 4,000-10,000
After supratentorial surgery
(incision behind hairline on forhead) elevate HOB 30-40 degrees
Kawasaki disease
(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.
Woman in labor (un-reassuring FHR)
(late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Proper lifting technique
(picture) bending at knees
Where to start IV first
(picture) hand
To prevent dumping syndrome
(post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals.
Autonomic Dysreflexia
(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
Magnesium sulfate interventions
(select all) calcium gluconate, stop infusion, UO less than 30, RR less than 12, decreased reflexes
Diabetic foot care
(select all) change shoes frequently, wash feet with soap and water
Ileostomy care and education
*-Empty pouch: 1/3 to 1/2 full. -Clean pouch 1-2 times daily. -Pouch change every 4-6 weeks. -Wafer size 1/8 to 1/4 larger than stoma -Avoid high fiber foods to prevent blockage.
Ileostomy bag
"Apply skin barrier" to protect skin from enzyme & bile salts
Depression; joking about committing suicide, RN to ask:
"Do you have a plan to hurt yourself"
Circumcision post op care: cleaning
-Change diaper every 4 hrs. -Clean penis with each change. -Apply petroleum jelly for at least 24 hrs after circumcision (prevent adhering). -Fan fold diaper (prevent pressure). -Avoid wrapping penis (impairs circulation) -Washing: trickle warm water over penis. -Do not clean yellowish mucus that appears by day 2. -Do not use moistened towelettes. -Healing: a couple of weeks.
Acute Mania Interventions
-Decrease stimuli and one to one observation if necessary.
COPD -conservative measurements -Rapid relief med
-High Fowler position -Increase fluids to liquify mucous -Albuterol
steps of problem solving
-ID problem -discuss possible solutions -analyze ID solutions -select solution -implement solution -evaluate
Buck's Traction -Goal -Following conservative measurements -Skin integrity/Neuro
-Immobilization -Follow RX orders: type of traction, weights, whether it can be removed. -Reposition every 2 hrs, provide pin care, neuro checks
Cholecystitis (inflammation of gallbladder) Diet
-Increase fruits, vegetables, whole grains. Ex: Melon -Avoid greasy/fatty foods
Ileostomy what pt expect on appearance.
-Initial drainage: dark green, odorless. -Some initial bleeding normal -Pink or red stoma color normal -Initial swelling; decreases 2-3 weeks later
Ventilator Alarms -Low Pressure -High Pressure
-Low: disconnection -High: suction for possible secretions, kinks.
monitor for these in Levodopa
-NV, drowsiness -dyskinesias (head bobbing, tics, grimacing, tremors)- decrease dose -orthostatic hypotension -CV effects- tachycardia, palpitations, irregular heartbeat -psychosis -discoloration of sweat and urine- normal -activation of malignant melanoma
Diabetic Foot Care
-Nailcare: Podiatrist, cut nail straight across. -Wear Clean Cotton Socks/Closed Shoes -Do not soak feet or wear ointments
Discomforts During Pregnancy
-Nausea -Fatigue -Backache -Constipation -Varicose Veins -Hemoroids -Heartburn -Nasal stuffiness -Dyspnea -Leg Cramps -Edema lower extremities
Patient education for Amniocentesis.
-Position: supine or rolled towel under right hip -Continue breathing normally when inserting needle -Rest 30 mins after procedure. -Increase fluids for next 24 hrs.
MMR contraindication
-Pregnancy, recent blood transfusion....
Chlorpromazine (med for psychoses) -Adverse Effects and given treatment
-Severe Spasms/Tremors Tx: benzotropine (Cogentin), diphenhydramine (Benadryl).
Indications of Fluid Volume Depletion (Hypovolemia)
-Thready pulse/Hypotensive -Tachy -Increased Respiration -Cool, Clammy, Diaphoretic -Decreased Urine Output -Thirst
Levothyroxine (Synthroid) -What is it? -What patients should use this medication with caution? -Best way to take?
-Thyroid hormone; treats hypothyroidism. -Cardiac pts; aggrevates tachy and anxiety -Take in the morning, on empty stomach
Ferrous Sulfate (Feosol) -Purpose -Reporting symptoms -Administration -How to monitor effectiveness
-Treats iron deficiency -GI distress: nausea, constipation, heartburn. -Take on empty stomach, drink with straw and rinse to prevent staining. - Increase Hgb of 2g/dL, Hct
Contraindicated Immunizations During Pregnancy
-Varicella -Zoster -MMR
ileal conduit
-continuous drainage into external pouch -monitor peristomal skin for redness, excoriation or infection -teach them how to care for the drains and their insertion site during the 3-6 weeks before removal -clean the insertion sites gently with water and then apply dry sterile dressing -intially catheterize stoma= emtpy pouch every 2-3 hours and irrigate pouch in the morning and evening -later they can cath every 4 hours while away or more often if they sense fullness -clean reusable catheter tip with warm soap and water, rinse it thoroughly and can use it for up to a month
Types of Decelerations: <120 fhr -early -late -variable
-early: head compression -late: uteroplacental insufficiency -variable: cord compression
newborn assessment
-expected head circumference (32-36 cm) -expected chest circumference (30-33 cm) -length 18-22 in
dehydration
-hypovolemia - elevated urine specific gravity
seclusion and restraints
-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min
jehovah's witness
-no blood -avoid foods having or prepared with blood
conflict resolution strategies
-open communication amont staff is needed -de-escalate the situation with open communication and problem-solving strategies -use "I" statements -listen carefully to what other people are saying, try to understand their perspective -move conflict that is escalating to private location -share ground rules
Does Port need flushing?
-open ended= require heparin flushing -valved= does not require heparin
TB precautions and care
-private room/negative pressure -N95 masks -pt wear mask when transported out of room or in any public place. -Medications: may be taking up to 4 meds at a time; up to 6-12 months -Test exposed family members -Sputum culture every 2-3 weeks; 3 negatives results in noninfectious.
Dehydration S&S (hypovolemia)
-pulse; weak and thready. hypotension -tachy -confused -decreased urine output -skin and mucous membranes dry Urine Specificity increased
Iron supplements
-should be taken with high-fiber foods to prevent constipation -avoid taking with milk because it interferes with absorption
for clients who are hearing imparied
-sit and face client -avoid covering mouth while speaking -encourage use of hearing devices -speak slowly and clearly -do not shout -try lowering vocal pitch before increasing volume -use brief sentences with simple words -write down what clients do not understand -minimize background noise -ask for sign language interpreter if needed
hinduism
-some are vegetarians -do not prolong life -want to lie on floor while dying -thread is placed around neck/wrist -pours water into mouth -bathes body -cremated
Buddhism diet
-some are vegetarians -may avoid alochol and tobacco -may fast on holy days -chanting is common -brain death is not considered a a requirement for death
christianity
-some avoid alcohol, tobacco, caffeine -fast during lent
lithium levels
0.4-1
. The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for 1. a client with Alzheimer's requiring assistance with feeding. 2. a client with osteoporosis complaining of burning on urination. 3. a client with scleroderma receiving a tube feeding. 4. a client with cancer who has Cheyne-Stokes respirations.
1
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says she feels pressure against her diaphragm when the baby moves.
1
A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium.
1
A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side.
1
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be 1. confused with cold, clammy skin and a pulse of 110. 2. lethargic with hot, dry skin and rapid, deep respirations. 3. alert and cooperative with a BP of 130/80 and respirations of 12. 4. short of breath, with distended neck veins and a bounding pulse of 96.
1
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client 1. in semi-Fowler's position. 2. prone, with the head turned to the side. 3. with the head of the bed elevated 45° and the neck extended. 4. supine, with the head in the midline position.
1
An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially 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. monitor the anticholinergic effects of the medication.
1
The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the client to limit his intake of 1. red meat and shellfish. 2. cottage cheese and ice cream. 3. fruit juices and milk. 4. fresh fruits and uncooked vegetables.
1
The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply
1
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions.
1
Fill in the blank: 1. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone.
1 & 2 = collaboration
Normal post-op output for an ileostomy is what?
1 L/day; may be bile colored and liquid; normal to see small amounts of blood
During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake.
2 3 4
Describe isolation in mental health.
A child who was physically abused by her uncle, but shows no emotion when speaking about him.
Describe reaction formation in mental health.
A client is angry about all aspects of care, but acts nice to all health care personnel.
Describe displacement in mental health.
A client who is angry with a physician, but yells at the RN.
Describe rationalization in mental health.
A client who is being treated for drug abuse says she can't stop because "her husband verbally abuses her and she takes the drugs to get through the painful experience."
Describe projection in mental health.
A client yells at the nurse saying she is fearful and withdrawn and should not be a nurse.
Describe identification in mental health.
A client, admitted, with epilepsy, and now wants to become a nurse.
Describe conversion in mental health.
A college freshman who is having difficulty organizing her workload and develops irritable bowel syndrome.
Describe sublimation in mental health.
A father who lost his son after binge drinking joins organizations to educate others about alcohol on college campuses.
What is an interdisciplinary team?
A group of health care professionals from different disciplines
Low Pressure Alarm
A leak within the ventilator circuitry. Either the tubing has come apart or that client has become disconnected from the ventilator tubing. Almost all low-pressure alarms are the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.
What is a Durable Power of Attorney for Health Care?
A legal document that designates a health care proxy, who is an individual authorized to make health care decisions for a client who is unable. The person who serves in the role of health care proxy to make decisions for the client should be very familiar with the client's wishes.
What are the two components of an advance directive?
A living will and the durable power of attorney for health care
Malpractice (professional negligence)
A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies.
Negligence
A nurse fails to implement safety measures for a client who has been identified as a risk for falls
False Inprisonment
A person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility). Physical or chemical restraints.
TB
A positive Mantoux test indicates pt developed an immune response to TB. Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by a positive culture for M TB A chest x-ray may be ordered to detect active lesions in the lungs QuantiFERON-TB Gold: DIAGNOSTIC for infection, whether it is active or latent
Splitting
A primitive ego defense mechanism that places people and not Arvad categories
A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item?
A straight leg cane
Describe intellectualization in mental health.
A wife who talks about the love of her family, but doesn't demonstrate love towards them.
Contraceptives and Hx of Osteoporosis
Avoid Medroxyprogesterone
SSRI (Duloxetine, Fluoxetine, Escitalopram, Fluvoxamine, Paroxetine, Sertraline) Teaching
Avoid alcohol, do not discontinue abruptly, monitor for agitation, confusion and halluciations within the first 72 hours. S/E Weight gain, sexual dysfunction, fatigue, drowsiness May cause serotonin syndrome (2-72 hrs after start of treatment): tremors, agitation, confusion, anxiety and hallucinations
Adverse effect of Verapamil
Avoid grapefruit juice
Hypocalcemia
CATS Convulsions, Arrythmias, Tetany, spasms and stridor
Hypo-parathyroid
CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet
ANGINA Containdications for vasodilators Nitros
CLIENTS WITH A HEAD INJURY Hypotensive risk with antihypertensive meds Erectile dysfunction meds (life threatening hypotension)
laparoscopy
CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup
Myxedema coma
COLD (hypothermia)
Delegate to AP
CPR compressions
measures to prevent injury with osteoporosis
Ca supplementation, adequate amounts of protein, mag, vit. K, Vit D, wt-bearing exercises, remove throw rugs, provide adequate lighting, clear walkways, mark thresholds, doorways and steps
Be ready to administer ____ for Magnesium sulfate toxicity
Calcium gluconate
What is the function of the parathyroid gland?
Calcium/phosphorus metabolism.
Helps with Orientation
Calendar on the wall
Vancomycin Precautions
Causes: Ototoxicity and nephrotoxicity Monitor creatinine and BUN Peak and Trough Levels Therapeutic Range 20-40 mcg/dL Infusion reactions (rash, flushing, tachycardia, hypotension) Thrombophlebitis DON'T TAKE WITH LOOP DIURETICS (OTOTOXICITY)
Ok to be DC in event of disaster:
Cellulitis receiving oral antibiotics
Vacuum-assisted Birth; Possible complications
Cervical Laceration; rare but can include perineal, vaginal, or cervical lacerations
Bowel elimination how to get a specimen collection
Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine.
Intussusception
Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements
Hepatitis A
Contaminated Food
Late decels & variable decels:
DC oxytocin
best pain management for 8-10 post open cholecystectomy; demerol, hydromorphine, fentanyl, morphine
DEMEROL NOT morphine or others; morphine can cause biliary spasms
Tetrology of Fallot
DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis)
first thing to do with a newborn; take temperature, weight, dry...
DRY
Immunization: booster every 10 years
DTP
Calculate Nagele's rule for the first day of LMP of March 2, 2015. Subject: Maternity
December 9, 2015
Nutrition for heart failure
Decrease Na, increase fluids, increase fiber; increase K with diuretic
What to do when pt complains of cramping during tube feeding?
Decrease infusion rate
Baclofen (Lioresal) therapeutic outcome:
Decrease the frequency and severity of muscle spasms (MS).
Urine Specific Normal Values and Significance
Decreased hypervolemia. Increased hypovolemia. 1.001-1.029
Assessment of DI
Decreased urine specific gravity and osmolality Hypernatremia Hypokalemia Increased urinary output Dehydration, weight loss and dry skin
Contraindication During Alcohol Withdrawal
Delirium, accompanied by hallucinations.
Advanced Directives:
Designates spouse
Purpose of Telemetry
Detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle
Failure to Thrive (toddler); POC:
Develop a structured routine
Graves disease
Difficulty focusing
Left Sided Heart Failure
Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea Fatigue Displaced apical pulse (hypertrophy) S3 heart sound (gallop) Pulmonary congestion (dyspnea, cough, bibasilar crackles) Frothy sputum (can be blood-tinged) Altered mental status Manifestations of organ failure, such as oliguria (decrease in urine output
S/E of Metoclopramide (Reglan) For Heartburn (antiematic)
EPS (bradykinesia, tremor, rigidy) (notify Ph, admin benadryl), hypotension, sedation, anticholinergic effects
Hyperemesis gravidarum
Eat to taste -Some food better than none
Sucralfate
Forms a protective barrier over ulcers
Celiac Disease
Foul, fatty stools (steatorrhea); malabsorption syndrome
Cranial nerve XI (Spinal accessory)
Function of the nerve: Motor - Turning head, shrugging shoulders System: Head and neck
Long term effects of NSAIDS (Ibuprofen)
Gastric Ulcerations, perforations, hemorrhage, hypertension
CG tells CN that pt is not being cared for properly; CN to:
Get specific concerns from CG
Inhalation Anthrax
Give Cipro
Diabetic Ketoacidosis
Glucose reading <300 mg/dL is improvement
Transactional analysis
Goal is that individuals in group will communicate from proper ego states/responses of others.
Most common cause of hyperthyroidism
Grave's Disease
What does 'gravida' mean in GTPAL?
Gravida indicates the number of times the woman has been pregnant, regardless of whether these pregnancies were carried to term.
What is the key finding for Diptheria?
Gray membrane on tonsils/pharnyx.
CABG
Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart.
Time-mgmt. strategies:
Group activities, Get equipment before entering room, delegate to AP, Develop a schedule that prioritizes client care
what test for breast cancer vs ovarian cancer?
HER2 (her 2 boobs) gene = breast AFTER biopsy but BRCA1 (bra) is for detecting breast cancer w/o biopsy.. ca-125 (clit area) for ovarian cancer
CSF meningitis
HIGH protein LOW glucose
Intermittent tube feedings
HOB @ 45 degrees feed and 1hr after feeding, admin. solution at room temp, formula is administered q4-6h in equal portions of 200-300mL over a 30m-60m time frame Flush 30mL every 4 hours
Ventilatory alarms
HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc
Thyroid storm
HOT (hyperthermia)
Apgar measures
HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate
Ideal location for drainage bag of catheters
Hang on bedframe below level of the bladder.
Post Thyroidectomy
Have Trach Tray available for airway disruption
erythromycin ointment; mother refuses:
Have mother sign the refusal form and document form completion.
Glycosylated blood test
HbA1C
Trendelenburg
Head is lower than feet
Contraindications for the use of Isosorbide Mononitrate (IMDUR) For Angina
Headache hypersensitivity to nitrates, traumatic head injury b/c med can increase ICP, use cautiously in Pt taking Hypotension: antiHTN meds or have renal or liver dysfucntion
estradiol; Report:
Headaches
Immunization is recommended for postexposure protection
Hep A (fecal route)
What is the key finding for mononucleosis?
Hepatosplenomegaly.
Valporic Acid for Seizure Control
Hepatotoxic, report jaundice
S/E of Atorvastatin (Lipitor)
Hepatotoxicity (liver fxn tests after 12wks then q6m); myopathy (obtain baseline CK levels); peripheral neuropathy (notify provider)
Methotrexate adverse affect
High blood pressure
Pt teaching; Wound Care at Home:
High protein diet
Urticaria
Hives
if HR is <100 (children)
Hold Dig
Dementia Living Coordination
Home health Agency>Assisted Living>Nursing Home
What does 'living' mean in GTPAL?
How many children are living.
DTAP contraindication
Hx of inconsolable crying
Cushings
Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump
What to monitor for when taking enoxaparin (lovenox)
Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported
Interaction between SSRI (e.g. fluoxetine) and St. John's Worts
Hypertension and Increased HR; may be life-threatening.
Addison's
Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress.
Trousseau and Chvostek's signs observed in
Hypocalcemia
Theophyline Toxicity
Hypotension, Albuminuria, Tachycardia and Anorexia 10-20
shock
Hypotension, tachypnea, tachycardia
Vaginal discharge during early pregnancy
Leukorrhea
Gentamicin
Like many antibiotics are nephrotoxic. Look at kidney functions tests
Salmeterol
Long-acting Bronchodilator
Tension Pneumothorax
Look for chest asymmetry
Status Epilepticus Meds
Lorazepam (Ativan) Drug of choice Diazepam (Valium) Phenytoin (Dilantin) (IV Slowly) Fosphenytoin (Cerebyx)
Crohn's Diet:
Low Fiber
Blood transfusion; indications of a hemolytic reaction:
Low back pain, tachycardia, hypotension
Valproic Acid:
May cause hepatic toxicity; undergo lab tests to assess liver function
LASIK
May still need reading glasses
Fluid Volume Overload: Delegate to AP
Measure I&O
community mental health clinic; RN to lead which therapy group:
Medication Education Group
EDB:
Minus 3 months + 7 days
Cor pumonae
Right sided heart failure caused by left ventricular failure (edema, jugular vein distention)
Right sided heart failure
Right ventricle heaves Murmurs Jugular venous distention Edema (e.g. pedal scrotum, sacrum,) weight gain increase heart rate ascites Anasarca (massive generalized body edema) Hepatomegaly (liver enlargement)
Signs of Peritonitis
Rigid, Board Like Abdomen Absent Bowel Sounds Fever High WBCs
Post surgical (ruptured appendix); Report:
Rigid, board-like abdomen, Absent bowel sounds, 102.6, WBC of 21,500
Cocaine use during pregnancy
Risk for Abruptio Placenta
Gonorrhea during pregnancy
Risk for Premature rupture of membranes
Preeclampsia during pregnancy
Risk for Proteinuria
What is the key finding for Scarlet fever?
Strawberry tongue.
What types of diseases require droplet precautions?
Streptococcal pharyngitis or pneumonia, haemophilus influenza type B, scarlet fever, pertussis, mumps, meningococcal meningitis.
What comorbidities may be observed with a patient who is bipolar?
Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD.
Teaching points for naltrexone (Vivitrol)?
Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen.
Long-term adverse effects of Haloperidol (Haldol)
Tardive dyskinesia (involuntary movements of tongue and face, lip smacking, involuntary movments of arms, legs, and trunk)
Coworkers discussing pt info in public:
Tell them to stop the conversation
Imprisonment
Telling the client you cannot leave the hospital
What does 'term' mean in GTPAL?
Term means how many were giving birth after 37 weeks.
shilling test
Test for pernicious anemia
Guthrie test
Tests for PKU. Baby should have eaten protein first
What are some ways to identify a patient before giving a medication?
The Joint Commission requires 2 client identifiers be used when administering medications. - clients name - assigned identification number - telephone number - birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients
SIADH
Tx: Fluid restriction plus hypertonic sodium chloride and Furosemide Water intoxication caused by the inappropriate, continuous secretion of ADH by the posterior pituitary gland, causing hypervolemia and hyponatremia.
Mother's Tests at 12 weeks
Ultrasound chorionic villi sampling NT Down Syndrome
pH 7.30, PaO2 56mmHg, PaCO2 54mmHg, HCO3 26mEq/L, SaO2 87%
Uncompensated Resp Acidosis
Amblyopia
Unilateral central blindness occurs as a result of another condition, such as strabismus.
Irrigating a granulating wound
Use 30 mL syringe
Sedative/ Hypnotic Medications Eszopiclone (Lunesta) Temazepam (Restoril) Zolpidem tartrate (Ambien)
Use cautiously with mental depression avoid with alcohol and medications with CNS depression S/E Dry mouth, decreased libido, respiratory depression
Rheumatoid Arthritis
Use cold to edematous joints
Suctioning Airway
Use surgical asepsis No more than three consecutive times When resistance is met, retract 1-2cm
Ace Inhibitors (end in "pril")
Used for: HTN, HF, MI, diabetic neuropathy Monitor potassium levels K+ persistent non-productive cough
Airborne Precautions
Used to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require: - A private room - Masks/ respiratory protection devices for caregivers and visitors -Negative pressure airflow exchange in the room of at least six exchanges per hour.
Levothyroxine effects
Used to restore client's metabolic rate * Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension
Self-control therapy
Uses combination of cognitive and behavioral approaches to dealing with.
Glaucoma
No atropine
SIDS
No correlation between DTP and SIDS. Exposure to cigarette smoke increases the risk of SIDS. Breastfeeding decreases risk of SIDS. Sleep on Back with Firm Mattress.
Dumping Syndrome
No liquids or carbs!
Palpate fontanels by 2-3 years?
No! bulging fontanels could mean increased ICP, meiningitis
What is avoidance of harm or injury
Non-maleficence
Discharge teaching on breast engorgement
Nonlactating Clients: avoid nipple stimulation & apply cold compresses 15m on and 45m off, cabbage leaves placed inside bra, pain meds, supportive bra. Lactating Clients: manually express some milk, frequent feeding or pumping, warm shower, beast massage, supportive bra, maternal meds after feed to avoid cross-over to breast milk.
L sided heart failure
Pathophysiology the most common form of heart failure is left sided. Left sided HF results from left ventricular dysfunction. This prevents normal, forward blood flow and causes blood to back up into the left atrium and pulmonary veins. The increased pulmonary pressure causes fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli. this manifests as pulmonary congestion and edema.
What is the process of taking a telephone order from a provider?
Patient name, drug, dose, route, frequency read back for accuracy
Which of the following is the initial nursing action for the nurse to take when late decelerations appear on the fetal monitor? a - reposition the client in to left-lateral position b - apply a fetal scalp electrode c - increase the iv fluid rate d - perform a vaginal exam to assess dilation
a - reposition the client in to left-lateral positioning
strip with no p waves
a fib
Triage: which requires immediate nursing intervention:
a middle adult client who has a sucking chest wound
Myesthenia Gravis
a positive reaction to Tensilon---will improve symptoms
Breastfeeding during 4th stage of labor is most important bc
Production and secretion of oxytocin cause the uterus to contract. Promotes involution and decrease risk for maternal hemorrhage and blood loss.
Hypocalcemia
Prolonged QT interval; Tingling, numbness, tetany, seizures, abdominal cramps, hypoTN
Quality Improvement DOES NOT:
Promote individual accomplishments.
Infant with Spina Bifida
Prone so that sac does not rupture
Prostate Cancer:
Prostate Specific Antigen (PSA) levels should be performs for men over 50.
Droplet Precautions
Protect against droplets larger than 5 mcg (streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meingococcal pneumonia/sepsis, pneumonic plague). Droplet precautions require: - A private room or a room with other clients with the same infectious disease -Masks
To Promote Wound Healing
Protein and Vit A
eclampsia is
a seizure
A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child's mother to determine if the medication is being administered correctly? a. "Are you using a straw to administer the medicine?" b. "Has your child been urinating more frequently?" c. "Have you increased your child's milk intake each day?" d. "Is there a change in the color of your child's skin?"
a. "Are you using a straw to administer the medicine?"
A nurse is preparing a client for a vaginal examination. Which of these statements should the nurse make? a. "Go into the bathroom and empty your bladder." b. "Cleanse your perineal area with betadine solution." c. "Hold your breath while the speculum remains in place." d. "Push down as the doctor inserts the speculum."
a. "Go into the bathroom and empty your bladder."
A client who has a history of asthma develops an acute asthma attack. Which of these questions should a nurse ask when assessing the etiology of this attack? a. "Have you eaten any new foods recently?" b. "How many hours did you sleep last night?" c. "Are you exercising every day?" d. "Have you reduced your fluid intake recently?"
a. "Have you eaten any new foods recently?"
A client has the following order for regular insulin (Humulin R) on a sliding scale: Blood sugar 150-180 mg: Give 2 units regular insulin Blood sugar 181-200 mg: Give 4 units regular insulin Blood sugar 201-220 mg: Give 6 units of regular insulin Blood sugar above 220 mg: Call MD At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer? a. 0.04 b. 0.4 c. 4 d. 40
a. 0.04
Which of the following clients should a nurse recognize is most likely to develop diabetic ketoacidosis? a. A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess. b. A 31-year-old gestational diabetic who has occasional bout of nausea. c. A 55-year-old who has type 2 diabetes mellitus and is adjusting well to the lifestyle changes. d. A 72-year-old who has type 2 diabetes mellitus and is managed with diet and exercise.
a. A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess.
Which of these techniques should a nurse use to assess for correct placement of a nasogastric tube prior to administering a feeding? a. Aspirate 10 mL contents and measure the pH. b. Slowly inject 50 mL of saline and observe for resistance. c. Inject 20 mL of water and listen for gurgling sounds. d. Observe for bubbles after submerging the end of the tube in a cup of water.
a. Aspirate 10 mL contents and measure the pH.
A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first? a. Assess the client. b. Notify the physician. c. Contact the nurse manager. d. Complete an incident report.
a. Assess the client.
Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to a nurse that the parent understands the teaching about a gluten-free diet? a. Broiled steak, baked potato, and spinach. b. Pork chop, egg noodles, and green peas. c. Fried chicken, white roll, and mixed vegetables. d. Baked macaroni with cheddar cheese and corn.
a. Broiled steak, baked potato, and spinach.
Which of these foods should a nurse suggest that a client who is diagnosed with iron-deficiency anemia choose for dinner? a. Cooked dry beans, green leafy vegetables, and dried fruits. b. Raw cabbage, tomato juice, and cantaloupe. c. Fresh fish, peanut butter, and oatmeal. d. Cheddar cheese, enriched bread, and yellow vegetables.
a. Cooked dry beans, green leafy vegetables, and dried fruits.
A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated? a. Encourage the client to verbalize feelings. b. Lock the client in a secluded room. c. Ask the other clients to give feedback regarding the client's behavior. d. Ignore the client's inappropriate behavior.
a. Encourage the client to verbalize feelings.
An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk? a. Increasing the time interval between medication doses. b. Limiting the client's oral fluid intake. c. Administering the medications with meals. d. Encouraging the client to void every three to four hours.
a. Increasing the time interval between medication doses.
A 22-year-old college student has a heart rate that is 48/minute and regular during a routine physical examination. Which of these questions should a nurse consider when analyzing this heart rate? a. Is this student an athlete? b. Does this student smoke? c. How much alcohol does this student drink? d. Is this student feeling anxious?
a. Is this student an athlete?
Which of these interventions should plan for a child who is receiving chelation therapy for lead poisoning? a. Keeping an accurate record of intake and output. b. Instituting measures to prevent skeletal fractures. c. Maintaining isolation precautions. d. Maintaining strict bed rest.
a. Keeping an accurate record of intake and output.
A 15-year-old child who has type I diabetes mellitus receives an injection of regular insulin 5 units and isophane (NPH) insulin 15 units subcutaneously at 7:00 A.M. before eating breakfast. At 10:30 A.M., the child tells the school nurse, "I am sweating and feel weak." Which of these actions should the nurse take first? a. Measure the blood sugar. b. Determine what the child ate for breakfast. c. Give a simple carbohydrate. d. Contact the physician.
a. Measure the blood sugar.
Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia? a. Measure the client's blood sugar level. b. Administer a concentrated form glucose to the client. c. Administer a prn dose of insulin. d. Measure the client's urine for ketones.
a. Measure the client's blood sugar level.
Which of these preventative measures should a nurse manager in a long-term care facility plan to institute to decrease clients' risks for falls? a. Monitoring clients frequently for evidence of activity intolerance. b. Placing all client personal items in the bedside drawers. c. Raising the side rails for all clients who have memory impairment. d. Maintaining all client beds in the highest position.
a. Monitoring clients frequently for evidence of activity intolerance.
Which of these strategies should a nurse plan for a client who is manic and has lost 30 pounds? a. Nutritious finger foods. b. Low-protein diets. c. Limiting fluids in between meals. d. Daily weights.
a. Nutritious finger foods.
Which of these assessments should a nurse make of a client who had a knee replacement this morning? a. Pain. b. Signs of infection. c. Bowel movement frequency. d. Range of motion.
a. Pain.
Which of these laboratory test results should a nurse monitor for a client who is receiving intravenous heparin therapy at a rate of 1,500 units per hour for the treatment of an acute pulmonary embolism? a. Partial thromboplastin time. b. Clot retraction time. c. Platelet levels. d. Bleeding time.
a. Partial thromboplastin time.
Which of these client care situations has the greatest potential for presenting an ethical dilemma for a nurse? a. Participating in pregnancy termination procedures. b. Counseling a client who is terminally ill with AIDS. c. Discussing contraception options with adolescents. d. Caring for a client who is from a different culture than the nurse.
a. Participating in pregnancy termination procedures.
A client's urine output is 500 mL in 24 hours. Which of these actions should a nurse take? a. Report the findings to the physician. b. Obtain an order for a diuretic. c. Encourage the client to limit fluid intake. d. Record the finding and continue to monitor the client.
a. Report the findings to the physician.
Which of these assessments is the priority for a client who sustained second-degree burns of the face and neck? a. Respiratory status. b. Renal function. c. Level of pain. d. Signs of infection.
a. Respiratory status.
A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my kingdom. I am not taking any medications. I do not want anyone to come near me. I need to protect myself if they do." Which of these problems should the nurse focus on first? a. Risk for violence. b. Delusions of grandeur. c. Disturbed personal identity. d. Risk for noncompliance.
a. Risk for violence.
A 75-year-old client who is newly admitted to a long-term care facility has all these nursing diagnoses. Which one is the priority? a. Risk of injury. b. Anxiety. c. Sleep pattern disturbance. d. Chronic.
a. Risk of injury.
Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy. a. Sharp unilateral abdominal pain. b. Uncontrollable vomiting. c. Marked abdominal distention. d. Profuse vaginal bleeding.
a. Sharp unilateral abdominal pain.
Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is appropriate? a. The UAP is assigned to measure a client's intake and output. b. The UAP is assigned to assess a client's lung sounds. c. The UAP is assigned to teach a client about diet restrictions. d. The UAP is assigned to change a client's postoperative wound dressing.
a. The UAP is assigned to measure a client's intake and output.
A nurse is obtaining the health history of a client who is admitted for surgical repair of an inguinal hernia. Which of these factors should the nurse recognize as having the greatest impact on the outcome of the surgery? a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain. b. The client drinks one glass of beer every evening with dinner. c. The client had a knee replacement six months prior to this admission. d. The client is allergic to all penicillin-type antibiotics.
a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain.
Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery, should a nurse report immediately? a. Vomiting and a pulse rate of 106/minute. b. Respiratory rate of 12/minute and urine dribbling. c. Blood pressure of 100/60 mm Hg and wound discomfort. d. Urine output of 100 mL/hr and flushed skin.
a. Vomiting and a pulse rate of 106/minute.
A nurse should assist a pregnant client who is in the first trimester to achieve the developmental task of this stage of pregnancy, which is: a. accepting the fact that she is pregnant. b. accepting the fact that the fetus is a separate being. c. accepting that she will soon deliver the child. d. accepting that her body image has changed.
a. accepting the fact that she is pregnant.
When determining the duration of a uterine contraction, a nurse should measure the contraction from the: a. beginning of one contraction to the end of that contraction. b. end of one contraction to the beginning of the next contraction. c. beginning of one contraction to the beginning of the next contraction. d. strongest point of one contraction to the strongest point of the next contraction.
a. beginning of one contraction to the end of that contraction.
A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the duration of the newborn's treatment, a nurse should: a. cover the newborn's closed eyes with patches. b. measure the newborn's pulse and respirations every two hours. c. keep the newborn under the light at all times, even during the feedings. d. notify the physician if the newborns stools become greenish yellow.
a. cover the newborn's closed eyes with patches.
A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which include: a. flushed skin and thirst. b. irritability and hunger. c. sweating and jitteriness. d. lethargy and tremors.
a. flushed skin and thirst.
A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A nurse should prepare the woman to have an immediate sonogram to determine the: a. location of the placenta. b. uterine response to labor. c. the fetus's current weight. d. condition of the uterine vascular bed.
a. location of the placenta.
When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include: a. the urinary meatus. b. vomitus. c. contaminated water. d. sexual intercourse.
a. the urinary meatus.
A nurse determines that the therapeutic effectiveness of magnesium sulfate (MgSO4) for client who has preeclampsia is achieved when there is increased: a. urinary output. b. blood pressure. c. respiratory rate. d. uterine movement.
a. urinary output.
Priority
abdominal pain and went away
Grave's Disease/ hyperthyroidism
accelerated physical and mental function. Sensitivity to heat. Fine/soft hair.
pt should sign consent when
accurately describes upcoming procedure
DKA
acetone and keytones increase! once treated expect postassium to drop! have K+ ready
contractions 3 minutes apart = what phase of labor?
active
older adult with pneumonia
acute confusion
Liver biopsy
administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk
IV pyelogram; RN action:
administer a laxative; check for allergies (seafood, milk, eggs or chocolate)
appropriate action for intravenous pyelogram for next day
administer laxative, npo, econurage fluids
what to ask before flu shot
allergy to eggs
Meds for Sinus Tachycardia
amiodarone, adenosine, and verapmil; synchronized cardioversion
meds of sinus tachycardia
amiodarone, adenosine, and verapmil; synchronized cardioversion
meds for sinus tachy
amiodarone, adenosine, verapamil, synchronized cardioversion
who should receive rhogam
an o- woman following spontaneous abortion
Contraindication for Hep B vaccine
anaphylactic reaction to baker's yeast
Kosher foods
animals which chew cud and have split hooves (cattle, sheep, goats, & deer), seafood with fins and scales, NO PORK (hotdogs, sausage, gelatin), and no meats mixed with milk
early detection of men's prostate cancer
annual measurement of prostate specific antigen (PSA) should be performed for men over 50
discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss
anticipatory grief
terminally ill patient only wants family, not friends with them. Type of grief?
anticipatory, not dysfunctional, normal or disenfranchised
Glucagon increases the effects of?
anticoagulants
Late S/S of cold stress in infant
apneic periods, bradycardia, acrocyanosis, decreased activity
RLQ
appendicitis watch for peritonitis
teaching for peripheral artery disease
apply lubricating lotion to the feet to pre even cracting of the skin. don't elevate feet above heart
Ileostomy Care
apply skin barriers to stoma, empty bag when it is 1/3 full, assess for fluid and electrolyte imbalances
ARDS and DIC
are always secondary to another disease or trauma
detached retina
area of detachment should be in the dependent position
Pregnant non-pharmacological pain management
aromatherapy, breathing techniques, imagery, music, use of focal points, subdued lighting
case manager with mental patients
arrange transportation to appointments
Breastfeeding and hepatitis c
as long as you don't have cracked nipples
gullian-barre syndrome
ascending muscle weakness
Gullian -Barre syndrome
ascending paralysis. watch for respiratory problems.
Elderly abuse
ask privately
24 hrs post op, won't ambulate. nurse to do first
ask pt to rate his pain
a nurse is caring for a client with a hx of agression, the client is playing cards and throws them at other patients- what should you do
ask the client how he is feeling (therapeutic cmcn) not take the cards away (this will increase aggression) explaining unit rules will not help either
NG
aspirate
NG tube proper function
aspirate residual
evaluating proper placement of NG tube
aspirate to collect gastric contents & test pH (4 or less), x-ray, injecting air into tube to listen over abdomen is NOT an acceptable practice
Evaluating proper placement of NG tube
aspirate to collect gastric contents and test pH (4 or less) before feeding. Hold if residual is >100 mL, X-Ray Injecting air into tube to listen over abdomen is NOT an acceptable practice
Sexual assault
assess anxiety
Low pressure alarm do what?
assess for leaks, displacement, if can't find anything wrong, MANUALLY ventilate & call respiratory stat, do NOT leave alone
emotional crisis:
assist the client in identifying the cause of the issue
indications for use of cardioversion
atrial dysrhythmia, SVT, ventricular tachycardia w/ pulse, tx of choice for pt who are symptomatic
Indications for use of cardioversion
atrial dysrhythmias, SVT, ventricular tachycardia with pulse & treatment of choice for patients who are symptomatic
GERD s/s
atypical chest pain, SOB
New Born HR Assessment:
auscultate the apical pulse and count beats for 1 full minute
Most managers can be categorized as
authoritative, democratic, and laissez faire
Early S/S of cold stress in infant
auxiliary temp < 97.7, increased resp. rate, increased HR, mottled skin
NG tube:
avoid Blue Dye
Teaching on Lasix
avoid admin late in day, report significant wt loss, lightheadedness, dizziness, GI distress, and general weakness, observe for signs of low Mg levels such as muscle twitching and tremors
Thoracentisis
avoid deep breathing during the procedure
THA
avoid flexion greater than 90
what foods should you avoid if you have diverticulitis?
avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber)
thrombocytopenia; POC:
avoid venipuncture if possible
Sprains
avoid warm compress
Early S/S of cold stress in infant
axillary temp < 97.7, increased respiration rate, increased HR, mottled skin
early s/s of cold stress in infants
axillary temp <97.7, increase rr, increased hr, mottled skin
A nurse is planning to interview a client who speaks limited English. Which of these strategies should the nurse include? a. Smile frequently during the interview interview to reduce the client's anxiety. b. Observe the client for indicators of confusion or not understanding questions. c. Maintain constant eye contact throughout the interview. d. Keep the interview short to decrease the client's fatigue.
b. Observe the client for indicators of confusion or not understanding questions.
A nurse should recognize which of these signs is a probably sign of pregnancy? a. Frequency of urination. b. Positive pregnancy test. c. Nausea in the morning. d. Abdominal distention.
b. Positive pregnancy test.
Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis episode? a. Monitoring for signs of bleeding. b. Providing pain relief. c. Administering cool sponge baths to reduce fevers. d. Offering a high calorie diet.
b. Providing pain relief.
A client has been in bed for the past three days. Which of these measures should a nurse include before assisting the client out of bed? a. Having the client drink a glass of water. b. Raising the head of the bed. c. Flexing the client's knees. d. Assessing the lung sounds.
b. Raising the head of the bed.
Which of these manifestations should a nurse expect to observe in a client who is diagnosed with paranoid schizophrenia? a. Regression. b. Suspiciousness. c. Catatonia. d. Hyperactivity.
b. Suspiciousness.
Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? a. Hyperreflexia. b. Tachycardia. c. Bradypnea. d. Agitation.
b. Tachycardia.
A client who has a head injury is drowsy and lethargic, and has clear nasal discharge. Which of these actions should a nurse take? a. Obtain a specimen of the drainage for culture and sensitivity. b. Test the drainage for glucose. c. Cover the nares with sterile gauze. d. Cleanse the nostrils with sterile saline solution.
b. Test the drainage for glucose.
Which assessment information should a nurse obtain first when a pregnant woman and her husband arrive at the Labor and Delivery Unit? a. Whether the couple attended birthing classes. b. The frequency and intensity of labor contractions. c. The number of previous pregnancies and outcomes. d. The amount and time of the client's last food intake.
b. The frequency and intensity of labor contractions.
Which of these actions best demonstrates cultural sensitivity by a nurse? a. The nurse talks in a slow-paced speech. b. The nurse asks clients about their beliefs and practices toward pregnancy. c. The nurse uses charts and diagrams when teaching pregnant clients. d. The nurse can speak several different languages.
b. The nurse asks clients about their beliefs and practices toward pregnancy.
Which of these actions should a nurse perform prior to a client's scheduled hemodialysis? a. Administer prophylactic antibiotics. b. Weigh the client. c. Give the client normal saline solution to drink. d. Measure the urine specific gravity.
b. Weigh the client.
When caring for a client who is receiving oxygen therapy via nasal cannula, a nurse should instruct the client: a. to inhale through the mouth. b. to breathe through the nose. c. to hold the catheter when coughing. d. to take quick, shallow breaths.
b. to breathe through the nose.
emphysema
barrel chest
Sources of potassium
beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas
Shock
bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)
Sleep promotion
bedtime routine, min number of times pt is awakened, assist w/ personal hygiene or back rub, exercise 2hr before bed, limit fluids 2-4hr before bed
Empty JP drain when? clean how?
before half full, or every 8-12 hrs, NOT 24 hours. Clean with soap and water, NOT antimicrobials or Dakin's etc.
vertebrae related to paralysis
below or above l1-l2 = paralysis
flumazenil, Romazicon
benzo overdose
a client should receive a dose of flumazenil ( romazicon) to treat symptoms of
benzodiazepine overdose
Glycosylate hemoglobin
best indicator for average blood glucose level for the past 120 days; normal range is 4-6%, diabetic range is 6.5-8%
glycosylate hemoglobin
best indicator for average blood glucose level for the past 120d, normal range is 4-6%, diabetic range is 6.5-8%
Glycosylate hemoglobin (HgA1c)
best indicator for average blood glucose level for the past 120d; normal range is 4-6%, diabetic range is 6.5-8%
s/s hyperglycemia
bg >250; thirst, frequency in urination, hunger, warm/dry/flushed skin, weakness, malaise, rapid/weak pulse, hypotension, deep rapid respirations
Cold stress and the newborn
biggest concern resp. distress
blood spill
bleach
Furosemide (Lasix) Purposes of Use
block reabsorption of Na and chloride and prevent reabsorption of water; cause extensive diuresis Used for: pulmonary edema caused by HF, emergent need for rapid mobilization of fluid
Fat embolism
blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids.
Contraindication of MMR
blood transfusion
contra to MMR
blood transfusion
Heart murmur sound
blowing or swishing
15 min immediate postpartum period requires immediate action by nurse?
bobby uterus
postpartum, immediate action?
boggy uterus, massage fundus
Hypervolemia
bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's
Which of these discharge instructions should a nurse include for a client who has a ruptured tympanic membrane that occurred during a fall? a. "No showers or washing of the hair for the next month." b. "Avoid yawning or holding your head down." c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization." d. "Avoid swallowing and coughing until your ear has healed."
c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization."
A nurse has been discussing the nutritional needs of children with a group of parents in a clinic. Which of these statements, if made by the parent of a 2-year-old child, should the nurse follow up? a. "I give my child slices of cheese as an afternoon snack." b. "I give my child a cup of skim milk as an afternoon snack." c. "I give my child some popcorn as an afternoon snack." d. "I give my child some yogurt as an afternoon snack."
c. "I give my child some popcorn as an afternoon snack."
Which of the statements if made by a client who is take furosemide (Lasix), supports a nursing diagnosis of knowledge deficit? a. "This medication will increase the amount and frequency of my urination." b. "This medication must be taken, even on days when I fell well." c. "I will need to add more salt to my diet because this medication will increase its excretion." d. "I should change my position slowly to avoid dizziness related to this medication."
c. "I will need to add more salt to my diet because this medication will increase its excretion."
A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is 250 mg/5 mL. How many milliliters should a nurse administer? a. 1.0 b. 1.5. c. 2.0 d. 2.5
c. 2.0
A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A 25-year-old client who is terminally ill with metastatic testicular cancer. b. A 37-year-old client who has second-degree burns on both feet. c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion. d. A 68-year-old client who is bed bound related to severe Parkinson's disease.
c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion.
Each of these clients has impaired mobility related to knee surgery. Which client should a nurse assess first? a. A 20-year-old who has a sports-related injury. b. A 37-year-old who reports limited mobility. c. A 59-year-old who has a history of hypertension. d. A 70-year-old who has bilateral cataracts.
c. A 59-year-old who has a history of hypertension.
The mother of a 2-month-old tells a nurse that the baby is consuming six ounces of plain commercial formula seven times a day, plus one ounce of cereal in the morning and at bedtime. Based on this information, the nurse should conclude that the baby's diet is: a. too high in calories. b. too high in iron content. c. deficient in calcium. d. insufficient for the baby's age and weight.
c. A 59-year-old who has a history of hypertension.
A nurse should question an order for a potassium chloride intravenous infusion for which of these clients? a. A client who has hypoxia. b. A client who is obese. c. A client who has anuria. d. A client who is congested.
c. A client who has anuria.
Which of these behaviors, if taken by a staff nurse on a psychiatric unit, indicates a correct understanding of therapeutic techniques? a. A nurse smiles when speaking with clients who are manic. b. A nurse uses touch to communicate concern with a depressed client. c. A nurse sets consistent limits with manipulative clients. d. A nurse shares own anxiety reduction techniques with a client who has panic attacks.
c. A nurse sets consistent limits with manipulative clients.
Which of these women, each of whom is in labor, should a nurse recognize as in need of immediate attention? a. A woman who is having contractions every 6 to 8 minutes of mild to moderate intensity. b. A woman who is receiving oxytocin augmentation and who has contractions lasting 60 to 70 seconds. c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement. d. A woman whose uterine contractions frequency is every two to give minutes.
c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement.
Which of these tasks should a licensed practical nurse (LPN) delegate to a nursing assistant? a. Checking the 11 A.M. blood sugar for a client who has ketoacidosis. b. Measuring the pulse oximetry level for a client who has status asthmaticus. c. AMbulating a client who had a hip replacement three days ago. d. Changing the dressing for a client who had wound debridement last week.
c. AMbulating a client who had a hip replacement three days ago.
Which of these nursing measures is the priority for a child who has hemophilia and who sustains a leg injury? a. Ensuring adequate hydration for the child. b. Soaking the child's injured leg in warm water. c. Administering the missing factor VIII to the child. d. Transfusing one unit of whole blood to the child.
c. Administering the missing factor VIII to the child.
A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan? a. Explaining that staff does not poison clients. b. Focusing on how the hospital staff helps clients. c. Allowing the client to eat food from sealed containers. d. Telling the client that not eating the food that is served will result in privilege restrictions.
c. Allowing the client to eat food from sealed containers.
Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should a nurse recognize as suggestive that the infant is dehydrated? a. Bulging anterior fontanel. b. Pulse rate of 120/minute. c. Decreased urine output. d. Cyanosis of the mucus membrane.
c. Decreased urine output.
Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia? a. Fruity breath odor. b. Polyuria. c. Diaphoresis. d. Flushed skin.
c. Diaphoresis.
Which of these lunch selections, if made by a client who has congestive heart failure, should a nurse recognize as indicative of a need for additional instructions? a. Cottage cheese with fresh fruit salad, whole wheat bread, and herbal tea. b. Baked chicken with brown rice, mixed green salad, and iced coffee. c. Egg salad sandwich with mayonnaise, pickles, and seltzer water. d. Beef tenderloin, carrots, mashed potatoes, and a baked apple.
c. Egg salad sandwich with mayonnaise, pickles, and seltzer water.
A nurse should recognize that which of these occupations increases a person's risk of developing hepatitis B? a. Sanitation worker. b. Nursery school teacher. c. Hemodialysis nurse. d. Fish market sales person.
c. Hemodialysis nurse.
Which of these nursing diagnoses is the priority for a young adult client who has first-degree burns of the legs and smoke inhalation from a fire in the home? a. Pain. b. Risk for infection. c. Impaired gas exchange. d. Body image disturbance.
c. Impaired gas exchange.
Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an acute care unit? a. Feeding a client who was admitted with a stroke yesterday. b. Ambulating a client who was admitted with a myocardial infarction yesterday. c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday. d. Suctioning the tracheostomy that was performed on a client yesterday.
c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday.
Which of these actions, if taken by a nursing assistant, should a nurse recognize as increasing the client's risk of developing a nosocomial infection? a. Wearing non-sterile gloves while emptying the Foley drainage bag. b. Taping a paper bag to the side rail for tissue disposal. c. Placing the Foley catheter drainage bag on the bed while transferring the client. d. Using the same cuff to measure the blood pressures of all the clients on the unit.
c. Placing the Foley catheter drainage bag on the bed while transferring the client.
Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours ago? a. Preventing hemorrhage. b. Preventing pneumonia. c. Preventing aspiration. d. Preventing dehydration.
c. Preventing aspiration.
A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less than body requirements related to diminished taste perception and nausea. Which of these additional nursing diagnoses should a nurse consider for the client? a. Risk for aspiration. b. Ineffective protection. c. Risk for deficient fluid volume. d. Altered tissue perfusion.
c. Risk for deficient fluid volume.
Which of these nursing diagnosis is the priority for a client who is one-hour postoperative after extensive abdominal surgery? a. Risk for impaired physical mobility. b. Risk for deficient fluid volume. c. Risk for ineffective airway clearance. d. Risk for infection.
c. Risk for ineffective airway clearance.
An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated blood pressure. Which of these actions should a nurse take? a. Add a 5% dextrose solution to the line. b. Raise the head of the bed. c. Stop the transfusion. d. Measure the client's temperature.
c. Stop the transfusion.
Which of these assessments is the initial priority of a client who is one-hour postoperative after an exploratory laparotomy? a. The appearance of the client's surgical incision. b. The client's level consciousness. c. The adequacy of the client's respiratory function. d. The client's fluid and electrolyte status.
c. The adequacy of the client's respiratory function.
A 12-month-old child is playing with the father. Which of these behaviors indicates that the child is demonstrating object permanence? a. The child transfers a toy to the other hand when given another one. b. The child returns a block to the same spot on the table. c. The child looks for a toy that the father has hidden under the table. d. The child recognizes that a ball of clay is the same when flattened out.
c. The child looks for a toy that the father has hidden under the table.
While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of these interpretations and additional assessments should the nurse make? a. The client's skin is sensitive to touch; lightly rub the client's chest area. b. The client has decreased circulation; palpate the peripheral pulses. c. The client is showing signs of pressure; press on the skin and observe for a return of color. d. The client is allergic to the soap; check the extremities for discoloration.
c. The client is showing signs of pressure; press on the skin and observe for a return of color.
A nurse assesses a client who is scheduled for a total abdominal hysterectomy at 10:00 A.M. WHich of the factors should the nurse recognize as most likely to influence the outcome of the surgery? a. The client has voided two times since 5:00 A.M. b. The client is not able to demonstrate leg exercises because of osteoarthritis. c. The client takes one acetylsalicylic acid (baby Aspirin) daily. d. The client reports mouth dryness.
c. The client takes one acetysalicylic acid (baby Aspirin) daily.
Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication? a. The student maintains continuous eye contact with the client. b. The student places one arm around the client's shoulder? c. The student sits quietly next to the client. d. The student leaves the room to provide privacy for the client.
c. The student sits quietly next to the client.
A client who had a coronary artery bypass graft four days ago suddenly develops sinus tachycardia and reports shortness of breath and dizziness. Which of these interpretations and actions should a nurse take? a. This is an expected occurrence following bypass surgery; continue to monitor the client. b. This indicates normalization of the blood pressure; hold all anti-hypertensive medications. c. This may be an early sign of heart failure; notify the physician. d. This indicates hypoxia; administer oxygen at 5/L per minute.
c. This may be an early sign of heart failure; notify the physician.
Which of these laboratory test results is more important for a nurse to assess for a client who reports chest pain? a. WBC count. b. PTT level. c. Troponin level. d. Hemoglobin.
c. Troponin level.
A nurse is caring for a client with burns and in reverse isolation. Which measures should the nurse include? a. Wearing disposable gloves when chaging the dressings. b. Having the client wear goggles when staff is in the room. c. Wearing a gown, mask, and gloves when providing care to the client. d. Disposing of the client's soiled laundry in a red bag.
c. Wearing a gown, mask, and gloves when providing care to the client.
When caring for a client who has hepatitis B, a nurse should wear: a. gloves when administering oral medications to the client. b. a gown when changing the client's position. c. gloves when removing the intravenous cannula. d. a gown when emptying the client's used bath water.
c. gloves when removing the intravenous cannula.
A nurse should explain to a primigravida that urine tests will be done at each prenatal visit throughout the pregnancy to measure: a. specific gravity and pregnancy hormones. b. culture and white blood cell count. c. glucose and protein. d. bacteria and red blood cell count.
c. glucose and protein.
A client has shortness of breath when lying down and usually assumes an upright or sitting position in order to breathe more comfortably. A nurse should document this observation as: a. dyspnea. b. bradypnea. c. orthopnea. d. apnea.
c. orthopnea.
A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of
calcium gluconate (because hypocalcemia causes Chvostek's sign)
Thorazine and Haldol
can cause EPS
Propanolol (-lol meds - Beta Blockers)
can cause bronchoconstriction
How to prevent adverse effects of oxycodone
can cause respiratory depression. What is the nursing intervention and/or client education ? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol).
Lice
can live for 48 hours on surfaces
what is important about the diet of someone taking ACE inhibitors?
can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas)
PVC's
can turn into V fib.
Wife progressing quickly
can you tell me more
Hodgkin's disease
cancer of the lymph. very curable in early stages
Low fat diet
canola oil instead of vegetable oil
Complications of pericarditis
cardiac tamponade: hypotension, muffled heart sounds, JVD, paradoxical pulse
Hospice:
care and tx will be provided to control symptoms and make me comfortable
retino blastoma
cat's eye reflex
insert catheter in male
cath tray on bedside table waist height
during Continuous Bladder Irrigation (CBI)
catheter is taped to the thigh. leg must be kept straight.
peripherally inserted central catheter (PICC)
catheter used for long-term intravenous access and inserted in the basilic or cephalic vein just above or below the antecubital space with the tip of the catheter resting in the superior vena cava Needs an informed consent
Isoniazid
causes peripheral neuritis
Addison's
causes sever hypotension!
CVA
cerebriovascular accident. brain tissue dies.
African American women are at increased risk for what?
cervical cancer
what does abnormal pap smear indicate?
cervical cancer
SIADH (increased ADH)
change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics
tpn
change q. 24 glucose q. 4
nephrotic syndrome
characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay
chronic kidney disease
check GFR
before IV antibiotics?
check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose.
PICC, prior to starting initial infusion
check chest xray
After endoscopy
check gag reflex
acid ash diet
cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
s/s of pericarditis
chest pressure/pain, FRICTION RUB, SOB, pain relieved when sitting and leaning forward
S/S of pericarditis
chest pressure/pain, friction rub, SOB, pain relieved when sitting and leaning forward
bryant's traction
children <3 y <35 lbs with femur fx
alcohol withdrawal heroin withdrawal nicotine withdrawal alcohol abstinence opioid over dose
chlordiazeproxide( Librium) methadone( dolophine) bupropion ( wellbutrin) disulfiram ( antabuse) naloxone (narcan)
NCLEX answer tips
choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment.
closed intermitten irrigation
clamp cath clense injection port insert irrigant unclamp
Steps in performing closed intermittent irrigation
clamp catheter w/ injection port and extension tubing, cleanse port slowly inject syringe w/ irrigant into catheter remove syringe and unclamp allow irrigant to drain into drainage bag
Safety for parkinson's
clear area
proper three-point gait use of crutches
client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward
Bulimia Plan of Care when meal planning
closely monitor the client during and after meals to prevent purging
what to look for for cataracts
cloudy lens with blurred vision
hypothyroid
coarse hair, bradycardia, periorbital edema
Sucralfate for PUD
coats stomach to prevent formation of ulcer and aids with healing existing ulcers
Unsaturated fat
coconut oil
Needle disposal at home
coffee container on top shelf
tape test for pinworms
collect in plastic bag
priority w/ a cast
compartment pain paralysis parathesia pallor pulselessness fat embolism
Cast with white extremity
compartment syndrome
sprain
compress
ileostomy
continuous output
Hypoglycemia
cool and clammy skin
ACE inhibitors
cough
fractured ankle ice applied every 20 min report what finding to provider?
cyanosis of nail beds
A nurse plans to assess a client's recent memory. Which of these questions should the nurse include? a. "Who is your closest friend?" b. "What was the name of the school you attended?" c. "What day were you admitted to the unit?" d. "What did you have for breakfast?"
d. "What did you have for breakfast?"
A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the wrong thing and not get the job." Which of these responses, if made by the nurse, will create a communication barrier? a. "Would you like to practice the interview?" b. "Have you thought about some possible questions that may be asked in the interview?" c. "Tell me more about your concerns." d. "You need to relax, and everything will be fine."
d. "You need to relax, and everything will be fine."
A nurse has received a report on these assigned clients. Which client should the nurse follow-up first? a. A client, admitted with acute diverticulitis, who has a white blood cell count (WBC) of 10,000 mm3. b. A client, admitted with acute pancreatitis, who has a fasting serum glucose of 130 mg/dL today, and had a reading of 160 mg/dL yesterday. c. A client, admitted with hepatitis, who has jaundice and tea-colored urine. d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today.
d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today.
Which of these clients is at the highest risk of developing osteoporosis? a. An obese African-American adolescent who does not exercise. b. A pregnant Asian client who is a vegetarian. c. A middle-aged Native-American male who is quadriplegic. d. A thin, elderly Caucasian female who lives alone.
d. A thin, elderly Caucasian female who lives alone.
A client who has Parkinson's disease has been identified as being at risk for falls. Which of these actions by a nurse is most likely to reduce the client's risk of falling? a. Monitor the client's blood pressure after ambulation. b. Ensure the client wears socks when ambulating. c. Encourage frequent weight-bearing exercise. d. Assign an assistant to remain with the client when ambulating.
d. Assign an assistant to remain with the client when ambulating.
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content? a. Peanut butter and jam sandwich. b. Chicken nuggets with rice. c. Tuna salad sandwich. d. Beefburger with cheese.
d. Beefburger with cheese.
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions? a. Suction the nasogastric tube. b. Flush the tube with 30 mL of sterile water. c. Remove the nasogastric tube. d. Check the residual volume.
d. Check the residual volume.
Which of these postoperative complications in the first hour after surgery requires immediate intervention? a. Serous draining on the dressing. b. Swelling of an extremity under a cast. c. Vomiting. d. Dehiscence of a wound.
d. Dehiscence of a wound.
A nurse reviews a client's prenatal record and notes that the client's last menstrual period (LMP) was on September 18th. Using the Naegele's rule, the nurse should calculate that the client's expected date of delivery (EDD) will be: a. May 11th. b. May 25th. c. June 11th. d. June 25th.
d. June 25th.
Which of these items should a nurse removed from the food tray of a client who is on a sodium-restricted diet? a. Packet of a salt substitute. b. Grapefruit juice. c. Container of jelly. d. Ketchup.
d. Ketchup.
Which of these actions should a nurse take prior to initiating prescribed antibiotic therapy for a client who has a urinary tract infection? a. Measure the body temperature. b. Cleanse the perineum. c. Weigh the client. d. Obtain a urine culture specimen.
d. Obtain a urine culture specimen.
A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these positions? a. Supine, flat. b. Orthopneic. c. Trendelenberg. d. Side-lying.
d. Side-lying.
Which of these actions, if taken by a nurse who is transferring a client from the bed to the chair, is correct? a. The bed is raised to a comfortable working height for the nurse. b. The wheelchair is placed perpendicular to the bed. c. The nurse stands behind the client during the transfer. d. The nurse supports the client in an upright standing position for a few moments.
d. The nurse supports the client in an upright standing position for a few moments.
Which of these assessment findings, if present in a primigravida, indicates that the client is experiencing true labor? a. The pains are felt in the lower abdomen, back, and groin. b. The Braxton-Hicks contractions have become stronger and more frequent. c. There is an increased amount of white mucus discharge. d. There is a progressive increase in effacement and cervical dilatation.
d. There is a progressive increase in effacement and cervical dilatation.
A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8-months-pregnant primarily to: a. turn the fetus in the uterus. b. ease the fetus into the true pelvis. c. assessment of the location of the placenta. d. determine the fetal presentation.
d. determine the fetal presentation.
When interacting with a client who is paranoid, a nurse should: a. use touch to place the client at ease. b. maintain a caring facial expression. c. stand close to the client. d. maintain a professional attitude towards the client.
d. maintain a professional attitude towards the client.
A nurse is monitoring a client who is taking acetylsalicylic acid (Aspirin) 975 mg daily for adverse effects, which include: a. loss of joint mobility. b. increased serum calcium levels. c. increasing heart failure. d. occult blood in the stools.
d. occult blood in the stools.
Foods that can cause gas for ostomy pt
dark green leafy veggies, beer, carbonated beverages, dairy products, and corn
lipid
dc 12.
Myasthenia gravis
decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration.
Purpose of ice
decrease inflammation
Atorvastatin (lipitor) purpose
decrease manufacture of LDL and VLDL and increase HDLs; promotes vasodilation, decreased plaque site inflammation, and decreased risk of thromboembolism
Iron toxicity reversal
deferoxamine
S/E of Furosemide (Lasix)
dehydration, hypoNa, hypoCl, hypoTN, hypoK OTOTOXICITY
Hyper Mg
depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY
Dying patient wants to be alone
depression or dysfunctional
myasthenia gravis
descending musle weakness
student nurse doing assessment, what was wrong
detailed notes of assessment
glucose reaches 250 on insulin, give what? isotonic, hypotonic, hypertonic, dextrose?
dextrose to prevent hypoglycemia
caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days
Depression; most important to report:
diminished appetite over the past week
bad sign with a mother with newborn?
disapproval
Sildenafil
discontinue if pt taking Isosorbide Mononitrate. Can cause severe hypotension
insulin, rotate sites or no?
do not rotate site
active labor receiving oxytocin. fur shows variability with accelerations. nursing action?
document and continue to monitor
How to access a venous access port (port a cath)
don a mask-use surgical asepsis- don sterile glove -prime access cap, extension tubing and non coring needle with pre filled NS syringe -cleanse the site with chlorahexadine for 30 seconds -immoblize the device with non dominant hand forming a U with index and thumb -insert non-coring, non-barbed (Huber) needle with dominant hand in a 90 degree angle Most facilities' policies allow access to the implanted port with the same needle for 7 days.
Advanced directive
don't need a lawyer
After total hip replacement
don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows.
is drainage at pin sites ok with bucks traction?
drainage ok, note the type/color/odor/amount; leave crust as a barrier, pin care 3x/day
ace-inhibitors?
dry cough
Cullen's sign
ecchymosis in umbilical area, seen with pancreatitis
Nursing Interventions for preventing delays in healing
encourage an intake of 2-3L of fluid/d, increase protein, keep serum albumin levels above 3.5
nursing intervention for preventing delays in healing
encourage fluid intake of 2-3L; increase protein, keep serum albumin levels above 3.5
Nutrition for preventing delays in healing
encourage intake of 2-3L of fluid per day; increase protein, keep serum albumin levels above 3.5
Toddler scheduled for surgery:
encourage parents to bring toys from home
pt with leukemia may have
epistaxis due to low platelets
Transesophageal fistula
esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis)
first priority for DKA patients?
establish venous access, before anything
radical masectomy
excersise 24 hr post op, 1 or more drains,
Interaction of diuretics and ACE inhibitors
excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia
Diabetes insipidus (decreased ADH)
excessive urine output and thirst, dehydration, weakness, administer Pitressin
hyperthyroidism/ grave's disease
exophthalmos
reglan
extrapyramidal side effects (twitching, facial spasms, give anthihistamine to help)
Glasgow coma scale
eyes, verbal, motor Max- 15 pts, below 8= coma
3 hr oral glucose test
fast the night before
Oral glucose tolerance test
fasting blood glucose level drawn at start then pt consumes a specified amount of glucose. Blood glucose levels drawn every 30m for 2hrs; instruct client to consume balanced diet for 3d prior then fast 10-12hr
otitis media
feed upright to avoid otitis media!
Pt teaching for external radiation therapy
gently wash skin over the irradiated area with mild soap and water; DO NOT remove radiation tattoos, DO NOT apply powders or lotions, wear soft clothing over irritated area, avoid tight clothing, DO NOT expose area to sun or heat
no consent from ed to do surgery, do what?
get official interpreter
misoprostal and nsaids
get pregnancy test
admit with DKA, first...
get vitals
Respite care
give caretaker break
status epilepticus
give diazepam
Major depression, OCD
give fluoxetine
osteosarcoma pain
give morphine
heavy lochia, boggy fundus, do what
give oxytocin
when giving blood transfusion
give with NaCl
Early decelerations
head compressions
estradiol monitor and report what to provider
headaches, hypertension
African american over Caucasian
heart disease
African Americans are at increased risk for what?
heart disease and stroke
What is cardiac output?
heart rate x stroke volume
TURP complication
hematuria
If JP drainage has doubled in last two hours, possible cause?
hemorrhage. Access, stat CBC, notify physician
vasoconstriction
heroin
iron deficiency anemia lab results
hgb <12, hct <33
Glasgow Coma Scale (head injuries) (eyes, verbal, motor)
highest number 15, good. lowest number 3, severe.
explain irrigating with solution
hold 1 inch above
thorazine
hold if shuffling
cytoxan for neuroblastomas in toddlers
hydrate liberally
Sickle cell priority
hydration
S/S of hypomagnesaemia
hyperactive DTRs, muscle tetany, positive Chvostek's and Trousseau's signs, hypoactive bowel sounds, paralytic ileus
Pheochromocytoma
hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor)
alcohol
keep safe, orient time and place
allopurinol
liver function test
Newborn w/ Resp Distress syndrome
maintain a normal body temp
Immobile Pt POC:
maintain correct body alignment with use of trochanter rolls
cyclophosphamide to toddler w/ neuroblastoma; RN intervention:
maintain hydration with liberal fluid intake; prevents hemorrhagic cystitis
Nurse Manager observing New RN's Time Mgmt Skills:
maintain notes
method to evaluate nurse's time management skills
maintain regular notes about the nurse's time management skills
boggy uterus, do what?
massage the fundus
for neutropenic pts
no fresh flowers, fresh fruits or veggies and no milk
Neutropenic pts
no fresh fruits or flowers
Head injury or skull fx
no nasotracheal suctioning
What is a kosher diet?
no shellfish but yes fish with fins and scales; no pork; no mixing meat with milk, ever
ECG
no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure.
with allopurinol
no vitamin C or warfarin!
Before starting IV antibiotics
obtain cultures!
chest tube pulled out?
occlusive dressing
fontanels close when?
posterior 2-3 months; anterior 12-18 months
Desmopressin (DDAVP) For Diabetes Insipidus
promote absorption of water within the kidneys; cause vasoconstriction; tx of diabetes insipidus Effectiveness of DDAVP is evidenced by: reduction in the large volumes of urine output associated with diabetes insipidus to normal levels
What does pericarditis commonly follow?
respiratory infection
pericarditis commoly follows a
respiratory infection
highest risk to patient is bed tray left in room, tray table at end of bed, restraints tied to bed rails?
restraints tied to bed rails, this is inappropriate
cholera
rice watery stool
When should a trough level be drawn for divided doses of Gentamicin?
right before next dose
When should a trough level be drawn for divided doses of Gentamycin?
right before next dose
when should a trough level be drawn for divided doses of gentamycin?
right before next dose
restraints
rom q. 2 hr doc rewrite 1. 24 hrs dont tie to bed rails tie frame bed
typhoid
rose spots on the abdomen
Vitamin K
routinely given to newborns to prevent bleeding
five interventions for psych patients
safety setting limits establish trusting relationship meds least restrictive methods/environment
client in crisis
safety, relationship, development, coordinate, plan and provide
Seizure precautions
saline lock IV
how infectious mono is spread
saliva
cystic fibrosis
salty skin
risk for osteoporosis
sedentary lifestyle
William's position
semi Fowler's with knees flexed to reduce low back pain
Paracentesis
semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia
Post-Thyroidectomy
semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside
a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider
serum potassium 5.2
130/86 BP, severe headache, what would you report in preterm labor to provider?
severe headache; hypertensive crisis
S/S of Hypoglycemia
shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache, weakness, confusion
s/s of hypoglycemia
shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache, weakness, confusion
give patient cooling blanket when febrile, what is sign of adverse reaction?
shivering
side effect of ECT
short term memory loss
Weight applied to skin traction
should be 5-10 lbs max to prevent skin injury
S/S of hyperkalemia
slow, irregular pulse; hypoTN, restlessness, irritability, weakness with ascending flaccid paralysis, N/V/D, hyperactive bowel sounds
Baby with reflux
small, frequent meals, thicken formula with rice cereal, HOB 30
Gastrectomy
small, frequent meals; vitamin B12, D, iron, and folate
decontamination for radiation?
soap and water & disposable towels
patient has stairs, has had a stroke, and has trouble communicating - priority therapy?
speech / ABCs
Droplet precautions
spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask)
lactose intolerant replace calcium
spinach
transmission precautions for infectious mono
standard contact
iv urography allergic reaction
swollen lips
Identifying manifestations of transient ischemic attacks
symptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke.
calculating pulse
systolic - diastolic
Equation for calculating pulse pressure
systolic - diastolic = pulse pressure 120-80=40
hypotension is classified with a reading below normal;
systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation
S/S for overhydration
tachycardia, bounding pulse, HTN, tachypnea, increased CVP, confusion, muscle weakness, wt gain, ascites, dyspnea, crackles
s/s overhydration
tachycardia, bounding pulse, HTN, tachypnea, increased CVP, confusion, muscle weakness, wt gain, ascites, dyspnea, crackles
SSRI's
take about 3 weeks to work
a nurse makes a mistake?
take it to him/her first then take up the chain
pt with TB is discharged
take meds for at least 6 mo
Levothyroxine
take on empty stomach, in am; increases tsh
Acarbuse
take with first bite of each meal
Teaching about iron supplements
take with orange juice on empty stomach; may cause constipation, N/V/D, can turn stool a dark green/black color
milieu therapy
taking care of pt and environmental therapy
Chvostek's sign
tapping on the facial nerve triggers facial twitching
haldol se
tardive dyskinesia lip smacking
a nurse responsible for a client receiving a antihypertensive medication is to
teach the client to change position slowly to avoid dizziness or fainting
AP's talking in cafeteria
tell them to stop talking
Bonding behaviors
tells visitors baby looks like family members
lead poisoning
test at 12 months of age
client with depression which if most important finding to report to an interdisciplinary conference
the client's appetite has diminished over the last week
glomuloneprhitis
the most important assessment is blood pressure
a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this client
the nurse should monitor the client respiratory depression
placenta previa s/s placental abrution s/s
there is no pain, but there is bleeding there is pain, but no bleeding (board like abd)
C Diff
think hand hygiene!
Hyperglycemia
thirst
a client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication
thrombocytes, amylase count and liver function test
Paget's disease
tinnitus, bone pain, elnargement of bone, thick bones
TIA
transient ischemic attack....mini stroke, no dead tissue.
hyperthyroid
tremors
Disaster Plan; RN to:
triage incoming victims to determine the priority of care
noncompliance with adv directives scenario
tube feeding for alzeimers patient
nursing action for a client who is receiving continuous passive motion (CPM) following a total knee arthroplasty
turn off the CPM mating during meal time
Peritoneal Dialysis (when outflow is inadequate)
turn pt from side to side BEFORE checking for kinks in tubing
nitrazine paper
turns blue with alkaline amniotic fluid. turns pink with other fluids
sickle cell crisis
two interventions to prioritize: fluids and pain relief.
crutches on what side when rising? when walking?
unaffected side when rising; affected side when walking;
Negotiation strategy
understand both sides
18 hr post op client following cesarean birth, highest priority finding
unilateral tenderness of the left lower extremity
Hyper reflexes absent reflexes
upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue
pt gets codeine, statement that needs further teaching
urinary freq
s/s of magnesium toxicity? 2 main interventions
urine output <30, rr <12, no deep patellar tendon reflexes, decreased LOC, cardiac dysrhythmia, immmmmmediately d/c, give calcium glucanate
Urine frequency in pregnancy
urine sensitivity test
mental client becoming increasingly loud and belligerent nurse action
use calm and clear statements to set limits
radiation
use dosimeter
dumping syndrome?
use low fowler's to avoid. limit fluids
Circumcision
use petroleum jelly with every diaper change
for phobias
use systematic desensitization
Opioid antagonist nalaxone (Narcan)
used for respiratory depression
Tensilon
used in myesthenia gravis to confirm diagnosis
S/S of bacterial vaginosis
vaginal oder, discharge, dysuria
S/S of Bacterial Vaginosis
vaginal odor, discharge, dysuria
s/s of bacterial vaginosis
vaginal odor, discharge, dysuria
Im injection
vastus lateralis
Buddhist patient
vegetarian
Doxazosin (Cardura) For HTN and BPH
venous & arterial dilation, smooth muscle relaxation of prostatic capsule and bladder neck
Ethical medical error
veracity
med error is what trait? (fidelity, veracity, beneficence?)
veracity
Parathyroid relies on
vitamin D to work
TPN fluid overload is evidenced by what?
weight gain > 1kg/day and edema
Clozapine side effect
weight gain, hypotension and hyperglycemia
clozapine s/e
weight gain, hypotension, hyperglycemia, agranulocytosis
thyroid therapeutic effect
weight loss no depression no bradycardia no anorexia no cold intolerance no dry skin no menorrhagia no decreased TSH levels
the best indicator of dehydration?
weight---and skin turgor
Cerebral angio prep
well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids.
a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid ibuprofen. why or why not ?
what , if any is the appropriate action for the nurse to take NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notify the provider of client headache and ibuprofen us
Family concern
what has the doctor told you
asthma
wheezing on expiration
When should admin RhoGAM
when mom is Rh-negative and had Rh-positive infant; admin w/n 28 weeks (3rd trimeter) and 72h after birth Spontaneous abortion, amneoscentesis
ventricular tachycardia/vtach=what ECG
widened QRS
COPD and O2
with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe.
pancreatic enzymes are taken
with each meal!
Stroke pt:
withhold meds until a swallow study is done
Myesthenia Gravis
worsens with exercise and improves with rest
can digoxin toxicity occur with 3.2 potassium?
yes
If patient has command hallucinations, withold med?
yes!
change a TPN infusion line every 24 hours or how often?
yes! every 24 hours
can you delegate an LPN to check NG tube placement? can they provide first feeding after CVA?
yes, according to book; not clear; but assume no beause high risk scenario
Preventing uric acid stones
yogurt
A client is admitted for opiate detoxification for the fifth time. Which of these statements, if made by a staff member, indicates a biased view of the client? a. "I feel so frustrated when clients are re-admitted." b. "Addicts relapse because they don't try hard enough." c. "I think this client needs to consider long-term placement after detoxification." d. "The team really needs to discuss this client's treatment plan."
b. "Addicts relapse because they don't try hard enough."
When a client who has a diagnosis of depression is taking a monoamine oxidase (MAO) inhibitor, which of these dieatry instructions should a nurse give to the client? a. "Increase your intake of foods that are high in vitamin C, such as oranges." b. "Avoid foods that contain tyramine, such as aged cheeses." c. "Increase your intake of foods high in tryptophan, such as fish." d. "Restrict foods high in sodium, such as canned soups."
b. "Avoid foods that contain tyramine, such as aged cheeses."
Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an amniocentesis today? a. "Drink at least six glasses of fluids during the next six hours after the test." b. "Call the clinic if you experience any abdominal cramps." c. "Don't be concerned if you have some vaginal spotting in the next 12 hours." d. "When you get home, stay on bed-rest for the next 48 hours."
b. "Call the clinic if you experience any abdominal cramps."
A client who has insulin-dependent diabetes mellitus asks a nurse, "What should I do when I feel nervous, sweaty, and hungry?" The nurse should give the client which of these instructions? a. "Lie down and rest." b. "Eat a carbohydrate snack." c. "Take your prn dose of insulin." d. "Add a slice of bread to your next meal."
b. "Eat a carbohydrate snack."
Which of these client reports should a nurse recognize as suggestive of hypothyroidism? a. "My hands shake whenever I reach for anything." b. "I feel cold and tired all the time." c. "I sweat whenever I walk more than one block." d. "My head aches each evening."
b. "I feel cold and tired all the time."
Which of these statements, if made by a nursing student prior to a sterile dressing change, is correct? a. "I understand that if objects touch other objects on the sterile field they are considered contaminated." b. "I understand that sterile objects that are below my waist are considered contaminated." c. "I understand that all objects in the sterile field must be dry." d. "I understand that contaminated objects can be used if rinsed with an antimicrobial solution."
b. "I understand that sterile objects that are below my waist are considered contaminated."
When assessing a group of children, a nurse should recognize which child is at increased risk of developing acute glomerulonephritis? a. A 3-year-old who has multiple urinary tract anomalies. b. A 4-year-old who had a streptococcal infection a week ago. c. A 5-year-old who has recurrent enuresis at night. d. A 6-year-old who had chicken pox infection two weeks ago.
b. A 4-year-old who had a streptococcal infection a week ago.
A nurse should recognize that a client's selection of which of these foods demonstrates a correct understanding of a high-fiber diet for colon cancer prevention? a. Corn muffin. b. Bran flakes. c. Raising muffin. d. Green salad.
b. Bran flakes.
An 8-month-old infant is admitted to the hospital because of failure to thrive. Which of these actions should a nurse plan? a. Limit the parents' interactions with the infant. b. Consistently assign the care of the infant to the same staff. c. Rotate assignments so that all staff can evaluate the infant. d. Limit the infant's activity until the cause of the problem is identified.
b. Consistently assign the care of the infant to the same staff.
Which of these actions should a nurse take prior to assisting an elderly client to shave his face? a. Have the client sign a consent form. b. Determine what medications the client takes. c. Soften the client's skin by applying lotion. d. Cleanse the face with a bactericidal solution.
b. Determine what medications the client takes.
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis? a. Elevated serum potassium level. b. Elevated serum amylase level. c. Elevated serum sodium level. d. Elevated serum creatinine level.
b. Elevated serum amylase level.
Which of these instructions should be included in the teaching plan for the parents of a 10-month-old infant who is admitted to the hospital for failure to thrive? a. Advise the mother to make sure the infant drinks the entire bottle at each feeding. b. Encourage the mother to feed the infant slowly in a quiet environment. c. Teach the mother to position the infant on the abdomen following feedings. d. Instruct the mother to play actively with the infant during bottle feedings.
b. Encourage the mother to feed the infant slowly in a quiet environment.
A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take? a. Include the 9:00 A.M. scenario in the shift report. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". c. Put the information in the margin and indicate the accurate time placement by drawing an arrow. d. Draw a line through the previous charting with "error" and then re-record everything, including the new information.
b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry".
When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should recognize which of these conditions as a probable cause of the newborn's jaundice? a. Dehydration. b. Liver immaturity. c. ABO incompatibility. d. Gallbladder immaturity.
b. Liver immaturity.
A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and lightheadedness. Which of these assessments should a nurse make? a. Determine the client's preferred diet. b. Measure the client's body temperature. c. Auscultate the lungs. d. Ascertain the client's typical sleep pattern.
b. Measure the client's body temperature.
Elasticized bandages
Keep toes and fingers open to check for blood circulation
Prolapsed cord
Knee to chest or Trendelenburg oxygen 8 to 10 L
Hypo Mg
Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity)
Crutches (stairs):
Tripod position, Transfer wt to crutches, unaffected then affected leg
Newly diagnosed Heart Failure patient
Try to walk at least 3 times a week for exercise
Continuous passive motion following a TKA:
Turn machine off during meal time (promotes comfort and dietary intake)
Variable Decels; 1st action:
Turn pt on Left Side
Increase ICP (signs and symptoms)
--JVD, --Glasgow Coma Scale <15 --sleepiness or difficulty arousing patient --Wide BP --Decerebrate and decorticate posturing
Hypocalcemia
--Muscle cramps --Tingling sensation
Suctioning a tracheostomy patient
--Preoxygenate at least 30 seconds --Suction pass 10-15 seconds --Set pressure between 80-120 mm Hg --Suction up to three times.
Neonatal sepsis signs
--Temperature instability --Tachypnea --Hypotonia --Lethargy --Nasal flaring --Irritability
Postpartum, resume sexual activity
--Use water soluble gel for lubrication to prevent discomfort --May resume sexual activity 2-4 weeks after
Body Mechanics
Knees kept at hip level, sit with back supported, wrist and forearms parallel to the ground, arms kept closely to the body, head level when looking at screen
phenytoin, SMZ-TMP, command hallucinations = what?
phenytoin toxicity!
What is the nurse's contribution to an interdisciplinary team?
- knowledge of nursing care & its management - a holistic understanding of the client, her/his healthcare needs & healthcare systems.
Type 1 diabetes & acute disease
--*Continue to take insulin at regular intervals regardless of meal* --Monitor blood glucose Q4h --Call provider if glucose >250 mg/dL --Notify provider if ketones present.
Newborn expected findings
--Breast nodule <10mm apart --Posterior fontanel smaller than anterior --overlapping suture lines --Lanugo over the shoulders --No yellow on skin
Newborn considerations
--Void once within 24 hrs; 6-10 times/day post 4th day. --Erythromycin in eyes within 1 hr from birth --Vit K for clotting --Hep B (birth + 1 mo + 6 mo) (NOT same thigh as Vit K)
naegeles rule
-3+7
Pressure Ulcer Strategies -Reposition time (bed/chair) -Incontinent Pt.
-Bed every 2hr, chair every hour. -Apply barrier cream and moisture absorbing pad.
Pt wants to see info in Chart:
"There is a protocol for reviewing your chart and I can initiate the process"
Fluid overload
--Crackles in lungs --Distended neck veins
How should you respond when client wants to discontinue dialysis
"What has changed to make you decide this?" = Seek clarification from client to establish mutual understanding while staying therapeutic
Right-sided heart failure
--Distended abdomen --Jugular vein distention --Dependent edema
S/S of pericarditis
- chest pressure/pain - friction rub - SOB - pain relieved when sitting and leaning forward
Levothyroxine (Synthroid) -Signs of Toxicity
*Cardiac: anxiety, chest pain, tachy, htn.
Case Management nursing involves:
*Decreasing cost by improving client outcomes * Providing education to optimize health participation * Advocating for services + client's rights
Reversal agents
*Flumazelin* --> Benzodiazepines *Narcan & Naloxone* --> Opioids *Atropine* --> Inhibitor overdose *Vitamin K* --> Warfarin *Protamine Sulfate* --> Heparin *Calcium gluconate* --> Magnesium sulfate toxicity *Acetylcysteine* --> acetaminophen toxicity *Digibind* --> Digoxin toxicity (prevent absorption) *Sodium Polystyrene* --> High levels of K in body
desmopressin monitor
*hypertension* hr fluid & electrolyte weight I & O specific gravity
The nurse has given a client instructions about crutch safety. Which client statement indicates that the client understands the instructions?
- "I should not use someone else's crutches." - "I need to remove any scatter rugs at home" - "I need to have spare crutches and tips available"
What can be delegated to Assistive personnel (AP)?
- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients
S/S of hyperglycemia
- Blood glucose level >250 - thirst - frequent urination - hunger - warm, dry flushed skin - weakness - malaise - rapid, weak pulse - hypotension - deep rapid respirations
islam
-avoid alcohol and pork -fast during ramadan -faces mecca -confesses sins during dying -white cloth washes body -prayer is said
mormonism
-avoid alcohol, tobacco and caffeine
dietary prevention nephrolithiasis
-avoid oxalates- rhubarb, spinach, beets -avoid excessive intake of protein, sodium and calcium
health promotion (injury prevention-suffocation): infant (birth-1 yr)
-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing
Stroke eating precautions
-check gag reflex -thickened fluids/puree -Sit upright/flexed neck forward
Pediculosis capitis- head lice
-intense itching -small, red bumps on the scalp -nits (white specks) on the hair shaft
scabies
-itchy, especially at night -rash, especially between fingers -thin, pencil mark lines on skin -most common head, neck, shoulders, palms, soles (young kids) -older kids- most common on hands, wrists, genitals, ab
MRSA Contact Precautions
-keep distance within 3 ft of client -Private room or share with someone with similar infection (wound infection, herpes simplex) -double bag dressing gauze. -PPE: Gloves and Gowns.
judiasm
-kosher diet-cannot have dairy and meat in the same meal and veggies and meat have to be cooked in different parts of the kitchen
when should a trough level be scheduled for a once daily dosing of gentamycin?
1 hr prior to next dose
proper steps of crutches while climbing stairs
1) stand in tripod position 2) place body weight on crutches 3) place unaffected e.g. on stair 4) move affected leg and crutches up to the stair
Amount of calcium needed daily
1,000-1,200 mg a day. 600 mg at a time.
what is normal pre-albumin values? what are normal serum levels of magnesium ? what is a normal potassium serum level?
17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia)
anterior fontanelle closes by...posterior by..
18 months, 6-8 weeks
Kidney glucose threshold
180
Sign of mag sulfate toxicity (4)
1. Absent deep tendon reflexes 2.Resp rate < 12 3. Urine output < 30 4.Mag levels above 8
List all the positive signs of pregnancy. Subject: Maternity
1. Can feel fetal parts through palpitation. 2. Electronic Doptone scope (audible at 8-11 weeks) 3. Sonogram (at 12 weeks) 4. Fetoscope or Leff stethoscope 5. Ultrasonographic (echographic) 6. Fetal movement palpable after 20 weeks
Compartment Syndrome
1. Compartment syndrome (ACS) is assessed by using the five P's (pain, paralysis, paresthesia, pallor, and pulselessness). 2. Increased pain unrelieved with elevation or by pain medication. 3. Intense pain when passively moved. 4. Paresthesia or numbness, burning, and tingling are early signs. 5. Paralysis, motor weakness, or inability to move the extremity indicate major nerve damage and are late signs. 6. Color of tissue is pale (pallor), and nail beds are cyanotic. 7. Pulselessness is a late sign of compartment syndrome. 8. Palpated muscles are hard and swollen from edema. 9. If untreated, tissue necrosis can result. Neuromuscular damage occurs within 4 to 6 hr. Surgical treatment is a fasciotomy.
Teaching and S/E of Alpha Blockers Doxazosin (Cardura) or Prazosin (Minipress)
1st dose orthostatic hypotension (syncope, dizzy or faint) take 1st dose at night and monitor BP 2hr after 1st dose, avoid activities requiring mental alertness for first 12-24h, instruct pt to change position slowly, take with food
When should a trough level be scheduled for a once daily dosing of Gentamicin?
1st hour prior to next dose
Latent phase of labor
1st part of the 1st stage of labor, lasts 4-6h, cervix 0-3cm, contractions irregular, mild to mod frequency 5-30m and duration of 30-45s, some dilation and effacement, pt talkative and eager Use slow/ deep breathing
Transurethral Resection of Prostate (TURP) - 12-hr post procedure
Priority Finding: Concentrated red urine with intermittent clots indicates client at greatest risk for hemorrhage.
Working Phase
Problem Solve
Lyme disease
Stage II experience: joint pain, cardiac and neurologic complications. If not treated at this stage becomes chronic and causes arthritis, peripheral neuropathy, vasculitis, and myocarditis.
What is the key finding for Rubeola?
Koplik spots.
S/S Hyperglycemia
Kussmaul Respirations, Increased UOP, Abdominal Cramping
antisocial personality disorder:
Lack of remorse
Sign of Autism in a Toddler:
Lack of responsiveness
List the presumptive signs of pregnancy? Subject: Maternity
1. Missed menstrual period. 2. Breast change: nipples tingle, fuller, darker. 3. More frequent urination. 4. Morning sickness. 5. Skin change: chloasma, linea nigra, striae.
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes
2
sinus tachy
picture?
Education on meds for Kidney Disease 1.Digoxin (Lanoxin) 2.Sodium plystyrene (Kayexalate) 3.Epoetin alfa (Epogen) 4.Ferrous sulfate (Feosol) 5.Aluminum hydroxide gel (Amphojel) 6.Furosemide (Lasix)
1. Take within 2 hrs of meal, monitor signs of toxicity, apical pulse for 1 min. 2. Monitor hypokalemia, restrict sodium intake. 3. blood twice a week, monitor HTN. 4. administer following dialysis with stool softner, take with food. 5. avoid pts with GI disorders, take 2 hrs before or after Digoxin. 6. Monitor I&O, bp, weight. Report thirst, cough.
Insulin Self-administration:
pinch skin before injecting
Stoma appearance should normally look
pink or red and moist/red and beefy
List the probable signs of pregnancy. Subject: Maternity
1. Uterus is enlarged. Hegar sign. 2. Goodell sign (cervix) 3. Chadwick sign (vagina) 4. Von Fernwald sign 5. Lab tests: pregnancy test (home test) 6. Braxton-Hicks contractions 7. Ballottement
After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube.
2
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client 1. eat a high-protein, low-residue diet. 2. lie on her unoperated side. 3. exercise her arms and legs. 4. cough and deep breathe.
4
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli.
2
An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 1. "Take the medication on a full stomach, or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors." 3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for two weeks."
2
The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 1. increased pulse rate. 2. decreased temperature. 3. fine tremors. 4. increased radioactive iodine uptake level.
2
The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? 1. The client advances the cane 18 inches in front of her foot with each step. 2. The client holds the cane in her left hand. 3. The client advances her right leg, then her left leg, and then the cane. 4. The client holds the cane with her elbow flexed 60°.
2
The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client.
2
makes very few decisions and does little planning motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation
Laissez faire
Non-Rebreather Mask
Ensure two "flaps" open during exhalation/close during inhalation.
What type of diseases are placed in contact precautions?
Enteric diseases caused by micro organisms, wound infection, herpes simplex, scabies, multidrug resistant organisms.
Classic S/S of MI
Epigastric and LUE pain, diaphoresis, N/V, dizziness, chest pain, anxiety and feelings of doom
Pt transferring to another unit, necessary to include in transfer report:
Last time pt had pain meds
What should the nurse do when one member of a support group expresses anger repeatedly?
Focus more on the group members who have a positive outlook (Speak to group member privately to uncover source of anger)
Vitamin to prevent neural defects
Folate is a B-vitamin found in spinach and leafy green vegetables, dried beans, liver, and citrus fruits. In vitamin supplements and fortified foods such as breakfast cereal, it is usually found in the form "folic acid."
Taking Coumadin. Which foods should the client limit?
Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes
Promotes good wound healing
Foods high in Vitamin A, high in protein, do not use povidone-iodine to clean wounds- it is TOXIC!, Avoid heat
Therapeutic effect of Levothyroxine (Synthroid)
For Hypothyroidism: decreased TSH 0.3-3.0, normal T4 levels, absence of hypothyroidism symptoms (depression, wt gain, bradycardia, anorexia, cold intolerance, dry skin, menorrhagia); takes several wks to notice a therapeutic effect
Tinnitus
Indication of ototoxicity. withhold aspirin
Epigastric pain in pregnancy
Indicator of hepatic involvement and clinical manifestation of severe preeclampsia
Erythrocyte Sedimentation Rate (ESR)
Inflammation marker test. Another inflammation test is: C-Reactive Protein.
The nurse is performing 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
The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the client to 1. use a new sterile catheter each time he performs a catheterization. 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. 3. perform the catheterization procedure every 8 hours. 4. limit his fluid intake to reduce the number of times a catheterization is needed.
2
Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.
2
Specific gravity
1.010 - 1.030
specific gravity
1.015-1.030
Normal magnesium
1.5 - 2.5
PT
10 - 12 sec
flush a central line with how many mL?
10! 3 if peripheral
daily % calories from protein
10%
LDH
100 - 190 U/L
1 g (gram)
1000 mg
Hgb
12-16
HGB
12-18
hgb
12-18
BUN
12-20
Suction for trach pressure not to exceed
120 Hg
Normal Fetal HR
120-160
#gtt/min
13
Total cholesterol
130 - 200
Adolescent
1300 mg of calcium
Normal Na levels
135 - 145 mEq/L
na
135-145
Sodium
136-144
platelets normal
150-400
I lb
16 oz
What temperature should pork be cooked at
160 degrees
Need for Sterile Gloves
Inserting Catheter
1 pint
2 cups
fruits per day
2 cups (1 small banana, orange, 1/4 cup dried apricots)
1 quart
2 pints
What are the precautions for vancomycin resistant enterococcus
Standard precautions including hand washing and gloving should be followed
postoperative are for a client following a colon resection for colorectal cancer includes which of the following? SATA; 1: report to the provider that the stoma is red in color and has serosanguineous discharge 2: monitor and treat pain & evaluate pain-relief measures 3: start a full liquid diet upon return to medical unit 4: provide wound care using surgical aseptic technique 5: advise the client to use stool softners to prevent straining
2, 4, 5
Developmental
2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup
3 years of age normals; immunization?
2-3kg/yr, 2.5-3 in/yr, picky eaters, initiative vs guilt, imaginary friends, ride tricycle, jump off bottom step, stand on one foot for a few seconds, DTaP, IPV, MMR, varicella, influenza
Battery
Intentional and wrongful physical contact with a person that involves an injury or of fensive contact (restraining a client and administering an injection against his wishes). Physical contact without a person's consent
CVA pt transferred to rehab; Address Family's concerns:
Interdisciplinary conference for family at new facility
Carbamazepine
Interferes with oral contraceptives
Orientation Phase
Introduce, Discuss confidentiality, Set goals
Re-educative therapy
Involves learning new ways of perceiving and behaving.
infant w/ hydrocephalus 6hrs post op following a venticularperitoneal shunt; Report:
Irritability when being held indicates increased ICP
What is the function of the pituitary gland?
It's the master gland. Controls everything.
Peritoneal dialysis
Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok
Calculate Nagele's rule for the first day of LMP of April 1, 2013. Subject: Maternity
January 8, 2014
valproic acid (Depakote) which side effects should nurse monitor and report?
Jaundice!! pulmonary edema
Hypoglycemia signs in newborn
Jitteriness, twitching, weak high-pitched cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures, blood glucose level <40
Right Sided Heart Failure
Jugular vein distention Ascending dependent edema (legs, ankles, sacrum) Abdominal distention, ascites Fatigue, weakness Nausea and anorexia Polyuria at rest (nocturnal) Liver enlargement (hepatomegaly) and tenderness Weight gain Cardiomyopathy (leading to heart failure)
What is fairness in care delivery and use of resources
Justice
Nursing Interventions for increased ICP
Keep HOB at 30 degrees, avoid extreme flexion, extension, or rotation of the head and maintain in midline neutral position; keep body aligned avoid hip flextion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid coughing or blowing nose
Wound Evisceration steps:
Stay with Pt/Call for Help Saline-soaked gauze Hips and Knees bent Take Vitals
Left Sided Heart Failure
Left ventricle heaves, Pulsus alternans, (alternating pulses, strong weak), Increased heart rate, PMI displaced inferiorly and posteriorly. (LV hypertrophy), decreased PaO2, slight increase in PaCO2, (poor O2 exchange), Crackles, pulmonary edema s3 and s4 heart sounds Pleural effusion Changes in mental status Restlessness, confusion
Peripheral Vascular Disease
Leg cramps and leg restlessness
The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for a duration of 6-9 months.
4
What is a living will?
Legal document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues.
The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room.
4
The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is 1. before breakfast. 2. with dinner. 3. with food. 4. at hs.
4
When performing nasotracheal suctioning what technique should be used?
Sterile asepsis bc the trachea is considered sterile and prevents infections
The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.
3
The nurse's INITIAL priority when managing a physically assaultive client is to 1. restrict the client to the room. 2. place the client under one-to-one supervision. 3. restore the client's self-control and prevent further loss of control. 4. clear the immediate area of other clients to prevent harm.
3
The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.
3
What is the key finding for Poliomyelitis?
Stiffness progressing to flaccid paralysis.
When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure.
3
When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.
3
Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function.
3
When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers
4
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae. 3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding.
4
1 kg
2.2 lbs
Normal phosphorus
2.5 - 4.5
veggies per day
2.5 cups (raw, cooked, or juice) broccoli, carrots dry beans and peas, corn, potatoes, tomatoes
0.5mg/kg/dose PO; Pt weighs 33lbs; Available is 15mg/mL. How many mL/dose?
2.5mL
Gestational Hypertension
20 weeks of pregnancy
daily % calories from fat
20-35%
platelets
200,000 to 400,000
1200mL NS for 6 hours. How many mL/hr?
200mL/hr
ranitidine 50mg IV bolus; available is 50mg in 100mL D5W to infuse over 30 min. How many mL/hr?
200mL/hr
CPK
21 - 232 U/L
aPTT
23 - 31
Bicarb (CO3)
24 - 26
CO2
25 - 45
aPTT normal level
25-35
milk per day
3 cups (2% milk, yogurt, cheese)
HPV vaccination doses
3 doses
What walking gate for stairs? (crutches)
3 point
short leg cast for fractured fibula
3 point gait
Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position her on her abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist her with heat application and ROM exercises.
4
tx for hypoglycemia
4 oz or 2 oz grape juice or 8 oz milk, recheck bg in 15 min if still low (<70) give 15 g more carbs, recheck in 15 min, if w/n normal limits eat 1g protein (peanut butter, cheese)
Pt needs PT after DC:
Let pt chose who they want to use
Cardiac cath
NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr
What position is good to use for a patient who is at high risk for a pressure ulcer
30 degree lateral position is recommended for clients at risk for pressure ulcers
Arms at what degrees when hands on crutch rails while standing?
30 degrees
when should a peak level be drawn for divided doses of gentamycin?
30 m after admin of med or infusion has finished
1 oz
30 mL
When should a peak level be drawn for divided doses of Gentamicin?
30 min after admin of med or infusion has finished
take peak gentamicin (amino glycoside) when? trough?
30 min after giving IM, or 30 min after IV has finished; trough immediately before giving next dose
Good diet
30% carbs
When should a peak level be drawn for divided doses of Gentamycin?
30m after admin of med or infusion has finished
Hct for females
37 - 47
Hit
37%-52%
what is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs?
37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL
A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness.
4
A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication five 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
A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 cc per hour.
4
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids.
4
Normal albumin levels
3.4 - 5 g/L
Normal K levels
3.5 - 5.5
Uric acid
3.5 - 7.5
potassium
3.5-5
Potassium
3.5-5.5
uric acid
3.5-7.5
how many mls in an ounce
30
PTT
30 - 45 sec
adult at risk for pressure ulcer
30 degree lateral position in bed
increase PAWP means what? reference?
4-12, increased means left sided heart failure
rbc
4-6
incubation period for infection mononucleosis
4-6 weeks
incubation period for infectious mono
4-6 weeks
Myelogram
NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his care
C
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound
C
grains per day
6 oz whole grains (cereals , rice, pasta) 1 oz = one slice of bread, 1 cup cereal 1/2 cup cooked pasta
Oils
6 tsp (canola, corn, olive, nuts, olives and some fish)
how should patients place crutches when standing on crutches?
6" to the front and side of the toes
A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride
C
What are total serum protein values (normals)
6-8 g/dL
Normal total protein levels
6.2 - 8.1 g/L
Refeeding syndrome
60%
Alzheimer's
60% of all dementias, chronic, progressive degenerative cognitive disorder.
Normal BUN levels
7 - 22
Tidal volume is
7-10 ml/kg
Stranger anxiety is greatest at what age?
7-9 months..separation anxiety peaks in toddlerhood
pH
7.35 - 7.45
Normal Glucose levels
70 - 110
glucose
70-110
rhogam
72 hours after baby comes out
fentanyl patch changing time
72 hours, 48 if intolerant
A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? a) "I had a bowel movement, but I was able to save the urine" b) "I have a specimen in the bathroom from about 30 minutes ago" c) "I flushed what I urinated at 7 am and have saved the rest since" d) "I drink a lot, so I will fill up the bottle and complete the test quickly"
C
A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmaleficence
C
1 cup
8 oz
Normal Calcium levels
8.5 - 10.9 mg/dL
calcium
8.5-10
PaO2
80 - 100%
Normal Chloride levels
95 - 105
chloride
95-105
Chloride
96-106
Bilirubin
< 1.o mg/dL
SaO2
> 95%
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
A
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter
A
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room
A
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside
A
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? a) serum albumin level of 3 g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20
A
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardia c) Warm moist skin d) Polyuria
A
When should planning discharge process begin? a. at time of admission b. 2 days after client is admitted c. whenever the nurse has the time to do planning d. when the physician has the discharge order
A
Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension c) flushing d) bradycardia
A
Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle.
A
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene
A B E
Describe regression in mental health.
A 3-year old hospitalized for leukemia only wants to be fed with a bottle while being held by his mother.
RBCs
4.5 - 5 million
hct
40
Triglyceride
40 - 50
Hct for males
40 - 54
aPPT value w/ hemophilia A
45
cabs how much of diet
45-65%
daily % calories from carbs
45-65%
Tx for Hypoglycemia
4oz OJ or 2 oz grape juice or 8 oz milk recheck BG in 15m if still low (<70) give 15g more carbs recheck BG in 15m, if w/n norm limits eat 1g protein (peanut butter, cheese)
Treatment for hypoglycemia
4oz orange juice, 2 oz grape juice, 8 oz milk, glucose tablets; recheck blood glucose in 15 minutes if still low (<70), give 15g more carbs; recheck blood glucose in 15 minutes, if within normal limits eats 1g protein (peanut butter, cheese)
1 tsp
5 mL
Give what for hypovolemic shock ?
5% dextrose in LR
a client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive & unresponsive. The nurse anticipates that which IV solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume & increase BP? (5% dextrose in LR, 0.33 NaCl, 0.225% NaCl, 0.45 NaCl)
5% dextrose in LR
WBC
5.2 - 12.4 5,000 - 10,000
protein per day
5.5oz (one small chicken breast 3 oz, one egg 1 oz, 1/4 cup dried cooked beans 1oz
hungtington's
50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure
Caradioversion should be initially set to?
50-100 joules
nurse is educating on losing one pound a week; how many calories?
500 calories/day
to lose 1 lb of body fat per week, an adult must have an energy deficit of ____ cals/day
500 or 3,500 cal/wk
wbc
5000-10000
Late Decelerations during labor at 38 weeks. Specify order of steps to follow
A. Reposition client on her side B. Elevate her legs C. Increase maintenance IV fluids D. Palpate uterus to assess tachysystole E. Administer Oxygen via face mask @ 8L/min
Adverse effect of ACE inhibitor (pril's)
ACE inhibitors, such as captopril, increase potassium levels (hyperkalemia)
Ethambutol
AE: loss of red/green color discrimination
Alkalosis/ Acidosis and K+
ALKalosis=al K= low sis. Acidosis (K+ high)
Nurses must follow what code of standards in delegating and assigning tasks
ANA codes of standards
A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step
C
Electrolytes
Na - 136-145 K - 3.5-5 Ca - 9-10.5 Mg - 1.3-2.1 P - 3-4.5 Cl - 98-106
What is Nagele's rule and how do you use it to determine the due date of birth? Subject: Maternity
Nagele's rule is a standard way of calculating the due date of a pregnancy (EDC). The process is adding 9 months and 7 days to the first day of the last menstrual period (LMP).
Used Opioid overdose
Naloxone (Narcan)
Narcotic antidote
Naloxone (narcan)
A nurse on a med surg unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk with a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer
C
A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake
C
After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver
C
Which of the following situations can be identified as an ethical dilemma? A. A nurse on a med surg unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form
C
Fontella Closing on Newborn (Anterior and Posterior)
Anterior: 12-18 months Posterior: 1-2 months
amitriptyline
Anticholinergic; monitor for dry mouth and constipation (CNS effects)
What are the therapeutic effects of protamine
Antidote to severe heparin overdose + Reversal of heparin administered during procedures
Indications for use of cardioversion
Atrial dysrhythmias, SVT, vent. tachy w/ pusle & tx of choice for pt who are symptomatic
Ipratropium
Atrovent
Projection
Attributing faults to others
makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings
Authoritative
What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest
Autonomy
Alcohol Use Manifestations of Withdrawal
Body burns 0.5 oz of alcohol per hour * Withdrawal appears within 4-12 hours * Irritability + Tremors + Anxiety * Nausea + Vomiting + HA * Diaphoresis * Sleep Disturbances * TACHYCARDIA + HTN Use Benzodiazepines = tx Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium)
15 minutes postpartum; Requires immediate action by the RN:
Boggy Uterus; indicates greatest risk for uterine atony. Immediately massage the fundus to prevent blood loss.
Infant Pulse
Brachial pulse is used because it is most easily accessible.
Priority for Panic Disorder
Breathing Technique
What medications can be taken to help with smoking cessation
Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a generic. Varenicline (chantix)
Coarctation of the aorta
Narrowing of aortic arch that causes increased resistance bloodflow between the proximal and distal aorta the resulting physiologic change is an increased pressure in the proximal area the upper distal extremities and decrease pressure in the lower extremities
Digoxin:
Nausea is a manifestation of toxicity
Mydriatic Eye Drops
Administered for ophthalmic examinations
Betamethasone & preterm labor
Administered to stimulate fetal lung maturity & prevent respiratory distress
Arterial lines
Need pressure bag around the solution, because pressure form an artery is greater than that of the line
PE
Needs O2!
Vaginal deliver & breastfeeding mom
Needs additional 330 calories/day while breastfeeding
Aversion therapy
Negative reinforcement is used.
BP check in 10 min:
AP who is helping a pt to bed will be done on time.
What does 'abortus' mean in GTPAL?
Abortus is the number of pregnancies that were lost for any reason, including induced abortions or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost. Stillbirths are not included.
What is the difference between respiratory acidosis and respiratory alkalosis?
Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45.
Cognitive therapy
Active, directive, time limited, structured approach.
Addison's & Cushings
Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia
Fetal Tachycardia; Variable decels FHR
Administer O2 8-10 L/min via a mask.
Bilateral pneumonia & PaO2 at 80 mm Hg
Administer oxygen per nasal cannula BEFORE High Fowler's position
Morphine (opiods)
Adverse Effect: nausea and vomiting
Hormone Replacement Therapy
Adverse Effects: --Calf pain = DVT --Numbness in arms & intense headaches= Cerebrovascular problems
Terbutaline
Adverse Effects: --Hyperglycemia --Hypokalemia --Hypotension
Magnesium Sulfate
Adverse effects: Respiratory paralysis (serious) Depressed or absent reflexes Hypotension Depressed cardiac function
opioid agonists can cause Constipation What is the nursing intervention and/or client education ?
Advise the client to increase fluid/fiber intake and physical activity. › Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel motility, or a stool softener such as docusate sodium (Colace) to prevent constipation.
Left hemisphere stroke
Affects language, mathematic skills, & analytic thinking --Anxiety concerning the future --Feelings of guilt --Expressive aphasia --Agnosia, Alexia (reading difficulty), agraphia (writing difficulty) --depression, anger, & quickly frustrated --visual changes
Right Hemisphere stroke
Affects visual and spatial awareness and proprioception (sense of our body's position) --Impulsive behavior --one-sided neglect syndrome --loss of depth perception --poor judgement --left hemiplegia or hemiparesis --visual changes
Lumbar Puncture
After the procedure, the pt should be supine for 4-12 hours as prescribed.
draw up regular and NHP?
Air into NHP, air into Regular. Draw regular, then NHP
TB
Airborne precautions
The ABC framework identifies, in order, the three basic needs for sustaining life
Airway Breathing Circulation
Chronic Anorexia w/ enteral tube feedings. What lab value indicates additional need for nutrients:
Albumin level of less than 3.5g/dL
A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. ____ Passive smoking ____ Carbon monoxide poisoning ____ Food poisoning A. Have water heaters inspected on an annual basis. B. Cook all meat at an appropriate temperature. C. Avoid enclosed areas with others who may be smoking.
C A B
If a patient has anorexia nervosa and works out constantly
Allow them to workout and continue their regimen
Osteoarthritis
Alternate: Heat Therapy for Pain and Cold Therapy for Inflammation -Use assistive devices (raised toilet to help not straining)
AP to assist with meals
Alzeimers patient demonstrating aphasia
What populations are at greater risk for diabetes?
American Indians, Alaskan natives, African Americans & Hispanics
Documentation for Ostomy Care (Stool)
Amount Consistency Color
Describe suppression in mental health.
An adolescent who was involved in a drunk driving accident in which his best friend died, says he doesn't remember drinking and driving, even though he gave a report of the incident to the police.
What does 'Positive Signs' of pregnancy mean? Subject: Maternity
An examiner is 100% positive that the woman is pregnant through examination.
Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair"
Anger stage
Theophylline Toxicity; Expected Finding:
Anorexia
Contraction stress test
Negative: (Normal finding) within 10 min period, three uterine contractions & no decels. Positive: (Abnormal finding) persistent and consistent decelerations on more than half the contractions. Cord or fetal head compression present.
what to check with pregnancy
Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope.
APGAR
Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent)
PAD:
Applies lotion to the feet to prevent cracking skin
RA; Managing Symptoms:
Apply Cold Therapy
Rheumatoid Arthritis
Apply heat and cold to decrease joint inflammation and pain.
Nursing Care for Engorgement
Apply moist heat for 5 min before breastfeeding. Ice compresses after feeding to reduce discomfort and swelling.
Amputation -Patient education
Apply prosthetic before ambulating.
Contraceptives and Hx Cardio, breast cancer, and poor liver function
Avoid: Combined estrogen-progestin oral contraceptive
Abduct:
Away from body
A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience
B
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals.
B
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Skim milk b) Nothing by mouth c) Regular diet d) Clear liquids
B
A nurse manager of a med surg unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client? A. Charge nurse B. RN C. LVN D. AP
B
The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stool
B
Hepatitis b
B= blood and body fluids (hep c is the same)
S/S of hyperglycemia
BG > 250, thirst, freq. urination, hunger; warm, dry flushed skin; weakness; malaise; rapid, weak pulse; hypoTN, deep rapid respirations
Breach of client safety:
BP cuff used on two different clients
New Born Reflex Assessments:
Babinki- Foot Palmer- Hands Rooting & Sucking- Cheek
Hep B contraindication
Baker's yeast
Which Grief Process when Client acknowledges the impending loss while remaining hopeful "If I could just make it through this, I'd never smoke again"
Bargaining Stage
What is the function of the thyroid gland
Basal metabolic rate/growth rate.
Bathing Newborn technique
Bathe from cleanest to dirtiest -Eyes -Face -Head -Chest -Arms -Legs -Groin (last)
Behavior therapy
Belief is that most behaviors are learned.
What are positive actions to help others
Beneficience
Where do you place droplet precautions clients?
Best is in a private room or can be placed in a room with others that have the same condition.
What is bipolar disorder?
Bipolar disorder is a mood disorder with recurrent episodes of depression and mania.
iron-deficiency anemia and elevated cholesterol
Black Beans (high iron, low fat)
Adverse affects of dogoxin
Bleeding gums, bloody urine and stools, arrhythmias, petichiae
Smallpox Transmission
Bodily fluids, contaminated objects, inhalation of droplets
HIV treatment
Effectiveness shows decreased viral load.
Better peripheral perfusion?
EleVate Veins, DAngle Arteries
What is the study of conduct and character?
Ethics
Terminal Phase
Evaluation (evaluate goals, experience, feelings)
what are good sources of folic acid?
Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils.
Cholinergic Crisis
Exhibits increased muscle weakness and twitching
Mastectomy
Expect presence of one or more surgical drains
STI must be reported to the health dept:
Explain the purpose of the legal requirement to the pt
AIDS (D/C Teaching):
Exposure to soil increases risk for infection
S/S of hip fx
External rotation, shortening adduction
centigrade to Fahrenheit conversion
F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40
Intervening to Promote Bonding
Facilitate the bonding process by placing the infant skin-to-skin in the en face position with the client immediately after birth. Promote rooming-in as a quiet and private environment that enhances the family bonding process. Promote early initiation of breastfeeding, and encourage the client to recognize infant readiness cues. Offer assistance as needed. Teaching the client about infant care facilitates bonding as the client's confidence improves. Encourage the parents to bond with their infant through cuddling, bathing, feeding, diapering, and inspection. Provide frequent praise, support, and reassurance to the client as she moves toward independence in caring for her infant and adjusting to her maternal role. Encourage the client/parents to express their feelings, fears, and anxieties about caring for their infant
What is most likely to happen during early deceleration?
Fetal Head Compression
What is an agreement to keep promises
Fidelity
Staffing Issues:
Find out what the issue is before implementing changes
Drawing up Insulin? Regular vs. NPH
First Regular (clear), then NPH (cloudy)
Turner's sign
Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis
Delirium
Fluctuating LOC throughout the day. Aware of cognitive changes. Acute memory deficit. More pronounced agitation in the evening.
Antidote for Valium intoxication
Flumazenil (Romazicon)
Hallucination
I understand you are scared
home care instructions for pacemaker
I will be able to take showers and baths
a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching
I will tell my doctor before I stop taking the medication
memory loss
ICP
What is the most appropriate method for contraception for an adolescent
IUD or implant
E.D: Child with fever and fluid-filled vesicles on the trunk and extremities; RN priority:
Implement transmission-based precautions
Effectiveness of Allopurinal (Zyloprim) is evidenced by
Improvement in pain caused by gout attack (decreased joint swelling, redness), decreased number of gout attacks, decreased uric acid levels
Angiotenson II
In the lungs...potent vasodialator, aldosterone attracts sodium.
What is the safest way to thaw out frozen foods
In the refrigerator
What are the appropriate episode findings for a client with bipolar experiencing depression?
Inability to make decisions Lack of energy Lack of self-confidence
What are the appropriate episode findings for a client with bipolar experiencing mania?
Inappropriate affect Inappropriate dress Inability to sleep or eat Becomes angry quickly Pressured speech Presecutory delusion
Biophysical profile for mother in 3rd trimester
Includes Amniotic fluid index
NG nutrition
Increase K
Hyperthyroidism
Increase nutritional intake with meals. (due to increased metabolism using up protein, lipid, and carbohydrate stores) *Priority finding*: Increased BP
SLE Findings
Increased ESR- SLE chronic system autoimmune disease that causes skin, heart, lung, and kidney inflammation. Usually die from ESRD. Dx: Hx and serologic tests Decreased RBCs; Anemia (Low Hct and Hgb)
Mannitol; Therapeutic Effects:
Increased diuresis
Diabetes Insipidus Indication:
Increased urine output (polyuria)
Zidovudine (AZT)
Not as toxic to the liver Used in Pneumocystis Carinii Pneumonia Monitor Hgb Hct- can cause severe anemia; monitor CBC- closely for first 2 weeks. Does not affect renal system.
Organ Donor:
Notify Organ Team, Collect Specimens, Remove all Tubes, Cleanse Body, Tag Body
Bacterial Meningitis sign of ICP
Nuchal Ridgidy, Kernig's Sign Sign of ICP: Memory Loss
Manifestations of Bacterial Meningitis:
Nuchal rigidity & Kerig's signs
Cefazolin
Nurse notices urticaria, dyspnea, anxiety, and SOB Administer Epinephrine to induce vasoconstriction & bronchodilation
Rh D Immune globulin:
O- mother after abortion may have been carrying an Rh-positive fetus and should receive the injection
Dialysis Teaching
Pt needs to report: muscle cramps, headache, nausea, or dizziness (hypotension)
Tube feeding with decreased LOC
Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration)
TB
Pt to wear a mask when being transported
What type of diet should a client who has dysphasia be on?
Pureed or mechanical soft diet
Chadwick's Sign
Purplish vulva during pregnancy
What is appropriate for an adolescent in the hospital?
Puzzles and books
Anemia lab
RBC 4.20-4.87
MH patient is becoming loud and belligerent:
Set clear limits (be calm)
Reinforcing Teaching About Oppositional Defiant Disorder
Set clear limits on unacceptable behaviors and be consistent. Reward system for acceptable behavior.
Infant safety
Set water heater <120 F
Oxycodone
Side effect: Constipation
Signs of abuse
Spiral fractures
Assault
The conduct of one person makes another person fearful and apprehensive (thr eatening to place a nasogastric tube in a client who is refusing to eat)
Which is a positive sign of pregnancy? A) Home pregnancy test is positive. B) Chloasma C) The examiner can feel fetal parts through palpitation. D) Frequent urination. Subject: Maternity
The examiner can feel fetal parts through palpitation.
hemophilia is x linked
passed from mother to son
FHR patterns for OB
Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill
Unilateral swelling
Think of DVT
What types of treatment are often addressed in a living will?
Those that have the capacity to prolong life. Ex: cardiopulmonary resucitation, mechanical ventilation, feeding by artificial means.
Assault
Threatening to give pt. medication putting another person in fear of a harmful or an offensive contact.
Med given in error; Document:
Time med was given
Adduct:
To Body
What is the purpose of advance directives?
To communicate a client's wishes regarding end-of-life care should the client become unable to do so.
a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk
Toxic level of digoxin
Displacement
Transfer of feelings to a less threatening person
fluoxetine; report:
Tremors
What does 'Probable Signs' of pregnancy mean? Subject: Maternity
What an objective examiner first notices.
Preparing for an In-service:
What do they know first
What does 'Presumptive Signs' of pregnancy mean? Subject: Maternity
What the mother first notices when she may be pregnant.
Do not delegate
What you can EAT E-evaluate A-assess T-teach
TPN
When TPN is getting low, and you do not have another bag, initiate 500ml of 10% dextrose solution. Do not decrease infusion rate or stop, or admin NS because it will lower BG
Check for NG tube placement in the jejunum
X-ray
In an emergency
patients with a greater chance to live are treated first
Autonomic dysreflexia
patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above)
Which of these instructions should a nurse include in the discharge teaching for a client who has diabetes mellitus? a. "Soak your feet in hot water once a day." b. "Cut your toenails in an oval shape weekly." c. "Avoid using any soap on your feet." d. "Apply lotion to your feet each day."
d. "Apply lotion to your feet each day."
A nurse should recognize that a client who has chronic obstructive pulmonary disease (COPD), needs additional instructions if the client makes which of these statements? a. "I will try to take slow, deep breaths when I feel short of breath." b. "I will use the albuterol (Proventil) nebulizer before I eat. c. "I will drink most of my fluids between meals." d. "I will turn up the oxygen flow rate if I have difficulty breathing."
d. "I will turn up the oxygen flow rate if I have difficulty breathing."
A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete all unfinished business as soon as possible." Which of these responses is appropriate? a. "Yes, you should do this immediately. b. "Don't you think you should stay focused on your treatment for now? c. "Exactly what things are you talking about?" d. "It sounds like you are concerned with your diagnosis."
d. "It sounds like you are concerned with your diagnosis."
Which of these instructions should a nurse give to a client who has venous insufficiency regarding the use of elastic stockings (TEDs)? a. "Bunch the TEDs up and pull them on like socks." b. "Lower the TEDs to your ankles if your legs ache." c. "Keep the TEDs on at all times." d. "Put the TEDs on before you get up in the morning."
d. "Put the TEDs on before you get up in the morning."
Which of these instructions should a nurse include in the teaching plan for a client who had removal of a cataract in the left eye? a. "Forcefully cough and take deep breaths every two hours to keep your airway clear." b. "Perform the prescribed eye exercises each day to strengthen your eye muscles." c. "Rinse your eyes with saline each morning to prevent postoperative infection." d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
d. "Take the prescribed stool softener to avoid increasing intraocular pressure."
S&S hyperglycemia
pee alot thirsty nasuea abdominal pain flush dry skin fruity breath
pt recovering from cva, nurse should...
id community resources, contact home health, verify med equip, coordinate OT
