QUIZ 1-2 Flashcards
1
Q
Which situation requires the nurse to complete an incident report?
A
1.A visitor having symptoms of illness; **
2 accidental omission of prescribed therapies; **
3 **circumstances that lead to injury or a risk for client injury;
4 medication administration errors; **
5 needlestick injuries
6 and client fall
2
Q
Hypokalemia
A
Low potassium levels in the body can be **caused by an adrenal gland disorder, **a prolonged bout of diarrhea or vomiting, chronic laxative abuse, diuretics, or a low magnesium level.
3
Q
Symptoms OF HYPOKALEMIA
A
weakness,
cramps,
twitching,
and abnormal heart rhythms.
4
Q
NORMAL POTASSIUM LEVEL
A
3.5-5.0 mEq/L
5
Q
CAN WE CRUSH POTASSIUM TABLET?
A
NO
Should not crush the medication as this releases all the medication at once and can increase the chances of adverse reactions.
6
Q
CAN WE BREAK THE POTASSIUM PILL INTO HALF?
A
YES
7
Q
SMART
A
* S-specific*
*
* M-measurable,
* A-achievable,
*
* R-relevant,
*
* T-time-bound.
8
Q
Anaphylaxis
A
A potentially life-threatening condition that is caused by a hypersensitivity reaction to an antigen.
9
Q
epinephrine ROUTE
A
administered by intramuscular (IM)
10
Q
SIGNS AND SYMPTOMS OF INFECTION?
A
1. WARMTH
2. REDNESS
3. INFLAMMATION
4. PURULENT OR FOUL-SMELLING
5. DRAINAGE
6. FEVER
11
Q
Clients with pressure ulcers need specialized care
A
skin maintenance,
wound management,
adequate nutrition,
pain control,
and pressure relief.
12
Q
signs and symptoms of an infected pressure injury
A
1** Fever**
2 Foul-smelling drainage
3 Wound redness
4 Wound warm to touch
5 Edema
13
Q
3 supplies
that are appropriate for the nurse to administer a pneumonia vaccine to a client
A
-
3 mL syringe
Since the pneumonia vaccine is 0.5 milliliters, a 3 mL syringe would be appropriate to prepare for its administration.
2.* 2 x 2 alcohol prep pad*
The nurse should obtain a 2 x 2 alcohol prep pad to clean the injection site before administration of the pneumonia vaccine. The alcohol prep pad reduces germs and bacteria in the injection area.
-
23 gauge, 1 ½ inch safety needle
A 23-gauge, 1 ½ inch safety needle is correct for the administration of the pneumonia vaccine to an obese adult client.
14
Q
Preventative strategies to decrease the risk for pressure injury include
A
-
DO NOT drag or pull the client up in bed, as this causes shearing to occur;
2 DO NOT massage bony prominences; -
Monitor nutritional status,
including serum albumin levels; 4. Provide prompt care for clients who are incontinent of bowel and/or bladder;
5 Reposition clients every 2 hours using appropriate assistive devices; - use** barrier creams to moisturize, protect, and reduce irritation** of the client’s skin;
7 use foam padding or wedges to decrease pressure on the client’s bony prominences.
15
Q
. Common risk factors associated with the development of pressure injury include*
A
- Advanced age;
- Altered levels of consciousness **(LOC); **
-
Comorbidities (e.g., HIV)
; 4.** Immobility; ** - Incontinence; **
6. Infection; ** - Use of medical devices;
- Poor oxygenation and perfusion (e.g., dopamine infusion);
- Poor nutrition (e.g., low serum albumin level);
- Unintentional weight loss.
16
Q
Albuterol
A
A short-acting bronchodilator relaxes and expands air passages in the lungs, thus helping the client breathe easier.
Side effects of this medication may include** shakiness, tachycardia, irritation, and headache; therefore, it is vital to monitor the client after the treatment.**
16
Q
Oxybutynin
A
very effective for clients with an overactive bladder.
17
Q
Methylergonovine
A
rapid and strong uterine and vascular contraction.
It is rarely given IV, however, because of the risk of stroke caused by the sudden vasoconstriction.
18
Q
How to administer oral medications to an infant.
A
****a reclining position **
give medication.
2 Use a measuring syringe to administer the medication slowly.
19
Q
Venlafaxine
A
serotonin and norepinephrine reuptake inhibitor (SNRI) prescribed for depression. venlafaxine can take 2-4 weeks to decrease symptoms of depression.
20
Q
Cyclosporine
A
An immunosuppressant medication that is prescribed to clients after organ transplantation decreases the risk of rejections. As with all immunosuppressants, the medication can result in leukopenia and thrombocytopenia, thus increasing the risk of infection and bleeding.
21
Q
Methotrexate
A
is an immunosuppressant medication used to treat rheumatoid arthritis (RA) and psoriasis. As an immunosuppressant, this medication weakens the immune system, thus increasing the client’s risk for infection.
21
Q
Thready pulse
A
A fast and thready pulse is a finding that indicates continued dehydration; t
22
Q
Brisk capillary refill
A
an assessment finding that indicates resolution of dehydration
22
Dry mucous membranes
a finding that indicates continued dehydration;
22
Acetaminophen
Acetaminophen is an OTC analgesic that can be safely administered during pregnancy to address fever, headache, and muscle and joint pain.
23
Naproxen sodium
Nonsteroidal anti-inflammatory drugs (NSAIDs), including naproxen sodium, increase the risk for spontaneous abortion during the first trimester of pregnancy;
24
**tamsulosin**
Tamsulosin is given **to relax the smooth muscles involved in urination,** promoting the ability to urinate and empty the bladder. The blockage of alpha-adrenergic receptors also contributes to orthostatic .
25
proper steps during mixing he insulin in the multi use vials
1. The nurse should clean the vials, place the amount of air (in units) into the NPH (cloudy) insulin,
2 . then place air into the Regular (clear) insulin. Immediately, without removing the needle, the nurse should pull back the amount of insulin units into the syringe (have another nurse check this)
3, pierce the NPH vial and withdraw the NPH insulin units into the syringe.
4 Another nurse should verify that the NPH insulin dosage is correct by confirming that the total is the sum of the two insulins (Regular insulin units + NPH insulin units = Total in the syringe).
26
NEWBORN IM INJ GAUGE ?
A 22 gauge needle is appropriate for the administration of IM injection for the newborn client
27
**IM** INJ SITES FOR **NEWBORN**
***The vastus lateralis ***
is the muscle of choice for administering IM injections to
**newborns and infants.**
Tuberculin syringe: Accurate measurement of medication that is** less than 1 mL.**
28
ibuprofen 800 mg 2 hours prior to surgery.
**Ibuprofen, along with other nonsteroidal anti-inflammatory drugs (NSAIDs), are often held for 7 days before surgical procedures** to decrease the client’s risk for bleeding; therefore, this prescription requires HCP clarification.
29
**cyclosporine after liver transplantation.**
**Immunosuppressant medications s**uppress bone marrow function increasing the risk for **leukopenia** (i.e., decreased white blood cell [WBC] production) and/or **thrombocytopenia (**i.e., decreased platelet production). Leukopenia increases the client’s risk for infection while thrombocytopenia increases the client’s risk for bleeding. Additionally, the prescribed cyclosporine can also cause **hypercholesterolemia, hyperglycemia, and hypertension**; therefore, monitoring the client’s blood pressure and serum cholesterol and glucose levels in the provision of client care.
30
Psyllium
a bulk-forming agent for **constipation.**
31
Simethicone
an ant flatulent medication
32
**Peptic ulcer disease (PUD)**
An** opening or sore in the mucosal lining of the stomach.** This condition is commonly caused by nonsteroidal anti-inflammatory drug **(NSAID) use and a bacteria called Helicobacter pylori (**H pylori). Treatment for PUD includes discontinuing NSAIDs and a**dministering H2 receptor blockers, proton pump inhibitors (PPIs), and antibiotic therapy.** Additionally, nausea and vomiting are often a concern for clients who are diagnosed with PUD, so antiemetic medications are important.
33
“Diphenhydramine
to decrease the allergic response to the PCN.
The nurse should explain to the client that drowsiness will occur.
34
**Methylprednisolone”**
a** steroid **ordered to decrease inflammation from the allergic response to PCN.
35
**Serotonin syndrome (SS)**
**Serotonin syndrome (SS) is a potentially life-threatening condition that can occur when the body has too much circulating serotonin.**
***Medications that can cause SS alone and in combination with selective serotonin reuptake inhibitor (SSRI), selective serotonin/norepinephrine reuptake inhibitors (SSNRIs), and monoamine oxidase inhibitors (MAOIs).
As the levels of serotonin increase from these medications, the client should be monitored for SS
36
Symptoms of SS
1. Restlessness
2. Agitation
3. Nausea
4. Vomiting
5. Diarrhea
6. Profuse sweating
7. Tachycardia
8. Hypertension
9. Elevated body temperature
10. Coordination issues
11. Hyper-reflexes
12. Psychosis
.
. Clients should be informed of these potential side effects and to report these immediately.
37
Normal PT (prothrombin time) range (i
1-12.5 seconds
38
normal INR (international normalized ratio) range
1.0-2.0
39
when a client is receiving an**anticoagulant, the therapeutic range for INR **
**2.0-3.0**
unless the client has had a mechanical valve replacement, in which case, the therapeutic range is 2.5-3.5.
40
bradykinesia
slow movement
41
**Multiple sclerosis (MS**
1. The disorder occurs when the client’s **immune system attacks itself and destroys the brain’s myelin **or the insulating covering that covers the nerves in the spinal cord and brain.
2. The age of onset is generally between the ages of** 20 and 50** years of age.
3. Like PD, MS affects the client’s nervous system and c**auses mild hand tremors, poor balance, and decreased extremity strength**
4. . Other MS symptoms include **muscle spasms, decreased sensation of touch, visual changes, and fatigue.**
5. Nevertheless, MS does **not have symptoms associated with PD, such as a forward head posture with rounded shoulders or bradykinesia.**
42
**Parkinson’s Disease**
**1. Age of onset: 67 years.
2. Mild hand tremors
3. Poor balance
4. Forward head posture with rounded shoulders
5. Bradykinesia SLOW MOMENTS
6. Decreased extremity strength**
43
**Attention-deficit hyperactivity disorder**
1. A disorder in children in which the** brain has low levels of the neurotransmitters dopamine and norepinephrine. **
2. These neurotransmitters help the brain** focus on a reward vs. risk basis, control impulsivity, and mood and can result in hyperactivity and restlessness.**
3. In addition to hyperactivity, children may** display an inability to focus, impulsive behavior, and even low self-esteem and poor social skills. **
4. When caring for a child with ADHD, the nurse should **prioritize client safety and caregiver education due to the increased risk of injury.**
5. The nurse should teach caregivers **how to decrease the child’s risk for injury and maintain a calm environment with clear boundaries**
6. . The nurse should encourage caregivers to provide children with a **written schedule with clear expectations and offer praise or positive reinforcement for completing tasks or following directions.**
44
➤Which **intervention** should the nurse include in the client’s nursing plan of care for ADHD ?
Sure, here is the revised text:
1. Encourage parents t****o** establish clear and consistent** limits with their child.
2. Recommend implementing an **Individualized Education Plan (IEP).**
3. Set up **consequences for inappropriate behavior.**
4. Monitor the child's **height and weight closely after starting pharmacotherapy.**
5. Advise parents to capture their **child's attention and then visually and verbally explain the daily schedule.**
45
**Urosepsis/Infection" Symptoms**
1. **an elevated temperature** (fever),
2. pain in the **lower back or side (flank),**
3.** generalized fatigue**
4. , **swelling, **
5. and** elevated WBCs.**
6. Elevated WBCs result due to the infectious process and ***elevation in creatinine and BUN*** reflect the decrease in kidney function due to extreme infection.
7. These symptoms should be monitored and ***reported t***o the health care provider.
46
Amikacin Adverse Effect”
ototoxicity and nephrotoxicity.
47
**Aminoglycoside antibiotics,**
such as **amikacin, gentamicin, neomycin, and tobramycin, **are most commonly **used to treat infections in cystic fibrosis or to treat urosepsis caused by pseudom****onas.
These medications block protein synthesis of the bacteria. The nurse recognizes that the primary safety consideration related to these medications include**s potential for ototoxicity and nephrotoxicity.**
48
The nurse is preparing to administer a **vaccine to a 7-month-old infant. Which injection site and needle length is appropriate for the nurse to use?**
**Anterolateral thigh, 1-in (25-mm) needle**
The anterolateral thigh (i.e., vastus lateralis muscle) is the site of choice when administering an IM injection to an infant. In addition, the needle length is within the prescribed range for IM injection; therefore, this reflects an appropriate injection site and needle length for this client
48
**digoxin** level
The therapeutic range is **0.5 to 2 mg/mL.**
48
****the **SIZE OF NEDDLE** when giving an IM injection. For the infant client,
********the needle size ranges from 7/8″ (22 mm) to 1″ (25 mm) and the gauge ranges from **23 to 25**. Therefore, to administer a vaccine to an infant client the nurse uses **the anterolateral thigh (i.e., vastus lateralis muscle) with a 1 inch (25 mm) needle.**
48
**azathioprine**
Azathioprine** suppresses cell-mediated immunity and alters antibody formation.** The medication is excreted by the kidneys and is associated with ***nephrotoxicity. ****The nurse must monitor the client for symptoms of kidney damage **(e.g., decreased urine output, dependent edema), i**ncluding evaluating laboratory data. The laboratory data monitored for clients at risk for **kidney damage is a BUN level.**
49
Common medication interactions with apixaban
SSRIs, phenytoin, NSAIDs, rifampin, and carbamazepine
49
Signs to report WITH **APIXABAN** include
**increased bruising
black or tarry stools, uncontrolled nose bleeds
blood in their urine.**
Clients should **not discontinue apixaban suddenly without the advice of their healthcare provider, as this increases the risk of thrombotic events.**
49
**Apixaban**
Apixaban is ***contraindicated in clients with an artificial heart valve *and other anticoagulants** should be used in those clients.
50
Oral candidiasis
fungal infection.
51
Clinical manifestations associated with this **fungal infection include**
**WHITE lesions o**n the inner cheeks, gums, roof of the mouth, tongue, and tonsils.
52
**MEDICATION FOR ORAL CANDIDIDASIS**
An ***oral nystatin suspension* **is often prescribed to treat oral candidiasis (i.e., thrush)
53
**NURSING EDUCATION FOR CLIENT WITH ORAL CANDIDIASIS**
1. Encourage the client to place and** soak oral dentures in nystatin suspension.**
2. The medication should be taken for the **prescribed course and not stopped when symptoms disappear.**
3. Shake **all suspension medications prior to administration**.
4. Instruct the client to **gargle the nystatin a few minutes before swallowing.**
54
**Hydrocortisone cream’s mechanism of action**
decrease skin inflammation.
***It reduces redness, swelling of the skin, and itching. This medication is used externally only and applied in a thin laye***r.
54
**Acyclovir**
An **antiviral medication** that is used to treat **shingles or herpes zoster. It terminates the virus and keeps it from replicating;**
55
phenazopyridine
1. Phenazopyridine** does not** t**reat the infection itself, b**ut it effectively manages the symptoms until the antibiotics take full effect.
2**. Phenazopyridine will change the color of the client’s urine and will stain clothing and even contact lenses.**
3. The nurse should also educate the client **to drink plenty of fluids and to take this medication for no more than two days unless the provider specifies otherwise. Remember, following the** provider's instructions is not just crucial; it puts you in control of your successful treatment.
55
**Citalopram**,
n*** SSRI***, is used to treat s**ymptoms of depression**. The medication begins to work in ***1 to 4 weeks***
55
Donepezil
***A medication used in the treatment of moderate to severe dementia.***
This pharmacotherapy can slow the progression of symptoms associated with dementia. It can also improve the client’s behavior and cognitive functioning. Improvement in the ability to perform daily living activities has also been noted.
56
**Entecavir**
a nucleoside analog used to help prevent **complications of hepatitis B**
57
Cephalexin
a c**ephalosporin antibiotic and used to treat bacterial infections**
58
Penicillin
Penicillin is used to treat gram – and gram + bacteria's
59
****The nurse is caring for a client with a **history of aggression who tests positive for cocaine. **
➤What is the **most appropriate nursing action?**
While **looking directly at the client, give a detailed schedule of the day.**
Providing **undivided attention is the most appropriate** intervention. Through a calm tone, facing the client, and providing clear thorough communication, the risk of violence can be reduced . Additional interventions include **encouraging active participation in care and promoting a low-stimulation environment.** Chemical and physical restraints are to remain a last resort to reduce the risk of harm.
59
four subcategories of symptoms in **PTSD**
1.** avoidance**
2. ; **hyperarousal**
3 **negative thoughts;**
4.**re-experiencing the trauma through dreams**
5 **recurrent intrusive thoughts**
60
**Anxiety**
**Excessive, intense, and persistent fear and worry about everyday**
This SNS activation can speed up the vital signs (tachycardia and tachypnea), increase sugar, and dilate the pupils; after these changes, the client may
**experience profound fatigue.**
.
61
**Depression**”
Depression is a** common mood disorder that is characterized by persistent sadness and a lack of interest or pleasure in previously enjoyable or rewarding activities.**
It can also d**isturb appetite and sleep in addition to causing poor concentration and tiredness. Social isolation**, changes in appetite, and a flat affect with avoidance of eye contact are also symptoms associated with depression.
62
**Posttraumatic stress disorder (PTSD)**
****A mental health condition that causes **a disturbing pattern of behavior from an individual who experiences, witnesses,** or is confronted with a traumatic event.
**
WITH ALL SYMPTOMS OF ANXIETY Additionally, the client may display avoidance of the activity that caused the intense fear (driving for this client
62
The nurse develops a nursing plan of care for the client. Which intervention should be considered for inclusion in the nursing plan of care
1. Conduct a** suicide risk** assessment,
2. then obtain a referral for **cognitive processing therapy.**
3 **Request a prescription for a selective serotonin reuptake inhibitor (SSRI) **
4 obtain a referral for a**** r**egistered dietitian to address the client’s weight loss.**
63
Airborne”
N95 mask
63
Droplet”
standard face mask, face shield or goggles, gloves, and a gown.
63
**DO NOT central venous access device (CVAD)**
I**nterventions not supported by EBP guidelines include
1 flushing unused ports with saline every 12 hours
2 replacing the occlusive site dressing every 3 days.**
64
**DO'S central venous access device (CVAD)**
1 **giving TPN at 25 mL/hr;**
2** monitoring CVP using the distal port**;
3 **using the proximal port for prescribed blood draws**
64
**Docusate** sodium
Docusate sodium i***s a stool softener that is often utilized to prevent and treat constipation.*** This medication works by increasing the amount of water the stool absorbs in the gastrointestinal tract thus making stool softer and easier to pass.
64
**Aluminum hydroxide**
It is an **antacid** that is utilized to provide symptom relief associated with **heartburn and sour stomach; ad**ditionally, this medication can also be prescribed to treat peptic ulcer disease as it reduces pain and promotes healing.
64
If left untreated, constipation can progress to
Serious problems include
1**. anal fissure
2. fecal impaction
3. fecal incontinence
4. rectal prolapse**
64
**Bismuth subsalicylate**
u**tilized for the treatment of diarrhe**a, not constipation. Additionally, it is also used to treat temporary stomach discomforts, including heartburn, indigestion, and upset stomach.
65
Constipation
impaired rectal sensory-motor dysfunction, mechanical factors, medications use, and the presence of comorbidities.
65
**Calcium carbonate**
t is an **antacid** that is administered for the treatment of a**cid indigestion, heartburn, and upset stomach.**
