ATI Exit Practice Question Note LATEST STUDY GUIDE 2020/2021

Carbohydrates: contain 4 calories per gram Proteins: contain 4 calories per gram Fats: contain 9 calories per gram Findings associated with Phlebitis • Erythema • Throbbing • Warmth at the insertion site • Strea ...

Carbohydrates: contain 4 calories per gram Proteins: contain 4 calories per gram Fats: contain 9 calories per gram Findings associated with Phlebitis • Erythema • Throbbing • Warmth at the insertion site • Streak formation Findings associated with infiltration: • Pallor • Local swelling • Decreased skin temperature. Telephone order (in addition to hand written notes): obtain the providers signature within 24 hours Preventing skin breakdown for a client with a spinal cord injury • Turn every 2 hours • Use pillows to keep the heels off the bed surface and prevent skin breakdown on the clients heels • Apply lotion and avoid applying powder to the skin, which would cause skin breakdown • Minimize skin exposure to moisture to prevent skin breakdown Multiple Myeloma: Increased Calcium • Decreased: Absolute Neutrophil Count (ANC), Platelets, and WBC count IV Cefoxitin (Mefoxin): a client with a suspected or documented history of allergy to penicillin’s may also have an allergy to cephalosporin’s that could result in anaphylaxis Fluoxetine (Prozac): the usual recommendation is to take fluoxetine as a single dose in the morning Dryness, Redness, and Scaling after radiation treatment: apply hydrating lotions that do not contain metal, alcohol, or perfume Early Signs of Lithium Toxicity: gastrointestinal distress, polyuria, muscle weakness, and slurred speech Late Signs of Lithium Toxicity: mental confusion, poor coordination, and coarse tremors Removal of PPE 1) Remove gloves 2) Removes protective eyewear 3) Remove gown 4) Remove mask 5) Perform hand hygiene Pneumonectomy: surgical removal of the lung, which is commonly performed to remove a tumor in a client who has lung cancer. • Positioning for a client with a right pneumonectomy: position on the right side (operative side), because it promotes ventilation of the only remaining lung. • After surgery: the operative side should be dependent so that the fluid in the pleural space remains below the level of the bronchial stump and the inoperative side can fully expand Contaminating a sterile field: opening a sterile package over the middle of the sterile field Estimating Age: 18 Months: anterior fontanels close 24 Months/ 2 years: child should speak in two-and-three word phrases 30 Months/ 2½ years: child completes primary dentition (24 deciduous teeth) Skeletal Traction Pin Care: Do not remove crust around pin site during cleaning because this provides a natural barrier from bacteria Urolithiasis (Uric Acid Stones): a diet high in foods containing purines is a risk factor for uric acid stones Iron sources in infants: iron sources deplete and needs to be supplemented in infants Chronic Bronchitis: resonance percussion sounds Pneumonia: dullness percussion sounds Pneumothorax: tympany percussion sounds Pleural Effusion: flatness percussion sounds “Dirty Bomb”: combines radiologic agents with an explosive device resulting in immediate effects of radiation exposure Jaundice in an African American client: most reliable source to diagnose is the hard palate Risk for Addisonian Crisis: daily weights will alert the nurse that dehydration is occurring, which could indicate an impending crisis Thrombophlebitis: vein inflammation related to blood clots • Bed rest is usually prescribed for 5 to 7 days Gout: painful and disabling form of arthritis caused by an excess of uric acid in the body. • Should not take aspirin: can interfere with uric acid excretion and may precipitate an acute onset • Fluid intake of a minimum of 2,500 mL/day: recommended to minimize uric acid stones • NO Purine: avoid all foods high in purines • Alcohol: men who have gout are instructed to limit alcohol consumption to no more than two drinks a day, and women Basal cell carcinoma: begins as a small, waxy nodule with rolled, translucent, pearly borders. Squamous cell carcinoma: appears as a rough, thickened, ulcerated tumor that may bleed; it may also be asymptomatic Right Cataract Extraction: 4.5 kg (10lb) for 1 week Sengstaken-Blakemore Tubes: provide oral and nares care every 2 hours • A client who has a Sengstaken-Blakemore tube in place will be unable to swallow. • If the client is alert, the nurse should provide tissues and encourage spitting of saliva into a tissue or basin. • If the client is not alert, gentle suctioning of the oral cavity may be needed to remove secretions. Sengstaken-Blakemore Tubes: maintain constant observation while balloons are inflated • A Sengstaken-Blakemore tube is used to stop or slow bleeding from the esophagus and stomach. • When balloons are inflated, they put pressure on the areas that are hemorrhaging to tamponade the bleeding. • While the balloons are inflated, the client must be observed constantly because displacement can cause airway obstruction. Cardiac Enzyme Studies and Acute MI • Cardiac enzyme studies are obtained because their degree of elevation reflects the degree of damage to the myocardium. • CPK and Troponin: enzymes have a characteristic rise and fall pattern after an MI Knee Arthroplasty: clients are allowed to walk, as tolerated, following the procedure but should not overuse or strain the joint. • Crutches or a knee brace are prescribed when weight-bearing limitations are indicated. Systemic Lupus Erythematosus (SLE): exacerbating factors • Sunlight • Pregnancy • Infection • Exercise is NOT an exacerbating factor Left Sided CVA program goals: establish the ability to communicate effectively • Left hemisphere: dominant for language • Right hemisphere: learn how to control impulsive behavior Skeletal traction: hang freely at all time and are never to be removed without a specific provider prescription unless there is a life-threatening situation Transsphenoidal hypohysecotomy & clear drainage seeping from the nasal packing • Check the drainage for glucose: indicates that the drainage is CSF Gastric drainage: pH of 4.0 Hypothyroidism: elevated thyroid stimulating hormone (TSH) Cranial Nerve III (Oculomotor), IV (Trochlear), and VI (abducens): eye movement and pupillary response to light Cranial Nerve II (Optic): visual acuity Cranial Nerve VII (Facial): motor nerve that controls facial asymmetry Cranial Nerves IX (Glossopharyngeal) and X (Vagus): controls gag reflex Aspirin and Rheumatoid Arthritis • Erythrocyte sedimentation rate (ESR) is useful in detecting and monitoring tissue inflammation in clients with RH Decreasing Serum Ammonia Levels in End-Stage Cirrhosis of the Liver: start the client on a low-protein, high-calorie diet Endometrial Cancer: hx. of postmenopausal bleeding • The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women. Cataracts symptoms: seeing halos and rainbows when looking at lights • Symptoms of cataracts include difficulty seeing at night, seeing halos around lights, having glare sensitivity, and experiencing decreased visual acuity, even in daylight Radiation therapy & maintaining skin integrity: use of ice packs is contraindicated • Avoiding ice packs helps avoid tissue damage. For clients undergoing radiation therapy, the most common issue is skin irritation in the area being irradiated. • Radiated skin also becomes thinner and may lack tissue receptors that would normally alert the client to a potential burn injury, so the use of ice packs is contraindicated Autonomic dysreflexia trigger: bladder distention • Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury • Catheter changes, a distended bladder or bowel, enemas, and sudden position Autonomic dysreflexia: clinical manifestations • Elevated blood pressure • Severe headache • Flushed face Most reliable screening tool for pulmonary TB: sputum culture for acid-fast bacillus • Noted in the sputum, secretions, or tissues of the client is the only method to actually confirm the diagnosis Most reliable screening tool for TB: Mantoux skin test • Most and valuable screening tool available for TB. A positive result means only that the client has been exposed to TB; it does not mean that the client has active TB disease. Systemic Scleroderma skin changes: finger contractures • Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. • Symptoms include skin changes, Raynaud’s phenomenon, arthritis, muscle weakness, and dryness of the mucous membranes • Contractures will occur with advanced systemic scleroderma unless the client follows a regimen of range-of-motion and muscle-strengthening exercises, pain management, and joint protection Aluminum hydroxide (Amphojel): aluminum-based formulas are also phosphate binder, helping to lower serum phosphorus levels in clients who have chronic renal failure. Complications for Hypothermia Blanket: Shivering • The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperature, or without protection), can cause the client to cool too fast, leading to shivering. • To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. • The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption Instructions for a client with a total abdominal hysterectomy and bilateral salpingo-oophorectomy: artificial lubrication can be used to treat vaginal itching and dryness • Atrophic vaginal changes occur due to the loss of estrogen postoperatively and can cause pain and dryness during sexual relations. • Artificial lubricants may reduce the symptoms associated with diminished mucous production. Emptying ileal conduit: every 2 hours • An ileal conduit is used to divert urine outside of the body when the urinary bladder has been removed. • The conduit cannot store urine the way the bladder did; therefore, urine will be flowing continuously, and an appliance must be worn as a collecting device. • The bag should be emptied approximately every 2 hours to prevent leakage, skin irritation, and infection. Active pulmonary tuberculosis and Ethambutol (Myambutol): monitor visual acuity • A significant adverse effect of Myambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. • Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals Suspicion of carpal tunnel syndrome: hold the wrist at a 90- degree flexion • Tapping over the median nerve at the wrist may cause pain to shoot from the wrist to the hand, and bending the wrist at a 90- degree flexion will usually result in numbness, tingling, or weakness. The classic three symptoms of increased ICP in a conscious client are nausea, headache, and diplopia (double vision). Venous access bacterial endocarditis: peripherally inserted central catheter • A PICC line is the venous access device commonly used when the client needs extended, but not permanent IV access. • May remain in place for weeks or months • Can also be used to draw blood samples without the need for additional venipunctures COPD and helping the client with tenacious bronchial secretions: encouraging the client to drink eight glasses of water daily • COPD is a term that is used to two closely related diseases of the respiratory system: chronic bronchitis and emphysema. • Maintaining hydration through the consumption of adequate fluids will help to liquefy the tenacious (thick) secretions. • It is advised that the client drink six to eight glasses of fluid (preferably water) daily to keep the bronchial secretions thin. Cardiac Catheterization and contrast dye: the dye used during a cardiac catheterization acts as a diuretic and causes increased urination. Unsafe Actions – Risk for Thrombophlebitis: Crossing the legs • Thrombophlebitis is vein inflammation related to a blood clot. • A client who is at risk for development of thrombophlebitis should not cross the legs. • This action can impede circulation and increase the client’s risk. • Early, frequent ambulation, use of sequential compression devices and support stockings, and therapeutic anticoagulation are important preventative measures for this client. Escharotomy: large incisions will be made in the eschar to improve circulation • A surgical incision is made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. • Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. • Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation. Paraplegia: paralysis of both legs is seen after a spinal cord injury below T1 Quadriplegia: paralysis of all four extremities is seen with spinal cord injuries in the cervical vertebrae above C7 Hemiplegia: paralysis of an arm and leg on the same side of the body is seen after a cerebral vascular accident, or stroke Hepatitis B and long history of IV drug use intervention: bed rest with commode privileges • Bed rest is usually recommended until the symptoms of hepatitis have subsided. • Bed rest will rest the liver and decrease energy demands. Hepatitis B virus is transmitted via blood and other body fluids. • A commode is used, rather than having the client share a common bathroom with a roommate, for infection control considerations Hemolytic transfusion reaction: flank pain • A hemolytic transfusion reaction occurs when antibodies in the recipient’s blood react to foreign blood cells introduced by the transfusion. • The antibodies bind to the foreign cells and destroy them in a process known as hemolysis. • Flank pain and hematuria are classic manifestations of a hemolytic transfusion reaction. Atomoxetine (Strattera): give the dose in the morning to help prevent insomnia • Treats attention-deficit/hyperactivity disorder • Insomnia is a common side effect of Atomoxetine. Administering the dose in the morning will help prevent this side effect. Indicator suggests to the nurse that hypoxemia is occurring: decreased Pa02 Autism teaching: manage behavioral outburst by limiting external stimuli and using a calming approach • Children who have autism respond well to a quiet environment and this can help minimize behavioral outbursts Hypermagnesemia interventions: initiate continuous cardiac monitoring • A client who has Hypermagnesemia is at risk for cardiac dysrhythmias. Therefore, it is appropriate for the nurse to initiate continuous cardiac monitoring New nurse intervene: tells the hospital chaplain the client’s diagnosis • Discussing the client’s diagnosis with the hospital chaplain is a breach of confidentiality Manic Phase of Bipolar Disorder: grandiose thoughts • Clients in the manic phase of bipolar disorder usually exhibit behaviors that appear to be euphoric. They usually have abrupt mood changes, expansiveness, and grandiose thoughts. A client who has a pacemaker does not have any restrictions on bathing or showering Gastric lavage actions: ask the client to lie on the left side • The nurse should ask the client to lie on the left side because this position will limit the flow of the instilled solution out of the stomach and prevent aspiration DKA action to perform first: obtain the client’s vital signs • The first action the nurse should take using the nursing process is to assess the client; therefore, the first action the nurse should take is to obtain the client’s vital signs Unit policy for medication administration: there is a significant risk of administering medication too frequently • Failing to document the administration of a medication immediately following the procedure may lead to inadvertent administration of additional dosages. Assessing a venous access device port: palpate skin to locate the body septum of the port • The first action the nurse should take using the nursing process is to assess for the body septum of the port Older adult client w/ pneumonia expected findings: acute confusion • An older adult client who has pneumonia commonly has acute confusion. Root-cause analysis on patient falls: investigate environmental factors that may be contributing to client injury during these hours • A root cause analysis identifies the basic cause of a problem and includes environmental factors • DOES NOT focus on individual performance when identifying the basic cause of the problem. Case Manager Role: arranging for transportation to health care appointments • The nurse case manager is a registered nurse who acts as a client advocate to address the client’s health care needs. Herpes Simplex Virus: Contact Isolation • The nurse should initiate contact precautions because clients transmit HSV by direct and indirect contact with others and the environment High Risk for Pressure Ulcer Formation: position the client in a 30-degree lateral position while in bed • When positioning the client in bed, the nurse should place the client in a 30-degree lateral position to relieve pressure on the sacral area. Adverse Reaction Propranolol: Coughing at night • The client may develop a cough at night as a result of beta blockage and subsequent heart failure, resulting in coughing at night PICC line insertion: review the chest x-ray report • Prior to using a new PICC line, the nurse should review the chest x- ray report to confirm tip placement Defense mechanism to cope: A client who engages in a hobby to compensate for a lack of physical energy • Engaging in activity to compensate for an illness is an adaptive use of a defense mechanism to cope A client who has hemianopsia should use visual scanning to accommodate for the loss of visual fields to prevent falls. Patient positioning intervention: places a pillow under the client’s right arm • The nurse should place a pillow under the client’s uppermost arm to maintain body alignment Clonidine adverse reaction: dry mouth • Dry mouth is a common adverse effect of clonidine Indwelling urinary catheter assessment: latex allergy • The nurse should assess the client for a latex allergy prior to the insertion of an indwelling urinary catheter due to the risk of an allergic reaction Teaching for a newborn: apply zinc oxide to your baby’s diaper area if it becomes red • Parents should apply zinc oxide to their baby’s diaper area if it becomes red to provide a moisture barrier and to prevent further skin breakdown. Triaging patients – most ready for discharge: a client who was admitted for dehydration and has a urine output of 680 mL in the last 12 hours • The nurse should recommend this client for discharge because the urine output indicated his condition is stable. Fecal impaction digitally evacuation: insert a lubricated gloved finger and advance along the rectal wall • Inserting a lubricated gloved finger and advancing along the rectal wall is the correct procedure when digitally evacuating stool. Apnea Monitoring at Home • Remove the leads when the newborn is not attached to the monitor: to ensure safety and promote comfort, the parents should remove the leads when the monitor is not in use. • Ensure the alarm can be heard throughout the house: to ensure a rapid response to an apneic event, the parents need to be able to hear the alarm throughout the house at all times • Avoid co-sleeping with the newborn: co-sleeping places any infant at risk for suffocation • The monitor should be placed on a hard surface outside of the crib CVA discharge planning • Identify community resources available for the client • Initiate contact with a home health care agency • Verify that arrangements have been made for medical equipment needed in the home • Coordinate occupational therapy services Radiation therapy – prostate cancer: I can wash the irradiated area with mild soap and water • The client should wash the irradiated area with mild soap and water to prevent further irritation from occurring Enteral feeding for infant who has cerebral palsy – need for further teaching: Allows feeding to run in gravity over an 8-min period • The nurse should NOT allow the feeding to exceed to 10mL/min. The feeding of 130 mL should last for at least 13 min Cystic Fibrosis Oxygen Toxicity: Bradypnea • Hypoventilation occurs secondary to oxygen toxicity because the hypoxic drive has been removed. The infant will respond with decreased respiratory rate because the body perceives it has enough oxygen. Narrow QRS complexes occurring irregularly at a rate of 170.min with no visible P waves: Atrial Fibrillation • Atrial fibrillation presents with no visible P waves and an irregular ventricular response. Effective Treatment w/ Nebulized Albuterol: Peak expiratory flow rate is 85% of personal best New diagnosis w/ who terminal illness intervention: make a referral for social services • A role of the nurse is to support individual client decisions. Making a referral for social services will ensure that the client’s needs are met and supports his decision to go home Caring for a child with a hemoglobin level of 7.8 g/dL: Observe for dyspnea on exertion • A child who has anemia will have decreased hemoglobin and hematocrit, resulting in decreased exercise tolerance and possible dyspnea on exertion. Physical Assessment need for further instruction: the student writes detailed notes while performing the head-to-toe assessment • The student should record quick notes during the assessment to avoid delays and write more detailed notes after completing the assessment Delegation to LPN: Insertion of a nasogastric tube • The nurse should delegate insertion of a nasogastric tube to the LPN because this task is within the LPN’s scope of practice. Fluoxetine Adverse Reaction: Headache • Headache is a symptom of serotonin syndrome, an adverse effect of SSRI 4oz = 120 mL 1 cup = 240 mL ½ cup = 120 mL Bipolar Disorder becoming increasingly restless, pacing, and speaking rapidly using profanities: Move the client to a quiet place away from others • The client’s behavior indicates the greatest risk is injury to others; therefore, the priority intervention is to move the client to a quiet place away from others to prevent harm Sickle cell anemia and vaso-occulsive crisis primary intervention: Start IV fluids • The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to start IV fluids to promote hydration and circulation. • This decreases tissue and organ ischemia caused by clumping of the RBCs Failure to thrive effective teaching: the mother smiles at the infant when the infant smiles at her • The mother smiling at the infant when the infant smiles at her indicates the mother is responding appropriately to the infant and understands infant psychosocial development Adverse Reaction IV Pyelogram: Itching • Itching indicates that the client may be having an allergic reaction to the contrast agent used during the IVP • Administer a laxative the day before procedure Skeletal traction for a fractured femur w/ highest priority: upper chest petechiae • Upper chest petechiae indicates the client is at greatest risk for fat embolism syndrome; therefore, this is the priority finding Providing care for a toddler admitted with infectious gastroenteritis requiring intervention: ensuring that the child is eating a BRAT diet • BRAT diets are contraindicated for children that have diarrhea. Agitated, confused, and attempting to pull out his IV line appropriate intervention: put mittens on the client’s hands and maintain close observation • Put mittens on the client’s hands and maintain close observation The omeprazole will minimize the acid in your stomach and metronidazole will treat the H.pylori infection PACU following general anesthesia report to the provider: auditory stridor • Auditory stridor indicates some type of airway obstruction, which could become life threatening and the nurse should report this finding to the provider. Closed Head Injury – medication to reduce intracranial pressure: Mannitol • The client should receive mannitol, an osmotic diuretic, to reduce intracranial pressure caused by cerebral edema Assessment for food and medication interaction: a client receiving an MAOI who requests a cheeseburger for dinner • This food selection contains tyramine. Clients prescribed an MAOI must restrict intake of foods that contain tyramine due to adverse effects, such as hypertension. Cataracts monitoring: cloudiness of the lens with blurred vision • A client who is developing a cataract will have cloudiness of the lens with blurred vision. Diaphragm need for further teaching: I will remove the diaphragm right after intercourse • Removing the diaphragm before the 6 hour period following intercourse increases the risk of pregnancy IM injection on an obese client: Use the Ventroglueteal site • The nurse should use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels. Cardiopulmonary Adaptations that occur in the neonate: Once the pulmonary circulation has been functionally established, blood is distributed throughout the lungs The nurse understands that in response to above normal serum calcium levels, the thyroid gland will increase release of calcitonin Epoetin alpha: is a synthetic from of erythropoietin, which is a substance produced by the kidneys that stimulates the bone marrow to produce red blood cells. • If the body does not produce enough erythropoietin, as in a case in a client who has renal failure, severe anemia can occur. • Increased iron is needed for the production of hemoglobin and red blood cells byt the bone marrow. Disruptive Behavior Interventions for a school aged child • Introduce some humor during interactions with the child • Explain to the child the need to pick up crayons when thrown on the floor • Shorten a reading activity when the child appears to become frustrated • Make an audible tapping sound when the child’s disruptive behavior begins Intervention for a client who has cirrhosis and ascites: decrease the client’s fluid intake • The nurse should restrict fluids for a client who has cirrhosis and ascites due to the client’s risk for increased fluid retention. COPD need for further teaching: I will take my bronchodilators after meals • Bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching Therapeutic response to newborn’s eyes crossing: This is expected because newborns lack the muscle control necessary to regulate eye movement. • This mother needs reassurance that al newborns lack eye muscle control and coordination. This response informs the mother that lack of eye muscle control is expected Hyperparathyroidism risk: Pathologic fractures • Hyperparathyroidism results in the release of calcium and phosphate into the blood, thereby decreasing bone density. This places the client at risk for pathologic fractures Interventions for postoperative client reporting pain following a cholecystectomy • Offer the client a back rub • Identify the client’s pain level • Change the clients position Assessing young adult’s capability to establish intimate relationships: What protection do you use when you have sexual intercourse? • Providing accurate information about certain sexual health risks is an important nursing intervention for young adults (18 – 25 years old) in Erikson’s Intimacy vs. Isolation stage. Bucks traction: relives muscle spasms • Buck’s extension traction (skin traction) immobilizes the fractured bone to relieve muscle spasms at the fracture site and thereby relieve pain. • Any movement of fracture fragments will aggravate severe muscle spasm and trigger pain. Providing oral care for an immobilized client: position the client on one side before starting oral care • Placing the client on one side encourages fluids to run out of the client’s mouth, lessening the risk for aspiration and choking. Running 10 miles to take mind off of home stress: Maladaptive coping • Substance abuse, beginning or increasing smoking, oversleeping, over – or undereating, over exercising, excessive daydreaming, and fantasizing are various ways individuals with the inability to cope with stress successfully deal with stress. Nursing Informatics role: the creation of an efficient information handling system that can store and retrieve clinical data Cataract surgery patient education: vision will be greatly improved the day of surgery Antibiotics for Bacillus anthracis (anthrax): Ciprofloxacin (Cipro) • The nurse should expect to administer ciprofloxacin in combination with doxycycline and amoxicillin to treat anthrax. PTSD need for further teaching for stress reduction technique: the client begins reading a book when he experiences hand tremors in response to loud noise. • This is an adaptive use of dissociation by temporarily blocking memories and perceptions from conscious thought. • Dissociation involves a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment. • This client has a physical response f hand trembling when he hears loud noise, and chooses to dissociate from the loud noise by reading. Nurses are the largest group of healthcare professionals including experts who serve on national committees and initiatives focus on policy, standards and terminology development, and standards coordination, and electronic health record adoption. Highest priority in treatment following a situational crisis: Determining if the client has psychotic thinking. • Clients experiencing a situational crisis are at greatest risk for injury to themselves or others; therefore, determining if psychotic thinking is present is the highest priority Highest Priority for client with an ectopic pregnancy who has developed DIC: Risk for deficient fluid volume • The client is at high risk for hypovolemia, which is life threatening and takes precedence over any psychosocial or less pressing diagnoses. Informatics Nurse Specialists do NOT: ensure that information is protected by securing computers and computer components Herbal remedies to reduce the irritation of gastric ulcers: Licorice Client at risk for metabolic alkalosis: a client who takes TUMS several times a day for indigestion Assessment finding of septic shock: oozing of blood at the IV site • The distinguishing feature is the lack of ability to clot blood, causing the client to bleed from areas of minor trauma and to lead to spontaneous bleeding. IV catheter sites for an adult client • Cephalic Vein • Basilic Vein Postmortem care order 1) Certification of death declared by the provider 2) Organ/tissue donation status verified by the nurse 3) Medical equipment removed from the client 4) Body cleansed while adhering to body fluid precautions 5) Identification tags applied to the body Sources of Potassium: soy nuts and pistachios Vitamin A: important for tissue synthesis, wound healing, and immune function Vitamin B: assists in the development of red blood cells and maintenance of nerve function but has no specific role in wound healing Vitamin C: important for capillary formation, tissue synthesis and wound healing. Vitamin D: functions in maintain serum levels of calcium & phosphorus, but has no specific role in wound healing Vitamin E: function, as an antioxidant to protect from cell proliferation, but has no specific role in wound healing Glomerular Filtration Rate (GFR) • Therapeutic Level: over 90 mL/min • Average Level: 125 mL/min • Renal Failure: below 60 mL/min Fat embolism: confusion is an early sign Acute compartment syndrome: edema is an early sign • Increased pressure within the fascia leading to reduced circulation to the area Multiple Myeloma: need for mechanical lift • Extensive bone pain and bone loss. • Weight bearing is limited and risk of fractures increases • Increased calcium Osteoarthritis: a disease of progressive loss of cartilage due to aging process Rheumatoid arthritis: caused by inflammation that affects both joints and other body tissues Osteoporosis: loss of calcium in the bones and fractures can occur Gout: occurs in several phases when deposits of crystals develop in joints and soft tissues Tyramine (contraindicated in patients taking MAOIS) • Aged cheeses: aged cheddar and swiss cheese; blue cheese (Stilton and Gorgonzola) and carrembert • Cured meats: dry-type summer sausage, pepperoni, and salami • Fermented cabbage: sauerkraut & kimchee Purines: contraindicated in gout patients and patients who have Urolithiasis (uric acid stones) • Anchovies, grains, gravies, sardines, mackerel, and sweet breads • Organ meats: liver and kidney Urine specific gravity: 1.010 – 1.025 ICP: 0-15 mm HG Venous Duplex Ultrasonography: noninvasive diagnostic test used to detect distal deep vein thrombosis Should not be taken with warfarin: Saw Palmetto, Glucosamine, and Gingko Biloba • Saw Palmetto: used to relieve symptoms associated with benign hypertrophy & has an antiplatelet effect. • Glucosamine: used to prevent osteoarthritis & may increase the risk of bleeding • Gingko Biloba: used to increase pain free walking in clients with peripheral vascular disease & may suppress coagulation Black cohosh: used for sleep disturbances & depression Echinacea: used to prevent cold and flu. HIV/ AIDS Testing • Elisa & Western Blot Assay: confirm the diagnosis • Quantitative RNA Assay: measures the viral load and is useful for monitoring disease progression and treatment effectiveness Cryoprecipitate: administered to clients with hemophilia or von Willebrand’s factor Platelets: administered for a client who has thrombocytopenia Fresh Frozen Plasma: replaces clotting factors in clients with hemorrhage, burns, shock, thrombotic thrombocytopenic purpura (TTP), and reverse effects of warfarin Packed Red Blood Cells: given to restore blood volume & replace hematocrit and hemoglobin levels in patients with hypovolemic shock. Oral Squamous Cell Carcinoma: history of HPV is an expected finding Alendronate (Fosamax): a bisphosphonate that prevents bone loss and increases bone density • Drug class: Bisphosphonate • May treat: Paget's skin disease and Postmenopausal osteoporosis Colorectal Cancer Screening w/ fecal occult blood every two years for patients who are: • Asymptomatic • Have no risk factors • Are 50 years or older Myasthenia Gravis Positive Tensilon Test: Muscle contractions become progressively stronger • Indicated by a 5-10 minute period of improve muscle tone and strength • Negative Test: muscle strength shows no change Refeeding syndrome: metabolic complication that occurs when nutritional support is given to severely malnourished patients • Metabolism shifts from catabolic to anabolic state • Insulin is released on carbohydrate intake, triggering cellular uptake of potassium, phosphate and magnesium • Glucose levels are low or normal • Hypophosphatemia: results as neurologic, cardiovascular, & respiratory damage Heat loss via conduction: heat is transferred between the newborns skin and the cooler surface BENEATH IT • Pad a scale with paper prior to weighing the infant Heat loss via evaporation: heat loss when a LIQUID is converted to a VAPOR • Dry the newborn immediately after birth Heat loss via convection: heat loss from the BODY SURFACE to COOLER AMBIENT air • Maintain an ambient room temperature at 75 F Heat loss via radiation: loss of heat from BODY SURFACE to cooler, solid surface NOT IN DIRECT CONTACT with the newborn, but in relative proximity • Place the newborns bassinet away from the outside windows Clozapine (Clozanil, FrazaClo) side effect: weight gain • Atypical antipsychotic that treats schizophrenia. • Decreases risk of suicidal behavior Blood transfusions: 0.9% sodium chloride (NS) to prevent clotting or hemolysis of blood cells • Isotonic solutions: go into the vascular space and stay there Uric Acid Based Urinary Calculi: allowed to eat citrus fruits • Avoid: organ meats, chicken & red wine Hypoglycemia Intervention 1. Give the client 4 oz. of orange juice 2. Wait 15 minutes 3. Recheck the blood glucose 4. Provide cheese and crackers Above the knee amputation: assist the client to the prone position every 4 hours to prevent flexion contractures Normal aPTT: 30- 40 seconds Therapeutic Range: 60 – 80 seconds Normal INR: 1 – 2 Normal PT: 11 – 12.5 seconds Grapefruit juice increases blood levels of verapamil by inhibiting metabolism = HYPOTENSION Mental Status Examination: appearance, behavior, speech, mood disorders of the form of though, perceptual disturbance, cognition, and ideas of harming self or others Amniocentesis: requires amniotic fluid for testing Haloperidol decanote (Hadol LA): improves meaningless imitation of movement (echopraxia) • Most effective in decreasing the positive signs of schizophrenia such as delusions, hallucinations, illusions, associative looseness, word salad, depersonalization, echolalia, and echopraxia • Atypical antipsychotic used in the treatment of schizophrenia Schedule II drugs: morphine sulfate, peritobarbital sodium Schedule III drugs: buprenorphine HCl (Bupvenex), butabarbital sodium, hydrocodone bitrate (Vicodin), thoperital sodium (peritothal) diazepam (Valium), Zopidem (Ambien) Intimacy Vs. Isolation: young adults (18-25) develop commitments to others and to their careers Pancreatic enzymes in cystic fibrosis: helps the client digest fat in foods Nalbuphine (Nubain) adverse reaction: blurred vision • Opioid agonist/antagonist Disaster Preparedness Individual Personal Readiness Supply it/Go Bag • Pocket knife • Whistle • Bank Account information • Household Bleach Hyperemesis Gravidarum: history of migraines, nulliparous, and twin gestations Lying supine (on the back) with the head elevated: drains the anterior segment of the right upper lobe Lying prone (on the abdomen) with pillows elevating the chest and abdomen: drains the posterior segment of the right middle lobe Lying about three quarters supine so the dependent lung is downward and is in Trendelenburg (head lower then feet): drains the anterior segment of the right middle lobe Lying prone (on the abdomen) in Trensdelsburg position (head lower than feet) with the right side of the chest elevated: drains the posterior segment of the right lower lobe Diabetes Mellitus Criteria • Fasting Plasma Glucose: above 126 mg/dL • 2-hour plasma glucose: greater than 200 mg/dL • Casual blood glucose: greater than 200 mg/dL • HgA1C: above 6.5% First step after a bomb threat is received: hospital administration and security should be notified • 1st step is to determine if the threat is credible Avoid the use of physical restraints in anxious and confused patients • Ensure effective pain management • Attend to the needs for toileting • Assign the client to a room near the nurses station • Orient client frequently to the environment Dehydration in older client: swollen tongue Greatest risk for airway obstruction of a burn patient: burns of the head neck and chest may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation Brudzinski sign: when passively flexing the client’s neck there is an involuntary flexion of both legs Kernig’s sign: the client is unable to extend the leg completely when the thigh is flexed on the abdomen Accurate telephone prescription/order • Repeat the order back to the prescriber • Question any part of the order that is unclear and inappropriate • Transcribe the prescription into the clients medical record Hypokalemia: Shallow respirations Interstitial cystitis: avoid drinking carbonated beverages • Bladder irritant and should be avoided Platelet infusion side effect: severe chills Yellow-zone peak expiratory rate for a child with asthma 1. The child should use his quick relief inhaler 2. The child’s asthma is getting worse 3. The child’s peak flow is 50% - 79% of his best peak flow Metabolic alkalosis • Bicarbonate excess • Hyperactive reflexes Restraint (need for intervention): straps of the restraints are tied in a knot • Restraints, when used, they are to be secured with a quick release tie and never in a know Car Seat Positioning: rear-facing in the middle of the backseat Further teaching regarding conception: implantation occurs between 2 – 3 weeks after conception • It occurs in 2 – 3 days Herpes Zoster: Acyclovir (Zovirax) is effective in treatment especially if administered within 24 hours of eruption Oral Acetylcysteine (Mucomyst): this medication has a very unusual odor • Similar to rotten eggs due to the presence of disulite linkages Synthetic hormone replacement for hypothyroidism adverse effect: photophobia • Increased levels may manifest as photophobia Transcutaneous electrical nerve stimulation (TENS) further instruction: “its unfortunate that I have to be at the hospital for this treatment” • TENS units are portable. • The client can use his TENS unit at home or whenever he chooses Plan of care for adult client who is at risk for falls 1. Teaching about balance & strengthening exercises 2. Providing information about home safety checks 3. Locking beds & wheelchairs during transfers 4. Placing a beside table within the clients reach Infant birth weight doubles: in 6 month Infant birth weight triples: in 12 months Normal Body Temperature: 98.6 F (37 C) Fever: Above 100.4 F (38 C) Nursing intervention when administering cyclophosphamide to a toddler who has neuroblastoma: maintain hydration with liberal fluid intake • The toddler should consumer 1 to 1 ½ times the recommended daily fluid requirement to maintain hydration and prevent hemorrhagic cystitis Charge nurse observing a staff nurse document a dressing change in a client that was not performed: gather more information about the staf f nurse’s actions • The first action the nurse should take using the nursing process is to assess reasons for the nurse’s actions; therefore, the charge nurse should discuss the issue with the staff nurse first Newborn Assessment – Need for Immediate Intervention • Grunting • Tachypnea • Nasal Flaring o ALL INDICATE RESPIRATORY DISTRESS IN A NEWBORN aPTT expected results in hemophilia A client: 45 seconds • This value is above the expected range (30 - 40 secs), indicating a risk for spontaneous bleeding, which is a manifestation of hemophilia A Antisocial Personality Disorder Finding: Lack of Remorse • Clients who have antisocial personality disorder show a lack of remorse Important Finding in Depressed Client to Report: The client’s appetite has diminished over the last week • When using Maslow’s hierarchy of needs, the nurse determines the priority finding to report to an interdisciplinary conference. Therefore, the nurse should report that the client’s appetite has diminished over the last week. Plan of care after thoracentesis for a client who has pleurisy: Instruct the client to avoid deep breathing during the procedure • It is important for the client to avoid deep breathing during a thoracentesis to avoid puncture of the pleura First step in successfully implementing staffing changes: form a staf f task force to investigate current staffing issues • Using the stages of change, the first action the nurse manager should take is to form a staff task force to investigate current staffing issues. Valproic Acid diagnostic tests: serum liver enzyme levels • Valproic acid may cause hepatic toxicity • Anticonvulsant/Anti-epileptic: treats seizures and also treats mood disorders and helps prevent migraine headaches. Digoxin Toxicity Manifestation: Nausea • Treats certain heart rhythm problems (atrial fibrillation). Also used to treat heart failure, usually in combination with a diuretic (water pill) and an angiotensin-converting enzyme (ACE) inhibitor. This medicine is also called digitalis. Quad Cane – Need for further instruction: places the cane on the affected side of the body • The cane should always be placed on the unaffected side of the body. Amitriptyline (Depression Medication) Understanding of discharge instruction: I should watch for common reactions like dry mouth and constipation • These are anticholinergic effects common when taking amitriptyline, a tricyclic antidepressant. Fluoxetine (Prozac) symptoms to report and monitor: Tremor • Fluoxetine can cause serotonin syndrome within 2 to 72 hours after starting treatment. • The client can experience tremors, agitation, confusion, anxiety, and hallucinations. Chlorpromazine teaching: “Sip fluids frequently throughout the day” • Phenothiazine/ Antiemetic • Clients taking chlorpromazine may experience dry mouth. Sipping fluids throughout the day can minimize dry mouth • Treats mental disorders, severe behavior disorders, severe hiccups, severe nausea and vomiting, and certain types of porphyria. Also used before and after surgery to relieve anxiety. Indications for Rh immune globulin administration: An O negative woman following a spontaneous abortion • The O negative mother following a spontaneous abortion may have been carrying an Rh positive fetus and should receive Rh (D) immune globulin 1 day post-op hip arthroplasty priority to report to the provider: dressing saturated with sanguineous drainage • The greatest risk to the client is excessive bleeding; therefore, a saturated dressing is the priority finding for the nurse to report Theophylline toxicity symptom: Anorexia • Anorexia is an expected finding of theophylline toxicity Vitamin K is routinely given to newborns to prevent bleeding IV Cefazolin w/ 0.9% sodium chloride: piggyback the cefazolin into the 0.9% NaCl infusion • Cephalosporin antibiotic: treats serious infections caused by bacteria. Also prevents infection after surgery Checking FHR near the end of 1st trimester: place the scope midline just above the symphysis pubis and apply firm pressure Client experiencing a wound evisceration 1. Stay with the client and call for help 2. Cover the client’s wound with saline soaked gauze: to keep the internal organs moist 3. Place the client in a supine position with the hips and knees bent: to relieve pressure from the open wound 4. Take the clients vital signs: to assess for changes in hemodynamics Thrombocytopenia patient care and teaching: avoid venipunctures when possible and tell the patient to avoid nose blowing • Deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury. Pneumonic for Crutches Cane Opposite Affected Leg Fat Emboli Symptoms (fracture complication) • Petechiae or rash over chest: caused by embolization of skin capillaries or thrombocytopenia • Conjunctival hemorrhage • Snow storm of chest x-ray: patchy infiltrates