ATI CAPSTONE COMBO ASSESSMENT A&B

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ATI CAPSTONE COMBO ASSESSMENT A&B 1. what is montelukast (singular) for? a. a leukotriene modifier, and is taken on a regular basis, once a day, and not prn, and is not used for exercise induced ast... hma 2. what does advance directives contain? a. written instructions regarding end of life care 3. what is the greatest risk to a pt receiving hemodialysis? a. disequilibrium syndrome as a result of rapid loss of fluids and decrease bun 4. what is the clinical manifestation of disequilibrium? a. restlessness and decreased level of consciousness 5. what are expected findings in hemodialysis? a. elevated temp weight loss decreased bp 6. what should the nurse do when a pt feels lightheaded and begins to fall? a. spread feet apart and extend one leg for the pt to slide down while lowering the pt to the floor 7. what are the characteristics of a pt with dependent personality disorder? a. they have problems making everyday decision without input from others 8. a pregnant pt who is bleeding is always? a. priority 9. what should a pregnant pt with urgency and frequent urination do? a. should perform kegel exercises 10. what should a pregnant pt with odorless vaginal mucus do? a. practice good hygiene, use perineal pads 11. a pregnant pt with edema of the ankles do? 12. avoid prolonged standing, to wear support hose, and rest through out the day with legs/hip elevated 13. when should a colostomy bag be changed? 14. when is 1/3 -1/2 full 15. how large should the opening of the stoma pouch be? 16. no larger than 1/4 inch 17. what should the pt with a colostomy avoid? 18. the use of moisturizers, which will decrease the adherence of the pouch to the skin 19. what should the pt do with the pouch removing it? 20. they should empty the pouch to avoid spilling the effluent on to the skin 21. where should drops be instill into? 22. into the conjuctival sac 23. what is a positive way of dealing with a terminal illness? 24. "remembering things they used to do together" 25. what are normal findings after a colonoscopy? 26. abd cramping fatigue passage of liquid stools 27. what are unexpected finding after a colonoscopy? 28. guarding- can indicate bowel perforation 29. what do you do if an order is questioned? 30. the nurse should record seeking clarification from the provider 31. what should pt with gastritis eat? 32. a well balanced diet, they should keep a record of foods that cause discomfort, pts can modify their diet accordingly 33. what is the cause autonomic dysreflexia? 34. bladder distention 35. what are s/s of icp? 36. restlessness change in LOC 37. what is late s/s of ICP? 38. widening pulse decerebrate posturing 39. when can a child with varicella(chickenpox) return school? 40. the child can return to school when the blisters are dry and no longer drained (scabbed over) 41. what is an appropriate behavior of a pt with hx of violence? 42. pt will avoid violence provoking situations 43. what is a skin cancer prevention? 44. pts should use sunscreen that protects against uva and uvb 45. what is the first thing you should do with excessive lochial discharge? 46. perform a fundal massage 47. what is the nurse responsibility of the nurse when witnessing the pts signature on an informed consent? 48. that the pt is fully informed and understands the procedure befor signing the consent form 49. who are at greater risk for std? 50. females because of increased vascularity to the vagina 51. does trichomonas vaginalis increased the risk for cervical cancer? 52. NO 53. Gonorrhea can lead to? 54. pelvic inflammatory disease and tubal scarring and can result in infertility 55. what should you do with postmortem care? 56. always check about religious practices prior to body preparation in order to honor fam wishes 57. what can you not give to a pt with thickened liquids? 58. no ice chips no water no icepops 59. what can a pt with thickened liquids have? 60. oatmeal 61. what should a pt do with incentive spirometer? 62. they should elevate the cylinder by inhaling deeply assume semi fowlers or high fowlers position 63. in order to maintain sterile technique what should the nurse do? 64. should open all sterile packages prior to donning sterile gloves 65. what is psycho-motor learning? 66. have the pt demonstrate back the procedure 67. what places a newborn at risk for respiratory depression? 68. administration of an opioid analgesic exa: fentanyl (sublimaze) 69. what is an effective method of bowel retraining? 70. anal stimulation with a gloved finger after the evening meal, it will help stimulate the gastrocolic reflex 71. when inserting an NG tube? 72. the nurse should insert the tube into the airway that is patent and has greater airflow 73. what technique should be NG tube insertion? 74. clean technique 75. if NG tube meets resistance? 76. the nurse should rotate the tube without forcing it past the area of resistance 77. what kind of lubricant should be used during NG tube insertion? 78. water- based lubricant NOT petroleum jelly 79. what is pediculosis capitis management? 80. store child's clothing in a separate cubicle at school boil brushes and combs in water for 10 mins dry bed lines and clothing in a hot dryer for at least 20 mins 81. what can visual disturbances indicate? 82. preeclampsia 83. what is expected 24 hrs after surgery? 84. hypo active bowel sounds pain 85. what is an abnormal finding 24 hrs after surgery? 86. low HGB 87. what must be done in bucks traction? 88. the pt must be in proper alignment boots are secured by 3 straps, around pt leg weights must hang freely footplate is resting 15.24 cm (6inches) from the footboard 89. what does pts with delirium demonstrate? 90. a fluctuating LOC often at night or in am 91. pt with dementia demonstrate? 92. difficulty finding correct words to use 93. pt with anxiety disorders demonstrate? 94. obsessive behavior 95. how would the nurse determine progression of ascites? 96. abdominal girth should be measured daily 97. what is a food high in potassium? 98. cantaloupe 99. what is an indication of peripheral venous disease? 100. brown pigmentation around ankles 101. what is indication of peripheral arterial disease? 102. intermittent, leg muscle pain 103. what is some skin care for pts on radiation therapy? 104. pat area when drying use hand to wash do not use sunscreen 105. what can hydromorpone cause? 106. urinary retention 107. what does bethanechol (urecholine) causes? 108. it stimulates urinary out put 109. how is nystatin best absorb? 110. if given 1 hour before or after a feeding 111. what is a sign that a newborn has finished eating? 112. a slowed suck/swallow pattern is a sign that the newborn is finished eating 113. what not to do when breastfeeding? 114. is not necessary for the entire areola be in the mouth each feeding should start at the opposite breast do not push back of newborns head-toward the nipple 115. what should be included in a stool specimen? 116. visible blood, pus, or mucus 117. what is the first action in an infiltrated IV? 118. to d/c the saline lock 119. what is the first action when preparing to do a dressing change? 120. to determine the pts level of pain 121. what should a with hemonymous hemionopsia with right visual field, what will help pt eat better? 122. the pt should turn head to the right to see all food on tray 123. what are some side effect for theophylline (theo-dur)? 124. is used to prevent wheezing,sob, chest tightness in asthma irregular pulse and dysrhythmias seizures anxiety urinary frequency anorexia n/v diarrhea 125. what should you do when given enoxaparin (lovenox)? 126. it should be injected SUBQ do not aspirate do not massage do not inject in same area 127. what is the babinski reflex? 128. stroke sole of the foot upward, toward the great toe 129. what is the moro reflex? 130. startle the infant by clapping hands` 131. what is the stepping reflex? 132. hold infant upright and allow one foot to touch tables surface 133. what is the palmer grasp reflex? 134. place an object in the palm of infant hand 135. what should you do when catheterizing a male pt? 136. pt should be place in supine position penis should be at 90 degree angle retract the foreskin and clean the glans prior to catherization 137. what color is the meconium? 138. it is the first stool passed and it is dark green and viscous 139. what is an inportant thing to ask when pt having cardiac catherization? 140. if pt allergic to iodine 141. what should be done with nitroglycerin (nitrostat)? 142. if pt continues to have pain after taking 1 tab, they should call 911 and take a second tab 143. what is normal after taking a nitroglycerin (nitrostat) tab? 144. h/a change positions slowly it should be kept in original, dark colored bottle to avoid light exposure 145. what to do for restrains use? 146. observe skin condition before applying restrains use a quick release knot to secure the restraints belt restrains should be placed over pts waist able to insert two fingers under restraints do not use all four side of rails to restrain pt 147. what would indicate an active peristalsis? 148. the presence of vowel sounds 149. what does pt with COPD have? 150. increased metabolism due to work of labored breathing they have dry mouth/thick mucus constipation decreased peristalsis 151. how to use a cane? 152. pt should hold cane on the stronger side of the body place it forward 6-10 inches and move his weaker leg forward to the cane distributing his weight between the cane and the stronger leg then he should move the stronger leg forward beyond the cane and distribute his weight between the cane and weaker leg 153. what does the use of cardiac catherization required? 154. that the pt have normal renal functions for excretion of the dye 155. how should drops be apply? 156. the nurse should apply gently pressure to the inner canthus of the eye for 30-60 seconds 157. what are hyperthyroidism findings? 158. tachycardia 159. what are hypothyroidism findings? 160. cold intolerance constipation brittle hair 161. how much should infants grow? 162. 1 inch per month, during the first 6 months they should be able to double their birth weight between 4-6 months of age and gain approximately 150-210 (about 5-7oz) per week 163. what should you do when evaluating an infant? 164. the nurse should measure ht/wt separately, and not combine 165. what can reduce the anti hypertensive effect of anti hypertensives? 166. ibuprofen (advil) or any NSAIDS 167. what is the first action when IV pump alarm is beeping? 168. to observe the iv site for infiltration or phlebitis 169. how are normal bowel sounds? 170. high pitched, irregular gurgles that occur every 5-15 seconds, in a rage of 5-30 per/min 171. what is hypoactive? 172. infrequent less than 5/min 173. what is hyperactive? 174. every 3 seconds or greater 175. what is actinic keratosis? 176. a pre-malignant lesion flat, scaly area with red edges 177. what are cherry angiomas? 178. bright red, raised spots (expected skin changes with aging) 179. what does a change in color mole indicate? 180. indicates skin cancer 181. what happens in passive ROM? 182. the pt does not actively participates the nurse should support the pts extremities distal and proximal to the joints to facilitate passive ROM 183. what do you do when inserting a urinary catheter, and urine is seen in the tubing? 184. the catheter should be advance another 2.5-5 cm to ensure that the balloon is inflated in the bladder 185. what to do when addressing pt dilemma? 186. determine the facts related to dilema identify possible solutions consider clients wishes 187. what should a pt with peripheral vascular disease do? 188. walk until feel pain, rest for 3 min and continue until tired should sit with legs in a dependent position 189. what are s/s of a detached retina? 190. photopsia= bright flashes of light 191. what are s/s of macular degeneration? 192. loss of peripheral vision 193. what is a normal s/s of aging? 194. presbyopia= difficulty focusing on close objects 195. what should a pt with DM and influenza report? 196. temp higher than 101.5 or greater for 24 hours 197. what should be done with pts with closed head injury? 198. should be log roll only suction on prn basis maintain HOB at least 30 degrees do not use an incentive spirometer ICP might go up 199. what should a pt with cardiac catherization experience? 200. they should drink adequate fluids may need to cough during test may experience a feeling of heat "hot flash" only need bed rest for 4-6 hours 201. what should pt with COPD do? 202. should perform pursed- lip breathing alternate activities with rest eat high protein snacks practice relaxation techniques 203. turp care? 204. monitor pt for fluid volume over load remind pt that they will feel urge while catheter is in place calculate urinary out put every 2 hours measure pain level every 2-3 hours pt should get up to a chair asap, risk for dvt 205. how to administer ear drops to children under 3 yrs? 206. pull pinna down and back 207. how will ventricular fibrilation look on ekg? 208. irregular rate without P waves, bizarre and variable QRS 209. what are sinus tachycardia look on EKG? 210. regular rate greater than 100/min normal P and QRS waves 211. atrial ventricular (AV) block look on EKG? 212. regular rate between 60-100/min with extended PR intervals 213. premature atrial contractions look on EKG? 214. irregular rate with ectopic atrial beats earlier than expected 215. what are s/s of febrile transfussion reaction? 216. chills 217. what are s/s of circulatory overload transfussion reaction? 218. bounding pulse and hypertension 219. what are s/s of hemolytic transfussion reaction? 220. lower back pain 221. what foods are rich in iron? 222. red meats, liver 223. what to look for in HCTZ (Hydrodiuril)? 224. flunctuation in weight encourage increase of potassium should be taken with food or right after a meal 225. what are s/s of anaphalictic reactions? 226. increased respiratory effort hypotension bronchoconstriction (laryngeal stridor) 227. what does benzodiazepines (lorazepam/ativan) causes? 228. lethargic and somnolent 229. what are pt with preclampsia at risk for? 230. seizures 231. how should the formula be to prevent gastric cramping in an enteral feeding? 232. administer the formula at room temp 233. what is a s/s of bulemia nervosa? 234. hemoptysis 235. what is a s/s of anorexia nervosa? 236. amenorrhea acrocynosis 237. what are interventions for a salem sump tube? 238. the most common ng tube it is a double lumen (two-channeled) it irrigates the stomach and removes fluid and gas from stomach. -pt should be reposition every 2 hours to promote emptiying of stomach content -set suction 80-100 -never clamp air vent pt should be NPO 239. what might cause dry skin in older adults? 240. a decrease in elasticity of the skin which is an expected change associated with aging 241. what is a bronchoscope? 242. a tube that allows the doctor to see in the lungs and airways and remove objects 243. what are nursing interventions for pts with dementias? 244. should encourage verbal praise do not exceed 20 mins in tub may not be able to follow direction they should not disrobe until right before entering the bath to prevent chilling 245. what to do with ankle sprain? 246. check for pedal edema wrap with a compression dressing apply ice elevate 247. what promotes venous return? 248. using sequential compression device 249. what is an expected PR interval? 250. should be 0.12 to 0.20 seconds it should be one P wave prior to each QRS complex an expected QRS duration is 0.04 to 0.10 second an expected ventricular rate of 60 to 100/min 251. what are s/s of atorvastatin (lipitor) side effects? 252. muscle weakness which can lead to rhabdomyolysis, report muscle cramps, pain or tenderness 253. when should keflex (cephalexin) not be given? 254. if pt has PCN allergy 255. what will facilitate understanding in a pt with anxiety? 256. the use of short, concise sentenses because they have difficulty concentrating 257. what should be done to pts with expressive aphasia? 258. give them a picture board, or pen and paper, because pt cannot verbally express needs or wants should use simple statements and speak normal voice 259. what are risk factors for colorectal cancer? 260. obesity high consumption of alcohol cigaret smoking high protein diet older pt fam hx of colon cancer/ polyps hx of gastrectomy and inflammatory bowel disease 261. what is given for long term alcohol abuse? 262. disulfiram (antabuse), which is an adversion therapy 263. what is a bladder scan? 264. it is a non invasive procedure, and pt should not experience discomfort not a sterile procedure no consent necessary 265. how would the nurse explain a procedure to a school age child? 266. using simple diagram 267. what does concave shape nails indicate? 268. emphysema, prolonged hypoxemia 269. how many grams of protein does peanut butter contains? 270. 7g 271. what do you do with a boggy uterus? 272. promote involution of the uterus, massaging the fundus because of hemmorhage 273. what position is best for COPD pt? 274. orthopnea position because it increases lung expansion 275. phototherapy risks? 276. dehydration report decreased urine output infant may sleep longer should be kept on a regular feeding schedule of every 3-4 hrs may have loose green stool 277. what to teach with hepatitis B? 278. pt should use own utensils and dishes avoid tylenol (acetaminophen) 279. what should you teach a pt about exercising? 280. they should warm up for atleast 5 mins first 281. what should the nurse avoid when placing ekg lodes? 282. avoid scar tissue 283. post bronchoscopy care? 284. pt should not eat until gag reflex is checked blood in sputum is expected have a ride home report horseness or wheezing 285. what to do with a stage 5 alzheimers diasease pt? 286. increase stress level, provide a variety of foods that the pt is able to eat by himself to maintain independence 287. what does metoprolol affect? 288. heart rate is a beta adrenergic antagonist 289. car seat? 290. should be secure with a seat belt 291. where do we do blood draws? 292. in the antecubital fossa 293. crutch teaching? 294. instruct pt to hold crutches on the side opposite the injured leg, when sitting to improve balance and prevent falls 295. antidepressants (elavil) amitriptyline? 296. pt may not feel better for 7 to 28 days and may not experience full effect for 6 to 8 weeks 297. what should pt with leukemia not have in the room? 298. fresh flowers 299. what is an indication of hydration status? 300. mucus membranes 301. what is a low sodium food? 302. canned peaches 303. what is high sodium foods? 304. wheat crackers lean ham cottage cheese 305. how often is a tetanus booster? 306. every ten years 307. what are some risk for fall findings? 308. the pt walks barefoot medications stored on top shelf 309. what is the greatest risk for a thyroidectomy? 310. hypocalcemia with tingling around the mouth 311. what are strategies for teaching toddlers? 312. picture books and simple words 313. what are strategies for teaching preschoolers? 314. role playing/ short stories 315. what are strategies for teaching school age children? 316. discussing and participating in hands on demonstration 317. what are strategies for teaching adolescents? 318. collaborative process/ problem solving 319. what is priority in palliative care? 320. pharmacological pain management 321. what should peritoneal fluid in dialyses look like? 322. bloody, clear, straw color 323. what color should peritoneal fluid not look like? 324. cloudy or opaque, this might means infections 325. what is the glascow coma scale? 326. motor response 327. what are s/s of IV infiltration? 328. pallor surrounding the infusion site 329. what is a s/s of phlebitis? 330. redness along the vein 331. what is a s/s of an extravasation? 332. tissue sloughing 333. what to do with a child with rotavirus? 334. the diaper should fit snuggly avoid using a rectal thermometer apply skin barrier they are NOT contagious 335. where should the chest tube be placed? 336. below the level of the pts chest 337. what should be done with a pen rose drain? 338. a safety pin is placed at the distal end of the drain 339. what to do with a colonoscopy? 340. should not take NSAIDS 1 week prior should be NPO 6-8 hours before 341. what to report with albuterol (proventil)? 342. tremors 343. what should the nurse do when removing a pt IV catheter? 344. the nurse should maintain the catheter parallel to the vein to reduce the risk of trauma to the vein 345. what will the child need prior to an IV urography (IVP)? 346. the child will need to have a soapsud enema administered before the procedure to assist in visualization of the kidneys, ureters, and bladder 347. what diet should the child with nephrotic syndrome be in? 348. low sodium diet to assist with diuresis of extracellular fluid 349. what is normal findings in a turp? 350. yellow urine with red sediment 351. what is abnormal finding in a TURP? 352. LOWER ABD CRAMPING BLOODY URINE WITH LARGE CLOTS INCREASED BLADDER SPASMS 353. what pt should not take cephalexin (Keflex)? 354. pts with PCN allergy 355. what should be used to clean the inner cannula of a tracheostomy? 356. sterile hydrogen peroxide 357. what should the nurse consider when using an interpreter? 358. the nurse should ensure that the interpreter and the pt speak the same dialect and share similar cultural norms and practices 359. what should a pt with leukemia and stomatitis eat? 360. a cold, soft, bland, and liquid foods to prevent further irritation to the oral mucosa exa: oatmeal and applesauce 361. what should the nurse do after a pt has have a ECT electroconvulsive therapy? 362. the pt should be reoriented frequently 363. nursing interventions for pts in hypovolemic shock? 364. place pt in trendelengurg position elevate legs to promote venous return to heart increase IV fluids keep pt warm 365. nursing interventions for pts with vein ligation and stripping? 366. elevate feet (recliner is appropriate) perform ROM walk 5 to 10 min/hr while awake for first 24 hrs the nurse should wrap legs with an elastic bandage for prevention of clots 367. when would a pt on antidepressant (amitriptiline) feel the effect? 368. 10-14 days and experience full effect for 4-8 weeks 369. how is mono (infectious mononucleosis) acquired? 370. direct contact with droplets of saliva of an infected person 371. how long after giving insulin should a nurse check for hypoglycemia? 372. 4-14 after administration of NPH (novolin N) insulin 373. what should the pt do after taking iron preparation? 374. pt should rinse mouth immediately after taking med 375. in respiratory acidosis what is elevated? 376. the Paco2 is elevated greater than 45 377. what is the first thing a pt with prosthesis do? 378. applied immediately the prosthesis after waking 379. what should a pt on suicide precautions be told to do? 380. sign a no harm contract aka no suicide contract 381. what to avoid with theophylline (theochron)? 382. avoid caffeine due to tachycardia 383. what would you see with dehydration? 384. low potassium levels 385. how can hep B be contracted? 386. blood transfusion sexual contact sharing IV drug needles 387. what are the risks for colorectal cancer? 388. obesity high consumption of alcohol cigarette smoking high protein diet (red meat) fam hx of colon cancer hx of gastrectomy and IBS 389. what are right sided heart failure s/s? 390. edema ascites anorexia 391. what are left sided heart failure s/s? 392. dizziness 393. following rupture of the membranes what is the greatest risk? 394. fecal cord compression of prolapse, which is a medical emergency and obtaining a fetal heart tone is priority 395. what should be done to a pt with anxiety? 396. they will have trouble concentrating therefore the nurse should speak to the pt using simple sentenses 397. what is a manifestation of type 2 DM? 398. infection and poor wound healing 399. what to monitor with timolol (Timoptic)? 400. a decreased in BP 401. what is inhibit with spinal cord damage at T1 and T2? 402. it inhibits function below the waist 403. wheel chair precautions? 404. use a gell- filled seat cushion limit time to 2 hours at a time avoid donut-shaped pads shift weight every 15 minutes 405. what kind of mask should pt with COPD use? 406. a venturi mask 407. what is priority in a child with sickle cell crisis? 408. oxygenation 409. what should be avoided with a mastectomy? 410. avoid raising elbow above the shoulder until drain are removed avoid abduction return to work in 4 to 6 wks resume driving in 7 to 10 days 411. during the initial tx of acute diverticulitis what is done? 412. the pt receives parenteral nutrition and should be kept NPO 413. what do do for a child with juvenile idiopathic arthiritis? 414. use heat therapy prior to physical activities because it promotes exercise they should attend school as much as possible promote exercise eat a well balanced diet 415. how often is a tetanus booster recommended? 416. every ten years 417. what to give prior to an NST? 418. administer 4 oz (120 ML) of orange juice to stimulate fetal movement 419. where should a cane be placed? 420. held in the hand of the stronger side of body 421. what is priority in a pt with anorexia nervosa? 422. record amount of food pt consumes weight daily restrict exercing 423. nitroglycerin (nitrostat)? 424. take up to 3 tabs during single episode place under tongue store in original container discard on expiration date 425. how should epoiten alfa be given? 426. sub Q 427. how should IM injections be given? 428. z tract method 429. what promotes drainage of stomach content in tubes/pumps? 430. turning pt every two hours 431. what should pt with cystic fibrosis eat? 432. a diet high in calories 433. what can long term use of corticosteroids induced? 434. osteoporosis 435. what should be priority when a pt with ketoacidosis come to hospital? 436. administer a 0.9 % sodium chloride becauses it replaces sodium looses 437. what is the greatest risk with a thyroidectomy? 438. hypocalcemia leading to tetany by s/s of tingling around mouth 439. what is a s/s of circulatory over load? 440. crackles, sob, jugular vein distention, cough 441. when taking care of a pt with meningitis what should the nurse wear? 442. a surgical mask within 3 feet ot the pt to prevent exposure 443. where would a pt with acute cholecystitis feel pain? 444. RUQ radiating to back 445. what to do first when IV pump is alarming? 446. observe the IV site for phlebitis 447. what should pt avoid before a colonoscopy? 448. NSAIDs because it increases risk for bleeding 449. when should a newborn repeat the hearing test if they fail the first time? 450. in 3 months 451. what helps pt with acute manic? 452. step by step direction 453. what is scleroderma? 454. is a chronic disease with skin changes causes thickening, hardening, or tightening of the skin, blood vessels, and internal organs 455. what is s/s of herpes zoster (shingles)? 456. results from reactivation of a dormant varicella virus, inflammation of the dorsal root ganglion. localized vesicular lesions unilateral localized, nodular skin lesions 457. genital herpes s/s? 458. fluid-filled vesicular rash in genital region 459. hepatitis A? 460. fecal-oral route, uncooked food 461. what is raynaud disease? 462. a disorder of the blood vessel that supply blood to the skin and causes the distal extremities and the tip of nose and ear to feel numb/cool in response to cold temps or stress s/s: tingling, swelling, painful throbbing attacks may last mins to hours the pt should not smoke 463. IGA? 464. associated with autoimmune diseases or chronic infections 465. IGE? 466. allergic manifestations, anaphylaxis, and asthma 467. IGM? 468. antibodies against ABO blood groups 469. IgG? 470. antibodies to all types of infections 471. what should the pt with SLE skin lesions do? 472. it affects any organ in the body is a chronic autoimmune disorder, pt should monitor body temp and report any elevations promptly apply moisturizer after bathing the lesions with warm water 473. what reduces exposure to allergens? 474. use a dehumidifier/ NOT humidifier no carpet bed linens should be washed weekly in hot water dont apply repellent to skin 475. what is pcp (pneumocystis carininii pneumonia? 476. it exist as part of the normal flora of the lungs, the infection results from an impaired immune system pt may need a bronchoscopy with biopsy of lung tissue 477. eosinophils? 478. usually with asthma 479. monocytes? 480. infection and several collagen disorders 481. lymphocytes? 482. cancers and malnourished pts 483. neutrophils? 484. infection, stress, and inflammation 485. RA s/s? 486. bilateral pain and swelling in fingers and joints with stiffness in morning, finger joints are erythematous and warm to touch 487. how to handle of an infant with HIV? 488. use disposable diapers, and discard in separate plastic bags use bleach solution and gloves to clean up blood spills hand washing is important anyone changing babies diaper should wear gloves 489. what should the pt with a desentization injection do? 490. must remain in clinic atleast 30 minutes 491. what are early manifestations of aids? 492. persistent fever swollen glands diarrhea weight loss fatigue 493. what does an elevated GFR indicate? 494. an acute inflammatory process pt will need thermal interventions (heat or cold) 495. what is an initial s/s of wound infection? 496. erythema (redness) at incision site 497. what is karposi sarcoma KS? 498. associated with aids it looks like hyperpigmented multicentric lesions that can be firm, flat, or nodular 499. what does histamine release causes? 500. increases mucus secretions bronchospasms bronchial constriction 501. what should a pt with active TB been transported wear? 502. a mask 503. what is early lyme disease characterized by? 504. fever influenza like manifestation erythema migrans distinct progressive circular rash (or bulls eye rash) 505. can pts with hepatitis a donate blood? 506. no 507. what does serum amylase has to do with? 508. pancreatitis 509. stoma care? 510. use mild soap apply skin sealant cut it 1/8 to 1/16 larger than the size measure it at least once a week 511. what is a early s/s of hepatitis A? 512. anorexia 513. what is a late s/s of hepatitis A? 514. pale feces dark urine jaundice 515. what to eat with peptic ulcer? 516. no soda eat as normal as possible eat 5-6 small meals a day 517. what foods to avoid with diverticulitis? 518. corn, strawberries, whole grain bread 519. what to do with spleenectomy? 520. promoting lung aeration is important 521. what is the position for an enema? 522. left lateral 523. TPN? 524. withdrawal look out for hypoglycemia (shakiness and diaphoresis) 525. SIADH? 526. is caused by excessive release of an antidiuretic hormone (ADH) as a result pt retains water creating a dilutional hyponatremia 527. what are dm type 2 manifestations of hyperglycemia? 528. increased urination and thirst 529. what are dm type 2 manifestations of hypoglycemia? 530. tremors cold, clammy skin 531. graves disease s/s? 532. difficulty slepping, diarrhea, increased appetite, heat intolerance 533. what does ketoacidosis causes? 534. dehydration by s/s of n/v 535. what are early s/s of hypoglycemia? 536. drowsiness clammy skin diaphoresis blurred vision 537. what are early s/s of hyperglycemia? 538. anorexia dry mouth urinary frequency 539. what are s/s of diabetes insipidus? 540. polydipsia polyuria 541. what does parathyroid hormone regulates? 542. calcium 543. what is the common cause of hyperthyroidism? 544. graves disease 545. what are s/s of thyroid storm? 546. fever hypertension pain tachycardia 547. what are s/s of diabetic ketoacidosis? 548. increased blood glucose levels positive urine acetone a low bicarbonate levels 549. what causes acromegaly? 550. excessive production of somatropin (growth hormone) after closing of the epiphyses 551. what is addisons disease? 552. hormone deficiency caused by damage to the outer layer of the adrenal gland they need diet high in salt, carbs, and protein low in potassium 553. what is primary therapy for a pt with JRA? 554. preservation of joint function 555. what is splitting? 556. a primitive ego defense mechanism that places people in good/bad categories 557. what is displacement? 558. transfer of feelings to a less threatening person 559. what is intellectualization? 560. a logical aproach 561. what is projection? 562. attribute her faults to others 563. what is the play mode in toddlers? 564. parallel play with each child performing similar activities 565. when are liver enzymes elevated? 566. in pts with HELLP 567. what to do with magnesium toxicity? 568. give calcium gluconate s/s of toxicity: loss of deep tendon reflex respiratory depression oliguria if left untreated can lead to cardiac and respiratory arrest 569. when taking iron supplement what would counteract with constipation? 570. eating raw fruit and vegetables 571. s/s of coarctation of the aorta? 572. unequal upper and lower extremity pulses 573. SSRI Side effects 574. Side effects of SSRIs may include, among others: Nausea Nervousness, agitation or restlessness Dizziness Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction) Drowsiness Insomnia Weight gain or loss Headache Dry mouth Vomiting Diarrhea 575. MAOI Side effects 576. The most common side effects of MAOIs include: Dry mouth Nausea, diarrhea or constipation Headache Drowsiness Insomnia Skin reaction at the patch site Dizziness or lightheadedness Other possible side effects include: Involuntary muscle jerks Low blood pressure Reduced sexual desire or difficulty reaching orgasm Sleep disturbances Weight gain Difficulty starting a urine flow Muscle aches Prickling or tingling sensation in the skin (paresthesia 577. Opioid 578. Other side effects of opioid analgesics include: Euphoria, dysphoria, agitation, seizures, hallucinations Lowered blood pressure and heart rate Muscular rigidity and contractions Nausea and vomiting Non-allergic itching Pupil constriction Sexual dysfunction Urinary retention 579. Do not delegate 580. What you can EAT E-evaluate A-assess T-teach 581. Addison's & Cushings 582. Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia 583. Better peripheral perfusion? 584. EleVate Veins, DAngle Arteries 585. APGAR 586. Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) 587. Airborne precautions 588. My chicken hez tb (measles, chickenpox (varicella) Herpes zoster/shingles TB 589. Airborne precautions protective equip 590. private room, neg pressure with 6-12 air exchanges/hr mask N95 for TB 591. Droplet precautions 592. spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room or cohort mask!) 593. Contact precaution 594. MRS WEE Multidrug resistant organism Rresiratory infection Skin infection Wound infection Enteric infection (C diff) Eye infection (conjunctivitis) 595. Skin infection 596. VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies 597. Air or Pulmonary Embolism 598. S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) 599. Woman in labor (un-reassuring FHR) 600. (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! 601. Tube feeding with decreased LOC 602. Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) 603. After lumbar puncture and oil based myelogram 604. pt is flat SUPINE (prevent headache and leaking of CSF) 605. Pt with heat stroke 606. flat with legs elevated 607. during Continuous Bladder Irrigation (CBI) 608. catheter is taped to the thigh. leg must be kept straight. 609. After Myringotomy 610. position on the side of AFFECTED ear, allows drainage. 611. After Cateract surgery 612. pt sleep on UNAFFECTED side with a night shield for 1-4 weeks 613. after Thyroidectomy 614. low or semi-fowler's position, support head, neck and shoulders. 615. Infant with Spina Bifida 616. Prone so that sac does not rupture 617. Buck's Traction (skin) 618. elevate foot of bed for counter traction 619. After total hip replacement 620. don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. 621. Prolapsed cord 622. Knee to chest or Trendelenburg oxygen 8 to 10 L 623. Cleft Lip 624. position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. 625. To prevent dumping syndrome 626. (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. 627. AKA (above knee amputation) 628. elevate for first 24 hours on pillow. position prone daily to maintain hip extension. 629. BKA (below knee amputation) 630. foot of bed elevated for first 24 hours. position prone to provide hip extension. 631. detached retina 632. area of detachment should be in the dependent position 633. administration of enema 634. pt should be left side lying (Sim's) with knee flexed. 635. After supratentorial surgery 636. (incision behind hairline on forhead) elevate HOB 30-40 degrees 637. After infratentorial surgery 638. (incision at the nape of neck) position pt flat and lateral on either side. 639. During internal radiation 640. on bed rest while implant in place 641. Autonomic Dysreflexia/Hyperreflexia 642. S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! 643. Shock 644. bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) 645. Head Injury 646. elevate HOB 30 degrees to decrease ICP 647. Peritoneal Dialysis (when outflow is inadequate) 648. turn pt from side to side BEFORE checking for kinks in tubing 649. Lumbar Puncture 650. After the procedure, the pt should be supine for 4-12 hours as prescribed. 651. Myesthenia Gravis 652. worsens with exercise and improves with rest 653. Myesthenia Gravis 654. a positive reaction to Tensilon---will improve symptoms 655. Cholinergic Crisis 656. Caused by excessive medication ---stop giving Tensilon...will make it worse. 657. Liver biopsy (prior) 658. must have lab results for prothrombin time 659. Myxedema/ hypothyroidism 660. slowed physical and mental function, sensitivity to cold, dry skin and hair. 661. Grave's Disease/ hyperthyroidism 662. accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. 663. Thyroid storm 664. increased temp, pulse and HTN 665. Post-Thyroidectomy 666. semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside 667. Hypo-parathyroid 668. CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet 669. Hyper-parathyroid 670. fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet 671. Hypovolemia 672. increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030 673. Hypervolemia 674. bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's 675. Diabetes insipidus (decreased ADH) 676. excessive urine output and thirst, dehydration, weakness, administer Pitressin 677. SIADH (increased ADH) 678. change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics 679. hypokalemia 680. muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) 681. Hyperkalemia 682. MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes 683. Hyponatremia 684. nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids 685. Hypernatremia 686. increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. 687. Hypocalcemia 688. CATS Convulsions, Arrythmias, Tetany, spasms and stridor 689. Hypercalcemia 690. muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! 691. Hypo Mg 692. Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) 693. Hyper Mg 694. depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY 695. Addison's 696. Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. 697. Cushings 698. Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump 699. Addesonian crisis 700. N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP 701. Pheochromocytoma 702. hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) 703. Tetrology of Fallot 704. DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) 705. Autonomic Dysreflexia 706. (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) 707. FHR patterns for OB 708. Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill 709. what to check with pregnancy 710. Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. 711. Position of the baby by fetal heart sounds 712. Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. 713. Ventilatory alarms 714. HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc 715. ICP and Shock 716. ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp 717. Cor pumonae 718. Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) 719. Heroin withdrawal neonate 720. irritable, poor sucking 721. brachial pulse 722. pulse area on an infant 723. lead poisoning 724. test at 12 months of age 725. Before starting IV antibiotics 726. obtain cultures! 727. pt with leukemia may have 728. epistaxis due to low platelets 729. when a pt comes in and is in active labor 730. first action of nurse is to listen to fetal heart tones/rate 731. for phobias 732. use systematic desensitization 733. NCLEX answer tips 734. choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. 735. ARDS and DIC 736. are always secondary to another disease or trauma 737. In an emergency 738. patients with a greater chance to live are treated first 739. Cardinal sign of ARDS 740. hypoxemia 741. Edema is located 742. in the interstitial space, not the cardiovascular space (outside of the circulatory system) 743. the best indicator of dehydration? 744. weight---and skin turgor 745. heat/cold 746. hot for chronic pain; cold for accute pain (sprain etc) 747. When pt is in distress. medication administration 748. is rarely a good choice 749. pneumonia 750. fever and chills are usually present. For the elderly confusion is often present. 751. before IV antibiotics? 752. check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. 753. COPD and O2 754. with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. 755. Prednisone toxicity 756. Cushings (buffalo hump, moon face, high blood sugar, HTN) 757. Neutropenic pts 758. no fresh fruits or flowers 759. Chest tubes are placed 760. in the pleural space 761. Preload/Afterload 762. Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. 763. CABG 764. Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. 765. Unstable Angina 766. not relieved by nitro 767. PVC's 768. can turn into V fib. 769. 1 tsp 770. 5 mL 771. 1 oz 772. 30 mL 773. 1 cup 774. 8 oz 775. 1 quart 776. 2 pints 777. 1 pint 778. 2 cups 779. 1 g (gram) 780. 1000 mg 781. 1 kg 782. 2.2 lbs 783. I lb 784. 16 oz 785. centigrade to Fahrenheit conversion 786. F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 787. Angiotenson II 788. In the lungs...potent vasodialator, aldosterone attracts sodium. 789. Iron toxicity reversal 790. deferoxamine 791. S3 sound 792. normal in CHF. Not normal in MI 793. After endoscopy 794. check gag reflex 795. TPN given in 796. subclavian line 797. pain with diverticulitis 798. located in LLQ 799. appendicitis pain 800. located in RLQ 801. Trousseau and Chvostek's signs observed in 802. Hypocalcemia 803. never give K+ in 804. IV push 805. DKA is rare 806. in DM II (there is enough insulin to prevent fat breakdown) 807. Glaucoma patients lose 808. peripheral vision. 809. Autonomic dysreflexia 810. patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) 811. Spinal shock occurs 812. immediately after injury 813. multiple sclerosis 814. myelin sheath destruction. disruptions in nerve impulse conduction 815. Myasthenia gravis 816. decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. 817. Gullian -Barre syndrome 818. ascending paralysis. watch for respiratory problems. 819. TIA 820. transient ischemic attack. mini stroke, no dead tissue. 821. CVA 822. cerebriovascular accident. brain tissue dies. 823. Hodgkin's disease 824. cancer of the lymph. very curable in early stages 825. burns rule of Nines 826. head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% 827. birth weight 828. doubles by 6 months triples by 1 year 829. if HR is <100 (children) 830. Hold Dig 831. early sign of cystic fibrosis 832. meconium in ileus at birth 833. Meningitis--check for 834. Kernig's/ brudinski's signs 835. wilm's tumor 836. encapsulated above kidneys...causes flank pain 837. hemophilia is x linked 838. passed from mother to son 839. when phenylaline increases 840. brain problems occur 841. buck's traction 842. knee immobility 843. russell traction 844. femur or lower leg 845. dunlap traction 846. skeletal or skin 847. bryant's traction 848. children <3 y <35 lbs with femur fx 849. eclampsia is 850. a seizure 851. perform amniocentesis 852. before 20 weeks to check for cardiac and pulmonary abnormalities 853. Rh mothers receive Rhogam 854. to protect next baby 855. anterior fontanelle closes by...posterior by.. 856. 18 months, 6-8 weeks 857. caput succedaneum 858. diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days 859. pathological jaundice occurs: physiological jaundice occurs: 860. before 24 hours (lasts 7 days) after 24 hours 861. placenta previa s/s placental abrution s/s 862. there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) 863. bethamethasone (celestone) 864. surfactant. premature babies 865. milieu therapy 866. taking care of pt and environmental therapy 867. cognitive therapy 868. counseling 869. five interventions for psych patients 870. safety setting limits establish trusting relationship meds least restrictive methods/environment 871. SSRI's 872. take about 3 weeks to work 873. patients with hallucinations patients with delusions 874. redirect them distract them 875. Thorazine and Haldol 876. can cause EPS 877. Alzheimer's 878. 60% of all dementias, chronic, progressive degenerative cognitive disorder. 879. draw up regular and NHP? 880. Air into NHP, air into Regular. Draw regular, then NHP 881. Cranial nerves 882. S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More 883. Hypernatremia 884. S (Skin flushed) A (agitation) L (low grade fever ) T (thirst) 885. Developmental 886. 2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup 887. Hepatitis A 888. Ends in a vowel, comes from the bowel 889. Hepatitis b 890. B= blood and body fluids (hep c is the same) 891. Apgar measures 892. HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate 893. Glasgow coma scale 894. eyes, verbal, motor Max- 15 pts, below 8= coma 895. Addison's disease: Cushing's syndrome: 896. "add" hormone have extra "cushion" of hormone 897. Dumping syndrome 898. increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink 899. Disseminated herpes zoster localized herpes zoster 900. Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered! 901. Isoniazid 902. causes peripheral neuritis 903. Weighted NI (naso intestinal tubes) 904. Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris 905. Cushings ulcers 906. r/t brain injury 907. Cushing's triad 908. r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) 909. Thyroid storm 910. HOT (hyperthermia) 911. Myxedema coma 912. COLD (hypothermia) 913. Glaucoma 914. No atropine 915. Non Dairy calcium 916. Rhubarb sardines collard greens 917. Koplick's spots 918. prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth 919. INH can cause peripheral neuritis 920. Take vitamin B6 to prevent. Hepatotoxic 921. pancreatitis pts 922. put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids 923. Murphy's sign 924. Pain with palplation of gall bladder (seen with cholecystitis) 925. Cullen's sign 926. ecchymosis in umbilical area, seen with pancreatitis 927. Turner's sign 928. Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis 929. McBurney's point 930. Pain in RLQ with appendicitis 931. LLQ 932. Diverticulitis 933. RLQ 934. appendicitis watch for peritonitis 935. Guthrie test 936. Tests for PKU. Baby should have eaten protein first 937. shilling test 938. Test for pernicious anemia 939. Peritoneal dialysis 940. Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok 941. Hyper reflexes absent reflexes 942. upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue 943. Latex allergies 944. assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches 945. Tensilon 946. used in myesthenia gravis to confirm diagnosis 947. ALS 948. (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems 949. Transesophageal fistula 950. esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) 951. MMR 952. is given SQ not IM 953. codes for pt care 954. Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival 955. Contraindication for Hep B vaccine 956. anaphylactic reaction to baker's yeast 957. what to ask before flu shot 958. allergy to eggs 959. what to ask before MMR 960. allergy to eggs or neomycin 961. when on nitroprusside monitor: 962. cyanide. normal value should be 1. 963. William's position 964. semi Fowler's with knees flexed to reduce low back pain 965. S/S of hip fx 966. External rotation, shortening adduction 967. Fat embolism 968. blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids. 969. complications of mechanical ventilation 970. pneumothorax, ulcers 971. Paget's disease 972. tinnitus, bone pain, elnargement of bone, thick bones 973. with allopurinol 974. no vitamin C or warfarin! 975. IVP requires 976. bowel prep so bladder can be visualized 977. acid ash diet 978. cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread 979. alk ash diet 980. milk, veggies, rhubarb, salmon 981. orange tag in psych 982. is emergent psych 983. thyroid med side effects 984. insomnia. body metabolism increases 985. Tidal volume is 986. 7-10 ml/kg 987. COPD patients and O2 988. 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less 989. Kidney glucose threshold 990. 180 991. Stranger anxiety is greatest at what age? 992. 7-9 months..separation anxiety peaks in toddlerhood 993. when drawing an ABG 994. put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2 995. Munchausen syndrome vs munchausen by proxy 996. Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child 997. multiple sclerosis 998. motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia 999. hungtington's 1000. 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure 1001. WBC left shift 1002. pt with pyelo. neutrophils kick in to fight infections 1003. pancreatic enzymes are taken 1004. with each meal! 1005. infants IM site 1006. Vastus lateralis 1007. Toddler 18 months+ IM site 1008. Ventrogluteal 1009. IM site for children 1010. deltoid and gluteus maximus 1011. Thoracentesis: 1012. position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing 1013. Cardiac cath 1014. NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr 1015. Cerebral angio prep 1016. well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids. 1017. lumbar puncture 1018. fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache. 1019. ECG 1020. no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3- 4 min and watch a bright flashing light. watch for seizures after the procedure. 1021. Myelogram 1022. NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site 1023. Liver biopsy 1024. administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk 1025. Paracentesis 1026. semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia 1027. laparoscopy 1028. CO2 used to enhance visual. general anesthesia. foley. post-- ambulate to decrease CO2 buildup 1029. PTB 1030. low grade afternoon fever 1031. pneumonia 1032. rusty sputum 1033. asthma 1034. wheezing on expiration 1035. emphysema 1036. barrel chest 1037. kawasaki syndrome 1038. strawberry tongue 1039. pernicious anemia 1040. red beefy tongue 1041. downs syndrome 1042. protruding tongue 1043. cholera 1044. rice watery stool 1045. malaria 1046. stepladder like fever--with chills 1047. typhoid 1048. rose spots on the abdomen 1049. diptheria 1050. pseudo membrane formation 1051. measles 1052. koplick's spots 1053. sle (systemic lupus) 1054. butterfly rash 1055. pyloric stenosis 1056. olive like mass 1057. Addison's 1058. bronze like skin pigmentation 1059. Cushing's 1060. moon face, buffalo hump 1061. hyperthyroidism/ grave's disease 1062. exophthalmos 1063. myasthenia gravis 1064. descending musle weakness 1065. gullian-barre syndrome 1066. ascending muscle weakness 1067. angina 1068. crushing, stabbing chest pain relieved by nitro 1069. MI 1070. crushing stabbing chest pain unrelieved by nitro 1071. cystic fibrosis 1072. salty skin 1073. DM 1074. polyuria, polydipsia,polyphagia 1075. DKA 1076. kussmal's breathing (deep rapid) 1077. Bladder CA 1078. painless hematuria 1079. BPH 1080. reduced size and force of urine 1081. retinal detachment 1082. floaters and flashes of light. curtain vision 1083. glaucoma 1084. painful vision loss. tunnel vision. halo 1085. retino blastoma 1086. cat's eye reflex 1087. increased ICP 1088. hypertension, bradypnea,, bradycarday (cushing's triad) 1089. shock 1090. Hypotension, tachypnea, tachycardia 1091. Lymes disease 1092. bullseye rash 1093. intraosseous infusion 1094. often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist. 1095. sickle cell crisis 1096. two interventions to prioritize: fluids and pain relief. 1097. glomuloneprhitis 1098. the most important assessment is blood pressure 1099. children 5 and up 1100. should have an explanation of what will happen a week before surgery 1101. Kawasaki disease 1102. (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. 1103. ventriculoperitoneal shunt 1104. watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees 1105. 3-4 cups of milk a day for a child? 1106. NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA 1107. MMR and varicella immunizaions 1108. after 15 months! 1109. cryptorchidism 1110. undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence 1111. CSF meningitis 1112. HIGH protein LOW glucose 1113. Head injury or skull fx 1114. no nasotracheal suctioning 1115. otitis media 1116. feed upright to avoid otitis media! 1117. positioning for pneumonia 1118. lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!) 1119. for neutropenic pts 1120. no fresh flowers, fresh fruits or veggies and no milk 1121. antiplatelet drug hypersensitivity 1122. bronchospasm 1123. bowel obstruction 1124. more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids) 1125. Basophils reliease histamine 1126. during an allergic response 1127. Iatragenic 1128. means it was caused by treatment, procedure or medication 1129. Tamoxifen 1130. watch for visual changes--indicates toxicity 1131. post spelectomy 1132. pneumovax 23 is administered to prevent pneumococcal sepsis 1133. Alkalosis/ Acidosis and K+ 1134. ALKalosis=al K= low sis. Acidosis (K+ high) 1135. No phenylalanine 1136. to a kid with PKU. No meat, dairy or aspartame 1137. never give potassium 1138. to a pt who has low urine output! 1139. nephrotic syndrome 1140. characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay 1141. the first sign of ARDS 1142. increased respirations! followed by dyspnea and tachypnea 1143. normal PCWC (pulmonary capillary wedge pressure) 1144. is 8-13 readings 18-20 are considered high 1145. first sign of PE 1146. sudden chest pain followed by dyspnea and tachypnea 1147. Digitalis 1148. increases ventricular irritability could convert a rhythm to v- fib following cardioversion 1149. Cold stress and the newborn 1150. biggest concern resp. distress 1151. Parathyroid relies on 1152. vitamin D to work 1153. Glucagon increases the effects of? 1154. anticoagulants 1155. Sucking stab wound 1156. cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a closed pneumo or tension pneumo! 1157. chest tube pulled out? 1158. occlusive dressing 1159. PE 1160. Needs O2! 1161. DKA 1162. acetone and keytones increase! once treated expect postassium to drop! have K+ ready 1163. Hirschprung's 1164. diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools 1165. Intussusception 1166. Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements 1167. laboring mom's water breaks? 1168. first thing--worry about prolapsed cord! 1169. Toddlers need to express 1170. independence! 1171. Addison's 1172. causes sever hypotension! 1173. pancreatitis 1174. first pain relief, second cough and deep breathe 1175. CF chief concern? 1176. Respiratory problems 1177. a nurse makes a mistake? 1178. take it to him/her first then take up the chain 1179. nitrazine paper 1180. turns blue with alkaline amniotic fluid. turns pink with other fluids 1181. up stairs with crutches? 1182. crutches first followed by good leg 1183. dumping syndrome? 1184. use low fowler's to avoid. limit fluids 1185. TB drugs are 1186. hepatotoxic! 1187. clozapine, Clozaril 1188. antipsychotic anticholinergic 1189. clozapine s/e 1190. weight gain, hypotension, hyperglycemia, agranulocytosis 1191. dehydration 1192. -hypovolemia - elevated urine specific gravity 1193. flumazenil, Romazicon 1194. benzo overdose 1195. umbilical cord compression 1196. reposition side to side or knee-chest 1197. short cord 1198. discontinue pictocin 1199. Discontinue oxypocin 1200. Discontinue oxytocin if uterine hyperstimulation occurs. Symptoms of uterine hyperstimulation include: ☐ Contraction frequency more often than every 2 min. ☐ Contraction duration longer than 90 seconds. ☐ Contraction intensity that results in pressures greater than 90 mm Hg as shown by IUPC. ☐ Uterine resting tone greater than 20 mm Hg between contractions. ☐ No relaxation of uterus between contractions 1201. Airborne Precautions 1202. My - Measles Chicken - Chicken Pox/Varicella Hez - Herpez Zoster/Shingles TB 1203. Droplet 1204. think of SPIDERMAN! S - sepsis S - scarlet fever S - streptococcal pharyngitis P - parvovirus B19 P - pneumonia P - pertussis I - influenza D - diptheria (pharyngeal) E - epiglottitis R - rubella M - mumps M - meningitis M - mycoplasma or meningeal pneumonia An - Adenovirus Private Room or cohort Mask 1205. Contact 1206. MRS.WEE M - multidrug resistant organism R - respiratory infection S - skin infections * W - wound infxn E - enteric infxn - clostridium difficile E - eye infxn - conjunctivitis 1207. Hypokalemia 1208. muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) 1209. Hyperkalemia 1210. muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac contractility, ECG changes, reflexes 1211. Hyponatremia 1212. nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids 1213. Hypernatremia 1214. increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution 1215. MAOI 1216. pirates say arrrr, so think; pirates take MAOI's when they're depressed. - explanation; MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil) 1217. FHR patterns 1218. V = variable decels; C = cord compression caused E = early decels; H = head compression caused A = accels; O = okay, not a problem! L = late decels = placental insufficiency, can't fill 1219. Cord Compression 1220. place the mother in the TRENDELENBERG position because this removes pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of hte body by gravity) If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection. 1221. Late decelerations 1222. turn the mother to her left side, to allow more blood flow to the placenta 1223. ICP 1224. increased BP, decreased pulse, decreased resp 1225. shock 1226. decreased BP, increased pulse, increased resp 1227. Conversions 1228. 1 t (teaspoon)= 5 ml 1 T(tablespoon)= 3 t = 15 ml 1 oz= 30 ml 1 cup= 8 oz 1 quart= 2 pints 1 pint= 2 cups 1 gr (grain)= 60 mg 1 g (gram)= 1000 mg 1 kg= 2.2 lbs 1 lb= 16 oz 1229. Antidotes 1230. heparin= protamine sulfate coumadin= vitamin k ammonia= lactulose acetaminophen= n-Acetylcysteine. Iron= deferoxamine Digitoxin, digoxin= digibind. Alcohol withdraw= Librium. 1231. Developmental 1232. 2-3 months: turns head side to side 4-5 months: grasps, switch & roll 6-7 months: sit at 6 and waves bye-bye 8-9 months: stands straight at eight 10-11 months: belly to butt (phrase has 10 letters) 12-13 months: twelve and up, drink from a cup 1233. Hepatitis 1234. Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B=Blood and Bodily fluids Hepatitis C is just like B 1235. Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfanomides 1236. with food 1237. Valium is treatment of 1238. status epilepticus (Ativan may be used also) 1239. Allopurinol 1240. Push fluids. Avoide purines Avoid Vit C and Warfarin 1241. Rifampin 1242. Red orange tears and urine, also contraceptives don't work as well 1243. LLQ 1244. diverticulitis , low residue, no seeds, nuts, peas 1245. Kayexalate 1246. Don't use with hypoactive bowel sounds 1247. Anticholinergic effects 1248. dry mouth==can't spit urinary retention=can't **** constipated =can't **** blurred vision=can't see 1249. TCA end in mine, pine or line 1250. ● Therapeutic Uses ◯ Depression ◯ Depressive episodes of bipolar disorders --- Side effects: Orthostatic hypotension, Anticholinergic effects, Sedation, sweating, increased chance of seizure Avoid use of MAOI and TCA Avoid TCA and anti-histamines 1251. SSRI (ends in pram, tine, line) 1252. ● Therapeutic Uses ◯ Major depression ◯ Obsessive compulsive disorder ◯ Bulimia nervosa ◯ Premenstrual dysphoric disorders ◯ Panic disorders ◯ Posttraumatic disorder --- Decreased sex libido CNS stimulation (inability to sleep, anxiety) Weight loss / gain Serotonin syndrome Hyponatremia GI bleeding Bruxism (report to provider) --- Do not use St. Johns Wart MAOI must be discontinued for 14 days --- May increase warfarin levels or NSAID levels 1253. MAOI (zine, zid, mine, line) 1254. ● Therapeutic Uses ◯ Atypical depression ◯ Bulimia nervosa ◯ Obsessive compulsive disorder Side effects CNS stimulation, orthostatic hypotension, hypertensive crisis (with tyramine) added effects with anti-hypertensives 1255. Welbutrin 1256. ● Therapeutic Uses ◯ Treatment of depression ◯ Alternative to SSRIs for clients unable to tolerate the sexual dysfunction side effects ◯ Aid to quit smoking ◯ Prevention of seasonal affective disorder --- Weight loss, sz, headache dry mouth [Show More]

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