Virtual ATI comprehensive review

A client has been prescribed spironolactone for treatment of heart failure. Which statement made by the client would indicate a need for further teaching?

"I will limit the use of salt in my diet and use a salt substitute instead." Correct: Spironolactone is a potassium sparing diuretic and caution should be taken when using this medication with anything that may increase potassium levels. Most salt substitutes contain potassium and should be avoided. Clients should also never take an oral potassium substitute, and be cautioned about large dietary changes that increase potassium. ACE inhibitors should also be used with cautions when on a potassium sparing diuretic.

A client expresses to the nurse that her husband is an alcoholic and has trouble keeping a job for longer than three months. Which of the following is the nurse's best response?

"What have you done in the past to help deal with the problem?" -provide broad opening--allows client to elaborate and give the nurse opportunity to assess problem-solving and coping skills of the client

A nurse manager is meeting with a staff nurse who is consistently late for work. What statement by nurse manager demonstrates an assertive communication style?

"When you come into work late, I am concerned that client care will be jeopardized." The nurse manager's statement is an example of assertive communication. It focuses on the impact the staff nurse's behavior has on the function of the unit. "I" statements are essential for conveying concerns.

A nurse is caring for a client recently diagnosed Hepatitis C. He asks the nurse to promise him his wife will find not out about his diagnosis. What is the best response by the nurse?

"Your medical information is considered confidential to be shared only if you agree." The client must give consent for health care information, including laboratory results, diagnosis, and prognosis, to be shared with anyone that is not involved in the client's care. This includes sharing the information with family members.

For what clients is isotretinoin cream contraindicated in?

(Accutane).. Contraindicated in pregnant clients b/c it is teratogenic

What is Trimethoprim-Sulfamethoxazole used for?

(Bactrim) is a sulfa antibiotic used for infections

What is cromolyn sodium?

(Brand Name: Intal) mast cell stabilizer-inhalation agent used to reduce bronchial inflammation and for prophylactic management of mild-moderate asthma

What is fluid resuscitation?

(fluid replacement)-replenishing bodily fluid lost through sweating, bleeding, fluid shifts or other pathologic processes

What is autologous transplant?

(of cells or tissues) obtained from the same individual autos=myself logos=word, speech, discourse, ratio

S/S of hypothyroidism?

*KEY: low and slow -weight gain -unable to tolerate cold -goiter -tired fatigued -Slow HR -Trimming hair/brittle -depression -memory loss -constipation -Myxedema (swelling of eyes and face, waxy type of appearance) -dry skin -menstrual problems (heavy, irregular)

What is an anastomosis?

*surgical connection* between two tubular structures, such as blood vessels or loops of intestine

What is buprenorphine?

- Opiod "partial" agonist-partial activation, but not enough to experience "high" or euphoria -Also acts indirectly as an opiod antagonist, blocking effects of other opiods

What is Prasugrel?

- platelet inhibitor and is used to prevent formation of blood clots. - Prasugrel is used in combination with low dose aspirin to prevent thrombosis in patients with acute coronary syndrome, including unstable angina pectoris, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI), who are planned for treatment with PCI. -Blood thinners- It can prevent blood clots, which can lead to heart attack, in patients who need percutaneous coronary intervention (PCI).

What is pentobarbital (Nembutal)?

- used for general anesthesia but in decline - can be used to induce coma

What are some strategies for clients experiencing auditory hallucinations?

-"Try not to listen to the voices right now. I have to talk to you." -Maintain eye contact -Call client by name -Speak simply but louder voice than usual -Do not seclude client

When should a nurse flush a PICC line with 10 ml of normal saline vs 5 mL of heparin?

-10 ml of normal saline before and after infusions (10 or less to avoided excessive pressure that could rupture catheter) -5 mL of heparin is recommended when PICC line is not actively in use

What clients are contraindicated for oral contraceptives?

->35 (e.g. 40 y/o or 70 y/o) -Smoker *Increases risk of thromboembolism

What are the S/S of Magnesium toxicity?

-Absence fo patellar deep tendon reflexes -Urine output <30 ml/hr -RR <12/min -Decreased LOC -Cardiac dysrhythmias

What are manifestations of severe dehydration in infants?

-Absence of tears -Sunken eyeballs -Parched mucous membranes -Sunken fontanelles -Hyperpnea -Oliguria -Loss of 10% body weight

What are assessment findings of premature babies?

-Abundant lanugo -Prominent clitoris and labia minora -Large amounts of vernix

What are some teaching points to manage postpartum depression?

-Advise client to get plenty of rest and nap when the infant sleeps -Reinforce importance of client taking time for herself -Schedule a follow-up visit prior to traditional 6-week postpartum visit -Encourage counseling and make social agency referrals

What drugs are significantly affected by grapefruit juice?

-Amiodarone -Atorvastatin, simvastatin -Anticoagulants (apixaban (Eliquis), rivaroxaban) -CCBs (amlodipine, felodipine, verapamil) -CNS drugs (quetiapine, buspirone)

A nurse is caring for a client who has HIV-1 infection and is prescribed zidovudine as part of antiretroviral therapy. The nurse should monitor the client for what adverse effects of this med?

-Aplastic anemia (severe myelosuppression resulting in anemia, agranulocytsos, and thrombocytopenia) -Lactic acidosis

What should the nurse teach to a client with juvenile idiopathic arthritis (JIA)?

-Apply moist heat to relieve pain and stiffness in affected joints -Wear splints during night to prevent joint deformities and reduce pain from inactivity

Nurses should only discuss client care when?

-Assigned to patient -Private setting, never in a public place

What are the indications of bleeding?

-Back pain -HA -Changes in level of consciousness -Decreased Hct and Hgb

What are late findings of increased ICP?

-Bradycardia -Dilated pupils (or decreased pupillary response) -Papilledema

What are the manifestations of autonomic dysreflexia?

-Bradycardia -Severe HA -Flushing -HTN -Tachypnea

What are two protective factors against SIDS?

-Breastfeeding -Use a pacifier when infant is sleeping

What medications are used to treat asthma?

-Bronchodilators (inhalers) -short acting beta2 agonists -albuterol, terbutaline for rapid relief of acute asthma attacks -Cholinergic antagonists-block parasympathetic nervous system, providing relief of acute bronchospasms-iprtropium -Anti-inflammatory agents-decrease airway inflammation for long-term management (corticosteroids-fluticasone, prednisone; Leukotriene modifiers-montelukast; mast cell stabilizers-cromolyn sodium; monoclonal antibodies-omalizumab)

What three meds are used to treat opioid withdrawal?

-Buprenorphine, a partial opioid agonist -Methadone, an opioid agonist -Clonidine, an alpha-2 adrenergic agonist

What characterizes action phase of labor?

-Cervical dilation of 4-7 cms -Contractions occurring every 3-5 minutes and lasting 30-60 seconds

Why is a client receiving IV chemo with an alarming infusion pump a priority?

-Chemo may be infiltrating (causing tissue damage) or line may be occluded (must regain patency or line will be lost)

What are S/S of hyperventilation, and subsequent respiratory alkalosis?

-Circumoral numbness -parasthesias -Dyspnea -Tetany -Chest pain or tightness *Acute hypocapnia can cause cerebral vasoconstriction and subsequent syncope, confusion, and seizures (even with normal O2 levels)

Routine urinalysis typically includes what?

-Color -Transparency -Specific gravity -pH -Protein -Glucose -Ketones -Nitrite -Blood -Bilirubin -Urobilirubin -Leukocyte esterase

What happens to skin as death nears?

-Cool to touch -Grayish-blue -Mottling in extremities that moves toward body core b/c decrease in CO and perfusion to extremities

What are two considerations for iron supplementation during pregnancy?

-DO NOT take with milk because calcium impairs absorption of supplement (take on empty stomach, and increase Vit C intake) -Consume diet high in fiber and increase fluids b/c iron causes constipation

What adverse effects should be monitored in anti-inflammatory asthma meds?

-Decreased immunity function -Monitor for hyperglycemia -Advise to report black, tarry stools -Observe for fluid retention and weight gain -Observe throat and mouth for aphthous (cold sore) lesions

What are some complications of untreated growth hormone deficiency?

-Delayed sexual development -Short stature -Delayed epiphyseal closure -Stunted bone age -Premature aging

Clients at risk for endocarditis should be treated with prophylactic antibiotics prior to what?

-Dental procedures -Respiratory and GI diagnostic procedures -GU and cardiac surgeries

What teaching should be done with acomprosate?

-Diarrhea may result -Maintain adequate fluid intake -Get enough rest

In what situations should a pregnant client contact their provider?

-Dimming vision (S/S of pregnancy induced HTN) -Epigastric pain (could indicate impending HELLP syndrome) -Severe continuous headaches (and visual changes could indicate CNS irritability and possible seizure onset)

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates and pulls back blood in the syringe. What action should the nurse take?

-Dispose of the med and get a new dose -Do not continue with injection. You are likely in a blood vessel which would mean putting the med in the wrong route (IV)

What are some ways to avoid preterm labor for at risk clients?

-Do not lift heavy objects (bags of groceries, young children, laundry baskets) b/c it increases strain of abd muscles -Hydraton -Low dose aspirin -cervical cerclage (a procedure to stitch around the uterus to prevent dilation) -weekly progesterone injections

What patient education is necessary for levothyroxine?

-Don't stop taking abruptly (it takes awhile... but stopping can put them into a myxedema coma) -Take early in the morning 1 hour before eating food -S/S of toxicity (hyperthermia S/S-increased HR, chest pain, heat intolerance) -Don't take within 4 hours of GI meds (such as carafate, aluminum hydroxide, simethicone) because they decrease absorption of thyroid meds

What is Echinacea?

-Echinacea purpurea-- root -Echinacea angustifolia--root (more pure) -Native North American herb -USED to improve immune system Alkylamide is the bitter taste

What is the goal of incentive spirometry?

-Encourage recruitment of alveoli -To correct or prevent atelectasis=alveoli collapse -To improve and promote cough mechanism -To increase resting lung volume (FRC)

Communication strategies for delirium and dementia patients?

-Encourage reminiscence about happy times; talk about familiar things -Break instructions and activities into short time frames -Limit number of choices when dressing or eating

How ought a nurse supervise a graduate nurse?

-Evaluate and determine if client outcomes are met -Provide necessary and appropriate feedback -Intervene if necessary

A nurse is caring for a newborn with fetal alcohol syndrome. What clinical findings should the nurse anticipate?

-Facial anomalies- eyes with epicanthal folds, strabismus, ptosis, mouth with a poor suck, small teeth, cleft lip or palate, -Deafness -Heart defects -Developmental delays and neurological delays -Growth retardation -Sleep disturbance

What are characteristics of the fetus that are reviewed to determine the biophysical profile (BPP) during an ultrasound?

-Fetal tone -Relative FHR in relation to activity -Fetal breathing movements -Gross body movements (body and libms) -Qualitative amniotic fluid volume

Should you use cromolyn nebulizer or albuterol inhaler first?

Abluterol inhaler used first because it is a bronchodilator that can open up airways. After waiting a few minutes, the cromolyn can be inhaled and will reach further into lungs because of dilatory effects of albuterol

What is delirium?

Abrupt disturbance in consciousness, typically manifesting as disorientation-first to time, then place, and lastly to person

A rigid abdomen is an expected finding of what condition?

Abruptio placentae

A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to the mental health unit. The client is confused and disoriented. When developing a plan of care, which of the following would be the priority intervention for this client?

Accept and make the client feel safe -Safety is the client's most important basic need making it the priority intervention

What is the developmental task for expectant mothers during the first trimester of pregnancy?

Accepting the fact that she is pregnant (allows client to see a provider and get prenatal care)

A nurse manager is evaluating staffing needs for a unit, including the need for overtime hours. What action should the nurse manager do first?

Access computerized data correlating client acuity, staffing, and scheduling. The first action the nurse manager should take using the nursing process is to assess acuity, staffing, and scheduling needs. Nurse managers have a responsibility to ensure that the staff delivers cost-effective, high-quality care. Collecting data that supports decision-making can help managers monitor and correlate staffing, client acuity levels, and scheduling patterns in relation to budget requirements.

What is isotretinoin?

Accutane. Used for severe acne that is resistant to treatments. It has serious teratogenic effects in pregnancy (craniofacial, CV, and CNS defects)

What is the antidote for acetaminophen toxicity?

Acetylcysteine (Mucomyst)

When is an epidural indicated?

Active phase of labor (Active labor is defined as: cervical dilation of 4-7 cms, contractions occurring every 3-5 minutes and lasting 30-60 seconds.)

What learning strategy is most effective with adolescent learners?

Actively involve participants in practice of techniques. Learn best when actively involved in participation and use of psychomotor skills

Herpes zoster or any skin infection is a contraindication for what?

Acupuncture. An open portal on the skin's surface could increase the risk for further infection

What does acute confusion, fatigue, lethargy, and anorexia indicate?

Acute confusion

What is thyroid storm?

Acute, life-threatening form of thyrotoxicosis that may present w/ -severe hyperthermia -hypertension -tachycardia (so much so that they have a heart attack or HF because heart gets worn out), Afib -high fever -diarrhea -respiratory distress from increased O2 demand (marked by irritability, restlessness, confusion.. leads to delirium, seizures, coma) **It's a storm, everything is hyper and moving fast

What is another name for Nifedipine?

Adalat and Procardia (calcium channel blockers)

What should the nurse teach about feeding an infant with GERD?

Add rice cereal to formula or breast milk to thicken feedings, which will decrease # of vomiting episodes

Postural hypotension and salt craving may occur with what disease?

Addison's disease

Skin pigmentation is a specific feature of what disease?

Addison's disease. Caused by increased production of melanin

What should the dietary intake of sodium be like when on lithium for bipolar disorder?

Adequate with 2-3+ L of fluid **Do not reduce dietary intake of sodium because it will increase lithium levels and increase toxicity risk

A nurse is admitting a client at 39 weeks gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks gestation. What intervention is necessary?

Administer IV antibiotic prophylaxis to decrease risk fo neonate contracting a GBS infection

A nurse is assessing a client who has just undergone a cesarean birth and was given epidural morphine for postpartum pain relief 1 hr ago. The nurse notes that the client's RR is 10/min. What should the nurse do first?

Administer O2 by nonrebreather face mask to treat respiratory depression from morphine administration

A nurse is caring for a client who received an injection of penicillin G procaine. The client begins to experience dyspnea and tongue swelling. What action should the nurse perform first?

Administer epinephrine subcutaneously. ABCs-it will act on adrenergic receptors, causing bronchodilation of the lungs and an elevation of BP (it stimulates both alpha and beta adrenergic receptors, accomplishing for anaphylaxis goals than any other therapy (vasoconstricts tongue swelling and opens lungs for dyspnea))

A nurse is caring for a client in active labor and scheduled to receive epidural anesthesia. What should the nurse do?

Administer lactated Ringer's 500 mL bolus via intermittent IV infusion before placement to prevent hypotension

What are Pirbuterol and salmeterol?

Adrenergic stimulants used for asthma

What is oculogyric crisis?

Adverse effect of antipsychotic meds in which eyes are locked in upward-looking position -Treated with IV benztropine

When are sitz baths used?

After a rectal surgery. Sit in a mini toilet that provides a warm, shallow bath to cleanse the perineum

What are the S/S of lead toxicity?

Aggression, sleep difficulties, changes in appetite, irritability, and HA

A client with measles should be on what type of precautions?

Airborne

What is an important contraindication to metformin?

Alcohol use disorder. Metformin can inhibit lactic acid breakdown causing lactic acidosis. Alcohol further inhibits lactic acid breakdown

What is the purpose of a fistula?

Allows high blood flow so the largest amount of blood can pass through the dialyzer. AV fistula is a blood vessel made wider and stronger by a surgeon to handle the needles that allow blood to flow out to and return from a dialysis machine

What is the therapeutic purpose of silence?

Allows the client time to think, gain insights, slows the pace of the interaction, and encourages the client to initiate conversation (while conveying nurse's support, understanding, and acceptance)

What natural supplement/homeopathic remedy is used to help heal burns and wounds?

Aloe vera

A nurse is assessing a client who has a diagnosis of RA. What nonpharmacological intervention should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to affected joints. Cold can relieve joint swelling and heat can decrease joint stiffness and pain

What is intensive outpatient therapy?

Alternative to partial hospitalization. Medication management can be available but a provider does not monitor the client which is necessary during alcohol detoxification. Participants attend 3 days/week for approximately 3 hr/day

What is a presumptive sign of pregnancy?

Amenorrhea

What is dissociative fugue?

Amnesia associated with overwhelming stress where clients are unable to recall past, confusion about identity, or assumption of a new identity

What is diclofenac and when is it administered?

An NSAID. It causes gastric irritation so it should be taken with food or milk to minimize the irritation

A client is having an exercise electrocardiography (stress test) performed. The nurse recognizes the need to stop the test if which of the following occurs?

An ST segment depression or T wave inversion on the EKG. Indicates myocardial ischemia

What is exophthalmos?

An abnormal protrusion of eyeballs, a classic hyperthyroidism sign. Elevated T4

How is alteplase administered?

An accelerated, or loading dose, to promote a rapid therapeutic effect of the med

The nurse assesses a 6 mo for vaccination readiness. What finding would require delaying the DTaP?

An acute bilateral ear infection. Vaccination in the presence of a moderate-severe infection, w/ or w/o fever, increases risk of injury and decreases chance of mounting a strong immune response to vaccine -DTaP is not a live vaccine

What is clonidine?

An alpha 2 agonist used for HTN, severe pain, and ADHD. Common adverse effect: dry mouth

What is gentamicin and what is an important adverse effect to be aware of?

An aminoglycoside antibiotic that can be toxic to the 8th cranial nerve and kidneys

What is aluminum hydroxide?

An antacid used for heartburn, upset stomach, and to reduce phosphate levels in people with certain kidney conditions)

What is Granisetron?

An antiemetic med that prevents nausea and vomiting for clients who receive chemo meds such as topotecan

What is sucralfate?

An antiulcer medication that coats the stomach.

What is Grave's Disease?

An autoimmune disease of unknown etiology affecting thyroid causing enlargement and excessive hormone secretion. 75% of hyperthyroidism cases.

What is the S4 heart sound?

An extra heart sound occurring immediately before the normal "lub-dub". It is caused by the atria contracting forcefully in an effort to overcome an abnormally stiff or hypertrophic ventricle

Fever for 2 consecutive days, chills, foul-smelling lochia and abdominal tenderness indicate what?

An infection of lining of uterus. Nurse should obtain a vaginal culture using a sterile swab to collect the fluid from the client's vaginal cavity to identify organism

What is urosepsis?

An infection that starts in the urinary tract and becomes systemic (sepsis)

Lipid emulsions need what to be administered?

An infusion pump to avoid a rapid influx of emulsion into intravascular system

What is Butorphanol?

An opioid analgesic

What is Nalbuphine?

An opioid analgesic

Incontinence is a manifestation of what?

Anaphylactic reaction

Adverse effect of echinacea?

Anaphylaxis, specifically in people with asthma

When and how often should females have mammograms (breast exams)?

Annual mammograms starting at age 40

What causes delirium?

Another medical condition such as: metabolic disorder, medication effect, systemic infection

What is Crycrimine (Pagitane)?

Anticholinergic used in Parkinson's disease

What is a contraindication for taking feverfew?

Anticoagulant therapy

What is carbamazepine?

Anticonvulsant used for seizures, trigeminal neuralgia, bipolar disorder, and diabetic neuropathy

What is atropine?

Antidote for muscarinic poisoning; anticholinergic

What is protamine sulfate used for?

Antidote to heparin for clients experiencing a severe bleeding episode

What is hydroxychloroquine?

Antimalarial med used for RA. High risk of SE of retinopathy, which can be irreversible and cause blindness

What is quetiapine (Seroquel)?

Antipsychotic used for schizophrenia, bipolar disorder, and depression

What's important to remember with Methimazole (Tapazole) in relation to pregnancy?

Antithyroid med -fewer SE than PTU -CANNOT be used during 1st trimester

What's important to remember with Propylthiauracil (PTU) in relation to pregnancy?

Antithyroid med -watch liver -can be used in 1st trimester

What is Kava used for and what is its adverse effect?

Anxiety reduction, insomnia Can cause severe liver damage

What happens to vital signs with delirium?

Anxiety-esque: increased HR, BP

A nurse is caring for a client who has type 1 DM and reports severe ankle pain after falling off a stepstool at home. What prescription should the nurse clarify with the provider?

Apply a cold pack to client's ankle for 30 min every hour. Should question b/c T1DM is contraindicated for receiving cold therapy b/c of impaired circulation d/t arteriosclerosis and loss of sensory perception d/t neuropathy

What should the nurse do to injection site after heparin administration?

Apply firm pressure to site for 1-2 minutes. DO NOT MASSAGE-can cause bleeding

A nurse is caring for a client who has a respiratory infection. What techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter to prevent mucosal injury

A client with an ileostomy calls the clinic reporting stomal swelling along with decreased drainage of ileostomy contents. The nurse instructs the client to do what?

Apply moist towels to abdomen (facilitate drainage), abdominal massage (same), Hot tea (same)

What can be applied to prevent pressure ulcers?

Apply moisturizer to damp skin after bathing. It prevents dry skin. The drier the skin, the greater the risk for skin breakdown

According to the American Hospital Association's Patient Care Partnership, the nurse understands that client rights in the health care setting does not include what?

Arrangements for home follow-up visits

A client ingested a full bottle of imipramine hydrochloride. What toxic effects is most important for the nurse monitor?

Arrhythmias. Tricyclic antidepressant (TCA) overdose causes cardiac problems such as arrhythmias, tachycardia, and myocardial infarction

What is an amniotomy?

Artificial rupture of the amniotic membrane's by the provider. try this first to progress labor before augmenting with pit

How does glomerular filtration rate affect potassium excretion?

As glomerular filtration rate decreases, the excretion of potassium decreases

A nurse is administering a heparin flush to a client with a subclavian central line, but is unable to use the syringe to administer the flush and cannot draw back any blood from the line. The nurse initially suspects a mechanical occlusion of the line. What action should the nurse take?

Ask client to sit up, take a deep breath and cough. Repositioning can resolve the occlusion

What is an inappropriate strategy for enhancing communication in the hearing-impaired?

Ask family members to interpret (cannot ensure that client is receiving correct information)

During a group therapy session on a psychiatric unit, the nurse leader observes that one of the clients frequently interrupts the session. Which of the following nursing actions is the most appropriate for this situation?

Ask the client to speak privately with a nurse after the meeting.

What is the greatest risk to a newborn with meconium-stained amniotic fluid?

Aspiration syndrome and respiratory distress. So... suction the mouth and nose with bulb syringe, then with endotracheal suctioning if needed.

A nurse is caring for a client post CABG. The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. What should the nurse do first?

Assess client's BP (because there's certain meds you can't give to address it if BP is too low)

A nurse is caring for a client who is intubated and receiving ventilatory assistance. The high pressure alarm is sounding on the ventilator. What is the priority?

Assess client's need for suctioning (pressure is building up in the lungs from a blockage)

What is an important intervention after an amniotomy?

Assess fetal heart for rate and variable decelerations (After an amniotomy everything shifts in the uterus and the cord can become compressed)

What is the purpose of a nonstress test (NST)?

Assess the fetal CNS (FHR in relation to fetal movement)

A client is hospitalized for multiple rib fractures following a motor vehicle accident (MVA). The results of an arterial blood gas (ABG's) are; pH 7.30, pCO2 48, HCO3 26 and pO2 91 on 2 L/min of oxygen per nasal cannula. What intervention has the highest priority?

Assist the client to deep breathe, splinting with a pillow. (The client is experiencing respiratory acidosis from hypoventilation caused by painful respirations from fracture ribs. Splinting the chest wall with a pillow will decrease pain associated with deep breathing. Deeper breaths will allow for better gas exchange, which will correct the acidosis)

What are methylxanthines?

Asthma meds that prevent nocturnal asthma by producing bronchodilation (by relaxing bronchial smooth muscle) E.g. Theophylline, Aminophylline

How long should a client avoid direct sunlight after radiation treatments?

At least one year

What is Scopolamine?

Atropine derivative-anticholinergic. Causes pupil dilation

What type of client needs to be introduced to new situations slowly?

Autistic clients

What is pernicious anemia?

Autoimmune destruction of parietal cells in the stomach, leading to loss of intrinsic factor and thus inability to take up vitamin B12

What types of foods are high in tyramine?

Avocados, bananas, salami

What should the nurse teach about methylphenidate?

Avoid afternoon doses to help you sleep better. Nervousness and insomnia are common SE, so take in morning

What should the nurse do if she meets resistance when pushing a med through a PICC line?

Avoid applying force -Gently aspirate the catheter, which can restore patency (if it doesn't work. Tell provider)

What should be taught about aspirin to a gout client?

Avoid aspirin! It can precipitate a gout attack causing pain and inflammation in joints

What should the nurse instruct a client when preparing for a thoracentesis?

Avoid coughing during procedure and lie still to avoid puncturing the pleura

How does aspirin affect gout?

Avoid it, it can induce a gout attack

A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? (Select all that apply). A. You will give the med every 4 hours B. Shake the med bottle well before each dose is given C. Store the med in the fridge D. Report diarrhea to the provider immediately E. Discard the unused portion of the med after 21 days

B, C, D B. Shake the med bottle well before each dose is given (suspension that should be mixed) C. Store the med in the fridge D. Report diarrhea to the provider immediately (could be manifestation of Cdiff and should be reported because antibiotics kill the bacteria that suppress Cdiff) *Discard unused med after 14 days *administer every 8-12 hr as prescribed

According to the American Hospital Association's Patient Care Partnership, the nurse understands that client rights in the health care setting include which of the following? a. Assistance with childcare arrangements b. Preparation for discharge c. Help with billing and filing insurance claims d. Client involvement in the plan of care e. Arrangements for home follow-up visits

B, C, D b. Preparation for discharge c. Help with billing and filing insurance claims d. Client involvement in the plan of care *identifies high quality of care, protection of client privacy, involvement in care, help when leaving the hospital, and help with billing claims as client rights during a hospital stay

A nurse is caring for a client with MRSA. In what order should PPE be donned? A. Goggles B. Gown C. Gloves D. Mask

B, D, A, C Gown, mask, goggles, gloves

A nurse is caring for a client with a tracheostomy. In which order should the tracheostomy care interventions be performed? A. Document the type and amount of secretions B. Suction the tracheostomy C. Clean the inner cannula with hydrogen peroxide followed by sterile saline D. Apply an O2 source loosely to prevent desaturation E. Change tracheostomy ties if soiled F. Apply a split 4x4 dressing around the tracheostomy

B, D, C, F, E, A

A nurse is obtaining a sterile specimen from an indwelling urinary catheter. Place the following steps in the order the nurse should use to obtain this specimen: A. Remove clamp to resume drainage B. Drain the catheter's tubing of urine C. Place urine sample in sterile container D. Clamp the catheter's tubing below port for 20 min E. Clean the injection port cap of the catheter drainage tubing with antiseptic F. Attach a sterile syringe to the port and aspirate quantity of urine required

B, D, E, F, C, A Draining urine from the tubing and then clamping allows fresh urine to collect. Aseptic technique should be maintained during procedure and cleansing port with an appropriate antiseptic solution will remove surface contaminates. Use of a sterile syringe and container is necessary to prevent contamination. Removing clamp after procedure allows for continued urine drainage

At 0715 the nurse is assigned to care for the following four clients. Which of the following clients should the nurse plan to see first? Select one: a. A client with pneumonia scheduled for a portable chest x-ray at 0730. b. A client with diabetes mellitus type I waiting for a breakfast tray at 0745. c. A client scheduled for a bronchoscopy at the bedside at 0900. d. A client who will be transferred to a skilled care facility at 0930.

B. A client with diabetes mellitus type I waiting for a breakfast tray at 0745 -The diabetic client waiting for breakfast should be assessed first. Prior to breakfast the client's blood glucose needs to be drawn and if insulin coverage is required it is administered before breakfast. Once the client begins to eat and digest food they will be at risk for increasing blood glucose levels without their insulin coverage.

When is an Allen test performed?

BEFORE AN ARTERIAL PUNCTURE to determine if you can use or remove them. You compress ulnar and radial artery and tell patient to clench and unclench hands 10 times. Hand will blanch (turn white). You then release one artery and count how long it takes for color to return. Do the same process again and release the other artery. If it takes more than 6 seconds, the other artery can't be trusted to adequately oxygenate hand if one is removed

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For what symptom should the parents seek immediate medical attention?

Baby cries inconsolably for more than 3 hours. Crying lasting 3_ hours and/or seizures within 48 hours of vaccination indicates encephalopathy that must be treated immediately

What does an increase of protein concentration in spinal fluid indicate?

Bacterial meningitis

A nurse is planning care for a client who is to receive a competitive neuromuscular blocking agent. What should the nurse have at the client's bedside?

Bag-valve-mask device. Competitive neuromuscular blocking agents prevent acetylcholine from activating receptors on the skeletal muscles and cause muscle relaxation. These agents can cause respiratory arrest due to relaxation of the respiratory muscles. The nurse should have a bag-valve-mask device, endobrachial intubation equipment, and oxygen at the bedside of a client who is receiving this medication to reduce the risk for respiratory arrest.

When should a client with COPD schedule controlled coughing exercises?

Before meals to clear mucus, which can improve dietary intake

What should a client do to identify pelvic muscles?

Begin urinating and then try to stop urine flow. *The client should not strain down, lift her bottom of the seat, or squeeze her legs together

When should a nurse complete large tasks that require the most time and energy?

Beginning of shift when energy levels are high

What services does patient-centered medical home (PCMH) provide?

Behavioral health and medical services. -extended hours of service 7 days/week

How should lipid emulsions be hung in relation to the filter?

Below filter tubing (so they don't clog filter)

When is chlordiazepoxide given?

Benzo given during acute alcohol withdrawal to prevent seizures, decrease agitation, stabilize vital signs, prevent delirium tremens

What is Flumazenil?

Benzodiazepine antagonist that counteracts CNS depression

What meds can be used to detoxify alcohol withdrawal?

Benzodiazepines: Diazepam Chlordiazepoxide Lorazepam

What receptor is not sensitive to norepinephrine that is sensitive to epinephrine?

Beta 2

What are class II antidysrhythmic meds?

Beta-adrenergic blockers that prevent sympathetic nervous system stimulation of the heart

What is timolol maleate?

Beta-adrenergic receptor antagonist-used to decrease aqueous humor production. Used to treat glaucoma *Uncle Tim has glaucoma. LOL. We beta help him

What does dark urine indicate?

Biliary atresia-Impaired excretion of bilirubin into the GI tract that instead is excreted in urine-dark urine

What is the focus of the National Institutes of Health?

Biomedical research to improve the prevention, diagnosis, and treatment of specific diseases

How long is the Pavlik harness used for?

Birth-6 mo for kids with hip dysplasia

A menopausal client states she is suffering from hot flashes and does not want to use hormone replacement. She asks the nurse if there are any natural supplements or homeopathic remedies she could use. What should the nurse recommend?

Black cohosh

What is exstrophy of the bladder and what should the nurse do?

Bladder disorder in which it is exposed externally and must be surgically repaired b/c it did not develop properly in abd during embryo *Place a protective non-adherent plastic film, such as saran wrap, to maintain moistness and prevent infection

What is turner's sign?

Bleeding into flank => hemorrhagic pancreatitis

How does diphenhydramine interact with acetylcholine?

Blocks acetylcholine. It's an anticholinergic

What do chills, rigor, fever, dyspnea, light-headness, and flank pain indicate?

Blood transfusion reaction

What is Chadwick sign?

Bluish discoloration of the vagina and cervix -a probable sign of pregnancy -indication of early pregnancy

How does Grave's Disease work?

Body starts secreting TSI (Thyroid Stimulating Immunoglobulin-antibodies to TSH receptors cause release of T3 and T4), leading to excessive production of thyroid hormones. Has remissions and exacerbations may lead to destruction and hypothyroidism

What are some SE of paclitaxel?

Bradycardia and hypotension

What do combination oral contraceptives often cause?

Breakthrough bleeding and spotting during the menstrual cycle (often resolves within 3 mo)

What is Piperacillin/tazobactam?

Broad spectrum anti-infective used in treatment of moderate-severe infections

When should a topical antiseptic be avoided for postpartum perineal care?

Broken, itchy, or irritated skin AND IT'S NOT REALLY RECOMMENDED FOR POSTPARTUM CLIENTS

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. What finding is an indication of lung re-expansion?

Bubbling in the water seal chamber has ceased

Prophylactic antibiotic therapy is NOT recommended for what?

Burns

A nurse is reinforcing teaching with a client who is prescribed buspirone (BuSpar). What should be taught regarding alcohol?

Buspirone is an anxiolytic med used to treat anxiety but is different than benzodiazepines because it is not a CNS depressant. Thus, it is acceptable to have 1-2 alcoholic drinks/week

A laboring client reports suddenly feeling something in her vagina. Upon assessment, the nurse identifies a prolapsed umbilical cord. What is the proper sequence of interventions? A. Prepare the client for cesarean birth B. Administer O2 at 8-10L via face mask C. Notify primary care provider of the prolapsed cord D. Reposition the client in either a knee-cheat or Trendelenburg position E. Using a sterile glove insert two fingers into the vagina to reduce pressure off the cord

C, D, E, B, A

The following clients have been assessed in the emergency department. Which of the following clients requires immediate attention? Select one: a. A 19 year-old client who is vomiting and complaining of new onset right lower quadrant pain with rebound tenderness. b. A 6 year-old client with an open tibial fracture that occurred two hours ago after being hit by a car. c. A 48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's. . d. An 81 year-old client with a history of heart failure and new onset pneumonia with a respiratory rate of 32 and a temp of 101 F (38).

C. 48 y/o male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVCs -While all of these clients require nursing care, the 48 year-old male with c/o chest pain and a cardiac rhythm of sinus tachycardia with occasional PVC's needs immediate attention! Chest pain is an indication of myocardial ischemia and this client has other factors that put him at risk for sudden death: gender, age and PVC's. PVC's are not normal in a 48 year old. PVC's occur when the myocardium is irritated, usually from hypoxia but also from electrolyte imbalance, usually involving K+. This client is young and as a result has not had sufficient time to develop adequate collateral circulation

What are class IV antidysrhythmic meds?

CCB that prolong cardiac conduction, depress depolarization and decrease O2 demand of heart

Which of the following info would be included on the psychosocial component of the comprehensive assessment? a. Carb intake b. BMI c. Amount of sleep d. Personal habits e. Recreational activities

CDE c. Amount of sleep d. Personal habits e. Recreational activities *focuses on relationships and environmental factors that can influence health

When would you need a phosphorus restriction?

CKD-to prevent renal osteodystrophy

A nurse is teaching a client who is to begin long-term therapy with prednisone to treat rheumatoid arthritis. The nurse should instruct the client to take what supplements?

Calcium and Vit D b/c long-term glucocorticoids place client at risk for osteoporosis

A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. What med should the nurse plan to administer?

Calcium carbonate. Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities.

What supplement interferes with the effectiveness of levothyroxine?

Calcium-can serve as an antacid. Should not be taken within 4 hours of levothyroxine administration

What should you do if you note an elevated serum amylase in a patient?

Call doctor immediately because this indicates a pancreatic disorder which is dangerous

What should a nurse do if a provider leaves a recorded order message (even if she can hear and understand it clearly)?

Call the provider and obtain the prescription verbally over the telephone

What is an adverse effect of ciprofloxacin?

Can cause tendinitis and tendon rupture. Monitor and report tendon pain or inflammation

How long does it take for respiratory depression to occur after an IV bolus of morphine?

Can occur within 7 minutes after

Client has a bronchoscopy scheduled. What should the nurse teach?

Can't eat or drink after procedure until able to cough (b/c local anesthetic can suppress cough reflex putting client at risk for aspiration)

What is acetazolamide?

Carbonic anhydrase inhibitor-decreases rate of aqueous humor production. Used to treat glaucoma.

Severe dehydration can cause what?

Cardiac arrhythmias d/t fluid and electrolyte imbalances

A nurse is caring for a client who was admitted for shock. The client has a prescription for an afterload-reducing med. The nurse should recognize this med is administered for which type of shock?

Cardiogenic shock, often caused by an MI. Reducing afterload will assist left ventricle ejection and allow more effective heart pumping

What is a major cause of death following a kidney transplant?

Cardiovascular disease

What is the priority intervention for acute urinary retention?

Catheterization

How do glucocorticoids affect potassium?

Cause hypokalemia

How do opioids affect urine output?

Cause urinary retention, so decreases it

How does lithium affect thyroid functioning?

Causes hypothyroidism by inhibiting the incorporation of iodine into the thyroid hormone.

How does Cushing's disease affect client activity?

Causes lethargy and depression

Foul, fatty, frothy stools are a manifestation of what disease?

Celiac disease. This is steatorrhea

What does acute onset of hypocapnia (from respiratory alkalosis or something similar) cause?

Cerebral vasoconstriction , reducing cerebral blood flow. This can cause neurological S/S such as syncope, confusion, and seizures

S/S of delirium

Change in level of consciousness (decreased awareness of surroundings) -Decreased attention span (disturbance in ability to focus and maintain attention, also memory impairment and poor judgment) -Hallucinations--increase fear and anxiety

A client has a clogged percutaneous gastrostomy feeding tube. What action should the nurse take first?

Change position of the client. Least restrictive and may remove any kinks in the tube, which can lead to clogging. (next nurse should attempt to flush or aspirate tube contents)

What are late signs of respiratory distress that indicate impending respiratory failure?

Characterized by inadequate oxygenation, ventilation or both -Cyanosis -Altered LOC -Apnea -Bradycardia

What is the most reliable method for verifying endotracheal tube placement?

Checking end-tidal CO2 levels using capnometry or chest X-ray

A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education?

Cheddar cheese. Clients with renal failure need to restrict protein and phosphorus which is present in cheese and many milk products

Eating what at bedtime can help you sleep better?

Cheese or drinking milk b/c dietary L-tryptophan found in these foods can help induce sleep

Why is COPD patients' stimulus to breathe PaO2 instead of CO2 like normal people?

Chemoreceptors lose their sensitivity and don't respond to CO2 levels accurately because COPD clients hypoventilate. Peripheral chemoreceptors then try to fill in the regulatory void and they are sensitive to amount of O2 in the blood. Thus, O2 becomes new stimulus to breathe because peripheral chemoreceptors now regulate body.

What is daunorubicin?

Chemotherapeutic for leukemia

What is etoposide?

Chemotherapy for testicular cancer, lung cancer, lymphomas, nonlymphocytic leukemia (Toposar and etophophos)

What is the most common symptom of pericarditis?

Chest pain. It is often exacerbated by deep inhalation by lying in the supine position and may be relieved by leaning forward. Often described as sharp or stabbing, but can also be dull/aching and radiate to neck or shoulder

When is an electroencephalogram performed?

Child has seizures or to determine brain death in an unconscious child

Who should not be allowed to visit a client with a radioactive implant?

Children

A nurse is preparing to initiate IV therapy on a client. What solution is the best choice for preparing the client's skin at the insertion site?

Chlorhexadine

What is the pathophys for myasthenia gravis?

Chronic autoimmune neuromuscular disease characterized by weakness of the skeletal muscles of the body. In this disorder, the body produces autoantibodies that block, alter, or destroy acetylcholine receptors at the NMJ. This prevents muscular contraction (spec. of eye/eyelid movement, facial expression, chewing, talking, and swallowing). Muscle weakness increases during periods of activity and improves during rest

What are some meds that decrease levothyroxine absorption?

Cimetidine, lansoprazole, and colestipol

What do dyspnea, restlessness and crackles indicate during a blood transfusion?

Circulatory overload. Nurse should slow or stop infusion to improve client's ability to breathe, place client upright position and notify provider (anticipate a diuretic to alleviate fluid overload)

A nurse in an ED is caring for a toddler who has partial-thickness burns on right arm. What action should the nurse take?

Cleanse affected area with mild soap and water to remove any loose tissue that could cause infection

A nipple with a wide base is used to feed what clients?

Cleft lip

What is exaggerated grief?

Client exhibits self-destructive behavior in response to grief such as risky behavior or suicide

How does a voluntary admission into mental health clinic affect treatments?

Client has same rights as clients receiving any other type of care. Still need to give informed consent for treatment and therapies such as ECT

What S/S should be reported to provider after initiation fo magnesium sulfate?

Client is drowsy and difficult to arouse (demonstrative of magnesium sulfate toxicity)

If a client is experiencing Cushing's Triad, what does that indicate?

Client is experiencing increased intracranial pressure. Nurse should administer mannitol 25%, an osmotic diuretic that promotes diuresis to treat cerebral edema

A primipara client with contractions occurring every 2 minutes, lasting 90 seconds, and cervical os is dilated 10 cms requests an epidural. Why is this a low priority.

Client is in transition phase of labor and is approaching second stage: cervical dilation of 8-10 cms, contractions every 2-3 minutes and lasting 45-90 seconds. Many clients in this phase of labor become exhausted. An epidural during this phase could prolong delivery as the epidural may interfere with the client's ability to push.

The nurse is caring for four clients receiving chemotherapy. Which of the following clients should the nurse see first? Select one: a. A client with cervical cancer and a hemoglobin level of 8.2 mg/dL b. A client with ovarian cancer with a white blood cell count of 4,500 cells/mcL c. A client with breast cancer and a sodium level of 115 mEq/L d. A client with endometrial cancer and a potassium level of 5.0 mEq/L

Client with breast cancer and a sodium level of 115 mEq/L (A sodium level less than 120 mEq/L is considered a medical emergency and needs immediate assessment and treatment)

A client with COPD has O2 therapy ordered. What principle should guide the nurse in managing the delivery of O2 to this client?

Clients with COPD should receive low concentrations (2-3L) of O2 since the stimulus to breathe is their low PaO2

Who is psychiatric home care for?

Clients with only a mental health illness and who cannot leave the home independently

What does generalized petechiae indicate on a newborn?

Clotting factor deficiency or infection. Report finding to provider immediately

"I have excellent job skills; I just need to find a new employer" is an example of what stress management technique?

Cognitive reframing=viewing a situation in a more positive light to experience them as less stressful

What is echinacea used for?

Colds and flu (boosts immune system)

What is atelectasis?

Collapsed lung. collapse of the alveoli in the lung prevents normal exchange of O2 and co2 hypoventilation occurs

What is caput succedaneum?

Collection of fluid or blood above periosteum (between it and scalp) that crosses suture lines

A 3-year-old hospitalized child is on bedrest. To meet developmental needs, the nurse should provide what?

Coloring book and crayons-child is developing hand-eye coordination

How does diphenhydramine (Benadryl) work?

Competes with histamine for receptors; thus reducing vasodilation of capillaries, pruritis, and inflammation (d/t lack of histamine binding)

Gross negligence

Conduct that constitutes an intentional, reckless disregard for a duty, standard of care, or consequences

Why shouldn't nurses confront clients (tell them to stop interrupting) that interrupt during group?

Confronting during the meeting could negatively affect self-esteem and increase social isolation

What is a risk factor of preeclampsia?

Connective tissue disease such as RA or systemic lupus erythematosus

What kind of teaching environment is best for ADHD clients?

Consistent environment that is predictable to assist w/ focus and the ability to complete expected tasks

What is the major adverse effect of calcium antacids?

Constipation

A nurse is teaching a client who has a new prescription for aluminum hydroxide to treat heartburn. The nurse should monitor for what adverse reactions?

Constipation (so increase fluid and fiber)

What is one complication of cystic fibrosis?

Constipation b/c of failure to properly breakdown foods, slowing intestinal motility, and thickened enzymatic secretions due to disease process. Therefore, give stool softeners

What does abd distention indicate in children?

Constipation, flatus, or lactose intolerance

A provider informs the wife of a comatose client with terminal cancer that she will need to sign the consent for insertion of a gastrostomy feeding tube. The nurse knows this is against the client's wishes. What is the appropriate action by the nurse?

Consult the hospital's ethics committee (consult if nurse believes provider's actions are directly against client's wishes)

Nurse is discharging a client with COPD. What should the nurse teach?

Consume a diet high in calories (dyspnea decreases energy available for eating. Nurse should encourage soft, high-calorie and high-protein foods to prevent weight loss)

What is one dietary modification to manage hyperemesis gravidarum?

Consume liquids and solids separately

What type of precautions should be initiated for Burkholderia cepacia?

Contact

What kind of precautions are needed for RSV?

Contact and droplet. Virus can live for several hours on fomites and on hands for 30 min

A nurse is preparing a client with terminal illness for discharge to a nursing home when he states: "I don't want to go to a nursing home to die. I would rather die at home." What would be the most appropriate action by the nurse? Select one: a. Continue to make the discharge arrangements. b. Assess the client's reasons for feeling this way. c. Inform the provider of the client's decision. d. Contact the client's case manager.

Contact the client's case manager. Contact the client's case manager would be the most appropriate action by the nurse. The case manger would be able to determine if the client's wishes could be carried out.

In most circumstances, when there is a med error, the initial appropriate response will be to?

Contact the primary care provider, so that an appropriate order can be given to counteract the med

A nurse is caring for a child who has had diarrhea for one day. The mother asks what diet to resume when the child's appetite returns. The child does not appear dehydrated. What should the nurse say?

Continue child's regular diet. Child will recover from mild-moderate diarrhea faster with this regular diet. -Lost fluids should be replaced, but not overcompensated. Consider popsicles, jell-o, diluted fruit juice, broth, pedialyte

What is assist control ventilation?

Continuous mandatory ventilation, delivers a preset ventilatory rate and preset tidal volume to client. Indicated when client is apneic

What is a positive Chvostek's sign and what does it indicate?

Contraction of facial muscle after the nurse taps the client's facial nerve. Indicates hypocalcemia or hypomagnesemia

What med class is contraindicated in children with asthma?

Cough suppressants because asthmatic children need to be able to cough up mucus to keep airway open

What sorts of products contain alcohol and should be avoided in clients taking disulfiram?

Cough syrup Aftershave

A nurse is teaching about adverse effects to a client starting captopril. What adverse effect should be reported to provider?

Cough, develops d/t buildup of bradykinin in lungs

A client presents to the ED with an abdominal stab wound. The nurse visualizes intestines protruding through the wound?

Cover the wound with warm saline-soaked gauze

What types of cheese are safe with MAOIs?

Cream cheese and cottage cheese b/c they're not aged

Acne, hirsutism and easy bruising are some manifestations of what disease?

Cushing's syndrome

Family history of seizures DOES NOT prevent administration of what?

DTaP vaccine (only if serious allergic reaction to previous dose or encephalopathy)

What does a mild moderate asthma diagnosis mean?

Daily symptoms occur in conjunction with exacerbations twice a week

How long must disulfiram be used?

Daily, uninterrupted doses must be continued until client recovers social and a basis for permanent self-control has been established

What does flaking of the scalp with pink, irritated, exposed skin indicate?

Dandruff or a dry scalp

How is a hydatidiform mole characterized?

Dark brown vaginal bleeding during 2nd trimester. NO abd pain

What types of foods are high in Vitamin K?

Dark green leafy vegetables, cabbage, broccoli, mayonnaise and canola

How do oral contraceptives affect menstrual-associated migraine headaches?

Decrease frequency

How do oral contraceptives affect pelvic inflammatory disease, benign breast disease?

Decrease risk

Why should you schedule clients with latex allergy early in the day?

Decrease the risk of contamination from powdered latex surgical gloves used in other procedures

How does chronic kidney disease affect a CBC?

Decreased Hgb and Hct (anemia) secondary to removal of folate and lack of erythropoietin secretion

What electrolyte changes occur with pancreatitis?

Decreased calcium and magnesium levels d/t fat breakdown

What assessment finding is the first sign of Mg toxicity?

Decreased deep tendon reflexes

What is an adverse effect of finasteride?

Decreased libido b/c of androgenic effect on prostate

How does chronic kidney disease affect serum electrolytes?

Decreased sodium (from dilution) Decreased calcium Increased K+ Increased phosphorus Increased Mg

A nurse is reviewing the lab results of a client who has liver failure w/ ascites and is receiving spironolactone. What electrolyte change should the nurse anticipate?

Decreased sodium level. Spironolactone is a potassium-sparing diuretic that inhibits the action of aldosterone, resulting in an increased excretion of sodium (also increases phosphate retention and chloride retention)

A nurse is assessing a client who has HIV. What finding should the nurse identify as a manifestation of HIV-associated muscle wasting?

Decreased strength caused by GI malabsorption of nutrients -loss of <5% of body weight in 6 mo

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported?

Decreased urine output. Indicates dehydration. S/S: Listlessness, sunken eyes, decreased tears, and dry mucous membranes are other S/S of dehydration

How does hypercalcemia affect deep tendon reflexes?

Decreases deep tendon reflexes

How does an increase in sodium levels affect lithium levels?

Decreases lithium levels *Indirectly related

What is ginger tea used for in pregnant women?

Decreasing episodes of nausea

What indicates infections in older clients?

Decreasing mental status

What is displacement?

Defense mechanism involving transfer of feelings to someone else because they can't cope with own feelings of sadness and loss. Blaming doctor for sibling's death.

What is clubfoot?

Deformity in which an infant's foot is turned inward, often so severely that the bottom of the foot faces sideways or even upward. Contractures of soft tissues maintain malalignments. Treated with the Ponseti technique=stretching foot, casting (5-10), tenotomy, following by wearing braces

Neglect of personal hygiene is NOT an early characteristic of what?

Delirium

When would you want to minimize need for decision making and abstract thinking?

Dementia and delirious patients (to avoid frustration)

What is St. John's wort used for and what is its adverse effect?

Depression *Precipitates serotonergic crisis with SSRIs *Precipitates HTNsive crisis with digoxin

What is a monospot test?

Detects the presence of heterophil antibodies via agglutination of sheep or horse RBCs •Positive = EBV •Negative = CMV

Early manifestations of acetaminophen toxicity?

Diaphoresis, N/V, diarrhea, abd pain

A provider prescribes gold salts for a client with rheumatoid arthritis. For what serious side effects will the client require monitoring?

Diarrhea Leukopenia Thrombocytopenia

Seizures from ECT lasting longer than 90 seconds should be treated with what?

Diazepam (Valium)

What is an early sign of relapse in psychosis?

Difficulty sleeping

An infant prescribed digoxin has a HR 88 bpm. What does this indicate and what should be done?

Digoxin toxicity. HR <90 bpm indicates toxicity

What should be done after using a suction catheter?

Discard it to eliminate the risk of reintroducing pathogens to the respiratory tract

A nurse is planning discharge interventions designed to promote and maintain independence and maintain health for a child with a spinal cord injury (SCI). What intervention is inappropriate?

Discussing sexuality issues. Specialty training is needed to discuss sexuality issues of a client who had experience a SCI and should be referred to a sexuality counselor or urologis

What is Cushing's disease?

Disease of adrenal gland where is produces too much hydrocortisone *Cushing's adds cushion through weight gain (such as buffalo hump, rounded face-moon face, stretch marks)

How should blood or body fluids of an AIDS patient be cleaned up?

Disinfected with a 10% bleach solution

Zolpidem (Ambien) causes what adverse effect?

Dizziness and daytime drowsiness *used for insomnia

A nurse is performing morning rounds for a client and finds the client's bedtime medications sitting at the bedside in a medication cup. What action should the nurse take?

Document the missed medication administration in the client's medical record. There should be enough information about the event so that treatment can be provided if needed

A nurse manager suspects that a staff nurse on the night shift has a substance use disorder. What should she do?

Document thoroughly any unusual behavior by the nurse. The nurse manager should collect reports from other employees, client concerns, and observations, as well as statements detailing any related incidents that support the nurse manager's suspicion that substance use may be involved. The nurse manager can then refer the nurse to an employee assistance program

A nurse is teaching the parents of a 3-year-old child who has persistent otitis media about prevention. What should be taught?

Don't smoke around the child b/c tobacco smoke can cause inflammation of the respiratory tract

Where is the best place to initiate IV therapy on an elderly client?

Dorsal surface of nondominant hand. These veins are relatively large and easy to puncture compared to other veins in the arm

What is lanugo?

Downy, unpigmented hair that covers the body of some newborns. It is the first type of hair that grows from hair follicles. It can be found everywhere on a baby's body, except on the palms, lips, and soles of the feet. Most fetuses develop lanugo around the fourth or fifth month of pregnancy

A nurse is teaching a client with gout who is starting allopurinol. What should be included in the teaching?

Drink 2-3 liters of fluid/day to prevent kidney injury, an adverse effect of this med.

What should fluid intake look like with allopurinol?

Drink 2L of fluids/day b/c adverse effect of allupurinol is renal damage

What type of precautions are necessary for mumps?

Droplet precautions

What type of precautions are necessary for scarlet fever?

Droplet precautions

What type of precautions are used for meningococcal pneumonia? and what PPE?

Droplet. Standard mask

What type of precautions are used for pharyngeal diphtheria? and what PPE?

Droplet. Standard mask

What is a miotic medication?

Drug causing miosis (constriction of pupil). It reduces eye pressure by increasing drainage of intraocular fluid through trabecular meshwork. Used for glaucoma

What is Palivizumab (Synagis)?

Drug for severe RSV infections. Only for most at-risk children

What is Acamprosate (Campral)?

Drug used to help clients with alcohol withdrawal (restores disrupted neural pathways to address anxiety, restlessness, and insomnia)

What are mydriatic medications?

Drugs that dilate the pupil. Can help reduce inflammation and discomfort in eye after surgery or injury

What are antilipemic drugs?

Drugs that reduce lipids. Lipemia is an excess of lipid (fat) in the blood

What are the classic anticholinergic side effects?

Dry mouth, blurred vision, urinary retention, constipation, photophobia, and tachycardia

What is a manifestation of pertussis?

Dry, hacking cough that is sometimes more severe at night

What are rhonchi?

Dry, low-pitched, snore-like noises produced in the throat or bronchial tube d/t a partial obstruction such as by secretions

What is a finding indicating that a client is experiencing fluid overload?

Dyspnea b/c fluid overload can lead to the backup of fluid in the pulmonary system resulting in SOB

What is an early manifestation of a fat embolism?

Dyspnea. Fat embolisms originate in the yellow bone marrow and travel through the vascular system, clogging small vessels -Tachypnea is another early sign

A client who is 34 weeks of gestation is reporting abd tenderness. What are you concerned about?

Early clinical finding associated with abruption placenta

What natural supplement/homeopathic remedy is used for colds and upper respiratory symptoms?

Echinacea

What does a depolarization mean on an ECG?

Electrical change in a cell membrane from negative to positive when sodium and calcium move into the cell stimulating an action potential, stimulating a contraction

What adverse effect should be monitored for acetazolamide?

Electrolyte imbalance. It promotes renal excretion of Na and K and reduce bicarbonate formation, increasing client's risk of electrolyte and acid-base imbalances.

What happens to bicarbonate levels in a client with COPD?

Elevate (above reference range of 22-26 mEq/L) to compensate for increased CO2 levels

A client admitted with an acute exacerbation of asthma has been prescribed methylprednisolone sodium succinate IV. What finding should the nurse report to the provider immediately?

Elevated temp. Infection is a potential adverse of glucocorticoids. The nurse should monitor this client for signs of infection such as fever and sore throat and report immediately if they occur.

When can a nurse put a client in restraints without a provider's order?

Emergency situation in which client is at risk for harm to self or others. Nurse must then get a provider's prescription ASAP.

How is SOB prioritized in the ED?

Emergent triage category. Implies a condition exists that poses an immediate threat to life or limb

When should rifampin be taken in relation to meals?

Empty stomach 1 hr before or 2 hrs after meals

What instructions should the nurse give after administering phenytoin?

Encourage client to brush teeth after each meal. Med can cause gingival hyperplasia. Risk can be reduced with good oral hygiene

A nurse is caring for a client who is experiencing a manic episode. What should the nurse do first?

Encourage client to rest each hour. Greatest risk to client is injury from exhaustion d/t manic phase; thus, encourage client to rest 3-5 min. every hour

How should the nurse handle discussion of a PTSD client's trauma?

Encourage client to talk about trauma at their own pace. Acknowledging and validating client's feelings can decrease anxiety. Talking about trauma in nonthreatening environment is first step in progressing toward resolution

A nurse is teaching about SUDs during pregnancy. What should be taught regarding methadone?

Encourage clients who are prescribed methadone to breastfeed because it can help newborns with withdrawal symptoms

What nutritional recommendation should nurse give to parents of school-age child who is immobilized after spinal surgery?

Encourage small, frequent meals high in protein. Immobilization decreases appetite. Small, frequent meals will be more readily tolerated. Adequate protein is needed for energy and tissue healing.

The nurse is providing care for a client who was admitted with an exacerbation of chronic obstructive pulmonary disease (COPD). On assessment the nurse finds the client to be pale, short of breath, and their lung sounds reveal rhonchi. What is the best initial action by the nurse?

Encourage the client to take several deep breaths and perform diaphragmatic coughing. The deep breaths will loosen secretions and coughing deeply will allow these secretions to be expectorated

A nurse is caring for a client who is experiencing panic level anxiety. What action should the nurse take first?

Engage the client in physical activity. Least restrictive, least invasive options first. Gross motor activities can reduce tension and lower anxiety levels.

What is creatinine kinase?

Enzyme present in muscle cells that leaks into blood when there is muscle damage

What causes mononucleosis?

Epstein-Barr virus (EBV)

When is herpes simplex most transmissible?

Equally transmissible in active and latent stages

What does a pink, nonpuritic macular rash on trunk and inner surfaces of extremities that appears and disappears rapidly indicate?

Erythema marginatum

What is scarlet fever?

Erythrogenic toxin-mediated disease that develops in association with infections of certain strains of S. pyogenes and is characterized by a coarse, erythematous, blanching rash; a strawberry tongue; petechial lesions in skin creases (Pastia sign); and desquamation of the skin AKA Scarletina

A nurse is admitting a client diagnosed with schizophrenia. In order to establish a therapeutic nurse-client relationship with the client, the nurse's initial actions should include what?

Establish trust. Creating an atmosphere in which trust can grow is a priority.

How often should a nurse document the behavior of a client in restraints?

Every 15 minutes

How often should the nurse check the clients physical, comfort and safety needs after putting client in seclusion?

Every 15 minutes to prevent risk of injury to client and provide legal record of care

How often should a newborn be bathed?

Every 2-3 days to avoid disrupting newborn's skin integrity. but, cleanse face and diaper area daily

How often should blood pressure be monitored after epidural placement?

Every 5-10 minutes to monitor for hypotension, a common adverse effect

Bag holding formula and other feeding equipment for intermittent enteral feedings should be discarded how often?

Every 6 hours to prevent bacterial contamination

How often should males and females have a fecal occult test done?

Every year

What does elevated serum amylase indicate?

Excess pancreas enzyme: amylase. Acute pancreatitis or other pancreas disorder

What s hyperemesis gravidarum?

Excessive N/V (related to elevated hCG levels) that is prolonged past 12 wks gestation and results in: - 5% weight loss from prepregnancy weight -Electrolyte imbalance -Acetonuria -Ketosis -Dehydration (hypotension and increased pulse)

What does rust-stained urine indicate in a newborn 48 hours after birth?

Expected finding occurring d/t presence of uric acid crystals in urine

What is moon facies?

Extra fat that builds up on the side of the face *Occurs with excess cortisol, glucocorticoid therapy, and cushing's syndrome

A nurse is caring for a client who has schizophrenia and is taking haloperidol. What adverse effect should the nurse monitor for?

Extrapyramidal symptoms include movement disorders

Ptosis

Eyelid drooping. Upper eyelid is lower than it should be in infants and children (can occur in one or both eyes)

What are S/S that a hallucination is taking place?

Eyes darting to one side, muttering, or watching vacant area of room

A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider?

FHR 120 bpm with late decelerations, contractions every 1-2 min -Late decels are signs of placental insufficiency which can cause fetal hypoxemia. The nurse should notify physician immediately

Children ages 2 mo to 7 years should use what pain scale?

FLACC. -Face (F) -Legs (L) -Activity (A) -Cry (C) -Consolability (C)

What is the antidote for severe digoxin toxicity?

Fab antibody fragments (AKA digoxin immune Fab). It binds to digoxin and blocks its action. Given IV

What drug class ends with -aban (e.g. Apixaban)?

Factor Xa inhibitors. A class of anticoagulants

True or false. used car seats should be inspected by health department

False, it is recommended to use a second-hand car seat

Why shouldn't you use a fan for a sepsis client with a fever?

Fans can disperse airborne or droplet transmitted pathogens

What is aluminum hydroxide gel?

Fast-acting antacid that binds to phosphate in food and stop phosphate absorption. Take it one hour after a meal to neutralize stomach acids. Contains sodium so check if the patient is on a sodium restricted diet

What is murophobia?

Fear of mice

What are the most common complications of blood transfusions?

Febrile nonhemolytic and chill-rigor reactions

What does colored amniotic fluid indicate?

Fetal distress -meconium stain -blood

What is an indication of early septic shock?

Fever (100.4F+) and chills -tachycardia

What supplement decreases the risk and severity of symptoms of migraines?

Feverfew *It also increases risk of bleeding by decreasing platelet aggregation

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. What nutrient should the nurse tell the client to decrease in diet?

Fiber. To help reduce diarrhea and inflammation

What is the point of maximal impulse for heartbeats?

Fifth intercostal space at the midclavicular line left of the sternum

TPN must be administered with what?

Filter tubing to reduce the risk of particle chunks from entering the bloodstream (two parts: lipid emulsion and amino acid/dextrose solution)

When are APGAR scores completed?

First few minutes after birth

What is chlorpromazine (Thorazine)?

First gen antipsychotic used for positive symptoms of schizophrenia.

What is compensatory shock?

First stage of shock. Decreased MAP, decreased BP, decreased cardiac output, but nothing is in the emergency zone, yet. Sympathetic nervous system compensates for decreases SO TACHYCARDIA. *hypoactive bowel sounds because blood shunts to vital organs

Calcium-containing antacids can cause what adverse effect

Flatulence

What are the manifestations of a detached retina?

Floating dark spots d/t bulges, folds, or holes in the affected retina

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. What restriction is necessary?

Fluid restriction, reduced to 24 hour output plus 500ml

What is the initial treatment for intussusception?

Fluid resuscitation and decompression of GI tract with an NG tube. Unless perforation or peritonitis, physician will then try an enema to nonoperatively reduct it

What should be done if a client on lithium for bipolar disorder exercises, develops diarrhea, vomits, or has any circumstance causing dehydration?

Fluids and electrolytes must be replaced promptly to maintain therapeutic lithium levels

What is the antidote for benzodiazepines?

Flumazenil (Romazicon)

What is ciprofloxacin?

Fluoroquinolone antibiotic. Can cause tendon rupture. **Fluoroquinolones cause phototoxicity

A nurse is preparing to administer phenytoin IV to a client with a seizure disorder. What action should the nurse take?

Flush the injection site with a saline solution after the injection of phenytoin to reduce and prevent venous irritation

What normal S/S will occur in a client who receives a bolus of magnesium sulfate?

Flushed, hot, and sedated

What is the purpose of leucovorin?

Folic acid derivative that is used to protect healthy cells from the cytoxic affects of methotrexate

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. What type of foods should client avoid?

Foods high in fiber. This irritates the bowels. Want low fiber but high nutrients.

What types of foods irritate the digestive tract of clients with Crohn's disease?

Foods that don't digest completely, leaving fiber and residue. These include raw vegetables, dried fruits, wild rice, rice/cereal/pasta made with whole wheat/bran/oats/flax/buckwheat

When is internal fetal monitoring used?

For high-risk clients o consistently assess fetal HR (in response to contractions) during labor *Can only be used after membranes have ruptured

How is the peak expiratory flow meter (PEFM) used?

Forcefully exhale for 1 second as quickly as possible to measure amount of air exhaled

What is distributive shock?

Form of hypovolemic shock in which fluid moves from vascular spaces to interstitial spaces (massive vasodilation of vascular bed causing maldistribution of blood)

A nurse manager is changing the ration of RNs to LPNs on a unit to decrease costs. What strategy should the nurse manager implement to reduce resistance from staff?

Formulate staffing schedule covering one month. The nurse manager should include the staff in the process by formulating a sample staffing schedule covering 1 month so that the staff can view the schedule and provide feedback. Resistance to change is an integral part of the process of change. A common reaction to scheduling changes is a fear of loss of hours and lack of trust of the employer

What are the S/S of left-sided HF?

Frothy sputum, dyspnea, and wheezing

What is the sublimation defense mechanism?

Funneling of an unacceptable impulse into a socially acceptable activity. ex: person who loves cutting and blood, becomes a surgeon instead of a murderer.

What prescription should a nurse question in a client with bipolar disorder and a lithium carbonate prescription?

Furosemide. Lithium ingestion predisposes the client to sodium loss which increases the risk of rapidly elevating the level of lithium. Diuretics would exacerbate sodium loss and predispose the client to lithium toxicity.

How and why should a client examine the bulbar conjuctivae?

Gently retracting lower and upper eyelids to evaluate color, texture, and assess for infection. To assess for infection

What supplement treats nausea caused by vertigo?

Ginger root

What natural supplement/homeopathic remedy is used to improve memory?

Gingko biloba

What is betamethasone (Celestone)?

Glucocorticoid used in prevention of respiratory distress syndrome in premature infants.

What supplement treats joint pain by reducing inflammation and promotes the body's ability to make cartilage and synovial fluid?

Glucosamine

What happens to glucose levels with bacterial meningitis?

Glucose level decreases

How does chronic kidney disease affect BUN?

Gradual increase. (normal is 10-20). Can be as high as 180-200 mg/dL

How does chronic kidney disease affect serum creatinine?

Gradually increases to exceed 4 mg/ml. May be as high as 15 to 30 mg/dL

How is a dependent personality disorder characterized?

Great need to be taken care of (leads to fear of separation, difficulty making decisions, avoidance of taking responsibility in life)

What does a green triage tag mean?

Green tags identify a client who has minor injuries that can wait for treatment, such as sprains, strains, closed fractures, and abrasions.

What is disenfranchised grief?

Grief or mourning that persons experience when they incur a loss that is not or cannot be openly acknowledged, publicly mourned, or socially supported. Situations in which this occur often relate to a socially unacceptable loss that cannot be spoken about, such as suicide, abortion, or giving a child up for adoption.

What is ranitidine (zantac)?

H2 blocker (gastritis/ulcers) used to prevent a stress ulcer

What are two adverse effects for ondansetron?

HA and urinary retention

What is a common adverse effect of epoetin alfa?

HTN and can lead to hypertensive encephalopathy

Where should the fundus be 6 days postpartum?

Halfway between symphysis pubis and umbilicus

Pramipexole has what adverse effect?

Hallucinations. It is used for parkinson's to stimulate brain's DA receptors to decrease tremors and rigidity associated with disease

What is a positive Trousseau's sign?

Hand/finger spasms with sustained BP cuff inflation. Indicates hypocalcemia.

Into which fo the following positions should the nurse assist a client to facilitate progress in labor when the fetus is in the occiput posterior position?

Hands and knees (should facilitate rotation of fetus from posterior to anterior position)

The nurse is conducting a physical examination of a 2-month-old with suspected pyloric stenosis. Which finding indicates pyloric stenosis?

Hard, moveable "olive-like mass" in the upper right quadrant

What is the most common cause of hypothyroidism?

Hashimoto's thyroiditis (others: iodine deficiency (in table salt in America but other countries struggle), pituitary tumor, Tx for hyperthyroidism (from radioactive iodine or antithyroid meds)

An involuntary commitment to a mental health facility does not affect a client's right to what?

Have visits from family

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. What question should the nurse ask to assess for true labor versus false labor?

Have you noticed any bloody show or fluid coming from your vagina? *False labor is characterized by painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes

Proton pump inhibitors can cause what adverse effect?

Headaches

What is the last sense to fail as death nears?

Hearing

Using hand-gestures and symbols to reinforce key points is not appropriate for what type of client?

Hearing-impaired (may confuse client)

Nursing intervention for a client scheduled for a thoracentesis?

Help client lean forward over the bedside table. This allows provider complete access to client's chest and back. It also expands spaces between ribs where pleural fluid accumulates

How does chronic kidney disease affect a urinalysis?

Hematuria and proteinuria present

What does low back pain, hypotension, tachycardia, and apprehension indicate?

Hemolytic transfusion reaction from infusion of incompatible blood products

What is a cephalohematoma?

Hemorrhage between skull and periosteum that can occur at any age. Its impact is limited by individual bones.

Hypersensitivity to yeast is a contraindication for what vaccine?

Hep B vaccine

Which type of hepatitis does not have a vaccine?

Hep C

What is uncal herniation?

Herniation of the uncus (anterior and most medial portion of the parahippocampal gyrus of the temporal lobe). As the uncus herniates, it first presses against the midbrain, resulting in an ipsilateral third nerve palsy. As the parasympathetic fibers are on the outside of the third nerve, the first sign of uncal herniation is usually pupillary dilation. Further compression results in paralysis of extraocular muscles. Life-threatening neurological emergency (indicates the failure of all adaptive mechanisms for intracranial compliance)

A nurse is assessing a client for a substance use disorder. Client exhibits yawning, pupillary dilation, rhinorrhea, and reports muscle cramps. The nurse should suspect that the client is withdrawing from what substance?

Heroin. Manifestations start 6-8 hours after withdrawal of at least 1 week of use

A nurse is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. What instruction should be given?

Hold pressure for 1-2 min on the lacrimal sac following drop administration. The action prevents excessive systemic absorption of the meds

A nurse is teaching for a client who is to begin taking tamoxifen to treat breast cancer. The nurse should instruct the client to expect what adverse effect?

Hot flashes b/c it is an antiestrogen med that blocks estrogen receptors

What injury is concerning for child abuse?

Humerus fracture, retinal hemorrhages

If a client with pneumonia is placed on oxygen, what would be the preferred choice of mask?

Humidified oxygen via face mask to help thin the secretions

What type of dressing promotes healing in stage 2 pressure injuries?

Hydrocolloid dressings by creating a moist wound bed

What type of K+ imbalance causes restlessness, irritability, weakness?

Hyper or Hypokalemia

A nurse is caring for a client with new onset bowel obstruction. What assessment finding would be anticipated when completing an abd assessment?

Hyperactive bowel sounds (typical in early stages of obstruction). Progresses to hypoactive in later stages

Constipation is a S/S of hypo or hypercalcemia?

Hypercalcemia

In what type of calcium imbalance do clients experience bone pain?

Hypercalcemia

In what type of calcium imbalance do clients experience constipation?

Hypercalcemia

What does immobilization increase risk for in children?

Hypercalcemia, leading to renal stones, muscle fatigue, and diminished reflexes

Children who have tetralogy of Fallot have what type of episodes that necessitate what nursing action?

Hypercyanotic episodes. Knee-to-chest position increases systemic vascular resistance in the lower extremities, increasing CO

What is an adverse effect of Olanzapine?

Hyperglycemia

Betamethasone (Celestone) causes what in the mother and what in the neonate?

Hyperglycemia in mom, predisposing neonate to hypoglycemia

Numbness of the extremities is a manifestation of what type of electrolyte imbalance?

Hyperkalemia

When do you administer IV fluids with dextrose and regular insulin in relation to K+ imbalance?

Hyperkalemia

When do you monitor for oliguria in relation to K+ imbalance?

Hyperkalemia (aldosterone promotes fluid retention and K+ excretion)

What is one cause of facial flushing?

Hypermagnesemia (>2.2 mg/dL)

What is one cause of soft tissue calcifications?

Hypermagnesemia (>2.2 mg/dL)

When should loop diuretics be administered in relation to magnesium levels?

Hypermagnesemia (most of the filtered magnesium gets passively reabsorbed in the ascending limb of the loop of Henle) -decrease in volume and osmolarity in loop of henle

What is clonidine (Catapres) used for?

Hypertension, ADHD (and opioid withdrawal)

What type of thyroidism are tremors a manifestation of?

Hyperthyroidism

A client with what electrolyte imbalance will display tetany?

Hypocalcemia

Hypo or hypercalcemia causes increased neuromuscular irritability which can progress to seizure activity?

Hypocalcemia

In what type of calcium imbalance should clients be encouraged to eat green leafy vegetables?

Hypocalcemia

During a visit to the home of a breast-feeding mother, a client reports to the nurse that she's been having leg cramps. The infant is 6 wks old and thriving on breast milk. The nurse suspects:

Hypocalcemia and tells her to increase her milk intake. After delivery, maternal calcium demand remains high d/t breastfeeding (esp. since most calcium demand for fetus is during third trimester and taken directly from mother)

A client who is postop following a thyroidectomy and reports tingling around mouth. What does this indicate?

Hypocalcemia which can lead to tetany and respiratory distress. Nurse should assess client for muscle twitching and respiratory distress and be prepared to administer IV calcium gluconate or calcium chloride

Hypo or hypercalcemia causes neuromuscular irritability and repetitive muscle spasms?

Hypocalcemia. This is a positive trousseau's sign (hand/finer spasms with sustained blood pressure cuff inflation).

What does a high pitched cry and jitteriness indicate in a neonate?

Hypoglycemia or opioid withdrawal

When do you monitor for shallow ineffective respirations in relation to K+ imbalance?

Hypokalemia

Shallow respirations occur with what electrolyte imbalance?

Hypokalemia d/t respiratory muscle weakness

A positive Chvostek's sign is a manifestation of what type of electrolyte imbalance?

Hypomagnesemia and hypocalcemia

A nurse is caring for a client in the resuscitation phase of burn injury. What finding should the nurse expect?

Hyponatremia. b/c sodium is drawn to edematous burn area and lost through plasma leakage

What is an assessment finding associated with fetal abstinence syndrome?

Hypothermia. Condition causes thermal regulation issues

What might an O2 saturation of 90% on 2L of O2 per nasal cannula indicate in the post-op period?

Hypoxemia can be caused by life-threatening conditions like atelectasis, pulmonary edema, or pulmonary embolism

What route is epinephrine given for anaphylaxis?

IM injection into anterolateral aspect of thigh

How do you treat oculogyric crisis?

IV benztropine

A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness burns over 60% of his body 24 hours ago. What route should the nurse administer the med?

IV for rapid absorption and absorption impaired in muscle and stomach in burned tissue (not oral because decreased motility while recovering from burn injury)

How is heparin administered?

IV or SUBQ

What does a yellow triage tag mean?

Identifies clients who have serious injuries that require intervention within 2 hr, such as open fractures and major wounds

A nurse works in a long-term care facility, where the residents wear street clothes and are not required to wear a hospital identification bracelet. What is an acceptable way for the nurses to identify the residents in order to administer meds?

Identify residents from their labelled photo on their med record. Visual recognition and a recent photo is an acceptable identifierfb

When should factor IX be administered to a client?

If they have hemophilia B

What is urography?

Imaging of the renal drainage or collecting system (kidneys, ureter, and bladder)

What are mummy restraints used for?

Immobilize very young children to keep them safe during procedures. It is likely to increase fear in toddlers and preschoolers

What is Mycophenolate mofetil (CellCept)?

Immunosuppressive agent used to prevent organ tissue rejection after transplant

What material is used for deep granulation of a pressure ulcer?

Impregnated gauze and alginate to promote packing of the tissue

What is word salad?

Incoherent jumble/mixture of words meaningless to listener -positive symptom schizophrenia

How do corticosteroids affect WBCs?

Increase WBC count (specifically neutrophils) because it stimulates RELEASE of WBCs from bone marrow

What is sodium polystyrene used for?

Increase elimination of life-threatening serum potassium

A nurse is providing discharge instructions to a client following an upper GI series with barium contrast. What teaching should the nurse provide?

Increase fluid intake to facilitate removal of barium used during the test

How should fluid intake change after a lumbar puncture?

Increase fluids to replace cerebrospinal fluid removed during the procedure

A nurse is caring for a client who has amyotrophic lateral sclerosis (AlS) and is being admitted to the hospital with pneumonia. What assessment finding is the nurse's priority?

Increased respiratory secretions b/c put client at risk for aspiration pneumonia d/t respiratory muscle weakness caused by ALS

What is a complication of an IUD?

Increased risk for an ectopic pregnancy S/S: abrupt, sharp unilateral lower quadrant pain that can occur with or without bleeding

Why does Mirtazapine have a black box warning?

Increased suicidality when used for treatment of children, adolescents, and young adults

Why shouldn't you give too much supplemental O2 to COPD clients?

Increases blood O2 level significantly, causing apnea because peripheral chemoreceptors won't stimulate breathing *Only give supplemental O2 at very low levels

How does grapefruit juice affect clonazepam?

Increases blood concentration of clonazepam, causing toxicity.

How does calcium affect contractility of the heart?

Increases contractility

How does a decrease in sodium levels affect lithium levels?

Increases lithium levels *Indirectly related

Why shouldn't you place a soft rug in front of the chair of a dementia client?

Increases risk of tripping and falling

how does Duloxetine (Cymbalta) work?

Increases serotonin levels by inhibiting serotonin reuptake; it does not directly increase them

What are the indications for an amniotomy?

Inducing or expediting labor or in anticipation of the placement of internal monitors (uterine pressure catheters or fetal scalp electrodes)

What does the presence of an odor in amniotic fluid indicate?

Infection

What does the erythrocyte sedimentation rate (ESR) measure?

Inflammation

What is C-reactive protein?

Inflammatory protein produced by liver during periods of acute inflammation. So it is a predictor of heart disease

What is Trousseau's sign?

Inflating a BP above systolic pressure that elicits wrist and hand flexion (carpal spasm), indicating hypocalcemia because of nerve excitability

An allergy to eggs is contraindicated with what vaccine?

Influenza immunization

A history of guillain-barre's syndrome is contraindicated with what vaccine?

Influenze vaccine

A nurse is performing an admission assessment for a client who appears withdrawn and fearful. What should the nurse do first?

Inform the client that this admission is confidential. Confidentiality is priority during orientation phase of nurse-client relationship. It establishes trust between nurse and client, decreasing client's anxiety level

A 15 y/o presents to ED with grandparent and needs open reduction and internal fixation of several fractures. How should nurse go about acquiring consent?

Inform the provider that the grandparent is the closest adult relative available for signing informed consent. Closest adult relative can provide consent in an emergency situation when client's parents or guardians are unavailable

What is the granulation phase of the healing process (of pressure ulcers)?

Initial repair of new tissues are formed to facilitate remodeling of the affected area

What is an appropriate intervention for a client with a conduct disorder?

Initiate a behavioral contract with the client. It helps develop trust and emphasizes client's responsibility to commit to work on changes in behavior

A nurse is caring for a client who has a Mg level of 2.7 mEq/L. What intervention should the nurse do?

Initiate continuous cardiac monitoring b/c client is hypermagnesemic and at risk for cardiac dysrhythmias

A nurse is assessing a client who is 6 hrs postpartum, tachycardic and has cool skin. The client reports bleeding excessively. What should the nurse do?

Initiate oxytocin infusion. Client is exhibiting signs of hypovolemic shock caused by uterine atony (this is a medical emergency). Initiate 10-20 units of oxytocin that will cause uterus to contract and decrease bleeding

What is akathisia?

Inner restlessness characterized by pacing or constant movement of legs. It is an adverse effect of antipsychotic meds

A nurse is caring for a client of the Buddhist faith who has just given birth to a stillborn infant. Which of the following interventions is most appropriate?

Inquire about any rituals the parents would like to perform at this time -Childbirth often has cultural or religious rituals. Nurse is not expected to know what the culture would prefer so asking about their preferences is best

A nurse is caring for a client who has an upper airway obstruction and an emergency needle cricothyrotomy must be performed. After penetration of the cricothyroid membrane and confirmation of the position of the incision (pulling back the syringe and watching air enter signifies entrance to trachea), what is the next step?

Insert the needle catheter at a 45 degree angle downward toward the trachea while retracting the needle. Then you'll connect IV extension tubing and attach it to O2

A nurse is preparing a client for a paracentesis. What action should the nurse take?

Instruct the client to void prior to the procedure b/c an empty bladder decreases risk of bladder puncture and minimizes client discomfort

What should the nurse monitor when a newborn is on phototherapy to reduce bilirubin?

Intake and output. Phototherapy increases rate of insensible water loss, contributing to fluid loss and dehydration

When mixing insulins, which type would be drawn into the syringe first?

Intermediate. Then rapid-acting. That way your insulin doesn't dip quickly and suddenly. Better to have it be delayed and gradually lower (if they even mixed in the vials)

What do decreased urinary output and bladder spasms indicate during continuous bladder irrigation?

Internal obstructions of the catheter. So, irrigate with 0.9% sodium chloride

What is gavage?

Introduction of nourishment into stomach by an NG or G-tube for an infant

Clients with RA should increase their dietary intake of what?

Iron (to promote tissue repair) *Also protein and vitamins (for the same reason)

Client should ingest adequate intake of what when on epoetin alpha?

Iron, folic acid, and Vit B12

Adverse effects of levothyroxine?

Irritability, tremors, tachycardia, palpitations, heat intolerance, and/or rapid weight loss

Toddler with hypoglycemia will exhibit what?

Irritable, labile mood

What religion prefers healthcare professionals of the same gender touch a dead body?

Islam

What religion prefers that the body be kept covered at all times when death occurs?

Islam

How does a DNR affect CPR, intubation and meds?

It bans CPR; however, intubation and meds are still acceptable unless specifically banned

How does a high-fat meal affect absorption of sildenafil?

It delays the absorption

Why is alcohol sanitizer insufficient for cleaning C. diff?

It doesn't kill C diff spores

How does the rubella vaccination affect a mother's ability to breastfeed?

It doesn't. Clients receiving rubella immunization can continue to breastfeed

Why can't you give oxytocin for long periods of time?

It has an ADH effect that can result in water intoxication if given with large amounts of (low sodium) fluid

What is placenta previa?

It is a condition in which the placenta develops over and covers the cervix from Abnormal placental implantation - total: covers cervical os - marginal: placenta extends to margin of the os - low-lying: placenta is in close proximity to os

Why shouldn't K+ be given IM or SQ?

It is a tissue irritant

Cimetidine (Tagamet) can cause what adverse effect?

It is an H2 receptor antagonist that can cause dysrthythmias

What is levofloxacin used for?

It is considered the "work horse" of the Fluorquinolones- broad spectrum anti-infective for the following infections: UTI's, CAP, sinusitis, travelers diarrhea and STI's

What is the role of iodine in relation to the thyroid gland?

It is necessary for the thyroid hormones T3 and T4 Must come from food When there's not enough, the thyroid works extra hard to make thyroid hormone, causing the gland to grow large (causing a goiter)

How does an ECT affect BP?

It may initially fall and then rise during the procedure (elevated BP should resolve shortly after termination of treatment)

What are some nursing responsibilities when giving spironolactone?

It's a potassium sparing diuretic, so you 1) do not want to give potassium supplements with it 2) Monitor potassium level 3) Teach to avoid salt substitutes that contain potassium

A nurse is caring for a client who is taking valproic acid for seizure control. For what adverse effect should the nurse monitor and report?

Jaundice b/c med places client at risk for liver damage

An NG tube can put you at risk for what electrolyte deficiency?

K+ because it exists in large amounts in the GI fluids and is lost when gastric fluids are lost

What is the purpose of a footboard?

Keep feet in dorsiflexion to prevent contractures if client has foot drop=difficulty lifting the front part of the foot from an underlying neurological, muscular or anatomical problem. If you have foot drop, the front of your foot might drag on the ground when you walk.

A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate?

Keep the affected extremity below the level of the heart (to facilitate arterial blood flow)

Nurse should teach what to a client with a cephalexin oral suspension?

Keep the medication refrigerated. Oral cephalosporin suspensions need to be refrigerated to maintain full strength

What is clonazepam?

Klonopin, a benzodiazepine used for relief of anxiety, convulsion, and muscle spasticity (cause sedation)

Pregnant women should not receive what types of immunizations?

LIVE attenuated (weak) viruses. So do not take live viruses like MMR, varicella, or influenza by nasal spray (influenza by shot is okay)

What is lactulose used for?

Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia from cirrhosis. These excessive stools can result in hypokalemia and dehydration.

What part of the GI tract does ulcerative colitis (UC) affect?

Large intestine and rectum -mucosal lesions

What type of nipple should be used for an infant with GERD?

Larger hole to help infant suck more easily

A nurse is preparing to performa non-stress test. Which position would the nurse recommend that the client be placed in?

Lateral position to avoid vena cava compression.

Where would a nurse expect abd pain for an exacerbation of diverticular disease?

Left lower quadrant. Diverticular commonly develop in the sigmoid colon b/c of high pressure it takes to move stool into rectum

What is Sims' position?

Left side-lying position. It is performed by having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. Laying forward on a pillow tuck arm under her pull arm out on the other side put pillow under arm pillow between legs

S3 gallop is expect in what condition?

Left-sided HF d/t pulmonary congestion and increased left ventricular pressure that causes a decrease in CO and poor tissue perfusion

What are transmural lesions?

Lesions that go all the way through a wall to the inner tissue -trans: across -mural: on or relation to a wall

Toddler with hyperglycemia will exhibit what?

Lethargy

What should the nurse expect to asses in an infant after delivery whose mother had high levels of magnesium sulfate?

Lethargy and respiratory depression. -Mag sulfate blocks neuromuscular transmission and is a CNS depressant and thus will have the same signs as the mother

What meds are given for hypothyroidism?

Levothyroxine (Synthroid)-most common -Liothyrenine sodium (Cytomel) -Liotrix (Thyrolar)

A nurse is caring for a client who had a stroke 6 hr ago. What intervention can be implemented to reduce risk of increased ICP?

Limit airway suctioning to 15 seconds at a time to reduce the risk of hypoxia and increased ICP

A nurse is planning care for a client who has anorexia and nausea d/t cancer treatment. What intervention should the nurse perform?

Limit drinking fluids with food. Drinking leads to early satiety and bloating which results in the client consuming fewer calories

What instruction should be given to a client on lithium for bipolar disorder to maintain therapeutic lithium level?

Limit outdoor exercise during hot weather. It promotes dehydration and sodium loss through diuresis, which can increase sodium levels

What limitations should be placed on people visiting a client being treated with brachytherapy?

Limited to one 30 minute visit per day

What are astringents?

Liquid-based formulas that contain alcohol that help cleanse skin, tighten pores and dry out oil. Astringent pads used to relieve itching, burning, and irritation caused by hemorrhoids

What drugs should be discontinued before an ECT and how long beforehead?

Lithium and MAOIs. 2 weeks before procedure

What does increased thirst indicate when taking lithium?

Lithium toxicity

How does liver interact with prothrombin time?

Liver cells produce prothrombin. Liver disease will prolong prothrombin time because it cannot create this clotting factor

How does the liver interact with ammonia?

Liver converts ammonia to urea. Liver disease will cause ammonia levels to rise b/c liver is not adequately doing its job

What is is an adverse effect of Atomoxetine (Strattera)?

Liver damage. Monitor for jaundice, upper abd tenderness, darkening of urine, and elevated liver enzymes

How does the liver interact with albumin?

Liver manufactures albumin. Liver disease will cause albumin levels to decrease

For the NCLEX: When you get interrupted from charting and have to attend to a patient, what should you do?

Log off the computer before responding. Always

What intervention should be used on a client who had a lumbar laminectomy?

Log rolling with a turning sheet to keep client's back straight and to prevent back spasms

What is Ethcrynic acid (Edecrin)?

Loop diuretic-

What is Bumex (bumetanide)?

Loop diuretic-blocks reabsorption of sodium and water in the tubules of the kidneys. It is usually prescribed for HF to reduce excessive fluid. It is more potent than lasix Common SE: -hypokalemia -postural hypotension -Ototoxicity -Nephrotoxicity -HA -loss of appetite

What will happen to the extremities as death nears?

Lose movement of lower extremities w/ progressive loss of movement up the body

A nurse is assessing an infant who has a ventricular septal defect. What finding should the nurse expect?

Loud, harsh murmur. D/t left-right shunting of blood (also causes hypertrophy of infant's heart muscle)

What is the consequence of disconnecting an endotracheal tube (ETT)?

Low pressure and the sounding of the low pressure alarm

abdominal cramping, weakness, confusion, lethargy, headache, and nausea indicate what type of electrolyte imbalance?

Low sodium

Abdominal cramping is a a manifestation of what type of electrolyte imbalance?

Low sodium levels

A nurse is assessing a client with diabetes insipidus. What finding should the nurse expect?

Low urine specific gravity (between 1.001-1.005). Decreased water reabsorption by the renal tubules is caused by an alteration in ADH release

Why should you cook with skim milk instead of whole milk with acute pancreatits?

Low-fat diet

Clients who have acute cholelithiasis should be prescribed what kind of diet?

Low-fat diet (such as sherbet, gelatin, and angel food cake)

Where is the safest location to assess the carotid artery?

Lower half of the artery at the level of the cricoid cartilage. Palpating it too high on the neck could stimulate carotid sinus, which could cause a HR drop

How does furosemide affect potassium levels?

Lowers them-Hypokalemia

How should a client with dumping syndrome be positioned after eating?

Lying down (NOT SITTING UP). Sitting up speeds the movement of gastric contents into duodenum and may trigger S/S of dumping syndrome (so flat in order to slow it)

In what position should Kegel exercises be performed?

Lying down, sitting up, and standing b/c it trains the muscles to squeeze effectively despite position

What type of drug is phenelzine and what is important to remember about it?

MAOI SHOULD NOT BE TAKEN WITH FOODS HIGH IN TYRAMINE (Salami, avocados, bananas)

What is the initial treatment for a STEMI?

MONA -Morphine -O2 -Nitroglycerin -Aspirin

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. What precaution should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area. An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

What is the most effective nursing time management strategy?

Making a list of activities to complete (other planning activities: setting goals, establishing priorities, and scheduling activities)

What is the treatment for Cushing's Triad?

Mannitol 25%, an osmotic diuretic that promotes diuresis to treat cerebral edema

A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client?

Maternal history of cytomegalovirus. -Cytomegalovirus can be transferred via the placenta directly onto the fetal circulatory system and transmitted directly from infected amniotic fluid

What does muscle pain indicate if a client is on hydrochlorothiazide?

May be an indication of hypokalemia

An allergy to neomycin with an anaphylactic reaction is a contraindication to receiving what vaccine?

Measles, mumps, and rubella (MMR) vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.

Sodium thiosulfate is the antidote for what?

Mechlorethamine or nitrogen mustard

What does bloody stool indicate in children?

Meckel diverticulum

Where on the body should a nurse assess for a venous ulcer in a client with chronic venous insufficiency?

Medial malleolus of ankle (most common area). Skin discoloration, edema, and/or ulcer with irregular borders that weeps exudate; pulse is palpable; moderate level of pain at site

A client has lump on the right breast. What finding increases the risk of developing cancer?

Menopausal obesity. During menopause, increased fat tissue can lead to higher stores of estrogen. Higher estrogen increases risk for postmenopausal breast cancer

Risperidone (Risperdal) causes what adverse effect?

Metabolic syndrome=set of 5 symptoms revolving around unhealthy weight gain: increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels *So eat low-calorie snacks to prevent weight gain

Sharpened perceptions are an expected finding of what type of anxiety?

Mild anxiety. This type helps people grasp more info and problem-solve more effectively. As stress increases, the client's perceptual field narrows and they are able to focus only on source of anxiety

What are standard precautions?

Minimum infection prevention measures that apply to all client care. All body fluids are assumed to be infected with blood-borne pathogens. -Hand hygiene -Use of PPE (gloves, gown, mask) -Respiratory hygiene -Safe injection practices -Safe handling of potentially contaminated equipment or surfaces in client's environment

Voice tremors expected finding of what type of anxiety?

Moderate anxiety. May also experience tremors of extremities as anxiety increases, urniary frequency

An infant losing 6% to 9% is experiencing what type of dehydration?

Moderate dehydration

Tachypnea is evidence of what type of dehydration?

Moderate dehydration

how does Trazodone (Desyrel) work

Moderately blocks serotonin receptors

Most types of extravasation are treated with what?

Moist cold compresses

A client is undergoing cystoscopy. What intervention should the nurse include in the client's plan of care?

Monitor for infection for 48-72 hours following procedure

A nurse is caring for an infant following surgical repair of cleft lip. What should nurse do?

Monitor temporal artery temp. for manifestations of infection. Also watch for redness, warmth, and drainage from incision

What is Phenelzine (Nardil)?

Monoamine Oxidase Inhibitor (MAOI) used to treat recalcitrant depression as well as Parkinson's and several other disorders

A nurse should expect what S/S with opioid withdrawal?

Muscle aches Insomnia Diarrhea Pupillary dilation *occurs within 6-8 hours of the last dose of opioid

A nurse is providing education to the mother of a 10-year-old child about to undergo scoliosis screening. Which statement by mother indicates a need for further teaching?

My child will be asked to stand upright, arms stretched above the head

What is phenylephrine?

Mydriatic medication to dilate pupils to facilitate intraocular surgery

What does an ST segment depression or T wave inversion indicate on an EKG?

Myocardial ischemia (and you should stop a stress test)

Do you need to check deep tendon reflexes before administering opioids?

NO

What is meperidine (Demerol)?

Narcotic used for moderate-severe pain

What are S/S of dumping syndrome?

Nausea, abdominal cramping, and tachycardia, anemia (leads to reduced absorption of iron in duodenum), fatigue

What is an adverse effect of cyclosporine?

Nephrotoxicity (e.g. BUN >20 mg/dL, Cr >1.2)

A sodium level of 129 mEq/L puts client at increased risk for what?

Neurological deficits and seizure activity. So, implement seizure precautions!

What is kernicterus?

Neurological syndrome caused by bilirubin depositing in brain cells and CSF. Bilirubin levels will be >25 mg/dL. Assessment: lethargy, hypotonia, high-pitched cry and backward arching of neck and trunk *Survivors may develop cerebral palsy, epilepsy, or mental retardation. Minor effects include learning disorders or perceptual-motor disabilities

A nurse s caring for a client with dysuria. A urine specimen is sent to the lab for routine urinalysis. What finding is most specific for a urinary tract infection?

Nitrate in the urine. Nitrates are a byproduct of breakdown of Gram- pathogens (such as E. coli) associated with UTIs

Does cream cheese contain tyramine?

No, so you can eat it when on an MAOI

Can graham crackers be given to a celiac client?

No, they contain wheat flour

Should you cluster invasive procedures for young children?

No. It creates an unnecessarily lengthy and painful period for the client, which increases fear

A client with hemophilia sustains abd trauma from an MVA. What movement should be provided to client?

None. rest the joints during acute bleeding to prevent stretching the joint or bleeding to recur

While using supplemental O2, the client should be using what type of materials?

Nonflammable, such as nail polish remover

How long until normal activities can be resumed after an appendectomy and how long until full recovery?

Normal activities: a few days Full recovery: 4-6 wks

What are normal functions of T3 and T4 and what happens during hypothyroidism?

Normal: -Burns calories (hypo-gain weight) -Food digestion (hypo-constipation) -Stimulates sympathetic nervous system (hypo-drowsy, lethargic) -Maintains/increases temp. (hypo-lower temp., feel cold)

A client is taking bacizumab for metastic colorectal cancer. What is an adverse effect and what should be done?

Nosebleeds. Should be reported to provider b/c client has an increased risk when taking this medication for severe bleeding from nosebleeds, vaginal bleeding, GI bleeding, intracranial bleeding and pulmonary bleeding, which may be caused from the development of thrombocytopenia and other blood disorders.

What is an advantage of buspirone?

Not a CNS depressant so it does not cause physical or psychological dependence nor produce tolerance

What does blurred vision indicate during pregnancy?

Not an expected finding. Indicates preeclampsia. -Arterial vasospasms and decreased perfusion to the retina can cause these visual disturbances (+ double vision or dark spots)

The nurse is caring for a client admitted with diverticulitis. The client reports severe abdominal pain and assessment reveals that the client's abdomen is rigid and tender. The client's vital signs are: T: 101.8 F (38C); HR: 120; B/P: 100/50. Urine output was less than 300 ml during the previous eight hours. The client states the pain is "worse than before". What is the priority nursing intervention for this client?

Notify healthcare provider. Client is declining-febrile, tachycardic, and hypotensive and verbalizing worsening abdominal pain. These indicate possible diverticulum rupture, pelvic abscess, or bowel obstruction

One hour ago, a nurse administered morphine sulfate 4 mg IVP to a client who reported pain of 9 on a scale of 10. The client now reports pain of a 7 on a scale of 10. What is the priority intervention?

Notify the provider because the prescribed therapy is not effective

What is the ethical principle of veracity?

Nurse's duty to tell the truth

What is decreased intracranial adaptive capacity?

Nursing diagnosis defined as the state in which intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure in response to a variety of noxious and nonnoxious stimuli

How should you conduct a pain assessment with a dementia client?

Observing the client's facial expressions

A client is admitted to the hospital for suspected infective endocarditis. The client is reporting chills, fatigue, myalgia and dyspnea upon exertion. When assessing the client the nurse notes a heart murmur and a temperature of 102.3 F (38.2 C). Which of the following orders should the nurse implement first? Select one: a. Administer acetaminophen 325 mg by mouth b. Administer IV Penicillin G, 2 million units c. Order the EKG d. Obtain the blood cultures from three sites

Obtain the blood cultures from three sites Obtaining blood cultures is the priority intervention. Cultures must be drawn prior to initiation of antibiotics so sensitivity results are not influenced. Obtaining specimens from three sites increases the reliability of the results. Clients at risk for endocarditis should be treated with prophylactic antibiotics prior to dental procedures; respiratory and GI diagnostic procedures; GU and Cardiac surgeries.

Heartburn is common what stage of pregnancy and why?

Occurs in all trimesters b/c of pregnancy hormone effects on lower esophageal sphincter and gastric clearance AND enlarging uterus pushing up on abd contents

What is cardiogenic shock?

Occurs when the heart is damaged (large portion of left ventricle dies) after an MI and is unable to supply sufficient blood to the body, resulting in hypotension

What is the general lead therapeutic communication technique?

Offering client encouragement to continue conversation

When do blood transfusion reactions occur and what is the nursing implication?

Often within the first 50 mL of the transfusion. So, nurse should remain with client for first 15-30 minutes of transfusion

How often should antiembolitic stockings be removed?

Once per shift to inspect the skin and check circulation

When can bariatric clients consume liquids to prevent dumping syndrome?

One hour before or after meals

When are live virus vaccines contraindicated in relation to pregnancy?

One month before and during pregnancy

What are purpura?

One of the three types of bleeding into the skin (others: ecchymosis-bruising, petechiae-small red or purple spots on skin cause by minor bleeding from purple capillaries)... That are nonblanching spots ranging from 3mm to 1cm

How are aldosterone antagonists administered?

Only orally (epleronone may take up to 4 weeks to be therapeutic)

When should endotracheal suctioning be performed?

Only when necessary to clear secretions and maintain a patent airway in a client who is unable to clear secretions or is in respiratory distress. Why? Can damage airway mucosa (leading to pulmonary hemorrhage), introduce airway infection, bronchospasm, bradycardia from vagal stimulation, pulmonary vasoconstriction

What is naloxone and how long does it take to kick in?

Opioid receptor antagonist (the reversal agent) *20-40 minutes and lasts 90 min

Dilated pupils are a manifestation of what type of withdrawal?

Opioid withdrawal

Vomiting is a manifestation of what type of withdrawal?

Opioid withdrawal

How do oral contraceptives and warfarin interact?

Oral contraceptives will decrease anticoagulant effects

A nurse is caring for an infant who is post-op following a surgical procedure to correct intussusception. What is the most appropriate way to re-introduce feedings after procedure?

Oral electrolyte solution. Clear liquids should be offered first post-op and then concentration should be increased as tolerable

At what point in the nurse-client relationship should the nurse clarify responsibilities of the nurse and client?

Orientation phase-establish rapport with client and lay framework for rest of nurse-client relationship

Client has Cushing's syndrome. What assessment finding should the nurse expect?

Osteoporosis. bones thin because of mineral loss and nitrogen depletion, and fracture risk increases

What is serotonin syndrome?

Overactivation of central serotonin receptors that causes mental status changes such as delirium, irrational thinking, and hallucinations; tachycardia, labile BP, CV shock, apnea, agitation

What indicates effective therapy for moderate asthma with salmeterol?

PEF in the green zone (80%+ personal best) Peak flow meter should be used twice daily to monitor asthma control?

What is Homan's sign?

Pain in the calf with forceful and abrupt dorsiflexion of client's foot at ankle with straight leg indicating DVT

What is murphy's sign?

Pain with deep inspiration when the gallbladder is palpated. Indicates acute cholecystitis

What is an expected finding of placenta previa?

Painless vaginal bleeding

What are the findings in false labor?

Painless, irregular, and intermittent contractions that decrease in frequency, duration, and intensity with walking or position changes

How painful is an electroencephalogram (EEG)?

Painless. Not dangerous or uncomfortable. They are placed on a reclining chair or in a bed for the 40-60 min. test.

What are the signs of hyperkalemia?

Palpitations, muscle twitching, weakness, parasthesia in extremities

What can be done to facilitate sibling acceptance of newborn?

Parent should plan to spend individual time with older sibling

What type of burn has blisters?

Partial-thickness burns. Epidermis and upper layers of dermis are light pink with denuded moist areas

What population is radioactive iodine contraindicated in and why?

Patients pregnant or nursing d/t radioactive material -This med is given over time

Lesion characteristics of basal cell carcinoma?

Pearly, waxy nodule, well-defined borders (results from sun overexposure esp on face, head, neck)

What is an adverse effect of glucocorticoids?

Peptic ulcers b/c glucocorticoids irritate the gastric mucosa

30 min after admission to nursery an infant appeared jittery and exhibits a weak, high pitched cry. What is the nurse's priority action?

Perform a heel stick to check serum glucose (BG level <40-45 mg/dL by heel stick is an urgent situation requiring therapy with oral glucose)

What route must lipids be administered in?

Peripheral IV or central line

What does a sudden relief of pain in a client scheduled for an appendectomy indicate?

Peritonitis from a ruptured appendix

What is the primary focus of group therapy?

Personal feelings that affect behavior. Group setting allows for feedback that may enhance discovery of how feelings and situations can drive behavior

What are the most effective treatments for clients with gambling addictions?

Personalized self-help programs because group discussions will not lead to long-term relationships that the client needs to recover

What is Zenker's diverticulum?

Pharyngeal pouch=herniation of esophagus occurring through cricopharyngeal muscle in midline of neck (out pouching of the posterior hypopharynx that causes regurgitation of undigested food several hours after eating)

What drug turns urine red-orange

Phenazopyridine

What is dilantin?

Phenytoin. anticonvulsant used to prevent seizure activity *use good oral hygeine (causes gingival hyperplasia)

What are Lecithin and sphingomyelin (L/S)?

Phospholipids found in fetal lungs that can indicate fetal lung maturity. L/S ratio of 2:1 indicates fetal lung maturity

Denying discomfort during assessment of injuries is indicative of what?

Physical abuse

What is physiotherapy?

Physical treatment of injuries/disease using methods such as mobilization, massage, heat treatment, and postural training instead of medications

Who is qualified to prescribe restraints?

Physicians (NOT nurse practitioners)

What are some nursing considerations when administering Mag sulfate?

Place on fluid restrictions of 100-125 ml/hr and maintain a urinary output of 30 mL/hr or greater

A nurse is caring for a client transported to the ED by ambulance after an MVA. The client has a GCS of 13 and suspected cervical spinal cord injury. There is a cervical collar in place. What intervention is the priority?

Place the client on a backboard to maintain cervical spine alignment (priority is to support alignment of spine in neutral position until spine is cleared via radiograph)

A nurse is planning to insert a peripheral IV catheter for an older adult. What action should the nurse take?

Place the client's arm in a dependent position because the veins will dilate d/t gravity

A client has just delivered her baby through an uncomplicated delivery. The healthcare provider hands the baby to the nurse. The newborn is pale and does not cry. What should the nurse do?

Place the infant in a radiant warmer and dry him with a towel to stimulate a cry (gentle stimulation after birth is usually enough tot make an infant cry). If no response, pressurized O2 may be necessary

How does sublingual medicine enter circulation?

Placement under the tongue allows med to be absorbed through mucous membranes of oropharynx and enter circulation

What does late deceleration indicate?

Placenta insufficiency, leading to poor perfusion to fetus. Caused by contractions too close together (baby is not handling things well-indicates fetal distress) (Turn client onto side, get BP, administer IV fluids, discontinue Oxytocin, give oxygen, and prepare for delivery)

A nurse is caring for a client who is in labor and is considering applying a scalp electrode to the baby for internal fetal monitoring. What condition is a contraindication for use of a scalp electrode?

Placenta previa

How should activities be structured throughout the day to help ADHD clients manage their symptoms?

Plan structured activities in the morning hours to maintain highest level of focus. Less structured activities should be planned later in the day.

What are the S/S of a PE?

Pleuritic chest pain, dyspnea, hemoptysis, tachypnea, and tachycardia. A large PE can result in hypotension, syncope, or hemodynamic collapse

In what trimester do uterine pain and significant bleeding occur?

Plot twist! They're never normal and should not occur in any trimester

What is the leading type of healthcare-associated infection?

Pneumonia

What do high fever and productive cough raise suspicion of?

Pneumonia. New onset pneumonia is considered an urgent triage category and should be treated quickly, but prioritized higher if respiratory failure seems imminent

What does subcutaneous emphysema indicate?

Pneumothorax

A nurse is caring for a client following a right below the knee amputation. What instruction should the nurse include in the plan of care to prevent infection?

Position affected limb in a dependent position

Raisins, bananas, spinach, avocados, beets, and carrots are high in what?

Potassium

What are class III antidysrhythmic meds?

Potassium channel blockers prolong the action potential and refractory period of the cardiac cycle

How does DKA affect serum potassium?

Potassium moves out of cells to compensate for increased hydrogen ion concentration

Hydrochlorthiazide (HCTZ) potassium wasting or sparing?

Potassium wasting, you'll experience hypokalemia

A client with a history of duodenal ulcers is admitted to the hospital with status asthmaticus. What meds should the nurse question?

Prednisone-Corticosteroids such as prednisone are associated with an increased incidence of peptic ulcers and should be questioned since client has a history of duodenal ulcers Naproxen-NSAIDs contribute to gastric irritation

Varicella vaccine is contraindicated with what?

Pregnancy

What are the indications for a non-stress test?

Pregnancy problems such as suspected intrauterine growth restriction (IUGR), maternal diabetes, or when mother has twins in womb

What does facial edema indicate in a client who is 14 weeks gestation?

Pregnancy-induced HTN. Should be reported immediately to the provider

What are PVCs?

Premature Ventricular Complexes- early beat that occur from an ectopic focus on the ventricle wall. •QRS will be wider than usual on the ECG strip. •Dangerous when they are more frequent than every 6 minutes, coupled, multifocal or R-on-T (PVC following closely on T-wave of the previous beat). •Assess for a pulse deficit. If one is present, the pulse will be different at the apical pulse then at a peripheral pulse.

What does being <18 y/o or older than 35 y/o put you at risk for?

Premature labor

What is an amniocentesis?

Prenatal genetic test to detect genetic anomalies associated with certain birth defects. A large needle is inserted into abd and a small amount of fluid is withdrawn from amniotic sac. The fluid is analyzed for specific neural tube defects such as Tay-Sachs disease, cystic fibrosis, and down syndrome

A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring FHR tracing from the external fetal monitor. What action should the nurse perform?

Prepare equipment needed for newborn resuscitation *endotracheal suctioning occurs if newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery

An ED nurse is caring for client who ingested kerosene. The child is lethargic, grunting, and gagging. What should the nurse do?

Prepare for intubation w/ a cuffed endotracheal tube b/c of risk of aspiration from lethargic, grunting, and gagging S/S

For what age group should a nurse provide a toy doctor's kit to play with when preparing for insulin administration?

Preschool

Why shouldn't client roll from side to side in buck's traction?

Prevent bony fragments from moving against each other. Client may only shift slightly with assistance

How do loop diuretics work?

Prevent sodium from leaving the filtrate (pre-urine), so water stays in filtrate too, leading to Na and water excretion. Also hypokalemia-Causes loss of K+ into urine. Risk of Ototoxicity, hyponatremia, hypokalemia,

A nurse in the ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. What action should the nurse take?

Proceed with provision of medical care. Life-saving care can proceed because the law considers it implied consent

What is cracking of TPN?

Process of developing oil or fat on top of TPN solution. Occurs as a result of Calcium or phosphorous amount being too high or poor-salt albumin added

What is biliary atresia?

Progressive process that leads to destruction of biliary tree (small ducts in liver, gallbladder, and bile ducts that join to become common bile duct). It is normally broken down by bacteria in intestines and excreted in feces. However, bile escapes the tree and is excreted in urine, making dark urine

What is chronic grief?

Prolonged emotional instability, a withdrawal from usual tasks or activities, and lack of progression to successful coping with loss

A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?

Promote bed rest. In vaso-occlusive criss, client has a cellular O2 demand. Therefore, reduce client's metabolic demands for O2 and limit cardiac O2 consumption by encouraging rest

How should an adolescent be positioned following a lumbar puncture?

Prone position or flat in bed for up to 12 hr after procedure to prevent postprocedural spinal headache

A nurse is caring for a client with reduced mobility who has RA. To help hip flexion deformities associated with RA; the nurse should help the client assume which of the following positions in bed several times a day?

Prone. It will help keep the hips and knees in an extended position

What is Latanoprost?

Prostaglandin used for treatment of glaucoma

What are the functions of the chorion?

Protect and nurture the embryo. Chorionic fluid protects the embryo from shock and chorionic villi allow exchange of nutrients, O2, and waste products with mother

A nurse is planning care for a client who has Hep B with jaundice. What intervention should the nurse include in the plan?

Provide high-calorie, high protein diet. Clients w/ Hep B are at increased risk for inadequate nutrition d/t N/V, anorexia, and fatigue

A newborn with cephalohematoma is undergoing assessment. The parents complained about the condition of their newborn. What should the nurse do?

Provide reassurance. It is a collection of blood between skull and periosteum that will resolve after 3 weeks (clot will be slowly reabsorbed from the periphery to the center of affected area). caused by prolonged labor and instrumental dlivery

The nurse is observing sibling adaptation behaviors to the newborn infant during a family visit. To facilitate sibling acceptance, which action by the parents can assist with bonding?

Provide the sibling a stuff animal that they care for while the parents nurture the newborn (helps sibling feel they are a part of the new family experience)

A nurse is caring for a client at risk for atelectasis. What should the nurse monitor?

Pulse oximetry

A nurse is caring for a client who is recovering after an MI. When advising the client to exercise gradually and slowly increase the distance walked, which vital sign should the nurse teach the client to monitor to guide wether to increase or decrease exercise levels?

Pulse rate. It increases in response to cardiac demand and is useful to guide a gradual build up/tolerance to exercise

How often should the nurse teach the client to shift in bed to prevent pressure points for pressure ulcers?

Q15 minutes

A nurse is preparing to administer an IM injection of meperidine to a client. What is the priority assessment the nurse should complete?

RR. Meperidine can cause respiratory depression

Children who have leukemia will not receive what treatment?

Radiation therapy. They will receive chemotherapy.

What is acute coronary syndrome?

Range of conditions associated with sudden, reduced blood flow to the heart

What is Tay-Sachs disease?

Rare disorder passed from parents to child. Caused by the absence of an enzyme (hexosaminidase that leads to GM2 ganglioside accumulation) that helps break down fatty substances which build up to toxic levels in the child's brain and affect the function of the nerve cells. As the disease progresses, the child loses muscle control. Eventually, this leads to blindness, paralysis and death Findings: weakness after 3-6mo, development slows and regresses. Exaggerated startle response. Cherry spot visible on macula.

Why is oxygen flow rate via nasal cannula only allowed to be 1-6 L/in?

Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired (FiO2)

What characterizes antisocial personality disorder?

Reckless disregard for self and others, impulsivity, deceitfulness, lack of remorse, consistent irresponsibility

What must be done to alteplase before it can be administered?

Reconstitute med with sterile water. Alteplase is available as a powder and must be reconstituted with water to be given.

Too rapid of an infusion of vancomycin causes what?

Red man syndrome-S/S are flushing of face and neck and can be itchy. Can progress to hypotension, dyspnea, anaphylaxis, renal failure, or hearing loss. Other minor reactions are chills, fever, and tinnitus

Why should a nurse instruct a client to avoid eating red meat for 3 days before collecting a fecal occult blood test?

Red meat contains Hgb, myoglobin, and some enzymes that can cause a false-positive result

How does Mag sulfate affect the heart?

Reduces striated muscle contractions d/t a depressant effect on the CNS. It blocks neuromuscular transmission. Thus, we would see a prolonged PR interval

What should be done with unused portion of formula used in intermittent enteral feedings?

Refrigerated (up to 24 hrs) to prevent bacterial contamination

What does a daily calcium supplement and flank pain indicate?

Renal stones

A nurse in a provider's office is assessing a client who has HTN and takes propranolol. What finding indicates an adverse reaction?

Report of a night cough. It is an early indication of HF

A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. What instructions should the nurse include?

Report swelling of eyelids and lips after dosage to provider b/c it indicates an allergic reaction to the med

A nurse on the med-surg unit is caring for a client after knee replacement surgery. What clinical sign requires immediate notification of the healthcare provider?

Respiratory rate of 28/min and chest tightness. This suggests a PE that dislodged from a DVT d/t reduced mobility.

A child with ADHD receives a new prescription for methylphenidate. What SE should the nurse advise the client about?

Restlessness. Methylphenidate (Ritalin) is a stimulant. Other SE include anorexia w/ growth delay, anxiety or jitteriness, insomnia, increased HR and BP, and HA

What is a weird SE of rifampin?

Rifampin is a TB drug that causes harmless red-orange discoloration of feces, sputum, tears, and sweat

Increased abd girth is an expected finding of what condition?

Right-sided HF. Systemic congestion, enlarged liver and spleen. It can lead to fluid retention and increased venous pressure with lower extremity edema

How should OR nurses rinse their hands and arms?

Rinse by keeping hands above arms so that water flows from clean to dirty

A client is developing a care plan for a client with hypocalcemia. The client's serum calcium level is below 8.5 mg/dL. What nursing diagnosis is appropriate?

Risk for injury. D/t laryngospasm, dysrhythmia, and seizures. Other hypocalcemia S/S include tetany and paresthesias

What is a STEMI heart attack?

ST elevated MI-characterized by a complete occlusion of a major epicardial coronary artery, resulting in necrosis of the full thickness of the myocardium

What finding on a newborn assessment should be reported to the healthcare provider?

Sacral dimple. It may be caused by spina bifida occulta or a dermal sinus tract

A nurse is preparing a client who speaks limited English for surgery. What is the most appropriate nursing action in obtaining informed consent from this client?

Seek the assistance of a nurse on the floor who is fluent in the client's language (nurse is responsible for ensuring client understands information regarding procedure)

How does Venlafaxine (Effexor) work?

Selectively blocks the reuptake of norepinphrine, it does not block serotonin receptors

Why shouldn't children with asthma receive aspirin?

Sensitive to it and it is associated with Reye syndrome

A client is on lisinopril. What is the most important thing for the nurse to assess before administering this med to the client?

Serum electrolytes

A nurse is caring for a school-age child who is taking valprioc acid. The nurse should expect the provider to order what test?

Serum enzyme levels b/c valproic acid can cause hepatic toxicity

In the initial phase of family therapy, what is the nurse's role?

Set a tone of respect, trust, and confidentiality among members while maintaining open and clear communication

How long does it take cromolyn sodium to take effect?

Several weeks

Capillary refill greater than 4 seconds is evidence of what type of dehydration?

Severe dehydration

Hyperpnea is evidence of what type of dehydration?

Severe dehydration

Lethargy is evidence of what type of dehydration?

Severe dehydration

What is aplastic anemia?

Severe myelosuppression that results in anemia, agranulocytosis (decreased WBCs), and thrombocytopenia

What does profuse sweating indicate in a client experiencing an acute asthma attack?

Severe respiratory distress from status asthmaticus. It requires immediate intervention and must be reported to provider. Other signs to report: nasal flaring, distended neck veins, tachypnea

A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. What instruction should the nurse include?

Shake the med prior to administration. It is given as a suspension so it should be shaken to evenly disperse the med

Where on the newborn's heel should it be punctured to obtain a blood specimen?

Side or outer aspect of heel. Puncturing center can lead to complications such as fibrosis or bone infection

If an infant has a propensity to vomit, in what position should they sleep in?

Side-lying (or upright)

How should client be positioned to obtain a rectal temp.?

Side-lying or prone position

What is a viscus?

Singular term for a viscera

What are adverse effects of radiation therapy?

Skin changes, esophagitis, and lymphedema

Client receives phenytoin to treat a seizure. What SE should the nurse instruct client to report immediately?

Skin rash (with measles-like appearance and may progress to exfoliative dermatitis) is an indication of Stevens-Johnson syndrome

How should the client's head be positioned when feeding a client with dysphagia?

Slightly flex head to a chin-down position to prevent aspiration

A nurse in a clinic is providing education to a client at 32 weeks gestation who has pruritis gravidarum. What should the nurse teach as the treatment.

Slightly increase exposure to sunlight b/c it can reduce itching. Pruritis gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash d/t stretching of the skin

How fast should IV phenytoin be administered?

Slowly, <50 mg/min to reduce hypotension risk

How does digoxin work?

Slows conduction through AV node 1 - Blocks Na/K ATPase leading to increased intracellular Ca++ (increased inotropy, tachyarrhythmias) 2 - Increases vagal tone (anti-arrhythmic, bradyarrhythmias)

A nurse is caring for a client who is prescribed lithium (Eskalith). What clinical finding should be immediately reported to the provider?

Slurred speech (can precipitate seizures or coma)

What part of the GI tract does Crohn disease (CD) affect?

Small intestine, large intestine, and rectum

What are recognizable signs of pediculosis capitis?

Small white spots that adhere to hair shaft, close to scalp

Is fresh salmon or smoked salmon contraindicated for a client on MAOIs?

Smoked salmon. Smoked, dried, cured, aged, or fermented fish are high in tyramine. However, fresh and vacuum-packaged fish are safe

What is glossitis and what causes it?

Smooth red tongue indicates pernicious anemia

What are class I antidysrhythmic meds?

Sodium channel blockers that slow cardiac conduction velocity (divided into three groups: 1A, 1B, 1C)

What is Ladin's sign?

Softening of midline of the uterus after 6 weeks

Infants allergic to what foods typically outgrow them?

Soy, cow's milk, eggs

What is an example of a food containing complete protein?

Soybeans, it contains all 9 essential amino acids

What is the best way to communicate with a client with a partial hearing impairment?

Speak slowly in a low-pitched voice

What condition is likely to lead to a high platelet count and increased risk of blood clots?

Splenectomy. Spleen is a reservoir for platelets. A splenectomy may release a bunch into the bloodstream

What is the only method to confirm the diagnosis of active TB?

Sputum culture for acid-fast bacillus

When are alginate dressings used?

Stage 3 and 4 pressure ulcers to absorb drainage. They form soft gel when they come into contact with drainage

What is the formal operations phase and who fits inside it?

Stage marked by abstract thinking and deductive reasoning. 11-16 y/o

What is the pre-operation stage and who fits inside it?

Stage marked by animism and symbolism (2-7 y/o)

What is the sensory-motor phase and who fits inside it?

Stage marked by egocentricity, simple cause and effect, and development of object permanence. (birth-2 yrs)

When and how often should colonoscopies be performed?

Start at age 50 and then every 10 years thereafter

What should the nurse do when a PTSD client has flashbacks?

Stay with client. Presence of trusted person can calm fears and anxiety and provide reassurance to client during traumatic time

What is a tonic-clonic seizure?

Stereotypical seizure (Previously referred to as grand mal) Onset without warning Tonic phase: 10-20 sec. eyes roll upward loss of consciousness tonic contraction of entire body, with arms flexed and legs, head, and neck extended possible piercing cry increased salivation loss of swallowing reflex apnea leading to cyanosis Clonic Phase: time varies violent jerking movements of the body may have foaming in the moth may be incontinent gradual slowing of movements until cessation

What type of water is used for flushing a gastrostomy tube?

Sterile or unsterile water. NOT SALINE!

Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. What is the correct intervention?

Stop oxytocin infusion and assess contractions and fetal HR

How should a client handle mild nosebleeds when on warfarin?

Stop the med and notify provider of bleeding

A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. What teaching instruction should the nurse include?

Store the med in its original dark glass container. It is inactivated by heat, light, and moisture.

What complication is most likely to occur following cardioversion?

Stroke. Clot may have formed in atria that can embolize to brain. SO, you need to give anticoagulants before cardioversion for a-fib

What is symbolic play?

Substituting one object to pretend it's another. Pretending a rug is a magic carpet. Starts at about 18 mo

What is Sumatriptan (Imitrex) used for?

Sumatriptan is a migraine abortive treatment that acts by causing vasoconstriction at the neural area, counteracting the vasodilation that is thought to cause migraines. It is best taken when the aura of a migraine presents. As a triptan, it is associated with fetal deaths, and therefore contraindicated in pregnancy.

What is an important consideration for clients following cataract surgery?

Sunglasses should be worn outside or in brightly lit areas due to light sensitivity

How should a client be positioned for nasal instillation?

Supine

What is the proper position for cesarean birth?

Supine w/ foam wedge under one hip. Wedge tilts hip laterally and reduces uterine weight on vena cava and descending aorta (helps maintain optimal perfusion of O2 blood to the fetus during the procedure)

How do excessive levels of magnesium affect breathing?

Suppress neuromuscular transmission, placing client at risk for respiratory depression

What is a gastric bypass?

Surgery to reduce the size of the stomach and bypasses part of the small intestine. Can lead to pernicious anemia because of loss of intrinsic factor from stomach with reduction. Intrinsic factor is required for Vit B12. Pernicious anemia is anemia resulting from insufficient Vit B12.

Universal consent does not cover what?

Surgical or invasive diagnostic procedures

What are the side effects of salicylism (aspirin toxicity)?

Sweating, HA, dizziness

What is papilledema?

Swelling of optic disc. Increase in intracranial pressure which causes elevated optic disk with blurred margins, bigger blind spot (can be seen in hydrocephalus)

What does a severe intermittent asthma diagnosis mean?

Symptoms occur continually, along with frequent exacerbation that limits the child's physical activity and quality of life

What does a mild intermittent asthma diagnosis mean?

Symptoms occur less than twice a week

What does a mild persistent asthma diagnosis mean?

Symptoms occur more than twice a week, but not daily

What is abstinence syndrome?

Symptoms of drug withdrawal as a result of physical dependence of the mother

A nurse is administering mannitol to the client with increased intracranial pressure. What supplies are necessary when administering this medication?

Syringe, filter needle, IV filter tubing. Mannitol is not available in an oral (PO) form, so this option is incorrect

What is ARDS?

Systemic inflammatory response to trauma, sepsis, burns, pancreatitis, and blood transfusions when excess lung fluid dilutes surfactant activity in lungs. Client will have refractory hypoxemia (hypoxemia that doesn't improve with O2 therapy) and extensive pulmonary edema on X-rays

What lab tests would be expected for hypothyroidism?

T3, T4, TSH T3-T4 decreased TSH would be increased with primary and decreased with secondary

What is thyroxine?

T4. A hormone released by the thyroid gland Regulates the basal metabolic rate and stimulates protein synthesis for growth and development Plays a significant role in many other body processes

What should you rinse your mouth with after inhaling with a metered dose inhaler (MDI)?

TAP WATER *Mouthwash can further dry the mouth

A nurse is assessing a client who has a prescription for oral albuterol for the long-term management of asthma. What adverse effects should the nurse monitor for?

Tachycardia and dysrhythmias because of beta2-agonist properties

A nurse is assisting a physician who is removing a client's central line. What instruction should the nurse give as the physician removes the catheter?

Take a deep breath and hold it. This will increase the intrathoracic pressure, reducing occurrence of air embolus

How should lithium be administered in relation to food?

Take it with food

A nurse is teaching a client who has iron deficiency anemia about ferrous sulfate. What instructions should the nurse give

Take medication between meals for optimal absorption (antacids interfere with ferrous sulfate absorption too; also diary products inhibit absorption)

A nurse is caring for a client who is prescribed diphenhydramine to relieve pruritis. The client asks the nurse how he can minimize the daytime sedation he is experiencing. What should the nurse teach?

Take most of the daily dose at bedtime. Allows client to obtain maximum relief of manifestations and rest without itching.

Client with constipation-predominant irritable bowel syndrom (IBS-C) should be taught what?

Take psyllium in the evening (bulk-forming laxative to increase stool bulk, reduce constipation, and promote regular BMs)

A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. What instruction should the nurse give?

Take the medication with a meal (to avoid hypoglycemia and GI upset, and to provide the most absorption of the med)

How does elevated K+ affect ECG readings?

Tall, peaked T waves, flat or absent P waves, prolonged PR intervals, wide QRS complex, and ectopic beats *can progress to heart block, V-fib, and asystole

What is chloasma?

Tan or dark pigmentation that increases on the face during pregnancy

What is Chvostek's sign?

Tap on facial nerve at angle of jaw (on cheek) and get a twitch of nose or lips on that side. Indicates hypocalcemia because of nerve excitability

A client receiving a prescription for fluoxetine states "I can eat whatever I want while I'm taking fluoxetine." What should the nurse do?

Teach weight gain is an adverse effect of fluoxetine, so caloric intake must be controlled and exercise increased.

A nurse is administering nasal decongestant drops to a client. What action should the nurse take?

Tell the client to blow her nose gently before the instillation. This will help remove any secretions or crusts that could interfere with the distribution and absorption of the med

What types of foods are recommended for clients with Crohn's disease?

Tender, ground, well-cooked meat, eggs, fish, poultry, refined pasta and cereal, white rice and bread, canned or cooked vegetables without skin or seeds and juices without pulp

What med can be used prophylactically by a client who doesn't have an HIV infection to reduce HIV transmission?

Tenofovir/emtricitabine (an oral med)

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor for what adverse effect of PEEP?

Tension pneumothorax (manifestations include tracheal deviation, absent breath sounds and distended neck veins)

What are some important differences between terbutaline and magnesium sulfate?

Terbutaline is short-acting and fast-acting Magnesium sulfate is delayed onset and long-acting **Don't give mag during labor in a full-term (because it well slow delivery). Terbutaline is so fast-acting that it won't delay delivery

What is the enzyme immunoassay (EIA test)?

Test to diagnose suspected Hep C virus and identify the Hep C antibodies

What is a biophysical profile?

Test used to assess mother and baby at high-risk. It involves an ultrasound to visualize characteristics of fetus and observe fetal responses to stimuli (combines ultrasound and nonstress test)

What is the Romberg test?

Tests the client's equilibrium, client stands with feet together and arms at sides eyes open and then closed. Client should be able to maintain the position for 20 secs with minimal or no swaying

A nurse is caring for a client with a history of rheumatoid arthritis who is receiving methotrexate. What should be included in the client education?

The CBC will be monitored. Bone marrow suppression is a common SE when using methotrexate for long-term therapy in RA treatment. Monitor with CBC to spot anemia, neutropenia, or thrombocytopenia

What is insensible fluid loss?

The amount of fluid lost that is not easily measured on a daily basis from the lungs, skin, respiratory tract, and water excreted in the feces

A nurse is caring for a client who has been committed to an acute Mental Health facility with an involuntary emergency commitment order. What should the nurse include when orienting the client to the facility?

The client has the right to refuse treatment, unless he has been judged to be incompetent. Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, unless they have gone through a legal competency hearing and have been judged incompetent. The client who has been judged incompetent has a temporary or permanent guardian, usually a family member if possible, appointed by the court. The guardian can sign informed consent for the client. The guardian is expected to consider what the client would want if they were still competent.

What must be done for a provider to make changes to a living will?

The client must request to make a change

A nurse is preparing to discharge an older adult client to the home of a family member while recovering from hip surgery. What situation may negatively affect the client's adjustment to living with family members?

The family is insisting on maintaining financial control for the client. While it might be appropriate for family members to assist with financial matters, unless client is declared incompetent there is no need for them to maintain complete control. This may be perceived as very threatening to the client

Tenesmus

The feeling that you need to pass stools, even though your bowels are already empty. It may involve straining, pain, and cramping.

What are the steps for administering packed RBCs?

The first step the nurse should take when preparing to administer packed RBCs is to initiate an IV site with an 18- to 20-gauge IV catheter. Next, the nurse should infuse a solution of 0.9% sodium chloride to maintain IV catheter patency. Then the nurse should obtain the unit of packed RBCs for transfusion from the blood bank. Once the blood is obtained, the nurse should verify the information on the blood bag with the client's medical record and arm bracelet with another nurse. Finally, the nurse should insert the Y spike of the tubing used for blood product infusion into the blood bag.

A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution?

The fundus will be one centimeter below the umbilicus. *Fundus descends 1-2 cms/day

A daughter of a client with a terminal illness pulls a nurse to the side and says, "Although my mother's living will states she is not to be resuscitated, the family wants everything done to save her if she has a cardiac arrest." How should the nurse respond? Select one: a. "I will contact the provider to make him aware of your request." b. "Since the living will is a legal document a lawyer will have to make the changes." c. "If your mother has a cardiac arrest, we will begin resuscitation if you wish." d. "The living will documents your mother's wishes and must be followed."

The living will documents your mother's wishes and must be followed." A living will is a document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. The client's wishes should be followed by the health care provider.

The designation of proximal, medial, and distal ports on a central venous catheter is related to:

The location of the eyelets at the end fo the catheter in the vein (the different endpoints of the central line along the SVC)

When do MIs usually occur and what is the usual cause?

The morning. No apparent cause and not caused by activity.

When should fluoxetine be taken?

The morning. All SSRIs should be taken in the morning because insomnia is a side effect

When the client is unable to make decisions and there is no spouse, who is next in the legal hierarcy?

The oldest adult child

What is cervical cerclage?

The surgical reinforcement of the cervix with a heavy ligature that is placed submucosally around the cervix to strengthen it and prevent premature cervical dilation/premature labor. It is usually done before 23 to 24 weeks

A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes these behaviors as?

The taking-in phase of maternal postpartum adjustment

How is a histrionic personality disorder characterized?

Theatrical emotional expression and exaggerated sense of self

What therapeutic communication technique communicates nurse's interest and concern for the well-being of client?

Therapeutic listening techniques

What is tocolytic therapy?

Therapy to delay delivery-relaxation of the uterus, administration of drugs that inhibit contractions

During a home visit, a 10-day postpartum client reports pain and tenderness with redness and swelling to her right breast. A localized hard mass is also noted upon palpation. How should the nurse respond to this client?

These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider (HCP)

What is important to remember about salt substitutes?

They are often high in potassium so they should not be giving with potassium-sparing diuretics or ACE inhibitors

How do beta blocker prescriptions change with scheduled surgery?

They don't change in clients who take them regularly. Client should continue to take beta blocker to reduce risk of adverse cardiac events during surgery

How do opioids affect your pupils?

They make them constrict

How do aspirin and other NSAIDs interact with captopril?

They reduce its antihypertensive effects

Pressure wounds with minimal to moderate exudates can be dressed with what?

Thin hydrocolloid

Triamcinolone ointment can have what adverse effects?

Thinning of the skin and delayed healing b/c it is a topical glucocorticoid *only put on dry skin because it can cause atrophy of dermis and epidermis and subsequent thinning

A residential rehabilitation program is used for what clients?

Those who require medical management. 24 hr medical staff and provide specialized care for clients with comorbid conditions

A client who does not wish to breastfeed can alleviate engorgement and swelling by wearing what type of bra?

Tight-fitting bra or breast binders to alleviate engorgement and swelling

What does the Kegel exercise therapy routine look like?

Tighten pelvic muscles for slow count of 10 and then relax for slow count of 10. This exercise should be done 15 times while lying down, sitting up, and standing (a total of 45 exercises). The client should then repeat the exercises rapidly contracting and relaxing the pelvic muscles 10 times. This should take no longer than 10-12 minutes for all three positions, or 3-4 minutes for each set of 15 exercises.

What is the concrete operations phase and who fits inside it?

Time when children develop more logical and systematic reasoning, become better listeners, and think more objectively... but still depend on concrete objects for understanding. Middle and late childhood (6-11 years)

A client with a digoxin level of 2.4 ng/ml has a heart rate of 39. The health care provider prescribes atropine sulfate. What best describes the intended action of atropine for this client?

To accelerate the HR by interfering with vagal impulses *Atropine-anticholinergics

What is the focus of the agency for Healthcare Research and Quality?

To improve quality of health care services for all populations, including low-income groups and minorities

A client diagnosed with preterm labor has been prescribed nifedipine. The client asks the nurse why this particular medication has been prescribed. How should the nurse respond?

To relax your muscles of your uterus

A nurse is to administer nitroglycerin to a client for the treatment of angina. What should the nurse first advise the client?

To sit or lie down prior to administration of the drug to promote venous return (to prevent blood pooling). The vasodilation effects of the medication cause a decrease in blood pressure

What do tonic and clonic mean?

Tonic means stiffening, and clonic means rhythmical jerking.

What is the most life-threatening complication associated with blood transfusions?

Transfusion-related circulatory overload. S/S of HF and dyspnea.

What kind of dressing is used for stage 1 pressure injuries?

Transparent dressings promote healing by preventing further friction and shearing

What is a common adverse effect of terbutaline?

Tremors

What is benztropine used for?

Tremors and extrapyramidal symptoms of Parkinson's disease

When removing a central line from a client's right internal jugular vein, how should the client be positioned?

Trendelenberg. Entry site should be below the level of the client's heart (limit blood's ability to flow for a bit)

What is urgent class II?

Triage framework in which client has major injuries but is not life threatening

What is doxepin (Silenor)?

Tricyclic antidepressant (TCA) used for depression, anxiety, and insomnia. Anticholinergic effects and postural hypotension

What is infliximab (Remicade)?

Tumor necrosis factor (TNF) inhibitor used to treat inflammatory disorders including ankylosing spondylitis, Crohn's disease, ulcerative colitis, and RA. *They suppress teh immune system, putting body at risk for serious infections including TB, zoster, pneumonia *Should not be taken with recurrent or chronic infections

A nurse is caring for a client in active labor and receiving epidural anesthesia. Client reports feeling nauseated and experiences a BP drop from 125/70 to 90/50 mmHg. What should the nurse do?

Turn the client to a lateral position to relieve pressure on vena cava and restore venous return

What may comfort the family and dying client of a muslim faith during the death process?

Turning the client on right side toward Mecca

What does external fetal monitoring consist of?

Two belts wrapped around mother's abdomen. One uses Doppler to detect FHR while the other belt measures length and timing of contractions

How long do disulfiram's effects last after discontinuing it?

Two weeks

How long until a newborn boy can have a bath?

Two weeks. Need to wait for circumcision to heal (2 wks) and umbilical cord to detach

What is a hydrothorax?

Type of pleural effusion in which fluid (from body gradually) accumulates in pleural cavity

How does the hypertensive crisis occur in MAOIs and tyramine combo?

Tyramine promotes norepinephrine release from sympathetic neurons causing massive vasoconstriction and excessive stimulation of heart

How does biophysical profile test work?

Ultrasound is used to visualize pockets in amniotic fluid surrounding fetus to evaluate fetal health.

What is the normal BUN range during pregnancy? What does an elevated BUN indicate?

Unchanged (actually decreases d/t increase GFR). Elevated indicates preeclampsia or HELLP syndrome

A nurse is preparing a feeding for a client with a gastrostomy tube using the gravity method. The nurse has already checked for correct placement of the tube and has hung the bag to drip from gravity. After hanging the bag, what is the next step in the gravity feeding process?

Unclamp tubing and allow feeding to fill the line (you can prime the tubing with feeding!)

The nurse is assisting the parents fo a school-aged child with a plan to prepare for impending death of family member. What potential behavior is expected with this stressor?

Uncooperative behavior. It's how school-aged children display fear of unknown

A nurse is caring for a client who is reporting lower abd pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy?

Unilateral abd stabbing, lower abd pain/tenderness (referred shoulder pain from blood irritation of the diaphragm or phrenic nerve is common... Also, may have N/V and shock s/s)

Why must estrogen and progesterone be used together to treat menopause symptoms in a woman with a uterus? What is used in a woman without a uterus?

Unopposed estrogen can cause abnormal cell growth in uterine lining. No uterus: just estrogen

What characterizes borderline personality disorder?

Unstable interpersonal relationships, emotional instability, impulsivity, engage in harmful behaviors (cutting, substance abuse, suicidal ideation), and unstable mood, and self image distortion

How long should a child be kept in a rear-facing car seat?

Until age 2 or until child reaches maximum height and weight for the seat

How long should infants be placed in rear facing position in the back seat?

Until they weight 9.1 kg (20 lbs)

In a normal baby, where are the ears relative to the face?

Upper tip of the pinna should be even with the eyes. (low set ears indicate a chromosome abnormality such as Down Syndrome or a renal disorder)

How should a client be positioned for a paracentesis?

Upright or in high fowler's

How does immobility affect urinary output?

Urinary output decreases resulting in urinary stasis, renal stones, urinary retention, and UTIs

What is the most accurate indication of organ perfusion in hemorrhagic shock?

Urinary output. Should be >30 mL/hr

A nurse is caring for a client who has a stage III pressure ulcer. What finding contributes to delayed wound healing?

Urine output 25 ml/hr. Inadequate urine output can indicate dehydration, which can delay wound healing

What does a firm and tender abdomen above the symphysis pubis indicate?

Urine retention

How should a client be instructed to clean an episiotomy?

Use a squeeze bottle with warm water or antiseptic solution to keep area clean or rinse away bacteria. Client should blot the area dry, DO NOT WIPE-it may damage or irritate perineal tissues

A nurse is caring for a client who is in active labor with ROM. On assessment, the nurse notes the client has extrusion of the umbilical cord at the vaginal introitus. What is the priority nursing intervention?

Use a sterile gloved hand and apply finger pressure to elevate the presenting part of the fetus. Compression of cord prevents adequate fetal blood flow and can cause anoxic brain damage. Nurse should emergently elevate part of fetus that is compressing the umbilical cord

When on warfarin, what safety measure should a patient take when shaving?

Use an electric razor to decrease risk for injury and bleeding

A nurse is preparing to administer an IM injection to a client who is obese. What action should the nurse take?

Use the ventrogluteal site because it has a thick area of muscle

What is Atomoxetine (Strattera)?

Used in ADHD with less insomnia or appetite suppression. May cause increased suicide ideation in children.

What is the Bishop score?

Used to determine maternal readiness for labor by evaluating whether the cervix is favorable by rating the following: 1. dilation, 2. effacement, 3. cervical consistency, 4. cervical position and 5. station of presenting part

How does dopamine affect the heart?

Useful in cardiogenic shock because it produces inotropic effects, thereby improving cardiac output. It also raises BP by causing vasoconstriction of the blood vessels

What are severe adverse effects of oxytocin administration?

Uterine rupture, postpartum hemorrhage, water intoxication (from ADH effect) and uterine tetany

A nurse is caring for a client receiving oxytocin to induce labor. Nurse must observe for what?

Uterine tetany. Oxytocin may induce uterine tetany, which may restrict blood flow to fetus and slow progression of labor

What is an implantable cardioverter defibrillator (ICD) used for?

V-fib and V-tach

A nurse is assessing a child with full-thickness leg burns. What manifestations should be expected?

Variable colors: cream to brown or black. Injury reaches to dermis and possibly muscles, tendons, and bone. Less painful than partial-thickness b/c of nerve destruction

What is Sumatriptan?

Vasoconstrictor. Can cause angina from coronary vasospasm. Contraindications include HTN, CAD, ischemic heart disease and angina pectoris

How do opioids affect blood vessels?

Vasodilation-can lead to edema, hypotension, and syncope

A charge nurse is planning a staff education session to discuss the meds used during the care of a client experiencing GI bleeding. What med should the charge nurse include in discussion?

Vasopressin (manmade ADH). It is a vasopressor that can constrict the arterioles and reduce inflow to portal vein

What is shigella and what precautions?

Vector: water and soil born Bacillary/bacterial dysentery (blood in stools) Contact precautions

A nurse is preparing to obtain a blood sample for Hgb from a child with hemophilia. How should it be collected?

Venipuncture. It causes less bleeding than a finger puncture

What is proportional assist ventilation?

Ventilatory mode that provides partial support in response to client's inspiratory efforts

What is the S3 heart sound?

Ventricular gallop that occurs in a short, low frequency sound with a cadence similar to the word "Kentucky"

What are the adverse effects for carbamazepine?

Vertigo, ataxia, and drowsiness -Used for bipolar disorder

What are the S/S of Herpes simplex 2?

Vesicular lesions Tingling pains Fever HA Swollen lymph nodes

Encephalitis occurs most frequently d/t what?

Viruses (e.g. herpes simplex I and II, varicella zoster (chickenpox and shingles); measles, mumps, and rubella

Consume foods with what to promote wound healing?

Vit A and C, zinc, and copper

Absorption of what micronutrients is altered after gastric bypass?

Vit B12, folate, Thiamine (Vit B1), and iron

A nurse is admitting a client at 12 weeks' gestation for treatment of a deep vein thrombosis. What therapeutic med is contraindicated in pregnancy?

Warfarin. It causes fetal malformations through 1st trimester

What type of nonpharmacologic method can be used to promote muscular relaxation, reduce pain, and relieve morning and evening stiffness in RA clients?

Warm bath or shower *Maintain mobility or you can lose joint mobility and function

A few vesicant extravasations such as those that result from administration of vincristine and etoposide are treated with what?

Warm compresses

What sort of compresses should be applied to an extremity with a DVT?

Warm, moist compresses

How should a neutropenic client who is receiving chemotherapy clean their toothbrush?

Wash it in the dishwasher and rinse it with bleach to prevent bacterial growth

What is lavage?

Washing out of a body cavity, such as a colon or stomach with water or a medicated solution

What is one med consideration when administering albuterol?

Watch for tremors and tachycardia

A nurse is assessing a client who has had nausea, vomiting, and diarrhea for the past 3 days. What finding would indicate hypovolemia?

Weak pulse d/t decreased circulating volume and less pressure within vessels (such pulses rated as +1 can be described as thready) *Another hypovolemia S/S is decreased skin turgor

Hypernatremia causes what S/S?

Weakness, dry lips, and muscle twitching

A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy. What should the nurse do?

Wear two pairs of gloves when handling the med. It's an antineoplastic agent

A nurse is assessing a client who is taking carvedilol for HF. What finding is the priority for the nurse to report to the provider?

Weight gain b/c it indicates a worsening of the client's HF and requires immediate intervention

A nurse is instructing a client with a right fractured tibia on the correct technique for using a three-point gait with crutches. What is this?

Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated.

A nurse should avoid what type of dressing for a pressure ulcer?

Wet-to-dry gauze dressing because they interrupt viable, healing tissues when removed

When is a noncoring needle used?

When accessing an implanted port

When should a nasotracheal suction catheter be inserted into the body?

When client is inhaling to avoid inserting it into the esophagus

When should an ileostomy pouch be emptied?

When it is 1/3 to 1/2 full to prevent stool leakage and skin irritation

What is dorsal recumbent position?

When patients are on their back with knees flexed and soles of the feet flat on the bed.

What are the S/S of cushing's triad?

Widened pulse pressure, bradycardia, and HTN

When should naltrexone be taken in relation to meals?

With meals to decrease GI distreess

How soon should alteplase be administered in accordance with client's arrival to ED?

Within 30 minutes

What is the taking-hold phase of maternal postpartum adjustment?

Woman starts initiating actions and makes decisions independently. Begins 2-3 days postpartum and lasts 10 days-several weeks. Focus on exerting independence and completely caring for newborn. May verbalize fears of incompetence or anxiety about exhaustion, and needs acceptance and encouragement. Postpartum depression may occur during this time

Who is mostly affected by hypothyroidism?

Women and middle-older adults

How does STI risk affect boys relative to girls?

Women are biologically more receptive than men to infection by sexually transmitted organisms. E.g. girls will get them more readily

What is sallow skin?

Yellow or brown tone to skin (especially face) that is losing its natural complexion

Is a nurse allowed to transcribe a provider's order into the client's health record?

Yes

Can children with tympanostomy tubes swim in lakes or oceans?

Yes, but parents need to put earplugs in to prevent contaminated water from entering the holes in the eardrums

When delegating, is it appropriate to ask a nurse if s/he is capable of completing a delegated task?

Yes, it is considered effective delegating

Can allupurinol be crushed?

Yes, it is not enteric-coated or sustained-release

Is it possible for you to get rheumatic fever twice?

Yes, so prophylactic treatment with monthly IM injections of benzathine penicillin G or dialy oral doses of penicillin or sulfadiazine will be needed

What happens if you suction for more than 10 seconds?

You can cause cardiopulmonary compromise

A nurse is providing teaching to a client at 24 weeks gestation and scheduled for a 3hr oral glucose tolerance test. What instruction should the nurse include in the teaching?

You will need to fast the night before the test (to prevent inaccurate results)

A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. What should the nurse say?

Your body has a process called fibrinolysis that will eventually dissolve/break down the clot over time

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply what to the area?

Zinc oxide-provides protective barrier against the instigating irritants: urine, feces, soap, or friction. The S/S are scaling, blisters, or papules with erythema

What is a peritoneal lavage?

a diagnostic test in which a catheter is inserted into peritoneal cavity and fluid is aspirated with a syringe. It is most commonly performed to assess for bleeding in abd cavity in clients who have experienced blunt trauma.

What is an anastomotic leak?

a leak of luminal contents from a surgical join

Colparrhaphy?

a minimally invasive surgical procedure that repairs and strengthens the vaginal wall after a pelvic organ prolapse (POP). A pelvic organ prolapse occurs when one of the organs in the pelvic floor region slips out of its normal location in the body

What is level of consciousness?

a person's awareness and understanding of what is happening in his or her surroundings

What is a hematoma?

a solid swelling of clotted blood within the tissues

What is lassitude?

a state of physical or mental weariness; lack of energy

What is the genogram?

a tool used to assemble a 3 generational family history. Its a diagram that depicts patterns, functioning, and influences.

What is phenazopyridine?

a urinary analgesic that discolors the urine (dark orange/red) -AKA Pyridium

A nurse is caring for a client experiencing an anaphylactic reaction. List the following interventions to be taken by the nurse in order beginning with highest priority. Administer epinephrine IVP Teach the client to carry an EpiPen at all times Begin an intravenous infusion with 0.9% sodium chloride Establish a patent airway. Administer diphenhydramine IVP

a. 4, 3, 1, 5, 2 -Airway is always the highest priority if there is the possibility of a compromised airway. -An intravenous line will be necessary to administer emergency drugs. -Epinephrine is the drug of choice for the treatment of anaphylaxis. The medication is administered every 10 to 15 minutes until the reaction has subsided. Epinephrine is given for its vasoconstrictive action. -Benadryl blocks histamine release and reduces capillary permeability. -Teaching is important to prevent or treat further reactions, but this will be done after the crisis period is over.

Atresia

absence of a normal body opening; occlusion; closure

What are catecholamines?

adrenal hormones: dopamine, norepinephrine, epinephrine that help with fight or flight reactions

What is Proventil?

albuterol-a short acting bronchodilator

What is eplerenone?

aldosterone antagonist intended for antihypertensive effect/HF achieved by blocking aldosterone (increase urinary excretion of sodium and water AND retain potassium)

How are ACE inhibitors administered?

all orally (except enalaprit - IV)

What is the postictal state?

an abnormal condition that lasts from when a seizure subsides and ends when the patient returns to baseline. Marked by arousing with difficulty, confusion for several hours, impairment of fine motor movements, lack of coordination, possible vomiting, headache, visual or speech difficulties sleeps for several hours no recollection of the seizure

What is tranylcypromine (Parnate)?

an antidepressant (monoamine oxidase inhibitor). Avoid tyramine because it can cause a hypertensive crisis

What are the adverse effects of Benztropine?

anticholinergic. Tachycardia, constipation, urinary retention,

What is olanzapine?

atypical antipsychotic med used for schizophrenia

A nurse is performing initial teaching with a client who will be receiving electroconvulsive therapy (ECT). Which statement by the client indicates a need for further teaching? Select one: a. "Before the procedure, I will have an EKG to assess for heart irregularities." b. "My Dilantin dose will be increased several days before the procedure." c. "I will need to continue taking my regular blood pressure medication." d. "I will stop taking my lithium for 2 weeks prior to my procedure.

b. "My Dilantin dose will be increased several days before the procedure." -Because the therapeutic action of ECT is to induce seizures, phenytoin must be decreased or discontinued so the ECT seizure can occur

The nurse manager observes a nurse placing several packages of suction catheters in her pocket to use as the nurse provides treatments to several clients with tracheostomies. Which of the following recommendations should the nurse manager make? Select one: a. Leave suction catheters in the supply room until needed b. Store suction catheters in a dedicated space at client's bedside c. Carry catheters in pocket but note how many catheters are used for each client d. Place suction catheters in a treatment tray rather than in a pocket

b. Store suction catheters in a dedicated space at client's bedside -Storing suction catheters in a dedicated space at client's bedside is the best choice. While the cost of supplies must be considered, clients with new tracheostomies for example require frequent suctioning and the client may be placed in jeopardy if the necessary equipment is not readily available. Resource allocation is a responsibility of the unit manager as well as every practicing nurse. Providing cost-effective client care should be balanced with quality care.

How are Hep B and C transmitted?

blood, semen, or other body fluids

What is Chadwick's sign?

bluish discoloration of cervix and vagina and indicates pregnancy

What are mongolian spots?

bluish discoloration over buttocks of dark-skinned newborns and base of spine, probably present on at least one of the parents. Benign and will usually fade in 1-2 years. Document this to avoid later confusion with bruises.

What is tamoxifen used for?

breast cancer

What is the antidote for Magnesium sulfate?

calcium gluconate

What kind of vegetables cause gas formation?

cauliflower and cabbage

What are mast cell stabilizers?

chromone medications used to prevent or control certain allergic disorders. They block mast cell degranulation, stabilizing the cell and thereby preventing the release of histamine and related mediators

What is Hashimoto's thyroiditis?

chronic autoimmune disease which thyroid tissue is replaced w/ lymphocytes and fibrous tissue, so it doesn't produce T3 and T4

What is a cardiac tamponade?

collection of fluid in pericardial sac placing extreme pressure on heart that prevents ventricles from expanding fully. Causes low BP, muffled heart sounds, distended neck veins

What does inotropic mean?

contractility=force of contraction in-sinew, strength, force tropos-turn, direction, way

What is strabismus?

cross-eyed

How often should a client or caregiver inspect O2 equipment?

daily

What is a paradoxical pulse?

decreased pulse amp on quiet inspiration systolic pressure is down by over 10mmHg during inspiration

What does insistently mean?

demanding something; not allowing refusal

What is an allogeneic transplant?

denoting, relating to, or involving tissues or cells that are genetically dissimilar and hence immunologically incompatible, although from individuals of the same species **Allo-different/other

What is an Allen test?

determine whether the patency of the radial or ulnar artery is normal

Dysarthria

difficulty communication, slurred speech

What is xerostomia?

dry mouth from decreased saliva production

What is cullen's sign?

ecchymosis and superficial edema at the umbilicus due to pancreatic necrosis and bleeding in severe pancreatitis

What is an effusion?

escape of fluid into a body part e.g. Fluid in pleural space (chest cavity, outside the lung)

What is the normal contraction frequency during active labor?

every 2-3 minutes

What is mysophobia?

fear of dirt and germs

What is acrophobia?

fear of heights

How is Hep A transmitted?

fecal-oral route

What does paradoxical chest movement indicate?

flail chest

What is a gastric lavage?

flushing out the contents or excess fluid from stomach

What is FiO2?

fraction of inspired oxygen (if you take the air that someone is breathing and find out how much of it is oxygen, you get the FiO2. )

What is intrinsic factor?

glycoprotein required for absorption of vitamin B12 in small intestine

What are the symptoms of Lyme disease?

headache, backache, chills, and fatigue. 3 stages... Stage 1: JOINT AND MUSCLE PAIN Stage 3: S/S become chronic, adding memory problems and fatigue

What is dry, coarse hair a manifestation of?

hypothyroidism

What is periorbital edema a manifestation of?

hypothyroidism

Refractory hypoxemia

hypoxemia that doesn't improve with O2 therapy

What is leukocytosis?

increase in WBCs

What is thrombophlebitis?

inflammation of a vein with clot formation. Common complication of immobility often showing up in calf

What is pleurisy (pleuritis)?

inflammation of the pleura

what is nystagmus?

involuntary eye movement (jerking)

What is myoclonus?

involuntary jerks of body parts

What is Clopidogrel (Plavix) used for?

it is an antiplatelet medication (anticoagulant) - used to prevent MI, stroke, or peripheral arterial disease during an acute myocardial infarction.

What foods are high in folic acid?

lentils, dark and leafy green vegetables

What is chlordiazepoxide (Librium)?

long acting benzodiazepine used for alcohol withdrawal and anxiety

What is aphasia and who is it found in?

loss of ability to understand or express speech, caused by brain damage (common in dementia clients)

What is homonymous hemianopsia?

loss of half of the field of view on the same side in both eyes. will turn head to see entire visual field.

What is the stimulus to breathe for COPD clients?

low PaO2 (normal is 80-100mmHg)

What does an albumin level of 2.8 indicate?

malnutrition and need for nutritional supplementation (albumin level below 3.5 g/dL)

Children who are under three years of age are at risk for what?

maltreatment. Also clients with congenital abnormalities or from unwanted pregnancies.

Capillary refill 2-4 seconds is evidence of what type of dehydration?

moderate dehydration

Irritability is evidence of what type of dehydration?

moderate dehydration

What is Pilocarpine?

muscarinic agonist, miotic drug used for the treatment of glaucoma

What is varenicline used for?

nicotine addiction. helps minimize cravings and minimize withdrawal intensity

What is Meckel diverticulum?

outpouching or bulge in the lower part of the small intestine. The bulge is a leftover of the umbilical cord

What is stomatitis?

painful inflammation and sores of the oral mucosa (can be seen in chemo pt's)

What is the LEEP procedure?

procedure for cervical CA that cuts out or freezes abnormal cells *minimal discomfort, mild cramping at most for several hours

What is malpractice?

professional negligence (failed to uphold standard of care)

What is a conduct disorder?

repetitive, persistent pattern of violating the basic rights of others or age appropriate societal norms or rules for one year or more. behaviors can be aggressive (rape, robbery, animal cruelty) or nonaggressive (stealing, lying, deliberately annoying people)

What is the moro reflex?

startle reflex-initiated by clapping hands and infant will have symmetric movement of arms and legs

What is borborygmi?

stomach growling; a rumbling or gurgling noise made by the movement of fluid and gas in the intestines

What is SIADH?

syndrome of inappropriate ADH: abnormal stimulation to the hypothalamus, causing excessive secretion of antidiuretic hormone (Vasopressin). So, volume expands causing dilutional hyponatremia and hypoosmolality. Sodium continues to be excreted despite hyponatremia, increasing urine osmolality

What is intussusception?

telescoping (folding bowel section in itself) of 1 bowel segment into a distal segment-can occur anywhere in the large or small intestine (ileocecal junction most common)

What is Mirtazapine (Remeron)?

tetracyclic antidepressant. It works by increasing release of norepinephrine and serotonin by central alpha2-adrenergic antagonist effects.

What is purulent drainage?

thicker than serous, contains pus with leukocytes and bacteria

What are the manifestations of a tension pneumothorax?

tracheal deviation, absent breath sounds and distended neck veins

What is a syngeneic transplant?

transplant from a twin

What is finasteride used for?

treats benign prostatic hypertrophy and also helps reduce the risk of prostate cancer.

What is leuprolide used for?

treats cancer of the prostate hormonally. It antagonizes the androgens that androgen-dependent neoplasms require

What is cyclophosphamide used for?

treats leukemia, multiple myeloma, lymphomas, and head, ovary, breast, and lung cancer.

Amitriptyline (Elavil) causes what adverse effects?

tricyclic antidepressant that causes anticholinergic side effects

What is a greenstick fracture?

type of fracture where the bone bends and splits, causing a crack or incomplete break; common in children

What do dilated pupils mean?

uncal herniation causing mechanical compression of the 3rd cranial nerve and subsequent brain stem compromise

What is rifampin used for?

used to treat TB

What is nitroprusside?

vasodilator that decreases cardiac preload and afterload by causing the arterial and venous smooth muscles to relax, resulting in a decreased CO

The nurse should advise what to relieve vaginal dryness and irritation during sex for a menopausal client?

water-based lubricant

What is vernix?

waxy or cheese-like white substance found coating the skin of newborn human babies

Carotenemia?

yellowing of the skin caused by excessive amounts of beta-carotene (Vitamin A precursor) in the body

What herbal supplements increase risk of bleeding?

-Garlic -Ginseng -Ginger -Feverfew -Ginkgo biloba

What are the five categories in the APGAR scale?

-HR -RR -Muscle tone -Reflex irritability -Color

What are the S/S of serotonin syndrome?

-HTN -tachycardia -hyperreflexia and muscle spasms -Hyperpyrexia, sweating

A nurse is creating a plan of care for an infant with an epidural hematoma from a head injury. What interventions should the nurse perform?

-Head slightly elevated in midline position to reduce risk of increased ICP -Perform neuro assessment q15 minutes to monitor changes and ICP -IMPLEMENT SEIZURE PRECAUTIONS (infant is at great risk)

What are indications of a blood transfusion?

-Hemorrhage causing 30% total blood volume loss -Sickle cell disease that causes severe anemia -Hgb 6g/dL or less

A nurse is preparing to administer immune globulin to a client exposed to Hep B. What is important to know about this treatment?

-Hep B immune globulin (HBIG) contains antibodies that provides passive-artificial immunity and protects for the next few weeks or months

How does Cushing's disease affect electrolytes?

-Hyperglycemia -Hypernatremia -Hypokalemia -Hypocalcemia

Important considerations when teaching about an IUD?

-If at risk for STDs you'll need to have cultures before IUD placement -Effective for 3-10 years -May experience irregular spotting during first few months after placement -Can still use tampons -Sign consent form before procedure

How should hemorrhoids be treated?

-Increase fluids and fiber to soften stool and reduce straining -Topical analgesic ointments -Astringent pads

A nurses is assessing a client in labor. What lab findings should the nurse expects?

-Increased WBCs (from physical and emotional stress) -Decreased in B/G from maternal metabolism, physical exertion, and delivery of placenta -Increased temp., flushed cheeks, and warm skin from vascular changes

What are the S/S of hypercalcemia?

-Increased pulse -Increased BP -Cyanosis -Pallor -Muscle weakness -Decreased deep tendon reflexes

How does cold stress affect the newborn?

-Increases O2 demand -Depletes glucose stores -Increases RR -Causes cyanosis

What are some concerns with levothyroxine?

-Increases effects of Coumadin -Increases need for insulin and digoxin -Cimetidine, lansoprazole, and colestipol -Start slowly and cautiously with older adults (esp. with CHD) because of increased O2 demands of the heart

How is acute pancreatitis treated?

-Initial NPO to calm pancreatic enzymes, then enteral nutrition to prevent intestinal atrophy (usually in jejunum to avoid pancreas) -Small, frequent meals (up to 6/day) started with decrease in pancreatic enzymes. Mod-high carbs, high in protein, low in fat *Avoid alcohol and caffeine which can cause GI irritation

What is the prenatal care visit schedule?

-Initial visit in first trimester -Monthly visits through week 28 -Every 2 weeks until week 36 -Every week until birth

How should open irrigation be performed when irrigating a client's indwelling urinary catheter?

-Instill 30-40 mL of irrigation fluid -Use a 30- to 50-mL syringe -Subtract amount of irrigant used from the client's urine output

A client is receiving radioactive iodine therapy (RAI) to treat papillary carcinoma. List three (3) radiation precautions for clients receiving brachytherapy

-Keep door closed as much as possible and keep client in a private room far from others -Wear a dosimeter film badge to track individual radiation exposure -Keep a lead container in client's room if delivery method could result in spontaneous loss of radioactive material. Tongs are available for placing radioactive material in this container. -Do not allow visitors or staff who are pregnant to interact with client or radiation source -Limit visitors to 30 min. visits and have them stand 6ft from source

What are some considerations for proper hearing aid care?

-Keep out of extreme heat or cold because it can cause damage and malfunction -Only wash ear mold (and only if it is detached from hearing aid to avoid damage) (If it doesn't detach, wipe with damp cloth) -Keep clean, cry, and free of ear wax

What are the indications for checking a newborn's B/G for hypoglycemia?

-Lethargy -Hypotonia -Jitteriness -Twitching -Poor feeding -Temperature instability -Apnea -Respiratory distress -Seizures

What findings would be expected in a client diagnosed with osteomyelitis?

-Leukocytosis -Elevated erythrocyte sedimentation rate (ESR) (elevates in presence of infection/inflammation) -Boring, constant pulsating pain -Positive wound cultures

A nurse is caring for a post op client following a knee arthroplasty and requires the use of thigh-length SCDs. What actions should the nurse take?

-Make sure two fingers can fit under the sleeves to avoid inhibiting circulation when sleeves inflate -Set the ankle pressure between 35-55 mmHg

What nursing interventions would be appropriate for a client who concerned about body image after a mastectomy?

-Meeting with someone from a local support group -Educate client about breast prostheses including properly fitting prosthesis -Encourage the client to discuss reconstruction alternatives with surgeon -

A nurse notes late decelerations on the fetal monitor. What priority actions should the nurse take?

-Monitor BP-Turn client onto side -Administer IV fluids -Discontinue oxytocin -Give O2 -Prepare for delivery

What are the nursing interventions for Grave's Disease?

-Monitor HR, BP, and weight (risk for nutrient issues) -Keep environment cool and quiet (b/c overstimulated, irritable) -Educate about meds, SE, treatments (radioactive iodine and thyroidectomy), thyroid storm -Give antithyroid meds (Tapazole "Methimazole" or PTU "Propylthiouracil"), BBs to treat S/S

Nursing interventions for hypothyroidism?

-Monitor for hypotension, bradycardia, dysrhythmias -Monitor for Myxedema Coma (exaggerated S/S of hypothermia that can cause death) -Avoid sedatives and opioids b/c they're very sensitive to them since everything is slowing down and can put them into Myxedema coma -Orient periodically if mental status is affected -Increase activity level gradually, provide rest periods to avoid fatigue and decrease myocardial O2 demands -Anti-embolism stockings to promote venous return -provide a low-calorie, high-bulk diet, and encourage activity to prevent constipation and weight loss -Provide meticulous skin care. Turn and position q2 hours -Provide extra clothing and blankets for decreased cold tolerance

What are some postpartum depression interventions?

-Monitor mother-baby interactions. Encourage bonding activities -Monitor client's mood and affect -Reinforce that feeling down in postpartum period is normal and self-limiting -Encourage communication of feelings, validate and address personal conflicts, and reinforce personal autonomy -Reinforce med compliance

What are some nursing interventions for CKD?

-Monitor vascular access or peritoneal dialysis insertion site -Restrict Na+, K+, phosphorus, and Mg -Diet high in carbs and moderate in fat -Restrict fluid intake based on urinary output -Prevent infection (clean broken skin areas and prevent damage elsewhere)

A nurse is caring for a neonate diagnosed with a congenital heart defect. Which of the following S/S would the nurse note if the client was experiencing HF? -Mottling -Tachypnea -Feeding difficulties -Hyperglycemia -Bounding pulses

-Mottling: tissue hypoxia and vessels are compensating for HF creating a mottled splotchy appearance -Tachypnea: compensatory mechanism to increase O2 supply -Feeding difficulties: Dyspnea and activity intolerance make it difficult for neonate to consume adequate calories

A nurse is assessing a client with Cushing's disease. What findings should be expected?

-Muscle atrophy (from decreased nitrogen and mineral loss) -thin skin -Bruising and striae from fragile blood vessels -HTN (from fluid overload

What are the S/S of addison's disease?

-Muscle or joint pain -N/V -abd pain -Postural hypotension -Fatigue -Salt craving -Weight loss

What are common alcohol withdrawal S/S?

-N/V -Tremors -Restlessness -Inability to sleep -Depressed mood or irritability -Increased HR, BP, RR, temp. -Tonic-clonic seizures -Illusions

What are some alcohol abstinence maintenance medications?

-Naltrexone (Vivitrol) -Acamprosate -Disulfiram

What strategies can help ADHD clients manage symptoms?

-Offer verbal instruction combined with visual cues (helps client better focus on request or task) -Model positive behaviors (helps client cope with appropriate behavioral outcomes) -Use charts to assist with organization

What are the two major complications of pericarditis?

-Pericardial effusion -Cardiac tamponade

What are some environmental interventions for delirium?

-Place client in a room with windows to help with time orientation -Provide a well-lit environment, minimizing contrasts and shadows -Cover or remove mirrors to decrease fear and agitation -Provide compensatory memory aids, such as clocks, calendars, photographs, memorabilia, seasonal decorations, and familiar objects. Reorient as necessary

What are some manifestations of mild lithium toxicity?

-Polyuria -Diarrhea -lassitude=state of physical or mental weariness; lack of energy -Muscle weakness

What conditions increase risk of postpartum hemorrhage?

-Pregnancy-induced HTN -Placental abruption (or retained placenta) -Uterine atony -Infection -Obesity -Prolonged labor -Clotting problems -Assisted delivery

What are the risk factors for preterm labor?

-Previous preterm labor or birth -Multiple gestation -Premature dilation or shortening of cervix -History of cervical trauma -High BP -Peeclampsia -<18 y/o or >35 y/o -infection -chronic illness -lack of prenatal care -untreated anxiety, depression, or stress -domestic violence -poor nutrition -use of ETOH, tobacco, or elicit drugs

What are the indications for discontinuing pitocin?

-Prolonged or excessively strong contractions -Signs of any fetal hypoxia and or fetal distress -Signs of uterine or placenta abruptio -Evidence of an ADH effect -HTN

A nurse is teaching parents of an infant how to administer antibiotic eardrops. Which of the following instructions should the nurse include in the teaching?

-Pull pinna downward and straight back during administration -otic solution should be at room temp. to avoid discomfort -Massage anterior ear after administration to assist med to reach target area

What are some symptoms indicating an anastomic leak?

-Restlessness -Oliguria -Tachycardia -Back, shoulder, or abd pain

What are the assessment findings of preeclampsia?

-Severe HA -Blurred vision -Confusion -N/V -Decreased urinary output

What are some teaching points for a client with a new prescription for a metered dose inhaler (MDI)?

-Shake inhaler for vigorously 3-5 seconds after inserting canister to mix med thoroughly -Rinse mouth with TAP WATER after inhaling med (med can cause irritation to the mucosa, mouth wash can further dry the mouth) -Only need to wait 20-30 seconds between inhalations of receiving more than one inhalation of med

What are some of the applications for a nerve block for pain relief?

-Short-term pain management after surgery -To use as a type of anesthesia for minor surgery

What maternal behaviors indicate birth is imminent?

-Sitting on one buttock -Making grunting sounds -Bearing down during contractions -Outright statements like "the baby is coming now"

How should a nurse instruct a mom to evaluate a completed newborn feeding?

-Slowing of newborn sucking -Softened breast -Sleeping

1. A nurse is providing dietary teaching to a client newly diagnosed with constipation-predominant irritable bowel syndrome. List two (2) teaching points the should share with the client about dietary practices.

-Slowly increase amount of fiber in diet. It helps reduce constipation, but can also worsen gas and cramping -Consider whole grains, beans, fruit, and vegetables -A fiber supplement might cause less gas and bloating

What factors increase GERD?

-Smoking -Eating large meals -ETOH -Coffee -Obesity -Pregnancy -Fried/fatty foods -NSAIDs/aspirin

What are some nursing care considerations for newborns with abstinence syndrome?

-Swaddle to reduce self-stimulation and protect skin from abrasions -Administer frequent, small feeding of high-calorie formula-may need gavage feedings -Try various nipples to compensate for a poor suck reflex -Ensure suction equipment is available to reduce aspiration risk -FOR COCAINE newborns - avoid eye contact and using vertical rocking, pacifier -Initiate consult with CPS

What are the signs of respiratory distress in children?

-Tachypnea (>32 breaths/min) -Tachycardia -Nasal flaring -Retraction of accessory muscles -agitation, irritability, anxiety -pallor -clammy, moist skin

A nurse is planning care for a client who has RA and has moderate-severe pain in multiple joints. What actions should the nurse take?

-Take frequent rest periods throughout day (while also exercising regularly to maintain muscle strength, joint function, and ROM) -Use ice to reduce inflammation and pain -

SE of radioactive iodine?

-Taste change-things taste like metal -Nausea -Swelling of saliva glands

What are some important things to remember with antithyroid meds?

-They can cause agranulocytosis and thrombocytopenia -Don't stop taking them abruptly (takes awhile, and ending abruptly can cause thyroid storm) -Take at same time every day -Watch for thyroid storm -Avoid iodine-rich foods b/c fosters thyroid hormone development (kelp, dairy products, eggs) -Don't take ASA b/c it increases thyroid hormone

What do you want to watch for after a thyroidectomy?

-Thyroid storm. When they remove it, lots of T3 and T4 can be released into the body causing a thyroid storm after surgery -Monitor calcium level b/c sometimes parathyroid gets damaged during surgery leading to hypocalcemia -Splint neck so they don't put extra pressure on neck -Monitor for respiratory distress and put in semi-fowler's in case of bleeding, swelling

Teaching instructions for levothyroxine?

-Treatment begins slow and the dosage increases every 2-3 weeks until therapeutic range is obtained -Take before breakfast -Lifelong med to promote ongoing thyroid function -Adverse effects: irritability, tremors, tachycardia, palpitations, heat intolerance and/or rapid weight loss

What are some leadership functions associated with delegation?

-Use it as a time management strategy -Function as a resource person in delegating tasks to subordinates -Identify situations appropriate for delegation

Some considerations for dementia clients?

-Use symbols instead of written signs b/c reading may confuse them -Provide finger foods at meal time b/c they have difficulty sitting still and tend to wander, creating a concern for weight loss and malnutrition (this helps them eat on the run)

A nurse is teaching a client and his family how to care for his tracheostomy at home. What instructions should the nurse give

-Use tracheostomy cover when outsdoors (protects airway from cold air, dust, and airborne particles) -Use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation -NEVER REMOVE OUTER CANULA FOR CLEANING-it stabilizes the airway

What S/S would indicate increased ICP in a school-aged child?

-Vomiting -HA -Increased clumsiness -(not high-pitched crying. That would be for an infant)

What are the S/S of Grave's Disease?

-Weight loss -HR increase -Diarrhea -Heat intolerance *Unique: -Goiter (overstimulation of thyroid) -pretibial myxedema (Red swelling of skin on lower legs/feet with orange peel texture that can progress to face, chest arms)

What are the markers of dehydration in a newborn?

-Weight loss >10% -Decreased urine output -Dry oral mucosa -Sunken or depressed fontanels

What are some risk factors for asthma?

-Young children are more susceptible to infections -Second-hand smoke

A nurse is providing client teaching about the basal body temp. method of birth control. What info should be included in teaching?

-Your body temp might decrease slightly (1 degree F) just prior to ovulation -Measure body temp upon waking each morning prior to getting out of bed -Body temp. rises about (0.7-1.4 degrees F) after ovulation and remains elevated until 2-4 days prior to start of menstruation

What are the S/S of irritable bowel syndrome?

-abd pain -diarrhea -constipation -feelings of incomplete evacuation -Bloating -Flatulence

What are the signs of dehydration in infats?

-dry mouth -sleepiness -decreased urine output (measured by >3 hours w/o wet diaper) -sunken eyes -sunken fontanelles -rapid heartbeat

What are examples of non-reassuring FHR patterns?

-fetal tachycardia -bradycardia -late decelerations with good, short-term variability

What is the presentation of ulcerative colitis?

-frequent diarrhea (containing blood) -weakness -anemia (from blood loss in fri -abd pain -weight loss

What are the SE of Bumex (bumetanide)?

-hypokalemia -postural hypotension -Ototoxicity -Nephrotoxicity -HA -loss of appetite

Universal consent covers what things?

-med administration -noninvasive diagnostic tests

Teaching instructions for CKD clients?

-notify provider if skin breakdown occurs -Avoid antacids containing Mg (because Mg is already high in these clients) -follow fluid intake guidelines

A nurse is teaching about injury prevention to the parent of a toddler. What safety measures should be taught?

-throw rug under crib in case toddler falls out -Toy box without a lid or that locks in open position. Not one that locks in closed position so toddler doesn't suffocate if entrapment occurs -Move toddler to youth bed when they can climb out of crib

What are the manifestations of acute pancreatitis?

-usually sudden and severe; right upper abdominal pain radiates to back, worse after eating, may lessen if patient leans forward or pulls knees to chest -Anorexia -N/V

What is the therapeutic range for lithium and when do toxic effects occur?

0.4-1.3 mEq/L 1.5+ mEq/L

Creatinine normal range?

0.6-1.2mg/dL

What score would a HR of 98 get on the APGAR?

1 0-absent 1-<100 2-<100

What score would a pink body, cyanotic hands and feet receive on the APGAR?

1 (color) 0-blue, pale 1-Pink body, cyanotic hands and feet 2-completely pink

What score would a grimace get on the APGAR? What category?

1 (for reflex irritability) 0-none 1-grimace 2-cry

How soon should a client be seen by a provider after the need for restraints has been determined?

1 hour

When should captopril be given for optimal absorption?

1 hour before meals

How far in advance should sildenafil be taken prior to sexual activity?

1 hr

What are the adverse effects of hydrochlorothiazide?

1) Dehydration and hyponatremia (monitor for minimal urine output, weight loss, electrolyte imbalances) 2) Hypokalemia and hypochloremia (Monitor cardiac status and K+ levels; teach to consume foods high in potassium, recognize manifestations of hypokalemia (N/V, general weakness, fatigue, leg cramps) 3) Hyperglycemia 4) Hyperuricemia, hypomagnesemia, increased lipids (Monitor uric acid, Mg, and total, HDL, LDL cholesterol and triglycerides; watch for low Mg (weakness, muscle twitching, tremors)

When are sublingual meds prescribed?

1) Drug needs to enter circulation quickly 2) Client has difficulty swallowing 3) Med is not well absorbed in GI tract 4) Digestion reduces the effects of the drugs

What are the adverse effects of acyclovir?

1) Phlebitis and inflammation at infusion site (so rotate IV sites and monitor for swelling and redness) 2) Nephrotoxicity (so give slowly over 1 hr, ensure adequate hydration during and 2 hrs after, and use with caution in dehydrated or renally impaired clients) 3) Nausea, HA, diarrhea (notify provider if seen)

What are two considerations for clients having surgery with a latex allergy?

1) Place monitoring devices in a stockinette to prevent direct contact with client's skin 2) Don't use rubber injection ports for fluid administration b/c they contain latex (should use latex-free products with stopcocks)

What are the two types of calcium channel blockers?

1) Those affecting peripheral arterioles (hypertension) 2) Those affecting arterioles (hypertension) and coronary arteries **(also treat dysrhythmias)

What are some actions to take to prevent rebound congestion when taking phenylephrine nasal spray?

1) Use for short time (3-5 days) 2) Taper use 3) Monitor CNS S/S 4) Avoid in clients who have heart or coronary artery **(True for other decongestants)

How fast does the fundus descend after birth?

1-2 cms/day

How often should smoke detector batteries be changed?

1-2 times/yr

How long does it take for sublingual nitroglycerin to kick in?

1-3 minutes

What are the S/S of sepsis?

1. Changes in LOC 2. Persistent recurrent fever, 3. Tachycardia 4. Tachypnea 5. Hypotension 6. Oliguria 7. Increased WBC count

What are some risk factors for chronic kidney disease (CKD)?

1. Diabetes Mellitus 2. HTN 3. Autoimmune disorders 4. Recurrent severe infections

What considerations should be present in transferring a CVA client?

1. Engage locks on wheelchair and bed 2. Utilize an assistive device to facilitate transfer (rope attached to headboard allows client to pull) 3. Assist client to move toward their stronger side 4. Detach arm and foot rests from wheelchair if possible to avoid tripping

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. What are the steps the nurse should take?

1. Obtain death pronouncement from the provider 2. Remove tubes and indwelling lines 3. Wash client's body 4. Ask the family members if they would like to view the body 5. Place a name tag on body before transfer

What does race mean?

1. rescue 2. alarm 3. confine 4. extinguish

What is the expected range for magnesium?

1.3-2.1 mEq/L

What is the expected reference range for magnesium?

1.3-2.1 mg/dL

What PT values should a nurse expect when a client is on warfarin?

1.5-2.5x the baseline of 11-12.5 seconds (so, 17-32 seconds)

When do umbilical detach?

10-14 days

Normal creatinine kinase levels for females?

10-70 units/L

What is the Montevideo unit (MVU) range?

100-250mmHg during first stage of labor and increase to 300-400 mmHg during second stage -Calculated by subtracting baseline uterine pressure from peak contraction pressure for every contraction occurring in 10 min period. Then add pressure produced by each contraction

What is the expected reference range for prothrombin time (PT)

11-12.5 seconds -During warfarin therapy, the nurse should expect values 1.5-2.5x the baseline (17-32 seconds)

What is a normal FHR?

110-160 bpm

A nurse is providing discharge instructions to a client who has a partial-thickness burn of the hand. How often should she teach dressings should be changed?

12-24 hours to allow for wound inspection *Wrap fingers individually to allow for functional use of hand while healing occurs *Perform ROM exercises for each finger to promote function of injured hand

How long does the pain of stable angina last for?

15 min or less -relieved by nitroglycerin

How long after ophthalmic meds are administered should contacts be put back in?

15 minutes

At what age should a child be able to speak 10+ words?

18 mo

What are the types of perineal lacerations?

1st degree-4th degree depending on size and depth of cut 1st degree-only perineal skin (skin between vaginal opening and rectum). Typically heals on its own 4th degree-extends through anal sphincter and into mucous membrane lining rectum

In what trimester will a woman develop breast tenderness?

1st trimester

What would a good cry get on the APGAR?

2 (for RR) 0-Absent 1-Slow, weak cry 2-Good cry

What would a well-flexed observation get on the APGAR?

2 (for muscle tone) 0-flaccid 1-some flexion 2-well-flexed

When can a client repeat the dose of sumatriptan for an unrelieved headache?

2 hrs

When does colostrum start to form?

2-3 days after birth

How long until a colostomy begins to function after surgery?

2-4 days

How far should a rectal thermometer be inserted to avoid injury?

2.5 cm (1 in.)

What normal bicarbonate (HCO3) range?

22-26 mEq/L

At what point during gestation does the fundus become even with the umbilicus?

22nd week of gestation

What type of needle should be used to administer heparin?

25- or 26-gauge 3/8 in or smaller

How long do seizures from electroconvulsive therapy (ECT) last?

25-60 seconds

Normal creatinine kinase levels for males?

25-90 units/L

A client should not have more than how much output from a drain after a surgery?

250 mL in first 24 hours

In what trimester will a woman feel a renewed sense of energy?

2nd trimester

In what trimester will a woman feel the first fetal movements?

2nd trimester

When does the grasp reflex disappear?

3 m

At what age should a client be able to hold head up?

3 mo

An infant should be able to raise its head when placed on abdomen at what age?

3 months. This tummy time helps infant strengthen upper body and neck muscles to get good head control when sitting upright and crawling

How long are IUDs effective at preventing pregnancy?

3-10 years

When does breast engorgement occur and how should it be managed?

3-5 days after birth. -Cold compresses applied AFTER breastfeeding -Warm shower or warm compresses applied before breastfeeding can increase milk flow and facilitate letdown reflex -Applying a small amount of breast milk to sore nipples and letting them air dry after feeding will soothe discomfort and promote healing (fats and protein in milk increase healing of cracks and fissures that develop)

When does breast engorgement begin?

3-5 days postpartum

How long are kids contagious with RSV?

3-8 days

What is the expected reference range for albumin?

3.5-5 g/dL

How long does the pain of an MI last for?

30 min or longer -requires opioids analgesics for relief

How long should a nurse hold direct pressure on puncture sites after administering alteplase?

30 min. or until oozing of blood stops

How long should a client with dysphagia sit up before and after meals?

30 minutes before and 30 minutes after to help them drain secretions

What is the normal urine output range?

30-50 ml/hr

What is the normal respiratory rate in a newborn?

30-60 breaths/minute

How long should the nurse elevate the HOB for a client after an intermitting feeding?

30-60 minutes

How many words should a child be able to speak at 24 mo?

300 words. Also two- and three-word phrases and pronouns

What is the expected reference range of Hct for a child?

32-44%

What is the normal range for HDL?

35-80 mg/dL

What is the normal hematocrit range for a female?

36-46%

What is the expected axillary temp. range for newborns?

36.5 C (97.7F) to 37.2 C (99F)

Expected Hct range for females?

37-47%

In what trimester will a woman experience frequent urination?

3rd trimester

When should antacids be taken relative to levothyroxine?

4 hours away on either side

When does the stepping reflex disappear?

4 weeks of age. (infant makes stepping movements when holding infant upright with feet touching a flat surface)

How long must a mom avoid getting pregnant after receiving the rubella immunization?

4-12 weeks to prevent risk of teratogenic effects to baby

Over how much time should morphine be administered over?

4-5 minutes to prevent hypotension and respiratory depression

Intermittent feedings are administered how often and for how long?

4-6x times/day in equal portions 30-45 min.

What is the magnesium level range for a client with preeclampsia?

4-7 mEq/L

What are therapeutic levels of magnesium sulfate?

4-8 mg/dl

What is the expected aPTT value?

40 seconds

What is the normal hematocrit range for a male?

41-53%

What is the expected Hct range for males?

42-53%

At what angle should a baby's carseat be set at?

45 degree angle to keep newborn from slumping and experiencing an airway obstruction

What is the normal aPTT value for a client on heparin?

45-80 seconds (normal is 30-40 seconds)

The nurse should instruct parents to set the water heater to what temperature?

49C (120F) to reduce burn risk for infants

If more than one opthalmic med is to be administered, how far apart should they be given?

5 minutes

How long should a client remain in the same position when administering nasal decongestant drops?

5 minutes to make sure drops do not run out when he sits up or stands up

What is the maximum recommended rate for K+ infusion?

5-10 mEq/hr **Too rapid of an infusion can result in irritation, pain, and post-infusion phlebitis, and cardiac arrhythmias

When should children take albuterol metered-dose inhalers relative to playing sports?

5-20 minutes before. Medication's effects begin immediately, peak in 30-60 min. and can last for up to 5 hours

What is the expected reference range for urine osmolality?

50-1200 mOsm/kg

How much blood must be lost to be considered a hemorrhage after birth?

500 ml (vaginal) 1000 ml (C-sectino)

How long should a diaphragm be left in place after sex?

6 hours

At what age should an infant be able to role from supine to prone?

6 mo

At what age should an infant exhibit a fear of strangers?

6 mo when the child develops ability to recognize parents

When will clients notice an improvement in urinary continence in relation to their Kegel exercise therapy?

6 wks, but may take several months

How long should you hold an insulin pen in place after injecting insulin?

6-10 seconds in subcutaneous skin to ensure insulin is received

How long does rifampin treatment last for?

6-9 months

What is the therapeutic aPTT level for a patient on heparin?

60-80 seconds (40 seconds multiplied by factor of 1.5 to 2)

What is the normal contraction duration during active labor?

60-90 seconds

A client diagnosed with atrial fibrillation has a pacemaker set at a ventricular rate of 70 bpm. Which of the following findings should the nurse immediately report to the provider? -HR 96bpm and irregular -HR 96bpm and regular -HR 76bpm and irregular -HR 60bpm and regular

60bpm and regular (b/c the pacemaker didn't stop it at the rate it was supposed to)

What is the therapeutic range for T3 level?

70-205 ng/dL

When must TPN tubing be changed by?

72 hours (but most often every 24 hours)

What is the expected range for fasting blood gluocse?

74-106 mg/dL

What is the normal score for a non-stress test?

8-10. Each variable is rated 0-2.

What's a normal APGAR score?

8-9 (Perfect is a 10/10)

How old must a client be to increase their risk for falls?

80 y/o

At what age should a child understand the word "no"?

9 mo

What is the normal fasting plasma glucose range for a diabetic client?

90-130 m/dl

What is the normal range for cardiac troponin T?

<0.20 ng/ml

Maximum amount of fluid that can be administered through an intradermal injection?

<0.5 mL 10- to 15-degree angle 1/4 inch depth

How often must a client saturate a perineal pad to be considered excessive vaginal bleeding/postpartum hemorrhage?

<1 hr. This can cause dizziness and syncope, increasing fall risk

What are normal lead levels in children?

<10 mcg/dl

When should you implement seizure precautions in relation to Na+ changes?

<135 mEq/L or >145 mEq/L

How long should a residual limb be elevated postop?

<24 hours. Longer can cause hip contractures and lead to difficulties with future ambulation

What Hct level is concerning in a pregnant woman?

<33%

A scalp electrode for internal fetal monitoring would not be used on a baby less than how many weeks gestation?

<34 wks

How soon should a diaphragm be inserted before sex?

<4 hours. If too early, it won't be effective and you'll need additional spermicide

At what HR should a nurse withhold a dose of a beta blocker med?

<50/min

How much fluid does a syringe pump push?

<60 mL (its the pump that sits on a surface and pushes a syringe's fluid over a preset period of time)

What is the normal HgA1C level?

<7%, with the optimal range being 4-6%

Chest tube drainage should be how much per hour?

<70 mL/hr

At what systolic blood pressure should a vasodilator be withheld?

<90 mmHg

When is melena seen?

=dark, tarry stools Associated with bleeding in the upper GI tract

When is steatorrhea seen?

=foul-smelling, fatty stools that result from malabsorption of dietary fats Seen in cystic fibrosis, chronic pancreatitis, and celiac disease

What triglyceride level increases risk of heart disease in females?

>135 mg/dL

What triglyceride level increases risk of heart disease in males?

>160 mg/dL

What total cholesterol level increases risk of heart disease?

>200 mg/dL

How do you measure dehydration in infants?

>3 hours without a wet diaper

What C-reactive protein level increases risk of heart disease?

>3.0 mg/L (1-3 mg/L is average risk)

At what lead level should a nurse schedule chelation therapy?

>45 mcg/dL

What is aminophylline?

A bronchodilator-used to treat the symptoms of asthma, bronchitis, and emphysema. How? It relaxes muscles in your lungs and chest to allow more air in, decreases the sensitivity of your lungs to allergens and other substances that cause inflammation, and increases the contractions of your diaphragm to draw more air into the lungs.

What is sodium polystyrene sulfonate?

A cationic exchange resin administered to treat hyperkalemia

What is iprtropium?

A cholinergic antagonist used for asthma. It blocks the parasympathetic nervous system, providing relief of acute bronchospasms

For what type of client should an antepartum nurse initiate seizure precautions?

A client with severe gestational HTN b/c it can trigger seizure activity

In a client with skeletal traction for tibia-fibula fracture. What does crusting at the pin sites mean?

A common finding and some providers may prefer crusts be left intact to create a natural barrier

A client is recovering from acute respiratory distress syndrome (ARDS). Which clinical manifestation requires immediate attention by the nurse?

A decrease in blood pressure. Fluid may leak into the interstitial space causing hypovolemia

Buck's traction

A device for applying traction for a femoral injury. Adhesive tape on skin pulls leg into traction with a weight tugging on a pulley. Promotes proper healing after a fracture so muscles don't pull broken bones inappropriately

What is aliskiren?

A direct renin inhibitor that inhibits RAAS cascade and effectively causes vasodilation

What is a positive inotropic drug?

A drug that increases availability of calcium (thereby increasing contractility)

What is a vesicant?

A drug that is capable of causing tissue injury/blistering -e.g. chemotherapeutic drugs, vasopressors, and antibiotics

Peripheral artery disease

A form of peripheral vascular disease in which there is partial or total blockage of an artery, usually one leading to a leg or arm.

A nurse is caring for a client who had a vaginal delivery 2 hr ago and is reporting increasing perineal pain and pressure. The nurse examines the client's perineum and sees a 4 cm (1.6 in) area of purplish discoloration with swelling. This should be interpreted as what?

A hematoma. This is a collection of blood in connective tissue while overlying skin or mucous membranes remain intact. Small ones reabsorb on their own but large ones may require incision and ligation of bleeding vessels

What is pertussis?

A highly contagious bacterial infection - it causes whooping cough, and vomiting that can last 6 weeks , and runny nose, sneezing, congestion, and mild fever

What is cromolyn?

A mast cell stabilizer that prevents exacerbations of chronic asthma. Should be taken routinely (3 or 4x/day)

What is hydroxyurea?

A medication used to prevent sickle cell crisis.

What is submersion injury?

A near drowning, hypoxic incident in which the child has survived for 24 hours after

What is didanosine?

A non-nucleoside reverse transcriptase inhibitor used for HIV. Reduces HIV infection's cognitive manifestations by inhibiting DNA synthesis and viral replication; however, it must be taken with other retrovirals to decrease risk for resistance development

What is a hiatus?

A pause or gap in a sequence, series or process In medicine, (a hiatal hernia) is the protrusion of stomach through the esophageal opening in the diaphragm-stomach goes through diaphragm

A client complaining of pain or vaginal pressure and has a large amount of bright lochia with a firm uterus likely has what?

A perineal laceration

How is internal fetal monitoring administered?

A probe that measures HR is inserted into baby's presenting part (usually scalp if cephalic presentation) *Mother must have a cervical dilation of at least 2 cm before probe can be internally placed

Friability

A state where mucosa becomes inflamed and bleeds readily

What does abdominal distention at birth indicate?

A tumor or an abd wall defect such as a ruptured viscus (singular for viscera)

What is open reduction and internal fixation?

A type of treatment to fix a broken bone. It puts the pieces of a broken bone back together so they can heal. Open reduction means the bones are put back in place during a surgery.

A nurse is assessing an adolescent who has scoliosis. What finding should the nurse expect?

A unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curve in the thoracic spine resulting in asymmetry of ribs, shoulders, hips, or pelvis

What is pressure support ventilation (PSV)?

A ventilatory mode in which spontaneous breaths are partially or fully supported by an inspiratory pressure assist to decrease work of breathing

A nurse is caring for an adolescent client admitted to the nursing unit three days ago. The client is withdrawn, unwilling to eat, and does not interact with the staff. The nurse correctly understands which of the following would provide the best support for this client?

A visit with friends from school. -Peers are the most important support and influential component of an adolescent's life

A nurse is planning discharge interventions designed to promote and maintain independence and maintain health for a child with a spinal cord injury (SCI). Which of the following interventions are appropriate? Select all that apply. a. Evaluating bowel training b. Promoting an exercise program c. Encouraging annual flu vaccinations d. Discussing sexuality issues E. Assessing food choices.

A, B, C, E a. Evaluating bowel training Effective bowel training that allows the client to be continent of stool with foster independence in the SCI client. b. Promoting an exercise program The nurse should make certain that structured exercise is provided through physical or occupational therapy to promote strength and endurance. c. Encouraging annual flu vaccinations An SCI client should take measures to prevent illnesses such as receiving the flu or pneumonia vaccination. e. Assessing food choices The nurse should promote a high fiber diet with increased fluid intake to assist with bowel and bladder training. At discharge an appropriate intervention would be to evaluate food choices made by the client.

A nurse is collecting data on a child who is diagnosed with bacterial epiglottis. Which of the following clinical findings are associated with the illness? A. Drooling B. Stridor C. Difficulty swallowing D. Croupy cough E. High-grade fever

A, B, C, E Drooling, stridor, difficulty swallowing, high-grade fever

A nurse is educating a client who is scheduled for a nonstress test (NST). Which of the following are correct (Select all that apply)? A. NST measures the relationship of FHR to fetal movement B. The NST is useful in calculating gestational age. C. The NEST is not useful after 38 weeks gestation. D. The NST is a primary method of antenatal fetal assessment. E. The NST can easily be performed in an outpatient setting.

A, D, E *NST is useful up to term

A nurse has received an inappropriate assignment. Which of the following actions should the nurse take? Select all that apply. a. File an unsafe staffing complaint with the appropriate personnel b. Accept the assignment and complete tasks as comfortable. c. Delegate care of assigned client(s) to another nurse d. Refuse the assignment and report to nurse manager e. Bring the inappropriate assignment to attention of charge nurse

A, E A. File an unsafe staffing complaint with appropriate personnel if no satisfactory resolution of assignment after reporting to charge e. Bring the inappropriate assignment to attention of charge nurse to negotiate new assignment at beginning of shift

A nurse is assessing a client's ECG strip and notes an irregular HR of 98/min with no clear P waves. Which cardiac dysrhythmia is it?

A-fib. Multiple rapid impulses from many foci cause rapid, disorganized depolarization of atria. This causes a chaotic rhythm with no clear P waves, no atrial contractions, and an irregular rhythm

A community based nurse receives a client referral. Which of the following actions should be performed first? Select one: a. Collaborate with the health care team and the referring agency to assess client needs. b. Educate the client about the community resources that are available c. Encourage the client to contact appropriate agencies. d. Obtain information about community resources accessible to the client.

A. Collaborate with health care team and the referring agency to assess client needs. Understanding client needs is the first step in the referral process. Continuous coordinated care among all health care providers involved in a client's care is essential to avoid duplication of effort by the various personnel caring for the client.

What are the five rights of delegation?

A. Right task B. Right circumstance (health status and complexity) C. Right person (competency and scope of practice) D. Right direction or communication E. Right supervision

A nurse is reviewing laboratory data for a client. The nurse should identify that which of the following results indicates the client is at risk for heart disease (Select all that apply.) A. Total cholesterol 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. C-reactive protein 0.5 mg/L

A. Total cholesterol 245 mg/dL C. LDL 140 mg/dL

How does lisinopril affect potassium levels?

ACE inhibitors may cause hyperkalemia. Suppression of angiotensin II leads to decreased aldosterone levels. Since aldosterone is responsible for excreting potassium, ACE inhibitors can lead to elevated K+.

Organization and structure are important for what type of clients?

ADHD clients

On what area of an infant should you assess for Hirschprung disease (HD)?

Abd for distention and visible peristalsis

Where should heparin be injected?

Abdomen above level of iliac crest, at least 2 inches from umbilicus

An elderly client is three days post-operative an anterior and posterior colporrhaphy. What assessment has the highest priority in this client's care?

Abdomen firm and tender to palpation above symphysis pubis. This is an indication of urinary retention-a possible complication of colporrhaphy