Comprehensive Review Material Flashcards
(259 cards)
1
Q
HGB normal range
A
12-18
2
Q
HCT normal range
A
37-52
3
Q
WBC normal range
A
5-10
4
Q
PLT normal range
A
150-400
Monitor on Heparin, hold if <100, risk for HIT
5
Q
PT normal range
A
11-12.5
6
Q
PTT normal range
A
20-30
7
Q
INR normal range
A
0.9-1.2
Monitor on Warfarin
8
Q
NA normal range
A
135-145
9
Q
K+ normal range
A
3.5-5
10
Q
CL normal range
A
98-106
11
Q
CA normal range
A
9-11
12
Q
BUN normal range
A
10-20
13
Q
CR normal range
A
0.5-1.2
14
Q
BG normal range
A
70-110
15
Q
ABGs normal ranges
A
pH 7.35-7.45
CO2 35-45
HCO3 22-28
16
Q
Incident Reports: indicated for, where do they not go
A
Do not go in pt chart
Indicated for: adverse reactions, med errors, injury, lost/stolen items, pt fight c doctor
17
Q
Airborne precautions
A
MTV: measles, TB, varicella
N95, private negative pressure room, door shut
18
Q
Droplet precautions
A
Spiderman: sepsis, scarlet fever, strep, pneumonia, pertussis, influenza, diphtheria, rubella, epiglottitis, rubella, mumps, meningitis, adenovirus
Mask, private room or share c same organism, mask on pt when transporting
19
Q
Contact precautions
A
c.diff, rsv, eye infections, wound or skin infections
Private room, gloves, gown when entering room
20
Q
Donning PPE
A
Gown
Mask
Goggles
Gloves
21
Q
Doffing PPE
A
Gown
Gloves
Mask
Wash hands
22
Q
Live Vaccines & contraindications
A
mmr, varicella, flumist, rotavirus
Contraindicated: pregnancy, fever >101, immune compromised, low wbcs
23
Q
RN scope of practice
A
EAT, PLAN CARE, DISCHARGE, BLOOD PRODUCTS, IV
24
Q
LPN scope of practice
A
Reinforce teaching, reassess, past medical history, accucheck, wound vac, dressing change, trach care
25
UAP scope of practice
transport, I&O, vitals, ADLs, positioning
26
Consent: Before signing
Risks and benefits of surgery, alternative treatments, plan of care in layman’s
no consent = no treatment
27
Emergency but no consent form
Implied consent granted
28
Minors and consent
Parent or legal guardian gives consent, EXCEPT for mental or reproductive health or substance abuse
29
What chronic conditions require an interdisciplinary team approach?
Parkinson’s
Hip dysplasia @ 6months
Cystic Fibrosis
NAS baby c drug addicted mother
30
What foods are high in potassium?
Avdocadoes, strawberries, potatoes, tomatoes, bananas
31
What foods are high in calcium & what vitamin do you take with calcium?
Milk, yogurt, shellfish, salmon, dark leafy greens
Vitamin D
32
Mass Casualty: What conditions are tagged **red**?
Life threatening: Airway obstruction, shock, cardiac arrest, pulseless fracture
33
Mass Casualty: What conditions are tagged **yellow**?
Can be delayed: open fracture c pulse, closed fracture, deep lacerations, hypoglycemia
34
Mass Casualty: What conditions are tagged **green**?
Walking wounded: episodic illness
35
Mass Casualty: What conditions are tagged **black**?
Dead/Death expected: fixed+dilated pupils, grey matter exposed, burns 60%+ of body
36
Lung Sounds: Where are bronchiole sounds heard?
Around the trachea, 2nd and 3rd ICS
37
Lung Sounds: Where are bronchovesicular sounds heard?
Heard over major bronchi, between the scapulae
38
Lung Sounds: Where are vesicular sounds heard?
Over lung bases
39
A low pitched ventilator alarm indicates _____________?
Low = leak,
Something is disconnected, dislodged, cuff leaking
40
A high pitched ventilator alarm indicates _____________?
High = pressure increase
Kink in tubing
41
When a ventilator alarm goes off what is the first nursing action?
Assess the patient then check the tubing and the ventilator.
42
What indicates correct understandings when asked about proper suctioning for a client with a trach (4 concepts)?
1. Suctioning is always PRN,
2. position semi to high Fowler
3. hyperoxygenate
4. suction 10-15 sec interval, 2-3 times
43
What is a contraindication for blood transfusions and what can you give to help?
febrile pt , premeditate c Tylenol + Benadryl
44
When is a transcutaneous pacemaker indicated?
Emergency situations only
Significant discomfort for client
45
What should you educate a client about related to their **permanent pacemaker**?
Don’t raise arms for two weeks
Phone on opposite side of pacemaker
Don’t submerge in water (initially)
46
Important nursing considerations **before** cardiac cath?
Check pt creatinine (0.5-1.2)
if over 2 kidneys not working = no cardiac cath, can’t excrete contrast
47
Important nursing considerations **after** cardiac cath?
Assess peripheral pulses (q15min/hr, q30min/hr, q1hr for 4 hours)
Bed rest 2-6 hours
Bleeding risk- apply pressure 15 min
48
What are the expected signs and symptoms of cardiac tamponade? (4)
Muffled heart sounds, JVD, hypotension, pulsus paradoxis
49
What are 3 signs of Impending rupture of a AAA?
Different BP in each arm
Sudden onset hypotension
Severe lower back pain
50
A client is following a low cholesterol diet and their LDLs are high and HDLs are low what is the nursing action?
Call PCP- low cholesterol diet indicates adherence, so LDLs should be low and HDLs should be high
51
What foods should a client avoid if they are prescribed a low cholesterol diet? (5)
Organ meats
Butter
Egg yolks
Fatty meats
Whole milk
52
What foods should a client consume if they are prescribed a low cholesterol diet? (5)
Walnuts
Salmon
Olive oil
Shellfish
Fruits + veggies
53
What indicates a correct understanding of NG tube insertion? (3)
Consent needed
Measure bridge of nose, around ear down to xyphoid process (mark)
Pt look up then insert
54
What are two important nursing interventions to consider when a client has an NG tube?
Disconnect from suction to auscultate bowel sounds
Perform oral care
55
What are 6 nursing considerations related to **tube feeds**?
No food coloring/dyes in tube
Check placement c pH <4
Keep schedule, do not increase rate if behind
If patient has to lie flat TURN OFF (prevent aspiration)
Check residual before feeding
Sit upright 1 hr after feed (prevent aspiration)
56
What are important nursing considerations when removing an NG tube?
Client sit in high fowler
Client take a deep breath + hold, quickly remove tube
57
What are four expected s/s associated with Crohn’s disease?
RLQ pain worse with eating
Steatorrhea
Wt loss
No blood in stool
58
What kinds of diets are indicated for a client with Crohn’s disease?
High calorie + High protein
Low fiber
(NO dairy, grains, raw fruits + veggies)
59
What are three expected s/s associated with Ulcerative Colitis?
20-40 liquid bloody stools/day
Abdominal distention
High pitched bowel sounds
60
A client with ulcerative colitis has been on a low residue diet with high calories and protein and fluids have been increased, they are having <10 liquid bloody stools/day what is the nursing action?
Send client home on prednisone
61
A **high fiber** diet is indicated for diverticul____?
DiverticulOSIS = pouch herniations
Increase fiber to get rid of waste so it doesn’t sit, get stuck in pouches
62
A **low fiber** diet is indicated for diverticul____?
DiverticulITIS = inflammation of intestine
Low fiber to decrease intestinal stimulation, irritation
-litis = low fiber
63
What are five expected s/s associated with IBS?
Bloating
Abdominal pain
Mucus in stool
Erratic bowel pattern
Diffuse abdominal tenderness
64
What medication would be a contraindication with IBS?
Loperamide - antidiarrheal
65
What are expected s/s associated with PUD [peptic ulcer disease]?
Dull gnawing pain
Decrease H+H ( blood transfusion maybe required)
66
What are the treatment options for PUD?
Place NG tube (coffee ground = old blood, bright red = active bleed)
Triple therapy: 2 antibiotics + one PPI
67
Cirrhosis is ___________ ____________ of the _________.
Irreversible
Scarring
Liver
68
Jaundice, enlarged liver and weight loss indicate what stage of Cirrhosis?
Early stage: increase protein
69
Splenomegaly, esophageal varices, clay colored stool, small modular liver indicate what stage of cirrhosis?
Late stage
70
Restlessness, coma, stupor and asterixis indicate what stage of cirrhosis?
End stage
Asterixis (hand flapping)
71
Moon face, trunchal obesity, irritability, buffalo hump, striae, hyperglycemia, hypernatremia, and hypokalemia indicate what endocrine disorder?
Cushing’s- excessive aldosterone/ over secretion
72
What diet is indicated for a client with cushing’s?
High calcium
Low sugar
Low salt
73
A client with Cushing’s is d/c with a new prescription for prednisone what is the next nursing action?
Question prescription, Cushings is caused by over steroid use, prednisone is a steroid
74
A client presents to the ED with bronze pigmentation, anorexia, salt craving, fatigue, what condition is associated with these signs and symptoms?
Addison’s- under secretion/ adrenalectomy, stress bomb, do not adapt to stress
Add a -sone = tx
Everything low + slow EXCEPT K+ & Ca+
75
What nursing considerations are important for Addison’s Disease? (4)
Fluid status- hydration
Check blood sugar frequently - prevent hypoglycemia
Assess cardiac function (hyperkalemia)
Monitor for adverse effects of tx (-sones) = s/s of Cushing’s
76
What three things can bring on Addisonian Crisis and what does a crisis look like (4)?
Bring on crisis: stress- **surgery, infection, trauma**
Looks like: **Low Na+, Low Glucose, Low BP, High K+** (shock)
77
Insulin drips can quickly (increase/decrease) K+ levels and are indicated for _____________? What other treatment options are indicated?
Quickly Decrease K+ levels
Indicated for Addisonian crisis
Other tx: IV fluid, D5W + NS, IV steroids
78
Excessive ADH (vasopressin), r/t small cell lung cancer, bounding pulses, severe HTN, hyponatremia, changes in LOC, concentrated/decreased UO are associated with what condition?
SIADH - soaked inside(low liquidy labs), sticky concentrated urine, Low blood osmolality
79
What are five important nursing considerations for a client with SIADH?
Restrict fluids (500-1000ml/24hr)
Seizure precautions (Na+ <135), HA = early sign
Monitor I&O (strict c daily wt)
Give/ eat salt (IV 3% NaCl + furosemide if Na+ normal & HF indicated)
Tolvaptin (ADH antagonist- promote water loss s losing Na+)
80
Diabetes Insipidus (DI) is suspected if a client present with what five s/s?
Polydipsia
Polyphagia
Oliguria
Tachycardia
Hypernatremia
-DI = dry inside, diuresing (high diluted UO), decreased BP, dry skin
81
What is a priority assessment finding in a client with DI?
**Headache** (HA) indicates low sodium <135 = seizures = DEATH
Tx: desmopressin decreases urine output
82
What is a priority nursing action if pheochromocytoma is suspected?
DO NOT palpate or percuss the abdomen
(BP in same arm, no caffeine, no smoking, tumor releases catacholimines= fight/flight
83
A client presents to the ED with HA, HTN, Hyperhydrosis, Hypermetabolism, and Hyperglycemia, what condition is most closely associated with these signs and symptoms?
Pheochromocytoma
S/S: 5 H’s
Tx: alpha adrenergic blockers (decrease blood pressure)
84
What are five expected signs and symptoms associated with Diabetic Keto Acidosis (DKA)?
BG >300, metabolic acidosis, kussmaul’s respirations, fruity breath, (+) positive ketones
Tx: regular insulin IV drip
GI upset: metoclopramide/ reglan
85
What are four important nursing interventions in the management of DKA?
Insulin bolus ( tx high BG) (increase BG 50- 75/hr)
Assess vitals q15 minutes until stable
Assess LOC and BG qhr until stable then q4h
Monitor for s/s of dehydration & hypokalemia = DEATH IN DKA
-(UO has to be at least 30 mL/ hr to give potassium)
86
A client presents to the ED with BG > 600, no ketones in urine, severe dehydration, and hypokalemia what condition can be suspected?
HHS: decreased urination, monitor hydration, neuro checks (seizures)
Tx: fluids, 1/2 NS, insulin (decrease 50-70ml/hr)
87
What is a priority nursing action to consider when a patient presents with HHS?
Ensure they stay hydrated!!!
88
A client presents with numbness and tingling of the lower extremities and upon initial assessment has decreased tendon reflexes, what condition is this client experiencing and what can be done about it?
Neuropathy- thickening of capillary basement membrane- ischemia and nerve death can result
Tx: gabapentin, cymbalta
89
What are three important nursing considerations to discuss when doing education on diabetic foot care?
Wash and inspect both feet DAILY c mirror
Always wear shoes
Use lotion NONE BETWEEN TOES
90
What is an early indicator a client is experiencing hardening of the glomeruli or nephropathy?
Early indicator: Microalbuminemia
(Avoid nephrotoxic substances i.e: gentamycin, contrast dye
91
What is epilepsy?
Chronic seizure activity
92
A generalized seizure affects the entire brain and includes _________ seizures which is stiffening and lasts 30 seconds to several minutes, and _________ seizures which is muscle contraction and relaxation (jerking).
Tonic , Clonic
93
A nurse has just arrived for her shift and witnesses her client fall to the floor. The client stiffens their body followed by rhythmic jerking motions, what kind of seizure did the nurse witness?
Tonic-Clonic; client becomes immediately unconscious
94
A ________ seizure is one where a client stays conscious, an aura may occur, and may experience [autonomic changes].
Partial
[change in heart rate, skin flushing, epigastric discomfort
95
What are important nursing considerations when implementing seizure precautions? (5)
O2, suction, airway at bedside
Iv access
Nothing in mouth, loosen restrictive clothing
Pt on side
Bed in lowest position
96
What is the priority nursing intervention when a client experiences a seizure?
Maintain patent airway
97
Benzodiazepines (-lams and -pams) are used to treat ________ seizure activity, while phenytoin is used for ________ seizure activity.
Acute: Diazepam and lorazepam (flumazenil is antidote)
Chronic: Phenytoin (oral hygiene to prevent gingival hyperplasia)
98
What is important to educate to a client with a new prescription for carbamazepine?
Use other forms of birth control
99
A client presents to the ED with symptoms of ICP (increased intracranial pressure) what does the nurse expect to observe? (5)
Change in LOC
Restlessness
HA
Sensory changes
Stupor
*Normal ICP: 10-15
100
A client presents with bradycardia, cheyne-stokes respirations and widened pulse pressure (Severe HTN) what is the client experiencing?
Cushing’s Triad= EMERGENCY brain stem compression
Late sign of ICP
101
What are important nursing interventions to implement when dealing with a client who has ICP? (5)
HOB 30,
neck neutral, log roll,
no shivering/control fever (increases ICP),
no cluster care,
decrease stimuli
102
What are key features of Multiple Sclerosis (MS)? (6)
Muscle weakness
Dysphagia - difficulty swallowing
Nystagmus - uncontrolled eye movement
Tinnitus - ear ringing
Diplopia - double vision
Vertigo
103
A client with MS is being discharged home what should be included in the discharge teaching? (4)
Avoid hot tubs + hot showers
Watch feet while walking
Walk c feet slightly apart
Use assistive devices
MS- autoimmune, periods of exacerbation + remission
104
A nurse is caring for a client diagnosed with MS what medications should the nurse expect the PCP to order?
Interferon - sub q inj, immunomodulator/ antiviral effect
Prednisone - glucocorticoid/ anti inflammatory
105
**Pyridostigmine** is a drug used in the treatment of Myasthenia Gravis, what is important to educate about this drug?
effectiveness = increase in strength
Do not miss a dose = crisis
*anticholinesterase- take 30-60 min before food to increase muscle strength for chewing/swallowing
106
Myasthenia Gravis is an autoimmune disorder characterized by ptosis (drooping eyelid), dysphagia and fatigue with symptoms worse later in the day, what are six important nursing interventions to implement in the care for this client?
Support Airway
CPT
Avoid sedatives
Falls risk
HOB up 30 - prevent aspiration
Activities early in day
107
A client presents with muscle weakness that starts in the lower extremities and spreads proximally, what condition is this client experiencing?
Guillian-Barre- inflammatory disease of peripheral nervous system, symmetrical temporary paralysis, begins in lower extremities and ascends bilaterally (goes up body)
108
A nurse has been assigned a client with a diagnosis of Guillian-Barre what nursing interventions should the nurse implement?
Monitor for DVT and pressure ulcers
Prevent paralytic ileus c tube feeds/ TPN
109
What is a complication of a spinal cord injury?
Autonomic Dysreflexia: severe HA, change in HR, hyperhydrosis, High BP
*severe HA is first sign
110
A secondary injury after a spinal cord injury may result from swelling, hemorrhage, ischemia or inflammation, what medication class will a nurse expect to be prescribed to prevent the secondary injury?
Glucocorticoids
111
A client understands cast care if they do what at home? (4)
Ice cast for 1-2 days after it’s put on
Never put anything inside cast
Use a hair dryer cool setting to “scratch” an itch
Bag over cast in shower, no fully submerging
112
What interventions are associated with the compensatory
stage of shock?
Promote safety
Monitor tissue perfusion
113
Preventing complications and promoting rest are associated with what stage of shock?
Progressive
114
A client in the irreversible stage of shock will need what interventions?
Fluid replacement
Nutrition support
115
What is shock?
Imbalance between oxygen supply + demand (cellular level) = poor perfusion
-Cardiogenic- pump (heart) stops working
-Hypovolemic- decreased body volume (dehydration/ hemorrhage)
-Distributive- blood volume pools, not enough reaches heart (septic, anaphylactic, neurogenic)
-obstructive-physical block of blood flow
116
What is sepsis?
Pathogens enter bloodstream, dx: lactate >4, low urine output, hypotension, high cardiac output, neutropenic fever
117
What do you do within three hours of a sepsis bundle? (4)
Obtain serum lactate,
cultures,
give broad spectrum antibiotics,
aggressive fluid resuscitation
118
What do you do within six hours of a sepsis bundle?
Administer Vasopressors if MAP <65
Reassess intravascular volume status/ tissue perfusion
-CVP goal: 8-12
-ScvO2 goal: >70%
-bedside echo
119
A client diagnosed with neutropenia would need what medication and why?
Filgrastim to increase white blood cells
120
Neutropenic precautions include doing what?
Private room
Strict hand washing
No fresh flowers, raw fruits/veggies
No live vaccines
Avoid large crowds
121
A client receiving internal radiation or brachytherapy has to follow strict rules, list some.
Nurses and visitors only allowed 30min/day
No one under 18 or pregnant allowed in room
Patient cannot ambulate
If it falls out, pick up with mitt + tongs- call pcp
Nurse must wear dosimeter in room, take off when going home.
122
What is important to educate about external radiation?
Don’t wash off radiation pen marks
Mild soap + water + hand (no washcloths)
Can have visitors
Avoid sun exposure for 1 year (sunscreen + long sleeves)
Keep follow up appointments
123
A medical emergency known as DIC happens secondary to sepsis, trauma, placental abruption or cancer, what important nursing interventions should be in place for a client with DIC? (4)
Maintain fluid balance
FFP + Platelets if needed
Bleeding precautions
Monitor Organ function: mods is a complication of DIC
124
A client is receiving Kayexalate, allopurinol, furosemide and is on dialysis. Their presenting symptoms were AKI, dysrhythmias and seizures, what condition does this client have?
Tumor Lysis Syndrome- EMERGENCY, release of tumor contents into body, rapid electrolyte imbalances
125
Amenorrhea, Nausea, and quickening are all _______________ signs of pregnancy.
(presumptive, probable, or positive)
Presumptive
126
Hegar’s sign (softening of lower uterus), positive pregnancy test, Chadwick’s sign (blue purple color), Braxton Hick’s are all _____________ signs of pregnancy.
(presumptive, probable, positive)
Probable
127
Fetal heart tones, visualization by ultrasound, movement felt by examiner and delivery of fetus are all ____________ signs of pregnancy.
(presumptive, probable, positive)
Positive
128
A Rhogam shot is indicated in pregnancy when a mother has (-/+) blood and the baby has (-/+) blood, given IM @ ____wks and ___-___hrs after delivery, fill in the bank.
(-) mother & (+) baby
@28wks and 48-72hrs after delivery
** cannot be done by an LPN**
129
What are the three priority nursing interventions immediately post delivery for the newborn?
Clear airway
Dry baby
Obtain Apgar within 1 **AND** 5 minutes- 2= normal, up to 10 points total
130
This type of screening is mandatory 24 hours after delivery because the condition being screened for causes mental disability?
PKU screening
Educate breastfeeding moms to avoid aspartame
131
A nurse is educating a new mother on umbilical cord care what should be included in the teaching? (4)
Let it fall off on its own 10-14 days
Keep dry
No baths until it falls off
Tuck diaper under
132
A client brings her newborn son in to the ED with complaints of a milky white discharge covering the top of his penis. The mother is frantic and thinks someone is abusing her son, she says she’s being doing all the correct things like squeezing warm water over the area and applying petroleum jelly. What should the nurse tell the client?
The milky white covering is normal and expected after a circumcision, you are doing a great job. I see no signs or symptoms of sexual abuse.
133
A client brings her newborn into urgent care with a runny nose, hasn’t been feeding well, and exhibits a high pitched cry, what is this baby experiencing?
Withdrawal
134
Normal HR ranges:
Newborn: 110-170
Infant: 90-160
Toddler: ___-___
Preschooler: 75-120
School age: 70-100
Adolescents+: 60-100
Toddler Normal HR : **80-140**
135
A client that is 0-2 years old that uses language for demands and cataloguing and develops object permanence is in what stage for Piaget?
Sensorimotor
136
A client that is 2-7 years old and uses imagination and intuition but still have trouble with abstract thoughts are in what stage for Piaget?
Preoperational
137
A client that is 7-11 years old, can understand concepts as concrete situations and understand time, space and quantity are in what stage for Piaget?
Concrete operational
138
A client that is 11 years old and older who has developed theoretical and hypothetical thinking, and can strategize and plan are in what stage for Piaget?
Formal operational
139
A client experiencing photophobia, nuchal rigidity, positive kernig and brudizinskis signs are most likely experiencing what?
Meningitis- organism enters blood stream+ crosses the brain barrier
- viral or bacterial meningococcal (most common): streptococcus
- preventable with vaccine 1st dose 11-12 years old and 2nd @ 16 years old
140
Discussing the terms of termination, building rapport and trust and defining the roles of the relationship are associated with what phase of the nurse patient relationship?
(Orientation/Working/Termination)
Orientation phase
141
Promoting problem solving skills, promoting alternate adaptive behaviors and overcoming resistance behaviors is associated with what phase of the nurse patient relationship?
(Orientation/Working/Termination)
Working phase
142
Summarizing the goals achieved, and discussing new coping strategies is associated with what phase of the nurse patient relationship?
(Orientation/Working/Termination)
Termination phase
143
What are behaviors associated with increased risk for suicide?
Recent break up- losing wt
Loss of partner- failure to socialize
Getting rid of personal belongings
144
What is the priority when a med error occurs?
Assess the patient **FIRST**
-then call pcp, fill out incident report
145
Medication wasting requires ______ nurse check and you must waste the medication ________ administration.
2 nurse check
Waste BEFORE administration
146
What do you draw first, the peak or the trough?
Trough first (right before next dose) then peak (30 minutes after administration)
147
Digoxin normal range 0.5-2
Toxic >2
What are the s/s of digoxin toxicity and what is the priority?
N/V and vision changes
Priority: obtain vitals
*apical pulse 1 full minute, eat foods high in potassium, report irregular pulses
148
Lithium normal range: 0.5-1.5
Toxic: when dehydrated
What are s/s of toxicity?
Loc change, vision changes, hand tremors
*avoid exercise, diuretics, tea, cola, coffee, excess salt (no nsaids=salt)
149
Enoxaparin/ lovenox is a low molecular weight heparin administered 2 inches above the umbilicus. What other important nursing interventions should be done with this drug?
Do not expel the air bubble, retain it
Do not massage or aspirate site
Rotate sites
150
What is the purpose of kayexalate?
Lowers potassium via bowel movements
151
What is Nitro?
Vasodilator, HA expected
152
Caution a penicillin allergy with what drug?
Ceftriazone
153
Furosemide adverse reaction will cause what to happen?
Tinnitus - report to pcp
154
Epoetin alpha is effective if
Hgb increases
*tx anemia: low RBCs
155
This type of care is done concurrently with treatment but is non-curative, it focuses on improving quality of life.
Palliative care
156
This type of care focuses on comfort at end of life, no antibiotics, no life saving procedures.
Hospice
Focus on energy conservation, suction, pain meds as needed, sitter ( so they don’t die alone), nutrition megestrol acetate (appetite stimulant)
*question dr sending pt home on hospice with picc line
157
Hospice criteria:
<6 months to live
Progressive, irreversible illness
158
Priority patients:
Kid c laceration falling asleep
Patient temp of 105- private room
Constipated taking loperamide
Creatinine of 2 scheduled for cardiac cath
Pt c JVD and crackles
Unstable, acute, new onset, altered loc,
159
Priority patients:
Starting IV sodium and potassium level 2.9
Multiple compound fractures reporting chest pain
Graves disease and high temp
Thoracentesis elevated hr 95-110
Burns UO 45mL/2 hrs
Pain on deep inspiration
Unstable, acute, new onset, altered loc,
160
Gushing laceration
Apply pressure (stop bleed FIRST) then get IV access
161
AAA pt c severe lower back pain
Prepare for surgery
162
Hypovolemic shock- increased HR
Give O2
163
Cardiogenic shock, what do you do first?
Fix BP first
164
Blood transfusion contraindication
Can’t hang if pt is febrile
165
Desmopressin
Decreases UO
166
Insulin drip, what do you do before you administer?
Waste first 50 units
167
Metformin
Hold 24 hours prior and 48 hours after contrast dye CT
Assess shellfish allergy (iodine)
168
D/C heparin
6 hours prior to sx
169
Alendronate for osteoporosis
Take c full glass of water on empty stomach, sit upright for 30 minutes after
170
PTU (propylthiouracil) medication for Graves Disease, what is important about it?
Dont stop abruptly
171
Amlodipine
Calcium channel blocker
172
Lisinopril
Adverse reaction - dry cough
Avoid spironolactone (K+ already high and increases)
Don’t take while pregnant
173
Clozapine (antipsychotic)
Report flu like symptoms
174
Aripiprazole (abilify)
Report agranulocytosis low wbc
175
Clopidogrel (prevent thrombus)
D/C 7 days prior to sx
176
Valsartan (ARB) and ACE -prils important consideration
Monitor K+ and renal function
Avoid spironolactone
177
Haloperidol (antipsychotic)
Causes urinary retention
178
Ciproflaxacin
Report deep tendon pain
179
Belladonna and opium
Suppository for bladder spasms
180
Sodium polystyrene (kayexalate) mechanism of action?
Decrease potassium in hyperkalemia via bowel movement
181
Baclofen and Diphenhydramine are prescribed for a client what is the next nursing action?
Call pcp, these meds cannot be taken together
182
What considerations are important to know about TPN?
Change tubing every 24 hours, 2 nurse check, runs out Hang D10, change dressing if wet or soiled
183
Change lipids
Every 12 hours
184
Residual < 250 for tube feed
Notify pcp
185
Check peg tube
Every 12 hours, rotate 360 every day
186
Prostate exam
Over 45 yearly (increase c age)
Digital and PSA yearly
187
Testicular Exam
Monthly after shower, index finger and thumb gently roll
188
HPV vaccine
9-26 years old BEFORE sexually active
189
Pneumonia vaccine
Over 65, immunocompromised, hx, over populated living condition
190
Postictal after seizure
Last 5-30 min
Sleepy and confused NOT PRIORITY
191
Dysphagia
Do not give juicy fruits or soft fruits
192
Ischemic stroke
TPA within 4 hours of onset
193
Hemorrhagic Stroke: what medication is contraindicated?
TPA -DO NOT GIVE (increases bleeding)
194
Stroke diet
Soft puréed food, thickened liquids
No juicy fruits
195
Menieres disease (older adults fluid buildup causes vertigo)
DO NOT increase fluids
RESTRICT sodium
Ear feels full
196
Skeletal traction, what indicates rejection?
Loose screws = rejection
197
Bucks traction
Weights hang freely
Pincare q 12 hours
MD required for weight change
198
FHR 140 no variability
Call MD
Assess mom
Fetal compromise
199
FHR over 170
Mom on lateral side
200
Self breast exam
7-10 days after period ends, same day each month, 2,3,4 finger in circular motions
201
Postpartum hemorrhage
Soaking 1 or more pads every 15 minutes
Massage fundus until firm
202
Cervical cancer risk
Smoking
203
Umbilical cord falls off at 5 days
Problem call pcp
204
Child abuse
Generalized bruising on child over 4
Under 4 (ten-4 rule)
205
5 Year old activity
Doll and coloring book
206
Hirschsprungs
Ribbon like stool
207
Suction control chamber
Gentle bubbling should be present
208
Chest tube disconnects
Put into sterile water
209
CKD pt c CR of 3
NOT PRIORITY
EXPECTED FINDING
210
Dialysis patient
Can drink
Problem if bag runs out before scheduled time
211
Expected c dialysis
N/V
212
Live donor kidney transplant
Instant urine output
213
Cadaver donor kidney transplant
1 week for urine output, pt needs dialysis until then
214
Kidney rejection
Elevated temp, CR, BUN, WBC, HR, <30 mL/hr
215
SIADH expected
Low sodium c bounding pulses, high BP
216
SIADH AVOID
HCTZ and do not raise hob over 10
217
Addisonian crisis
Monitor BG less than 60
218
TURP expected
Pink drainage
Gross or bloody- irrigate
Irrigation wide open c red return notify PCP monitor h&h
219
Acute glomerulonephritis
Risk of fluid over load
CRACKLES = EMERGENCY
220
Metabolic Acidosis
DKA, diarrhea, renal failure
221
Metabolic alkalosis
Vomit or NG suction
222
Respiratory alkalosis
Hyperventilation
223
HHS PRIORITY
Fluid volume deficit , HYDRATE
224
DM BG less than 100 or over 240
Do not exercise
225
Colostomy
Beefy red is expected, dull call pcp
Eat yogurt
226
Dumping syndrome diet
Increase protein, low carb
Lay flat
No fluids between meals
227
Celiac disease s/s
Diarrhea, steatorrhea, decreased weight, migraines
Gluten allergy
228
NG tube assessment
Disconnect before auscultation of bowel
229
Clean catch urine
Dominant hand holds cup
Non dominant hand spreads labia
230
PUD
Bright red blood = active bleed
Coffee grounds = old blood
Type and cross
231
Crohns
RLQ PAIN, NO BLOOD, AVOID DAIRY, NUTS , RAW FOODS
232
Appendicitis
RLQ pain , if pain stops = EMERGENCY
233
GERD NURSING INTERVENTIONS
Sit up 30 minutes after, no carbonation or spicy foods, avoid tight clothes,
Heartburn give PPI (-zole)
Wedge pillow
234
Spina bifida + multiple sx
Increase risk for latex allergies
235
Scabies
Wash/dry HOT, OINTMENT NECK DOWN 8-14 hrs
236
Delegate to LPN
Get blood sugar
237
Stroke pt becomes restless
See first
238
Hypothermia
Rewarm trunk before extremities
239
Peritoneal dialysis
Cloudy= infection
240
Pyloric stenosis
Projectile vomiting in infant
241
Kidney transplant 1 week ago
BP decreases = good
242
HDL high pt on correct diet
Genetics
243
Crying baby c cleft palate
Swaddle, hold close and rock
244
Lateral violence
Bullying NOT SEXUAL HARASSMENT
245
PVC
Check peripheral pulses
246
Report temp 1 degree change
Kidney transplant, Graves’ disease
247
Child c WBC of 3.9
No vaccine
248
No honey
Before 1 years old
249
Delegate vitals signs after biopsy to
PCA
250
Atherosclerosis what food is contraindicated for this disease process?
NO EGGS
251
Sickle cell
Avoid high altitudes
252
Radiation materials stay in room (v/s machine)
Further teaching
253
Blood transfusion everything stops next
Run NS
254
Post mortem
Lines out before autopsy
255
Gi bleed c black tarry stool caused by?
H pylori ulcer
256
Hold Sippy cup
12 mos at 14 mos is concerning if still can’t hold it
257
Social smile
2-3 months
258
Outside agency
Stage three pressure ulcer
14 year old pregnant
259
Hypovolemic shock
Pulse increase HR 80-100
