Incorrect/Need to Learn Concepts Flashcards
(190 cards)
1
Q
Chlamydia
A
-Bacterial infection (STI)
-Causes: New partners, multiple partners, unprotected sex
-Complications: Pelvic Inflammatory Disease (PID), infertility, ectopic pregnancy, PROM, preterm pregnancy, postpartum endometriosis
-Screening: Yearly for all sexually active females <25 yrs + older females + pregnant pts screen @ 1st and 3rd trimester
-S/S: Penile discharge, dysuria, spotting, gray-white discharge
Diagnostic: Endocervical swab culture + urine culture
-Intervention: Doxycycline, Azithromycin (preg-safe), Erythromycin, barrier contraceptive, report to local health dept
-Rescreened for re-infection: 3-12m after tx
2
Q
Triage Categories
A
-Emergent (RED): Life threatening injuries => immediate tx + HIGHEST priority
-Urgent (YELLOW): Serious + extensive injuries => not immediate threat + potential survival w/ DELAYED tx
-Non-urgent (GREEN): Less serious + less extensive injuries => no threat to life even w/ DELAYED tx
-Expected (BLACK): Potential for survival DOESN’T EXIST, even w/ tx => expected to DIE/FATAL + LOWEST PRIORITY
3
Q
Fire Safety Evacuation
A
-Know location of exits, alarms, fire extinguishers, and O2 shut-off valves
-Make sure equipment doesn’t block fire doors
-Know evacuation plan for unit + facility
-RACE: Rescue, Alarm, Contain/Confine Fire, Extinguish
-PASS: Pull, Aim, Squeeze, Sweep
4
Q
RACE
A
R: Rescue + protect clients in close proximity to the fire by moving them to a safer location (pts who are ambulatory can WALK independently to a safer location) HEALTHIEST/STABLE/AMBULATORY PT = HIGHEST PRIORITY
A: Alarm activated + then report the fire’s details and location
C: Contain/confine the fire by closing doors and windows + turning off any sources of O2/electrical devices (ventilate pts who are on life support w/ bag-valve mask)
E: Extinguish fire if possible w/ appropriate fire extinguisher
5
Q
Incident Report
A
-Unusual occurrences (med error, falls, omission of prescription, needlestick, device malfunction)
-Complete incident report within 24 hrs
-Patient ID, time/place of incident, accurate account of event, who you notified, what action you took, signature
-DON’T reference/include incident report in client’s medical record/chart
6
Q
Unintentional tort
A
-Negligence: nurse fails to implement safety measures for a client at risk for falls
-Malpractice: professional negligence; a nurse administers a large dose of med due to a calculation error (pt dies)
7
Q
Quasi-intentional tort
A
-Breach of Confidentiality: a nurse releases a client’s med diagnosis to a member of the press
-Defamation of Character: a nurse tells a coworker that they believe the client has been unfaithful to their partner
8
Q
Intentional tort
A
Assault: conduct of one person makes another person fearful + apprehensive; a nurse threatens to place an NG tube in a client who is refusing to eat
Battery: Intentional + wrongful physical contact w/ a person that involves an injury/offensive contact; a nurse restrains a client + administers an injection against their wishes
False imprisonment: a person confined/restrained against their will; a nurse uses restraints on a competent client to prevent their leaving the health care facility
9
Q
Informed Consent
A
-Written permission for a procedure/tx + consent is informed
-Nurse witnesses client signing consent form + ensure the provider has obtained the form
-Implied consent: adhere to instructions the nurse provides
-Must have written consent for an invasive procedure/surgery
-Signed by competent adult (capable to understand the info)
10
Q
DNR Legality
A
-Ordered by HCP
-“Allow natural death”
-Prescription in the client’s medical records
-HCP consults the client + family prior to administering DNR
11
Q
Bleeding Dressing
A
-Hemorrhage control: apply DIRECT pressure to visible, significant external bleeding
-Drainage: Serous (CLEAR), Serosanguineous (PINK), Sanguineous (BRIGHT RED), Purulent (YELLOWISH-GREEN)
-Wet, saturated dressing should be REINFORCED by adding more dressing to the existing dressing
-FIRST dressing change is performed by surgeon
12
Q
2 Point Crutch Gait
A
Partial weight is placed on the affected foot moving the crutch at the same time as the affected leg
OPPOSITE CRUTCH + FOOT MOVE AT SAME TIME
13
Q
3 Point Crutch Gait
A
Weight is distributed on both crutches + then on the unaffected leg w/ the sequence being repeated (affected leg DOESN’T touch the ground)
CRUTCHES FIRST, THEN UNAFFECTED FOOT
14
Q
4 Point Crutch Gait
A
Weight is evenly distributed, with each leg being moved alternately w/ the opposing crutch
R CRUCTH, L FOOT, L CRUTCH, R FOOT
15
Q
Swing-thru Crutch Gait
A
Weight is placed on both legs, and crutches are place one stride in front and then legs swing to the crutches
CRUTCH, SWING BOTH LEGS TO CRUCTHES
16
Q
Crutches/Canes Up + Down Stairs
A
GOOD = UP
BAD = DOWN
17
Q
Pneumonia O2 sat
A
-Expected for pneumonia pt to have low reading
-Even though O2 Sat is within NORMAL range, REASSESS using another site before any other interventions are completed
-Low readings caused by mvmt, hypothermia, decreased peripheral blood flow, sunlight, decreased Hgb, edema, fingernail polish
18
Q
Patient doesn’t recognize med
A
-Hold off on administering ANY med until verified against provider’s orders in client’s records
-Once complete, nurse can tell client w/ certainty that all meds were verified + answering any questions
-Prevent errors + build trust
19
Q
Learning Barriers
A
-Self confidence
-Fear, anxiety, depression
-Physical discomfort, pain, fatigue
-Envmt distractions
-Sensory/perceptual deficits
-Psychomotor deficits
20
Q
Spill kit (Chemotherapy)
A
-Spill is an envmt hazard + chemotherapy is a carcinogen & teratogen to anyone who handles it in a unprotected manner
-Small spill => use chemotherapy spill kit (goggles, mask, protective clothing, shoe covers, absorbent pads, detergent cleansers, and chemotherapy waste disposal bag
-Large spill=> contact OSHA
21
Q
Ergonomics for transferring patients
A
-Lifting is a high-risk activity (postural stressors)
-Manual lifting client’s full weight is BAD
-Use client-handling equipment
-Lift w/ legs not back
-Lift from close proximity
22
Q
Amyl Nitrate
A
-Antidote for cyanide poisoning
-Cyanide poisoning is an AE for nitroprusside
-S/S: HA, dizziness, anxiety, SOB, bitter almond breath
23
Q
Amputation Positioning
A
-First 24hrs = ELEVATED on pillow (above heart level)
-After 24hrs = DEPENDENT/DANGLING
24
Q
Blood Pressure Electronic Device
A
-For pts who require frequent evaluation
-Can have inaccurate readings
-Hypotension or movement
25
Contact Infections
RSV, Hep A, E. coli, Shigella, Herpes simplex, Impetigo, Scabies, MRSA, VRE
26
Droplet Infections
Strep, Pneumonia, Hib, Scarlet fever, Rubella, Pertussis, Mumps, Meningococcal pneumonia
27
Airborne Infections
Measles, TB, Varicella
28
Biliary Atresia
-Blockage in the tubes (ducts) that carry bile from liver to gallbladder (underdeveloped liver)
-Cause increase bilirubin (buildup)
-Common in infants
-S/S: Jaundice, dark urine, clay-colored stools, weight loss, irritability
29
NG Tube Suction
-For decompression/relieve abd distension
-Assess lab results (electrolytes & Hct)
-Monitor potassium levels (HYPO)
-Cause metabolic acidosis (low obstruction) or metabolic alkalosis (high obstruction)
30
Ciprofloxacin
-Fluoroquinolone; broad-spectrum antimicrobial
-For urinary tract, respiratory, GI tract infections
-Anthrax prevention
-Complications: GI discomfort, Achilles tendon rupture, supra-infection, phototoxicity
31
ABG Specimen Care
-Preprocedure: Perform Allen's test
-Intraprocedure: Perform arterial puncture, collect + cap specimen into basin of ice water, transport to lab ASAP
-Postprocedure: Hold direct pressure over the site for 5min, monitor for bleeding, document
32
Leukemia
-Causes increase of immature WBCs w/ neoplastic characteristics (AML/ANLL)
-Common in childhood
-Decreased PLTs (PLT transfusion)
-Low-grade fever, anorexia, HA, fatigue
-Bone marrow aspiration (needle biopsy)
33
Magnesium Sulfate
-Tocolytic; CNS depressant + relaxes smooth muscles (neuromuscular)
-Stops labor
-Prevent seizures (preeclampsia)
-Cause maternal hypocalcemia + transient hypotension
-Causes fetal nonreactive NST + reduced FHR variability
-Monitor DTR
-Antidote: Calcium gluconate
34
Hypoxia
-Decrease in tissue oxygenation
-Early: Tachypnea, Tachycardia, Restlessness, Pallor, Hypertension
-Late: Bradypnea, Bradycardia, Cyanotic, decreased LOC, Hypotension
-Position in semi-fowlers/fowlers, O2 therapy, promote turning/coughing/deep breathing/using incentive spirometer/suctioning
35
Abruptio Placentae
-Premature separation of placenta from uterus
-After 20 wks gestation
-Cause maternal death
-Vaginal bleeding (Dark red) => hypovolemic shock
-Sharp abd pain
-Tender rigid uterus
-IV fluids, blood products, continuous monitoring
36
Placenta Previa
-Placenta implants in lower segment of uterus/over cervical os
-Bleeding during 3rd trimester
-Painless vaginal bleeding
-Fetus in breech, oblique, transverse
-Decreased UO
-REST + don't insert anything into vagina
37
Paranoid Personality Disorder
-Distrust
-Suspiciousness
38
Schizoid Personality Disorder
-Emotional detachment
-Disinterest in close relationships
-Indifference to praise/criticism
-Uncooperative
39
Schizotypal Personality Disorder
-Eccentric personality
-Magical thinking
-Perceptual distortions
40
Antisocial Personality Disorder
-Disregard for others
-Lack empathy
-Criminality
-Deceitful
-Sense of entitlement
-Seductive/charming
41
Borderline Personality Disorder
-Instability
-Splitting behavior
-Manipulation
-Impulsiveness
-Suicidal
42
Histrionic Personality Disoder
-Emotional attention-seeking behavior
-Center of attention
-Seductive/flirtatious
43
Narcissistic Personality Disorder
-Arrogance
-Grandiose views
-Need consistent admiration
-Lack empathy
-Sensitive to criticism
44
Avoidant Personality Disorder
-Social inhibition/avoidance
-Extreme fear of rejection
-Anxious in social situations
45
Dependent Personality Disorder
-Extreme dependency in close relationships
-Fear of abandonment
-Cannot make own decisions
46
Obsessive-Compulsive Personality Disorder
-Indecisiveness
-Perfectionism
-No control over life
47
EXPECTED Lithium Toxicity (<1.5 mEq/L)
-N/V/D
-Thirst
-Polyuria
-Fine hand tremors
-Slurred speech
-Muscle weakness
(Improve over time)
48
EARLY Lithium Toxicity (1.5-2.0 mEq/L)
-GI distress (ongoing)
-N/V/D
-Confusion
-Coarse hand tremors
-Sedation
(Withhold med, notify HCP, promote excretion)
49
ADVANCED Lithium Toxicity (2.0-2.5 mEq/L)
-Tinnitus
-Blurred vision
-Ataxia/Seizures
-Severe hypotension
-Respiratory complications
(Whole bowel irrigation)
50
SEVERE Lithium Toxicity (>2.5 mEq/L)
-Oliguria
-Seizures
-Coma/Death
(Hemodialysis)
51
Erikson (Infant)
-Trust vs. Mistrust
-Birth to 1 year
-Delayed gratification
-Meet needs
52
Erikson (Toddlers)
-Autonomy vs. Shame vs. Doubt
-1 to 3 years
-Independence (do everything themselves)
-Negativism
-Ritualism
53
Erikson (Pre-schooler Children)
-Initiative vs. Guilt
-3 to 6 years
-Energetic
-Guilt from misbehaving/unable to accomplish task
-Guide to attempt activities within capabilities
-Set limits
54
Erikson (School-Age Children)
-Industry vs. Inferiority
-6 to 12 years
-Develop skills + knowledge (contribute to society)
-Sense of accomplishment
-Cooperate + compete w/ others
-Challenge w/ tasks
-Create system (rewarding)
55
Erikson (Adolescents)
-Identity vs. Role Confusion
-12 to 20 years
-Try different roles + experiences
-Sense of personal identity
-Unique individuals
-Group identity (social influences)
56
Colporrhaphy
-Surgery to fix weakness of vaginal walls
-Anterior (Cystocele) or Posterior (Rectocele)
-Pelvic muscles are shortened or tightened
-Increase bladder support or reduce rectal protrusion into the vaginal canal
57
Post-Op Colporrhaphy
-Administer PCA, antimicrobials, stool softeners
-Apply warm compress to abd
-Frequent sitz baths
-Low-residue diet
-Avoid straining at all (tighten/support pelvic muscles when straining)
-Avoid strenuous activity, sex for 6wks, carrying >5lbs
58
Post-Op Open Radical Prostatectomy
-Monitor I+O
-Check dressing, incision, and drainage
-Encourage client to void (urge)
-Dribbling is expected
-Administer stool softener (no straining)
-Administer abx (infection)
-Increase fiber
-Avoid tub baths
-Encourage fluid intake
-Do perineal exercises
59
Intermittent Tube Feeding Intervention
-For non-critical, home tube feedings, or rehab clients
-Tube placement verified by radiography
-Measure tube each shift/prior to feeding
-Verify presence of bowel sounds
-Maintain patency by flushing w/ warm water
-Check gastric residual volume before feeding
-Prevent aspiration
60
Indwelling Catheter Perineal Care
-Avoid inadvertently advancing cath into bladder
-Monitor for infections
61
Determine Strength for Ambulation
-Client should be able to move affected extremity in active motion
-Assess client's plantar flex the feet against resistance (most appropriate)
62
Buck's Traction
-Uses pulling force to promote + maintain alignment of injured area
-Preoperatively for hip fractures in immobilized adults
-Decrease muscle spasms + pain
-Immobilize extremity prior to surgery
-Weights free hanging attached to rope to client's skin (not on floor)
-Avoid lifting/removing weights
-Monitor skin integrity
-Prevent wrinkling of traction bandage
63
Ileostomy Diet
-Liquid only + slowly advance based upon client's tolerance
-High in fluids + low fiber
-Avoid foods that cause gas, stomal blockage, odorous
-Increase calories + protein intake
64
Growth + Development (Infant)
-Lose 5-10% birth weight in first few days (regained by 2nd wk) => increase 1.5lbs/month
-Palpable fontanels (A: closes 2-3m & P: closes 12-18m)
-Startling, sucking, palmar grasping, positive Babinski, respond to visual stimuli, mimic smile
-Cry = communication > vocalize "oohs + aahs" > laugh + squeals
-6 to 8 teeth erupt by end of year (teething)
-Object permanence @ 9m
-Solitary play
65
Contractions
-Braxton Hicks (false): painless, irregular, relieved by walking
-True: increase in intensity + frequency w/ regularity
-To subside: change position/walk around
-At least 3 contractions/10 min
-Duration: 40-60 sec/each
-Oxytocin: induces uterine contractions
-BAD => contractions > 90 secs or occurring more frequently than q 2 min
66
Abnormal Infant Symptoms
-Decreased UO
-Lethargic
-No response to voice
-Excessive crying > 3hrs
67
Nonpharmacological Comfort Measures for Pre-schooler
-Encourage child to watch favorite cartoon on TV
-Distraction > progressive relaxation
-Magical thinking, animism, centration (focus on one thing)
-Play w/ favorite toy/watch favorite cartoon to ease fears
68
Chronic Renal Failure Diet
-Low-protein, low-phosphorus, low-potassium, low-sodium
-Restrict fluids
-Limit phosphorus intake (meat, PB, dried beans, cola, chocolate, beer)
-Limit dairy products
-High biologic value protein recommended (eggs, soy, fish)
69
Restful Sleep
-Drinking hot milk
-Take bath before going to bed
-Go to bed and get up @ same time each day
-Don't take naps during day
-No TV until falling asleep
70
Crohn's Diet
-Low residue
-High protein
-High calorie w/ vitamins + mineral supplements
-IV fluids
-Enteral nutrition (exacerbation)
-Avoid nicotine/substances that cause diarrhea
-Ex: eggs, cooked ground meat, fish, poultry, white rice, cooked veggies w/o skin, pasta
71
Dumping Syndrome Interventions
-Avoid consuming milk, sweets, and sugars
-Eat small, frequent meals during the day
-Eliminate liquids w/ meals & one hour before + after meals
72
Guillain-Barre Syndrome Mobility Assessment
-Assess bowel sounds/frequency of stools
-Observe skin color over sacral, heels, scapulae areas
-Performing ROM of joints
73
Pneumonia Prevention
-Ambulate regularly (daily)
-Use humidifier
-Reassure client during resp. distress
-Well-rounded diet
74
Advanced Directive Legality
-Do NOT share client's wishes to ALL family members
-Document in medical chart
-Confirm if current
-Provide written information to client
75
Prioritizing Care Mgmt
-Prepare written list
-Postpone items that do not have immediate deadlines
76
Digoxin Toxicity Expected Findings
-Bradycardia
-Yellow vision/Halos
-Tinnitus
77
Ileostomy Stomal Swelling Intervention
-Moisten towels applied to abd (facilitate draining)
-Abd massage (promote drainage)
-Drink hot tea (facilitate drainage)
78
Hearing Impaired Interventions,
-Provide client w/ written instructions
-Turn off TV + close door (background sounds)
-Include client's spouse in teaching session
79
Action for Bladder Irrigation
-Closed intermittent irrigation: use soap + water w/ washcloth + gloves @ insertion site
-Cleanse catheter 3x/day + after pooping
-Check patency of catheter
-If obstructed, turn off CBI + irrigate w/ 50 mL irrigation solution or contact surgeon
80
Administering Intermittent Enteral Feedings (G-Tube)
-If using syringe, hold high for formula to empty gradually via gravity
-Fill syringe w/ 40-50 mL
81
Promote Sleep
-Exercise regularly at least 2hrs before bedtime
-Establish bedtime routine + regular sleep pattern
-Limit alcohol, caffeine, nicotine (4hrs before bed)
-Engage in muscle relaxation (stressed)
82
Prevent Pressure Injuries (Positioning)
-HOB @ or below 30 degrees (or flat)
-Relieve pressure on sacrum, buttocks, and heels
83
Progressive Relaxation
-Promotes relaxation using breathing techniques while TENSING + RELAXING specific muscle groups
84
Complicated Grief (Delayed/Inhibited)
-Delayed/Inhibited
-Doesn't demonstrate expected behaviors of normal grief
-Cultural expectations can influence
-Remain denial for long time
-Inability to progress through stages (trigger grief response after extended period of time)
85
Complicated Grief (Distorted/Exaggerated)
-Somatic manifestations (exaggerated)
-Unable to perform activities of daily living
-Remain in anger stage (project to themselves or others)
-Develop clinical depression
86
Complicated Grief (Chronic/Prolonged)
-Maladaptive
-Difficult to identify
-Remain denial (unable to accept reality)
-Inability to perform ADLs
87
Complicated Grief (Disenfranchised)
-Cannot be publicly shared or not socially accepted ----Ex: suicide/abortion
88
Normal Grief
-Uncomplicated
-Anger, Resentment, Withdrawal, Hopelessness, Guilt
-Changes to acceptance (overtime)
-Acceptance achieved by 6 months after loss
-Somatic manifestations: chest pain, palpitations, HA, nausea, changes in sleep pattern, fatigue
89
Anticipatory Grief
-"Letting go" of person BEFORE loss
-Have opportunity to grieve before actual loss
90
Complicated Grief
-Difficult progression through expected stages of grief
-Prolonged + more severe manifestations
-Suicidal ideation, intense guilt, lower-self esteem
-Somatic complaints
91
Alzheimer's Disease + Anxiety Communication
-Encourage reminiscence about happy times
-Talk about familiar things (memories)
-Break instructions + activities into short time frame
-Limit # of choices
-Minimize need for decision making
-Approach slowly + from front (address by name)
-Encourage family visitation
-Calm, reassuring voice
-Reinforce reality, orientation to time/place/person
-Establish eye contact
92
Assessing Peripheral Pulse w/ US Stethoscope
-Using bell to listen to low-pitched sounds (unexpected heart sounds or bruits)
93
Interpreting Cardiovascular Assessment
-Carotid Artery: over carotid pulses for bruits
94
Teaching Health Promotion Priority
-Nursing Process: ADPIE
-Assess client's ability to make health decisions
-Health literacy + health beliefs
-Determine additional info is needed PRIOR to calling HCP/making decision (DATA COLLECTING)
95
Newly Licensed Nurse Requires Intervention
D/Cing IV therapy:
-Check prescription
-Prepare equipment
-Perform hand hygiene/don gloves
-Clamp tubing
-Remove tape + dressing + stabilize
-Apply sterile gauze over site
-Withdraw catheter (pull straight back)
-Elevate extremity + apply pressure from 2-3 min
-Examine site, apply gauze + tape
-Document removal
96
Moving Client UP in Bed
-Widen base of support
-Pull object toward center of gravity
-PUSH: move front foot forward
-PULL: move rear leg back to promote stability
-Face direction of mvmt
-Use own body as counterweight
-Sliding, rolling, pushing require less energy than lifting
-Avoid twisting spine/bending your back
97
Removing PPE
-Clinical judgment needed
-Set priorities
-Gloves and gowns worn by the caregivers + visitors (contact precautions)
-REMOVE: Glove, Gown, Goggles, Mask
-DON: Gown, Mask, Goggles, Gloves
98
Items that Trigger Allergic Reactions
-Fruits (Kiwi/banana) => LATEX
-Eggs/Soybean oil => PROPOFOL
-Shellfish => IODINE
-Let client + ALL members of health care team know about allergy
-Use latex-free gloves/equipment/supplies
-Use nitrile gloves
-Schedule surgery FIRST!
99
Using Gait Belt (Ambulation)
-Complete fall-risk assessment (Romberg test)
-Instruct orthostatic hypotension pt => AVOID getting up too fast, sit on side of bed for few seconds before standing/walking
100
Evaluating ABGs
-Use tic-tac-toe method
-pH: low, PaCO2: high, HCO3: normal => respiratory acidosis
-pH: low, PaCO2: normal, HCO3: low => metabolic acidosis
-pH: high, PaCO2: low, HCO3: normal => respiratory alkalosis
-pH: high, PaCO2: normal, HCO3: high => metabolic alkalosis
101
ABG: Uncompensated vs Compensated
-Uncompensated: pH is outside expected range & either HCO3 or PaCO2 is outside expected range
-Partially compensated: pH, HCO3, and PaCO2 are outside the expected range
-Fully compensated: pH is within expected range, but PaCO2 + HCO3 are both outside the expected range
-Look at pH to see if its <7.40 (acidosis) or >7.40 (alkalosis)
102
Mechanical Ventilation Interventions
-Maintain patent airway + monitor respiratory status q hour
-Oxygenate before suctioning
-Assess + document sputum
-Continuous ECG
-Perform oral care q 2 hrs
-Wear PPE (gown, gloves, mask)
-Position HOB at least 30 degrees
-Administer enteral/parenteral feedings +confirm NG tube placement
-Prevent aspiration
103
Fever Intervention
-Antipyretics (aspirin, acetaminophen, ibuprofen) to reduce fever + discomfort)
-NO aspirin for children + adolescents who have VIRAL illness (Reye's Syndrome)
-Prevent shivering (increase energy demand)
-Offer blankets during chills + remove when warm
-Provide oral hygiene + dry clothing
-Provide fluids + rest
104
Focused Assessment of Sensory Functions
-Babinski Reflex (Plantar Reflex)
-Positive BAD in adults, but GOOD in newborns
-BAD => vertigo, hemiparesis, cranial nerve dysfunction, papilledema
105
Calculating Infusion Flow Rate
-For electronic infusion pumps (mL/hr) and manual IV tubing (gtt/min)
-Electronic pumps => x mL/hr = given mL/given hrs
-Convert minutes to hours
-Manual tubing => x gtt/min = (given mL/given mins) * (given gtt/mL)
106
Central Venous Access Device Care
-Wipe all ports w/ alcohol or antiseptic swab before connecting IV lines or inserting syringe to prevent infections
-Never disconnect tubing/reposition client
-Change IV sites q 72 hrs
-Remove catheters as soon as no need for them (clarify with HCP)
-Don't label IV bags w/ ink
107
Client Confidentiality
-Nurses must NOT disclose clients' information to unauthorized individuals or family members who request it in person/over phone
-Code system to identify individuals who can receive info
-Unauthorized individuals should ask client permission for medical information DIRECTLY
108
Diarrhea Priority Action
-F+E disturbances (metabolic acidosis) => excessive loss of HCO3
-Monitor for dehydration (weak, rapid pulse; hypotension, poor skin turgor, high temp)
-Monitor for hypernatremia + hypokalemia
-Replace F+E (IV fluids => rehydration therapy)
-Safety risk priority
109
Transferring Client from Bed to Stretch
-Evaluate need for additional staff/assistive devices
-Ex: transfer belt, hydraulic lift, sliding board
-Determine client's ability to help w/ transfer
-Ex: balance, muscle strength, endurance, use of trapeze bar
110
Antianginals
-Nitroglycerin or BB
-Relieve chest pain + prevent MIs + improve blood flow (decreasing O2 demand)
-Dilate blood vessels
-Determine cause active/rest
-Continuous ECG monitoring + cardiac labs (check effectiveness)
-Complications: orthostatic hypotension
111
Anticoagulants
-Prevent clotting (DVT, PE, MI, stroke)
-Heparin (IV), Enoxaparin (IM), Warfarin (PO)
-Need frequent blood tests
-Check therapeutic levels + clotting times (aPTT, PT, INR, PLT)
-Manage Vit K levels (warfarin)
-NO 5 G's => garlic, ginseng, gingko biloba, glucosamine, ginger!
-Complications: Chest pain, altered LOC, coughing blood, increased risk of bleeding (GI)
-Use electric razor, soft toothbrushes, no contact sports, don't blow nose too hard, avoid alcohol
112
Antirheumatics
-Treat rheumatoid arthritis (decrease inflammation + pain)
-Prevent further joint deformities
-DMARDs (methotrexate, sulfasalazine, hydroxychloroquine) + etanercept
-Complication: infection, hepatotoxicity, hyperglycemia, F+E imbalance, HTN, osteoporosis, glaucoma
113
Antituberculosis
-Treat TB and decrease risk of transmission
-Combo tx: RIPE (Rifampin, Isoniazid, Pyrazinamide, Ethambutol)
-Give with active/suspected TB
-Check sputum culture for clearance + CXR (3 consecutive negatives)
-Expect: orange-tinged body fluids
-"RIPE orange"
-Taken 6-12 m
-Complications: GI upset, peripheral neuropathy, hepatoxicity, hyperglycemia
-Antidote: Vit B6
-Monitor liver functions + avoid alcohol
114
Antimicrobial
-Decrease-prevent post-op infections/further systemic infections (PROPHYLACTIC)
-Penicillin, Cephalosporin, Tetracyclines, Aminoglycosides, Macrolides, Fluoroquinolones
-Monitor WBCs
-Complications: GI upset, nausea, allergic reaction, thrush
115
Glucorticoids
-Treat allergies, anti-inflammatory, control metabolism
-Prednisone + dexamethasone
-Affect thyroid function
-High doses => reduce conversion of active T4 to T3
-Complications: hyperglycemia, immunosuppression, infection, weight gain,
-Monitor blood sugar +administer insulin
116
Opioids Analgesics
-Pain relief (moderate to severe)
-Highly addictive
-Morphine sulfate, oxycodone, hydrocodone, codeine, methadone, fentanyl
-Complete pain assessment q 2 hrs (effectiveness)
-Complication: constipation, overdose, tolerance, depression, sedation
-Give stool softeners
117
Atropine
-Increases HR by interfering w/ vagal impulses
-Increasing work + oxygen demand
-Treats bradycardia + manage digoxin toxicity & dysrhythmias
-ACh effects => blurry vision, dry mouth, urinary retention, constipation, dilated pupils
-"PINE" = like a pine tree goes UP
-For unresponsive patients
118
DigOxin
-Decrease electrical conduction thru AV node + decrease automaticity in the SA node
-Increase myocardial contraction
-For: HF, A-Fib, A-flutter, paroxysmal SVT
-Complication: digoxin toxicity + hyPOkalemia + arrhythmias
-DON'T give to pregnant, Vtach/Vfib pt
-Contraindication: CCB, antidysrhythmic, diuretic, corticosteroids, antacids
-Take apical pulse BEFORE giving (BAD < 60bpm)
119
Digoxin Toxicity Intervention
-Hold drug + call HCP
-Eat high-potassium diet (hyPOkalemia)
-Administer @ same time daily
-Monitor digoxin + potassium levels
-Antidote: Digiband
-Educate on complications
-Administer potassium IV/PO (hyPOkalemia)
120
Nifedipine
-CCB + tocolytic
-For decreased BP and relaxing smooth muscles (uterine + blood vessels)
-For angina pectoris, HTN, cardiac dysrhythmias, stop labor/contractions
-Monitor for tachycardia, lightheadedness, swelling
-Complications: orthostatic hyPOtension, peripheral edema, reflex tachycardia, HA
-NOT for cardiac pts
-NO grapefruit juice, BB, Mg Sulfate
121
DKA: Insulin HyPOglycemia Tx
-Frequent blood glucose level checks HOURLY
-Administer glucose (conscious) => snack, OJ, milk, glucose tablets, candy
-Administer IV glucose, IM glucagon, D50 (not conscious)
-Wear medical bracelet
-Always have snack of glucose on you
122
Captopril Interventions
-ACh effects (REPORT)
-Dry cough: notify HCP to d/c, encourage increasing fluids, consume candy
-HyPERkalemia: monitor, low-potassium diet
-Altered taste: notify HCP
-Angioedema: epinephrine + d/c
-Take 1 hr before meals (with or without food)
-Rise slowly
123
TPN Effectiveness
-Albumin levels 5.0 g/1 mL (4.5-5.0 g/100 mL)
-Gaining up to 1 kg/day
-Increase in prealbumin levels (15-36 mg/dL)
-BUN within expected level (7-20)
-Monitor electrolytes, CBC, BUN, glucose, albumin
124
Type 1 DM Lab Interpretation
-Fasting plasma glucose for diabetic (90-130 mg/dL)
-HbA1C level (4-6%)
-HbA1C is long-term glycemic control indicator for 3 months
-Fasting plasma glucose is short-term
125
Digoxin Abnormal Labs
-HyPOkalemia (<3.5)
-Digoxin levels (>2.0)
126
Nitroglycerin Nursing Care
-NOT for anemic, close-angle glaucoma, traumatic head injury pts
-Administer before activities
-Encourage pt to sit/lie down!
-Store in cool, dark places
-Don't crush/chew
-Shave + dry area, remove old patch, remove @ night, rotate sites (patch)
-Measure dose + wear gloves (ointment)
-Continuous cardiac + BP monitoring
-Call 911 + administer second tablet, if first one doesn't work (wait 5 min to take third)
-Don't stop abruptly!
127
Penicillin Injection Safety
-Assess for allergies to penicillin or cephalosporins
-HARMFUL => infants, older adults, pregnant, acutely ill
-Hand hygiene
-Check for up to date immunization status
-Test sensitivity
-Monitor kidney functions/labs
-Sit still for 30 min after injection (reduce anaphylactic reaction)
128
Imipramine HCl Toxicity
-Tricyclic Antidepressant
-"Inhibit my PEEING"
-Orthostatic hyPOtension
-ACh effects
-Sedation
-Excessive sweating
-Dysrhythmias/Arrythmias (overdose/toxicity)
-Confusion/Seizures
129
Digoxin Effectiveness
-Normal cardiac status + potassium/digoxin levels
-HF is controlled
-Absence of cardiac dysrhythmias
-Decrease pulmonary crackles (from left HF + pulmonary edema)
130
Lisinopril Assessment (BEFORE)
-ACE inhibitor
-Check BP before administration
-Check serum electrolytes (HYPERkalemia)
-Check lithium
-Stop using NSAIDs
-Stop taking diuretics 2-3 days before
131
Angioedema vs Peripheral Edema
-Angioedema: severe allergic reaction => swelling underneath skin of face, oropharynx, neck, tongue
-Peripheral edema: swelling of leg tissue from fluid retention
132
Gentamicin Sulfate A/E
-Harmful to fetus
-Ototoxicity
-Nephrotoxicity (low UO)
-Muscle weakness
-Hypersensitivity
133
Fluoxetine (SSRI) Priorities
-Take in the morning (prevent insomnia)
-Take same time DAILY
-Take as prescribed (DON'T abruptly stop)
-S/E: ACh effect, blurry vision, constipation, drowsiness, euphoria, weight changes, sexual dysfunction
-Monitor for Serotonin Syndrome (SADHEAD)
-Administer w/ food
-Takes up to 4 wks to work
-No St. John's wort, MAOIs, TCAs
134
Methylprednisolone Sodium Succinate IV S/E
-Infection (fever/sore throat)
-Hyperglycemia
-Bone loss
-Muscle weakness
-Peptic Ulcer Disease (PUD)
-Hypokalemia
-Weight gain
-Insomnia
135
Mannitol Supplies
-Continuous IV infusion
-Syringe
-Filter needle
-IV filter tubing
-Alcohol wipes
-Potassium supplements (hypokalemia)
136
Jehovah's Witness Culture
-No blood transfusions
-Avoid foods having or preparing with blood
-Burial or cremation
-Epoetin Alfa: growth factor for anemic pts or to increase erythrocyte counts in clients who will undergo elective surgery (appropriate)
-Allowed to use albumin, growth factors, immunoglobulins, and clotting factors
137
Duodenal Ulcer w/ Status Asthmaticus Wrong Med
-Prednisone (increase incident of peptic ulcers)
-Naproxen (gastric irritation)
138
Corticosteroids A/E
-Susceptibility to infection
-Truncal obesity (Cushing's)
-Osteoporosis
139
Digoxin Education
-Slows heart rate
-Contact HCP if experiencing visual changes
-Digoxin level test @ beginning of drug therapy
-Takes 1-2 wks to work
-Monitor levels routinely
-Contact if experiencing excessive nausea (toxicity)
140
Glaucoma (Meds to Avoid)
-Scopolamine ( ACh effects)
-Diphenhydramine (ACh effects)
-Methylphenidate (ACh effects)
-All cause blurry vision + dilated pupils
141
PCA (Morphine sulfate) interaction
-Decreased respiration (Respiratory depression)
-Decreased SpO2
-Excessive sedation
-Shallow respirations
142
Warfarin Education
-Concurrent use of glucocorticoids should be avoided (increase anticoagulant effect)
-Oral contraceptives will decrease anticoagulant effects
-Intake of Vit K should be monitored
143
DKA expected S/S
-Decreased serum pH (<7.35)
-Kussmaul breathing
-Fruity breath
-Increased serum potassium (>5.3)
144
Older Adult Fluid Imbalance
-Oliguria (decreased urine production)
-Sunken eyes
-Capillary refill > 5 sec
-Tenting of skin over sternum, collar bone, forehead
145
Methotrexate Education
-Monitor CBC (decrease WBC, liver functions, and kidney functions)
-Check for infection (sore throat)
-Monitor temperature (fever)
-Hepatotoxicity (jaundice)
-GI ulcers (toxicity)
146
Allopurinol
-For chronic gout/gout attacks
-Complications: hypersensitivity, kidney injury, hepatitis, GI distress, increase in gout attacks
-Slows metabolism of warfarin (bleeding)
-Take w/ food or after meals (decrease GI upset)
-Avoid alcohol + high purine foods
-Drink 2-3 L of fluids/day (prevent kidney injurt)
147
Antilipemic Agents
-Lower LDL cholesterol levels/triglycerides + raise HDL cholesterol levels
-Prevent coronary events (CAD) + strokes
-Include lifestyle modifications
-Check cholesterol, liver, and kidney function levels
-Complications: Hepatotoxicity + myopathy
-Avoid alcohol
-Take w/ low-fat, low-cholesterol diet & regular exercise
148
Statins
-Rosuvastatin/Lovastatin/Atorvastatin (-statin)
-Check baseline cholesterol levels + CK levels
-Report anorexia, GI upset, jaundice, muscle pain
-NOT for pregnant people
-DON'T take Fibrates
-Administer in evening
149
Cholesterol Absorption Inhibitor
-Ezetimibe
-Report liver + muscle issues
-NO bile acid sequestrants/statins/fibrates
-Administer 1 hr before/after bile sequestrants
150
Bile-Acid Sequestrants
-Colestipol/Colesevelam
-Complications: Constipation, bowel obstruction, pancreatitis
-Decrease oral contraceptive effect
-Administer 1 hr before or after meds that interact w/ them
-Increase fiber + fluids
-Administer vitamin supplements
151
Fibrates
-Gemfibrozil/Fenofibrate
-Complications: GI upset, Gallstones, Myopathy, Hepatotoxicity
-Report RUQ pain, fat intolerance, bloating
-NO warfarin + statins
-Take 30 min before breakfast + dinner
-Monitor for biliary disease
152
Nicotinic Acid
-Niacin
-Monitor BUN + creatinine
-Advise to take aspirin 30 min before/dose
153
Gingko Biloba
-Mild GI upset, HA, lightheadedness, caution w/ seizure pt
-Lower seizure threshold
-Interfere w/ coagulation (risk of bleeding)
154
St. John's Wort
-Dry mouth, constipation, GI upset, skin rash (sun-exposure)
-Decrease contraceptive, warfarin, digoxin, CCB, steroids, HIV, cancer drug effects
-Risk for bleeding
155
Ginseng
-Nervousness, agitation, insomnia, diarrhea, HA, heart palpitation
-No MAOIs
-Interrupt heart med effects
-Risk of bleeding (anticoagulants)
156
Garlic
-GI upset
-Risk for bleeding
-Hypoglycemic effect
157
Echinacea
-Bitter taste, mild GI upset, fever
-Chronic use decreases TB drug effects
-Risk of bleeding
158
Saw Palmetto
-Mild GI upset + interrupt detection for cancer marker
-Additive effects w/ finasteride
159
Kava Kava
-Dry flaky skin, jaundice, liver damage
-Sedation when taken w/ CNS depressants
160
Black Cohosh
-GI upset, lightheadedness, rash, weight gain
-Increase antihypertensive drug effects
-Hypoglycemia
161
Valerian
-Drowsiness, lightheadedness, depression, risk of physical dependence
-CNS depression
162
Feverfew
-Agitation, tiredness, insomnia, HA, joint discomfort
-Risk of bleeding (NSAID, heparin, warfarin)
163
Ganciclovir
-Treat + prevent cytomegalovirus (CMV), HIV/AIDS, organ transplant, immunocompromised
-DON'T give pregnant pt
-Obtain CBC + PLT (suppress bone marrow)
-Administer w/ food (N/D)
-Administer IV slowly
-Increase fluid intake
164
Near Miss Medication Error
-Must file an incident report
-Notify HCP of all errors
-Implement corrective measures ASAP
165
Oxybutynin A/E
-ACh effects: constipation, dry mouth, blurred vision, photophobia, dry eyes, tachycardia, anhydrosis
-Anhydrosis: decrease ability to produce sweat to cool body => avoid activities that cause overheating (hyperthermia)
166
Neonatal Abstinence Syndrome S/E
-Maternal substance use during pregnancy consist of use of alcohol/drugs
-CNS: high-pitched cry, hyperactivity, increased DTR, convulsions, tremors
-Metabolic/Resp: nasal congestion w/ flaring, frequent yawning, apnea/tachypnea, high temp
-GI: poor feeding, projectile vomiting, diarrhea, constant sucking
167
Raloxifene Client Teaching
-Chemotherapy agent used to treat/prevent breast cancer
-Stop growth of breast cancer cells (estrogen-dependent) => blocks estrogen receptors
-Oral
-Complications: endometrial cancer, hypercalcemia, N/V, thromboembolic events, hot flashes, vaginal discharge/bleeding
-DON'T give to pt taking anticoagulants and SSRIs
168
Digoxin Contraindications
-Digoxin slows down AV conduction
-DON'T give to pts w/ ventricular rhythm disturbances (V-fib, V-tach, second- or third-degree heart block), hypokalemic, partial AV block, advanced HF, impaired kidneys
169
Promethazine Client Teaching
-Antihistamine (1st gen H1 antagonist)
-Causes sedation, ACh effects, GI discomfort, acute toxicity, seizures, respiratory depression
-Take @ night
-Avoid activities that involve alertness + alcohol/CNS depressants
-Increase fluid intake (2-3 L) + eat w/ meals
170
Metformin Contraindication
-Severe infection (WBCs)
-Shock
-Kidney impairment (check creatinine levels)
-Hypoxic condition (O2 saturation)
-Alcohol use disorder
171
Procainamide Action
-Antidysrhythmic med
-Sodium Channel Blocker: slows cardiac conduction velocity => delay
-For SVT, V-tach, A-flutter/fib
172
Neostigmine A/E
-For Parkinson's + MG
-REVERSABLE
-Cholinergic crisis: excessive stimulation, resp. depression, paralysis
-Excessive muscarinic stimulation: increased GI motility/secretions, diaphoresis, increased salivation, bradycardia, urinary urgency
173
Exenatide
-Antidiabetic med (supplemental glucose control)
-For Type 2 DM
-SQ (thigh, abd, upper arm)
-Complications: GI upset + pancreatitis
174
Levodopa/Carbidopa A/E
-N/V/Drowsiness
-Dyskinesias (antidote: amantadine)
-Orthostatic HyPOtension
-Psychosis (clozapine)
-Sweat/urine discoloration (harmless)
-Activation of malignant melanoma
175
Hydromorphone Toxicity
-Antidote: naloxone (opioid antagonist)
-Resp. depression, coma, + pinpoint pupils
-Provide mechanical ventilation
176
Epoetin Alfa Effectiveness Labs
-H+H (weekly or 2x/week)
-Iron
177
Dextroamphetamine A/E
-CNS stimulation (insomnia + overstimulation)
-Mania/aggressiveness
-Dysrhythmias
-Psychosis (hallucinations + paranoia)
-Physical tolerance/withdrawal (TAPER OFF)
-Toxicity (dizziness, palpations, HTN, seizures)
178
Zidovudine Client Teaching
-Antiretroviral med (HIV)
-Cause suppressed bone marrow (neutropenia) + liver disease
179
Pregabalin Contraindication
-Benzodiazepines
-Alcohol
-Opioids
-Intensify depressive effects (AVOID)
-Avoid activities that require alertness
180
Meperidine Priority
-Opioid: resp. depression, sedation
-Check ABCs
-Report if RR <12/min (WITHHOLD + Notify HCP)
-Administer SLOWLY
-Double-check dosage w/ another nurse
181
Isoflurane (General Anesthesia) Priority
- Check ABCs (sedation + anesthetic effects)
-HyPOtension can occur (lower HOB, administer IV fluid + monitor BP)
-Encourage pt to urinate BEFORE administering
-Bed is in low position
182
Unsafe Abx for Preschooler
-Tetracycline: yellow/brown tooth discoloration + hypoplasia of enamel
-Avoid giving to children < 8yrs + pregnant pt
183
Hydrochlorothiazide A/E
-Hyperglycemia (monitor BG)
-Dehydration/HyPOnatremia
-HyPOkalemia
-Hyperuricemia
-HyPOmagnesemia
184
Self-Administering Enoxaparin
-Self inject SQ @ 45-90 degrees
-20G or 22G needle
-2 inches from umbilicus
-DON'T aspirate
185
Atenolol A/E
-BB 1 (ONLY HEART)
-Orthostatic HyPOtension (sit/lie down + change positions slowly)
-Lightheadedness
-Bradycardia
-AV Block
186
Atenolol Assessments Prior
-Monitor pulse (< 50/min = HOLD + notify)
-Check BG (hypoglycemia)
-Monitor BP (orthostatic hyPOtension)
187
Oxytocin A/E
-Uterine tachysystole: more intense, longer, and more frequent contractions
-Uterine rupture: rupture/tear of uterus + internal bleeding
-Abruptio placentae: displacement of the placenta that causes sharp pain, vaginal bleeding
188
Mannitol Complications
-Rebound ICP
-F+E imbalances (hypovolemia + hyper/hyponatremia)
189
Acute Respiratory Failure (ARF)
-Occurs when one of the gas exchange functions FAIL => inadequate gas exchange
-Acid-base imbalance (uncompensated resp. acidosis) -Ventilation-perfusion mismatch
-Hypoxemic vs. Hypercapnic
-V/S: decreased O2 Sat, increased RR
-Symptoms: lethargic
190
Hypoxemic vs. Hypercapnic
