q review2
DKA, what CVP would the nurse anticipate?
1 mm of Hg normal is 2-6, low is fluid volume deficit, dka think polyuria, polyuria think shock
PTT levels
30-40; patient on heparin should be 1.5-2.5 times the control limit, report below 30-40
The inactivated polio vaccine
4 dose series given during early childhood and is not recommended for children 18 and older
Which client should the nurse see first?
53 year old with chest pain, scheduled for a stress test today
The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory tests?
AST, alkaline phophatase, serum cholesterol, serum triglyceride
Patient admitted to ICU after overdosing on meperidine, what is the nurse's first priority?
Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes PRN ; initiates a reversal of respiratory depression
What is the first intervention the emergency department nurse should implement when caring for a lethargic toddler with a diagnosis of near-drowning?
Administer oxygen-hypoxia
Patient unsure if she wants an ordered hysterectomy for cervical cancer, she states, "I want children" what is the nurses best action?
Allow the client to discuss her fears, and encourage her to talk more with her primary healthcare provider
A client has returned to the burn unit after an escharotomy of the forearm, what is the priority nursing intervention?
Assess bilateral radial pulses to compare for adequate circulation
Two hours after a gastrectomy, pink tinged drainage is found in the NG tube and appears occluded, what is the nurses initial action at this time?
Call the primary healthcare provider; do not tamper with fresh surgery tubes
The nurses assesses a client post thyroidectomy for complications by performing which assessment?
Chovostek's; this can indicate tetany and low calcium when thyroid is removed
5 year old presents to ER with fractured arm, parents give conflicting stores about the accident, which action is most appropriate for the nurse?
Consult social services
Patient wants to start herbal medication kava-kava, what is the nurse's best response:
Explanation; kava-kava can cause liver damage so we need to consult PCP
What information should be included when a nurse is teaching a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)?
Hepatitis B is more readily transmitted via needle sticks than HIV
Suicidal elderly man tells the nurse, " I think I am ready to go see my wife again, please don't tell anyone". appropriate nurse response:
I can't keep a secret like that, are you planning to harm yourself
Appropriate response for patient who calls in "sitting here with a bottle of pain killers in my hand" and voicing intent to commit suicide
I want to help you resolve the problem You did the right thing by calling I want you to stay on the phone with me Have another person call 911 for an ambulance
Fluoxetine actions:
It increases the production of serotonin
Patient has just returned from ECT and is very drowsy, what is the position of choice until consciousness is regained?
Lateral; when someone is sedated and not fully conscious we want them on their side so the airway remains open and secretions can drain
Priority nursing assessment for patient with suspected rupture of the appendix with perforation:
Monitor for increasing pain and rigidity of the abdomen
Nurse has never handled formalin before, what is the nurse's best action?
Read about formalin on the MSDS
Statement by a student nurse that indicates understanding of witnessing consent signatures:
Signing as a witness implies that the client willingly signed the consent
Include in POC for patient receiving chemotherapy for leukemia?
Teach family and visitors hand washing techniques
After drawing up insulin for subcutaneous administration, the nurse receives a return phone call from a primary healthcare provider who wants to give prescription orders on a new admit. The nurse asks a new nurse to administer the insulin dose. What action should the new nurse take?
Tell the nurse that whoever draws up the medication has to administer that medication
Women in ER following an argument with her husband, she describes a verbal argument that began to get physical with shoving of the client, which phase of the cycle of violence is the client describing?
Tension-building phase; growing tension causes the control of the situation
suicide precautions are initiated why?
The client has the right to a safe care enviornment
Instructions for using a cane?
With cane on the stronger side of the body, support body weight with BOTH legs, move cane forward 6-10 inches advance weaker leg forward toward the cane advance stronger leg forward
Greatest risk for ineffective oral hygiene
a client with breast cancer who is experiencing severe nausea and vomiting after chemo, a client who takes phenytoin for partial seizures
Clients appropriate for LPN
a client with copd complaining of shortness of breath on exertion, a client receiving heparin injections for deep vein thrombosis, a client receiving a blood transfusion that requires monitoring
Actions by nurse that understand blood administration:
a filter was used when administering the blood, a second nurse checked the blood compatibility, a set of vital signs was taken 5 minutes after infusion started
Clients NOT appropriate for an LPN
a post cardiac catherization needing assistance with bedpan, a client with atrial fibrillation currently on a diltiazem drip ( they are at risk for blood clots and assessing and titrating the medication requires the skills of an RN), a client post pacemaker insertion and awaiting discharge instructions
clinical pathway
a set of client care guidelines based on specific client diagnosis, which provides an overview of the multidisciplinary plan of care
myasthenia gravis in cholinergic crisis, signs and symptoms
abdominal cramping, lethargy, salivation, hypotension, lacrimation, miosis
inhaled anthrax exposure findings
abrupt onset of dyspnea, fever
post kidney transplant, post-op interventions
administer furosemide, weigh daily, measure urine output every 30-60 minutes
patient arrives at the ER with crushing substernal chest pain that radiates down the left arm, which measure should the nurse initiate FIRST
administer oxygen at 2 L/nasal cannula
patient started haloperidol 5 days ago and appears restless, muscle weakness, drooling, and a shuffling gait, what should be the nurse's first action?
administer the PRN benztropine mesylate
small pox precautions
airborne precautions; negative pressure room
New onset of hypertyroidism, what medication should concern the nurse while reviewing client's routine meds?
amiodarone, has a high iodine content that is toxic to the thyroi
Graves' disease and exophthalmos returns to clinic for evaluation, which assessment indicates the client is adhering to the teaching plan
an absence of corneal irritation ; client is using eye drops or ointment
coughing poses the greatest risk to which post op patient?
an elderly client who had cataract removal
Following a lumbar puncture, patient reports a 8/10 headache, what is the nurse's priority action?
assist the client to a supine position in bed, headaches are a sign of leaking of cerebrospinal fluid from puncture site
What to expect for infants eyes and vision:
at 4 weeks of age, the infant should be able to gaze at objections, visual acuity is about 20/300 at 4 months of age, during the first two months of life, infants's eyes may appear to be crossed, depth perception begins around the 5th month of age
food items for diverticulosis
avocados, acorn squash, lima beans, raspberries
symptoms to expect in an overdose of diazepam
bradypnea, bradycardia, somnolence
What steps should the quality assurance manager include in the evaluation of performance improvement of fall precautions for at risk clients:
chart review for fall precaution documentation, direct observation of unit staff, identify at risk clients on unit, make unannounced visits to the unit for evaluating staff performance
iron deficiency anemia; foods to increase in diet
chickpeas, oysters, raisins, spinach, tuna
Proper care for the mother to provide to her two day old newborn to prevent infection
cleans perineum from front to back after newborn soils diaper, applies alcohol to the umbilical cord with diaper change, placing the diaper just below the umbilicus
In which situations should the nurse notify the PCP of a medication incident?
client is harmed or dies, nurse administer an incorrect dosage
What actions should the nurse take for a patient receiving a unit of whole blood and begins to experience lower back pain
collect a urine specimen (check for presence of hemoglobin), stop the transfusion, take the clients vital signs, change iv tubing to remove all blood and maintain the IV line with normal saline -this is a sign of an acute hemolytic reaction
Nurse is caring for client with a perineal burn. The skin is not intact. What signs are suggestive of infection?
color changes, drainage, odor, fever, increased pain
The hospice nurse has been assigned a new client who is being cared for at home by family members. Based upon the client's physical assessment, the nurse is aware that the client's death is imminent. What is the nurse's most important role in the care of the family at this time?
communication the client's impending death to the family while they are all together-compassionate communication is the nurses most important role
patient states, "I just do not feel well, something is wrong". Vitals are BP 130/88, HR 102, RR 28, what should the nurse do next
connect to oxygen saturation monitor, think hypoxia
Which factors should the nurse include in teaching a parent about risk factors for otitis media?
contact with siblings, day care attendance, season of the year
D/C IV nitro if what symptoms occurs
cool, clammy skin; decreased cardiac output
response to painful stimuli- the upper extremities exhibit flexion of the arm, wrist and fingers with adduction of the limb, the lower extremity exhibits extension, internal rotation, and plantar flexion, how should you document this finding?
decoricate posturing
Why is glycopyrrolate given
decreases stomach secretions
Explanation of why epoetin is used for an oncology patient
decreases the need for transfusion
diabetic with numb feet, priority nursing action
examine the client's feet for signs of injury
Proper use of an inhaler
exhale completely before using inhaler, inhale slowly and push down firmly on the inhaler, rinse mouth with water after using inhaler
signs and symptoms to assess for TB
fatigue, hemoptysis, diaphoresis during sleep, anorexia
second best pulse with neck trauma
femoral artery
signs that should be reported after cesarean birth 2 days ago
fever greater than 100.4 for 2 or more days, calves with localized pain/redness/swelling, burning with urination, feeling of apathy toward newborn
small pox assessment findings
fever, cough, malaise, vesicle rash on face, palms, and soles of feet
mandatory reports
financial abuse of an elder, gunshot victim, client diagnosed with gonorrhea, client diagnosed with west nile virus
Violent patient and demands to be seen immediately, but refuses to tell the triage nurse the problem, for the nurses safety what should the nurse's initial action be?
find a safe place away from the client and then notify security
What position should the nurse place a client post intracranial surgery?
head of bed elevated 30 degrees
What should the nurse monitor for related to epoetin alfa
hypertension, hemoptysis, induce rapid weight gain, and swelling of the feet and hands, RBCs go up
right side stroke
impaired judgment, impulsiveness
Acute battering phase in the cycle of violence
includes the release of tension through extreme physical violence, also called the explosion phase
Dopamine is administer to increase....?
increase BP and cardiac output
Hypothyroidism diet plan
increase fiber
Indication that albumin has been effective for a client who had hypovolemic shock
increase in urinary output
Dietary needs for patient receiving hemodialysis three times a week
increase protein intake, restrict fluids, decrease sodium, decrease potassium
Finding during a non stress test that would indicate a potential problem for the fetus?
increases 8 beats per minute for 10 seconds with fetal movement-fetal compromise
incorrect statement regarding tracheostomy suctioning:
instilling normal saline bullets to liquefy secretions
acetaminophen overdose, which symptom is the client most likely to exhibit?
jaundiced conjunctiva-liver damage
Physical changes to discuss with patient entering menopause:
loss of bone density, loss of muscle mass, increase fat tissue
Presentation for early prevention and early detection of colon cancer?
maintain a diet high in fruits, vegetables, and whole grains, exercise regularly, yearly guaiac-based fecal occult blood test
Measles precautions
measles can be transmitted via contact, droplet, and airborne, so airborne precautions are needed, N95 respirators should be worn by staff and surgical masks worn by patient to prevent spread of particles
What immunizations should the nurse suggest a 19 year old preparing to enter college ask the doctor about?
meningococcal, tdap, HPV, seasonal flu vaccine, hepatitis B
diabetic reports normal blood glucose levels at bedtime and high in the morning what instruction do you give the client?
monitor blood sugar around 2 am
SLE patient urinalysis reveals proteinuria and hematuria, what is most important for the nurse to do?
monitor intake and output and daily weight, proteinuria think kidneys
signs & symptoms to assess for when caring for a client diagnosed with bulimia nervosa?
muscle cramps, tingling of lips, constipation, weakness, fatigue, and arrhythmias; hypokalemia and metabolic alkalosis are associated with bulimia
initial therapy for hhns
normal saline
Post cataract removal, patient reports nausea and severe eye pain, priority intervention?
notify the PCP, indicates an increase in intraocular pressure
Crohn's disease; low residue foods:
oatmeal, spaghetti, cantaloupe; decrease fiber in order to limit bowel peristalsis
dizziness and weakness while walking down the hall, cardiac rhythms present PVCs, what actions should the nurse take?
obtain blood pressure, auscultate lung sounds
Myasthenia gravis; interventions to include in the plan of care to decrease the risk of aspiration:
offer small bites of food, allow client to rest between each bite of food, position client upright with head slightly forward
Most immediate relief with what intervention for PTSD
opportunity to verbalize memories
panic disorder symptoms
palpitations, trembling, nausea, shortness of breath, and feeling of losing control
Intense perineal pain post partum is a symptom of what
perineal hematoma, which is a medical emergency
laboring client who is about to start oxytocin, what interventions should the nurse include in the plan of care:
piggy back oxytocin into the main IV fluid, discontinue if contractions last longer than 60 seconds, maintain one on one care
Interventions for a client with measles:
place a surgical mask on the client when transferring to x-ray, initiate airborne precautions, assign a nurse who has received the measles vaccine to care for the client
What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung?
place in semi fowler's position, connect to oxygen saturation monitor, assess respiratory status every 2 hours, prevent dependent loops in closed drainage unit tubing
What symptoms of meningeal irritation would the nurse anticipate when performing an assessment on a newly admitted client with the diagnosis of bacterial meningitis?
positive Kernig's sign, positive Brudzinski's sign, photophobia, severe headache, nuchal rigidity
hypokalemia; monitor for which dysrhythmia?
premature ventricular contractions
Best assessment for the nurse to determine if chest compressions are done with enough force and depth
presence of a carotid pulse with each compression
Include in plan of care for patient with aphasia:
present one thought at a time, use and encourage use of gestures, do not push communication if client is tired, give client time to generate a response, ask question that can be answered with yes or no
What interventions should the nurse include for a patient with myasthenia gravis to manage swallowing and chewing impairment?
provide foods that are soft and tender, allow client to rest between bites, encourage client to drink thickened liquids
What interventions should the nurse include in the plan of care for a patient with a recent stroke and has adequate swallowing ability?
provide mouth care prior to feeding, flex head forward for eating, used crushed ice as a stimulant for swallowing, offer thickened liquids to drink
OD of acetylsalicylic acid, assessment reveals lethargy, excessive sweating, hyperventilation, and hyperthermia, what interventions should the nurse initiate?
provide tepid water sponge bath, start and IV for fluid resuscitation, insert a NG tube, pad side rails, obtain blood gases
Teaching interventions for prevention and treatment of fungal infections in the feet
put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks, wash feet daily with soap and water, wear shower sandals when showering in public places, wear shoes that allow the feet to breath
Teaching for client with Grave's disease who is scheduled to receive radioactive iodine?
radioactive iodine will leave the body in urine and saliva within a few days, you cannot receive iodine if you are pregnant, stay away from babies and do not kiss anyone for 1 week, it is given in a capsule or liquid form;only one dose needed
Honeymoon phase in the cycle of violence
remorse with promises to never hurt the victim again, the abuser is sorry and apologetic
Position for patient with gastric reflux
reverse trendelenberg
signs and symptoms to assess for when monitoring a client who has a brain injury:
rhinorrhea, bp 150/60, papilledema, projectile vomiting
left side stroke
right sided hemiplegia, depression, impaired language comprehension, impaired speech
Patient is being discharged home on a ventilator, what is the most critical assessment for the nurse care manager to make?
safe home enviornment
Black disaster tag for burns
second and third degree burns over 60% of the body put patients at triage category of black
Nurses best response to a client asking what advance directives are:
specifies your wishes regarding healthcare and treament options should you become incapacitated, the person signing the advanced directive must be competent
MVA one week ago, returns with drunken behavior and unable to control his right foot and arm, what do you suspect?
subdural hematoma; slow venous bleed, does not show symptoms until compensation is exhausted
Patient trying to lose weight, what interventions could help the client stay on track?
suggest that the client eat yogurt and a piece of fruit upon returning home, suggest the client order low fat options at the restaurants, encourage the client to pack a healthy snack to eat on the way home from work
A client reports crushing chest pain 3 hours prior to arrival in the emergency department. Initial assessment by the nurse reveals a BP of 90/50, a weak, thready pulse at 108/min, cool, clammy skin, and confusion. Which interventions should the nurse perform?
suspect cardiogenic shock initiate cardiac monitoring, monitor intake and output hourly, limit physical activity, administer dopamine @ 5 micgrograms/kg/min
tasks to perform at the end of shift:
talk to each nurse about concerns related to assigned clients, complete a client assignment sheet for the oncoming staff, receive report from the emergency department on a new client
A client is seen in an outpatient clinic for anxiety after losing the family home in a hurricane. What nursing interventions would be appropriate for the nurse to make?
teach the client how to use progressive muscle relaxation, assist the client in correctly any distortion being experienced, allow the client time to talk about the loss
patient has a long history of being manipulated by his employer and spouse, what is the best rationale for including assertiveness training in the client's treatment plan?
the client is being taught self advocacy
Ebola virus
there is not a vaccine to prevent ebola
A client is more likely to make healthy choices when:
they are accessible, available, and affordable
Salmeterol inhaler:
this inhaler should be used routinely as prescribed even when free of symptoms
What should the nurse document after a client has died?
time of death, who pronounced the death, disposition of personal articles, destination of body, time body left facility
Fractured hip nursing interventions
turn every two hours, place a pillow between legs when turning, encourage fluid intake, encourage ankle and foot exercises
preeclampsia, assessment finding to report to the doctor immediately:
urine output of 80 ml over four hours; less than the required 30 ml per hour
meal for gout patient
vegetable soup, whole wheat toast, skim milk; low in purine and fat
Adult client just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include in the plan of care?
vital sign checks every 15 minutes 4 times, NPO until return of gag reflex
Which action by a nurse would require the charge nurse to intervene?
walking in the hallway outside the operating room without a hair covering; the hallway outside the OR is restricted to personnel with surgical attire and coverings.
schizo behaviors
waxy flexibility, grandiose delusion, anxiety, agitated behavior
cleaning and dressing a diabetic foot ulcer
wear sterile gloves to clean the ulcer, clean ulcer with normal saline, clean ulcer in a full circle beginning in the center and working toward the outside
