Passpoint 1
PP client asks nurse why she's wearing gloves:
"they are required for standard precautions"
low fowlers
15-30 degrees
The client in balanced suspension traction is transported to surgery for closed reduction and internal fixation of his fractured femur. Which of the following should the nurse do when transporting the client to the operating room? 1. Transfer the client to a cart with manually suspended traction. 2. Call the surgeon to request an order to temporarily remove the traction. 3. Send the client on his bed with extra help to stabilize the traction. 4. Remove the traction and send the client on a cart.
3
Standard Fowler's
45-60 degrees
Measles
A viral infection that's serious for small children but is easily preventable by a vaccine; droplet precautions caused by coughing or sneezing
Abrasion
A wearing away or rubbing away by friction.
Why are children more susceptible to the effects of a chemical attack than adults?
Because children have thinner skin than adults.
A client diagnosed with acute myelocytic leukemia has been receiving chemotherapy. During the last 2 cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia?
Closely observe the client's skin for petechiae and bruising.
How does the nurse on the obstetrics unit assure client safety?
Communication among staff; reconciliation of medication prescriptions; staff training; use of two unique identifiers
The nurse is preparing care for a client with severe post-op pain. there is a prescription for morphine written as "10 mg MS04" on the medical record. What should the nurse do first?
Contact HCP who prescribed the medication. Question!
When is morning sickness?
First trimester
hyperthyroidism/ grave's disease
Graves is often cause of hyperthyroidism
shoulder dystocia
Head is delivered but shoulders become impacted above mother's symphysis pubis/her pelvis.
a nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?
Help the client dangle his legs
Wilms tumor (nephroblastoma)
Kidney cancer in children; good survival rate
xiphoid process in newborn
Looks like a small bump in the middle of the chest and is an extension of the sternum; normal but looks more prominent in infants
atypical antipsychotics
Olanzapine Clozapine Respiradone
Toxoplasmosis:
Pregnant women at risk for this; cook meat thoroughly and don't come in contact with cat feces
Osmolarity Test
Reflects the concentration of substances such as sodium, potassium, chloride, glucose, and urea in a sample of blood, urine, or sometimes stool
burn
Run cool water and wrap in clean cloth.
Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis?
Signs of increased intracranial pressure (ICP)
Ortolani test
To detect hip dislocation
Why will hospitalization occur for TB?
To prevent spread of disease
Tracheoesophageal fistula:
Tracheoesophageal fistula is an abnormal connection in one or more places between the esophagus (the tube that leads from the throat to the stomach) and the trachea (the tube that leads from the throat to the windpipe and lungs). Normally, the esophagus and the trachea are two separate tubes that are not connected.
Typical vs atypical antipsychotics:
Typical: greater risk of EPS/hyperprolactinemia Atypical: greater risk of METABOLIC syndrome - bad b/c pts with schizo already have increase risk of CV disease
Outcome for hep b patient:
adhere to measures to prevent spread of infection to others
Ecchymosis
bruise
Azotemia
elevated BUN
recumbent position
lying down
A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which info is most important for the nurse to discuss?
Infection control
When completing pre-op checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?
Inform the anesthesiologist.
Biot breathing pattern
Irregularly interspersed periods of apnea in a disorganized and irregular pattern, rate, or depth.
After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the HCP?
Laryngeal stridor (hemoptysis is normal...)
Diet for PKU patients
Low in phenylalanine but enough to support growth; low protein
Scabies education:
Maintain contact precautions until skin scrapings from a patient with crusted scabies are negative; persons with crusted scabies generally must be treated at least twice, a week apart; oral ivermectin may be necessary for successful treatment.
Trimesters of pregnancy
- 1st trimester: week 1-13 - 2nd trimester: week 14-26 - 3rd trimester: week 27-40
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
-Determine that there will be latex-safe environment for surgery -Notify HCP at surgery center -Report sx experienced with latex allergy
Semi-Fowler's Position
30-45 degrees
high fowlers
60-90 degrees
cellulitis
A common and potentially serious bacterial skin infection.
Tachypnea
Breathing pattern regular but more in number; shock, panic, fever
Cerebral palsy and seizures
Children with CP are likely to have at least one seizure or more during their lifetime
Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?
Diaphragms should not be used if the client develops acute cervicitis
While caring for a primigravid client with class II heart disease at 28 weeks' gestation, the nurse would instruct the client to contact her primary HCP immediately if the client experiences which symptom?
Dyspnea at rest
adolescent with anorexia has abnormal BUN level why?
Elevated because she is dehydrated
While the nurse is performing a complete assessment of a term neonate, which finding would alert the nurse to notify the HCP?
Expiratory grunt
Cushing's triad:
HTN; bradypnea; bradycardia
A client with ascites had a paracentesis. Which post-procedure intervention should the nurse implement?
Monitor the client's temp
Which nursing intervention is appropriate for a client with an arm restraint?
Monitoring circulatory status every 2 hours
Highest priority for a client placed in restraints:
Monitoring the client every 15 minutes
When performing an initial assessment of a postterm male neonate weighing 4,000 g (8 ib 13 oz) who was admitted to the observation nursery after a vaginal birth with a low forceps, the nurse detects Ortolani's sign. Which action should the nurse take?
Notify the HCP immediately.
Cushing's syndrome symptoms
Obesity, wasted extremities, buffalo hump, acne, hirsutism, amenorrhea, proximal muscle weakness, striae, HTN
Moving an obese patient from stretcher to bed:
Obtain the sliding board or two other people to assist us.
Measure taken to maintain surgical asepsis:
Performing a pre-operative surgical scrub for at least 3 to 5 minutes
A client with acute lymphocytic leukemia (ALL) is at risk for infection. What action should the nurse take?
Place the client in a private room.
A client with human immunodeficiency virus (HIV) has a low CD4 level. What interventions should the nurse implement as a result of this finding?
Place the client in reverse isolation
A client, 7 months pregnant, is admitted to the unit with abdominal pain and bright red vaginal bleeding. Which action should the nurse take?
Place the client on her left side and start supplemental oxygen, as ordered.
Before assisting a client to ambulate to surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed?
Place the client on high fowler's position
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?
Placing the client in respiratory isolation
To prevent ankle ankyloses following chest surgery the nurse should teach the client to:
Raise the arm on the affected side over the head.
Biot pattern
Rapid gasping followed by period of apnea. CNS insults; infections especially meningitis
A nurse notes the following lab values for a client receiving chemotherapy: white blood cell count 6,000, RBC count 3.7 million, hematocrit 35%, platelet count 80,000. Which order should the nurse question?
Rectal temp every 4 hours.
An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant? 1. Single-hole nipple 2. Plastic spoon 3. Paper straw 4. Rubber dropper
Rubber dropper
Airborne precautions are for what 4 diseases?
SARS (Severe Acute Respiratory Syndrome), TB, Measles and Varicella
Upon the child's return from the postanesthesia recovery unit (PACU) after a tonsillectomy, the nurse should place the child in which position?
Side-lying
How long until TB results?
Skin test reaction between 48 and 72 hours
Potassium sparing diuretic
Spironolactone
Arthoscopy
Surgical examination of a joint
A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access. Which action would be most appropriate for the nurse to take?
Tell the nursing assistant to stay with the client during infusion.
Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education?
The client is receiving physical therapy twice per day, so he doesn't need a continuous passive motion device.
an infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff?
The client needs to be placed in a private, negative air pressure room.
How is hep A spread?
The hepatitis A virus is transmitted primarily by the fecal-oral route; that is when an uninfected person ingests food or water that has been contaminated with the faeces of an infected person. In families, this may happen though dirty hands when an infected person prepares food for family members
hand hygiene needs further education if...
The nurse dries from the forearms towards his fingers
A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics?
The nurse uses a rocking motion while helping the client to stand.
Nurse is preparing a community education program about preventing hep b infection. What will she teach?
The use of condom is advised during sex.
When is TB pt not contagious?
They will stop being contagious when they have a negative acid-fast bacilli test.
The nurse finds a confused client with soft wrist restraints in place. What should the nurse do first?
Untie the restraint and resecure to the bed frame using a quick-release knot.
To prevent spread of C dif when working with a patient who has it what should nurse do?
Wash hands with soap and water (not hand sanitizer!) Wear a protective gown
a client with COPD and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
Weigh yourself daily and report a gain of 2 ib in 1 day.
Using a walker:
When max support is required, the walker should be moved ahead approx 6 '' (15 cm) while both legs support the client's weight
Where does the bile go after the gallbladder is removed?
When the gallbladder is removed, bile made by the liver can no longer be stored between meals. Instead, the bile flows directly into the intestine anytime the liver produces it. Thus, there still is bile in the intestine to mix with food and fat.
A client is about to undergo bone marrow aspiration of the sternum. what should the nurse tell the client?
You will feel a pulling type of discomfort for a few seconds.
Which statement if made by the student would indicate to the nurse that the student understands the concept of liability?
a client can still file a lawsuit outside of the statute of limitations if the discovery of harm has been more recent.
a client is caring for a group of clients on a med-surg floor. Which client is at greatest risk for developing pneumonia?
a client with a nasogastric tube
Phenylketonuria
a genetic disorder in which the essential digestive enzyme phenylalanine hydroxylase is missing
a female client with HIV receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate?
a latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse
Toxoplasmosis
a parasite which is most commonly transmitted from animals to humans by contact with contaminated feces; mild, flu-like sx; disease
Schizophrenia (negative symptoms)
apathy (no feeling) a motivation (no motivation) flat affect (empty expression) social withdrawal, poverty of speech, anhedonia (inability to feel pleasure)
the nurse develops a teaching plan for the client about how to prevent the transmission of hepatitis A. Which discharge instruction is appropriate for the client?
ask family members to wash hands frequently
a client with an IV of normal saline at 150 mL/hour reports dyspnea and restlessness. which of the following is the priority nursing action?
assess the lung sounds
the nurse is assessing children at risk for phenylketonuria (PKU). Which child is at greatest risk?
blonde, blue-eyed, fair-skinned child with eczema.
The thyroid
butterfly shaped gland in neck
negative symptoms of schizophrenia
can be described as a reduction or loss of functions; they include slowed thoughts or speech, loss of expressed emotions, lack of motivation, attention deficits and loss of social interest.
Tuberculous meningitis
caused by mycobacterium tuberculosis. usually spread fom another site in the body. symptom onset is usually gradual/ very rare disorder that usually only occurs in people with compromised immune system. fatal if untreated.
asphyxia
condition caused by insufficient intake of oxygen
pneumatic
containing or operated by air or gas under pressure
hemoptysis
coughing up blood or blood-stained sputum
apnea
death and certain CNS injury
positive symptoms of schizophrenia
delusions and hallucinations
BUN test
determines how well kidneys are working. Urea Nitrogen is a waste product that's created in the liver when the body breaks down proteins. Increased if liver or kidneys are damaged
after administering an IM injection, a nurse should:
discard the uncapped needle and syringe in a puncture-proof container
Cullen's sign
ecchymosis in umbilical area, seen with pancreatitis
What type of post-op restraint for child with cleft palate repair?
elbow restraints
hirsutism
excessive body hair
Side effects associated with typical antipsychotics:
extrapyramidal sx
Schizophrenia (positive symptoms)
hallucinations and delusions
which question has been added to the nursing admission assessment to screen for the Zika virus?
have you recently traveled to south america?
Diseases droplet precautions:
influenza; bacterial meningitis; pneumonia; whooping cough
a client is to have a below-the-knee amputation. Prior to surgery, the circulating nurse in the operating room should:
initiate a time-out
in which areas of the US and canada is the incidence of tuberculosis highest?
inner-city areas
which dietary strategy best meets the nutritional needs of a client with acquired immunodeficiency syndrome (AIDS)?
instruct the client to cook foods thoroughly and adhere to safe food-handling practice
tardive dyskinesia
involuntary repetitive movements of the facial muscles, tongue, and limbs; a possible neurotoxic side effect of long-term use of typical antipsychotic drugs that target certain dopamine receptors
a nurse discovers scabies when assessing a client who has just been transferred to the medical surgical unit from the day surgery unit. To prevent scabies infection in other clients, the nurse should:
isolate the client's bed linens until the client is no longer infectious
a mother tells the nurse that her preschool-aged daughter with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently she had an allergic reaction after eating kiwi fruit and bananas. Based on the mother's report, the nurse suspects that the child may have an allergy to:
latex
a nurse is caring for a client after a hemorrhoidectomy. Which of the following orders would the nurse question on the medical record?
low-fiber diet
the nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child?
maintain a tidy environment around the child
a hospitalized client, with a productive cough, chills, and night sweats is suspected of having active TB. What is the nurse's most important intervention?
maintain the client on respiratory isolation
a nurse is leading a group of parents of toddlers in a discussion on home safety. The nurse should emphasize which fact?
most toddler deaths are accidental
Do you need to wear sterile gloves to bathe a neonate at 2 hours of age?
no
Do you wear sterile gloves to bathe a neonate 2 hours of age?
no
Eupnea
normal breathing pattern
parenteral nutrition
nourishment provided via IV therapy
Addison's disease
occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone
a nurse is performing a sterile dressing change. Which action contaminates the sterile field?
pouring solution onto a sterile field cloth
While caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?
prescription drug intoxication
a 26-year-old is being treated for delirium due to acute alcohol intoxication. The client is restless, does not want to stay seated, and has a staggering gait. What should the nurse do first?
provide one-to-one supervision of the client until detoxification treatment can begin
HHNS treatment
rehydration; insulin administration; monitor fluid volume and electrolyte status; Prevention: SBGM (self monitoring blood glucose), diagnosis and management of diabetes; assess and promote self-care management skills
the nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use?
remain in the semi-fowler's position
cor pulmonale
right ventricular hypertrophy and heart failure due to pulmonary hypertension
bradypnea
slow breathing; we see in sleep, certain CNS injury, drug overdose
As the nurse administers a tap water enema, the client begins to have abdominal cramping. The nurse should first:
temporarily stop the infusion until the cramping subsides
red reflex
the red glow filling the person's pupil which is caused by the reflection of your ophthalmoscope light iff the inner retina; normal newborn; question
Why shouldn't a pt with heart disease have their temperature taken rectally?
the vagus nerve runs from the brain to the rectum, passing the heart in the process. pressure on the vagus nerve can cause the heart to slow down and blood pressure to drop. this is the main reason a lot of elderly people come into the hospital. (they passed out on the toilet) taking a rectal temp can put pressure on the vagus nerve, causing a decline in the blood pressure and heart rate of the patient. you can actually cause a cardiac event, and even death in some cases by taking the rectal temp on a cardiac pt (a pt with heart disease)
T-tube
tube placed in the bile duct for drainage into a small pouch (bile bag) on the outside of the body; used while the duct is healing
Which nursing intervention is most important when working with neonates who are suspected of having congenital hypothyroidism?
Identifying the disorder early.
Why do they do a bone marrow aspiration?
Your doctor may order a bone marrow biopsy if your blood tests show your levels of platelets, or white or red blood cells are too high or too low. A biopsy will help determine the cause of these abnormalities, which can include... cancers of the bone marrow or blood, such as leukemia or lymphomas.
what is the priority action that a nurse should take after omitting an ordered med?
notify the prescriber
which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital?
side rails in the halfway position
which approach would be most effective when the nurse is communicating with a client who has a hearing impairment?
stand in front of the client and speak slowly and clearly
Which precautions should a nurse include in the care plan for a client with leukemia and neutropenia?
Eliminate fresh fruits and vegetables, avoid using enemas, and practice frequent hand washing.
Science behind ketosis:
If your cells don't get enough glucose, your body burns fat for energy instead. This produces a substance called ketones which can show up in your blood and urine. High ketone levels in urine may indicate diabetic ketoacidosis (DKA), a complication of diabetes that can lead to coma or even death.
A client develops a facial rash and urticaria after receiving penicillin. Which lab value does the nurse expect to be elevated?
IgE
Which symptom is an early indication that the client's serum potassium level is below normal?
Muscle weakness in the legs
Signs death is imminent:
Cheyne Stokes: tachypnea followed by apnea; increase followed by decrease followed by apnea Death rattle: secretions gather in throat can't clear them out; doesn't cause pain but scares families; change in patient position or medication can help to reduce this
Tuberculosis
An infectious disease that may affect almost all tissues of the body, especially the lungs; caused by bacteria
ankylosing spondylitis
An inflammatory arthritis affecting the spine and large joints.
The risk for injury during an attack of Meniere's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?
Assume a reclining or flat position.
Anatomy
Do this!
the nursing assessment of a client with osteomyelitis of the left great toe reveals pain with partial weight-bearing, unsteady gait, and general weakness. Based on these data, the nurse should institute which safety measure?
Falls precautions
While making rounds, a nurse observes that a client's primary bag of IV solution is light yellow. The label on the IV bag says the solution is D5W. What should the nurse do first?
Hang a new bag of D5W, and complete an incident report.
The nurse is aware that frequent repositioning in bed will assist in the prevention of which of the following for the client?
Pneumonia
an older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do?
Remove any unsafe items from the area in which the infant is mobile.
Sx of resp distress in newborn:
Tachypnea, nasal flaring, chest retractions, or grunting
cushing syndrome
group of signs and symptoms produced by excess cortisol from the adrenal cortex
Side effects associated with atypical antispychotics:
metabolic syndrome: weight gain; diabetes; hyperlipidemia
conjunctiva
mucous membrane that lines the eyelids and outer surface of the eyeball
Spironolactone
potassium-sparing diuretic; aldosterone antagonist (responsible for sodium conservation); prevents body from absorbing too much sodium and keeps potassium levels from getting too low. Used to treat CHF, high BP, and hypokalemia.
toddler age group:
safety is priority concern
Peritoneum
the serous membrane lining the cavity of the abdomen and covering the abdominal organs.
carbamezepine (Tegretol)
used to prevent and control seizures; anticonvulsant/antiepileptic
a client with alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place himself closer to the nurse's station because of his tendency to:
wander
an adolescent with well-controlled type 1 diabetes has assumed complete management of the disease and wants to participate in gymnastics after school. To ensure safe participation, the nurse should instruct him to adjust his therapeutic regimen by:
eating a snack before each gymnastics practice
Typical Antipsychotics
A class of older drugs to treat schizophrenia and related psychotic disorders primarily by reducing excess levels of dopamine in the brain. Risk for extrapyramidal sx
Rubella
AKA german measles Caused by rubella virus Droplet precautions Mild in children; medical danger in pregnant women because it can cause congenital rubella syndrome in developing babies.
Which method is reliable for identifying a preschooler before admin of a med?
Check the hospital identification bracelet
if the client's ICPis increasing, the nurse should expect to observe which sign first?
Declining LOC
How does Lidocaine decrease HR?
Decreases the sensitivity of heart muscle to electrical impulses. This slows the conduction of electrical signals in the heart muscle, which in turn, helps to restore a regular heart rhythm.
Which of the following nursing assessments would indicate a decline in the condition of a client 2 hours after admission for a subdural hematoma?
Disorientation, increasing BP, bradycardia, and bradypnea
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
Encouraging increased fluid intake.
a nurse is helping a client move up in the bed. Which action maintains good body mechanics?
Having the client help himself as much as possible.
Which discharge instruction would be appropriate for a client who has had a laparoscopic cholecystectomy and has sutures covered by a dressing?
Leave dressing in place until seeing the surgeon at a postoperative visit.
Pubis symphysis location-
Look at fundus chart!
Psoas sign
RLQ pain with extension of right thigh indicative of appendicitis
Why are enemas on the left side?
The reason for laying on the left side is for gravity to assist the fluid filling the colon. When you lay on the left side, the fluid can go up further into the colon because of the way the anatomy is- the fluid is basically flowing downhill into the colon.
The nurse is preparing a client for nonemergency surgery. The nurse should:
Verify the client understands the informed consent form.
Sx of hypothyroidism
fatigue, cold sensitivity, constipation, dry skin, and unexplained weight gain.
tearing of tissue with irregular wound edges:
laceration
Is it ok to place bloody sheets in a container designated for contaminated linens?
yes
during a well-baby visit, a toddler's mom states that she keeps all of the medications out of the toddler's reach in the kitchen cabinet. Which of the following is an appropriate response by the nurse?
"medications should be kept in a locked location"
Which signs and symptoms might a nurse observe in a client having an adverse reaction to a loop diuretic?
-Weakness -Irregular pulse -Decreased muscle tone -Potassium level of 3.1 mEq/L -Ventricular arrhythmias (hypokalemia...)
While making rounds the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. What does nurse do?
1. Assess client's current condition and VS 2. If no acute injury, get help, and carefully assist client back to bed 3. Notify HCP and fam 4. Document as required by facility
For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which of the following acie-base imbalances? 1. Respiratory alkalosis. 2. Respiratory acidosis. 3. Metabolic alkalosis. 4. Metabolic acidosis.
3
A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? 1. "I told my husband to give my son aspirin for his fever." 2. "I'll ask the physician about giving the baby an immunization shot." 3. "I don't have to worry because I've had the measles." 4. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."
4
Rheumatic fever
A disease that can result from inadequately treated strep throat or scarlet fever. It can damage body tissues by causing them to swell, but its greatest danger lies in the damage it can do to your heart.
DKA
A life-threatening problem that affects people with type I diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic; kussmaul resp deep and rapid; once treated expect potassium to drop so have potassium ready.
a nurse reports to the hospital occupational health nurse (OHN) that he/she was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when he/she will know whether he/she is positive or negative for HIV infection. Which of the following is the most appropriate response by the OHN?
Accurate results will be obtained by testing at 3 months and again at 6 months
When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent:
Adduction of the hip joint.
The nurse is reviewing a client's daily labs. Which lab report would concern the nurse related to the client' risk for skin breakdown?
Albumin.
Smallpox
An eradicated virus that used to be contagious, disfiguring, and often deadly. SE of vaccine is too high to warrant routine vaccination.
atypical antipsychotics
Antipsychotics that do not have significant side effects common to older antipsychotics Risperdal (risperidone) Zyprexa (olanzapine) Seroquel (quetiapine)
A 14-year-old male reports having right lower quadrant pain, nausea, vomiting, and a low-grade fever for the past 12 hours. A physical examination reveals rebound tenderness and a positive psoas sign. Based on these findings, what should the nurse report?
Appendicitis
The nurse meets with a client in the outpatient clinic who is suicidal and refuses to sign a "no suicide" contract. What should the nurse do next?
Arrange for immediate hospitalization on a locked unit.
Is measles life-threatening?
As many as one out of every 20 children with measles gets pneumonia, the most common cause of death from measles in young children.
Nurse administering oxycodone for leg pain, what priority actions should the nurse implement?
Assess client for allergies; verify HCP order; identify the client; assess the client's respirations.
The HCP plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first?
Assess the FHR for 1 full minute.
A multigravid client is receiving oxytocin augmentation. When the client's cervix is dilated to 6 cm, her membranes rupture spontaneously with meconium-stained amniotic fluid. Which action should the nurse perform first?
Assess the fetal HR (question!)
a wife brings her husband to the ED with a bleeding gunshot wound to the leg. The wife tells the nurse that her husband was trying to commit suicide. In what order should the nurse perform the actions from first to last?
Assess the gunshot wound Remove potentially harmful objects from the area Ensure constant observation Assess current suicide risk
What level should arm be during blood pressure?
At level of heart
Which finding would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
Auscultation of moist crackles.
A nurse is discharging a client diagnosed with a UTI. Which information should the nurse include in the discharge teaching? Select all that apply.
Avoid coffee, tea, and alcohol; take all the abx prescribed
Wilms tumor (nephroblastoma)
Avoid palpating tumor; spreads cancer cells
A student with type I diabetes mellitus complains of feeling lightheaded. Her blood sugar is 60 mg/dL. Using the 15/15 rule, the nurse should: A. give 15 mL of juice, and repeat does in 15 minutes B. give 15 grams of carbohydrates and retest blood sugar in 15 minutes C. Give 15 grams of carbohydrates and 15 g of protein D. Give 15 ounces of juice and retest blood sugar in 15 minutes
B
internal medicine
Branch of medicine involving the diagnosis and treatment of diseases and conditions of internal organs such as the respiratory system. The physician is an internist.
the student nurse is caring for a client who has an order of 2 units of packed red blood cells. The nurse educator asks the student, "Prior to the administration of blood, another nurse must do what?" What would be the most appropriate responses for the student to include?
Check the blood; check the hcp's order; check the ABO compatability
While administering medication, the client tells the nurse, "I've never seen this pill before." The nurse should:
Check the medication orders.
cholecystectomy
Cholecystectomy is surgery to remove the gallbladder. The gallbladder is a small sac that is under the liver and is part of the digestive system. The liver makes bile to help digest the fats you eat. Bile ducts drain bile from the liver into the gallbladder to be stored. When you eat, bile moves from the gallbladder, through the bile ducts and into the small intestines. You may need a cholecystectomy if you have swelling, infection, or gallstones in the gallbladder.
Which nursing intervention for catheter care should have the highest priority?
Cleaning the area around the urethral meatus
A nurse assessing a client who underwent cardiac catheterization find the client lying flat on the bed. His temp is 99.8 F (37.7 C). His blood pressure is 104/68 mm Hg. His pulse is 76 BPM. The nurse assesses the limb and detects weak pulses in the leg distal to the puncture site. Skin on the leg is cool to the touch. The puncture site is dry, but swollen. What is the most appropriate action for the nurse to take?
Contact the physician and report the findings.
A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states, "I am so tired. Even my vision is blurry." What is the nurse's best action?
Decrease the lidocaine infusion rate
Lab findings indicate that a child with leukemia is also anemic. The nurse interprets this finding as most likely resulting from which of the following?
Decreased red blood cell production.
Nurse is evaluating the infection control actions taken on the unit for a client with a decreased WBC count. Which of the following infection control practices does the nurse consider most important for this client?
Diligent adherence to aseptic technique.
Prevent burns of baby:
Do not heat infant's formula in the microwave
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?
Every 15 minutes
DKA treatment
Fluid replacement first! Then electrolyte replacement and insulin therapy. Insulin causes K level to drop which is why we need to replace the K.
Loop diuretic example
Furosemide (Lasix)
the nurse is caring for a toddler in contact isolation for respiratory syncytial virus (RSV). In what order from first to last should the nurse remove personal protective equipment (PPE)?
Gloves Gown Goggles Mask
A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps are kept in the client's hospital room for:
Handling of the dislodged radiation source
Someone calls about bomb threat what do you do?
Have them stay on line to gather details about bomb
Pathophys behind diabetes:
Having diabetes means that there is too much sugar (glucose) in your blood. When you eat food, your body breaks down much of the food into glucose. Your blood carries the glucose to the cells of your body. An organ in your upper belly, called the pancreas, makes and releases a hormone called insulin when it detects glucose. Your body uses insulin to help move the glucose from the bloodstream into the cells for energy. When your body does not make insulin (type 1 diabetes), or has trouble using insulin (type 2 diabetes), glucose cannot get into your cells. The glucose level in your blood goes up. Too much glucose in your blood (also called hyperglycemia or high blood sugar) can cause many problems.
when checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a hx of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first?
Hold the medication and report the information to the physician to ensure client safety.
A woman in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition? 1. Morning sickness 2. Eclampsia 3. Hyperemesis gravidarum 4. Hydramnios
Hyperemesis gravidarum
The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement?
I should use a pillow to elevate my child's foot as he sleeps.
a client with Meniere's disease is having an attack of vertigo. Which nursing intervention is priority?
Instruct the client to remain in bed.
Pregnant women and their left side:
It makes heart's job easier because it keeps baby's weight from applying pressure to the large vein (inferior vena cava) that carries blood back to the heart from your feet and legs.
The nurse is caring for a client in the 13th week of pregnancy who develops hyperemesis gravidarum. The nurse is reviewing the client's lab report. Which finding indicates the need for intervention?
Ketones in urine.
bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, what should the nurse recommend to the client?
Maintain a regular program of weight-bearing exercise.
Causes of ketosis and ketonuria:
Metabolic abnormalities such as diabetes, renal glycosuria, or glycogen storage disease. Dietary conditions such as starvation, fasting, low carb diets, prolonged vomiting, anorexia, also hyperemesis gravidarum.
the nurse is assessing the client (show photo) who has just returned from a 2-month mission in Africa. What type of respiratory protection is appropriate for the staff?
N95 particulate respirator
A nursing assistant escorts a client in the early stages of labor to the bathroom. When nurse enters client's room she detects strange odor coming from bathroom and suspects client has been smoking marijuana. What should the nurse do next?
Notify the physician and security immediately.
Pregnant women should sleep:
On left side because this increases the amount of blood and nutrients that reach the placenta and your baby.
A 6 y/o child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery?
Permit the child to play with the blood pressure cuff, electrocardiogram pads, and a face mask.
A nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the HCP because these signs are indicative of which problem?
Pyloric stenosis
When removing protective covering, what action should the nurse take to avoid spreading nosocomial infections?
Remove the face mask.
a new nurse is asked to start an IV on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the IV pumps used in this facility. The new nurse should:
Review the unit's procedure manual
How to tell on strip uteroplacental insufficiency...
Review!
Seclusion room should have:
Security window in door or camera
Following a diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. What should the nurse instruct the client to do?
Take a nitroglycerin tablet before climbing the stairs.
Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur?
Talking with the nurse
Two hours ago, a neonate at 38 weeks' gestation and weighing 3, 175 g (7 ib) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which finding would alert the nurse to notify the HCP?
Temperature instability
a client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:
The chest tube system is functioning properly
The nurse working in an internal medicine clinic receives four phone calls from clients with chronic pancreatitis. Which client should the nurse contact first?
The client reporting increased thirst and hunger. Pancreatic cancers cause diabetes (high blood sugar) because they destroy the insulin-making cells. Symptoms can include feeling thirsty and hungry, and having to urinate often.
The client is admitted with a 2-day history of vomiting and diarrhea, accompanied by abdominal pain. The HCP diagnoses the client with gastroenteritis. What type of room assignment should the nurse make for this client?
The nurse should be assigned to a single isolation room or The client should be assigned to a double room with another client having the same diagnosis of the same organism
Hyperemesis gravidarum
Uncontrollable vomiting during pregnancy that results in dehydration, weight loss, and ketosis. Extreme form of normal nausea and vomiting during pregnancy.
The nurse in the ICU is giving a report to the nurse in a cardiac step-down unit about a client who had a coronary artery bypass surgery. Which of the following is the most effective way to assure essential info about the client is reported?
Use a printed checklist with info individualized for the client
After his spouse has visited, a client begins crying and saying that his spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels she can't handle the situation. What should the nurse do at this time?
Use the call system to request assistance.
Which measure should the nurse take that will be most helpful in preventing wound infection when changing a client's dressing after coronary artery bypass surgery?
Wash hands before changing the dressing.
a school age child is admitted to the medical facility with a diagnosis of acute lymphocytic leukemia (ALL). Which of the following nursing interventions is most important?
Washing hands before/upon entering room.
Laryngeal stridor
a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway. CALL A CODE
esophageal stricture
a significant narrowing of the esophagus that may significantly interfere with swallowing
Addison's disease symptoms:
chronic fatigue, muscle weakness, anorexia, nausea, vomiting, diarrhea, hypotension, hypoglycemia, sweating, irritability, weight loss
negative pressure isolation room
commonly used for patients with airborne infections; when the pt with active TB sneezes or coughs, other people may become infected when they inhale. however, by using a negative pressure room you can better contain the bacterium within the room.
Meniere's disease
disorder of inner ear causing vertigo, tinnitus, and hearing loss
A nurse observes a 10-month-old infant chewing on the security alarm attached to his identification bracelet. The nurse should:
distract the infant with a more appropriate toy.
metabolic alkalosis
elevation of HCO3- usually caused by an excessive loss of metabolic acids; common causes include prolonged vomiting, hypovolemia, diuretic use, and hypokalemia.
the ED nurse is assessing a client with reports of right-sided dull, abnormal and flank pain, nausea, and vomiting. The client's temp is 101.2 F, pain is 10 out of 10, and rebound tenderness is exhibited. The HCP orders: VS q 30 min, CBC, morphine 2 mg IM q 4 hours, regular diet, and enemas until clear. Which orders should the nurse question?
enemas until clear; regular diet
which action is the best precaution against transmission of infection?
eye prophylaxis with abx for a neonate whose mother has gonorrhea infection
Kussmaul respiration
increase in both rate and depth of respirations *christmas trees
Osteomyelitis
inflammation of the bone and bone marrow (caused by bacterial infection)
a nurse, who witnesses an accident involving an adolescent being thrown from a motorcycle, stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emergency medical service to arrive, what should the nurse do?
leave the adolescent as he is, stay close by
a client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family?
nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia.
before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed?
place the client in a high fowler's position
Cheyne-Stokes
progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. Brain stem insult and increase ICP
a nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route?
rectal
CD4 cells
referring to human white blood cells, which contain the cell surface recognition protein CD4
the nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every one to two hours?
remove restraints and assess skin and circulation
extrapyramidal symptoms
side effects of antipsychotic medications that affect a person's gait, movement, or posture; drug-induced movement disorders that include acute and tardive symptoms. These symptoms include dystonia (continuous spasms and muscle contractions), akathisia (motor restlessness), parkinsonism (characteristic symptoms such as rigidity), bradykinesia (slowness of movement), tremor, and tardive dyskinesia (irregular, jerky movements). -More often caused by typical (older) antipsychotics such as haloperidol
a staff nurse is caring for a child with a urinary tract infection. The nurse is 1 hour late administering the child's prescribed antibiotic therapy and pain medication. The charge nurse challenges the staff nurse about the lateness of the medications. The staff nurse responds, "it's no big deal; at least the child got the medication." What is the best course of action for the nurse to take?
speak to the unit manager and fill out a med error report.
Contact Isolation Precautions
used for infections, diseases, or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should: Wear a gown and gloves while in the patient's room.
Types of Meningitis
viral (most common), bacterial, fungal
when planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?
30-degree head elevation Raising the HOB to 30 degrees reduces ICP and improves CPP without compromising CO in euvolemic pt with traumatic brain injury.
BPP chart:
8-10: no fetal asphyxia 6: chronic asphyxia 4: chronic asphyxia 0: certain asphyxia; deliver regardless of gestational age
Haloperidol (Haldol)
Antipsychotic-typical-used to treat certain mental disorders; it can also control sx of Tourette syndrome.
a school-age child has just spilled hot liquid on his arm, and a 4-in (10-cm) area on his forearm is severely burned. His mother calls the ED. What should the nurse advise the mother to do?
Apply cool water to the burned area.
After an instructor has posted assignments, a person claiming to be a nursing student arrives on a unit and asks a nurse for access to the medication records of a client to whom she's assigned. The student's only identification (ID) is a laboratory coat with the school's name on it. What is the nurse's most appropriate response?
Ask the student to provide a photo ID for comparison with the names on the assignment
During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What should the nurse do first?
Clear the neonate's airway with suction or gravity
Diabetic kidney disease
Diabetes is the leading cause of kidney disease. About 1 out of 4 adults with diabetes has kidney disease. Diabetic kidney disease is also called DKD, chronic kidney disease, CKD, kidney disease of diabetes, or diabetic nephropathy. High blood glucose, also called blood sugar, can damage the blood vessels in your kidneys. When the blood vessels are damaged, they don't work as well. Many people with diabetes also develop high blood pressure, which can also damage your kidneys. Having diabetes for a longer time increases the chances that you will have kidney damage. If you have diabetes, you are more likely to develop kidney disease if your blood glucose is too high or blood pressure is too high.
When taking the diet hx from the mother of a 7 y/o child with phenylketonuria,a report of an intake of which food should cause the nurse to gather additional info?
Diet cola
A nurse is assisting with a subclavian line insertion when the client's oxygen saturation drops rapidly. He reports SOB and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:
Diminished or absent breath sounds on the affected side -inserted into subclavian vein...
PKU diet
Low phe diet; avoid high protein foods, such as milk, dairy products, meat, fish, chicken, eggs, beans, and nuts. These foods cause high blood phe levels for people with PKU. Also avoid diet cola because aspartame (artificial sweetener) contains phe.
Barlow's sign
Indicates hip dysplasia
Leukemia
Leukemia, also spelled leukaemia, is a group of cancers that usually begin in the bone marrow and result in high numbers of abnormal white blood cells.
The nurse is planning care for a client on complete bed rest. To prevent venous thrombosis, what should the nurse include in the plan of care?
Maintaining the client in the supine position.
A nurse expects to find which signs and symptoms in a client experiencing hypoglycemia?
Nervousness, diaphoresis, and confusion.
Is NG tube placement sterile?
No.
The school nurse is assessing a child for "pinkeye." Which of the following findings would cause the nurse to send the child home?
Purulent discharge noted from the eyes
Complications of type 2 diabetes:
Short-term: hypoglycemia and hyperosmolar hyperglycemic nonketotic syndrome (HHNS) Long-term: retinopathy; nephropathy; neuropathy; macrovascular problems
The nurse is caring for a client with Clostridium difficile infection. Upon entering the room, which of the following steps should the nurse take?
Put on an isolation gown and gloves
Kussmaul's pattern
Rapid resp rate with deep breaths (tachypnea and hyperpnea) Metabolic acidosis and DKA Rapid breaths dispel carbon dioxide and cecrease acidity of the blood
Signs that suggest an overdose of an anti-anxiety agent:
Slurred speech, dyspnea, and impaired coordination.
Droplet Precautions
Used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Wear mask, gown, and gloves.
when teaching school-age children important injury prevention strategies, the nurse must use creativity to gain cooperation because children tend not to comply with:
wearing safety apparel (helmets, knee pads, elbow pads)
A nurse is preparing to administer a medication to a client and discovers that the seal on the vial is broken. What is the priority action by the nurse?
contact the pharmacy for a new vial.
urticaria
hives; an eruption of wheals on the skin accompanied by itching
How antidepressants and antipsychotics work:
http://www.heretohelp.bc.ca/visions/medications-vol4/how-antidepressant-and-antipsychotic-medications-work
the nurse has just completed a client's home visit and has scheduled another client's visit immediately after. Which of the following measures should the nurse take to minimize risks of infection during home visits?
implement standard precaution during home visits; perform hand hygiene before and after client contact
nuchal rigidity
inability to flex the neck forward due to rigidity of the neck muscles; sign of meningitis
Sx of Graves disease
include anxiety, hand tremor, heat sensitivity, weight loss, puffy eyes and enlarged thyroid.
a parent tells the nurse that their 6-year-old child has severe nosebleeds. To manage the nosebleed, the nurse should tell the parent to:
place the child in a sitting position with the neck bent forward and apply firm pressure on the nasal septum.
Nurses were identified by the Centers for Disease Control and Prevention (CDC) as the people most likely to care for clients infected after the intentional release of the smallpox virus. Based on CDC guidelines, which group should volunteer to receive the small pox vaccine? 1. Nurses ages 50 and older who work in the emergency departments of community hospitals. 2. Nurses who served in the military who are now working in public health settings. 3. Nurses born after 1971 who are employed as triage nurses in large medical center emergency departments. 4. Nurses vaccinated against smallpox as children who are now working in a pediatric unit.
1
An alarm signals, indicating that a neonate's security identification band requires attention. The nurse responds immediately and finds that the identification bands are no longer on the neonate. Which action should the nurse take next? 1. Reprimand the parents for allowing the identification bands to come off. 2. Replace the identification bands. 3. Compare the information on the neonate's identification bands with that of the mother's, then reattach the identification bands to the neonate's extremities. 4. Obtain the neonate's footprints and compare them with the footprints obtained at birth.
3
Lidocaine
A medication used to numb tissues in a specific area (local anesthetic). It is also used used to treat ventricular tachycardia and to perform nerve blocks.
Cheyne-Stokes vs Biotts
Both followed by period of apnea but cheyne stokes is gradual increase followed by decrease whereas biotts pattern is rapid gasping
Facts about sexual predators:
Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention Child molesters gain the child's trust before making sexual advances so that the child feels obligated to comply with sex Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret
The HCP prescribes pulse assessments through the night for a school-age child with rheumatic fever who has a daytime heart rate of 120 BPM. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by which factor?
Routine activity during waking hours Rheumatic fever- can damage body tissues by causing them to swell, but its greatest danger lies in the damage it can do to your heart.
Typical Antipsychotics examples:
Block D2 (Gs) Haloperidol (high potency) Chlorpromazine (low)f
A client with nausea, vomiting, and abdominal cramps and distention is admitted to the health care facility. Which test result is most significant? a) Urine specific gravity of 1.025 b) Serum sodium level of 132 mEq/L c) Blood urea nitrogen (BUN) level of 29 mg/dl d) Serum potassium level of 3 mEq/L
D
Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)
People with type 2 diabetes are at risk for a problem called hyperosmolar hyperglycemic nonketotic syndrome (HHNS). It is very rare in people with type 1 diabetes. HHNS is an emergency caused by very high blood sugar, often over 600 mg/dL. Your kidneys try to get rid of the extra blood sugar by putting more sugar into the urine. This makes you urinate more and you lose too much body fluid, causing dehydration. As you lose fluids, your blood becomes thicker and your blood sugar level gets too high for the kidneys to be able to fix. With the high blood sugar and dehydration there is also an imbalance of minerals, especially sodium and potassium in the blood. The imbalance of fluids, glucose, and minerals in the body can lead to severe problems, such as brain swelling, abnormal heart rhythms, seizures, coma, or organ failure. Without rapid treatment, HHNS can cause death.
"A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes, which is controlled by tolazamide (Tolinase). What is the most important laboratory test for confirming HHNS?
Serum osmolarity
The nurse is admitting a newborn to the nursery. Report reveals that the newborn was slow to crown and delivery of the head and chin was difficult. For which complication would the nurse need to assess?
Shoulder dystocia.
a client who is homeless is admitted for the treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?
Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.
Airborne precautions
Used for diseases or very small germs that are spread through the air from one person to another (examples: tuberculosis, measles, chickenpox). Wear gown, gloves, and respirator.
A nurse is caring for pt on chemo. Which action wold be the most appropriate for the nurse to implement?
Washing hand before and after entering the room.
A nurse is caring for a client with watery diarrhea and dehydration. Given client's recent history of heavy abx use, what intervention should the nurse consider?
Wearing gown and gloves when working in the room
The charge nurse observe two nurses using inappropriate technique when starting an IV on a child. The charge nurse should first:
talk with the nurses about proper technique and the risk of infection resulting from improper technique.
the nurse is caring for a neonate diagnosed with early onset sepsis and is being treated with IV abx. Which instructions will the nurse include in the parents' teaching plan?
wash hands thoroughly before touching the neonate.
glycosylated hemoglobin (HbA1C)
Glycosylated hemoglobin is tested to monitor the long-term control of diabetes mellitus.
During the preoperative interview, the nurse obtains information about the client's medication history. Which information is not necessary to record about the client?
Use of all drugs taken in the last 18 months.
Fundus location post-delivery.
At 12 hours after delivery, the fundus is typically 1 cm above the umbilicus, but this does vary. The uterus descends into the pelvis approximately 1 to 2 cm per day. About a week after delivery, the fundus should be halfway between the umbilicus and the symphysis pubis. Photo
Which nursing intervention is priority for an infant during the first 24 hours following surgery for cleft lip repair?
Carefully clean the suture line after feedings to reduce the risk of infection
A home care nurse is caring for a client with complaints of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test? a) "I'll drink full liquids the day before the test." b) "There is no need for special preparation before the test." c) "I'll take a laxative to clear my bowels before the test." d) "I'll avoid eating or drinking anything 6 to 8 hours before the test."
D
A nurse is preparing a client for bronchoscopy. Which if the following instructions is appropriate for the nurse to give to the client?
Don't eat for 6 hours prior to the procedure.
When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication?
Esophageal stricture.
After lobectomy for lung cancer, the nurse instructs the client to perform deep-breathing exercises to:
Expand the alveoli and increase lung surface available for ventilation.
A nurse is administering IV fluids to an infant. Infants receiving IV therapy are particularly vulnerable to:
Fluid overload
A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?
Fundus two fingerbreadths above the umbilicus.
What test should the nurse review to best assess the effectiveness of treatment for a child with type I diabetes?
Glycosylated hemoglobin.
Thiazide diuretics
Hydrochlorothiazide (HCTZ) Only type of diuretic to widen blood vessels to lower blood pressure. Often first drug given to treat high BP.
A1C levels
<5.7%: normal. 5.7-6.4%: prediabetes. >6.5%: type II diabetes
A school-age child with a severe head injury is unconscious and has coarse breath sounds, a temp of f39 C (102.2 F), a HR of 70 bpm, a BP of 130/60 mm Hg, and an intracranial pressure (ICP) of 36 mm Hg. Which action should the nurse perform?
Administer prescribed IV mannitol Normal ICP is 5-15 mm Hg
What to do with bleeding pregnant woman?
Lay in recovery position on left side no matter what!
A client with a well-managed ileostomy has sudden onset of abdominal cramps, vomiting, and watery discharge from the ileostomy. What should the nurse tell the client to do?
Notify the HCP. Question!
The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable for the last 24 hours, but the client now has a temperature of 38.4 C (101.1 F), a heart rate of 116 bpm, a respiratory rate of 26 breaths/minute. The client has an IV infusion running at a keep-open rate. The nurse contacts the HCP and receives several prescriptions. Which prescription should the nurse implement first?
Obtain blood cultures.
What can a nurse tell an adolescent prepared for an emergency appendectomy?
The scar will be small; the teen will be back in school in 1 week
A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? a) Vital capacity b) Functional residual capacity c) Tidal volume d) Maximal voluntary ventilation
Tidal volume
lymphoma
cancer of the lymph nodes
purulent
producing or containing pus
When developing the discharge plan for a child who had a nephrectomy for a Wilms' tumor, the nurse identifies outcomes to prevent damage to the child's remaining kidney and to accomplish which goal?
Prevent UTI
Grey Turner's sign:
ecchymosis in the flank, part of the body beetween the last rib and the top of the hip.
Electrolyte Imbalances:
Question!
A client is receiving intravenous fluids and upon assessment presents with increased pulse, increased respirations, and jugular vein distention. What is the priority action by the nurse?
Slow the IV rate and notify the physician.
A school-age child is being discharged with a diagnosis of rheumatic fever. Which instructions should be included in the teaching plan for the family?
The child should stay on penicillin and return for a follow-up appt.
During a nonstress test (NST), a nurse notes three fetal heart rate (FHR) increases of 20 bpm, each lasting 20 seconds. These increases occur only with fetal movement. What does this finding suggest?
The fetus is not in distress at this time.
What happens if there is meconium in the amniotic fluid?
This can happen when babies are "under stress" due to a decrease in blood and oxygen supply. This is often due to problems with the placenta or the umbilical cord. Once the baby passes the meconium into the surrounding amniotic fluid, they may breathe it into the lungs. Meconium particles in the amniotic fluid can block small airways and prevent the exchange of oxygen and carbon dioxide after birth. Some babies have immediate respiratory distress and have to be resuscitated at birth. IN CONCLUSION- can result in fetal asphyxia
A client is receiving monthly doses of chemotherapy for treatment of stage III colon cancer. Which lab results should the nurse report to the oncologist before the next dose of chemotherapy is administered? Select all that apply. Hemoglobin of 14.5 WBC count of 2,300 BUN level of 12 Temp of 101.2 F (38.4 C) Urine specific gravity of 1.020 Platelet count of 40,000
WBC count of 2,300 Platelet count of 40,000 Temp of 101.2 F (38.4 C)
pneumothorax
air in the pleural cavity caused by a puncture of the lung or chest wall; a collapsed lung; occurs when air leaks into the space between lung and chest wall (pleural cavity). This air pushes on the outside of your lung and makes it collapse. In most cases, only a portion of the lung collapses. Understand!
Which finding will the nurse assess in a client diagnosed with peritonitis?
Abdominal wall rigidity.
Abudction/Adduction
Abduction- away from body's midline Adduction- toward body's midline
Position for enema administration
Lying on left side with right knee flexed
