Fundamentals
After a total hip replacement, the patient should not stay in the same position for more than
1 hour. Frequent standing, stretching, and movement is encouraged
Tuberculosis
An infectious disease that may affect almost all tissues of the body, especially the lungs
Benztropine Mesylate
Antiparkinson Agent
A newly diagnosed diabetic is receiving consultation about the disease process. The nurse explains that insulin is normally secreted from the
Beta cells of the pancreas
Pheochromocytoma
Hypertension
Bumetanide is a loop diuretic. What is worrisome about giving this medication is the fact that the client is allergic to sulfonamides.
It is contraindicated because there is a cross-sensitivity with thiazides and sulfonamides.
Hyperbilirubinemia is?
Normal, physiologic jaundice appears after 24 hours of age and disappears at about one week.
purpose of anti-embolic stockings. What is the nurse's best response?
Promotes the return of venous blood to the heart and assists in preventing blood clots
pancreatitis
Standard precautions
Sulfonylureas Adverse Effects
hypoglycemia
A first time mother is to be discharged with infant. The LPN asks the client about the discharge teaching presented earlier in the shift. What statement by the client would indicate the need for further instruction?
"I will wake my baby every two hours to feed so she does not dehydrate." / The LPN knows the client needs further teaching when an inaccurate statement is made. In this case, the client states it is necessary to wake an infant every two hours for feeding in order to prevent dehydration. This is not an accurate statement. Infants feeding appropriately do not dehydrate unless there is an ongoing problem with emesis or fever. Also, infants need to begin developing extended sleep patterns and purposely waking the newborn is not necessary.
An expectant mother asks about fetal movements. What is the best explanation by the nurse?
"You should feel activity between weeks 16 to 20."
Expressive aphasia (Broca's)
-Individual knows what wants to say but cannot say it
Oliguric phase
-Urine output decreases -UO of 100-400 mL/24 hours -This client is in fluid volume excess -The potassium will be increased!
The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What actions should the nurse initiate?
1. Measure the calf and thigh daily. 2. Apply sequential compression device to legs. 3. Position paralyzed leg with each distal joint higher than the proximal joint.
early warning signs of Alzheimer's Disease (AD). What signs should be included in the program?
1. Mild disorientation 2. Difficulty with words and numbers
A normal resting heart rate for adults ranges from
60 to 100 beats per minute
pulmonary embolus
Blockage of the pulmonary artery or one of its branches due to a translocated clot
varicose veins
Get moving. Walking is a great way to encourage blood circulation to the legs. Low-heeled shoes work calf muscles more, which is better for veins. To improve circulation in legs, take several short breaks daily to elevate legs above the level of the heart. Do not cross legs as it decreases circulation distally.
tall (stature)
Gigantism: Excess of growth hormone prior to puberty Prior to fusion of the epiphyses Acromegaly Excess secretion of growth hormone in an adult Usually secreted by an adenoma Broader bones Enlarged hands and feet Protruding mandible Large tongue
The nurse cares for a client who is scheduled for an upper GI series. The nurse dicusses information with the client about the test. Which statement by the client indicates an understanding of the nurse's discussion?
I'll have to drink contrast while x-rays are taken.
The nurse is caring for a postpartum client with an episiotomy and external hemorrhoids. Which comfort measures are appropriate for this client?
1. Apply ice to perineum for first 12 hours. 2. Take sitz baths at temperature of 107.6°-111.2°F (42-44°C). 3. Use witch hazel compresses on rectal areas for hemorrhoids. 4. Take ibuprofen for pain. 5. Apply topical anesthetics to perineal area. 6. Avoid sexual intercourse until episiotomy has healed. / 1., 3., 4., 5., & 6. Correct: Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Chemical ice packs or clean gloves filled with ice may be used during the first 12 hours after a vaginal birth. Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling and help repair broken skin. Analgesics such as acetaminophen and nonsteroidal anti inflammatory drugs (NSAIDs) such as ibuprofen frequently are prescribed to provide relief for mild to moderate discomfort. Topical anesthetic may be used as needed to decrease surface discomfort and allow more comfortable ambulation. Sexual intercourse prior to healing of the episiotomy may contribute to further perineal damage. 2. Incorrect: This temperature is too hot and can damage the injured tissue. The sitz bath should be at a temperature of 100-104°F (38-40°C).
Bacterial Meningitis
inflammation of the protective membranes covering the brain and spinal cord caused by various types of bacteria
A client is admitted to the LDR from the emergency department at 34 weeks gestation with profuse, painless, bright red vaginal bleeding. The priority action by the nurse is to prepare for which procedure?
Ultrasound exam
Kernig's sign
a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down
continuous ambulatory peritoneal dialysis (CAPD)
allow waste products, including creatinine and extra fluids, to be removed from the blood through the process of osmosis and diffusion , dialysis solution is left in the abdomen for 3 to 5 hours, and the patient is allowed to walk around during the dwell time
Impetigo is a severe skin infection characterized by itchy, red, fluid-filled blisters caused by either staphylococcus or streptococcus bacteria
contact precautions
orotracheal suctioning
deep suctioning, soft catheter to the level of the carina preoxygenate check equipment insert catheter to desired location no further than carina, no suction apply suction and withdraw the catheter with a twistin motion DO NOT EXCEED 15 SECONDS to prevent hypoxia
Redness, swelling, and warmth of the calf would suggest either a
deep vein thrombosis or cellulitis infection
primigravida
first pregnancy
Common clinical manifestations of hypothyroidism include
fluid retention, facial edema, cold intolerance, weight gain, bradycardia, and depression
Oral cholecystography confirms the presence of
gallstones
A surgical floor nurse is caring for a post-operative client who has undergone a total thyroidectomy. Which of the following are important nursing assessment measures during postoperative care?
hemorrhage,d positive Chvostek's and Trousseau's signs; and decreased serum calcium levels. Tetany
Tensilon test confirms the diagnosis
of myasthenia gravis
hemiplegia
paralysis of one side of the body
Agnosia
the inability to recognize familiar objects.
Hemodialysis uses the process of
ultrafiltration, which requires continuous contact between the blood and dialyzer to clear toxins
multigravida
woman who has been pregnant more than once
pyelonephritis after being treated for a UTI. Which of the following interventions is most important?
• Fluid intake of 3 L/day will help clear the bladder and urinary tract of contaminated urine. This will also help prevent calculus formation
ascending weakness
Guillain-Barre
The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which actions should be included when caring for this client?
Incorrect: Medications to stop diarrhea will not be prescribed with c. diff. because they cause even further irritation
A client was started on haloperidol 5 days ago, the nurse notes restlessness, muscle weakness, drooling, and a shuffling gait. What should be the nurse's first action?
1. Hold the next haloperidol dose. 2. Administer the prn benztropine mesylate. 3. Notify the primary healthcare provider to discontinue the haloperidol. 4. Draw a blood sample for drug level. 2. Correct: Benztropine mesylate is an anticholinergic that counteracts the extrapyramidal symptoms (EPS) seen with the use of haloperidol. 1. Incorrect: Holding a single dose of haloperidol does not correct the extrapyramidal symptoms. 3. Incorrect: The primary healthcare provider has prescribed benztropine mesylate to combat the side effects of the haloperidol. There is no need to notify the primary healthcare provider, which will delay treatment. 4. Incorrect: The client is showing extrapyramidal symptoms associated with haloperidol therapy. Benztropine mesylate is an anticholinergic agent that can be used to treat the extrapyramidal effects that may be seen as a side effect of haloperidol therapy.
gastroesophageal reflux disease (GERD)
My last daily meal should not be within 2 hours of bedtime
The nurse knows that the insulin should start to lower the blood sugar within how many minutes?
15 minutes
The nurse is reinforcing teaching with a client who is at risk for developing a stroke. What primary prevention strategies should the nurse include?
3-4 sessions per week of moderate-vigorous intensity aerobic physical exercise to reduce stroke risk factors
A primigravida admitted with a diagnosis of placenta previa
A client with a diagnosis of placenta previa is at high risk for bleeding and must be monitored closely. Placenta previa is a complication of pregnancy in which the placenta is either partially or wholly inserted in the lower uterine wall and blocks the cervix. It is the leading cause of antepartum hemorrhage. Clients with this complication will have to have a C-section to prevent harm to the mother and fetus from bleeding.
A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider?
Blood pressure 90/62 / Hypotension is an adverse effect of epidural analgesia due to vasodilation. Maternal hypotension reduces blood supply to the placenta, decreasing fetal oxygen supply. Immediate intervention is required.
Parathyroid
Calcium
During client care rounds with the multidisciplinary team, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client. The primary healthcare provider writes the prescription. Which statement best describes this action?
Collaboration of care among members of the multidisciplinary team.
The nurse is caring for a patient with an arteriovenous (AV) fistula on the right arm for hemodialysis treatments. To promote safety, the nurse should do which of the following?
Evaluate the fistula for the presence of a thrill and bruit,take blood pressure on the left arm
Tyramine foods
Fruits and Veggies are okay except remember salad BAR, avoid Banannas, Avacados, Raisins, Grains are okay except for active yeast, no organ meats, no preserved meats, no dairy, no alcohol, tinctures, caffiene, chocolate, licorice, soy sauce
A patient with acute renal failure has passed the anuric/oliguric phase and is starting to produce urine. Her creatinine is returning to normal but she is losing serum electrolytes. Which of the following characteristics of this phase would explain the loss of electrolytes
Increased glomerular filtration rate
Uhtoff's phenomenon
Multiple sclerosis /worsening in symptoms with heat or increases in body temperature
The nurse is assessing a patient who has been suffering from low back pain for the past three weeks. Which of the following suggests a herniated disc?
Numbness and pain in the foot,pain radiating down the posterior hip and thigh,weakness when raising big toe and ankle
Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)?
People with Alzheimer's disease (AD) get more confused over time. They also may not see, smell, touch, hear and/or taste things they once did. By creating a contrast in color between the floors and walls makes it easier for the person with AD to see.
Episiotomy care
Perineal care; fill a squeeze bottle with warm water and an ounce of povidone/iodine solution; lavage perineum with several squirts and blot dry instead of rubbing; avoid anal area
A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety?
Restrict any visitors with visible illnesses./Awesome! You have realized the client's immune system, which is impaired from the disease process, will be further weakened from the methylprednisolone infusions. The client would be highly susceptible to any contagious diseases or illnesses. Restricting visitors with obvious illnesses or respiratory symptoms helps to protect the client from developing additional illnesses.
Buerger's disease
The disease is characterized by inflammation in the arteries that results in a vaso-occlusion type phenomena. The claudication, with symptoms described here, can quickly progress to a critical degree of limb ischemia. As it progresses, revascularization may not be possible, and amputation may be the only viable option. This is seen almost exclusively in heavy smokers or those who use other forms of tobacco. Medications are not generally helpful, so stopping tobacco use is basically the only way to stop the progression of this disease
Who often performs the responsibilities of a case manager? Select all that apply: 1. Physical therapist 2. Social worker 3. Primary healthcare provider 4. Nurse 5. Unlicensed assistive personnel
2. & 4. Correct: A client's case manager can be a nurse, social worker, or other appropriate professional.
Rigidity, bradykinesia, and small, shuffling steps are all symptoms seen with
Parkinson's disease and can put a patient at risk for falls
A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse reinforce to the client about how to take these medications?
Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate / When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least 30 minutes after taking the lansoprazole before taking sucralfate.
Timolol Maleate (ophthalmic)
This medication decreases the production of aqueous humor
rigidity
lacking flexibility; fixed in opinion
The nurse is assessing a patient with chronic renal failure (CRF). Which assessment finding would the nurse look for?
• Uremia is the build up of nitrogenous waste products due to the kidneys inability to excrete
Haemophilus influenzae
meningitis
Zolpidem
"I may do things in my sleep that I will not remember the next day."
Psychiatric advance directives (PADs)
1. "The PAD permits a client to express his/her wishes regarding future treatments, such as administration of medications and electroconvulsive treatment." 2. "The PAD should be followed even if an emergency situation exists." 3. "The PAD should be followed even if the client expresses that he does not wish to be involuntarily committed." 4. "The PAD should be followed even if the client's wishes conflict with accepted practice standards." 5. "The PAD is usually created by a client who experiences acute episodes of psychiatric illness and becomes unable to make treatment decisions." 1. & 5. Correct: Psychiatric advance directives permit clients to express their wishes regarding future treatments. Psychiatric advance directives are usually created by clients who experience acute episodes of psychiatric illness and become unable to make treatment decisions. 2. Incorrect: Psychiatric advance directives do not have to be followed in an emergency situation. 3. Incorrect: Psychiatric advance directives do not have to be followed if the client must be involuntarily committed to prevent harm to self or others. 4. Incorrect: A client's PAD is not followed if it conflicts with accepted practice standards.
three classifications indicating pregnancy.
1. Probable 2. Positive 3. Presumptive
Positive Chvostek's sign
Hypocalcemia
Sodium reabsorption and potassium excretion is the responsibility of
aldosterone
Osteomyelitis
inflammation of bone and bone marrow
Abdominal Assessment
inspection, auscultation, percussion, palpation (IAPP)
The nurse is caring for a client who had a transurethral resection of the prostate (TURP). What should alert the nurse of the need to increase the flow of the continuous bladder irrigation?
The drainage is bright red./ The red color indicates bleeding is still present. The irrigation is used to prevent clot formation. Increasing the rate of solution helps flush the catheter
The nurse is assisting an elderly woman with ambulation after a femur fracture. When educating the patient on safe walker use, the nurse should provide the following instructions
The walker should be moved first, followed by a step forward with the affected leg, then a step with the unaffected leg • The walker should have all four tips or wheels on the ground and the patient should be looking ahead when they take steps forward to avoid hazards • The walker should be adjusted to ensure the handles are in line with the hips and that elbows are slightly bent when grasping them
pregestational diabetes
alteration in carbohydrate metabolism identified before conception
Presumptive signs and symptoms suggestive of pregnancy
amenorrhea, breast tenderness, and urinary frequency
Tuberculosis
fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis
hemianopia
is a decreased vision or blindness in half the visual field, usually on one side of the vertical midline. The most common causes of this damage are stroke, brain tumor, and trauma. So nursing actions should be focused on helping the client to see their environment, as well as items and individuals within their environment. As the client is able to compensate for the neglect, then the nurse can gradually move personal items and activity to the affected side
Lactated Ringer's, 0.9% normal saline, and 5% dextrose in 0.225% saline are all
isotonic solutions, capable only of expanding the ECF
infratentorial craniotomy for a brain tumor
keep the head of bed flat and place a small pillow under the nape of the patient's neck to promote venous return and reduce ICP
Hypocalcemia and agitation are the opposite of what is expected due to the inability of the
kidneys to filter and rid the body of toxins
Normal heart rate
60-100 bpm
benefit most from a quad cane?
A recent stroke victim with partial left leg paralysis
dysrhythmia
Abnormal heart rhythm
Hypoglycemia, hyperkalemia, and hypotension are associated with
Addison's disease
Measles (also called Rubeola)
Airborne precautions
auscultate breath sounds
Anterior and posterior aspects of all lung fields
Enoxaparin
Anticoagulant
Haloperidol
Antipsychotic
prevent chronic obstruction pulmonary disease (COPD)?
Ceasing cigarette smoking
A pregnant woman who has just been admitted to the labor and delivery room states that her "water just broke". What should the nurse do immediately?
Check fetal heart rate (FHR) pattern / Check the FHR immediately following the rupture of membranes. Changes in FHR pattern such as bradycardia or variable decelerations may indicate prolapsed umbilical cord.
Suddenly, the resident crosses her hands at her neck. What action should the nurse perform first?
Checking to see if the client can speak or cough is first. Then 6-10 abdominal thrusts should be attempted
most accurate in predicting kidney function?
Creatinine clearance
Patient's often have adipose deposits on the face (moonface), trunk, and upper back (buffalo hump)
Cushing's syndrome
oliguria
Decreased urine output
when administering fentanyl
Do not shave area where patch will be applied and do not apply over dense hair areas. If there is hair on the skin, clip the hair as close to the skin as possible, but do not shave
A nurse is administering a tuberculosis skin test to a patient at high risk for TB. During patient education, the nurse should include which of the following facts about the tuberculosis skin test?
It doesn't differentiate between dormant and active TB
What menopausal changes, in general, would the nurse explain to the client?
Loss of muscle mass
A definitive diagnosis of Alzheimer's disease
MRI, Positron emission tomography (PET) scan , Computed tomography (CT)
Staphylococcus aureus
Most common cause of osteomyelitis, MSSA: nafcillin, oxacillin, dicloxacillin (antistaphylococcal penicillins); MRSA: vancomycin, daptomycin, linezolid, ceftaroline
backache
Provide heat therapy, Providing a back massage, Assisting the client into a side lying position.
Pseudomonas
The most common organism in burn-related infections.
Respiratory rate:
The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.
Which of the following are a result of ADH secretion?
Urine concentration
assume the
Worst
thromboembolism
a piece of detached blood clot (embolus) blocking a distant blood vessel
orthopnea
ability to breathe only in an upright position
Dysgraphia
difficulty in handwriting
Decreased BUN would be a result of
diuretic phase
The caregiver should be taught to expect the infant's stools to be
green and the urine dark because of photo degradation products (breakdown of bilirubin for excretion).
Fiber
is healthy for post partum clients to prevent constipation, but especially for those with heart disease.
The RN is responsible for assessment, evaluation, formulating the care plan, and teaching plan, and teaching complex topics. The RN cannot delegate these tasks
to the PN and UAP.
precipitous delivery
very rapid delivery
cataract surgery indicates to the nurse that follow up is needed?
"I will notify my primary heathcare provider for any amount of discharge, redness or scratchy feeling because these symptoms are abnormal.
An LPN is providing care for a post-Cesarean section client with a history of cardiac disease. When reviewing home dietary plans, the LPN realizes further instruction is needed when the client makes what statement?
1. "I should eat extra fiber to prevent constipation." 2. "I must drink lots of fluid to increase breast milk." 3. "I will check my weight and record it every day." 4. "I need to rest frequently throughout the day." Always start by analyzing what clues are provided in the question! You see this client has a history of heart disease and has delivered an infant by Cesarean section. Recall that pregnant clients with pre-existing heart disease have many additional problems to consider, especially following the birth. Increased fluid volume during pregnancy places the client at risk for congestive heart failure (CHF). Additionally, a Cesarean section actually places the client at an even higher risk for complications. It is vital for this client to understand specific instructions to follow after discharge. The second important factor to note is the LPN realizes the client needs further teaching, which means you are looking for a client statement that is incorrect! Even though this is not a "select all that apply", you should use the same true/false process with each option. As you read each option, ask yourself if the comment is accurate or incorrect. Remember - you are looking for an incorrect statement by the client! Option 1: Not what you are looking for! This client comment is true. Fiber is healthy for post partum clients to prevent constipation, but especially for those with heart disease. Constipation causes an increased workload on an already weakened heart, potentially leading to more complications. Try another option. Option 2: Excellent choice! You are looking for a false statement, and you found it! While most new mothers are instructed to stay well hydrated for breast feeding, extra fluid is dangerous for a client with known cardiac disease. The client's heart is already overwhelmed from the pregnancy and then the Cesarean section. What this client needs is rest, reevaluation by the cardiologist, and proper diet. Obviously the LPN recognizes the teaching needs reinforced with this client. Option 3: Definitely not. Recall that you are looking for a false statement from the client; however, this comment is accurate. Any client with existing cardiac disease is aware that among the earliest indications of heart failure would be a 2 or 3 pound increase in body weight overnight. This client is aware a daily weight is crucial to detect early complications, indicating successful teaching. Try again. Option 4: Wrong choice. You are searching for an incorrect client comment, but this statement is accurate. Pregnant females need to rest often, particularly those with pre-existing cardiac disease. After delivery, as the heart recovers from the strain of the pregnancy, delivery and increased fluid volume, rest is even more crucial for this new mother. This client will also be dealing with the responsibilities of a newborn. This comment by the client indicates that teaching was very successful. Remember you are looking for a false statement.
The nurse is assisting a new mother with breastfeeding her newborn baby. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake?
1. Birth weight regained in 14 days 3. Pulse rate of 135/min 4. Six to eight wet diapers a day 5. Baby appears satisfied after feedings. Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breast feeding.
orotracheal suctioning
1. Drooling 2. Bradypnea. / 1., 3., 4. & 5. Tachypnea 3. Apprehension 4. Tachycardia 5. Gurgling.
A client was admitted to the medical unit after an acute stroke. What is the best nursing activity that the LPN/VN can accept from the RN?
1. Screen client for contraindications for tissue plasminogen activator (tPA) therapy. 2. Place seizure precaution equipment in client's room. 3. Perform passive range of motion (ROM) exercises. 4. Administer enoxaparin 1 mg/kg subcutaneously every 12 hours. 4. Correct: The LPN/VN can administer subcutaneously medications. 1. Incorrect: This is an RN only responsibility and cannot be delegated. 2. Incorrect: The unlicensed assistive personnel (UAP) can be assigned to place equipment in a client's room. 3. Incorrect: Passive ROM exercises can be done by the UAP.
We need a minimum urinary output of
30 mL's per hour!
Forty eight hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action?
Administer 100% oxygen per mask / This client has developed signs of cardiogenic shock, one of the complications post CABG. Cardiac output is decreased, so the client needs more oxygen for the circulating blood volume
Which nursing action takes priority once a term infant has delivered vaginally?
Dry the baby
A client's sodium is 122 mEq/L (122 mmol/l). Which nursing action is a priority?
Initiating seizure precautions
Brudzinski's sign
One of the physically demonstrable symptoms of meningitis, Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed
non-stress test tell the nurse about a pregnant client?
The baby is doing well and the placenta is providing enough oxygen at this time / Yes, the non-stress test identifies whether an increase in the fetal heart rate (FHR) occurs when the fetus moves, indicating adequate oxygenation, a healthy neural pathway from the fetal central nervous system to the fetal heart and the ability of the fetal heart to respond to stimuli
acromegaly
abnormal enlargement of the extremities
amenorrhea
absence of menstruation
pulmonary embolus s/s
chest and back pain on inspiration, hemoptysis, and dyspnea. This is a potentially life threatening complication and must be reported to the primary healthcare provider immediately
Homan's signs
considered a sign of deep vein thrombosis
An LPN has been pulled from the adult medical surgical unit to the pediatric unit for the shift. What clients would be appropriate for an LPN to accept from the charge nurse on this unit?
1. A 12-year-old with diabetes mellitus. 2. A 6-year-old one day post tonsillectomy. 3. A 3-year-old admitted in sickle cell crisis. 4. A 9-year-old with Hirschsprung's disease. 5. A 2-year-old in a mist tent with epiglottitis. 1 and 4. CORRECT. The LPN scope of practice is task oriented. An LPN floated to a specialty floor, such as pediatrics, should be assigned the most stable, uncomplicated clients, and ideally those that may have a disease process which also occurs on a medical-surgical floor. The 12-year old with diabetes mellitus is a good choice. This client will require accu-checks and SubQ insulin, both of which are within the scope of practice for the LPN. A client with Hirschsprung's disease experiences bowel dysfunction, usually with constipation, pain or anorexia. This client could also be assigned to an LPN who would have experience with bowel issues. 2. INCORRECT. Even though this child is one day post-op, throat surgery would require frequent assessments of the airway and the client's ability to swallow. Additionally, pain medication is usually given I.V. since the child still has difficulty swallowing. LPN's may not give I.V. meds. 3. INCORRECT. Children in sickle cell crisis require on-going assessments of the vascular system as well as the need for supplemental oxygen and pain medication. In addition to the young age of the client, the disease process requires advanced assessments. This client is not appropriate for the LPN. 5. INCORRECT. A two-year-old with epiglottitis in a mist tent will need airway and respiratory assessments frequently, along with teaching the parents about this illness. This client is not appropriate for the LPN.
A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority?
1. Administer an antacid per standing orders. 2. Check client's blood pressure. 3. Call the primary healthcare provider immediately. 4. Assure client this is a normal discomfort of pregnancy. 3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. 1. Incorrect: Not a concern as much as impending seizure symptoms. Administering an antacid will not fix the problem if PIH is worsing. This is delaying care. 2. Incorrect: Not a concern as much as impending seizure symptoms. Checking the client's blood pressure is not the priority in this situation. It will not fix the problem. 4. Incorrect: Not in this situation. Heartburn is a normal discomfort or right upper quadrant pain in a client with PIH may indicate impending rupture of the liver capsule which is a life threatening complication.
Which actions should the nurse include for a client with sickle cell crisis who is experiencing pain?
1. Apply cold compresses to affected joints. 2. Massage affected areas gently. 3. Support and elevate swollen joints.
What instructions regarding phototherapy and its effects should the nurse reinforce with a mother whose newborn has hyperbilirubinemia?
1. Breastfeeding should be discontinued until phototherapy is completed. 2. Feed newborn at least every 2-4 hours. 3. Make sure the newborn's eyes are closed when applying eye patches. 4. Keep the baby quiet and swaddled. 5. Report immediately if the urine becomes dark in color. Phototherapy is the most common treatment for reducing high bilirubin levels that cause physiologic and breastfedding jaundice in the newborn. The newborn is exposed to a type of fluorescent light that is absorbed by the baby's skin. During this process, the bilirubin is changed into another form that can be more easily excreted in the stool and urine. During phototherapy the newborn is undressed so that as much of the skin as possible is exposed to the light. The eyes should be covered to protect the retina from the bright light. Feeding should continue on a regular schedule. There is no need to stop breastfeeding. The bilirubin level is measured at least once a day. Let's look at the options now to see if we can identify what we need to reinforce with the mom about phototherapy. Option 1: Breastfeeding should be discontinued until phototherapy is completed. This is false. Breastfeeding does not have to be discontinued as the milk is not affected. Breast feeding is encouraged and is an important part of meeting both the nutritional and emotional needs of the newborn. Option 2: Feed newborn at least every 2-4 hours. This is true. Do not withhold feeding. Providing adequate breast milk or formula by feeding at least every 2-4 hours is key in preventing and treating jaundice because it promotes elimination of the bilirubin in the stools and urine. Option 3: Make sure the newborn's eyes are closed when applying eye patches. True. When applying the eye patches, the newborn's eyes should be closed to avoid causing a corneal abrasion. Option 4: Keep the baby quiet and swaddled. False. We want the baby's clothing to be removed to allow maximum exposure of the skin to the phototherapy. The genitalia should be covered. Option 5: Report immediately if the urine becomes dark in color. Sounds important, but this is false. The caregiver should be taught to expect the infant's stools to be green and the urine dark because of photo degradation products (breakdown of bilirubin for excretion).
A newly admitted client gives a nurse a pile of legal documents stating, "Put these in my chart." The nurse carefully reviews each document. Which documents should the nurse identify as an advance directive and place in the client's medical record?
1. Living will 2. Last will and testament 3. Patient's Bill of Rights 4. Durable Power of Attorney for health care 5. Health Insurance Portability and Accountability Act. 1. & 4. Correct: The living will is an advanced directive that should be placed in the client's medical record. A living will is a document prepared by a competent individual that specifies the client's wishes regarding health care treatments, resuscitation and life-support measures, end-of-life care, and other specific wishes of the client should the client become incapacitated in the future. The Durable Power of Attorney for health care is an advance directive and should be placed in the client's medical record. The Durable Power of Attorney for health care identifies a health care proxy or surrogate decision maker for the client should the client become unable to make informed health care decisions. 2. Incorrect: The last will and testament is not an advance directive. It is a document that describes the client's wishes regarding the settlement of his/her financial estate after death. This document should be returned to the client. 3. Incorrect: The Patient's Bill of Rights is not an advance directive. It is a document that informs clients of their rights as patients. This document should be given to the client for his/her records. 5. Incorrect: The Health Insurance Portability and Accountability Act (HIPAA) is not an advance directive. HIPAA is a law that provides for the protection of individually identifiable health information. This document should be given to the client for his/her records.
Which referral would the nurse anticipate that the primary healthcare provider would make for a client who has difficulty eating using regular utensils?
1. Occupational therapist 2. Physical therapist 3. Rehabilitation nurse 4. Registered Dietitian. 1. Correct: An occupational therapist helps physically disabled clients adapt to physical limitations and is most qualified to help clients improve their ability to perform activities of daily living. OT's help clients learn to approach tasks differently, use assistive devices or equipment, make adaptations to the home or work environments and find ways to assist the client in meeting personal goals. 2. Incorrect: The physical therapist is trained to deal with problems that limit their abilities to move, perform daily functions, or remain active and independent. However, physical therapists do not assist with special adaptations needed to perform activities of daily living such as eating. 3. Incorrect: A rehabilitation nurse can help a client eat, but isn't trained in modifying utensils. The rehabilitation nurse assists clients as they adapt to altered lifestyles and assists clients to attain and maintain the highest level of functioning. Some of the aspects included in the role of the rehab nurse includes encouraging self care, preventing complications and further disability, setting goals for independent functioning, and assisting clients to access additional care needed. The rehabilitation nurse would work collaboratively with the occupational therapist (OT). The OT is the one who will best meet the needs of this client who is experiencing difficulty eating with regular utensils. 4. Incorrect: A registered dietitian manages and plans for the nutritional needs of clients but isn't trained in modifying or fitting utensils with assistive devices. This would be the role of the OT.
A nurse is caring for a client diagnosed with the ebola virus who is experiencing vomiting and diarrhea. What personal protective equipment should be worn by the nurse while providing care to this client?
1. Single use impermeable gown 2. Powered Air Purifying Respirator (PAPR) or N95 respirator 3. One pair of sterile gloves 4. Single use boot covers 5. Single use apron. 1., 2., 4., & 5. Correct: The nurse should wear a single use (disposable) impermeable gown OR a single use impermeable coverall. Either a PAPR or a disposable, NIOSH-certified N95 respirator should be worn to reduce the risk of contamination in the case of an emergency situation where a potentially aerosol-generating procedure would be performed. The PAPR reduces the risk of self-contamination while providing client care, but the N95 respirator is less bulky. If the N95 respirator is selected for use, nurses should be extremely careful to make sure that they do not accidentally touch their faces under the face shield during client care. Disposable boot covers should be worn and should extend to at least mid-calf. Some agencies may add the single use shoe covers over the boot covers to reduce the risk of contaminating the underlying shoes. If clients with Ebola are vomiting or have diarrhea, a single use (disposable) apron should be worn over the gown to cover the torso to mid-calf. This will provide additional protection to reduce the risk of contaminating the gown (or coveralls) by the infectious body fluids and also provides a way to rapidly remove a soiled outer layer if contamination occurs on the apron. 3. Incorrect: Sterile gloves are not required, but two pairs, instead of one pair, of gloves should be worn so that a contaminated outer glove can be safely removed when providing client care or safely removed without self-contamination when removing the PPE. These gloves should at the very least have extended cuffs.
A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs?
1. Turn the client to the left side. 2. Administer oxygen. 3. Start an intravenous line. 4. Prep the mother for cesarian section. 5. Notify the primary healthcare provider. 1., 2. & 5. Correct: Late fetal heart rate decelerations are associated with fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increases maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary healthcare provider are deviations from the standard of care.
venous thromboembolism (VTE). What actions should the nurse initiate?
1., 2., & 3. Correct: Monitoring for VTEs is accomplished by measuring the calf and thigh daily, observing swelling, noting unusual warmth of the leg, and asking the client about pain in the calf. Prevention of VTEs include the use of sequential compression devices for bedridden clients. This device helps promote venous return. Positioning the paralyzed leg with each distal joint higher than the proximal joint will prevent dependent edema. 4. Incorrect: A trochanter roll does not prevent VTEs. They are used for the prevention of external hip rotation. 5. Incorrect: Passive range of motion exercises should be done several times a day to promote venous return and muscle tone. Once a day is not adequate. 6. Incorrect: Routinely checking the Homan's sign can actually cause a clot to dislodge. The nurse should not perform this procedure.
What should the nurse discuss with a client who has iron deficiency anemia?
1., 2., & 4. Correct: These are examples of iron rich foods. Foods high in iron will help with correcting iron deficiency anemia. Glossitis, anorexia, and paresthesias can result from iron deficiency anemia. Foods high in vitamin C such as citrus fruits, dark green leafy vegetables and strawberries help with absorption. 3. Incorrect: Iron is needed for red blood cell development and oxygen transport to the cells. Iron is not needed for white blood cell development. White blood cells are produced in the bone marrow. 5. Incorrect: Clients should dilute liquid iron with water or juice, drink with a straw, and rinse mouth after swallowing. Iron will stain the teeth.
hypertonic solutions, raising the osmolality of ECF
10% dextrose in water, 5% dextrose in 0.9% saline, and 5% dextrose in 0.45% saline are all considered
Normal respiratory rate
12-20
A low residue diet is recommended for clients with inflammatory bowel diseases such as Crohn's Disease
2 Oatmeal 4. Spaghetti 5. Cantaloupe
A client tells a clinic nurse of plans to travel to Europe by plane. What tips should the nurse provide the client regarding prevention of clot formation?
3. Wear compression stockings while traveling. 4. Frequently move legs while sitting. 5. Avoid coffee while traveling. client should get up and move around at least every 2 hours. When walking, the muscles of the legs squeeze the veins and move blood to the heart
The nurse is administering an ACTH stimulation test to a patient suspected of having Addison's disease. Which of the following is true regarding the ACTH stimulation test?
ACTH levels should be drawn at 30 minutes and 60 minutes after ACTH administration
urological endoscopic procedure
Administer analgesics and antispasmodics for pain and spasm
The nurse is assisting the community health nurse to plan a discussion on how to prevent pesticide ingestion at a local health fair. What should the nurse include in this discussion?
Before we review the options, let's look at the question. The key words in a question should be identified. The key words in this question are community health nurse, prevent pesticide ingestion, health fair, and teaching session. Each option stands alone with the question. After reviewing the question, look at each option and identify if it is true or false. Remember client safety is always a priority. The question is asking about a teaching session to prevent pesticide ingestion. So let's look at the options. Option 1 is true. The outer leaves of green, leafy vegetables such as lettuce, and cabbage should be discarded as pesticide residue likely remains there. Option 2 is false. One of the most common mistakes people make in their attempt to remove all pesticide residue from their produce is that they wash their fruits and vegetables with dish soap. Unless the soap is entirely made of natural and organic materials, it tends to contain harmful compounds that easily penetrate the skin of the fruits. Simply wash with tap water. Option 3 is true. Another great idea to reduce overall exposure to pesticides is to buy organic foods. Organic foods are grown without the use of pesticides or synthetic fertilizers. Option 4 is true. If you can't buy organic, peel fruit and vegetables prior to eating. Option 5 is true. Washing your fruits and veggies is not enough if you want to reduce the pesticide load you expose yourself to, as it is very important to thoroughly dry them with disposable paper towels as well. This will remove all the remaining pesticide residue and make the produce safer to eat. Option 6 is true. A scrub brush is very effective in cleaning the crevices and areas around the stem. The scrub brush should not break the skin of the produce
Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage?
C-section delivery / A client with a surgical wound is at risk for hemorrhage and is at greater risk than birth from a vaginal delivery. The surgical opening of the abdomen and the uterus makes this the highest risk
The nurse is caring for a patient with Cushing's syndrome. The nurse should instruct the patient to:
Check for black tarry stools
The nurse is reinforcing dietary teaching with a client who has been diagnosed with iron deficiency anemia. Which food selections by the client would indicate a correct understanding of foods that should be increased in the diet?
Clients with iron deficiency need foods high in iron. So what foods are high in iron? Red meat, pork and poultry. Seafood. Beans. Dark green leafy vegetables, such as spinach. Dried fruit, such as raisins and apricots. Iron-fortified cereals, breads and pastas. Peas. Do you see any of those options? Yes. Option 1 - peas Option 3 - seafood Option 4 - dried fruit Option 5 - dark green leafy vegetable Option 6 - seafood Option 2, milk is false. Milk slows the absorption of iron.
Cushing's disease. Which of the following statements by the patient indicates an understanding of the management of Cushing's disease
Consume foods high in potassium / Cushing's disease commonly causes hypokalemia by increasing renal excretion of potassium • Cushing's disease also causes hypocalcemia. Therefore, foods high in calcium should be encouraged • Fluid retention is a common side effect of Cushing's disease, fluid intake should not be increased • Contact sports should be discouraged because Cushing's disease causes fragile skin and increased bruising
A newly admitted patient has sustained deep partial-thickness burns to his face and trunk. Which of the following abnormal values can the nurse expect during the emergent phase?
Due to the fluid shift after a burn injury, the blood becomes concentrated and the hematocrit will be elevated • Heart rate will increase (not decrease) due to hypovolemia associated with fluid shift (third spacing) • Potassium levels will increase along with cellular destruction • Hemoglobin levels will be decreased due to the hemolysis of red blood cells • Lactic acid level will increase due to impaired tissue perfusion, not decrease
What response from the nurse would be most appropriate for a 68 year old client who states that they have started experiencing tremors?
Fine tremors are the first symptom reported in 70% of client's diagnosed with Parkinson's Disease
On morning rounds, the nurse finds a somnolent client with a blood glucose of 89 mg/dL(4.9 mmol/l). A sulfonylurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?
Give proton pump inhibitor and hold sulfonylurea until client eats / Hold sulfonylureas for BS <100 until the client eats
Foods that are safe to eat (low in purines)
Green vegetables and tomatoes; Fruits; Breads and cereals that are not whole-grain; Butter, buttermilk, cheese, and eggs; Chocolate and cocoa; Coffee, tea, and carbonated beverages; Peanut butter and nuts
A client arrives at the emergency department (ED) in obvious emotional distress, reporting numbness around the mouth and tingling of the fingers and toes. The nurse notes a respiratory rate of 56/min. What should be the initial intervention performed by the nurse?
Have the client breathe into a paper bag / Recognize the respiratory rate is too fast. This client is hyperventilating and blowing off too much CO2 which has resulted in symptoms of respiratory alkalosis, perioral numbness, and tingling of the fingers and toes. The nurse should try to help calm the client and encourage the client to slow the rate of breathing. This will help hold onto CO2. By breathing into a paper bag, the client will re-breathe CO2 therefore increasing the CO2 level.
Which teaching should the LPN/VN plan to reinforce with the family members of a client diagnosed with hepatitis B?
Hepatitis B is a bloodborne pathogen that can spread via sharing personal items, such as razors or toothbrushes where infected blood can get into a person's cut, mucous membranes, etc
A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse?
I feel like food gets stuck in my throat when I eat /Clients with systemic scleroderma have multiple health problems that need to be managed, so start by remembering Maslow and the basics of the A-B-C's. Hardening tissue in the digestive track results in severe acid reflux and constipation. But of greater concern is difficulty swallowing, placing the client at risk for aspiration or choking with every meal. Airway is always a major concern!
The nurse is instructing a diabetic patient about proper foot care. Which statement by the patient indicates the need for additional teaching?
I should trim corns and calluses with a file to prevent complications / Removal of corns and calluses should be done by a podiatrist or other healthcare professional to prevent open wounds from formin
What signs and symptoms would a nurse expect to see in a client who is close to death?
In the hours before death, blood will be shunted to the vital organs and not the periphery. This will make the extremities cool to the touch and mottled in appearance. Both cool extremities and mottling are due to reduced blood flow. Cheyne-Stokes respirations is a respiratory pattern that consists of loud deep inhalations followed by a pause of apnea. Loss of appetite will occur as energy needs decline. The use of moistened clothes around the mouth and lip balm may help with keeping lips moist and comfortable.
Which victim would the nurse decontaminate first in a biological terrorist event?
Look at each option as true or false. 2. Option 1 is true. The goal is to decontaminate victims who have been exposed, yet are salvageable. 3. Option 2 is false. Clients are ranked for decontamination by who is the most salvageable. Therefore those with injuries needing maximum care are decontaminated after those who have no symptoms and those with minor injuries. 4. Options 3 is false. Clients who are dead are unsalvageable and have the lowest priority for decontamination. 5. Option 4 is false. Clients are ranked for decontamination by who is the most salvageable. Therefore those with minor injuries are decontaminated after those who have no symptoms.
A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin, and uremic halitosis. Which nursing interventions would be appropriate for this client?
Look at the clues. end stage renal failure, pruritus, white crystals on skin, uremic halitosis. What does this point to? Uremic frost.The build up of uremic frost associated with end stage renal disease causes pruritus. What actions can the nurse take to help protect the client's skin from injury and make the client more comfortable? Option 1: Encourage use of cotton gloves during sleep. Would this help to protect the skin? Yes, true. The client may damage the skin while being unaware that they are scratching the skin while sleeping. Option 2: Apply emollients to the skin. True. Emollients and lotion will aid dry, itchy skin. Apply after bathing. Option 3: Increase protein rich foods in the diet. Will this help with uremic frost? No. This is false. In fact, a client in end stage renal disease needs to decrease the amount of protein in the diet. Unhealthy kidneys lose the ability to remove protein waste and it starts to build up in the blood.Dietary restrictions include protein, sodium, potassium, and phosphate. Option 4: Cut fingernails short. Will doing this decrease the risk of skin injury? Yes, true. Cutting nails short will decrease risk of skin breakdown when scratching. Option 5: Provide mouth care prior to meals. Is this true or false? True. Why? Uremic halitosis occurs from a build-up of urea in the body. It produces a metallic taste in the mouth. Mouth care prior to meals will help in eliminating this taste.
A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft. What is the priority nursing intervention?
Massage the fundus. / If the fundus is boggy and soft, massaging the fundus until firm will increase uterine tone and decrease bleeding. This is the only option that will fix the problem
A client who is 3 days post abdominal hysterectomy reports left sided chest and back pain on inspiration. The nurse notes hemoptysis, shortness of breath, and auscultates bilateral rales. Vital signs are BP 140/90, HR 122, Resp 28, T 100°F (37.78°C) . O2 sat is 89%. Based on this data, what is the nurse's priority action?
Notify the primary healthcare provider/The client has likely developed a pulmonary embolus post abdominal hysterectomy. The classic symptoms are chest and back pain on inspiration, hemoptysis, and dyspnea. This is a potentially life threatening complication and must be reported to the primary healthcare provider immediately
After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which action by the nurse is priority?
Place the client in the knee-chest position. The fetal heart pattern is that of repetitive deep variable decelerations. This pattern is likely due to a prolapsed umbilical cord after AROM. The priority action is to relieve the pressure on the cord from being trapped between the presenting part and the pelvis. This can be accomplished by manual pressure on the presenting part, placing the client in Trendelenburg position, or placing her in the knee-chest position.
carina of trachea
Point at which the trachea divides into bronchi
The nurse observes a primary healthcare provider removing gloves after performing an invasive procedure on a client, and then entering another client's room without washing hands. What should be the nurse's action?
Remind the primary healthcare provider of the importance of standard precaution
Proper use of an inhaler
Shake the inhaler well before use (3 or 4 shakes) Remove the cap Breathe out, away from inhaler Bring the inhaler to mouth. Place it in mouth between teeth and close mouth around it. Start to breathe in slowly. Press the top of inhaler once and keep breathing in slowly until a full breath has been taken. Remove the inhaler from mouth, and hold breath for about 10 seconds, then breathe out. If a second puff is needed, wait 30-60 seconds, shake inhaler again, and repeat steps 3-6.
A nurse is assessing the sacral pressure ulcer of a 89-year-old female. She notes that the skin is not intact and the wound bed appears pink with serum fluid. How would the nurse stage this ulcer?
Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallow • Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful • Stage III pressure ulcers: Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present • Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling
A nurse is assisting a post-stroke patient with using a wheelchair. A safe transport from the bed to the wheelchair is observed when which of the following is implemented?
The chair is placed beside the patient on the strong side, with the nurse on the weaker side to help • Blocking the unaffected knee when it buckles helps maintain support and stability during transfer
In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority.
The first client that should be seen is the client with a tracheostomy that needs to be suctioned. This client has an airway problem. Maintaining a patent airway is vital to life and is always the first priority. The next client to be seen is the client whose water seal chamber is empty which prevents the CDU from being a closed system. This can create a breathing problem. The purpose of the water seal chamber is to allow air to escape from the pleural space and yet prevent air from re-entering the pleural space. It is a one-way system. The water should be at the prescribed level (2 cm) to maintain this one-way water seal. If air is allowed to re-enter the pleural space, the lung can collapse again (pneumothorax). Once the other client's airway is suctioned, this would be the next priority. The third client to be seen is the client with a heart rate of 40/min which may be affecting cardiac output. This is a circulatory problem. Circulation follows airway and breathing in priority setting. The fourth client to be seen is the client on bedrest for a DVT. If the client gets up and ambulates, the clot can break lose and form an embolus. Although this could potentially be dangerous, it does not take priority over airway or circulatory issues that exist. The fifth client would be the one reporting frequency and dysuria. This client does not have a life-threatening problem. Therefore, this would be the lowest in priority from the events presented
A patient has symptoms of persistent cough, wheezing, weight loss, shortness of breath, hemoptysis, and lymphadenopathy of the neck. On examination of the patient, the nurse observes a large nodule on the thyroid and firm non-movable infraclavicular lymph nodes. Which one of the following best explains this patients current situation?
This patient presents with several symptoms of lung cancer (coughing, wheezing, dyspnea, hemoptysis, and weight loss) and shows clinical evidence of lymph node involvement and metastasis to the thyroid. The size of the tumor is unknown based on clinical presentation. Cancer Staging T: Size •Tx - Tumor cannot be evaluated •Tis - Carcinoma in situ •T0 - No signs of tumor •T1,T2,T3,T4 - size and/or extension of primary tumor
The nurse is reinforcing discharge teaching for a client with thrombocytopenia. Which should the nurse include?
Thrombocytopenia is a deficiency of platelets, and platelets help your blood clot which stops bleeding. Hard food can cause bleeding as it passes through the esophagus and can cause gums to bleed. A stool softener should be taken daily to prevent a hard stool. Straining and hard stools can lead to tissue trauma and bleeding from the rectum. Well fitting shoes can prevent injury while ambulating. Cool compress will prevent hematoma formation and stop bleeding. 1. Incorrect: This client should not floss the teeth, as bleeding can result. Soft bristle toothbrush will be needed also to prevent injury to gums.
chicken pox
airborne precautions
Hodgkin's disease
are enlarged, but painless lymph nodes, fever, weight loss, and night sweats.
independent nursing interventions
are those sanctioned by professional nurse practice acts. They do not require direction or a prescription from another health care professional.
At a senior citizen program, the nurse who was invited to speak to the group is teaching them about detecting the early signs of cancer. Which of the following should the nurse include?
breast self-exam is the only choice that aids in early detection of cancer
A patient attends a wound clinic for a foot ulcer that will not heal. The patient asks for an explanation as to why his ulcer is not healing. Which of the following diseases would have a negative impact on wound healing, and in turn would require further patient education by the nurse?
diabetes and Peripheral vascular disease (PVD)
acromegaly
enlargement of the extremities/ hands
bradykinesia
extreme slowness in movement
IV fluids should not be administered through a
fistula
Thyroidectomy complications
hypocalcemia = tetany (chvostek's/trusseau's) paresthesia thyrotoxicosis (thyroid storm) throat swealling (glottal edema) hemorrhage/hematoma vocal cord paralysis (hoarseness) dmg to parathyroid glands
Depression and constipation are consistent with
hypothyroidism
placenta previa
implantation of the placenta over the cervical opening or in the lower region of the uterus
Apraxia
inability to perform particular purposive actions, as a result of brain damage.
Diuretic phase
increased urine (water, not wastes). Kidney unable to conserve Na and H20. High BUN. Deficit of K, Na and H20. Azotemia
preeclampsia
indicates the mother's blood pressure has consistently been elevated; that is, a systolic greater than 140, and/or a diastolic greater than 90
Tetnay
involuntary contraction of muscles due to increased frequency of action potentials -typical symptoms: nervousness and hyperirritability, tremors and convulsions, twitching of facial muscles, staggering gait
Bumetanide
is a loop diuretic used to treat edema due to heart failure by inhibiting the reabsorption of sodium and chloride from the loop of Henle and the distal renal tubule. This increases renal excretion of water, sodium, magnesium, potassium, and calcium. The problem with administering this medication to the client is that the client is allergic to sulfonamides. Chemically, bumetanide is 3-(butylamino)-4-phenoxy-5-sulfamoylbenzoic acid. Notice sulfamoylbenzoic acid. Therefore, there can be a cross sensitivity between taking bumetanide and sulfonamides. This is the correct answer.
Shigellosis
is an infectious disease caused by a group of bacteria called Shigella (shih-GEHL-uh). Most who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria. Shigellosis usually resolves in 5 to 7 days. Some people who are infected may have no symptoms at all, but may still pass the Shigella bacteria to others. The spread of Shigella can be stopped by frequent and careful handwashing with soap and taking other hygiene measures
expressive aphasia
is associated with brain trauma or cerebral vascular accident (CVA) and prevents the client from verbalizing appropriate or desired terminology
Increased glomerular permeability and damage to the basement membrane describes
nephrotic syndrome
Anuric
not producing urine
A patient with renal failure has developed uremic syndrome. While assessing this patient, the nurse would expect to note which of the following?
oliguria, edema, hypercalcemia, hyperkalemia, and other electrolyte imbalances, diminished mental status, and fatigue
glaucoma
optic nerve deteriorates, blind spots develop in your visual field, starting with your peripheral (side) vision
The nurse is caring for a patient dependent on a mechanical ventilator. In order to reduce the risk of developing pneumonia, the nurse should
perform oral cares every 4 hours, reposition every 2 hours, and keep the head of bed elevated to prevent aspiration
Painless, bright red vaginal bleeding is a sign of a
placenta previa. Ultrasound can confirm this diagnosis with minimal risk to the mother and her fetus. This is the safest action for this client and best for fixing the problem
Elevated hemoglobin and hematocrit are signs of
polycythemia
hyperglycemia includ
polyphagia, polydipsia, polyuria. Later signs or symptoms of hyperglycemia may include pruritus, dry mouth, confusion, a fruity odor of the breath, rapid breathing, and abdominal pain
The most common negative side effect of epidural anesthesia is a
precipitous drop in blood pressure.
When caring for a patient with Alzheimer's disease, which of the following is the most important?
regular assessment of the patient's cognition
Knee flexion should
relieve pain caused by disc herniation
Vitamin B12 deficiency can cause
reversible memory and attention problems
Suctioning is indicated with the presence of wet respirations
rhonchi, increased peak inspiratory pressure, bubbling in the ET tube, restlessness, and increased respiratory and heart rates. Increase 02 requirements would result from poor ventilation secondary to mucous in the airways
Signs and symptoms of hypoglycemia include
shakiness, anxiety, nervousness, diaphoresis, weakness, palpitations, chills, hunger, irritability, confusion, unconsciousness, impaired vision, and headache
thyroidectomy
surgical removal of the thyroid gland
Vitamin K reverses the anticoagulant effects of
warfarin, so instruct the client to avoid foods high in vitamin K (examples are green leafy vegetables, brussels sprouts, prunes, cucumbers and cabbage).
Phlebotomy and blood pressures should not be performed on the arm
with the fistula
