Comprehensive Predictor Adult Med Surg
at 28 weeks gestation you screen for: administer: begin:
diabetes mellitus RhoGAM for Rh negative mothers NST twice a week for any pregnancy at risk for intrauterine fetal death
ambivalence
during 1st trimester nursing intervention: assess meaning of pregnancy to the client/partner and socioeconomic supports; refer if needed
When is chorionic villus sampling done?
during the first trimester
CNS findings of hypoglycemia in newborns
lethargy, hypotonia, jitteriness, twitching, poor feeding, temperature instability, apnea, respiratory distress, and seizures
L
living children
Thrombocytopenia
low platelet count
ulcerative colitis diet
low-residue high calorie high protein limits high fiber
Why should the nurse encourage ROM exercises in an extremity with an AV fistula?
maintain muscle strength
Sickle cell disease: manifestation of vaso-occlusive crisis
-Hematuria, resulting from ischemia of the kidneys -painful swelling of the hands -visual disturbances
Regular insulin peak time
1-5 hours
Potassium level
3.5-5
Resp range for newborn
30-60
The expected value for aPTT is
40 seconds
A contraindication to Clozapine admin is what?
A low WBC count
Loperamide
Antidiarrheal
Mechanical restraints
Assess physical needs, safety, comfort X 15-30 min Provider must renew script X 4 hr
ET Placement verifying
Check for end-tidal carbon dioxide levels by using a capnometry chest x-ray
What does generalized petechiae indicate in newborns
Clotting factor deficiency or infection. Report to the provider immediately
Manifestations of endometritis (infection of uterus lining) postpartum
Fever for 2 consecutive days, chills, foul-smelling lochia, abdominal tenderness
A home health nurse is providing teaching about home safety to an older client. Which of the following statements by the client indicates that teaching has been effective
I have grab bars next to my tub
Vaginal exams are contraindicated when?
If vaginal bleeding is present
What is misoprostol used for in labor?
It is a cervical ripening agent causing uterine contractions, which result in dilation and effacement.
When a nurse receives change of shift report for a group of clients, what is a good action to take in order to manage time effectively?
Make a client to do list for the day
Fetus' source of oxygen
Placenta
A nurse is developing an in-service about personality disorders. What information should the nurse include when discussing borderline personality disorder?
The client's impulsive behavior
What do Category 1 fetal heart rate tracing indicate
This is an expected finding and does not mean the fetal distress
Can a client who is prescribed methadone able to breastfeed?
Yes
Heparin lab tests
aPTT
Lupus
an inflammatory disease caused when the immune system attacks its own tissues. it can affect the joints, skin, kidneys, blood cells, brain, heart, and lungs Symptoms vary but can include fatigue, joint pain, rash, and fever. These can periodically get worse and then improve.
Rifampin
antiviral medication used to treat TB
A client is admitted to the telemetry unit for sustained paroxysmal supraventricular tachycardia. Which of the following medications should the nurse prepare to administer? a. Atropine b. Adenosine c. Nitroprusside d. Norepinephrine
b. Adenosine
Probable signs of pregnancy
blood and urine tests, Chadwick's sign, Goodell's sign, Hegar's sign
Maternal metabolism, physical exertion, and delivery of the placenta can lead to a decreased what
blood glucose level
Magnesium sulfate antidote
calcium gluconate 10%
Leukemia
cancer of white blood cells
Carbidopa/Levodopa
change positions slowly
Infiltration
cold compress
Diplopia
double vision
Bacterial meningitis precautions
droplet seizure
adverse effect of sertraline
excessive sweating
Glaucoma
increase in intraocular pressure
Tetany
intermittent muscle spasms
Stage 3 pressure ulcer
visible sub q tissue
what kind of lubricant should a client use on the nares of an at home oxygen tank
water-soluble
A nurse is caring for a client who is receiving radiation therapy to the neck. Which of the following client statements is the priority to report to the provider?
"I have had a fever for 2 days." - manifestation of infection. Bone marrow suppression and decreased immunity can occur with radiation therapy -Dry mouth is an expected finding Altered taste is an expected finding - Fatigue is an expected finding
A nurse is providing teaching to a client who has type 2 diabetes mellitus and is starting repaglinide. Which of the following statements by the client indicates understanding of the administration of this medication?
"I'll take this medicine 30 minutes before I eat."
Amitriptyline adverse effect
-constipation -urinary retention -dry mouth -blurred vision -TCA -ortho hypotension -all anticholinergic effects -photophobia, tachycardia -toxicity AEB: dysrhythmias, mental confusion, agitation, seizures, coma and possibly death -MAOI and St. John's wort=serotonin syndrome -antihistmaines and other anticholinergics have additive aeffects -increase effects of pi, dopamine occur -decrease effects of ephedrine, amphetamine
Abnormal BPP score
0-4
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take actions when preforming a fundal massage?
1. Ask the client to lie on her back with her knees flexed 2.Place a hand just above the client's symphysis pubis 3.Position a hand around the top of the client's fundus 4. Rotate the upper hand to massage the client's uterus 5.Use slight downward pressure to compress the client's fundus
Five variables of a biophysical profile
1. fetal breathing 2. gross body movements 3. fetal tone 4. reactive FHR 5. Amniotic fluid
Urine specific gravity range
1.005-1.030
A therapeutic level of heparin increases the aPTT by a factor of
1.5-2 making the aPTT 60-80 seconds
INR expected reference range for a client with pulmonary embolism
2.5-3.5
glucose tolerance test performed at how many weeks gestation
24-28
Hematocrit reference range for children
32-44 higher indicates dehydration
When is the Group B Strep culture obtained during pregnancy, how do you treat it
35-36 weeks treat positive cultures with PCN IVPB every 4 hours during labor and monitor newborn for infections
What maternal temperature should be reported to the provider
38 C (100.4) or greater -this is associated with chorioamnionitis
Term Births
38 weeks or more
Preparing for birth
3rd trimester teach manifestations of onset of labor, newborn care, feeding methods, birth control, and home preparation for baby, as well as birthing plan
Reference range of glycosylated hemoglobin
4-5.9%
BUN reference range for a child
5-18 mg/dL
urine osmolality range
50-1200 mOsm/kg
WBC range
5000-10,000
equivocal/borderline BPP score
6
When can hCG be detected?
6-11 days in serum and 26 days in urine after conception following implantation
A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at greatest risk for developing acute post streptococcal glomerulonephirites?
7 year old boy who is recovering from impetigo (starts with strep A infection)
ideal blood glucose level during pregnancy
70-110
Normal BPP score
8-10
Temp range for newborn
97.7-99
Total gastrectomy and vitamins
B12
A nurse is rceiving the lab results of a client who has osteomyelitis and is receivign tobramycin. What findings would indicate an adverse effect of the medication
BUN 30
How often do we flush a PICC line?
Before, between, and after medication
What blood work must you obtain prior to a cardiac cath
CBC with differential
What nutrient aids in blood clotting and muscle contraction
Calcium (Do not take with warfarin)
Neuroblastoma
Cancer that develops from immature nerve cells Most commonly arises in and around the adrenal glands
The nurse should discontinue oxytocin infusion and apply oxygen for what fetal heart rate tracings? What do you do if discontinuing oxytocin does not resolve?
Cat 2 (indeterminate) and Cat 3 (abnormal) the nurse should admin 0.25 mg sub q of terbutaline (terbutaline - and nifedipine - is also used in patients going into preterm labor)
A nurse is caring for a client who has C. Diff. What actions should the nurse take
Change gloves after contact with infectious material Wear gown while providing care
A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. What action should the nurse take FIRST
Change position of the client -when providing client care, the nurse should use the least restrictive intervention first. Therefore, the nurse should reposition the client to remove any kinks in the tube, which can lead to clogging. If this method is unsuccessful, the nurse should attempt to flush or aspirate the client's tube to remove the clog
A client who is in active labor is admitted to a labor and delivery unit and reports, "My water just broke and my baby is breech." What is the first action the nurse should take?
Check fetal heart tones
Cardiac Tamponade
Compression of the heart caused by fluid collecting in the sac surrounding the heart -hypotension -light headedness -SOB -pulses paradoxus
A nurse is assessing a client who is postoperative following surgery using general anesthesia. Which of the following findings is the priority to report to the provider?
A decrease in blood pressure from 130/72 to 110/68
Gastrin
A hormone that is produced in the stomach mucosa that stimulates the release of gastric secretions during the process of digestion
Contraindication for a diabetes insipidus patient to receive vasopressin
A low creatinine clearance -this indicates renal impairment which increases the likelihood of life-threatening adverse effect of water intoxication
A client is admitted to the telemetry unit for a sustained paroxysmal supraventricular tachycardia. Which of the following medications should the nurse prepare to administer?
Adenosine -Adenosine 6mg rapid IVP (over 1-2 seconds) is given to convert paroxysmal supraventricular tachycardia (PSVT) to a normal sinus rhythm.
A client is in active labor and is positive for GBS. What action should the nurse expect to take?
Administer IV antibiotic prohylaxis
A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of the following instructions should the nurse include in the teaching?
Apply petroleum jelly to the glans with diaper changes -you don't want it to stick to the diaper
What nonpharm interventions should the nurse provide to manage a cline'ts back labor pain?
Apply sacral counterpressure -using the heel of the hand or fist against the client's sacral area will lift the fetal head off the spinal nerves and provide relief of the pain in the lower back
Nursing interventions when administering Betamethose
Assess for signs of preterm labor Administer 12 mg deep IM for 2 doses 24 hours apart Monitor blood glucose levels and lung sounds
A charge nurse is assigning the care of a client who has an internal radiation implant. Which of the following actions should the nurse take?
Assign the client to nurses who are not pregnant or trying to conceive. -should be in a private room -all visitors to remain at least 6 feet away -limit visits to 30 min
A nurse at a community health clinic is planning care for an adolescent who recently learned that she is pregnant and is concerned about hr ability to afford and care for her baby. What should the nurse do?
Assist the adolescent in applying for medicaid
The nurse should do what in the event of an umbilical cord prolapse
Assist the client in to a knee-chest position
A client who has Addison's disease with have what kind of skin appearance?
Darkening/bronzing of the skin on both exposed and unexposed parts of the body due
Macular degeneration
Decreased central vision -due to bleeding into the macula or yellow spots under the retina
Why is eating large amounts of protein a risk for osteoporosis
Eating large amounts of protein can result in more calcium loss through the kidneys
What lab findings are indicative of rheumatic fever
Elevated sedimentation rate and C-reactive protein
Benzodiazepine Antidote
Flumenazil
Prenatal STI screening includes
HIV Rubella titer Heb B
A nurse is assessing a client who has sickle cell anemia. The nurse should identify which of the following findings as a manifestations of vaso-occlusive crisis?
Hematuria -resulting from ischemia to the kidneys -painful swelling of the hands and feet -visual disturbances
Addisonian diet
High protein, high carb, high sodium, increase fluids Low potassium Consume small frequent meals to prevent hypoglycemia avoid caffeine and alcohol
A nurse observes a client on the psych unit muttering and standing near a window. The client states, "The voices are telling me to jump." Which of the following is an appropriate response by the nurse?
I understand the voices are frightening you, but I do not hear any voices
Limiting feedback to the staff and avoiding change initiation is what kind of leadership style
Laissez-faire
A nurse is caring for a client following a thyroidectomy. What complication should the nurse assess for?
Laryngeal stridor
What is the first action to take when implementing an emergency preparedness plan
Notify the incident commander
The first action to take when implementing an emergency preparedness plan
Notify the incident commander to initiate the command hierarchy and maintain order
orienteer
Noting the progress of the group toward assigned goals
Nursing interventions for administration of misoprostol, dinoprostone
OBTAIN INFORMED CONSENT Monitor contraindications and FHR Monitor vital signs Evaluate Bishop score Use cautiously in women with history of asthma, glaucoma, renal, hepatic, or cardiovascular disorders Contraindicated in presence of fetal distress or vaginal bleeding
What are some foods containing purine?
Organ meats Chicken Red Wines Red meat some seafoods
Warfarin lab tests
PT/INR
A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. What action should the nurse take?
Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate
Which nutrient is necessary for muscle activity and fluid balance
Potassium
Kehr's sign
Referred pain down the left shoulder; indicative of a ruptured spleen or liver trauma
Paracentesis
Removing fluid from abdominal space through a slender needle
Lumbar Laminectomy
Removing the back portion of a vertebra in the lower back to create more room within the spinal canal
How to tell if clacium gluconate was effective in the treatment of magnesium toxicity
Rep rate between 12-20
A nurse is caring for a child who reports migraine headaches for the past 4 months. What should be the first actions of the nurse
Review the child's electronic pain diary
A nurse is providing teaching to a client who has urinary incontinence. Which of the following instructions should the nurse include?
Run water in the sink prior to toileting - Instruct the client to run water prior to toileting. The sound of the running water can trigger the client's urge to urinate -Establish a new interval schedule by increasing the amount of time between urination by 10-15 min beyond the last interval -Using absorption briefs between scheduled toileting diminishes habit training to reduce urinary incontinence
ARBS
SARTAN Antihypertensive, heart failure, MI, diabetic neuropathy
A nurse is caring for a client who has Chron's disease. What diagnostic procedure should the nurse plan to teach the patient regarding pernicious anemia?
Schilling test
Lab value and nutritional status
Serum Albumin
LPN
Supervised by RN or Provider -Meets healthcare needs of clients -Cares for stable and/or chronic patients with expected outcome -Reinforcement teaching -Contributes to care plan -Calculates and monitors IV flow rate -Administers IVPB meds -Monitor IV fluids -tube insertion -Trach suction
TORCH infections
T - toxoplasmosis O - other (syphilis, varicella, parvovirus) R - rubella C - cytomegalovirus H - herpes
If a missed dose of iron
Take a dose as soon as you realize you missed as long as it is within 12 hours of the missed dose. Do not double up
A nurse is caring for a client who has an NG tube. What action does the nurse take in order to verify placement prior to each feeding?
Test the pH of gastric contents
uterine atony
The most common cause of postpartum hemorrhage.
COPD patients should receive low concentration of O2 because of what
The stimulus to breathe is their low PO2 (partial pressure of O2)
Presence of S3 ventricular gallop means what?
This can be detected in clients who have left-sided heart failure due to altered ventricular filling
after acute inflammation has subsided in a patient with diverticulitis, he or she should increase the intake of what foods?
Those that are high in fiber, such as wheat bran, while-grain bread, and fresh fruits and vegetables that do not contain seeds.
Why is an amniocentesis performed late in pregnancy?
To assess fetal lung maturity and fetal well being
Magnesium Sulfate
Tocolytic used for preterm labor CNS depressant to prevent seizures in preeclampsia
Zollinger-Ellison Syndrome (ZES)
Too much gastric acid lab profile: gastric aspirate -hydrochloric acid and pepsin NPO 12 hours Avoid alcohol, tobacco, meds that change gastric pH for 24 hour
Urinalysis of urolithiasis
Uric acid crystals
What is an expected lab finding in a urinalyses for a client who has urolithiasis
Uric acid crystals -urolithiasis is the process of forming stones in the kidney, bladder, and/or urethra
Urinalysis of UTI
WBC's and nitrates
UTI urinalysis findings
WBC, Nitrates
How should a child who has heart failure take his or her digoxin medication?
With a small glass of water after swallowing the med
What food allergy indicates a risk for a latex allergy
bananas -avocados and chestnuts
At what lead level should a nurse schedule chelation therapy
blood lead level greater than 45 mcg/dL
hypervolemia
bounding pulse
The fetus is especially vulnerable to teratogens during what trimester?
first
When can someone visit a nephew who has chicken pox
five days after the sores have crusted over
taking valproic acid with food causes what
minimization of nausea, vomiting, and indigestion
Narcotic antidote
naloxone (narcan)
Do fetal and maternal blood mix?
no
initiator-contributor
offering new and fresh ideas on an issue
inability to remember one's current age is an example of
orientation defecit
Stage 2 pressure ulcer
partial thickness skin loss
Heparin antidote
protamine sulfate
The Schilling test for pernicious anemia involves:
the administration of radioactive cobalamin and the measurement of its excretion in the urine.
At what week gestation does a client get tested for maternal serum alpha-fetoprotein?
week 16
A nurse is caring for a toddler who has retinoblastoma. What should the nurse expect?
white eye reflex
Can an AP remind a client to use an incentive spirometer?
yes
Warfarin
daily blood draws for the first 5 days avoid calcium avoid Tylenol/ibuprofen report changes in stool color
A nurse is providing teaching to a client who has a prescription for pramlintide for type 1 diabetes mellitus. Which of the following should the nurse include in the teaching (Select all that apply.)
"Inject pramlintide just before a meal." "Discard open vials after 28 days."
A nurse is teaching a client who has breast cancer about receiving radiation therapy. Which of the following statements should the nurse make?
"You might develop a rash on the skin under your arm during therapy." -Radiation dermatitis, or a skin rash, near the axilla is to be expected. This can range from redness of the skin to desquamation, or a peeling, puckers appearance. The nurse should teach the client to wash the affected skin with a mild soap and to use hydrophilic lotions to assist with keeping the skin dry. Dry the skin gently, using a patting motion rather than rubbing. -Weight gain is not an expected finding -Instruct the client that radiation usually takes places several days each week for a period of 5-6 weeks. -A session of radiation therapy will last only a few minutes
Bottle feeding newborn prevent engorgement
-Avoid nipple stimulation -Avoid expressing milk -Place ice packs on breasts for 15 min several times daily -Wear tight-fitting supportive bra or breast binder
Newborn safety
-set hot water @ or below 120 -crib slats should be no more than 2.25 inches apart -place car seat rear facing until 2
Radiation
-wear led apron -instruct visitors to stand 6 feet away -place "caution: radioactive material" sign on door
AST level
0-35 -enzyme that is measured as part of liver function tests
Lithium therapeutic level
0.4-1.4
Normal range for INR
0.8-1.1
therapeutic Digoxin level
0.8-2.0
Antiembolic stockings should be removed how frequently
1-3 X daily to check skin
What is the sequence in which a nurse should follow when moving clients who can partially bear weight from a bed to a chair
1. Assist the client to a sitting position on the side of the bed. 2. Apply the transfer belt to the client. 3.Grasp the transfer belt along the client's sides 4.Rock the client to a standing position. 5.Request the client pivot on the foot farther from the chair.
What mL syringe is used for flushing a PICC line?
10 mL
BUN range for adults
10-20
Theophylline Levels
10-20 toxic greater than 20 asthma
BUN range
10-20 mg/dL
At what week gestation should a client get the influenza immunization?
11 weeks
Normal range for PT
11-13.5
A nurse is caring for a client who has pneumonia and tells the nurse, "I feel like an elephant is sitting on my chest." The client is weak and unable to walk. After the nurse initiates chest pain protocol, which of the followign is the priority diagnostic test?
12-lead ECG
Sodium level
136-145
When is an amniocentesis first performed?
14-16 weeks
A positive blood glucose of what needs additional testing with a 3-hr glucose tolerance test
140 or greater
The nurse should instruct the maternity patients to feed the newborn approximately how long per breast?
15-20 minutes or until the newborn shows signs of satiety (satisfaction)
Reference range of prealbumin
15-36
platelet range (normal)
150,000-450,000
How many ounces of water should a woman at 28 weeks gestation consume after exercise?
16-24
fluid intake of how much for ileostomy
1920
pernicious anemia
lack of mature erythrocytes caused by inability to absorb vitamin B12 into the bloodstream
A nurse should teach a patient who is taking iron to consume what daily?
28 grams of fiber -constipation often occurs when a client is taking an iron supplement.
The client will have a prenatal visit once every 2 weeks for how long
28-36 weeks, then once a week until birth
What is the appropriate L:S ratio for matured fetal lungs?
2:1
Accepting
2nd trimester assess if ambivalence is increased and how the client views the fetus
Diverticular disease
3 conditions that involve numerous small sacs or pockets in the wall of the colon Diverticulosis: presence of pouchlike herniation (diverticula) along the intestine wall (sigmoid colon most common) (high fiber) Diverticular bleeding: injury of small vessels Diverticulitis: inflammation of one or more diverticula (clear diet, go onto low fiber)
Admin a Unit of plasma over how long
30-60 minutes
Cyclophosphamide
Maintain hydration with liberal fluid intake -prevents hemorrhagic cystitis: adverse effect of medication
Newborns might lose up to how much of their birth weight?
7-10% - the nurse should notify the provider if a breastfed newborn loses more than 7% or if a formula fed newborn loses more than 10%
How much force to do you apply if met with resistance while flushing a PICC line?
None. Never apply force if met resistance
What is a flexion contracture
A bent (flexed) joint that cannot be straightened actively or passively. It is thus a chronic loss of joint motion due to structural changes in muscle, tendons, and ligaments, or skin that prevents normal movement of joints. (Think of lock jaw)
A client who has systemic lupus erythematosus will have what kind of skin appearance?
A butterfly rash across the bridge of her nose
A nurse is caring for four clients. Which of the following clients is at risk for skin breakdown?
A client who has a prealbumin level of 8.6 -low prealbumin level may be experiencing malnutrition, a risk factor for skin breakdown
A nurse in an acute care facility is caring for four clients. Which of the followign clients should the nurse refer for speech therapy?
A client who has dysphagia following a stroke (speech swallow)
A nurse is providing an in-service about client evacuation during a fire. What kind of patient should the nurse instruct the staff to evacuate first?
A patient who is ambulatory and receiving oxygen
Chyme
A semi-solid mixture of food and gastric secretions that is formed in the stomach
Nulliparous
A woman who hasn't given birth to a child
At what lead level should a nurse contact poison control
lead level grater than 20 mcg/dL
Amniotic fluid BPP
Normal score 2: At least 1 pocket of fluid equal to or greater than 2 cm, or more than 5 cm total fluid Abnormal score 0: Pockets absent or less than 5 cm total
Reactive FHR BPP
Normal score 2: Reactive NST Abnormal score 0: nonreactive NST
Nursing interventions for Calcium Gluconate administration
Administer calcium gluconate 1 g (10 mL in 10% solution) IV for signs of toxicity Dilute with equal parts normal saline and administer 0.5-1 mL/min
A nurse is caring for a client who is in active labor and is scheduled to receive epidural anesthesia. What action should the nurse take prior to epidural placement?
Administer lactated ringer's 500 mL bolus via intermittent IV infusion -This is to prevent hypotension -If hypotension occurs, the nurse should admin o2 via a nonrebreather face mask at 10 L/min
A nurse is caring for a client who is 48 hours postop following a total hip arthroplasty. What actions should the nurse make sure to include in the plan of care?
Administer low dose heparin -this will help prevent dvt during long periods of innactivity
When should a newborn genetic screening be done?
After the baby is 24 hours old
ADH/Vassopresson
Anti-diuretic hormone -regulates the amount of water in body -accomplishes in kidneys -tubules to retain Increased in SIADH -Decrease in Di
Anti-depressants and older adults
Antidepressants should be given at half of the adult dose. This is due to altered rates of absorption and the increased risk for adverse effects
Calcium Gluconate
Antidote for magnesium sulfate toxicity
Naloxone
Antidote for opioid-induced respiratory depression Reverse pruritus from epidural opioid
A nurse is preparing to perform a venipuncture for an older adult client who has a prescription for IV fluids. Which of the following actions should the nurse plan to take?
Apply a warm compress to the extremity - the nurse should apply a warm compress or wrap the client's extremity in a warm towel to dilate the vein. The compress can be applies to the entire extremity for 10-20 min. - The nurse should place the client's extremity in a dependent position to promote venous dilation and facilitate insertion of the IV catheter
What should a new mother do if her nipples become sore and cracked due to breastfeeding?
Apply colostrum to the nipples after feeding to help them heal. -colostrum and breast milk have healing properties and can help reduce soreness
What should a new mother do upon getting mastitis?
Apply moist heat to the affected breast. -the application of warm compresses prior to feeding or pumping promotes the flow of the breast milk and assists to ensure complete emptying of the breast. This is important to prevent the development of further complications such as the formation of a breast abscess or chronic mastitis. -The client CAN and SHOULD continue to breast feed from both the unaffected and the affected breast. this is to prevent abscess formation. If it is too painful, the client should pump.
A nurse is planning to admin 2 units of packed RBC's to an older adult client who has anemia. What actions should the nurse plan to take
Asses the client's lung sounds prior to the infusion Verify with another nurse that the unit of blood is compatible with the client's blood type
When do you empty an ileostomy
At 1/3-1/2 of the way full
While feeding a client who has dysphagia, the nurse should sit where?
At or below the clients eyes level during feedings
What should a nurse do prior to removing a client's NG tube?
Auscultate for bowel sounds -The nurse should verify the presence of bowel sounds prior to removing the NG tube to evaluate the success of abdominal decompression and the return of peristalsis
A nurse is assessing a newborn's heat rate. What actions should the nurse take?
Auscultate the apical pulse for at least 1 minute Assess the apical pulse when the newborn is in a quiet state
Making decisions quickly and relying solely on their own judgement/not seeking input from others is what kind of leadership style?
Autocratic
Clients should avoid what while taking iron?
Avoid taking the supplement with milk because calcium impairs absorption of the supplement. Iron is best absorbed when taken on an empty stomach. Consuming a diet high in vitamin C will increase the absorption of iron supplements.
A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching?
I will use a soft bristle tooth brush to clean my teeth after meals
Where should a patient place a scopolamine patch for motion sickness?
Behind the ear
A nurse is providing dietary teaching to a client who has a new diagnosis of IBS. What food recommendation should the nurse include?
Bran fiber (it forms the stool)
A nurse is planning dietary teaching for a client who has cholecystitis. The nurse should instruct the client to limit intake of which of the following foods?
Broccoli -avoid gas-producing foods, which include broccoli and cabbage
what should the nurse observe for when administer alteplase revombinant (fibrolytic) for a thrombus in the coronary artery?
Bruising of the skin
Pleural Effusion
Buildup of pleural fluid in the pleural cavity
A nurse is providing teaching to the parents of an infant who has a cleft lip palate. Which of the following feeding techniques should the nurse include in the teaching?
Burp the infant frequently during feedings
Medications used to initiate induction
IV oxytocin -obtained inform consent -monitor FHR every 15 min and with every change in dose -observe for an report uterine tachysystole -Obtain vital signs every 30 min and with every change in dose -admin pain management
giver
sharing experiences as an authority figure
A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? Select all that apply
Lochia serosa Fundus 4 cm below the umbilicus
A nurse is preparing to administer an IV bolus medication for a client who has an implanted port. Which of the following actions should the nurse take?
Check for blood return - before infusion a medication through an implanted port, the nurse should check for blood return. If there is no blood return, the medication should be withheld until patency can be established and needle placement is confirmed - The nurse should flush the catheter using a 10 mL syringe with 5 mL heparin 10 units/mL or 0.9% sodium chloride after each use and at least once per month. - The nurse only needs to cleanse the implanted port insertion site with dressing changes and should use chlorhexidine gluconate solution rather than alcohol -The nurse should place the client supine or in Trendelenburg position when changing the admin set or connectors of a central line to prevent air emboli.
A nurse is creating a plan of care for a client who is postop followign a coronary artery bypass graft (CABG). To prevent complications of cardiac surgery, which of the following instructions should the nurse include in the plan of care?
Check the client's hgb level is chest tube drainage is 300 mL in the first 1 hr. Notify physician if >100 mL/hr drainage
Why administer high-dose antibiotic therapy to child with cystic fibrosis
Children who has cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections
What foods should the nurse recommend to a client taking an iron supplement?
Citrus foods, strawberries, melons, and tomatoes -foods high in vitamin C are encouraged. Vitamin C helps with iron absorption
A community health nurse receives a referral for a facility home visit. What task should the nurse perform first?
Clarify the source of the referral
A nurse is teaching a client who has a colostomy. Which of the following instructions should the nurse include?
Clip hair in the peristomal area before applying the barrier wafer. - Certain foods like cruciferous vegetables can increase flatus and odor. The nurse should instruct the client to decrease dietary intake of these foods -The client should use mild soap and water to clean the peristomal area instead of moisturizing soaps, which can prevent adhesion of the barrier wafer. - Th nurse should teach the client to use pouch deodorizers or breath mints in the pouch to decrease odor rather than an aspirin tablet, which can cause ulceration of the stoma.
Foods that decrease the absorption of iron
Coffee, tea, milk, oxalates: spinach and swiss chard, some whole grains such as bran
A nurse is preparing to administer a unit of fresh frozen plasma (FFP) to a client. Which of the followingactions should the nurse plan to take prior to the transfusion?
Confirm the plasma compatibility with another nurse. - The nurse should confirm the plasma ABO compatibility with another nurse by verifying the client's identity and comparing the bag of FFP to the medical record to prevent an adverse reaction. The nurse should also check the expiration time on the FFP. - Blood products can ONLY be mixed with 0.9% sodium chloride solution if necessary. The nurse is not required to initiate a continuous IV infusion when administering plasma - Rh compatibility is not required for FFP transfusion. ABO compatibility is required for transfusion of plasma because donor antibodies could react with the recipient's antigens. - Liver function testing is not indicated for a plasma infusion; however, the nurse should review the client's PT or PTT prior to the transfusion.
Manifestation of Lithium toxicity
Confusion Course hand tremors Incoordination ECG changes Sedation
A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 sec. The newborn is pink with acrocyanosis. What should the nurse do?
Continue to monitor -the newborn is exhibiting a normal respiratory rate and rhythm.
What kind of diet for acute diverticulitis?
Low fiber, low residue
Function of liver/gallbladder
DIGESTING FATS -Liver produces biles. Bile accumulates in the gallbladder and is discharged into the duodenum when needed. Bile acids emulsify the fat in the intestine. Liver is also involved in carbohydrate and protein metabolism and storage of various substances such as glycogen. Vitamin and protein production and detoxification of drugs. Liver is involved in the metabolism of carbohydrates, protein and metabolization of lipids. One of main functions of liver is metabolism (detoxification) of drugs
Calcium Channel Blockers
DIPINE Antihypertensive Admin iv injection over 2-3 min, slowly taper Use: angina, hypertension cautious in patient taking digoxin and beta blocker -contraindicated for heart failure, heart block, bradycardia side/adverse effects: constipation, reflex tachycardia, peripheral edema, toxicity verapamil and diltiazem: a fib, a flutter, SVT
A nurse is preparing to teach about dietary management to a client who has Chron's disease and an enteroenteric fistula (formation of a fistula between two parts of the small bowel). What nutrient should the client decrease in their diet? what should they increase?
Decrease fiber - The nurse should instruct the client who has Chron's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation In crease caloric intake to at least 3000 cal per day to promote healing of the fistula, increase protein intake to promote healing, increase dietary potassium due to the risk of hypokalemia
A nurse is caring for a client who has a prescription for chlorpromazine. What finding should the nurse identify as an indication that the medication is effective?
Decreased hallucinations
A nurse is updating the plan of care for a client who is 48 hours postoperative following a laryngectomy and is unable to speak. What action should the nurse plan to take?
Determine the client's reading skills -The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost
A nurse is performing an admission assessment for a client who is in the manic phase of bipolar disorder. What behaviors should the nurse expect?
Distractibility and poor judgement
A nurse manager is updating protocols for the urse of belt restraints. Which of the following guidelines should the nurse include?
Document the client's condition every 15 minutes
Cataracts
Double vision
A nurse is preparing to administer an IV medication to a client and accidentally punctures the IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handline of a hazardous material spill?
Doxorubicin hydrochloride (chemo drug)
Xerpstomia
Dry Mouth (Not autoimmune itself, but component of Sjogren Syndrome)
A nurse is teaching a client who is to have external beam radiation therapy. Which of the following instructions should the nurse include?
Dry the affected area in a patting motion after washing. -Gently wash the area each day, then us a patting motion to dry it, rather than rubbing, to reduce the risk of irritation - Instruct the client to use their hand rather than a washcloth when cleaning the affected area to reduce the risk of injury - Instruct the client to avoid sun exposure to the affected area to reduce the risk of injury. The client should wear clothing to cover the affected area and remain in the shade when possible - Instruct the client to only use some creams that are prescribed by the provider to reduce the risk for irritation or injury to the affected area
When is pushing during labor indicated?
During the second stage of labor once the client reaches full cervical dilation, which is 10 cm
A nurse is teaching self-admin of insulin glargine to a client that has type 1 diabetes mellitus. What statement by the client indicates an understanding of mixing insulins?
I will not mix this insulin with other types of insulin
A nurse provides care for a client who was just admitted to the emergency department reporting chest pain. Which of the following diagnostic tests should the nurse provide?
Electrocardiogram -An ECG is one of the first diagnostic tests performed for the client experiencing chest pain because it is a fast, noninvasive test to provide immediate information. The ECG graphically shows cardiac electrical activity and cardiac ischemia
A nurse is assessing a client who is receivign IV levofloxacin through a peripheral catheter. The nurse notes edema, skin blanching, and tightness around the client's IV site. Which of the following actions should the nurse take?
Elevate the affected extremity after discontinuing the IV - the nurse should identify that the client's IV infiltrated and should stop the infusion, remove the IV, and elevate the client's affected extremity to decrease edema.
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?
Elevated central venous pressure - The nurse should expect a client who has right-sided heart failure to have an elevated central venous pressure due to right ventricular failure. Central venous pressure is the pressure in the vena cava, near the hear atrium of the heart, which reflects the amount of blood returning to the heart.
What do late or variable decelerations indicate for nursing interventions?
Emergency caesarean birth
A nurse is teaching the parent of a child who has a new onset of seizures and is to undergo an EEG about the procedure. What instructions should the nurse include in the teaching regarding the child's hair
Ensure the child's hair is clean and without conditioner before the procedure
A home health nurse is caring for a child who has Lyme disease. What does the nurse have to do?
Ensure the state health department has been notified
A nurse is caring for a client who has permanent drooping on the left side of the face following a cerebrovascular accident (CVA). The client refuses to see any family members. Which of the followign interventions will best assist the client to adapt to this body imagine change?
Establish short-term goals that will enable the client to look in a mirror
How often should the scopolamine patch be replaced?
Every 72 hours
A nurse is caring for a 3 day old newborn who has a congenital heart defect. What intervention should the nurse include to decrease cardiac demand for the newborn regarding feedings
Feed the infant when she is awake and crying
A nurse is administering medication to a client who has a percutaneous gastrostomy tube for enteral feedings. How should the nurse prevent clogging of the tube?
Flush the client's gastrostomy tube with 30 mL of water before and after administering the medications -this will clear the tube of any residuals and ensures patency -Crush each medication separately from the tube feeding formula and administer them separately -Change the feeding bag every 72 hours: this prevents clogging, and reduces the risk of infection
After obtaining a blood specimen from a client's peripherally inserted central catheter (PICC), which of the following actions should the nurse take next?
Flush with 20 mL 0.9% sodium chloride.
Sickle Cell disease
Genetic disorder in which red blood cells have abnormal hemoglobin molecules and take on an abnormal shape.
A nurse in an acute care mental health facility is placing a client in seclusion and restraints. What action should the nurse plan to take in regards to the provider?
Have the provider evaluate the client IN PERSON within one hour
a nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a cerebrovascular accident. Which of the following actions by the nurse best promotes communication among staff caring for the client
Having interdisciplinary team meetings for the client on a regular basis
A nurse in an emergency departmnt is reviewing the medical record of a client who is having an acute MI. Which of the following findings places the client at risk if he receives alteplase?
Hip arthroplasty 1 week ago (more bleeding)
A nurse is reviewing the medical record of a client who has a prescription for liraglutide. Which of the following findings should the nurse identify as a contraindication to this medication?
History of thyroid cancer - The nurse should identify a personal or family history of thyroid cancer as a contraindication to taking liraglutide and notify the provider. Other contraindications to receiving this medication can include type 1 diabetes mellitus, diabetic ketoacidosis, and a history of suicidal thoughts or attempts.
An occupational health nurse is preparing to teach a class on prevention of back injuries to a group of workers in a factory setting Which of the following interventions should the nurse include in the teaching?
Hold the object lifted close to the body.
A nurse is caring for a client with Addison's disease who has been admitted with muscle weakness, dehydration, and nausea and vomiting for the past 2 days. What medication should the nurse plan to administer?
Hydrocortisone -this will assist with replacing cortisol levels.
Complications of Obstructive Sleep Apnea
Hypertension, heart failure, cardiac dysrhythmias, decreased O2, urinary retention
A nurse is obtaining vital signs for a client and notes muscular twitching of the wrist and fingers when inflating the blood pressure cuff
Hypocalcemia - a positive Trousseau's sign is an indication of hypocalcemia and is assessed by inflating a blood pressure cuff on the upper arm. Spasms of the hand and fingers when the blood pressure cuff is inflated indicate a positive Trousseau's sign. Manifestations of hypocalcemia can include muscle twitching, tingling, and numbness, which can lead to tetany. -manifestations of Hypophosphatemia can include muscle pain and weakness, which can affect respiratory muscles and cause impaired ventilation -manifestations of hypokalemia can include muscle weakness, orthostatic hypotension, and dysrhythmias -manifestations of hyponatremia can include altered mental status, muscle cramping, seizures, and confusion
A nurse is assessing a client who is receiving hemodialysis. Which of the following findings is the nurse's priority to report to the provider?
Hypotension
Fundus after birth
Immediately after birth, the fundus should be firm, midline with the umbilicus, and approximately 2 cm below the level of the umbilicus. Every 24 hours the fundus should be descended approximately 1-2 cm. It should be halfway between the symphysis pubis and the umbilicus by 6 days of postpartum
Glycogen is stored where
In the liver and is released in the form of glucose to meet the body's energy needs
Bronchitis
Inflammation and hypersecretion of mucus in the bronchi and bronchioles caused by chronic exposure to irritants
Kawasaki disease
Inflammation of in the walls of some blood vessels in the body signs include rash and fever, peeling of skin IVIG High-dose aspirin live vaccines must be pushed off keep a record of the child's temp until they have no fever for several days will be irritable for up to two months
A nurse is caring for a client in an inpatient facility who tells the nurse that she is leaving because the facility prohibits smoking inside. Which of the following actions should the nurse take?
Inform the client of the risks involved if she leaves AMA
A nurse is providing discharge instruction to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?
Install a raised toiler seat at home -this minimizes hip flexion and prevents hip dislocation -The client should maintain the hip at an angle less than 90 when sitting to minimize hip flexion and prevent hip dislocation -The client should use a walker -Instruct the client to not use pillows under the knees when lying down. This can impede circulation and result in flexion contractures
What adverse effect shoudl tyhe nurse instruct a client who is taking nifedipine for gestational hypertension to report to the provider?
Irregular heartbeat -Cardiac arrhymia is a potential life-threatening adverse effect of nifedipine.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. What action should the nurse take?
Irrigate the catheter with 0.9% sodium chloride irrigation -decreased urinary output and bladder spasms indicate internal obstruction of the catheter. Therefore, the nurse should irrigate the cath with 0.9% sodium chloride and notify the provider if the obstruction does not clear. Avoid increasing tension on the urinary catheter - this can cause bladder irritation, bleeding, and subsequent catheter blockage, and can ultimately lead to urinary retention Keep the client in bed - the findings indicate an internal obstruction Removing the catheter can cause further harm
A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placement of a ventriculoperitoneal (VP) shunt. What finding should the nurse report to the provider?
Irritability when being held -the nurse should recognize irritability is a manifestation of increased intracranial pressure, which is an indication that the VP shunt is malfunctioning.
When is ambulation indicated during labor?
It is indicated for management of hypotonic uterine dysfunction
When is oxytocin indicated during labor?
It is indicated for management of hypotonic uterine dysfunction
A nurse provides care for a client who has a Jackson-Pratt (JP) drain. Which of the following actions will ensure proper function?
Keep bulb compressed -A JP drain is an evacuator unit that exerts constant low pressure as long as the bulb of the device is fully compressed
What is effleurage?
Lightly stroking the abdomen during a contraction. This is a technique used for pain management during labor.
in order to promote intake for a client who has COPD with severe dyspnea, what should the nurse include in the plan of care?
Limit fluid intake with meals
Clients who take valproic acid are at risk for what
Liver damage
Tizanidine can cause what
Liver damage. This medication should be used with extreme caution in a client who has a preexisting impairment of hepatic function
A nurse is caring for a client who has been taking acarbose for type 2 diabetes mellitus. Which of the following lab tests should the nurse plan to monitor?
Liver function test
What lab values should a nurse monitor for a client who is takign Valproic acid
Liver function tests (AST ALT) -valproic acid can cause severe hepatotoxicity and liver failure
Does a nurse have to document whether or not a client has prepared his or her advance directives?
yes
A nurse is administering cylcophosphamide orally to a school-age child who has neuroblastoma. Which of the following actions should the nurse take when administering this medication?
Maintain hydration with liberal fluid intake -this maintains hydration and prevents hemorrhagic cystitis, which is an adverse effect of this medication -administer an antiemetic 30 min prior to medication administration
Creatinine clearance levels
Male: above 107 mL/min Woman: above 87 mL/min
A nurse is providing palliative care to a client who has cancer. Besides helping to relieve pain, which of the following interventions will improve circulation?
Massage therapy
Indomethacin
May be used as tocolytic for preterm labor or for oxytocin induced tachysystole prostaglandin synthetase inhibitor
Refeeding Syndrome
Metabolic Disturbance that occurs due to the reinstitution of nutrition to person or animals who are starved -fatigue, weakness, confusion, inability to breath, high blood pressure, arrhythmias, seizures, heart failure
A nurse is caring for a client who has a soft uterus and increased lochial flow. What medication should the nurse plan to administer to promote uterine contractions?
Methylergonovine
Post Amniocentesis care
Monitor FHR, fetal activity Assess for sign of labor (risk with amniocentesis) Assess for vaginal bleeding or hemorrhage Administer RhoGAM for clients who are Rh negative
Nursing interventions for Methylergonovine maleate (methergine)
Monitor bleeding and uterine tone Obtain baseline blood pressure Massage fundus Administer 0.2 mg IM or PO as prescribed
Nursing interventions for Magnesium Sulfate administration for preterm labor
Monitor contractions and FHR Monitor fetal movement and FHR variability Monitor vital signs and urine output
Nursing interventions for oxytocin
Monitor contractions and FHR Monitor vital signs Administer IV infusion pump through secondary line Stop immediately for late decels or tachysystole (hyperstimulation) Have tocolytic (such as terbutaline) immediately available for tachysystole
Nursing interventions for Indomethacin administration
Monitor contractions and FHR Monitor vital signs: note that indomethacin can mask maternal fever Administer with food as to limit GI distress Only administer if gestational age is LESS THAN 32 WEEKS
Nursing interventions for terbutaline administration
Monitor for contractions and FHR Monitor vital signs Administer terbutaline subcutaneous 0.25 mg every 20 min as needed Monitor for adverse effects Do not administer if client reports chest pain Notify provider if blood pressure is less than 90/60, pulse is greater than 130, signs of pulmonary edema, FHR greater than 180 Administer Beta Blocking agent as antidote
Nursing interventions for Naloxone administration
Monitor respiratory effort Do not administer if mother is opioid-dependent Newborn: administer 0.1mg/kg IV, IM, SQ, ET tube Adult: administer 0.4 to 2 mg IV, may repeat IV at 2-3 minute intervals up to 10 mg, can also admin IM or SQ
A nurse is caring for a client who has immunosuppression and a continuous IV infusion. What actions should the nurse take?
Monitor the client's IV site for manifestations of an infection every 4 hours Monitor the WBC count every 24 hours Monitor the client's mouth every 8 hours for manifestation of an infection, such as sores and lesions Change the IV tubing every 24 hours
A nurse is planning care for a client who is experiencing the Somogyi effect and takes intermittent-acting insulin. Which of the following actions should the nurse include in the plan?
Monitor the client's nighttime blood glucose levels -monitoring the client's nighttime blood levels over time can provide an accurate diagnosis of this effect -The nurse should plan to administer a smaller dose of intermediate-acting insulin at bedtime or increase the client's bedtime snacks to avoid conditions that can lead to the effect -The nurse should evaluate the client's evening caloric intake based on the insulin dose and exercise programs during the day to avoid conditions that could lead to the effect
Nursing interventions for magnesium sulfate administration for preeclampsia
Monitor vital signs, urine output, DTRs, and LOC Monitor magnesium levels (therapeutic range 4-8) Administer via infusion pump in dilated form Use indwelling catheter to monitor urinary elimination Stop immediately if: resp rate goes below 12, altered LOC, magnesium level is 10 mEq/L or 9 mg/dL Administer calcium gluconate 1g/10 mL in 10% solution at 0.5-1 mL/min for signs of toxicity Observe neonate for signs of respiratory depression, hypotonia, lethargy, and hypocalcemia Contraindicated in women who has myasthenia gravis
care and maintenance of TPN
Monitor weight daily Monitor and record I and O, note fluid balance Monitor serum glucose levels every 4-6 hours Monitor for signs of infection Change dressing every 48-72 hours Change IV tubing and fluid every 24 hours
Tizanidine (Zanaflex)
Muscle Relaxant
A nurse is monitoring a client who has a prescription for ciprofloxacin 400 mg IV every 12 hr. Which of the following manifestations should the nurse identify as an adverse effect of this medication?
Myalgia - The nurse should identify that myalgia is an adverse effect of ciprofloxacin and can be an indication that the client might be experiencing tendonitis, which could lead to tendon rupture. Other adverse effects can include dizziness, agitation, and confusion.
Medications to not take while on Warfarin
NSAIDS Vitamin K Calcium Gingko Biloba
Lumbar spinal surgery drainage amount in the first 24 hours
No more than 250 mL -risk for fluid volume deficit if higher
Elevate leg with dvt when sitting
yes
A nurse is caring for a client following a thoracentesis. Which of the following actions should the nurse take?
Obtain a prescription for a chest x-ray. - the nurse should obtain a prescription for a chest x-ray to assess the client for a pneumothorax or a mediastinal shift, which can occur if the lung is punctured during the thoracentesis. -encourage the client to breath deeply to promote lung expansion -The nurse should apply a dressing to the puncture site and monitor it for leakage or bleeding -Position the client on the unaffected side for 1 hour to promote healing of the pleural puncture site
Occurrence Report
Occurrence report is created for unexpected or unused events not consistent with the operations of a client -can include events affecting: client, employee, visitor, volunteer
A nurse is caring for a client who is nulliparous and experiencing hypertonic uterine dysfunction. An assessment indicates 3 cm dilation. Which of the following actions should the nurse take?
Offer the client hydrotherapy -therapeutic rest measures should be initiated for a client who has hypertonic uterine dysfunction. -therapeutic rest can include hydrotherapy and analgesia to relieve pain. Decreasing the uterine contractions and helping the client relax and sleep will help prevent early exhaustion
How many scopolamine patches can be applied at a time?
One. If this is ineffective the patient should contact the provider
What does orthopnea at night indicate
Orthopnea, or difficulty breathing when lying flat, is a manifestation of left-sided heart failure due to pulmonary congestion.
An increased intake of phosphate-containing foods, such as carbonated beverages, a lack of time outdoors in sunlight, and decreased estrogen or testosterone are risk factors for what disease?
Osteoporosis
ACE Inhibitors
PRIL Antihypertensive Monitor potassium levels, use with caution with diuretic therapy, do not use in 2nd or 3rd trimester adverse/side effects: persistent, nonproductive cough angioedema(painless swelling under the skin, common in face), hypotension: admin epinephrine 0.5 of 1:1000 sub q
An increase in Amylase is indicative of what?
Pancreatitis, cholecystitis, or renal failure
What does a bruit indicate in an extremity with an AV
Patency
What does a thrill upon fistula palpation indicate
Patency
A nurse is caring for a client who has a newly placed endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take?
Perform mouth care once every 2 hours -Reduces the risk of ventilator-associated pneumonia -Sometimes there will be a prescription for soft mittens so the patient does not pull the tube out -Check respirations at least once every 4 hours for the first 24 hours and then as needed thereafter -do not empty the moisture from the ventilator tubing into the cascade because this can lead to bacterial growth and increases the risk for the client to develop ventilator-associated pneumonia.
abruptio placentae
Persistent uterine contractions Board-like abdomen Dark red vaginal bleeding
A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan?
Place a pillow between the client's legs - this reduces the risk of hip dislocation -Position the client with her legs abducted to reduce the risk of hip dislocation -Avoid internal rotation of the client's affected hip to reduce the risk of hip dislocation -Avoid flexing her hip more than 90 degrees to reduce the risk of hip dislocation
A home health nurse is planning care for a client who has Alzheimer's disease. What should the nurse include in the plan of care regarding locks?
Place locks at the tops of exterior doors
A nurse obtaining blood pressure from a lower extremity would do what
Place the bladder of the cuff over the posterior aspect of the thigh
Is informed consent required prior to PICC placement?
yes
A nurse is providing colostomy care for a client using a two-piece oouching system. Which of the following actions should the nurse take?
Place the skin barrier over the stoma and hold it for 30 seconds -this activates the adhesive in the skin barrier
A charge nurse is discussing care of clients who are in labor with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching regarding situations requiring an amniotomy?
Placing a fetal scalp electrode - a fetal scalp electrode is attached to the presenting part of the fetus in order to provide accurate continuous monitoring of the fetal heart rate. If the client's membranes are intact, the amniotic sac must be artificially ruptured prior to attaching the electrode to enable access to the presenting part
Atherosclerosis
Plaque build-up in artery wall
A nurse is caring for a client who has an intra-arterial blood pressure monitor. Which of the following actions should the nurse take?
Position the transducer's stopcock at the level of the atrium -The nurse should position the transducer's stopcock on the pressure monitoring system at the level of the client's atrium to maintain accurate blood pressure readings. -Maintain the pressure bag around the flush solution at 300 to reduce the backflow of blood into the system and minimize the risk of clotting -Ensure that the flush system delivers 3-5 mL of solution per hour to reduce the backflow of blood into the system and minimize the risk of clotting -Administer 0.9% sodium chloride through the flush system to reduce the backflow of blood into the system and minimize the risk of clotting
A nurse on a telemetry unit is reviewing the medical record of a client who is taking digoxin. For which of the following findings should the nurse withhold the medication and notify the provider?
Potassium 3.1 - A potassium level of 3.1 is below the expected reference range of 3.5-5. The nurse should identify that hypokalemia increases the sensitivity of cardiac muscle to digoxin and can increase the risk of dig tox -The nurse identify that a digoxin level of 1.5 is within the expected reference range of 0.8-2. Toxic digoxin levels are greater than 2.4 and can result in bradycardia and ventricular dysrhythmias
The nurse should administer magnesium sulfate to pregnant patient who has
Preeclampsia -this will lower the blood pressure and minimize the risk for seizures
A nurse is reviewing the medical record of an older adult client as a part of a fall risk assessment. Which of the following client conditions should the nurse identify as increasing risk for falls?
Presbyopia (near sightedness)
What is the main cause of ascites?
Pressure builds up in the veins of the liver and it doesn't work as it should. The pressure blocks the blood flow in the liver
Betamethasone
Preterm labor (24-32 weeks) - Prevent or reduce neonatal respiratory distress syndrome in preterm infants -Stimulates production or release of lung surfactant in preterm fetus
Medications for cardiac disease or heart failure during pregnancy
Propranolol: beta blocker, used to treat tachyarrhythmias and to lower maternal blood pressure Ampicillin antibiotic: prophylaxis given to prevent endocarditis Heparin sodium: anticoagulant used in treating clients with pulmonary embolus, dvt, prosthetic valves, cyanotic heart defects, rheumatic heart disease Digoxin: cardiac glycoside; used to increase cardiac output during pregnancy, and may be prescribed if fetal tachycardia is present
chemical methods to soften the cervix
Prostaglandin E2 -placed transvaginally near cervix -client must remain supine with wedge or in side-lying position for 30 min after insertion of gel -delay pitocin use for 6-12 hours after last gel insertion Prostaglandin E1 -administered intravaginally or PO tabs
A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Protein -due to increased glomerular permeability, protein is allowed to filter through into the urine. -this is a group of diseases that injure the part of the kidney that filters blood.
Urinalysis of glomerulonephritis
Protein -increased glomerular permeability which allows protein to filler into the urine
What does an elevated pulmonary artery wedge pressure mean
Pulmonary pressure increases in left-sided heart failure because of the increased pressure and volume of blood in the left ventricle
A client who is prone to uric acid calculi should avoid eating foods containing what?
Purine
A client who is prone to uric acid calculi should avoid what?
Purine: organ meats, chicken, red wines, red meats
A client who has Cushing's disease will have what kind of skin appearance?
Purple striae on the chest and abdomen
When preparing to initiate IV access for an older adult client, what site should the nurse select?
Radial vein of the inner arm -this site will have adequate subcutaneous tissue
A nurse in a provider's office is caring for an 18-month-old toddler who has a blood lead level of 3 mcg/dL. What actions should the nurse take?
Recommend rescreening in 1 year -the nurse should identify a blood level of 3 mcg/dL is within the expected reference range. The nurse should recommend rescreening in 1 year
Ulcerative Colitis
Recurrent ulcerative and inflammatory disease of the superficial mucosa of the colon contiguous (touching) ulcers left lower q pain liquid and bloody stools (10-20 a day) fever, high pitched bowel sounds, rebound tenderness-perforation, passage of mucus and pus from the bowel
action for fraying on the electrical cord of a CPM
Remove the device from the room
A nurse is caring for a client who has undergone a modified radical mastectomy. The client has a closed-suction drain. What action should the nurse take in regards to resetting the vacuum
Rest the vacuum by compressing the container
The client can experience pain where after a laparoscopic cholecystectomy
Right shoulder -the client can experience pain in the right upper shoulder due to gas (Carbon dioxide) being injected into the abdominal cavity during the lap procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1-2 days. Mild analgesics and a recumbent (lateral lying) position can promote client comfort
A suspension medication must be what prior to admin?
Shaken well
What should the nurse do if a client who is receiving intermittent enteral feedings starts to develop diarrhea?
Slow the infusion rate
A nurse provides care for a client who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory values would be expected? (Select all that apply)
Sodium 128 Urine specific gravity 1.035 -Clients who have SIADH RETAIN fluid. This results in the dilutional hyponatremia and increased urine specific gravity.
A nurse is providing teaching for a client who has a new prescription for metformin. Which of the following findings should the nurse instruct the client to report as an adverse effect of metformin?
Somnolence -can indicate lactic acidosis, which is manifested by extreme drowsiness hyperventilation, and muscle pain. It is a rare but very serious adverse effect caused by metformin and should be reported to the provider
Expected findings in autonomic dysreflexia
Spots in the visual field blurred vision nasal congestion severe headache facial flushing
Methylergonovine maleate (Methergine)
Stimulate uterine contractions after delivery Treat postpartum hemorrhage
A nurse is caring for a client who is receiving the first dose of IV ampicillin and develops a rash and flushed skin and begins wheezing. Which of the following actions should the nurse take first?
Stop the infusion - the first action the nurse should take when using the airway, breathing, and circulation approach to client care is to stop the infusion. However, the nurse should keep the IV open and infuse 0.9% sodium chloride until epinephrine is available to administer. -The nurse should notify the rapid response team to prepare to intubate the client if needed; however, there is another action -The nurse should give oxygen via a nonrebreather facemask to a client experiencing anaphylaxis due to their inability to breathe and risk for hypoxemia. However, there is another action the nurse should take -The nurse should prepare to admin epinephrine IV or IM to treat the client who is experiencing anaphylaxis to promote vasoconstriction and reduce capillary permeability
The most accurate indication of organ perfusion is what
The client's urine output
Rubella teaching for client postpartum client
You can still breastfeed You should refraim from gtting pregnant for 4-12 weeks after receiving the immunization You will be checked for immunity if you become pregnant again
can an AP measure oral intake?
yes
can an AP provide postmortem care?
yes
A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?
The fluid in the collection chamber is draining at 75 mL/hr - an increase in drainage greater than 70 mL/he is an indication that client might be bleeding. The nurse should report this finding to the provider -Gentle continuous bubbling in the suction chamber indicates that the suction is working as intended -The nurse should keep at least 2 cm of water in the water seal chamber to reduce the risk of air flowing into the client's chest
How should the nurse dry the skin around the stoma and when
The nurse should dry the skin around the stoma using a patting motion The nurse should do this prior to applying the barrier to ensure the pouch adheres to the skin
A parish nurse is leading a support group for clients whose family members have committed suicide. How should the nurse initiate a discussion?
The nurse should initiate a discussion with clients about ways to cope with changes in family dynamics
A client is having left sided weakness following a stroke. Why should th nurse support the client's left arm on a pillow while sitting?
The nurse should support the client's affected arm to prevent the extremity from hanging freely because this can cause shoulder subluxation
A nurse is performing gastric lavage for a client who has GI bleeding and an NG tube in place. What action should the nurse take?
The nurse should use 0.9% sodium chloride, sterile water, or tap water for irrigation of the client's NG tube -The nurse should use lavage solution that is at room temperature to reduce the risk of injury to the client -After installing the lavage solution, the nurse should manually withdraw the solution and blood from the client's NG tube -The nurse should instill the solution in volumes of 200-300 mL at a time to reduce injury
A nurse provides end-of-life care to a client of Chinese heritage. What does this heritage practice following a death?
The oldest child will bathe the body
Pneumothorax
The presence of air or gas in the pleural cavity -tracheal deviation
Hemothorax
The presence of blood in the pleural cavity
A nurse is assessing a client following abdominal surgery. What should the nurse report to the provider regarding output?
Urine output less than 30 mL/hour
A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. What instruction should the nurse include?
Use a three-point gait -a three point gait allows the clients to be mobile without bearing weight on the affected extremity A health care provider will initially measure crutches for the client. Clients should not perform their own adjustments to the crutches. When walking upstairs, the client should advance the unaffected leg first. When walking downstairs, the client should advance the crutches and the affected leg first and then follow with the unaffected leg
Biophysical profile
Uses real-time ultrasound to visualize physiological characteristics of the fetus
A newly licensed nurse working at an HIV clinic is reviewing the responsibilities of her position at the clinic. Which of the following tasks should the nurse identify as tertiary prevention
Using an electronic messaging system to remind clients when to take medication
What nutrient helps promote the functioning of the nervous system
Vitamin B1
A nurse is caring for a client who has a large wound by secondary intention. The nurse should inform the client that what nutrient (in addition to protein) promotes wound healing?
Vitamin C
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. What should the nurse respond?
We can provide a copy of your records, but the therapists notes are not included
What is an expected finding for an infant who has coarctation of the aorta?
Weak femoral pulses
hypotonic uterine dysfunction
Weak, ineffective uterine contractions usually occurring in the active phase of labor; often related to cephalopelvic disproportion or malposition of the fetus; secondary uterine inertia
A nurse is teaching a female client who has recurrent urinary tract infections. Which of the following instructions should the nurse include?
Wear loose fitting cotton underwear -Drink 2000-3000 mL of fluid each day to reduce the risk of urinary tract infections
Can an Ap provide gastrostomy feedings through a clients already established gastrostomy tube?
Yes
Can tachysystol cause fetal distress?
Yes, initial intervention would to reposition patient to side lying and monitor for an additional 10 minutes to see if it resolves
A mental health nurse is caring for a client who recently states, "I wish I was dead." following a suicide attempt. What response by the nurse is appropriate
You seem like you're feeling hopeless
A nurse is conducting visual acuity testing using the Snellen letter chart for a school-age child who has eyeglasses. Which of the following instructions should the nurse give to the child?
You should keep both eyes open during the test Leave your glasses on during the exam Instruct the child stand 10 feet away from the chart during testing In order to pass a line, the child should identify four to six symbols correctly
A nurse is teaching a client who is at 41 weeks gestation about a nonstress test. What information should the nurse include in the teaching regarding what will be attached to her?
You will have a Doppler transducer applied to your abdomen during the test
A nurse is providing teaching to a client who is receiving misoprostol for induction of labor. What information should the nurse include in the teaching regarding position post admin
You will lie on your side for 30 minutes after the medication is inserted
A nurse is providing client teaching about the basal body temperature method of birth control. What information should the nurse include?
Your body temp might decrease slightly just prior to ovulation Body temp rises about 0.7-1.4 degrees after ovulation. The temp remains elevated until 2-4 days prior to the start of menstruation You should measure your body temp upon waking up each morning prior to getting out of bed
a nurse is caring for a client who asks for information regarding organ donation. What should the nurse respond?
Your desire to be an organ donor must be documented in writing
How long does it take for amitriptyline to take effect
a couple of weeks
What must all implanted ports be accessed with
a non coring needle
intravenous pyelogram
a radiographic study of the kidneys and ureters
laporoscopic cholecystectomy
a surgery to remove your gallbladder
what kind of medication is alteplase
a thrombolytic medication
umbilical cord
a tube containing the blood vessels connecting the fetus and placenta -2 arteries carrying deoxygenated blood to the placenta -1 vein carrying oxygenated blood to the baby
Paternalism
a type of relationship between clients and health care providers in which the health care providers believe they know what is best for the clients.
A nurse explains what to expect during a thoracentesis. Which client statement validates teaching was effective? a. "I need to be still during the procedure." b. "It will be difficult to swallow for a few hours." c. "A cough may develop during aspiration of fluid." d. "My breathing may be labored for several minutes."
a.
A nurse provides care to a client who has a fracture femur after falling from a ladder. Which of the following actions may reduce the incidence of fat emboli? a. immobilize the extremity b. provide supplemental oxygen c. maintain a semi-fowlers position d. administer sub q hep
a. -Immediate immobilization of the fracture in addition to early surgical fixation may reduce the incidence of fat embolism
A nurse plans care for a client who requires continuous ambulatory peritoneal dialysis. Which of the following actions is appropriate? (Select all that apply) a. Notify provider of cloudy or opaque effluent b. Prepare client for exchange of two our three times weekly c. Apply mask to client during system connect and disconnect d. Require client to remain in reclining position during exchange e. Warm dialysis bag by applying heating pad prior to installation
a. c. e. - cloudy or opaque effluent can be indicative of an infection. peritonitis is the major cause for discontinuous - Surgical asepsis (sterile technique) is employed during connection and disconnection. Infection is the most common complication - The dialysis should be warmed by wrapping a heating pad around the solution
A nurse assess a client who has Guillain Barre syndrome. Which of the following findings would be expected for this client? select all that apply a. Diplopia b. paresthesias c. thrombocytopenia d. rebound tenderness e. hyperactive reflexes
a. b.
A nurse provides care to client who is admitted for sepsis. Which of the following circumstances requires an occurence report? Select all that apply a. Eye glasses are lost b. Visitor falls in hallway c. Syncopal episode occurs d. Oxygen therapy is refused e. Blood cultures are positive
a. b.
A nurse prepares to perform a dressing change. Which of the following identifiers should the nurse use to ensure client safety? Select all that apply a. Name b. Birthdate c. Phone number d. Facility armband e. Photo identification f. Hospital room number
a. b. c. d. e.
parasthesia
abnormal sensation such as numbness, burning and tingling
A nurse plans care for a client who has a serum potassium of 7. Which of the following actions should be implemented? a. Place on a cardiac monitor b. Obtain a serum creatinine level c. Infuse 100 mL of 10% glucose IV d. Begin IV infusion of regular insulin e. Administer sodium polystyrene f. Initiate 0.33% sodium chloride IV fluid bolus
a. b. c. d. e. f. - cardiac monitoring is crucial with patients with hyperkalemia. Potassium maintains resting membrane potential of cardiac muscle. Hyperkalemia cab cause life-threatening dysrhythmias and cardiac arrest. -Serum creatinine levels should be evaluated in clients with hyperkalemia. Elevated serum creatinine can be an indication of renal function, a major cause of hyperkalemia. -Glucose is required to prevent hypoglycemia caused by insulin therapy. IV regular insulin is typically infused with severe hyperkalemia. -Sodium polystyrene sulfonate may be given for hyperkalemia. Sodium polystyrene sulfonate binds with the potassium for excretion.
A nurse cares for a client who is receiving mechanical ventilation, and the high-pressure alarm sounds. Which of the following conditions can cause this to occur? select al that apply a. coughing b. kinked tubing c. bronchospasm d. tube is disconnected e. occluded ET tube
a. b. c. e. -The high pressure alarm will sound when there is an increased resistance to the delivery of breath. This increased resistance can occur if the client coughs or "fights" the vent. Additional causes include kinks in the tube (from biting), client experiencing a bronchospasm, and if the ETT becomes plugged with mucus
A nurse is assessing a client who has acute pyelonephritis. Which of the following findings would be expected? select all that apply. a. fever b. flank pain c. tachycardia d. cough and dyspnea e. nausea and vomiting
a. b. c. e. -fever and chills are manifestation of pyelonephritis related to inflammation responses. -Flank and back pain are manifestations related to inflammation and infection. -Tachycardia and tachypnea are manifestations related to fever and/or pain. -Nausea and vomiting are manifestations related to infectious process
A school nurse teaches a course about health and safety for 11-year-old students. Which of the following topics would be appropriate for this class? Select all that apply a. Activity and exercise b. STIs and pregnancy c. Alcohol and drug use d. Memory and cognition e. Peer pressure and violence f. Eating disorders and nutirtion
a. b. c. e. f.
A client who has liver failure is scheduled for a paracentesis. Which of the following actions should the nurse implement prior to the procedure? Select all that apply a. Instruct client to void b. insert NG tube c. elevate head of bed d. measure abdominal girth e. obtain informed consent
a. c. d. e. -a distended bladder would increase the risk of an unintended puncture of the bladder. Excessive ascetic fluid may cause ineffective lung expansion and dyspnea -HOB should be elevated to at least 30 degrees. During the procedure, the client sits on the edge of the bed or in a chair -Abdominal girth is a good indicator of the degree of ascites. The girth should decrease significantly after the procedure. To measure the girth, the client lays flat and is measured around the umbilicus are at the end of exhalation -A paracentesis is an invasive procedure and requires informed consent
A nurse provides teaching to a client regarding the use of a hearing aid. Which of the following information is needed? Select all that apply a. "Avoid hairspray while wearing the aid." b. "A whistling sound indicates proper fit." c. "The hearing aid can be worn continuously." d. "Batteries should be removed when not in use." e. "Follow-up with an audiologist is recommended."
a. d. e.
A nurse reviews client room assignments. Which of the following infectious disease requires droplet precautions? Select all that apply a. Mumps b. Measles c. Varicella d. Pertussis e. Pneumonia
a. d. e.
A client had a modified radical mastectomy yesterday. Which of the following actions should the nurse implement to prevent transient edema of the affected arm? Select all that apply a. Elevate arm on pillow. b. Administer furosemide. c. Apply heating pad to site. d. Milk drainage device tubing. e. Encourage gentle arm exercises
a. e. -The arm on the affected side should be elevated above the level of the heart. A modified radical mastectomy involves removal of a portion of the axillary lymph nodes, which can cause transient edema. This usually resolved when collateral circulation is established, which generally occurs within a month. -Gentle muscle pumping exercises (such as making a fist and releasing) can help decrease postoperative edema by causing muscle contraction, which improves circulation. This is usually started on the first postoperative day and exercises gradually increase to improve circulation and range of motion.
A nurse in the emergency departmnt is caring for a client who has a new diagnosis of acute myocardial infarction and is being treated with thrombolytic, aspirin, and IV heparin. What finding should indicate to the nurse that the client is experiencing a satisfactory response to those interventions?
aPTT is two times the control
Manifestations of ovarian cancer
abdominal bloating increase in abdominal girth pelvic or abdominal pain early satiety urinary frequency or urgency
ascites
abnormal accumulation of fluid in the abdomen
preeclampsia
abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria, edema, hyperactive deep tendon reflexes, and headache
Magnesium sulfate toxicity
absent deep tendon reflexes, slurred speech, decreased perfusion to organs and tissues causing oliguria, respiratory depression, blurred vision, decreased consciousness, and cardiac dysrhythmias and arrest
A nurse is teaching the parents of a 6 year old child who has sickle cell anemia about managing the disease. The nurse should emphasize the importance of what factor in the prevention of sickle cell crisis?
adequate hydration
If TPN is unavailabl
admin dextrose 10% in water to prevent hypoglycemia
A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?
administering potassium via IV bolus
When should you discard any unused amoxicillin?
after 14 days
Emphysema
air sacs in the lungs (alveoli) are damaged -over time the inner walls weaken and rupture -narrowing of bronchioles -trapping air resulting in loss of elasticity, presents as barrel chest -shortness of breath, put in high fowlers
contraindication for iodine or contrast agents
allergy to shellfish
Presumptive signs of pregnancy
amenorrhea, nausea, breast tenderness, deepening pigmentation, urinary frequency, quickening
Before 32 weeks gestation, FHR acceleration is defined as what
an increase of at least 10 beats/min lasting at least 10 seconds
chorioamnionitis
an infection caused by bacteria ascending from the vagina into the uterus
MAOI's
antidepressant -avoid foods high in tyramine: smoked meat, cheeses, ripe avocado
Medications for hyperemesis gravidarium
antiemetics such as ondansetron Vitamin B6, no more than 100 mg daily used solo or in combination with doxylamine
A nurse is caring for a client who repeatedly refuses meals. The nurs overhears an ap telling the client "if you don't eat, i'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitues what tort
assault
Inability to count backward indicates an
attention span defecit
Positive signs of pregnancy
audible fetal heartbeat, fetal movement felt by examiner, ultrasound visualization of fetus
Nutrition during pregnancy
average weight gain 25-35 pounds caloric increase 300-400kcal/day protein increase by 25 g/day iron intake 30 mg/day folate intake 600 mcg/day limit caffeine intake
Diverticular diet
avoid laxatives, morphine is contraindicated
A home care nurse is making a follow-up visit with a client who has COPD and is using a compressed oxygen system at home. What action should the nurse take in regards to where to set the oxygen
away from curtains or drapes
A nurse prepares for the admission of a client who has temps of 34 (93). Which of the following rewarming methods should be implemented? a. infuse warm IV fluids b. Apply a heating blanket c. Offer sips of warm coffee d. Administer heated oxygen
b. -This patient has symptoms of mild hypothermia. The treatment includes external rewarming devices such as heating blankets, warm blankets, warm packs. and convective air warmers. Treatment may also include warm, high carb fluids that do not contain caffeine or alcohol
A nurse provides discharge education to a client who has MRSA. Which of the following statements should be included? Select all that apply a. "Discontinue antibiotics after a scab forms b. "Do not share athletic equipment with others." c. "Discard soiled bandages in a sealed plastic bags." d. "Keep the infected area covered with a dry bandage." e. "Showering is recommended rather than taking a bath." f. "Wash all uninfected skin areas prior to infected areas."
b. c. d. e. f.
At what lead level should a nurse refer a family to social srevices
blood lead level greater than 5 mcg/dL
Expected vital sign changes in pregnancy
blood pressure decreases 5-10 mm Hg during second trimester Pulse increases by 10-15/min around 20 weeks Resp increase by 1-2/min due to elevation of the diaphragm
What should a patient monitor for and report to a provider if they start experiencing it while taking metoprolol
bradycardia
A fetal heart rate baseline of 90 indicates what
bradycardia. This should be reported to the provider -fetal bradycardia is associated with fetal cardiac defects, maternal hypoglycemia, and fetal viral infections
A client states, "I have not been sleeping well." The nurse should recommend which of the following activities prior to bedtime? a. Walk briskly b. Watch television c. Take a warm bath d. Drink a glass of wine
c. Take a warm bath
How often should a client check their at home oxygen equipment for functioning
daily
contraindications for labor induction
cephalopelvic disproportion (CPD) Nonreassuring FHR Placenta previa or vasa previa Prior classical uterine incision or uterine surgery Active genital herpes HIV Cervical cancer
A nurse is caring for a newborn who has hyperbilirubinemia and a new prescription for phototherapy. Which of the following actions should the nurse plan to take a,. discontinue is the newborn's urine turns brown b. Feed the newborn 15 mL glucose water every 3 hr c. Apply a moisterizing lotion to the newborns skin twice daily d. change the newborn position every 2 hr
change the newborn position every 2 hours -this will maximize exposure of the skin to the light
A nurse is caring for a client who is immunocompromised. What antiseptic solution should the nurse use to preform hand hygiene?
chlorhexidine
Chron's disease
chronic inflammation of the intestinal tract that extends through all layers -bleeding is rare -right lower q pain
A nurse should expect to find ascites in a client who has what?
chronic pancreatitis or pancreatic cancer
Prior to a newborn glucose heelstick
clean the chosen puncture site with alcohol warm the newborn heel for 5-10 min to dilate the blood vessels Puncture either side of the outer aspects of the newborn's heel. Puncturing the middle can lead to complications, such as fibrosis, or bone infection
gastric lavage
cleansing procedure in which the stomach is irrigated with a prescribed solution
atelectasis
collapsed lung
Diseases that must be reported to Public Health Officials
communicable diseases -chicken pox (varicella) -herpes simplex -resp syncytial virus -HIV -TB (pulmonary) -Vancomycin-resistant enterococci (VRE)
Biofeedback requires what
concentration to control physiological responses
coarctation of the aorta
congenital cardiac condition characterized by a narrowing of the aorta
If no stool is passed after 6-12 hours of an ileostomy
contact provider
Discontinue oxytocin if
contraction frequency more often than every 2 mins contraction duration longer than 90 seconds contraction intensity greater than 90 no relaxation of uterus between contractions uterine resting tone greater than 20 mmHg between ctx
At what temperature should amoxicillin/clavulanate be kept?
cool (the fridge)
Which of the following actions should the nurse perform prior to obtaining a specimen from an indwelling cath for a client who has sepsis? a. don sterile gloves b. provide cath care c. elevate the drainage bag above bladder d. clean tubing port with an antiseptic solution
d
Greatest risk for heart failure during when in pregnancy
end of second trimester (28-32 weeks) During labor firs 48 hours after delivery
A client performing self-catheterization might be required to do it how frequently
every 2-3 hours, with the frequency eventually increasing to every 4-6 -use clean technique -empty bladder completely with each catheterization
ileostomy appliance should be changed
every 3-7 days to prevent skin irritation around the stoma
Following epidural placement, how often should the nurse monitor the client's blood pressure? How often should the nurse reposition?
every 5-10 minutes bp every hour reposition
how often is amoxicillin given to children
every 8-12 hours as prescribed to maintain blood levels
hyperparathyroidism
excessive levels of parathyroid hormone hypercalcemia, hypophosphatemia
A nurse is caring for a client who has a C. Diff infection. Which of the following interventions should the nurse use to prevent transmission?
eye protection
Stimulant withdrawal
fatigue
Fat overload syndrome
fever increased triglycerides clotting multiple organ system failure discontinue infusion and notify provider immediately
Retinal detachment
floating dark spots
Amniotic fluid
fluid within the amniotic sac that surrounds and protects the fetus -replaced every 3 hours -800-1200 mL at the end of pregnancy -Functions: temp regulation, protection, promotes musculoskeletal development
Internal pressure in long bone fractures does what?
forces fat globules from the marrow into the systemic circulation, where they act as emboli -s and s include: confusion, combativeness secondary to hypoxia
Preterm births
from 20 weeks up to 37 completed weeks
Lithium toxic level
greater than 2
Digoxin toxic level
greater than 2.4
Phenytoin toxic level
greater than 30
Nonpharmacologic measures for PTSD
guided imagery
Hormone tested for during a pregnancy test
hCG
Phelbitis
heat compress
Chron's Disease Diet
high calorie, high protein, low fiber, no dairy
Addison's disease electrolytes
high potassium, low sodium as a result of fluid depletion (Cushings opposite)
What condition should a nurse identify as a contraindication to being a living kidney donor?
hypertension
contraindication for methylergonovine
hypertension
Complications of obstructive sleep apnea
hypertension, heart failure, cardiac dysrhythmias
A nurse is caring for a newborn whose mother was taking methadone during her pregnancy. Which of the following findings indicates the newborn is experiencing withdrawal?
hypertonicity
Addison's disease
hyposecretion of adrenal cortex hormones caused by autoimmune disease, TB, histoplasmosis, adrenalectomy, tumors, HIV; can be induced by abrupt cessation of steroid medication
Hypoparathyroidism
hyposecretion of parathyroid hormone; may result in hypocalcemia, hyperphosphatemia and tetany
placenta previa
implantation of the placenta over the cervical opening or in the lower region of the uterus
uterine atony
inability of the uterus to contract effectively
short term memory loss is manifested as what
inability to recall events or actions that just occurred, such as where the client recently placed her eyeglasses
What does a peak flow meter rate in the yellow zone indicate
inadequate control of asthma -the client should obtain 3 readings and write down the highest reading
Peritonitis
inflammation of the peritoneum and lining of abdominal cavity -rigid board like abdomen (hallmark sign) -Nausea and vomiting -Tachycardia, febrile -rebound abdominal tenderness Fowlers and semi fowlers Ng tube to low intermittent suction
pyelonephritis
inflammation of the renal pelvis and the kidney
thrombophelbitis
inflammation process that causes a blood clot to form and block one or more veins -ambulate -antiembolic stockings and SCD's -anticoagulant prophylaxis
Total hip arthroplasty
install a raised toilet seat maintain hip @ 90 degree when sitting to minimize hip flexion and prevent hip dislocation use a walker no pillow under the knees when lying down for this can impede circulation and result in flexion contractures
Nystagmus
involuntary eye movement which causes the ye to rapidly move from side to side, up and down, or in a circle, may blur vision
A nurse is caring for a client who is in active labor and notes FHR baseline has been 100.min for the past 15 min. The nurse should identify which of the possible causes of fetal bradycardia
maternal hypoglycemia
evaluator
measuring the group's work against the assigned objectives
A client who received Mantoux test 48 hours ago and has an induration
needs follow up care
Gentamicin Adverse Effects
nephrotoxicity and ototoxicity -look for creatinine increase
How big should the nurse cut the skin barrier opening for a stoma
no more than 0.3 cm (0.13 in) larger than the stoma, this reduces skin irritation
Reactive NST
normal finding two or more fetal heart rate accelerations within 20 minutes
Fetal tone BPP
normal score 2: At least 1 episode of extensions with return to flexion abnormal score 0: Slow extension and flexion, lack of flexion, or absence of movement
Fetal breathing BPP
normal score 2: at least 1 episode of 30 seconds in 30 minutes abnormal score 0: Absent or less than 30 seconds duration
Gross body movements BPP
normal score 2: at least 3 body or limb extensions with return to flexion in 30 min abnormal score 0: less than 3 episodes
Gravidity
number of pregnancies including current
There should be at least how long of resting between contractions?
one minutes. -this allows adequate placental perfusion, less than one minute resting time can lead to fetal hypoxia and should be reported to the provider
Inability to recall family members' names indicates an
orientation deficit and possible long-term memory loss
risperidone can cause what
orthostatic hypotension, dizziness, which can lead to falls. Nurse should initiate fall precautions for the client
Estrogen deficiency and sedentary lifestyle are risk factors for
osteoporosis
Tachysystole
overstimulation: more than 5 contractions in 10 minutes
medication for postpartum hemorrhage include
oxytocin methylergonovine carboprost tromethamine
A nurse is caring for a client who is experiencing acute mania. Which of the following foods should the nurse provide for this client?
peanut butter sandwich -high fat, finger food, high cal
Symptoms of abruptio placentae
persistent uterine contractions board like abdomen dark red vaginal bleeding
A nurse is assessing the peripheral catheter insertion site of client who is receiving an infusion. The nurse notices redness and warmth to touch around the insertion site. The nurse should document the finding as which of the following complications?
phlebitis
Position and blood pressure during pregnancy
position affects blood pressure; supine position may cause supine hypotensive syndrome. S and S include dizziness, lightheadedness, pale, clammy skin. Interventions include left-lateral side position, semi-fowlers position, or wedge under one hip if supine
Spironalactone (Aldactone)
potassium sparing diuretic
Chlopromazine
potentially life threatening adverse effects: neurolopetic malignant syndrome can cause: high temp, dysrhythmias, decrease in LOC, labile BP
Misoprostol, dinoprostone
preinduction cervical ripening (bishop score 4 or less)
abruptio placentae
premature separation of the placenta from the uterine wall
What is a risk factor that is the best predictor of future violence in a client?
previous violent behavior
Approximated surgical incision heals by what
primary intention
Abortion/miscarriage
prior to viability: 20 weeks
What should a nurse do when she has suspicions of elder abuse?
privately interview the client about her condition
clients who have rheumatoid arthritis require foods high in should get what medications
protein, vitamins, and iron NSAIDS should take hot showers to help relieve morning stiffness
A nurse is caring for a client who has an indwelling urinary cath. What should the nurse do to provide cath care>
provide perineal hygiene after defecation
A fib puts your at risk for
pulmonary emboli
Blumberg's sign
rebound tenderness common in appendicitis, cholecystitis
placentae previa symptoms
relaxed uterus and bright red vaginal bleeding fundal height that is greater than expected gestational age
A charge nurse observes a coworker who has imparied coordination and is drowsy while performing routine tasks. Which of the actions should the charge nurse take?
report to the nursing manager dont confront
chorionic villus sampling
sampling of placental tissue for microscopic and chemical examination to detect fetal abnormalities
Maternal serum alpha-fetoprotein (MSAFP)
screening tool for NTDs (neural tube defects) ideally performed between 16-18 weeks lower than normal levels: follow up for down syndrome higher than normal levels: follow up for neural tube defects
A nurse is teaching about home care to the parents of an infant who has a tracheostomy. What instruction should the nurse include in the teaching regarding suction level
set the suction machine to 60
A nurse is assessing a client who has acute-angle closure glaucoma. What finding should the nurse expect?
severe periocular pain
bronchospasm
spasmodic contraction of the bronchi
A nurse in a long term care facility is managing the care of an older adult client who has difficulty swallowing and occasionally chokes during meals. The nurse should initiate a referral to what interprofessional care team?
speech-language pathologist
A nurse is reviewing lab results for a client who has heart failure and notes a serum potassium level of 5.2. WHat medication should the nurse withhold?
spironolactone
Oxytocin use
stimulates uterine contractions may be used in all stages of labor
Skin in the 2nd and 3rd trimesters
striae, linea nigra, chloasma (darkening of the skin) -discuss that commercial treatments are not useful; pigmentation usually disappears after pregnancy; striae may fade
home health nurse is assessing a client who has ALS and has had recent weight loss. What is the priority admission data for the nurse to obtain?
swallowing ability
Autonomic Dysreflexia
syndrome in which there is a sudden onset of excessively high blood pressure -common in spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above)
Stage 4 pressure ulcer
tendon exposure and muscle damage
After emergent discontinuation of oxytocin, prepare to administer what
terbutaline 0.25 mg subcutaneously to decrease uterine activity
A nurse should measure what daily on a patient who has a PICC line
the arm circumference above the insertion site
Non stress test measures what
the fetal CNS
Client's will have a monthly prenatal visit for how long
the first 28 weeks of pregnancy
catarcts is what
the increased opacity of the lens
A nurse is assessing a client who has a chest tube with a water seal drainage system. Upon assessment, the nurse notes tidaling in the water seal. What is an explanation for the tidaling?
the system is working properly. -an air leak would have to be continuous bubbling
Why are eggs bad for those with hypertension
they are high in cholesterol
Client will develop gestational diabetes in what semester (usually)
third
parathyroid hormone
this hormone helps maintain an appropriate balance of calcium in the bloodstream and in tissues that depend on calcium for proper functioning
What do early decelerations indicate in the second stage of labor?
this indicated the progression of labor and they are an expected findings. Continue to monitor.
What is the Somogyi effect?
this is a high blood glucose level in the morning after an extremely low blood glucose level at night. This swing is caused by the release of stress hormones to counter low glucose levels.
Terbutaline
tocolytic used for preterm labor or oxytocin induced tachysystole last resort for preterm labor
Terbutaline adverse effects
tremors, dizziness, headache, tachycardia, hypotension, anxiety
Amitriptyline
tricyclic antidepressant anticholinergic effects: dry mouth and constipation, hypotension -increase fiber, fluid intake, chewing sugar free gum take @ bedtime to promote sleep and minimize drowsiness
Retinoblastoma
tumor arising from a developing retinal cell
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. How frequently should this be done and when?
twice a day and prior to meals (not right before)
A client will hear the baby's heart beat when
typically at 10-12 weeks
hypertonic uterine dysfunction
uncoordinated uterine activity. Contractions are frequent and painful but ineffective in promoting dilation and effacement.
AP/UAP
under the direction of an LPN or RN skills: -basic hygiene care and grooming -provides assistance with ADL such as nutrition elimination and mobility -Basic skills: vital signs, pulse oximetry, and I and O -Maintains safe environments -Noninvasive/Do not require sterile technique
Acupressure Bands on the wrists during first trimester of pregnancy
used to alleviate nausea and vomiting
Prior to administering oxytocin
vaginal exam performed for effacement, dilation, and station: -fetus must be at 0 station
What vitamin should a client be instructed to increase while taking phenytoin
vitamin D -this medication causes a vitamin D deficiency
Warfarin antidote
vitamin k
Category C and D medications:
warfarin, lithium, methimazole, phenytoin, tetracycline, and antipsychotics
What should the nurse cleanse the skin at the stoma site with
washcloth and warm water -this reduces irritation
What clothing should a client wear while using at home oxygen
wear clothing made with cotton fabrics while oxygen is in use
Are patients who are allergic to shellfish also at risk for an allergic reaction to IVP?
yes