Practice

tracheoesophageal fistula

"3 Cs"—coughing and choking with feedings and unexplained cyanosis- a fistula is present that forms an unnatural connection with the trachea.

Serum ADH

(1-5 pg/mL) Increased serum ADH is indicative of SIADH (when testing serum ADH-client must fast 12 prior & blood obtained must be transported to lab w/i 10min)

HCO2-

(21-28 mEq/L) BICARBONATE=Metabolism

PaCo2

(35-45 mm Hg) RESPIRATORY=CO2

PaO2

(80-100 Hg) Partial pressure of Co2 in arterial blood

Uric Acid Levels

(F: 2.7-7.3 mg/dL) (M: 4.0-8.5 mg/dL) *Hyperuricemia=cause of hyperKalemia

HypoKalemia ECG changes

NORMAL QRS ST Depression shallow flat or inverted T wave prominent U wave

Glimepiride

oral hypoglycemic agent *(NSAIDs) & glimepiride should not be combined OR Hypoglycemia may result

PPE

to put on: Gown, mask, eye protection, gloves last. take off: gloves first, eye protection, gown, mask.

phytonadione: Mephyton:

vitamin K

Magnesium

(1.3-2.1 mEq/L) *CALCIUM GLUCONATE/CALCIUM CHLORIDE is antidote for mag toxicity! Foods: similar to K+, avocado,spinach, pork, beef, chicken, potato, raisin, milk, yogurt, PB, almonds, soybeans, green leafy veggies, broccoli, oatmeal, wheat bran, canned white tuna.

Sodium

(136-145 mEq/L) cation-Extracellular fluid needed for transmission of NERVE IMPULSES. Na+ pushes Lithium*If taking Lithium, Hyponatremia precipitates Lithium toxicity b/c of diminished excretion. Foods: milk, cheese, butter, condiments, bacon, hot-dogs, lunch meat, anything processed, boxed, canned.

INR (International Normalized Ratio)

(2-3) for standard WARFRIN therapy=aFIB (3-4.5) High dose therapy=mechanical heart valves an INR >3=initiate bleeding precautions If PT & INR ^-Hold Warfarin PT>32 sec & INR>3=Risk for bleeding PURPOSE:determine the client's anticoagulation status and risk for bleeding.

aPTT (Activated Partial Thromboplastin Time)

(28-35 sec) should be 1.5-2.5 x normal when receiving HEPARIN therapy.Screens for deficiencies in clotting factors aPTT is checked for deep vein thrombosis Tx *aPTT longer than 87.5 sec & receiving HEPARIN or has thrombocytopenia=Initiate Bleeding precautions!

Phosphorus (Phosphate)

(3.0-4.5 mg/dL) Foods: Dairy, fish, nuts, pork, beef, chicken, Organ meat, pumpkin, squash, whole grains, bread & cereal.

Potassium

(3.5-5.0 mEq/L) cation-Intracellular fluid needed for water balance &electrical conduction in muscle cells & acid/base balance. NEVER IV PUSH K+ or give more than 20 mEq in 1 hour! Foods: avocado, banana, cantaloupe, Oranges, strawberries, tomato, carrot, mushroom,spinach, fish, pork, beef, veal, potato, raisin.

HgbA1C (Glycosylated hemoglobin)

(4.0 %-6.0%) HgbA1C=blood glucose bound to hgb It is a reflection of how well blood glucose levels have been controlled for 3-4 months. (Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways.)

BUN (blood urea nitrogen)

(6-20 mg/dL) RENAL FUNCTION-The break down of urea in liver. ^BUN=DEHYDRATION decreased BUN=Fluid volume overload.

PH

(7.35-7.45) Out of norm reading & PH is w.i limits=compensated Out of norm reading & PH NOT w/i limits=Uncompensated ROME Resp. >< >< Met << >>

Glucose

(70-110 mg/dL) needed for Brain & RBC-main source of Energy! (fasting needed, Diabetes must hold insulin for test

Calcium

(9.0-10.5 mg/dL) Vitamin D aids in calcium absorption. Foods: Dairy-cheese, milk, soy milk, yogurt, tofu, collard greens, kale, rhubarb, sardines.

Sao2

(95-100%)

Body temp conversion F-C C-F

(F-C) F-32 x 5/9 =Celsius (C-F) C x 9/5 + 32=Fahrenheit

hgb (Hemoglobin)

(F: 12-16 g/dL) (M:14-18 g/dL) Main component of RBC transport of 02 & CO2 ^hgb=Anemia d/c hgb=Dehydration ^hgb is seen in heart failure & COPD

hct (Hematocrit)

(F:37%-47% or 0.37-0.47) (M:42%-52% or 0.42-0.52) hct=RBC mass-measures anemia or polycythemia(no fasting needed) Hematocrit measures % volume of RBCs in whole blood; normal: men 42 - 50%, women 40 - 48%; it increases in severe dehydration (volume).

Hodgkin's disease

(a type of lymphoma) is a malignancy of the lymph nodes. Specific clinical manifestations associated with Hodgkin's disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas and abdominal pain as a result of enlarged retroperitoneal nodes. **Remember that the Reed-Sternberg cell is characteristic of Hodgkin's disease.

NPH insulin

NPH insulin is never administered by the IV route.

Opioid anidote

Naloxone (have 02 + CPR equipment available)

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

Prolonged QT interval Prolonged ST segment The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

VITALS T Sao2 P R BP

Temp=36.5-37.5 or 97.5-99.5 Sao2=95%-100% P=60100 b/min R=12-20 BP+ <120/80 Prehypertension=120=139/80-89 Stage 1=140-149/90-99 Stage 2=>160/100

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflexes

Twitching The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

U waves Inverted T waves Depressed ST segment The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

Amlodipine

a calcium channel blocker (A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker such as amlodipine; therefore, this combination should be avoided) Norvasc Antihypertensive-Calcium Channel Blocker

Digoxin

a cardiac glycoside. VOMITING =TOXCICITY, after digoxin is administered, DO NOT repeat the dose IF VOMITING. if a dose is missed and is not identified until 4 hours later, the dose should not be administered.

Cryptorchidism

a condition in which 1 or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. * monitor the temperature, provide analgesics as needed, and monitor the urine output.

Hypospadias

a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias.

Epispadias

a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine.

Aortic stenosis

a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods.

Reye's syndrome

an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses.

Kawasaki disease

an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

Nephrotic syndrome

defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.

pyloric stenosis

hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output.

warfarin sodium (Coumadin):

inhibits prothrombin synthesis. long acting anticoagulant that inhibits Vitamin K-dependent clotting factors. Side effects: excessive dosage may cause hemorrhage, rash, fever. Prothrombin time (PT) used to control dosage. Therapeutic range is 1.5 - 2 times normal level. Antidote vitamin K (phytonadione: Mephyton)

Phenylketonuria

is a genetic (autosomal recessive) disorder that results in central nervous system damage from toxic levels of phenylalanine (an essential amino acid) in the blood. It is characterized by blood phenylalanine levels greater than 20 mg/dL (12.1 mcmol/L); (normal level is 0 to 2 mg/dL (0 to 121 mcmol/L).

Abacavir

is an antiretroviral agent that is used to treat human immunodeficiency virus (HIV) infection in combination with other medications. It will not cure HIV infection, nor will it reduce the risk of transmitting the infection to others

Patent ductus arteriosus

patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure.

Isotretinoin

prescribed for a client with severe acne.Before the administration Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on the triglycerides has been evaluated. Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy.

Silver sulfadiazine

prescribed for burns. is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

HypoCalcemia ECG changes

prolonged ST segment prolonged QT interval

Glomerulonephritis

refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A β-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks.

Celiac disease

refers to intolerance to gluten, the protein component of wheat, barley, rye, and oats. The important factor to remember is that all wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements—especially the fat-soluble vitamins, iron, and folic acid—may be needed to correct deficiencies. Dietary restrictions are likely to be lifelong.

bladder exstrophy

the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed.

A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication? 1. Applying a nonrebreather mask 2. Discontinuing the infusion after 24 hours 3. Monitoring the cardiac rhythm every hour 4. Administering the IV bolus over 2 to 3 seconds

2. Discontinuing the infusion after 24 hours Rationale: Diltiazem hydrochloride is a calcium channel blocker used in the treatment of atrial flutter and fibrillation. It decreases myocardial contractility and workload, thereby decreasing the need for oxygen. A bolus of 0.25 mg/kg is given slowly over 2 minutes, and a continuous infusion of 5 to 10 mg/hour may be administered for up to 24 hours. Therefore, the nurse should prepare to discontinue the infusion after 24 hours. Upon discontinuation of infusion, heart rate reduction may last from 0.5 hours to more than 10 hours (median duration 7 hours). A nonrebreather mask is not necessary. The client's cardiac rhythm is monitored continuously. Test-Taking Strategy: Focus on the subject, a continuous IV infusion of diltiazem hydrochloride. Specific knowledge of the classification, action, and administration by the IV route of this medication will assist in eliminating the options of applying a nonrebreather mask and monitoring the cardiac rhythm hourly. Eliminate the option that indicates giving the medication over 2 to 3 seconds due to the short time frame.

The nurse caring for a terminally ill client has developed a close relationship with the client's family. Which interventions should the nurse include in dealing with the family during this difficult time? Select all that apply. 1. Making decisions for the family 2. Encouraging family discussion of feelings 3. Accepting the family's expressions of anger 4. Preserving the family's sense of self-direction and control 5. Maintaining open communication among family members 6. Facilitating the use of spiritual practices identified by the family

2. Encouraging family discussion of feelings 3. Accepting the family's expressions of anger 4. Preserving the family's sense of self-direction and control 5. Maintaining open communication among family members 6. Facilitating the use of spiritual practices identified by the family Maintaining effective and open communication among family members affected by death and grief is of utmost importance. The nurse needs to maintain and enhance communication as well as preserve the family's sense of self-direction and control. The incorrect option removes autonomy and decision-making from the family at a time when they are already experiencing feelings of loss of control. This is an ineffective intervention that could impair communication. Encouraging family discussion of feelings and maintaining open communication among family members are likely to enhance communication. Spiritual practices give meaning to life and have an impact on how people react to crisis, so this option should be included. Accepting the family's expression of anger and preserving the family's sense of self-direction and control are effective techniques, so that the family knows there is someone there who is supportive and nonjudgmental.

Urine Specific Gravity

(1.010 -1.025) Urine specific gravity depends on hydration; normal: 1.010 - 1.030; will increase if patient is dehydrated.

Segmented neutrophils

segmented neutrophils 60%-70% (0.60-0.70)

Creatinine

serum creatinine 0.6-1.3 mg/dL (53-115 mmol/L) Specific indicator or RENAL function

Hypercalcemia ECG changes

shortened ST segment Widened T wave

Azelaic acid

a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion.

PT (Prothrombin Time)

(11-12.5 sec.) Vit K dependent protein produced by the liver for fibrin clot formation. Measures amount of time it takes to monitor WARFARIN therapy, liver disease, vit K deficiency. PT>32 sec. & INR >3=Risk for bleeding PT & INR go together **WARFAIN= aFIB PURPOSE:determine the client's anticoagulation status and risk for bleeding.

lactate

0.5-2.2 elevated lactate indicates sepsis or tissue ischemia

The nurse has been assigned to care for a client with an immune disorder. In developing a plan of care for this client, the nurse incorporates knowledge that the immune system consists of specific major types of cells. Which types of cells are associated with the immune system? Select all that apply. 1. Dendritic cells 2. B lymphocytes 3. Red blood cells 4. Helper T lymphocytes 5. Cytolytic T lymphocytes

1. Dendritic cells 2. B lymphocytes 4. Helper T lymphocytes 5. Cytolytic T lymphocytes Rationale: Immunity is composed of many cell functions that protect against the effects of injury or invasion. The immune system has 5 major types of cells: dendritic cells, B lymphocytes or B cells, helper T lymphocytes or CD4+ cells, cytolytic T lymphocytes or CD8+ cells, and macrophages.

The nurse is caring for a client with a Penrose drain from an abdominal incision. Which is an appropriate nursing intervention for this client? 1. Ensure that a sterile safety pin is through the drain. 2. Measure the amount of drainage in a measuring container. 3. Establish that the drain is at the prescribed amount of suction. 4. Squeeze the suction device and close the port after emptying the drain

1. Ensure that a sterile safety pin is through the drain. Rationale: A Penrose drain is a soft, flat, flexible drain in which one end is placed in the wound or incision and the other end is outside the wound. It is an open drainage system that drains onto the skin surface or onto a dressing. It is not sutured in place and thus should have a sterile safety pin (or other device per agency procedure) inserted through it to prevent the drain from going all the way into the wound. Thus, option 1 is the correct option. Options 2, 3, and 4 are incorrect, as a Penrose drain is an open drainage system with no suction and it drains onto the skin or into a dressing, not into a collection container, so the amount of drainage cannot be measured in a measuring container.

The nurse is developing a plan of care for an infant after surgical intervention for imperforate anus. The nurse should include in the plan that which position is the most appropriate one for the infant in the postoperative period? 1. Prone position 2. Supine with no head elevation 3. Side-lying with the legs extended 4. Supine with the head elevated 45 degrees

1. Prone position Rationale: The appropriate position following surgical intervention for an imperforate anus is a side-lying position with the legs flexed or a prone position to keep the hips elevated. These positions will reduce edema and pressure on the surgical site. The remaining options will promote pressure at the surgical site.

The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply. 1. Red, raised papules 2. Large plaques covered by silvery scales 3. Tiny red vesicles that weep serous material 4. Erythema noted mostly under the breast area 5. Pink to dark red, patchy eruptions on the skin

1. Red, raised papules 2. Large plaques covered by silvery scales Psoriasis lesions appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Eczema can manifest as tiny red vesicles that weep serous or purulent material. Erythema noted mostly under the breast area is characteristic of seborrheic dermatitis. Pink to dark red, patchy eruptions on the skin may be indicative of exfoliative dermatitis.Focus on the subject, psoriasis. Recall that these lesions appear as red, raised papules that may coalesce into large plaques covered by silvery scales. This will assist in directing you to the correct options.

The nurse is caring for a client with acute back pain. Which are the most likely causes of this problem? Select all that apply. 1. Twisting of the spine 2. Curvature of the spine 3. Hyperflexion of the spine 4. Sciatic nerve inflammation 5. Degeneration of the facet joints 6. Herniation of an intervertebral disk

1. Twisting of the spine 3. Hyperflexion of the spine 6. Herniation of an intervertebral disk Rationale: Acute back pain is sudden in onset and is usually precipitated by injury to the lower back, such as with hyperflexion, twisting, or disk herniation. Scoliosis (curvature), sciatica, and degenerative vertebral changes are more likely to cause chronic back pain, which can be more insidious in onset and may also be accompanied by degeneration of the intervertebral disk.

A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank.

14,940 mL. Rationale: The Parkland (Baxter) formula for estimating fluid requirements is 4 mL × kilograms of body mass × percent total BSA. Half of this total is administered in the first 8 hours after the burn. First, convert pounds to kilograms by dividing 198 lbs by 2.2, which equals 90. Therefore, 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL.

Platelets

150,000-400,000 x mm3 (150-400 x 10 9/L PLUG formation made by bone marrow

A client reports frequent use of sodium bicarbonate to relieve heartburn after meals. The nurse should monitor the client for which condition that the client is at risk for with long-term frequent use of this medication? 1. Urinary calculi 2. Chronic bronchitis 3. Metabolic alkalosis 4. Respiratory acidosis

3. Metabolic alkalosis Rationale: Sodium bicarbonate is an electrolyte modifier and antacid. With large doses or long-term use, it can cause metabolic alkalosis. The other options are incorrect.

The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the client is at risk for preterm labor? 1. The client is a 35-year-old primigravida. 2. The client has a history of cardiac disease. 3. The client's hemoglobin level is 13.5 g/dL (135 mmol/L). 4. The client is a 20-year-old primigravida of average weight and height.

2. The client has a history of cardiac disease. Rationale: Preterm labor occurs after the twentieth week but before the thirty-seventh week of gestation. Several factors are associated with preterm labor, including a history of medical conditions, present and past obstetric problems, social and environmental factors, and substance abuse. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus; anemia, which decreases oxygen supply to the uterus; and age younger than 18 years or first pregnancy at age older than 40 years.

During the termination phase of the nurse-client relationship, the clinic nurse observes that the client has made several sarcastic remarks and has an angry affect. Which is the most appropriate interpretation of the client's behavior? 1. The client is not ready to be discharged. 2. The client is displaying typical behaviors. 3. The client requires further outpatient treatment. 4. The client has not benefited from the relationship.

2. The client is displaying typical behaviors. Rationale: In the termination phase of a relationship, it is normal for a client to demonstrate a number of regressive behaviors that can be disturbing to the nurse. Typical behaviors include return of symptoms, anger, withdrawal, and minimizing the relationship. The anger that the client is experiencing is a normal feeling during the termination phase and does not necessarily indicate the need for hospitalization or treatment.

A client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate. Postoperatively the client is receiving continuous bladder irrigations. The nurse assesses the client for manifestations of transurethral resection syndrome. Which assessment data would indicate the onset of this syndrome? 1. Tachycardia and diarrhea 2. Bradycardia and confusion 3. Increased urinary output and anemia 4. Decreased urinary output and bladder spasms

2. Bradycardia and confusion Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting. Focus on the subject, manifestations of transurethral resection syndrome. Recalling that increased intracranial pressure is the concern in transurethral resection syndrome will direct you to the correct option.

The nurse assesses for a therapeutic effect of ziprasidone by asking the client which question? 1. "Have you had more restful sleep during daytime naps?" 2. "Have you experienced relief of heartburn and indigestion with meals?" 3. "Have you experienced an increase in concentration during daily activities?" 4. "Have you had a decrease in heart palpitations with outside physical activities?

3. "Have you experienced an increase in concentration during daily activities?" Ziprasidone is an antipsychotic used as a mood stabilizer. The nurse should evaluate a therapeutic response by determining if the client obtained an increase in concentration. None of the remaining options are related to the use of this medication.

The nurse should monitor the client prescribed thioridazine hydrochloride carefully for which adverse effect? 1. Weight gain 2. Photosensitivity 3. Cardiac dysrhythmias 4. Extrapyramidal movements

3. Cardiac dysrhythmias Rationale: Thioridazine hydrochloride is an antipsychotic medication that may be prescribed for the schizophrenic client when other medications have failed to manage the symptoms. Cardiac dysrhythmias are an adverse effect of thioridazine. Weight gain and extrapyramidal movements are not associated with this medication. Photosensitivity is a rare side effect.

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas. Note the strategic word, priority. Focus on the subject, concerns regarding the ability to meet role expectations and financial obligations. Option 1 can be eliminated because the client was previously experiencing anxiety. Eliminate options 2 and 4 because there are no data in the question that address these problems.

The ambulatory care nurse is reviewing an adult client's laboratory test results and notes that the hematocrit level is 60% (0.60). The nurse recognizes that this level is most likely to be found in clients with which diagnosis? 1. Leukemia 2. Hemolytic anemia 3. Pernicious anemia 4. Iron deficiency anemia

3. Pernicious anemia Rationale: The normal hematocrit level is approximately 42% to 52% (0.42 to 0.52) in a male and 37% to 47% (0.37 to 0.47) in a female. The hematocrit level measures the percentage of red blood cells in whole blood. Elevated hematocrit levels are seen in persons with dehydration, pernicious anemia, or polycythemia. Therefore, the conditions in the remaining options are incorrect.

WBC

5000-10,000 x mm 3 (5.0-10.0 x 10 9/L) ^shift to Left=infection or inflammation <d/c=shift to left=recovery or bone marrow infection Shift to the right=UNUSUAL=found in liver disease, down syndrome, pernicious anemia MUST MONITOR WBC w/chemo=Risk for infection

neutrophils

55-70% of all wbc. An elevation in neutrophils indicates bacterial infection

Chloride

98-106 mEq/L

RBC

4-6 million

Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions? 1. Apply once a day and leave it open to the air. 2. Apply twice a day and leave it open to the air. 3. Apply twice a day and cover it with a sterile dressing. 4. Apply once a day and cover it with a sterile dressing.

4. Apply once a day and cover it with a sterile dressing. Collagenase is used in the treatment of dermal lesions and severe burns. Its action is to debride the affected area. It is applied once daily and covered with a sterile dressing. Options 1, 2, and 3 are incorrect application procedures. Focus on the subject, wound treatment with collagenase. Knowledge regarding the use of this medication is required to answer this question. Remember that this medication is applied daily and covered with a sterile dressing.

Cardiac monitoring leads are placed on a client who is at risk for premature ventricular contractions (PVCs). Which heart rhythm will the nurse anticipate in this client if PVCs are occurring? 1. A P wave preceding every QRS complex 2. QRS complexes that are short and narrow 3. Inverted P waves before the QRS complexes 4. Premature beats followed by a compensatory pause

4. Premature beats followed by a compensatory pause PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, the presence of wide and bizarre QRS complexes, and a compensatory pause that follows the ectopy.

Thiamine supplementation and other nutritional vitamin support measures are prescribed for clients who have been using alcohol to prevent or decrease the risk of which complication? 1. Cirrhosis 2. Delirium tremens 3. Esophageal varices 4. Wernicke-Korsakoff syndrome

4. Wernicke-Korsakoff syndrome Rationale: Wernicke-Korsakoff syndrome is the only item in the options that is directly and significantly associated with severe nutritional deficits, particularly of B vitamins. Delirium tremens may be partially attributed to nutritional deficits but will not occur unless alcohol withdrawal ensues. The other options are sequelae of chronic alcohol abuse but are owing to other effects on the gastrointestinal system. Test-Taking Strategy: Focus on the subject, complications associated with alcohol use. Eliminate options that are not reliant upon nutritional support and supplements, such as damage to the liver and gastrointestinal tract. This leaves delirium tremens and Wernicke-Korsakoff syndrome. Although the nutritional supplements may decrease the severity of withdrawal and delirium tremens, they will not prevent the symptoms.

A client is resuming a diet after hemigastrectomy, and the nurse provides dietary instructions. Which statement by the client indicates a need for further teaching? 1. "I plan to lie down after eating." 2. "I know to avoid sweets in my diet." 3. "I will eat several small meals per day." 4. "I will drink plenty of liquids with meals."

4. "I will drink plenty of liquids with meals." Rationale: The client who has had a hemigastrectomy is at risk for dumping syndrome. This client should be placed on a diet that is high in protein, moderate in fat, and high in calories. The client should avoid drinking liquids with meals. Frequent small meals are encouraged, and the client should avoid concentrated sweets. Lying down for a short period of time after eating is beneficial.

Anidote for Acetominophin

Acetycysteine

hypoglycemia

Cold clammy skin, irritability, sweating, and tremors Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (4 mmol/L). Hypoglycemia occurs as a result of too much insulin, not enough food, or excessive activity. If possible, the nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbohydrate and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not planned for more than 30 minutes or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, and the blood glucose level is retested in 15 minutes; if the reading remains low, additional glucose is administered. If the child remains unconscious, administration of glucagon may be necessary, and the nurse should be prepared for this intervention.

Diabetic ketoacidosis

Diabetic ketoacidosis is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. **Normal saline is the initial IV rehydration fluid

multiple myeloma

Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules.

HyperKalemia ECG changes

Flat P waves Tall peaked T waves widened QRS Prolong PR interval

PHANTOM LIMB PAIN medication used

Gapapentin is an antiepilitic med to treat phantom pain

Anasarca

Generalized edema an excessive accumulation of fluid in the interstitial space throughout body ex. Cardiac, liver, renal failure

Hep A Hep B Hep C modes

Hep A fecal-oral-contaminated foods Hep B Hep C blood and parental (iv)

Hepatitis

Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. Jaundice is an expected finding with hepatitis and would not warrant notification of the HCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous owing to the liver's inability to detoxify and excrete them. Hand washing is the most effective measure for control of hepatitis in any setting, and effective hand washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

Cholesterol

Total <200 mg/dL HDL=(F: >50mg/dL) (M:>40mg/dL) LDL <100mg/dL *if >130 @ risk for CAD Triglycerides <150 mg/dL

Imperforate anus

Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. During the newborn assessment, this defect should be identified easily on sight. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum.

hypotonic dehydration

In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride should not be administered.

Hirschsprung's disease

It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul-smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction, especially in the neonatal period; abdominal pain and distention; and failure to thrive are also clinical manifestations.

heparin

It prevents conversion of fibrinogen to fibrin. It inactivates thrombin.

lithium carbonate

Lithium is an antimanic medication and is used to treat the manic phase of a manic-depressive disorder. Remember that this medication is used to treat the manic phase.

Metabolic acidosis

Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting.

TPN (Total Parental Nutrition)

Nutrition via central, subclavian or jugular vein *Use 10% dextrose to prevent hypoglycemia when awaiting another bag

PN (Parental Nutrition)

Nutrition via veins Brachial or cephalic

Hypermagnesemia ECG changes

Prolonged PR interval widened QRS complex

Hypomagnesemia ECG changes

Tall T waves Depressed ST segment

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complexes

Tall peaked T waves Widened QRS complexes The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

intussusception

The passage of currant jelly-like stools Bile-stained fecal emesis Sausage-shaped mass palpated in the upper right abdominal quadrant **Intussusception is a telescoping of 1 portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools.

thioridazine hydrochloride

Thioridazine hydrochloride is an antipsychotic medication that may be prescribed for the schizophrenic client when other medications have failed to manage the symptoms. Cardiac dysrhythmias are an adverse effect of thioridazine.

Anidote for Warfrin Tx

Vitamin K (phytonadione: Mephyton) Test=PT/INR

Metabolic alkalosis

Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis.

Calcitonin

a thyroid hormone, decreases the plasma calcium

Hydralazine

potent vasodialator to lower bp