Sample Tests Flashcards
(48 cards)
if a client becomes combative and hits personnel, you want to
inform client behavior is unacceptable to set limits
sending people out of the room gives client power. speak calmly to client to help them regain control
reporting behavior first to the provider is passing the buck
a client in a balanced suspension traction for a compound fracture reports that their hands, feet and nose is cold. you want to assess for
dependent edema-
in recumbent position, cardiac workload increases and if the heart can’t keep up, then the peripheral areas of the body will be colder
holding breath causes the ______ maneuver, which increases the workload on the heart.
Valsalva
to prevent this occurrence, teach the immobilized clients about exhaling when moving about in bed
an older adult client reports muscle weakness and drowsiness. nurse observes decreased deep tendon reflexes and hypotension. nurse should ask if the client has taken ______
antacids
increased intake of magnesium containing antacids and laxatives can cause hypermagnesemia (>2.1). this depresses the CNS and cardiac impulse transmission.
D/C oral Mag, support ventilation as needed, administer loop diuretics of IV calcium, and educate
Chvostek signs is seen with
hypocalcemia
to elicit the sign, tap the face just below and anterior to the ear to trigger facial twitching on that side of the face
remaining 800mL of dialyslate remaining in peritoneal cavity. what is an important question to ask?
when was your last BM?
full colon can interfere with emptying process
shoulder pain can occur during _____ of peritoneal diasylate
intake
what foods are cross contaminated with latex?
apple, avocado, banana, carrot, celery, chestnut, kiwi, melon, papaya, raw potato, and tomato
if a client taking citalopram notices a fever, what should they do?
notify provider immediately
could be serotonin syndrome
don’t take tylenol
citalopram is an SSRI used to treat depression
S&S of serotonin syndrome
abdominal pain, fever, sweating, tachycardia, HTN, delirium, myoclonus, irritability, mood changes, may result in death
a child has a sore throat, fever and sudden drooling. what could be going on?
acute epiglottis
life threatening
drooling occurs d/t difficulty swallowing. child may become apprehensive or anxious. the child should be transported to hospital in sitting upright position to aid in breathing
take to ED immediately!!
don’t inspect the through unless immediate intubation can be performed if needed. touching the back of the throat may cause spasms cutting off the ability to breathe
normal bilirubin levels day 3-5 of life
13-15
if an infant with a congenital heart disease becomes easily fatigued during feedings, the nurse should first
feed the infant soon after awakening, every three hours, make nipple wider.
increasing caloric content of feeding requires provider prescription, takes time to implement. and should only increase by 2 kcal/oz/day
regular formulas provide ____ kcal/oz
20
muscular weakness produces by repeated movements that soon disappear following rest describes
myasthenia gravis
6 month old with rotavirus with severe diarrhea and dehydration requires ____ precautions
contact precautions (fecal-oral) required since child is incontinent/diapered
private room necessary
primipara client is in labor, cervix is 5cm dilated 100% effaced, fetal head at -1 station. membranes rupture and fluid is clear. what do you do next?
*encourage the client to void every 1-2 hours to facilitate descent of fetal presenting part; and take temperature every hour because of the ruptured membranes (infection risk?)
no ambulating client, could cause cord prolapse
too early to deliver
IV and electronic fetal monitor is probably already in place
impetigo is caused by untreated staphylococcus and can cause
acute glomerulonephritis
periorbital edema is a good indicator of
acute glomerulonephritis (poststreptococcal)
chlordiazepoxide is an anti-anxiety and sedative/hypnotic medication used to treat
anxiety and alcohol withdrawal
medication causes drowsiness and sedation
patient comes in with a severe headache and has a cervical spinal injury. what action does the nurse take first?
place client in sitting position
pounding headache and perfuse sweating are signs of autonomic hyperreflexia experienced by client with spinal injury
placing client in sitting position immediately decreases BP to head reducing risk of cerebral hemorrhage
partial thromboplastin time monitors the effectiveness of
heparin
therapeutic level 1.5-2 times the control
oral anticoag therapy (warfarin) must be instituted ______ before d/c heparin therapy
4-5 days
warfarin interferes with the hepatic synthesis of
vitamin-K dependent clotting factors
