Basic care and comfort

Client with history of diabetes...which the nurse suspects? exhibit: Spec gravity 1030 Protein none Glucose is High RBC none Leukocytes Medium

Dehydration and possible UTI

The nurse is caring for a patient with myasthenia gravis who is recovering from a total thymectomy. Which would be the highest priority to have at this patient's bedside?

Bag-valve mask; This patient should have a bag-valve-mask setup (Ambu) and suction equipment at the bedside. Recent total thymectomy procedure puts this patient at risk for myasthenic crisis (an exacerbation of myasthenia gravis symptoms due to insufficient cholinergic medications) and risk for impaired gas exchange (due to potential hemothorax/pneumothorax)

Hemoglobin

Normal range 12-18 Risky 8-11- report to HCP or surgeon below 7 go to heaven or blood transfusion top S/S= pale skin, pallor, dusky skin tone, cool clammy skin, fatigue and weakness

RBC

Normal range 4-6 million low renal failure, anemia Treatment- Iron, Erythropoietin

The nurse assesses a client with damage to cranial nerve III. Which finding would be expected?

Ptosis: Ptosis, or eye drooping, occurs with cranial nerve III (oculomotor) lesions, myasthenia gravis, and Horner syndrome. Dysfunction of cranial nerve III is also associated with dilated pupil, absent light reflex, and impaired extraocular muscle movement.

BNP

brain natriuretic peptide

respiratory acidosis causes

-hypoventilation slow and low breathing. retains to much carbon dioxide treatment: hyperventilation to blow off the CO2

The nurse is educating the parents of a child diagnosed with impetigo. Which of the following statements, if made by the parent, would indicate effective understanding?

1) "I should keep my child home from swim practice until the blisters heal." 2)I should not share my child's linens with anyone else in the house."

Positioning

1. Low fowler: is 30-degree position of head of bed. 2. Semi-fowler- 30-45 degree mostly use for breathing/feeding. 3. Fowler position- 45-60 degree( Sx, Ng feeding) 4.

List of clients of most at risk for Metabolic acidosis? select all.

1. renal failure 2. pyelonephritis 3. patient waiting for dialysis

Urine Specific Gravity

1.003-1.030 Higher: dehydration Lower: diabetes insipidus

Mg +

1.3-2.1 meq/l low mag- Vfib/ torsade de pointe= kills your client

Basic care/ Comfort

1.Position 2. Non- pharmacological 3. mobility and immobility, 4. assistive devices 5. Nutrition, 6. elimination, 7. postmortem care.

The nurse determined that the hemoglobin is normal if which value is noted on the laboratory report?

14 g/dl

INR therapeutic level?

2-3 (Critical at 4 and above)

Lactulose KeyPoint

2-3 soft stool per day Ammonia decreases level. Cognition improves. Mental status improves

The non diabetic client is admitted for a kidney infection that has now turned septic. The blood sugars have increased from 150 to 225, what is the best answer to give a family member who is asking why insulin is used? 1. the client now has type 2 diabetes because of the infection. 2. Insulin is given to control the hypoglycemia 3. High sugar is common during infection and stress to the body; the insulin will help lower the sugar until the infection resolves. 4. Be quiet and let me do my job.

3. High sugar is common during infection and stress to the body, the insulin will help lower the sugar until the infection resolves.

PTT

30-40 sec The therapeutic range for coag therapy is 1.5 - 2 x the control value.

PTT (Heparin therapeutic range)

46-70 seconds

The nurse has become aware of the following client situations. The nurse should first follow up with which client?

A client with pneumonia that has become restless and confused.

Which potential problems is the client at risk for developing?

AFIB, CVA

highest priority ABC

Airway, Breathing, Low PaO2 norm 80-100 High CO2 over 45 Mental changes restless, agitation. Skin; Pale dusky, cool and clammy. Circulation Bleeding- High PTT/INR Shock-sever low BP chest pain(any kind) HTN crisis over 180

Liver failure labs

Ammonia HIGH- Hepatic encephalopathy Albumin low under 3.5 / Calcium low/ platelet count low Bilirubin HIGH Coagulation panel clotting time HIGH, PTT, INR, PT Elevated ALT/AST

Procedure for collecting sterile urinalysis from a foley bag?

Answer: 1. clamp the drainage tube below the port 2. wait 15-30 minutes 3. scrub the port using an antiseptic swab 4. Attach sterile, needless access to aspirate via the port

Anti acid

Anti mixing with other meds it block the absorption of other meds. take 1 hour before or after medication

Bleeding High priority

INR over 4 aPTT over 100 Action: 1. Stop/Hold drug 2. Access any bleeding 3. Prepare antidote: Vitamin K for warfarin; Protamine sulfate for Heparin. 4. Notify HCP

MI causes/risk factors

Atherosclerosis. S-stress, stimulant's, smoking. O-obesity D-diabetes. D-Diet high cholesterol A-African American men

Renal lab values

BUN 20 max creatinine over 1.3 is bad kidney urine output 30mL/hr or less= Kidney distress

Ca= contracts the muscles

Ca 9.0- 10.5 Meq/L

The nurse is caring for a client who recently had a total parathyroidectomy. Which of the following medications should the nurse anticipate that the primary health care provider (PHCP) will order?

Calcium carbonate, Cholecalciferol Hypocalcemia sign: Convulsion, arrythmia, spasms, Tetany

The nurse notes that the 39-week pregnant client is experiencing placenta previa. Knowing the contexts surrounding this condition, the nurse refrains from performing which of the following standard procedures?

Checking the cervix for dilation, the cervix should not be assessed for dilation. Placenta previa arises when the placenta develops in a problematic spot, close to or over the cervical os. To prevent bleeding or premature labor, women with placenta previa shouldn't have their cervix checked manually. Instead, an ultrasound may be performed.

H2 blockers

Cimetidine Ranitidine Famotidine Nizatidine

Cholesterol panel

Clogged arteries risk. total cholesterol 200 or less LDL 100 or less HDL 40 or more excellent triglycerides 150 or less

Which form of therapy would most likely be used to treat a group of clients affected by phobias?

Cognitive behavioral psychotherapy

Client diagnosed fluid volume overload. the nurse would expect to note finding about the hematocrit levle?

Decreased

Which of the following signs does the nurse know to expect for her 1-year-old patient in heart failure?

Diaphoresis is an expected clinical manifestation of heart failure. As the heart works harder and harder to maintain cardiac output, the body starts to tire, which manifests in signs such as diaphoresis. Poor feeding: is another expected clinical manifestation of heart failure in infants and children. As the left side of the heart begins to fail, fluid backs up in the lungs (pulmonary edema). This causes dyspnea and makes eating increasingly tricky for patients.

Dalteparin

Fragmin Low Molecular Weight Heparin

"HePTT" the frog

H= heparin P = Antidote = Protamine sulfate PTT = 46-70 _______________________________________________________________________ Frog jumps because heparin = works fast

Hypoglycemia S/S

Headache, Irritability weak anxious sweaty hunger

Which blood lab test result should the nurse report to HCP?

Hemoglobin 6, Potassiom 6.5, sodium 150, WBC 2,000

CKD priorty treatment

High K+ IV calcium gluconate- Dysrhythmias IV 50% Dextrose + regular insulin Kayexalate Dialysis

Labs: High priority= safety

Infection: Priority: Less than 5,000 WBC "Leukopenia" Kidney labs: creatinine over 1.3 = bad kidney pain: Chest pain #1 priority, compartment syndrome broken limb pain/cast, unrelieved with pain meds

Client with a hemoglobin of 10.8 g...is most likely caused by which condition?

Iron deficiency- Anemia

Client presents with a concern for intermittent palpitations. He reports they come on suddenly and that he also gets dizzy, short of breath, and fatigued. He indicated that they last anywhere from twenty to thirty minutes. He reports experiencing three episodes of palpations in the past week. He reports he has not taken any new medications or an increase in stress. He reports full adherence to all his prescribed medications.

Irregular pulse, Reports of palpitations

Which of the following does the APGAR scoring system indicates?

Irritability, heart rate, respiratory, muscle tone and color. The APGAR systematic method assessing newborn physical condition.at birth.

magnesium hydroxide

It can upset the stomach and liquid bowel movements

Potassium= K+ High potassium

K+ 3.5-5.0 meq/L= NML high potassium( 5.0+) High pumps peaked T waves, ST elevation

Reglan (metoclopramide) prescription order & report to HCP immediately

Lip smacking Puffing of cheeks Blinking of eyes

57-year-old male reporting increasing dyspnea and abdominal pressure after missing his previously scheduled paracentesis. The client reports he feels 'uncomfortable.' He is alert and oriented x 4; sclera is yellow along with jaundice skin appearance. Respirations were labored, tachypnea, and clear breath sounds. Abdominal distention noted, hypoactive bowel sounds in all four quadrants. Ascites and dependent edema were noted. Peripheral pulses were intact.

Labored breathing, Respiratory rate Oral temperature

WBC

Normal 5,000 - 10,000

Enoxaparin

Lovenox

Potassium low

Low K+ below 3.5 Low pump Low T waves, ST depress, U waves

The nurse is in the postpartum unit assessing a client who gave birth 2 hours ago. The nurse notes that the client's fundus is soft and boggy. Her perineal pads have been changed twice over the past 2 hours. What is the initial action of the nurse?

Massage the fundus until it is firm.fundus is soft and boggy is to massage it until it is firm. Massaging the fundus stimulates it to contract and expels blood clots.

patient teaching bleeding precautions

NO EGGGOS Vitamin E Omega 3 ginseng St john wart ginkgo biloba garlic

Sodium = Na+

Na= 135 - 145 Meq/L Low Na- mental status changes Seizure/ coma, raspatory arrest High Na- Edema, increase muscle tone, flush red rosy cheeks.

CD4 count

Norm: over 200 anything below 200 indicates aids

Acid-Base & ABGs

PH 7.35 - 7.45 PaCO2 35 - 45 HCO3 22 - 26

Hyperglycemia S/S

Polydipsia, polyuria, polyphagia, blurred vision, weakness, weight loss, syncope. Acute 115 or more 4 s Sepsis #1 infection cause Stress (surgery, stress skip insulin Steroids

respiratory alkalosis causes

hyperventilation (anxiety, PE, fear), mechanical ventilation treatment: Breathing into paper bag slow down breathing/retain CO2

Diabetes Labs

Random level: 70-115 Fasting: under 100 Hemoglobin: less 6.0 is controlled and fixed

acid prevention drugs

Regular bone density test.

Client with GI bleeding...laboratory results hct level of 30%. Which action should the nurse take?

Report the critical labs

INR

international normalized ratio 0.9 - 1.2

1-1 . 58-year-old client with a history of hypertension and diabetes mellitus type I reports headaches and elevated blood pressure. The client reported the headaches started one day ago and have worsened.

Specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress: DX Hypertensive emergency, Administer prescribed nitroprusside, Blood Pressure. Check Thiocyanate levels,

Neutropenic precautions

low grade fever priority private room, no fresh flower or fruits avoid crowds and sick people no drinking water from a pitcher or sitting more than an hour

The 6-year-old immigrant child has been diagnosed with Hepatitis A. He was brought from Mexico by his grandparents a few days ago. You would expect that treatment for this child will include

Supportive care: Hepatitis A is typically an infection that is self-limiting if the child receives the appropriate supportive care. The disease is usually transmitted by drinking water and food that is contaminated with fecal matter. Removing the source of the infection and providing a healthy diet will often help resolve the infection. A hepatitis A vaccine is available that should be given to all children and high-risk adults. This vaccine should be given in two doses.

MI (myocardial infarction)/ heart attack

T- tropin over 0.5 T- trauma to the heart

Hypoxia sign

mental status changes restlessness, confusion, agitation

metabolic acidosis

decreased pH in blood and body tissues as a result of an upset in metabolism like excessive diarrhea, renal failure,

Elevated HCT

dehydration

The nurse is preparing to administer a regular insulin IV bolus to a client. The primary health care provider (PHCP) has prescribed an initial bolus dose of 0.1 unit/kg. The client weighs 242 lbs. How much regular insulin should the nurse administer to the client as an IV bolus?

To solve this problem, the client's weight needs to be converted to kilograms. 242 lbs / 2.2 = 110 kg. Next, multiply the ordered dose of 0.1 units by the weight of 110 kg. This should equate to 11 units

what would be high RBC

dehydration

The charge nurse is reviewing room assignments and recognizes that only one private room is left. It would be appropriate to assign this room to the client with

disseminated herpes zoster. Disseminated herpes zoster requires airborne and contact precautions until lesions are dry and crusted.

cardiac enzymes

Troponin: <0.2 ug.L, if elevated indicates MI BNP: <300 pg/mL, if elevated indicates CHF, MI CK-MB: <10.5 pg/mL; determines the occurrence of recent MI

The nurse is caring for a client with a phosphorus level of 5.3 mg/dL. The nurse identifies which of the following as possible causes of this condition?

Tumor lysis syndrome, Hypoparathyroidism, renal failure: #This client has a phosphorus level of 5.3, which is greater than the normal 3.0-4.5 mg/dL. Tumor lysis syndrome can cause increased phosphorus levels, because when a tumor lyses the cellular contents (including phosphorus) are spilled out into the blood causing an increase in their serum levels.

Cirrhosis S/S

Twitching extremities in the arm= Asterixis Mental status change: confusion and Bizzard behavior ded.

what type of diabetes is nondependent for insulin?

Type 2 with diet and exercise

metabolic alkalosis

elevation of HCO3- usually caused by an excessive loss of metabolic acids like vomiting or NSG suction

Decreased HCT

fluid volume overload

Client with an infected toe due to diabetes is scheduled for cardiac cath with contrast, which lab values should the nurse report to the provider? BUN level 1.9 Blood glucose 155 Creatinine level 1.9

answer is Creatinine level 1.9.

Cirrhosis key assessment

assesses hand movements with arm extend Assess mental status with from previous shifts Assess recent blood draws for Ammonia level

ANP

atrial natriuretic peptide

Platelets

blood clotting 150K- 400K less than 150 notify HCP less than 50k VERY RISKY

Alkalosis

pH above 7.45

acidotic

pH less than 7.35

The nurse is interviewing a client who reports frequent urination and nausea. The client is concerned that she may be pregnant. The nurse understands that these manifestations are

presumptive sign of pregnancy: Nausea and urinary frequency are manifestations associated with presumptive signs of pregnancy

CHF (congestive heart failure)

the heart is unable to pump its required amount of blood BNP is under 100

Hematocrit

total blood value Normal range- 36- 54%

H2 blocker

treat peptic ulcers by blocking H2 (histamine 2) receptors in the stomach that trigger the release of hydrochloric acid

What type of diabetes is insulin dependent?

type 1 diabetes