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IV heparin Precaution

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- The anticoagulant effect of heparin increases the risk of bleeding. therefore, the client should use an electric razor to reduce the risk of cuts and bleeding during shaving - client should not use suppositories for constipation because suppository use increases the risk of bleeding - client should avoid flossing because bleeding can easily occur -Green leafy vegetables do not interfere with the effects of heparin, so client can have green leafy vegetables

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Premature ventricular contractions

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The nurse should administer lidocaine, an antidysrhythmic for short-term treatment of ventricular dysrhythmias The nurse should defibrillate the client's heart for a ventricular tachycardia or ventricular fibrillation

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supraventricular tachycardia

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The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia

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hypokalemia

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Decreased peristalsis is a clinical manifestation of hypokalemia

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hyperkalemia

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Facial twitching is a clinical manifestation of hyperkalemia Bounding peripheral pulses are a clinical manifestation of hypernatremia Hyperreflexia is a clinical manifestation of hyperkalemia

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Respiratory alkalosis

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Hyperreflexia is an expected finding in a client who has respiratory alkalosis Hypertension Tetany is an expected finding in a client who has respiratory alkalosis

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Kussmaul respirations

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respiratory acidosis with manifestations of Kussmaul respirations Kussmaul respirations are an effort to rid the body of increased CO2 levels and usually occur with hyperglycemia

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The client should take an antacid to manage

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The client should take an antacid to manage symptoms of gastric reflux and dyspepsia

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Monitor client with heart failure and is receiving a blood transfusion for

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Crackles in the lungs indicate fluid overload, which is a risk during blood transfusions for older adult clients who have heart failure Tachycardia is more likely to occur for an older adult client who has heart failure and is receiving a blood transfusion

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telemetry monitoring

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This identifies if pacemaker cells of my heart are working properly Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle

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peripheral venous disease

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keep my legs elevated when I'm not wearing the stockings put the stockings on before I get out of bed in the morning ake the stockings off every day and check my skin

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autonomic dysreflexia

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Bradycardia is a manifestation of autonomic dysreflexia

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aortoiliac disease

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The greatest risk to this client is injury from decreased perfusion to the lower extremities therefore, the first pulse site the nurse should palpate is the femoral pulse

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General anesthesia

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Hypothermia is an expected finding in a client following general anesthesia Expectoration of thick, clear sputum is an expected finding due to intubation for general anesthesia Absent bowel sounds is an expected finding in a client following general anesthesia

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Deep-vein thrombosis

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A warm, red area on the calf may indicate the presence of a deep-vein thrombosis The nurse should report this finding to the provider

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Client with sealed radiation implant

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The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant the nurse should limit each visitor to 30 min per day to prevent exposure The nurse should wear a dosimeter badge to monitor exposure to radiation The nurse should keep all soiled linens in the client's room until the client has the radioactive source removed

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client who has chronic kidney disease should avoid protein

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Salmon contains high in protein

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Dehydration

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check clients BUN, when BUN is increased client can be dehydrated

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when a client's blood pressure is low and also complains of nausea, the nurse should

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Place the client on side lying position To prevent any further drop in blood pressure, the nurse should keep the client's head flat and maintain the client in a side-lying position to prevent aspiration if vomiting occurs

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Febrile blood reaction

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The nurse should plan to administer an antipyretic such as acetaminophen for a febrile reaction to a blood transfusion

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Febrile reaction

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- a reaction to the white blood cells in the donated blood - more common in clients who have had previous transfusions and in multi-para women Findings: fever within 24 hours of the transfusion including headache, nausea, chills, or a general feeling of discomfort may be treated with antipyretic acetaminophen

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Give Furosemide when client experience overload from blood transfusion

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The nurse should plan to administer a loop-diuretic such as furosemide if the client displays manifestations of circulatory overload due to a blood transfusion

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Give Diphenhydramine for mild allergic reaction

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Diphenhydramine The nurse should plan to administer an antihistamine such as diphenhydramine if the client displays a mild allergic reaction during a blood transfusion

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Allergic reaction

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most common type of reaction findings: hives and itching may be treated with antihistamines, diphenhydramine

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Give cephalexin for sepsis

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The nurse should plan to administer an IV antibiotic such as cephalexin if the client displays manifestations of sepsis due to receiving contaminated blood from a transfusion

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Right hemispheric cerebrovascular accident

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Visual spatial deficits is correct - Visual spatial deficits occur secondary to a right hemispheric cerebrovascular accident. Left hemianopsia is correct - Left hemianopsia occurs secondary to a right hemispheric cerebrovascular accident. One-sided neglect is correct - One-sided neglect occurs secondary to a right hemispheric cerebrovascular accident

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Left hemispheric cerebrovascular accident

answer

Expressive aphasia occurs secondary to a left hemispheric cerebrovascular accident Right hemiplegia occurs secondary to a left hemispheric cerebrovascular accident

question

Diabetic ketoacidosis

answer

Give Regular insulin 20 units IV bolus 1- Ketoacidosis indicates decreased insulin - Regular insulin is a fast-acting insulin and may be effective within 10 min when given IV Ketoacidosis indicates increased blood glucose and not enough insulin

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NPH and Regular insulin

answer

NPH insulin is a long-acting insulin and would not affect the client rapidly Regular insulin is a fast-acting insulin and may be effective within 10 min when given IV

question

Endometrial biopsy

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An endometrial biopsy involves removal of a sample of the endometrial tissue, which lines the uterus The provider inserts an instrument through the vagina and cervix to obtain the specimen The provider performs an endometrial biopsy in an outpatient setting under local anesthesia and the client is not hospitalized

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Prevention of atherosclerosis

answer

Follow a smoking cessation program Smoking cessation is an important lifestyle modification to prevent atherosclerosis Maintaining an appropriate weight is an important lifestyle modification to prevent atherosclerosis Eating a low-fat diet is an important lifestyle modification to prevent atherosclerosis

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with hepatic encephalopathy check blood ammonia for the effectiveness of the treatment

answer

Toxic substances absorbed by the intestines that are not broken down, leading to increased ammonia levels

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Blood urea nitrogen BUN

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Blood urea nitrogen levels increased as a result of liver or renal disease (kidney)

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Serum aspartate aminotransferase

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Serum aspartate aminotransferase levels are commonly elevated in liver disease because this enzyme is released from the liver as a result of hepatic inflammation

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Serum total bilirubin

answer

Total bilirubin levels increased if client have problem with liver, due to the inability of the liver to excrete bilirubin

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client who has heart failure give Digoxin

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The client takes digoxin to increase cardiac contractility

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Nitroglycerine

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The client takes nitroglycerin to dilate the coronary arteries and lower blood pressure

question

furosemide

answer

The client takes furosemide to reduce circulating blood volume

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Lovastatin

answer

The client takes lovastatin to reduce cholesterol levels

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Adverse effects of enalapril

answer

Enalapril is an antihypertensive agent; therefore, the nurse should assess the client for orthostatic hypotension.

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peripherally inserted central catheter (PICC)

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can be inserted in the upper extremity - Using this insertion site decreases the risk of infection because there are fewer types and numbers of organisms on the upper extremities as compared to the torso, where the client would have a nontunneled percutaneous central catheter

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Clostridium difficile

answer

- The nurse should implement contact precautions for a client who has C difficile because the mode of transmission is direct contact - The nurse should use soap and water for hand hygiene when caring for a client who has C. difficile because alcohol-based cleansers do not kill the spores of this pathogen

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A client with shingles

answer

A client who has shingles requires airborne precautions and therefore requires a private room

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Client with Pancreatitis

answer

decreased serum calcium due to fat necrosis increased serum amylase increased alkaline phosphatase increased serum bilirubin

question

ciprofloxacin for a urinary tract infection

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The client should restrict caffeine intake to reduce CNS stimulation The client should avoid products containing calcium for 6 hr before or 2 hr after taking ciprofloxacin because it interferes with absorption of the medication

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Omeprazole

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The nurse should administer omeprazole for GERD

question

Ranitidine

answer

The nurse should administer ranitidine for peptic ulcer disease

question

Hydromorphone

answer

The nurse should administer hydromorphone to manage the client's pain caused by biliary colic - Biliary colic is the term used to describe a type of pain related to the gallbladder that occurs when a gallstone transiently obstructs the cystic duct and the gallbladder contracts

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Phenytoin

answer

The nurse should administer phenytoin for seizures

question

If client is schudled for allergy testing and is taking glucocorticoid the nurse should:

answer

nurse should postpone the testing - The client should discontinue prednisone, a glucocorticoid, for up to 4 weeks before allergy testing to avoid suppressing the immune response

question

In case of sezuire the nurse should:

answer

The client's airway can become obstructed and the nurse may need to suction to clear the client's airway after the seizure Loosen restrictive clothing on the client The nurse should not insert anything into the client's mouth The nurse should keep the client flat on her back or turned onto her side during a seizure to prevent aspiration

question

MI

answer

Troponin I and is a specific marker of myocardial infarction

question

client who is taking carvedilol for heart failure

answer

if client gain weight, the nurse should notify the provider. That means the medication is not effective.

question

carvedilol, for heart faliure

answer

Fatigue is an expected finding for a client who is taking carvedilol Diarrhea is an expected finding for a client who is taking carvedilol Orthostatic hypotension is an expected finding for a client who is taking carvedilol

question

total hip arthroplasty

answer

The nurse should place a pillow between the client's legs to prevent hip dislocation The client should not flex the hip greater than 90° to prevent hip dislocation The nurse should assist the client to maintain abduction of the client's legs

question

lumbar puncture

answer

The nurse should maintain the client in a dorsal recumbent position The nurse should not place a pillow under the client's knees because it can impede circulation The nurse should encourage fluid intake to replace lost cerebrospinal fluid The client should be maintained in a supine position for 1 to 12 hr following the procedure

question

Intra-arterial radial catheter

answer

The nurse should check capillary refill distal to the catheter insertion site to monitor for impaired circulation Monitor for bleeding The nurse should place an occlusive dressing over the catheter insertion site The nurse should maintain patency of the catheter with a continuous infusion of 0.9% sodium chloride

question

postoperative following a parathyroidectomy

answer

1- The high priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is place a tracheostomy tray at the client's bedside in case of airway obstruction. 2- The nurse should use sandbags to support the head and neck to prevent stress on the suture line 3- The nurse should place the client in semi-Fowler's position to avoid neck extension

question

opioid analgesic

answer

The client should take opioid analgesics with food to prevent nausea should increase your fiber intake to prevent constipation

question

Partial thromboplastin Time (aPTT) (Heparin)

answer

16-40 second therapeutic range 1.5-2x normal or control value

question

Adverse reaction to furosemide

answer

Look for serum sodium, if decreased is a adverse effect of it weight loss is a expected finding

question

postoperative teaching following an ileostomy

answer

Feces will gradually become thicker and more paste-like over time The stoma should remain cherry red and moist The client should expect a minimal or a sweet odor of the feces The skin around the stoma should remain free of irritation and excoriation

question

When preparing the medications

answer

The nurse should not open time-released medications because they will be absorbed into the gastrointestinal tract immediately, which defeats the purpose of a time-released capsule The nurse should use a medicine cup to avoid handling the pills The nurse should open the medication package at the bedside to reduce the risk for medication error.

question

complications of hypothermia

answer

Hypertension, Hypothermia can cause vasoconstriction leading to hypertension Metabolic acidosis can result from hypothermia due to shivering

question

Cast

answer

The nurse should report an increase in drainage, which may indicate infection or an improperly fitting cast The nurse should expect capillary refill of 3 to 4 seconds, which indicates adequate circulation to the extremity The nurse should expect a bounding dorsalis pedis pulse, which indicates adequate circulation to the extremity The nurse should expect to find cold areas on the cast as the cast dries

question

Dehydration

answer

When caring for client with dehydration always look and monitor muscle strenght. The greatest risk to this client is injury from falls; therefore, the priority assessment is muscle strength to prevent falls Assessing skin turgor is important to monitor hydration status Assessing weight is important to monitor hydration Assessing urine specific gravity is important to monitor hydration

question

Adverse effect of mannitol

answer

Muscle rigidity is an adverse effect of mannitol

question

Nephrostomy tube

answer

The nurse should notify the provider if there is a decrease in urinary output, which can indicate impaired renal function or dysfunction of the nephrostomy tube The nurse should report back pain, which can indicate that the nephrostomy tube is dislodged or clogged Red-tinged urine is an expected finding for the first 12 to 24 hr following a nephrostomy tube insertion A low-grade fever is expected in the first 24 hr following a nephrostomy tube insertion

question

Mechanical ventilation

answer

When providing nursing care, the nurse should first use the least restrictive intervention Because anxiety and restlessness indicate that the client is "fighting the ventilator," the nurse should first provide verbal instructions and emotional support to help the client relax and allow the ventilator to work Many factors can cause a high-pressure alarm to sound. In the event of a ventilator failure, the nurse may need to disconnect the machine and manually ventilate the client

question

total parenteral nutrition (TPN)

answer

if running out of TPN and the next bag is not ready, administer 10% dextrose in water until the new bag arrives TPN solutions have a high concentration of dextrose. If a TPN solution is temporarily unavailable, the nurse should administer 10% or 20% dextrose in water to avoid a precipitous drop in the client's blood glucose level Keeping the line open with 0.9% sodium chloride can cause injury to the client, so only 10% to 20% dextrose in water

question

Acetylcysteine

answer

Acetylcysteine thins pulmonary secretions, which increases the client's ability to cough up secretions, is a good thing

question

with a client history of anxiety disorder reports numbness and tingling in the fingertips and pulse rate is increased and respirations is increased too

answer

Apply a nonrebreather mask without oxygen The greatest risk to the client is hypocapnia and subsequent development of respiratory alkalosis; therefore, the priority intervention is to assist the client to retain more carbon dioxide, minimizing the potential for development of respiratory alkalosis by using a nonrebreather mask

question

client who has a Stage III pressure ulcer

answer

The nurse should use a hydrocolloid dressing to keep the wound bed moist The nurse should use a nonadherent gauze dressing for a wound that has little to no drainage The nurse should use adhesive transparent film over intact skin The nurse should use a wet-to-damp dressing for mechanical debridement

question

bowel obstruction

answer

Insert a nasogastric tube Inserting a nasogastric tube will decompress the bowel and may alleviate the obstruction A client who has a small bowel obstruction should not receive enemas The nurse should place the client in semi-Fowler's position to promote peristalsis and facilitate breathing

question

Administering RBCs to a client

answer

Prime the administration set with only 0.9% sodium chloride solution The nurse should administer blood with 0.9% sodium chloride solution and Never with lactated Ringer's solution or with a solution that contains dextrose These solutions cause clotting or lysis of RBC The nurse should stay with the client for at least 30 min, as most transfusion reactions manifest during the infusion of the first 50 to 100 mL of the blood product The nurse should administer blood products as soon as possible after obtaining them from the blood bank to decrease the risk of bacterial growth Blood components are too viscous to infuse properly through a needle with a lumen any narrower than 20 gauge. The nurse should use an 18- or 19-gauge needle

question

Heart Faluire

answer

The nurse should report a weight gain of 3 lb or more per week

question

UTI

answer

A client who is at risk for developing UTIs should increase her intake of ascorbic acid to acidify the urine A client who is at risk for developing UTIs should take showers rather than baths because bacteria in the bath water can enter the urethra A client who is at risk for developing UTIs should urinate on a regular basis, at least every 4 hr A client who is at risk for developing UTIs should wipe from the front to the back after voiding to avoid bacterial contamination.

question

Omeprazole

answer

Omeprazole is a proton pump inhibitor, which relieves symptoms of gastric ulcers by suppressing gastric acid production

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