Practice Milestone

The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, the nurse should provide which of the following instructions?

"Close lips tightly around the mouthpiece and breathe in deeply and quickly.

A client is admitted to the mental health unit and reports taking extra anti anxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement?

"I don't want to walk. Nothing matters anymore."

A patient is ordered by the physician to take allopurinol (Zyloprim) for treatment of gout. You've provided education to the patient about this medication. Which statement by the patient requires you to re-educate them about this medication?

"This medication will help relieve the inflammation and pain during an acute attack"

PUD NGT

- During surgery stomach contents are drained by NG tube - Confirmation that obstruction is the cause of pt discomfort us done by assessing the amount of of fluid aspirated a residual of >400 mL indicated obstruction In PUD, during surgery and postoperatively, the stomach contents are drained by means of an NG tube

Violence handling

- Engage in dialogue to prevent escalation, intervene early in the cycle - Approach as non threatening, calm manner and convey empathy - Encourage the client to express their anger, build trust, anticipate need for meds, be consistent

Self-care and Maslow's hierarchy

- Physiologic, safety, love and belonging, self esteem, self-actualization - Basic drive and needs that motivate people -Maslow uses the terms physiologic, safety and security, belonging, self-esteem, and self-actualization needs to describe the process that generally motivates individuals to move through life.

Bizarre social behavior

- assess physical needs, suicide risk, ensure safety at all time - sit w/ client, silence, tell when leaving - limit stimuli / 1-1 interaction

Type I DM tight control

- glucose checks at home - A1C should be 4-6% *** LESS THAN 7%

When caring for a child sickle cell disease, the nurse knows that the child will most likely exhibit which sign when experiencing a sickle cell crisis?

- pain - fatigue - swollen hands and feet - dehydration **give oxygen, fluids, pain med, infection prevention

Postanesthesia care

- systolic under 90 = immediately reportable unless baseline!!

Aggression response

-5-phase cycle= Triggering (event), Escalation (movement toward a loss of control), -Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation) ***Hx = likely to occur again

Nurse discovers the postpartum client has a boggy uterus and is on the left side

-Encourage patient to void - fundal massage and administer uterotonic to increase uterine contraction. - give oxytocin

the nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply.

-Monitor daily weight. -Monitor intake and output. -Assess extremities for edema

RN is caring for client w DX of HF who suddenly experiences dyspnea & RN suspects pulmonary edema. RN immediately:

-Places client in high fowlers -feet hanging over edge of bed

a mental health care worker caring for a client with escalating aggressive behavior. What action by the mental healthcare worker wards immediate interventions?

-attempting to physically restrain patient

PE report findings

-hypotension -tachycardia -tachypnea -SOB -anxiety -chest pain w/ -inspiration -petechiae -diaphoresis ***** INCREASE D-DIMER!!!

Scoliosis post op

-neuro assess -log roll 5 days -iv fluids and pain meds -NPO, mouth care -NG tube, bowel sounds -assist with ambulation -body jacket for bone fusion

A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.)

1) Buffalo hump 2) Purple striations 3) Moon face

Acute pancreatitis assessment

1. Severe midepigastric pain radiating to back; usually related to excess alcohol ingestion or a fatty meal 2. Abdominal guarding; rigid, board-like abdomen, and abdominal pain 3. Nausea and vomiting 4. Elevated temperature, tachycardia, decreased BP 5. Bluish discoloration of flanks (Grey Turner sign) or periumbilical area (Cullen sign)

Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? 1. Limit caffeine intake to two cups of coffee per day 2. Do not lie down for 2 hours after eating 3. Follow a low-protein diet 4. Take medications with milk to decrease irritation

2. Do not lie down for 2 hours after eating

A client who has been diagnosed with GERD has heartburn. To decrease the heartburn, the nurse should instruct the client to eliminate which of the following items from the diet? 1. Lean beef 2. Air-popped popcorn 3. Hot chocolate 4. Raw vegetables

3. Hot chocolate

Fetal tachycardia

>160 bpm for 10 minutes or longer - antipyretic for maternal fever - IV fluids - oxygen

The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse?

A 78 year old female on a fixed income who lives with her relatives

While in labor at 39 weeks' gestation, a primigravida develops a temperature of 38.2°C (100.7°F), and fetal tachycardia is noted at 170 beats per minute. The student nurse asks the experienced nurse what this could indicate. How should the experienced nurse respond?

A temperature of 38.2°C (100.7°F) may indicate an infection such as chorioamnionitis, and the practitioner should be notified.

The patient has an order for each of the following inhalers. Which of the following should the nurse offer to the patient at the onset of an asthma attack?

A. Albuterol (Proventil) Albuterol (Proventil) Albuterol is a short-acting bronchodilator that should initially be given when the patient experiences an asthma attack

Grief process therapeutic response

A. Encourage client to express anger in a supportive, nonthreatening environment. B. Discourage rumination. C. Assist client in giving up idealized perception of deceased; point out misrepresentations. D. Encourage interaction with others. E. Assist client with identification of support systems. F. Consult spiritual leader as indicated by client need and preference. G. Assist client toward a comfortable, peaceful death

Cardiomyopathy care plan

A. Monitor vital signs at least every 4 hours for changes. B. Monitor apical HR with vital signs to detect dysrhythmias, or abnormal heart sounds such as S3 or S4. C. Assess for hypoxia. 1. Restlessness 2. Tachycardia 3. Angina F. Elevate head of bed to assist with breathing. G. Observe for signs of edema. 1. Weigh daily. 2. Monitor I&O. 3. Measure abdominal girth; observe ankles and fingers.

When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?

A: Refer child to the family healthcare provider

If Hypoglycemia occurs during Addison's crisis, what should the nurse do?

Administer IV glucose

The nurse is teaching the parents of a 5-year-old child with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand?

Administer aerosol therapy followed by postural drainage before meals.

Which features are prominent in anorexia nervosa?

Amenorrhea for three cycles -Perfectionism -Powerlessness -Rigid food rituals

The nurse is administering a dose of digoxin to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom?

Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity.

A male pt calls the clinic and complains because he can't tie his shoes? What should the nurse do next?

Ask if the pt has gained weight in the past few days

The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with congestive heart failure. Which intervention should the nurse implement prior to administering the digoxin?

Assess the serum potassium level

A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg (7.95 kPa). On the basis of the ABG result, what does the nurse prepare to do?

Assist in intubating the client and beginning mechanical ventilation

During a follow up clinical visit a mother tells the nurse that her 5 month old son who had surgical correction for tetralogy of fallot has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?

Auscultate heart and lungs while infant is held

The nurse then reviews Ms. Jackson's preoperative lab results drawn earlier in the week. Which serum lab value requires follow-up by the nurse? A. Sodium of 135 mEq/L B. WBC of 14,000/mm3 C. Creatinine of 0.8 mg/dl D. Hemoglobin of 14 g/dl

B. WBC of 14,000/mm3 WBC of 14,000/mm3Rationale: The normal WBC count is 5,000 to 10,000/mm3. An increase my indicate the onset of an infection which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.

The nurse is evaluating a male client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan?

Carefully cleans and peels all fresh fruit and vegetables

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Check the client's vital signs.

chronic inflammatory bowel disease

Crohn's disease and ulcerative colitis are chronic inflammatory bowel diseases (IBDs). Causes unknown Genetic factor appears to be involved. Crohn's disease—often during adolescence Ulcerative colitis—second or third decade Many similarities between Crohn's disease and ulcerative colitis

A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client?

D. Do you hear sounds or voices that others do not hear?

A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement?

D. Encourage the client to express her feelings regarding the upcoming procedure.

A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct?

Decrease the oxygen to 2 L/min to improve respiratory rate

A 77-year-old female client is admitted to the hospital. She is confused and has had no appetite for several days. She has been nauseated and vomited several times prior to admission. She is currently complaining of a headache. Her pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to what medication?

Digitalis (Lanoxin)

Peritonitis Signs and Symptoms

Diminished bowel sounds Tachycardia & Tachypnea Abdominal Distention Hiccups Respiratory Distress Decrease in H&H, pulse ox Increased WBC count (20,000 and above)

The chest x-ray for a client who is admitted for pneumonia shows pleural effusion with decreased air flow in the entire left upper lobe. What breath sounds that verify the x-ray findings should the nurse document after auscultation of the left upper lobe?

Diminished breath sounds

A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first?

Do you have a plan in place when you are not safe? (SAFETY!!!)

IVF hydration

Eliminate parenteral K from IV infusions and medications. Administer 50% glucose with regular insulin. Administer cation exchange resin (Kayexalate). Monitor ECG. Administer calcium (Ca) gluconate to protect the heart. IV loop diuretics may be prescribed

A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?

Encourage finger foods, distraction, speak therapeutically

Who is most prone to being abused (elder abuse)?

Females over 75 living with their families.

IBD - peritonitis

Fluid, colloid, and electrolyte replacement is the major focus - Antibiotic therapy

BPH signs and symptoms

Frequent or urgent need to urinate, Increased frequency of urination at night (nocturia), Difficulty starting urination, Weak urine stream or a stream that stops and starts, Dribbling at the end of urination, Straining while urinating, Inability to completely empty the bladder

The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. Which action should the nurse implement?

Give IV fluids with electrolytes.

A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

Has his weight changed in the last several days

A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

Has his weight changed in the last several days?

A 17-year-old male student with cystic fibrosis talks with the school nurse about his disease and wonders how it will affect getting married and having children. Which relevant information would the nurse include in this discussion?

He is likely to have infertility problems and further evaluation

Which action should the nurse implement during the termination phase of the nurse-client relationship?

Help summarize accomplishments.

ARDS management

Hypoxemia that persists even when 100% oxygen is given

The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 ml/daily

The schizophrenic client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

Ineffective denial related to situational anxiety

A client admitted to the hospital with a small bowel obstruction is to have an intestinal tube inserted. When preparing the client for the procedure, what action should the nurse take? a. Place the client in the right side-lying position b. Instruct the client about techniques for mouth breathing c. Spray the client's oropharynx with a local anesthetic solution d. Reassure the client that the procedure will not cause discomfort

Instruct the client about techniques for mouth breathing

The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to osteoarthritis?

Long distance runner since high school.

A 4-year-old boy was recently diagnosed with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during the initial teaching?

Lower legs become progressively weaker, causing waddling, unsteady gait

A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysrhythmias. What would you give first?

Magnesium

A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the UAP who is completing morning care for this client?

Maintain a quiet environment

A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase?

Making appropriate referrals

Shoulder dystocia actions

McRoberts' maneuver and suprapubic pressure (need step stool)

While caring for an older client, the RN observes multiple bruises in Over the client's legs, arms, back, and gluteal areas. When the RN suspects elder abuse. What action should the RN take?

Measure and document size, shape and color of the bruised areas.

GERD instructions

Minimize symptoms by wearing loose and comfortable clothes

Pt with Addison's has started taking hydrocortisone in a divided dose. What should the nurse do next?

Monitor pt's glucose

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

Monitor urinary stream for decrease in output

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Muscle twitches in the back and neck

Rheumatoid Arthritis pain tx

NSAIDs and specifically the cyclo-oxygenase 2 (COX-2) enzyme blockers are used for pain and inflammation relief. NSAIDs, such as ibuprofen (Motrin) and naproxen (Naprosyn),

Patient having to get treated for benzodiazepine and methadone overdose. What do you use?

Narcan

A child with possible Duchenne muscular dystrophy ( MD) undergoes an electromyogram (EMG). Following the procedure, the child's parents tell the nurse that the child is complaining of sore muscle. How should the nurse respond?

Offer reassurance that muscle soreness following this procedures is temporary and does not indicate a problem

Ulcerative colitis bloody diarrhea

Patients with ulcerative colitis may experience as many as 10-20 liquid, bloody stools per day.

A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child's plan of care?

Pin and incisional care after surgery

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority

Place the client on NPO status.

Which action should the nurse implement first for a client experiencing alcohol withdrawal?

Prepare the environment to prevent self-injury.

A 32-year-old male client is admitted with paranoid schizophrenia

Reassure the client that he is safe and should rest.

The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

Rebound tenderness in the upper quadrants

After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. What action should the nurse take?

Recommend assignment to the receptionist's office.

Regular insulin peak-action

Regular insulin/Humulin R/Novolin R Onset 30-60m Peak 2-5h Duration 5-8h Short-acting

intimate partner abuse

Remember to document objective factual assessment data and the client's exact words in cases of sexual abuse and rape

Osteoarthritis

Remind client that excessive use of the involved joint aggravates pain and may accelerate degeneration

The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client?

Remove the brace 1 hour each day for bathing only.

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge

Report weight gain of 2 pounds (0.9kg) in 24 hours

An older adult woman is seen in the clinic 3 months following her diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client's current finger-stick and daily log of blood glucose levels. Which intervention is most important for the nurse to implement?

Review the client's glycosylated hemoglobin (A1c) level

ADHD medications

Ritalin, Concerta, Adderal ( stimulants/dopamine) Straterra (norepinephrine)

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain?

Sensory pattern, area, intensity, and nature of the pain.

A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis?

Serum amylase

Which assessment finding should indicate to the nurse that a client with arterial HTN is experiencing a cardiac complication?

Shortness of breath on exertion

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

Side-lying, to facilitate drainage of oral secretions

A patient returns to the medical-surgical unit after having extracorporeal shock wave lithotripsy (ESWL). What is an appropriate nursing intervention for the postprocedural care of this patient?

Strain the urine to monitor the passage of stone fragments.

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the UAP who is assisting with a bed bath?

Take measures to promote as much comfort as possible

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care?

Teach coping skills for living with a chronic illness

The nurse formulates the nursing diagnosis of Urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement?

Teach the client techniques of intermittent self-catheterization.

When conducting discharge teaching for a client who has had a mechanical valve replacement, which information should the nurse plan to include?

The client will need to take an antibiotic before dental procedures.

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment?

The client's pain rating

BPH treatment

The most common treatment is transurethral resection of the prostate gland (TURP). The prostate is removed by endoscopy (no surgical incision is made), allowing for a shorter hospital stay

You're having a one on one session and nurse begins to get angry at patient.

Then the nurse needs to terminate the session before the feelings escalate.

A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery?

Thiamine will replenish alcohol effects on the body (something to do with iron)

The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, "How can our son have this disease? We are wondering if we should have any more children." What information should the nurse provide to parents?

This is an inherited X-linked recessive disorder, which primarily affects male children in the family

A nurse is assigned to care for a client who has a seizure disorder. Which of these nursing actions will the nurse implement first if the client has a seizure?

Turn client to the side and protect airway

termination stage

Unresolved feelings related to loss most likely may be recognized during this stage

A female pt was in an MVC and admitted with a fractured L femur. Nurse assessment include diminished pulses. What should the nurse do next? SATA

Verify pedal pulses with a Doppler Monitor L leg for pain, pulselessness, pallor,paralysis Evaluate the app of the splint to the L leg

Pre op labs which is abnormal

WBC count higher than 5,000-10,000/mm3 = possible infection

Diverticulitis NPO

What are the nutritional needs of this client throughout recovery? Acute phase: NPO, IV fluids • Recovery phase: no fiber or foods that irritate the bowel • Maintenance phase: high-fiber diet with bulk-forming laxatives

The client hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism. The priority action for the nurse is to:

a) discontinue dialysis and notify the physician

The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply

a. Close car windows and use air conditioner b. Avoid sudden changes in temperature c. Keep away from pets with long hair d. Stay indoors when grass is being cut

Ulcerative colitis-goal

a. Determine bowel elimination pattern, and control diarrhea with diet and medication as indicated. b. Provide a nutritious, well-balanced, low-residue, low-fat, high-protein, high-calorie diet, with no dairy products. c.Administer vitamin supplements and iron. d.Advise client to avoid foods that are known to cause diarrhea, such as milk products and spicy foods. e.Avoid smoking and alcohol

HbA1c

a. HbA1c > 6.5% b.The ADA now recommends that all patients with diabetes strive for glucose control (HgbA1c less than 7%) to reduce their risk of complications

Thrombocytopenia s/s

a. Signs and symptoms Patechiae, expatisis, excessive bleeding after surgery b. Expected lab values <20,000 patachie, less than 5000: hemorraghe

The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply a. Spaghetti with fresh tomatoes b. Boiled lobster with baked potato c. Grilled chicken with turnip greens d. Instant hot cereal with bacone. Tomato soup with a ham sandwich

a. Spaghetti with fresh tomatoes c. Grilled chicken with turnip greens

Rheumatoid arthritis-mexate

a.immunosuppressant b. can cause bone marrow depression c. rheumatoid arthritis d. lab=hemoglobin decrease =adverse side effect e. Prior to and during therapy, monitoring the CBC, renal function, and liver function is essential. Keep a record of time and dose of medication. Eat with medicine to avoid gi upse

Seizure nursing care

a.loosening restrictive clothing , b.removing the pillow and raising the padded side rails c.positioning the client to the side if possible with head flexed forward d. always allow the tongue to fall forward and facilitates saliva and mucus drainage

When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide?

all clients are screened for domestic abuse because it is common in our society

A client with hemophilia has a very swollen knee after falling from bicycle riding. Which of the following is the first nursing action?

apply ice pack and compression dressings to the knee

A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to the mother?

apply padding to sharp edges

The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating?

b. Normal sinus rhythm and complaining of chest pain 60-100 bpm P wave always in front P:QRS ratio 1:1

A client with a newly diagnosed crohn's disease asks the nurse about dietary restrictions.How should the nurse respond?

describe the use of an elimination diet to find trigger foods

BPH

don't give antihistamines - do not give decongestant, anticholinergics, antidepressants

A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check?

glycosylated hemoglobin level

DASH diet

increase fruit, vegetables, and low fat dairy; k, mg, ca

CHF

left-sided heart failure symptoms dyspnea, orthopnea, pulmonary edema, paroxysmal nocturnal dyspnea - backs up into the lungs Upon physical assessment bubbling ,crackling, tachycardia present (acute phase) rhonchi heard , frothy pink sputum

2 days after admission from alcohol withdrawal what should the nurse do?

monitor HR and BP

With RA, joint pain is the result of synovitis, an inflammation of the synovial membranes

movement causes pain, rather than relieving pain.

Chemo side effects

nausea & vomiting are the most common side effect of chemotherapy and may persist for as long as 24-48 hours after it is administered

What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks?

not attempt to commit suicide

Meningitis first step

o Antibiotics - penicillin (ampicillin) AND cephalosporin o Corticosteroids

Valve replacement teaching

o Anticoagulant therapy (frequent follow-up/lab tests) Pt on warfarin has specific normal ratios o Prevent infection o ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURES!!!

Pneumonia Treatment

oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified air, chest physiotherapy, suctioning prn,

A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained.The child's color becomes blue and respiratory rate increases to 44 bpm.Which of the following actions would the nurse do first?

place the child in knee-to-chest position

The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action?

place the client on a cardiac monitor

which action should the nurse implement first for a client experiencing alcohol withdrawal?

prepare the environment to prevent self injury: self

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse is contraindicated?

restraining the clients limbs

a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to my potential." which of maslows developmental stages is the sales manager attempting to achieve

self actualization

Chronic inflammatory bowel disease

surgery : proctocolectomy Keep a food dairy Meds for severe: corticosteroids When would antibiotics be used For comlication such as abscesses or fistula formation

Hyperglycemia-IV

tube feeding formulas contain more simple carbohydrates and less protein and fat than the typical meal plan for diabetes. This results in increased levels of glucose in patients with diabetes who are receiving tube feedings

A middle school male student was recently diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues to have learning problems. Which action should the school nurse take?

• Refer the child to the school counselor for educational testing

A hospitalized child stiffens and starts to seize as the nurse enters the room. What actions should the nurse take? (Select all apply)

• Turn client to the side if possible • Pad side rails with available pillows and blankets• Monitor duration and progress of the seizure

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety?

■ Padding the side rails of the bed ■ Placing an airway at the bedside ■ Placing oxygen and suction equipment at the bedside ■ Flushing the intravenous catheter to ensure that the site is paten

What should you ask a patient after their seizure has occurred?

■ So you can ask them about a recent injury to their head ■ Ask if they have been an accident or somehow they hit their head ■ Ask if they lost consciousness or not. ■ Ask about Any substance abuse, alcohol, drugs ■ Ask about Allergies

Dementia care

● Tx of the underlying cause ■ What are some safety precautions for pts with delirium? ● Safety is important ● Stoves (use caution). It's too much excitement for the patient. ● Keep a calm environment