question

This diagnostic test is performed prior to initiating radial cannulation to ensure adequate circulation proximal and distal to the site

answer

Allen's test

question

Defined as the fear or anxiety about being in (or anticipating) certain situations or physical spaces; Ex- being on a train for an extended period of time

answer

Agoraphobia

question

Defined as an acute onset cognitive dysfunction where consciousness is impaired, memory may be impaired and is reversible; Seen in ICU's

answer

Delirium

question

Defined as a chronic, gradual condition which causes irreversible and progressive cognitive decline; LOC intact, some memory loss is present and is irreversible

answer

Dementia

question

Defined as a disease with gradual progression, may be episodic & is reversible

answer

Depression

question

When caring for a child with autism spectrum disorder, what are nursing actions/interactions that should be implemented?

answer

- Providing a calming environment with minimal stimulation - Private room AWAY from nurses station is key - Use quiet/monotone voice - Use eye contact/gestures carefully - Limit visual clutter - Maintain minimal lighting - Provide child with single object to focus on

question

Patients with this cognitive disorder often exhibit sensory processing problems to sounds, movement, touch, taste and smells

answer

Autism Spectrum Disorder (ASD)

question

A condition characterized by low amniotic fluid volume

answer

Oligohydramnios

question

What are two major complications of oligohydramnios at time of birth?

answer

Pulmonary hypoplasia & umbilical cord compression

question

A complication of oligohydramnios defined as lack of normal alveolar dissension by aspirated amniotic fluid

answer

Pulmonary hypoplasia

question

A complication of oligohydramnios which can present as late/variable decelerations; Requires continuous fetal monitoring at birth

answer

Umbilical cord compression

question

Defined as a complication of excessive amniotic fluid volume, putting the mother at risk for post partum hemorrhage

answer

Polyhydramnios

question

When administering an otic medication to an adult or child age 3 and older, how should the nurse manipulate the pinna?

answer

Pull the pinna upward & back to straighten the external ear canal

question

Why should otic medication be warmed to room temperature before administration?

answer

Instilling cold drops into the ear can cause vestibular reaction, resulting in dizziness/vomiting

question

What class of blood pressure medications is category X in pregnancy and are extremely teratogenic?

answer

ACE inhibitors

question

Defined as a complication of preeclampsia that occurs when the placenta tears away from the wall of the uterus due to stress, causing significant vaginal bleeding

answer

Placental abruption (Placento abrupto)

question

A complication of pregnancy defined as severe eclampsia; What does this acronym stand for?

answer

HELLP syndrome: H - Hemolysis EL - Elevated liver enzymes LP - Low platelets

question

What is normal urine output for an adult?

answer

At least 0.5 mL/kg/hr or approximately 30 mL/hr

question

An endocrine disorder characterized by breakdown of fat for fuel and the resulting byproducts are acidic ketones; Polyuria & kussmaul respirations are present to help blow off extra co2

answer

DKA - Diabetic Ketoacidosis

question

This disorder of pediatrics presents as an abdominal pass. What nursing intervention is PROHIBITED with this diagnosis?

answer

Palpation

question

This disorder can present as a vasoocclusive crisis leading to ischemia and severe pain; Bilirubin released from the destroyed RBC's leads to jaundice and brownish hue to urine

answer

Sickle cell anemia

question

This medication is an opioid drug prescribed to treat mild/moderate pain & is also an antitussive to suppress the cough reflex

answer

Codeine

question

This medication is prescribed to prevent gout attacks characterized by pain/inflammation in the joints due to uric acid deposits; Will need to be taken for the rest of life

answer

Allopurinol

question

What is the MOST important teaching topic when educating a patient about administration of allopurinol?

answer

Allopurinol should be taken with a FULL glass of water & overall fluid intake should be increased when taking this medication

question

This childhood condition is defined as inflammation of arterioles, also known as vasculitis

answer

Kawasaki Disease (KD)

question

For pediatric patients diagnosed with Kawasaki Disease (KD), what are they most at risk for developing?

answer

Coronary aneurysms

question

This phase of Kawasaki Disease is characterized by acute, sudden onset of high fever that does not respond to antibiotics or antipyretics; Strawberry tongue develops

answer

Acute phase

question

This phase of Kawasaki Disease is characterized by peeling of skin on hands and feet

answer

Subacute phase

question

This phase of Kawasaki Disease begins when the symptoms begin to slowly disappear; Temperature returns to normal

answer

Convalescent phase

question

What is the initial treatment of Kawasaki Disease?

answer

IV immunoglobulin (IVIG) and high dose aspirin

question

What is the therapeutic aPTT value for a client receiving a continuous heparin infusion?

answer

46-70 seconds (1.5-2x control)

question

What are the reversal agents for warfarin & heparin?

answer

Warfarin - Vitamin K Heparin - Protamine sulfate

question

This occurs when parents of newborns dilute formula to "stretch" the feeding and save money

answer

Water intoxication resulting in hyponatremia

question

What are some s/s of hyponatremia?

answer

Irritability, lethargy, hypothermia and seizure activity

question

What diseases require airborne precaution in the hospital?

answer

"Airing MTV:" - Measles - Tuberculosis - Varicella

question

For patients under airborne isolation precaution, what kind of room placement is required?

answer

A private room with negative airflow pressure

question

Defined as a process in which one part of the intestine prolapses and then telescopes into another part; Very common during infancy

answer

Intussusception

question

What would the clinical manifestations be for an infant suspected of having intussusception?

answer

- Legs drawn up toward abdomen - Continuous crying due to pain - Grossly bloody "Currant jelly" stools (Mixture of blood and mucus)

question

What is the treatment for intussusception?

answer

An air (Pneumatic) enema

question

This disease is defined as a collection of symptoms resulting from various causes of glomerular injury

answer

Nephrotic Syndrome

question

What are the 2 classic manifestations of nephrotic syndrome?

answer

- Massive proteinuria*** - Hypoalbuminemia in serum (Massive loss in urine) - Edema (Periorbital and peripheral) - Hyperlipidemia

question

What is the normal level of total cholesterol?

answer

< 200 mg/dL

question

What is normal serum albumin?

answer

3.5-5.0 (Same as K)

question

What are examples of risk factors of developing colorectal cancer?

answer

- Personal/family history of colorectal cancer/polyps - Personal history of IBS, Crohn's or UC - Lifestyle factors such as obesity, smoking, alcohol consumption and diet high in red meat

question

For patients with musculoskeletal issues, this device is a metallic device composed of metal pins, which are screwed into the bone to stabilize it

answer

External fixator

question

For patients that underwent open gastric surgery, what are examples of complications that they are at risk for post-op?

answer

Wound dehiscence & evisceration

question

Which clients that underwent open gastric surgery are at GREATEST risk for dehiscence and evisceration?

answer

Obese (Bariatric) patients

question

What are 3 examples of loop diuretics that may be prescribed for patients with CHF?

answer

- Furosemide (Lasix) - Tursemide (Demadex) - Bumentanide (Bumex)

question

This class of blood pressure medications are prescribed for patients that cannot tolerate ACE inhibitors. They block the angiotensis-aldosterone system

answer

ARB inhibitors

question

SOB, fever, low back pain, flushing & itching upon initiation of transfusion of a blood product indicate what?

answer

Transfusion reaction

question

After recognizing that a patient is experiencing a transfusion/hemolytic reaction to a blood product, what is the nurses next actions?

answer

- Stop transfusion ASAP and disconnect tubing at catheter hub - Maintain IV access with NS to prevent vascular collapse - Notify HCP and blood bank - Monitor vital signs

question

For patients prescribed warfarin, what is the therapeutic value for their INR?

answer

2.0-3.0; Up to 3.5 for prosthetic heart valves/valve disease

question

Defined as inflammation of the meninges of the brain and spinal cord caused by infection

answer

Meningitis

question

What are the clinical manifestations of meningitis in an infant?

answer

- Fever - Restlessness - High pitched cry - Bulging/tense fontanels (Due to hydrocephalus and increased ICP - Increased head circumference

question

Defined as the difference between systolic and diastolic blood pressures

answer

Pulse pressure

question

What does Cushing's triad consist of r/t increased ICP?

answer

Systolic HTN, widened pulse pressure, bradycardia, altered respirations (Hypo or hyper)

question

For patients suspected of being exposed to radiation, when triaging, what victims should the RN assess first?

answer

The patients farthest away from the exposure site because they are most salvageable

question

Clinical manifestations of this biological weapon include: - Symmetrical descending flaccid paralysis - Cranial nerve palsies (Ptosis, diplopia, dysphagia, dysphonia)

answer

Botulism - Caused by clostridium botulinum

question

What are the classic s/s of hypoglycemia?

answer

- Shakiness - Palpitations - Nervousness - Diaphoresis - Anxiety - Hunger - Pallor - Change in LOC

question

What is the appropriate treatment for hypoglycemia for an alert & oriented patient?

answer

15-20 grams of a quick acting carbohydrate: - 4-6 ox regular soda - 8-10 lifesaver candies - 1 tbs honey or syrup - 4 tsp jelly - 4-6 oz orange juice - 8 oz low fat milk - Commercial dextrose products

question

What is the appropriate treatment for hypoglycemia for an unconscious patient?

answer

Subq or IM injection of 1 mg glucagon; Alternate treatment of 25-50 mL of 50% glucose IV

question

For patients with a hx of c-section that attempt a vaginal birth (VBAC), what are they at highest risk for?

answer

Uterine rupture

question

What is the first sign of uterine rupture? What are other clinical manifestations?

answer

First sign: Abnormal fetal heart rate patterns Other manifestations: Constant abdominal pain, loss of fetal station, sudden cessation of uterine contractions

question

This diagnostic test is a non-invasive test used to visualize the biliary and hepatic ducts via MRI

answer

Magnetic resonance cholangiopancreatography (MRCP)

question

For patients scheduled to undergo a magnetic resonance cholangiopancreatography (MRCP), what are some contraindications to this procedure?

answer

- Presence of certain metal implants (Pacemaker, aneurysm clip, cochlear implant) - PREGNANCY - Allergy to gadolinium (Contrast media used) - Most orthopedic implants are safe

question

This neurotoxin is found in soil and can grow in any food contaminated with the spores; Main source is improperly canned or stored foods

answer

Botulism

question

Ingestion of what food can potentially cause infection with botulism in infants?

answer

-Raw (Wild) honey

question

What are the 4 phases of seizures?

answer

- Prodromal phase - Aural phase - Ictal phase - Postictal phase

question

This phase of seizures is the period with warning signs that precede the seizure

answer

Prodromal phase

question

This phase of seizure is the period before the seizure occurs when the client experiences visual or other sensory changes

answer

Aural phase

question

This phase of seizures is the period of active seizure activity

answer

Ictal phase

question

This phase of seizures is where the client may experience confusion from recovering

answer

Postictal phase

question

When caring for a patient post total hip arthroplasty, what are proper nursing interventions?

answer

- AVOID HIP ADDUCTION AND FLEXION - Place abductor wedge pillow between the legs/knees when turning client from side to side - Educate the pt not to cross legs at ankles OR knees to avoid adduction - HOB should be maintained at < 45 degrees - Educate pt that they should not sleep or be position on AFFECTED side unless directed by HCP

question

Defined as a rare but life threatening inherited muscle abnormality that is triggered by specific inhaled anesthetic agents and the depolarizing muscle relaxant succinlcholine to induce general anesthesia

answer

Malignant hyperthermia (MH)

question

For patients experiencing malignant hyperthermia due to depolarizing muscular blocker, Succinylcholine, excessive release of which element from the muscles causes sustained muscle rigidity and contraction?

answer

Calcium

question

What are the clinical manifestations of malignant hyperthermia?

answer

- Jaw/upper body rigidity (early sign) - Increased oxygen demand and metabolism - Dangerously high temperature (later sign)

question

Defined as a measure of glomerular function and is a sensitive indicator of renal disease progression

answer

Creatinine clearance (Cr)

question

How is creatinine clearance measured?

answer

- A 24 HOUR urine collection is necessary for this test - First urine specimen is discarded and time is noted - All other voided urine in next 24 hours is collected and kept cool (On ice or refrigerated) - Blood is drawn to measure serum Cr in addition to urine Cr

question

This diagnostic test is a noninvasive procedure that is performed to visualize calcification of the coronary arteries and heart valves. What type of client preparation is required?

answer

Calcium scoring CT exam; No preparation is required

question

What is normal urine specific gravity?

answer

1.010-1.025

question

When caring for a patient with a chest tube, where can the nurse expect continuous, gentle bubbling in the collection device?

answer

Suction control chamber

question

When caring for a patient with a chest tube, where can the nurse expect tidaling to be observed?

answer

Water seal chamber

question

When caring for a patient with a chest tube, the nurse notices that tidaling in the water seal chamber has ceased. What has most likely occurred?

answer

The lung has re-expanded

question

What home care interventions should the RN teach a patient r/t minor burns?

answer

- Briefly soak area in cool water to stop the burning process - Remove any clothing or jewelry around the era - Cover with a clean, dry cloth to prevent contamination and further trauma

question

When educating a patient on home care for minor burns, what should the nurse instruct the patient NOT to do?

answer

- Do not apply ice directly to burn as this will cause further tissue damage - Do not apply ointments, creams or

question

For a patient scheduled to undergo a percutaneous left kidney biopsy, what are proper nursing interventions for before/after procedure?

answer

Before: - Nurse must witness informed consent - D/c all anticoagulants and anti platelet agents for at least one week - Client should be typed/crossmatched for blood in case of a hemorrhage situation After: - Nurse should monitor vitals for at least every 15 min for s/s of hypovolemia due to bleeding - Assess puncture site for bleeding

question

Related to the Beers criteria, what are classes of medications that should be avoided or administered in caution in the elderly?

answer

- Antipsychotics - Anticholinergics - Antihistamines - Antihypertensives - Benzos - Diuretics - Opioids - Sliding scale insulins

question

This complication of HTN occurs when the arterial wall intimal layer tears and allows blood between the inner and middle layers; EMERGENCY*

answer

Aortic dissection

question

What clinical manifestations would a patient report suspected of having an aortic dissection?

answer

- Abrupt onset and "worst ever", "tearing," or "ripping," pain with HTN being a contributing factor

question

After administration of an antibiotic, the patient develops SOB and parities. What are proper nursing interventions when caring for a patient experiencing anaphylaxis?

answer

- STOP INFUSION & CALL FOR HELP* - Ensure patent airway & administer o2 via high flow non-rebreather - Give IM epinephrine (Bronchodilation and vasoconstriction) - Administer adjunctive therapies (Corticosteroids, bronchodilators, antihistamines) - Monitor and reassess vitals for changes - Notify HCP

question

When educating a patient with active genital herpes infection about application of acyclovir topical cream, how should the patient apply the cream?

answer

Gloves should be worn when applying the medication to prevent the spread of

question

When assessing the babinski reflex in newborns, when will this reflex disappear?

answer

At 1 year of age

question

Defined as white, pearl like epithelial cysts on gum margins and the palate in newborns

answer

Epstein's pearls

question

When do Epstein's pearls disappear in newborns?

answer

Within a few weeks of birth

question

When assessing the umbilical cord of a newborn, how many arteries/veins should be present?

answer

2 arteries & 1 vein

question

When performing an ABG on a sedated, ventilated patient, what nursing intervention should be avoided prior which could skew the results?

answer

Suctioning - This will deplete the client's oxygen level and cause inaccurate results

question

What is normal MAP (Mean arterial pressure)?

answer

Greater than or equal to 65 mm Hg

question

A complication of IV therapy defined as infiltration of a drug into the tissue surrounding the vein

answer

Extravasation

question

A patient receiving norepinephrine via peripheral IV catheter is suspected of extravasating. What are the nurse's first actions?

answer

Discontinue the infusion ASAP - Disconnect the IV tubing - Aspirate the drug with a syringe - Elevate extremity above heart - Notify HCP and prepare for administration of antidote, phentolamine

question

What is the anecdote for norepinephrine? What class of medications is this?

answer

Phentolamine (Regitine) - A vasodilator that counteracts effects of some adrenergic agonists (Norepi, dopamine)

question

What bacteria are UTI's most commonly caused by?

answer

E. coli

question

For patients diagnosed with a UTI, what is a complication of a UTI that may be present if left untreated?

answer

Cystitis - lower urinary tract infection that involves inflammation of the bladder mucosa

question

What are the clinical manifestations of cystitis (Lower UTI)?

answer

- Burning with urination (Dysuria) - Urinary frequency - Urinary urgency - Hematuria - Suprapubic discomfort

question

For a patient diagnosed with a UTI, what assessment findings would be indicative that this patient developed pyelonephritis?

answer

- Development of N&V - Present fever and chills - Flank pain - Costovertebral angle tenderness

question

Defined as a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma; Associated diseases include ascites, varices and encephalopathy

answer

Cirrhosis

question

What are the classic signs of neurogenic shock?

answer

Hypotension, bradycardia and pink/dry skin due to vasodilation

question

What are examples of presumptive (Subjective) signs of pregnancy?

answer

- Amenorrhea - N&V - Urinary frequency - Breast tenderness - Quickening - Excessive fatigue

question

What are examples of probable (Objective) signs of pregnancy?

answer

- Uterine/cervical changes (Goodell's, chadwick's, hegar, uterine enlargement) - Braxton hicks contractions - Ballottement - Fetal outline palpation - Uterine & funic souffle - Skin pigmentation changes (Linea nigra, cholasma, areola darkening) - Striae gravidarum (stretch marks) - Positive pregnancy test

question

What are examples of positive (diagnostic) signs of pregnancy?

answer

- Fetal heartbeat with doppler device - Fetal movement palpated by HCP - Visualization of fetus by ultrasound

question

This skin infection is caused by Sarcoptes scabies mite

answer

Scabies

question

How is scabies infection spread?

answer

Person-to-person contact

question

What is proper treatment regimen when a child in a household is diagnosed with scabies?

answer

- Treat all persons who have had contact with the infested child - Apply permethrin cream to all areas of body below the head - Place clothes, linens and stuffed animals in a plastic bar or wash them in hot water with hottest drying cycle

question

What two classes of commonly used drugs can cause problems for clients with asthma?

answer

NSAIDs and BBs NSAIDs - such as Motrin can cause hypersensitivity in asthmatics which can cause bronchospasm BB - Non-cardioselective beta blockers block beta cells in heart and lungs, leading to pulmonary compromise in asthmatics

question

Defined as a cogenital defect in which the urethral opening os on the underside of the penis

answer

Hypospadias

question

For a male infant post op hypospadias repair, what is most important for the nurse to monitor for?

answer

Presence of urine output, indicating urethral patency

question

What are the 5 H's that are reversible causes of asystole/PEA?

answer

- Hypovolemia - Hypoxia - Hydrogen ions (Acidosis) - Hypokalemia or hyperkalemia - Hypothermia

question

What are the 5 T's that are reversible causes of asystole/PEA?

answer

- Tension pneumothorax - Tamponade, cardiac - Toxins (Benzo, narcotics) - Thrombosis (Pulmonary/coronary) - Trauma

question

On the EKG, this rhythm occurs when the cardiac monitor shows organized electrical activity but there is not adequate mechanical activity of the heart muscle

answer

Pulseless electrical activity (PEA)

question

Defined as an acyanotic congenital heart defect causing blood to shunt from the left side of the heart to the right, resulting in pulmonary hypertension

answer

Ventricular septal defect

question

What is a child diagnosed with a cleft palate at risk for related to feeding?

answer

Aspiration and inadequate nutrition to to eating/feeding difficulties

question

What is proper feeding technique for an infant with a cleft palate?

answer

- Hold infant upright - Tilt bottle so that nipple is always filled with formula - Keep nipple down and away from cleft - Use special bottles and nipples - Burp infants often to avoid stomach dissension and regurgitation - Feed slowly over 20-30 minutes to prevent risk of aspiration - Feed q3-4hr

question

What are examples of reports of patients with PTSD?

answer

- Re-experiencing traumatic event (Dreams, flashbacks, pounding HR, diaphoresis) - Avoiding reminders of trauma (Inability to set goals, amnesia) - Increased anxiety and emotional arousal (Insomnia, rage, fear, difficulty concentration, exaggerated startle response)

question

Ethical principle defined as exhibiting loyalty and fulfilling commitments made to oneself and others

answer

Fidelity

question

Ethical principle defined as taking responsibility for ones actions

answer

Accountability

question

Ethical principle defined as doing no harm and protecting clients from danger when they are unable to do so themselves due to mental/physical condition

answer

Nonmaleficence

question

Ethical principle defined as the patients right to make decisions for oneself; Ex: Informed consent

answer

Autonomy

question

Ethical principle defined as "Doing good!"

answer

Beneficence

question

Ethical principle defined as treating all clients fairly and without bias

answer

Justice

question

Ethical principle defined as telling the truth as a fundamental part of building a trusting relationship

answer

Veracity

question

What is the therapeutic index for theophylline?

answer

10-20 mcg/mL

question

At what level does theophylline toxicity occur?

answer

> 20 mcg/mL

question

This medication is the firs tline anti tubercular drug prescribed to treat TB

answer

Isoniazid (INH)

question

What two serious adverse effects are possible with Isoniazid (INR) therapy? What should the RN instruct the patient to report?

answer

Hepatotoxicity and peripheral neuropathy - Educate pt to report yellowing of skin/sclera or numbness and tingling of extremities

question

For patients taking Isoniazid (INH) to treat TB, what beverage should the RN educate the patient to AVOID?

answer

Alcohol - INH causes hepatotoxicity

question

For clients with history of alcoholism, what vitamin should be administered to prevent Wernickle encephalopahy?

answer

Thiamine (Vitamin B1)

question

Wernickle encephalopathy is caused by what chronic condition and lack of what vitamin?

answer

Alcoholism - Lack of thiamine (vitamin b12)

question

What is the average normal hematocrit value?

answer

39-50%

question

What is the average normal hemoglobin value?

answer

13.2-17.3 g/dL

question

For patients diagnosed with epilepsy being treated with Phenytoin, what are nursing education points the RN should teach the patient?

answer

- Avoid excessive caffeine and alcohol - Never abruptly discontinue anti seizure medications - Perform adequate oral hygiene (Gingival hyperplasia) - Use alternative birth control methods other than PO meds - Wear a medic alert bracelet identifying seizure hx

question

What nursing education points should be given when teaching on how to prevent dental caries?

answer

- Brush after meals - Floss at least BID - Rinse mouth with water after meals if brushing isn't possible - Chew sugar free gum instead of sugary gum - Avoid simple sugars, sticky goods, sugary beverages and other sodas and fruit drinks

question

When catheterizing a patient with acute urinary retention, what can rapid decompression of the bladder cause?

answer

Hematuria, hypotension and diuresis

question

Defined as a toxic inhalant that enters the blood and is more readily available to hemoglobin than oxygen

answer

Carbon monoxide (CO)

question

When hemoglobin is saturated with CO, how will the pulse oximeter read?

answer

Falsely high - Pulse oximeters cannot differentiate between CO and o2

question

For patients suspected of CO poisoning, what kinds of nonspecific symptoms will be present?

answer

- Headache - Dizziness - Fatigue - Nausea - Dyspnea - Normal pulse ox reading

question

What is the normal serum carboxyhemoglobin level for non smokers? Smokers?

answer

- Non smokers: < 5% - Smokers: < 10%

question

For patients that underwent a previous mastectomy, what does a small, firm and non-tender axillary lymph node indicate?

answer

It is an expected finding - Normal

question

What does a tender, hard, fixed or enlarged axillary lymph node possibly indicate?

answer

Malignancy - Cancer

question

What does the mnemonic CAUTION mean when educating patients on s/s of possible malignancy?

answer

- C: Change in bowel or bladder habits (Black stool, painless hematuria) - A: A sore that does not heal - U: Unusual bleeding/discharge (From vagina, cervix or endometrium) - T: Thickening or lump in breast or elsewhere - I: Indigestion or difficulty swallowing - O: Obvious change in wart/mole - N: Nagging cough or hoarseness (Lung cancer, larynx)

question

This condition occurs when muscle fibers are realized into the blood usually after an intense muscle injury from exercise, heat stroke or physical trauma

answer

Rhabdomyolysis

question

For patients suspected of having rhabdomyolysis, what clinical manifestations would be present?

answer

- Oliguria - Dark amber urine (Myoglobinuria) - Muscle pain

question

For patients diagnosed with rhabdomyolysis, what are vital nursing interventions to implement?

answer

- Fluid resuscitation (Prevent kidney damage from elevated myoglobin) - Urine sample (Myoglobinuria) - ECG (Hyperkalemia) - IV morphine

question

Prior to liver biopsy, what laboratory values does the nurse need to check and why?

answer

- PT/INR and aPTT due to increased bleeding risk

question

This CN is involved in the gag reflex, ability to swallow, phonation and taste

answer

CN IX: Glossopharyngeal

question

For patients who are lactose intolerant, what foods will these patients receive adequate calcium and vitamin D from?

answer

Ca: - Fish - Sardines, salmon, trout - Tofu - Green vegetables - Spinach, kale, broccoli - Almonds Vitamin D: - Egg yolks - Oily fish: Salmon, sardines, tuna

question

Presentation of mucous, and pink/dark brown blood is present during this phase of labor; Aka bloody show

answer

Transition phase

question

When does the second stage of labor begin?

answer

Once complete dilation (10cm) is achieved

question

For clients in the ICU diagnosed MRSA on the skin, what is the recommended bathing procedure for the UAP?

answer

- Bathe patients with MRSA with pre-moistened cloths or warm water containing chlorhexidine solution

question

For newborns suspected of having esophageal atresia with tracheoesophageal fistula, how would this newborn most likely present? What are they at greatest risk for?

answer

- Apnetic and cyanotic during feeding - Frothy saliva, coughing, choking & drooling - At greatest risk for aspiration!

question

Defined as a prolonged, painful erection (>2 hours) caused by trapping blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis

answer

Priapism

question

For a patient with an acute stroke presentation, what type of blood pressure management is required and for how long?

answer

These patients require "Permissive hypertension" during the first 24-49 hours to allow for adequate perfusion through the damaged cerebral tissues

question

What are the most common clinical manifestations of hip fractures?

answer

- Ecchymosis and tenderness over the thigh/hip - Groin/hip pain with weight baring - Muscle spasm in the injured area - Shortening of the affected extremity* - Abduction or adduction of the affected extremity - Affected extremity usually externally rotated*

question

When is screening for cervical cancer in women begin?

answer

Age 21

question

For patients undergoing allergy skin testing, what class of medications needs to be withheld prior?

answer

Antihistamines & corticosteroids

question

Emergency medical condition in which the blood flow to the testis (scrotum) has stopped; The testicle rotates and twists the spermatic cord, initially causing obstruction that leads to severe pain & will lead to testicular ischemia and necrosis

answer

Testicular torsion

question

This disorder is also called degenerative joint disease, seen in knees, hips and fingers

answer

Osteoarthritis (OA)

question

What are the clinical manifestations of OA in the knee joint?

answer

- Pain - Exacerbated by weight baring - Crepitus: Grating noise/sensation with movement that can be palpated - Morning stiffness - Decreased ROM/mobility - Atrophy of the muscles that support the joint (Quads, hamstrings)

question

For patients with a diagnosis of atrial fibrillation prescribed Cardizem, what client outcome best indicates that the medication has taken its intended effect?

answer

Ventricular rate decreased from 158/min to 88/min

question

What clinical manifestations will be present in a toddler suspected of having hearing deficit?

answer

- Withdrawn behavior - Monotone speech that is difficult to understand - Speaks with a loud voice

question

This congenital defect is characterized in which the spinal cord contents can protrude through the vertebrae that did not close

answer

Spina bifida

question

Upon examining a newborn, the nurse suspects spina bifida a when she assess which finding?

answer

A tuft of hair or a hemangioma at site

question

Deficit of which supplement can lead to neural tube defects in newborns?

answer

Folic acid

question

Defined as bluish discolored areas on the lower back and or buttock, most commonly seen in african american, asian, hispanic and native american infants

answer

Mongolian spots - Congenital dermal melanocytosis

question

What are examples of clients that are at highest risk for MRSA?

answer

- Older adults - Patients with suppressed immunity - Long history of antibiotic use - Invasive tubes/lines - Patients in ICU - Patients on ventilators

question

During pregnancy, this disorder causes pregnancy clients severe nausea and vomiting leading to fluid and electrolyte imbalances, nutritional deficiencies, ketonuria and weight loss

answer

Hyperemesis gravidarum

question

What are the clinical manifestations of hyperemesis gravidarum?

answer

- Positive urine ketones - BP/HR changes for hypovolemia (Tachycardia, hypotension) - Poor skin turgor - Delayed capillary refill - Urine specific gravity > 1.025 due to concentrated urine - BUN > 20

question

During pregnancy, defined as an abnormal implantation of the placenta resulting in partial or complete covering of the cervical os (opening)

answer

Placenta previa

question

A woman at 20 weeks of gestation reports mild contractions & painless vaginal bleeding. What should the nurse suspect?

answer

Placenta previa

question

When caring for an expectant mother suspected of having placenta pre via, what nursing interventions are appropriate?

answer

- Blood draw for type/screen (Possible hemorrhage) - Continuous electronic fetal monitoring - Initiation of 2 large bore IV catheters - Assessment of peripads to assess amount of bleeding/saturated pads per hour

question

When placenta previa, abrupt placenta & vaginal bleeding of unknown origin are suspected, what nursing intervention is completely CONTRAINIDICATED?

answer

Digital vaginal examinatio

question

For patients on long term therapy with PPI's, what is an adverse effect that may develop over time? What test will need to be performed?

answer

Osteoporosis - PPI's decrease absorption of calcium and a bone density test will need to

question

What are contraindications to a patient being able to sign out AMA?

answer

- Alcohol/drug intoxication - Altered consciousness - Mental illness (Hearing voices) - Chemical influence (Narcotics, benzos) - If deemed a danger to self or others

question

For a patient wishing to sign out of the hospital APA, what must be discussed with patient & what documentation must be present?

answer

- Documentation on discussion of risks with client's decision & understanding of these risks - Signature of client on AMA document (Client's cannot be held against will if not willing to sign) - Should be witnessed and documented

question

According to the beer's criteria, what anti diabetic agents are contraindicated in older adult clients? What is an example of this medication class?

answer

Sulfonylureas - Glyburide (long acting agent); can cause severe and prolonged hypoglycemia

question

What are some risk factors associated with DVTs?

answer

- Trauma - Major surgery - Prolonged immobilization (Stroke, long travel) - Pregnancy - Oral contraceptives - Underlying malignancy - Smoking - Old age - Obesity & vericose veins - Myeloproliferative disorders

question

Defined as acts of aggression carried out by a co-worker against another co-worker and designed to control, diminish, or devalue a colleague

answer

Lateral (horizontal) violence

question

What is the treatment and management for periculosis capitis?

answer

- Permethrin 1% cream to the head - Removal of knits with a nit comb or by hand - Frequent vacuuming of furniture, rugs and carpets - Washing of client's bedding with hot water and dried on the hottest dryer setting - Non-washable items must be sealed in a plastic bag for 2 weeks to kill lice larva - Hairbrushes, combs and hair accessories should be soaked in boiling water for 10 minutes or lice killing products for 1 hour - Other family members will also need to be treated with a pediculicide - Household pets do not transmit human lice so they do not need to be treated

question

When does the American Dental Association recommend that a toddler has their first visit to the dentist?

answer

Within 6 months of first tooth erupting or by their first birthday

question

What is the normal range for mean arterial pressure (MAP)?

answer

70-105 mm Hg

question

If the MAP (Mean arterial pressure) falls below what value, the vital organs may be under perfused and can become ischemic

answer

< 60 mm Hg

question

Prior to administration of packed RBC's, what should the nurse ask the patient to do and why?

answer

Empty their bladder - a fresh urine specimen will be necessary if a hemolytic reaction occurs to assess for hemolyzed RBCs

question

For patients that undergo a gastrectomy, what are instructions for the nurse to include to prevent dumping syndrome?

answer

- Avoid intake of fluids with meals - Consume low carb meals - Eat small, frequent meals - Eat slowly in a relaxed environment - Consume meals high in protein, fat & fiber which take longer to digest - Avoid sitting up after meals, lying down is preferred to slow gastric emptying

question

For patients post gastrectomy, what position is recommended after meals?

answer

Supine - to delay gastric emptying & prevent dumping syndrome

question

For patients that underwent gastric surgery, what are s/s of dumping syndrome?

answer

Hypotension, abdominal pain, diarrhea, N&V, dizziness, generalized diaphoresis and tachycardia

question

Defined as when gastric contents are emptied too rapidly into the duodenum, causing a fluid shift into the small intestine

answer

Dumping syndrome

question

Pertaining to fires in the clinical setting, what does the mnemonic RACE stand for?

answer

R: Rescue A: Alarm C: Contain E: Extinguish

question

When caring for patients on mechanical ventilation receiving tube feedings, how does the RN prevent aspiration in these clients?

answer

- Assess for intolerance to tube feedings by assessing gastric residual, abdominal dissension and bowel movements - Assess tube placement at regular intervals - Keep HOB > 30 degrees - Keep endotracheal cuff INFLATED, low cuff pressure increases risk for aspiration - Suction any present secretions - Use caution when administering sedatives - Avoid bolus tube feedings***

question

When caring for patients on a mechanical ventilator receiving tube feedings, what should be absolutely avoided which puts the patient at increased risk for aspiration?

answer

Bolus tube feedings

question

For clients on mechanical ventilation receiving tube feedings, how often should gastric residual be checked by the RN?

answer

No less than q4hr

question

How do you calculate MAP (Mean arterial pressure)?

answer

Systolic BP + diastolic BP x2 /3 (Multiply by 2 divide by 3)

question

What is the RN's role in informed consent?

answer

- To witness that the client signed the consent voluntarily and that the client was competent at the time of signing - That the client received enough necessary information and has no remaining questions r/t procedure - Must document the time/date of the signature & when informed consent was given

question

This procedure involves the insertion of a resectoscope to excise obstructing prostate tissue

answer

Transurethral resection of the prostate (TURP)

question

When caring for a patient post TURP, while receiving continuous bladder irrigation, how does the RN know that the irrigation is running at an adequate rate?

answer

Urine remains light pink without clots

question

When caring for a patient post TURP, while receiving continuous bladder irrigation, how does the RN know that the irrigation is NOT running at an adequate rate?

answer

Urine is dark red with positive clots present

question

What two STD's are the leading causes of pelvic inflammatory disease (PID) and infertility?

answer

Gonorrhea and chlamydia

question

For patients diagnosed with hyperthyroidism, what patient education points does the nurse need to touch on?

answer

- Adherence to a high calorie diet (4000-5000/day) - Consumption of 6 full meals and snacks high in protein, carbs and vitamins/minerals - Avoidance of high fiber foods do to increased stimulation of GI tract - Avoidance of stimulating substances (Caffeinated drinks, coffee, tea, soda) - Avoidance of spicy foods (Will increase gastric stimulation)

question

This endocrine disorder refers to sustained hyper functioning of the thyroid gland due to excessive secretion of thyroid hormones (T3, T4) leading to increased metabolic rate

answer

Hyperthyroidism

question

When caring for a patient who does not speak their native tongue, how should the nurse implement proper use of a professional interpreter?

answer

- Use interpreter of same gender if topic sensitive - Make good eye contact when communicating with client (Communication with client, not interpreter) - Interpreter should translate words literally - RN should use simple terms not medical terms - RN should speak slowly and in short sentences

question

This nursing intervention involves removing secretions from a client's airway

answer

Suctioning

question

When suctioning a patient, how long should suction be applied for?

answer

No more than 10 seconds

question

When suctioning a patient, how long should the nurse wait between suction passes?

answer

1-2 minutes

question

Prior to suctioning a patient, what does the nurse need to do?

answer

Hyperoxygenate the patient with 100% o2

question

When suctioning a patient, at what pressure should the suction be set at for adults? Children?

answer

Between 100-120 mm Hg for adults & 50-75 mm Hg for children

question

What is the normal lab value for platelets?

answer

150,000-400,000

question

For patients with trouble sleeping, what should the RN educate the patient about for better sleep patterns?

answer

- Reduce stimuli in bedroom (Reading, TV) - Avoid naps later in day - Keep bedroom slightly cool, quiet & dark - Avoid caffeine, nicotine and alcohol within 6 hours of sleep - Avoid exercising or strenuous activity within 6 hours of going to bed - Avoid going to bed hungry - Practice relaxation techniques

question

For patients in the rehabilitation phase of burn injury, what are proper interventions to include in plan of care?

answer

- Counseling or psychosocial support - Gentle massage with water based lotion to alleviate itching and minimize scarring - Plan for reconstructive surgery - Pressure garments to prevent hypertrophic scars and promote circulation - ROM exercises to prevent contractors - Sunscreen to prevent sunburn

question

For patients set t undergo a pharmacologic nuclear stress test, what are pre-procedure client instructions?

answer

- Do not eat, drink or smoke on the day of test - Avoid caffeine 24 hours before test - Avoid decaffeinated products 25 hours before test - Ask HCP about diabetes medications prior to test; Hypoglycemia can result while patient is NPO for test - Avoid nitrates, dipyridamole and BBs prior to test*** will masks s/s of angina

question

What are some s/s of varicella immunization administration?

answer

- Discomfort, redness and a few vesicles at the injection site

question

What is proper nursing intervention when a patient develops several small vesicles at the injection site of varicella vaccine?

answer

- Cover the vesicles with clothing or a small bandage until they are dried or crusted over (No longer contagious)

question

What medication is completely contraindicated in children due to the development of Reye syndrome?

answer

Aspirin

question

For a patient that underwent a colonoscopy, what is a concerning finding that could indicate perforation of the colon?

answer

Positive abdominal tenderness & rigid abdomen

question

When caring for a newborns umbilical cord, what is proper technique and what needs to be reported to HCP?

answer

- Keep cord stump clean and dry - Keep cord open to air to allow for adequate drying - Do NOT apply antiseptics (Alcohol, chlorhexidine) to stump - Report any s/s of infection to HCP

question

How long after cutting the umbilical cord will it begin to shrivel and turn black?

answer

2-3 days

question

This GI disorder is due to a deficiency in the enzyme lactase, which is required for digestion of lactose

answer

Lactose intolerance

question

For patients with lactose intolerance, what vitamin supplementation will be required?

answer

Calcium and vitamin D

question

This disorder is caused by a deficiency in coagulation proteins, lacking factor VIII or factor IX

answer

Hemophilia

question

For patients diagnosed with hemophilia, what is a long term complication associated with this bleeding disorder and why?

answer

Joint destruction - Most frequent sites of bleeding are the joints, especially the knee, causing chronic swelling and deformity

question

This disease involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow , vascular stasis and cell damage

answer

Frostbite

question

What is proper treatment of frostbite?

answer

- Remove clothing and jewelry to prevent constriction - DO NOT MASSAGE, rub, or squeeze area involved - Immerse affected area in heated water - Provide analgesia as appropriate - Elevate injured areas due to possible edema - Keep wounds open and allow them to dry before applying a loose, sterile dressing

question

Defined as a potentially life threatening condition that develops when drugs affecting the body's serotonin levels are administered simultaneously in overdose

answer

Serotonin syndrome

question

What herbal supplement taken in conjunction with an antidepressant can potentially cause serotonin syndrome?

answer

St. John's Wort

question

What are examples of clinical manifestations that may be present with serotonin syndrome?

answer

- Mental status changes (Disorientation, anxiety) - Autonomic dysregulation (Hyperthermia, diaphoresis, tachycardia, HTN) - Neuromuscular hyperactivity (Tremor, muscle rigiditu, clonus, hyperreflexia) - Fever - Warm, moist skin

question

When auscultating heart sounds, where is the aortic valve located?

answer

2nd ICS right sternal border

question

When auscultating heart sounds, where is the pulmonic valve located?

answer

2nd ICD left sternal border

question

When auscultating heart sounds, where is the erg's point located?

answer

3rd ICS left sternal border

question

When auscultating heart sounds, where is the tricuspid valve located?

answer

5th ICS lower left sternal border

question

When auscultating heart sounds, where is the mitral valve located?

answer

5th ICS midclavicular line

question

This valve is also called the apex & point of maximum impulse

answer

Mitral valve

question

Where is the apex or the point of maximum impulse located for auscultation?

answer

5th ICS midclavicular line

question

What are common causes of metabolic acidosis?

answer

- Gi bicarb losses (Diarrhea) - Ketoacidosis (DKA, alcoholism, starvation) - Lactic acidosis (Sepsis, hypoperfusion) - Renal failure (Hemodialysis with inaccessible AV fistula) - Salicylate toxicity

question

What are examples of causes of SIADH?

answer

- CNS disruption (Stroke, infection, trauma, neurosurgery) - Malignancies (Small cell lung carcinoma) - Drugs (Desmopressin, carbamazepine) - Pulmonary disorders (Pneumonia)

question

Defined as an endocrine disorder in which too much ADH is produced causing water retention, increased total body water and dilution serum hyponatremia

answer

SIADH - Syndrome of inappropriate antidiuretic hormone

question

How often should the dressing on a central line (PICC)be changed?

answer

q48hr with gauze dressing or q7days with a transparent semipermeable dressing

question

When drawing blood from a PICC line, what other infusing medications should be paused and why?

answer

ALL infusing medications (except vasopressors) must be paused before drawing blood to prevent false interpretation of the client's levels

question

How long should an antiseptic be used to "scrub the hub" of a central venous catheter before medication administration?

answer

10-15 seconds

question

What antiseptic solution is used to "scrub the hub" of a central venous catheter before medication administration?

answer

Alcohol or chlorhexidine/alcohol

question

What are examples of adverse effects of the sympathomimetic inotropic medication, dopamine?

answer

- Tachycardia - Dysrhythmias - Myocardial ischemia

question

What class of medication is dopamine in, MOA and are the therapeutic effects of administration?

answer

Dopamine is a sympathomimetic inotropic medication used to improve hemodynamic status in clients with shock and HF - Enhances cardiac output by increasing myocardial contractility, increasing HR and elevating blood pressure through vasoconstriction

question

What is the range for normal central venous pressure (CVP)?

answer

2-8 mm Hg

question

What is the range for normal systemic vascular resistance?

answer

800-1200 dynes/sec/cm5

question

What kind of drug is Methotrexate and what is it used to treat?

answer

A non biologic disease-modifying antirheymatic drug (DMARD) used to treat RA

question

What are some AE associated with Methotrexate administration?

answer

- Bone marrow suppression - THROMBOCYTOPENIA** - Hepatotoxicity - Immunosuppression - GI irritation (N&V, diarrhea)

question

For patients taking Methotrexate, what AE is suspected if petechiae is assessed on a patients body?

answer

Thrombocytopenia

question

Defined as when a newborn is delivered < 3 hours after the onset of contractions

answer

Precipitous birth

question

Signs that this is happening during the birth process include, cord lengthening, a gush of blood, uterine cramping and vaginal pressure

answer

Placental separation & expulsion

question

What nursing intervention is performed after expulsion of the placenta to increase uterine tone and decrease bleeding?

answer

Fundal massage

question

Why is fundal massage performed?

answer

To increase uterine tone and decrease risk for post partum hemorrhage

question

Defined as a common but serious complication of peritoneal dialysis

answer

Peritonitis

question

What is the typical, earliest indication of peritonitis infection?

answer

Cloudy peritoneal effluent

question

What are late clinical manifestations of peritonitis?

answer

- Low grade fever - Chills - Generalized abdominal pain - Rebound tenderness - Board like abdomen*

question

What are the steps for administering a continuous enteral feeding to a patient?

answer

- Identify patient using 2 identifiers - Perform hand hygiene and apply clean gloves - Elevated HOB > 30 degrees and keep elevated for at least 30 minutes to prevent aspiration - Validate tube placement by checking gastric pH and comparing it with measurement of tube length at time of insertion - Check residual volume - Flush tube with 30 mL of water - Administer prescribed enteral feeding solution by setting the rate on infusion pump

question

What ethnic group is at highest risk for developing a dry cough with ACE inhibitors?

answer

Asians

question

What are vital nursing interventions when caring for a patient post mastectomy?

answer

- Elevating the affected harm to heart level (Reduces fluid retention and lymphedema) - Hand and arm exercises (to maintain muscle tone, prevent contractors and improve circulation) - Keeping patient in semi fowler position - Place sign over bed that says "restricted left/right extremity" - No BP, venipuncture or injections on affected extremity

question

What is the current vaccination recommendations for patients with COPD, regardless of age?

answer

- Pneumococcal vaccine & annual influenza vaccine

question

When triaging victims after a major disaster, what does see saw movement with respirations indicate?

answer

Flail chest - multiple ribs sustained multiple fractures and become independent of chest wall, floating on top of the lung and pleura

question

Complication of pregnancy that occurs when the umbilical cord slips below the presenting fetal part and may cause cord compression and impaired fetal oxygenation

answer

Umbilical cord prolapse

question

What is the treatment for umbilical cord prolapse?

answer

Emergency c-section unless vaginal birth is imminent and considered safe by HCP

question

Upon vaginal assessment of a patient in labor, the nurse visualizes a loop of umbilical cord protruding from the vagina. What is the nurse's first action?

answer

Position the client on hands and knees to relieve cord compression

question

What are examples of weight maintenance behaviors of a patient diagnosed with bulimia nervosa?

answer

- Self-induced vomiting - Fasting - Laxative abuse - Excessive exercise

question

For clients diagnosed with bulimia nervosa, when is it vital the nurse monitor the patient?

answer

1-2 hours after meals

question

Complication of IV therapy defined as leaking of solution into surrounding tissues of the infusion site

answer

Infiltration

question

What are proper nursing interventions when observing that an IV line is infiltrating?

answer

- D/C IV line ASAP - Start IV on opposite extremity - Elevate the affected extremity to decrease swelling - Apply a cold/warm moist compress to site - Notify HCP if other complications develop

question

How often should peripheral IV sites be changed?

answer

q82-96hr

question

Upon abdominal assessment of a patient, the nurse notes a pulsatile mass in the periumbilical area. What does she suspect?

answer

Abdominal aneurysm

question

What are the clinical manifestations of a AAA?

answer

- Back/abdominal pain (Due to compression of nearby anatomical sites) & a pulsatile abdominal mass

question

What is the treatment for a AAA?

answer

- Emergency surgery to repair the aneurysm to prevent rupture

question

What is the preferred treatment for oral candidiasis due to corticosteroid/antibiotic use?

answer

Nystatin

question

For the treatment of oral candidiasis, how should the nurse instruct the patient to administer oral nystatin?

answer

Swish liquid in mouth for several minutes and then swallow it

question

When removing PPE after a wound dressing change for a patient with MRSA, what article of PPE should be removed first?

answer

Gloves - the most dirty

question

Defined as a buildup of fluid in the pericardium

answer

Pericardial effusion

question

Defined as a serious complication of a pericardial effusion

answer

Cardiac tamponade

question

What is the immediate treatment of cardiac tamponade?

answer

Emergency pericardiocentesis - Needle inserted into pericardial sac to remove excess fluid constricting the heart from beating

question

What are the s/s and clinical manifestations of cardiac tamponade?

answer

- Hypotension - Narrowed pulse pressure - Muffled/distant heart tones - JVD - Pulsus paradoxus - Dyspnea, tachypnea - Tachycardia - Weak, thready pulses

question

How long after cessation of an MAOI can an SSRI be started and why?

answer

14 days - to prevent risk of developing serotonin syndrome

question

What medications are administered prior to ECT therapy?

answer

General anesthesia & a skeletal muscle relaxant

question

What are common side effects after ECT therapy?

answer

Confusion and memory loss

question

What medication class is contraindicated prior to ECT therapy and why?

answer

Anticonvulsants - ECT is used to provoke convulsion

question

Defined as a life threatening emergency & if left untreated will cause intracranial hemorrhage, HF, MI, renal failure, aortic dissection or retinopathy

answer

Hypertensive crisis

question

What is the emergency treatment for hypertensive crisis?

answer

- IV vasodilators (Nitroprusside sodium)

question

When caring for a patient diagnosed with a hypertensive crisis, what is the initial goal of treatment?

answer

- To decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg

question

When caring for a patient diagnosed with a hypertensive crisis, what is the risk in lowering the BP too quickly?

answer

Too rapid of a drop may cause decreased perfusion to the brain, heart and kidneys, resulting in stroke, renal failure or MI

question

After IVIG administration for Kawasaki disease, what immunizations should be delayed in this client?

answer

Live vaccinations - IVIG administration will interfere with desired immune response to live vaccines (Varicella, MMR, influenza)

question

What is a probable electrolyte imbalance seen in chronic pancreatitis and why?

answer

Hypocalcemia - due to chronic ingestion of alcohol

question

What are s/s of hypocalcemia?

answer

- Numbness/tingling in finers and lips - Trousseau's sign (BP cuff) - Chvostek's sign (Facial twitching)

question

In critical care, this is a measurement of right ventricular preload and reflects fluid volume status

answer

CVP - Central venous pressure

question

What does a high CVP potentially indicate?

answer

Right ventricular failure of FVE

question

What does a low CVP potentially indicate?

answer

Hypovolemia (FVD)

question

Patients diagnosed with this mental illness often make suicidal threats, gestures and attempts & may use these behaviors when real/perceived abandonment is present

answer

Borderline personality disorder (BPD)

question

This type of traction is used to immobilize a fractured hip and reduce pain and swelling until the client can be stabilized for surgery

answer

Buck's traction

question

When caring for patients in Buck's traction, what is the MOST important nursing assessment?

answer

Skin/neurovascular assessment q2-4hr

question

For patients in Buck's traction, how are they positioned in bed?

answer

Supine in the center of the bed

question

For patients in Buck's traction, how should the weights be visualized?

answer

Hanging freely and not touching the bed/floor

question

What are the components of an adequate neuromuscular nursing assessment?

answer

- Peripheral pulses - Capillary refill - Color/temperature of extremities - Sensation - Movement - 5 P's (Pain, pallor, pulselessness, paresthesia, paralysis)

question

How should the extremity of a patient in Buck's traction be kept?

answer

Above the level of the heart

question

When repositioning a patient in Buck's traction, how should they NOT be turned?

answer

From side-to-side

question

For patients in Buck's traction, what is used to prevent adduction of the hips when repositioning?

answer

Abduction pillow

question

Prior to beginning statin treatment, what lab value does the nurse need to check?

answer

LFT's

question

What is an important education point prior to beginning a patient on statin therapy?

answer

REPORT muscle aches/pain/weakness!!

question

What are lifestyle modifications that need to be implemented if diagnosed with peptic ulcer disease (PUD)?

answer

- Avoid spicy, acidic foods - Avoid substances that stimulate acid secretion (NSAIDs, alcohol, caffeine, chocolate, tobacco) - Reduce stress and obtain sufficient rest

question

For patients diagnosed with peptic ulcer disease (PUD), what should the nurse educate the pt about to report to the provider?

answer

- GI Bleeding: Report orthostatic hypotension, tachycardia & melena/black stools - Perforation: Report increased epigastric pain, N&V, fever

question

What are two risk factors for developing peptic ulcer disease?

answer

Infection with h. pylori and treatment with NSAIDs

question

What is the treatment for peptic ulcer disease?

answer

Antibiotics for infection and PPIs for acid suppression

question

If a patient achieving enteral tube feedings via NG tube begins to experience dyspnea and a productive cough, what does the nurse suspect has occurred? How?

answer

Aspiration due to movement of placement of NG tube

question

If a patient achieving enteral tube feedings via NG tube is suspected of having aspirated, what is the nurses first action?

answer

Stop tube feeding ASAP and assess tube placement (Tube insertion depth, gastric pH)

question

How long should emergency contraception be taken after unprotected sex? When is efficacy reduced?

answer

Must be taken within 5 days of intercourse; Efficacy is reduced after 72 hours (3 days)

question

For a patient recently beginning oral contraception, for what amount of time does the nurse need to educate the pt on how to use back up contraception?

answer

7 days

question

Defined as condition that occurs due to insufficient production/suppression go antidiuretic hormone (ADH)

answer

Diabetes insipidus (DI)

question

When can DI potentially develop?

answer

- After manipulation of the pituitary - Brain tumors - Head injury - CNS infections

question

This disorder is characterized by polyuria, polydipsia and decreased urine specific gravity

answer

Diabetes insipidus (DI)

question

What is the preferred treatment of DI?

answer

Desmopressin (DDAVP)

question

For infants undergoing balloon angioplasty to repair congenital pulmonic stenosis, what assessment finding would potentially delay this procedure?

answer

Severe diaper rash - Due to catheterization insertion site being in the groin, this could lead to a bloodstream infection

question

For patients diagnosed with cirrhosis, what are nursing interventions to reduce pruritus?

answer

- Encourage the patient to cut nails short - Wear cotton gloves - Wear long sleeved shirts to avoid injury by itching - Taking baking soda baths - Applying calamine lotion - Applying cool, wet cloths to irritated skin

question

For patients diagnosed with cirrhosis, why do they experience pruritus?

answer

Due to buildup of bile salts beneath the skin

question

What medication will be prescribed for patients with cirrhosis to decrease the pruritus experienced due to accumulation of bile salts underneath the skin?

answer

Cholestyramine (Questran)

question

What is proper medication administration for Cholestyramine (Questran) when treating pruritus in cirrhosis?

answer

- Powder; Must be mixed with food (Applesauce) or juice and should be given one hour AFTER other medications are administered

question

This childhood disorder is also known as mucocutaneous lymph node syndrome

answer

Kawasaki Disease (KD)

question

This pediatric disease is characterized by > 5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash and extremity swelling

answer

Kawasaki Disease (KD)

question

Why is IV immunoglobulin and aspirin given to treat Kawasaki Disease (KD)?

answer

To prevent coronary aneurysms and subsequent occlusion

question

What is the therapeutic effect of IVIG and aspirin for Kawasaki Disease (KD)?

answer

To prevent heart disease

question

For patients prescribed loop diuretics, how should potassium supplementation be taken?

answer

- Patient should take potassium tablets with plenty of water - Patient should remain sitting up right for > 30 minutes after ingestion

question

If potassium supplementation tablets are not taken with enough water or if the patient does not sit upright for > 30 minutes after ingestion, what can potentially happen?

answer

Pill induced esophagitis and erosion of esophagus

question

What vitamin helps with calcium absorption?

answer

Vitamin D

question

When administering a rectal suppository to an infant, what is proper procedure?

answer

- Apply clean gloves and position the client supine with knees and feet raised - Lubricate the tip of suppository with water soluble jelly - Insert suppository past internal sphincter using the fifth finger - Angle suppository and guide it along the rectal wall - Hold buttocks together for several minutes or until urge to defecate has passed

question

Defined as a unilateral or bilateral retinal tumor and is the most common childhood intraocular malignancy

answer

Retinoblastoma

question

How is retinoblastoma usually first recognized in children?

answer

Parents report a white "glow" of the pupil

question

What are the most common clinical manifestations of retinoblastoma?

answer

Leukocoria (white glow of pupil) & strabismus (Misalignment of eyes)

question

What is the treatment for retinoblastoma in children?

answer

Radiation therapy or enucleation (Removal of eye)

question

What are risk factors for infants developing recurrent otitis media?

answer

- Frequent use of pacifier - Infant's immunization status - Infant's position while drinking from bottle

question

Defined as inflammation or infection of the middle ear

answer

Otitis media (OM)

question

What are modifiable risk factors to alter to prevent recurrent otitis media in infants?

answer

- Recurring exposure to tobacco spoke - Regular pacifier use - Drinking from a bottle when lying down - Lack of immunizations

question

What is a risk factor for infants and children contracting otitis externa?

answer

Bathing or swimming and getting water in the ears

question

What are absolute contraindications for an MRI?

answer

- Cardiac pacemaker - Implantable cardioverter defibrillator (ICD) - Cochlear implant - Retained metallic foreign body, such as in the eye

question

This medication is an oral medication that forms a protective layer in the GI mucosa which provides a physical barrier against stomach acids and enzymes

answer

Sucralfate

question

When is sucralfate typically prescribed and why?

answer

- 1 hour prior to meals on an empty stomach with a full glass of water - Provides protective layer and physical barrier against stomach acids and enzymes

question

What medication is typically used to manage dyspnea, tachycardia and restless associated with withdrawing mechanical ventilator support at end of life?

answer

Morphine

question

Defined as a congenital disorder in which the bladder was not developed in the abdominal cavity during fusion in the embryo and is exposed externally at birth

answer

Bladder exstrophy

question

What is the most important nursing intervention when caring for an infant with bladder exstrophy?

answer

Placing a protective film of plastic over the exposed bladder to keep the tissue moist and help prevent infection

question

Defined as a life threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher

answer

Autonomic dysreflexia

question

What are examples of foods high in folic acid?

answer

- Asparagus - Turnip/mustard greens - Fortified breakfast cereal - Cooked dried beans - Liver - Leafy greens (Broccoli, spinach) - Beats - Rice - Peanut butter

question

What are some s/s of alcohol withdrawal syndrome (DTs)?

answer

- Mild: Anxiety, insomnia, diaphoresis, palpitations, GI upset Seizures: Single or generalized Hallucinosis: Visual, auditory or tactile hallucinations

question

What are s/s of delirium tremens (DTs)?

answer

- Confusion - Agitation - Fever - Tachycardia - Hypertension - Diaphoresis - Hallucinations

question

How can the DT's be prevented during hospitalization?

answer

Administration of benzos

question

When palpating a pulse on an infant, where should the nurse place her fingers? What artery is this?

answer

The nurse should place her fingers halfway between the shoulder and elbow, palpating the brachial artery

question

Defined as a fungal infection on the superficial keratin layers of the skin, hair and/or nails

answer

Ringworm aka tinea corporis

question

What are examples of proper management of ringworm?

answer

- Teaching appropriate hygiene (Hand washing) - Limited contact with infected person's personal items (Hair brush) - Treatment with prescribed shampoo and/or topical/oral medications

question

This intervention is used to temporarily control bleeding from esophageal varicose

answer

Balloon tamponade tube

question

For a symptomatic patient with a potassium level of 7.3, what is the fastest intervention that can be implemented to decrease dysrhythmias associated with hyperkalemia?

answer

IV calcium gluconate

question

What does CBIG KDROP stand for related to hyperkalemia?

answer

C - Calcium gluconate B - Bicarbonate I - Insulin (Regular) G - Glucose (D20W) K - Kayexalate D - Diuretics ROP - Removal of patient (Dialysis)

question

When an autopsy is REQUIRED due to legal reasons, what should the nurse NOT do during post portum care?

answer

Remove any tubes or IV lines

question

This disorder is the result of prolonged exposure to excess corticosteroids, especially glucocorticoids

answer

Cushing syndrome

question

What are the clinical manifestations associated with Cushing syndrome?

answer

- Acne - Hirsutism (Unwanted hair growth) - Menstrual irregularities - Truncal obesity - Hypertension - Moon face - Buffalo hump - Hyperglycemia - Easy bruising - Muscle weakness and osteoporosis

question

What electrolyte abnormalities are present in Cushing syndrome?

answer

- Hyperglycemia - Hypernatremia - Hypokalemia

question

What electrolyte imbalances are present in Addison's disease?

answer

- Hypoglycemia - Hyponatremia - Hyperkalemia

question

What is contraindicated for HIV positive mothers post delivery?

answer

Breastfeeding - HIV can be transmitted to the newborn via breast milk

question

Defined as a program of care and support that assists clients who have a terminal illness by improving their quality of life through comfort measures

answer

Hospice

question

What is the eligibility for hospice?

answer

- Must be terminally ill with a life expectancy of 6 months or less - Willing to accept palliative care

question

What are appropriate statements for the nurse to make when discussing hospice care with a patient and their family?

answer

- Hospice can be provided in the home, nursing home or in the hospital - Hospice care is covered by Medicare - Hospice helps people die naturally in their own time - If your condition improves, you can be discharged from hospice

question

What is the therapeutic drug level for Phenytoin (Dilantin)?

answer

10-20 mcg/mL

question

What are early signs of Phenytoin (Dilantin) toxicity?

answer

- Horizontal nystagmus - Gait unsteadiness - Slurred speech - Lethargy - Confusion - Coma

question

What OTC medications are contraindicated during pregnancy?

answer

NSAIDs

question

This medication is a central nervous system depressant that is commonly prescribed to prevent seizures in clients with preeclampsia

answer

Magnesium sulfate

question

For patients receiving magnesium sulfate for preeclampsia, what are proper nursing assessments/interventions to perform at this time?

answer

- Continuously assess deep tendon reflexes - Have calcium gluconate at bedside (Reversal agent) - Decrease environmental stimuli to minimize risk for seizure activity - Decrease lights in room and other environmental stimuli

question

What is the reversal agent for magnesium sulfate?

answer

Calcium gluconate

question

What nursing interventions are vital to prevent the occurrence of dehiscence after abdominal surgery?

answer

- Administration of stool softeners (Colace) to prevent straining - Administering antiemetics (Zofran, Reglan) to prevent N&V which will increase intra abdominal pressure - Applying an abdominal binder to support the incision - Monitoring BG to prevent infection and promote wound healing - Educating about splinting the abdomen by holding a pillow or folded blanket against abdomen when coughing and moving

question

What is proper storage/handling of formula/milk related to infant feeding?

answer

- Keep bottles/nipples/caps as clean as possible - Wash the tops of formula cans prior to opening to prevent contamination - Prepared formula must be kept in fridge and discarded after 48 hours - Prepared bottles can be warmed in a pain of hot water NOT MICROWAVE - Test temperature of bottle on inner wrist before giving to infant

question

Why is infant formula NEVER microwaved?

answer

Microwaving formula can cause irregular heating and mouth burns in infants

question

Why should formula never be diluted or concentrated?

answer

- Water intoxication r/t hyponatremia

question

Defined as primary adrenocortical insufficiency or hypo function of the adrenal cortex

answer

Addison's disease

question

What are the adrenal glands responsible for secreting?

answer

- Glucocirticoids - Androgens - Mineralocorticoids

question

What are clinical manifestations of Addison's disease?

answer

- Bronze pigmentation of skin in sun exposed areas - Vitiligo (Patchy/blotchy skin) - Slow, progressive onset of weakness and fatigue - Anorexia/weight loss - Orthostatic hypotension - Hyponatremia & Hyperkalemia - Salt cravings - N&V - Depression and irriaibility

question

Infectious mononucleosis (Mono) is caused by what virus?

answer

Epstein-Barr virus

question

What is a serious complication of infectious mononucleosis?

answer

Spleen rupture

question

This medication is a mood stabilizer that is most often used to treat bipolar affective disorders

answer

Lithium

question

What is the therapeutic range of Lithium? (Think Cr)

answer

0.6-1.2

question

What is the therapeutic range of Lithium?

answer

0.6-1.2

question

What are some risk factors for developing lithium toxicity?

answer

- Dehydration - Decreased renal function - Diet low in sodium - Drug-drug interactions (NSAIDs, thiazide diuretics)

question

Reduction in which electrolyte potentiates lithium toxicity?

answer

Sodium

question

What is the sequence of basic life support (BLS) for an unconscious, pulseless patient?

answer

- Verify unresponsiveness by tapping/shaking & saying "Hello are you all right?" - Activate emergency response system by calling for help or calling 911 - Simultaneously check for the carotid pulse and assess for spontaneous breathing for no more than 10 seconds - Attempt CPR if no pulse is felt

question

At what rate should chest compressions be in BLS?

answer

100-120/min

question

During a vaso-occlusive crisis, a complication of sickle cell anemia, what is there an increased presence of in the laboratory values?

answer

Elevated bilirubin & elevated reticulocytes

question

For a patient diagnosed with Addison's disease, what can abrupt discontinuation of corticosteroids lead to?

answer

Addisonian crisis - life threatening complication

question

What is an ocular problem that results from long term corticosteroid use, specifically glucocorticoids?

answer

Cataracts

question

These types of contractions come in regular intervals; frequency, duration and intensity increase over time

answer

True contractions

question

These types of contractions come in irregular intervals; No increase in frequency, duration or intensity & may dissipate over time

answer

Braxton Hicks Contractions

question

These types of contractions increase despite implementation of comfort measures (Change of position, hydration, walking)

answer

True contractions

question

These types of contractions may lessen or dissipate with comfort measures (Walking, change of position, hydration)

answer

Braxton Hicks Contractions

question

These types of contractions cause an increase in cervical dilation and effacement

answer

True contractions

question

These types of contractions cause no cervical change in the mother

answer

Braxton Hicks Contractions

question

Defined as the leading cause of death among infants aged 1 month to 1 year

answer

Sudden infant death syndrome (SIDS)

question

What measures does the RN need to educate new parents about r/t prevention of SIDS?

answer

- Place infants less than 1 year old on their BACK (Supine) to sleep - Firm mattress should be chosen - Avoid soft objects such as stuffed animals, heavy blankets etc - Avoid bumper crib pads* - Maintain SMOKE FREE house hold - Avoid overheating of infant* - Encourage use of pacifier - Breast feeding is encouraged - Keept infant up to date with immunizations

question

What two factors contribute greatly in the prevention of SIDS?

answer

Breastfeeding & up to date immunizations

question

This ventilator setting applies a given pressure at the end of expiration during mechanical ventilation

answer

PEEP - Positive end-expiratory pressure

question

What is the therapeutic effect of PEEP?

answer

It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange

question

At what level is PEEP typically kept on?

answer

5 cm of h2o

question

What is the range for high levels of PEEP?

answer

10-20 cm of h2o

question

What can continuously high levels of PEEP cause?

answer

Overdistension and rupture of alveoli resulting in barotrauma to the lung

question

What is the nurses role when assisting with an LP?

answer

- Verify informed consent - Gather the lumbar puncture tray and needed supplies - Explain the procedure to older child and adult - Have client empty their bladder - Place client in appropriate position (Side lying with knees drawn up to chest) - Assist client in maintaining proper position - Provide a distraction measure throughout procedure 0 Label specimen containers as they are collected - Apply bandage to the insertion site - Deliver specimens to lab

question

Defined as a parasitic infection which may be acquired from exposure to infected cat feces or ingestion of undercooked meat or soil contaminated fruits/veggies

answer

Toxoplasmosis

question

What position is a patient typically placed in for an LP?

answer

Lateral recumbent or sitting up right

question

After an LP, what does the nurse need to educate the patient on related to positioning?

answer

- Patient must lie flat with no pillow for at least 4 hours to reduce chance of CSF leaking resulting in a headache - Increase fluid intake for at least 24 hours to prevent dehydration

question

What do late decelerations indicate?

answer

Placental insufficiency

question

If late decelerations are seen on the fetal heart monitor tracing, what are proper nursing interventions at this time?

answer

- Administer supplemental o2 via facemask - Reposition patient to right or left side - STOP oxytocin infusion - Administer IV fluid bolus

question

What are early signs of methadone toxicity?

answer

N&V and lethargy

question

What kind of delusion is this: "I need to get to Washington for my meeting with the president."

answer

Delusion of Grandeur

question

What kind of delusion is this: "Don;t drink the tap water. That's how the government controls us."

answer

Delusion of Control

question

What kind of delusion is this: " It doesn't matter if I take my medicine. I am already dead."

answer

Delusion of Nihilism

question

What kind of delusion is this: "The doctor said I am fine, but I really have lung cancer."

answer

Delusion of Somatism

question

What kind of hallucination is this: "I need for you to get rid of these bugs that are crawling under my skin."

answer

Tactile hallucination

question

What kind of hallucination is this: "Hear that? She told me to kill my father."

answer

Auditory hallucination

question

What type of delusion is this: "Those martians are trying to poison me with that tap water."

answer

Persecutory (Paranoid) delusion

question

What are clinical manifestations of acute otitis media (AOM)?

answer

- High fever - Ear pain - Irritability/restlessness - Loss of appetite - Pulling on affected ear - Bulging/red tympanic membrane

question

During disaster triage, these patients have suffered life-threatening injuries with good prognosis after minimal intervention

answer

Red tag

question

During disaster triage, these patients have suffered injuries requiring treatment within hours

answer

Yellow tag

question

During disaster triage, these patients have suffered injuries requiring treatment within a few days

answer

Green tag

question

This complication of pregnancy occurs when trauma to the tissues of the perineum occurs during delivery

answer

Vaginal hematoma

question

A client that just delivered a term infant reports persistent, severe vaginal pain & a feeling of fullness. What does the nurse suspect?

answer

Vaginal hematoma

question

Defined as inflammation of a vein

answer

Phlebitis

question

What are common manifestations of phlebitis?

answer

- Pain - Swelling - Warmth at the site - Redness extending along the vein

question

What is proper nursing intervention when assessing phlebitis?

answer

Immediately remove the IV catheter

question

What drug classes are commonly associated with orthostatic hypotension?

answer

- Antihypertensives - Antipsychotics - Antidepressants - Diuretics - Vasodilators - Narcotics

question

What are proper nursing interventions for the acute phase of hepatitis?

answer

- Alternate periods of rest and activity - AVOID ALCOHOL - Encourage small frequent meals - Provide oral care and avoid extremes in food temperature - Drink adequate amounts of fluids

question

To prevent injury in a client who is actively falling, what are proper actions by the nurse?

answer

- Step behind client and place arms under axilla/around waist - Place feet wide apart with knees bent - Place one foot behind the other and extend front leg - Let patient slide down the extended leg to the floor

question

This condition is considered a severe neural tube defect resulting in little to no brain tissue or skull formation in utero

answer

Anencephaly

question

What is the prognosis for infants born with anencephaly?

answer

Many are born stillborn and those that are born alive are not compatible with life

question

Defined as a rare but potentially life threatening complication that can occur in clients during the initial stage of hemodialysis

answer

Dialysis disequilibrium syndrome (DDS)

question

What are the clinical manifestations of dialysis disequilibrium syndrome?

answer

- N&V - Headache - Restlessness - Change in mentation - Seizure activity

question

If dialysis disequilibrium syndrome (DDS) is suspected, what is the nurses first action?

answer

Contact the HCP ASAP! EMERGENCY*

question

What medication class is held prior to dialysis to minimize the risk for hypotension?

answer

Antihypertensives

question

Defined as low molecular weight heparin

answer

Enoxaparin (Lovenox)

question

How should the nurse administer LMWH, Enoxaparin (Lovenox)?

answer

Subq injection at a 90 degree angle, to the right or left side of abdomen (Love handles), at least 2 inches away from the umbilicus

question

For patients diagnosed with chronic kidney disease, what are they at greatest risk for?

answer

Hyperkalemia & fluid volume overload (FVE)

question

Greater than what amount of chest drainage needs to be reported to the HCP?

answer

> 100 mL/hr

question

For patients that underwent placement of a permanent pacemaker, what education should the nurse give the patients?

answer

- Report any s/s of infection (Redness, swelling, drainage, fever) - Keep a pacemaker ID card with you - Wear a medic alert bracelet - Microwave ovens are safe to use* - Report if pulse is under HCP recommendation - Do not place cell phone directly over pacemaker - AVOID MRI SCANS - Avoid lifting arm above the shoulder until approved by HCP - Air travel is not restricted - Notify airport security that you have a pacemaker (Will set off metal detector)

question

This type of head injury occurs when a body in motion stops suddenly, causing contusions of brain tissue as the brain moves back and fourth within the skull

answer

Coup- countercoup

question

With a coup-cointrecoup head injury due to a car accident, what types of deficit can the nurse expect?

answer

Frontal lobe - Deficit in memory, speech & executive function (Decision making) Occipital lobe - Deficit in vision and interpretation

question

This medication is an example of a thrombin inhibitor that reduces the risk of clot formation and stroke in clients with chronic atrial fibrillation

answer

Dabigatran (Pradaxa)

question

For patients prescribed Dabigatran (Pradaxa), how should this medication be stored?

answer

Capsules should be kept in their original container blister pack until time of use to prevent moisture contamination

question

For patients prescribed Rifapetine, a derivative of rifampin, how should the nurse instruct these patients on use of birth control?

answer

Rifampin and rifampin derivatives reduce efficacy of oral contraceptives by increasing their metabolism; Alternative BC method will need to be implemented during treatment

question

What is the appropriate time range from TPA to treat an ischemic stroke?

answer

< 3-4.5 hours

question

Defined as an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction

answer

Myasthenia gravis

question

What are examples of clinical manifestations of myasthenia gravis?

answer

- Weakness of skeletal muscles - Ptosis/diplopia - Bulbar signs (Difficulty speaking/swallowing) - Difficulty breathing

question

What is the treatment for myasthenia gravis?

answer

Anticholinesterase drugs - Pyridostigmine (Mestinon)

question

In treating myasthenia gravis, when are anti cholinesterase medications administered?

answer

Before meals

question

What is the greatest risk for patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF)?

answer

Aspiration

question

What are priority nursing interventions for patients diagnosed with EA/TEF?

answer

- Maintaining NPO status - Positioning pt supine with HOB at > 30 degrees - Keep suction equipment at bedside - Prevent aspiration

question

This form of therapy can be effective in treating anxiety disorders, eating disorders, depressive disorders and medical conditions such as insomnia and smoking

answer

Cognitive behavioral therapy (CBT)

question

What are the 5 basic components of cognitive behavioral therapy (CBT)?

answer

- Education about client's specific disorder - Self observation and monitoring - Physical control strategies - Cognitive restructuring - Behavioral strategies

question

When discharging a patient with COPD with home oxygen, what are nursing education points that should be voiced at this time?

answer

- Avoid oil based lubricants on nostrils (Flammable) - Water-soluble lubricants are acceptable - Keep oxygen canisters at least 5-10 feet away from fire sources - Do NOT increase o2 flow rate without HCP prescription; Drive to breath can be potentially decreased - Avoid nail polish remover with oxygen (Flammable) - Avoid synthetic and wool fabrics (Flammable) - Cotton blankets/fabrics are recommended

question

Defined as a hand held device that is used to measure peak expiratory flow rate (PEFR) and is most helpful for patients with moderate-severe asthma

answer

Peak flow meter

question

How should a nurse instruct a patient on how to use a peak flow meter? What does it measure?

answer

- Move the indicator on the numbered scale to 0 before using device - Exhale as quickly and forcibly as possible through the mouthpiece - Mouthpiece evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath

question

For a patient suspected of having an air embolism, what are the proper nursing interventions to prevent further patient decline?

answer

- Clamp catheter to prevent more air from embolizing into circulation - Place pt in trendelenburg position on the left side, causing air to rise and become trapped in right atrium - Administer o2 prn - Notify HCP

question

For a patient suspected of having an air embolism, why is it best for them to be placed in trendelenburg on the left side?

answer

This position will cause any existing air to rise and become trapped in the right atrium

question

For patients diagnosed with oral mucositis, inflammation or ulceration of the oral mucosa, what is proper nursing care?

answer

- Cleanse mouth with NS after meals and hs - Use soft bristled tooth brush - Apply prescribed viscous lidocaine to alleviate oral pain - Use water soluble lubricating agents to moisten mouth tissues - Avoid hot liquids/spicy/acidic foods

question

How often will most newborns want to breast feed?

answer

8-12 times/day

question

Approximately how often should an infant be fed on each breast?

answer

15-20 minutes/breast

question

Where can an abdominal aneurysm be auscultated?

answer

The periumbilical or epigastric area, slightly left of midline

question

If strep throat is left untreated, what extremely dangerous complication can develop?

answer

Rheumatic fever

question

What is the proper positioning for a paracentesis?

answer

High fowler's position

question

Upon insertion of a chest tube, how should the patient be positioned?

answer

The patient's arm should be raised above head ob affected side; if possible, HOB should be raised 30-60 degrees to reduce risk of injury to diaphragm

question

How should a patient be positioned after a liver biopsy and for how long?

answer

On the right side for a minimum of 2 hours & then supine for an additional 12-14 hours

question

What immunizations are appropriate to get during pregnancy?

answer

- Influenza injection - Tdap

question

What immunizations are NOT appropriate to get during pregnancy?

answer

- Influenza nasal spray - MMR - Varicella

question

Defined as a urinary analgesic prescribed to relieve pain and burning associated with a UTI

answer

Phenazopyridine hydrochloride (Pyridium)

question

For patients prescribed Pyridium, what are important nursing education points to discuss with the patient?

answer

- Body secretions will turn bright red-orange (Urine, sweat, tears) & it is normal - Avoid contact lenses while taking medication (They will stain)

question

What are s/s of postpartum endometritis?

answer

- Fever - Chills - Tachycardia - Uterine tenderness - Foul smelling lochia

question

What are examples of vaccines that are not live?

answer

- Haemophilus influenzae type b (Hib) - Hepatitis B - Pneumococcal conjugate (PCV) - Influenza IM

question

What are s/s of an impending PE?

answer

- Dyspnea - Hypoxemia - Tachypnea - Cough - Chest pain - Hemoptysis - Tachycardia - Syncope - Hemodynamic instability

question

For a patient diagnosed with cholelithiasis who is actively vomiting, what is the priority nursing action and why?

answer

To main strict NPO status to avoid additional gallbladder stimulation

question

During pregnancy, what hormone causes the esophageal sphincter to relax, leading to pyrosis (Heartburn)?

answer

Progesterone

question

This extra heart sound is also known as a ventricular gallop

answer

S3

question

What does auscultation of S3 upon assessment most likely indicate?

answer

Heart failure or FVE

question

For a patient that experienced multiple rib fractures, what nursing interventions are vital for this patient?

answer

Pain management and pulmonary hygiene (Coughing, deep breathing)

question

A nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. What CN's are being tested? (Think saying learned in ATI)

answer

"CN's 3, 4 & 6 make the eyes do tricks" - III - IV - VI

question

This clinical symptom of major depressive disorder include slowed speech, decreased movement and impaired cognitive function

answer

Psychomotor retardation

question

What are examples of foods that are high in iron?

answer

- Meats (Beef, lamb, liver, chicken, pork) - Shellfish (Oysters, clams, shrimp) - Eggs - Green leafy veggies - Dried fruits - Beans - Brown rice - Oatmeal

question

A child is experiencing anal itching and trouble sleeping. What infection does the nurse suspect?

answer

Pinworm infection

question

For a patient with lobular pneumonia, how should they be positioned in bed to prevent drops in pulse oximetry and increased respiratory distress?

answer

The patient should be positioned with the good lung down which promotes better ventilation and drainage of bad lung

question

Pediatric ailment that ewers to inflammation of the epiglottis that may result in a life threatening airway obstruction

answer

Epiglottitis

question

What is the most common causative agent for epiglottitis?

answer

Haemophilus influenzae type b (Hib)

question

What are the 4 D's r/t epiglottitis?

answer

- Drooling - Dysphonia (Trouble speaking) - Dysphagia (Trouble swallowing) - Distressed airway (Stridor)

question

This pediatric ailment presents as tripoding (Sitting up and leaning forward) with inspiratory stridor

answer

Epiglottitis

question

For a patient diagnosed with TB being treated with ethambutol (Myambutol), what AE does the nurse need to instruct the patient to report to HCP?

answer

Blurred vision - Optic neuritis is possible to develop

question

This area of the brain integrates somatic and sensory input & injury to this area can result in a deficit with sensation

answer

Parietal lobe

question

This area of the brain controls higher-order processing, such as executive function and personality. Injury to this area results in behavioral changes

answer

Frontal lobe

question

This area of the brain integrates visual and auditory input and past experiences. Injury to this area may result in inability for the client to understand verbal/written language

answer

Temporal lobe

question

This area of the brain registers visual images. Injury to this area can result in a deficit with vision

answer

Occipital lobe

question

Bell's palsy is characterized by facial paralysis resulting from inflammation of which CN?

answer

CN VII - Facial nerve

question

What are clinical manifestations of Bell's palsy?

answer

- Inability to completely close eye on affected side - Flattening of the nasolabial fold on the side of paralysis - Inability to smile/frown symmetrically - Alteration in tear production due to eyelid muscle weakness - Loss of taste on the anterior 2/3 of tongue

question

According to Maslow, what are considered physiological needs that are vital for survival?

answer

- Oxygen - Fluids - Maintenance of body temperature (Homeostasis) - Sleep - Proper elimination - Adequate shelter

question

What is the best way the nurse can assess for autonomic neuropathy?

answer

- Take BP sitting then standing

question

What is the autonomic nervous system in control of?

answer

Involuntary body functions: - BP - HR - Perspiration - Sexual function - Digestion

question

What are clinical manifestations of impending respiratory failure?

answer

- PaCO2 > 45 mm Hg - PaO2 < 60 mm Hg - Respiratory acidosis - Paradoxical breathing (Abnormal inward movement of chest on inspiration and outward movement on expiration) - Mental status changes (Restlessness, confusion) - Absence of wheezing and silent chest - Single word dyspnea

question

What is the therapeutic level of magnesium?

answer

1.5-2.5 mEq/L

question

What is the therapeutic level of magnesium sulfate for a pre-eclamptic patient?

answer

4-7 mEq/L

question

What is the normal range for WBCs?

answer

4,000-11,000/mm3

question

Considered an absolute neutrophil count below 1,000/ mm3

answer

Neutropenia

question

Considered an absolute neutrophil count below 500/mm3

answer

Severe neutropenia

question

What is an intervention to prevent morning stiffness of affected joints in patients with RA?

answer

Take a warm shower/bath upon awakening; Heat decreases stiffness and promotes muscular relaxation/mobility

question

Defined as the accumulation of blood between the skull bone and dura mater

answer

Epidural hematoma

question

This kind of hematoma results from an arterial bleed, therefore it develops quickly and is an emergency

answer

Epidural hematoma

question

This kind of hematoma results from a venous bleed, therefore it develops slowly and is an extreme emergency

answer

Subdural hematoma

question

When walking with a client who is blind, what is proper protocol?

answer

Offer an elbow for guidance and walk slightly ahead of the patient

question

For clients with a tracheostomy on mechanical ventilation, what nursing intervention is vital to prevent aspiration?

answer

Ensure cuff is inflated

question

This type of stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space

answer

Hemorrhagic stroke

question

What types of activities/interventions increase ICP?

answer

- Too much stimulation (Bright room, frequent visitors) - Straining bowel/bladder - Coughing/sneezing - Exertion - HOB supine - Head off from midline position

question

What are the clinical manifestations of an anaphylactic reaction?

answer

- Vasodilation: Hypotension and edema - Tachycardia - Stridor/hoarseness - Bronchospasm: Wheezing - Urticarial rash - Pruritus - N&V, abdominal pain

question

Defined as an abnormal collection of fluid in the pleural space between the parietal and visceral pleurae that prevents the lung from expanding fully

answer

Pleural effusion

question

This defense mechanism uses excuses to explain away threatening circumstances

answer

Rationalization

question

This defense mechanism transfers thoughts and feelings toward one person or object onto another person or object

answer

Displacement

question

This defense mechanism involves returning to a previous level of development

answer

Regression

question

This defense mechanism involves taking on the qualities or attitudes of others without thought to examination

answer

Introjection

question

This defense mechanism involves behaving in a manner or expressing a feeling of opposite of one's true feelings

answer

Reaction formatio

question

This defense mechanism involves keeping unacceptable thoughts or traumatic events buried in the unconscious

answer

Repression

question

This defense mechanism involves transforming unacceptable thoughts or needs into acceptable actions

answer

Sublimation

question

What defense mechanism is this: "I did poorly on the test because the questions were so tricky."

answer

Rationalization

question

What defense mechanism is this: A person who is angry with a boss comes home and yells at their spouse.

answer

Displacement

question

What defense mechanism is this: An adult has a "temper tantrum" when stuck in traffic

answer

Regression

question

What defense mechanism is this: A person may take on the political views of a famous admired actor

answer

Introjection

question

What defense mechanism is this: A parent who is resentful of an "unplanned" child becomes overprotective of that child

answer

Reaction formation

question

What defense mechanism is this: A person who was raped cannot recall the event

answer

Repression

question

What defense mechanism is this: A person may turn to voting to deal with aggression

answer

Sublimation

question

This defense mechanism involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person

answer

Projection

question

What defense mechanism is this: A husband with thoughts of infidelity who then accuses his wife of being unfaithful

answer

Projection

question

What nursing intervention is contraindicated post bariatric surgery due to potential disruption of the surgical site?

answer

NG tubes

question

When diverticula become inflamed, the patient is diagnosed with what?

answer

Diverticulitis

question

Defined as a disease of the colon in which sac-like protrusions in the large intestine are caused by chronic increased intra-abdominal pressure and/or chronic constipation

answer

Diverticular disease

question

For children who develop Reye syndrome, what infections did they most likely have?

answer

Vital infections such as varicella or influenza

question

In pregnant patients, when is quickening (awareness of fetal movements) detected?

answer

18-20 weeks in primigravidae 14-16 weeks in multigravidae

question

What are the routine immunizations for a 6 month client? (Think acronym)

answer

Be DR HIP - B: Hepatitis B - D: DTaP - R: RV - H: Hib -I: IPV - P: PCV

question

Related to immunizations for a 6 month old patient, what does the acronym Be DR HIP stand for?

answer

Be DR HIP - B: Hepatitis B - D: DTaP - R: RV - H: Hib -I: IPV - P: PCV

question

Under what circumstances is consent from family for an autopsy not required?

answer

- Suicide - Homicide - Accident - Within 24 hours of admission of facility

question

Related to metabolic syndrome, what does the nematic "We Better Think High Glucose" stand for?

answer

We - waist circumference Better - blood pressure Think - Triglycerides High - HDL Glucose - Glucose

question

During a typical episode of this disease, digital arteries constrict and blood flow is impaired, causing the skin to turn pale and then blue, and feel numb and cold

answer

Raynaud's phenomenon

question

This electrolyte is released when cellular damage occurs with burns

answer

Potassium

question

What are the clinical manifestations of hyperkalemia?

answer

- Muscle weakness - ECG changes (Tall, peaked t-waves, shortened QT interval) - Cardiac arrhythmias

question

Defined as nearsightedness

answer

Myopia

question

What are the clinical manifestations and parent reports of children suspected of having myopia (Nearsigntedness)?

answer

- Headaches - Dizziness - Difficulty seeing objects clearly - Poor performance in school - Rubbing of eyes - Frequent blinking or squinting

question

This congenital disease occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering anal sphincter unable to relax; No peristalsis occurs & no stool is passed

answer

Hirschsprung disease (HD)

question

What is a major AE of high dose IV furosemide (Lasix) administration?

answer

Ototoxicity

question

For furosemide doses > 120 mg, what should the dosage/min not exceed?

answer

4 mg/min (Over 40 min)

question

Neonate abstinence syndrome is typically caused by abuse of what drug classes during pregnancy?

answer

Opioids & benzos

question

What are clinical manifestations of neonate abstinence syndrome?

answer

- ANS: Stuffy nose, sweating, frequent yawning and sneezing - CNS: Irritability, restlessness, high pitched crying, abnormal sleep pattern, hyperactive reflexes - GI: Poor feeding, vomiting & diarrhea

question

What are proper nursing interventions when discontinuing a central venous catheter to prevent an air embolism from forming?

answer

- Supine positioning - Instruct pt to bear down & exhale - Apply air occlusive dressing - Pull line out cautiously (Do NOT pull harder if there is resistance)

question

For a patient with advanced kidney disease with a serum potassium of 7.1 and a serum creatinine of 4.5 with NO CURRENT ECG changes, what is the priority for the nurse to administer?

answer

IV 50% dextrose and regular insulin

question

For a patient with advanced kidney disease with a serum potassium of 7.1 and a serum creatinine of 4.5 with ECG CHANGES, what is the priority for the nurse to administer?

answer

Calcium gluconate IV followed by insulin/dextrose IV

question

What are the adverse effects of Metoclopramide (Reglan)? (Think antipsychotics)

answer

- EPS - Tardive dyskinesia (TD) - Protruding and twisting of tongue - Lip smacking - Puffing of cheeks - Frowning/blinking of eyes - Twisting fingers - Twisted/rotated neck (torticollis)

question

This class of blood pressure medications has a direct effect on the HR and should be held for HR < 60 bpm

answer

CCB - Non-dihydropiridine (Verapamil, Diltiazem)

question

Positive orthostatic vital signs is a rise in pulse of how many bpm?

answer

Greater than or equal to 20 bpm increase

question

For patients diagnosed with CF, should bronchodilator treatments be administered before or after chest physiotherapy?

answer

Before

question

A complication of hyperthyroidism defined as a protrusion of the eyeballs caused by increased orbital tissue expansion and can be irreversible

answer

Exophthalmos

question

What is proper nursing management for patients experiencing the complication of Graves disease, exophthalmos?

answer

- Maintaining HOB in raised position to facilitate drainage from periorbital area - Use of artificial tears to moisten eyes - Taping eyelids shut during sleep if they do not close on their own - Educate on importance of regular visits to ophthalmologist - Educate on importance of anti-thyroid medications - Restrict salt intake - Encourage smoking cessation - Use dark glasses to prevent irritation to eyes - Do eye ROM exercises

question

How many mL in one ounce?

answer

30 mL

question

When administering a non-rebreather mask, the oxygen flow rate must be high enough to keep the reservoir bag how inflated?

answer

2/3 inflated

question

What are proper nursing interventions to assess proper cerebellum functioning?

answer

- Finger tapping (tapping each finger to that hand's thumb) - Rapid alternating movements (Rapid supine and pronation) - Finger to nose testing - Heel to shin testing (Run heel down opposite shin)

question

What blood pressure medication class can actually worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility

answer

Beta Blockers (BBs)

question

Defined as an autoimmune disorder in which an abnormal immune response leads to chronic inflammation in different parts of the body

answer

Systemic lupus erythematosus (SLE)

question

What is the trade name for sodium polystyrene sulfonate

answer

Kayexalate

question

What is the generic name for Kayexalate?

answer

Sodium polystyrene sulfonate

question

For an infant diagnosed with Edward's syndrome, what is an appropriate nursing action at birth?

answer

Request a meeting with the palliative care team and the parents to discuss end of life choices

question

For patients diagnosed with Raynaud phenomenon, what are proper nursing interventions/teaching points to educate the client about?

answer

- Wear gloves when handling cold objects - Dress in warm layers in cold weather - Avoid extreme abrupt weather changes (Cold to hot) - Avoid vasoconstriction drugs (Cocaine, amphetamines, ergotamine, pseudoephedrine) - Refrain from tobacco products - Implement stress management strategies (Toga, tai chi)

question

For patients diagnosed with Raynaud phenomenon, what pharmacologic remedy may be prescribed if non-pharmacological methods are unsuccessful?

answer

CCBs- relax arteriole smooth muscle and prevent recurrent episodes

question

One gram of weight is equal to how much in mL?

answer

1 gram = 1 mL of weight

question

Which patient reports would indicate a possible latex allergy?

answer

- Blowing up balloons causes lip swelling - Hands itch after wearing rubber gloves - Allergy to bananas, avocados, tomatoes, chestnuts, kiwis, potatoes, peaches, grapes and apricots

question

Allergy to what food group indicates a potential reaction to iodinated contrast dye used during CT scans, catheterizations and angiograms?

answer

Shellfish

question

If the nurse inevitably needs to draw blood from a new site of an extremity with a current IV infusion, where should the blood draw be done?

answer

Distal to the current site

question

A patient reporting light gray or "Clay colored," stool is most likely suffering from what?

answer

Biliary obstruction

question

A patient reporting mucus or pus visible in their stool is most likely suffering from what?

answer

Ulcerative colitis or infectious colitis

question

A patient reporting greasy, foamy, foul smelling or fatty stool is most likely suffering from what?

answer

Chronic pancreatitis

question

A patient reporting black tarry stools is most likely suffering from what?

answer

Upper GI bleed

question

A patient reporting bright red bloody stools is most likely suffering from what?

answer

Lower GI bleeding

question

The occurrence of this disease is higher among hispanics, american indians and african americans

answer

Cervical cancer

question

What ethnic group has the highest incidence of hypertension in the world

answer

African Americans

question

Defined as an acute skin disorder, most commonly associated with a medication reaction, resulting in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis and skin erosion; Severe form of SJS

answer

Toxic epidermal necrolysis

question

When caring for a patient with a tracheostomy, what is an effective way to ensure adequate tightness of the ties?

answer

Check the tightness by allowing 1 finger to fit underneath the ties

question

For patients prescribed Vancomycin, what are proper nursing assessments during administration?

answer

- Assess skin for flushing and red rash on face and torso (Red man syndrome) - Infuse medication over at least 60 minutes - Monitor BP during infusion - Observe IV site q30min for pain, redness and swelling

question

At what rate does Vancomycin need to be administered to prevent Red Man Syndrome?

answer

Infuse medication over at least 60 minutes

question

A patient is receiving a Vancomycin infusion and begins to develop skin flushing and a red rash on the face and torso. What does the nurse suspect? Why did this occur?

answer

Red man syndrome - Infusion is too fast, slow it down

question

What is the first sign of pubertal changes that occur in boys?

answer

Testicular enlargement

question

Defined as an extremely contagious disease with a high mortality rate; Also known as hemorrhagic fever

answer

Ebola

question

What type of isolation precautions is required for a patient diagnosed with Ebola?

answer

- Standard - Contact - Droplet - Airborne * Impermeable gown/coveralls, N95 respirator, full face mask, doubled gloves with extended cuffs, single-use boot covers, single-use apron

question

What PPE is required when caring for a patient with Ebola?

answer

- Impermeable gown/coveralls - N95 respirator - Full face mask - Doubled gloves with extended cuffs - Single-use boot covers - Single-use apron

question

What is the visitor policy for client's diagnosed with Ebola?

answer

Visitors are prohibited unless absolutely necessary for the client's well-being

question

This endocrine disorder is characterized by high TSH levels and low T3 and T4 levels

answer

Hypothyroidism

question

This endocrine disorder is characterized by low TSH levels and high T3 and T4 levels

answer

Hyperthyroidism

question

What are the clinical manifestations of hypothyroidism? (Think slow)

answer

- Constipation - Cool/pale skin - Brittle nails/hair - Hair loss - Bradycardia - Joint pains/muscle aches - Dementia/depression due to mental slowing - Cold intolerance - Weight gain - Forgetfulness

question

What are the clinical manifestations of hyperthyroidism? (Think fast)

answer

- Diarrhea - Warm, moist skin - Smooth, silky hair - Tachycardia/palpitations - Heat intolerance - Weight loss

question

What is proper procedure for measurement of pulses paradoxus?

answer

1) Place client in semi recumbent position 2) Have client breathe normally 3) Determine SBP using manual cuff 4) Inflate BP cuff to at least 20 mm Hg above previously measured SBP 5) Deflate cuff slowly, noting first korotkoff sound during expiration along with the pressure 6) Continue to slowly deflate cuff until you hear sounds throughout inspiration/expiration 7) Determine difference between two measurements, equaling amount of paradox

question

This electrolyte imbalance can lead to seizures, confusion or other neurologic complications

answer

Hyponatremia

question

What is the treatment for SIADH?

answer

- Fluid restriction to < 1000 mL/day - Oral salt tablets - Hypertonic saline (3%) - Vasopressin

question

Defined as the second most common health-care associated infection in the US, associated with increased mortality, hospitalization and length of stay

answer

VAP - Ventilator associated pneumonia

question

What are the clinical manifestations of VAP (Ventilator associated pneumonia)?

answer

- Purulent sputum - Positive sputum culture - Leukocytosis - Elevated temperature (> 100.4 F) - New progressive pulmonary infiltrates on chest x-ray

question

Defined as a chronic autoimmune disease that causes a rapid turnover of epidermal cells

answer

Psoriasis

question

Though there is no cure for psoriasis, what is proper nursing management?

answer

- Avoid triggers (Stress, trauma, infection) - Topical therapy (Corticosteroids, moisturizers) - Phototherapy (Ultraviolet light) - Systemic medications (Methotrexate, infliximab) - Avoidance of alcohol

question

What pharmacologic agents are shown to assist in treatment of psoriasis?

answer

Cytotoxic and biologic agents such as: - Methotrexate - Infliximab

question

Defined as an overproduction of collagen that causes tightening and hardening of the skin and connective tissue; Progressive and no current cure

answer

Scleroderma

question

Defined as a life threatening complication of scleroderma that causes malignant hypertension; Potentially fatal

answer

Renal crisis

question

For patients post laparoscopic cholecystectomy, what is proper positioning post op and why?

answer

Sims' position - to facilitate movement of co2 utilized during surgery to fill the abdominal cavity

question

Defined as a surgically created opening (stoma) in the abdomen that connects the small intestine to the external abdomen (Think placement)

answer

Ileostomy

question

In this type of ostomy, stool from the small intestine bypasses the colon and exits through external opening of abdomen via ostomy bag

answer

Ileostomy

question

For patients with an ileostomy, what kind of stool will form and why?

answer

Liquid stool - when stool bypasses the colon, fluid and electrolyte absorption and vitamin k production do not occur, resulting in liquid stool

question

What diet items should be absolutely avoided for a patient with an ileostomy?

answer

- High fiber (popcorn, coconut, multigrain bread) - Stringy veggies (Celery, broccoli, asparagus) - Seeds or pits (Strawberries, rasberries, olives) - Edible peels (Apple slices, cucumber, dried fruit)

question

The parathyroid gland regulates what serum electrolyte levels?

answer

Calcium

question

What is the trade name for Oseltamivir?

answer

Tamiflu

question

What is the generic name for Tamiflu?

answer

Oseltamivir

question

What is the trade name for Loratadine?

answer

Claratin

question

What is the generic name for Claratin?

answer

Loratadine

question

What is the generic name for Phenergan?

answer

Promethazine

question

What is the trade name for Promethazine?

answer

Phenergan

question

Leakage of this fluid can confirm skull fracture has occurred and transversed the dura

answer

Cerebrospinal fluid (CSF)

question

What are two clinical indications that confirm a skull fracture? What does this indicate?

answer

- Raccoon eyes & Battle's sign; Indicates leakage of CSF

question

What does the treatment of frostbite consist of?

answer

- Remove clothing & jewelry to prevent constriction - DO NOT MASSAGE, rub or squeeze area involved (Will lead to further tissue damage) - Immerse affected area in heated water (98.6-102.2F) - Provide analgesia during rewarming (Painful) - Monitor for compartment syndrome

question

This procedure is commonly used to treat pleural effusions

answer

Thoracentesis

question

What are some complications of thoracentesis?

answer

- Pneumothorax - Bleeding - Tension pneumothorax - Infection

question

What are the clinical manifestations of a patient developing a pneumothorax?

answer

- Increased RR - Increased respiratory effort - Respiratory distress - Low pulse ox - Absent breath sounds on affected side

question

What are some important patient teaching points related to anticoagulation therapy?

answer

- Take medication at the same time daily - Report for periodic blood tests to assess for therapeutic effect - Avoid contact sports, vigorous teeth brushing and use of razor blades - Avoid aspirin and other NSAIDs - Avoid changing eating habits (Increase of leafy greens) - Do NOT take vitamin K supplements if on warfarin - Consult HCP before starting/stopping any herbal supplements (Ginko, garlic etc) - Wear a medical alert bracelet indicating what anticoagulant is being taken

question

What are some clinical manifestations of PTSD?

answer

- Re- experiencing the traumatic event - Flashbacks - Nightmares - Feelings of distress in reaction to reminders - Avoiding reminders of the trauma - Increased anxiety - Emotional arousal

question

What does a client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min indicate?

answer

- Pacemaker malfunction; Immediate skilled intervention required

question

Defined as a serious bone infection that requires long-term treatment with antibiotics

answer

Osteomyelitis

question

Insulin Aspart (NovoLOG) is what kind of insulin? What is the onset?

answer

Rapid-acting insulin - onset of 10-15 minutes

question

Swelling of the neck and increased pain post thyroidectomy may indicate what post op? What is the priority nursing action?

answer

Hematoma formation - Maintain patent airway

question

What is the trade name for Guaifenesin?

answer

Mucinex

question

What is the generic name for Mucinex?

answer

Guaifenesin

question

What is the trade name for Loratadine?

answer

Claritin

question

What is the generic name for Claritin?

answer

Loratadine

question

What two medication classes can be a potential problem for patients with asthma?

answer

NSAIDs & Non-cardioselective BB's

question

Defined as rapid swelling of the lips, tongue, throat, dace and larynx during ACE/ARB inhibitor therapy

answer

Angioedema

question

For patients with diabetes, the Hemoglobin A1C test measures what?

answer

Blood glucose control over a period of 2-3 months

question

During this irregular heart rhythm, premature ventricular contractions (PVCs) occur every third heartbeat

answer

Ventricular trigeminy

question

What are the most common causes of PVC's?

answer

- Hypoxia - Electrolyte imbalances - Emotional stress - Fever - Stimulants (Caffeine, drugs) - Exercise

question

What 3 factors does bone healing depend on?

answer

- Adequate nutrition - Adequate circulation - Age

question

When sudden dislodgment of a chest tube occurs & a sterile occlusive dressing is unavailable, what is the next best nursing intervention?

answer

Cover the insertion site with something clean & occlusive, such as a GLOVED HAND, to prevent air from entering the pleural cavity

question

When caring for a patient receiving TPN, what is it extremely important for the nurse to monitor for?

answer

S/S of hyperglycemia

question

What are s/s of hyperglycemia?

answer

- Polyuria - Polydipsia - Polyphagia - Headaches - Blurred vision

question

What are potential AE of atypical antipsychotics, such as Seroquel & Zyprexa?

answer

- EPS: Parkinsonism, akathisia, shuffling gait - Neuroleptic malignant syndrome (NMS) - Anticholinergic effects: BUDCAT - Orthostatic hypotension - Sedating effects: Drowsiness, hypersomnia

question

No longer than what amount of time can blood products remain at room temperature after picking them up from the blood bank? What is proper nursing action if in this situation?

answer

No longer than 30 minutes - Should return blood to blood bank

question

How often should an ostomy appliance be changed?

answer

q5-10days

question

This pregnancy condition is defined as new-onset HTN after 20 weeks gestation accompanied with proteinuria or signs of end-organ damage

answer

Preeclampsia

question

What are common clinical manifestations of preeclampsia?

answer

- Net onset HTN - Proteinuria > 300mg/24hr - Signs of end organ damage - Headache - Visual changes - Pitting pedal edema

question

The nurse has orders to administer both blood products and Amphoteracin B. How should the nurse go about administering both of these medications? Why?

answer

The nurse should complete administration of the blood products and allow one hour of observation post administration, then begin initiation of Amphoteracin B; This is done because adverse effects of both blood products and the anti fungal medication are too similar to differentiate between

question

If accidental extubation occurs when repositioning/turning a sedated patient in the ICU, what are vital nursing actions?

answer

- Remain with client - Protect airway using head tilt chin lift OR jaw thrust if spinal injury suspected - Deliver rescue breaths using bag-valve-mask with 100% o2 until re-intubation is achieved

question

After administering IV nitroglycerin to a patient with angina, what is an expected side effect from medication therapy and why?

answer

Headache due to vasodilation of cranial vessels

question

What could a low pressure alarm on a ventilator indicate?

answer

Tubing became disconnected OR there is an air leak

question

What could a high pressure alarm in an endotracheal or tracheostomy tube indicate?

answer

- Tubing is kinked - Obstruction (secretions) in tube - Pt is biting endotracheal tube (Fighting ventilator)

question

What are examples of client incidents that would require completion of an incident report?

answer

- Falls - Mislabeled laboratory specimens - Medication administration errors - Failure to communicate pertinent patient information to HCP

question

Where is the best area to assess for petechiae in dark skinned clients?

answer

Buccal mucosa & conjunctivae

question

Where is the best area to assess for jaundice in dark skinned clients?

answer

Palms of hands and soles of feet

question

What are assessment findings found in patients with emphysema?

answer

- Activity intolerance - Barrel chest - Hyperresonance on percussion - Use of accessory muscles - Pursed lip breathing - Placement in tripod position

question

What does TORCH stand for related to gestational infections that can cause fetal abnormalities

answer

T- Toxoplasmosis O - Other: Parovirus, varicella R - Rubella C - Cytomegalovirus H - Herpes simplex virus

question

Before applying AED pads to a patient in the community setting, what are nursing considerations to have?

answer

- Move patient out of large bodies of water - Dry chest area before applying pads - Remove transdermal medication patches before application of AED

question

What are the severe electrolyte abnormalities seen in chemotherapy induced tumor lysis syndrome?

answer

- Hyperphosphatemia - Hyperkalemia - Hyperuricemia - Hypocalcemia

question

Defined as an oncologic emergency occurring when cancer treatment successfully kills cancer cells, resulting in release of intracellular components, such as electrolytes

answer

Tumor lysis syndrome

question

What are s/s of meningitis in an infant?

answer

- Fever or hypothermia - Poor feeding - Vomiting - Altered LOC (Irritable, restless) - Increased ICP (Bulging fontanelle)

question

In pediatric clients, an occasional barking cough without stridor is most likely what?

answer

Laryngotracheobronchitis aka Croup

question

Upon examination of an IV bag containing blood products, what are examples of indications of contaminated blood?

answer

- Green, black, white or dusky coloration - Accumulations of air - Evidence of clotting or presence of inclusions - Malodor

question

Upon examination of an IV bag containing blood products, what does a large air bubble at the top of the bag indicate? What is the proper nursing action?

answer

Contamination - Return blood to blood bank & obtain a new bag

question

Patients with what two characteristics/history will have atypical presentation of MI symptoms?

answer

- Female gender - Older adults - Patiens with DM experiencing neuropathy

question

What are the TYPICAL clinical manifestations of impending MI?

answer

- Described as chest pressure, heaviness, tightness - Pain may radiate to jaw, arm, back or upper abdomen - CP lasting more than 30 minutes - CP not improved with rest or position changes - CP worsens with exertion

question

What drug class is Cyclosporine in? What does the nurse need to educate patients prescribed this about?

answer

DMARD: Immunosuppressant Educate about: - Increased risk for infection - Bone marrow suppression - Avoid large crowds - Avoid known sick contacts

question

What is an AE of the gastrointestinal tract upon taking calcium channel blockers, specifically Verapamil?

answer

Constipation

question

In relation to increased ICP, what defines the Cushing triad?

answer

- Bradycardia - Irregular respirations - HTN with a widening pulse pressure

question

Upon assessment of a patient, what assessment finding can indicate possible smoke inhalation injury?

answer

Singed facial hair

question

What are s/s of pacemaker malfunction?

answer

- Hypotension - Bradycardia - Dizziness

question

What are examples of medications/medical conditions that can prolong QT interval and precipitate an episode of torasdes de points?

answer

- Antiarrhythmics (Sotolol, amiodarone, ibutilide, dofetilide) - Macrolide antibiotics (Erhtyromycin, azithromycin) - Electrolyte abnormalities (Hypokalemia, hypomagnesemia)

question

For patients in restraints, what position is contraindicated due to increased risk for aspiration?

answer

Supine

question

What 3 positioning techniques are recommended for patients in restraints?

answer

- Side lying - Semi Fowler - High Fowler

question

For patients with chronic kidney disease receiving treatment with erythropoietin (Epotein alfa, Epogen), when would therapy be discontinued and why?

answer

- Hemoglobin > 11 g/dL - Uncontrolled HTN - Increased risk of thrombotic events

question

For patients with chronic kidney disease scheduled for erythropoietin therapy, what are proper nursing assessment prior to administration?

answer

- Assess BP - Assess Hgb level

question

For patients with chronic kidney disease prescribed erythropoietin, what is a contraindication for therapy with this medication?

answer

Uncontrolled HTN

question

This disease process results from the liver's failure to detoxify the body of ammonia

answer

Hepatic encephalopathy (HE)

question

What are the clinical manifestations of patients developing hepatic encephalopathy?

answer

- Cognitive deficits (Confusion, disorientation) - Mental status changes (Sleep disturbances, altered LOC, hypersomnia, coma) - Motor alterations (Asterixis: Flapping hand tremor when arms are extended) - Fector hepaticus (Sweet, musty odor to breath)

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