Flashcards in Comprehensive 2013 B Deck (19)
Teaching on allowable foods for a p who has a history of uric-acid based urinary calculi formation. Wotf foods can be included?
d. red wine
b. oranges - this p can eat oranges but should avoid liver (organ meats), chicken, and red wine (alcohol). Urolithiasis S&S= renal colic pain, oliguria or anuria, N/V, pallor, diaphoresis, bladder distention, hematuria. Uric acid stone formation is usually r/t Gout (purine metabolism d/o) or due to bone marrow d/o's, thiazide diuretics or cancer. Pts. should avoid purine sources in the diet, which includes organ meats, poultry, fish, gravies, red wines, and sardines.
Child w/ DM type 1 has BS 55mg/dL, is shaky, nervous, and sweaty. ID the sequence of steps?
a. wait 15 minutes
b. recheck the blood glucose
c. provide cheese and crackers
d. give 4 oz of OJ
d. give the p. 4 oz of OJ, then wait 15 minutes, then recheck the BS, and finally give cheese and crackers (a high-protein snack).
Hyperthyroidism expected finding?
a. dry, coarse hair
d. periorbital edema
c. tremors - along w/ diaphoresis, fine body hair, warm skin, SOB- tachypnea, palpitations, increased systolic BP, tachy-c, wt loss, increased appetite, muscle wasting, hypoproteinemia, eye fatigue, hyperactive DTRs, insomnia, heat intolerance, decreased attention span, restlessness, manic behavior, amenorrhea, goiter are all signs of hyperthyroidism.
coarse hair, bradycardia and periorbital edema are all signs of hypothyroidism
Wotf peds p's should RN assess first?
a. 6 mth old w/ croup and SaO2 92%
b. 15 yo 2 hr postop ORIF of the left ankle who is in pain
c. 3 yo w/gastroenteritis, dehydration, and loose BMs
d. 10 yo awaiting surgery for appendectomy and exp. sudden relief from pain
d. sudden relief from pain, followed by an increase in pain may indicate that the appendix has ruptured and peritonitis is present. This child is at the greatest risk for injury
3 days postop AKA, include in POC?
a. wrap the bandage on the residual limb in a proximal to distal direction
b. elevate the residual limb on a pillow when the p is supine
c. assist the p to the prone position every 4 hours
d. request a soft foam mattress for the p's bed
c. Assist the p to the prone position q4h to help prevent flexion contractures. Bandages should be wrapped in a distal to proximal direction to prevent blood flow restriction. Elevating the limb will cause flexion contractures (so avoid), as will a soft mattress (so need firm mattress).
P. w/ PE receiving hep IV at 1200 units/hr and warfarin 5 mg PO daily. AM labs are aPTT 98 seconds and INR 1.8. RN action?
a. prep to administer vitamin K
b. prep to administer streptokinase
c. hold the hep infusion
d. hold the next dose of warfarin
c. hold the heparin infusion - the nml value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60-80 seconds. 98 seconds is above this, so hold hep. P. may also need protamine sulfate. Vitamin K is the antidote for warfarin OD. Steptokinase is another thrombolytic medication, thus, is not needed bc the pt is already receiving anticoagulants.
P. has a deficit with cranial nerve II. Based on this, RN should plan to?
a. maintain the p on bed rest
b. ask the p to restate directions
c. clear objects from the p's walking area
d. evaluate the p's ability to swallow
c. clearing objects will help prevent falls as deficits in CN II can cause visual impairments.
a - no indication for this
b - this should be done w/ deficits in CN VIII (vestibulocochlear) as these p's may have a hearing impairment
d - this should be done w/ deficits in CN IX (glossopharyngeal) and CN X (vagus) as these innervate motor nerves for swallowing
P. reports taking verapamil and other meds w/ a glass of grapefruit juice q-am. Wotf indicates a possible interaction?
b. hypotension. Grapefruit juice increases blood levels of verapamil by inhibiting metabolism, causing an excessive drop in blood pressure.
- constipation (not diarrhea), bradycardia (not tachy-c), and fluid volume excess (not diuresis) would also ccur bc metabolism of verapamil is inhibited.
Teaching regarding common SEs of Clozapine?
a. wt gain
c. sexual dysfunction
a. wt gain. Clozapine is a second-generation antipsychotic (so low risk for EPS SEs) that blocks serotonin and dopamine receptors (along with NE, histamine, and acetylcholine receptors). Common SEs include wt gain, orthostatic hypotension, anticholi effects. AEs include agranulocytosis, diabetes (hyperglycemia) and dyslipidemia (increased total cholesterol and LDLs). Clozapine does not cause sex dysfunction
Include in teaching for parents of child w/ autism?
a. autism is c-b psychological influences r/t impaired parent-child bonding
b. autism is c/b motor and verbal tics that impair communication and social functioning
c. promote social interaction by encouraging group activites
d. manage behavioral outbursts by limiting external stimuli and using a calming approach
d. children w/ autism respond well to a quiet environment and this can help minimize behvrl outbursts.
a- autism may have a genetic component and can affect individuals regardless of SES, race, or cultural background.
b- this describes Tourette's syndrome
c - children w/ autism respond better to activities w/ one person and have difficulty communicating in groups
Intervention for p. w/ serum magnesium 2.5 mEq/L?
a. initiate continuous cardiac monitoring
b. give 40 mEq/L KCl PO w/ OJ
c. provide a diet rich in meat, nuts and whole-grain cereal
d. monitor the p for tetany
a. Initiate continuous cardiac monitoring - p's with hypermagnesemia are at risk for cardiac dysrhythmias
b- this is not appropriate for a p w/ high mag levels
c - meat, nuts, and whole grain cereals are high in magnesium (thus CI'd w/ this p)
d - p's w/ hypermagnesemia have depressed muscle movements
P. w/ CHF is being d/c'd with Rxs for digoxin and furosemide. Teaching? (mult mult)
a. methods for mx-ing fluid intake
b. how to monitor pulse rate before taking digoxin
c. need to report muscle weakness to the HCP
d. reason for taking furosemide at night
e. importance of obtaining body wt daily
a, b, c, and e are all correct to include in teaching. Fluid restrictions and daily wts are necessary to prevent exacerbations of HF. Digoxin is w/held if the p's HR is less than 60bpm. Muscle weakness may indicate hypokalemia (a common and serious SE of furosemide) which needs to be reported.
P w/ renal failure received hemodialysis the day before. Report wotf lab values
a. Platelets 268,000
b. calcium 9.2
c. wbc 5,200
d. Na 148
d. Na 148 = hypernatremia, report this to HCP. Dialysis removes excess fluids and waste products and restores chemical and electrolyte balance in the body. This may indicate that the patient is dehydrated.
Manic phase of Bipolar d/o, expected finding?
a. lack of remorse
b. feelings of emptiness
c. grandiose thoughts
c. grandiose thoughts - p's in the manic phase exhibit behaviors that are seemingly euphoric including abrupt mood changes, expansiveness, and grandiose thoughts.
a- this is typical of antisocial personality d/o
b- typical of depression, borderline personality d/o
d- typical of borderline personality d/o
Home care instructions for a permanent pacemaker, wotf indicates understanding?
a. I will be able to take baths or showers
b. I will not use my microwave to reheat my food
c. I will check my pulse weekly
d. I will return for a f/u MRI next month
a. The p. with a pacemaker has no restrictions on bathing.
b- p's w/ pacemakers can safely use a microwave
c- pulse should be checked daily
d- pacemaker p's should not undergo MRIs due to the risk for pacemaker malfunction
Caring for pt. in a crisis. ID the sequence of steps the RN should take to help the p to cope?
a. assist the p w/ the development of an action plan
b. coordinate w/ support agencies and other resources
c. provide for p safety
d. develop a therapeutic relationship
e. plan and provide for f/u care
a. provide for safety first (as the greatest risk to p is injury)
b. develop a therapeutic relationship
c. assist with the development of an action plan
d. coordinate with support agencies and other resources
e. plan and provide for follow up care
Caring for p w/ GI bleeding and an NG tube. While performing gastric lavage, wotf actions should the RN take?
a. instill 50 mL of sterile water
b. instill 75 mL of NS
c. ask the p to lie on his left side
d. ask the p to lie supine
c. ask the p to lie on his left side - this position will limit the flow of the instilled solution out of the stomach and prevent aspiration. When performing lavage, the nurse should instill 200-300 mL of the facility approved solution (sterile water, tap water, or NS). Lying supine can cause the p to aspirate.
Teaching new nurse how to ID true labor. Include that?
a. UCs felt primarily in the upper abdomen
b. cervix transitions to an anterior position
c. UC intensity decreases with ambulation
d. cervix progressively thickens
b. in true labor, the cervix transitions to an anterior position and progressively thins. UCs are felt primarily in the lower abd. and back and their intensity increases w/ ambulation in true labor.