MN 556 RN COMPREHENSIVE PREDICTOR NURSING [2020/2021] STUDY GUIDE

MN 556 RN COMPREHENSIVE PREDICTOR NURSING [2020/2021] STUDY GUIDE What can be delegated to Assistive personnel (AP)? - ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - position ...

MN 556 RN COMPREHENSIVE PREDICTOR NURSING [2020/2021] STUDY GUIDE What can be delegated to Assistive personnel (AP)? - ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection - I&O - VS (stable clients A nurse on a med surg unit has recieved change of shift report and will care for 4 clients. Which of the following clients needs will the nurse assign to an AP? A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia B. Reinforcing teaching with a client who is learning to walk with a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure ulcer C A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following info should the nurse share with the AP? Select all: A. the roommate is up independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front wheeled walker when ambulating D. The client had pain meds 30 minutes ago E. The client is allergic to codeine F. the client ate 50 % of his breakfast this morning B C D An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question? A. Assisting a client who is 24 hr postop to use an incentive spirometer B. Collecting a clean catch urine specimen from a client who was admitted on the previous shiftC. providing nasopharyngeal suctioning for a client who has pneumonia D. Replacing the cartridge and tubing on a PCA pump D A nurse is preparing an inservice program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation. Select all: A. Right client B. Right supervision/evaluation C. Right direction/communication D. Right time E. Right circumstances B C E A nurse manager of a med surg unit is assigning care responsibilities for the oncoming shift. A client is waiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign the client? A. Charge nurse B. RN C. LVN D. AP B What is the study of conduct and character? Ethics What are the values and beliefs that guide behavior and decision making? Morals What is the right to make ones own personal decisions, even tho those decisions might not be in the persons best interest Autonomy What are positive actions to help othersBeneficience What is an agreement to keep promises Fidelity What is fairness in care delivery and use of resources Justice What is avoidance of harm or injury Non-maleficence A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of what principles? A. Fidelity B. Autonomy C. Justice D. Nonmalificience B A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficience D A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. NonmaleficenceC A nurse questions a med prescription as too extreme and light of the clients advanced age and unstable status. The nurse understands that this action is an example of which ethical principle A. Fidelity B. Autonomy C. Justice D. Nonmalificence D Which of the following situations can be identified as an ethical dilemma? A. A nurse on a med surg unit demonstrates signs of chemical impairment B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she will restrain him C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form C Most managers can be categorized as authoritative, democratic, and laissez faire makes decisions of the group motivates by coercion communication occurs down the chain of command Work output by the staff is usually high-good for crisis situations and bureaucratic settings Authoritative includes the group when decisions are made Motivates by supporting star achievements Communication occurs up and down the chain of command Work output by staff is usually of good quality-good when cooperation and collaboration is necessary Democraticmakes very few decisions and does little planning motivation is largely the responsibility of individuals staff members Communication occurs up and down the chain of command and between group members Work output is low unless an informal leader evolves from the group *the use of any of these styles may be appropriate depending on the situation Laissez faire The nurse should consider the hierarchy of human needs when prioritizing interventions, which are? - Physiological needs first (oxygen, shelter, food) - Safety & security needs (physical safety) - Love and belonging - Self esteem - Self actualization The ABC framework identifies, in order, the three basic needs for sustaining life Airway Breathing Circulation Nurses must follow what code of standards in delegating and assigning tasks ANA codes of standards What values would a nurse possess to be a client advocate? - caring - autonomy - respect - empowerment What do the nurse need to keep in mind about the client when being their advocate? Client's religion & culture When should planning discharge process begin? a. at time of admission b. 2 days after client is admittedc. whenever the nurse has the time to do planning d. when the physician has the discharge order A What is an interdisciplinary team? A group of health care professionals from different disciplines Fill in the blank: 1. _______ is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. ________, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone. 1 & 2 = collaboration What is the nurse's contribution to an interdisciplinary team? - knowledge of nursing care & its management - a holistic understanding of the client, her/his healthcare needs & healthcare systems. A four-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5 °C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding would indicate an increase in intracranial pressure? 1. Positive Babinski. 2. High-pitched cry. 3. Bulging posterior fontanelle. 4. Pinpoint pupils. 2 A client is receiving total parenteral nutrition (TPN). To determine the client's tolerance of this treatment, the nurse should assess for which of the following? 1. A significant increase in pulse rate. 2. A decrease in diastolic blood pressure. 3. Temperature in excess of 98.6°F (37°C). 4. Urine output of at least 30 cc per hour. 4The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 1. increased pulse rate. 2. decreased temperature. 3. fine tremors. 4. increased radioactive iodine uptake level. 2 A nonstress test is scheduled for a client at 34-weeks gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test? 1. Start an intravenous line for an oxytocin infusion. 2. Obtain a signed consent prior to the procedure. 3. Instruct client to push a button when she feels fetal movement. 4. Attach a spiral electrode to the fetal head. 3 Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis? 1. Provide support to flexed joints with pillows and pads. 2. Position her on her abdomen several times a day. 3. Massage the inflamed joints with creams and oils. 4. Assist her with heat application and ROM exercises. 4 The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient 1. with his neck in a midline position and the head of the bed elevated 30°. 2. side-lying with his head extended and the bed flat. 3. in high Fowler's position with his head maintained in a neutral position. 4. in semi-Fowler's position with his head turned to the side. 1 The nurse is teaching a 40-year-old man diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at home. The nurse should instruct the client to1. use a new sterile catheter each time he performs a catheterization. 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. 3. perform the catheterization procedure every 8 hours. 4. limit his fluid intake to reduce the number of times a catheterization is needed. 2 A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 1. take the medication five minutes after the pain has started. 2. stop taking the medication if a stinging sensation is absent. 3. take the medication on an empty stomach. 4. avoid abrupt changes in posture. 4 A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? 1. Potassium chloride for IV administration. 2. Calcium gluconate for IV administration. 3. Tracheostomy set-up. 4. Suction equipment. 1 A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 1. acknowledges willing participation in an incestuous relationship. 2. reestablishes a trusting relationship with his/her other parent. 3. verbalizes that s/he is not responsible for the sexual abuse. 4. describes feelings of anxiety when speaking about sexual abuse. 3 An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg PO bid. Which of the following instructions should be given to this client by the nurse? 1. "Take the medication on a full stomach, or with a glass of milk." 2. "Wear sunscreen and a hat when outdoors."3. "Continue taking the medication until you feel better." 4. "Avoid the use of soaps or detergents for two weeks." 2 After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? 1. Alteration in mobility related to paralysis. 2. Alteration in skin integrity related to decrease in tissue oxygenation. 3. Alteration in skin integrity related to immobility. 4. Alteration in communication related to decrease in thought processes 2 A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -4.0 mEq/L. Which nutrient should be restricted in the client's diet? 1. Protein. 2. Fats. 3. Carbohydrates. 4. Magnesium. 1 An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. The MOST important nursing intervention is to 1. monitor vital signs, especially blood pressure, every 30 minutes. 2. remain at the client's side to provide reassurance. 3. tell the client the name of the medication and its effects. 4. monitor the anticholinergic effects of the medication. 1 The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the nurse's IMMEDIATE attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine.3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization. 1 The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations? 1. The staff maintains a calm manner when interacting with the client. 2. The staff attends to client's physical needs as necessary. 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 4. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety. 3 A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD). Which of the following would require an intervention by the nurse? 1. The client complains of pain during the inflow of the dialysate. 2. The client complains of constipation. 3. The dialysate outflow is cloudy. 4. There is blood-tinged fluid around the intra-abdominal catheter. 3 The clinic nurse is performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the client to limit his intake of 1. red meat and shellfish. 2. cottage cheese and ice cream. 3. fruit juices and milk. 4. fresh fruits and uncooked vegetables. 1 A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? 1. Agitation and decreased level of consciousness.2. Lethargy and decreased respiratory rate. 3. Restlessness and increased heart rate. 4. Hostility and increased blood pressure. 3 A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol) 2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST? 1. "You are seeing things that aren't real." 2. "Why don't we go make some fudge." 3. "You are experiencing a side effect of Haldol." 4. "I'll contact your physician to change your medication." 3 The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for a client. The nurse should advise the client the BEST time to take this medication is 1. before breakfast. 2. with dinner. 3. with food. 4. at hs. 4 . If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe 1. increasing respiratory difficulty seen with exertion. 2. cough productive of a large amount of thick, yellow mucus. 3. peripheral edema and anorexia. 4. twitching of extremities. 3 The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty metal can. 2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the placeand time. 3. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain. 4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL. 2 The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? 1. The client advances the cane 18 inches in front of her foot with each step. 2. The client holds the cane in her left hand. 3. The client advances her right leg, then her left leg, and then the cane. 4. The client holds the cane with her elbow flexed 60°. 2 A client returns to his room following a myelogram. The nursing care plan should include which of the following? 1. Encourage oral fluid intake. 2. Maintain the prone position for 12 hours. 3. Encourage the client to ambulate after the procedure. 4. Evaluate the client's distal pulses on the affected side. 1 The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? 1. "Take three deep breaths, hold your incision, and then cough." 2. "That was good. Do that again and soon it won't hurt as much." 3. "It won't hurt as much if you hold your incision when you cough." 4. "Take another deep breath, hold it, and then cough deeply 1 A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder? 1. "I keep having recurring nightmares."2. "I have a headache and my stomach has bothered me for a week." 3. "I always check the door locks three times before I leave home." 4. "I don't know who I am and I don't know where I live." 4 A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? 1. Unequal and dilated pupils. 2. Decerebrate posturing. 3. Grand mal seizures. 4. Decreased level of consciousness. 4 . The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignments appropriate if the nursing assistant is assigned to care for 1. a client with Alzheimer's requiring assistance with feeding. 2. a client with osteoporosis complaining of burning on urination. 3. a client with scleroderma receiving a tube feeding. 4. a client with cancer who has Cheyne-Stokes respirations. 1 An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include that the client 1. eat a high-protein, low-residue diet. 2. lie on her unoperated side. 3. exercise her arms and legs. 4. cough and deep breathe. 4 Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae? 1. Infection related to obstetrical trauma. 2. Potential for fetal injury related to abruptio placentae.3. Potential alteration in tissue perfusion related to depletion of fibrinogen. 4. Fluid volume deficit related to bleeding. 4 An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client 1. in semi-Fowler's position. 2. prone, with the head turned to the side. 3. with the head of the bed elevated 45° and the neck extended. 4. supine, with the head in the midline position. 1 Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence? 1. Steadily increasing vital signs. 2. Mild tremors and irritability. 3. Decreased respirations and disorientation. 4. Stomach distress and inability to sleep. 1 The home care nurse is instructing a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan? 1. During the first two weeks of treatment, the client should cover his mouth and nose when he coughs or sneezes. 2. It is necessary for the client to wear a mask at all times to prevent transmission of the disease. 3. The family should support the client to help reduce feeling of low self-esteem and isolation. 4. The client will be required to take prescribed medication for a duration of 6-9 months. 4The nurse's INITIAL priority when managing a physically assaultive client is to 1. restrict the client to the room. 2. place the client under one-to-one supervision. 3. restore the client's self-control and prevent further loss of control. 4. clear the immediate area of other clients to prevent harm. 3 A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be 1. confused with cold, clammy skin and a pulse of 110. 2. lethargic with hot, dry skin and rapid, deep respirations. 3. alert and cooperative with a BP of 130/80 and respirations of 12. 4. short of breath, with distended neck veins and a bounding pulse of 96. 1 The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed? 1. The child is placed in a private room. 2. The staff removes a toy from the child's bed and takes it to the nurse's station. 3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack. 4. The staff uses standard precautions. 1 When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention? 1. The restraints/seclusion policies set forth by the institution. 2. The patient's competence. 3. The patient's voluntary/involuntary status. 4. The patient's nursing care plan.3 The nurse is caring for an 80-year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process in the client. 2 A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following? 1. Sit up for at least 30 minutes after eating. 2. Avoid fluids between meals. 3. Increase the intake of high-carbohydrate foods. 4. Avoid eating large meals that are high in simple sugars and liquids. 4 A nurse is caring for a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which of the following is the BEST indication that the patient's nutritional status has improved after 4 days? 1. The patient eats most of the food served to her. 2. The patient has gained 1 pound since admission. 3. The patient's albumin level is 4.0mg/dL. 4. The patient's hemoglobin is 8.5g/dL. 3 A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, would indicate a possible complication? 1. The client's urine test is positive for glucose and acetone. 2. The client has 1+ pedal edema in both feet at the end of the day. 3. The client complains of an increase in vaginal discharge. 4. The client says she feels pressure against her diaphragm when the baby moves.1 After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? 1. Irrigate the nasogastric tube with distilled water. 2. Aspirate the gastric contents with a syringe. 3. Administer an antiemetic medicine. 4. Insert a new nasogastric tube. 2 After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician? 1. The client has slight edema of the eyelids. 2. There is clear fluid draining from the client's right ear. 3. There is some bleeding from the child's lacerations. 4. The client withdraws in response to painful stimuli. 2 The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions? 1. Take the client to the dining room with 1:1 supervision. 2. Inform the client he may go to the dining room when he controls his behavior. 3. Hold the meal until the client is able to come out of seclusion. 4. Serve the meal to the client in the seclusion room. 4 A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respirations 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed. 2. Administer oxygen via facemask or nasal prongs.3. Administer naloxone (Narcan). 4. Place epinephrine 1:1,000 at the bedside. 3 What type of infectious diseases are required to be reported to the health department? - severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus aureus (MRSA) What is the process of taking a telephone order from a provider? Patient name, drug, dose, route, frequency read back for accuracy A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene A B E A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting D A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter.Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter A A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room A A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside A Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant hand B A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Whichof the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his care C A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? a) serum albumin level of 3 g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20 A A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? a) "I had a bowel movement, but I was able to save the urine" b) "I have a specimen in the bathroom from about 30 minutes ago" c) "I flushed what I urinated at 7 am and have saved the rest since" d) "I drink a lot, so I will fill up the bottle and complete the test quickly" C A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride CA nurse is reinforcing teaching regarding the use of a cane to a client who has leftleg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step C Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension c) flushing d) bradycardia A A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound C A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbet DA nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? a) assess for bladder distention after 6 hr b) encourage the client to use a bed pan in the supine position c) restrict the clients intake of oral fluids d) pour warm water over the clients perineum D When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? 1. Cancer of any kind. 2. Impaired hearing. 3. Prescription drug intoxication. 4. Heart failure. 3 Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications. 2 Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium? 1. Explain the experience of having delirium. 2. Resume a normal sleep-wake cycle. 3. Regain orientation to time and place. 4. Establish normal bowel and bladder function. 3 A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?1. Administer PRN haloperidol (Haldol) to decrease the need to walk. 2. Assess the client's gait for steadiness. 3. Restrain the client in a geriatric chair. 4. Administer PRN lorazepam (Ativan) to provide sedation. 2 During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. 1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 4. Promote relaxation before bedtime with a warm bath or relaxing music. 5. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake. 2 3 4 The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal. 3 The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement.2. Headache. 3. Slowing of reflexes. 4. Fatigue. 1 When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers 4 What are some ways to identify a patient before giving a medication? The Joint Commission requires 2 client identifiers be used when administering medications. - clients name - assigned identification number - telephone number - birth date or other personal-specific identifiers. Bar code scanners may be used to identify clients What are some things to teach about home safety with elderly patients? - Removing items that could cause the client to trip, such as throw rugs and loose carpets - Placing electrical cords and extension cords that against a wall behind furniture - Making sure that steps and sidewalks are in good repair - Placing grab bars near the toilet and in the tub or shower and installing a stool riser - Using a non-skid mat in the tub or shower - Placing a shower chair in the shower - Ensuring that lighting is adequate both inside and outside of the home A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about usingoxygen safely in his home? (Select all that apply.) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use. B. Nail polish should not be used near a client who is receiving oxygen. C. A "No Smoking" sign should be placed on the front door. D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire extinguisher should be readily available in the home. B C E A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk with the appropriate instruction. ____ Passive smoking ____ Carbon monoxide poisoning ____ Food poisoning A. Have water heaters inspected on an annual basis. B. Cook all meat at an appropriate temperature. C. Avoid enclosed areas with others who may be smoking. C A B When performing nasotracheal suctioning what technique should be used? Sterile asepsis bc the trachea is considered sterile and prevents infections A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. BradycardiaC. Clammy skin D. Bradypnea A What do you do when a client has a seizure - lower to bed/floor - protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement seclusion and restraints -must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min What position is good to use for a patient who is at high risk for a pressure ulcer 30 degree lateral position is recommended for clients at risk for pressure ulcers health promotion (injury prevention-suffocation): infant (birth-1 yr) -avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing hypotension is classified with a reading below normal;systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation What temperature should pork be cooked at 160 degrees What is the safest way to thaw out frozen foods In the refrigerator What are the precautions for vancomycin resistant enterococcus Standard precautions including hand washing and gloving should be followed What does a newborns poop look like If your baby is exclusively breastfed, her poop will be yellow or slightly green and have a mushy or creamy consistency What is appropriate for an adolescent in the hospital? Puzzles and books What is the proper nutrition during pregnancy - Folic acid is important for pregnancy, as it can help to prevent birth defects known as neural tube defects, including spina bifida - green leafy vegetables and brown rice What should be avoided during pregnancy Do not take vitamin A supplements, or any supplements containing vitamin A (retinol), as too much could harm your baby What is the most appropriate method for contraception for an adolescent IUD or implant If a patient has anorexia nervosa and works out constantly Allow them to workout and continue their regimen What medications can be taken to help with smoking cessation Bupropion hydrochloride is a medicine for depression, but it also helps people quit smoking. Brand names include Zyban®, Wellbutrin®, Wellbutrin SR® andWellbutrin XL® but this medication is also available as a generic. Varenicline (chantix) What are the five stages of grief denial anger bargaining depression acceptance discrete and applies the letting go of an object or person before the loss as in the case of terminal illness individuals have the opportunity to greet before the actual loss anticipatory grief involves difficult progression through the expected stages of the grieving process grief work is prolonged and manifestations more severe client may develop suicidal ideation, intense feelings of guilt and lowered selfesteem somatic complaints persist for an extended period of time dysfunctional grief Signs for meningococcemia Vomiting, febrile, petechial rash (unstable) Levothyroxine effects Used to restore client's metabolic rate * Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension Multiple Sclerosis Patient Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug) * Report Sore Throat (greatest risk for client is severe infection due to myelosuppression from mitoxantrone) * Vomiting = causes dehydration* Hair Loss = emotional distress * Amenorrhea = emotional distress Malnourished COPD patients (1) Limit liquid intake at meal times (2) Consume foods w/ protein (like eggs) (3) Maintain an upright position (High Fowler's position) to promote ventilation (4) Use milk instead of water when making soup Which grief process is it when Client exhibits increased anxiety + may project anger toward self + others "I don't deserve to die, this isn't fair" Anger stage Which Grief Process when Client acknowledges the impending loss while remaining hopeful "If I could just make it through this, I'd never smoke again" Bargaining Stage How should you respond when client wants to discontinue dialysis "What has changed to make you decide this?" = Seek clarification from client to establish mutual understanding while staying therapeutic What should the nurse do when one member of a support group expresses anger repeatedly? Focus more on the group members who have a positive outlook (Speak to group member privately to uncover source of anger) What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be given? Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella) Should give = TDaP (Tetanus, Diphtheria, Pertussis) Long term effects of NSAIDS (Ibuprofen) Gastric Ulcerations, perforations, hemorrhage, hypertensionAlcohol Use Manifestations of Withdrawal Body burns 0.5 oz of alcohol per hour * Withdrawal appears within 4-12 hours * Irritability + Tremors + Anxiety * Nausea + Vomiting + HA * Diaphoresis * Sleep Disturbances * TACHYCARDIA + HTN Use Benzodiazepines = tx Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) When does Discharge planning begin? At Admission Case Management nursing involves: *Decreasing cost by improving client outcomes * Providing education to optimize health participation * Advocating for services + client's rights What is bipolar disorder? Bipolar disorder is a mood disorder with recurrent episodes of depression and mania. What comorbidities may be observed with a patient who is bipolar? Substance use disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. What therapy will be useful for patients with bipolar? Electroconvulsive therapy for the patient who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective. Used to subdue manic behavior. What kind of medications are indicated for abstinence maintenance of alcohol? Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral) Teaching points for naltrexone (Vivitrol)?Take with meals to supress GI distress. Monthly IM injections should be suggested for patients who have difficulty to adhering to the medication regimen. A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to: a) restrict fluid intake to 1 qt (1,000 ml)/day. b) drink liquids only between meals. c) don't drink liquids 2 hours before meals. d) drink liquids only with meals. B A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient? a) Instruct the patient to keep a record of food intake b) Instruct the patient to avoid prune or apple juice c) Suggest fluid intake of at least 2 L per day d) Assist the patient regarding the correct diet or to minimize food intake C A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the nurse would expect to find rebound tenderness at which location? a) Left lower quadrant b) Left upper quadrant c) Right upper quadrant d) Right lower quadrant D Which outcome indicates effective client teaching to prevent constipation? a) The client reports engaging in a regular exercise regimen. b) The client limits water intake to three glasses per day. c) The client verbalizes consumption of low-fiber foods. d) The client maintains a sedentary lifestyle. A Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the following is a sign of potential hypovolemia? a) Hypotension b) Bradycardiac) Warm moist skin d) Polyuria A The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a) Green color and texture b) Black and tarry appearance c) Clay-like quality d) Bright red blood in stool B After teaching a group of students about the various organs of the upper gastrointestinal tract and possible disorders, the instructor determines that the teaching was successful when the students identify which of the following structures as possibly being affected? a) Large intestine b) Ileum c) Stomach d) Liver C A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? a) Skim milk b) Nothing by mouth c) Regular diet d) Clear liquids B Bladder retraining for the treatment of urge incontinence: • Use timed voidings to increase intervals between voidings/decrease voiding frequency. • Perform pelvic floor (Kegel) exercises. • Perform relaxation techniques. • Offer undergarments while the client is retraining.• Teach the client not to ignore the urge to void. • Provide positive reinforcement as client maintains continence. • Eliminate or decrease caffeine drinks. • Take diuretics in the morning. what are normal creatinine levels? what are normal BUN levels? 0.8-1.4 mg/dL 8-25 mg/dL What are total serum protein values (normals) 6-8 g/dL Describe pre-albumin this is the best tool for evaluating nutrition. it has a half-life of 2 days which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3 weeks) what is normal pre-albumin values? what are normal serum levels of magnesium ? what is a normal potassium serum level? 17-40 mg/dL 1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is considered hypokalemia) what are good sources of folic acid? Excellent sources of folate include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley, collard greens, broccoli, cauliflower, beets, chicken liver and lentils. Sources of potassium beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas what is important about the diet of someone taking ACE inhibitors?can result in high potassium levels. Limit potassium intake (beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas) Taking Coumadin. Which foods should the client limit? Foods containing Vitamin K. Dark leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes what is a normal hematocrit level in a female? What are normal Hgb values (female)? what are normal values for WBCs? 37-48% (male is 42-52%) 12-16 g/dL (male 13-17) 4500-11,000 / uL what foods should you avoid if you have diverticulitis? avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in fiber) When taking MAOI's, limit your consumption of thyramine--it can cause elevated BP. This is found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi), sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil), Selogilive, Emsam, Eldepryl, Zelapar... At what age does bone loss begin with osteoporotis what are normal Calcium levels? at age 35 (women) 8.6-10 mg/dL A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of calcium gluconate (because hypocalcemia causes Chvostek's sign) What are the S/S of lithium toxicity? (depakote for bipolar disorder)fine hand tremors, mild GI upset, slurred speech and muscle weakness a nurse is obtaining a medication history from a client who is to start a new prescription for warfarin ( Coumadin) . which of the following over the counter medication should the nurse instruct the client to avoid Aspirin a nurse responsible for a client receiving a antihypertensive medication is to teach the client to change position slowly to avoid dizziness or fainting a client should receive a dose of flumazenil ( romazicon) to treat symptoms of benzodiazepine overdose a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following statement indicated the client understand the teaching I will tell my doctor before I stop taking the medication a nurse is reinforcing teaching to a client who is starting amitriptyline ( Elavil) for treatment of depression which of the following should the nurse include 1. change position slowly to minimize dizziness 2. chewing sugarless gum to prevent dry mouth a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid ibuprofen. why or why not ? what , if any is the appropriate action for the nurse to take NSAIDS such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notify the provider of client headache and ibuprofen us a client has prescription for valproic ( Depakote) which of the following laboratory value should the nurse anticipate monitor for the client taking this medication thrombocytes, amylase count and liver function test alcohol withdrawal heroin withdrawal nicotine withdrawalalcohol abstinence opioid over dose chlordiazeproxide( Librium) methadone( dolophine) bupropion ( wellbutrin) disulfiram ( antabuse) naloxone (narcan) a client who has parkinson's disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for which of the following should the nurse monitor this client orthostatic hypotension a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam ( ativan IV) . for what adverse effect should the nurse monitor this client the nurse should monitor the client respiratory depression a client has a new prescription for spironilactone ( aldactone ) which of the following laboratory value should the nurse recognized as a reason to withhold the morning dose of the medication and notify the provider serum potassium 5.2 a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication interaction is the client at risk Toxic level of digoxin a nurse is reinforcing a teaching on a client who has a prescription for verapamil ( calan) which of the following statement by the client indicated need further teaching i should decrease the amount of calcium in my diet while taking the medication A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes multiple other medications. Concurrent use of which of the following medications places the client at risk for digoxin toxicity? * Verapamil (Calan)Adverse effect of Verapamil Avoid grapefruit juice Interaction of diuretics and ACE inhibitors excessive reduction in blood pressure and symptomatic hypotension or hyperkalemia What can prevent MI, stroke, or death in high-risk patients Ramipril What to monitor for when taking enoxaparin (lovenox) Hyperkalemia Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic liver injury reported What are the therapeutic effects of protamine Antidote to severe heparin overdose + Reversal of heparin administered during procedures How to prevent adverse effects of oxycodone can cause respiratory depression. What is the nursing intervention and/or client education ? Monitor vital signs. › Stop opioids for respiratory rate less than 12/min, and notify the provider. › Have naloxone and resuscitation equipment available. › Avoid use of opioids with CNS depressant medications (barbiturates, benzodiazepines, consumption of alcohol). opioid agonists can cause Constipation What is the nursing intervention and/or client education ? Advise the client to increase fluid/fiber intake and physical activity. › Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract decreased bowel motility, or a stool softener such as docusate sodium (Colace) to prevent constipation.Adverse effects of ferrous sulfate constipation; upset stomach; black or dark-colored stools; or. temporary staining of the teeth. Baclofen (Lioresal) therapeutic outcome: Decrease the frequency and severity of muscle spasms (MS). What is the difference between respiratory acidosis and respiratory alkalosis? Acidosis refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers to an excess of base in the blood that causes the pH to rise above 7.45. Bowel elimination how to get a specimen collection Collect stool specimens for serial fecal occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine. Identifying manifestations of transient ischemic attacks symptoms r/t afffected area. Rapid onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke. Musculoskeletal congenital disorders Monitor skin for breakdown areas and prevent pressure sores. The nurse caring for a child in Buck's skin traction will keep the: Child pulled up in bed Where should the cath bag be placed when urinary catheterization Make sure the catheter bag/system is at a level below the client's bladder to avoid reflux. What are the signs and symptoms of fluid volume deficit loss of total body Na. Causes include vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic hypotension.What is the nursing action for dehiscence Cover with a sterile towel moistened with sterile saline; Have patient flex knees slightly and put in Fowler's . Which of these instructions should a nurse include in the teaching plan for a client who had removal of a cataract in the left eye? a. "Forcefully cough and take deep breaths every two hours to keep your airway clear." b. "Perform the prescribed eye exercises each day to strengthen your eye muscles." c. "Rinse your eyes with saline each morning to prevent postoperative infection." d. "Take the prescribed stool softener to avoid increasing intraocular pressure." d. "Take the prescribed stool softener to avoid increasing intraocular pressure." A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions? a. Suction the nasogastric tube. b. Flush the tube with 30 mL of sterile water. c. Remove the nasogastric tube. d. Check the residual volume. d. Check the residual volume. Which of these actions best demonstrates cultural sensitivity by a nurse? a. The nurse talks in a slow-paced speech. b. The nurse asks clients about their beliefs and practices toward pregnancy. c. The nurse uses charts and diagrams when teaching pregnant clients. d. The nurse can speak several different languages. b. The nurse asks clients about their beliefs and practices toward pregnancy. Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? a. Hyperreflexia. b. Tachycardia. c. Bradypnea. d. Agitation. b. Tachycardia.When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include: a. the urinary meatus. b. vomitus. c. contaminated water. d. sexual intercourse. a. the urinary meatus. A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated? a. Encourage the client to verbalize feelings. b. Lock the client in a secluded room. c. Ask the other clients to give feedback regarding the client's behavior. d. Ignore the client's inappropriate behavior. a. Encourage the client to verbalize feelings. Which of these measures should a nurse include when planning care for a schoolaged child during a sickle cell crisis episode? a. Monitoring for signs of bleeding. b. Providing pain relief. c. Administering cool sponge baths to reduce fevers. d. Offering a high calorie diet. b. Providing pain relief. Which of these instructions should a nurse include in the plan of care for a 32- week gestation client who had an amniocentesis today? a. "Drink at least six glasses of fluids during the next six hours after the test." b. "Call the clinic if you experience any abdominal cramps." c. "Don't be concerned if you have some vaginal spotting in the next 12 hours." d. "When you get home, stay on bed-rest for the next 48 hours." b. "Call the clinic if you experience any abdominal cramps." An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content? a. Peanut butter and jam sandwich. b. Chicken nuggets with rice.c. Tuna salad sandwich. d. Beefburger with cheese. d. Beefburger with cheese. A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis? a. Elevated serum potassium level. b. Elevated serum amylase level. c. Elevated serum sodium level. d. Elevated serum creatinine level. b. Elevated serum amylase level. Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery, should a nurse report immediately? a. Vomiting and a pulse rate of 106/minute. b. Respiratory rate of 12/minute and urine dribbling. c. Blood pressure of 100/60 mm Hg and wound discomfort. d. Urine output of 100 mL/hr and flushed skin. a. Vomiting and a pulse rate of 106/minute. Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication? a. The student maintains continuous eye contact with the client. b. The student places one arm around the client's shoulder? c. The student sits quietly next to the client. d. The student leaves the room to provide privacy for the client. c. The student sits quietly next to the client. Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia? a. Measure the client's blood sugar level. b. Administer a concentrated form glucose to the client. c. Administer a prn dose of insulin. d. Measure the client's urine for ketones. a. Measure the client's blood sugar level.An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk? a. Increasing the time interval between medication doses. b. Limiting the client's oral fluid intake. c. Administering the medications with meals. d. Encouraging the client to void every three to four hours. a. Increasing the time interval between medication doses. A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan? a. Explaining that staff does not poison clients. b. Focusing on how the hospital staff helps clients. c. Allowing the client to eat food from sealed containers. d. Telling the client that not eating the food that is served will result in privilege restrictions. c. Allowing the client to eat food from sealed containers. Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring? a. Gatch the knee of the bed. b. Administer anticoagulants preoperatively. c. Apply sequential compression devices. d. Maintain the legs in a dependent position. c. Apply sequential compression devices. When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is: a. at least 15 pounds. b. 15 to 20 pounds. c. 25 to 35 pounds. d. at least 45 pounds. c. 25 to 35 pounds. Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy.a. Sharp unilateral abdominal pain. b. Uncontrollable vomiting. c. Marked abdominal distention. d. Profuse vaginal bleeding. a. Sharp unilateral abdominal pain. Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation? a. "Please bathe the client in room 12, and then bring the client to the dining room for breakfast by 9 A.M." b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort." c. "Please measure the intake and output for the client's in rooms 8. 9. and 10, and record each on the intake/output sheets by 2 P.M." d. "Please toilet the clients in rooms 11, 12, and 13 mid-morning and after lunch." b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the client's discomfort." A client has the following order for regular insulin (Humulin R) on a sliding scale: Blood sugar 150-180 mg: Give 2 units regular insulin Blood sugar 181-200 mg: Give 4 units regular insulin Blood sugar 201-220 mg: Give 6 units of regular insulin Blood sugar above 220 mg: Call MD At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer? a. 0.04 b. 0.4 c. 4 d. 40 a. 0.04 Which of these nursing diagnosis is the priority for a client who is one-hour postoperative after extensive abdominal surgery? a. Risk for impaired physical mobility. b. Risk for deficient fluid volume.c. Risk for ineffective airway clearance. d. Risk for infection. c. Risk for ineffective airway clearance. A nurse should recognize that which of these occupations increases a person's risk of developing hepatitis B? a. Sanitation worker. b. Nursery school teacher. c. Hemodialysis nurse. d. Fish market sales person. c. Hemodialysis nurse. Which of these assessments is the priority for a client who sustained second-degree burns of the face and neck? a. Respiratory status. b. Renal function. c. Level of pain. d. Signs of infection. a. Respiratory status. A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these positions? a. Supine, flat. b. Orthopneic. c. Trendelenberg. d. Side-lying. d. Side-lying. Which of these instructions should a nurse include in the discharge teaching for a client who has diabetes mellitus? a. "Soak your feet in hot water once a day." b. "Cut your toenails in an oval shape weekly." c. "Avoid using any soap on your feet." d. "Apply lotion to your feet each day." d. "Apply lotion to your feet each day."A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first? a. Assess the client. b. Notify the physician. c. Contact the nurse manager. d. Complete an incident report. a. Assess the client. An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated blood pressure. Which of these actions should a nurse take? a. Add a 5% dextrose solution to the line. b. Raise the head of the bed. c. Stop the transfusion. d. Measure the client's temperature. c. Stop the transfusion. When caring for a client who has hepatitis B, a nurse should wear: a. gloves when administering oral medications to the client. b. a gown when changing the client's position. c. gloves when removing the intravenous cannula. d. a gown when emptying the client's used bath water. c. gloves when removing the intravenous cannula. Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance? a. Absence of wheezing throughout the lung fields. b. Clear lung sounds on auscultation. c. Pulse oximetry level of 80%. d. Frequent coughing throughout the day. b. Clear lung sounds on auscultation. A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child's mother to determine if the medication is being administered correctly? a. "Are you using a straw to administer the medicine?" b. "Has your child been urinating more frequently?"c. "Have you increased your child's milk intake each day?" d. "Is there a change in the color of your child's skin?" a. "Are you using a straw to administer the medicine?" Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should a nurse recognize as suggestive that the infant is dehydrated? a. Bulging anterior fontanel. b. Pulse rate of 120/minute. c. Decreased urine output. d. Cyanosis of the mucus membrane. c. Decreased urine output. Which of these instructions should be included in the teaching plan for the parents of a 10-month-old infant who is admitted to the hospital for failure to thrive? a. Advise the mother to make sure the infant drinks the entire bottle at each feeding. b. Encourage the mother to feed the infant slowly in a quiet environment. c. Teach the mother to position the infant on the abdomen following feedings. d. Instruct the mother to play actively with the infant during bottle feedings. b. Encourage the mother to feed the infant slowly in a quiet environment. When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should recognize which of these conditions as a probable cause of the newborn's jaundice? a. Dehydration. b. Liver immaturity. c. ABO incompatibility. d. Gallbladder immaturity. b. Liver immaturity. Which of these items should a nurse removed from the food tray of a client who is on a sodium-restricted diet? a. Packet of a salt substitute. b. Grapefruit juice. c. Container of jelly. d. Ketchup.d. Ketchup. Which of these statements, if made by a client who had a total hip replacement, would indicate a correct understanding of the postoperative instructions? a. "I will stoop carefully to pick up items from the floor." b. "I will use a raised toilet seat in the bathroom." c. "I will bend forward when tying my shoes." d. "I will put my leg through the full range of motion each day." b. "I will use a raised toilet seat in the bathroom." Which of these measures should a nurse include when planning care for an 88- year-old client who is admitted to the hospital with pneumonia? a. Restricting visitors to the client's immediate family members. b. Limiting the client care activities to no more than five minutes each. c. Allowing the client to perform self-care as tolerated. d. Providing the client with a non-stimulating environment. c. Allowing the client to perform self-care as tolerated. A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete all unfinished business as soon as possible." Which of these responses is appropriate? a. "Yes, you should do this immediately. b. "Don't you think you should stay focused on your treatment for now? c. "Exactly what things are you talking about?" d. "It sounds like you are concerned with your diagnosis." d. "It sounds like you are concerned with your diagnosis." Which of these interventions should plan for a child who is receiving chelation therapy for lead poisoning? a. Keeping an accurate record of intake and output. b. Instituting measures to prevent skeletal fractures. c. Maintaining isolation precautions. d. Maintaining strict bed rest. a. Keeping an accurate record of intake and output. A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up first? a. Heart rate, 60/minute and regular.b. Respiration, 30/minute and deep. c. Temperature, 97.1 °F (36.2 °C) d. Blood pressure, 136/86 mm Hg b. Respiration, 30/minute and deep. When determining the duration of a uterine contraction, a nurse should measure the contraction from the: a. beginning of one contraction to the end of that contraction. b. end of one contraction to the beginning of the next contraction. c. beginning of one contraction to the beginning of the next contraction. d. strongest point of one contraction to the strongest point of the next contraction. a. beginning of one contraction to the end of that contraction. A nurse should recognize which of these signs is a probably sign of pregnancy? a. Frequency of urination. b. Positive pregnancy test. c. Nausea in the morning. d. Abdominal distention. b. Positive pregnancy test. All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown? a. An 82-year-old client who bathes once a week. b. An 83-year-old client who applies powder after drying the skin. c. An 84-year-old client who has been NPO for four days. d. An 85-year-old client who has coronary artery disease. c. An 84-year-old client who has been NPO for four days. A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A nurse should interpret this to mean that the client has: a. had a period of sustained hyperglycemia. b. been non-compliant with home management. c. been in relatively good diabetic control. d. eaten a high carbohydrate snack just prior to testing. c. been in relatively good diabetic control.A nurse is caring for a client with burns and in reverse isolation. Which measures should the nurse include? a. Wearing disposable gloves when chaging the dressings. b. Having the client wear goggles when staff is in the room. c. Wearing a gown, mask, and gloves when providing care to the client. d. Disposing of the client's soiled laundry in a red bag. c. Wearing a gown, mask, and gloves when providing care to the client. A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is 250 mg/5 mL. How many milliliters should a nurse administer? a. 1.0 b. 1.5. c. 2.0 d. 2.5 c. 2.0 A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take? a. Include the 9:00 A.M. scenario in the shift report. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". c. Put the information in the margin and indicate the accurate time placement by drawing an arrow. d. Draw a line through the previous charting with "error" and then re-record everything, including the new information. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of these interpretations and additional assessments should the nurse make? a. The client's skin is sensitive to touch; lightly rub the client's chest area. b. The client has decreased circulation; palpate the peripheral pulses. c. The client is showing signs of pressure; press on the skin and observe for a return of color. d. The client is allergic to the soap; check the extremities for discoloration.c. The client is showing signs of pressure; press on the skin and observe for a return of color. A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the duration of the newborn's treatment, a nurse should: a. cover the newborn's closed eyes with patches. b. measure the newborn's pulse and respirations every two hours. c. keep the newborn under the light at all times, even during the feedings. d. notify the physician if the newborns stools become greenish yellow. a. cover the newborn's closed eyes with patches. Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia? a. Fruity breath odor. b. Polyuria. c. Diaphoresis. d. Flushed skin. c. Diaphoresis. A client is eight hours postoperative after a transurethral resection of the prostate (TURP). Which of these observations, if noted by a nurse, indicates a complication? a. Hourly urine output of 90 mL. b. Reports of bladder spasms. c. BP 92/60 mm Hg, pulse rate 118/minute. d. Pink-tinged urine output. c. BP 92/60 mm Hg, pulse rate 118/minute. A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which include: a. flushed skin and thirst. b. irritability and hunger. c. sweating and jitteriness. d. lethargy and tremors. a. flushed skin and thirst. Which of these laboratory test results should a nurse monitor for a client who is receiving intravenous heparin therapy at a rate of 1,500 units per hour for thetreatment of an acute pulmonary embolism? a. Partial thromboplastin time. b. Clot retraction time. c. Platelet levels. d. Bleeding time. a. Partial thromboplastin time. Which of these techniques should a nurse use to assess for correct placement of a nasogastric tube prior to administering a feeding? a. Aspirate 10 mL contents and measure the pH. b. Slowly inject 50 mL of saline and observe for resistance. c. Inject 20 mL of water and listen for gurgling sounds. d. Observe for bubbles after submerging the end of the tube in a cup of water. a. Aspirate 10 mL contents and measure the pH. A client has shortness of breath when lying down and usually assumes an upright or sitting position in order to breathe more comfortably. A nurse should document this observation as: a. dyspnea. b. bradypnea. c. orthopnea. d. apnea. c. orthopnea. Which of these instructions should a nurse give to a client when collecting a sputum specimen? a. "Take a deep breath, then cough and spit into this container." b. "Gargle with antiseptic mouthwash before you spit into this container. c. "Spit whatever sputum you have in your mouth into this container." d. "Drink some fluids to loosen your secretions and the spit into this container." a. "Take a deep breath, then cough and spit into this container." A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less than body requirements related to diminished taste perception and nausea. Which of these additional nursing diagnoses should a nurse consider for the client? a. Risk for aspiration.b. Ineffective protection. c. Risk for deficient fluid volume. d. Altered tissue perfusion. c. Risk for deficient fluid volume. Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to a nurse that the parent understands the teaching about a glutenfree diet? a. Broiled steak, baked potato, and spinach. b. Pork chop, egg noodles, and green peas. c. Fried chicken, white roll, and mixed vegetables. d. Baked macaroni with cheddar cheese and corn. a. Broiled steak, baked potato, and spinach. Which of these statements, if made by a nurse, is non-therapeutic because it disregards a client's feelings and concerns? a. "You appear anxious and tense." b. "Everything will be okay." c. "I notice you're biting your nails." d. "I'm not sure I understand what you're saying." b. "Everything will be okay." A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the wrong thing and not get the job." Which of these responses, if made by the nurse, will create a communication barrier? a. "Would you like to practice the interview?" b. "Have you thought about some possible questions that may be asked in the interview?" c. "Tell me more about your concerns." d. "You need to relax, and everything will be fine." d. "You need to relax, and everything will be fine." A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and lightheadedness. Which of these assessments should a nurse make? a. Determine the client's preferred diet. b. Measure the client's body temperature.c. Auscultate the lungs. d. Ascertain the client's typical sleep pattern. b. Measure the client's body temperature. Which of these nursing measures is the priority for a child who has hemophilia and who sustains a leg injury? a. Ensuring adequate hydration for the child. b. Soaking the child's injured leg in warm water. c. Administering the missing factor VIII to the child. d. Transfusing one unit of whole blood to the child. c. Administering the missing factor VIII to the child. Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours ago? a. Preventing hemorrhage. b. Preventing pneumonia. c. Preventing aspiration. d. Preventing dehydration. c. Preventing aspiration. A client who had a coronary artery bypass graft four days ago suddenly develops sinus tachycardia and reports shortness of breath and dizziness. Which of these interpretations and actions should a nurse take? a. This is an expected occurrence following bypass surgery; continue to monitor the client. b. This indicates normalization of the blood pressure; hold all anti-hypertensive medications. c. This may be an early sign of heart failure; notify the physician. d. This indicates hypoxia; administer oxygen at 5/L per minute. c. This may be an early sign of heart failure; notify the physician. Which of these lunch selections, if made by a client who has congestive heart failure, should a nurse recognize as indicative of a need for additional instructions? a. Cottage cheese with fresh fruit salad, whole wheat bread, and herbal tea. b. Baked chicken with brown rice, mixed green salad, and iced coffee. c. Egg salad sandwich with mayonnaise, pickles, and seltzer water. d. Beef tenderloin, carrots, mashed potatoes, and a baked apple.c. Egg salad sandwich with mayonnaise, pickles, and seltzer water. Which of the statements if made by a client who is take furosemide (Lasix), supports a nursing diagnosis of knowledge deficit? a. "This medication will increase the amount and frequency of my urination." b. "This medication must be taken, even on days when I fell well." c. "I will need to add more salt to my diet because this medication will increase its excretion." d. "I should change my position slowly to avoid dizziness related to this medication." c. "I will need to add more salt to my diet because this medication will increase its excretion." Which of these statements, if made by a client who has chronic obstructive pulmonary disease, indicates improvement? a. "I hope to attend my grandson's graduation next month." b. "I can now walk one more block than I could last month." c. "I take several quick breaths when I begin to cough." d. "I do my breathing exercises in the evening after I eat dinner." b. "I can now walk one more block than I could last month." An 8-month-old infant is admitted to the hospital because of failure to thrive. Which of these actions should a nurse plan? a. Limit the parents' interactions with the infant. b. Consistently assign the care of the infant to the same staff. c. Rotate assignments so that all staff can evaluate the infant. d. Limit the infant's activity until the cause of the problem is identified. b. Consistently assign the care of the infant to the same staff. Which of these actions should a nurse include to enhance the effectiveness of client teaching sessions? a. Include all content in one session so as not to overwhelm the client. b. Initially demonstrate and explain the procedure to the client. c. Avoid repetition of content. d. Include all clients on the unit in the sessions. b. Initially demonstrate and explain the procedure to the client.Which of these laboratory test results is more important for a nurse to assess for a client who reports chest pain? a. WBC count. b. PTT level. c. Troponin level. d. Hemoglobin. c. Troponin level. A nurse should explain to a primigravida that urine tests will be done at each prenatal visit throughout the pregnancy to measure: a. specific gravity and pregnancy hormones. b. culture and white blood cell count. c. glucose and protein. d. bacteria and red blood cell count. c. glucose and protein. Which of these manifestations should a nurse expect to observe in a client who is diagnosed with paranoid schizophrenia? a. Regression. b. Suspiciousness. c. Catatonia. d. Hyperactivity. b. Suspiciousness. Which of these measures should an emergency room nurse include when speaking with a family experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)? a. Explaining to the parents how SIDS could have been predicted. b. Discouraging the parents from viewing the infant's body. c. Encouraging the parents to take the opportunity to say goodbye. d. Interviewing the parents in-depth about the circumstances of the infants death. c. Encouraging the parents to take the opportunity to say goodbye. Which of these assessments is the priority for a client who is admitted with recurrent depression? a. Previous episodes of depression. b. Compliance with prescribed medications.c. Presence of a suicide plan. d. Problems with communication. c. Presence of a suicide plan. Which of these changes in the assessment data of a child who has congestive heart failure should a nurse recognize as indicative of a therapeutic response to prescribed medication therapy? a. Increased weight. b. Increased urine output. c. Increased respiratory rate. d. Increased heart size. b. Increased urine output. Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is appropriate? a. The UAP is assigned to measure a client's intake and output. b. The UAP is assigned to assess a client's lung sounds. c. The UAP is assigned to teach a client about diet restrictions. d. The UAP is assigned to change a client's postoperative wound dressing. a. The UAP is assigned to measure a client's intake and output. A client who has a history of asthma develops an acute asthma attack. Which of these questions should a nurse ask when assessing the etiology of this attack? a. "Have you eaten any new foods recently?" b. "How many hours did you sleep last night?" c. "Are you exercising every day?" d. "Have you reduced your fluid intake recently?" a. "Have you eaten any new foods recently?" Which of these foods should a nurse suggest that a client who is diagnosed with iron-deficiency anemia choose for dinner? a. Cooked dry beans, green leafy vegetables, and dried fruits. b. Raw cabbage, tomato juice, and cantaloupe. c. Fresh fish, peanut butter, and oatmeal. d. Cheddar cheese, enriched bread, and yellow vegetables. a. Cooked dry beans, green leafy vegetables, and dried fruits.A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8- months-pregnant primarily to: a. turn the fetus in the uterus. b. ease the fetus into the true pelvis. c. assessment of the location of the placenta. d. determine the fetal presentation. d. determine the fetal presentation. A child is brought to the clinical for serum lead screening because of ingestion of lead-based paint. Which of these manifestations, if present in the child, would indicate early signs of lead toxicity? a. Convulsive seizures. b. Behavior changes. c. Bleeding tendencies. d. Low-grade fever. b. Behavior changes. Which of these recommendations should a nurse make when teaching a client who is to start taking oral prednisone (Deltasone)? a. "Take this medicine at bedtime, on an empty stomach." b. "Take this medicine with a hot beverage in the evening." c. "Take this medicine in the morning, one hour before breakfast." d. "Take this medicine in the morning with food or milk." d. "Take this medicine in the morning with food or milk." Which of these actions should a nurse take prior to initiating prescribed antibiotic therapy for a client who has a urinary tract infection? a. Measure the body temperature. b. Cleanse the perineum. c. Weigh the client. d. Obtain a urine culture specimen. d. Obtain a urine culture specimen. When caring for a client who is receiving oxygen therapy via nasal cannula, a nurse should instruct the client: a. to inhale through the mouth. b. to breathe through the nose.c. to hold the catheter when coughing. d. to take quick, shallow breaths. b. to breathe through the nose. Each of these clients has impaired mobility related to knee surgery. Which client should a nurse assess first? a. A 20-year-old who has a sports-related injury. b. A 37-year-old who reports limited mobility. c. A 59-year-old who has a history of hypertension. d. A 70-year-old who has bilateral cataracts. c. A 59-year-old who has a history of hypertension. The mother of a 2-month-old tells a nurse that the baby is consuming six ounces of plain commercial formula seven times a day, plus one ounce of cereal in the morning and at bedtime. Based on this information, the nurse should conclude that the baby's diet is: a. too high in calories. b. too high in iron content. c. deficient in calcium. d. insufficient for the baby's age and weight. c. A 59-year-old who has a history of hypertension. A nurse plans to assess a client's recent memory. Which of these questions should the nurse include? a. "Who is your closest friend?" b. "What was the name of the school you attended?" c. "What day were you admitted to the unit?" d. "What did you have for breakfast?" d. "What did you have for breakfast?" A client who has a breast tumor says to a nurse, "I am so anxious. Why did I have to get sick now?" Which of these responses, if made by the nurse, is therapeutic? a. "You will need to find someone to talk over your fears on a regular basis." b. "What do you think is making you feel so anxious now?" c. "Are you aware that there are newer, more effective treatments for breast cancer?" d. "Tell me more about your concerns."d. "Tell me more about your concerns." Which of these actions, if taken by a nurse who is transferring a client from the bed to the chair, is correct? a. The bed is raised to a comfortable working height for the nurse. b. The wheelchair is placed perpendicular to the bed. c. The nurse stands behind the client during the transfer. d. The nurse supports the client in an upright standing position for a few moments. d. The nurse supports the client in an upright standing position for a few moments. A nurse should assist a pregnant client who is in the first trimester to achieve the developmental task of this stage of pregnancy, which is: a. accepting the fact that she is pregnant. b. accepting the fact that the fetus is a separate being. c. accepting that she will soon deliver the child. d. accepting that her body image has changed. a. accepting the fact that she is pregnant. When interacting with a client who is paranoid, a nurse should: a. use touch to place the client at ease. b. maintain a caring facial expression. c. stand close to the client. d. maintain a professional attitude towards the client. d. maintain a professional attitude towards the client. Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an acute care unit? a. Feeding a client who was admitted with a stroke yesterday. b. Ambulating a client who was admitted with a myocardial infarction yesterday. c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday. d. Suctioning the tracheostomy that was performed on a client yesterday. c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday. Which of these techniques should a nurse plan to use with a client who is delusional?a. Explore the delusion so the client will know it is false. b. Explain clearly why the client's belief is incorrect. c. Focus on reality-based topics. d. Avoid speaking with the client when he/she is delusional. c. Focus on reality-based topics. Which of the following manifestations should a nurse recognize as suggestive of right-sided heart failure? a. Cool extremities and frothy sputum. b. Jugular vein distention and pedal edema. c. Orthopnea and frequent cough at night. d. Weight loss and lower calf pains. b. Jugular vein distention and pedal edema. Which of these statements, if made by a nursing student prior to a sterile dressing change, is correct? a. "I understand that if objects touch other objects on the sterile field they are considered contaminated." b. "I understand that sterile objects that are below my waist are considered contaminated." c. "I understand that all objects in the sterile field must be dry." d. "I understand that contaminated objects can be used if rinsed with an antimicrobial solution." b. "I understand that sterile objects that are below my waist are considered contaminated." A nurse reviews a client's prenatal record and notes that the client's last menstrual period (LMP) was on September 18th. Using the Naegele's rule, the nurse should calculate that the client's expected date of delivery (EDD) will be: a. May 11th. b. May 25th. c. June 11th. d. June 25th. d. June 25th. Which of these instructions should a nurse give to a client who has venous insufficiency regarding the use of elastic stockings (TEDs)?a. "Bunch the TEDs up and pull them on like socks." b. "Lower the TEDs to your ankles if your legs ache." c. "Keep the TEDs on at all times." d. "Put the TEDs on before you get up in the morning." d. "Put the TEDs on before you get up in the morning." A nurse assesses a client who is scheduled for a total abdominal hysterectomy at 10:00 A.M. WHich of the factors should the nurse recognize as most likely to influence the outcome of the surgery? a. The client has voided two times since 5:00 A.M. b. The client is not able to demonstrate leg exercises because of osteoarthritis. c. The client takes one acetylsalicylic acid (baby Aspirin) daily. d. The client reports mouth dryness. c. The client takes one acetysalicylic acid (baby Aspirin) daily. A client's urine output is 500 mL in 24 hours. Which of these actions should a nurse take? a. Report the findings to the physician. b. Obtain an order for a diuretic. c. Encourage the client to limit fluid intake. d. Record the finding and continue to monitor the client. a. Report the findings to the physician. A nurse should question an order for a potassium chloride intravenous infusion for which of these clients? a. A client who has hypoxia. b. A client who is obese. c. A client who has anuria. d. A client who is congested. c. A client who has anuria. A 22-year-old college student has a heart rate that is 48/minute and regular during a routine physical examination. Which of these questions should a nurse consider when analyzing this heart rate? a. Is this student an athlete? b. Does this student smoke?c. How much alcohol does this student drink? d. Is this student feeling anxious? a. Is this student an athlete? Which of the following clients should a nurse recognize is most likely to develop diabetic ketoacidosis? a. A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess. b. A 31-year-old gestational diabetic who has occasional bout of nausea. c. A 55-year-old who has type 2 diabetes mellitus and is adjusting well to the lifestyle changes. d. A 72-year-old who has type 2 diabetes mellitus and is managed with diet and exercise. a. A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess. Which of these postoperative complications in the first hour after surgery requires immediate intervention? a. Serous draining on the dressing. b. Swelling of an extremity under a cast. c. Vomiting. d. Dehiscence of a wound. d. Dehiscence of a wound. Which of these assessments should a nurse make of a client who had a knee replacement this morning? a. Pain. b. Signs of infection. c. Bowel movement frequency. d. Range of motion. a. Pain. Which of these actions should a nurse take prior to assisting an elderly client to shave his face? a. Have the client sign a consent form. b. Determine what medications the client takes.c. Soften the client's skin by applying lotion. d. Cleanse the face with a bactericidal solution. b. Determine what medications the client takes. Which of these factors should a nurse consider when delegating tasks to unlicensed assistive personnel (UAP)? a. The UAP's relationship with clients. b. The UAP's willingness to perform tasks. c. The UAP's previous experiences on the unit. d. The UAP's duration of employment on the unit. c. The UAP's previous experiences on the unit. Which of these nursing diagnoses is the priority for a young adult client who has first-degree burns of the legs and smoke inhalation from a fire in the home? a. Pain. b. Risk for infection. c. Impaired gas exchange. d. Body image disturbance. c. Impaired gas exchange. A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks. To determine if the desired effects of the Pancrease are achieved, a nurse should consider which of these questions? a. Is the child's blood sugar level within normal limits? b. Has the child's appetite improved with the medications? c. Are the child's stools of normal consistency? d. Does the child report increased belching and flatus? c. Are the child's stools of normal consistency? When assessing a group of children, a nurse should recognize which child is at increased risk of developing acute glomerulonephritis? a. A 3-year-old who has multiple urinary tract anomalies. b. A 4-year-old who had a streptococcal infection a week ago. c. A 5-year-old who has recurrent enuresis at night. d. A 6-year-old who had chicken pox infection two weeks ago. b. A 4-year-old who had a streptococcal infection a week ago.A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my kingdom. I am not taking any medications. I do not want anyone to come near me. I need to protect myself if they do." Which of these problems should the nurse focus on first? a. Risk for violence. b. Delusions of grandeur. c. Disturbed personal identity. d. Risk for noncompliance. a. Risk for violence. When a client who has a diagnosis of depression is taking a monoamine oxidase (MAO) inhibitor, which of these dieatry instructions should a nurse give to the client? a. "Increase your intake of foods that are high in vitamin C, such as oranges." b. "Avoid foods that contain tyramine, such as aged cheeses." c. "Increase your intake of foods high in tryptophan, such as fish." d. "Restrict foods high in sodium, such as canned soups." b. "Avoid foods that contain tyramine, such as aged cheeses." Which of these strategies should a nurse plan for a client who is manic and has lost 30 pounds? a. Nutritious finger foods. b. Low-protein diets. c. Limiting fluids in between meals. d. Daily weights. a. Nutritious finger foods. A 15-year-old child who has type I diabetes mellitus receives an injection of regular insulin 5 units and isophane (NPH) insulin 15 units subcutaneously at 7:00 A.M. before eating breakfast. At 10:30 A.M., the child tells the school nurse, "I am sweating and feel weak." Which of these actions should the nurse take first? a. Measure the blood sugar. b. Determine what the child ate for breakfast. c. Give a simple carbohydrate. d. Contact the physician. a. Measure the blood sugar.A client who has a head injury is drowsy and lethargic, and has clear nasal discharge. Which of these actions should a nurse take? a. Obtain a specimen of the drainage for culture and sensitivity. b. Test the drainage for glucose. c. Cover the nares with sterile gauze. d. Cleanse the nostrils with sterile saline solution. b. Test the drainage for glucose. Which of these actions, if taken by a nursing assistant, should a nurse recognize as increasing the client's risk of developing a nosocomial infection? a. Wearing non-sterile gloves while emptying the Foley drainage bag. b. Taping a paper bag to the side rail for tissue disposal. c. Placing the Foley catheter drainage bag on the bed while transferring the client. d. Using the same cuff to measure the blood pressures of all the clients on the unit. c. Placing the Foley catheter drainage bag on the bed while transferring the client. A nurse is preparing a client for a vaginal examination. Which of these statements should the nurse make? a. "Go into the bathroom and empty your bladder." b. "Cleanse your perineal area with betadine solution." c. "Hold your breath while the speculum remains in place." d. "Push down as the doctor inserts the speculum." a. "Go into the bathroom and empty your bladder." A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A 25-year-old client who is terminally ill with metastatic testicular cancer. b. A 37-year-old client who has second-degree burns on both feet. c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion. d. A 68-year-old client who is bed bound related to severe Parkinson's disease. c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion. Which of these preventative measures should a nurse manager in a long-term care facility plan to institute to decrease clients' risks for falls? a. Monitoring clients frequently for evidence of activity intolerance.b. Placing all client personal items in the bedside drawers. c. Raising the side rails for all clients who have memory impairment. d. Maintaining all client beds in the highest position. a. Monitoring clients frequently for evidence of activity intolerance. Which of these assessment findings, if present in a primigravida, indicates that the client is experiencing true labor? a. The pains are felt in the lower abdomen, back, and groin. b. The Braxton-Hicks contractions have become stronger and more frequent. c. There is an increased amount of white mucus discharge. d. There is a progressive increase in effacement and cervical dilatation. d. There is a progressive increase in effacement and cervical dilatation. A client is admitted for opiate detoxification for the fifth time. Which of these statements, if made by a staff member, indicates a biased view of the client? a. "I feel so frustrated when clients are re-admitted." b. "Addicts relapse because they don't try hard enough." c. "I think this client needs to consider long-term placement after detoxification." d. "The team really needs to discuss this client's treatment plan." b. "Addicts relapse because they don't try hard enough." Which of these women, each of whom is in labor, should a nurse recognize as in need of immediate attention? a. A woman who is having contractions every 6 to 8 minutes of mild to moderate intensity. b. A woman who is receiving oxytocin augmentation and who has contractions lasting 60 to 70 seconds. c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement. d. A woman whose uterine contractions frequency is every two to give minutes. c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement. A nurse has received a report on these assigned clients. Which client should the nurse follow-up first? a. A client, admitted with acute diverticulitis, who has a white blood cell count (WBC) of 10,000 mm3.b. A client, admitted with acute pancreatitis, who has a fasting serum glucose of 130 mg/dL today, and had a reading of 160 mg/dL yesterday. c. A client, admitted with hepatitis, who has jaundice and tea-colored urine. d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today. d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today. Which of these statements, if made by a client who is taking a diuretic, should a nurse recognize as indicative of the need for additional instructions? a. "I take all of my medications at bedtime so I don't forget them." b. "I eat one or two bananas every day." c. "I weigh myself every day in the morning." d. "I will call my doctor if I have muscle weakness." a. "I take all of my medications at bedtime so I don't forget them." A nurse is monitoring a client who had a cystoscopy six hours ago. The nurse should inform the physician of which these manifestations? a. The client has pink-tinged urine. b. The client reports burning on urination. c. The client's white blood cell count is 15,000 mm3. d. The client appears drowsy. c. The client's white blood cell count is 15,000 mm3. Which of these actions should a nurse perform prior to a client's scheduled hemodialysis? a. Administer prophylactic antibiotics. b. Weigh the client. c. Give the client normal saline solution to drink. d. Measure the urine specific gravity. b. Weigh the client. Which of these behaviors, if taken by a staff nurse on a psychiatric unit, indicates a correct understanding of therapeutic techniques? a. A nurse smiles when speaking with clients who are manic. b. A nurse uses touch to communicate concern with a depressed client. c. A nurse sets consistent limits with manipulative clients.d. A nurse shares own anxiety reduction techniques with a client who has panic attacks. c. A nurse sets consistent limits with manipulative clients. A client has been in bed for the past three days. Which of these measures should a nurse include before assisting the client out of bed? a. Having the client drink a glass of water. b. Raising the head of the bed. c. Flexing the client's knees. d. Assessing the lung sounds. b. Raising the head of the bed. A client who has insulin-dependent diabetes mellitus asks a nurse, "What should I do when I feel nervous, sweaty, and hungry?" The nurse should give the client which of these instructions? a. "Lie down and rest." b. "Eat a carbohydrate snack." c. "Take your prn dose of insulin." d. "Add a slice of bread to your next meal." b. "Eat a carbohydrate snack." Which of these tasks should a licensed practical nurse (LPN) delegate to a nursing assistant? a. Checking the 11 A.M. blood sugar for a client who has ketoacidosis. b. Measuring the pulse oximetry level for a client who has status asthmaticus. c. AMbulating a client who had a hip replacement three days ago. d. Changing the dressing for a client who had wound debridement last week. c. AMbulating a client who had a hip replacement three days ago. A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A nurse should prepare the woman to have an immediate sonogram to determine the: a. location of the placenta. b. uterine response to labor. c. the fetus's current weight. d. condition of the uterine vascular bed. a. location of the placenta.A nurse is planning to interview a client who speaks limited English. Which of these strategies should the nurse include? a. Smile frequently during the interview interview to reduce the client's anxiety. b. Observe the client for indicators of confusion or not understanding questions. c. Maintain constant eye contact throughout the interview. d. Keep the interview short to decrease the client's fatigue. b. Observe the client for indicators of confusion or not understanding questions. A nurse takes the weight of a normal 2-year-old child who comes in to the pediatric clinic for a well-child visit. If the child weighted 7 lbs, 2 oz. at birth, how much should the nurse expect the child to weight at this visit? a. 14 lbs, 2 oz. b. 18 lbs, 6 oz. c. 28 lbs, 8 oz. d. 45 lbs, 10 oz. c. 28 lbs, 8 oz. A nurse has been discussing the nutritional needs of children with a group of parents in a clinic. Which of these statements, if made by the parent of a 2-year-old child, should the nurse follow up? a. "I give my child slices of cheese as an afternoon snack." b. "I give my child a cup of skim milk as an afternoon snack." c. "I give my child some popcorn as an afternoon snack." d. "I give my child some yogurt as an afternoon snack." c. "I give my child some popcorn as an afternoon snack." Which of these client care situations has the greatest potential for presenting an ethical dilemma for a nurse? a. Participating in pregnancy termination procedures. b. Counseling a client who is terminally ill with AIDS. c. Discussing contraception options with adolescents. d. Caring for a client who is from a different culture than the nurse. a. Participating in pregnancy termination procedures. Which assessment information should a nurse obtain first when a pregnant woman and her husband arrive at the Labor and Delivery Unit? a. Whether the couple attended birthing classes.b. The frequency and intensity of labor contractions. c. The number of previous pregnancies and outcomes. d. The amount and time of the client's last food intake. b. The frequency and intensity of labor contractions. A client who has Parkinson's disease has been identified as being at risk for falls. Which of these actions by a nurse is most likely to reduce the client's risk of falling? a. Monitor the client's blood pressure after ambulation. b. Ensure the client wears socks when ambulating. c. Encourage frequent weight-bearing exercise. d. Assign an assistant to remain with the client when ambulating. d. Assign an assistant to remain with the client when ambulating. A nurse determines that the therapeutic effectiveness of magnesium sulfate (MgSO4) for client who has preeclampsia is achieved when there is increased: a. urinary output. b. blood pressure. c. respiratory rate. d. uterine movement. a. urinary output. Which of these assessments is the initial priority of a client who is one-hour postoperative after an exploratory laparotomy? a. The appearance of the client's surgical incision. b. The client's level consciousness. c. The adequacy of the client's respiratory function. d. The client's fluid and electrolyte status. c. The adequacy of the client's respiratory function. Which of these client reports should a nurse recognize as suggestive of hypothyroidism? a. "My hands shake whenever I reach for anything." b. "I feel cold and tired all the time." c. "I sweat whenever I walk more than one block." d. "My head aches each evening." b. "I feel cold and tired all the time."A nurse is monitoring a client who is taking acetylsalicylic acid (Aspirin) 975 mg daily for adverse effects, which include: a. loss of joint mobility. b. increased serum calcium levels. c. increasing heart failure. d. occult blood in the stools. d. occult blood in the stools. Which of these rationales explains the purpose of nasogastric tube with suction for a client who had abdominal surgery? a. Prevention of gastric decompression. b. Removal of secretions from the stomach. c. Provision of postoperative nutrition. d. Promotion of abdominal distention. b. Removal of secretions from the stomach. A 75-year-old client who is newly admitted to a long-term care facility has all these nursing diagnoses. Which one is the priority? a. Risk of injury. b. Anxiety. c. Sleep pattern disturbance. d. Chronic. a. Risk of injury. A 12-month-old child is playing with the father. Which of these behaviors indicates that the child is demonstrating object permanence? a. The child transfers a toy to the other hand when given another one. b. The child returns a block to the same spot on the table. c. The child looks for a toy that the father has hidden under the table. d. The child recognizes that a ball of clay is the same when flattened out. c. The child looks for a toy that the father has hidden under the table. A nurse should recognize that a client's selection of which of these foods demonstrates a correct understanding of a high-fiber diet for colon cancer prevention? a. Corn muffin. b. Bran flakes.c. Raising muffin. d. Green salad. b. Bran flakes. Which of these discharge instructions should a nurse include for a client who has a ruptured tympanic membrane that occurred during a fall? a. "No showers or washing of the hair for the next month." b. "Avoid yawning or holding your head down." c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization." d. "Avoid swallowing and coughing until your ear has healed." c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization." Which of these nursing measures is appropriate for a client who has recurrent renal calculi? a. Weighing the client daily before breakfast. b. Measuring the blood pressure every four hours. c. Encouraging a daily intake of three liters of fluids. d. Testing the urine for protein each shift. c. Encouraging a daily intake of three liters of fluids. When auscultating the lungs of a woman who is admitted for severe pregnancyinduced hypertension, a nurse notes the presence of crackles and moist respirations. These assessment findings most likely indicate which of these complications? a. A convulsion is imminent. b. Pulmonary edema has developed. c. Bilateral lobar pneumonia is present. d. Respiratory failure is evident. b. Pulmonary edema has developed. A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A client who is eight-hours postoperative after a hip replacement. b. A client who is drowsy after falling out a third story window.c. A client who is four hours post-colonoscopy and polyp removal. d. A client who is dysphasic after a transient ischemic attack. b. A client who is drowsy after falling out a third story window. Which of these clients is at the highest risk of developing osteoporosis? a. An obese African-American adolescent who does not exercise. b. A pregnant Asian client who is a vegetarian. c. A middle-aged Native-American male who is quadriplegic. d. A thin, elderly Caucasian female who lives alone. d. A thin, elderly Caucasian female who lives alone. A nurse is obtaining the health history of a client who is admitted for surgical repair of an inguinal hernia. Which of these factors should the nurse recognize as having the greatest impact on the outcome of the surgery? a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain. b. The client drinks one glass of beer every evening with dinner. c. The client had a knee replacement six months prior to this admission. d. The client is allergic to all penicillin-type antibiotics. a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain. A nurse should recognize that a client who has chronic obstructive pulmonary disease (COPD), needs additional instructions if the client makes which of these statements? a. "I will try to take slow, deep breaths when I feel short of breath." b. "I will use the albuterol (Proventil) nebulizer before I eat. c. "I will drink most of my fluids between meals." d. "I will turn up the oxygen flow rate if I have difficulty breathing." d. "I will turn up the oxygen flow rate if I have difficulty breathing." A woman is treated in the emergency room for a broken arm and multiple facial bruises caused by her spouse. Which of these statements, if made by a nurse, is therapeutic? a. "You should leave this relationship now or you will be sorry." b. "Are you aware that women who remain in abusive relationships eventually are killed?" c. "This type of abuse typically recurs after a period of remorse by the abuser." d. "Can you think of what you did to cause this abuse?"c. "This type of abuse typically recurs after a period of remorse by the abuser." Which is a presumptive sign of pregnancy? A) More frequent urination B) Goodell sign (cervix) C) Chadwick sign D) Fetal movement palpable Subject: Maternity More frequent urination. List the presumptive signs of pregnancy? Subject: Maternity 1. Missed menstrual period. 2. Breast change: nipples tingle, fuller, darker. 3. More frequent urination. 4. Morning sickness. 5. Skin change: chloasma, linea nigra, striae. What does 'Presumptive Signs' of pregnancy mean? Subject: Maternity What the mother first notices when she may be pregnant. What does 'Probable Signs' of pregnancy mean? Subject: Maternity What an objective examiner first notices. List the probable signs of pregnancy. Subject: Maternity 1. Uterus is enlarged. Hegar sign. 2. Goodell sign (cervix) 3. Chadwick sign (vagina)4. Von Fernwald sign 5. Lab tests: pregnancy test (home test) 6. Braxton-Hicks contractions 7. Ballottement Which is a probable sign of pregnancy? A) Darkened areolas B) Fetal movement felt at 20 weeks C) Von Fernwald sign D) Hearing FHT (Fetal Heart Tones) Subject: Maternity Von Fernwald sign What does 'Positive Signs' of pregnancy mean? Subject: Maternity An examiner is 100% positive that the woman is pregnant through examination. List all the positive signs of pregnancy. Subject: Maternity 1. Can feel fetal parts through palpitation. 2. Electronic Doptone scope (audible at 8-11 weeks) 3. Sonogram (at 12 weeks) 4. Fetoscope or Leff stethoscope 5. Ultrasonographic (echographic) 6. Fetal movement palpable after 20 weeks Which is a positive sign of pregnancy? A) Home pregnancy test is positive. B) Chloasma C) The examiner can feel fetal parts through palpitation. D) Frequent urination. Subject: MaternityThe examiner can feel fetal parts through palpitation. What is Nagele's rule and how do you use it to determine the due date of birth? Subject: Maternity Nagele's rule is a standard way of calculating the due date of a pregnancy (EDC). The process is adding 9 months and 7 days to the first day of the last menstrual period (LMP). Calculate Nagele's rule for the first day of LMP of March 2, 2015. Subject: Maternity December 9, 2015 Calculate Nagele's rule for the first day of LMP of July 12, 2012. Subject: Maternity April 19, 2013 Calculate Nagele's rule for the first day of LMP of April 1, 2013. Subject: Maternity January 8, 2014 Determine Gravidity and Parity: A woman is pregnant for the 3rd time. She had one son born at 42 weeks gestation, another son at 40 weeks gestation. ... What does 'gravida' mean in GTPAL? Gravida indicates the number of times the woman has been pregnant, regardless of whether these pregnancies were carried to term. What is 'parity' mean in GP? Parity, or "para" indicates the number of >20-week births (including viable and non-viable; i.e., stillbirths). Pregnancies consisting of multiples, such as twins or triplets, count as one birth.What does 'abortus' mean in GTPAL? Abortus is the number of pregnancies that were lost for any reason, including induced abortions or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost. Stillbirths are not included. What does 'living' mean in GTPAL? How many children are living. What does 'term' mean in GTPAL? Term means how many were giving birth after 37 weeks. What are the appropriate episode findings for a client with bipolar experiencing mania? Inappropriate affect Inappropriate dress Inability to sleep or eat Becomes angry quickly Pressured speech Presecutory delusion What are the appropriate episode findings for a client with bipolar experiencing depression? Inability to make decisions Lack of energy Lack of self-confidence Describe isolation in mental health. A child who was physically abused by her uncle, but shows no emotion when speaking about him. Describe identification in mental health. A client, admitted, with epilepsy, and now wants to become a nurse. Describe conversion in mental health. A college freshman who is having difficulty organizing her workload and develops irritable bowel syndrome. Describe displacement in mental health.A client who is angry with a physician, but yells at the RN. Describe regression in mental health. A 3-year old hospitalized for leukemia only wants to be fed with a bottle while being held by his mother. Describe intellectualization in mental health. A wife who talks about the love of her family, but doesn't demonstrate love towards them. Describe projection in mental health. A client yells at the nurse saying she is fearful and withdrawn and should not be a nurse. Describe rationalization in mental health. A client who is being treated for drug abuse says she can't stop because "her husband verbally abuses her and she takes the drugs to get through the painful experience." Describe suppression in mental health. An adolescent who was involved in a drunk driving accident in which his best friend died, says he doesn't remember drinking and driving, even though he gave a report of the incident to the police. Describe reaction formation in mental health. A client is angry about all aspects of care, but acts nice to all health care personnel. Describe sublimation in mental health. A father who lost his son after binge drinking joins organizations to educate others about alcohol on college campuses. Re-educative therapy Involves learning new ways of perceiving and behaving. Self-control therapy Uses combination of cognitive and behavioral approaches to dealing with. Gestalt therapyEmphasis is on "here and now". Aversion therapy Negative reinforcement is used. Cognitive therapy Active, directive, time limited, structured approach. Supportive therapy Reinforcement of client's existing coping mechanisms. Reconstructive Emotional/cognitive restructuring takes place. Desensitization therapy Repeated exposure to stimulus which gradually reduces intense reaction. Behavior therapy Belief is that most behaviors are learned. Transactional analysis Goal is that individuals in group will communicate from proper ego states/responses of others. What is the key finding for Rubeola? Koplik spots. What is the key finding for Rubella? Petechial spots on soft palate. What is the key finding for Roseola? Rose-pink macules that blanche on pressure.What is the key finding for Mumps? Parotid gland swelling. What is the key finding for Varicella? Vesicles. What is the key finding for Pertussis? Paroxysmal coughing episodes. What is the key finding for Diptheria? Gray membrane on tonsils/pharnyx. What is the key finding for Poliomyelitis? Stiffness progressing to flaccid paralysis.What is the key finding for Scarlet fever? Strawberry tongue. What is the key finding for fifth disease? Slapped face rash appearance. What is the key finding for mononucleosis? Hepatosplenomegaly. What is the key finding for Rocky Mountain Spotted Fever? Maculopapular rash on ankles/wrists. What is the function of the pituitary gland?It's the master gland. Controls everything. What is the function of the Adrenal gland? Sodium/electrolyte balance/SNS response. What is the function of the thyroid gland Basal metabolic rate/growth rate. What is the function of the parathyroid gland? Calcium/phosphorus metabolism. What is the function of the pancreas? Carbohydrate/fat/protein metabolism. What is the function of the ovaries? Progesterone/estrogen production. What is the function of the testes? Development secondary sex characteristics. What types of airborne diseases require a negative pressure room and N-95 fitted masks? Rubeola, Vericella and Tuberculosis What types of diseases require droplet precautions? Streptococcal pharyngitis or pneumonia, haemophilus influenza type B, scarlet fever, pertussis, mumps, meningococcal meningitis. Where do you place droplet precautions clients? Best is in a private room or can be placed in a room with others that have the same condition. What type of diseases are placed in contact precautions? Enteric diseases caused by micro organisms, wound infection, herpes simplex, scabies, multidrug resistant organisms. Caradioversion should be initially set to? 50-100 joulesWhat is cardiac output? heart rate x stroke volume What is a kosher diet? no shellfish but yes fish with fins and scales; no pork; no mixing meat with milk, ever woman is post pelvic surgery and asks why she has a foley catheter inserted, what is your response? it avoids stress on the incision site/bladder crutches on what side when rising? when walking? unaffected side when rising; affected side when walking; Arms at what degrees when hands on crutch rails while standing? 30 degrees What walking gate for stairs? (crutches) 3 point Normal stoma findings moist shiny/pink; mild soap and water, then dry gently and completely, apply paste if used, apply barrier pastes to creases Cholecystitis diet no cheese! low fat, low cholesterol (<200), if AST & lipase, any type of bilirubin, WBC, amylase, LDH, are elevate = bad expect what during latent phase of labor? (0-3, 5-30, 30-45) 0-3 cm, contractions mild and moderate, 5-30 min apart/30-45 seconds contractions 3 minutes apart = what phase of labor? active variable decelerations = what? intervention?cord compression! prep for emergency c-section or inducing labor. also can change position, d/c oxytocin, o2 8-10L/min per mask, perform/assist with vaginal exam, assist with amnioinfusion if ordered Which of the following is the initial nursing action for the nurse to take when late decelerations appear on the fetal monitor? a - reposition the client in to left-lateral position b - apply a fetal scalp electrode c - increase the iv fluid rate d - perform a vaginal exam to assess dilation a - reposition the client in to left-lateral positioning best pain management for 8-10 post open cholecystectomy; demerol, hydromorphine, fentanyl, morphine DEMEROL NOT morphine or others; morphine can cause biliary spasms fontanels close when? posterior 2-3 months; anterior 12-18 months do you report chlamydia, do you need consent, etc? mandated reporting to CDC, without verbal or written consent Empty JP drain when? clean how? before half full, or every 8-12 hrs, NOT 24 hours. Clean with soap and water, NOT antimicrobials or Dakin's etc. If JP drainage has doubled in last two hours, possible cause? hemorrhage. Access, stat CBC, notify physician What do bananas, avocado and spinach have in common? If patient on what med, these are good foods? high K+, so good for hypokalemic patients; if patients on thiazide diuretics (Diuril, enduron), may be HYPOKalemic, so give these! MAOI's/Nardil, avoid what? Cheese! Cheese is not good with what? Cheese is good for what and why?nardil/maoi! good for hyponatremia because high in sodium, high in protein is drainage at pin sites ok with bucks traction? drainage ok, note the type/color/odor/amount; leave crust as a barrier, pin care 3x/day phenytoin, SMZ-TMP, command hallucinations = what? phenytoin toxicity! If patient has command hallucinations, withold med? yes! methergine risk? what does it do? treats postpartum hemorrhage by inducing uterine contractions; reducing hemorrhage; HYPERTENSION is a risk, so check bp prior to administration, watch for n/v, headache high pressure alarm, do what? assess for kinkds, client bitingg, excess secretions (suction), pulmonary edema, etc. Notify provider Low pressure alarm do what? assess for leaks, displacement, if can't find anything wrong, MANUALLY ventilate & call respiratory stat, do NOT leave alone 2 years of age, presentation of arms longer than torso, or round & soft abdomen round & soft abdomen, NOT arms longer than torso 3 years of age normals; immunization? 2-3kg/yr, 2.5-3 in/yr, picky eaters, initiative vs guilt, imaginary friends, ride tricycle, jump off bottom step, stand on one foot for a few seconds, DTaP, IPV, MMR, varicella, influenza first thing to do with a newborn; take temperature, weight, dry... DRY terminally ill patient only wants family, not friends with them. Type of grief? anticipatory, not dysfunctional, normal or disenfranchiseda client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive & unresponsive. The nurse anticipates that which IV solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume & increase BP? (5% dextrose in LR, 0.33 NaCl, 0.225% NaCl, 0.45 NaCl) 5% dextrose in LR Give what for hypovolemic shock ? 5% dextrose in LR Client's family asks you to pray with them. Response? refer to spiritual services After a blood transfusion, will you look at hub, hct, BP or HR for changes? hgb!!! 1-2 pt increase per unit of blood can you give an antibiotic in a TPN infusion line? what can you add to a TPN infusion line? NO! Nothing! change a TPN infusion line every 24 hours or how often? yes! every 24 hours can clients family change dressing daily? tie tubing to neck? no, every 8 hours? yes, square knot with 1-2 finger width TPN, slow down infusion before endingg, d/c until new bag ready? no, dont d/c or change rate, don't change flow rate! hip arthroplasty, what to watch out for? peripheral pulses! cool & weak, 1+ peripheral pulses, sign to call provider mom engorged, don't do what? dont self express milk; ice packs, support bra all ok Rifampin, isoniazid, phenytoin, what's up?INH/Isoniazid increases phenytoin toxicity, meaning ataxia and hallucinations may present; decrease phenytoin dosage; hepatotoxicity possible with rifampin Palpate fontanels by 2-3 years? No! bulging fontanels could mean increased ICP, meiningitis first priority for DKA patients? establish venous access, before anything DKA patient drops glucose from 450-250; do what? measure glucose, temp, what and how often? measure glucose & potassium hourly, provide IV glucose at 250 to prevent hypoglycemia patient has l1-l2 paralysis, lives with spouse, bathroom & bedroom on 2nd floor. Needs PT, respite, speech therapy and what? needs occupational and physical therapy, but social services is number one for help with home adapation highest risk to patient is bed tray left in room, tray table at end of bed, restraints tied to bed rails? restraints tied to bed rails, this is inappropriate infant has scaly spots, erythemic papillae, and something on lips. Report which to physician/ lips a woman comes in to you and says she is on contraception and wants to get pregnant. waht is she at risk for? if IUD, then ectopic pregnancy. infant has substernal heaves, expect what? o2, suction, survanta for surfactant, vent support aPTT normal level 25-35 platelets normal150-400 aPTT 30 and platelets 200, what's wrong? nothing can you delegate an LPN to check NG tube placement? can they provide first feeding after CVA? yes, according to book; not clear; but assume no beause high risk scenario ventricular tachycardia/vtach=what ECG widened QRS what can a 3 month old eat? carrots, grapes, graham crackers or popcorn graham crackers dehydration = what v/s low bp, high hr, metabolic acidosis (low ph, high bicarb), postural hypotension, h&h, BUN, elevated glucose reaches 250 on insulin, give what? isotonic, hypotonic, hypertonic, dextrose? dextrose to prevent hypoglycemia bend at waist to pick up, or tuck pelvis and flex abs? flex & tuck, never bend at waist! give patient cooling blanket when febrile, what is sign of adverse reaction? shivering can digoxin toxicity occur with 3.2 potassium? yes 130/86 BP, severe headache, what would you report in preterm labor to provider? severe headache; hypertensive crisis s/s of magnesium toxicity? 2 main interventions urine output <30, rr <12, no deep patellar tendon reflexes, decreased LOC, cardiac dysrhythmia, immmmmmediately d/c, give calcium glucanatetuna good for what? bad for what? high in protein and potassium; so watch out if anemic, increase or decrease milk and give iron or no? decrease milk as it interferes with iron absorption, and they need iron; give iron! report what after a craniotomy? aphasia, because this means increased ICP r/t increased bleeding, which is the highest risk. keep HOB at 30 prednisone 10 months ok? watch for what? long term not recommended, never change dosage, watch for osteoporosis, avoid large crowds due to increased risk for infection; nurse is educating on losing one pound a week; how many calories? 500 calories/day bad sign with a mother with newborn? disapproval diet for glomerulonephritis? low sodium, water restriction pediatric patient dehydrated, after initial oral rehydration, give water, juice or ginger ale? none! postoperative are for a client following a colon resection for colorectal cancer includes which of the following? SATA; 1: report to the provider that the stoma is red in color and has serosanguineous discharge 2: monitor and treat pain & evaluate pain-relief measures 3: start a full liquid diet upon return to medical unit 4: provide wound care using surgical aseptic technique 5: advise the client to use stool softners to prevent straining 2, 4, 5 naegeles rule-3+7 boggy uterus, do what? massage the fundus vertebrae related to paralysis below or above l1-l2 = paralysis priority infection for amniotomy fever/infection patient has stairs, has had a stroke, and has trouble communicating - priority therapy? speech / ABCs best to orient what? what not? follow nurse, not skills checklist what can grant informed consent? parent of minor, spouse or closest relative granted power of attorney, court-ordered rep, legal guardian impaired nurse, do what? report to charge nurse med error is what trait? (fidelity, veracity, beneficence?) veracity patient up & walking, pain 8, need what type of pain management? PCA pump, prn morphine singulair prevent exercise-induced bronchospasm, and for long-term use; take ONCE DAILY AT BED TIME take peak gentamicin (amino glycoside) when? trough? 30 min after giving IM, or 30 min after IV has finished; trough immediately before giving next doselithium levels 0.4-1 s/s of early lithium toxicity slurred speech, nvd, thirst, polyuria, muscle weakness whats up with central lines and pushing meds with resistance ? dont do it! may be dislodging a thrombosis if you run out of TPN, do what? hang dextrose have client do what with anthrax? strip down asthma & beta blockers don't give lol's/beta blockers to asthma patient's ace-inhibitors? dry cough how does dopamine work, by vasodilating or increasing cardiac output? increasing cardiac output thorazine hold if shuffling fentanyl patch changing time 72 hours, 48 if intolerant long term effect of corticosteroids losing hair on legs chronic emphysema ABG? RESP, acid (low ph, low co2) increase PAWP means what? reference?4-12, increased means left sided heart failure a patient is experiencing umbilical cord prolapse - intervention? put hand up vagina and hold it there GERD s/s atypical chest pain, SOB reglan extrapyramidal side effects (twitching, facial spasms, give anthihistamine to help) iron deficiency anemia lab results hgb <12, hct <33 ateriovenous fistula fact dont measure bp on this side with oxygen toxicity, will you see hypo or hyperventilation? hypoventilation and bradypnea explain irrigating with solution hold 1 inch above wound has dehisced, do what? put saline soaked sterile gauze over what is histrionic personality disorder? flirty & seductive expected findings of schizo? memory deficit, difficulty concentrating, disordered thinking, poor problem solving and decision-making what test for breast cancer vs ovarian cancer? HER2 (her 2 boobs) gene = breast AFTER biopsy but BRCA1 (bra) is for detecting breast cancer w/o biopsy.. ca-125 (clit area) for ovarian cancerappropriate post-op care for diabetes/ vitamin c flush a central line with how many mL? 10! 3 if peripheral what does abnormal pap smear indicate? cervical cancer what to tell woman if trying to get pregnant after stops, may take awhile treatment for chlamydia, both mom & baby? timing for baby? zithromax, amoxicillin and erthromycin for both mom & baby; immmmmmmediately following delivery decontamination for radiation? soap and water & disposable towels insulin, rotate sites or no? do not rotate site valproic acid liver failure, jaundice first thing for implementing staff changes? investigate staffing issues with task force no consent from ed to do surgery, do what? get official interpreter heavy lochia, boggy fundus, do what give oxytocin autism ati lack of responsiveness frequent variable decelsturn on left side first post EGD, what to watch for? cool/clammy skin, sign of perforation cytoxan for neuroblastomas in toddlers hydrate liberally risk for diabetes inspidus monitor for polyuria postpartum, immediate action? boggy uterus, massage fundus cushings disease, 2 things moon face and increased cortisol memory loss ICP equation for calculating a pulse pressure sbp - dbp = pp when should a trough level be scheduled for a once daily dosing of gentamycin? 1 hr prior to next dose when should a peak level be drawn for divided doses of gentamycin? 30 m after admin of med or infusion has finished when should a trough level be drawn for divided doses of gentamycin? right before next dose s/s dehydration hyperthermia, tachycardia, thready pulse, hypoTN, orthostatic hypotension, decreased CVP, tachypnea, dizziness, cool/clammy skin, diaphoresis, sunken eyeballs s/s overhydrationtachycardia, bounding pulse, HTN, tachypnea, increased CVP, confusion, muscle weakness, wt gain, ascites, dyspnea, crackles s/s hyponatremia hypothermia, tachycardia, rapid thready pulse, hypoTN, ortho hypo, headache, confusion, decreased DTR's, hyperactive bowel sounds s/s hypernatremia hyperthermia, tachycardia, rapid thready pulse, ortho hypo, restlessness, irritability, muscle twitching, reduced to absent DTR's, hyperactive bowel sounds s/s hypokalemia hyperthermia, weak irregular pulse, hypotn, resp distress, muscle cramping, pvc's, bradycardia, decreased mobility s/s hyperkalemia slow/irregular pulse, hypotn, restlessness, irritability, weakness with ascending flaccid paralysis, n/v/d, hyperactive bowel sounds complications following hypophysectomy (removal of pituitary gland) monitor for bleeding and nasal drainage for possible csf leak, assess neurological condition every hour for first 24 h and every 4h after; nursing intervention for preventing delays in healing encourage fluid intake of 2-3L; increase protein, keep serum albumin levels above 3.5 meds for sinus tachy amiodarone, adenosine, verapamil, synchronized cardioversion s/s hyperglycemia bg >250; thirst, frequency in urination, hunger, warm/dry/flushed skin, weakness, malaise, rapid/weak pulse, hypotension, deep rapid respirations complications of pericarditis cardiac tamponade (hypotension, muffled heart sounds, JVD, pardoxical pulse) pericarditis commoly follows arespiratory infection s/s of pericarditis chest pressure/pain, FRICTION RUB, SOB, pain relieved when sitting and leaning forward fasting blood glucose post pone admin of antidiabetic med until after levels are drawns, ensure patient has fasted for 8 hours prior to blood drawn oral glucose tolerance test fasting blood glucose level drawn at start then pt consumes a specified amount of glucose; blood glucose levels drawn every 30 m for 2 hrs, instruct client to consume balanced diet for 3d prior then fast 10-12 hr glycosylate hemoglobin best indicator for average blood glucose level for the past 120d, normal range is 4- 6%, diabetic range is 6.5-8% evaluating proper placement of NG tube aspirate to collect gastric contents & test pH (4 or less), x-ray, injecting air into tube to listen over abdomen is NOT an acceptable practice IV urography used to detect obstruction; assess for a parenchymall mass, and assess size of kidney before an IV urography procedure the nurse should check if patient is allergic to iodine & check creatinine levels b/c dye can cause renal failure complications of chest tube insertion air leaks - monitor the water seal chamber for continuous bubbling (air leak); tension pneumothorax - sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstructing can cause this pt teaching for external radiation therapygently wash skin over the irradiated area w/ mild soap/water, DONT remove radiation tattoos, DONT apply powders or lotions, wear soft clothing over irradiated area, avoid tight clothing, DON'T expose area to sun or heat how infectious mono is spread saliva incubation period for infectious mono 4-6 weeks s/s of infections mono fever, sore throat, swollen lymph glands, increased WBC, atypical lymphocytes, splenomegaly, enlarged liver transmission precautions for infectious mono standard contact complications of infections mono ruptured spleen nursing interventions for patient who has HSV-2 monitor fetal well being, fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible c-section of lesions present during labor early s/s of cold stress in infants axillary temp <97.7, increase rr, increased hr, mottled skin late s/s of cold stress in infants apneic episodes, bradycardia, acrocyanosis, decreased activity indications for use of cardioversion atrial dysrhythmia, SVT, ventricular tachycardia w/ pulse, tx of choice for pt who are symptomatic s/s of hypoglycemia shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache, weakness, confusiontx for hypoglycemia 4 oz or 2 oz grape juice or 8 oz milk, recheck bg in 15 min if still low (<70) give 15 g more carbs, recheck in 15 min, if w/n normal limits eat 1g protein (peanut butter, cheese) nursing interventions for increased ICP keep HOB at 30, avoid extreme flextion, extension or rotation of the head & maintain in midline neutral position; keep body aligned to avoid hip flextion/extentio, minimize endotracheal suctioning; instruct pt to avoid coughing or blowing nose s/s of bacterial vaginosis vaginal odor, discharge, dysuria nursing interventions for boggy uterus massage the fundus then administer oxytocin what acid base imalance w/ a pt with chronic emphysema most likely have respiratory acidosis; compensatory metaboli alkalosis calcium 8.5-10 chloride 95-105 glucose 70-110 potassium 3.5-5 na 135-145 BUN 12-20creatinine 0.7-14 specific gravity 1.015-1.030 hgb 12-18 hct 40 wbc 5000-10000 rbc 4-6 uric acid 3.5-7.5 Cranial nerve XI (hot spot) shoulder Proper lifting technique (picture) bending at knees 24 month old walk up steps Food label greatest weight listed first IV technique advance catheter Refeeding syndrome60% Low fat diet canola oil instead of vegetable oil Prior to amniocentesis empty bladder Radiation implant limit visitors to 30 minutes Levothyroxine take on empty stomach, in am; increases tsh Metformin contraindication kidney disease, severe infection, shock, hypoxic conditions Mastectomy lay of affected side to promote drainage, support arm on pillow, HOB 30 Circumcision use petroleum jelly with every diaper change Check for NG tube placement in the jejunum X-ray Colostomy care cut the bag Seizure precautions saline lock IV Ethical medical error veracity Early decelerations head compressionsMagnesium sulfate interventions (select all) calcium gluconate, stop infusion, UO less than 30, RR less than 12, decreased reflexes Thoracentesis causes pneumothorax expected finding not friction rub; tracheal deviation AP's talking in cafeteria tell them to stop talking Safety for parkinson's clear area Warfarin vitamin k for toxicity; INR 2-3; PT 11-12.5 Contraindication of MMR blood transfusion Diabetic foot care (select all) change shoes frequently, wash feet with soap and water Sprains avoid warm compress Expected finding of small pox rash in mouth 16 weeks pregnant alpha protein Psych med lip smacking Where to start IV first (picture) hand PRBC need further teachingstart IV on other arm Delegate to AP CPR compressions Delegate to LPN sterile dressing Postural drainage give albuterol, trendelenberg; 1 hour before meals or 2 hours after Dumping syndrome high protein and fat; avoid milk, sweets, and sugar; small, frequent meals DASH diet increase fruit, vegetables, and low fat dairy; k, mg, ca Baby with reflux small, frequent meals, thicken formula with rice cereal, HOB 30 Cleft palate repair periodic restraints Nephrotic syndrome vitamin K Pernicious anemia schilling's test Peritoneal dialysis report cloudy; monitor glucose; warm solution before Gastric surgery eat 3 meals Gastrectomy small, frequent meals; vitamin B12, D, iron, and folateStatin grapefruit Preventing uric acid stones yogurt RSV have own stethoscope in room Change of shift report orthostatic hypotension by nurses station Confused patient raise 1 side rail Hypoglycemia cool and clammy skin Hyperglycemia thirst Glycosylated blood test HbA1C Priority for patient in seclusion document Buddhist patient vegetarian Positive TB hard raised bump Heart murmur sound blowing or swishing Dehydrationoliguria NST ... PAD pain/cramping when walking, calf muscle atrophy, shiny cool extremities; elevate legs Cast with white extremity compartment syndrome Alcohol withdrawal expected finding n&v, tachycardia, diaphoresis, tremors, seizures Varicella scabs okay Hyperthermia not blanket or ice Purpose of ice decrease inflammation Sexual assault assess anxiety THA avoid flexion greater than 90 Beta blocker teaching don't stop abruptly; avoid in asthma; take with food Combination contraceptives increase BP Myelosuppression flu shotGlucocorticoid increase dose in DM; take with meals; avoid NSAIDs; Addison's crisis if stopped abruptly Extreme focus mild anxiety Good diet 30% carbs Family concern what has the doctor told you Adolescent 1300 mg of calcium Lyme disease report to health department Organize workload goals for the day Intervene pacing around wife Renal failure decrease protein, K, Na, increase carbs, strict I&O Preeclampsia proteinuria Urine frequency in pregnancy urine sensitivity test Lice can live for 48 hours on surfaces Chest tube complicationsbubbling in water seal Elderly abuse ask privately Informed consent signed willingly Sibling bonding offer gift each time sibling gets one TURP complication hematuria African american over Caucasian heart disease Sickle cell priority hydration Sickle cell complication SOB Respite care give caretaker break Acarbuse take with first bite of each meal Hallucination I understand you are scared Fire extinguisher PASS Advanced directive don't need a lawyerBreastfeeding and hepatitis c as long as you don't have cracked nipples ICP keep HOB midline Long term use of proton pump inhibitors osteoporosis Diabetes insipidus polyuria Difficulty voiding warm water ACE inhibitors cough What do you hear when you palpate abdomen resonance Negotiation strategy understand both sides Dying patient wants to be alone depression or dysfunctional Wife progressing quickly can you tell me more Pregnant non-pharmacological pain management aromatherapy, breathing techniques, imagery, music, use of focal points, subdued lighting Hypnosis purpose alter perception of pain Complication of conscious sedation with RR 6stop infusion or give something Major depression, OCD give fluoxetine What causes constipation iron Patient can't sleep don't drink caffeine before bed Collecting urine culture on baby straight cath Electrolytes Na - 136-145 K - 3.5-5 Ca - 9-10.5 Mg - 1.3-2.1 P - 3-4.5 Cl - 98-106 Hypervolemia bounding, JVD, edema, confusion, increase everything Anorexia prealbumin 10 Dehydration improving baby flat fontanelle Unsaturated fat coconut oil Priority abdominal pain and went away Opioid agonistnaloxone (Narcan) COPD increase calories and protein Needle disposal at home coffee container on top shelf Give RhoGAM in second pregnancy protect future pregnancy Swallow problem refer to speech therapist Nutrition for heart failure Decrease Na, increase fluids, increase fiber; increase K with diuretic Adverse affects of dogoxin Bleeding gums, bloody urine and stools, arrhythmias, petichiae NG nutrition Increase K Methotrexate adverse affect High blood pressure Most common cause of hyperthyroidism Grave's Disease S/S of thyroid storm hyperthermia, HTN, delirium, vomiting, abdominal pain, hyperglycemia, tachydysrhythmias Antidote for Valium intoxication Flumazenil (Romazicon) Valium, monitor for what? decreased respirationsAppropriate actions for bacterial meningitis droplet precautions, decrease environmental stimuli, maintain best rest w/ HOB at 30, seizure precautions, replace fluid and electrolytes position crutches on affected or unaffected side when sitting or rising from chair? unaffected side 2-3 finger widths Crutches no weight bearing Tripod position weight on UNAFFECTED side. advance both crutches and affected extremity move unaffected forward (beyond crutches) advance both crutches then affected extremety continue sequence (steps equal length) Crutches with weight bearing move crutches forward about 1 step length move AFFECTED leg forward level with crutches move unaffected leg forward continue sequence (steps equal length) Intervention for sprain (PRINCE) Protect, Rest, Ice, NSAIDs, Compress, Elevate Airborne Precautions Used to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require: - A private room - Masks/ respiratory protection devices for caregivers and visitors -Negative pressure airflow exchange in the room of at least six exchanges per hour. Droplet Precautions Protect against droplets larger than 5 mcg (streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meingococcal pneumonia/sepsis, pneumonic plague). Droplet precautions require: - A private room or a room with other clients with the same infectious disease -Masks Contact Precautions MRS WEE) Multidrug resistant organism, respiratory infection, skin infection (varicella, diphteria, shingle, impetigo, scabies), wound infection, enteric infection (c-diff), eye infectionProtect visitors and caregivers against direct client/ environmental contact infections(respiratory syncytial virus, shigella, enteric diseases caused by microorganisms, wound infections, herpes simplex, scabies, multi-resistant organisms). Contact precautions require: - A private room or a room with other clients with the same infection - Gloves and gowns worn by the caregivers and visitors. - Disposal fo infectious dressing material into a single, nonporous bag without touching the outside of the bag. use of restraints provider must rewrite order every 24h, Toileting and ROM exercises and assessment of neurovascular and neurosensory status q2h, tie to bed frame (loose knots that are easily removed) Care for Pt who has clostridium difficile contact precautions, encourage increased fluid intake, antiemetics, antimicrobial therapy clinical manifestations of smallpox high fever, fatigue, sever headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding sealed radiation implant pt in private room, nurse should wear dosimeter film badge, visitors limited to 30m visits and maintain distance of 6ft, visitors who are pregnant or under 16yrs. should not contact Pt, lead container in room, instruct pt to call nurse for assistance with elimination Latent phase of labor 1st part of the 1st stage of labor, lasts 4-6h, cervix 0-3cm, contractions irregular, mild to mod frequency 5-30m and duration of 30-45s, some dilation and effacement, pt talkative and eager Use slow/ deep breathing Periodic FHR ChangesVariable Cord Compression Move client Early Head Compression Identify progress Acceleration Other (Okay) No action needed Late Placental Insufficiency Execute action fast equation for calculating due date 1st day of last period + 1yr - 3 months + 7d = due date grains per day 6 oz whole grains (cereals , rice, pasta) 1 oz = one slice of bread, 1 cup cereal 1/2 cup cooked pasta veggies per day 2.5 cups (raw, cooked, or juice) broccoli, carrots dry beans and peas, corn, potatoes, tomatoes fruits per day 2 cups (1 small banana, orange, 1/4 cup dried apricots) milk per day 3 cups (2% milk, yogurt, cheese) protein per day 5.5oz (one small chicken breast 3 oz, one egg 1 oz, 1/4 cup dried cooked beans 1oz nutrients for healthy nervous system B complex vitamins (thiamine, niacin, B6 & B12, Ca, and Na Oils 6 tsp (canola, corn, olive, nuts, olives and some fish) Lab Results of an MI elevated troponin, CK-mb enzymes, elevated LDH daily % calories from protein 10% daily % calories from carbs45-65% daily % calories from fat 20-35% expected physiological changes of aging decreased EVERYTHING (skin turgor, wt, chest wall movement, senses, ht, subQ fat) measures to prevent injury with osteoporosis Ca supplementation, adequate amounts of protein, mag, vit. K, Vit D, wt-bearing exercises, remove throw rugs, provide adequate lighting, clear walkways, mark thresholds, doorways and steps African American women are at increased risk for what? cervical cancer African Americans are at increased risk for what? heart disease and stroke What populations are at greater risk for diabetes? American Indians, Alaskan natives, African Americans & Hispanics Discharge teaching on breast engorgement Nonlactating Clients: avoid nipple stimulation & apply cold compresses 15m on and 45m off, cabbage leaves placed inside bra, pain meds, supportive bra. Lactating Clients: manually express some milk, frequent feeding or pumping, warm shower, beast massage, supportive bra, maternal meds after feed to avoid cross-over to breast milk. to lose 1 lb of body fat per week, an adult must have an energy deficit of ____ cals/day 500 or 3,500 cal/wk Positive symptoms of schizophrenia hallucinations, delusions, alterations in speech, bizarre behaviorNegative symptoms of schizophrenia flat, blunt affect; algoia (poverty of thought/speech); avolition (lack of motivation); anhedonia (lack of pleasure/joy); anergia (lack of energy) Nursing interventions for domestic partner abuse help Pt develop a safety plan, identify behaviors and situations that might trigger violence and provide information regarding safe places to live; encourage participation in support groups Nursing interventions for Pt who is manic decrease stimulation, frequent rest periods, observe for escalating behavior, provide outlets for physical activity, provide portable nutritious food, use a calm, matter-of-fact approach, give concise explanations Nursing interventions for alcohol withdrawal syndrome self-assess ones own feelings regarding abuses; use open-ended questions, close/one-on-one observation; low-stimulation enviro, encourage attendance of self-help groups Nursing interventions for Pt with PTSD provide safety and comfort, remain w/ Pt through episode, give reassurance, group/family therapy is best, assist client to eval. coping mechanisms that work, assist Pt in determining triggers Nursing interventions for dementia reinforce reality, orientation to Person Place Time, encourage reminiscence about happy times, talk about familiar things, minimize need for decision making and abstract thinking to avoid frustration Ileostomy Care apply skin barriers to stoma, empty bag when it is 1/3 full, assess for fluid and electrolyte imbalances Normal post-op output for an ileostomy is what? 1 L/day; may be bile colored and liquid; normal to see small amounts of blood Stoma appearance should normally lookpink or red and moist/red and beefy Steps in performing closed intermittent irrigation clamp catheter w/ injection port and extension tubing, cleanse port slowly inject syringe w/ irrigant into catheter remove syringe and unclamp allow irrigant to drain into drainage bag Benefits of applying ice to extremity decreases inflammation, bleeding, fever, swelling, muscle spasms and pain Kosher foods animals which chew cud and have split hooves (cattle, sheep, goats, & deer), seafood with fins and scales, NO PORK (hotdogs, sausage, gelatin), and no meats mixed with milk Nutritional needs for Hepatic Encephalopathy high carb, high cal, low to mod fat, and low to mod protein; small, frequent meals; supplement w/ vitamins (B complex), folic acid, and iron Nursing intrvetions for Pt receiving TPN monitor serum and urine glucose, monitor for "cracking" of solution, use sterile technique when changing central line, bag and tubing should be changed q24h TPN fluid overload is evidenced by what? weight gain > 1kg/day and edema Interventions for chronic renal failure diet high in carbs and mod. fat, control protein intake, restrict Na, K, Ph, and Mg Sleep promotionbedtime routine, min number of times pt is awakened, assist w/ personal hygiene or back rub, exercise 2hr before bed, limit fluids 2-4hr before bed Intermittent tube feedings HOB @ 45 degrees feed and 1hr after feeding, admin. solution at room temp, formula is administered q4-6h in equal portions of 200-300mL over a 30m-60m time frame Flush 30mL every 4 hours Bariatric surgeries Dietary planning limited to liquids or pureed foods for first 6wks, meal size shouldn't exceed 1c, vit & min supplements Foods that can cause odor for ostomy fish, eggs, asparagus, garlic, beans, and dark green leafy veggies Foods that can cause gas for ostomy pt dark green leafy veggies, beer, carbonated beverages, dairy products, and corn What type of diet should a client who has dysphasia be on? Pureed or mechanical soft diet Contraindications for the use of Isosorbide Mononitrate (IMDUR) For Angina Headache hypersensitivity to nitrates, traumatic head injury b/c med can increase ICP, use cautiously in Pt taking Hypotension: antiHTN meds or have renal or liver dysfucntion If Pt develops reflex tachycardia from taking Imdur give what? metoprolol (Lopressor) Atorvastatin (lipitor) purpose decrease manufacture of LDL and VLDL and increase HDLs; promotes vasodilation, decreased plaque site inflammation, and decreased risk of thromboembolism S/E of Atorvastatin (Lipitor)Hepatotoxicity (liver fxn tests after 12wks then q6m); myopathy (obtain baseline CK levels); peripheral neuropathy (notify provider) Teaching for Atorvastatin (Lipitor) don't take with grapefruit juice, take in evening S/E of Metoclopramide (Reglan) For Heartburn (antiematic) EPS (bradykinesia, tremor, rigidy) (notify Ph, admin benadryl), hypotension, sedation, anticholinergic effects Doxazosin (Cardura) For HTN and BPH venous & arterial dilation, smooth muscle relaxation of prostatic capsule and bladder neck Teaching and S/E of Alpha Blockers Doxazosin (Cardura) or Prazosin (Minipress) 1st dose orthostatic hypotension (syncope, dizzy or faint) take 1st dose at night and monitor BP 2hr after 1st dose, avoid activities requiring mental alertness for first 12-24h, instruct pt to change position slowly, take with food Clozapine (Clozaril) Chlorpromazine (Neg and Pos s/s Schizophrenia) S/E What to do? neg and pos s/s of schizophrenia, relief of psychotic symptoms DRINK FLUIDS AVOID SUNLIGHT New onset diabetes/loss of glucose control (report s/s of increased thirst, urination, appetite), wt gain, hypercholesterolemia, orthostatic hypotension, anticholinergic effects, symptoms of agitation, dizziness, sedation, and sleep disruption, mild EPS such as tremor, risk for dyslipidemia, risk for fatal agranulocytosis (baseline & wkly monitor of WBC, notify of S/S of infection) Stop med for signs of neuroleptic malignant syndromeTherapeutic effect of Levothyroxine (Synthroid) For Hypothyroidism: decreased TSH 0.3-3.0, normal T4 levels, absence of hypothyroidism symptoms (depression, wt gain, bradycardia, anorexia, cold intolerance, dry skin, menorrhagia); takes several wks to notice a therapeutic effect Long-term adverse effects of Haloperidol (Haldol) Tardive dyskinesia (involuntary movements of tongue and face, lip smacking, involuntary movments of arms, legs, and trunk) Effectiveness of Allopurinal (Zyloprim) is evidenced by Improvement in pain caused by gout attack (decreased joint swelling, redness), decreased number of gout attacks, decreased uric acid levels Leukotrien Modifiers Montelukast (Singulair) suppress inflammation, bronchoconstriction, airway edema, and mucus production long-term therapy for asthma and to prevent exercise-induced bronchospasm Take once daily at bedtime Assessment of DI Decreased urine specific gravity and osmolality Hypernatremia Hypokalemia Increased urinary output Dehydration, weight loss and dry skin Desmopressin (DDAVP) For Diabetes Insipidus promote absorption of water within the kidneys; cause vasoconstriction; tx of diabetes insipidus Effectiveness of DDAVP is evidenced by: reduction in the large volumes of urine output associated with diabetes insipidus to normal levels Contraindications to MMR Immunizationpregnancy, allergy to gelatin and neomycin, hx of thrombocytopenia, immunosuppression, recent blood transfusion; common cold NOT a contraindication Administration of Enoxaparin (Lovenox) Anticoagulant subq q12h for 2-8d; use 20-22G needle to draw up; 25-26G needle to admin; admin in abdomen at least 2" away from umbilicus; apply pressure for 1-2m after injection; DON'T RUB Teaching about iron supplements take with orange juice on empty stomach; may cause constipation, N/V/D, can turn stool a dark green/black color Furosemide (Lasix) Purposes of Use block reabsorption of Na and chloride and prevent reabsorption of water; cause extensive diuresis Used for: pulmonary edema caused by HF, emergent need for rapid mobilization of fluid S/E of Furosemide (Lasix) dehydration, hypoNa, hypoCl, hypoTN, hypoK OTOTOXICITY Teaching on Lasix avoid admin late in day, report significant wt loss, lightheadedness, dizziness, GI distress, and general weakness, observe for signs of low Mg levels such as muscle twitching and tremors Sedative/ Hypnotic Medications Eszopiclone (Lunesta) Temazepam (Restoril) Zolpidem tartrate (Ambien) Use cautiously with mental depression avoid with alcohol and medications with CNS depression S/E Dry mouth, decreased libido, respiratory depressionOpioids (relief and sedation) Duragesic, Dilaudud, Morphine, Demerol, Codeine, oxycodone Opioid antagonist nalaxone (Narcan) used for respiratory depression Ace Inhibitors (end in "pril") Used for: HTN, HF, MI, diabetic neuropathy Monitor potassium levels K+ persistent non-productive cough SSRI (Duloxetine, Fluoxetine, Escitalopram, Fluvoxamine, Paroxetine, Sertraline) Teaching Avoid alcohol, do not discontinue abruptly, monitor for agitation, confusion and halluciations within the first 72 hours. S/E Weight gain, sexual dysfunction, fatigue, drowsiness May cause serotonin syndrome (2-72 hrs after start of treatment): tremors, agitation, confusion, anxiety and hallucinations When should admin RhoGAM when mom is Rh-negative and had Rh-positive infant; admin w/n 28 weeks (3rd trimeter) and 72h after birth Spontaneous abortion, amneoscentesis Does does Magnesium Sulfate do? relaxes smooth muscle of the uterus and inhibits uterine activity by suppressing contractions What are s/s of Mag sulfate toxicity? What is the antidote for Mag Sulfate? loss of Deep Tendon Reflexes, urinary output < 30ml/hr, resp depression, pulmonary edema, and/or chest pain Calcium Gluconate to fix!What are the contraindications for Mag sulfate? active vagninal bleeding, dilation of cervix is > 6cm, chorioamnionitis, > 34 wks gestation, acute fetal distress, severe pregnancy induced HTN or eclampsia Indications to withhold Propranolol (inderal) Beta Blocker bradycardia, SOB, edema, fatigue, AV block, Pt has asthma ANGINA Containdications for vasodilators Nitros CLIENTS WITH A HEAD INJURY Hypotensive risk with antihypertensive meds Erectile dysfunction meds (life threatening hypotension) Uses for methadone (Dolophine) relief of mod to severe pain; sedation; reduction of bowel motility Equation for calculating pulse pressure systolic - diastolic = pulse pressure 120-80=40 When should a trough level be scheduled for a once daily dosing of Gentamycin? 1hr prior to next dose When should a peak level be drawn for divided doses of Gentamycin? 30m after admin of med or infusion has finished When should a trough level be drawn for divided doses of Gentamycin? right before next dose S/S of dehydration hyperthermia, tachycardia, thready pulse, hypoTN, orthostatic hypotension, decreased CVP, tachypnea, dizziness, cool clammy skin, diaphoresis, sunken eyeballs S/S for overhydrationtachycardia, bounding pulse, HTN, tachypnea, increased CVP, confusion, muscle weakness, wt gain, ascites, dyspnea, crackles S/S of hyponatremia hypothermia, tachycardia, rapid thready pulse, hypoTN, ortho hypo, headache, confusion, decreased DTRs, hyperactive bowel sounds S/S of hypernatremia hyperthermia, tachycardia, rapid thready pulse, ortho hypo, restlessness, irritability, muscle twitching, reduced to absent DTRs, hyperactive bowel sounds S/S of hypokalemia hyperthermia, weak irregular pusle, hypoTN, resp. distress, muscle cramping, hypoactive DTRs, PVCs, bradycardia, decreased motility S/S of hyperkalemia slow, irregular pulse; hypoTN, restlessness, irritability, weakness with ascending flaccid paralysis, N/V/D, hyperactive bowel sounds S/S of hypocalcemia muscle twitches/tetany, hyperactive DTRs, positive Chvostek's sign (tapping on the facial nerve triggering facial twitching), positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation), seizures S/S of hypomagnesaemia hyperactive DTRs, muscle tetany, positive Chvostek's and Trousseau's signs, hypoactive bowel sounds, paralytic ileus Complications following a hypophysectomy (removal of pituitary gland) monitor for bleeding and nasal drainage for possible CSF leak (assess drainage for glucose or halo sign); assess neurological condition every hour for first 24h and every 4h after Nursing Interventions for preventing delays in healing encourage an intake of 2-3L of fluid/d, increase protein, keep serum albumin levels above 3.5 Meds for Sinus Tachycardiaamiodarone, adenosine, and verapmil; synchronized cardioversion S/S of hyperglycemia BG > 250, thirst, freq. urination, hunger; warm, dry flushed skin; weakness; malaise; rapid, weak pulse; hypoTN, deep rapid respirations Complication of pericarditis cardiac tamponade (hypoTN, muffled heart sounds, JVD, paradoxical pulse) Pericarditis commonly follows a respiratory infection S/S of pericarditis chest pressure/pain, friction rub, SOB, pain relieved when sitting and leaning forward Fasting blood glucose post pone admin of antidiabetic med until after levels are drawn; ensure pt has fasted for 8hr prior to blood draw Oral glucose tolerance test fasting blood glucose level drawn at start then pt consumes a specified amount of glucose. Blood glucose levels drawn every 30m for 2hrs; instruct client to consume balanced diet for 3d prior then fast 10-12hr Glycosylate hemoglobin (HgA1c) best indicator for average blood glucose level for the past 120d; normal range is 4- 6%, diabetic range is 6.5-8% Evaluating proper placement of NG tube aspirate to collect gastric contents and test pH (4 or less) before feeding. Hold if residual is >100 mL, X-Ray Injecting air into tube to listen over abdomen is NOT an acceptable practice IV Urography Procedureused to detect obstruction, assess for a parenchymal mass, and assess size of kidney Before procedure check allergy to iodine and check creatinine levels because dye can cause renal failure. Complications of chest tube insertion air leaks - monitor the water seal chamber for continuous bubbling (air leak); tension pneumothorax - sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause this Tidaling in water seal chamber is normal! Pt teaching for external radiation therapy gently wash skin over the irradiated area w/ mild soap and water, DON'T remove radiation tattoos, DON'T apply powders or lotions, wear soft clothing over irradiated area, avoid tight clothing, DON'T expose area to sun or heat Infectious Mononucleosis Spread? saliva Transmission Precautions? Standard Contact Incubation Time? 4-6 Weeks S/S: fever, soar throat, swollen lymph glands, increased WBC, atypical lymphocytes, splenomegaly, enlarged liver Complication: ruptured spleen Nursing Interventions for Pt who has HSV-2 monitor fetal well-being, fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible c section if lesions present during labor Early S/S of cold stress in infant auxiliary temp < 97.7, increased resp. rate, increased HR, mottled skin Late S/S of cold stress in infantapneic periods, bradycardia, acrocyanosis, decreased activity Indications for use of cardioversion Atrial dysrhythmias, SVT, vent. tachy w/ pusle & tx of choice for pt who are symptomatic S/S of Hypoglycemia shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache, weakness, confusion Tx for Hypoglycemia 4oz OJ or 2 oz grape juice or 8 oz milk recheck BG in 15m if still low (<70) give 15g more carbs recheck BG in 15m, if w/n norm limits eat 1g protein (peanut butter, cheese) Nursing Interventions for increased ICP Keep HOB at 30 degrees, avoid extreme flexion, extension, or rotation of the head and maintain in midline neutral position; keep body aligned avoid hip flextion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid coughing or blowing nose S/S of Bacterial Vaginosis vaginal odor, discharge, dysuria Nursing Interventions for Boggy Uterus Postpartum massage first then administer oxytocin what acid-base imbalances w/ a pt with chronic emphysema most likely have? resp. acidosis and compensatory metabolic alkalosis Respiratory Syncytial Virus Transmission Precautions Contact Precautions PPE: Gloves, Gown (mask and goggles as needed) Private Room Gloves and gown by visitors Disposal of infectious dressing material into nonporous bag Dedicated equipment to room or disinfectDroplet Precautions PPE: Mask when 3 feet of the client Private room Keep door closed In Baby: Maintain normal body temperature Care at Birth Vital signs should be checked on admission/birth and every 30 min x 2, every 1 hr x 2, and then every 8 hr. Weight should be checked daily at the same time, using the same scale. Inspect the newborn's umbilical cord. Observe for any bleeding from the cord, and ensure that the cord is clamped securely to prevent hemorrhage. In the first 6 to 8 hr of life as body systems stabilize and pass through periods of adjustment, observe for periods of reactivity. First period of reactivity - The newborn is alert, exhibits exploring activity, makes sucking sounds, and has a rapid heart rate and respiratory rate. Heart rate may be as high as 160 to 180/min, but will stabilize at a baseline of 100 to 120/min during a period that lasts 15 to 30 min after birth. Period of relative inactivity - The newborn will become quiet and begin to rest and sleep. The heart rate and respirations will decrease, and this period will last from 30 min to 2 hr after birth. Second period of reactivity - The newborn reawakens, becomes responsive again, and often gags and chokes on mucus that has accumulated in his mouth. This period usually occurs 2 to 8 hr after birth and may last 10 min to several hours. Intervening to Promote BondingFacilitate the bonding process by placing the infant skin-to-skin in the en face position with the client immediately after birth. Promote rooming-in as a quiet and private environment that enhances the family bonding process. Promote early initiation of breastfeeding, and encourage the client to recognize infant readiness cues. Offer assistance as needed. Teaching the client about infant care facilitates bonding as the client's confidence improves. Encourage the parents to bond with their infant through cuddling, bathing, feeding, diapering, and inspection. Provide frequent praise, support, and reassurance to the client as she moves toward independence in caring for her infant and adjusting to her maternal role. Encourage the client/parents to express their feelings, fears, and anxieties about caring for their infant Combination Oral Contraceptives Contradictions 1. Are smokers and over the age of 35. 2. Have a history of thrombophlebitis and cardiovascular events. 3. Have a family history or risk factors for breast cancer. 4. Are experiencing abnormal vaginal bleeding. 5. Use cautiously in clients who have hypertension, diabetes mellitus, gall bladder disease, uterine leiomyoma, seizures, and migraine headaches Left Sided Heart Failure Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea Fatigue Displaced apical pulse (hypertrophy) S3 heart sound (gallop) Pulmonary congestion (dyspnea, cough, bibasilar crackles) Frothy sputum (can be blood-tinged)Altered mental status Manifestations of organ failure, such as oliguria (decrease in urine output Right Sided Heart Failure Jugular vein distention Ascending dependent edema (legs, ankles, sacrum) Abdominal distention, ascites Fatigue, weakness Nausea and anorexia Polyuria at rest (nocturnal) Liver enlargement (hepatomegaly) and tenderness Weight gain Cardiomyopathy (leading to heart failure) Compartment Syndrome 1. Compartment syndrome (ACS) is assessed by using the five P's (pain, paralysis, paresthesia, pallor, and pulselessness). 2. Increased pain unrelieved with elevation or by pain medication. 3. Intense pain when passively moved. 4. Paresthesia or numbness, burning, and tingling are early signs. 5. Paralysis, motor weakness, or inability to move the extremity indicate major nerve damage and are late signs. 6. Color of tissue is pale (pallor), and nail beds are cyanotic. 7. Pulselessness is a late sign of compartment syndrome. 8. Palpated muscles are hard and swollen from edema. 9. If untreated, tissue necrosis can result. Neuromuscular damage occurs within 4 to 6 hr. Surgical treatment is a fasciotomy. Vitamin to prevent neural defects Folate is a B-vitamin found in spinach and leafy green vegetables, dried beans, liver, and citrus fruits. In vitamin supplements and fortified foods such as breakfast cereal, it is usually found in the form "folic acid." Disposing of insulin syringes at homeCoffee container on a high shelf Status Epilepticus Meds Lorazepam (Ativan) Drug of choice Diazepam (Valium) Phenytoin (Dilantin) (IV Slowly) Fosphenytoin (Cerebyx) Brachytherapy (Radiation) Radiation source is within the client who emits radiation and is a hazard to those around for a period of time. Varicella/ Chickenpox Direct contact and airborne precautions. 2-3 week incubation. Contagious until all lesions have scabbed. Pregnant women should not be in contact. Amount of calcium needed daily 1,000-1,200 mg a day. 600 mg at a time. Refeeding Syndrome Potassium, magnesium, and phosphate move intracellularly during enteral nutrition, electrolyte disturbances can result. Patients who are severely malnourished are at high risk for refeeding syndrome and require careful management of fluid and electrolytes when tube-fed. For patients who are severely ill or malnourished, provide feedings at 50% of estimated requirements and increase gradually over 24 to 48 hours if careful monitoring does not suggest clinical or biochemical abnormalities. Circulatory collapse that occurs when a client's completely compromised cardiac system is overwhelmed by a replenished vascular system after normal fluid intake resumes. Anorexia Abnormal Lab Values 1. Hypokalemia 2. Serum Albumin less than 3.5 (malnutrition) 3. Anemia and leukopenia with lymphocytosis 4. Possible impaired liver function, shown by increased enzyme levels 5. Possible elevated cholesterol 6. Abnormal thyroid function tests.7. Elevated carotene levels, which cause skin to appear yellow. 8. Decreased bone density 9. Abnormal blood glucose level 10. ECG changes Cranial nerve XI (Spinal accessory) Function of the nerve: Motor - Turning head, shrugging shoulders System: Head and neck Mother's Tests at 12 weeks Ultrasound chorionic villi sampling NT Down Syndrome Amniocentesis Performed at 14-16 weeks assess fetal lung maturity and well being Rh-negative mothers get Rhogam Complications are bleeding, contractions, signs and symptoms of infection peripherally inserted central catheter (PICC) catheter used for long-term intravenous access and inserted in the basilic or cephalic vein just above or below the antecubital space with the tip of the catheter resting in the superior vena cava Needs an informed consent How to access a venous access port (port a cath) don a mask-use surgical asepsis- don sterile glove -prime access cap, extension tubing and non coring needle with pre filled NS syringe -cleanse the site with chlorahexadine for 30 seconds -immoblize the device with non dominant hand forming a U with index and thumb -insert non-coring, non-barbed (Huber) needle with dominant hand in a 90 degree angle Most facilities' policies allow access to the implanted port with the same needle for 7 days. Does Port need flushing?-open ended= require heparin flushing -valved= does not require heparin Vancomycin Precautions Causes: Ototoxicity and nephrotoxicity Monitor creatinine and BUN Peak and Trough Levels Therapeutic Range 20-40 mcg/dL Infusion reactions (rash, flushing, tachycardia, hypotension) Thrombophlebitis DON'T TAKE WITH LOOP DIURETICS (OTOTOXICITY) Who Cannot Give Consent kids less than 18 intoxicated- blood alcohol level of .08 client with a dose of morphine a nurse is caring for a client with a hx of agression, the client is playing cards and throws them at other patients- what should you do ask the client how he is feeling (therapeutic cmcn) not take the cards away (this will increase aggression) explaining unit rules will not help either Cocaine/Amphetamines Dilated pupils, tachycardia, elevated BP, impaired judgement, grandiosity, paranoia with delusions Opiates (Heroin, fentanyl) Constricted pupils, decreased respirations, decreased BP, initial euphoria followed by dysphoria Dialysis Teaching Pt needs to report: muscle cramps, headache, nausea, or dizziness (hypotension) Total Gastrectomy is total removal of the stomach; long term complication include dumping syndrome- undigested food rapidly enters the duodenum or jejunum usually 5-30minutes after eating, epigastric pain with cramping, loud hyperactive bowel sounds- managed primarily with smaller and more frequent meals- no liquids with meals- increase in protein and fats- reduce carbs; Anemia may also be problem after gastric surgery due to decreased iron absorption; intrinsic factor is also lost so B12 cant be absorbed; folic acid deficiency, poor absorption of nutrients Gastrectomy Medications Needed Vitamin B12 is absorbed in the stomach and must be supplemented with regular injections by patients who underwent a total gastrectomy. Absorption may be impaired in those who still have part of their stomach, so it is necessary to have B12 levels checked periodically. Supplementation with folate, iron, and calcium may also be necessary to correct deficiencies caused by the surgery. Purpose of Telemetry Detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle Gestational Hypertension 20 weeks of pregnancy Seizure Precautions Rescue equipment at bedside Establish IV Site Position seizing pt to ground, stay with them Protect Head If in bed, pad side-rails Side lie with head flexed and slightly forward Loosen restrictive clothing Document time, behavior, aura, etc. Report seizure to the provider In Case of Fire Rescue Pull Alarm Aim Contain Squeeze Extinguish Sweep Bacterial Meningitis sign of ICPNuchal Ridgidy, Kernig's Sign Sign of ICP: Memory Loss To Promote Wound Healing Protein and Vit A Digoxin Toxicity Diarrhea, Nausea and Muscle Weakness 0.8-2.0 Theophyline Toxicity Hypotension, Albuminuria, Tachycardia and Anorexia 10-20 Valporic Acid for Seizure Control Hepatotoxic, report jaundice Warfarin Do not take with acetaminophen report dark stools Signs of Peritonitis Rigid, Board Like Abdomen Absent Bowel Sounds Fever High WBCs Rheumatoid Arthritis Use cold to edematous joints Suctioning Airway Use surgical asepsis No more than three consecutive times When resistance is met, retract 1-2cm Dumping Syndrome No liquids or carbs! Right CVAMinimizes problems Short attention span Impaired judgement and time Impulsive Left CVA Impaired speech and comprehension Slow and depressed HGB 12-18 Hit 37%-52% gtt Volume/time * gtt = gtt 1 min 100ml/20min * 10gtt 50 gtt 1 min If given hours multiply by 60 Fontella Closing on Newborn (Anterior and Posterior) Anterior: 12-18 months Posterior: 1-2 months Best time to perform bladder scan. Immediate after void Cholecystitis (inflammation of gallbladder) Diet -Increase fruits, vegetables, whole grains. Ex: Melon -Avoid greasy/fatty foods Moro Reflex (one of many reflexes present at birth) -Startled (arms out sideways, palms up, thumb flexed). Ex: strike surface next to newborn.Position for suppository or enema administration. -Sim's/left lateral/Rt. knee to chest Varicella contraindication Corticosteroids DTAP contraindication Hx of inconsolable crying Newborn Car Seat Safety Snug harness across axillary. Not across abdomen or neck. Ileostomy what pt expect on appearance. -Initial drainage: dark green, odorless. -Some initial bleeding normal -Pink or red stoma color normal -Initial swelling; decreases 2-3 weeks later Ileostomy care and education *-Empty pouch: 1/3 to 1/2 full. -Clean pouch 1-2 times daily. -Pouch change every 4-6 weeks. -Wafer size 1/8 to 1/4 larger than stoma -Avoid high fiber foods to prevent blockage. Delirium (occurs quickly) Simple orientation and low stimuli environment Hep B contraindication Baker's yeast MMR contraindication -Pregnancy, recent blood transfusion.... Anorexia Nervosa Electrolytes increasing: Sodium, Potassium, Chloride, BUN, Liver function, Cholesterol.Bulimia Therapeutic Nursing Care offer small and frequent meals 89% oxygen postoperative: what to do... Change oxygen to another finger Non-Rebreather Mask Ensure two "flaps" open during exhalation/close during inhalation. Venturi Mask Ensure reservoir bag 2/3 full during inspiration and expiration. Thoracentesis position sitting position, arms raised and resting overbed table. Chlorpromazine (med for psychoses) -Adverse Effects and given treatment -Severe Spasms/Tremors Tx: benzotropine (Cogentin), diphenhydramine (Benadryl). Contraction Stress Test (CST). Description, Purpose, normal range. -Brush palm across nipple for 2-3min to release natural oxytocin that produce contractions. -Determine how fetus will tolerate stress of labor. -3 contractions, 10 min period, duration 40-60 secs. What is most likely to happen during variable deceleration? Cord compression What is most likely to happen during early deceleration? Fetal Head Compression Cystic Fibrosis (Respiratory Disorder) -Diagnostic Test -Possible Medication Administration-DNA mutant gene identification. -Open capsule sprinkle on food (Enzyme: Pancrease). Levothyroxine (Synthroid) -What is it? -What patients should use this medication with caution? -Best way to take? -Thyroid hormone; treats hypothyroidism. -Cardiac pts; aggrevates tachy and anxiety -Take in the morning, on empty stomach Levothyroxine (Synthroid) -Signs of Toxicity *Cardiac: anxiety, chest pain, tachy, htn. Buck's Traction -Goal -Following conservative measurements -Skin integrity/Neuro -Immobilization -Follow RX orders: type of traction, weights, whether it can be removed. -Reposition every 2 hrs, provide pin care, neuro checks Amputation -Patient education Apply prosthetic before ambulating. Ferrous Sulfate (Feosol) -Purpose -Reporting symptoms -Administration -How to monitor effectiveness -Treats iron deficiency -GI distress: nausea, constipation, heartburn. -Take on empty stomach, drink with straw and rinse to prevent staining. - Increase Hgb of 2g/dL, Hct Orientation PhaseIntroduce, Discuss confidentiality, Set goals Working Phase Problem Solve Terminal Phase Evaluation (evaluate goals, experience, feelings) Chadwick's Sign Purplish vulva during pregnancy Patient is having a hysterectomy and states, "I can possibly plan a pregnancy". What needs to be reinforced? Outcome Vaginal Flush Complications Preterm Labor: Ruptured membranes, signs of infection Sucralfate for PUD coats stomach to prevent formation of ulcer and aids with healing existing ulcers 17 year old having an emergency surgery. What type of consent is best to intervene? Verbal Insulins not to mix garglarine and determis Malfunctioning IV machine mark as defected and get new one What is the best recommendation for a newly diagnosed diabetic 2 patients that lives independently? Refer to support group Circumcision post op care: cleaning -Change diaper every 4 hrs. -Clean penis with each change.-Apply petroleum jelly for at least 24 hrs after circumcision (prevent adhering). -Fan fold diaper (prevent pressure). -Avoid wrapping penis (impairs circulation) -Washing: trickle warm water over penis. -Do not clean yellowish mucus that appears by day 2. -Do not use moistened towelettes. -Healing: a couple of weeks. TB precautions and care -private room/negative pressure -N95 masks -pt wear mask when transported out of room or in any public place. -Medications: may be taking up to 4 meds at a time; up to 6-12 months -Test exposed family members -Sputum culture every 2-3 weeks; 3 negatives results in noninfectious. Vaginal discharge during early pregnancy Leukorrhea MRSA Contact Precautions -keep distance within 3 ft of client -Private room or share with someone with similar infection (wound infection, herpes simplex) -double bag dressing gauze. -PPE: Gloves and Gowns. Metformin most common side effect Renal (kidney) failure Drawing up Insulin? Regular vs. NPH First Regular (clear), then NPH (cloudy) Interaction between SSRI (e.g. fluoxetine) and St. John's Worts Hypertension and Increased HR; may be life-threatening. Diabetic Foot Care-Nailcare: Podiatrist, cut nail straight across. -Wear Clean Cotton Socks/Closed Shoes -Do not soak feet or wear ointments Used Opioid overdose Naloxone (Narcan) Contraindication During Alcohol Withdrawal Delirium, accompanied by hallucinations. Patient education for Amniocentesis. -Position: supine or rolled towel under right hip -Continue breathing normally when inserting needle -Rest 30 mins after procedure. -Increase fluids for next 24 hrs. Indications of Fluid Volume Depletion (Hypovolemia) -Thready pulse/Hypotensive -Tachy -Increased Respiration -Cool, Clammy, Diaphoretic -Decreased Urine Output -Thirst Type Stomas: Appearance -Single -Loop -Divided -Double-Barrel -Single (one stoma); brought through onto anterior abd wall. -Loop (two openings); proximal (active) and distal (inactive). -Divided (two separate stomas); proximal (digestive) and distal (secretes mucus). -Double-Barrel (distal and proximal sutured together are both brought up onto abd wall). Documentation for Ostomy Care (Stool)Amount Consistency Color Priority for Panic Disorder Breathing Technique Education on meds for Kidney Disease 1.Digoxin (Lanoxin) 2.Sodium plystyrene (Kayexalate) 3.Epoetin alfa (Epogen) 4.Ferrous sulfate (Feosol) 5.Aluminum hydroxide gel (Amphojel) 6.Furosemide (Lasix) 1. Take within 2 hrs of meal, monitor signs of toxicity, apical pulse for 1 min. 2. Monitor hypokalemia, restrict sodium intake. 3. blood twice a week, monitor HTN. 4. administer following dialysis with stool softner, take with food. 5. avoid pts with GI disorders, take 2 hrs before or after Digoxin. 6. Monitor I&O, bp, weight. Report thirst, cough. Newborn Water and Room Temp Water: 120F or lower Room: 97.9-99 F Bathing Newborn technique Bathe from cleanest to dirtiest -Eyes -Face -Head -Chest -Arms-Legs -Groin (last) Newborn reflex shown on day 1 hear voice Immunization is recommended for postexposure protection Hep A (fecal route) Arthroplasty pt education -How to avoid contractures, dislocations; prevent DVT's. -Non-pharmalogical treatment -Do not bend at waist. -Use abductor pillow in between legs. -Perform Continuous Passive Motion -Ice pack COPD -conservative measurements -Rapid relief med -High Fowler position -Increase fluids to liquify mucous -Albuterol Dementia Living Coordination Home health Agency>Assisted Living>Nursing Home Need for Sterile Gloves Inserting Catheter Discomforts During Pregnancy -Nausea -Fatigue -Backache -Constipation -Varicose Veins -Hemoroids-Heartburn -Nasal stuffiness -Dyspnea -Leg Cramps -Edema lower extremities Acute Mania Interventions -Decrease stimuli and one to one observation if necessary. Bulimia Plan of Care when meal planning closely monitor the client during and after meals to prevent purging Reinforcing Teaching About Oppositional Defiant Disorder Set clear limits on unacceptable behaviors and be consistent. Reward system for acceptable behavior. Osteoarthritis Alternate: Heat Therapy for Pain and Cold Therapy for Inflammation -Use assistive devices (raised toilet to help not straining) What to do before bolus feeding or administration of medication Check for residuals (60 mL syringe) What to do when pt complains of cramping during tube feeding? Decrease infusion rate Ideal location for drainage bag of catheters Hang on bedframe below level of the bladder. Ventilator Alarms -Low Pressure -High Pressure -Low: disconnection -High: suction for possible secretions, kinks. Glasgow Coma Scale (head injuries) (eyes, verbal, motor)highest number 15, good. lowest number 3, severe. Pressure Ulcer Strategies -Reposition time (bed/chair) -Incontinent Pt. -Bed every 2hr, chair every hour. -Apply barrier cream and moisture absorbing pad. Immunization: booster every 10 years DTP HPV vaccination doses 3 doses How to measure Fundal Height top of symphysis pubis to top of fundus How to calculate due date: LMP 8/2/15 -subtract 8-3=5 -add 7 + 2= 9 May 9, 2016 Contraindicated Immunizations During Pregnancy -Varicella -Zoster -MMR True Labor vs False Labor Abdominal Discomfort true: low back and abdominal false: abd and groin Types of Decelerations: <120 fhr -early -late -variable-early: head compression -late: uteroplacental insufficiency -variable: cord compression Nursing Interventions during late or variable deceleration left lateral position, oxygen, c-section Normal Fetal HR 120-160 Nursing Care for Boggy Uterus Ask pt to void; if still boggy massage top of fundus with fingers and reassess every 15 mins. Nursing Care for Engorgement Apply moist heat for 5 min before breastfeeding. Ice compresses after feeding to reduce discomfort and swelling. Nursing Care for Mastitis Continue breastfeeding and take antibiotics as prescribed. Narcotic antidote Naloxone (narcan) What is wrong with the script? gentamicin 50 mg po every 4 hours #30 Drug name: Gentamicin (capital G) Anemia lab RBC 4.20-4.87 BUN/Creatinine normal values (for kidney function) 7-20/0.8-1.4 WBC normal values (for infection) 4,000-10,000Sodium 136-144 Potassium 3.5-5.5 Chloride 96-106 Be ready to administer ____ for Magnesium sulfate toxicity Calcium gluconate Sign of mag sulfate toxicity (4) 1. Absent deep tendon reflexes 2.Resp rate < 12 3. Urine output < 30 4.Mag levels above 8 Understanding Rh. Administration of antibody and time. Mother Rh negative. Fetus Rh positive. Rhogam at 28 weeks, then 72 hrs after birth. Stroke eating precautions -check gag reflex -thickened fluids/puree -Sit upright/flexed neck forward Dehydration S&S (hypovolemia) -pulse; weak and thready. hypotension -tachy -confused -decreased urine output -skin and mucous membranes dry Urine Specificity increasedUrine Specific Normal Values and Significance Decreased hypervolemia. Increased hypovolemia. 1.001-1.029 JVD. What side of heart? Right Adverse effect of ACE inhibitor (pril's) ACE inhibitors, such as captopril, increase potassium levels (hyperkalemia) Buddhism diet -some are vegetarians -may avoid alochol and tobacco -may fast on holy days -chanting is common -brain death is not considered a a requirement for death christianity -some avoid alcohol, tobacco, caffeine -fast during lent hinduism -some are vegetarians -do not prolong life -want to lie on floor while dying -thread is placed around neck/wrist -pours water into mouth -bathes body -cremated islam -avoid alcohol and pork -fast during ramadan -faces mecca -confesses sins during dying-white cloth washes body -prayer is said jehovah's witness -no blood -avoid foods having or prepared with blood judiasm -kosher diet-cannot have dairy and meat in the same meal and veggies and meat have to be cooked in different parts of the kitchen mormonism -avoid alcohol, tobacco and caffeine conflict resolution strategies -open communication amont staff is needed -de-escalate the situation with open communication and problem-solving strategies -use "I" statements -listen carefully to what other people are saying, try to understand their perspective -move conflict that is escalating to private location -share ground rules steps of problem solving -ID problem -discuss possible solutions -analyze ID solutions -select solution -implement solution -evaluate scabies -itchy, especially at night -rash, especially between fingers -thin, pencil mark lines on skin -most common head, neck, shoulders, palms, soles (young kids) -older kids- most common on hands, wrists, genitals, ab Pediculosis capitis- head lice-intense itching -small, red bumps on the scalp -nits (white specks) on the hair shaft newborn assessment -expected head circumference (32-36 cm) -expected chest circumference (30-33 cm) -length 18-22 in for clients who are hearing imparied -sit and face client -avoid covering mouth while speaking -encourage use of hearing devices -speak slowly and clearly -do not shout -try lowering vocal pitch before increasing volume -use brief sentences with simple words -write down what clients do not understand -minimize background noise -ask for sign language interpreter if needed use of three way indwelling catheter continuous bladder irrigation prostate issues gentamicin otoxicity (tinnitus, HA, hearing loss, nausea, dizziness, vertigo) nephrotoxicity hypersensitivity- rash, pruritus dietary prevention nephrolithiasis -avoid oxalates- rhubarb, spinach, beets -avoid excessive intake of protein, sodium and calcium monitor for these in Levodopa -NV, drowsiness -dyskinesias (head bobbing, tics, grimacing, tremors)- decrease dose-orthostatic hypotension -CV effects- tachycardia, palpitations, irregular heartbeat -psychosis -discoloration of sweat and urine- normal -activation of malignant melanoma ileal conduit -continuous drainage into external pouch -monitor peristomal skin for redness, excoriation or infection -teach them how to care for the drains and their insertion site during the 3-6 weeks before removal -clean the insertion sites gently with water and then apply dry sterile dressing -intially catheterize stoma= emtpy pouch every 2-3 hours and irrigate pouch in the morning and evening -later they can cath every 4 hours while away or more often if they sense fullness -clean reusable catheter tip with warm soap and water, rinse it thoroughly and can use it for up to a month ventriculoperitoneal shunt post op for infant with hydrocephalus report what to provider irritability when being held early detection of men's prostate cancer annual measurement of prostate specific antigen (PSA) should be performed for men over 50 method to evaluate nurse's time management skills maintain regular notes about the nurse's time management skills after receiving report assess who first? post op client with abdominal distention and no bowel sounds because of paralytic ileus nurses documents dressing change that was not performed what should charge nurse do first? gather more info about staff nurse's actions ASSESSSSSassessing newborn immediate intervention grunting, tachypnea, nasal flaring proper steps of crutches while climbing stairs 1) stand in tripod position 2) place body weight on crutches 3) place unaffected e.g. on stair 4) move affected leg and crutches up to the stair antisocial personality disorder lack of remorse thrombocytopenia instruct nurse to avoid what nose blowing estradiol monitor and report what to provider headaches, hypertension client with depression which if most important finding to report to an interdisciplinary conference the client's appetite has diminished over the last week 12 yr old bacterial meningitis which finding indicates client is experiencing increased intracranial pressure (ICP) Memory Loss nurse assisting with thoracentesis for a client who has pleurisy nurse should plan to do what instruct the client to avoid deep breathing during procedure appropriate action for client who will need physical therapy involve client in selection of pt provider nursing action for a client who is receiving continuous passive motion (CPM) following a total knee arthroplasty turn off the CPM mating during meal timeurine output 15 ml/hr what additional assessment data is indicative of fluid volume deficit orthostatic hypotension! inc bun, tachy, nurse difficulty staffing weekend shifts. which actions should nurse manager take first to successfully implement staffing changes form a staff task force to investigate current staffing issues mental client becoming increasingly loud and belligerent nurse action use calm and clear statements to set limits teaching for peripheral artery disease apply lubricating lotion to the feet to pre even cracting of the skin. don't elevate feet above heart esophagogastroduodenoscopy (EGD) findings to report cool, clammy skin digoxin toxicity nausea!!! diarrhea failure to thrive develop a structured routine epinephrine adverse effects report of chest pain! client to see first? older client who is confused and attempting to pull on IV valproic acid (Depakote) which side effects should nurse monitor and report? Jaundice!! pulmonary edema crohns disease decrease what in diet? fiber 18 hr post op client following cesarean birth, highest priority findingunilateral tenderness of the left lower extremity fractured ankle ice applied every 20 min report what finding to provider? cyanosis of nail beds appropriate action for early decelerations continue observing the fetal heart rate active labor receiving oxytocin. fur shows variability with accelerations. nursing action? document and continue to monitor community mental health clinic which group is appropriate for nurse to lead? medication education group risk for osteoporosis sedentary lifestyle 15 min immediate postpartum period requires immediate action by nurse? bobby uterus who should receive rhogam an o- woman following spontaneous abortion first trimester routine prenatal exam when checking if fetal heart can be detected nurse should place scope midline just above the symphysis pubis and apply firm pressure appropriate action for intravenous pyelogram for next day administer laxative, npo, econurage fluids Pacreatitis -- Upper left quadrant pain (abdominal pain) Priority Finding: Absent bowel sounds (indicative of paralytic ileus. Expected findings: (H) amylase + (H) Lipase Liver enzymes elevatedGlucose may be elevated - (L) insulin N/V, jaundice, (H) WBC Hepatitis A Contaminated Food Lab values (Per ATI) BUN: 10-20 Cr: 0.6-1.2 Creatinine Clearance: 80-139 Na: 135-145 K: 3.5-5 Ca: 9-11 Cl: 98-106 Mg: 1.3-2.1 Albumin: 3.5-5 (slow changes in protein) Prealbumin: 23-43 (better indication of malnutrition - for acute changes in protein) Urine Specific Gravity: 1.010-1.025 Fasting Glucose: <110 Oral glucose tolerance test: <140 HbA1c: <5%; pre-diabetes: 5.7-6.4%; DM: >6.5% ICP: 10-15 mm Hg pH: 7.35-7.45 O2: 95-100% PaCO2: 35-45 mm Hg HCO3: 22-26 CO: 4-7 L/min D-dimer: 0.43-2.33 mcg/mL (elevated = clot formation occurred--> pulmonary embolism occurred) CK-MB: 0% (30-170 units/L); elevated 4-6 hrs; lasts 3 days Troponin I: <0.03 ng/L; elevated @ 3hrs; lasts 7-10 days Troponin T: <0.2 ng/L; elevated @3-5hrs; lasts 14-21 days Cholesterol: <200 mg/L HDL: 35-80 (female): 35-65 (male) -- High Desirable LDL: >130 mg/dL -- Low Desirable (up to 70% of total cholesterol)Triglycerides: 40-160 (males); 35-135 (females); 55-220 (older adults) -- Evaluates Atherosclerosis RBC: 4.2-5.4 (female); 4.7-6.1 (male) WBC: 5,000-10,000 Platelets: 150,000-400,000 Hgb: 12-16 (females); 14-18 (males) Hct: 37-47 (females); 42-52 (males) (3x Hgb) PT: 11-12.5 -- See clotting & vit. K aPTT: 30-40 seconds -- Monitor for Heparin; increased if DIC, liver disease INR: 2-3 on warfarin (checked with PT) Magnesium Sulfate Adverse effects: Respiratory paralysis (serious) Depressed or absent reflexes Hypotension Depressed cardiac function Prednisone inhaler Wait 20-30 seconds between puffs Exhale with pursed lips Rinse mouth afterwards (to decrease chance of infection) hold breath for 10 seconds Detached Retina "feels like a curtain is pulled over my eye" Hypothyroidism Causes constipation (due to decreased metabolism) Hyperthyroidism Increase nutritional intake with meals. (due to increased metabolism using up protein, lipid, and carbohydrate stores) Priority finding: Increased BP Chest Tubes Keep collection chamber below lungsWeight applied to skin traction should be 5-10 lbs max to prevent skin injury Ileostomy bag "Apply skin barrier" to protect skin from enzyme & bile salts Non-tunneled percutaneous central venous catheter Place client in trendelenburg position to provide easier access to vessels & decrease risk of air embolus Newly diagnosed Heart Failure patient Try to walk at least 3 times a week for exercise Arterial lines Need pressure bag around the solution, because pressure form an artery is greater than that of the line Iron supplements -should be taken with high-fiber foods to prevent constipation -avoid taking with milk because it interferes with absorption Propanolol (-lol meds - Beta Blockers) can cause bronchoconstriction Morphine (opiods) Adverse Effect: nausea and vomiting Mastectomy Expect presence of one or more surgical drains Blood transfussions OK to use 0.9% sodium chloride. --5% dextrose & Ringer's lactate will cause clots --0.45% cannot use because it's hypotonic Adverse reaction: Low back pain. Stop transfusion immediately.Burns Priorities: --Resuscitation Phase (first 48 hrs): Fluid balance & maintain Electrolyte balance. --Acute phase (36-48 hrs): Have adequate nutrition to maintain weight, including increased caloric intake. --Rehabilitative phase: encourage use of affected extremity to maintain maximal limb function. Erythrocyte Sedimentation Rate (ESR) Inflammation marker test. Another inflammation test is: C-Reactive Protein. Inflammation markers --Increase Erythrocyte Sedimentation Rate (ESR) --Increase WBC --Decreased Serum complement level --Increased Globulin level Diabetic Ketoacidosis Glucose reading <300 mg/dL is improvement Above the knee amputation and temporary prosthesis --Have firm mattress (avoid soft mattress) --Wear compression bandage at all times --Keep residual limb in extension Tension Pneumothorax Look for chest asymmetry Type 1 diabetes & acute disease --Continue to take insulin at regular intervals regardless of meal --Monitor blood glucose Q4h --Call provider if glucose >250 mg/dL --Notify provider if ketones present. Elasticized bandages Keep toes and fingers open to check for blood circulationFluid overload --Crackles in lungs --Distended neck veins Irrigating a granulating wound Use 30 mL syringe Rheumatoid Arthritis Apply heat and cold to decrease joint inflammation and pain. Left-sided heart failure Sign: Oliguria during the day from decreased blood flow to kidneys Right-sided heart failure --Distended abdomen --Jugular vein distention --Dependent edema Sildenafil discontinue if pt taking Isosorbide Mononitrate. Can cause severe hypotension Gentamicin Like many antibiotics are nephrotoxic. Look at kidney functions tests Lyme disease Stage II experience: joint pain, cardiac and neurologic complications. If not treated at this stage becomes chronic and causes arthritis, peripheral neuropathy, vasculitis, and myocarditis. HIV treatment Effectiveness shows decreased viral load. Right Hemisphere stroke Affects visual and spatial awareness and proprioception (sense of our body's position)--Impulsive behavior --one-sided neglect syndrome --loss of depth perception --poor judgement --left hemiplegia or hemiparesis --visual changes Left hemisphere stroke Affects language, mathematic skills, & analytic thinking --Anxiety concerning the future --Feelings of guilt --Expressive aphasia --Agnosia, Alexia (reading difficulty), agraphia (writing difficulty) --depression, anger, & quickly frustrated --visual changes Diabetes Type I and traveling --Change shoes often to decrease risk of blisters and sores. --Limit physical activity if blood glucose <65 mg/dL --carry insulin in insulated tote bag to protect against temperature changes --Drink water every 2 hrs to reduce risk of dehydration Increase ICP (signs and symptoms) --JVD, --Glasgow Coma Scale <15 --sleepiness or difficulty arousing patient --Wide BP --Decerebrate and decorticate posturing Oxycodone Side effect: Constipation Bilateral pneumonia & PaO2 at 80 mm Hg Administer oxygen per nasal cannula BEFORE High Fowler's position GuaifenesinMucolytic medication. removes thick mucus secretions from COPD patients w/ SOB, cough, and fatigue. COPD patients considerations If hypoxic, deliver O2 to 90%. --sit up in orthopneic position, with arms resting over bed table to facilitate breathing. Suctioning a tracheostomy patient --Preoxygenate at least 30 seconds --Suction pass 10-15 seconds --Set pressure between 80-120 mm Hg --Suction up to three times. Transurethral Resection of Prostate (TURP) - 12-hr post procedure Priority Finding: Concentrated red urine with intermittent clots indicates client at greatest risk for hemorrhage. Hormone Replacement Therapy Adverse Effects: --Calf pain = DVT --Numbness in arms & intense headaches= Cerebrovascular problems Hypocalcemia --Muscle cramps --Tingling sensation Digoxin --Don't miss a dose --Antiacids reduce absorption --Adverse Effect = N/V --Check pulse rate before each dose Cholinergic Crisis Exhibits increased muscle weakness and twitching Postpartum, resume sexual activity--Use water soluble gel for lubrication to prevent discomfort --May resume sexual activity 2-4 weeks after Cocaine use during pregnancy Risk for Abruptio Placenta Hyperemesis gravidarum Eat to taste -Some food better than none Pregnancy Lab tests --Group B Strep (GBS) @ 35-37 wks --3-hr glucose tolerance @ 28 wks --Rubella Titer @ initial consult Contraceptives and Hx of Osteoporosis Avoid Medroxyprogesterone Contraceptives and Hx Cardio, breast cancer, and poor liver function Avoid: Combined estrogen-progestin oral contraceptive Pregnant woman, water breaks Monitor Fetal HR Betamethasone & preterm labor Administered to stimulate fetal lung maturity & prevent respiratory distress Infant safety Set water heater <120 F Vaginal deliver & breastfeeding mom Needs additional 330 calories/day while breastfeeding Contraction stress test Negative: (Normal finding) within 10 min period, three uterine contractions & no decels.Positive: (Abnormal finding) persistent and consistent decelerations on more than half the contractions. Cord or fetal head compression present. Newborn expected findings --Breast nodule <10mm apart --Posterior fontanel smaller than anterior --overlapping suture lines --Lanugo over the shoulders --No yellow on skin Newborn considerations --Void once within 24 hrs; 6-10 times/day post 4th day. --Erythromycin in eyes within 1 hr from birth --Vit K for clotting --Hep B (birth + 1 mo + 6 mo) (NOT same thigh as Vit K) Newborn complications Cold stress - leads to hypoxia, acidosis, and hypoglycemia (due to use of energy to establish respirations and maintain body heat) Tx: Cold: warm slowly across 2-4 hrs; Hypoglycemia: breastfeed or formula feed. Hypoxia: Oxygen Epigastric pain in pregnancy Indicator of hepatic involvement and clinical manifestation of severe preeclampsia Biophysical profile for mother in 3rd trimester Includes Amniotic fluid index Neonatal sepsis signs --Temperature instability --Tachypnea --Hypotonia --Lethargy --Nasal flaring --Irritability Gonorrhea during pregnancyRisk for Premature rupture of membranes Preeclampsia during pregnancy Risk for Proteinuria Late Decelerations during labor at 38 weeks. Specify order of steps to follow A. Reposition client on her side B. Elevate her legs C. Increase maintenance IV fluids D. Palpate uterus to assess tachysystole E. Administer Oxygen via face mask @ 8L/min Terbutaline Adverse Effects: --Hyperglycemia --Hypokalemia --Hypotension Client in labor and reports back pain with right occiput posterior position Apply sacral counterpressure Hypoglycemia signs in newborn Jitteriness, twitching, weak high-pitched cry, irregular respiratory effort, cyanosis, lethargy, eye rolling, seizures, blood glucose level <40 Mastitis Sudden onset of fever, chills, body aches, and unilateral breast pain with tenderness Cefazolin Nurse notices urticaria, dyspnea, anxiety, and SOB Administer Epinephrine to induce vasoconstriction & bronchodilation Ergotamine sublingual for migraine headaches Take one table at onset of migraine. Up to 3 tablets/dayMethotrexate Immunosuppressant --Monitor signs of infection such as fever Flumazenil Reversal agent for Benzodiazepine Toxicity Narcan & Naloxone Reversal agent for Opioid toxicity Atropine Reversal agent for inhibitor overdose Neostigmine Reversal agent for neuromuscular blocker overdose Salmeterol Long-acting Bronchodilator Graves disease Difficulty focusing Carbamazepine Interferes with oral contraceptives Reversal agents Flumazelin --> Benzodiazepines Narcan & Naloxone --> Opioids Atropine --> Inhibitor overdose Vitamin K --> Warfarin Protamine Sulfate --> Heparin Calcium gluconate --> Magnesium sulfate toxicityAcetylcysteine --> acetaminophen toxicity Digibind --> Digoxin toxicity (prevent absorption) Sodium Polystyrene --> High levels of K in body Urticaria Hives Tinnitus Indication of ototoxicity. withhold aspirin Sucralfate Forms a protective barrier over ulcers Atorvastatin (statins medications) Monitor CK (due to muscle breakdown) Projection Attributing faults to others Displacement Transfer of feelings to a less threatening person Splitting A primitive ego defense mechanism that places people and not Arvad categories Ventricular septal defect vSD Most common congenital heart defect irritability and restlessness our clinical manifestations Coarctation of the aorta Narrowing of aortic arch that causes increased resistance bloodflow between the proximal and distal aorta the resulting physiologic change is an increased pressurein the proximal area the upper distal extremities and decrease pressure in the lower extremities Hydatidiaform Mole Called gestational trophoblastic disease. The trophoblastic cells become fluid filled and the embryo fails to grow fetal loss usually occurs a 16 weeks and rarely is fetus carried to term Left Sided Heart Failure Sx Symptoms Weakness, fatigue, anxiety, depression, dyspnea, shallow respirations up to 32-40 min, Paroxysymal Nocturnal Dyspnea, Orthopnea (SOB in recumbent position, dry hacking cough, nocturia, frothy pink tinged sputum (advanced pulmonary edema) Left Sided Heart Failure Left ventricle heaves, Pulsus alternans, (alternating pulses, strong weak), Increased heart rate, PMI displaced inferiorly and posteriorly. (LV hypertrophy), decreased PaO2, slight increase in PaCO2, (poor O2 exchange), Crackles, pulmonary edema s3 and s4 heart sounds Pleural effusion Changes in mental status Restlessness, confusion Right sided Heart failure Sx Symtpoms fatigue, anxiety depression, dependent bilateral edema, right upper quadrant pain, anorexia and GI bloating, nausea Right sided heart failureRight ventricle heaves Murmurs Jugular venous distention Edema (e.g. pedal scrotum, sacrum,) weight gain increase heart rate ascites Anasarca (massive generalized body edema) Hepatomegaly (liver enlargement) R sided Heart Failure occurs when the right ventricle fails to contract effectively. right sided heart failure causes a backup of blood into the right atrium and venous circulation. Venous congestion in the systemic circulation results in jugular venous distention, hepatomegaly, splenomegaly, vascular congestion of the gastrointestinal tract, and peripheral edema. Right sided heart failure may result from an acute condition sich as right ventricle infarction or pulmonary embolism. Cor Pulmonale (right ventricular dilation and hypertrophy caused by pulmonary disease) can also cause right sided HF. Thr primary cause of heart failure is left sided heart failure. In this situation, left sided heart failure results in pulmonary congestionand increased pressure in the blood vessels of the lung (pulmonary hypertension). Eventually, chronic pulmonary hypertension (increased right ventricular afterload) results in right sided hypertrophy and HF. L sided heart failure Pathophysiology the most common form of heart failure is left sided. Left sided HF results from left ventricular dysfunction. This prevents normal, forward blood flow and causes blood to back up into the left atrium and pulmonary veins. The increased pulmonary pressure causes fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli. this manifests as pulmonary congestion and edema. Doxazosin teachingstay with patient orthostatic hypotension thyroid therapeutic effect weight loss no depression no bradycardia no anorexia no cold intolerance no dry skin no menorrhagia no decreased TSH levels desmopressin monitor hypertension hr fluid & electrolyte weight I & O specific gravity Im injection vastus lateralis NG aspirate diet dysphagia oatmeal phototherapy child protect eyes dumping syndrome S&S nausea, distension, cramping pains, diarrhea within 15 minutes after eating cancer treatment monitor plateletssinus tachy picture? mononucloesis fever sore throat swollen lymph nodes increased WBC atypical lymphocytes spleanomegaly enlarged liver cleft palate remove restraints calcium gluconate antidote mag increased ICP intervenstions head 30 degrees avoid flexion sneezing coughing minimize suction body in alignment priority w/ a cast compartment pain paralysis parathesia pallor pulselessness fat embolism hot spot increased drainage warm to touchodor immobility SOB skin breakdown constipation HSV2 and pregnant watch for active lesions interventions with kid with gastroenteritis skin barrier 241 comp iv urography allergic reaction swollen lips gastric bypass protein first rhogam 72 hours after baby comes out early deceleration head compression advance directives power of attorney restraints rom q. 2 hr doc rewrite 1. 24 hrs dont tie to bed rails tie frame bed crutches good side small poxhigh fever fatigue severe headache rash center out pus lesions chills vomitting delirium propofol allergy eggs, egg products, soy iv pump incident report iv pump malfunction ice num antiinflammatory rsv contact radiation use dosimeter o2 sat move q. 4 hrs gardening double glove stem falls of when dry do nothing old ppl decreased taste sensation due date0711 osteoporosis weight bearing lactose intolerant replace calcium spinach cabs how much of diet 45-65% AWS diazepam lorezepam tegretol catapress osteosarcoma pain give morphine reaction formation ocer compensation or demnostrating the opposite behacior of what is felt dementia orient with calendar closed intermitten irrigation clamp cath clense injection port insert irrigant unclamp allopurinol liver function test ileostomy continuous outputchronic kidney disease check GFR nutritional needs for patient with hepatic encephalopathy decreased protein, increased ammonia lvl contra isorbide monitrate hypersensitive to nitrates head injury carefull liver renal tpn change q. 24 glucose q. 4 lipid dc 12. iv pump incident report sprain compress blood spill bleach reportable diseases report lyme disease resspiratory synictal virus contact meningitis appropriate actions droplet mask until 24 hrs after with antibiotics or if culture comes back negative stump keep dryearly decel head compression latent phase 2cm dilated talkative bipolar disorders for manic quiet area, not isolated give finger food alcohol keep safe, orient time and place ptsd assessment lost of interest withdrawal things they enjoy kosher milk and meat seperate nutrition and oral hydration to report albumin 3.5-5 tpn monitoring glucose q. 4 hrs contraindications of statin medications lipitor hepatitis haldol se tardive dyskinesia lip smacking vasoconstriction heroin montelukastmaintanence, not rescue inhaler iron replacement drink oj contra to MMR blood transfusion calculating pulse systolic - diastolic S&S hyperglycemia pee alot thirsty nasuea abdominal pain flush dry skin fruity breath pericardidtis pulses paradoxes ausculating heart valve top left chest tube bubbling continuous NG tube proper function aspirate residual cancer treatment for radiation loose clothing wash mild soap + water, protect from sun bacterial vaginosisodor discharge dysuria manifestations cold stress mottled skin apneic temp lower 97.7 respiration increased HR increased acrocynanosis decreased activity cardioversion indication Vtach Vacuum-assisted Birth; Possible complications Cervical Laceration; rare but can include perineal, vaginal, or cervical lacerations 15 minutes postpartum; Requires immediate action by the RN: Boggy Uterus; indicates greatest risk for uterine atony. Immediately massage the fundus to prevent blood loss. Two different Eye Drops; Pt Education: Close eyes for 1 minute following administration of each eye medication; wait 10- 15 minutes between each medication to prevent dilution of the med NS w/ new script for cefazolin (over 30 min): Piggy back cefazolin into the NS. Assessment: Following Vaginal Delivery; Heacy lochia and a boggy fundus. Med to administer: Oxytocin CVA; Prior to transferring: Assess the clients functional limitations Theophylline Toxicity; Expected Finding:Anorexia Prevent breast engorgement: Place ice packs on the breasts for 15 min 3-4 times daily chlorpromazine: tx: hallucinations Ed: Sip water frequently and minimize exposure to the sun New Born Reflex Assessments: Babinki- Foot Palmer- Hands Rooting & Sucking- Cheek Nurse Manager observing New RN's Time Mgmt Skills: maintain notes New Born HR Assessment: auscultate the apical pulse and count beats for 1 full minute CVA pt transferred to rehab; Address Family's concerns: Interdisciplinary conference for family at new facility pH 7.30, PaO2 56mmHg, PaCO2 54mmHg, HCO3 26mEq/L, SaO2 87% Uncompensated Resp Acidosis Fluid Volume Overload: Delegate to AP Measure I&O Pt wants to see info in Chart: "There is a protocol for reviewing your chart and I can initiate the process" cyclophosphamide to toddler w/ neuroblastoma; RN intervention: maintain hydration with liberal fluid intake; prevents hemorrhagic cystitis SIDS No correlation between DTP and SIDS. Exposure to cigarette smoke increases the risk of SIDS.Breastfeeding decreases risk of SIDS. Sleep on Back with Firm Mattress. E.D: Child with fever and fluid-filled vesicles on the trunk and extremities; RN priority: Implement transmission-based precautions 1200mL NS for 6 hours. How many mL/hr? 200mL/hr Asthma: Encourage children to stay active Avoid extreme temp changes, get the flu vaccine, use peek flow meter at the same time daily Wound Evisceration steps: Stay with Pt/Call for Help Saline-soaked gauze Hips and Knees bent Take Vitals RN Suspects Abuse; RN's legal responsibility: Contact proper legal authority Pt has Catheter and Incision: Change gloves between wound care and cath care erythromycin ointment; mother refuses: Have mother sign the refusal form and document form completion. Clang Association Rhyming words or words that all start with the same letter; "Big Bad Box Bouncing Back" Echopraxia Repeating what someone else is sayingNeologisms Makes up and uses words that have no meaning except to the speaker Blocking Suddenly stops speaking for no reason Ovarian Cancer; Pt Education Clinical manifestations are vague in the early stages estradiol; Report: Headaches FHR pattern shows variability with accelerations; RN to: document and continue to monitor Late decels & variable decels: DC oxytocin Verify NG tube placement: Aspirate contents from tube and test pH content Disaster Plan; RN to: triage incoming victims to determine the priority of care Stg II pressure ulcer: Partial-thickness skin loss Pt teaching; Wound Care at Home: High protein diet Variable Decels; 1st action: Turn pt on Left Side Pt transferring to another unit, necessary to include in transfer report: Last time pt had pain meds 0.5mg/kg/dose PO; Pt weighs 33lbs; Available is 15mg/mL. How many mL/dose?2.5mL ranitidine 50mg IV bolus; available is 50mg in 100mL D5W to infuse over 30 min. How many mL/hr? 200mL/hr Cane Place on unaffected side of the body. 6-12" in front of the body prior to stepping forward Step forward with affected leg 1st. RN to see 1st: Older client confused and trying to pull IV PTSD; Effective Tx response: Recognizes the personal effects of the traumatic experience Delirium Fluctuating LOC throughout the day. Aware of cognitive changes. Acute memory deficit. More pronounced agitation in the evening. Promote circulation following an episiotomy: warm sitz baths RA; Managing Symptoms: Apply Cold Therapy Depression; most important to report: diminished appetite over the past week Depression; joking about committing suicide, RN to ask: "Do you have a plan to hurt yourself" FHR monitoring for: PROM, decreased fetal movement, pt with gestational HTNAssessment; 18hr post of C-Section during breastfeeding: unilateral tenderness of the LLE; potential DVT Valproic Acid: May cause hepatic toxicity; undergo lab tests to assess liver function Warfarin Report changes in stool color (may indicate GI bleed) Continuous passive motion following a TKA: Turn machine off during meal time (promotes comfort and dietary intake) iron-deficiency anemia and elevated cholesterol Black Beans (high iron, low fat) aplastic anemia ... RN to see 1st: Post op with abd distention and no bowel sounds Indication of Increased ICP: Memory Loss Manifestations of Bacterial Meningitis: Nuchal rigidity & Kerig's signs Failure to Thrive (toddler); POC: Develop a structured routine Moving pt up in bed: Lower side rails, bed in high position, as pt to flex knees and push if possible, DO NOT GRAB UNDER ARMS 1st Stg of Labor ... 2nd Stg of Labor... 3rd Stg of Labor ... 4th Stg of Labor ... Early Decels: Associated with the progression of labor and are benign; Continue to Observe if seen Late Decels: ... Variables: ... Staffing Issues: Find out what the issue is before implementing changes Quality Improvement DOES NOT: Promote individual accomplishments. Digoxin: Nausea is a manifestation of toxicity TB Pt to wear a mask when being transported Med given in error; Document: Time med was given EDB: Minus 3 months + 7 days Vitamin K routinely given to newborns to prevent bleedingPAD: Applies lotion to the feet to prevent cracking skin infant w/ hydrocephalus 6hrs post op following a venticularperitoneal shunt; Report: Irritability when being held indicates increased ICP mild preeclampsia Report swelling of hands/feet, rest in a side-lying position, report decreased urinary output, and perform daily fetal kick count Coworkers discussing pt info in public: Tell them to stop the conversation Thoracentisis avoid deep breathing during the procedure Infant Pulse Brachial pulse is used because it is most easily accessible. Crohn's Diet: Low Fiber Rh D Immune globulin: O- mother after abortion may have been carrying an Rh-positive fetus and should receive the injection BP check in 10 min: AP who is helping a pt to bed will be done on time. Fractured Ankle; Report: Cyanotic Nail Beds Chronic Anorexia w/ enteral tube feedings. What lab value indicates additional need for nutrients: Albumin level of less than 3.5g/dL Organ Donor:Notify Organ Team, Collect Specimens, Remove all Tubes, Cleanse Body, Tag Body Prostate Cancer: Prostate Specific Antigen (PSA) levels should be performs for men over 50. CG tells CN that pt is not being cared for properly; CN to: Get specific concerns from CG Ok to be DC in event of disaster: Cellulitis receiving oral antibiotics Time-mgmt. strategies: Group activities, Get equipment before entering room, delegate to AP, Develop a schedule that prioritizes client care Diabetes Insipidus Indication: Increased urine output (polyuria) MH patient is becoming loud and belligerent: Set clear limits (be calm) Dehydration (Therapeutic Lab Values): Sodium: 136-145mEq/L Urine Specific Gravity: Crutches (stairs): Tripod position, Transfer wt to crutches, unaffected then affected leg Crutches: Make sure rubber tips are secure AIDS (D/C Teaching):Exposure to soil increases risk for infection Preparing for an In-service: What do they know first emotional crisis: assist the client in identifying the cause of the issue Med Error Documentation Do not document in MAR if IV med was given orally Narcotic: RN to waste remainder of Med w/ another RN fluoxetine; report: Tremors Abduct: Away from body Adduct: To Body Sign of Autism in a Toddler: Lack of responsiveness Pt needs PT after DC: Let pt chose who they want to use X-ray of Femur; RN to: Cover pelvic area with a lead shield "I don't know what to do without my wife. Life is just not worth living." "You seem to be having a difficult time right now." Post surgical (ruptured appendix); Report: Rigid, board-like abdomen, Absent bowel sounds,102.6, WBC of 21,500 RN intervention; toddler tonsillectomy: administer pain meds on a regular schedule 1st day post op Mannitol; Therapeutic Effects: Increased diuresis Cushing's Disease Moon Face is expected; HTN Spanish speaking patient: have an official interpreter provide translation Buck's Traction; AP can NOT adjust the pt's hanging weights IV pyelogram; RN action: administer a laxative; check for allergies (seafood, milk, eggs or chocolate) AP delegation: Arranging the lunch tray for a client with a hip fracture STI must be reported to the health dept: Explain the purpose of the legal requirement to the pt Osteoporosis; risk factors: sedentary lifestyle Insulin Self-administration: pinch skin before injecting Limited knowledge re: chest tubes; Charge Nurses Action: Ask the nurse about her knowledge Surgical aseptic technique:Keep sterile objects in the line of vision, hands above waist, 1" border of sterile drape Epinephrine; A/E: Chest pain Stroke pt: withhold meds until a swallow study is done Blood Transfusion: Verify the pt and blood product with another RN Lymphocytic leukemia; Labs to report: WBC 1,000 Inappropriate prescription: Rn to tell charge nurse Advanced Directives: Designates spouse Toddler scheduled for surgery: encourage parents to bring toys from home Incident Report: IV pump delivers inadequate dose of meds Following esophagogastroduodenoscopy (EGD); Report: Cool, clammy skin tracheostomy tube suctioning: pass the catheter no more than three consecutive times Blood transfusion; indications of a hemolytic reaction: Low back pain, tachycardia, hypotension Immobile Pt POC: maintain correct body alignment with use of trochanter rollsTriage: which requires immediate nursing intervention: a middle adult client who has a sucking chest wound Have infection rates decreased following a policy revision? Outcome thrombocytopenia; avoid: nose blowing; increases the risk of bleeding and hemorrhaging Hand Rolls: maintains a functional position antisocial personality disorder: Lack of remorse Valproic acid for seizure control; A/E to report: jaundice (liver damage) community mental health clinic; RN to lead which therapy group: Medication Education Group dry, shiny red skin over the clients neck and clavicular area; RN education regarding skin care: Wash with mild soap and water Breach of client safety: BP cuff used on two different clients Infertility Clinic Offer support group info Foods that contain tyramine; Avoid w/ MAOI's: Smoked meat, cheeses and ripe avacados amitriptyline Anticholinergic; monitor for dry mouth and constipation (CNS effects) band w/ bead that applies pressure to the P6 meridian on her wrist:to relieve nausea thrombocytopenia; POC: avoid venipuncture if possible Domestic Violence: discuss escape plan Staff nurse documents dressing change but doesn't do it: gather info about it alternate communication methods postop laryngectomy pt use a pad and pencil to write requests seizure precautions suction nearby TKA 1 day post op; report: drsg saturated w/ sanguineous drainage Bonding behaviors tells visitors baby looks like family members aPPT value w/ hemophilia A 45 Newborn Assessment; Report: grunting, tachypnea, nasal flaring FHR detection: place the scope midline just above the symphysis pubis and apply firm pressure NG tube: avoid Blue Dye Newborn w/ Resp Distress syndromemaintain a normal body temp Change-of-shift report: level of assistance needed from bed o wheelchair Symptom that is indicative of Fluid Volume Deficit: Orthostatic hypotension impaired vision: mark steps with colorful tape Hospice: care and tx will be provided to control symptoms and make me comfortable Interdisciplinary Care Conference: Reoccurring hospitalizations If client decides to leave the facility without a discharge order, the nurse notifies the provider and discusses with the client __________ Potential risks associated with leaving What is the purpose of advance directives? To communicate a client's wishes regarding end-of-life care should the client become unable to do so. What are the two components of an advance directive? A living will and the durable power of attorney for health care What is a living will? Legal document that expresses the client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. What types of treatment are often addressed in a living will? Those that have the capacity to prolong life. Ex: cardiopulmonary resucitation, mechanical ventilation, feeding by artificial means. What is a Durable Power of Attorney for Health Care?A legal document that designates a health care proxy, who is an individual authorized to make health care decisions for a client who is unable. The person who serves in the role of health care proxy to make decisions for the client should be very familiar with the client's wishes. Battery Intentional and wrongful physical contact with a person that involves an injury or of fensive contact (restraining a client and administering an injection against his wishes). Physical contact without a person's consent Assault The conduct of one person makes another person fearful and apprehensive (thr eatening to place a nasogastric tube in a client who is refusing to eat) False Inprisonment A person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility). Physical or chemical restraints. Malpractice (professional negligence) A nurse administers a large dose of medication due to a calculation error. The client has a cardiac arrest and dies. Negligence A nurse fails to implement safety measures for a client who has been identified as a risk for falls Doxazosin teaching stay with patient orthostatic hypotension thyroid therapeutic effectweight loss no depression no bradycardia no anorexia no cold intolerance no dry skin no menorrhagia no decreased TSH levels desmopressin monitor hypertension hr fluid & electrolyte weight I & O specific gravity Im injection vastus lateralis NG aspirate diet dysphagia oatmeal phototherapy child protect eyes dumping syndrome S&S nausea, distension, cramping pains, diarrhea within 15 minutes after eating cancer treatment monitor platelets sinus tachy picture?mononucloesis fever sore throat swollen lymph nodes increased WBC atypical lymphocytes spleanomegaly enlarged liver cleft palate remove restraints calcium gluconate antidote mag increased ICP intervenstions head 30 degrees avoid flexion sneezing coughing minimize suction body in alignment priority w/ a cast compartment pain paralysis parathesia pallor pulselessness fat embolism hot spot increased drainage warm to touch odor immobility SOBskin breakdown constipation HSV2 and pregnant watch for active lesions interventions with kid with gastroenteritis skin barrier 241 comp iv urography allergic reaction swollen lips gastric bypass protein first rhogam 72 hours after baby comes out early deceleration head compression advance directives power of attorney restraints rom q. 2 hr doc rewrite 1. 24 hrs dont tie to bed rails tie frame bed crutches good side small pox high fever fatigue severe headache rash center outpus lesions chills vomitting delirium propofol allergy eggs, egg products, soy iv pump incident report iv pump malfunction ice num antiinflammatory rsv contact radiation use dosimeter o2 sat move q. 4 hrs gardening double glove stem falls of when dry do nothing old ppl decreased taste sensation due date 0711 osteoporosis weight bearinglactose intolerant replace calcium spinach cabs how much of diet 45-65% AWS diazepam lorezepam tegretol catapress osteosarcoma pain give morphine reaction formation ocer compensation or demnostrating the opposite behacior of what is felt dementia orient with calendar closed intermitten irrigation clamp cath clense injection port insert irrigant unclamp allopurinol liver function test ileostomy continuous output chronic kidney disease check GFR nutritional needs for patient with hepatic encephalopathydecreased protein, increased ammonia lvl contra isorbide monitrate hypersensitive to nitrates head injury carefull liver renal tpn change q. 24 glucose q. 4 lipid dc 12. iv pump incident report sprain compress blood spill bleach reportable diseases report lyme disease resspiratory synictal virus contact meningitis appropriate actions droplet mask until 24 hrs after with antibiotics or if culture comes back negative stump keep dry early decel head compression latent phase2cm dilated talkative bipolar disorders for manic quiet area, not isolated give finger food alcohol keep safe, orient time and place ptsd assessment lost of interest withdrawal things they enjoy kosher milk and meat seperate nutrition and oral hydration to report albumin 3.5-5 tpn monitoring glucose q. 4 hrs contraindications of statin medications lipitor hepatitis haldol se tardive dyskinesia lip smacking vasoconstriction heroin montelukast maintanence, not rescue inhaler iron replacement drink ojcontra to MMR blood transfusion calculating pulse systolic - diastolic S&S hyperglycemia pee alot thirsty nasuea abdominal pain flush dry skin fruity breath pericardidtis pulses paradoxes ausculating heart valve top left chest tube bubbling continuous NG tube proper function aspirate residual cancer treatment for radiation loose clothing wash mild soap + water, protect from sun bacterial vaginosis odor discharge dysuria manifestations cold stressmottled skin apneic temp lower 97.7 respiration increased HR increased acrocynanosis decreased activity cardioversion indication Vtach TPN When TPN is getting low, and you do not have another bag, initiate 500ml of 10% dextrose solution. Do not decrease infusion rate or stop, or admin NS because it will lower BG Unilateral swelling Think of DVT Post-Op Cholecystectomy Sanguineous drainage 2 hours post op is expected finding. Trach Suctioning Suction pass: 10-15 sec Preoxygenate: 30 sec to 30 min 100% O2 Pressure: 80-120 mmHg Suction up to 3 times Sildenafil Viagra Monitor when taking Isosorbide Mononitrate S/S Hypoglycemia Cool, clammy skin S/S Hyperglycemia Kussmaul Respirations, Increased UOP, Abdominal CrampingPromotes good wound healing Foods high in Vitamin A, high in protein, do not use povidone-iodine to clean wounds- it is TOXIC!, Avoid heat Valproic Acid Watch for Jaundice- liver damage. Fetal Tachycardia; Variable decels FHR Administer O2 8-10 L/min via a mask. Fetal bradycardia, late deceleration of the FHR, decrease or loss of FHR variability, and variable deceleration of FHR Place the client in a side-lying position. For late or variable - can also DC the oxytocin. Radiation Exposure Med Potassium Iodide (Pima) Blocks the thyroid gland's uptake of radioactive iodine and thus could reduce the risk of thyroid CAs Inhalation Anthrax Give Cipro Smallpox Transmission Bodily fluids, contaminated objects, inhalation of droplets Classic S/S of MI Epigastric and LUE pain, diaphoresis, N/V, dizziness, chest pain, anxiety and feelings of doom Ipratropium Atrovent Immunizations Primary Prevention Cipro TeachingWear large-brim hat and long sleeves (phototoxicity), limit intake of coffee, tea or colas, do not take with milk or other products, do not take with an antacid. Amblyopia Unilateral central blindness occurs as a result of another condition, such as strabismus. Strabismus muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. Will result in central blindness if not treated by 6 y/o. Patch the eye. Mydriatic Eye Drops Administered for ophthalmic examinations LASIK May still need reading glasses Post Thyroidectomy Have Trach Tray available for airway disruption Low Pressure Alarm A leak within the ventilator circuitry. Either the tubing has come apart or that client has become disconnected from the ventilator tubing. Almost all low-pressure alarms are the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator. High Pressure alarm Indicates an increase in resistance each time the ventilator administers a breath to the client. Excessive airway secretions, decreased lung compliance (COPD), client is coughing or attempting to talk. Body Mechanics Knees kept at hip level, sit with back supported, wrist and forearms parallel to the ground, arms kept closely to the body, head level when looking at screenSLE Findings Increased ESR- SLE chronic system autoimmune disease that causes skin, heart, lung, and kidney inflammation. Usually die from ESRD. Dx: Hx and serologic tests Decreased RBCs; Anemia (Low Hct and Hgb) Detached retina Curtain pulled over the visual area with occasional flashes of light. Medical emergency Manifestations: sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field. Addison's Disease Adrenal Gland Hypofunction; inadequate production of glucocorticoids. Acute adrenal insufficiency can be a life-threatening event- severe fluid and electrolyte imbalances. Sodium levels will fall, potassium levels will increase. Rapid infusion of IV fluids (NS), high dose corticosteroids (Solu-Cortef)- are started as soon as venous access is established. So Hyponatremic, Hyperkalemic, Hypoglycemic Breastfeeding during 4th stage of labor is most important bc Production and secretion of oxytocin cause the uterus to contract. Promotes involution and decrease risk for maternal hemorrhage and blood loss. Peripheral Vascular Disease Leg cramps and leg restlessness TB Airborne precautions Age appropriate toys for a 2 -year old Puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. Allow for manipulation and exploration and meet the child's developmental and diversional activity needs.Want interactive. No dolls bc of choking hazard (better for Preschooler or school-aged child) Doxycycline (Vibramycin) Watch for photosensitivity Tetracycline ABX GI Distress: A/N/V/D Aminoglycosides or Minocycline (Minocin) Watch for ototoxicity; think mycin- Gentamicin C Diff think hand hygiene! Lactose Intolerant Recommend collard greens; contain lactose-free calcium. Otitis Media Ask about smoking- allergies to common irritants; not contagious. Otitis Externa could could from water exposure. Candidiasis Opportunistic infection Affects oral cavity of infants, diabetics, or other clients with immature or compromised immune systems. Often the initial opportunistic infection noted in an HIV + child who is developing AIDS Fluid Balance Most sensitive indicator is daily weights. Especially critical in children under 2 y/o- greater body weight of fluid Dialysis Disequilibrium Syndrome (DDS) Occurs in patients new to dialysis- rapid removal of solutes and changes in blood pH levels. S/S: HA, nausea, disorientation, restlessness, blurred vision, and asterixis. Zidovudine (AZT)Not as toxic to the liver Used in Pneumocystis Carinii Pneumonia Monitor Hgb Hct- can cause severe anemia; monitor CBC- closely for first 2 weeks. Does not affect renal system. Trendelenburg Head is lower than feet Hypocalcemia Prolonged QT interval; Tingling, numbness, tetany, seizures, abdominal cramps, hypoTN Causes of Prolonged QT Parathyroid function, chronic renal disease, massive blood transfusions, and diarrhea Helps with Orientation Calendar on the wall St. John's Wort Do not take with Zoloft SIADH Tx: Fluid restriction plus hypertonic sodium chloride and Furosemide Water intoxication caused by the inappropriate, continuous secretion of ADH by the posterior pituitary gland, causing hypervolemia and hyponatremia. S/S Hypovolemia Weak pulse, hypoTN, decreased CVP, decreased CO, elevated BUN and serum osmolality, increased urine sp gravity and osmolality, decreased UOP, hematocrit elevated Celiac Disease Foul, fatty stools (steatorrhea); malabsorption syndrome Signs of abuse Spiral fracturesEthambutol AE: loss of red/green color discrimination Equation for calculating pulse pressure SBD-DBP = PP When should a trough level be scheduled for a once daily dosing of Gentamicin? 1st hour prior to next dose When should a peak level be drawn for divided doses of Gentamicin? 30 min after admin of med or infusion has finished When should a trough level be drawn for divided doses of Gentamicin? right before next dose S/S of dehydration - hyperthermia - tachycardia - thready pulse - hypotension - orthostatic hypotension - decreased CVP - tachypnea - dizziness - cool clammy skin - diaphoresis - sunken eyeballs S/S of overhydration - tachycardia - bounding pulse - HTN - tachypnea - increased CVP - confusion - muscle weakness - weight gain- ascites - dyspnea - crackles S/S of hyponatremia - hypothermia - tachycardia - rapid thready pulse - hypotension - orthostatic hypotension - headache - confusion - decreased deep tendon reflexes - hyperactive bowel sounds S/S of hypernatremia - hyperthermia - tachycardia - rapid thready pulse - orthostatic hypotension - restlessness - irritability - muscle twitching - reduced to absent DTRs - hyperactive bowel sounds S/S of hypokalemia - hyperthermia - weak irregular pulse - hypotension - restlessness - irritability - weakness with ascending flaccid paralysis - N/V - diarrhea - hyperactive bowel sounds S/S of hypocalcemia- muscle twitches/tetany - hyperactive DTRs - positive Chvostek's sign (tapping on the facial nerve triggering facial twitching) - positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation) - seizures S/S of hypomagnesaemia - hyperactive DTRs - muscle tetany - positive Chvostek's and Trousseau's signs - hypoactive bowel sounds - paralytic ileus Chvostek's sign tapping on the facial nerve triggers facial twitching Trousseau's sign hand/finger spasms with sustained blood pressure cuff inflation Nutrition for preventing delays in healing encourage intake of 2-3L of fluid per day; increase protein, keep serum albumin levels above 3.5 Complications following a hypophysectomy monitor for bleeding and nasal drainage for possible CSF leak (assess drainage for glucose of halo sign); assess neurological condition every hour for first 24 hours and every 4 hours after meds of sinus tachycardia amiodarone, adenosine, and verapmil; synchronized cardioversion S/S of hyperglycemia - Blood glucose level >250 - thirst - frequent urination - hunger- warm, dry flushed skin - weakness - malaise - rapid, weak pulse - hypotension - deep rapid respirations Complications of pericarditis cardiac tamponade: hypotension, muffled heart sounds, JVD, paradoxical pulse What does pericarditis commonly follow? respiratory infection S/S of pericarditis - chest pressure/pain - friction rub - SOB - pain relieved when sitting and leaning forward Fasting blood glucose postpone administration of anti-diabetic medication until after blood glucose levels are drawn; ensure patient has fasted for 8 hours prior to blood draw Oral glucose tolerance test fasting blood glucose level drawn at start then pt consumes a specified amount of glucose; blood glucose levels drawn every 30min for 2hours; instruct client to consume balanced diet for 3 days prior to test, then fast for 10 to 12 hours Glycosylate hemoglobin best indicator for average blood glucose level for the past 120 days; normal range is 4-6%, diabetic range is 6.5-8% Evaluating proper placement of NG tube - aspirate gastric contents and test pH (4 or less) - X-ray - note: injecting air into tube to listen over abdomen is NOT an acceptable practice IV urographyused to detect obstruction, assess for a parenchyma mass, and assess size of kidney what should the nurse check before an IV urography procedure allergy to iodine and check creatinine levels because dye can cause renal failure complications of chest tube insertion air leaks - monitor the water seal chamber for continuous bubbling; tension pneumothorax - sucking chest wounds, prolonged clamping of the tube; kinks in the tubing, or obstruction may cause this Pt teaching for external radiation therapy gently wash skin over the irradiated area with mild soap and water; DO NOT remove radiation tattoos, DO NOT apply powders or lotions, wear soft clothing over irritated area, avoid tight clothing, DO NOT expose area to sun or heat how is infectious mononucleosis spread? saliva incubation period for infection mononucleosis 4-6 weeks S/S of infectious mononucleosis fever, sore throat, swollen lymph glands, increased WBCs, atypical lymphocytes, splenomegaly, enlarged liver tranmission precautions for infectious mononucleosis ruptured spleen Nutrition for pt who has HSV-2 monitor fetal well-being, fetal consequences - include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible C-section of lesions present during labor Early S/S of cold stress in infant axillary temp < 97.7, increased respiration rate, increased HR, mottled skin Late S/S of cold stress in infantapneic periods, bradycardia, acrocyanosis, decreased activity Indications for use of cardioversion atrial dysrhythmias, SVT, ventricular tachycardia with pulse & treatment of choice for patients who are symptomatic S/S of hypoglycemia - shakiness - diaphoresis - anxiety - nervousness - chills - nausea - headache - weakness - confusion Treatment for hypoglycemia 4oz orange juice, 2 oz grape juice, 8 oz milk, glucose tablets; recheck blood glucose in 15 minutes if still low (<70), give 15g more carbs; recheck blood glucose in 15 minutes, if within normal limits eats 1g protein (peanut butter, cheese) Nutrition for increased ICP keep HOB at 30 degrees, avoid extreme flexion, extension or rotation of the head and maintain in midline neutral position keep body aligned, avoid hip flexion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid coughing or blowing nose S/S of bacterial vaginosis vaginal oder, discharge, dysuria Nutrition of boggy uterus postpartum massage first then administer oxytocin What acid-base imbalance with a pt with chronic emphysema most likely have? respiratory acidosis and compensatory metabolic alkalosisNormal Calcium levels 8.5 - 10.9 mg/dL Normal Chloride levels 95 - 105 Normal Glucose levels 70 - 110 Normal K levels 3.5 - 5.5 Normal Na levels 135 - 145 mEq/L Normal BUN levels 7 - 22 Normal creatinine levels 0.6 - 1.35 Specific gravity 1.010 - 1.030 Normal total protein levels 6.2 - 8.1 g/L Normal albumin levels 3.4 - 5 g/L Hgb 12-16 Hct for females 37 - 47 Hct for males40 - 54 WBC 5.2 - 12.4 5,000 - 10,000 Normal phosphorus 2.5 - 4.5 Normal magnesium 1.5 - 2.5 platelets 200,000 to 400,000 RBCs 4.5 - 5 million LDH 100 - 190 U/L CPK 21 - 232 U/L Uric acid 3.5 - 7.5 Triglyceride 40 - 50 Total cholesterol 130 - 200 Bilirubin < 1.o mg/dL Bicarb (CO3) 24 - 26CO2 25 - 45 PaO2 80 - 100% SaO2 > 95% pH 7.35 - 7.45 PT 10 - 12 sec PTT 30 - 45 sec aPTT 23 - 31 INR 0.9 - 1.2 therapeutic lithium level 0.8 - 1.1 S/S of hypothryoidism - persistent lethargy - feeling cold - puffiness of the face - loss of body hair proper use of crutches: going down the stairs crutches and affected leg down, followed by unaffected leg The nurse has given a client instructions about crutch safety. Which client statement indicates that the client understands the instructions?- "I should not use someone else's crutches." - "I need to remove any scatter rugs at home" - "I need to have spare crutches and tips available" proper three-point gait use of crutches client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward how should patients place crutches when standing on crutches? 6" to the front and side of the toes Nurse is giving a client with a left leg cast crutch-walking instructions using the tree-point gait. The client is allowed touch-down of the affected leg. The nurse should tell the client to perform which action? Advance the crutches along with the left leg, and then advance the right leg A client has slight weakness in the right leg. On the basis of this assessment finding, the nurse determines that the client would benefit most from the use of which item? A straight leg cane Baby from mom w/ gestational diabetes at risk for low Ca & Mg & glycemia. high bili Suction for trach pressure not to exceed 120 Hg Clozapine side effect weight gain, hypotension and hyperglycemia radical masectomy excersise 24 hr post op, 1 or more drains, prevent heat loss in infant via conduction paper on scale when giving blood transfusion give with NaClfindings w/ severe preeclampsia oliguria, proteinuria, blurred vision, facial edema blood glucose monitoring what to do first wash patients hands to stimulate blood flow & decrease infection steps to take when child is hypoglycemic OJ, wait 15 min, recheck glucose, give crackers & cheese AP to assist with meals Alzeimers patient demonstrating aphasia hyperthyroid tremors hypothyroid coarse hair, bradycardia, periorbital edema how many mls in an ounce 30 gastric lavage lay patient on left side, instill 2-300 ml sterile water pt should sign consent when accurately describes upcoming procedure total hip going home teaching install raised toilet seat TB patient precautions wear N95 mask, neg pressure room, 3 days post op aka move to prone position q 4 hr to prevent flexion contracture, don't elevate for 48 hr, wrap limb distal to promimal to prevent restriction of blood flow case manager with mental patientsarrange transportation to appointments agitated and confused pt with head injury pulling iv put on mittens and watch insert catheter in male cath tray on bedside table waist height pt had cva 6 yrs ago, decrease ICP how? quiet environment, HOB no more than 30 degrees PICC, prior to starting initial infusion check chest xray infant with CP getting enteral feeding, intervene when allowing to run for 8 min med admin what is risk too frequently strip with no p waves a fib adult at risk for pressure ulcer 30 degree lateral position in bed client in crisis safety, relationship, development, coordinate, plan and provide 24 hrs post op, won't ambulate. nurse to do first ask pt to rate his pain cardiac tamponade pulsus paradoxus hypermagnesiumemia monitor for cardiac dysrhythmiasstatus epilepticus give diazepam pt not going to have surgery clarify, notify, AMA, Document nurse manager changing scheduling provide info about sched issues to staff student nurse doing assessment, what was wrong detailed notes of assessment adverse reaction propanolol coughing at night #gtt/min 13 prone to urinary calculi, include in diet... oranges home care instructions for pacemaker I will be able to take showers and baths adverse effect of fluoxetine h/a...also urinary freq, hypotension child to see first waiting appendectomy has sudden relief of pain infant with apnea monitoring remove leads, ensure alarm can be heard, avoid cosleeping 3 hr oral glucose test fast the night before potential food and med interactionMAOI wants cheeseburger what to look for for cataracts cloudy lens with blurred vision noncompliance with adv directives scenario tube feeding for alzeimers patient admit with DKA, first... get vitals pt gets codeine, statement that needs further teaching urinary freq pt with TB is discharged take meds for at least 6 mo side effect of ECT short term memory loss older adult with pneumonia acute confusion pt recovering from cva, nurse should... id community resources, contact home health, verify med equip, coordinate OT tape test for pinworms collect in plastic bag short leg cast for fractured fibula 3 point gait misoprostal and nsaids get pregnancy test Do not delegate What you can EAT E-evaluate A-assess T-teachAddison's & Cushings Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? EleVate Veins, DAngle Arteries APGAR 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) Airborne precautions MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution MRS WHISE protect visitors & caregivers when 3 ft of the pt.Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) After lumbar puncture and oil based myelogram pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke flat with legs elevated during Continuous Bladder Irrigation (CBI)catheter is taped to the thigh. leg must be kept straight. After Myringotomy position on the side of AFFECTED ear, allows drainage. After Cateract surgery pt sleep on UNAFFECTED side with a night shield for 1-4 weeks after Thyroidectomy low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida Prone so that sac does not rupture Buck's Traction (skin) elevate foot of bed for counter traction After total hip replacement 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. Prolapsed cord Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome (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. AKA (above knee amputation) elevate for first 24 hours on pillow. position prone daily to maintain hip extension.BKA (below knee amputation) foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina area of detachment should be in the dependent position administration of enema pt should be left side lying (Sim's) with knee flexed. After supratentorial surgery (incision behind hairline on forhead) elevate HOB 30-40 degrees After infratentorial surgery (incision at the nape of neck) position pt flat and lateral on either side. During internal radiation on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis worsens with exercise and improves with restMyesthenia Gravis a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) must have lab results for prothrombin time Myxedema/ hypothyroidism slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm increased temp, pulse and HTN Post-Thyroidectomy semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030 Hypervolemia bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's Diabetes insipidus (decreased ADH)excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH) change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia CATS Convulsions, Arrythmias, Tetany, spasms and stridor Hypercalcemia muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hypo Mg Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hyper Mg depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Addison'sHypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Cushings Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addesonian crisis N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma 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) Tetrology of Fallot DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Autonomic Dysreflexia (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) FHR patterns for OB 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 what to check with pregnancy Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart soundsPosterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc ICP and Shock ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp Cor pumonae Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) Heroin withdrawal neonate irritable, poor sucking brachial pulse pulse area on an infant lead poisoning test at 12 months of age Before starting IV antibiotics obtain cultures! pt with leukemia may have epistaxis due to low platelets when a pt comes in and is in active labor first action of nurse is to listen to fetal heart tones/rate for phobias use systematic desensitizationNCLEX answer tips 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. ARDS and DIC are always secondary to another disease or trauma In an emergency patients with a greater chance to live are treated first Cardinal sign of ARDS hypoxemia Edema is located in the interstitial space, not the cardiovascular space (outside of the circulatory system) the best indicator of dehydration? weight---and skin turgor heat/cold hot for chronic pain; cold for accute pain (sprain etc) When pt is in distress....medication administration is rarely a good choice pneumonia fever and chills are usually present. For the elderly confusion is often present. before IV antibiotics? check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. COPD and O2with 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. Prednisone toxicity Cushings (buffalo hump, moon face, high blood sugar, HTN) Neutropenic pts no fresh fruits or flowers Chest tubes are placed in the pleural space Preload/Afterload Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. CABG Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. Unstable Angina not relieved by nitro PVC's can turn into V fib. 1 tsp 5 mL 1 oz 30 mL 1 cup 8 oz 1 quart 2 pints1 pint 2 cups 1 g (gram) 1000 mg 1 kg 2.2 lbs I lb 16 oz centigrade to Fahrenheit conversion F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Angiotenson II In the lungs...potent vasodialator, aldosterone attracts sodium. Iron toxicity reversal deferoxamine S3 sound normal in CHF. Not normal in MI After endoscopy check gag reflex TPN given in subclavian line pain with diverticulitis located in LLQ appendicitis pain located in RLQ Trousseau and Chvostek's signs observed inHypocalcemia never give K+ in IV push DKA is rare in DM II (there is enough insulin to prevent fat breakdown) Glaucoma patients lose peripheral vision. Autonomic dysreflexia patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) Spinal shock occurs immediately after injury multiple sclerosis myelin sheath destruction. disruptions in nerve impulse conduction Myasthenia gravis decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Gullian -Barre syndrome ascending paralysis. watch for respiratory problems. TIA transient ischemic attack....mini stroke, no dead tissue. CVA cerebriovascular accident. brain tissue dies. Hodgkin's disease cancer of the lymph. very curable in early stages burns rule of Nineshead and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% birth weight doubles by 6 months triples by 1 year if HR is <100 (children) Hold Dig early sign of cystic fibrosis meconium in ileus at birth Meningitis--check for Kernig's/ brudinski's signs wilm's tumor encapsulated above kidneys...causes flank pain hemophilia is x linked passed from mother to son when phenylaline increases brain problems occur buck's traction knee immobility; dont adjust weights russell traction femur or lower leg dunlap traction skeletal or skinbryant's traction children <3 y <35 lbs with femur fx eclampsia is a seizure perform amniocentesis before 20 weeks to check for cardiac and pulmonary abnormalities Rh mothers receive Rhogam to protect next baby anterior fontanelle closes by...posterior by.. 18 months, 6-8 weeks caput succedaneum diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days pathological jaundice occurs: physiological jaundice occurs: before 24 hours (lasts 7 days) after 24 hours placenta previa s/s placental abrution s/s there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) bethamethasone (celestone) surfactant. premature babies milieu therapy taking care of pt and environmental therapy cognitive therapy counselingfive interventions for psych patients safety setting limits establish trusting relationship meds least restrictive methods/environment SSRI's take about 3 weeks to work patients with hallucinations patients with delusions redirect them distract them Thorazine and Haldol can cause EPS Alzheimer's 60% of all dementias, chronic, progressive degenerative cognitive disorder. draw up regular and NHP? Air into NHP, air into Regular. Draw regular, then NHP Cranial nerves 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) BrasAnd (accessory XI) Matter Hymen (Hypoglossal XII) More Hypernatremia S (Skin flushed) A (agitation) L (low grade fever ) T (thirst) Developmental 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 Hepatitis A Ends in a vowel, comes from the bowel Hepatitis b B= blood and body fluids (hep c is the same) Apgar measures HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate Glasgow coma scale eyes, verbal, motor Max- 15 pts, below 8= coma Addison's disease: Cushing's syndrome: "add" hormone have extra "cushion" of hormone Dumping syndromeincrease fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink Disseminated herpes zoster localized herpes zoster 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! Isoniazid causes peripheral neuritis Weighted NI (naso intestinal tubes) 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 Cushings ulcers r/t brain injury Cushing's triad r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) Thyroid storm HOT (hyperthermia) Myxedema coma COLD (hypothermia) Glaucoma No atropine Non Dairy calcium Rhubarb sardines collard greens Koplick's spots prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouthINH can cause peripheral neuritis Take vitamin B6 to prevent. Hepatotoxic pancreatitis pts put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids Murphy's sign Pain with palplation of gall bladder (seen with cholecystitis) Cullen's sign ecchymosis in umbilical area, seen with pancreatitis Turner's sign Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis McBurney's point Pain in RLQ with appendicitis LLQ Diverticulitis RLQ appendicitis watch for peritonitis Guthrie test Tests for PKU. Baby should have eaten protein first shilling test Test for pernicious anemia Peritoneal dialysis 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 Hyper reflexes absent reflexesupper motor neuron issue (your reflexes are over the top) Lower motor neuron issue Latex allergies assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches Tensilon used in myesthenia gravis to confirm diagnosis ALS (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems Transesophageal fistula esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) MMR is given SQ not IM codes for pt care 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 Contraindication for Hep B vaccine anaphylactic reaction to baker's yeast what to ask before flu shot allergy to eggs what to ask before MMR allergy to eggs or neomycin when on nitroprusside monitor:cyanide. normal value should be 1. William's position semi Fowler's with knees flexed to reduce low back pain S/S of hip fx External rotation, shortening adduction Fat embolism blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids. complications of mechanical ventilation pneumothorax, ulcers Paget's disease tinnitus, bone pain, elnargement of bone, thick bones with allopurinol no vitamin C or warfarin! IVP requires bowel prep so bladder can be visualized acid ash diet cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread alk ash diet milk, veggies, rhubarb, salmon orange tag in psych is emergent psych thyroid med side effects insomnia. body metabolism increases Tidal volume is 7-10 ml/kgCOPD patients and O2 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less Kidney glucose threshold 180 Stranger anxiety is greatest at what age? 7-9 months..separation anxiety peaks in toddlerhood when drawing an ABG put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2 Munchausen syndrome vs munchausen by proxy 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 multiple sclerosis motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia hungtington's 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure WBC left shift pt with pyelo. neutrophils kick in to fight infections pancreatic enzymes are taken with each meal! infants IM site Vastus lateralis Toddler 18 months+ IM site VentroglutealIM site for children deltoid and gluteus maximus Thoracentesis: 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 Cardiac cath 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 Cerebral angio prep well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids. lumbar puncture fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache. ECG 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. Myelogram 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 Liver biopsy 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 Paracentesissemi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia laparoscopy CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup PTB low grade afternoon fever pneumonia rusty sputum; when percuss-will hear dull sounds asthma wheezing on expiration emphysema barrel chest kawasaki syndrome strawberry tongue pernicious anemia red beefy tongue downs syndrome protruding tongue cholera rice watery stool malaria stepladder like fever--with chills typhoid rose spots on the abdomen diptheriapseudo membrane formation measles koplick's spots sle (systemic lupus) butterfly rash pyloric stenosis olive like mass Addison's bronze like skin pigmentation Cushing's moon face, buffalo hump hyperthyroidism/ grave's disease exophthalmos myasthenia gravis descending musle weakness gullian-barre syndrome ascending muscle weakness angina crushing, stabbing chest pain relieved by nitro MI crushing stabbing chest pain unrelieved by nitro cystic fibrosis salty skin DM polyuria, polydipsia,polyphagiaDKA kussmal's breathing (deep rapid) Bladder CA painless hematuria BPH reduced size and force of urine retinal detachment floaters and flashes of light. curtain vision glaucoma painful vision loss. tunnel vision. halo retino blastoma cat's eye reflex increased ICP hypertension, bradypnea,, bradycarday (cushing's triad) shock Hypotension, tachypnea, tachycardia Lymes disease bullseye rash intraosseous infusion 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. sickle cell crisis two interventions to prioritize: fluids and pain relief. glomuloneprhitisthe most important assessment is blood pressure children 5 and up should have an explanation of what will happen a week before surgery Kawasaki disease (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. ventriculoperitoneal shunt 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 3-4 cups of milk a day for a child? NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA MMR and varicella immunizaions after 15 months! cryptorchidism undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence CSF meningitis HIGH protein LOW glucose Head injury or skull fx no nasotracheal suctioning otitis media feed upright to avoid otitis media! positioning for pneumonialay 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!) for neutropenic pts no fresh flowers, fresh fruits or veggies and no milk antiplatelet drug hypersensitivity bronchospasm bowel obstruction more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids) Basophils reliease histamine during an allergic response Iatragenic means it was caused by treatment, procedure or medication Tamoxifen watch for visual changes--indicates toxicity post spelectomy pneumovax 23 is administered to prevent pneumococcal sepsis Alkalosis/ Acidosis and K+ ALKalosis=al K= low sis. Acidosis (K+ high) No phenylalanine to a kid with PKU. No meat, dairy or aspartame never give potassium to a pt who has low urine output! nephrotic syndrome characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstaythe first sign of ARDS increased respirations! followed by dyspnea and tachypnea normal PCWC (pulmonary capillary wedge pressure) is 8-13 readings 18-20 are considered high first sign of PE sudden chest pain followed by dyspnea and tachypnea Digitalis increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion Cold stress and the newborn biggest concern resp. distress Parathyroid relies on vitamin D to work Glucagon increases the effects of? anticoagulants Sucking stab wound 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! chest tube pulled out? occlusive dressing PE Needs O2! DKA acetone and keytones increase! once treated expect postassium to drop! have K+ ready Hirschprung'sdiagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools Intussusception Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements laboring mom's water breaks? first thing--worry about prolapsed cord! Toddlers need to express independence! Addison's causes sever hypotension! pancreatitis first pain relief, second cough and deep breathe CF chief concern? Respiratory problems a nurse makes a mistake? take it to him/her first then take up the chain nitrazine paper turns blue with alkaline amniotic fluid. turns pink with other fluids up stairs with crutches? down stairs with crutches? good leg first followed by crutches(good girls go to heaven) crutches with the injured leg followed by the good leg. dumping syndrome? use low fowler's to avoid. limit fluids TB drugs are hepatotoxic!clozapine, Clozaril antipsychotic anticholinergic clozapine s/e weight gain, hypotension, hyperglycemia, agranulocytosis dehydration -hypovolemia - elevated urine specific gravity flumazenil, Romazicon benzo overdose umbilical cord compression reposition side to side or knee-chest short cord discontinue pictocin TB A positive Mantoux test indicates pt developed an immune response to TB. Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by a positive culture for M TB A chest x-ray may be ordered to detect active lesions in the lungs QuantiFERON-TB Gold: DIAGNOSTIC for infection, whether it is active or latent Battery performing procedure without consent Assault Threatening to give pt. medication putting another person in fear of a harmful or an offensive contact. Imprisonment Telling the client you cannot leave the hospital Defamationis a false communication or careless disregard for the truth that causes damage to someone's reputation. in writing(Libel) or Verbally(Slander) Sprain or Strain RICE Rest Ice Compress Elevate quad cane place of unaffected side of body place it 6-12 in in front of the body before walking steps forward with affected leg first bring the unaffected leg as well, bringing the foot past the cane hand roll in each hand maintains functional position Fluoxetine (Prozac) report tremors, agitation, confusion, anxiety, hallucinations=serotonin syndrome (risk in the first 2-72 hrs after given first time); client will stop the meds; weight gain/diabetes/ hyperglicemia asthma kid should participate in sports, inhaler prior to sports, stay inside when cold, use peak flow meter every day same time, annual influenta vaccine important