ATI Flashcards
1
Q
What is the normal TSH level?
A
0.4 - 4.2
2
Q
What can be expected with a TSH level of 8.3?
A
Elevated TSH level indicates hypothyroidism. So weight gain and bradycardia are expected.
3
Q
Weight gain, bradycardia, cold intolerance, paresthesia, hearing loss, depression, are clinical manifestations of?
A
Hypothyroidism.
4
Q
A client is just diagnosed with malignancy. What psychosocial intervention is appropriate?
A
Providing emotional support with presence.
5
Q
What is a nerve block?
A
Nerve block is a form of treatment that interrupts the conduction of pain with chemical agents.
6
Q
How does the aging process related to an increase in diastolic and systolic blood pressure?
A
An expected age-related change is decreased elasticity of blood vessels. When arterial walls stiffen, blood pressure increases.
7
Q
How are a patient’s psychosocial needs met when placed in isolation?
A
Scheduling time separate from care to talk. Providing time away from routine distraction and promotion of a relaxed atmosphere will enhance communication.
8
Q
What is the normal amylase level?
A
56 - 90 unit/L.
9
Q
An increase in serum amylase (56 - 90 unit/L), indicates what?
A
Increased WBC and Amylase indicates acute pancreatitis.
10
Q
What is an intervention for a client taking mannitol (Osmitrol) IV for ICP?
A
Monitor intake and output. Osmotic diuretics, like mannitol, are used to decrease cerebral edema. Strict intake and output is necessary to assess the effect of the medication and monitor for severe dehydration and indications of acute renal failure.
11
Q
What is the first step in preparing an automated external defibrillator (AED)?
A
Steps include:
- Obtain AED
- Apply defibrillator pads to client’s chest
- Stop CPR and move away from the client.
- Press the analyze button on the machine.
- Push the charge button to prepare to shock.
12
Q
Which findings indicate myocardial infarction?
A
Nausea. Nausea is an expected finding with MI.
13
Q
Nausea, chest pain, vomiting, diaphoresis, dyspnea, fatigue, palpitations, and dizziness are clinical manifestations of what disease process?
A
Myocardial Infarction.
14
Q
Client receives home peritoneal dialysis, what assessment finding should be reported to the provider immediately?
A
Cloudy effluent. Cloudy dialysate drainage indicates a possible bacterial infection in the peritoneum and should be reported to the provider immediately.
15
Q
Regarding a patient-controlled analgesia (PCA), which treating indicates a need for further instruction?
A
Instructs the family to press the PCA button when the client is asleep. Pushing the PCA pump’s button by “proxy” is discouraged due to the possibility of overdose.
16
Q
When communicating with a hearing-impaired patient, what is the appropriate action?
A
Facing the client when speaking; Facing the client will allow facial expressions to be observed and to lip read during the communication process.
17
Q
Regarding a radial arterial line in place for blood pressure monitoring, which observation requires corrective action by the nurse?
A
The transducer is positioned at the level of the right wrist; The level of the right wrist is not correct, and will result in an inaccurate reading.
18
Q
Where should the transducer be positioned for a patient that has a radial arterial line in place for blood pressure monitoring?
A
The transducer should be positioned at the level of the right atrium, known as the phlebostatic axis, located at the fourth intercoastal space, midaxillary line.
19
Q
Teaching has been effective regarding health care-associated infections (HAIs) when the newly licensed nurse states that an iatrogenic infection is one that results from?
A
HAIs of iatrogenic infections result from a diagnostic or therapeutic procedures.
20
Q
Improper hand hygiene is an example of?
A
Breaks in infection control protocols are sources of nosocomial HAIs.
21
Q
Drug resistance is an example of?
A
Drug resistance is a source of nosocomial HAIs.
22
Q
Inappropriate waste disposal is an example of?
A
Inappropriate waste disposal is a source of nosocomial HAIs.
23
Q
A flash of light and sudden loss of vision are symptoms of what?
A
Retinal detachment.
24
Q
As a nurse, what are you likely to document for a left intracranial hemorrhage?
A
Right-sided hemiparesis; intracranial bleeding in the left hemisphere of the brain results in right-sided paralysis.
25
How do you perform the Babinski's test?
The test is performed by stroking upward along the lateral edge.
26
P110, R18, BP 160/100 should be reported to the provider?
Yes, the Pulse rate is elevated as well as the BP.
27
What is the desired outcome for Health and Wellness?
Desired outcomes are to obtain and maintain optimal state of wellness and function.
28
How can one obtain and maintain an optimal state of wellness and function?
This can be achieved through health education and positive action (smoking cessation, weight loss, seeking health care).
29
The _______ is a model used to compare the present state of health of a client to that of his previous state of health.
The health/wellness continuum is a model used to compare the present state of health of a client to that of his previous state of health. It is useful as an assessment guide and also as a tool to set goals and find ways to improve the client's state of health.
30
What are examples of modifiable variables?
These may be changed; such as smoking, nutrition, health education and awareness, and exercise.
31
Gender, age, developmental level, and genetic traits, are examples of what?
Non-modifiable variables.
32
What is the Weber Test used for?
The Weber Test is used to support the diagnosis of sensorinueral hearing loss.
33
What test supports the diagnosis of sensorineural hearing loss in the left ear?
Weber test lateralized to the right ear.
34
What is an unexpected finding when performing the otoscopic examination?
Black cerumen partially occluding the TM. Black cerumen that is packed and partially occluding the TM is an unexpected finding and indicates that the client uses cotton-tipped swabs and is pushing the cerumen back into the ear against the TM.
35
What does black cerumen indicate?
Black cerumen indicates that the client is using cotton-tipped swabs and is pushing the cerumen back into the ear against the TM. This is not a normal finding.
36
Age 85, Antibiotic therapy with reduced renal function, employed as a ground crew member at a large airport, Presbycusis, High doses of IV furosemide (Lasix) for heart failure exacerbation, and Chronic use of NSAIDs for rheumatoid arthritis management are what?
Age 85, Antibiotic therapy with reduced renal function, employed as a ground crew member at a large airport, Presbycusis, High doses of IV furosemide (Lasix) for heart failure exacerbation, and Chronic use of NSAIDs for rheumatoid arthritis management are factors that can contribute to sensorineural hearing loss.
37
How should a hearing aid be cleansed?
The earpiece of a hearing aid should be cleaned with mild soap and water, not alcohol.
38
A client is newly fitted with a hearing aid. A statement of "____" indicates a need for intervention.
"I was the earpiece of my hearing aid with alcohol".
39
What is a tympanogram?
A tympanogram measures the mobility of the tympanic membrane and middle ear structure relative to sound.
40
What is Audiometry?
An audiogram identifies if hearing loss is sensorineural and/or conductive.
41
What is Otoscopy?
An otoscope is used to examine the external auditory canal, the tympanic membrane (TM), and malleus bone visible through the TM.
42
When do you use an Otoscopic examination?
Otoscopic examinations are done is audiometry results indicate a possible impairment or if a client is reporting ear pain.
43
When using an Otoscopic examination on an adult with curved ear canals, what is the nursing action?
If the ear canal curves, pull up and back on the auricle of adults to straighten out the canal and enhance visualization.
44
When using an Otoscopic examination on children with curved ear canals, what is the nursing action to enhance visualization?
The appropriate nursing action to enhance visualization if the ear canal curves, pull down and back on the auricle of children.
45
The tympanic membrane should be a waxy gray color. What does it indicate when there is an indication of fluid of infection?
In the presence of fluid of infection in the middle ear, the tympanic membrane will become inflamed and may bulge from the pressure of the exudate.
46
How should an Audiogram examination be performed?
Test should be done with the client wearing audiometer headphones and facing away from person performing the test.
47
What are the 2 types of hearing loss?
(1) Conductive hearing loss
| (2) Sensorineural hearing loss
48
What is conductive hearing loss?
Conductive hearing loss occurs when there is an alteration in the middle ear and sound waves are blocked before reaching the inner ear.
49
When does sensorineural hearing loss occur?
Sensorineural hearing loss occurs when there is an alteration in the middle ear that involves cranial nerve VIII and/or cochlear damage.
50
Which type of hearing loss occurs when sound waves are blocked before reaching the inner ear?
Conductive hearing loss is the type of hearing loss that occurs when sound waves are blocked before reaching the inner ear.
51
What cranial nerve is involved in sensorineural hearing loss?
Cranial nerve VIII and/or cochlear damage is involved in sensorineural hearing loss.
52
A cochlear implant is used for which type of hearing loss?
A cochlear implant is used for Sensorineural hearing loss because it involved cranial nerve VIII and/or cochlear damage.
53
What is an cochlear implant?
A cochlear implant consist of a microphone that picks up sound, a speech processor, a transmitter and receiver that converts sound into electric impulses, and electrodes that are attach to the auditory nerve.
54
True or False? Client education: for cochlear implant, the unit is turned on immediately after surgery.
False. Educate the client that immediately after the surgery the unit is not turned on. Two to six weeks after surgery, the external unit is applied and the speech process is programmed.
55
What is Labyrinthitis?
Labyrinthitis is an infection of the labyrinth, usually secondary to otitis media. (This is a middle and inner ear disorder).
56
What is Ménière's disease?
Ménière's disease is a vestibular disease characterized by a triad of symptoms: tinnitus, unilateral sensorineural hearing loss, and vertigo.
57
What are the triad symptoms of Ménière's disease?
The triad symptoms of Ménière's disease are: Tinnitus, unilateral sensorineural hearing loss, and vertigo.
58
Tinnitus, unilateral sensorineural hearing loss, and vertigo are the three triad symptoms of what?
Ménière's disease.
59
A hearing aid is used for which type of hearing loss?
A hearing aid is used for conductive hearing loss (when sounds are blocked before reaching the inner ear).
60
Do hearing aids help the client interpret what they are hearing?
No, hearing aid amplify the sounds, but DO NOT help the client interpret what they are hearing.
61
What is the right setting for a hearing aid?
Client's with a hearing aid should use the lowest setting without feedback noise.
62
True or False: The client with a hearing aid should use the HIGHEST setting without feedback noise.
FALSE! Client's with hearing aids should use the LOWEST setting without feedback noise.
63
How to communicate with a client with client with hearing disability?
- Get the client's attention before speaking.
- Stand/sit facing the client in a well-lit, quiet room without distraction.
- Speak clearly of slowly to the client without shouting and without hands or other objects overing the mouth.
- Arrange for communication assistance (sign language, interpreter, closed-caption, TTY capabilities).
64
If a client is taking ototoxic medications (drugs for the ear) for more than 5 days, what should to want to check?
The appropriate action is the nurse to check the hearing in client's receiving ototoxic medications for more than 5 days.
65
Who should the client be referred to if an abnormality is identified during an Audiometry examination?
If there is an abnormality identified during an audiometry, the client should be referred to audiologist for more sensitive testing.
66
True or False: Refer the client to an Audiologist for further examination if an abnormality is identified during an audiometry.
True.
67
You have a client with a newly prescribed hearing aid, as a nurse you know that amplification of sound in a load environment can be distracting and disturbing, what nursing action would you recommend regarding the settings of a hearing aid?
Regarding the setting, always teach the client to use the lowest setting that allows for hearing without feedback noise.
68
Regarding the use of a newly prescribed hearing aid, how should a client be taught how to clean it?
To clean the ear mold, use mild soap and water while keeping hearing aid dry.
69
True or False? Client education: using soap and water while keeping the hearing aid dry is okay!
True! Clean the ear mold with soap and water! Not Alcohol.
70
Client education regarding the use of hearing aids when not in use.
When the hearing aid is not in use, make sure to turn it off to conserve the life of the batteries. Replacement batteries should always be kept on hand.
71
Client education regarding batteries of a hearing aid.
Replacement batteries should always be kept on hand.
72
What is a Tympanoplasty/Myringoplasty? And which type of hearing loss are they used for?
Tympanoplasty: is surgical reconstruction of the middle ear structures.
Myringoplasty: eardrum repair.
They are surgical interventions used for conductive hearing loss.
73
A client just had a Tympanoplasty/Myringoplasty (surgical interventions for conductive hearing loss), what are appropriate nursing actions?
- Place sterile packing postoperatively.
| - Position the client flat with the operative ear facing up for 12 hours.
74
What is the appropriate position for a client who just had surgical intervention for conductive hearing loss?
- The nurse should position the client flat with the operative ear facing up for 12 hours.
75
Client education for Tympanoplasty/Myringoplasty?
- Avoid forceful straining, coughing, sneezing with the mouth close, and air travel.
- Hair can be washed if the ear is covered with a dressing. Not water should enter the ear.
- Remind the client that hearing will be impaired until packing is removed from the ear.
76
Regarding a tympanoplasty/myringoplasty, can a client's hair be washed?
Yes, hair can be washed if the ear is covered with a dressing. No water should enter the ear.
77
What is the postoperative nursing action after surgical interventions for conductive hearing loss? Also, what are the surgical interventions called?
The nurse should place sterile packing postoperatively.
The surgical interventions are Tympanoplasty (reconstruction of middle ear structures), and Myringoplasty (eardrum repair).
78
True or False: These statements indicate understanding of how to safely manage an external fixation device:
- "I will clean the pins three times a day"
- "I will use on cotton swab on each pin"
- "I will report loosening of the pins to the provider"
True. Pin care protocols are based on provider preference and institution policy. Every 8 hours is a common parameter for a pin care schedule. A primary concept of pin care is that one cotton-tip swab is used per pin to avoid cross-contamination. Loosening of the pins may indicate infection and should be reported to the provider.
79
Regarding pin care protocols, what does the loosening of pins indicate? And what should be done?
Loosening of the pins may indicate infection and should be reported to the provider.
80
Client education: The client uses the same cotton swab for each pin, what should the nurse do?
The client needs further teaching, the nurse should educate the client to use one cotton-tip swab per pin to avoid cross contamination.
81
Client education: Regarding external fixations devices, how often should pins be cleansed?
Every 8 hours is a common parameter for a pine care schedule.
82
Regarding external fixations devices, a client states "I will lift my arm by the middle of the device to reposition it". Do you re-educate the client?
The client need to be re-educated, the external devices should not be used to move or lift the extremity.
83
Does the client need to be re-educated if he states "I should remove any crusting that forms around the pins"?
Yes! The client needs re-education! Teach them that crusting is part of the normal healing process and that crusting around the pins should be allowed to develop as it produces a natural barrier to bacteria.
84
What immobilization device should the nurse anticipate for a client admitted for surgery after being diagnosed with a right hip fracture?
The nurse should anticipate Buck's traction as the immobilization device, which is a boot applied to the lower part of the affect extremity. This will temporarily immobilize the extremity until surgery can be done.
85
What is Buck's Traction?
Buck's traction is an immobilization device that should be anticipated for an older adult client who is admitted with a right-hip fracture and has surgery scheduled for the next morning.
86
Is skeletal traction necessary for a older adult client who is admitted with a right-hip fracture and has surgery scheduled for the next morning.
Skeletal traction will not be necessary, since a surgical repair is scheduled for the next day.
87
What is an EARLY sign of neurovascular compromise for a client who has a compound fracture of the right forearm?
Paresthesia is an early sign of neurovascular compromise.
88
What are LATE signs of neurovascular compromise?
LATE signs of neurovascular compromise include: Pulselessness, paralysis, and polar or coldness of the extremity.
89
Is Paresthesia an early or late sign of neurovascular compromise? But first, what is paresthesia anyways?
First, paresthesia is an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves. Secondly, it is an EARLY sign of neurovascular damage.
90
Pulselessness, paralysis, and polar or coldness of the extremities are signs of what?
These are later signs of neurovascular compromise.
91
What is compartment syndrome?
Compartment syndrome is a complication that occurs when pressure within one or more of the muscle compartments in an extremity compromises circulation, resulting in an ischemia-edema cycle.
92
How is compartment syndrome monitored?
Compartment syndrome is monitored with a handheld device or with a catheter connected to a transducer.
93
What is the normal compartmental pressure?
Normal compartmental pressure is 0 to 8 mm Hg.
94
Clinical findings of compartment syndrome include?
- Increased pain unrelieved with elevation.
- Intense pain when passively moved.
- Paresthesia or numbness.
- Color of tissue is pale (pallor).
95
If left untreated, what can result from compartment syndrome?
Compartment syndrome results in an ischemia-edema cycle, if left untreated, tissue necrosis can result. Neuromuscular damage occurs within 4 to 6 hours.
96
An external fixation device is applied 2 hours ago for a fractured left tibia and fibula. These findings indicate the possibility of compartment syndrome:
- Pedal pulse is diminished.
- Pain is unrelieved by second dose of oral narcotic.
- Left toes will not move.
97
- Pedal pulse is diminished.
- Pain is unrelieved by second dose of oral narcotic.
- Left toes will not move.
Do these manifestations indicate a possibility of compartment syndrome?
Yes! The symptoms of compartment syndrome include diminished pedal pulses on the affected limb, pain unrelieved by the second dose of oral narcotic, and the inability to move toes on the affected limb.
98
Preventing Complications of Fractures: Compartment syndrome Nursing Actions.
Prevention includes:
- Cutting the cast on one side or both sides.
- Loosening the constrictive dressing or cutting the bandage or tape.
- Elevating the extremity and applying ice. If CS is suspected, extremity should not be elevated above the level of the heart to ensure adequate perfusion.
99
A newly licensed nurse is caring for a client suspected of having compartment syndrome, which action requires immediate intervention by the charge nurse.
The newly licensed nurse elevates the extremity above the level of the heart requires intervention by the charge nurse. If a client is suspected of having compartment syndrome the extremity should not be elevated above the level of the heart to ensure adequate perfusion.
100
A client is experiencing diminished pedal pulses, pain is unrelieved by second dose of oral narcotic, and his left toes will not move. The nurse notes that this is a complication of fractures, what is the name of this complication? And what is the surgical intervention for it?
The client is experiencing compartment syndrome (CS), the surgical treatment for CS, is a fasciotomy.
101
What should the nurse do with the open wounds after a fasciotomy?
After the fasciotomy, the open wounds require sterile packings and dressings until secondary closure occurs. Skin grafts may be necessary.
102
What is a fasciotomy?
A fasciotomy is the surgical treatment of compartment syndrome (a potential complication of fractures). A surgical incision is made through the subcutaneous tissue and fascia of the affect compartment to relieve the pressure and restore circulation.
103
Client education regarding Compartment Syndrome (Complication of Fractures).
- Instruct the client to report pain not relieved by analgesics or pain that continues to increase in intensity.
- Client should also be instructed to report numbness, tingling, or a change in color of the extremity.
104
Client education regarding teaching the client about home care of osteomyelitis?
Education should include that antibiotic therapy will need to continue for at least 3 months. Some client go home with an IN in place so intravenous antibiotics can continue to be administered. Early discontinuation of antibiotics can allow infection to continue and become chronic.
105
What is osteomyelitis and what is it a complication of?
Osteomyelitis is an inflammation within the bone secondary to penetration by infectious organisms (trauma, surgery). It is a complication of fractures.
106
Signs and Symptoms of Osteomyelitis include:
- Bone pain that is worse with movement
- Erythema and edema at the side of the infection
- Fever
- Leukocytosis (increased WBC) and possible elevated sedimentation rate.
NOTE: Many of these signs will disappear if the infection becomes chronic.
107
What is important to note in regards to symptoms of Osteomyelitis if the infection is chronic?
If the infection is chronic, most the signs will disappear:
- Bone pain that is worse with movement
- Erythema and edema at the side of the infection
- Fever
- Leukocytosis (increased WBC) and possible elevated sedimentation rate.
108
What is the treatment of osteomyelitis?
- Long course (3 months) of IV and oral antibiotic therapy.
- Surgical debridement may be indicated. If significant amount of bone needs removal, bone graft may be necessary.
- Hyperbaric oxygen treatments may be needed to promote healing in chronic cases of osteomyelitis.
- Unsuccessful treatment can result in amputation.
109
What is the primary treatment of osteomyelitis?
The primary treatment of osteomyelitis is a 'Long course (3 months) of IV and oral antibiotic therapy.
110
Client education regarding Osteomyelitis: "Relief of pain indicates the the infection has been eradicated".
The client needs to be re-educated, pain may disappear prior to the entire infection being eradicated, so this should not be used as an indicator of a cure.
111
Does aseptic technique need to be used during dressing changes regarding an osteomyelitis?
No, since the would is already infected, most providers only recommend contact precautions be implemented if the wound is draining and clean technique be used for dressing changes.
112
What is a "manual" type of traction?
Manual: a pulling force is applied by the hands of the provider for temporary immobilization, usually with sedation or anesthesia, in conjunction with the application of an immobilizing device.
113
What is "Skin" type of traction?
Skin: Used intermittently. The pulling force is applied by weights that are attached by rope to the client with tape, straps, boots, or cuffs.
114
What are examples of "skin" tractions?
Examples of "skin" tractions that use a pulling force applied by weights attached by tape, straps, boots, etc, are :
Chin halter straps, Bryant's traction, and Buck's traction.
115
What is Bryant's traction used for?
Bryant's traction is an example of "skin" tractions, it is used for congenital hip dislocations in children.
116
What is Buck's traction used for?
Buck's traction is an example of "skin" traction, it is used for hip fractures preoperatively for immobilization in adult clients.
117
Bryant's traction, Buck's traction, and Chin halter straps are example of ______.
These are examples of Skin tractions.
118
What is "Skeletal" traction?
Skeletal traction is used continuously. The pulling force is applied directly to the bone by weights attached by rope directly to a rod/screw placed through the bone.
119
What are examples of "Skeletal" tractions?
Examples of "Skeletal" tractions include: Skeletal tong (Gardner-Wells) and femoral or tibial pins (Steinmann pin)
120
How many pounds can be applied to a client using skeletal traction?
Weights up to 25 pounds can be applied.
121
What is "Halo" tractions?
Screws are placed through a halo-type bar that encircles the head into the outer table of the bone of the skull. This halo is attached to either bed traction or rods that are secured to a vest worn by the client.
122
When using "Halo" tractions, what needs to be attached to the vest?
Assure that the wrench to release the rods is attached to the best when using Halo traction in the event CPR is necessary.
123
Which type of traction is used in congenital hip dislocations of children?
Bryant's traction is used, this is a type of skin traction.
124
In this type of traction, a pulling force is applied by the hands.
A manual type of traction.
125
In this type of traction, it is used continuously, and the pulling force is applied directly to the bone by weights attached by rope directly to a rod/screw through the bone.
Skeletal Traction.
126
A client had a fracture and traction is applied. What are the priority nursing actions you should take?
- Maintain body alignment and realign if the client seems uncomfortable or reports pain.
- Avoid lighting or removing weights.
- Assure that weights hang freely.
- If the weights are accidentally displaced, replace the weights. If the problem is not corrected, notify the provider.
- Notify the provider if the client experiences severe pain from muscle spasms unrelieved with medications and/or repositioning.
- Move the client in halo traction as a unit, without applying pressure to the rods. This will prevent loosening of the pains and pain.
- Routinely monitor skin integrity and document.
127
If the client is in traction, and the client experiences sever pain from muscle spasms unrelieved by medication/repositioning, what should you do as a nurse?
You need to notify the provider immediately.
128
You are caring for a client in traction and notice that the weights have been accidentally displaced, what do you do?
Replace the weights, if the problem is not corrected, notify the provider.
129
Why is pin care done frequently throughout immobilization (skeletal traction and external fixation methods)?
They are done to prevent and to monitor for signs of infection.
130
Regarding pin site care, what are common signs of infection to monitor for?
- Drainage (color, amount, odor).
- Loosening of the pins.
- Tenting of the skin at pin site (skin rising up pin).
131
What is the expected reference range for potassium?
3.5 to 5.0 mEq/L
132
A potassium level of < 3.5 indicates?
Hypokalemia.
133
A potassium level of > 5.0 indicates?
Hyperkalemia.
134
What are the three causes of hypokalemia?
- Decreased total body potassium.
- Insufficient potassium.
- Intracellular shift (metabolic alkalosis, after correction of acidosis during periods of repair: burns, trauma, starvation)
135
What are vitals signs are common in a client experiencing hypokalemia (K < 3.5 mEq/L)?
Vital signs of a client experiencing hypokalemia include: weak, irregular pulse, hypotension, respiratory distress.
136
A client's potassium level is 5.4 mEq/L, the nurse should assess the client for?
The client has hyperkalemia, so the nurse should monitor the client for ECG changes; potassium levels can affect the heart, resulting in arrhythmias. An ECG would indicate these findings.
137
What are classic signs of hypokalemia?
Constipation, polyuria, and hypotension are classic signs of hypokalemia.
138
True or False: Diabetic ketoacidosis may result in hyperkalemia.
True. Diabetic ketoacidosis might result in hyperkalemia.
139
As a nurse you are performing testing the client for Chvostek's sign. How and where are you performing this test?
The nurse should tap on the client's facial nerve just below the anterior to the ear. A positive response is facial twitching of the mouth, nose, and cheek on the side being tested.
140
You are caring for a client with the following lab results: Na+ 133 mEq/L and K+ 3.4 mEq/L. Which treatment could cause these results?
Three tap water enemas could be the result of these lab results. Tap water is hypotonic and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution.
141
What are some neuromusculoskeletal signs and symptoms of hypokalemia?
- Weakness to the point of respiratory collapse and paralysis.
- Muscle cramping
- Decreased muscle tone and hypoactive reflexes
- Paresthesias
- Mental confusion.
142
The client you are caring for shows signs of weakness, muscle cramping, decreased muscle tone and hypoactive reflexes, with mental confusion. As an experienced nurse, you know that the client may be experiencing?
Hypokalemia: These are neuromusculoskeletal signs and symptoms of Hypokalemia.
143
Regarding electrolyte imbalances: the client is experiencing decreased motility, abdominal distention, constipation, ileus, nausea, vomiting, and anorexia. What electrolyte imbalance is this client experiencing?
This client is experiencing hypokalemia.
144
Regarding hypokalemia, what foods should you encourage the client to eat?
Encourage foods high in potassium: Avocados, broccoli, diary products, dried fruits, cantaloupe, and bananas.
145
A client is encouraged to eat avocados, broccoli, bananas, dried fruit, cantaloup, and dried fruits. As an experienced nurse you know that these foods are high in ______?
These foods are high in potassium. The client may be experiencing hypokalemia.
146
You are caring for a patient with a potassium level of 2.5, and an IV potassium supplementation is prescribed. As a experienced nurse, you know never to give the potassium supplements through _______ and the maximum recommended rate is ________ mEq/hr.
As a experienced nurse, you know potassium supplements are NEVER given through IV bolus (high risk of cardiac arrest) and that the recommended rate is 5 to 10 mEq/hr.
147
What is the recommended rate of administering potassium supplements?
5 to 10 mEq/hr.
148
True or false: Hypokalemia increases the risk for digoxin toxicity.
True. You need to monitor clients receiving digoxin (Lanoxin). Hypokalemia increases the risk for toxicity.
149
You are caring for a client with hypokalemia (Serum K+ < 3.5 mEq/L), what do you need to monitor for?
- Monitor and maintain adequate urine output.
- Observe for shallow ineffective respirations.
- Monitor client's cardiac rhythm and intervene properly as needed.
- Monitor client's receiving digoxin (Lanoxin), because they have increased risk for toxicity.
- Monitor level of consciousness.
- Monitor bowel sounds and abdominal distention and intervene as needed.
- Monitor kidney function (BUN, GFR, Creatinine).
- Provide assistance with ADLs.
150
What do you want to include in patient education regarding hypokalemia?
Regarding hypokalemia (K+ < 3.5 mEq/L), educate the client by:
- Regarding a potassium-rich diet and what foods are high in potassium.
- Teach the client ways to prevent a decrease in potassium by excessive use of diuretics and laxative.
151
The client you are caring for experiences Respiratory failure, as a complication of hypokalemia, what are your priority nursing actions?
- Maintain an open airway and monitor the client's vital signs.
- Monitor the client's level of consciousness.
- Monitor for hypoxemia (low level of O2), and hypercapnia (excessive CO2 in the blood).
- Assist with intubation and mechanical ventilation if needed.
152
The client you are caring for experiences Cardiac Arrest, as a complication of hypokalemia, what are your priority nursing actions?
- Perform continuous cardiac monitoring.
| - Treat dysrhythmias.
153
Client education regarding antihypertensive therapy and positioning?
Clients who are taking antihypertensives should be instructed to change positions slowly, be careful when getting out of bed, and climbing stairs until the medications effects are full known.
154
Client education regarding a client taking Angiotensin-converting enzyme (ACE) inhibitors for hypertension.
- Teach the client to report a cough, which is a side-effect of ACE inhibitors.
- Teach the client to report signs of edema (heart failure).
155
Why should the client report a cough to the provider if he/she is taking an ACE inhibitor for hypertension?
The client should notify the provider of this side effect, as the medication an be discontinued due to its persistent nature and occasional relationship to angioedema (swelling of the tissues in the throat that can progress to a life-threatening obstruction).
156
A client is taking ACE-inhibitors for hypertension, what do you take into consideration regarding this patient?
- Monitor the client's blood pressure and pulse. (hypotension is a common side effect).
- Monitor the client for signs of heart failure, such as edema. This medication may care heart and renal complications.
157
A client is taking an ACE-inhibitor for hypertension and reports cough, what other medications are good options?
A client who is taking an ACE-inhibitor for hypertension, report a cough, and has hyperkalemia may be prescribed Angiotensin-II receptor antagonist (ARBs).
158
What are examples of Angiotensin-II receptor antagonist/Angiotensin-receptor blockers (ARBs)?
Examples of ARBs include candesartin (Atacand), losartan (Cozaar), and telmisartan (Micardis). These are drugs are good options for clients who take ACE-inhibitors and report a cough.
159
Why is reporting a cough to the primary care provider important in a patient receiving ACE-inhibitors for hypertension?
ACE-inhibitors are related to angioedema (swelling of the tissues in the throat that can progress to a life-threatening obstruction).
160
Client education regarding positioning and signs to report during the use of Angiotensin-II receptor antagonist/Angiotensin-receptor blockers.
- Teach the client to change positions slowly.
| - Teach the client to report signs of angioedema (swollen lips or face) or heart failure (edema).
161
The client is on antihypertensive therapy for which he is prescribed a Beta blocker, metoprolol (Lopressor) and atenolol (Tenormin), what do you want to teach the client?
- Teach the client that these medications may cause fatigue, weakness, and depression, and sexual dysfunction.
- Advise the client to not suddenly taking the medication without consulting with the provider. Stopping suddenly can cause rebound hypertension.
- Teach the client symptoms of hypoglycemia that do not include tachycardia, which is suppressed with beta blockers.
162
Client education regarding Beta Blockers, metoprolol (Lopressor) and atenolol (Tenormin).
Do not stop the medication abruptly! This could lead to rebound hypertension!
163
The client reports fatigue, weakness, depression, and sexual dysfunction while taking metoprolol (Lopressor). What do you explain to the client? Is this normal?
Explain to the client that this is a normal expected finding for a client taking beta blockers.
164
What are two examples of Beta Blockers?
Metoprolol (Lopressor) and atenolol (Tenormin).
165
A client is taking Calcium-channel blockers as part of his antihypertensive therapy, which medications would the nurse expect to administer?
Calcium-channel blockers include: Verapamil hydrochloride (Calan), amlodipine (Norvasc), and diltazem (Cardizem).
166
A client is taking amlodipine (Norvasc) for hypertension, what are your nursing considerations?
As a experienced nurse you know that amlodipine (Norvasc) is a Calcium-channel blocker. You want to:
- Monitor the client's blood pressure and pulse, and change the client's position slowly. Hypotension is a common side effect.
- Calcium-channel blockers should be used cautiously with clients who have heart failure.
167
A client is experiencing constipation with verapamil hydrochloride (Calan), you know that this is a Calcium-channel blocker, what do you want to encourage/teach?
Encourage a to eat foods that are high in fiber if constipation occurs.
168
A client is taking furosemide (Lasix) for hypertension because it decreases sodium reabsorption and increases potassium excretion. What should you monitor the client for?
Monitor the client closely for hypokalemia.
169
How do Thiazide diuretics, such as hydrochlorothiazide (Hydrodiuril), work as a antihypertensive drug?
Thiazide diuretics, such as hydrochlorothiazide, inhibit water and sodium reabsorption, and increase potassium excretion.
170
Client education regarding Diuretics.
Teach the client to keep all appointments with the provider and to monitor efficacy or pharmacologic treatment and possible electrolyte imbalances (hyponatremia, hyperkalemia).
171
Client education regarding the use of heparin during surgery.
These medications should not be used during or following surgeries of the eye(s), brain, or spinal cord; lumbar puncture; or regional anesthesia.
172
________ is contraindicated in clients with low platelet counts (thrombocytopenia) or uncontrollable bleeding.
Heparin (parenteral anticoagulants) are contraindicated in patients with a low platelet count (less than 100,000/mm3).
173
Lumbar puncture is an invasive procedure that is contraindicated with patient receiving which drug?
Lumbar puncture is an invasive procedure that is contraindicated with patients receiving Heparin or any other anticoagulants.
174
This type of central catheter is ideal for emergency situations where short term central venous access is required for multiple therapies.
A nontunneled percutaneous central catheter.
175
How long can you use a non-tunneled percutaneous central catheter?
Length of use is up to 3 months.
176
Indications for a non-tunneled percutaneous central catheter?
Administration of blood, long-term administration of chemotherapeutic agents, antibiotics, and total parental nutrition.
177
Where is the insertion location of a non-tunneled percutaneous central catheter?
Subclavian vein, jugular vein, tip in the distal third of the superior vena cava.
178
When using a PICC line for medication administration, explain the flushing technique.
Performing flush for an intermittent medication administration per facility protocol, usually with 10 mL of 0.9% sodium chloride before, between, and after medications.
179
How do you obtain blood samples from a PICC line?
Obtain samples by withdrawing 10 mL of blood and discarding; taking a second syringe and withdrawing 10 mL of blood for sample; taking a third syringe and flushing with 10 mL of 0.9% sodium chloride.
180
How often should dressing changes be done on a PICC?
Dressing changes should be done following facility protocol; usually every 7 days and when indicated (wet, loose, soiled). Use of a transparent dressing is best.
181
A patient has a PICC line in the right arm, can you use this arm to obtain blood pressure?
No! Educate the patient not to have blood pressure taken in arm with a PICC line.
182
How often should you assess a PICC line? and what are you assessing for?
Assess the site at least every 8 hours. Note redness, swelling, drainage, tenderness, and condition of the dressing.
183
When caring for a PICC line, how often should you change the tube and positive pressure cap?
You change the tube and positive pressure cap per facility protocol (usually a minimum of every 3 days for the hospitalized client).
184
What size syringe will you use when flushing a PICC line?
In regards to flushing the PICC line, you must use a 10 mL or larger syringe to flush the line.
185
Before accessing the port of a PICC line, what should you do?
Prior to accessing the PICC line, clean the insertion port with alcohol for 3 seconds and allow it to dry completely.
186
A client has a PICC line, in regards to water, what should you include in education?
Advise the client not to immerse his arm in water. To shower, cover the dressing site to avoid water exposure.
187
How are loop diuretics such as furosemide (Lasix), bumetanide (Bumex) used in heart failure and pulmonary edema?
Loop diuretics are used to decrease preload.
188
A client is taking furosemide (Lasix) for heart failure, what do you want to teach them?
Client education regarding furosemide (Lasix) for heart failure should include foods that are high in potassium, to counter effects of hypokalemia.
189
If a patient is taking furosemide (Lasix), what do you want to monitor for?
Monitor for signs of hypokalemia!
190
What is the administration rate when administering furosemide (Lasix) IV?
Administer furosemide (Lasix) IV no faster than 20 mg/min
191
What is the therapeutic usage for furosemide (Lasix) in regards to pulmonary edema?
Furosemide (Lasix) is used when there is an Emergent need for rapid mobilization of fluid such as during pulmonary edema caused by heart failure.
192
A client is experiencing pulmonary edema, you know that this is caused by heart failure, do you want to administer furosemide (Lasix)?
Yes, because Lasix decreases preload and is used for emergent need for rapid mobilization of fluid.
193
You are caring for a visually impaired client about the management of diabetes mellitus, what do you include in your teaching?
As a registered nurse, you know that vision impairment (diabetic retinopathy) can be a complication of diabetes mellitus, client education should include: yearly eye exams to ensure health of the eyes and to protect vision.
194
Eye exams for a client with diabetes mellitus should be done how often?
Client education: encourage yearly eye exams to ensure health of the eyes and to protect vision.
195
A client who is diagnosed with heart failure and pulmonary edema is prescribed an Inotropic agent. As a nurse you know Inotropic agents include with medications?
Inotropic agents include digoxin (Lanoxin), dopamine, dobutamine (Dobutrex), and milrinone (Primacor).
196
Why are inotropic agents, such as digoxin (Lanoxin), used in patients with heart failure and pulmonary edema?
Inotropic agents are used to increase contractility and thereby improve cardiac output.
197
Prior to administering digoxin, what important nursing consideration comes to mind?
For a client taking digoxin, take the apical heart rate for 1 min. Hold the medication is pulse is less than 60/min and notify the provider.
198
A client is being discharged home and is prescribed digoxin (Lanoxin). What do you want to include in your discharge teaching in regards to self-administration of digoxin (Lanoxin)?
Teach the client to count pulse for 1 minute before taking the medication. If the pulse rate is irregular or thepulse rate is outside of the limitations set by the provider (usually less than 60/min or greater than 100/min), instruct the client to hold the dose and to contact the provider.
199
You know that patient teaching regarding digoxin administration has been effective if the client states:
"I should take the digoxin at the same time each day".
200
The client states "I can take digoxin at the same time as antacids", does this indicate teaching has been effective?
No, this indicates teaching was ineffective and needs to be done again. Digoxin (Lanoxin) should not be taken at the same time as antacids. The medications should be taken separately by at least 2 hours.
201
A client that you are caring for states "feelings of fatigue, muscle weakness, confusion, and a loss of appetite". After reviewing the clients charts, you notice that the client is taking digoxin (Lanoxin) for heart failure/pulmonary edema. What does this mean to you?
Digoxin toxicity!
Fatigue, muscle weakness, confusion, and a loss of appetite should indicate to you that the patient is experiencing digoxin toxicity.
202
When inotropic agents such a Dopamine, dobutamine, ad milrinone are administered via IV, what should be monitored?
The client's ECG, blood pressure, and urine output should be closely monitored.
203
Guidelines for safe IV medication administration include:
- Certain medications, such as potassium chloride, can cause serious adverse reactions and should be infused on an IV pump for accurate dosage control and never given by IV bolus.
- Add medication to a new IV fluid container, not to an IV container that is already hanging.
- Never administer IV medication through tubing that is infusing blood, blood products, or
parenteral nutritional solutions.
- Verify the compatibility of medications before infusing a medication through tubing that is
infusing another medication.
204
You noticed that a client's IV site has pallor, local swelling at
the site, decreased skin temperature around the site, a damp dressing, a slowed infusion. What does this indicate and what are your actions to treat this?
The client is experiencing infiltration at the insertion site, nursing actions to treat this include:
- Stop the infusion and remove the catheter.
- Elevate the extremity.
- Encourage active range of motion.
- Apply warm compresses three to four times/day.
- Restart the infusion proximal to the site or in another extremity.
205
The client is experiencing phlebitis/thrombophlebitis at the IV insertion site, what clinical manifestations would you expect to see?
Clinical manifestations of phlebitis/thrombophlebitis include: edema; throbbing, burning, or pain at the site; increased skin temperature; erythema; a red line up the arm with a palpable band at the vein site; a slowed infusion
206
You notice that there is a red line up the arm of a patient receiving IV therapy, what is your initial action?
Your initial action is to promptly discontinue the infusion and remove the catheter.
207
A client is receiving IV fluid replacement. Upon assessment of the client, you notice distended neck veins, increased blood pressure, tachycardia, shortness of breath, and crackles upon auscultation of the lungs. These are assessment findings indicative of what complication of IV therapy?
These findings are indicative of fluid volume overload.
208
What are some common examples of fluid overload?
Distended vein distention, increased blood pressure, tachycardia, and crackles of the lungs.
209
Should you administer propranolol to a patient with heart failure? Why or why not?
As a registered nurse, you SHOULD NOT administer propranolol to a patient with heart failure. Propranolol and metoprolol (beta blockers) have a negative inotropic effect and would worsen the failing heart.
210
In the event of a patient having heart failure, what medication would you expect to administer?
Digoxin is a medication that would be expected to be administered to a patient with heart failure.
211
After bariatric surgery, how much protein should the client have per day?
Teach the client to eat at least 2 servings of protein a day to prevent complications.
212
What do you do if a client is experiencing a seizure?
- Your priority action is to protect the client from injury (move furniture away, hold head in lap if on the floor).
- Position the client to provide a patent airway.
- Be prepared to suction oral secretions.
- Turn the client to the side to decrease the risk of aspiration.
- Loosen restrictive clothing.
213
A client that you are taking care of is experiencing a seizure, do you attempt to open the jaw? Do you use tongue blades?
No. Do no attempt to open the jaw or insert airway during seizure activity or use tongue blades. (this may damage teeth, lips, and tongue).
214
When caring for a patient who had a seizure what do you want to document?
Document the onset and duration of seizure and client findings/observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, motor activity, incontinence).
215
After a seizure, what are your nursing actions?
- Maintain side-lying position to prevent aspiration.
- Check vital signs.
- Assess for injuries.
- Perform neurological checks.
- Allow the client to rest if necessary.
- Institute seizure precautions; placing best in the lowest position and padding the side rails to prevent future injury.
216
What is a Mantoux test?
A Mantoux test is a diagnostic test used in the diagnosing patients with TB.
217
The client just received a Mantoux test, when should the client be asked to come back to have the results of the test read?
The Mantoux test should be read in 48 to 72 hours.
218
A patient has an induration (palpable, raised hardened area) or 10 mm or greater indicates a positive skin test. What is this induration size in immunocompromised patients?
An induration of 5 mm is considered a positive skin test for immunocompromised patients.
219
Does a positive Mantoux test indicate that the client has active TB?
No, A positive Mantoux test indicates that the client has developed an immune response to TB. It does not confirm that active disease is present. Clients who have been treated for TB may retain a positive reaction.
220
Client education regarding Mantoux Test:
Reinforce to the client the importance of returning for a reading of the injection side by a health care personnel within 48 to 72 hours.
221
This diagnostic procedure may be ordered to detect active lesions of TB in the lungs.
A chest x-ray may be ordered to detect active lesions in the lungs.
222
True or False: A positive acid-fast test suggest an active infection of TB.
True. A positive acid-fast test suggests an active infection.
223
How is a diagnosis of TB confirmed?
The diagnosis for TB is confirmed by a positive culture for Mycobacterium tuberculosis.
224
What are some safety precautions when obtaining culture samples from a patient suspected of having TB?
- Three early morning sputum samples are obtained.
- Wear PPE when obtaining specimens.
- Samples should also be obtained in a negative airflow room.
225
True or False: Use of standard precautions is implemented in a patient with TB.
False: TB is transmitted through air particles, therefor airborne precautions should be implemented and the patient should be placed in a negative airflow room.
226
A client suspected of having TB is being transported, what nursing action should the nurse take?
Have the client wear a mask if transportation to another department is necessary. The client should be transported using the shortest and least busy route.
227
What is the most definitive diagnostic procedure regarding liver cancer?
A liver biopsy is the most definitive diagnostic procedure and is done through the skin (percutaneously) with a biopsy needle.
228
Nursing actions for a liver biopsy include:
Nursing actions for liver biopsy include:
- Obtain coagulation studies as prescribed.
- Obtain client consent for the liver biopsy.
- Review and explain to the client the biopsy procedure and what is expected following the procedure.
229
What position should you instruct the client assume after the biopsy? Why?
After the biopsy, you want to instruct the client to lie on the affect side after the biopsy in order for hemostasis (the stopping of a flow of blood) to occur.
230
Regarding pulse oximetry, how would you want to position the client?
Preprocedure - Be sure the client is in a comfortable position, supporting the arm if a finger is used as a probe site.
Postprocedure - Place the client in a semi-Fowler's position to maximize ventilation.
