Nclex
Animal and poultry flesh are not consumed because it means taking the life of the animal. Taking the life is forbidden.
Fiods are not consumed Hindu diet.
Renal failure (urine is not concentrated is not diluted anymore)
Fixed urine specific gravity indicates
Syndrome Of Inappropriate Antidiuretic Hormone (Siadh)
Fluid retention- opposite of diabetes insipidus.
antidote for Benzodiazepines.
Flumazenil
60-80 seconds
For a client taking warfarin, the PT should be between
client should use a pillow between the legs for the first six weeks post surgery when lying on the nonoperative side or when supine.
For the first 6 wks after hip replacement (arthoplasty)
3rd stage, lasts 5-30 minutes
From the birth of infant to birth of placenta
(3rd degree): Total destruction of epidermis and dermis, decreased blood flow due to eschar. Painless, varied color edema. extensive contact with hot objects,
Full thickness burn.
By day 10.
Fundal position: Becomes pelvic organ again usually by _____
At or 1 cm/finger breadth above the umbilicus for the first 12 hours. Descend by one finger breadth each succeeding day
Fundal position: each succeeding day after 12 hours
At or 1 cm/finger breadth above the umbilicus for the first 12 hours.
Fundal position: for the first 12 hours. postpartum,
• 15 = Highest Score • 8 = intubate REPORT Decreasing GCS score!
GCS Score Highest Score intubate
of 35.
General guidelines recommend attempting to get pregnant for at least one year before undergoing fertility testing and treatment until the age
health care provider may recommend treatment and testing right away.
General guidelines recommend attempting to get pregnant for at least one year before undergoing fertility testing and treatment until the age of 35. If between the ages of 35-40, it is recommended to attempt 6 months of unprotected intercourse before seeking treatment. If over the age of 40,
6 months
General guidelines recommend attempting to get pregnant for at least one year before undergoing fertility testing and treatment until the age of 35. between the ages of 35-40, it is recommended to attempt
insulin has no peak time and can be given at night (long-acting insulin)
Glargine
long acting insulin with a duration of 24 hours. The onset of long acting insulin is 3-4 hours. A small amount has no peak.
Glargine
conversion of proteins and fats into glucose.
Glucocorticoids Cortisol or steroids provide
Almonds Yogurt Sardines Cheese Many juices are fortified with calcium and other nutrients.
Good sources of calcium
#of pregnancies #of luve births
Gravida____ Para____
More than 40
HDL (when statins are effective)
Lungs: "Cheyne Stokes Respirations" Neck: "Can not FLEX chin toward chest" Eyes: "Fixed & Dilated" • 8 mm Foot: Babinski reflex Seizures & Coma Abnormal posturing: Decorticate • Decerebrate CUSHING TRIAD LOW HR LOW RR HIGH NARROW BP
Late DEADLY Signs: ICP
accountable for the task.
In delegation, The nurse delegates care to the LPN/LVN and unlicensed assistive personnel. Delegatir remains
Fluid volume overloadd 2-8
Increased CVP indicates Normal CVP
Altered LOC: Restlessness, Agitation Decreased Mental
Increased ICP Early Sign:
100
Increased drainage after initial placement of the chest drainage system is an expected finding. Drainage greater than _____mL in the first hour would be an unexpected finding and the health care provider should be notified.
osteoarthritis
Increased joint pain and stiffness after periods of activity. Joint pain is precipitated by activity and relieved by rest Pain may be due to articular distension, or stretching of the joint fibers It may involve single or multiple joints
Garlic, ginger or ginko Alcohol: client can take 1 beer a day
Increased risk of bleeding when aspirin combined with....
Potent medications such as Long-term IV antibiotic therapy, Chemotherapy, IV potassium chloride Long term parenteral nutrition (PN) Blood Hemodynamic monitoring
Indications for central venous access device
Developmental delays Abdominal pain Irritability
Indications for lead poisoning
Insulin requirements will increase during pregnancy and decrease after delivery.
Insulin requirements will _____during pregnancy and _____ after delivery.
200-300 mL
Intake and output should be within ____ of each other.
Normal when it coughs
Intermittent bubbling in water seal chamber
30 min per 8 hour shift
Internal Radiation Nursing Care Limit Time with Client to
Less than 5 mm o Negative response for everybody 5-9 mm Positive for people who: Are in close contact with a patient who has infectious tuberculosis HIV infection immunocompromised organ transplant 10-15 mm Birth in a high-prevalence country congregate settings last ke prison, nursing home More than 15 mm Positive for all people
Interpreting Tuberculin Test Results Less than 5 mm 5-9 mm 10-15 mm More than 15 mm
Position - Semi Fowler's Place neck in neutral position Teach avoid valsalva maneuver avoid flexion of hips, waist, and neck Suction only as necessary but no longer than 10 seconds 100% O2 before and after suctioning Perform neuro checks using GCS Teach to take a breath when turn
Interventions for increased ICP? Position - neck Teach
We Never give for patients who are already DRY.
Ipratropium Contraindication ALL anticholinergics:
Avoid anticholinergic with glaucoma
Ipratroplum for a patient with glaucoma
dyspnea, chronic fatique, paleness, severe palpitations, sensitivity to cold and profound weakness Irin deficency anemia is caused by blood loss, increased metabolic energy demands, gastrointestinal malabsorption and dietary inadequacy
Iron deficiency anemia Symptoms Caused by
False
Irregular contractions
Hepatitis pop
Isoniazid ss
Rheumatoid arthritis
Joint pain and stiffness after stressful event (infection, work stress, childbirth)
Meningitis
Kernig Resistance, pain, or an inability to extend the knee is indicative of a positive Kernig's sign. Brudzinski can't flex
less than 139 mg/dL
LDL (when statins are effective)
Active phase:
Lasts about 3 hours in a primipara and 2 hours in a multipara
Discontinuing IV Supporting ventulation IV Ca gluconate Hemidialysis
Treatment of hypermagnesimia
Oxytocin
Treatment: If contractions do not increase in frequency, duration, and intensity. If labor does not progress.
Tocolytic
Treatment: If contractions too intense. If contractions preterm.
Oxytocin contractions do not increase in frequency, duration, and intensity. If labor does not progress.
Treatment: Oxytocin
• High protein, high calories, tolerated fat. Pancreatic enzyme replacement is required. Postural drainage, chest physiotherapy. Breathing Expectorants, mucolytic agents.
Treatment: cystic fibrosis
Irrigate the NG tube with 20 mL of normal saline. Lead invasive, best to try it first to unclogged the NG
Two hours after the insertion of an NG tube attached to suction, a client vomits a moderate amount of green fluid. Which action by the nurse is best? 3. Replace the NG tube with a larger one. 4. Irrigate the NG tube with 20 mL of normal saline.
LACK of UTERINE TONE SOFT, SPONGY,BOGGY UTERUS lead to SLOW STEADY Loss of BLOOD
UTERINE ATONY
symptoms of rheumatoid arthritis.
Upper and lower extremity joints warm to touch and reddened in appearance. Crepitus and grinding are evident when the joint is moved. The joint may be painful to touch.
client's weight should be placed on the upper arms at the hand grip, not the axilla.
Using crutches The client's weight should be placed on the
VRE requires contact precautions.
VRE vancomycin-resistant enterococcus requires precautions.
Deep breath, exhale, bear down During removal of chest tube to prevent air entering pleural space
Valsalva maneuver (teach how to do it and when it done)
Cord compression
Variable Deceleration why
Airborne A fit-tested respiratory device is used with pathogens transmitted by airborne route. The client should also be put in a private room with monitored negative air pressure. Keep the door closed and client the client in the room.
Varicella precautions
amniotic fluid alkaline, vaginal secretions acidic.
Verify membranes have ruptured: Obtain sample of vaginal fluid with sterile, cotton-tipped applicator. Test fluid with Nitrazine paper amniotic fluid _______pH vaginal secretions______pH
Absent respirations and pulse occur with ventricular fibrillation. Cardiopulmonary resuscitation is necessary for all clients with ventricular fibrillation and includes bag-valve-mask ventilation and chest compression defibrillation 150 joules Epinephrine IV every 5 min if needed
Vfib (with no pulse) immediate interventions
Vitamin K decrease the effectiveness of Warfarin
Vit K and warfarin
Warfarin has prolonged action. The duration is 2-5 days and the client should be taught that a risk of bleeding continues for several days after the medication is discontinued.
Warfarin duration
2-3 days after
Warfarin what is the greatest risk for bleeding after starting the therapy
C and B6
Water soluble vitamins
Osteoarthritis
Wear and tear disease with stiffness after periods of inactivity, resolving within 30 min
Beta-blockers -lol
What BP medicine increase risk for bronchospasm
22 to 28
What are normal HCO3 Bicarbonate
Lung reexpanded or there is a leak
What if the water doesn't fluctuate in chest tube
Glargine
What insulin has no peak time and can be given at night (long-acting insulin)
Redness, warmth Decreased ROM
What is expected to see in sickle cell anemia (extremities)
Inform the client about the eventual results of refusal of care.
priority action for declining treatment
Assess the pH of the gastric aspirate (should be less than 4)
priority action for enteral feeding
Administer O, by mask at 6 L/min. Left lateral sideline
priority action for late deceleration
Confusion
priority adverse effect cimetidine (assessment most important to investigate)
Administer morphine sulfate 4 mg IV, relieve pain and dilate (Drink water to push calculi out)
priority for renal calculi
Request an orientation to the unit and inform the supervisor that the nurse has not cared for this type of client in several years.
priority safe care of clients when floating to a new floor
"Avoid all sexual contact until you have been tested." Don't notify sex partners until diagnosis of chlamydia established
priority suspected chlamydia infection
cataracts
progressive opacity of the lens. clouded, blurred, or dim vision.
Antiemetic orthostatic hypotension. The nurse needs to determine if dehydration is contributing to the dizziness. Adverse effects of promethazine include anorexia, dry mouth and eyes, constipation, and orthostatic hypotension. The client is at risk for dehydration due to vomiting, which exacerbates the orthostatic hypotension
promethazine
Position the client on the right side with the head elevated 45°. Risk for aspiration with projectile vomiting
pyloric stenosis. The most important action the nurse should take immediately after feeding the client? Risk for?
Lispro
rapid acting insulin with a duration of 3 to 5 hours The onset of this insulin is 15 to 30 minutes and the peak is 30 minutes to 1 5 hours
leukopenia
reduction in the number of white cells in the blood, typical of various diseases.
Dialysis
required in stage V (end-stage kidney disease) when the kidney is no longer functioning.
Multiple sclerosis
sclerosis progressive neuromuscular disease that is caused by an immune-mediated destruction of the myelin sheath that covers the nerve fibers in the brain and spinal cord. Muscle weakness, paresthesias (numbness, tingling, burning sensation) and motor problems are common
The client is at greater risk for suicide necessitating close monitoring. (first 6 weeks due to increase energy level) SSRI
sertraline hydrochloride. One week later, significance of increased energy level
Regular insulin
short acting insulin with a duration of 6 to 10 hours. The onset is 30 to 60 minutes and peak is 1 to 5 hours.
substance which can inhibit platelet aggregation, such as aspirin, NSAIDS, or alcohol injections Injections due to high risk of bleeding
should be avoided for the client diagnosed with hemophilia
The client is at high risk for bleeding because of their low platelet count because of chemotherapy and bine marrow suppresion
soft-bristled toothbrush,
Oliguria, Swelling
stage Il of kidney disease what happens
LPN/LVN
sterile dressing change should be assigned to the LPN or RN
Headache and vertigo
symptoms of Ménière disease.
Some babies with tetralogy of Fallot have episodes called tet spells, when they suddenly turn bluish and may faint. These spells are serious. A tet spell may be caused by activities that change the pressure in your baby's heart and increase the flow of oxygen-poor blood to their body.
tet spell
pneumothorax because of the proximity of the central veins and the lung cavity. A pneumothorax can occur due to perforations of the pleura by the catheter.
the most probable cause of symptoms after insertion of central venous pressure line.
Erbs 3rd intercoastal space left midsternal boarder
the nurse places the stethoscope to auscultate the heart sounds heard at Erb's point. where is Erb's point?
Signs and symptoms of bleeding.
thrombocytopenia purpura Which teaching is a priority
bleeding and should recognize signs and symptoms of overt bleeding as well as occult bleeding. client should immediately report tarry, black stools, bleeding from gums, seizures or sudden weakness of a limb. The nurse will protect the client from a situation that can cause bleeding, avoid IM injections, apply firm pressure after needlestick, ice areas of trauma, and avoid insertion of indwelling urinary catheters. The nurse will test urine and stool for occult blood, and teach the client to use an electric razor and soft toothbrush.
thrombocytopenia purpura risk for
Prothrombin time (PT) The international normalized ratio (INR) is the standardized system of reporting the PT based on a referenced calibration.
to measure the therapeutic level of warfarin.
Pavlik harness
to treat hip dysplasia in a newborn client to stabilize and keep the hip joint in proper alignment. During the early newborn period, ____is applied to hold the hips in wide abduction. socks placed
intraocular pressure (IOP) and is used to diagnose glaucoma. The normal IOP reading is 10-21 mm Hg, requiring no action by the nurse
tonometer measures
applies suction for 10 seconds during withdrawal of the catheter. suction regulation pressure is 80-120 mm Hg when applying suction.
tracheostomy care: Suction for how many sec? Regulation pressure?
Insulin therapy Regular or crystalline insulin is given intravenously.
treatment of diabetic ketoacidosis.
magnesium sulfate IV
treatment of preeclampsia.
brief interruptions of consciousness.
typical absence seizures.
1O10-1030 remember like time How Clear urine is
urine specific gravity normal range
tonometer normal IOP reading is 10-21 mm
used to diagnose glaucoma.
Prothrombin time (PT)
used to measure the therapeutic level of warfarin.
A partial thromboplastin The therapeutic level is 1,5 to 2 times the control.
used to monitor the effectiveness of heparin,
Hot chocolate, tea contains caffeine; beverages that contain caffeine are usually restricted prior to an electroencephalogram (EEG) for 12 to 24 hours. The client should also avoid sedatives prior to the test.
usually restricted prior to an electroencephalogram (EEG) for 12 to 24 hours.
PT should be between 60-80 seconds or 1.5-2 times INR in the range of 2-3
warfarin should lab value
Cimetidine Ciprofloxacin
• 2 drugs that INCREASE toxicity risk Theophylline
Vaso-occlusive crisis: Can occur priapism
• Most common complication of sickle cell disease. • Painful due to hypoxia and necrosis of tissues or organ. • Occurs when sickled cells block blood flow to an organ or body part.
Antiseizure meducations like carbamazepine
Treatment for trugeminal neuralgia
hypothyroidism
"I become easily fatigued and am always cold. My periods are irregular and my hair is brittle." what it can be and what to ask to confirm it?
Altered LOC: Irritability, Restlessness - Decreased Mental Status - Flat affect and drowsiness
(INTRACRANIAL PRESSURE) Early Sign:
5 - 15 mmHg
(INTRACRANIAL PRESSURE) Imaging • CT scan ICP monitoring • Normal:
lumbar puncture (spinal tap)
(INTRACRANIAL PRESSURE) NO
Imaging • CT scan ICP monitoring • Normal: 5 - 15 mmHg
(INTRACRANIAL PRESSURE) monitoring
Observe the amount and color of lochia. Priority
A client undergoes admission to the postpartum unit after the vaginal birth of a 9-lb 2-oz (4.139 kg) newborn. Which is the priority action by the nurse when providing care to this client?
colorectal cancer.
-A recommended health promotion activity for an older adult is a stool DNA test every 3 years. This test is one approach to screen for American Cancer Society (ACS) ______recommends that people at average risk of colorectal cancer start regular screening at age 45.
prostate cancer
-A recommended health promotion activity for an older adult male is a digital rectal examination every year to screen for ____
Dark and pigmented (melanocytes-stimulating hormone)
-Addison disease skin
to Lower BP only (not HR)
-pril, -sartan A • ACE (-pril) Lisinopril "chill pril" A • ARBS 2nd choice BP HR
effectiveness of heparin,
3) A partial thromboplastin time is used to monitor
Low BP (nothing helps) Supper pain Syncopy Shock Severe Vomiting and diarrhea (hyponatremia, hypoglycemia, hyperkalemia)
5 s of addisonial crisis
Kaposi sarcoma
A cancer that causes lesions in the soft tissues. skin, lymph nodes, internal organs, and mucous membranes lining the mouth, nose, and throat. It often affects people immune deficiencies, such as HIV or AIDS.
Periorbital edema.
A child client has a diagnosis of impetigo. The nurse notes the infection has not improved. The nurse learns the parent has not been caring for the child's skin because it "takes too much time." It is most important for the nurse to assess for which finding? Can cause acute glomerulonephritis -> periorbital edema
Hemorrhage and shock
A client had a cesarean delivery, the highest priority on monitoring the client for which two potential complications?
Applies pressure over the hole with a dressing. Decreases the chance of atmospheric air will enter the pleural space.
A client has a chest tube. Two days after insertion, the chest tube is accidentally pulled out of pleural space. Which action does the nurse take first?
Maintain respiratory function. Lack of acetylcholine results in easy fatigue and muscle weakness especially muscles engaging in repitative action. Weakness of resp muscles can lead to resp arrest if untreated
A client is admitted to the hospital with a diagnosis of myasthenia gravis. When caring for this client, the nurse gives priority to which nursing goal?
Postoperative activities and restrictions to protect the eye from increased Intraocular pressure such as bending from knees, blowing the nose and vomiting.
A client is scheduled for extracapsular cataract removal. It is most important for the nurse to include which information during preoperative teaching?
Transition phase: Contractions reach maximum intensity
Contractions last more then one minute
Measure the urine specific gravity. Can be diabetes insipid us if low specific gravity
A client undergoes hospitalization for a head injury. The client receives 0.9% sodium chloride at 100 mL/hour and has an indwelling urinary catheter. The client's urinary output is 1,000 mL in 3 hours. Which action by the nurse is best?
Shock, requires imm attention
A client with a BP of 90/60 mmHg and apical P of 120 beats/minute. This indicates
weight bearing on the affected leg.
A four-point gait requires
Begins an IV with normal saline. Dehydration perpetuates cell sickling. Intake at leasr 200mL/hr
A pregnant client diagnosed with sickle cell disease is in vasoocclusive crisis. Which action does the nurse take first?
Impetigo Antibiotic cream Can be with other children 24 hours after starting antibiotic
A toddler-age client has fluid-filled vesicles, honey-colored crusts, and reddened areas around the mouth and axillae. What is that?
A• Antihypertensive (Low BP-NOT HR) A• AVOID pregnant (NOT BABY SAFE) A• Adds Potassium "HyperKalemia" (normal 3.5 - 5.0)
ACE & ARBS -prils & -sartans
2 inches
ADULTS CHILDREN 1-8 press down CPR:
A - Albuterol 1st I - Ipratropium 2nd M- Methyl-predniso-lone (brand: Solu Medrol)
AIM for Acute Asthma Attack
5-35 U/L
ALT elevation indicates liver damage. Normal levels run between
Platelet
ANTI-COAGULANTS LMW HEPARIN what lat to FOCUS?
10-40 U/L
AST These enzymes are released from the liver due to damaged cells. Normal levels are between
Beta Blockers Atenolol NSAIDS Naproxen, Ibuprofen
AVOID with asthma and albuterol
Angioedema High K Dry cough 1st dose syncopy
Ace inhibitors serious SS (-pril)
Adding medications to an IV is within the RN scope of practice. It is not within the LPN/LVN scope of practice.
Adding medications to an IV is LPN/LVN scope of practice.
Adrenal insufficiency Cortisol and aldosterone
Addison disease insufficiency.
volume depletion. fluid volume deficit
Addison disease, fluid volume
hydrocortisone therapy and vasopressors, rest, and monitor vital signs. The client should increase fluids and salt during hot weather or excessive perspiration.
Addisonian crisis Nursing care
Salt intake and fluids
Addisonian crisis increase
Cortisol (no cortisol) Damaged adrenal cortex Adrenolectomy (pt needs to take glucicirticoids to supplement cortisol) Pituitary hand damaged
Addisonian crisis key player
LPN
Administer a tube feeding for the client with dysphagia. RN or LPN
BP goes down HR goes up
Administer nitroglycerin 0.4 mg sublingually. Which finding does the nurse expect to observe (BP, HR)?
Na wasting (clients urinate a lot) K saving Weight loss
Adrenal crisis Na+water? K? Weight
Can continue normal activities after the fluid has drained from the abdomen
Advantages continuous ambulatory peritoneal dialysis (CAPD).
First Generation Antipsychotic Agents high sedation, moderate-high orthostatic hypotension
Adverse Effects chlorpromazine
Normal. frequent urge to void is common after cystoscopy. The tissues have been traumatized, and the bladder responds with an urge to void when moderate amounts of urine are present. This is normal and will subside soon. Abnormal. Urinary retention.
After cystoscopy urination normal and abnormal?
Administers the vitamin K slowly. Intramuscular injections given slowly for better absorption and decreased pain during injection
After inserting a needle into the ventrogluteal muscle to inject vitamin K, which action does the nurse take next?
MTV is on air. • MMR measles, mumps, rubella • Tuberculosis • Varicella (chicken pox)
Airborne precautions deseases
Bone health It can treat or prevent osteoporosis. It can also treat Paget's disease of the bone. Can cause esophagitis
Alendronate
Phase three (transition):
Contractions: 2 to 3 minutes apart.
prevention and treatment of osteoporosis. This medication should be taken with 6 to 8 ounces of water to prevent esophageal irritation. Alendronate should be taken on an empty stomach 30 minutes or more before eating or taking other medications. Take weekly
Alendronate Indication Instructions to avoid esophageal irritation
Alka Seltzer contains aspirin and should be avoided with increased risk of bleeding (bone marrow suppression)
Alka Seltzer contains ______ And should be avoided with_____
Benzodiazepine? How you can recognize a Benzodiazepine is that the middle of the generic drug name will have either "ze" or "zo" and most end with "pam" or "lam" Benzos are medications used to help treat panic attacks, seizures, alcohol withdraw etc.
Alprazolam (classufucation, for what)
Cushing syndrome or hypercortisolism (increase cortisol).
Although there is truncal obesity, clients will have thin arms and legs due to muscle wasting. Clients may also present with edema, purple skin striations, and decreased resistance to infection.
Meniere's disease
An inner ear disorder that causes episodes of vertigo (spinning). It usually starts in one ear, but later may involve both. Smoking, infections, or a high-salt diet may worsen the disease.
Altered mental status.
An older adult client is diagnosed with a fractured femur. The nurse recognizes which observation is an early sign of fat embolism?
Cararact
An older adult client tells the nurse that reading has become difficult and colors seem to have changed, glare at night. What can be the problem
1.5 to 2 Heparin therapy
Anticoagulation is effective when the aPTT is___ times the control. For what check it?
caloric needs decrease as a person gets older. If the calorie intake remains the same as in younger life, the person is likely to gain weight.
As the person ages calorie intake?
Pantoprazole, a proton pump inhibitor (PPI)
Assist control mechanical ventilation with positive end-expiratory pressure (PEEP) What medication decreases the risk of aspiration of gastric contents.
Symptomatic bradycardia (for example syncope) If doesn't help pacer may be indicated
Atropine indicated for
depressants,
Benzodiazepines are CNS
opioids
Benzodiazepines should NOT be used with
Glaucoma, can cause increase in intraocular pressure
Benztropine Contradicted in
food, milk, or large glass of water to reduce gastrointestinal upset.
Better to take an aspirin with
normal saline to prevent clotting or hemolysis of blood cells.
Blood is hung with
prevent clotting or hemolysis of blood cells.
Blood is hung with normal saline to
5 ug/dL
Blood lead levels of or above _____ require further testing or monitoring.
four hours of removal from the refrigerator. This action minimizes the risk of bacterial growth.
Blood must be infused within
5 mL/min for the first 15 min
Blood must be run slowly at first (no faster than
A febrile reaction
Blood transfusion most common reaction. It is seen in clients after multiple transfusions.
transfusions. hemolytic reaction
Blood transfusion. hemolysis or destruction of blood cells. Symptoms include hematuria, cyanosis, and kidney pain. blood
glaucoma
Blurred vision, headache, rainbows around lights.
type of internal radiation therapy in which seeds, ribbons, or capsules that contain a radiation source are placed in your body, in or near the tumor.
Brachytherapy
Placenta previa (painless, soft utetus)
Bright red vaginal bleeding
This is a marker of inflammation
C- reactive protein levels are elevated.
Neutropenic 1. NO fresh Flowers, or fresh Fruits 2. AVOID crowds & sick people!
CHEMOTHERAPY Doxorubicin & Cisplatin Precautions?
First stage: Phase one (latent):
Contractions: 30 to 60 seconds long.
Phase three (transition):
Contractions: 45 to 90 seconds long.
3-12 High indicates fluid overload
CVP normal
hypervolemia or fluid volume overload.
CVP reading of 15 mm Hg indicates
(2nd degree): Epidermis affected deeper than 1/3 of dermis. Painful, red/white, moderate edema, blisters are rare. prolonged contact with hot object
Caused by energy transferring from heat source to body. Deep partial-thickness
Deep partial-thickness (2nd degree):
Caused by energy transferring from heat source to body. Epidermis affected deeper than 1/3 of dermis.
Superficial partial-thickness (2nd degree):
Caused by energy transferring from heat source to body. Epidermis affected to 1/3 of dermis, intact blood supply.
(2nd degree): Painful, red exudes fluid, edema, blistered. brief contact with hot objects
Caused by energy transferring from heat source to body. Superficial partial-thickness
Trauma Surgery Age related changes
Causes of retinal detachment
Insufficient thyroid hormone Hashimoto thyroiditis Decreased metabolic rate
Causes: Thyroid Disease- Hypothyroidism
due to autism.
Characteristics include poor eye contact, fixed facial expression, and delay of the development of spoken language.
diminished numbers of white blood cells leukocytosis, red blood cells low erythrocytes, and platelets.
Chemotherapy causes bone marrow depression because it affects rapidly growing and dividing cells. All cells produced in the bone marrow are affected, resulting in
This is a normal finding, indicating the lungs have fully expanded and there is no drainage from the chest.
Chest tube. The amount of drainage in the collection chamber has not changed in the last 12 hours. What does it mean? Does it indicate problem?
Airborne
Chickenpox (varicella zoster) precautions
normal play activity 3-year-old, parallel play
Children this age enjoy being with each other during playtime, even though they may not communicate with each other.
CHEMOTHERAPY • Give antiemetics (nausea med) prophylactically • Saline rinse before and after meals • Increase fluid intake for next 3 days • Teach how to manage fatigue
Cisplatin nursing teaching
CHEMOTHERAPY Renal toxicity - Creatinine OVER 1.3 = Bad kidney - BUN OVER 20 - Urine ouput 30ml/hr or LESS = Kidney Distress
Cisplatin toxic for what?
(1st degree): Painful, red, no edema. Sunburn, flash burns.
Classifications of burn depth: Superficial
• Admin. bolus of IV normal saline
Client admitted for bacterial meningitis with a BP of 78/56... priority action?
Spine immobilization & CT scan to rule out intracranial bleed
Client found on the floor, appearing lethargic, bleeding at the back of head, heart rate of 45 BPM & a blood pressure of BP 220/88. First action?
Immediately report this finding to the HCP!!!
Client with suspected meningitis... when neck flexes, the hip and knee also flex. Priority action?
fluids and electrolytes. Replacing potassium via an IV will prevent hypokalemia from occurring. Symptoms of hypokalemia (less than 3.5 mEq/L) include muscle weakness, paresthesias, and dysrhythmias, and it increases sensitivity to digitalis. IV potassium can cause irritation and phlebitis so the nurse will assess the IV site every 2 hours/per agency policy.
Clients with NG tubes connected to nasogastric suction lose a large amount of
rest. If the client is given an activity to perform, the tremors seem to go away as the client pursues the purposeful activity due to the diversion.
Clients with a diagnosis of Parkinson disease usually only exhibit tremors at
Benzodiazepine How you can recognize a Benzodiazepine is that middle of the generic drug name will have either "ze" or "zo" and most end with "pam" or "lam" Benzos are medications used to help treat panic attacks, seizures, alcohol withdraw etc.
Clorazepate (classification)
Clubfoot - surgery Positional deformity of foot - manipulations, proper alignment
Clubfoot Positional deformity treatment
Neuroleptuc malignant syndrome Therapy antipsychotics altered consciousness, elevated body temperature, severe EPS, hypertension, tachy, diaphoresis, incontinence, elevated serum creatinine phosphokinase
Complication of what and symptoms NMS
Complications: Fistula formation. Anemia. Intestinal obstruction. Abscess formation. Osteoporosis. Malnutrition. Adhesions. Dehydration with uc
Complications: crohn's and ulcerative colitis
Need to start transfusion within 30 minutes after taking it from blood bank
Considaration with blood product
Avoid taking blood pressure and blood specimens from area with picc Change dressing 2-3 time a week or when wet or nonoclusive Flush with 2 mL of normal saline and 1mL of heparin
Considerations with PICCTURE line
Air bubbling through the water seal chamber intermittently is normal when the patient coughs or exhales, but if there is continuous air bubbling in the chamber, it can indicate air leak that should be evaluated.
Continuous bubbling in water seal chamber in chest tube
Stages of Labor: First stage: Phase one (latent):
Contractions 10 to 30 seconds long.
First stage: Phase two (active):
Contractions 3 to 5 minutes apart.
First stage: Phase one (latent):
Contractions 5 to 30 minutes apart.
Metallic implants. Claustrophobia. Pacemakers, although new protocols allow imaging in selected cases. MR-incompatible prosthetic heart valves. Contrast allergy. Body weight (MRI tables have specific weight limitations)
Contraindications for MRI, m for?
Active phase: Membranes may rupture spontaneously. Contractions stronger and last about 40 to 60 seconds
Contructions lasts one minute
Latent phase: Contractions are mild and last 20 to 40 seconds
Contructions less then one minute phase?
ANTI-INFLAM PREVENTS activity induced asthma Take 15 minutes before exertion for maximum effects
Cromolyn
hypertension.
Cushing syndrome causes an increase in sodium and blood volume which will cause
IMMUNOSUPPRESSANTS BEFORE giving Check WBC + Pits • REPORT leukopenia Low WBC < 4000 • Monitor for bleeding • No pregnant patients - Use Contraception Multiple Sclerosis (M.S.)
Cyclosporine
Variable
Deceleration may appear at random and may be unrelated to contractions
Early
Decelerations that mirror mom's contractions?
Diabetes Insipidus
Decreased production of ADH from posterior pituitary or decreased kidney response to ADH. Causes; Brain tumor. • Head injury. Brain surgery. Lithium therapy.
(4th degree): Deep wounds to muscle or bone. No pain or edema, black color, monitor for shock, amputation or grafting possible Extensive contact with electrical or other burning situations.
Deep thickness burn.
Deep thickness (4th degree):
Deep wounds to muscle or bone. burn.
Deep thickness (4th degree):
Degree burn No pain or edema, black color, monitor for shock, amputation or grafting possible
Diabetes insipidus Decrease
Diabetes insipidus urine osmolarity ____ specific gravity (less than 1.005)._____
African American Hispanic American Native American Hx of hypertension! HDL less than 60 Family history of diabetes Overweight Triglycerides more than 150 Age more than 50
Diabetes mellitus (DM). risk factors
only in Crohn disease.
Differential diagnosis between Crohn disease and ulcerative colitis: Presence of granulomas
Ulcerative colitis usually limited to colon.
Differential diagnosis between Crohn disease and ulcerative colitis: Ulcerative colitis usually limited
POTASSIUM (K+) BELOW 3.5 (Increases the RISK for Dig Toxic)
Digoxin K
Digoxin: 0.5-2. TOXIC OVER 2.
Digoxin: TOXIC OVER
No.
Do we have to check blood sugar before taking the beclomethasone by metered dose inhaler?
Everything is in normal range (people before paperwork)
Document when
tricyclic antidepressants.
Doxepin (is contraindicated for clients diagnosed with glaucoma)
PIMP stands for: • Pertussis or whooping cough • Influenza or the flu • Meningitis (bacterial or viral) • Pneumonia
Droplet precautions deseases
Diphenhydromine Benztropine Discontinue antipsychotic
Dystonia-abnormal muscle movements (neck twusting) EPS TREATMENT
E- Edema "Angioedema" P- Pruritus & Hives I- Insp. / Exp. "Wheezes"
EPINEPHRINE anaphylaxis
hyperthyroidism or worsen it in some cases Seafood and milk is known for its high levels of iodine
Eating too many iodine-rich or iodine-fortified foods may lead to
Enlarged joints — osteoarthritis Inflamed (hot and reddened) joints —— rheumatoid arthritis
Enlarged joints —— Inflamed (hot and reddened) joints ——
24 hours Avoid adding formula to formula already in bag
Enteral feeding through gastrostomy tube, hang a new bag and tubing every
BG
Estrogen therapy what to check
Hypertension Hyperglycemia Is increased
Everything is ____ in Cushing's
treatment consists of reducing antipsychotic med dose and administering anticholinergic meds like benztropine
Extrapyramidal Side Effects (more common with First Generation Antipsychotics Akathisia -restlessness treatment
Anticholinergic benzotropine Reducing dose of antipsychotic
Extrapyramidal Side Effects (more common with First Generation Antipsychotics Pseudo-Parkinsonism manifested by tremors, rigidity, motor retardation, excessive salivation, masklike expression, and shuffling gait Treatment
dystonias, akathisia, Parkinsonism, and tardive dyskinesia (TD). Long term use of psychiatric drugs No concern with ABC
Extrapyramidal Symptoms. EPS include
Overweight and Obesity Infection Joint Injuries Occupation (bending knee) Smoking Age Gender (women) Genetics
Factors that Increase Risk of Getting Arthritis
At the time of admission
Fall risk assessment done
Left side Oxygen IV
Fetal bradycardia, nursing interventions
enlarged during menstruation.
Fibrocystic disease of the breast involves benign cysts of the breast. It presents as soft, tender, freely moving cysts that become
1st generation antiphycotics Anticholinergic effects (blurred vision, everything dry, photosensitivity) Agranulocytosis (check WBC) EPS Complication: NMS (altered consciousness, ekevated body temperature, severe EPS, hypertension, tachy, diaphoresis, incontinence, elevated serum creatinine phosphokinase)
Haloperidol classification and side effects
Surgical procedure that stretches the spine to correct scoliosis. Potential Neuromuscular compromise
Harrington rod insertion. Potential.....
Urine Specific Gravity, diluted urine
Head injuryDiabetes insipidis what to check to confirm
Meningitis
Headache & Photophobia Hard stiff neck High Temp "Fever"
whisper test helps determine if the client has a normal level of hearing, or if there is hearing impairment.
Hearing screeening test that assesses the clients hearing
The Rinne
Hearing test determines if hearing is different through air or bone. The test uses a tuning fork paced against the head on bone and beside the ear through air. In the question situation, the nurse first wants to determine if hearing is impaired, not necessarily which type of hearing may be lost.
Weber test
Hearing test. Uses tuning fork and helps determine if one ear hears better than the other. It is rarely used and is not a screening test.
peptic ulcer disease and stomach cancer.
Helicobacter pylori is frequently associated with
Blood-streaked sputum (a sign of lung cancer)
Hemoptysis (sign of)
fecal-oral route by ingestion of fecal contaminants. This may include transmission through contaminated water. may include transmission through contaminated foods. 3) Raw shellfish may be a transmission route of hepatitis
Hepatitis A is spread
Dehydration
High BUN indicates (can be in DKA Because of pilyuria)
BRADYCARDIA (60 or Less) & BP low BREATHING BAD FOR HEART FAILURE
Hold beta blocker when
"The brace should be worn 23 hours a day."
How many hours a day wear brace to correct a scoliosis deformity.
Don't apply lotions Avoid sun Lukewarm water, par dry Cotton clothes Soft bristle toothbrush
How to care for irradiated skin
Elevate the whole foot of the bed, DONT USE PILLOW Affected limb shoukd be above level of the heart
How to elevate resudual limb after amputation
Less animal fat
How to keep low cholesterol
On the right side
How to position the client after liver biopsy
Regularly! every 4 hours or as needed
How to take morphine in cancer pain?
weakness and paralysis.
Hyperkalemia causes muscle
by acute kidney injury or chronic kidney disease, use of potassium supplements, or burns.
Hyperkalemia is caused
hypertonic tube feedings without water supplements, diarrhea, diabetes insipidus, inadequate water ingestion,
Hypernatremia is caused
methimazole Radioactive iodine therapy Surgery Monitor cardiac output Promote visual health Promote balanced nutrition
Hyperthyroidism Graves disease Excess secretion Pharmacologic therapy methimazole
Nasogastric drainage, vomiting, diarrhea, and the use of diuretics all involve the loss of extracellular fluid, which contains potassium.
Hypokalemia is caused by
vomiting, diuretics, excessive administration of IV dextrose and water, excessive water intake, or a prolonged low-sodium diet.
Hyponatremia is caused by
1.5 inches
INFANTS press down Perform CPR:
25-35 (3-5 first trimester, 12-15 second, 12-15 third)
Ibs gains during pregnancy
1st 3-5 Ibs 2nd 12-15 3rd 12-15
Ibs weight gains during first, second and third trimester
discontinue the IV and start a new IV. Apply warm compress to infiltrated site, and elevate arm.
If IV infiltrate happens
push one spray into the air
If the patient haven't used the inhaler for several days, he/she should
parenteral administration fluids and medications used to quickly and effectively control symptoms and provide relief. Nursing interventions are planned to minimize vertigo and keep the client safe. Severe vertigo often triggers nausea and vomiting, making it difficult for clients to retain medications, food, and fluids ingested orally. Consuming foods high in sodium can cause fluid retention, which can aggravate Mėnière disease.
In an acute attack of Ménière disease
Positioning the client on the left side decreases the weight of the uterus on the vena cava and increases oxygen flow to the placenta. Increasing the infusion of LR is called fluid resuscitation and decreases the viscosity of the blood. The end effect is increasing oxygenation to the fetus. O2 Stop infusion of oxytocin
Late decelerations (nursing action)
with spina bifida due to the repeated procedures and examinations these clients receive over the course of their lives. Clients have repeated exposure to latex containing products such as urinary catheters,
Latex allergy is a serious health hazard for clients with
Acidosis
Less than 7.35 acidosis or alkalosisis
Short-acting insulin, peak effect 15 minutes, eat after injection
Lispro
rapid acting insulin with a duration of 3 to 5 hours
Lispro
Lithium: 0.6-1.2. TOXIC OVER 2.
Lithium: TOXIC OVER
Frequent urination Dehydration Loss of sodium Fine tremors and change of handwriting maybe expected Instruct the client to drink water (12 glasses of water daily)
Lithuum therapy adverce effect
ACE INH help relax your veins and arteries to lower your blood pressure. -pril
Look for dry cough with what medication
Benzodiazepine you can recognize a Benzodiazepine is that the middle of the generic drug will have either "ze" or "zo" and most end with "pam" or "lam" expect Benzos are medications used to help treat panic attacks, seizures, alcohol withdraw etc.
Lorazepam (classification)
Antihypertensive
Losartan
Reduce thyroid hormone
Low iodine diet
IVIG Interferon Steroids - Prednisone Muscle Relaxants - Baclofen Immunosupressanrs - cyclosporin (check WBC and Plts)
M.S. MULTIPLE SCLEROSIS Pharmacology
Determine if the client is immunocompromised.
Mantoux induration 5 mm Implementation
Low noise Quiet room Low light photophobia Low pressure all over (no flex, no cough)
Meningitis interventions
Hypermagnesemia (toxicity, ss: hypotention, facial flushing, muscle weakness, absent deep tendon reflexes, shallow rr)
Mg level 2.5
140/90 mm
Mild preeclampsia: Blood pressure____ 2+ to 3+ proteinuria. Slight generalized edema.
Alkalosis
More than 7.45 acidosis or alkalosis
Followers do not partake of alcohol, caffeine, or other stimulant beverage.
Mormon Dietary Restrictions
cancer that forms from white blood cells called plasma cells.
Multiple myeloma
droplet precautions. Droplet precautions are used with pathogens transmitted by infectious droplets. The client should be put in a private room or with a client diagnosed with a like infection. Maintain spacial separation of three feet. The client may keep the door open.
Mumps require precautions.
Adrenal crisis
Na wasting K saving
1/2-1 inches
Newborn length should add ___ every month
Double triple If the newborn weights 8 Ibs, by 6 month - 16 Ibs, by 12 month 23 Ibs
Newborn weight Weight should ____ by 6 month Weight should ____ by 12 month
Antihypertensive
Nimodipine
80/45-60/40
Normal Bp fit newborn
is 2-8 mm Hg.
Normal CVP
1.5-2.5
Normal Mg levels
Less than 160
Normal Serum triglycerides (when statins are effective)
0.5-1.2
Normal creatinine level
110-160
Normal feral hr
Less than 4
Normal gastric pH
5.7%
Normal hemoglobin A1c is below
1500-3000
Normal intake _____ mL per day.
93% on room air.
Normal newborn oxygen saturation is greater than
140,000
Normal platelet count is 150,000 to 450,000/mm3 What value indicates the client is at risk for bleeding.
3.5-5.5 g/dL
Normal serum albumin
60 mL
Normal urine output hourly
Promote bed rest. Monitor intake and output. Seizure precautions. Vital signs. Fetal heart tones. Administer antihypertensive medications and others as prescribed.
Nursing care: severe preeclampsia
Watch Sodium, glucose, potassium
Nursing intervention in Addisonian adrenal cris
Educate never stop medication abraptly Monitor for thyroid storm (fever, HR and BP increased, very restlessness) Obtain weight, EKG Sedatives Avoid iodine foods (seaweeds, eggs, dairy) No aspirin Toxicity symptoms hypothyroidism slow HR, hypothermia
Nursing interventions with hyperthyroidism
Position leg in abduction using abduction splints or wedge or 2 to 3 pillows between the legs. Flex hip no more than 90 degrees. • Elevate head of the bed no more than 45 degrees. • Turn from back to unaffected side.
Nursing responsibilities: hip arthplasty
This requires assessment of the nurse. Immediately after the procedure electro convulsive therapy, orient client, take blood pressure and respirations, and stay with the client during times of confusion. Unlicensed assistive personnel (UAP) can obtain vital signs after the client is alert, orientated, and stable.
Obtain vital signs for the client immediately after ECT. RN or LPN
Decreased concentration of urine.
Older adults concentration of urine.
sense self-worth and self-acceptance that is not based on appearance. Making jewelry
One of the goals for a client diagnosed with anorexia is to achieve What avtuvity recommeneded?
Check for any edema or weight gain. Can be heart failure
One week following a myocardial infarction, a client reports experiencing fatigue to the nurse. The nurse notes the client is slightly short of breath and the pulse rate is 110 bpm. Which action by the nurse is best?
stimulate beta cells in the pancreas to release endogenous insulin
Oral hypoglycemic agents act to
balancing activity and periods of rest, heat and cold applications, low-impact exercise, weight loss, nutritional support, and acupuncture
Osteoarthritis Non-pharmacologic treatments
Painkess gradual loss of hearing and the sensation of ringing, buzzing or roaring in the ears.
Otosclerosis characteristic findings include
To cause contraction of the uterus to start labor, increase the soeed of labor, stop bleeding foliwung delivery
Oxytocin used for
PLACENTAL FRAGMENTS RETAINED in UTERINE CAVITY PLACENTA INVADES MYOMETRIUM AND DOESN'T EASILY SEPARATE
PLACENTA ACRETA
Abruptio placenta
Painful vaginal bleeding
Placenta previa
Painless vaginal bleeding
Priority nursing action is to stop the chemo, flush the line and administer ondansetron
Patient Scenario: During chemo infusion, child reports nausea and vomiting Priority
Based on the patient's signs and symptoms, the patient may be experiencing discontinuation syndrome which can happen if a patient suddenly quits taking an SSRI (Fluoxetine). The nurse should immediately ask the patient when the last dose of Fluoxetine was taken.
Patient is taking Fluoxetine patient presents to the ER with severe stomach pain, diarrhea, insomnia, and ataxia. In addition, the patient reports experiencing electrical shock sensations and tingling in his body. Whar kind of med is Fluoxetine and what patient is experiencing?
alcohol consumption and opioids
Patients taking Benzo Benzodiazepine should AVOID.
skin breakdown 2-3 times per day, avoid lotions and powders, and place the diaper under straps. If the treatment does not achieve the correct hip placement in a few months, then surgery is indicated and a postoperative spica hip bandage or body cast is applied.
Pavlik harness is used to treat hip dysplasia in a newborn client to stabilize and keep the hip joint proper alignment. During the early newborn period, a Pavlik harness is applied to hold the hips in wide abduction. An undershirt is placed on the client under the chest straps. Knee socks are placed on the client under the foot and leg pieces: The parents are taught to check
deficiency of Vitamin B3 (niacin).
Pellagra is not considered an autoimmune disease. It is a disease resulting from
sitting upright, whereas angina pain is relieved with rest
Pericarditis is often relieved by
Vitamin B12
Pernicious anemia, lifelong injections of
of Pneumocystis Pneumonia
Persons in stage 3 HIV (AIDS) with a CD4 +T cell count less than 200 cells/mm3 are at high risk for the development
Seizure prevent = Phenytoin Swelling prevent Dexamethasone Phenobarbital Mannitol!
Pharmacology ICP
Phenobarbital is a barbiturate.
Phenobarbital (classification)
Protein
Phenylketonuria consumption of foods that contain low
Phenytoin: 10-20. TOXIC OVER 20.
Phenytoin: TOXIC OVER
droplet precautions.
Pneumonia requires precautions.
Prone (30 min at least 3-4 hours a day) to prevent hip flexion contractures
Position after amputation
Droplet precautions
Precautions cold and influenza
corticosteroid is important to withdraw this medication gradually to minimize the reaction of the body to the sudden loss of exogenous steroids. Stopping the medication suddenly may result in adrenal insufficiency.
Prednisone for rheumatoid arthritis
vena cava syndrome Help the client to turn onto her left side.
Pregnant client suddenly says, "I am dizzy. I feel as if l'm going to faint." topic?
It is important that client eat small meals more frequently. How the client specifically plans to ensure adequate nutrition is important information. Fatique is a complication of anemia. The client may be too fatiqued to climb stairs If necessary, the nurse needs to arrange for the client to have a bed on the first floor until the anemia is resolved. Encourage the client to balance rest and activity
Problem the patient has at home with anemia
Antiemetic After cataract surgery guven to prevent presure on suture lines by preventing nausea
Prochlorperazine Cataract surgery?
Applying ice to the knee and elevating the leg is the most appropriate action to take initially because it will help to stop the bleeding, decrease the swelling, and help alleviate the pain.
Pt with hemophilia develops painful swelling after bumping the leg. What to do?
APT-M 2245
Pulmonic Aortic Tricuspid Mitral Intercostal spaces
The decrease in blood flow to the fingers of a patient with Raynaud Phenomenon may interfere with the pulse oximeter's ability to read correctly when applied to the fingers. A special oximeter that is applied to the forehead can be used for an accurate reading if available. Hands turn blue when its cold or the person is under stress
Raynaud disease
True labor
Regular contractions
Protein is restricted because the diseased kidneys do not filter well. Carbohydrates and fats do not require as much filtration and so the majority of calories should be from these nutrients. Fluids are usually restricted because the kidneys do not function very wel. Both sodium and potassium are limited in the diet because the kidney does not filter the byproducts very well anymore.
Renal diet: Proteins? Carbohydrates and fats? Fluids? sodium and potassium?
Hypoxia
Restlessness means
Steroids
Risk factors for fractures
Risk for Infection Bleeding Anemia Kidney Stones Renal Failure • Bone Pain
Risks in leukemia
foods that stimulate intestinal motility, such as vegetables and fruits, fatty, spicy, and sweet foods, alcohol, and caffeine. Avoid when diarrhea
Roughage Avoid when
most serious effect being respiratory depression, which is generally preceded by sedation. Other common adverse effects associated with opioid therapy include dizziness, nausea, vomiting, constipation, sedation, delirium, hallucinations, falls, hypotension, and aspiration pneumonia, weak cough, urinary retention. Adverse events can occur with the use of any opioid; among these are fentanyl, hydrocodone, hydromorphone, methadone, morphine, oxycodone.
SE opioids
syndrome of inappropriate antidiuretic hormone (SIADH) Clients retain water and experience fluid volume overload and doutional hyponatremia.
SIADH Clients experience fluid volume _____ and
Diarrhea Abd pain Ulcers in mouth Anal fissures Weight loss
SS Crohn's
nocturia and a decreased voiding force. Other findings include urinary frequency, hesitancy, dysuria, and decreased ejaculatory force, hesitancy.
SS benign prostatic hyperplasia (BPH).
Weight loss-burning calories Heat intolerance- increase body temp HR and BP increase Diarrhea-GI system overdrive
SS hyperthyroidism
Flashes of light Retina perceives light and transmits impulses to the optic nerve
SS of retinal detachment
Urgent BM Loss of weight, low RBC CRAMPS IN ABD ELECTROLYTE IMBALANCE RECTAL BLEEDING
SS ulcerative collitis Mnemonic ulcer
Schilling test is used to diagnose pernicious anemia. The client fasts for 12 hours and is then given a small dose of radioactive B12 orally, followed by a large, nonradioactive dose IM. The client then will collect a 24-hour urine. If the urine is not radioactive, the radioactive B12 stayed in the GI tract. Schilling test includes the collection of urine for 24 hours.
Schilling test for what
Complete dilation to the birth
Second STAGE of labor from to
Less than 200
Serum cholesterol (when statins are effective)
Serum triglycerides less than 160 LDL less than 140 Serum cholesterol less than 200 HDL more than 40
Serum triglycerides LDL Serum cholesterol HDL Levels when statins are effective?
Hyponatremia Hypoglycemia Hyperkalemia
Severe Vomiting and diarrhea (hyponatremia, hypoglycemia, hyperkalemia) in addisonian crisis lead to
preeclampsia: Indications: blood pressure of 150-160/100-110 mm Hg. 4+ proteinuria. Facial edema. Headache. Epigastric pain. Dizziness. Anginal pain.
Severe preeclampsia: ____blood pressure Facial ______ _____pain.
Lispro
Short-acting insulin, peak effect 15 minutes, eat after injection
vaso-occlusive crisis Risk for infection, give a client to wear a mask
Sickle cell disease when hemoglobin S molecules stick together and form aggregates. Occurs what condition? Risk for?
water enema or Fleet's is given until returns are clear the morning of the procedure.
Sigmoidoscopy (what to do prior?)
The client will be asked to change into a gown and assume a side-lying position on the exam table, usually with the knees to the chest. The HCP will insert a sigmoidoscope into the rectum. The average length of the procedure is 15 minutes. tap water enema or Fleet's is given until returns are clear the morning of the procedure. The procedure is done to screen for colon cancer or explore possible causes of abdominal pain, rectal bleeding, changes in bowel habits, chronic diarrhea, and other intestinal problems. The air expands the colon, which provides a better view of the colon lining. When the scope is moved or air is introduced, the client may feel abdominal cramping or the urge to move the bowels.
Sigmoidoscopy is a direct visualization of sigmoid colon, rectum, and anal canal. Describe procedure
dyspnea, cough, rales, and jugular vein distention.
Signs and symptoms of circulatory overload include
low potassium level Hypokalemia
Signs and symptoms of ehat? muscle weakness, paresthesias, fatigue, nausea, vomiting, and dysrhythmias. increase the client's sensitivity to digitalis.
low sodium level
Signs and symptoms of what? include nausea, muscle cramps, increased intracranial pressure, confusion, and muscular twitching.
Ménière Disease Treatment: Salt and fluid restriction to decrease amount of endolymphatic fluid. Antihistamines. Antiemetics. Surgery.
Signs and symptoms: Tinnitus. Unilateral sensorineural hearing loss. Vertigo.
Some early warning signs of overdose are confusion, loss of appetite, nausea, vomiting, diarrhea, or vision problems. Other signs of overdose are changes in the rate or rhythm of the heartbeat (becoming irregular or slow), palpitations (feeling of pounding in the chest), or fainting.
Signs of digoxin overdose
Severe nasal congestion Hypertension Bradycardia Pounding pulse
Spinal cord injury at the level or above T6 (T1-T-6), complication: autonomic disreflexia SS
autonomic disreflexia SS Severe nasal congestion Hypertension Bradycardia Pounding pulse
Spinal cord injury at the level or above T6 KTI-T-6), complication:
Edema. skin will be pale and cool to touch, Crackles Tachycardia.
Ss of flyid volume overload
Kidney function is reduced, but the healthier kidney is able to compensate. Since the kidney is not as able to concentrate urine, the client has polyuria and nocturia,
Stage I kidney disease Kidney function is diminished. Assessment.
otosclerosis.
Stapedectomy: • Surgical removal of stapes and replacement with a prosthesis to treat hearing loss caused by
blood at 5 mL per min for first 15 min.
Start transfusion (how many mL per min for the first 15 min)
Steatorrhea is.stool that is fatty, greasy, and foul smelling. This is due to malabsorption of fats in the diet.
Steatorrhea due to
80-120
Suction pressure
Immunosuppressant
Suffix -mab tells us? (adalimumab)
Neuroleptic Malignant Syndrome Long term use of psychotics
Symptoms very high fever (102 to 104 degrees F), irregular pulse, accelerated heartbeat (tachycardia), increased rate of respiration (tachypnea), muscle rigidity, concerns with ABCs, altered mental status, autonomic nervous system dysfunction resulting in high or low blood pressure, profuse perspiration, and excessive sweating.
cataract is progressive opacity of the lens. Cataracts are painless. clouded, blurred, or dim vision.
Symptoms of cataracts
excessive urine output, severe dehydration, excessive thirst, anorexia, and weight loss. - Low specific gravity
Symptoms of diabetes insipidus include
loss of deep tendon reflexes (9.6-12 mg/dL) (> 7 mEq/L), respiratory depression (12-18 mg/dL) (> 10 mEq/L), and cardiac arrest (24-30mg/dL) (> 25mEq/L).
Symptoms of magnesium sulfate toxicity
water intoxication.
Syndrome Of Inappropriate Antidiuretic Hormone (Siadh) Results in water
• Fluid restriction - 500 to 600 mL/24 hours. Sodium replacement. Diuretics.
Syndrome Of Inappropriate Antidiuretic Hormone (Siadh) Treatment:
Fluid restriction Na replacement Diuretics
Syndrome Of Inappropriate Antidiuretic Hormone (Siadh) treatment
Hypothyroidism (5-10)
TSH is high
Hyperparathyroidism (less than 0)
TSH is low
treat men with symptoms of an enlarged prostate (benign prostate enlargement). It's also occasionally taken to treat kidney stones. Tamsulosin is available on prescription and you can also buy it from pharmacies. Administer at night to to minimize the chances of getting dizzy or fainting
Tamsulosin When to administer?
1. High Fowler position to inhale deeply 2. Seal the lips tightly around the mouthpiece 3. Inhale slowly for better placement if alveoli 4. Hold the breath for at least 3 seconds 5. Exhale slowly through the mouth for 2-6 secinds 6. Cough and deep breathe 2-3 times to clear the airway
Teach about use of incentives spirometer 6 steps
Avoid hot and cold beverages
Teach with trigeminal neuralgia tic douloureux
Verify membranes have ruptured: Test fluid with Nitrazine paper - amniotic fluid alkaline, vaginal secretions acidic.
Test Nitrazine paper
infection.
The The nurse identifies which factor most contributed to the vaso-occlusive crisis?
Pernicious anemia
The body needs vitamin B12 to make red blood cells.
affected leg and moved with the affected leg.
The cane should be placed in the hand on the side of the
One third full.
The client should be instructed to empty the ileostomy pouch when it is
Help the client to turn onto her left side.
The client suddenly says, "I am dizzy. I feel as if l'm going to faint." Topic: priority action for vena cava syndrome
prevent weight bearing on the affected leg.
The client uses a swing-through crutch gait to prevent ___ on the affected leg.
prevent weight bearing on the affected leg
The client uses a three-point crutch gait to prevent
sodium.
The client with Cushing disease may have hyperglycemia, as well as an increased
18.5
The client with a BMI of less than_____ is underweight.
fundus is about at the umbilicus or 1 cm above the umbilicus within 12 hours of the birth. After this time, it should descend 1-2 cm each day.
The fundus is about ______the umbilicus within 12 hours of the birth. After this time, it should be _____.
"I am able to give liquid medicines through the tube." Many liquid medixations contain sorbidolwhich can cause osmotic diarrhea
The home health care nurse makes a visit to a client receiving enteral feeding through a gastrostomy tube. The client's adult caregiver reports the client has frequent loose stools. Which statement made by the adult caregiver needs further investigation by the nurse?
Stapedectomy is the removal of otosclerotic lesions and the creation of a tissue implant with a prosthesis to maintain adequate conduction. After surgery temporary hearing loss. Hearing may be impaired temporarily postoperatively due to edema and packing improvement in hearing takes several weeks following a stapedectomy.
The improvement in hearing following a stapedectomy when?
pyloric stenosis
The infant client with a palpable olive-shaped mass in the epigastrium and frequent vomiting. What is that?
1.7 to 2.2
The normal range for blood magnesium
Client appears to be physically relaxed. If pt stoped moaning and crying it dosent mean he doesnt have pain The clien may expeess pain relief but mat still be experience pain.
The nurse administers morphine sulfate to an adult client. The nurse expects to observe which finding?
Crackles are heard during auscultation in both lungs. High urine output.
The nurse assesses a client receiving parenteral nutrition (PN). Which assessment most concerns the nurse? priority complication PN
30 minutes
The nurse assesses circulation of a client's extremities every ___while the client is in extremity restraints.
responsibility and accountability.
The nurse assign a client to another nurse and both _____ are transferred.
Assess for nausea and vomiting. (Can increase intraocular pressure)
The nurse cares for a client following a scleral buckling. Which nursing action is most important?
LPN/LVN and unlicensed assistive personnel.
The nurse delegates care to the
Avoid Na, protein (increase ammonia), NCAIDS such as ibuprofen
The nurse instructs a client diagnosed with alcoholic cirrhosis and ascites. Which client statement indicates that the teaching is effective? Avoid
The client reports severe nasal congestion. T6 and higher autonomic disreflexia
The nurse performs a home care visit on a client diagnosed with a spinal cord injury at the T1. Which observation most cancerns the nurse?
30 sec
The nurse preoxygenates the client with 100% O, for at least _____prior to suctioning.
eye may water and itch for several weeks after the surgery." will increase my intake of fluids and roughage." Don't dim the light, can impair vision!
The nurse prepares a client for discharge following a scleral buckle repair of a detached retina. eye may water and itch for_____ after surgery What to eat to avoid constipation ? Dimmer light or not?
Bedrest Ultrasound to lacate placenta No vaginal exams/ intercourse Amniocentesis for lung maturity Daily hemihlibi, hematocrit 2 units of blood
Treatment for placenta previa
Exhale when turning or moving The nurse should discourage coughing, Valsalva maneuver, bearing down because it will cause increased intracranial pressure. The nurse will encourage the client to deep breathe and turn side to side.
The nurse provides care for a client diagnosed with a closed head injury and increased intracranial pressure. Which action by the nurse is best?
Obtain the client's blood pressure. Can be a circulatory collapse in the vascular space CIRCULATION!
The nurse provides care for a client immediately after an abdominal paracentesis. It is most important for the nurse to take which action? 1. Weigh the client. 2. Measure the client's abdominal girth. 3. Obtain the client's blood pressure. 4. Check the dressing.
Contractions are at 2 minute intervals and last 90 to 120 seconds.
The nurse provides care for a client receiving an oxytocin infusion to induce labor. The nurse stops the infusion if which occurs? Contractions are at ____ intervals and last_____seconds.
Administer the pain medication as prescribed
The nurse provides care for a preschool-age client after surgery. Using a pain-rating scale, the child indicates severe pain. The nurse notes that the child is sitting quietly looking at a book. Which action by the nurse is best? Continue to assess or administer pain meds?
Sits forward with the neck extended, contraction of supraclavicular muscles. Using accessory muscles, bronchospasm
The nurse provides care for a toddler-age client after a bronchoscopy and removal of an aspirated peanut. Which assessment requires an immediate intepvention by the nurse? O 1. BP 90/60 mm Hg, apical heart rate 110 beats/min with a sinus arrhythmia. O 2. Weak cough effort with scant production of sputum, drowsy but arousable. O 3. Abdominal muscles contract during inspiration, respiratory rate 30 breaths/min. O 4. Sits forward with the neck extended, contraction of supraclavicular muscles.
Polycythemia. (Body tries to compensate by producing more RBC) to carry limited amount of O2
The nurse provides care for an infant client diagnosed with a cyanotic congenital heart defect. The nurse understands that chronic hypoxia from this disorder can result in which finding?
Give the client a small towel to hold. (Safest, most effective)
The nurse provides care for an older adult client three hours after a transurethral resection of the prostate. The client has a continuous bladder irrigation, is confused, and continuously pulls at the catheter tubing. Which action by the nurse is best? 1. Give the client a small towel to hold. 2. Explain to the client that the catheter should not be touched. 3. Ask the client's spouse to sit with the client. O 4. Explain to the client's family why distraction is needed.
Obtain the BP in the sitting and standing positions. Dehydration. Circulation. River in the body is not full. When pt moves BP going down.
The nurse provides care for an older adult çlient just transferred from a long term care unit. The record indicates that the client has refused to eat or drink for several days Which action by the nurse is best?
Covers the eye with a protective shield and send to eye specialist
The nurse provides care for clients in the outpatient clinic. A client comes stating, "I think I have a piece of glass in my eye." Which action does the nurse take first?
Antianxiety Can channel blocker Lipid-lowering agent Seizure buspirone. verapamil. carbamazepine.
The nurse reviews the health records of several clients. Which client does the nurse identify as requiring teaching about the need to avoid grapefruit juice?
Trigeminal.
The nurse understands which cranial nerve is affected in tic douloureux?
isometrics exercise contractions of a particular muscle or group of muscles, such as quadriceps setting or straight leg raises
The only safe method of enhancing muscle strength and venous return in a casted extremity is by ____
100 beats per minute.
The pulse of a newborn should be auscultated apically for 60 seconds and should be greater than
bearing weight.
The three-point gait keeps the affected leg from
Theophylline: 10-20. TOXIC OVER 20.
Theophylline: TOXIC OVER
Graves disease Excess secretion
Thyroid Disease- Hyperthyroidism • Causes:
levothyroxine Monitor cardiac output Prevent constipation Maintain skin integrity
Thyroid Disease- Hypothyroidism Myxedema coma therapy
In transition phase: frequency,
Timing of Uterine Contractions every 1 to 2 minutes,
active phase:
Timing of Uterine Contractions every 2 to 5 minutes;
In latent phase:
Timing of Uterine Contractions every 5 to 10 minutes;
If contractions too intense. If contractions preterm.
Tocolytic
Hyperthyroidism
Too much iodine
Less than 200
Total cholesterol should be
More than 2
Toxic digoxin level
Toxic hepatitis refers to inflammation of the liver due to medication or exposure to toxic chemicals, alcohol or acetaminophen. NO INFECTION!
Toxic hepatitis
Tracheoesophageal defects are a group of congenital anomalies in which esophagus ends in a blind pouch, and the trachea is attached to the esophagus via a fistula. The infant will exhibit respiratory difficulty from birth, and experience choking with the first feeding. 3 Cs: Chocking Coughing Cyanosis An excessive amount of oral secretions
Tracheoesophageal defects what are 3 SS or 3Cs?
hypotension
Transfusion reactions cause BP
room temperature to prevent chills.
Transfusion. blood is warmed to
Transsphenoidal means through the sphenoid sinus. This is the air sinus (cavity) at the back of the nose. The client is not allowed to brush teeth for 1-2 weeks to allow the incision to heal.
Transsphenoidal hypophysectomy (microadenoma of the pituitary glandis) the surgical removal The client is not allowed to
Pureed, soft, or semisoft foods are easier to swallow than liquid foods. client may need learn to use the unaffected hand for feeding, but this is not the priority intervention
What is helpful for person with hemiplegia when eating?
Cerebral palsy
What is that? Poor head control after 3 month Stuff arms Arching back Limp body posture hypotonic
Nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen High doses of corticosteroids
What medication reduces the child's immune response, which could compromise the effectiveness of the vaccine?
Acetaminophen can impede vit K cycle from the liver
What medication to avoid with Warfarin
infiltration check the site, If no infiltration is present, then the nurse can reposition the client's arm or raise the solution.
When an intravenous infusion stops running, most common cause.
Vtack without pulse Vfib
When we defibrillate
Serum creatinine. NSAID - RENAL!
Which assessment is a priority to make prior to administration of ketorolac? (liver or renal toxicity?)
Aminophylline
Which medication prescribed for asthma causes of dysrhythmias?
It causes Na and water retention
Why Cushing goes with hypertention?
To promote healing by decompressing the bladder. An overextended bladder may interfere with wound healing by pressing on the wound. The indwelling urinary catheter is usually removed when the client begins ambulating.
Why need indwelling urinary catheter immediately after surgery.
Kinks
Why no fluctuations in water chamber? (chest tube)
Increase flexion which we have to avoid
Why not to use pillow with amputation fir elevation
They are manipulative and disruptive (no card games, no support groups for them) Also don't leave them alone
Why social activity is contraindicated for manic phase patients?
High
With DKA client becomes dehydrated and hematocrit is
Diuretics Ace inh
With what meds monitor K?
12 hours
____hours after birth. newborn assessment for withdrawal (start tachypnea, high pitched cry, hyperactive Moro) Before that time don't assess for withdraw
stomach doesn't secrete the necessary substance for B12 to be absorbed
a client diagnosed with pernicious anemia asks why vitamin B12 cannot be given in pill form. Which response by the nurse is best?
Nystagmus
abnormal, involuntary, rapidly oscillating eye movements. The movements may be horizontal, vertical, rotary, or mixed in direction. It may reflect labyrinth or vestibular dysfunction, neurologic disease, barbiturate intoxication, congenital factor, or occupational factors.
Addisonian crisis is
acute adrenal insufficiency precipitated by physical and psychological stressors.
Meningitis. Observe for headache, stiff neck, and increasing temperature.
acute otitis media. What important to prevent?
Aminophylline is used for long-term control of reversible airway obstruction caused by asthma and COPD. Its therapeutic action is bronchodilation, therefore the respiratory rate should decrease. Aminophylline is known to cause tachycardia, nervousness, restlessness, and nausea. Aminophylline is used cautiously in clients with cardiac impairment.
aminophylline Considerations What does this drug do?
appointed by the relevant government body, NOT the health care provider.
an incapacitated client has not previously authorized a health care proxy, and has no one readily available for the role, a guardian may become _____ health care proxy should know the client well and be able to carry out the client's end-of-life wishes. Desires for treatment or refusal of treatment may be included in the durable power of attorney document. It may help the health care proxy make better decisions if needed.
myringotomy primary purpose of the procedure is to relieve the pressure on the eardrum to avert a rupture
an incision made into the posterior, inferior aspect of the tympanic membrane to relieve pressure on the eardrum and drain the middle ear. The nurse will instruct the client to keep external ear and canal dry while the incision is healing
12 to 18 months
anterior fontanel takes _____months to fully close.
Flumazenil
antidote for Benzodiazepines.
cross-reactive foods with latex.
apple, avocado, banana, carrot, celery, chestnut, kiwi, melon, papaya, raw potato, tomato.
multiple sclerosis
autoimmune disorder with viral and genetic components. It is a chronic progressive disease characterized by deterioration of the myelin sheath of the central nervous system (CNS) and subsequent scarring via plaques throughout the brain and spinal cord. Symptoms include ataxia, weakness, spasticity, nystagmus, paresthesias, incontinence, and emotional instability.
Not alone with group and social interactions (cook, make something but not watching TV)
best activity depressed client
prevent chills.
blood is warmed to room temperature to
8.2 to 10.2 mg/dL
calcium level is in the normal range
Increase fluid intake (at rush for fluid volume deficit)
care for an ileostomy at home. Fluids? (client at Risk for what) Avoid?
autoimmune disorder
cause of multiple sclerosis
roll the client to the left side and apply oxygen.
is sustaining late decelerations, the appropriate action is to
aPTT
lab value that is used when the client is on a heparin drip.
Late decelerations !Fetal hypoxia and acidosis usually result! The goal of the nursing actions is to increase oxygenation to the fetus. O2, left side Increase IV infusion The infusion of oxytocin must be turned off to decrease the frequency of contractions.
caused by uteroplacental insufficiency or maternal supine hypotensive syndrome.
Osteoporosis
causes a loss of calcium and a thinning of the bones. This may cause a spontaneous fracture resulting in the client falling
pneumothorax (collapse of a lung) is a potential complication during the insertion of any central venous pressure line, especially a subclavian line because of the proximity of the central veins and the lung cavity. A pneumothorax can occur due to perforations of the pleura by the catheter. Symptoms include pain and respiratory distress
central venous pressure line is inserted in a client. Following the catheter insertion, the client reports dyspnea, shortness of breath, and chest pain.
Autonomic hypereflexia Places the client in a sitting position to decrease BP to the head to reduce the risk of cerebral hemorrhage
cervical spine injury and severe headache.
6-month-old
child can roll over from stomach to back and begins to distinguish and recognize strangers. Age?
24-month-old
child goes up and down stairs alone, runs well with a wide stance, builds a tower of six to seven blocks, and has a vocabulary of about 300 words.
Encourage the child to continue coughing. Not abdominal thrusts because it's not time to begin it. It's appropriate when child is not able to speak or breathe or developed stridor
child who appears to be choking. The nurse observes that the child is conscious and coughing. The other children report that the child was eating raisins. Which action will the nurse take first?
Anemia, seizures
chronic lead poisoning. Which symptoms does the nurse expect to see?
corticosteroids. Amounts of hormone replacement may need to be adjusted during times of stress due to the inability of the adrenal gland to produce increased amounts of steroid.
client diagnosed with Addison disease is unable to produce adequate amounts of
Prednisone. Estrogen. Atenolol.
client diagnosed with type 1 diabetes mellitus. Which medication, from the client's list, requires frequent blood glucose monitoring?
LDCT every year. (Low dose CT scan)
client has a 30-year pack history of smoking, is a current smoker, or has quit in the past 15 years, the ACS recommends a
Hematuria Hematuria (blood in urine) indicates hemolytic reaction due to ABO incompatibility Other symptoms of ABO incompatibility include nausea, vomiting, hypotension, increase in pulse rate, and decreased urinary output The nurse will stop the transfusion administer oxygen and prescribed diphenhydramine, and maintain the client's
client receiving a blood transfusion. The nurse is most concerned if
diet high in protein, vitamin C, and calories.
client recovering from a serious burn needs what diet
2-3.
client who is taking warfarin should have an INR in the range
A scant amount of bright bloody bleeding. Report excessive amount of bleeding.
colostomy. 24 hours after the surgery the colostomy drainage will be which description?
Polycythemia vera
condition where the body makes extra red blood cells which causes hyperviscosity (thickening) of the blood. Symptoms increased blood volume and viscosity. Symptoms from an increase in blood volume include headache, dizziness, tinnitus, fatigue, paresthesias, and blurred vision. Symptoms related to blood viscosity include angina, claudication, dyspnea, thrombophlebitis, and an elevated blood pressure
bleeding within the past 6 months. History of stroke. Timeframe 3-4 hours
contraindication for thrombolytic therapy
after 1 hour."
correct information for a client diagnosed with HIVIAIDS I should discard an open bottle of water after
Foods to avoid include apple, avocado, banana, carrot, celery, chestnut, kiwi, melon, papaya, raw potato, and tomato. Other foods may also have some reaction for some individuals.
cross-reactive foods with latex. Foods to avoid with latex allergy
variable deceleration
deceleration? On the fetal tracing, the heart rate will go up and down and present when the cord is being compressed.
early decelerations.
decelerations. The baby's head is pressing against the pelvis or soft tissue
glaucoma.
decrease in peripheral vision is a symptom of (often caused by an abnormally high pressure in eye)
Accumulation of sodium and water inside the neurons in the affected area.
describes death of neurons after an ischemic stroke
C
desired diet for iron deficiency anemia includes iron sources as well as vitamin
intermittent cramping pain in my lower abdomen
diagnosis of ulcerative colitis. pain
High protein, high calories, tolerated fat. Pancreatic enzyme replacement is required.
diet cystic fibrosis
low-iodine
diet helps to reduce thyroid hormones.
prednisone because 1. prednisone -- risk for hypokalemia, 2. digoxin -- risk for digoxin toxicity with hypokalemua or hypomagnesemia)
digoxin drug interaction with
Aplastic anemia
disease condtion due to bone marrow depression
Bell palsy The cause is unknown, but viruses and inflammatory diseases can predispose a client to it.
distortion of one side of the face, inability to close the affected eye, and lacrimation. Treatment includes steroids initiated within the first 72 hours of the symptoms appearing to reduce inflammation. The nurse will educate the client about comfort measures, facial muscle exercises, and prevention of corneal abrasion.
No eggs and meat just dairy
lacto-vegetarian diet is a diet that
Reduce carbohydrates, simple sugars and high fiber (it increase gi motility) Eat 6 small meals include foods that contain fats and protein at every meal. (fats and proteins move slower in gi) Lay down or sit in a recliner for 30 to 60 minutes after eating. (use gravity to slow gi motility) wait for 1 hour after I eat before drinking fluids.(increase fluids -- > more rapid gi tempting)
dumping syndrome. Considerations about meal consuming
First Generation Antipsychotic Agents high risk for EPS
dverse Effects fluphenazine
high risk for EPS
dverse Effects haloperidol
Nausea and vomiting client needs to be seen first. The digoxin should be held symptoms monitored while waiting to see the health care provider.
early effects of digoxin toxicity
Serum amylase normal range is 60-160
elevated in acute pancreatitis.
Oxygen equipment. Ambu bag Suction equipment
equipment at the client's bedside? safety for client at risk for tonic-clonic seizures
characteristic of diabetes insipidus.
excessive urine output, severe dehydration, Low specific gravity
client should notify the health care provider immediately if there is a fever. A fever is a symptom of serotonin syndrome, which is a rare, life-threatening event caused by SSRIS. Symptoms include abdominal pain, fever, sweating, tachycardia, hypertension, delirium, myoclonus, irritability, mood changes, and may result in death. Citalopram is a selective serotonin reuptake inhibitor (SSRI) used to treat depression. Adverse effects of citalopram include mania, hypomania, insomnia, impotence, headache, and dry mouth. It takes some time before improvement is seen when taking this medication.
fever and citalopram (SSRIs)
Fistulas. Abnormal tracts b/n two or more body areas (skin, bladder, vagina)
finding is expected by the nurse as a common complication of Crohn disease?
Check the drainage tubing for kinking or obstructions.
for a client one hour after transurethral resection of the prostate (TURP) with a continuous bladder irrigation. The client reports to the nurse, "I really have to urinate!" Which action will the nurse take first? priority action TURP
candidiasis
fungal infection common in HIVIAIDS. Common symptoms white patch-like lesions in the mouth, loss of taste, and dysphagia. Dysphagia could indicate the lesions have spread to the esophagus.
reduced health care costs and the focus is on client outcomes.
goal of managed care is
suspected meningitis
headache and sensitivity to light. rash on the back and has been napping frequently. What it is?
males."
hemophilia "It is an X-linked recessive trait found primarily in
Activated partial thromboplastin time. At leadt ince a wk
heparin therapy. which laboratory test is used to monitor the effectiveness of heparin?
unprotected sex with anyone who has hepatitis B? recent blood transfusion? share needles with anyone?
hepatitis B virus is shed in the body (route)
cough and deep breathe
herniorrhaphy hermia repair, the chent should avoid
premature rupture of membranes (PROM)
highest risk of developing a postpartum uterine infection?
Cushing syndrome Symptoms include an increase body fat causing a buffalo hump, truncal obesity, and moon face.
hypercortisolism (increase cortisol).
decreased deep tendon reflexes, drowsiness and confusion, and muscle weakness.
hypomagnesemia. causes deep tendon reflexes,
Addison disease
hyposecretion of corticosteriod hormones from the adrenal gland. Reduced aldosterone secretion results in increased sodium and water excretion, resulting in volume depletion.
NSAID Bleeding Avoid in cirrhosis (risk for bleeding)
ibuprofen (risk for)
Eat raw meat Eat refrigirated leftovers more than 24 hours after preparation Use alcohol-based mouthwash (it dries oral mucosa) No direct contact with soil Use razor blade
incorrect action for a client diagnosed with leukopenia
Vitamin C
increase the absorption of iron.
Eczema Milk, wheat, eggs
inflammatory rash caused by an allergic immune response. What food yo avoid
Phenylketonuria
inherited disorder where there is an absence of an enzyme needed metabolize the essential amino acid phenylalanine. The treatment is dietary with consumption of foods that contain low phenylalanine levels, such as vegetables, fruit, juices, and some low protein breads and cereals. Oranges are allowed on the diet. No protein diet!
Decrease the myocardial irritability and myocardial automacity. Used in ventricular arrhytmias
intravenous lidocaine purpose of this medication?
Strabismus
involuntary drifting of one eye out of alignment with the other eye. A "lazy eye" may be inherited or paralytic.
dried beans, dried fruits, eggs, fortified cereals, liver, lean red meats, and poultry
iron Good dietary sources
Pernicious anemia
is caused by the inability of gastric mucosa to absorb vitamin B12 due to deficiency of intrinsic factor
Diarrhea
is consistent with hyperkalemia.
Cisplatin Can cause ototoxicity
is one of the most powerful chemotherapeutic drugs used for the treatment of ovarian cancer
incorrect client will be asked to lie still while a scanning probe is passed back and forth over the body.. the client will recieve trace amount of radioactive colloid by IV infusion
liver scan description
Glargine
long acting insulin with a duration of 24 hours.
Reflex hammer (check reflexes) and calcium gluconate (block the cardiac effect of hypermagnesemia)
magnesium sulfate IV for treatment of preeclampsia. important to have at the bedside?
Headache, nausea, and fatigue may occur after hemodialysis due to dsequilbrium syndrome This is caused by the rapid removal of electrolytes and solutes from blood contributes Improve over time
may occur after hemodialysis due to dsequilbrium syndrome
Place the manometer at level of the right atrium.
measuring the central venous pressure, it is most important to take which action?
Halo traction
method of gently stretching and straightening a severely compressed or curved spine. The procedure is typically a first step in correcting severe scoliosis, kyphosis, and other spine deformities.
Stimulant for ADHD Cause weight loss, appetite successor NEED TO INCREASE HIGH-calorie nutritious foods
methylphenidate For what and considerations
Methylphenidate is a CNS stimulant used for ADHD. Watch for elevated blood pressure. Assess the client for restlessness, dilated pupils, tremors, and possible tonic-clonic seizures.
methylphenidate watch for
attention deficit hyperactive disorder (ADHD) Central nervous system stimulant.
methylphenidate.
chronic hepatitis C infection and alcohol-induced liver disease.
most common causes of cirrhosis are
Social isolation
most common result of hearing loss.
Hypocalcemia
most common underlying cause of tetany.
Schilling test is used to diagnose pernicious anemia. The client fasts for 12 hours and is then orally, followed by a large, nonradioactive dose IM. The client then will collect a 24-hour urine. given a small dose of radioactive B12 The most important information how to correctly collect a 24-hour urine otherwise the test may be unsuccessful
most important information in Schilling test
Osteoporosis.
musculoskeletal changes that occur with aging. Which change is likely to cause a client to fall?
Addisonian crisis
nausea and vomiting, extreme weakness, severe hypoglycemia, signs and symptoms of shock.
12-month-old child
needs help walking, eats with fingers, and says three to five words other than "dada" and "mama."
pyloric stenosis, fluid and e imbalance immediate intervention
newbom client experiencing projectile vomiting and imitabiity
Determine blood glucose level. hypoglycemia
newborn's admission to the nursery, the nurse observes the baby having spontaneous jerky movements of the limbs. What tf?
18.5 - 24.9.
normal BMI
100-120 bpm.
normal fetal heart rate is between
3.5-5.5 g/dL (35-55 g/L).
normal value for serum albumin
Increased pulse rate, increased BP, increased respirations. (Signs of heart failure)
nurse provides care for a client receiving a blood transfusion. The nurse observes which symptoms if fluid overload occurs dúring the transfusion? hr, bp, rr
smallest gauge needle possible (24 and 26)
nurse will use what needle when starting an IV for older adult clients.
30 - 39.9.
obese BMI
benign prostatc hyperplasia (BPH). decreased ejaculatory force
older male clent reports hesitancy and dribbling with urination Nocturia, decreased voiding force.
Lispro is a rapid acting insulin
onset of this insulin is 15 to 30 minutes and the peak is 30 minutes
Syndrome Of Inappropriate Antidiuretic Hormone (Siadh) Results in water imbalance causing water intoxication. Fluid retention
opposite of diabetes insipidus.
25.0 - 29.9.
overweight BMI
4 or less
pH of gastric aspirate is
Otosclerosis
painless abnormal bone growth in the middle ear and is a leading cause of deafness.
change the maternal position and assess the FHR again.
pattern of variable deceleration is most likely a result of compression of the umbilical cord. The nurse should
The emergent (resuscitative) phase decreased cardiac output and decreased kidney perfusion. Urine output is decreased and urine is concentrated and has a high specific gravity.
phase is the first phase of a burn injury and occurs during the first 24-48 hours. Fluid is lost through open wounds or extravasation of plasma from damaged blood vessels near the burned area into the interstitial tissues. Hypovolemic shock is a common cause of death in the emergent phase of a major burn. Blood pressure is decreased. Urine output?
Latent
phase: Lasts for about 6 hours in the primipara and 4½ hours in the multipara.
Tuberculosis
positive PPD reading, what is that?
2
posterior fontanel closes at around ____months of age.
Maintains the client on bedrest to minimaze the movement of the eyes to reduce the progression of detachment
preoperative care for a client diagnosed with a detached retina, the nurse takes which action?
unstable blood glucose level.
primary reason for maintaining a constant rate of infusion with parenteral nutrition (PN) is to prevent which complication?