A nurse al pediatric unit is preparing to msert an IV catheter for 7-year-old. Which of the following actions should the nurse take?
Tell the child they will feel discomfort during the catheter insertion
A nurse is caring for a client who has arteriovenous fistula. Which of the following findings should the nurse report?
Absence of a bruit
A nurse is providing discharge teaching for a client who has an implantable cardioverter
defibrillator which of the following statements demonstrates understanding of the teaching?
“I will wear loose clothing around my ICD”
A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence
about being pregnant. Which of the following responses should the nurse make?
“Describe your feelings to me about being pregnant”
A nurse is planning care for a client who has a prescription for a bowel- training program
following a spinal cord injury. Which of the following actions should the nurse include in the
Plan of care?
Administer a rectal suppository 30 minutes prior to scheduled defecation times
A nurse is caring for a client who is in active labor and requests pain management. Which of
the following actions should the nurse take?
Place the client in a warm shower
a nurse in an emergency department is performing triage for multiple clients following a
disaster in the community. To which of the following types of injuries should the nurse assign
the highest priority?
Below-the knee amputation
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include?
Document the client’s condition every 15 min
A nurse is teaching an in-service about nursing leadership. Which of the following information
should the nurse include about an effective leader?
Acts as an advocate for the nursing unit
A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports
that she has been following her (unable to read) care. The nurse should identify which of the
following findings indicates a need to revise the client’s plan of care.
Hbalc 10 %
A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The
nurse should identify that which of the following sexually transmitted infections is a nationally
notifiable infectious disease that should be reported to the state health department?
Chlamydia
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a
group on a mental health unit. Which of the following group facilitation techniques should the
nurse include in the teaching?
Use modeling to help the clients improve their interpersonal skills
A nurse is planning for a client who practices Orthodox Judaism. The client tells the nurse
that (Unable to read) Passover holiday. Which of the following action should the nurse include in
the plan of of care?
Provide unleavened bread.
A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the
effectiveness of the treatment
The client reports feeling less anxious
A nurse in an emergency department is assessing a client who reports ingesting thirty
diazepam tablets (Unable to read) a respiratory rate of 10/min. After securing the client’s airway
and initiating an IY, which of the following actions should the nurse do next.
Administer flumazenil to the client.
A nurse in an emergency department is caring for a client who reports cocaine use 1hr ago
Which of the following findings should the nurse expect?
Elevated temperature
A nurse is assessing a newborn who has a blood glucose level of 30 mg/dl. Which of the following manifestations should the nurse expect?
Jitteriness
A nurse in a pediatric clinic is reviewing the laboratory test results of a school age child.
Which of the following findings should the nurse report to the provider?
WBC 14.000/mm3
A charge nurse is teaching a newly licensed nurse about ctlients designating a health care
proxy in situations that require a durable power of attorney for heal care (DPSHC). Which of the
following information should the charge nurse include?
“The proxy can make treatment decisions if the client is under anesthesia”
A nurse in the PACU is caring for a client who reports nausea. Which of the following actions should the nurse take first?
Turn the client on their side.
A nurse is caring for a client who has a history of depression and is experiencing a situational
crisis. Which of the following actions should the nurse take first?
Confirm the client’s perception of the event
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The
nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?
Document the client’s condition every 15 minutes.
A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the (Unable to read) unit due to a staffing shortage. Which
of the following client should the nurse delegate to to the LPN?
A client who is postoperative following a bowel resection with an NG tube set to contnuous suction.
A nurse is working on a surgical unit is developing a care plan for a client who has paraplegia. ‘The client has an area of nonblanchable erythema over his ischium. Which of the
following interventions should the nurse include in the care plan?
Place the client upright on a donut-shaped cushion
A nurse is caring for a client who is dilated to 10 cm and pushing. Which of the following
pain-management (Unable to read) a safe option for the client?
Pudendal block.
A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse identify as the (Unable to read) (Most important?)
The client reports giving away personal items
A nurse is providing teaching about immunizations to a client who is pregnant. The nurse
should inform the client that she can receive which of the following immunizations during
pregnancy? (Select all that apply)
-Tetanus diphtheria and acellular pertussis vaccine
-Inactivated influenza vaccine.
A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following condition in the child’s medical history should the nurse identify as a contraindication to the procedure?
Hypertension
A nurse is providing discharge teaching for a group of clients. The nurse should recommend
a referral to a dietitian
A client who has gout and states, “I can continue to eat anchovies on my pizza.”
A hospice nurse is visiting vith the son of a client who has terminal cancer. The son reports
sleeping very little during the past week due to caring for his mother . Which of the following
responses should the nurse make?
“I can give you information about respite care 1 you are interested.”
A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child’s glucose. The nurse should identify this finding as an adverse effect of
which of the following medications
Methylprednisolone
The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching?
“You can increase your dietary intake of folic acid by eating cereals and citrus fruits”
A community health nurse is assessing an adolescent who is pregnant. Which of the
following assessments is the nurse’s priority?
(Unable to read) (Picked this one) Medicaid?
A nurse manager is planning to teach staff about critical pathways. Which of the following
information should the nurse include?
(Unable to read) decrease health care costs
A nurse is reviewing the medical record of a client who has schizophrenia. Which of the
following should the nurse report to the provider?
Exhibit
Blood pressure: 102/56 mm Hg. Heart rate: 95/min
Respiratory rate: 18/min Temperature: 37.4C (99.3F)
Exhibit 2
Medication Administration Record
Clozapine 150 mg PO twice daily
Benztropine 0.5 mg PO twice daily as needed for tremors
Exhibit 3
Vurse’s notes:
Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 1b.) in the
past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of
breakfast and reports slightly nauseous.
Sore throat.
A charge nurse is educating a group of unit nurses about delegating client tasks to assistive
personnel
“An RN evaluates the client needs to determine tasks to delegate”
A nurse is assessing a client who is in active labor. Which of the following findings should
the nurse report to the provider?
FHR baseline 170/min
A nurse working in a rehabilitation facility is developing a discharge plan for a client who
has left-sided hemiplegia the following actions is the nurse’s priority?
Ensure that the client has a referral for physical therapy
A nurse in a mental health unit is planning room assignments for four clients. Which of the
following client should be closest to the nurse’s station?
A client who has depressive disorder and reports feeling hopeless
A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take?
Place the tip of the thermometer under the center of the infant’s axilla.
A nurse is planning care for a client who has bipolar disorder and is experiencing mania.
Which of the following interventions should the nurse include in the plan?
Encourage the client to take frequent rest periods
A nurse is admitting medications to a group of clients, Which of the following occurrences
requires the completion of an incident report?
A client receives his antibiotics 2hr late
A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns.
The client asks the nurse to warm up seaweed soup that the client’s partner brought for her.
Which of the following responses should the nurse make?
“Does the doctor know you are eating that?”
a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing.
Which of the following examples should the nurse include in the teaching?
Administering potassium via IV bolus
a nurse is providing teaching to family members of a client who has dementia. Which of the
following instructions should the nurse include in the teaching?
Establish a toileting schedule for the client
The nurse is reviewing the medical record of a elient who is requesting combination oral
contraceptives. Which of the following conditions in the client’s history is a contradiction
to the use of oral contraceptives?
Thrombophlebitis
A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations
The client states, “It’s hard not to listen to the voices.” Which of the following questions should
the nurse ask the client?
“What helps you ignore what you are hearing?”
A charge nurse is teaching a group of newly licensed nurses about the correct use of
restraints. Which of the following should the nurse include in the teaching?
Applying elbow immobilizers of an infant receiving cleft lip injury
A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following
Inject air into the NPH insulin vial.
A Nurse is working with a client who has an anxiety disorder and is in the orientation phase
of the therapeutic relationship. Which of the following statements should the nurse make during
this phase?
“We should establish our roles in the initial session.”
A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster
Which of the following information should the nurse include?
Children who have varicella are contagious until vesicles are crusted.
A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of
the following requires intervention by the staff nurse?
Waits 2 minutes between suctions
A nurse is teaching at a community health fair about electrical fire prevention. Which of the
following information should the nurse include in the teaching?
Use three pronged grounded plugs
A nurse is providing care for a group of clients. Which of the following elient’s should the
nurse identify as having the highest risk for developing a pressure injury?
A client who has a T-tube following an open cholecystectomy
A nurse is teaching a client who has glaucoma and a new prescription for timolol eyedrops.
Which of the following statements indicates an understanding of the teaching?
“I will place pressure on the corner of my eye after using he eye drops”
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
Swelling of the face
A nurse is caring for a client who has a diagnosis of stage IV metastatic cancer. Which of the following responses should the nurse make?
“I can give you information about making end of life decisions”
A nurse is caring for a client wo has severe hypertension and is to receive nitroprusside via
continuous IV infusion. Which of the following actions should the nurse plan to take?
(Limit or remove?) IV bag from exposure to light
A nurse is caring for a client who is experiencing mild anxiety. Which of the following
findings should the nurse expect?
Heightened perceptual field
A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes lithium level of 0.8 mEq/L. Which of the following
orders from the provider should the nurse expect?
Administer the medication
A nurse is providing teaching to an older adult client about methods to promote nighttime
sleep. Which of the following instructions should the nurse include?
Eat a light snack before bedtime
A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of
the following medications should the nurse administer?
Pregabalin
A nurse is caring for a client following insertion of a chest tube 12 hr. ago. ‘The (Unable to read) following actions should the nurse take?
Report continuous bubbling in the water seal chamber.
A nurse is caring for a client who is receiving morphine4 mg via IV bolus every 4 hr. PRN.
The nurse should monitor for which of the following adverse effects?
Urinary retention.
A nurse is interviewing the partner of a client who was admitted in the manic phase of a bipolar disorder. The partner states “I don’t know what to do, Everything has been happening so
quickly.” Which of the following by the nurse is therapeutic?
“Can you talk about what happens with your partner at home?”
A nurse is providing dietary teaching to a guardian of a preschooler who has a new diagnosis of celiac disease. Which of the following statements by the guardian indicates an understanding of the teaching?
“I will put my child on a gluten-free diet”
A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?
Prime IV tubing with 0.9% sodium chloride.
A nurse is admitting a client who has diabetic ketoacidosis. Which of the following types of
continuous infusions should the nurse initiate?
0.9% normal saline.
A nurse is teaching who has chronic pain about avoiding constipation from opioid
medications. Which of the following should the nurse include in the teaching?
Increase exercise activity
A nurse is teaching about preventative measures to a female client who has chronic urinary
ract infections. Which of the following interventions should the nurse include in the teaching?
“Drink 2 liters of warm water per day”
A nurse is receiving change-of-shift report for a group of clients. Which of the following
clients should the nurse plan to assess first?
A client who has a hip fracture and a new onset of tachypnea
A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
Consume food high in bran fiber
A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototheraps
Which of the following actions should the nurse take?
Ensure that the newborn wears a diaper.
a nurse is teaching a group of newly licensed nurses about client advocacy Which of the
following statements by a newly licensed nurse indicates an understanding of the teaching?
“I will intervene if there is conflict between a client and his provider”
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?
Evaluate the client’s ability to help with repositioning
A nurse is caring for an nfant who has coaction of the aorta. Which of the following should
the nurse identify as an expected finding?
Weak femoral pulses
A nurse is assisting with the development of an informed document for participation in a
research study. Which of the following information should the nurse include?
A statement that participants can leave the study at will.
A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the
following adverse effects should the nurse include?
Excessive sweating
A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of
the following should the nurse report to the provider?
The client develops hiccups
A nurse is preparing discharge information for a client who has type 2 diabetes mellitus
Which of the following resources should the nurse provide to the client?
Food exchange lists for meal planning from the A merican Diabetes Association
A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of
the following statements should the nurse include in the teaching?
“You should push the button before physical activity to allow maximum pain control.”
A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin
for blood glucose management. The nurse should anticipate administering which of the
following types of insulin?
Glargine insulin
A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the
following should the toddler participate?
Playing with a large plastic truck.
A nurse is caring for a client who is receiving intermittent feedings via
feeding pump and is experiencing dumping syndrome. Which of the following actions should the
nurse take?
(Unable to read) rate of the client’s feedings.
A nurse in an emergency department is caring for a client who received a dose of penicillin
and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following
actions is the nurse’s priority?
Administer oxygen
A nurse is caring for a client who has Raynaud’s disease Which of the following actions
should the nurse take?
Provide information about stress management
A nurse is reviewing the medical history of a client who has angina. Which of the following
findings in the client’s medical history should identify as a risk factor for angina?
Hyperlipidemia.
A nurse iS caring for a client who is 12 hr. postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
Magnesium hydroxide 30 ml PO
A nurse overhears two assistive personnel (AP) discussing care for a client while in the
elevator. Which of the following actions should the nurse take?
Report the incident to the AP’s charge nurse
A nurse is planning care for a client who is receiving hemodialysis. Which of the following
actions should the nurse include in the plan of care?
Check the vascular access site for bleeding after dialysis
A nurse in the emergency department is caring for a client who reports intimate partner
violence. Which of the following interventions is is the nurse’s priority?
Determine if the client has any injuries
A nurse iS caring for a client who is U active labor and note the FHR baseline has been
100/min for the past 15 min. The nurse should identify which of the following conditions as a
possible cause of fetal bradycardia?
Maternal hypoglycemia
A nurse is assessing a school-age child who has a urinary tract infection. Which of the
following findings should the nurse expect?
Enuresis
A A charge nurse on a medical-surgical unit is assisting with the emergency response plan
following an exteral disaster in the community. In anticipation of multiple client admissions,
which of the following current clients should the nurse recommend for early discharge?
A client who is 1 day postoperative following a vertebroplasty
A nurse is preparing to administer dopamine hydrochloride 4 meg/kg/min via continuous
infusion. A vailable is dopamine hydrochloride in a solution of 800 mg in a 250 ml bag. The
client weighs 80 kg. The nurses should set the IV infusion to deliver how many mL/hr? (Round
the answer to the nearest whole number)
6 mL/hr
A nurse is providing teaching to the parents of a newborn genetic screening. Which of the
following statement should the nurse include in the teaching?
“This test should be performed after your baby is 24 hours old.”
A nurse is providing discharge teaching to a client who is postoperative following a colon
resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching?
“I should avoid eating popcorn and fresh pineapple”
A nurse is admiting a client who had a stroke and exhibits facial drooping. drooling and
hoarseness. Which of the following is the nurse’s priority?
Place the client on NPO status.
A nurse is providing teaching to a client who has heart. failure and a new prescription for
furosemide. Which of the following statements should the nurse make?
“Rise slowly when getting out of bed”
A nurse 1S planning teaching session for a client who is postoperative following a colon
resection. Which of the following actions should the nurse take first?
Determine the client’s current pain level
A nurse is caring for a client who has chronie pancreatitis. Which of the following dietary
recommendations should the nurse make?
Broiled skinless chicken breast with brown rice.
A nurse is caring for a client who asks for information regarding organ donation. Which of
the following should the nurse make?
“Your desire to be an organ donor must be documented in writing.”
A nurse is teaching a female client about personal hygiene. Which of the client actions
indicates an understanding go the teaching?
The client brushes her teeth twice daily.
A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should
the nurse plan to take?
Auscultate the newborn’s apical pulse for 60 seconds
A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 1b) over the last
5 days. The client’s laboratory values this morning are the following: WBC 10,000/mm3, RBC
5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse
should report these finding to which of the following members of the interdisciplinary team?
Nephrologist
A nurse is caring for an infant who is in contact isolation and received a blood transfusion.
Which of the following actions is appropriate for the nurse to take to provide cost-effective care?
Return unopened equipment to the supply center
A nurse is reviewing the medical record of a client who is postoperative following a total
hip arthroplasty. For which of the following findings should the nurse contact the provider?
WBC count 14,000 mm3
A nurse is preparing education material for a client. Which of the following techniques
should the nurse use in creating material?
Emphasize important information using bold lettering
A nurse is creating for a client who has aids. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?
“Ice chips”
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis
The nurse should monitor the client for which of the following complications?
Contractions
A nurse is caring for a client who is at 38 weeks gestation. is in active labor, and has ruptured membrane, Which of the following actions should the nurse take?
Apply fetal heart rate monitor.
A local home health provider. nurse Identify is the preparing sequence to make of an steps initial the nurse visit to should family take when following conducting referral from a
home visit. (Move the steps into the box on the right. Placing them in the order of performance)
-Clarify the reason for the referral with the provider office.
-Contact the family to determine availability and readiness to make an appointment.
-Identify family needs interventions using the nursing process.
-Record information about the home visit according to agency policy.
-Discuss plans for future visits with the family.
A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for pateral fluid therapy. The guardian asks. “What are the indications that my
baby needs an IV?” Which of the following responses should the nurse make?
“Your baby needs an IV because she is not producing any tears”
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?
g. Place the bedside table on the right side of the bed
A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care?
j. Have suction equipment available for use
k. Feed the client thickened liquids
l. Place food on the unaffected side of the client’s mouth
n. Teach the client to swallow with her neck flexed
A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client’s plan of care?
o. Speak to the client at a slower rate
p. Assist the client to use flash cards with pictures
s. Give instructions one step at a time
A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding?
v. Inability to recognize familiar objects
A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take?
a. Position the client in an upright position, leaning over the bedside table.
A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCo2 32mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances?
f. Respiratory alkalosis
A nurse is assessing a client following bronchoscopy. Which of the following findings should the nurse report to the provider?
l. Bronchospams
A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client’s room?
m. Oxygen equipment
o. Pulse oximeter
p. Sterile dressing
A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications?
r. Dyspnea
t. Fever
u. Hypotension
A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client’s room?
a. oxygen
b. sterile water
c. Enclosed hemostat clamps
e. Occlusive dressing
A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?
g. Apply sterile gauze to the insertion site
A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings?
k. gentle constant bubbling in the suction control chamber
l. rise and fall in the level of water in the water seal chamber with inspiration and expiration
A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do?
r. perform the Valsalva maneuver
A nurse is planning care for a client following insertion of a chest tube and drainage system. Which of the following should be included in the plan of care?
s. encourage the client to cough every 2 hours
t. check the continuous bubbling in the suction chamber
w. obtain a chest x-ray
A nurse is orientation a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV?
b. “it allows preset pressure delivered during spontaneous ventilation”
A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize?
f. Pale skin
i. elevation blood pressure
A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?
m. assess breath sounds every 1 to 2 hours
A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?
o. venturi mask
A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client’s respiratory muscles should the nurse include in the plan of care?
s. synchronized intermittent mandatory ventilation
t. continuous positive airway pressure
u. pressure support ventilation
A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk?
a. client who has dysphagia
b. client who has AIDS
e. client who has a closed head injury and is receiving ventilation
f. client who has myashtenia gravis
A nurse in a clinic is caring for a client whose partner states that the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse’s priority?
g. obtain a baseline vital signs and oxygen saturation
A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder?
r. palpation of the orbital areas
A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching?
s. “I should wash my hands after blowing my nose to prevent spreading the virus”
A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?
b. wheezing
c. retraction of sternal muscles
e. premature ventricular complexes (PVC’s)
A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?
i. Beta2 agonist
A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding in the teaching?
l. “I will take my medication with meals”
A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma?
o. environmental allergies
a nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. which of the following client statements indicates an understanding of the teaching?
s. “I take this medication to prevent asthma attacks”
A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements made by the client indicates an understanding of the teaching?
c. “I can have an increase in my heart rate while taking this medication”
A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication?
a. hypokalemia
c. fluid retention
e. black, tarry stools
A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?
a. “There are portable oxygen delivery systems that you can take with you”
A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?
d. “I will take in a deep breath and hold it before exhaling”
A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care?
c. Take a deep breath in through your nose
A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazanimide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching?
b. “I will wash my hands each time i cough”
c. “I will wear a mask when i am in a public area”
A nurse is teaching a client who has tuberculosis. which of the following statements should the nurse include in the teaching?
b. “you will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication”
A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi-medication regimen. which of the following instructions should the nurse give the client related to ethambutol?
c. “watch for any changes in vision”
A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?
c. “You might notice tingling of your hands”
A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching?
a. persistent cough
c. fatigue
d. night sweats
e. purulent sputum
A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism?
a. a client who has a BMI of 30
c. a client who has a fracture femur
e. a client who has chronic atrial fibrillation
A nurse is assessing a client who has pulmonary embolism. Which of the following information should the nurse expect to find?
g. pleural friction rub
i. petechiae
j. tachycardia
a nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. the client states she is anxious and is unable to get enough air. vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. which of the following nursing actions is the priority?
m. administer oxygen therapy
A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate a immediate concern for the nurse?
p. “i take antacids several times a day”
A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy?
a. hip arthroplasty 2 weeks ago
A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax?
a. tachypnea
b. deviation of the trachea
e. pleuritic pain
a nurse is reviewing the prescriptions for a client who has pneumothorax. which of the following actions should the nurse perform first?
b. obtain a large-bore IV needle for decompression
a nurse is reviewing discharge instructions for a client who experienced a pneumothorax. which of the following statements should the nurse use when teaching the client?
d. “notify your provider if you experience a productive cough”
A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect?
b. cyanosis
c. hypotension
d. dyspnea
e. paradoxic chest movement
A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first?
c. administer oxygen via high-flow mask
a nurse is reviewing the health record of five clients. which of the following clients are at risk for developing acute respiratory distress syndrome?
a. a client who experienced a near-drowning incident
b. a client following coronary artery bypass graft surgery
d. a client who has dysphagia
e. a client who experienced a drug overdose
a nurse is planning care for a client who has a severe respiratory distress system (SARS). which of the following actions should be included in the plan of care for this client?
b. provide supplemental oxygen
d. administer bronchodilators
e. maintain ventilatory support
a nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. which of the following medications should the nurse anticipate administering with this medication?
a. fentanyl
c. midazolam
a nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. which of the following statements by the newly licensed nurse indicates effectiveness of the teaching?
d. “a chest x-ray is needed to verify placement after the procedure”
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. which of the following should the actions the nurse take?
d. document the client’s condition every 15 minutes
A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. which of the following actions should the nurse include in the plan of care?
d. administer analgesics on a scheduled basis for the first 24 hr
a nurse is receiving change-of-shift report for a group of clients. which of the following clients should the nurse plan to assess first?
d. a client who has a hip fracture and a new onset of tachypnea
A nurse is preparing to apply a transdermal nicotine patch for a client. which of the following actions should the nurse take?
b. wear gloves to apply the patch to the client’s skin
A nurse has just received a change-of-shift report for four clients. which of the following clients should the nurse assess first?
a. a client who was just given a glass of orange juice for a low blood glucose level
A nurse is caring for a client who is receiving intermittent enteral tube feedings. which of the following places the client at risk for aspiration?
a. a history of gastroesophageal reflux disease
A nurse is reviewing the laboratory results for a client who has Cushing’s disease. the nurse should expect the client to have an increase in which of the following laboratory values?
a. serum glucose level-increased
a nurse is caring for a client who has severe preeclampsia and is receiving mafnesium sulfate intravenously. the nurse discontinues the magnesium sulfate after the client displaces toxicity. which of the following actions should the nurse take?
d. administer calcium gluconate IV
a charge nurse is teaching the new staff members about factors that increase a client’s risk to become violent. which of the following risk factors should the nurse include as the best predictor of future violence?
c. previous violent behavior
a nurse is preparing to perform a sterile dressing change. which of the following actions should the nurse take when setting up the sterile field?
a. place the cap from the solution sterile side up on clean surface
a nurse is providing teaching to an older adult client about methods to promote nighttime sleep. which of the following instructions should the nurse include?
a. eat a light snack before bedtime
a home health nurse is preparing for an initial visit with an older adult client who lives alone. which of the following actions should the nurse take first?
c. identify environmental hazards in the home
a nurse is assessing the remote memory of an adult client who has mild dementia. which of the following questions should the nurse ask the client?
b. “what high school did you graduate from?”
a nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. which of the following goals should the nurse include in the teaching?
d. HbA1c level less than 7%
a nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. which of the following should the nurse conclude if the client develops ataxia and incoordination?
c. the client is showing evidence of phenytoin toxicity
a nurse is caring for a client who is 1 hr postoperative following rhinoplasty. which of the following manifestations requires immediate action by the nurse?
a. increase in frequency of swallowing -> may indicate bleeding
a nurse is planning care for a preschool-age child who is in the acute phase of Kawasaki disease. which of the following interventions should the nurse include in the plan of care?
b. monitor the child’s cardiac status
a nurse is planning an educational program for high school students about cigarette smoking. which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?
c. use of tobacco decreases the level of athletic ability
a nurse is assessing a client who is prescribed spironolactone. which of the following laboratory values should the nurse monitor for this client?
c. serum potassium- diuretic that retains potassium = hyperkalemic risk
a nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. which of the following statements by the nurse indicates an understanding of this role?
a. “I will let the client know that I am available as the interpreter”
A nurse is performing assessments on newborns in the nursery. which of the following findings should the nurse report to the provider?
a. a two day old newborn who has a respiratory rate of 70 –> 30-6- is normal
a nurse on an acute unit has received change of shift report for 4 clients. which of the following clients should the nurse assess first? (pain pallor pulselessness paresthesia)
b. a client who has fractured left tibia and pallor on the affected extremity
a nurse is providing discharge instructions to a client who has a new prescription for haloperidol. which of the following adverse effects should the nurse instruct the client to report to the provider?
d. shuffling gait -> A/E EPS: is an indication of parkinsonism and should be reported
a nurse is planning discharge teaching about cord care for the parents of a newborn. which of the following instructions should the nurse plan to include in the teaching?
d. keep the cord stump dry until it falls off
a nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client?
b. potato pancakes
a nurse working in acute care mental health facility is assessing a client who has schizophrenia. which of the following findings should the nurse expect?
c. disorganized speech
a nurse is caring for a client who is immobile. which of the following interventions is appropriate to prevent contracture?
c. apply an orthotic to the clients foot
a public health nurse working in a rural area is developing a program to improve health for the local population. which of the following actions should the nurse plan to take?
a. provide anticipatory guidance classes to parents through public schools
a nurse in the emergency department is performing triage for multiple clients following a disaster in the community. to which of the following types of injuries are of top priority? (it cut off between types and priority)
a. below the knee amputation -> ESI level 1
a nurse is preparing a change of shift report for an adult female client who is postoperative. which of the following client information should the nurse include in the report?
d. platelets 100,000/mm3 – 150,000-300,000 risk for bleeding
a nurse is admitting a client who has anorexia nervosa. which of the following is an expected finding?
b. prealbumin 10 mcg/dl (normal: 16-40)
a charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. which of the following client assignments should the nurse delegate to the LPN?
a. a client who is postoperative following a bowel resection with an NGT set to continuous suction
a nurse is caring for a client who is at 41 weeks of gestation and is receiving oxycotin for labor induction. the nurse notes early deceleration on the fetal heart rate monitor. which of the following nursing actions should the nurse take?
a. continue to monitor the fetal heart rate — not a problem – absent or late are a problem however confirmed
a nurse is conducting an initial assessment of a client and noticed a discrepancy between the client’s current IV infusion and the information received during the shift report. which of the following actions should the nurse take?
b. compare the current infusion with the prescription in the client’s medication record
a nurse is reviewing the medical record of a client who schizophrenia. which of the following findings should the nurse identify as a contraindication to the administration of clozapine?
a. WBC count 2,900/mm3 – AGRANULOCYTOSIS – 4,800-15,000 is normal range
a nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis c. the client asks the nurse if she will be able to breastfeed. which of the following responses by the nurse is appropriate?
a. you may breastfeed unless your nipples are crack or bleeding
a nurse is caring for a client who has returned to the medical-surgical unit following a transuretheral resection of the prostate. which of the following should the nurse identify as priority nursing assessment after reviewing the client’s information?
a. level of consciousness (priority)- decreased LOC can mean less o2 going to the brain ?
c. deep-tendon reflexes
a nurse is caring for a client who has hyperthermia. which of the following actions for the nurse to take?
d. initiate seizure precautions
a nurse manager is updating protocols protocols for belt restraints. which of the following guidelines should the nurse include?
a. document the client’s conditions every 15 minutes
a nurse in emergency department is caring for a client who has full thickness burns of the thorax and upper torso. after securing the client’s airway, which of the following is the nurse’s priority intervention?
d. initiating IV fluid resuscitation – they are at risk for hypovolemic shock d/t 3rd spacing
a nurse is caring for a client who has cancer and is being transferred to hospice care. the client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA)
c. “Let’s talk about your mom’s cancer and how things will progress from there. tell me how you are feeling about it.”
e. “you should like you have questions about your mom dying. let’s talk about it”
a nurse is reviewing the medical record of four clients. the nurse should identify that which of the following client findings follow up care?
c. a client who received a Mantoux test 48 hours ago and has induration phosphate
a community health nurse receives a referral for a family home visit. which of the following tasks should the nurse perform first?
a. clarify the source of the referral
a nurse is caring for a client who will undergo a procedure. the client states he does not want the provider to discuss the results with his partner. which of the following is an appropriate response for the nurse to make?
a. you have the right to decide who receives information
a nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lbs) from an original weight of 90.7 kg (200 lbs). the nurse should identify the weight of the following total percentage?
a. 7.5%
a nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. which of the following interventions should the nurse implement?
b. pour water from a squeeze bottle over the client’s perineal area
a nurse is providing discharge teaching to a client who has cancer and a prescription for fentanyl 25 mcg/hr transdermal patch. which of the following instructions should the nurse include in the teaching?
a. avoid hot tub while wearing the patch
a nurse working on a surgical unit is developing a care plan for a client who has paraplegia. the client has an area of non-blanchable ertyhema over his ischium. which of the following interventions should the nurse include in the care plan?
a. teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic)
a nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. which of the following statements should the nurse make during this phase?
d. “we should establish our roles in the initial session”
a nurse is providing discharge teaching to a client who has a new prescription for phenelzine. the nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?
b. whole grain bread
a nurse enters a client’s room and sees a small fire in the client’s bathroom. identify the sequence of steps the nurse should take.
- transport the client to another area of the nursing unit
- activate the facility’s fire alarm system
- close all nearby windows and doors
- use the unit’s fire extinguisher to attempt to put out the fire
a nurse is caring for a client who is experiencing mild anxiety. which of the following findings should the nurse expect?
a. heightened perceptual field
a nurse is caring for a client who has type 1 diabetes mellitus. the client reports that she is not feeling well. which of the following findings should indicate to the nurse that the client is hypoglycemic?
a. tremors
d. diaphoresis
e. inability to concentrate
a nurse is caring for an infant who has coarctation of the aorta. which of the following should the nurse identify as an expected finding?
d. weak femoral pulses
a community nurse is planning primary prevention activities to reduce the occurrence of abuse. which of the following strategies should the nurse include in the plan?
c. teach parenting skills to families at risk for abuse
a nurse and an assistive personnel (AP) are caring for a group of clients. which of the following tasks is appropriate for the nurse to delegate to the AP?
c. applying a condom catheter for a client who has a spinal cord injury
a nurse is providing teaching to an adolescent who has peptic ulcer disease. which of the following statements by the client indicates an understanding of the teaching?
b. “I will avoid food and beverages that contain caffeine”
a nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. which of the following is an appropriate action by the nurse?
a. offer the client saltine crackers between meals
c. provide humidification of the room air.
a nurse is caring for four clients. which of the following tasks can the nurse delegate to an assistive personnel?
b. perform chest compressions during cardiac resuscitation
a nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. the nurse should recognize which of the following findings as a potential contraindication for using lavender?
c. the client has a history of asthma
a nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. the nurse should monitor for which of the following adverse effects?
c. urinary retention
a nurse is conducting a health promotion class about the use of oral contraceptives. which of the following disorders is a contraindication for oral contraceptive use?
b. hypertension
a nurse is preparing to witness a client’s signature on a consent form for a colon resection. the nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA)
a. explain the procedure
b. expected outcome of the procedure and potential complications
c. possible alternative treatments
a nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. which of the following statements is appropriate to include in the teaching?
a. “you should not have this procedure if you are allergic to iodine”
a nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. the nurse should recommend increasing dietary intake of which of the following vitamins?
d. vitamin B12
a nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. which of the following actions should the nurse include in the plan of care?
a. initiate IV fluid replacement
a nurse is teaching a parent about safety securing her 3-month-old infant in a car seat. which of the following images indicates that the parent understands the teaching?
image b
a nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. which of the following actions should the nurse take?
c. flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
a nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. after notifying, which of the following actions is appropriate for the nurse to take?
b. explain the risks of leaving
a nurse is making an initial postpartum home visit. which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?
b. “I think the baby should be sleeping through the night by now”
a nurse is caring for an infant who has gestroenteritis. which of the following assessments should the nurse report to the provider?
d. sunken fontanels and dry mucous membranes
a nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding. the nurse does not speak the same language as the client. the client’s partner and a 10 year old child are accompanying her. which of the following actions should the nurse take to gather the clients information?
d. request a female translator interpreter through the facility
a nurse is caring for a client who has pernicious anemia. which of the following laboratory values should the nurse evaluate effectiveness of the treatment?
c. vitamin B12 level
a nurse is assigning tasks to assistive personnel (AP). which of the following tasks should the nurse assign to the AP?
c. perform post mortem care
a nurse is caring for a client who is postpartum and reports difficulty voiding. which of the following findings should indicate to the nurses that the client’s ability to eliminate urine from the bladder is restored?
a. two voids of 150 mL each over the past 2 hours = 2×30 = 60 mLs
a nurse is caring for a client who has acute glomerulonephritis. which of the following should the nurse expect?
c. hematuria – urinalysis will show red blood cells and protein, also reddish brown colored urine
a nurse is providing teaching to a client about the adverse effects of sertraline. which of the following effects should the nurse include?
a. excessive sweating
a nurse is providing teaching to the parents of a newborn about genetic screening. which of the following statements should the nurse include in the teaching?
d. this test should be performed after your baby is 24 hours old
a nurse is caring for a child who has cystic fibrosis and requires postural drainage. which of the following actions should the nurse take?
b. perform the procedure twice a day
a nurse is preparing an inservice for a group of nurse about malpractice issues in nursing. which of the following examples should the nurse include in the teaching?
b. administer (writer’s note: and then it’s blocked off from there)
a nurse in a clinic is assessing a client who reports frequent headaches. identify the area the nurse should palpate to check the client’s maxillary sinus for tenderness.
palpate the maxillary sinuses by pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth
a nurse is caring for an adolescent client who has cystic fibrosis. which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
d. use an albuterol inhaler
a nurse is caring for a client following a cardiac catheterization through the left groin. which of the following actions should the nurse take?
a. monitor the dorsalis pedis pulse every 15 minutes -> circulation
a nurse is caring for a client who has depression and is experiencing loss of appetite. which of the following actions should the nurse take?
a. offer high-calorie, high protein snacks to the client
a nurse is caring for a client who requests to ambulate in the hallway with his own clothing. the nurse is demonstrating which of the following ethical principles when respecting the client’s decision to wear his own clothing?
c. autonomy
A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first?
Check the mouth for smooth and smoky breath – airway obstruction via foreign body
A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor?
Hyponatremia- loop diuretic (Lasix) – wherever water goes sodium and potassium will follow
a nurse Is caring for a client who weighs 75 kg. the client has a prescription from a dietician to decrease calorie intake by 500 cal/day for 25 weeks produce a weight loss of 1 pound per week. What is the expected goal weight for the client in pounds at the end of the 25 weeks? (round the answer to the nearest whole number. Use leading zero if it applies. No trailing Zero)
140??(not sure).
pounds 1 lb per week x
25 week= 25 lbs
75 x 2.2= 165 lbs
165 Ibs-25 Ibs=140 lbs or 63.6 kg (64 kg)
a nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
I will change my baby’s diaber at least every 4 hours
a home health nurse is caring for an adult client who reports, “I keep coughing when I try to swallow my food, but not at other times.” Which of the following actions should the nurse take?
initiate a consultation with a speech→ language pathologist; swallow eval
A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control?
HbA1c 6.5%
A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication?
Blood pressure
A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention?
Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client’s abdomen
A nurse has identified tasks to delegate to a group of assistive personnel ……… the sequence of steps the nurse should follow when delegating tasks to the APs.
- Review the skill level of and qualifications of each AP
- Communicate appropriate tasks to the APs with specific expectations
- Monitor progress of task completion with each AP
- Evaluate the APs’ performance of each task
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
“I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
A nurse I caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child’s dressing. Which of the following actions should the nurse take?
Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy?
Peripheral neuropathy
A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure?
Sensation of skin warmth
A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification?
Lorazepam 0.5 mg PO one tablet daily
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
Swelling of the face
A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority?
Dysphagia
A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take?
Palpate the client’s fundus
A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?
This type of seizure can be mistaken as daydreaming.
A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client?
Tape stockinet over monitoring device and cords
A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication.
dumping syndrome
A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA)
B. Wear a lead apron when providing care
C. Limit visitors to 30 mins
{E. Close the door to the client’s room – also bolded but B and C were only highlighted}
A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching?
Client might feel guilt over some aspect of their loss
A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate?
Offer your son a gift when the baby receives one
A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation?
New prescription for an iron supplement
A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except?
Bounding pulse
A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?
Measure the client’s urine output every hour. – monitor for toxicity.
A nurse is caring for a client who has end stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child’s medic history should the nurse identify as a contraindication to the procedure?
Hypertension
A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take?
Request non gas forming foods from the dietary department
A nurse in a provider’s office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department?
Chlamydia
A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client’s lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take?
Place a cardiac monitor on the client
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
I can resume activities, such as sewing.
A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?
Give the dose over 60 min
A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching?
Eat 1g/kg of protein per day
A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make?
Tell me the standing weight of the client in room 102 before breakfast
A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority?
Erythema 5 cm (2in) above the IV site
A nurse is providing teaching about the use of crutches using a three – point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?
Positioning both hands on the grips with his elbows slightly flexed
A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform?
Kick a ball forward
A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?
We can review some information to help you select a safe alternative practitioner
A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider?
The client coughs after swallowing
A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure?
Compare the client’s current weight with preprocedure weight.
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
Minimize noise in the newborn environment
A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness?
Participate in community drills and mock events.
A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect?
Preoccupied with aging
A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
Encourage the client to take frequent rest periods
A nurse is obtaining a client’s medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution?
Severe renal impairment. (Stage IV Kidney Disease)
A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings?
Murmur at the mitral area
A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching?
I will remove bananas from my diet
A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin?
Renal insufficiency
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
Contractions
A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first?
8 year old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing – bleeding
A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching?
I will determine which muscles to contract by stopping and starting my stream of urine
A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching?
I should urinate before the test
A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect?
Elevated temperature
A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client?
Scratchy, high pitched sound upon chest auscultation
A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?
Consume food high in bran fiber
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse?
Privately interview the client about her condition.
A nurse is caring for a client following a stroke. The client has right- sided weakness and facial drooping. Which of the following nursing actions is the priority?
Maintain NPO status for client(ABC)
A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
“I will need to increase my insulin doses later in my pregnancy”
A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first?
Test the client for Trousseau’s sign
A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching?
“I should change the stoma pouch every day”
Rationale: ATI ostomy care video pouches good for up to 2-7 days, empty at 1⁄4 or 1⁄2 full.
A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity?
Hyporeflexia
A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero)
Answer is 1.7 mL per dose
Rationale:
100mg X 4.34 kg= 434 mg/day
434mg/125mgX1= 3.472 /day
3.472/2= 1.736
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
“Your desire to be an organ donor must be documented in writing.”
A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?
Administer enalapril 2.5 mg PO twice daily
A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?
Clamp the catheter distal to the injection port
A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations?
orthostatic hypotension
A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?
The client exhibits impulsive behavior.
A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider?
Protruding Hemorrhoids
A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first?
Inform the provider of the time of the last dose of pain medication
A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
The estimated blood loss was 250 milliliters
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?
“Have your child drink a small glass of water after swallowing the medication.”
A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?
Left ventricular failure
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
A client who is 1 day postoperative following vertebroplasty; (this is an out patient procedure)
A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery?
Potassium 5.2 mEq/L
A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?
Establish a toileting schedule for the client
A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations
orthostatic hypotension
A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder?
The client exhibits impulsive behavior – spending money giving away money or possessions.
A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider?
3+ deep tendon reflexes -preeclampsia
A nurse is administering an analgesic to a client who has a chest tube . The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first?
Inform the provider of the time of the last does of pain medication
A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report?
The estimated blood loss was 250 milliliters
A nurse is assessing a clients PAWP. The nurse should recognize that an elevated PAWP indicates which of the following complication?
Left ventricular failure
A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge?
A client who is 1 day postoperative following a vertebroplasty
A nurse is caring for four client who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention ………?
Potaissium 5.2 meq / L 3.5 – 5.0
A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the charge nurse use to promote effective negotiation?
Attempt to understand both sides of the issue
A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take?
Please a warm moist compress on the site
A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take?
Use a syringe to allow the medications to Flow by gravity
The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
Seductive Behavior
A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching?
I can use my ultrasound picture as a focal point during contractions
A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider?
ST segment elevations_ Remember this could possibly lead to infarctions
A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?
Uses the tpn IV tubing to administer the clients next dose of antibiotic
A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching?
Use modeling to help the clients improve their interpersonal skills
A nurse is assessing a client’s respirations which of the following actions should the nurse take?
Count respirations for 1 minute if the rhythm is irregular
A client’s partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take?
Report the information to the charge nurse
A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client’s medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive?
Migraines with aura
Rationale: MN RM 10.0 Ch.1 p.6; Exacerbates conditions affected by fluid retention, such as migraine, epilepsy, asthma, kidney, or heart disease.
A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
A client who has preeclampsia and reports a persistent headache
A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?
Instruct the client to empty her bladder prior to the procedure
A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia?
Maternal hypoglycemia
A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, “I don’t know what to do. Everything has been happening so quickly.” Which of the following responses by the nurse is therapeutic?
“Can you talk about what was happening with your partner at home.”
A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor?
Liver function test
A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?
“You should push the button before physical activity to allow maximum pain control.”
A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take?
Don sterile gloves prior to the procedure.
A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider?
Potassium 3.2 mEq/L 3.5 – 5.0 is normal
A nurse is admitting a client who has schizophrenia. The client states, “I’m hearing voices.” Which of the following responses is the priority for the nurse to state?
“What are the voices telling you?”
a nurse is caring for a client who is receiving intermittent etemnal tube feeding. Which of
the following places the client at risk for aspiration?
A History of gastroesophageal reflux disease
A nurse is providing discharge teaching to a client who has chronic kidney disease and is
receiving hemodialysis. Which of the following instructions should the nurse include in the
teaching?
Eat lg/kg of protein per day
A nurse on telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. ‘The nurse
should interpret this finding as which of the following cardiac rhythms?
First degree AV block
A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse
observes that the client coughs after each bite. After asking the AP to stop feeding the client,
which of the following actions should the nurse take next?
Listens to the client’s lung sounds
A nurse is developing a plan of of care for a client who has schizophrenia and is experiencing
auditory hallucinations. Which of the following actions should the nurse include in the plan?
Ask the client directly what he is hearing
The nurse is teaching a group of of clients at at a a community health fair about genetic disease.
Which of the following statements by a client indicates an understanding of the teaching?
“My family has genctic risk for breast cancer, so I am considering a total mastectomy”
a nurse is planning discharge teaching about cord care for the parents of a newborn. Which
of the following instructions should the nurse plan to include in the teaching?
“Keep the cord stump dry until it falls off.’
a nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the
following statements by the client indicates understanding of the teaching?
“I take a calcium vitamin supplement daily”
a nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching?
Uses a mechanical lift to move client from bed to chair.
A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make?
“This test will determine if there is leaking amniotic fluid”
a Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy?
Peripheral edema
a nurse is conducting a home visit
for a family who has two young children. The nurse notes several welts across the backs of the legs of of one of the children. Which of the following
actions should the nurse take first?
Contact child protective services.
a nurse is planning care for a client who has thrombocytopenia. Which of the following
actions should the nurse include?
Provide the client what a stool softener
A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report?
Chest pain
(Unable to read)
(Unable to read) I think this answer was 0.9% sodium chloride
a nurse is caring for a client who has left-sided heart failure, and the provider is concerned
that the client might develop (Unable to read) Which of the following actions should the nurse
take?
Place the client in high fowler’s position
A charge nurse is teaching a newly licensed nurse about the administration of total
parenteral nutrition. Which of the following should the charge nurse include?
“You will need to monitor the client’s electrolytes daily”
a nurse is teaching a prenatal class about infection at a community center. Which of the
following statements by a client indicates an understanding of the teaching?
“I can visit my nephew who has chickenpox 5 days after the sores have crusted.”
a nurse is caring for a client who has end-stage liver cancer. Which of the following
statements should the nurse make to support the client’s right to autonomy?
“We encourage you to participate in all decisions about your treatment”
a nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating?
Quality improvement.
A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of
the following actions should the nurse take?
Notify the nursing manager about the suspected alcohol use.
a charge nurse is teaching new staff members about factors that increase a client’s risk to
become violet. Which of the following risk factors should the nurse include as the best predictor of future violence?
Previous violent behavior
A charge nurse is teaching a newly licensed nurse about medication administration. Which
of the following information should the charge nurse include?
Avoid preparing medications for more than two clients at one time.
a charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
Documents the clients care tasks at the end of the shift
A nurse is caring for a client who has diaper dermatitis. Which of the following action should the nurse take?
Apply zinc oxide ointment to the irritated area.
a nurse is assessing a client who had an uncomplicated vaginal birth 3 days ago. In which of the following locations should the nurse expect to palpate the client’s fundus?
C
A nurse is developing an in-service about personality disorders. Which of the following
information should the nurse include when discussing borderline personality disorder?
“The client exhibits impulsive behaviors.”
a nurse is caring for a client who has a prescription for warfarin. When reviewing the client’s current medications, which of the following medications should the nurse identify as
contraindicated for use with warfarin? (Select all that apply)
Aspirin
Gingko biloba.
Ibuprofen.
a nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect?
Preoccupied with aging
A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165
and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client’s BMI value as which of
following?
23
a nurses is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding?
The child believes the person will retum.
A nurse is assessing a client in the emergency department Which of the following actions in
should the nurse take first?
Exhibit 1
Laboratory Results Cerebrospinal fluid WBC 2.000/mm3 Neutrophils 88% Protein 320 mg/dl
Glucose 35 mg/dl Cloudy in appearance
Exhibit2
History and Physical
Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic.
Exhibit 3
Vital Signs
BP 166/96 mm Hg
Respiratory rate 24/min
Pulse rate 112/min
Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9
Obtain arterial blood gas levels.
a client is caring for a client following a paracentesis. Which of the following findings
should the nurse identify as as an indication of a complication?
Tachycardia.
a certified IV nurse is providing education about peripherally inserted catheters (PICC) to a
newly licensed nurse. Which of the following statements by the newly licensed nurse indicated
an understanding of the teaching?
“Informed consent is required prior to PICC placement.”
a nurse is reviewing admission prescriptions for a group of clients. Which of the following
prescriptions should the nurse identify as complete?
Metoprolol Smg IV now.
A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of
the following actions should the nurse take?
Perform the procedure prior to meals
A nurse is reviewing the medical records of four clients. The nurse should identify that
which of the following client findings requires follow up care?
A client who is taking warfarin and has an INR of 1.8
a nurse is caring for a client who is postpartum and request information about
contraception. Which of the following instructions should the nurse include?
“Place transdermal birth control patch on your upper arm”
A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching?
“I will not publish public announcement about my baby’s birth”
A nurse is is developing a plan of care for a client who has precclampsia and is to receive
magnesium sulfate via continuous IY infusion. Which of the following actions should the nurse
include in the plan?
Measure the client’s urine output every hour
a nurse is receiving a telephone prescription from a provider for a client who requires
additional medication for pain control. Which of the following entries should the nurse make in
the medical record?
“Morphine 3 mg Subcutancous (Unable read)
A nurse is assessing a client who has acute kidney injury and respiratory rate of 34/min.
The client’s ABG results are ph. 7.28 HC03 18 mEg/l. (Unable to read) PaO2 90 mm Hg.
Which of the following conditions should the nurse expect?
Metabolic acidosis
a nurse realizes that the wrong medication has been administered to a client. Which of the
following actions should the nurse take first?
Monitor vital signs.
recieves a telephone call from a parent reporting that their school-age child has a nosebleed
and that they cannot stop the bleeding. Which of the following instructions should the nurse
provide to the provider?
“Use your thumb and forefinger to to apply pressure to the (Unable to read) of your child’s
nose
A nurse is preparing to to administer an autologous blood product to a client. Which of the
following actions should the nurse take to identify the client?
Ensure that the client’s identification band matches the number on the blood unit.
A nurse is transcribing new medication prescriptions for a group of client. For which of the
following prescriptions should the nurse contact the provider for clarifications?
Lorazepam .5mg PO one tablet daily
A nurse is caring for a client who requires seclusion to prevent harm to toa others on the unit
Which of the following is an appropriate action for the nurse to take?
Offer fluids every 2hr.
a nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?
“Dehydration can increase the risk of preterm labor”
a nurse is assessing a client who is postoperative following abdominal surgery and has an
indwelling urinary catheter that is draining dark yellow urine at 25 mV/hr. Which of the following
interventions should the nurse anticipate?
Obtain a urine specimen for culture and sensitivity
A nurse is reviewing the medical record of a client who has schizophrenia and is taking
clozapine. Which of the following findings should the nurse identify as a contraindication to the
administration of clozapine?
WBC count 2,900/mm3
a nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy?
“Lately, I feel like my feet are freezing up, as they are stuck to the ground”
a nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect?
Increased creatine.
A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take?
“I will call the pharmacist now to check on this medication”
A nurse is teaching at a community health fair about electrical fire prevention. Which of the following information should the nurse include in the teaching?
Use three pronged grounded plugs.
a charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge?
a client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.
a nurse in provider’s office is reviewing the laboratory results of a group of of clients. Which to report?
Chlamydia
a nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a as dietitian
a client who has gout and states, “i can continue to eat anchovies on my pizza.”
a nurse is receiving a change-of-shift report for an adult female client who is postoperative
Which of the following client information should the nurse report?
Answer might be lower platelets.
a nurse is caring for a client who has depression and reports taking ST. John’s wort along
with citalopram. The nurse should monitor the client for which of the following conditions as a
result of an interaction between these substances?
Serotonin syndrome
a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse nutritional requirements?
(Unable to read) (Chose this one)
A nurse in a provider’s office is preparing to administer the inactivated influenza vaccine
The nurse should collect additional (Unable to read) for which of the following client prior to administering the vaccine?
Client has a sensitivity to eggs.
a nurse is providing teaching about digoxin administration to the parents of a toddler which
as heart failure. Which of the following statements should the nurse include in the teaching?
“Have your child drink a small glass of water after swallowing the medication”
a nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the
following actions should the nurse take’?
Obtain the specimen immediately upon the client waking up.
a nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For
which of the following laboratory results should the nurse withhold the medication and notify the
provider?
Potassium 3.1 mEq/l.
A nurse is caring for a client who wears glasses. Which of the following actions should the
nurse take?
Store the glasses in a labeled case
a school nurse is teaching a parent about absent seizures. Which of the following
information should the nurse include?
“This type of seizure can be mistaken for daydreaming”
a nurse is planning care for a client who has cancer and is about to receive low dose
brachytherapy via a vaginal implant applicator. Which of of the following interventions should the
nurse include in the plan of care?
Insertion of an indwelling urinary catheter
a nurse is caring for a client who has deep vein thrombosis and is receiving heparin
therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications?
aPTT
a charge nurse 1s preparing to lead negotiations among nursing staff due to contlict about
overtime requirements. Which of the following strategies should the murse use to promote
effective negotiation?
Attempts to understand both sides of the issue
A nurse manager is developing a protocol for an urgent care clinie that often eares for
-lients who do not speak the same language as clinical staff. Which of the following instructions
should the nurse include?
(Answer was the nurse was going to do the interpretation)
a nurse is caring for a clieat who experienced a traumatie brain injury 72 hr. ago. Which of
the following findings should the nurse identify as an indication of intercranial pressure?
Incrcasingly severe headache.
a nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child
Which of the following instructions should the nurse take?
Administer the feeding over 30 min.
A nurse is administering digoxin 0.125 mg Po to an adult chient. For which of the following findings should the nurse report to the provider? A_ Potassium level 4.2 mEqL.
Digoxin level 1 ne ml
A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustalining measures. Which of the following action should the nurse take?
Arange for an cthics conunillee meeting to address the family’s concerns.
a nurse is caring for a client who wears glasses., Which of the following actions should the nurse take?
Store the glasses in a labeled case
a nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who
on contact precautions. Which of the following should the nurse include in the teaching?
Wear gloves when providing care to the client.
a nurse is planning on care for a client who is is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include?
Obtain a cardiac rehabilitation consultation.
the nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client’s history is a contradiction to the use of oral contraceptives?
Thrombophlebitis.
a nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take?
Evaluate the chient’s understanding of life-sustaining measures.
a nurse is caring for an adolescent who has ickle-cell anemia. Which of the following manifestations
indicates acute chest syndrome and should be immediately reported to the provider?
Substernal retractions
a nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following action should the nurse take?
Insert a large-bore NG tube.
a nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS
Which of the following referrals is the nurse’s priority?
Speech-language pathologist
a nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the
following findings should the nurse report to the provider? A. WBC count 8,000/mm3.
Erythrocyte sedimentation rate 75 mm/hr
a nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests?
Platelet count.
A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first?
Palpate the pulse distal to the cast.
A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply)
Keep objects in the client’s room in the same place.
Ensure there is high-wattage lighting in the client’s room.
Allow extra time for the client to perform tasks
a nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles?
CINAHL.
a nurse in an emergency department is assessing newly admitted client who is experiencing drooling
and hoarseness following a burn injury. Which of the following should actions should the nurse take first?
Administer 100% humidifited oxygen
a nurse is planning care for a client who has unilateral paralysis and dysphagia following a right
hemispheric stroke. Which of the following interventions should the nurse include in the plan?
Place the client’s left arm on a pillow while he is sitting.
a nurse is caring for a client who is in seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?
Confront the client about this behavior.
a nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take?
Limit the client’s visitors to 30 min per day.
a nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse
identify as a manifestation of pulmonary congestion?
Bradypnea
a nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin.
Postterm with oligohydramnios. (l think Maternal Newborn Chapter 15 page 100)
A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse
identify as a manifestation of pulmonary congestion?
Bradypnea
a nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make?
“Your baby needs an IV because she is not producing any tears”
a nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make?
“Rise slowly when getting out of bed”
a nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?
Allow the client enough time to perform rituals.
a nurse is caring for a client who has depression and reports taking ST. John’s wort along with citalopram
The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?
Serotonin syndrome
a nurse is assessing a client who is recciving packed RBCs. Which of the following findings indicate fluid overload?
Dyspnea.
A nurse is calculating a client’s expected date of delivery. The client’s last menstrual period began on April. Using Nagele’s rule, what date should the nurse determine to be the client’s expected delivery date? (Use mmdd format.)
0119 date
A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a a characteristic ofa a therapeutic group?
The group encourages members to focus on a particular issue. (Mental Health Chapter 8 Page 42)
A nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching
“Administered 8 u regular insulin sq.”
A nurse is preparing to administer cye drops to a school-age child. ldentify the actions the nurse should take. (Move the steps into the box on the right. placing them in the order of performance. Use all the steps.)
- Place the child in a sitting position.
- Ask the child to look upward
- Pull the lower eyelid downward
- Instill the drops of medication.
- Apply pressure to the lacrimal punctum.
a nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take?
Review the facility policy about the use of an interpreter.
a nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following finding
indicates that the nurse should increase the rate of infusion?
Montevideo units constantly 300 mm Hg
a public health nurse is managing severa projects for the community. Which of the following
interventions should the nurse identify as a primary prevention strategy?
Teaching parenting skills to expectant mothers and their partners
a nurse is preparing to administer an autologous blood product to a client. Which of the following
actions should the nurse take to identify the client?
Match the client’s blood type with the type and cross match specimens
a nurse is performing physical therapy for a client who has Parkinson’s disease. which of the following statements by the client indicates the need for referral to physical therapy?
c. “lately, i feel like my feet are freezing up, as they are stuck to the ground”
a nurse is reviewing laboratory data for a client who has chronic kidney disease. which of the following findings should the nurse expect?
a. increased creatine
a nurse is administering a scheduled medication to a client. the client reports that the medication appears different than what they take at home. which of the following responses should the nurse take?
d. “I will call the pharmacist now to check on this medication”
a nurse is teaching at a community health fair about electrical fire prevention. which of the following information should the nurse include in the teaching?
a. use three pronged grounded plugs
a charge nurse is recommending postpartum client discharge following a local disaster. which of the following should the nurse recommend for discharge?
d. a client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration
a nurse in a provider’s office is reviewing the laboratory results of a group of clients. which to report?
d. chlamydia
a nurse is providing discharge teaching for a group of clients. the nurse should recommend a referral to a dietitian
b. a client who has gout and states, “I can continue to eat anchovies on my pizza”
a nurse is preparing to measure the temperature of an infant. which of the following action should the nurse take?
a. place the tip of the thermometer under the center of the infant’s axilla
a nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. which of the following information should the nurse include?
a. children who have varicella are contagious until vesicles are crusted
a nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. the nurse notes a lithium level of 0.8 mEq/L. which of the following orders from the provider should the nurse expect?
d. administer the medication
a nurse is caring for a client who has fibromyalgia and requests pain medication. which of the following medications should the nurse administer?
a. pregabalin
a nurse is caring for a client who is to receive a transfusion of packed RBCs. which of the following actions should the nurse take?
a. prime IV tubing with 0.9% sodium chloride
a nurse is caring for a toddler who has acute lymphocytic leukemia. in which of the following should the toddler participate?
b. playing with a large plastic truck
a nurse is caring for a client who has chronic pancreatitis. which of the following dietary recommendations should the nurse make?
c. broiled skinless chicken breast with brown rice
a nurse is preparing to assess a 2-week-old newborn. which of the following actions should the nurse plan to take?
c. auscultate the newborn’s apical pulse for 60 seconds
a nurse caring for a client who is at 38 weeks gestation is in active labor and has ruptured membrane. which of the following actions should the nurse take?
b. apply fetal heart rate monitor
a nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. which of the following findings should the nurse report?
a. chest pain
a nurse is completing an incident report after a client fall. which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating?
a. quality improvement
a nurse is talking with another nurse on the unit and smells alcohol on her breath. which of the following actions should the nurse take?
d. notify the nursing manager about the suspected alcohol use
a nurse is caring for a client who has diaper dermatitis. which of the following actions should the nurse take?
a. apply zinc oxide to the irritated area
a nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. which of the following statements indicates an understanding of the teaching?
b. “I will not publish public announcements about my baby’s birth”
a nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. which of the following entries should the nurse make in the medical record?
b “morphine 3 mg Subcutaneuous (Unable to read)”
a nurse realizes that the wrong medication has been administered to a client. which of the following actions should the nurse take first?
c. monitor vital signs
a nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. which of the following statements should the nurse make?
b. “dehydration can increase the risk of preterm labor”
a nurse is receiving a change-of-shift report for an adult female client who is postoperative. which of the following client information should the nurse report?
c. answer might be lower platelets
a nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. which of the following instructions should the nurse include?
b. (answer was the nurse was going to do the interpretation)
a nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. which of the following examples should the nurse include in the teaching?
c. administering potassium via IV bolus
a nurse is providing discharge teaching to a client who has a new prescription for pheneizine. the nurse should instruct the client that is safe to eat which of the following foods while taking this medication?
a. whole grain bread
a nurse manager is updating protocols for the use of belt restraints. which of the following guidelines should the nurse include?
c. document the client’s condition every 15 min
a charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. in anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
d. a client who is 1 day postoperative following a vertebroplasty
a nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. which of the following findings should the nurse include in the teaching?
c. swelling of the face
a nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. which of the following actions should the nurse include in the plan?
a. ask the client directly what he is hearing
a nurse is preparing to perform a sterile wound irrigation and dressing change for a client. which of the following actions by the nurse indicates a break in surgical aseptic technique?
b. balancing the bottle on the sterile basin while pouring the liquid
a nurse is teaching a prenatal class about infection prevention at a community center. which of the following statements by a client indicates an understanding of the teaching?
a. “I can visit my nephew who has chickenpox 5 days after the sores have crusted”
a nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). which of the following actions should the nurse take first to manager her time effectively?
c. determine goals of the day
a nurse is providing teaching to an adolescent who has peptic ulcer disease. which of the following statements by the client indicates an understanding of the teaching?
d. “I will avoid food and beverages that contain caffeine”
a nurse is reviewing legal issues in health care with a group of newly licensed nurses. which of the following recommendations should the nurse make?
c. ensure that each client has a living will on file prior to treatment
a nurse is providing preoperative teaching about patient-controlled analgesia (PCA) to a client. which of the following statements should the nurse include in the teaching?
d. “you should push the button before physical activity to allow maximum pain control”
a charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for health care (DPAHC). which of the following information should the charge nurse include?
c. “the proxy can make treatment decisions if the client is under anesthesia”
a nurse is caring for a client who has a history of depression and is experiencing a situational crisis. which of the following actions should the nurse take first?
a. confirm the client’s prescription of the event
a nurse is caring for a client who has end-stage kidney disease. the client’s adult child asks the nurse about becoming a living kidney donor for her father. which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?
c. hypertension
a nurse is planning care for a client who has bipolar disorder and is experiencing mania. which of the following interventions should the nurse include in the plan?
c. encourage the client to take frequent rest periods
a nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. which of the following statements should the nurse make during this phase?
b. “we should establish our roles in the initial session”
a staff education nurse is evaluating a group of nurses during a new employee orientation on the use of proper body mechanics when lifting. which of the following images indicates an appropriate use of ergonomic principles?
c.
a nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. the partner states, “I don’t know what to do. Everything has been happening so quickly.” which of the following responses by the nurse is therapeutic?
a. “Can you talk about what was happening with your partner at home?”
a nurse is receiving a change-of-shift report for a group of clients. which of the following clients should the nurse plan to assess first?
b. a client who has a hip fracture and a new onset of tachypnea
a nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. which of the following recommendations should the nurse include?
a. consume food high in bran fiber
a nurse is providing teaching to a client about the adverse effects of sertraline. which of the following adverse effects should the nurse include?
a. excessive sweating
a nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. the nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
c. maternal hypoglycemia
a nurse is providing teaching to the parents about newborn genetic screening. which of the following statements should the nurse include in the teaching?
a. “This test should be performed after your baby is 24 hours old”
a nurse is caring for a client who asks for information regarding organ donation. which of the following responses should the nurse make?
c. “your desire to be an organ donor must be documented in writing.”
a nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. the nurse should monitor the client for which of the following complications?
d. contractions
a nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. which of the following instructions should the nurse include in the teaching?
c. eat 1g/kg of protein per day
a charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. which of the following risk factors should the nurse include as the best predictor of future violence?
a. previous violent behavior
a nurse is teaching a client who is trying to conceive. which of the following should the nurse instruct the client to increase in her diet to prevent neutral tube defect?
a. folate
a nurse is caring for a client who is experiencing acute mania. which of the following foods should the nurse provide for this client?
a. peanut butter sandwich
a nurse is preparing to administer an IV medication to a client and accidentally punctures the IV bag, causing the medication to leak on the counter. which of the following medications requires the nurse to follow facility procedures in the safety handling of a biohazardous material spill?
a. doxorubicin hydrochloride
a nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. the nurse should recommend increased dietary intake of which of the following vitamins?
c. vitamin B12
a nurse is developing an in-service about personality disorders. which of the following information should the nurse include when discussing borderline personality disorder?
c. “the client exhibits impulsive behavior”
a nurse is completing an admission assessment for a client who has narcissistic personality disorder. which of the following findings should the nurse expect?
d. preoccupied with aging
a nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. which of the following findings should the nurse identify as a contraindication to the administration of clozapine?
d. WBC count 2,900/mm
a nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. which of the following statements should the nurse include in the teaching?
d. “Have you child drink a small glass of water after taking the medication”
a school nurse is teaching a parent about absence seizures. which of the following information should the nurse include?
a. “this type of seizure can be mistaken for daydreaming”
a nurse is reviewing assessment data from several clients. for which of the following clients should the nurse recommend referral to a dietitian?
b. a client who has a non healing leg ulcer
a nurse is caring for a client who is receiving intermittent enteral tube feedings. which of the following places the client at risk for aspiration?
b. a history of gastroesophageal relux disease
a nurse is caring for several clients on a medical-surgical unit. for which of the following nursing activities is it required that the nurse use sterile gloves?
d. performing tracheostomy care
a nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist’s notes. which of the following responses should the nurse make?
a. “we can provide a copy of your records, but the therapist’s notes are not included”
a nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. which of the following actions should the nurse include in the plan?
d. measure the client’s output every hour
a nurse is assessing a client who is in active labor. which of the following findings should the nurse report to the provider?
b. FHR baseline 170/min
a nurse is caring for a client who is in labor and has received an epidural. which of the following actions should the nurse take?
c. reposition the client side-to-side each hour
a nurse is building a therapeutic relationship with a newly admitted client. which of the following actions should the nurse plan to take during the orientation phase of the relationship?
b. establish the responsibilities of the nurse and client
a nurse is reviewing the medical records of four clients. the nurse should identify that which of the following client findings requires follow up care?
c. a client who is taking warfarin and has an INR of 1.8
a nurse is caring for a client who is 2 hr postoperative following a cardiac catheterization. which of the following is the priority assessment finding?
b. absence of pedal pulse in the affected extremity
a nurse is caring for a child who has cystic fibrosis and requires postural drainage. which of the following actions should the nurse take?
c. perform the procedure prior to meals
a nurse in a mental health facility receives a change-of-shift report for four clients. which of the following clients should the nurse plan to assess first?
a. a client placed in restraints due to aggressive behavior
a nurse is providing discharge teaching about car safety to a parent of a newborn. which of the following statements by the parents indicate an understanding of the teaching?
d. “I will position my baby at a 45-degree angle in the car seat”
a nurse in a clinic is assessing a 6-month-old infant. which of the following findings should the nurse report to the provider?
b. closed anterior fontanel
a nurse is caring for a client following a cardiac catheterization through the left groin. which of the following actions should the nurse take?
a. monitor the dorsalis pedis pulse every 15 min
a nurse is reviewing the medical record for a client who has a prescription for intermittent heat therapy for a foot injury. which of the following findings should the nurse identify as a contraindication for heat therapy?
a. peripheral neuropathy
a nurse in an emergency department is caring for a toddler who has burns following a house fire. which of the following actions should the nurse take first?
c. check the mouth for soot and smoky breath
a nurse is caring for a client following a stroke. the client has right-sided weakness and facial drooping. which of the following nursing actions is the priority?
d. maintain NPO status for the client
a nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. which of the following actions should the nurse take?
d. flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
intradermal injection areas:
b. upper back
a nurse is caring for a client who has experienced a right-hemispheric stroke. which of the following are expected findings?
a. impulse control difficulty
b. left hemiplegia
c. loss of depth perception
e. lack of situational awareness
RBC
females 4.2-5.4 million
males 4.7-6.1 million
decrease RBC
anemia
WBC
5,000-10,000
elevated WBC
infection
decreased WBC
immunosuppression
Iron
females 60-160 mcg
males 80-180
elevated iron
hemochromatosis, iron excess
liver disorder, magaloblastic anemia
decreased iron
anemia or hemorrhage
platelets
150,000-4000,000
increased platelets
malignancy or polycythemia vera
decreased platelets
autoimmune disease
bone marrow suppression or enlarged spleen
Hbg
females 12-16
males 14-18
decrease Hgb and Hct
anemia
Hct
females 37%-47%
males 42-52%
anemia in children
S & SX:
pallor, brittle spoon shaped nails
irritability, muscle weakness
systolic heart murmur, enlarged heart, HF
iron supplements
give 1 hr before or 2 hr after antacid to prevent malabsorpt
N/D and constipation common at start of therapy
use straw for liquid iron to prevent staining of teeth
aPTT
1.5-2X control range of 30-40 seconds
test clotting factors and monitor heparin therapy
increased aPTT
hemophilia
disseminated intravascular coagulation DIC
liver disease
PT
11-12.5 seconds, 85-100%
increased PT time
evidence of deficiency or clotting
decreaed PT time
evidence of vit K excess= bleed out
acute hemolytic blood transfusion reactions
**low back pain, TACHYcardia, HYPOtension
febrile reactions
30 min-6 hr after transfusion
-chills, fever, flushing, headache
use WBC filter, administer antipyretics
mild allergic reactions
during or up to 24hr after transfusion
- itching, urticarial, flushing
administer benadryl
anaphylactic shock
wheezing, dyspnea, cyanosis, hypotension
maintain airway, admin O2, IV fluids, antihistamines, corticosteroids and vasopressor
fluid overload
HYPERtension,
jugular vein distention, peripheral edema
orthopnea, crackles at base of lungs
sudden anxiety
sepsis and septic shock
-fever, N/V, abdominal pain, chills HYPOtension
administer antibiotics, blood cultures, vasopressor (dopamine)
if disseminated intravascular coagulation (DIC)
admin heparin in early stage
-blood products and clotting factors in late stage
PICA
eating things like soil, chalk, for at least 1 month
parenteral iron
given Z track
erythropoietin – epoetin alfa (epogen, Procrit)
used to increased production of RBC
monitor increase in BP, Hgb, Hct
folic acid
turn urine dark yellow
necessary for new RBC
hypovolemia causes
peritonitis, ascites, burns , NPO
causes of dehydration
hyperventilation
DKA
tube feeding without sufficient water intake
subjective and objective HYPOvolemia
Hyperthermia, Tachycardia, HYPOtension
decreased central venous pressure
hypoxia
thirst, dizziness, N/V,
-poor skin turgor, tentin
lab test hypovolemia
increased: HCT, specific gravity, NA, protein, BUN, glucose
Hypervolemia causes
HF, cirrhosis, increased gluccorticosteroids
hypertonic fluids
S & SX HYPERvolemia
bounding pulse, increased CVP, HYPERtension, confusion, muscle weakness, ascites, diminished breath sounds, distended neck veins
lab test HYPERvolemia
Decreased: HCT, BUN, electro
respiratory alkalosis PaCO2 less than 35, increased PH
notify doctor if
weight gain 1-2 lb/24 or 3 lb in a wk
foods high in potassium
avocados, broccoili, dairy products, dried fruit, cantaloupe, bananas
HYPOcalcemia
positive chvosteks ( facial twitching)
positive trousseau (hand/finger spasm with blood pressure cuff inflation
excess caffeine causes excretion
calcium in urine
secondary osteoporosis results from
hyperparathyroidism, long term corticosteroid
long term anticonvulsant (Dilantin)
manifestations: kyphosis
stages of grief
- denial 4. depression
- anger 5. acceptance
- bargaining
theophylline
relaxation of bronchioles causing bronchodilator
oral used to control asthma or COPD
therapeutic range 5-15
avoid in HTN, liver and kidney dysfunction
theophylline interactions
caffeine
glucocorticoids:
beclomethasone- inhalation
prednisone- PO
prevent inflammation, suppress airway mucus production
leukotriene (monelukast)
suppressing inflammation, bronchoconstriction’s, airway edema, mucus production
digoxin
makes the heart beat stronger and regular rhythm
therapeutic 0.5-2.0
S & SX of dig tox
fatigue, weakness, vision changes, GI effects
infuse over 5 min
hemophilia
difficulty controlling bleeding
X linked recessive disorder
joint pain and stiffness, impaired mobility, easy bruising
slurred speech
lab test indication of hemophilia
prolonged aPTT
avoid unnecessary needle sticks, apply pressure for 5 mins after needle sticks
monitor for occult blood
DDAVP
synthetic form of vasopressin increases plasma factor VIII
not for hemophilia B
acute hemolytic blood transfusion reactions
**low back pain, TACHYcardia, HYPOtension, hemoglobinuria,
ICP
10-15 mm Hg
mannitol
osmotic diuretic treat cerebral edema
phenytoin (Dilantin)
prophylactically to prevent or treat seizures
crainiotomy
removal of nonviable brain tissue that allows for expansion or removal of epidural or subdural hematomas
KUB (kidneys, urter, bladder
determines size shape and position of structures
cystoscopy
use a scope to visualize the bladder and urthera
reflex incontinence
Reflex – The involuntary loss of a moderate amount of urine usually without warning due to
hyperreflexia of the detrusor muscle, usually from altered spinal cord activity.
treatment for urinary infections
gentamycin and Keflex take with food
may change urine odor and report loose stools
TCA (nortriptyline (pamelor)
helps relieve urinary incontinence
-cause dizziness
monitor BP, don’t take with MAOI
phenazopyridine (pyridium)
treats urinary spasms, analgesic
wont treat infection only bladder discomfort
liver and renal contraindication
take with food and change urine organge
interventions for reflex incontinence
Bladder compression techniques (Credé, Valsalva, double-voiding, splinting) to help clients
manage.
ORCHIECTOMY
removal of testes
BPH
impaired outflow, fam Hx,
-urine hesitancy and retention, plainless hematuria
TRUS
diagnosis and R/o BPH
ways to reducuse prostatic fluids
frequent ejaculation
TURP
using a scope inserted though urethra and trims away excess prostatic tissue, enlarging passage through prostate
CBI
irrigation to keep clots from forming, if bright red blood or clots increase rate
intervention for CBI obstruction
- turn off CBI
- irrigate with 50 mL of irrigant sol with lg piston syringe
- contact doc if cant dislodge clot
expectations of D/c of CBI
red in color, expect 150-200 output every 3-4 hrs
contact doc if cant void
discharge instructions after TURP
avoid sex 2-6 wks, 12+ glasses of water of day, avoid caffeine, expect pink urine
abnormal PSA
less than 4
DRE signs of prostate CA
hard palpable irregular
fluoxetine (prozac
monitor tremors, AE: headache, urinary freq, hypotension
-agitation, confusion, anxiety, hallucination (Serotonin syndrome
tonsilectomy
milk products coat throat causing coughing; coughing should be avoided
admin pain on a reg sched or 1st 24 hrs to prevent breakthrough pain
hypovolemic shock
cool clammy skin
mannitol
direurtic
anaphylactic reaction
wheezing, rah
ataxia
involuntary movement
digoxin
monitor HR
digoxin tox
nausea, muscle weakness, diarrhea
IVP
admin lasix
estrogen
helps prevent osteroposis
estradiol SE
headaches and HTN
epi
teaching: report chest pain,
increases work load and O2 demand can result in angina
NPO
can cause dehydration and low grade fever
hemolytic blood reaction
**low back pain, tachycardia, hypotensiokn
structure audit
eval of avail resources
precess audit
examine how nursing care is provided
prospective audit
performance on a new
valporic acid
monitor LFT
chlorpromazine (haloperidol)
decrease hallucinations
teach: sips fluids freq, minimize sun exposure
cyclophosphamide
maintain hydration with liberal intake
doesn’t affect glucose
dehiscence
stay with client, 2. place saline over organs, 3. put in supine 4. take vitals
overdose of valporic acid
pulmonary edema
amitriptyline (TCA)
anticholinergic effect, (dry mouth, constipation, take with or after foods, avoid tyramine,
-turns urine blue green
neurtopenia
restrict visitors, avoid fresh flowers
stroptkinase
thrombolytic drug
cranial nerve VII
hearing impairment
CNIX
swallowing
verapamil effects if taken with grapefruit juice
constipation, hypotension,
bradycardia, FVE
clozapine
weight gain, hyperglycemia, ortho BP
hypermagnesium
initiate cardiac monitoring
foods high in mg
meat, nuts, whole grain cereal
gastric lavage
left side lying to prevent regurgitation of contents can use sterile water, tap or NS
misoprostol
reduces gastric acid
take preg test before starting treatment
-avoid mg causes diarrhea
UTI
pyelonephritis- WBC
trachea care steps
- suction (80-120)
- clean cannula
- rinse stoma site
- change ties
BRAT is contraindicated in
diarrhea
vacuum assited birth complication
cervical laceration
retained placenta
common in preterm births
endometrial infection common with
prolonged ROM
what is expected after delivery
elevated temp
late deceleration and variable decels
side lie position and DC oxytocin
terbutaline
muscle relaxant decrease contractions during preterm labor
nalbuphine
opioid pain relief during labor
mgso4
muscle relax, decrease contractions during labor
oxytocin
stimulates contractions
used for bleeding and boggy uterus
theophylline tox
anorexia**
hypotension, tachycardia
adverse effect of theophylline
albuminuria
echopraxia
repeating what a person says
neologism
pt makes up works only they understand
clang assoc
uses words that sound alike
pap detects what
cervical cancer; not ovarian cancer
protein
required for tissue repair
vitamin A
promotes wound healing
RA
apply cold therapy, no narcotic analgesic
avoic purines in gout ( organ meat and chicken, can have citrus fruit)
when is Braxton hicks expected by
28 wks
evidence of ICP
memory loss
lie at 30 degree angle
signs of bacterial meningitis
nuchal rigidity ( reduction of flexion in the neck)
kernigs sign
kernigs sign
patient put knee at 90 degree angle if cant extend straight and pain its positive
peripheral arterial disease
lotion to prevent cracked feet
claudication when walking and stops after rest
hypothyroidism
coarse dry hair, bradycardia
periorbital edema (swelling around eyes)
hyperthyroidism
tremors, wght loss, exothalamus,
sudden abdomen pain relief indication of
ruptured appendix and peritonitis
pneumothorax expect
subcutaneous emphysema, trach deviation,
pneumonia expect
acute confusion (delirium)
flail chest
paradoxic movement
core pulmonale
distended neck veins
sealed radiation implant
visitors maintain 6 ft from pt
dehydration
increases urine specific gravity (1.003-1.030
agranulocytosis
decreased WBC
clonidine (HTN med)
s. E. constipation, dry mouth
fidelity
fulfill commitment
nonmalefience
do no harm
justice
treat fairly
cardiac tamponade
pulse paradoxus, muffled sounds
tube feed for infants
10mL/min
newborn temp
36.5-37.2
MAOIs
metallic taste
tyramine foods
aged cheese (cheddar, blue cheese, swiss
cured meats (salami, sausages, pepperoni)
sauerkraut, soy sauce, shrimp sauce
yeast, fava beans,
flumazenil counteracts
benzodiazepine OD
acetyleysteine counteracts
acetaminophen OD
atropine counteracts
cholinesterase inhibitor OD
acute angle glacoma
sharp pain radiates through eye
physiological normal age changes
increase BP, decrease lung expansion
decrease CO
Do not delegate
What you can EAT E-evaluate A-assess T-teach
Addison’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
Addisons
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 tbSmeasles(Rubeola), 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 (German measles),
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
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 rest
Myesthenia 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)
Hypokalemia Strip changes
Hyperkalemia
MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes
hyperkalemia strip changes
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’s
Hypo 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 sounds
Posterior –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 desensitization
NCLEX 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 O2
with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt’s stimulation to breathe.
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 pints
1 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 in
Hypocalcemia
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 Nines
head 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
russell traction
femur or lower leg
dunlap traction
skeletal or skin
bryant’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
counseling
five 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) Bras
And (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 syndrome
increase 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 mouth
INH 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 reflexes
upper 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/kg
COPD 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
Ventrogluteal
IM 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
Paracentesis
semi 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
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
diptheria
pseudo 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,polyphagia
DKA
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.
glomuloneprhitis
the 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 pneumonia
lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!)
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 mainstay
the 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’s
diagnosed 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
Defamation
is 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
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.)
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 Cataract 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
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 infratentorial surgery
(incision at the nape of neck) position pt flat and lateral on either side.
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 rest
Myesthenia 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’s
Hypo 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)
Position of the baby by fetal heart sounds
Posterior –heard at sides
Anterior—midline by unbilicus and side
Breech- high up in the fundus near umbilicus
Vertex- by the symphysis pubis.
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
ARDS and DIC
are always secondary to another disease or trauma ARDS:Severe shortness of breath
•Labored and unusually rapid breathing
•Low blood pressure
•Confusion and extreme tiredness
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)
pneumonia
fever and chills are usually present. For the elderly confusion is often present.
COPD and O2
with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must kept 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.
1 tsp
5 mL
1 oz
30 mL
1 cup
8 oz
1 quart
2 pints
1 pint
2 cups
1 g (gram)
1000 mg
1 kg
2.2 lbs
I lb
16 oz
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 in
Hypocalcemia
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
birth weight
doubles by 6 months
triples by 1 year
early sign of cystic fibrosis : mucus blocks in lungs
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
buck’s traction
knee immobility:widely used in the lower limb for femoral fractures, lower backache, acetabular and hip fractures.
russell traction
femur or lower leg
dunlap traction
skeletal or skin
bryant’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..
AF -18 months, PF – 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
previa – there is no pain, but there is bleeding
abrution – 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
counseling
SSRI’s
take about 3 weeks to work
patients with hallucinations
patients with delusions
redirect them
distract them
Thorazine and Haldol:
can cause EPS: such as akathisia, dystonia, psuedoparkinsonism, and dyskinesia, are drug-induced side effects
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
Hepatitis A
Ends in a vowel, comes from the bowel
Hepatitis b
B= blood and body fluids (hep c is the same)
Addison’s disease:
Cushing’s syndrome:
“add” hormone
have extra “cushion” of hormone
Dumping syndrome
increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink
Cushing’s triad
r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)
Thyroid storm
HOT (hyperthermia)
Myxedema coma
COLD (hypothermia)
Glaucoma
No atropine
Koplick’s spots
prodomal stage of measles. Red spots with blue center, in the mouth–think kopLICK in the mouth
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 reflexes
upper motor neuron issue (your reflexes are over the top)
Lower motor neuron issue
Tensilon
used in myesthenia gravis to confirm diagnosis
ALS
(amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems
MMR
is given SQ not IM
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
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
a chronic disease of elderly people characterized by deterioration of bone tissue
with allopurinol
no vitamin C or warfarin!
IntraVenous Pyelogram (IVP) requires
X-ray test that provides pictures of the kidneys, the bladder, the ureters, and the urethra (urinary tract ).
bowel prep so bladder can be visualized
acid ash diet
cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread, that when catabolized leaves an acid residue to be excreted in the urine.
alk ash diet
milk, veggies, rhubarb, salmon
orange tag in psych
is emergent psych
thyroid med side effects
insomnia. body metabolism increases
COPD patients and O2
2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less
Stranger anxiety is greatest at what age?
7-9 months..separation anxiety peaks in toddlerhood
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
pancreatic enzymes are taken
with each meal!
infants IM site
Vastus lateralis
Toddler 18 months+ IM site
Ventrogluteal
IM 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
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
Paracentesis
semi 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
pneumonia
rusty sputum
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
diptheria
pseudo 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,polyphagia
DKA
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.
glomerulonephritis
the 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 pneumonia
lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!)
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 mainstay
the 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’s
diagnosed 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!
the umbilical cord drops (prolapses) through the open cervix into the vagina ahead of the baby. The cord can then become trapped against the baby’s body during delivery
Toddlers need to express
independence!
Addison’s
causes sever hypotension!
pancreatitis
first pain relief, second cough and deep breathe
Cystic Fibrosis 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?
crutches first followed by good leg
dumping syndrome?
use low fowler’s to avoid. limit fluids
TB drugs are
hepatotoxic!
LAB
WBC: 5.0 – 10
Rbc: 4.0 – 5.0 , 4-6
Hgb: 12 – 16 (female), 14-18 (male)
Hct: 37 – 47, 42- 52 (high-loss of V/dehydration)
Plt: 150,000 – 450,000
blood glucose: 70-110 (<70: do sth)
BUN: 10-20,
Cr: 0.5-1.2
trop: < 0.2 for MI
CK-MB: 30-170
INR: 0.9-1.2 (2-3 on coumadin)
aPTT: 30-40
PTT: 60-70 (heparin: 30-45)
ALT: 8-20
AST: 5-40
amylase: 56-90
lipase: 0-110
Mg: 1.3 – 2.1
P: 3 – 4.5
digoxin level: 0.8 – 2
lithium level: 0.8-1.4 (initial maniac episode), 0.4-1 (maintenance level), toxic >1.5
valproric acid: 50-100
lochia after birth
rubra (dark red): 3-4 days
serosa (pinkish brown) : 4-10
alba (whitish yellow) 10-28
placenta previa
painless vag bleeding
abruptio placentae
persistent uterine contraction, dark red bleeding, board-like abdomen
boggy uterus
risk for uterine atony
–> massage now
theopylline
bronchodilator
- toxicity: anorexia, tachy, albuminuria, hypoTN
mandatory to do erythromycin on baby
no
variable acceleration of FHR
good, baby is reacting, healthy, exchanging oxygen
variable or late deceleration, fetal tachy
give O2, side-lying, discont oxytocin
verify placement for NG tube placement
pH of gastric content
pressure ulcer stages
Stage 1: non-blanchable redness
Stage 2: partial thickness loss
Stage 3: full thickness loss, w/o undermining, see fat
Stage 4: 3+ undermining, see tendon, muscle
pre-eclampsia
HTN, proteinuria, edema
report facial and peripheral edema and decrease U/O, side-lying, fetal kick count,
prolapsed cord
knee-chest position, push forward
peripheral arterial disease PVD
exercise intolerant, DONT elevate feet or cross leg (ischemia distally), straight toe nail, apply lubricating lotion, loose clothing,
corh’s disease
LOW fiber,
HIGH protein, HIGH calories
hydration
gestation week
38-42 weeks
EDD= estimated date of delivery
LMP – 3 mo + 7 days + 1 yr
Rho(D) immune globulin
for Rh- mom at 28 wks
Hegar’s Sign
softening of uterus
Chadwick’s sign
bluish vagina
Goodell’s sign
softening of cervical lip
minimum albumin level
3.5
CPM- Continous passive motion
prescribed setting, can be turned off at meals
hyponatremia
loss of H20, Na follows H20 –> dehydrated
hypotonic hyponatremia
< 130 (regular Na: 135-145)
crutch education
2-3 fingers between axillary bars and axilla
flex elbow 30 when palms rest on the handles
myasthenia gravis
- weakened muscle, facial troop
- small bites/eat slowly
- take meds 45-60 min before
- monitor wt every day
tonsillectomy
- place in lateral/prone (head lower than chest) prevent aspiration
- pain med Q4H 1st day
- avoid coughing, blowing nose, NO straw
- sign of bleeding: frequent clearing throat, bright red emesis
- NO red stuff and milk
transfusion reaction
hemolytic transfusion rxn
anaphylactic transfusion rxn
wheezing, rash
Buck’s traction
remove q8h for skin breakdown, apply lotion to back, foot exercise
IV Pyelogram
give laxative to clear system
NPO midnight
allergic to seafood
chest tube water seal chamber
-check for tidaling in water-seal chamber as pt breathes
- expect continuous bubbling initially then occasionally bubbling, constant=leak
disconnected tubing from drainage unit
instruct pt to exhale and cough then submerge the end of chest tube in 1 inch of sterile water until u can cleanse the tips and reconnect quickly.
if there is excessive bubbling in water seal chamber
try to locate the leak by clamping the tube momentarily at various points along its length go from proximal
borderline personality disorder
self-mutilating behavior
newborn
apnea < 20s, acrocyanosis is normal
not: grunt, tachy, flaring
crutch use going up stair
Tripod position, transfer wt to crutch, advance unaffected leg to stair, then put wt on unaffected leg and crutch, advance affected leg and crutch
pt decides to leave AMA
inform risks, sign AMA, document
advance directives=
durable power of attorney (who makes decision when I cant) + living will (choose what Tx)
assault
threatening, make sb scared
battery
touch
incivility
rude, insulting, teasing, dirty look
breach of confidentality
no paper copies
restraint
quick-release to bedframebedframe, movable but not rail
RACE
rescue, alarm, contain, extinguish
no cold application to
vascular insufficency, raynaud
DVT
pain, edema, warmth, red
- encourage ambulate, elevate legs above heart (circulation), avoid pressure in site, intermitten warm moist compression, stocking or compression
- no pillows beneath LE
Cane
- on normal side
- cane 6-10 in front of feet
- advance weak one first
- advance normal one past the cane
FHR
110-160
FHR <110 for 10 min
discontinue oxy, side lying, oxygen mask 8-10L, give tocolytic med
FHR>160 for 10 min
if fever, give antipyretic
- oxygen mask
- IV bolus
late deceleration (utero insufficiency)
side-lying, discont. oxy, oxygen
variable deceleration
reposition L-R, or knee-chest
- discont. oxy, give oxygen, vag exam, amnioinfusion
postpartum: DVT
Stocking until ambulate, elevate legs when sitting, no cross legs, fluids, no smoking
DVT/thrombophlebitis
bed rest, elevate extremity above heart level (no pillow under knee), warm moist compression, No massage, give anticoagulants
pulmonary embolus
semi-Fowler, oxygen, thrombolytic meds
DIC- can’t stop bleeding
decreased platelets & fibrinogen, increase PTPT
Tx: fluid, platelets, splenectomy, uterotonic agents
postpartum hemorrhage
500ml (vag birth)
1000ml (C/S)
- If boggy uterus, massage fundus
- elevate legs 20-30degrees to promote venous return
- give oxytocin, uterine stimulants : methylergonovine (Methergine -not for HTN pt), Misoprostol (Cytotec), carboprost (Hemabate)
breast engorgement
cool compression between feedings, warm before shower to milk letdown
NOT breastfeeding
no nipple stimulation, tight bra, cold compress, no express milk daily
osteoporosis
– vitamin D (fish, egg yolk, milk, cereal), calcium (milk, green, beans, figs)
estrogen therapy
- help osteoporosis but risk for breast + endometrial cancer, DVT
infant
stranger anxiety 6-18mo
toddler
separate anxiety
give choices
preschooler
magical thinking
simple clear language
choices and independence
thought its punishment
maternal attachment
- taking-in (24-48hr)- personal needs
- taking-hold (on 2-3d, last 10d-wks)- baby care
- letting go – family role
autism
limit stimuli, promote calm and quiet
tourette’s syndrome
motor & verbal tics impair social fnc, communicate
oxygen home therapy
- no electrical razors, radio, TV hearing aids, no gas range (prefer electric range), no extension cord to oxygen, hook it directly to ground outler
–>sparking potential - no woolen blankets, synthetic fabric. Cotton is good
- no oil, alcohol based products
- oxygen tanks stored upright, not on their sides
trach suction pressure
80-120
-intermitten 10-15 sec each pass
baby heat loss
- conduction: thru surface
- convection: thru air
- evaporation: right after birth
- radiation to close proximity: windows, doors
preeclampsia
HTN, proteinuria, HA, blurred vision, facial edema, oliguria, hyperactive DTR
1 cup=
1 oz=
8 oz
30 cc
lithotomy position
pap smear
gastric NG lavage
200-300 cc (h20 or Nacl)
lay on left side to prevent aspiration
hip arthroplasty
- raised seat to prevent hip dislocation and reduce hip flexion
- keep hip angle < 90
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.
knee ambutation
- prone q4h
- dont elevate residual leg after 48hr OR, elevate during the 1st 24hrs
- firm mattress
- dressing distal to proximal
nurse case manager
arrange services, apt, supplies
enteral feeding baby
-gravity method <10 cc/hr
- residual <25% is goodgood
- after feed, side-lying, HOB 30
TPN
only PICC/Central, BS q4h
celiac disease
- gluten free
- rice is okay
hemianopia
blind 1/2 vision flied
Infant temperature up to 1 y.o
36.5-37.2 (99.4-99.7)
3 hrs oral glucose test
Fasting – give glucose – test BG q1h
Radiation skin
Wash with mild soap and water
NO lotion
electroconvulsive therapy
Short term memory loss side eff
Oxygen toxicity
Hypo ventilation,bradypnea
Stoma care
Healthy stoma: pink, red moist, out 2 cm (dusky, black,white not good)
Peristoma skin: mild soap, or just water ( no alcohol, iodine, oil based products- skin breakdown)
Diet: low residual, avoid high fiber food
Flail chest
Ribs come off, paradoxic chest movement
Tape test pinworm
Get specimen asap when awaking in AM
Return it in plastic bag
Get it before bathing and pooping
crutches
Rubber shoes, three point gait
Stages of labor
1st stage: complete when 10 cm dilated, 100% decent (latent-active-transition)
Latent: slow deep breath
Transition: pattern paced breathing
Dont delegate when
EAT – evaluate, assess, teach
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)
birth weight
doubles by 6 months
triples by 1 year
anterior fontanelle closes by…posterior by..
18 months, 6-8 weeks
pathological jaundice occurs:
physiological jaundice occurs:
before 24 hours (lasts 7 days)
after 24 hours
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)
sealed radiation therapy implant
- limit visitors 30 min/day, stay 6 ft away from clients
- no powders, lotion, cream, ointment
- RN wear film badge all the time
- no pregnant RN
- wear lead apron, avoid turning away from clients
RN jobs
do plan of care, evaluate, assess, teach
LVN
reinforce teaching
MDMA use (methamph)
diaphoresis, tactile sensitive, cramping,, teeth clenching, chills, hallucination
type 1 DM
No cold therapy
baby reflexes
- tonic neck: turn side to side to see arm/leg extend
- rooting: touch R, head turns R
vitamin K
baby has low vitamin K so can bleed
neostigmine OD
give atropine
cataract extraction
no aspirin (bleed), use cold compress when itchy eyes, avoid lifting > 10 lbs and avoid bend at waist due to risk of increase IOP,
uric acid food restriction
no organ meat/chicken/alcohol
- citrus food is ok
OSA complication
Risk for hypoxia, CHF, dysrythmias
narcissistic personality disorder
sensitive to rejection
antisocial
no remorse
FFP
transfuse STAT, 1 unit/30-60min
instill ear drop
pull upward and back in >3 y.o (down in <3), massage tragus after, don’t instill cold gtt/ wait to room temp
hypoK
muscle weakness, <<DTR
umbilical cord care
-keep clean, dry, clean stump with water, watch swelling/redness/purulent d/c
- fold diaper edge down to keep stump dry
- will fall of after 10-14 days
circumcision care
-petroleum jelly in 1st 24hrs
- loose diaper
- no soap, commercial wipes until 5-6days later
- dont remove yellow exudate
diaper rash
- air dry, apply zinc oxide ointment to protect skin
car seat
rear-facing until 2, 45 degrees, snug harness, clip at armpit level, dont cross infant neck or abd
- no swaddle blanket before securing
vaso-occlusive crisis
visual disturbance, hematuria, painful swelling extremities, fever, tachy, PAIN
ovarian CA
- back pain, postcoital bleeding, abd bloating/pain/urinary urgency (early s/sx)
Raynaud’s disease
white finger, blue tips when exposing to cold or emotional stress
thrombocytopenia
<<<<<<plt
lithium toxicity
confusion, coarse hand tremor, sedation
clang association
big back bop bouncing
baby bath
max 120 F, nothing except for clothes when sleeping
kawasaki disease
red tongue/eye/sole, unrelieved fever, peeling skin, rash trunk
hemoptysis
cough up blood
blood lead toxic
5: social services
20: poison control
45: chelation therapy
IM injection
2 in needle for mixture big meds;
- deltoid: < 1 cc
COPD
barrel chest, anorexia, wt loss, Res acidosis (bradypnea)
doxurubicin
-chemo, cause thrombocytopenia (bleeding risk)
-inject over 5min, give antiemetic 30-60min before
romberg balance test
open/close eyes
sense balance
feet together, arms side
albuterol inhaler
wait 1 min between each inhale, clean mouthpiece qd, take long slow deep breath, take 5-20 min prior to exercise
AV fistula arm
-elevate it for circulation, ROM, no venipuncture
home safety older adults
remove throw rugs, loose carpets, install stool riser, nonskid mat and footwear
pacemaker teaching
minimize shoulder movement intially, assess hiccup, make sure grounded connection
- permanent: carry ID card, first 2 weeks (wear sling, avoid raising arm above shoulder), no heavy lifting for 2 mo.
- dont place alarm, magnet, stereo speaker, generators, garage opener on top of pacemaker
-inform dentist
Group roles
-evaluator: measures obj
- orienter: note progress toward goals
- info giver: share experience
- initiator-contributor: offer new ideas
paracentesis in ABD
-void before procedure, position in Fowler’s position
snellen chart
- 20 ft
- with glasses first
- pass: >4 letters
- both eyes open
blood glucose tolerance test
- NPO midnight
- avoid caffeine
TYRAMINE FOOD
ok: yogurt, cream cheese
- aged cheese, beer, soy sauce, ferment/air-dried meat, red wine,avocado, fig, banana,
No maoi w coffee, chocolate, ginseng, fava beans
hypocalcemia
chvostek sign, numbling, tingling
asthma kid
no aspirin, highest reading flow meter, vaccine
Lithium (Category D)
avoid NSAIDs bc increasing lithium, drink lots H2O, take w/ food
Adverse: NV, tremor, increased thirst, polyuria, renal toxicity (hypoNa), hypoTN/brady, goiter and hypothyroidism later
phenytoin
for partial/tonic-clonic seizure
- cause CNS depression, gingival hyperplasia
- report nystagmus (unsual eye movement)
macular degeneration
glaucoma
detached retina
cataract
retinal detachment
-cant see central
- cant see around, halo around lights
- floating dark spot
- cloudy visions
- painless, develop suddenly
time management
- most important: planning activities
triage
stable vs unstable
acute vs chronic
basal body temperature method of birth controlling
- drop in 0.5 F prior to ovulation
- Temp highest after ovulation, remain elevated 2-4 days prior to start of period
Defense mechanism
-sublimation: negative thing –> hobby
- rationalization: make sense as convenient
- displacement: place anger somewhere else
glomerulonephritis
protein in urine
prenatal discomfort
- high fiber food, rash is common due to hormone, sleep on firm mattress on side, wear supportive bra overnight, acetaminophen for HA, ginger for NV
BABY
dont bathe daily, cover body when washing hair, suction mouth 1st then nose,
cystic fibrosis diet
HIGH calorie, HIGH protein ,HIGH fat + fat vitamin
- need higher abx dose
- regular exercise
- give 3 meals + snacks, pancreatic enzymes given within 30 min, increase dose if high calorie, watch 1-2 stools/day for effectiveness, can sprinkle on food
- tend to have pulm infection
pulmonary edema
pink frothy sputumsputum, clammy cyanotic skin, crackles, tachycardia
give an enema
left SIM position, R knee flexed, adult 7-10 cm in